A 26-year-old G6P6 Client

ANO1
Prof. Mary Ann Nery

Submitted by:
Alvarez, Joshua
Awayan, Karen
Corpuz, Donn Denrik
Santos, Christel Mae
Sayana, Krizzia Krizzel
Soriano, Randolph
Tatualla, Jospeh Bret
CHAPTER 1 - ASSESSMENT
A. Nursing Health History

Client Profile
I. General Information

Name: C. DC.
Hospital: Lying-in Ward, Quirino Memorial Medical Center
Age: 26 years old
Birthdate: July 17, 1989
Birthplace: Bacolod City
Address: Batasan Hills, Quezon City
Occupation: Housewife
Religion: Roman Catholic
Educational Attainment: Grade 5
Spouse’s Name: J. DC.
Age: 22 years old
Occupation: sells bottle and metals
Name of child: G1
Age: 9 years old
Educational Attainment: GRADE 3
Name of child: G2
Age: 7 years old
Educational Attainment: GRADE 1
Name of child: G3
Age: 6years old
Educational Attainment: none
Name of child: G4
Age: 4 years old
Educational Attainment: none
Name of child: G5
Age: 1 years old
Educational Attainment: none
Name of child: G6
Age: 0 years old
Educational Attainment: none

II. Chief Complaint:

Labor Pain
III. OB HISTORY
CHILD YEAR MODE OF WHERE SEX OUTCOME
DELIVERY
G1 2001 NSD LI M (-)EMC
G2 2003 NSD hilot F (-)EMC
G3 2004 NSD hilot M (-)EMC
G4 2006 NSD hilot M (-)EMC
G5 2009 NSD hilot F (-)EMC
G6 2010 NSD QMMC M (-)EMC
INDICATION: This table shows the OB history of the client, her children, year of birth,
mode of delivery, location of birth, sex and outcome of delivery

IV. Current Pregnancy

LMP: January 27, 2010

EDC: 39 4/7 weeks by LMP

Prenatal Course: According to her, she goes to the hospital once a month during her
pregnancy. She stated that she could not follow her scheduled checkups because of her
work.

October 31, 2010: admission to Quirino Memorial Medical Center

V. Admitting Diagnosis

 October 31, 2010

 39 4/7 weeks AOG by LMP
 Pregnancy uterine size:
 OB Score: G6P5 (6005)

Physical Exam
 BP: 100/80
 general survey: conscious, coherent, ambulatory
 Heart: AP, NRRR, (-)murmurs
 Lungs: ECE, CBS
 Extremities: (-)edema
 Fundic height: 28 cm
 FHT: 140/min location: UQ

Exam
 Cervical dilatation 2-3 cm
 Presentation: Cephalic in beginning labor
 station -2
 BOW: +
VI. Labor:
Time BP Fundic Height Fetal Heart Internal
Tone Examination

4:25 pm 120/80 28 140s 2-3cm, 60%,

eff, ceph, -2,
(+) BOW

5 :00 pm 130s

6:00 pm 130s 3cm, 60% eff,

-2, (+) Bow

7:00 pm 100/70 130s 3-4cm, 60%

eff, -2

8:00 pm

9:00 pm 140s 3-4cm, -2

10:00 pm 150s

11:00 pm 100/60 140s 5cm, 60% eff,

-2, (+) BOW

12:00 am 140s 5-6cm, 60%

eff, -2, (+) Bow

1:00 am 140s

2:00 am 100/80 6 cm, 65% eff,

-2, (-) BOW,
irregular VC

3:00 am 100/80 7-8 cm, (-)

BOW

4:00 am 140 s 9 cm, (-) BOW

INDICATION: This table shows the information about the client’s labor process on her
last delivery.

VI. Final Diagnosis

 Operation ended: November 1, 2010 @ 4:20 AM
 OB Score: G6P6 (6006)
 39-40 weeks uterine pregnancy
 Delivered spontaneously to a live boy at 4:09 AM
VII. Past Medical History
She stated that she had chickenpox, measles and German measles in her
childhood, though, the exact years of occurrence cannot be recalled. She has complete
immunizations. The client has no allergies. She has been hospitalized for her past
deliveries and has undergone a surgical operation which is ligation on her last delivery.

VIII. Family Health History

Intis, C. Intis, B. Santos, V. Santos, R.

78 years old, M 75 years old, F 67 years old, F 72 years old, M

COD: COD: Tuberculosis hypertension

Myocardial
infarction

Santos, Ma. Santos C.

Intis, A. Intis, Roberto Santos , F.
50 years old, F 46 years old.
50 years old, F 56 years old, M 48 years old, F.
Stray bullet
COD: Tricycle hypertension
accident
LEGEND:
Married

Offspring

Intis N, Intis, L. Intis , H M Male

24 years old, M 22 years old, M 23 years old F Female

hypertension
Deceased

COD Cause of Death

Dela Cruz, Dela Cruz, Joel
Cyrell
22 years old,
26 years old, F M

VIII. Social History

The client currently lives with her partner and her parents in Batasan, Quezon City.
She stated that she is happy about her pregnancy. According to her, her family was very
supportive to her. She stated that she has good relationship with her family and
neighbors. She is not a member on any organizations on their community or church.
B. Physical Examination

*Physical Examination was done 3 days post partum

General Appearance
Patient C has a small body frame. She is 142 centimeters tall and weighs 35
kilograms which indicates disproportion in her body built. She has a weak appearance,
slouched and bent posture, and shows signs of anxiety, discomfort and distress upon
movement, such as grimacing and guarding. The patient is appropriately dressed with
minor body odor but no breath odor. Patient C’s responses are appropriate to situations.
Her speech is understandable and moderate in pace, she also exhibits association of
thoughts. Her thoughts have a logical sequence and sense of reality.

Mental Status
She has a well organization of her thoughts. She was pleasant and cooperative
during the assessment. The client made use of simple words when answering upon
assessment and interrogation. She has a well organization of her speech.

Skin

Patient C has a dark skin color. Her skin color is generally uniform except in
areas exposed to the sun. Being dark-skinned, there are areas with lighter pigmentation
such as the palms, lips and nail beds. A patch (birth mark) which is 3 millimeters in
length and 5 millimeters in width, light brown in color and irregular in shape is located in
the upper outer quadrant of her right breast. She has 2 papules (elevated moles) about
1 millimeter in length and 1 millimeter in width located in her left mandible area and
right maxillary area. An irregular scar can also be located in the left side of her
forehead. There is a lesion located below the umbilicus. Her skin is warm and sweaty
upon palpation due to the humid environment, with the warmth of her skin being
uniform with all parts of her body. When pinched, her skin springs back to previous
state which indicates normal skin turgor.

Hair

Patient C has a soft, silky, black hair. Her thick hair is evenly distributed and
showed no signs of infection or infestation. The patient has a moderate body hair.

Nails

The patient’s fingernail plate shape has a convex curvature with an angle of
about 160°. Her fingernail and toenail texture is smooth. There are no signs of cyanosis
or pallor and it has a prompt return of usual color that lasted about less than 3 seconds
when blanch test was performed. The tissues surrounding her nail is intact and shows
no signs of lesions or infection.

Skull and Face

Patient C’s head is normocephalic and symmetric with smooth skull contour.
There are no nodules or masses noted upon palpation. Her scalp is light brown in color.
She has symmetric facial features. Her eyes showed no signs of edema or hollowness.
Symmetric facial movements are noted when the patient was asked to elevate and lower
her eyebrows, frown and smile, show teeth, close eyes tightly and puff the cheeks.

Eyes

Patient C has evenly distributed eyebrows. The skin is intact. Her eyebrows are
symmetrically aligned and equal in movement. Her eyelashes are also equally distributed
and curved slightly outward. The patient’s eyelids also have intact skin with no discharge
and no discoloration observed. Her lids close symmetrically. She blinks bilaterally, 17
times per minute upon inspection. When she opens her lids, there are no visible scleras
above the corneas, the upper and lower borders of corneas are slightly covered.

The patient’s bulbar conjunctiva is transparent. The sclera appears white with
few capillaries evident. The palpebral conjunctiva is shiny, smooth and pink in color.
There is no edema or tenderness noted upon palpation and inspection of the lacrimal
gland, nasolacrimal duct and lacrimal sac. The cornea is transparent and smooth with
the visible details of the iris. The pupils are black in color, round and have smooth
borders. They are equal in size about 4 millimeters in diameters each.

In the corneal sensitivity test, the patient blinks whenever the cornea is touched
which indicates that the trigeminal nerve (CN V) is intact. During the pupil’s light
sensitivity test, the illuminated pupil constricted, denoting direct response, as well as the
nonilluminated pupil, indicating consensual response. This shows normal functioning of
the oculomotor (CN III) and the trochlear (CN IV) cranial nerves. During the assessment
of the pupil’s reaction to accommodation, pupils constricted when looking at near
objects and dilated when looking at far objects. The pupils converged when an object is
moved toward her nose. The patient has no difficulty, when looking straight ahead. She
can see objects in the periphery. During the extraocular muscle test, her both eyes
moved in unison. Her uncovered eye didn’t move during the cover test. After assessing
distance vision, these are the acquired readings: 20/40 for the right eye, 20/50 for the
left eye and 20/30 for both eyes.

Ears

Patient C’s auricles have same color as the facial skin. They are symmetrical and
aligned with the outer canthus of the eye. They are flexible and firm, the pinna recoiled
after it was folded.

Patient C is able of hearing normal voice tones without difficulty. She is negative
in the Weber’s test meaning that sound is heard in both ears. Air-conducted hearing is
greater than bone-conducted hearing which indicates positive Rinne.

Nose and Sinuses

The external nose of Patient C is symmetric and straight, it has no discharge or

flaring and uniform in color. There are no lesions or tenderness. Air movement is not
restricted in both nares. The mucosa is pink with no lesions. There is a presence of clear
watery discharge. The nasal septum is intact and located in midline. The maxillary and
frontals sinuses are not tender.
Mouth and Oropharynx

Patient C has symmetrical, soft and moist, dark pink, outer lips. She can purse
her lips. The inner lips are uniform pink in color; it is moist, smooth, soft and elastic.
Patient C has 30 present teeth with the 2 of them having dental caries, particularly the 2
3rd molars in the lower set of her teeth. She no longer has her first molar located in the
upper right portion as well as her second molar in the upper left. Her teeth are light
yellow in color. She has dark pink, moist gums; however, there is presence of redness
and tenderness of gums in the 2 3 rd molars in the lower set of her teeth. Patient C’s
tongue is centrally located. It is moist and pink in color with a whitish coating. There are
no lesions or palpable nodules observed and palpated. Patient C is able to mover her
tongue freely. The base of her tongue is smooth with prominent veins. The soft palate is
pink and smooth. Her hard palate is also pink in color but with irregular texture. Patient
C’s uvula is centrally positioned in the soft palate. Patient C’s oropharynx has a pink and
smooth posterior wall. The tonsils are pink and smooth with no signs of inflammation.
They are grade 1 in size. Patient C’s gag reflex is present when elicited.

Neck

Patient C’s neck muscles are equal in size. Head movement is coordinated and
smooth with no discomforts. She is able to flex her head in 45° angle, hyperextend in
60° angle, laterally flex in 40° angle to the right, and laterally rotate in 70° angle to
both left and right. She is able to laterally flex her head to the right in < 40° angle with
presence of pain. The patient has equal muscle strength assessed when asked to shrug
the shoulders against the resistance of the observer’s hand. However, there is unequal
muscle strength when asked to turn the head to one side against the resistance of the
observer’s hand, as there is presence of pain when the head was turned to the left.
Patient C has palpable submental, right submandibular, right anterior cervical and right
posterior cervical lymph nodes. The trachea is located in the midline of the neck with
equal spaces on both sides. The thyroid gland is not visible upon inspection. It ascends
during swallowing. The lobes of the thyroid gland is palpable, it is small and smooth.
The left lobe is tender.

Thorax and Lungs

The anteroposterior diameter of Patient C’s thorax is half its transverse diameter.
Her chest is symmetric. Her spine is straight and centrally aligned. The skin in her
posterior thorax is intact and uniform in temperature. The chest wall is intact. There is
presence of tenderness in the 11th left rib along the left posterior axillary line, as well as
in the 9th rib along the left scapular line. When the patient took a deep breath, the
observer’s thumbs moved apart an equal distance at about 1 ½ inches. There is bilateral
symmetry of vocal fremitus which is heard clearly at the apex of the lungs. Percussion
notes resonate except over the scapula. There is dullness in the 10 th ICS. There is the
presence of vesicular and bronchovesicualr breath sounds upon auscultation.

The patient’s respirations are quiet and effortless. The coastal angle in the
anterior thorax is < 90°, and the ribs inserts into the spine at approximately 45°. Again,
after assessing for respiratory excursion, the observer’s thumbs moved apart an equal
distance at about 1 ½ inches. Same as the posterior vocal fremitus, it is decreased over
heart and breast tissue. Percussion notes are resonant down to the 6 th rib at the level of
the diaphragm, flat over areas of heavy muscles and bones, dull on areas over the heart
and liver, and tympanic over the underlying stomach. The bronchial breath sounds are
heard upon auscultation in the trachea. Bronchovesicular and vesicular breath sounds
are heard upon auscultation in the anterior chest.

Heart

There are no pulsations in the aortic, pulmonic and tricuspid and apical area
upon inspection and palpation. The heart rate in all four anatomic sites are as follows:
71 bpm in the aortic area, 77 in the pulmonic area, 78 in the tricuspid area and 75 in
the mitral area. The loudest is at the base of the heart. No sound was heard upon
auscultation in the carotid arteries. Jugular veins are not visible upon inspection.

Breasts and Axillae

Patient C’s breasts are sagging and generally symmetric. The skin is uniform in
color with prominent veins. The areolas are black in color, round and bilaterally the
same. The nipples are round, everted and equal in size. They are soft and smooth with
no signs of lesions or sores. There are no discharges other than breast milk. There is
tenderness when palpated. Masses are also present particularly: along the right
midclavicular line just an inch above the nipple; laterally 2 centimeters from that point in
the upper outer quadrant; laterally an inch from the nipple; from that point, about 1
centimeter downward in the lower outer quadrant; and from that point, 2 centimeters
downward also in the lower outer quadrant. Masses are also palpated in the following
areas: 1 centimeter above and laterally 1.5 centimeters from the left nipple; and, an
inch away from that point along the left midaxillary line. The left central, left and right
anterior and left posterior lymph nodes are palpable.

Abdomen

There are presence of linea nigra, striae gravidarum and a lesion just below the
umbilicus of the patient (ligation wound). The abdomen has a rounded contour. There
are 6 bowel sounds per minute heard in the RUQ, 9 bowel sounds per minute in the
RLQ, 8 bowel sounds per minute in the LUQ and 6 bowel sounds per minute in the LLQ
upon auscultation. Percussion of the abdomen and liver, light and deep palpation of the
abdomen, palpation for the liver, spleen and bladder were not performed due to the
surgical incision in the patient’s abdomen.

Uterus

Palpation for the involution of the uterus was not performed due to the surgical
incision in the patient’s abdomen.

Musculoskeletal

Muscles are equal in size on both sides of the body. There are no tremors noted.
Muscles are firm. Based on the muscle and joint swelling scale, all muscles and joints
are graded 0 except for the R sternocleidomastoid which is grade 2.
The following are the findings for the muscle strength:

R sternocleidomastoid - 4/5 (with pain)

L sternocleidomastoid - 4/5

Trapezius - 5/5

R deltoid - 4/5

L deltoid - 4/5

R biceps - 5/5

L biceps - 5/5

R triceps - 5/5

L triceps - 5/5

Wrist and finger muscles - 5/5

Grip strength - 5/5

Muscles of the ankles and feet - 5/5

The range of motion exercise for hip muscles, hip abduction, hip adduction,
hamstrings and quadriceps were not performed due to Patient C’s surgical incision in the
abdomen and inadequate space.

Reflexes

The biceps, triceps, brachioradialis, patellar, Achilles and plantar are graded +2.

Genitalia and Inguinal Area

The patient refused to be assessed in the genitalia. The patient verbalized that
she has normal distribution of pubic hair. She has no wounds, sores, parasites or
inflammation in the pubic area; however she has a right mediolateral episiotomy scar
from her first child, as verbalized by the patient.

She stated that she has a discharge. Her lochia is red without blood fragments
and scant in amount. She said that she consumes 2 to 3 pads a day.

Vital Signs (assessed at November 3, 2010, 8 AM)

Patient C’s temperature was 36.2°C. Her blood pressure was 90/50 millimeters of
mercury. Her pulse rate was 105 beats per minute and her respiratory rate was 23
breaths per minute.

Homan’s Sign

Patient C is negative for Homan’s sign.

 Gordon’s Functional Pattern

Health Perception-Health Management Pattern

According to Patient C, a healthy person is “masigla, di sakitin at mahilig sa

gulay.” She maintains her health by eating at the right time, eating fruits and
vegetables, drinking milk and having regular exercise. Patient C has no allergies. The
patient also stated that she didn’t have any colds in the past year. She has no absences
from work lasting longer than 1 week. She said that she is afraid to examine her
breasts, that is why she doesn’t perform monthly breast self-examination. She said that
she has no vices and hasn’t had any accidents or falls in the past. She stated that she
didn’t miss any of her prenatal check-ups for all of her past pregnancies and that she
always find ways to follow the doctor’s or nurses’ suggestions about health
management.

Nutritional-Metabolic Pattern

Patient C stated that normally, at home, they only have a maximum of P100
budget for the day. She said that they usually eat porridge or biscuit for breakfast, and
fish, particularly “galunggong”, vegetables and rice for lunch and dinner; however, there
are also days in which they only eat rice and salt as lunch and dinner. She also said that
she always takes at least 8 glasses of water.

3-Day Meal Recall

November 1 November 2 November 3

Breakfast None None 1 bowl of lugaw,

500 mL of water

Snack 6 pcs of marie None 3 pcs of marie

biscuit, 500 mL of biscuit, 1 cup of
water chocolate drink, 1
glass of water

Lunch ½ cup of rice, 1 9 pcs of marie

serving of pork biscuit, 500 mL of
giniling, 500 mL of water
water

Dinner 6 pcs of marie 9 pcs of marie

biscuit, 500 mL of biscuit, 500 mL of
water water

*assessed at 9 AM, November 3, 2010

 After delivery, the client started taking 500 mg of Ferrous Sulfate and
multivitamins once a day. She stated that she does not have any discomfort in eating,
only when chewing due to her dental caries. Patient C has 30 present teeth with the 2 of
them having dental caries, particularly the 2 3 rd molars in the lower set of her teeth. She
no longer has her first molar located in the upper right portion as well as her second
molar in the upper left. Her teeth are light yellow in color. She has dark pink, moist
gums; however, there is presence of redness and tenderness of gums in the 2 3 rd molars
in the lower set of her teeth. She also does not have any diet restrictions. She
mentioned that she’s taking at least 8 glasses of water daily. The client has no skin
problems and has normal skin turgor. She has no problems in healing. She is 142
centimeters tall and weighs 35 kilograms which indicates disproportion in her body built.
Patient C’s BMI is 17.4 kg/m² which indicated her being underweight.

Elimination Pattern

Patient C stated that before pregnancy, she was always sweating heavily with
her clothes soaking wet. She voids at least 7 to 8 times a day. She described her urine
as clear and transparent, it has an ammonia odor. She defecates twice a day, usually, it
is brown in color and formed. She said that she was not experiencing any discomforts
when urinating or defecating. She also didn’t have difficulties in holding urine until
getting to the bathroom.

During pregnancy, she stated that she still sweats heavily. She voids at least 7 to
8 times a day. She described her urine as clear and transparent, it has an ammonia
odor. The same as before,she defecates twice a day, usually, it is brown in color and
formed. She said that she was not experiencing any discomforts when urinating or
defecating.

After pregnancy, she said, she hasn’t defecated yet. She voids at least 4 to 5
times a day since that time. She described her urine as transparent to light yellow in
color with ammonia odor. She was not experiencing any troubles when urinating or
defecating.

Activity/Exercise Pattern

Patient C described her activity level for most days of the week which is very
active. She always gets up very early in the morning to sweep outside and clean the
house. She does this 30 minutes everyday. She said that she has no leisure activities
since she is very busy with her work. But after pregnancy, she experienced difficulty in
breathing.

Sleep/Rest Pattern

Before and during pregnancy, Patient C said that she was usually sleeping from 9
PM to 5 AM. She said that she was comfortable with this and according to her, the only
time she was having disturbance during sleep and rest was whenever she’s sick. She
said that she doesn’t use any form of sleeping regimen or medication.
 After pregnancy, she said that she only have 1 to 2 hours of sleep. It’s not
comfortable for her because of the very small and crowded bed and also the disturbance
whenever her baby cries.

Cognitive-Perceptual Pattern

After assessing distance vision, these are the acquired readings: 20/40 for the
right eye, 20/50 for the left eye and 20/30 for both eyes. Patient C is able of hearing
normal voice tones without difficulty. She is negative in the Weber’s test meaning that
sound is heard in both ears. Air-conducted hearing is greater than bone-conducted
hearing which indicates positive Rinne.

She doesn’t go to have her eyes checked-up and she also doesn’t wear any
glasses or contact lenses. She stated that she has no difficulties in hearing. She said that
she was dizzy during assessment. She also complained about her pain in her lower
abdomen due to her post-operative incision. When the patient was asked to rate her
pain on a scale from 1 (no pain) to 10 (worst pain), she graded it 7. She said she is not
experiencing any changes in tasting food, smelling, feeling or touch and memory.
According to her she is able to concentrate with work well but is not able to decide
effectively on her own especially when it is for her family. She said she doesn’t have
any difficulty in learning. She said, “Mas maano (effective) sa akin ung tenga, pati isip.
Pagnakikita ko ginagawa mo, kaya ko na syang gawin.” “10 years old ako nag grade 1,
15 years old ako nag grade 5,” she said.

Self Perception-Self Concept Pattern

When asked to describe herself, she answered, “Mapayat na masipag, ganito

ako. Mahilig tumulong sa kapwa ko. Kapag gipit, maparaan.” She said that she is
generally happy in her life and about who she is, ut as of the moment she said she is
feeling sad. According to her, there has been a great difference before and now that she
has given birth. Before and during pregnancy, she was able to find easy ways to deal
with life; however, after she gave birth, she seemed not able to do anything. When
asked the desire to do something about them, the patient replied, “Gusto ko makuha
yung dati kong lakas. Gusto ko na talaga umuwi , wala lang talaga pera.” Aside form
feeling lonely, she said she was also feeling anger for her husband who has a habit of
drinking, he didn’t look like she was supporting his wife through this all.

Role-Relationship Pattern

She said they are 8 in the family. She lives with her mother, husband and their
offsprings. “Yung asawa ko, bumibili ng bakal at bote at itinitinda sa junkshop. Kumikita
naman ako sa pamamagitan ng paggupit ng buhok, pag ahit ng kilay, paggawa ng kalan
de uling, lagi lang ako sa bahay,” she stated. When asked how problems are dealt with,
she answered, “Nagsasama-sama kami para maiwasan ang problema, maayos naman
ang komunikasyon namin, tapos ako ang nagdedesisiyon kapag walang nagkasundo sa
mga desisyon ng iba. Kapag may problema kami ng asawa ko, pinag uusapan namin,
nagsisisgawan minsan pero nagkakaayos naman sa huli.” Even though, it’s like this, she
said she feels safe in her relationship with her husband. She said that even though she
is not really decisive, when she needs to be, she is able to come up with solutions to
their problems. She usually asks for the help of her neighbor when she needs someone
to talk to. She stated that she is grateful that when she is not around, her eldest is
always there to take care of the house and the other siblings. She said that she is not a
member of any social groups. They only have P100 budget for the day, not enough but
she always finds way to make the most of it.

Sexuality-Reproductive Pattern

The client had her menarche when she was 13 years old. Her last menstrual
period was on December 17, 2009. The client is a G6P6 (6006) mother. According to
Patient C, she is not always satisfied with her sexual intercourse with her husband.
Usually they have sexual intercourse twice a week. When she was younger, they did it
everyday, they stopped when they had their first child. She said, she doesn’t think she
can be this active again. During the 5 th month of pregnancy, they had sexual
intercourse. They don’t use any form of medication to enhance sexual performance.
Before, they used condoms and pills, now she is ligated. She said that they didn’t have
any problems using these contraceptives.
She is not bothered and attentive during the interview.

Coping Stress-Tolerance Pattern

Patient C does not take drugs for relaxation. According to her, she is relaxed all
the time. “Masaya ako sa buhay, di baling mahirap basta masaya. Basta malusog mga
anak ko, ayos na yun,” she said. She only feels tension whenever there is emergency,
cases which are sudden that she is not sure of solving. To alleviate stress, she prays to
God. Her children, friends and siblings are the people often helpful whenever she has
problems. When asked for a big change in her life in the last year or two, she replied,
“Nung nagbago yung asawa ko, nag-iiba na ang desisyon niya, mas nakapokus na sya
sa pamilya. Medyo nagbago na sya, happy ako dun.”

She is relaxed and concentrated during the interview.

Value-Belief Pattern

She feels satisfied with her life. Her family is the most important thing for her
because she came from a broken family, she said she doesn’t want to have them
experience, what she had experienced in the past. For her, religion is not important,
there are various kinds of religion, bur what important is that God is always inside your
heart and soul. For her, God is very helpful whenever problems arise. She said that she
has no religious practices which were interfering when she was admitted to the hospital.

C. Diagnostic Procedures

Type of test: Urinalysis

Date Ordered:

TESTS NORMAL VALUES CLINICAL NURSING

VALUES OBTAINE INTERPRETATION RESPONSIBILITY
D
Color: Pale yellow light yellow Normal  The fluid intake
to amber and output
Transparency: Clear to slight hazy Normal must be
slightly hazy accurately
Reaction: 4.5-8.0 6.0 Normal measured and
monitored
Specific 1.015-1.025 1.005 Increase  Teach client
gravity: how to perform
clean-catch
WBC: 0-2/HPF none Normal method

RBC: 0-2/HPF 0-2/HPF Normal

Epithelial cells: Few few Normal

Bacteria: contains many
bacteria
Albumin:

Sugar: Negative (-) Normal

INDICATION: This test was performed for baseline Urinalysis tests to help determine
the general health status of the client and to detect renal and metabolic diseases.

Type of test: Complete Blood Count (Hematology)

Date Ordered:

TESTS NORMAL Values CLINICAL NURSING

VALUES Obtained INTERPRETATION RESPONSIBILITY
Red Blood 4.20-5.40 4.05 x1012 L decrease  Prepare the
Cell Count x1012 L client for the
Hemoglobin 120.0-160.0 114 g/L decrease procedure
g/L  Monitor VS
Hematocrit 0.36-0.47 0.35 decrease
Level
MCV 80.0-96.0fL 87.4fL Normal
MCH 27-31pg 28.6pg Normal
MCHC 32.0-36.0% 32.8% Normal
Platelet Count 150-450 371 x109 L Normal
x109 L
White Blood 5.0-10.0 9.2 x109 L Normal
Cell Count x109 L
INDICATION: This test was performed for baseline CBC tests to help determine their
general health status of the client. This will help determine the client’s oxygenation,
bleeding tendencies, infection, or anemia.

Type of test: Complete Blood Count (Differential Count)

Date Ordered:

TESTS NORMAL VALUES CLINICL NURSING

VALUES OBTAINED INTERPRETATION RESPONSIBILITY
Neutrophils 0.500- 0.672 Normal  Prepare the
0.700 client for the
Lymphocytes 0.200- 0.237 Normal procedure
0.700  Monitor VS
Eosinophils 0.000- 0.038 Normal
0.060
Monocytes 0.020- 0.050 Normal
0.090
Basophils 0.000- 0.003 Normal
0.020
INDICATION: This test was performed for baseline purposes and to know if the client
had developed infection cause by microorganisms.

D. Anatomy and Physiology

 REPRODUCTIVE ORGANS THAT GOES THROUGH CHANGES DURING
PREGNANCY

REPRODUCTIVE ORGANS THAT GOES THROUGH CHANGES DURING

PREGNANCY

VAGINA- when pregnant, vagina will become swollen, and the lining will thicken. The
walls will become slicker and may produce some discharge. These changes will make
the birth easier.

The secretions caused by the vaginal changes may make you feel sore or possibly cause
unwanted odor. Call your doctor if this occurs. Don't douche to help control the problem.
In fact, you should never douche during pregnancy. Wash the genital area often and dry
carefully. Wear cotton underclothes for comfort.

UTERUS- it increases to 20 times its original weight, and 1,000 times its initial capacity.
The amount of its muscle, connective and elastic tissue, blood vessels, and nerves
increases. Its shape changes from elongated to oval by the second month, to round by
midge station, then back through oval to elongate at term (the end of a normal nine-
month pregnancy).
The uterus softens beginning at the sixth week. It changes position as it increases in
size, ascending into the abdomen by the fourth month and eventually reaching to the
liver.

CERVIX- the cervical tissue becomes very glandular, producing a mass of thick mucus
that plugs the cervical canal called a mucus plug or 'show'. This seals the uterus from
outside infection.

(1) The cervix undergoes a marked softening which is referred to as the Goodell's sign.

(2) A mucus plug, which is known as "operculum" is formed in the cervical canal. This is
the result of enlarged and active mucus glands of the cervix. It serves to seal the uterus
and to protect the fetus and fetal membranes from infection. The mucus plug is expelled
at the end of the pregnancy. This may occur at the onset of labor or precede labor by a
few days. When the mucus is blood-tinged, it is referred to as a "bloody show."

(3) Additional changes and softening of the cervix occur prior to the beginning of labor.

OVARIES- (1) The follicle-stimulating hormone (FSH) ceases its activity due to the
increased levels of estrogen and progesterone secreted by the ovaries and corpus
luteum. The FSH prevents ovulation and menstruation.

(2) The corpus luteum enlarges during early pregnancy and may even form a cyst on
the ovary. The corpus luteum produces progesterone to help maintain the lining of the
endometrium in early pregnancy. It functions until about the 10th to 12th week of
pregnancy when the placenta is capable of producing adequate amounts of
progesterone and estrogen. It slowly decreases in size and function after the 10th to
12th week.

Fertilization:
Sperm travels through the female's vagina through the cervix and uterus
 

Sperm meets the mature egg



Only one sperm penetrates the egg



The nuclei of the sperm and egg fuse to form a new cell (the zygote)


Zygote travels to the uterus



Zygote divides then formed a cluster of cells (the morula)



The morula develops a cavity (blastocyst)



Blastocyst floats freely within the uterine cavity for about 48 hours


Blastocyst attach itself to a site in the endometrium (uterine lining)



About 10 days following fertilization, the blastocyst is completely embedded into the
endometrium, and forms the placenta.


10 days – mother’s menses stop



18 days – heart begins to beat



21 days – pumps own blood through separate close circulatory system with own blood type


28 days – eye, ear, and respiratory system begin to form



42 days – brain waves recorded skeleton complete, reflexes present


 8 weeks – all body systems present


11 weeks – spontaneous breathing movements, has fingernails, all body systems working


16 weeks – genital organs clearly differentiated, grasps with hands, swims, kicks, turns,
somersaults, (still not felt by the mother)


18 weeks – vocal cords work



23 weeks – 15% chance of viability outside of womb if birth premature



25 weeks – 79% of babies survive premature birth

 Fallopian tube anatomy
Fallopian Tube Anatomy

The fallopian tube is a narrow

muscular organ arising from the
uterus and ending just next to the
ovary. The inner tubal lining is rich
in cilia, the microscopic hair-like
projections that beat in waves and
move the egg to the uterus.

The fallopian tube is about 10 cm (4

inches) long and consists of several
segments. Starting from the uterus and proceeding toward the ovary, these are the:

 Interstitial segment -- passes through the uterine muscle

 Isthmic segment -- narrow muscular segment by the uterus
 Ampullary segment -- wider middle segment
 Infundibular segment -- funnel shaped segment near the ovary
 Fimbrial segment -- ciliary lining facing the ovary


Pomeroy Technique

The Pomeroy method involves creating and tying off a loop of the fallopian tube. The
tied off section is then surgically removed. The ligatures are designed to dissolve,
eventually leaving two sealed ends.
Tubal Rings or Clips

Tubal ring ligation is similar to the Pomeroy technique; the main difference is that an
elastic ring is used to bind the loop in the fallopian tube. The constriction of the ring cuts
off the blood supply to the tissue in the loop, and scar tissue forms in its place. The
segments of the fallopian tube eventually separate.

Tubal Ligation and Resection

The tubal ligation and resection method involves the removal of a portion of the fallopian
tube. This form of tubal ligation is most commonly utilized immediately following
delivery (post partum). Ligatures are used to tie off a section of the fallopian tube, then
the section in between is removed. Typically only one to two centimeters of fallopian
tube are taken from the middle of the tube.

Tubal Coagulation

Tubal coagulation is primarily used for laparoscopic tubal ligation procedures. A pair of
forceps that can conduct electricity is used to grasp the fallopian tube at the appropriate
point. An electrical current passes through the forceps and coagulates the blood vessels in
adjoining tissue.

PATHOPSHYSIOLOGY
A woman's fallopian tubes move eggs from the ovary to the uterus about once a month.

If a man's sperm meets up with an egg, pregnancy can result.

If the tubes are closed or ‘tied’ the sperm cannot fertilized an egg and pregnancy will not
occur.

After ligation, a woman’s ovaries still releases eggs each month

Eggs has nowhere to go

Eggs disintegrate in the tube

↓
 After sexual intercourse, the sperm are blocked at the isthmus of the fallopian tube

Ligation prevents sperm from getting to the eggs in the ovary

Fertilization is prevented

Pathophysiology/Disease Process

Labor Pain

Theoretical Based

Mechanical, chemical (prostaglandins, histamine, bradykinin and serotonin) or thermal stimuli

Nociceptors transmit pain along small, unmyelinated C fibers and large myelinated alpha-delta
fibers

Travels to the spinal cord

On the dorsal horn of the spinal cord, somatostatin, cholecystokinin and substance P serve as
neurotransmitters

Pain impulse ascends to the cerebral cortex

Neurons from the somatic sensory cortex

 Neurons project to the midbrain, to a region called the periaqueductal gray matter

Neurons project to neurons in the medulla in the nucleus Raphe magnus and other nuclei in the
rostral ventral medulla, particularly one called the nucleus reticularis paragigantocellularis

neurons project axons down the spinal cord in the same regions of the dorsal horn

synapse onto primary sensory nerve terminals in the myometrial muscle cells

begin and remain irregular

In early labor, the uterotubal pacemaker first felt and remain confined in the
abdomen

may not work in a synchronous manner often disappear with

ambulation or sleep

do not increase in frequency, duration

or intensity

begin irregularly but become regular

Becomes more attuned to calcium concentrations felt first in the lower back & then the

abdomen

in the myometrium and begins to function smoothly

continue no matter what activity

increase in frequency, duration and

intensity
Client Based

Fig.2 Client based pathophysiology of Labor Pain

Ms. C (26 years old, G6P6)

Mechanical, chemical (prostaglandins, histamine, bradykinin and serotonin) or thermal stimuli

Nociceptors transmit pain along small, unmyelinated C fibers and large myelinated alpha-delta
fibers

Travels to the spinal cord

On the dorsal horn of the spinal cord, somatostatin, cholecystokinin and substance P serve as
neurotransmitters

Pain impulse ascends to the cerebral cortex

Neurons from the somatic sensory cortex

Neurons project to the midbrain, to a region called the periaqueductal gray matter

Neurons project to neurons in the medulla in the nucleus Raphe magnus and other nuclei in the
rostral ventral medulla, particularly one called the nucleus reticularis paragigantocellularis

neurons project axons down the spinal cord in the same regions of the dorsal horn
 synapse onto primary sensory nerve terminals in the myometrial muscle cells

begin and remain irregular

In early labor, the uterotubal pacemaker first felt and remain confined in the
abdomen

may not work in a synchronous manner often disappear with ambulation or

sleep

do not increase in frequency, duration or intensity

begin irregularly but become regular

Becomes more attuned to calcium concentrations felt first in the lower back and then the
abdomen

in the myometrium and begins to function smoothly continue no matter what

activity

inc in frequency, duration

and intensity
Pain
Theoretical Based

Stimuli

Skin or tissue damage

Stimulation of Peripheral Nervous System

C-fiber

A-beta fiber

A-delta fiber

Dorsal Root Ganglion

Dorsal Horn

Spinal Cord

Brain

Spinal Cord

Dorsal Horn

Dorsal Root Ganglion

A-delta Fiber

A-beta Fiber

C-fiber

Stimulation of Peripheral Nervous System

Pain

Client Based
 Patient C. DC

G6P6(6006)

Mechanical Stimula (incision in the abdomen)

Skin or tissue damage

Stimulation of Peripheral Nervous System

C-fiber

A-beta fiber

A-delta fiber

Dorsal Root Ganglion

Dorsal Horn

Spinal Cord

Brain

Spinal Cord

Dorsal Horn

Dorsal Root Ganglion

A-delta Fiber

A-beta Fiber

C-fiber

Stimulation of Peripheral Nervous System

Pai

Chapter 2-Planning
Concept Map
 1.Teach recommended positions (eg. lying down or kneeling with your chest down, etc.) and help position the client in a comfortable positio
2. Encourage patient to gradually increase her activities.
3. Explain to the client that the pain is temporary and will eventually disappear.
4. Explain and teach various kinds
of distractions (eg. guided imagery, music, etc.)
5. Explain and teach relaxation
techniques (eg. deep breathing exercises, progressive muscle relaxation, etc.)
6. Provide optimal pain relief with prescribed analgesics, instruct client to request PRN pain medication before the pain is severe.

Patient C. DC
1. Maintain
previous
G6P6 (6006)
relationship
with higher
being QMMC
1. position the client in a
2. Continue comfortable position.
spiritual 2.Instruct deep breathing exercises
practices not 3. encourage patient to have
adequate resting periods
detrimental to Impaired
health 4. assist client in her daily
nutrition less activities
than body 5. instruct client to increase intake
requirements of iron by taking supplements and
r/t eating foods rich in iron like dark
green leafy vegetables
6. monitor vital signs
1. Discuss 5 importance of 1. Explain physiologic
sleep. changes and nutritional
2. Discuss 5 environmental
factors that affect sleep. needs during pregnancy and
3. Discuss 3 effects of diet in lactation,
sleeping. 2. Discuss the food pyramid
4. Discuss on how to do proper 3. Discuss foods items that are rich
in carbohydrates, proteins, fats,
time management to the
vitamins, and minerals; oral
client for effective self-care
recitation
and neonatal care.
4. Inform client about alternative,
affordable nutritious foods.
5. Provide diet modifications.
Prioritization

“It can significantly

affect the client
Ineffective
ability to breathe,
Breathing Pattern
transport gases and
r/t decreased
participate in
hemoglobin and (1)High
everyday activity”
hematocrit level
( Kozier and Erb’s,
in the blood
p1357 )
Based
.
“It can directly impair
health and prolong
Acute Pain r/t
recovery from
suture line in the (2)High
surgery, disease and
abdomen
trauma.” (Kozier and
Erb, 2008.)
“Because Nutritional
Impaired problems may affect
nutrition less many other areas of
(3)High
than body human functiuoning.”
requirements (Kozier and Erb’s ,
p1281)
“In a sleep-deprived
client, the loss of
NREM sleep causes
Disturbed immunosuppression,
sleeping pattern slows tissue repair,
r/t parental lowers pain
concern as (4)Medium tolerance, triggers
manifested by profound fatigue, and
workload and increases
parenting roles susceptibility to
infection.” (Lower,
Bonsack & Guion,
2003)
 “Faith is necessary
for spiritual growth,
particularly for a
relationship to a
Enhanced higher beinhg. Hope
(5)Low
Spirituality is also critical for
spiritual development
and intergral to the
horizontal and
vertical processes.”

CHAPTER 3
I. Medical Management
A. Drug Study

Drug Drug Mechanism Side Effects Adverse Effects Contraindi Nursing

Class of Action cations Responsibilities
Cephalexin Antibiotic Bactiricidal: CNS: Hematologic: Contraindi Arrange for
Cephalos Inhibits headache, Bone marrow cated with culture and
Dose: porin synthesis of dizziness, depression allergy to sensitivity tests
5mg (1st bacterial lethargy, cephalosp of infection
Route: Generati cell wall paresthesias Hypersensitivity orins or before and
PRM on) : ranging from penicillins during therapy
Frequency: GI: nausea, rash to Use if infection does
TID, 7 days vomiting, anaphylaxis; cautiously not resolve
diarrhea, serum sickness with renal Give drug with
anorexia, Other: failure, meals; arrange
abdominal superinfections lactation for small
pain, and frequent meals
flatulence, pregnancy if GI
pseudomem complications
branous occur
colitis, Refrigerate
hepatotoxicit suspension,
y discard after 14
days
Report severe
diarrhea with
blood, pus, or
mucus; rash or
hives; difficulty
in breathing;
unusual
tiredness,
fatigue; unusual
bleeding or
 bruising
Avoid alcohol
while taking this
drug
Ampicillin Antibiotic Bactiricidal: CNS: CV: heart Contraindi Arrange for
Penicillin Inhibits lethargy, failure cated with culture and
Dose: synthesis of hallucination allergies sensitivity tests
2gm bacterial s, seizures GU: Nephritis to of infection
Route: cell wall, Hypersensitivity penicillins, before and
TIV causing cell GI: sore : anaphylaxis cephlospo during therapy
death mouth, rins, or if infection does
nausea, Other: other not resolve
vomiting, superinfections allergies Take drug
abdominal around the
pain, bloody Use clock
diarrhea cautiously
with renal Take full course
Hematologic disorders therapy
: Anemia,
thrombocyto Take oral drug
penia, on an empty
leucopenia, stomach. One
neutropenia, hour of before 2
prolonged hours after
bleeding meals; do not
time take with fuit
juice or
Local:pain, softdrinks
phlebitis,
thrombosis Report pain or
at injection discomfort at
site sites, unusual
bleeding or
bruising, mouth
sores, rash,
hives, fever,
itching, severe
diarrhea,
difficulty
breathing.
Ferrous Iron Elevates CNS: CNS CNS: coma and Contraindi Confirm that
Sulfate Preparati the serum toxicity, death with cated with patient does
on iron acidosis overdose allergy to have iron
Dose: concentrati any deficiency
500 mg on, which GI: GI ingredient anemia before
Route: then helps upset, ; sulfite treatment.
PO to form hgb anorexia, allergy;
Frequency: or trapped nausea, hemachro Give drug with
OD in the nausea, matosis, meals if GI
reticuloend vomiting, hemosider discomfort is
othelial constipation, osis, severe; slowly
cells for diarrhea, hemolytic increase to
storage drak stools, anemias build up
and temporary tolerance.
eventual staining of Use
conversion the teeth cautiously Administer
to a usable with liquid
form of normal preparations in
iron iron water or juice
balance; to mask the
peptic taste and
ulcer, prevent staining
regional of teeth.
enteritis,
Warn patient
ulcerative
that stool may
colitis
be dark green.

Arrange for
periodic
monitoring of
Hct and Hgb
levels.

Take drug on
an empty
stomach with
water. Take
after meals if GI
upset is severe.

Take liquid
preparations
diluted in water
or juice, and sip
them through a
straw to
prevent staining
of the teeth.

Have periodic
blood tests
during therapy
to determine
the appropriate
dosage.

Do not take this

 preparation
with antacids or
tetracycline.

Report severe
GI upset,
lethargy, rapid
respirations and
constipation.
Mefenamic NSAID Anti- CNS: GU: renal Evaluate
Acid inflammato headache, impairment hematopoietic
ry, dizziness, status before
Dose: analgesic somnolence, Other: and frequently
500mg and insomnia, anaphylactoid during therapy
Route: antipyretic fatigue, reactions to
PRM activites tiredness, anaphylactic Ensure that the
Frequency: related to dizziness, shock patient is well
Q6 inhibition of tinnitus, hydrate before
prostagland ophthalmic and during
in effects therapy to
synthesis; minimize
exact GI: nausea, adverse of
mechanism dyspepsia, hyperuricemia
s of action GI pain,
are not diarrhea, Caution patient
known vomiting, about the risk
constipation, of serious fetal
flatulence harm while
taking this
drug; advise
patient to use
barrier
contraceptives

Drink adequate
fluids; drink at
least 8-10
glasses of fluid
each day

Have frequent
regular medical
follow-up visits,
including blood
tests to follow
the drug effects

Report fever,
 chills, sore
throat, unusual
bleeding or
bruising, yellow
discoloration of
the skin or
eyes, abdominal
pain, flank pain,
joint pain,
fever,
weakness,
diarrhea

B. Surgical Management

Date of Type of Operation Effect of Side effects Nursing

Operation operation Responsibility

November 3, Bilateral Tubal Permanent Abnormal Before:

2010 Ligation sterility bleeding after Prepare the
surgery client before the
 Heavy procedure
menstrual Inform the
flow client about the
 Pelvic pain effects after the
 Hormonal operation
Imbalance
During:
Assist the
doctor in
performing the
operation

After:
Assess client for
any signs of
complication

Assist client
when moving
Provide
adequate
resting periods
Inform client to
avoid coitus as
long as she can
feel a pain in
 her abdomen
Inform client to
avoid strenuous
activities

II. Client’s Daily Progress Chart

Date and Time Focus Data/ Action/ Response

Oct. 31, 2010

4:09 am >cervix fully dilated

>placenta out complete

>oxytocin 20 units inc. to

improve postpartum care

>admitted a 26 y/o pt.

4:50 pm Labor Pain ambulatory accompanied by
relatives

>S/E by ROD orders made

to carried out

>NPO maintained

>v/s checked

>awaits vaginal delivery

November 2, 2010

6:00 am >Continue needs

>proximal hygiene

>vs q 4 and record

November 3, 2010

6-3pm Fundus stable vs -MGH

(-) subj. complains -ff up @ opd after 1 week

 -daily would care

-on bed awake

-vs monitored

CHAPTER 4 – EVALUATION
I. Evaluation of Actual Nursing Problem

Patient C. DC is a 26- year old G6P5(5006) admitted to Quirino Memorial Medical

Center on October 31, 2010 due to labor pain. Prior to admission, the client’s uterine
size measured 28 cm and her AOG is 39-40 weeks. She delivered spontaneously to a live
boy at 4:06 am on November 1, 2010. Her final diagnoses include G6P6(6006). No
surgical operation was done after the operation.

II. Discharge Planning Instruction

DISCHARGE PLAN

Medication *Encourage patient to take 1 tablet of Ferrous Sulfate,

per orem, twice a day, an iron supplement to reduce
anemia. Take drug with citrus juice to increase absorption
of Iron. Discuss the side effects of taking this drug, such
as black tarry stool.

*When experiencing pain, take Mefenamic Acid 500mg

every 6 hours, orally. Do not take this drug with empty
stomach.

Exercise *Advise client to perform simple exercises like Kegel’s

exercise, household chores, abdominal breathing and
walking.

Treatment *Instruct client to do wound care daily to prevent

infection. The client can use betadine or NSS to clean the
wound.

Health Teaching *Teach client ways to provide proper hygiene like taking
a bath daily and doing the wound care to minimize
infection.

*Teach client to take proper nutrition with high-protein,

sufficient calories, vitamins and mineral supplements to
facilitate healing.

*Teach client that adequate periods of rest and sleep is

important.
 *Teach client about proper disposal of soiled dressings to
prevent spread of infection.

*Instruct client to continue breastfeeding because it

promotes bond between mother and baby and for its
nutritious content.

Diet Breakfast Lunch Afternoon Dinner

snack
Total KCAL: 2120 kcal
2 serving Sinigang na (2) saba 2 Fried
Fried dilis, tilapia and (ripe) galunggong,
2 serving fried 1 fried
boiled egg, chicken Total KCAL: chicken leg,
with 1 cup with 1 cup 80 kcal 1 cup of
of rice, 3 of rice; 1 rice, and 1
serving slice mango slice mango
boiled (2) rice (2) rice
potatoes (1) tilapia, (1) tsp
(2) rice (2) string vegetable
(2) chicken beans, (3) oil
egg (boiled) gabi (root) (2) Fried
(2) dilis (1) serving Galunggong
(fried) chicken leg (1) chicken
(1) (fried) leg (fried)
vegetable oil (1) tsp 1 slice
(3) potato vegetable mango
oil
Total KCAL: 1 slice Total: 489
762 kcal mango kcal

Total KCAL:
821 kcal