Name of Student: AUSTRIA, GIA LOURDES CAMILLE U.

Section: BSN 2-A2

Concept: Maternal and Child Health Nursing

Name of Clinical Instructor: Rhea Rica F. Montefalcon

Patients Data:

Name: Rhiza Mercado Noel Occupation: Sales Agent

Gender: F Nationality: Filipino
Birth Date: 03/18/1997 Religion: Roman Catholic
Birth Place: Minglanilla, Cebu Source of Data:
Age: 23 Date & Time of Admission: 07/22/2020.
Address: Minglanilla, Cebu 12:53 AM

Educational Level: Attending Physician: Dr. Seboa

Marital Status: Single Diagnosis: Watery Vaginal Discharge
Chief Complaint: Watery Vaginal Discharge

LMP :
AOG :
EDC :
 Anatomy & Physiology
(This will show a drawing of the organ affected related to the diagnosis of the
patient.)
ANATOMY

Vagina
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• PLACENTA: The placenta is an organ that develops in your uterus during pregnancy. This structure provides oxygen
and nutrients to your growing baby and removes waste products from your baby's blood.
• UMBILICAL CORD: The umbilical cord is a tube-like structure that connects a fetus to the mother's placenta,
providing oxygen and nutrient-rich blood and removing waste.
• AMNIOTIC SAC (BAG OF WATER): It is the double-walled fluid-filled sac that encloses and protects the fetus in
the womb and that breaks releasing its fluid during the birth process.
• AMNIOTIC FLUID: The amniotic fluid is the protective liquid contained by the amniotic sac of a gravid amniote. This
fluid serves as a cushion for the growing fetus, but also serves to facilitate the exchange of nutrients, water, and
biochemical products between mother and fetus.
• UTERUS: Uterus, also called womb, an inverted pear-shaped muscular organ of the female reproductive system,
located between the bladder and the rectum. It functions to nourish and house a fertilized egg until the fetus, or
offspring, is ready to be delivered.
• CERVIX: Cervix, lowest region of the uterus; it attaches the uterus to the vagina and provides a passage between
the vaginal cavity and the uterine cavity.
• VAGINA: The vagina serves three purposes: It's where the penis is inserted during sexual intercourse. It's the pathway
(the birth canal) through which a baby leaves a woman's body during childbirth. It's the route through which menstrual
blood leaves the body during periods.

PHYSIOLOGY

• During pregnancy, your baby is surrounded and cushioned by

a fluid-filled membranous sac called the amniotic sac. Typically,
at the beginning of or during labor your membranes will
rupture —
also known as your water breaking.
• If your water breaks before labor starts, it's called
prelabor rupture of membranes (PROM). Previously it was
known as
premature rupture of membranes.
• When your water breaks you might experience a sensation
of wetness in your vagina or on your perineum, an
intermittent or
 constant leaking of small amounts of watery fluid from your
vagina, or a more obvious gush of clear or pale-yellow fluid.
• Typically, after your water breaks at term, labor soon follows —
if it hasn't already begun.
• When you’re pregnant and your water breaks, it means that the
fluid-filled sac around your baby has ruptured. This sac of
amniotic fluid holds your little one snug and safe in your belly.
Also called a bag of waters, it makes room for your baby to
grow, keeps them in a steady temperature, and cushions the
umbilical
cord so it won’t get squeezed.
• When your body gets ready to deliver the baby, your water
breaks and drains through your vagina. This can happen before
or during your labor. That’s when you start feeling contractions
and your
cervix thins and widens so your baby can pass through.
Followed by:
Parts of the organ and functions of each
part Definition of the disease:
Clinical Manifestation/Signs & Symptoms

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Laboratory Test
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Date Type of exam Patient’s Result Normal Values Significance / Interpretation
02/22/2020 CBC WBC: 20.7 4.4 – 11.0 - HIGH (sign of inflammation
or infection)
*Pregnant women are allowed
an increase in leukocytes by 4 to
5
wbc/hpf, only if all other indicators
remain unchanged. An increase
above 5wbc/hpf indicates that there
is most likely an inflammation
NEU: 85.2 37.0 – 80.0 somewhere in the urinary system or
the kidneys. - HIGH (sign of
neutrophilia)
*The total white cell count will
frequently be elevated in pregnancy
due to increased numbers of
neutrophils.
Neutrophils can also demonstrate a
“left shift” (increased number of band
neutrophils). However, this neutrophilia
LYM: 8.7 10.0 – 50.0
is not usually associated with infection
or inflammation.
- LOW
*Lymphocyte count decreases during
pregnancy through the first and second
MON: 4.5 0.0 – 12.0 trimesters and increases during the
EOS: 1.1 0.0 – 7.0 third trimester.
BAS: 0.5 0.0 – 2.5 - NORMAL
RBC: 4.10 4.5 – 5.1 - NORMAL
- NORMAL
- LOW (sign of Iron Deficiency
Anemia) *Iron-deficiency anemia is
common in pregnant women. When
you're
pregnant, the volume of blood in your
body increases by as much as 50% to
support both you and your growing
baby. This, in turn, decreases your
bloods’ hemoglobin concentration.
Since your body needs iron to make
hemoglobin, without sufficient iron
HGB: 13.3 12.3 – 15.3 stores, red blood-cell production slows,
HCT: 38.9 35.9 – 44.6 along with their energy-boosting
oxygen supply.
MCV: 95 80 – 96
- NORMAL
MCH: 32.4 27.5 – 33.2
- NORMAL
MCHC: 34.1 32.0 – 36.0
- NORMAL
RDW: 10.1 11.6 – 14.8
- NORMAL
- NORMAL
- LOW (sign of Iron Deficiency
Anemia) *Iron-deficiency anemia is
common in pregnant women. When
you're
pregnant, the volume of blood in
your body increases by as much as
50% to support both you and your
growing baby. This, in turn,
decreases your
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PLT: 240 150 – 450 bloods’ hemoglobin concentration.
MPV: 7.3 6.0 – 11.0 Since your body needs iron to
make hemoglobin, without
sufficient iron
stores, red blood-cell production slows,
along with their energy-boosting
oxygen supply.
- NORMAL
- NORMAL

02/22/2020 Urinalysis Color: YELLOW Pale Yellow- - NORMAL

Clarity: CLOUDY Yellow Clear / - can be a sign of hormonal
Transparent changes; dehydration; vaginal
discharge
*The primary cause of cloudy urine in
pregnancy is hormonal changes. During
pregnancy, your body will undergo
hormonal changes to support the
growing fetus. Some hormones like
human chorionic gonadotropin (HCG)
may increase rapidly during the first
trimester, thus making your urine
cloudy.
*Nausea and vomiting are not only
an extremely uncomfortable
experience but it may also lead to
dehydration. If you are dehydrated
during pregnancy, your urine will
become darker and concentrated and
may appear cloudy.
*Vaginal discharge is very common
during pregnancy. However, if there
is excessive vaginal discharge during
pregnancy, it may make your urine
Specific Gravity: 1.020 cloudy.
pH: 6.5 1.005-1.025 - NORMAL
Albumin: 1+ 4.5 – 8.0 - NORMAL
Negative - SMALL
*Having small amounts of protein in
your urine is common in pregnancy. It
can happen for a number of reasons. It
probably just means that your kidneys
are working harder now that you're
pregnant. It could also mean that your
Ketone: 1+ body is fighting a minor infection. -
Negative SMALL
*The changing pregnancy hormones can
prevent the cells from using up the
glucose, leading to a glucose deficiency.
In case of the deficiency of this element,
the body starts using up the fat reserves
to attain the required energy. This
condition leads to the production of
ketones.
Blood: 4+ - HIGH (sign of urinary tract infection)
Negative * If you’re pregnant and see blood in
your urine, or your doctor detects blood
 during a routine urine test, it could be a

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Glucose: 4+
Nitrite: NEGATIVE
Bilirubin: NEGATIVE
Urobilinogen: NORMAL
WBC: 1-3 / HPF
RBC: TNTC / HPF
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Negative sign of a urinary tract infection (UTI). A
UTI is an infection in the urinary tract
typically caused by bacteria. UTIs are
more common during pregnancy
because the growing fetus can put
pressure on the bladder and urinary
Negative tract. This can trap bacteria or cause
Negative urine to leak.
Negative or - HIGH (sign of gestational diabetes)
traces 0.2 – 1.0 *Up to half of women have glucose
mg/dL in their urine at some time during
0-5 / HPF pregnancy. Glucose in the urine
0-4 / HPF may mean that a woman has
gestational diabetes.
- NORMAL
- NORMAL
- NORMAL

Epithelial Cells: FEW
Mucus Threads: RARE
Bacteria: FEW
- NORMAL
- HIGH
*A high count of red blood cells in
the urine can indicate infection,
Few/ Small
trauma, tumors, or kidney stones. If
amount Few/
red blood cells seen under
Small amount
microscopy look distorted, they
None
suggest kidney as the possible source
and may arise due to kidney
inflammation
(glomerulonephritis).
- NORMAL
- NORMAL
- FEW
*Asymptomatic bacteriuria is a
bacterial infection of the urine without
any of the typical symptoms that are
associated with a urinary infection, and
occurs in 2% to 15% of pregnancies. If
left untreated, up to 30% of mothers
will develop acute pyelonephritis.

Diagnostic Tests
Date Type of test Patient’s result Significance/ interpretation
02/22/2020 HBA1C Result: 4.3 % - NORMAL
(Reference Range: 4.0-6.0)

HGT Results: 103 mg/Dl - NORMAL

 > 190 mg/dL – GESTATIONAL
DIABETES < 140 mg/dL – NORMAL

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Problem List
Number of Priority Focus / Nursing Diagnosis

1 Acute pain related to laceration (episiotomy) of the delicate tissues as evidenced by a facial grimace

2 Knowledge Deficit: Postpartum care related to the absence of information as evidenced by request
for information needed

3 Risk for infection related to stasis of body fluids (lochia)

Drug Study
NOTE: All drug studies for the medications found in the case are already made from the previous case studies.

Nursing Care Plan

Defining Nursing Scientific Analysis Goal of Care Intervention Rationale
Characteristics Diagnosis
Subjective: Knowledge A lack of cognitive SHORT TERM: Independent - To gain
“Miss, onsa Deficit: information or After 4 hours 1. Establish rapport. patient’s trust
akong mga Postpartum psychomotor ability of nursing and have a
angay timan an care related needed for health intervention, good nurse-
og buhaton to absence restoration, the patient patient
preservation, or will be relationship
para ma of 2. Assess the
health promotion is
ampingan information able to: client’s level of - Provides
identified as a
nako ako as - Participate in knowledge, ability information
knowledge deficit.
kaugalingon?” evidenced by learning to learn. Talk necessary to
Knowledge plays an
as verbalized request for influential and process - and listen to the develop an
by the pt. information significant part of a Verbalize client in a calm individual plan of
needed patient’s life and understanding demeanor. Provide care and engage
“Single mother recovery. It may - Initiate time for in problem-
nako karon, og include any of the postpartum questions and solving
walay motudlo three domains: care clarifications. techniques.
nako kung cognitive domain interventions Reduces anxiety
onsa akong (intellectual and stress, which
mga activities, can block
buhaton igka problem-solving, LONG TERM: learning, and
and provides
human ani After 1 week
others); affective clarification and
tanan” as of nursing
domain (feelings,
verbalized by intervention, repetition to
attitudes,
the pt. the patient enhance
belief); and
will be 3. Provide an understanding.
psychomotor domain
(physical skills or able to: atmosphere of - Important when
Objective: procedures). It is the - Understand respect, providing
- conscious duty of the nurse to proper self- openness, trust, education to
and determine care patients with
and
cooperative with the patient what techniques, different values
collaboration.
- V/S to teach, when to exhibit and beliefs about
BP: 110/70 teach, and how to adequate health and illness
4. Determine the
HR: 85 teach certain bonding/role - Fatigue related
matters and concerns
availability of
RR: 19 acceptance, to hemorrhage
on health. Adult personal
Temp: 36.8 and will
learning resources/support
O2 Sat: 98% importance of slow down the
principles guide the groups. Explain the
client’s
Weight: 117 lbs teaching-learning process. follow up importance of
resumption of
- lack of care. having an adequate
normal activities,
source of rest,
necessitating
information healthy living and
problem solving
pacing of activities. and dependence
on
others for a period

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 5. Instruct the of time.
client to report - These are the
inability to signs of Sheehan’s
breastfeed, syndrome which
fatigue, is caused by the
amenorrhea, loss destruction of
of cells of the
pubic/axillary hair, anterior
premature aging pituitary gland
and genital by oxygen
atrophy. starvation,
usually at the
time of
childbirth. The
condition may
also result from
septic shock, or a
massive
hemorrhage. It
often results in
premature aging,
irreversible
fertility,
decreased
resistance to
infection, or
Dependent increased risk of
shock.
1. Administer right
medications and its
dosage as - Right
prescribed by the medication and
physician. dosage reduce
more risks and
Collaborative complications;
and promotes
1. Inform and
efficacy.
update all the
assessment or
changes in the - Being an
patient’s data to effective advocate
the attending in the care of
physician or patient is
obstetrician. important for
health
improvement and
Source:
https://nurseslabs.com/ recovery.
pos tpartum-
hemorrhage
nursing-care
plans/#deficient_knowledg

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FDAR
Date Focus Time DAR
02/22/2020 Acute pain 12:30 PM D: The patient is awake, conscious, face grimacing.
related to Complained pain of laceration with a scale of 8 out of 10;
laceration and presence of diaphoresis
(episiotomy) Vital Signs: BP: 110/70; HR: 85; RR: 19; Temp: 36.8; O2 Sat:
of the 98%; Weight: 109 lbs
delicate
tissues as A: Encourage the pt to do deep breathing exercise and
evidenced by relaxation techniques. Perform a comprehensive
facial grimace assessment of pain. Provide nonpharmacologic pain
management. Provide pharmacologic pain management as
ordered. Provide health teachings based on the patient’s
condition. Assist pt with comfort measures.

R: Patient verbalized that pain was minimized and relieved.

Patient will report decreased scale of pain.

Discharge Planning
Date Focus Time DAR

07/23/2020 Discharg 07:00 AM D: With discharge order from attending physician Dr. Seboa A
es ctivity: The client is instructed not to do light exercises and avoid
instructio heavy chores or work and also, to avoid heavy works especially
ns lifting and straining heavy things that may shock the pt’s body
physically. The following are specific suggestions by the
physician:
- Do mild exercise such as slow walking to improve muscle
tone, quicker healing and a more positive attitude.
- Avoid heavy lifting, strenuous exercise and excessive
stair climbing.
M edication: The client knows the name, action, purpose, dose,
route of administration and side effects of each drug she is
taking. The client is instructed to report or contact the physician if
adverse reactions are present.
- Cefuroxime 500 mg cap BID x 6 days
- Mefenamic Acid 500 mg cap q 6ᵒ
- FeSO₄ Cap OD
- Calcium tab OD
- Vit. C cap OD
E nvironment: The client knows the importance of having a
clean, comfortable and healthy environment free from any actual
or potential hazards. This can contribute to the client’s
improvement of her health condition. Homemaking services; and
emotional and economic support systems are in place. T
reatment: The client and family will know the purpose and action
of any treatment. Take home medications are vital for the
improvement of the client’s condition.
H ealth Teaching: Sitz Bath: sitting in a tub of warm water for 15
minutes, two to three times per day, will help relieve the
discomfort. Do deep breathing exercise and relaxation techniques.
Encourage to start doing Kegel exercise. Elevate your

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 feet when sitting or lying down and make sure you drink a lot of
fluids to help your body get rid of the excess fluid. Continue to use
the peri-bottle to clean your perineum, rinsing front to back with
warm water until the bleeding stops. Use your sitz-bath as
directed; this will help dissolve any stitches and aid in healing the
perineum.
O utpatient Follow up at RHU after 1 week through call D iet:
Good nutrition and adequate fluids are necessary for tissue
repair, healing, breastfeeding and general health. Refrain from
any weight-reducing diets until after your postpartum checkup.
Eat a well-balanced diet that is high in protein (meat, fish,
legumes), fiber (fruits, vegetables, whole grains), calcium (milk,
yogurt, cheese, green leafy vegetables) and fluids. If you have a
family history of food allergies or are concerned about food
allergies for your baby while breastfeeding, consult your
physician for guidance.
R: Out of the room per wheelchair with improved condition

Bibliography (a summary of all the resources used)

https://www.scribd.com/doc/48996400/Acute-pain-NCP
https://nurseslabs.com/postpartum-care/
https://www.coursehero.com/file/17857156/Postpartum-general-Care-Plan/
https://www.scribd.com/doc/113764102/NCP-Knowledge-Deficit
https://www.healthline.com/health/postpartum-care#7
https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/postpartum-care/art-20047233
https://www.stanfordchildrens.org/en/topic/default?id=the-new-mother---taking-care-of-yourself-after birth-90-
P02693
https://nurseslabs.com/deficient-knowledge/
https://www.healthline.com/health/postpartum-care#1 https://nurseslabs.com/postpartum-
hemorrhage-nursing-care-plans/#deficient_knowledge
https://www.coursehero.com/file/26896971/POSTPARTUM-NCPdoc/
http://thenurseszone.com/nursing-care-plan-ncp/deficient-knowledge/

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