College of Nursing and Health Sciences

Samar State University

CASE STUDY
Normal Spontaneous Delivery
(NSD)

Submitted by:

LABINE, KRYSTELLE JADE A. (BSN-3A)

MACALDE, IZZA BELLE C. (BSN-3A)
Patient: Aniana, Santa Clara Juanerio (G1P0)
Age: 23

I. INTRODUCTION

A 23-year-old resident of Brgy. Guinon Calbayog City, was referred to the SPH
from Calbayog District Hospital (CDH) with the chief complaint of labor pains few hours
prior to the arrival. The patient has an internal examination and it showed that the
patient has a fully dilated cervix but still in a prolonged second stage of labor due to
cephalopelvic disproportion. The patient was brought to the Samar Provincial Hospital
and got admitted.

II. PATIENT’S HISTORY

PAST On October 2, 2023, the patient had a pelvic ultrasound

HISTORY examination; the fetal presentation was breech.
The last menstrual period (LMP) of the patient took place on February 13,
2023, placing her at 41 weeks and 1 day gestation at the time the patient
was admitted (November 28).

PRESENT Upon admission, the fetal presentation is cephalic, cervix is fully

HISTORY dilated, (-) BOW, and has cephalopelvic disproportion (CPD).
It was shown in the lab result that the patient’s white blood cells
have increased and the hemoglobin has decreased.
Test Name Result Unit Normal Value
WBC 32.70 x10^9/L 4.8 – 10.8

HEMOGLOBIN 10.3 g/dL 13-17

III. PATHOPHYSIOLOGY

Cephalopelvic Disproportion

Prolonged Second Stage of

Labor

Increased White Blood Cells

& Decreased Hemoglobin

Normal Spontaneous
Delivery with Right
Mediolateral Episiotomy

Meconium-stained amniotic
sac; <500 cc blood loss
 IV. 3 PROBLEMS IDENTIFIED ACCORDING TO THE PATIENT’S DIAGNOSIS

1. Risk for Infection

2. Acute Pain
3. Fatigue/Exhaustion

V. NURSING CARE PLAN

ASSESSMENT NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION
Subjective Risk for To reduce  Assess vital  To see if the  Maintained vital
data: Infection risk of signs that may patient has signs such as
“Yana, waray related to infection in indicate fever that may the
ma gud ako Episiotomy the incision infection indicate temperature at
inaabat na site. especially the infection a normal state.
masakit ha temperature.
akon tahi” as
verbalized by  Maintain  First line of  Maintained the
the patient. aseptic defense wound from
technique in against getting
wound care. infection infected.
Objective
Data:  Keep the area
BP – 110/80 that surrounds  Microorganism  Maintained the
HR – 95 the incision s can easily surroundings of
RR – 19 clean and dry. harbor on moist the incision site
Temp. – 36.7 area free from
Ht. - 150 microorganism
Wt. – 55 s.
O2 sat. – 98  Emphasize
 the  Helps drying  The patient has
importance of the wound that able to take the
taking promotes fast- medications as
medications healing. the physician
as prescribed prescribed.
by the
physician.

 Monitor  To know if
 Significant
laboratory there are
changes in the
results, significant
laboratory
focusing on changes in the
result were
white blood laboratory
monitored and
cell count. changes,
observed.
increase white
blood cell count
may indicate
infection.
 VI. DRUG STUDY
DOSAGE/
NAME OF MECHANISM OF
FREQUENCY INDICATION CONTRAINDICATION ADVERSE EFFECT
DRUG ACTION
/ROUTE

Phlebitis,
thrombophlebitis with IV
injection, Diarrhea,
pseudomembraneous
colitis, anorexia, glossitis,
dyspepsia, abdominal
cramps, anal pruritus,
oral candidiasis, genital
pruritus, candidiasis,
Inhibits cell-wall Used for
D: 1 g vaginitis, neutropenia,
synthesis, promoting surgical
Cefazolin R:Parenteral Hypersensitivity leukopenia,
osmotic instability; prophylaxis
IV nutrition thrombocytopenia,
usually bactericidal
eosinophilia,
maculopapular and
erythematous rashes,
urticarial, pain,
induration, sterile
abscesses, tissue
sloughing at injection site,
hypersensitivity
reactions, drug fever,
anaphylaxis

Mefenamic D: 500 mg/ 1 Mefenamic acid binds For the Known Increased risk of
Acid capsule the prostaglandin treatment of hypersensitivity miscarriage,
F: TID synthetase receptors mild to (e.g., anaphylactic Persistent pulmonary
R: Oral COX-1 and COX-2, moderate pain reactions and
hypertension of the
inhibiting the action of serious skin
prostaglandin reactions) to newborn (PPHN),
synthetase. As these mefenamic acid Oligohydramnios,
receptors have a role as or any Premature closure of the
a major mediator of components of ductus arteriosus (DA),
inflammation and/or a the drug product Structural cardiovascular
role for prostanoid defects,
signaling in activity- Use of mefenamic
Other congenital
dependent plasticity, acid during
the symptoms of pain pregnancy is not anomalies, including
are temporarily advised unless orofacial clefts.
reduced. prescribed by a
doctor, especially
if 30 or more
weeks pregnant.
 Seizures in epileptic
patients receiving
Multivitamins have a
phenobarbital,
therapeutic effect by
primidone, or
providing essential
diphenylhydantoin
vitamins and minerals
Stomach upset and pain
that may be lacking in
Constipation
an individual's diet,
Diarrhea
helping prevent or
Nausea
correct nutrient
Vomiting
deficiencies.
Allergic reactions
Anorexia
Iron supplement
Abdominal distention
replaces those iron Prevention and
Flatulence
stores and to encourage treatment of
Bitter or bad taste
erythropoiesis and iron deficiency Hypersensitivity
Altered sleep patterns
oxygen transportation anemia and to Ferrous Sulfate
D: 500 mg/1 Difficulty in concentrating
throughout the body. Vitamin B + Folic Acid +
Multivitami capsule Irritability
Iron transport occurs via complex Vitamin B
ns _+ Iron F: Overactivity
the divalent metal deficiency, Complex Capsule
R: Oral Excitement
transporter 1 (DMT1) prenatal
Mental depression
across the cell hematinic.
Confusion
membrane, where it is
Impaired judgment
incorporated and stored
Decreased vitamin b12
as ferritin in the
serum levels
macrophage. This form
Decreased
then is converted to an
diphenylhydantoin serum
absorbable Fe2+ ion,
levels in folate-deficient
then sequestered by
patients
transferrin to various
Polycythemia vera
sites in the body,
Peripheral vascular
including the bone
thrombosis
marrow for RBC
Itching transitory
synthesis.
exanthema
Feeling of swelling of
entire body
Calcium + D: 600 mg Calcium For prevention Hypersensitivity Abdominal Distention,
Vitamin D R: Oral Used to prevent or treat and treatment to the active Abdominal Pain,
negative calcium of osteoporosis ingredients or any Constipation, diarrhea,
imbalance; as antacids, other eructation, flatulence,
increases gastric and components of nausea, vomiting,
duodenal bulb pH >4 the product. hypercalcemia,
and increase lower hypercalcaemia, and
esophageal sphincter People who have nephrolithiasis.
tone; in osteoporosis renal
helps prevent or insufficiency.
decrease the rate of
bone loss; calcium is
also involved in normal
cardiac function; also
treats
hyperphosphatemia in
patients with chronic
kidney disease

Vitamin D
The active metabolite,
calcitriol, stimulates
calcium and phosphate
absorption from the
small intestine,
promotes renal tubule
phosphate resorption,
and secretion of calcium
from bone to blood