CALAMBA DOCTORS’ COLLEGE

Virborough Subdivision, Parian, Calamba City, Laguna

COLLEGE OF NURSING

Name: Kyle Villamor Date: 09-19-23

Year and Section: BSN 2A Score: __________________

Course Title: NCM 107 Care of the Mother, Child and Adolescent (Well Clients)

Seat work No. 2: Case Study

Direction: Read and analyze this case study. Consider the steps in clinical
decision-making in answering the questions.

Client Profile:

Analyn Santos, a 30-year-old pregnant woman, attended the antenatal clinic 2

weeks ago and has now come to the hospital with her mother-in-law. She complained

of labor pains for 3 hours. Mrs. Santos reports that the pain starts in her back and

radiates forward that last 20 seconds and occurs about every 8 minutes. She appears

very anxious.

A. Pre-assessment

1. Before beginning your assessment, what should you do for and ask Mrs.
Santos? (Assessment: Information gathering that will you assess the patient)
1.1. Greet her respectfully ang with kindness and offer a seat to
help her feel comfortable and welcome.
1.2. Demographic data, Vital signs and LMP
1.3. Last prenatal visit
2. What history will you include in your assessment of Mrs. Santos? Why?
2.1. History of current pregnancy, because it is an important
predictor of pregnancy risk in multiparous women.
2.2. HiNormal or Cesarean Delivery

3. What nursing procedure(s) will you include in your assessment to your patient
and why?
3.1. Identify stage and phase of labor
-choice and timing of medications are affected by degree
of dilation and contractile pattern.
3.2. Evaluate degree of discomfort through verbal and
nonverbal cues
-Attitudes and reactions to pain are individual and based on
past experiences
3.3. Ascertain presence of a birth plan, individual expectations,
and delivery process.
-cultural influences may include how the laboring mother
views pain management
3.4. Encourage use of comfort measures (back/ leg rubs, sacral
pressure, back rest, mouth care, and hot compress to
perineum and abdomen; perineal care
-promotes relaxation and hygiene, which enhance feelings
of well-being and may reduce use of anesthesia.

4. What laboratory or diagnostic test will you include in your assessment of Mrs.
Santos? Why?
4.1. Urine Sample- to indicate potential problems such as a
bladder or kidney infection, gestational diabetes,
dehydration and preeclampsia.
4.2. Blood Sample - to confirm your blood type and check for
prenatal antibodies and to do a Complete Blood Count
(CBC), which includes hemoglobin, platelets, and white cell
counts.
4.3. Complete Blood count - to estimate blood loss during
delivery and to identify patients who will need blood
transfusions.
 4.4. Contraction stress test - to make sure the fetus can handle
contractions during labor and get the oxygen needed from the
placenta.
4.5. Ultrasound - provide more accurate information about fetal
position than digital examination.
4.6. Amniocentesis - to check if your baby has a genetic or
chromosomal condition, such as Down's syndrome, Edwards'
syndrome or Patau's syndrome.

B. Diagnosis

You have completed your assessment of Mrs. Santos and your main findings are
as follows:

Clinical History:

❒ Mrs. Santos, a 38-weeks-old pregnant

❒ This is her 3rd pregnancy
❒ Her first pregnancy is a 37-weeker, a live term baby girl. The second
pregnancy is a triplet with an AOG of 35th weeks, delivered via Caesarian
section procedure.
❒ She confirms that the labor started 3 hours ago and the contractions
seems to be growing increasingly longer and frequent.
❒ All other aspects of her history were normal and no other significant
findings.
❒ Mrs. Santos exhibits facial grimace and cries out in every contraction.
❒ Vital Signs: T: 36.8 degrees Celsius, RR of 21 cpm, PR: 87 bpm, BP: 146/87
mmHg, and Oxygen saturation level of 98-99% via room air.

1. Compute for the Obstetrical History of Mrs. Santos.

G- 3 P- 2 (T- 1 P- 2 A- 0 L- 4)

2. What do you think is the cause of elevated high blood pressure of the
patient?
- blood pressure rises as a result of pain due to the effect of uterine
contractions, causing an increase in both stroke volume and heart rate.

Abdominal Examination:
 ❒ Fundic Height is 33 cms
❒ Presenting part is Fourth-Fifths above the pelvic brim (crowning)
❒
❒ Fetal Heart Rate: 139 bpm, in the right lower quadrant
❒ Contractions are irregular every 8-10 minutes and last for 14 to 18 seconds.

Internal Examination:

❒ Dilatation of cervix: 4cm

❒ Membranes are intact
❒ Presentation is Cephalic, no molding

Others:

❒ Her physical examination reveals no abnormal findings

❒ Blood type: “O” Rh positive
❒ VRDL: Non-reactive (Clear), Hepa-B Sceening: Non-reactive, and HIV
Screening was also negative

C. Plan of Care

Mrs. Santos continues to have regular contractions; by 2 hours after hospital

admission, she is having 2 contractions in 10 minutes, each lasting for 20-40 seconds.
Maternal pulse remains between 80-90 beats per minute while fetal heart rate remains
between 140-150 bpm. The patient’s level of anxiety remains high and she continues
become agitated during contractions

1. Based on the given findings, what do you think will be nursing diagnosis
appropriate to your patient? Give at least 2 top priority nursing diagnosis.
1.1. Acute pain related to latent phase of labor as evidenced by 2
contractions in 10 minutes with a frequency of 20-40 seconds.
1.2. Elevated high blood pressure related to anxiousness and pain
as evidence by facial grimace and cries out every contraction
 2. With your identified nursing problems, make a nursing care plan for your
patient.

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Acute pain After 5 Independent: After 10
She related to hours of - Identify stage -choice hours of

complained latent nursing and phase of and timing nursing

phase of interventio labor; perform of intervention
of labor
labor as n, patient vaginal medication , the
pains for 3 evidenced will be able examination. s are patient was
hours. Mrs. by 2 to report affected able to
contraction pain at a by degree report pain
Santos
s in 10 manageab of dilation at a
reports that minutes le level. and manageabl
the pain with a contractile e level.
frequency After 5 pattern.
starts in her
of 20-40 hours of -Determine -presence After 10
back and seconds. nursing availability and of a hours of
radiates interventio preparation of supportive nursing
n, patient support partner, intervention
forward
will be able person(s) family/frien , the
that lasts 20
to d can patient was
seconds participate provide able to

and occurs in the labor emotional participate

process support in the labor
about every
providing and process
8 minutes. the client's enhance providing
desired level of the client's
level of discomfort. desired
support. -Provide/encou -promotes level of
Objective:
rage use of relaxation support.
She comfort and
After 5 measures hygiene,
appears
hours of (back/leg rubs, which After 10
very nursing sacral pressure, enhance hours of
anxious. interventio mouth care, feelings of nursing
n, patient well being intervention
Agitated will be able perineal care, and may , the

during to feel less and shower. reduce the patient was

anxious need for able to feel
contraction
and anesthesia. less anxious
s. agitated. -touch may and
-assess client’s serve as a agitated.
Patient is
desire for distraction,
having 2 physical touch provide

contraction during supportive

contractions. reassuranc
s in 10
e and
minutes, encourage
each lasting ment.
-
for 20-40
-time and information
seconds. record the necessary
Maternal frequency, for
intensity, and choosing
pulse
duration of appropriat
remains uterine e
between contractile intervention
pattern per s and
80-90 beats
protocol. preventing
per minute
or limiting
while fetal undesired

heart rate side effects

of
remains
medication
between .
140-150 Collaboration:
-prepare -provides
bpm.
for/assist with relief once
Vital signs: neuraxial active
anesthesia. labor is
BT: 36.8°C established
.
RR: 21 cpm
 PR: 87 bpm

BP:146/87m

mHg

SPO: 98-99%

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Elevated After hours Independent: After hours

She high blood of nursing -Monitor vital -to of nursing
pressure intervention, signs, especially maintain intervention,
complained related to the patient's noting blood cardiac the patient's
of labor anxiousness blood pressure perfusion. blood
and pain as pressure will changes. pressure has
pains for 3 evidenced decrease. decreased.
hours. Mrs. by facial -Provide/encour
grimace After hours age use of -promotes After hours
Santos and cries of nursing comfort relaxation of nursing
reports that out every intervention, measures and intervention,
contraction. the patient (back/leg rubs, hygiene, the patient
the pain will be able sacral pressure, which was able to
starts in her to feel less mouth care, enhance feel less
anxious and perineal care, feelings of anxious and
back and agitated. and shower. well being agitated.
and may
radiates
After hours reduce the After hours
forward that of nursing need for of nursing
intervention, anesthesia intervention,
lasts 20
the patient and to the patient
seconds will be able lessen pain was able to
to report that could report pain
and occurs
pain at a cause at a
about every manageabl hypertensio manageabl
e level. n. e level.
8 minutes.

-Determine
Objective:
availability and -presence
preparation of of a
She appears
support person(s) supportive
very partner,
family/frien
anxious.
d can
provide
Agitated
emotional
during support
and
contractions
enhance
. level of
discomfort,
Patient is that could
result in
having 2
managing
contractions stress to
manage
in 10
blood
minutes, pressure.
Dependent:
each lasting
-Administer
for 20-40 Intravenous (IV)
labetalol and -for
seconds.
hydralazine managem
Maternal ent of
acute-onse
pulse t, severe
hypertensio
remains
n.
between

80-90 beats

per minute

while fetal

heart rate

remains

between

140-150

bpm.

Vital signs:

BT: 36.8°C

RR: 21 cpm

PR: 87 bpm

BP:146/87m

mHg

SPO: 98-99%