Group 1b Case Presentation NRMF

FAR EASTERN UNIVERSITY
INSTITUE OF NURSING
A Case of
Labor Pain associated with Spontaneous Rupture of Membranes with thick Meconium
stained in the Amniotic Fluid
Presented by:
Co, Beverly E.
Dacuycuy, Jahnn Chester
Dancel, Edgar Nelson C.
Edusada, Jamelle P.
Espenida, Sophia E.
Esto, Rhada Justine G.
Estrovillo, Kenneth M.
Fernando, Gabrielle Marie Z.
Gatchalian, Llana Nicole G.
Gaviola, Clara Gabrielle Yukiko T.
Idago, Diana Joyce M.
BSN 216 – Group 1B
Presented to:
Ms. Jocelyn Quiboloy RN
FEU – NRMF Preceptor
Submitted on:
November 23, 2021
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I. DEMOGRAPHIC PROFILE
Name: Milagrosa, Veronica Villa

Address: Blk 42 Lot 3 Bagong Silang, Caloocan City
Age: 29 Birthdate: May 27, 1992 Birthplace: Metro Manila
Gender: Female
Religion: Born Again Christian Race/Ethnic Origin: Filipino
Occupation: Charge Clerk Educational Attainment:
Marital Status: Married Name of Spouse: Abraham Milagrosa
Chief Complaints: Pregnancy Uterine 39 weeks 3 days ; Cephalic in Labor ;
Spontaneous Rupture of Membranes – Thickly Meconium Stained Amniotic Fluid
Date of Admission: November 9, 2021
Room and Bed Number: Room 329 Bed B
Attending Physician: Dr. Elizabeth Reyes Admitting Physician: Dr. Cherry
Paloma
Admitting Diagnosis: G2 P1 (1001) Pregnant at 39 weeks and 3 days
Final Diagnosis: G2 P2 (2002) Term, Cephalic Delivered, Spontaneous Rupture of
Membranes- Thickly Meconium Stained Amniotic Fluid
Medical Insurance: Philhealth
II. NURSING HEALTH HISTORY
A. Present Health History
Patient VM, a 29 year old female is G2P1 (1001), 39 weeks and 3 days age
of gestation, admitted in the hospital for Normal Spontaneous Delivery. Her membrane
ruptures spontaneously with thick meconium stained amniotic fluid. Upon admission,
vital signs taken are normal. Blood Pressure of 110/60 mmHg, Pulse Rate is 92bpm,
Respiratory Rate is 20 bpm, 02 Sat is 98% and body temperature of 36 degree Celsius.
The patient also tested negative in the RT-PCR test for Covid-19. The patient denies
any problems in any of the trimesters. She delivered her baby in a cephalic presentation
through NSD with Right Medio-Lateral Episiotomy.
B. Past Health History
The patient had her first baby in Normal Spontaneous Delivery with no date
mentioned during assessment. She stated that she had complete immunization during
her childhood and that she received doses of tetanus toxoid during her first and
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second pregnancy. The patient stated no past and childhood serious illnesses except
for chicken pox. She hasn’t been to any major accidents and injuries. Also, the
patient doesn’t mention any allergies to food and drugs. According to the patient, she
doesn’t know any family genetic diseases. She was never hospitalized before
because of major surgeries or illnesses except that she gave birth to her first born.
Lastly, she has not been to any places aside from their home and hospital for her
prenatal checkup.
C. Obstetric and Gynecologic History
Menstrual Menarche at the age of thirteen, lasting for 3-5 days, using 3-5 pads per day.
History Menses were regular and sometimes associated with mild dysmenorrhea.
The cycle of her period is 26-30 days
Sexual History The patient mentioned that she has an active sexual relationship with her
husband.
Obstetric First pregnancy: no details indicated

History
Second pregnancy:
G2P2
LMP: February 5, 2021
AOG: 39 weeks and 3 days
Newborn: Boy, 3000 grams weight, APGAR 9 & 10
Delivered full term via Normal Spontaneous Delivery (NSD) with right
mediolateral episiotomy. Repair under CPEA. Presence of meconium
staining up to the cord
Assisted by obstetrician/surgeon at FEU NRMF Hospital
Gynecologic No menstrual abnormality mentioned.

History
Pap Smear result during her 2 pregnancies, detects no abnormal changes
D. Family History (Genogram)
Patient V.M is a 29 year old female who was born in Metro Manila and first child
among the 5 children of Mr. and Mrs. V. Patient is married to Mr. M. and they have 2
children including the baby inside the patient’s womb. She is working as a clerk in a
hospital and her husband works as a Policeman in their town. Her mother, 54 years is
working as a public school teacher and her father, 55 years of age works as an assistant
chef in a restaurant. Mrs. V used to live with her family in Novaliches in a compound
together with her aunts and uncles in her maternal side. When she got married, she
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moved in with her husband in Caloocan City and there she got pregnant with her first
and second baby. They live with her in-laws but in a different house inside the same
compound. She has a good relationship with her in-laws and still keep in touch with
her family.
Both of her maternal and paternal side doesn’t have any history of serious illnesses that
can be genetic. Both of her grandparents on both sides of the family are still alive and
healthy. Her 4 siblings are aged 23, 20, 18, and 13 years old. All of them are healthy
with no history of illnesses except for her 20-year-old sister who experienced dengue
fever before. Mrs. V together with her siblings had experienced to have chicken pox in
different times.
Legend:
Male - Committed Relationship ------
Female - Deceased - X
Grandparents Grandparents
Aunts/Uncle Aunts/Uncles
Father Mother
Spouse Patient Siblings
Children
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III. GORDON’S HEALTH ASSESSMENT
1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN
 When asked about her health, the client characterizes herself as a healthy person. She goes
to her prenatal check-ups on a monthly basis, as prescribed by her doctor. She takes
pregnancy supplements suggested by her doctor, such as cefuroxime, metronidazole,
ibuprofen, multivitamins, ferrous sulfate with folic acid, and calcium carbonate with
vitamin D. In addition, the client eats nutritious foods such as fruits and vegetables on a
regular basis. The client maintains her health by avoiding smoking, drinking alcoholic
beverages, or using illegal substances. She rigorously adheres to her doctor's
recommendations and maintains herself physically active through frequent exercise.
Interpretation: Normal
Analysis: Prenatal care is aimed at monitoring the baby's growth and the mother's well-being in
most pregnant women who are otherwise healthy. Any worries, or if the woman has a history of
health problems, will be carefully addressed to ensure the health of both the mother and the baby.
2. NUTRITIONAL – METABOLIC PATTERN
 The client said that she eats three to four times a day that includes breakfast, lunch, snacks,
and dinner on time. Since she is pregnant, she stated that she frequently adds fruits and
vegetables to her meals. She said that she even tracked her calories to make sure that she
eats the exact amount of food for her and for her baby. She made sure that she had water
beside her to keep her hydrated. She also stated her food intake three days before
admission.
Day Time Food and Beverages Amount eaten
November 6, 8:00 am Eggs (boiled) 2 large eggs (156 calories)

2021 Medium size apple (95
Apple calories)
1 glass (42 calories)
Milk
12:00 Rice 1 cup (206 calories)

pm Beef Broccoli 1 cup (232 calories)
Banana 1 piece banana (89 calories)
1 glass (46 calories)
Apple juice
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3:00 pm Muffin 2 small muffins (498

calories)
6:00 pm Pork chop with 1 piece pork chop (231

calories)
Rice 1 cup (206 calories)
Pineapple juice 1 glass (60 calories)
November 7, 8:00 am Oatmeal with berries 1 bowl (300 calories)

2021 1 cup yogurt (59 calories)
Yogurt

pm Pork sinigang 1 cup (222 calories)
Water 1 glass (8 oz)
3:00 pm Avocado toast with 1 slice (188 calories)

Sunny Side up egg 1 medium egg (70 calories)
6:00 pm Rice 1 cup (206 calories)

Fried chicken 1 piece (246 calories)
4 oz
Ginger tea
November 8, 8:00 am Pancake 2 pieces (454 calories)

2021 Banana smoothie 1 glass (220 calories)

pm Ginataang kalabasa with 1 cup (245.8 calories)
malunggay 1 piece (52 calories)
Apple
3:00 pm Vegetable salad with dressing 1 bowl (235 calories)
6:00 pm Rice 1 cup (206 calories)

Tuna sisig 1 cup (184 calories)
Milk 1 glass (42 calories)
Pears 1 piece (102 calories)
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Analysis: During pregnancy, eating a balanced diet is connected to optimal brain development
and a healthy birth weight, as well as lowering the chance of numerous birth abnormalities. Eating
healthy foods can reduce morning sickness and exhaustion caused by pregnancy.
3. ELIMINATION PATTERN
 In the span of 24 hours the client had a total of 2,300 ml of urine with the color of light
yellow and the client does not feel any discomfort when urinating. Around 6:00 am to 2:00
pm the client had a urine output of 1,500 ml. While around 2:00 pm to 10:00 pm the client
had a urine output of 800 ml. On a daily basis, the client states the she approximately
urinates 1-15 times a day since her pregnancy. Her stool elimination has no problem at all.
It is smooth and soft with no unusual odor.
Analysis: The usual 24-hour urine volume is between 800 and 2,000 milliliters each day (with a
normal fluid intake of about 2 liters per day). Because your body generates more fluids when you're
pregnant than it does at other times, you'll have to urinate more frequently. Your kidneys, which
create urine, increase their efficiency as well. Your uterus, which is located right below your
bladder, expands to accommodate your developing baby and presses against your bladder as a
result.
4. ACTIVITY – EXERCISE PATTERN
Time Sunday Monday Tuesday Wednesday Thursday Friday Saturday
6:00am Slept the Do yoga Do yoga Do yoga Do yoga Do Slept the

- entire and self and self and self and self yoga entire
8:00am time. meditatio meditatio meditation meditation and self time.
n for 15 n for 15 for 15 for 15 meditati
minutes. minutes. minutes. minutes. on for
15
minutes
.
8:00am Prepares Rest for a Rest for a Rest for a Rest for a Rest for Prepares
- breakfast minute. minute. minute. minute. a breakfast
11:00a for her Prepares Prepares Prepares Prepares minute. for her
m family breakfast breakfast breakfast breakfast Prepare family and
and for her for her for her for her s watches
watches family. family. family. family. breakfas TV.
TV. t for her
family.
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11:00 She She She She cooks She cooks She She cooks
am- cooks cooks cooks lunch and lunch and cooks lunch and
3:00pm lunch lunch and lunch and does some does some lunch does some
and does does does household household and household
some some some chores. chores. does chores.
househol househol househol some
d chores. d chores. d chores. househo
ld
chores.
3:00pm Walk Walk Walk Walk Walk Walk Walk

- outside. outside. outside. outside. outside. outside. outside.
6:00pm
6:00pm Prepare Prepare Prepare Prepare Prepare Prepare Prepare

- dinner, dinner, dinner, dinner, take dinner, dinner, dinner,
9:00pm take a take a take a a bath, and take a take a take a
bath, and bath, and bath, and put herself bath, and bath, bath, and
put put put to sleep. put herself and put put herself
herself to herself to herself to to sleep. herself to sleep.
sleep. sleep. sleep. to
sleep.
Analysis: Maintaining a regular exercise routine can help you stay healthy and feel your best
during your pregnancy. Regular exercise throughout pregnancy will help you maintain a better
posture and alleviate typical discomforts like backaches and exhaustion. Physical activity has been
shown to reduce gestational diabetes (diabetes that develops during pregnancy), decrease stress,
and increase labor and delivery endurance.
5. SLEEP – REST PATTERN
 The client usually sleeps around 9:00-9:30 pm after she does all the household chores. She
usually wakes up around 6:00 am and automatically prepares herself to do self-meditation
or prepare some food for her family. She said that she always sleeps on her left side since
it is more comfortable for her. She usually sleeps for 8-9 hours, but sometimes, her sleep
is being interrupted due to muscle contractions and frequent urinations that were caused by
her pregnancy.
Analysis: Sleep should never be regarded as a luxury. It's a must, especially if you're pregnant.
According to the National Institutes of Health, pregnant women require a few additional hours of
sleep each night or should supplement nighttime sleep with naps throughout the day.
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6. COGNITIVE – PERCEPTUAL PATTERN
 The client reported that she did not have any issues with her vision or hearing. She
understands that remembering tasks and following instructions are not difficult for her.
During the assessment, the client responds, listens, and participates actively. However, the
examiner noticed that the client was having a facial grimace. The client stated that
“Sobrang sakit po ng contractions, pero kaya naman po. May oras lang po talaga na sobrang
lumalala po yung sakit.” But overall, the client can still respond to the examiner even
though she experienced muscle contractions.
Analysis: A contraction occurs when the muscles of your uterus contract and then release like a
fist. Contractions assist in the delivery of your baby. When you're in full-blown labor, contractions
last 30 to 70 seconds and happen every 5 to 10 minutes. You can't walk or talk during them because
they're so powerful. Over time, they grow stronger and closer together. However in this case, the
patient can still participate actively even though she is experiencing true labor.
7. SELF-PERCEPTION – SELF-CONCEPT PATTERN
 The patient describes herself as a hands-on mother to her first born and she look forward
to be this kind of other to her second as well. As she had her last pregnancy, she accepted
that it is normal if her body figure changes since being a mom is really a sacrifice. She also
accepted that her mood suddenly changes the moment that she gets pregnant. But all in all,
she accepted all of these changes since it’s all a part of being a mom and that is normal as
long as she does not cross the line.
Analysis: "Hormonal changes play a huge role in your moods during and after pregnancy,"
explains Lucy Puryear, M.D. The physical changes in a woman's body during pregnancy get a lot
of attention, but the mental changes she goes through get a lot less. Pregnancy may be a thrilling
experience, but it can also be a difficult one, causing emotions to run high. A mother's emotional
and mental health, in addition to her physical health, are equally vital.
8. ROLE – RELATIONSHIP PATTERN
 The patient has a good relationship with the father of her children, which is her husband.
She states that she is grateful and happy with what she has. She and her husband
communicated properly and they ended up having the same opinion and thoughts about
their plans in their lives and their family. In terms of disciplining their child, she said that
they teach their child on how to give respect, and they are introducing the right manners
and right conduct to their child so that they will be able to treat people with respect without
any judgments. She also has a good relationship with her in-laws, siblings and parents.
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Analysis: Pregnancy is the right time to start having a healthy relationship with your partner
Because of the emotional and physical changes you're both going through, as well as the new
responsibilities you're considering.
9. SEXUALITY – REPRODUCTIVE PATTERN
 The client said that she had her first menstrual period at the age of 13. It is regular at 26 to
30 days lasting 3 to 5 days and using 3 to 5 pads per day. This is the second time that the
client got pregnant and she doesn’t have any history of abortion. Regarding sexual activity
she verbalizes that she is sexually active. As being asked about her thoughts about family
planning, the client said that “Mahilig kami ng asawa ko magbasa ng articles tungkol sa
family planning. Open naman kami tungkol doon. Kung tutuusin gumawa na kami ng
family planning bago pa ikasal at so far naman ay nasusunod yun.”
Analysis: A couple or an individual can use family planning to assist them select what is best for
their sexual and reproductive health. A couple can create financial stability by strategically spacing
pregnancies, allowing them to raise a family they can adequately care for. A well-cared-for family
is a healthy family, and a healthy community is built on the foundation of a healthy family.
10. COPING – STRESS TOLERANCE PATTERN
 The client is an employed charge clerk. She always thinks about her salary knowing that
she and her husband will be raising two children together. She stated “Hindi ko maiwasan
isipin yung tungkol sa pera. May trabaho naman kami ng asawa ko pero syempre
nakakastress isipin na yung sahod ko ay minimum lang. Lalo na’t magkaka-maternity leave
ako. Ayoko naman i-asa lahat sa asawa ko kasi dalawa kaming magulang dito.” However,
the client still feels grateful for her husband since he always stays by her side whenever
she feels stressed, since they thought being stressed might affect the baby in her womb.
Analysis: During pregnancy, stress is a frequent emotion. During pregnancy, physical discomforts
and other changes in your everyday life might cause stress. In this case, the client’s husband always
does his best to cope up with the stress that his wife is experiencing. He never let his wife feel
alone.
11. VALUE – BELIEF PATTERN
 According to the client, she is a Born Again Christian who prays very passionately to
God asking for protection, a healthy pregnancy, and blessings. The client kept on
communicating with their God and she puts her trust and faith in him to gain confidence
upon her delivery. She considers her family as the most important thing in her life as she
believes that it was sent by God to provider her joy and motivation in life.
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Analysis: Religion is a collection of structured ideas, rituals, and systems that most commonly
revolve around the belief in and worship of a supreme entity such as a personal god or another
supernatural creature.
IV. PHYSICAL ASSESSMENT
Assessment Normal Findings Actual Findings Interpretation
Observe for signs No distress noted. Facial expression is Deviation from Normal
of distress in in pain due to labor
posture or pain Analysis:
facial expression. The client’s facial
expression expresses pain
due to labor pain which
becomes stronger each
time her uterus contracts.
Observe body Proportionate, Appearance is Normal

build, height, and varies with the proportionate and
weight in relation lifestyle varies with lifestyle
to the client’s
age,
lifestyle, and
health.
Observe the Relaxed, erect The client shows Normal

client’s posture posture, gradual lordosis due
and gait, coordinated to pregnancy.
standing, sitting, movement
and walking.
Observe the Clean; neat The client is clean Normal

client’s and is neat.
overall hygiene
and
grooming. Relate
these to the
person’s
activities prior to
the
assessment.
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Note body and No body No body odor and Normal

breath odor in odor/breath odor no breath odor
relation to or minor body noted/
activity odor
level. relative to work or
exercise
Note obvious Healthy The client has a Normal

signs of health or appearance healthy appearance
illness.
Assess the Cooperative Client is Normal

client’s cooperative and is
attitude. appropriate to
situation
Note the client’s Appropriate to the Client is alert, Normal

affect/mood; situation awake, and
assess the conversant.
appropriateness
of the client’s
responses.
Listen for Understandable, Understandable, Normal

quantity, quality, moderate pace, moderate pace,
and organization exhibits thought exhibits thought
of speech. association association
Listen for Logical sequence, Logical sequence, Normal

relevance and makes sense, has makes sense, has
organization of sense of reality sense of reality
thoughts.
 SKIN
Assessment Normal Actual Findings Interpretation

Findings
Inspect skin Varies from The client’s skin Normal

color light to deep varies from light
brown, from to deep brown.
ruddy pink to
light pink
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Inspect Moisture in The client’s skin Normal

uniformity of skin folds and moisture
skin color the axillae,
affected by
different
factors
Assess edema, if No edema There is edema Normal

present present in the lower
extremities Analysis:
Fluid may build in tissues as preg

nancy advances, most commonly
in the feet, ankles, and legs, causi
ng them to swell and seem puffy.
Edema is the medical term for thi
s ailment. The face and hands occ
asionally swell as well. It's typical
for some fluid to accumulate thro
ughout pregnancy, especially in t
he third trimester. It's known as p
hysiologic edema. (BUNCE.EMI
LY, Swelling During Late Pregna
ncy - Women's Health Issues - MS
D Manual Consumer Version 202
1)
Inspect, palpate, Freckles, some No lesions noted Normal

and describe birthmarks,
skin lesions. some flat and
Apply gloves if raised nevi, no
lesions are open abrasion or
or draining. other lesion
Observe and Moisture in The client’s skin Normal

palpate skin skin folds and is moist.
moisture. the axillae,
affected by
different
factors
Palpate skin Uniform; The client’s skin Normal

temperature within normal is uniform and is
range within normal
range
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Note skin turgor When pinched, After being Normal

by lifting and skin springs pinched and
pinching the back to released, the
skin on an previous state client's skin
extremity recoils
immediately
suggest good
hydration.
 HAIR
Assessment Normal Actual Interpretation

Findings Findings
Inspect the evenness of growth over Evenly The client’s hair Normal
the scalp distributed is evenly
hair distributed hair
Inspect hair thickness or thinness. Thick hair The client’s hair Normal
is thick.
Inspect hair texture and oiliness. Silky, The client’s hair Normal
resilient hair is silky and is
resilient
Note presence of infections or No infection No infection or Normal

infestations by parting the hair in or infestation infestation
several areas and checking behind noted.
the ears and along the hairline at the
neck.
Inspect the amount of body hair. Variable The amount of Normal

body is variable.
 NAILS
Inspect fingernail Convex curvature; The client’s shape is Normal

plate shape to angle between nail convex curvature.
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determine its and nail bed usually

curvature and angle 160°
Inspect fingernail Highly vascular and The client’s fingernail Normal

and toenail bed color pink in light skinned; and toenail is highly
dark skinned may be vascular and skin varies
brown or black from the client’s skin
color.
Palpate fingernail Smooth texture The client’s fingernail is Normal

and toenail texture smooth.
Inspect tissues Intact epidermis Intact epidermis noted. Normal

surrounding nails
Perform blanch test Prompt return or pink The client’s nail regains Normal
of capillary refill or usual color, less pink appearance after 3
than four seconds seconds.
 EYES
Inspect the eyelids The upper lid margin should The upper lid Normal
and eyelashes be between the upper margin covers the upper
of the iris and the upper portion of the
Note width and margin of the pupil. The cornea when the
position of palpebral lower lid margin rests on the patient is looking
fissures. lower border of the iris. No straight.
white sclera is seen above or
below or iris. No white sclera
is seen above or below the Eye lashes span
iris. outwards.
The upper and lower lids

close easily and meet
completely when closed.
Assess ability of
The
eyelids to close The lower eyelid is upright client’s upper and
with no inward or outward lower lids close
turning. Eyelashes are evenly easily and meet
distributed and curve outward completely when
Note the position of along the lid margins.
eyelids in closed.
Xanthelasma, raised yellow
comparison with the
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eyeballs. Also note plaques located most often The eyeballs are
any unusual near the inner canthus, are in the same plane
 Turnings normal variations associated as the eyebrow
 Color with increasing age and high and maxilla.
 Swelling lipid levels.
 Lesions
 Discharge Skin on both eyelids is
without redness, swelling, or
lesions.
Observe redness,
swelling, discharge,
or lesions
Skin of both
eyelids shows
without redness,
swelling, or
lesions.
Observe the Eyeballs are symmetrically Normal

position and aligned in sockets without Eyeballs are
alignment of the protruding or sinking. symmetrical in
eyeball in the eye size and position.
socket.
Inspect the bulbar Bulbar conjunctiva is clear, Anicteric sclera Normal

conjunctiva and moist, and smooth.
sclera Underlying structures are
clearly visible. Sclera is
white.
Inspect the Pinkish in color, shiny, moist, The palpebral Normal

palpebral and smooth. Palpebral conjunctiva is
conjunctiva conjunctiva is free of pinkish in color,
swelling, foreign bodies, or shiny, moist, and
trauma smooth.
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 MOUTH AND OROPHARYNX
Inspect the Lips are smooth and moist without Lips are smooth Normal
lips lesions or swelling. and moist without
lesions or
swelling.
Inspect teeth Thirty-two pearly whitish teeth with Teeth are Normal
and gums smooth surfaces and edges. Upper complete; no
molars should rest directly on the decayed areas
lower molars and the front upper noted.
incisors should slightly override the
lower incisors. Some clients
normally have 28 teeth if the four
wisdom teeth do not erupt.
No decayed areas; no missing teeth
Inspect the Tissue is smooth and moist without Tissue is smooth Normal
buccal lesions and moist without
mucosa lesions
Inspect and Tongue should be pink, moist, a The client’s Normal

palpate moderate size with papillae (little tongue is pink,
tongue protuberances) present. moist, and
moderate in size.
Inspect the Tonsils may be present or absent. The client’s tonsil Normal
tonsils They are normally pink and is present, pink,
symmetric and may be enlarged to and symmetric.
1+ in healthy patients. No exudate, No exudate,
swelling, or lesion. swelling, or
lesion noted.
Inspect the Throat is normally pink, without The client’s tonsil Normal
posterior exudate or lesions. is pink; no lesions
pharyngeal noted.
wall
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 NECK
Inspect the neck Muscles equal in size; Muscles equal in size; Normal
head centered. head centered.
Palpate the There is no swelling or No swelling, tenderness, Normal

lymph nodes enlargement and no and enlargement noted.
tenderness
 CHEST/LUNGS
Assessment Normal Findings Actual Interpretation

Findings
Auscultate for breath Three types of normal Clear breath Normal

sounds. breath sounds may be sounds.
auscultated - bronchial,
Place the diaphragm of bronchovesicular, and
the stethoscope firmly vesicular
and directly on the
posterior chest wall at the
apex of the lung at C7.
Ask the client to breathe
deeply through the mouth
for each area of
auscultation (each
placement of the
stethoscope) in the
auscultation sequence so
that you can best hear
inspiratory and expiratory
sounds. Be alert to the
client’s comfort and offer
for rest and normal
breathing if fatigue is
becoming a problem.
Observe for use of Use of accessory muscles The client Normal

accessory muscles. (sternomastoid and rectus breathes
abdominis) is not seen with effortlessly,
normal respiratory effort. without using
After strenuous exercise or his accessory
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Ask the breathe normally activity, clients with muscles. Equal

and observe for use of normal respiratory status chest
accessory muscles. may use neck muscles for a expansions and
short time to enhance no retractions.
breathing.
 HEART AND NECK VESSELS

Findings
Auscultate Rate should be 60-100 beats/min, with Normal rate Normal

heart rate and regular rhythm. and has a
rhythm regular
rhythm.
Auscultate to S1 corresponds with each carotid Distinct S1 Normal

identify S1 and pulsation and is loudest at the apex of and S2
S2 the heart. S2 immediately follows
after S1 and is loudest at the base of
the heart.
Auscultate for No murmurs are heard. No murmurs Normal

murmurs are heard.
 EXTERNAL GENITALIA
Inspect the mons Pubic hair is Pubic hair is present. Normal

pubis, labia distributed in an Labia majora increases
majora, and inverted triangular slightly in size and looks
perineum pattern and there are puffy or swollen. Perineum
no signs of infestation. stretches due to pregnancy.
The labia majora are

equal in size and free
of lesions, swelling,
and excoriation.
The perineum should

be smooth.
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Inspect the labia The labia minora Labia minora increases Normal
minora, clitoris, appear symmetric dark slightly in size and looks
urethral meatus, pink, and moist. puffy or swollen. Clithoris
and vaginal is engorged. Urethral
opening The clitoris is a small meatus is stretched and
mound of erectile distorted. Vaginal opening
tissue, sensitive tissue is swollen.
to touch; normal size
of the clitoris varies.
The urethral meatus is

small and slit-like.
The vaginal opening is

positioned below the
urethral meatus; size
depends on sexual
activity or vaginal
delivery.
Palpate Bartholin Bartholin is soft, non- Soft, non-tender ; no Normal

glands tender, and drainage discharge noted.
free.
Palpate the No drainage should be No drainage noted. Normal

urethra noted from the urethral
meatus. The area is
normally soft and
nontender.
 INTERNAL GENITALIA

Findings
Inspect the size of The vaginal opening varies in size N/A

the vaginal according to the client's age, sexual
opening and the history, and whether she has given
angle of the birth vaginally. The vagina is typically
vagina tilted posteriorly at a 45-degree angle
and should feel moist.
Inspect the cervix The surface of the cervix is normally Client’s Normal
smooth, pink, and even. It is midline cervix
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in position and projects 1 to 3 cm into appears

the vagina. blue.
Palpate the cervix The cervix is firm and soft. It is N/A

rounded, and can be moved somewhat
from side to side without eliciting
tenderness.
Palpate the uterus Uterus normally round, firm and N/A

smooth.
Palpate the Ovaries are approximately 3 x 2 x 1 or N/A

ovaries the size of a walnut and almond-
shaped.
 ABDOMEN
Observe the Abdominal skin may be paler The client’s Normal

coloration of the than the general skin tone abdominal skin is
skin. because this skin is so seldom lighter than the
exposed to the natural rest of his body.
elements.
Note the Scattered fine veins may be The client has a Normal
vascularity of the visible. Blood in the veins visible scattered
abdominal skin. located above the umbilicus vein on the
flows toward the head; blood abdominal skin.
in the veins located below the
umbilicus flows toward the
lower body.
Note any striae New striae are pink or bluish in The client has a Normal
color; old striae are silvery, presence of striae
white, linear, and uneven along the upper
stretch marks from past borders of his
pregnancies or weight gain. abdomen.
Inspect for scars. Pale, smooth, minimally raised The client has no Normal
old scars may be seen. scar
Assess for lesions Abdomen is free of lesions or The client’s Normal

and rashes. rashes. Flat or raised brown abdomen is free
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moles, however, are normal of lesions and

and may be apparent. rashes.
Inspect the Umbilical skin tones are The client’s Normal

umbilicus. similar to surrounding umbilical skin
abdominal skin tones or even tone is similar to
pinkish . its surrounding
abdominal skin
tone.
Inspect abdominal Abdomen is flat, rounded, or The client’s Normal

contour. scaphoid. abdominal
Abdomen should be evenly contour is
rounded. rounded.
Assess abdominal Abdomen is symmetric The client’s Normal

symmetry. abdomen is
symmetric
Inspect abdominal Abdominal respiratory The client has a Normal

movement when movements may be seen, minimal
the client breathes especially in male clients. observable
abdominal
respiratory
movement.
Observe aortic A slight pulsation of the N/A

pulsations. abdominal aorta, which is
visible in the epigastrium,
extends full length in thin
people.
Observe for the Peristaltic waves are not seen, The client has no Normal
peristaltic waves. although they may be visible in observable
very thin people as slight peristaltic waves.
ripples on the abdominal wall.
Auscultate for A series of intermittent, soft N/A

bowel sounds. clicks and gurgles are heard at
a rate of 5-30 per minute.
Percuss for tone. Generalized tympany N/A

predominates over the
abdomen because of air in the
stomach and intestines.
Dullness is heard over the liver
and spleen.
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Percuss the span The lower border of liver N/A

or height of the dullness is located at the costal
liver by margin to 1-2 cm below.
determining its
lower and upper
borders.
Perform blunt No tenderness is elicited. N/A

percussion on the
liver and the
kidneys.
Perform light Abdomen is nontender and N/A

palpation. soft. There is no guarding.
Deeply palpate all Normally (mild) tenderness is N/A

quadrants to possible over the xiphoid,
delineate aorta, cecum, sigmoid colon,
abdominal organs and ovaries with deep
and detect subtle palpation.
masses.
Palpate the liver. Usually not palpable, although N/A

it may be felt in some thin
clients.
Palpate the Empty bladder is neither N/A

urinary bladder. palpable nor tender.
Perform leopold’s Cephalic: baby’s position head Fetus is in Normal

maneuver 1 down cephalic
presentation
Breech: baby's buttocks is
facing downwards.
Perform leopold’s Fetal back is smooth,hard,

maneuver 2 and a resistant surface.
Knees and elbows of fetus feel

with a number of angular
modulation
Perform leopold’s The presenting part is not

maneuver 3 engaged if it is not movable. It
is not yet engaged if it is still
movable.
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Perform leopold’s Good attitude if the row

maneuver 4 corresponds to the side (2nd
maneuver)that contains the
elbows and knees.
Poor attitude of examining

fingers will meet an
obstruction on the same side as
fetalback (hyperextended head)
Also palpates
infant’s anteroposterior
position. If brow is very easily
palpated, fetus isat posterior
position(occiput pointing
towards woman's
back)
 MUSCLES, BONES, AND JOINTS
Assessment Normal Actual Findings Interpretation

Findings
Inspect the muscles Equal size on The client’s muscle sizes are Normal
for size. both sides of equal on both sides of the
body body.
Inspect the muscles No contractures The client’s muscles and Normal

and tendons for tendons have no
contractures. contractures.
Inspect the muscles No fasciculation The client’s muscles have no Normal

for tremors. or tremors tremors
Palpate muscles at Normally firm The client’s muscles at rest Normal

rest to determine are normally firm.
muscle tonicity.
Palpate muscles Smooth The client’s muscles during Normal

while the client is coordinated active and passive palpation
active and passive for movements have smooth and coordinated
flaccidity, spasticity, movements.
and smoothness of
movement.
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Test muscle strength Equal strength on The client’s head and muscle Normal
of the head & each body side strength are equal on each
shoulders body side with a grade of 5.
Test muscle strength Equal strength on The client’s muscle strength Normal
of upper extremities each body side on the upper extremities is
equal on each body side with
a grade of 5.
Test muscle strength Equal strength on The client’s muscle strength Normal
of lower extremities each body side on the lower extremities is
equal on each body side with
a grade of 5.
Inspect the skeleton No deformities The client’s skeletal Normal

for normal structure structure has no deformities.
and deformities.
Palpate the bones to No tenderness of The client’s bones have no Normal

locate any areas of swelling tenderness and edema.
edema or tenderness.
Inspect the joint for No swelling, The client’s joints have no Normal
swelling tenderness, swelling and nodules upon
crepitation, or inspection.
nodules
Palpate each joint for Smooth, The client’s joints are Normal
tenderness, nontender, no smooth, non-tender, not
smoothness of swelling, swelling, and nodules. The
movement, swelling, crepitation, and temporomandibular joint
crepitation, and presence of (TMJ), however, has
presence of nodules. nodules. crepitations.
A. Measurements (Height, Weight, BMI, Vital signs)
Parameters Normal Actual Interpretation/

Findings Findings Analysis
Blood <120/80 110/60 Interpretation: Normal

Pressure mmHg mmHg
Analysis:
According to the American Heart Association
(AHA), a normal blood pressure reading is
120/80 mm Hg and below. Readings below
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90/60 mm Hg indicate low blood pressure or

hypotension. (Cherney, 2108)
Heart Rate 60-100 bpm 92 bpm Interpretation: Normal
Analysis:
During pregnancy, the amount of blood
pumped by the heart (cardiac output)
increases by 30 to 50%. As cardiac output
increases, the heart rate at rest speeds up from
a normal prepregnancy rate of about 70 beats
per minute to as high as 90 beats per minute.
(Artal-Mittelmark, 2021)
Respiratory 12-20 20 Interpretation: Normal

Rate breaths/min breaths/min
Analysis:
The respiration rate is the number of breaths
you take each minute. The rate is usually
measured when you are at rest. It simply
involves counting the number of breaths for
one minute by counting how many times your
chest rises. Respiration rates may increase
with exercise, fever, illness, and with other
medical conditions. When checking
respiration, it's important to also note whether
you have any trouble breathing.
Normal respiration rates for an adult person at
rest range from 12 to 20 breaths per minute.
(Health library, n.d)
Temperature 36.1°C- 36°C Interpretation: Normal

37.2°C
Analysis:
For an adult, the normal body temperature can
be anywhere between 36.1°C -- - 37.2°C..
During pregnancy, hormonal changes also
raise your body temperature a small
amount.Blood vessels throughout your body
widen to deliver all this blood. This includes
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the blood vessels near your skin. More blood

flows to your skin — causing you to flush (or
glow) and making you feel warmer. (Iftikhar,
2019) and (WebMD, 2017)
Oxygen 95%-100% 98% Interpretation: Normal

Level
Analysis:
A person’s blood oxygen level is an indicator
of how well the body distributes oxygen from
the lungs to the cells, and it can be important
for people’s health. Normal blood oxygen
level varies between 75 and 100 millimeters
of mercury (mm Hg). A blood oxygen level
below 60 mm Hg is considered low and may
require oxygen supplementation, depending
on a doctor’s decision and the individual case.
(Silva, 2021)
Weight Varies 60.5 kg Interpretation: Normal
Height Varies 5’6 ft Interpretation: Normal
V. LABORATORY/DIAGNOSTIC EXAMINATIONS
COMPLETE BLOOD COUNT and RT-PCR
Date Laboratory/Diagnostic Normal Actual Clinical Interpretation

Done Examination Values Results Interpretation & Analysis
(with reference)
October RBC Count 4.50 – 3.58 x Deviation from Normal

28, 2021 5.50 10^12/L A low RBC count may also
indicate a deficiency in
vitamin B6, B12, or folate. It
could also indicate internal
bleeding, kidney disease, or
malnutrition or your body
didn't meet the nutrients it
needed. (NHS, 2018)
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October Deviation from Normal

28, 2021 Hemoglobin 120.0 – 108.0 If a hemoglobin results show
1 140.0 g/L that your hemoglobin level is
lower than normal, this
indicates that you have a low
red blood cell count.
(Mayoclinic, 2019)
October
28, 2021 Hematocrit 0.370 – 0. 321 Deviation from Normal
0.470 L/L A low in hematocrit indicates
that the body has an
insufficient number of red
blood cells. In these cases, a
person may exhibit symptoms
of anemia. (Martin, 2021)
October
28, 2021 MCV 80.0 – 89.7 fL NORMAL
100.0
October
28, 2021 MCHC 320 – 336 g/L NORMAL
380
October
28, 2021 MCH 27.0 – 30.2 pg NORMAL
33.0
October
28, 2021 RDW-CV 11.0 – 13.5% NORMAL
16.0
October
28, 2021 RDW-SD 35.0 – 44.6 fL NORMAL
56.0
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October
28, 2021 Platelet Count 150 – 396 x NORMAL
450 10^/L
October MPV 6.5 – 8.7 fL

28, 2021 12.0 NORMAL
October
28, 2021 PDW 9.0 – 8.6 fL NORMAL
17.0
October WBC Count 5.00 – 11.61 x Deviation from Normal

28, 2021 10.00 10^/L
A high white blood cell count
could indicate that the immune
system is working hard to
eradicate an infection. It could
also be an indication of
physical or emotional stress.
(Smith, 2021)
October Neutrophils 0.350 – 0.669 Deviation from Normal

28, 2021 0.650
Neutrophilia is characterized
by a high percentage of
neutrophils in the blood. This
is an indication that your body
is infected. Neutrophilia can
indicate a variety of underlying
conditions and factors, such as
bacterial infection, injury,
surgery, smoking, high stress
level, and so on.
. (Sampson 2018)
Lymphocytes Deviation from Normal
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October 0.250 – 0.214

28, 2021 0.350 Lymphocytopenia, or a
low lymphocyte count,
is usually caused by:
Your body does not
generate enough
lymphocytes. and
Lymphocytes are being
destroyed. And in that
the lymphocytes are
trapped within your
spleen or lymph node.
(Sampson, 2018)
October Monocytes 0.020 – 0.094 Deviation from Normal

28, 2021 0.060
A high monocyte count, also
known as monocytosis, is
frequently linked to chronic or
subacute infections. It has also
been linked to certain types of
cancer, particularly leukemia.
When you are recovering from
an acute infection, you may
have a high monocyte count.
(Brennan, 2021)
October Eosinophils 0.030 – 0.021 Deviation from Normal

28, 2021 0.050 A low eosinophil count can be
caused by alcohol intoxication
or excessive cortisol
production, such as in
Cushing's disease. Cortisol is a
hormone that the body
naturally produces. The time of
day may also play a role in low
eosinophil counts. Eosinophil
counts are lowest in the
morning and highest in the
evening under normal
conditions. (Underwood, 2018)
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October
28, 2021 Basophils 0.000 – 0.002 NORMAL
0.010
November SARS-CoV-2 (causative SARS- SARS- NORMAL

9, 2021 agent of COVID-19) CoV-2 CoV-2
virus detection by Real- viral viral
Time Polymerase Chain RNA: RNA:
Reaction (RT-PCR) Not Not
Detected Detected
ULTRASONOGRAPHIC REPORT
GENERAL SURVEY
No. of Fetus: Singleton
Chorionicity/Amnionicity:
Presentation: Cephalic
FHR: 134 BPM
SVP: cm AFI: 8.52 cm
Placenta:
Location: Posterior
Grade: III
Relation to cervical os:
Apperance:
FETAL BIOMETRY
BPD 9.05cm 36weeks 5days
HC 32.45cm 36weeks 5days
OFD 11.07cm 36weeks 6days
AC 31.89cm 35weeks 6days
FL 6.58cm 33weeks 6days
EFW 2694+/- 393 grams
Weight Percentile
AUA 35 weeks 5 days
EDD by Ultrasound 12-04-21
RATIOS
CI 81.75%
FL/BPD 72.71%
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FL/AC 20.63%
HC/AC 1.02%
BIOPHYSICAL PROFILE NONBIOMETRICPARAMETERS
Amniotic Fluid 2 AUA
Fetal Tone 2 Placenta
Fetal Movement 2 Colonic Grade
Fetal Breathing 2 Lung/Liver ratio
Non-stress test - DFE
Total: 8/8
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VI. DRUG STUDY
Name of Mechanism of Action Indication Contraindication Side Effects Adverse Effects Nursing Responsibilities
Drug
Generic Inhibits cell-wall  Serious lower  Patients  Diarrhea  Observe and treat the
CV: phlebitis,
Name: synthesis, promoting respiratory tract hypersensitive to thrombophlebitis
patient for signs and
cefuroxime osmotic instability ; infection, UTI, drug or other  Nausea symptoms of
usually bactericidal skin or skin- cephalosporins GI: superinfection and
Brand Name: structure  Anorexia pseudomembranous diarrhea.
Cefurox Classification: infections, bone Cautions:
Therapeutic Class: or joint Use cautiously in  Vomiting Hematologic:  The drug may raise the
Route: Oral Antibiotics infection, patients hypersensitive Hemolytic anemia, INR and increase the risk
Pharmacologic Class: septicemia, to penicillin because thrombocytopenia, of bleeding. Keep an eye
Dosage: 500 Second-generation meningitis, and of possibility of cross- transient on the patient.
mg (1 tablet cephalosporins gonorrhea sensitivity with other neutropenia,
twice a day) beta-lactam eosinophilia
Peak Effect:  Perioperative antibiotics.
PO: 2-4hr Prophylaxis Skin:
Use cautiously in maculopapular and
 Mild to patients with history of erythematous
moderate acute colitis and in those rashes. Urticarial,
bacterial with renal pain, induration,
exacerbations insufficiency. sterile abscesses,
of chronic temperature
bronchitis Pregnancy- elevation
Lactation-
 Acute bacterial Reproduction: Other:
maxillary anaphylaxis,
sinusitis  There are no hypersensitivity
adequate studies in reactions, serum
 Pharyngitis and pregnant women. sickness
Tonsillitis Use during
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pregnancy only if
 Otitis Media clearly needed and
potential benefit
 Uncomplicated justifies potential
skin and skin- risk to the fetus.
structure
infection  Drug appears in
human milk.
 Uncomplicated Patient should
UTI consider
temporarily
 Uncomplicated discontinuing
gonorrhea breastfeeding
during treatment.
 Early Lyme
disease
 Impetigo
Drug
Generic Reversibility inhibits  Ankylosing  Treatment of Pain  Dizziness CNS: anxiety  Evaluate signs and
Name: the enzymes spondylitis after CABG symptoms of heart attack
diclofenac cylooxygenase 1 and 2, surgery  Drowsiness CV: HF, edema, or stroke immediately
reducing  Osteoarthritis fluid retention, while monitoring the
Brand proinflammatory  Patients  Headache HTN patient.
Name: activities, possesses  RA hypersensitive to
Cataflam antipyretic, analgesic, drug and in those
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and anti-inflammatory  Analgesia with hepatic  Abdominal EENT: blurred  Because NSAIds impair
Route: Oral effects porphyria or Pain or vision, epistaxis, the synthesis of renal
 Primary history pf asthma, Cramps eye pain, night prostaglandins, they can
Dosage: 50 Classification: dysmenorrhea urticaria, or other blindness, decrease renal blood
mg (1 tablet Therapeutic Class: allergic reactions  Diarrhea reversible hearing flow and lead to
every 8 NSAIDs  Migraine after taking aspirin loss, swelling of reversible renal
hours) Pharmacologic Class: or other NSAIDs.  Irritability the lips and impairment, especially in
NSAIDs tongue, tinnutis patients with renal
Pregnancy-Lactation-  Nausea failure, HF or liver
Peak Effect: Reproduction: GI: abdominal dysnfunction; in elderly
PO (delayed release): Drug can cause fetal  Vomiting distention, patients; and in those
2-3hr harm when bleeding, taking diuretics. Monitor
PO (extended release): administered at 30 constipation, for these patients closely.
5-6hr weeks gestation or flatulence,
PO: 1hr later. Use during indigestion,  LFT values may increase
pregnancy before 30 melena, nausea, during therapy. Monitor
weeks gestation only if peptic ulceration, transaminase, especially
potential benefit taste disorder, ALT, levels periodically
justifies potential risk bloody diarrhea, in patients undergoing
to the fetus. appetite change, long-term therapy. Make
colitis first transaminase
NSAIDs can cause measurement no later
premature closure of GU: nephrotic than 8 weeks after
the ductus arteriosus. syndrome, acute therapy begins.
Avoid use during renal failure,
pregnancy, particularly fluid retention,
late pregnancy. interstitial
Drug may appear in nephritis,
human milk. Patient oliguria, papillary
should discontinue necrosis,
breastfeeding or proteinuria
discontinue drug,
taking into account
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importance of drug to Hepatic:

the mother. jaundice,
hepatitis,
Cautions: hepatotoxicity
 Use cautiously in
patients with Metabolic:
history of peptic hypoglycemia,
ulcer disease, hyperglycemia
hepatic
dysfunction, Musculoskeletal:
cardiac disease, back, leg or joint
HTN, fluid paint
retention, or
impaired renal Respiratory:
function. asthma, laryngeal
edema
 Drug may cause
photosensitivity as Skin: SJS,
well as serious skin allergic purpura,
adverse events, alopecia, bullous
including eruption,
exfoliative dermatitis,
dermatitis, SJS, and eczema,
toxic epidermal photosensitivity
necrolysis, which reactions, pruritus
can be fatal. rash, urticaria
Discontinue at first Other:
sign of rash or anaphylactoid
hypersensitivity. reactions,
anaphylaxis,
angioedema
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Drug
Generic May inhibit  RA,  Patients  Dizziness CNS: nervousness  Check renal and hepatic
Name: prostaglandin osteoarthritis, hypersensitive to function periodically in
ibuprofen synthesis, to produce arthritis drug and in those  Headache CV: Edema, fluid patients on long term
anti-inflammatory,  Mild to with angioedema, retention therapy. Stop drug if
Brand analgesic, an moderate pain; syndrome of nasal  Abdominal abnormalities occur and
Name: antipyretic effects. moderate to polyps, or Pain EENT: tinnitus notify prescriber.
Faspic severe pain as bronchospastic
Classification: an adjunct to reaction to aspirin  Bloating GI: dyspepsia,  Monitor BP because
Route: Oral Therapeutic Class: opioid or other NSAIDs. epigastric distress, drug can lead to new
NSAIDs analgesics;  Treatment after of  Constipation flatulence, onset HTN or worsening
Dosage: 400 Pharmacologic Class: fever reduction perioperative pain heartburn, of preexisting HTN,
mg (1tablet NSAIDs in children after CABG  Diarrhea nonnecrotizing which may contribute to
every 8 hours  Mild to surgery. enetrocolitis the increased incidence
as needed for Peak Effect: moderate pain,   Decreased of CV events.
pain) PO: 1-2hr fever Appetite GU: acute renal
 Relief of signs Pregnancy- failure, azotemia,  Because of their
and symptoms Lactation-  Vomiting cystitis, hematuria antipyretic and anti-
of juvenile Reproduction: inflammatory actions,
arthritis There are no adequate Hematologic: NSAIDs may mask and
 Migraine studies in pregnant agranulocytosis, signs and symptoms of
 Clinically women. Drug can aplastic anemia, infection.
significant cause fetal harm and is leukopenia,
patent ductus contraindicated in neutropenia,  Blurred or diminished
arteriosus pregnant women pancytopenia, vision and changes in
starting at 30 weeks thrombocytopenia, color vision may occur.
gestation. Before 30 anemia, prolonged
weeks gestation, use bleeding time  Full-anti-inflammatory
during pregnancy only effects may take 1 or 2
if potential benefit weeks to develop.
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justifies potential risk Metabolic:

to the fetus. hypokalemia,
hypoglycemia
Drug appears in Skin: rash,
human milk. Patient pruritus, injection-
should discontinue site irritation
breastfeeding or
discontinue drug.
Name of Drug Mechanism of Indication Contraindication Side Effects Adverse Nursing Responsibilities
Action Effects
Generic Name: Stimulates motility of  To prevent or  Patients  Drowsiness CNS: Anxiety,  Monitor bowel sounds
metoclopramide upper GI tract, reduce nausea hypersensitive to dystonic
increases lower and vomiting drug and in those  Fatigue reactions,  For treatments lasting
Brand Name: esophageal sphincter from with lassitude, longer than 12 weeks, the
Reglan tone, and blocks emetogenic pheochromocytoma  Dizziness restlessness, drug's safety and
dopamine receptors at cancer or other seizures, effectiveness have yet to
Route: the chemoreceptor chemotherapy catecholamine-  Fever suicidal be determined.
Parenteral IV trigger zone. releasing para- ideation,
 To prevent or gangliomas, tardive  Headache akathisia,  Tardive dyskinesia,
Dosage: 10g Classification: reduce dyskinesia, or confusion, parkinsonian symptoms,
Therapeutic Class: GI postoperative seizure disorders.  Diarrhea depression, and motor restlessness
Stimulants nausea and extrapyramidal are all possible side
Pharmacologic Class: vomiting  Patients for whom  Nausea symptoms effects of this drug.
Dopamine stimulation of GI hallucinations, Involuntary movements
Antagonists  To facilitate motility might be headache, of the face, tongue, and
small-vowel dangerous insomnia, extremities should be
Peak Effect: intubation tardive monitored since they
IV: Unknown dyskinesia could indicate tardive
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 To aid in Pregnancy-Lactation- dyskinesia or other

radiologic Reproduction: CV: extrapyramidal side
exam There are no adequate bradycardia, effects.
studies in pregnant supraventricular
 Delayed gastric women. Use during tachycardia,  Fever, CNS symptoms,
emptying pregnancy only if hypotension, irregular pulse cardiac
secondary to clearly needed. transient HTN, arrhythmias, or abnormal
diabetic HF blood pressure are all
gastroparesis Drug appears in human signs of NMS. Monitor
milk. Use cautiously in GI: bowel patient.
 GERD breastfeeding women. disorders
 After stopping
Cautions: GU: metoclopramide, check
 Use cautiously in incontinence, for dizziness, headaches,
patients with history urinary or nervousness in the
of depression, frequency, patient; these could be
Parkinson disease erectile signs of withdrawal.
or HTN. dysfunction
 Extrapyramidal side
Hematologic: effects from high doses
agranulocytosis, can be mitigated using
neutropenia diphenhydramine or
benztropine.
Skin: rash,
urticarial
Other: loss of
libido, prolactin
secretion,
gynecomastia,
amenorrhea
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Name of Mechanism of Indication Contraindication Side Effects Adverse Effects Nursing Responsibilities
Drug Action
Generic Direct-acting  Amebic liver  Patients  Headache CNS: seizures,  Monitor LFT results
Name: trichomonacide and abscess hypersensitive to vertigo, ataxia, carefully in elderly
metronidazole amebicide that works drug or other  Fever syncope, patients.
inside and outside the  Intestinal nitroimidazole incoordination,
Brand Name: intestines. It’s thought amebiasis derivatives. The  Dizziness confusion,  Observe patient for
Dazomet to enter the cells of (immediate sue of disukfiram depression, edema, especially if
microorganisms that release) within 2 weeks of  Weakness insomnia, patient is receiving
Route: Oral contain metronidazole peripheral corticosteroids; Flagyl
nitroreductase,  Trichomoniasis therapy and the  Nausea neuropathy IV RTU may cause
Dosage: forming unstable (immediate use of alcohol or sodium retention.
500mg (1 compounds that bind release) propylene glycol  Abdominal CV: flattened T
tablet every 8 to DNA and inhibit products during Pain wave, edema,  Record number and
hours PO) synthesis, causing cell  Bacterial treatment and for flushing, character of stools when
death. infections 3 days after  Vomiting thrombophlebitis drug is used to treat
caused by treatment ends are after IV infusion amebiasis. Give drug
Classification: anaerobic contraindicated.  Diarrhea only after Trichomonas
Therapeutic Class: microorganisms EENT: rhinitis, vaginalis infection is
Antiprotozoals Pregnancy-  Constipation sinusitis, confirmed by wet smear
Pharmacologic Class:  To prevent Lactation- pharyngitis or culture or Entamoeba
Nitroimidazoles postoperative Reproduction:  Dry Mouth histolytica is identified.
infection in Contraindicated during GI: stomatitis,
Peak Effect: contaminated or first trimester. Consult epigastric  Sexual partners of
PO: 1-2 hr potentially current guidelines for disease, anorexia, patients being treated
contaminated appropriate use in proctitis, metallic for T. vaginalis
colorectal pregnant women. taste infection, even if
surgery. asymptomatic, must also
Drug appears in GU: vaginitis, be treated to avoid
 Bacterial human milk. Patient darkened urine, reinfection.
vaginosis should discontinue polyuria, dysuria,
(non-pregnant breastfeeding or cystitis,
women) discontinue drug. dyspareunia,
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dryness of vagina
 Giardiasis Cautions: and vulva,
 Use cautiously in vaginal
 Pouchitis patients with candidiasis,
history of blood genital pruritus,
dyscrasia, CNS UTI,
disorder, or retinal dysmenorrhea.
or visual field
changes. Hematologic:
 Use cautiously in transient
patients who take leukopenia,
hepatotoxic drugs neutropenia
or have hepatic
disease, alcoholism Musculoskeletal:
or renal Transient joint
impairments. pains
Respiratory:
URI
Skin: rash,
Other:
decreased libido,
overgrowth of
nonsusceptible
organisms,
candidiasis,
flulike symptoms
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Name of Mechanism of Action Indication Contraindication Side Effects Adverse Nursing Responsibilities
Drug Effects
Generic Inhibits proton pump  Symptomatic Patients hypersensitive  Dizziness CNS: asthenia  May increase risk of
Name: activity by binding to GERD without to drug or its CDAD. Evaluate for
omeprazole hydrogen-potassium esophageal components and in  Headache GI: flatulence, CDAD in patients who
adenosine lesions patients receiving acid develop diarrhea that
Brand Name: triphosphatase, located rilipivirine-containing  Abdominal regurgitation doesn’t improve.
Losec at secretory surface of  Erosive products. Pain  False-positive results in
gastric parietal cells, to esophagitis Respiratory: diagnostic investigations
Route: suppress gastric acid (EE) Pregnancy-  Constipation cough, URI for neuroendocrine
Parenteral IV secretion. Lactation- tumors may occur due to
 Pathologic Reproduction:  Diarrhea Skin: rash increased CgA level.
Dosage: 40g Classification: hypersecretory Use during pregnancy Temporarily stop
Therapeutic Class: conditions only if potential  Nausea omeprazole treatment at
Antiulcer drugs (such as benefit justifies risks least 14 days before
Pharmacologic Class: Zollinger- to the fetus. When  Vomiting assessing CgA level and
PPIs Ellison treating GERD in consider repeating the test
syndrome) pregnant women, PPIs  Back Pain if initial CgA level is
Peak Effect: may be sued when high. If serial tests are
IV: 15-60 mins  Duodenal Ulcer necessary; however,  Weakness performed, the same
(short-term lifestyle modification commercial labs should
treatment) is the initial treatment. be used for testing, as
reference ranges between
 Helicobacter Drug appears in tests may vary.
pylori infection human milk. Use  Long-term therapy may
and duodenal cautiously in cause vitamin B12
ulcer disease, to breastfeeding women. absorption problems.
eradicate H. Assess patient for signs
pylori with Cautions: and symptoms of
clarithromycin  Use cautiously in cyanocobalamin
(dual therapy) patients with deficiency.
hypokalemia and  Because risk of fundic
respiratory gland polyps increases
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 H. pylori alkalosis and in with long-term use,

infection and patients on a low- especially beyond 1 year,
duodenal ulcer sodium diet. use for shortest duration
disease to appropriate to the
eradicate H. condition being treated.
pylori with  Periodically assess patient
clarithromycin for osteoporosis.
and amoxicillin  Monitor patient for signs
(triple therapy) and symptoms of acute
interstitial nephritis.
 Short-term  Discontinue drug if signs
treatment of and symptoms of
active benign cutaneous lupus
gastric ulcer erythematosus or SLE
develop ; refer patient to
 Frequent the appropriate specialist
heartburn (2 or for evaluation.
more days a  Drug increases its own
week) bioavailability with
repeated doses. Drug is
 Dyspepsia unstable in gastric acid;
less drug is lost to
hydrolysis because drug
increases gastric pH.
 Gastrin level rises in most
patients during the first 2
weeks of therapy.
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VII. PROBLEM IDENTIFICATION AND PRIORITIZATION
Nursing Diagnosis Cues Rank Justification according to ABC or Maslow’s
P - Labor Pain 1 Labor pain is prioritized first because it is an existing

problem that produces extreme pain because the patient is
E - related to contractions about to give birth and her membranes have ruptured.
of uterus muscles and Upon arrival to the hospital, the contractions of the patient
pressure on the cervix should be checked and also an internal examination should
be done to know if her cervix is dilated to give birth. This
S - as evidenced by facial kind of pain can lead to hyperventilation of the patient in
grimace and spontaneous which she will be having a shortness of breath. According
rupture of membranes with to ABC, maintaining optimal health require good
meconium in the amniotic breathing pattern for the patient.
fluid
P – Risk for maternal 2 Because meconium in the amniotic fluid might harm both
infection the mother and the baby, the risk of maternal infection
should be the second priority. The baby may aspirate the
E- related to vulnerable to meconium, which can be fatal, and the harmful organisms
invasion and multiplication in the meconium may spread to the patient's vital organs,
of pathogenic organisms causing death. According to Maslow's hierarchy of needs,
which may compromise health is one of an individual's basic needs, along with
health safety and security that must be met right away.
S - as evidenced by thick
meconium stain mixed in
the amniotic fluid
P - Impaired comfort 3 The patient's discomfort is related to the pain she is feeling
as a result of contractions. The pain and possible infection
E - related to lack of ease must be relieved initially in order to improve her comfort.
and relief in physical According to Maslow's hierarchy of needs, one of the
dimensions individual’s basic demands is comfort.
S- as evidenced by body
motility and moaning
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P - Fatigue 4 Rest is one of an individual's physiological needs, and

according to Maslow's hierarchy of needs, it should be the
E – related to feeling of first priority. However, because the patient is suffering
exhaustion and decreased from intolerable labor pain, her exhaustion will be
capacity for physical work addressed after the pain and discomfort have improved, as
pain and discomfort can also be a factor in fatigue.
S – as evidenced by her
existing anemia due to
decreased levels of blood
components
P - Risk for severe anemia 5 Risk for severe anemia is the fourth priority because
though the patient has existing anemia, it normally
E - related to low red blood happens in pregnancy. After the patient has delivered the
cells count baby, this should be addressed to prevent it from
worsening. According to Maslow, the health of an
S - as evidenced by individual is under the safety and security which is one of
hematocrit and hemoglobin the basic needs. Therefore, an existing disease should be
having less value than addressed to prevent serious illnesses.
normal
P – Readiness for 6 This is at sixth priority because the patient has already
enhanced breastfeeding experienced breastfeeding on her first child. This should
be addressed just to enhance her desire to breastfeed her
E – related to feeding of baby. According to Maslow’s hierarchy of needs, this kind
milk from the breasts to an of achievement to be able to give milk to your child is part
infant or child which may of the esteem needs under psychological needs in which it
be strengthened should be addressed after all the basic needs are settled.
S – as evidenced by
verbalization of desire to
breastfed
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P – Readiness for 7 Since this is the second child of the patient, she and her
enhanced parenting husband has both experienced parenting in which they
might need to enhance in order for them to have a healthy
E – related to providing an family and home environment. Achieving one’s full
environment for children to potential in doing something is part of the self-
nurture growth and actualization which has the least priority in Maslow’s
development which may be hierarchy of needs.
strengthened
S – as evidenced by
expressing of desire to
enhance home
environment
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VIII. NURSING CARE PLAN
Cues Nursing Analysis Goal Implementation Rationale Evaluation

Diagnosis
Subjective cues: Stem: Scientific Short-term Independent: Independent: Summative:
“Masakit na talaga Labor Pain Analysis: Goal: a. Instruct the patient a. To make the The patient was able to feel
yung tiyan ko” -The -After 30 minutes to the use of patient more relief from labor pain after
Related to: contractions of nursing appropriate comfortable 30 minutes of nursing
“Kagabi bago ako related to of the interventions, the breathing/relaxation while also intervention. (Met)
natulog pasakit sakit contractions uterine pain that the techniques as a reducing labor
na siya, pero nung of uterus muscles and patient is labor pain discomfort. Formative:
nag madaling araw muscles and the pressure experiencing will management This will Effectiveness:
na lumalala na yung pressure on on the be relieved and method. allow the 1. The patient was able to
sakit kaya the cervix cervix create will be patient and the experience relief within
nagpadala na ako pain during manageable. b. Instruct the patient baby to have 30 minutes of nursing
dito.” AEB: childbirth. to stay hydrated adequate intervention
as Strong Objectives: while experiencing oxygen.
“Habang nasa daan evidenced cramping, as labor pain. 2. The patient was able to
kami pumutok na by facial well as an -The patient will b. A laboring manage and control
ang panubigan ko” grimace and achy feeling, be able to c. Encourage the patient should labor pain through the
spontaneous can be felt experience relief spouse of the increase use of non-
rupture of in the belly, from pain after 30 patient to be at the intake of fluid pharmacological
“Parang isang membranes groin, and minutes of patient’s side and to prevent methods.
minute bawat with back. Some nursing give touch and dehydration.
contractions na meconium women may intervention massages. 3. The patient was able to
nararamdaman ko” in the get c. Pain-relieving recognize the
amniotic discomfort -The patient will d. Instruct the patient messages can importance of
Objective cues: fluid in their sides be able to control to try to envision be prioritizing non-
-Observed Facial and thighs. the pain through pleasant scenes that communicated pharmacological
Grimacing Other non- may distract her through touch. methods than having
reasons for pharmacological from her pain. A care the use of medications
-Contraction with a labor pain methods message to manage labor pain.
diameter of 3-4 cm include the might be
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having regular, baby's head -After health e. Instruct the patient communicated Efficiency: The strategies
strong contractions, pressing on education, the to take a walk or do to the laboring were suitable for the given
the active phase has the bladder patient will be such movements to mother with a time frame.
begun. Contractions and bowels, able to know the help reduce the hand placed
are regular and may as well as importance of pain. on a painful Appropriateness: The
be every 5 minutes the birth prioritizing non- location, a selected
or so and getting canal and pharmacological f. Inform the patient reassuring pat, strategies/interventions
closer together until vaginal methods than regarding the an were appropriate to the
they're 2 to 4 stretching. having the use of possible affectionate client’s needs.
minutes apart and medications to medications that stroking of the
lasting from 45 manage labor can be administered cheek, or a Adequacy: The specific
seconds to one Situational pain. to her to ease the close learning objectives and its
minute or more. Analysis: pain. embrace. A content were enough to
-The labor solid support meet the client’s needs.
-Body movements pain of the g. Monitor the and care from
are restless and client is the patient’s frequency, the husband Acceptability: The
unrelaxed. first duration, and will be helpful strategies interventions
prioritized intensity of too. were acceptable for the
-Moaning can be problem in contractions. client.
heard when the client’s d. Distraction is
contractions occur. case since it a more
is the most h. Monitor the
passive
critical patient’s vital signs
Vital signs: method of
condition and fetal movement
focusing
BP: 110/60 among the attention that
other Dependent:
PR: 92 bpm involves using
problems a. Give analgesics
RR: 20 cpm external
that were medications as
Temp: 36 degree stimuli to
identified. prescribed by the
Celsius divert
The client’s doctor.
02 Sat: 98% attention away
labor pain from your
was due to b. Administer regional
Pain Scale: 9 suffering.
her anesthesia to the
These
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contractions patient like approaches

with the Epidural to relieve are designed
diameter of labor pain. to help you
3-4 cms. cope with
worry,
anxiety, and
pain.
e. To distract the
patient from
the pain of
labor. Moving
is usually
more
comfortable
than staying
still.
f. To inform the
patient on the
possible side
effects of the
medication
that can be
administered
to her.
g. To know the
progress of
the labor and
to ready the
patient for the
expected
49 | P a g e
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delivery of the
baby.
h. To know if
the patient is
still stable and
that the fetus
is ready for
delivery.
Dependent:
a. To reduce the
pain through
pain-reliever
medications.
b. To block
specific nerve
pathways that
cause pain
during labor.
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IX. DISCHARGE PLAN
MEDICATIONS Provide the client instructions on the following:

 The medicines that the patient needs to take at home:
A. Cefuroxime (Cefurox) 500 mg/tablet, one tablet two times a day
for seven days
B. Metronidazole (Dazomet) 500 mg/tablet, one tablet every eight
hours for seven days
C. Ibuprofen (Faspic) 400 mg/tablet, one tablet every eight hours as
needed for pain
D. Multivitamins, one tablet once a day
E. Ferrous Sulfate + Folic Acid (FA), one tablet once a day
F. Calcium + Vitamin D, one tablet two times a day
EXERCISE  Walking for 10 to 15 minutes

 Back stretches
TREATMENT  Provide client instructions on prescriptions and doctors’ advice.

 Encourage compliance on treatments as well as prevention of
complications.
HEALTH Provide the client instructions on the following:

TEACHING  The medicines that the patient needs to take at home:
A. Cefuroxime (Cefurox) 500 mg/tablet

 1 tablet should be taken twice daily in order to prevent
further infections.
 Instruct the patient with the prescribed tablet to swallow
them whole.
 Warn the patient that the drug may cause dizziness,
headache, nausea, vomiting, and itching/swelling; advise
her to take precautions.
 Emphasize the need to seek emergency care if side-effects
worsen or persist .
B. Metronidazole (Dazomet) 500 mg/tablet

 1 tablet should be taken every eight hours for seven days;
for example, the patient takes it at 8:00 am, then the next
schedule that the patient will take the tablet is at 4:00 pm.
 This is for the antibiotic of the client for the prevention of
bacterial infection in the membrane rupture.
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 Emphasize the importance of taking Metronidazole

exactly as prescribed. Warn about possible side-effects
such as diarrhea or constipation.
C. Ibuprofen (Faspic) 400 mg/tablet

 One tablet of Ibuprofen should be taken every eight hours
as needed for pain.
 Tell the patient to take drugs at the same time each day to
maintain its effects.
 Advise the patient to notify the prescriber immediately if
she develops difficulty in breathing or changes in heart
rate, discoloration of feces, and blood in vomit.
D. Multivitamins
 The client should take one tablet once a day only.
 Advise patients to contact prescriber if he develops muscle
weakness or uneven heart rate that does not improve
especially if she has recently taken or is taking an
antibiotic.
E. Ferrous Sulfate + Folic Acid (FA)

 One tablet should be taken once a day.
 The most common side-effects are diarrhea and
constipation.
F. Calcium + Vitamin D
 One tablet should be taken two times a day.
 Calcium + Vitamin D may cause bone pain, constipation,
and muscle weakness.
Instruct the client for the following exercises:

 The client should move around each day. A light physical activity,
such as walking for 10 to 15 minutes outside their house, is
permissible. Stretching is another example that should be done on
a daily basis, especially back stretches since it is an important
exercise for keeping your muscles in good shape. Stretch your
neck, back, chest, belly, sides, arms, thighs, and calves, among
other muscles. Any amount of activity stimulates the release of
endorphins, which are important neurotransmitters associated
with pain relief and a sensation of well-being. After doing such
activities, the client should remember to drink an adequate
amount of water in order to promote good hydration.
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OUTPATIENT  Your doctor will need to monitor your improvement. It is

FOLLOW UP necessary to attend all advised appointments.
 Follow-up appointment after a week of medication.
 November 16, 2021 at 9:00 AM
 FEU NRMF Hospital 3rd Floor
 Dr. Elizabeth Reyes
DIET Prescribed diet:
 Encourage the patient to eat a variety of protein-rich foods such

as fish, cheese, yogurt, meat, and beans in order to recover from
childbirth. This is important for the body to regain strength.
 Drink mostly water, milk, and fruit juice.
Restrictions:
 Limit your intake of caffeine
SPIRITUALITY/  Spirituality is defined as the search for meaning and direction by

SEXUALITY which one develops one's connection with time, oneself, others,
and God. The client is encouraged to spend time strengthening
her faith because it can give comfort and support during times of
regaining strength.
 The patient should have a talk with her husband regarding safe
sexual intercourse.
 The patient and her husband should consider different family
planning methods.
X. THE EBN PER LEVEL REQUIREMENT
Labor Pain related to contractions of uterus muscles and pressure on the cervix as evidenced by a
facial grimace and spontaneous rupture of membranes with meconium in the amniotic fluid
1. General Question
- What are the possible interventions that would help the patient to relieve labor pain?
2. Reconstruction of General Question related to client’s problem identified in the RLE.

- Does non-pharmacological interventions can really help the laboring patient to relieve the pain
without having to use pharmacological methods?
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a. COPES (Client-Oriented Practical Evidence Search)
Client type & What might you do Alternate course of action What you want to
problem accomplish
If the possible intervention The researcher’s goal is

Pregnant Non- does not meet the to identify if the non-
women pharmacological expectation, alternate pharmacological
experiencing pain relief course of action would be strategies can decrease
labor pain strategies in dealing mixing both non- the severity of labor pain
with labor pain. pharmacological and without using
pharmacological strategies pharmacological
in relieving labor pain. strategies.
b. PICO
Patient Intervention Comparison Outcome

Focus
population
57 pregnant 1. Teaching the patient of 1. Breathing/relaxation Substantial

women in breathing/relaxation techniques not practiced by progress
Ahvaz, Iran techniques pregnant women
2. Recommend the client 2. Pregnant women who did There has been a
to go for a walk, get a not walk, get a massage, or significant
massage, or change change positions decreased level
positions of pain during
labor.
3. Critical Review with Summary of the Literature
In 2008, mother-friendly hospitals in Iran started a normal physiologic childbirth program.

In this program, researchers aim to evaluate the result of normal physiologic childbirth on labor
pain relief. One of the reasons of increasing of C/S in childbirth because of women’s fear, that's
why management of labor pain is a serious aspect to obtain the main goal of childbirth care
The study was an interventional study and was approved by the Ethics Committee of
Mashhad University of Medical Sciences. The study was a clinical trial that was implemented in
2016, in Sina mother-friendly hospital in Ahvaz, Iran. 57 women in an intervention group were
offered a childbirth preparation class during pregnancy. The intervention consisted of an
implementation of the physiologic delivery program, which includes antenatal preparation classes
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and physiologic labor using a combination of non-pharmacological pain relief techniques. Women
that were happy in their class belonged to an intervention group and those who did not agree to
attend belonged to the control group.
Results show that there was no significant difference between the groups in pain score at
the beginning of the study however, an independent t-test showed that in the cervical dilatations
of 6 cm, 8 cm, and 10 cm, it was clear that the intervention group was lower than the control group.
Resulting, labor pain was lower than the control group.
In conclusion, completing the implementation of a normal physiologic childbirth program

could result in decreasing the severity of labor pain. Hence, it is useful for all pregnant women to
participate in the program and get benefits in it.
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more. Medical News Today. https://www.medicalnewstoday.com/articles/hematocrit-
levels#summary.
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0of,noninfectious%20inflammation.
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57 | P a g e

Group 1b Case Presentation NRMF

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Group 1b Case Presentation NRMF

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FAR EASTERN UNIVERSITY

Name: Milagrosa, Veronica Villa

II. NURSING HEALTH HISTORY

A. Present Health History

B. Past Health History

C. Obstetric and Gynecologic History

Obstetric First pregnancy: no details indicated

Gynecologic No menstrual abnormality mentioned.

D. Family History (Genogram)

Male - Committed Relationship ------

Spouse Patient Siblings

III. GORDON’S HEALTH ASSESSMENT

1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

2. NUTRITIONAL – METABOLIC PATTERN

Day Time Food and Beverages Amount eaten

November 6, 8:00 am Eggs (boiled) 2 large eggs (156 calories)

12:00 Rice 1 cup (206 calories)

3:00 pm Muffin 2 small muffins (498

6:00 pm Pork chop with 1 piece pork chop (231

November 7, 8:00 am Oatmeal with berries 1 bowl (300 calories)

12:00 Rice 1 cup (206 calories)

3:00 pm Avocado toast with 1 slice (188 calories)

6:00 pm Rice 1 cup (206 calories)

November 8, 8:00 am Pancake 2 pieces (454 calories)

12:00 Rice 1 cup (206 calories)

3:00 pm Vegetable salad with dressing 1 bowl (235 calories)

6:00 pm Rice 1 cup (206 calories)

4. ACTIVITY – EXERCISE PATTERN

Time Sunday Monday Tuesday Wednesday Thursday Friday Saturday

6:00am Slept the Do yoga Do yoga Do yoga Do yoga Do Slept the

3:00pm Walk Walk Walk Walk Walk Walk Walk

6:00pm Prepare Prepare Prepare Prepare Prepare Prepare Prepare

5. SLEEP – REST PATTERN

6. COGNITIVE – PERCEPTUAL PATTERN

7. SELF-PERCEPTION – SELF-CONCEPT PATTERN

8. ROLE – RELATIONSHIP PATTERN

9. SEXUALITY – REPRODUCTIVE PATTERN

10. COPING – STRESS TOLERANCE PATTERN

11. VALUE – BELIEF PATTERN

IV. PHYSICAL ASSESSMENT

Assessment Normal Findings Actual Findings Interpretation

Observe body Proportionate, Appearance is Normal

Observe the Relaxed, erect The client shows Normal

Observe the Clean; neat The client is clean Normal

Note body and No body No body odor and Normal

Note obvious Healthy The client has a Normal

Assess the Cooperative Client is Normal

Note the client’s Appropriate to the Client is alert, Normal

Listen for Understandable, Understandable, Normal

Listen for Logical sequence, Logical sequence, Normal

Assessment Normal Actual Findings Interpretation

Inspect skin Varies from The client’s skin Normal

Inspect Moisture in The client’s skin Normal

Assess edema, if No edema There is edema Normal

Fluid may build in tissues as preg

Inspect, palpate, Freckles, some No lesions noted Normal

Observe and Moisture in The client’s skin Normal

Palpate skin Uniform; The client’s skin Normal

Note skin turgor When pinched, After being Normal

Assessment Normal Actual Interpretation

Note presence of infections or No infection No infection or Normal

Inspect the amount of body hair. Variable The amount of Normal