Revised 2022

Mindanao State University

COLLEGE OF HEALTH SCIENCES
Marawi City

Name of Student: PANARA-AG, JOEHARA MACAUROG Clinical Instructor: DR. MONALINDA M. MACAWADIB, RN, MAN, RM, LPT, MBA, CGM, MAEd, PhD
Area of Assignment: DELIVERY ROOM Date Submitted: OCTOBER 20, 2023

NURSING ASSESSMENT I

PATIENT’S PROFILE
Name: PATIENT XX Address: BANSAYAN, POONA BAYABAO, LANAO DEL SUR Age: 27 YEARS OLD
Sex: FEMALE Religion: ISLAM Civil Status: MARRIED Occupation: HOUSEWIFE

HABITS

Frequency Amount Period/Duration

1. Tobacco x x x
2. Alcohol x x x
3. OTC-drugs/ non-prescription drugs x x x

A. CHIEF COMPLAINT
Labor pain

B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and
vocational responsibilities, affected diagnoses}.
A 27-year-old patient, 26hrs PTA while she was watching the television with her husband, felt a reoccurring pain which she thought were irregular contractions. She estimated that it
occurs hourly and lasts for an uneven amount of time. The pain is aggravated when she lies down in supine position but alleviates it by walking short distances and massaging her lumbar
region. The associated symptoms were pressure in the pelvic area and tightening of the abdomen. The patient wasn’t previously treated for the same complaint as it was her first pregnancy.
Her social and vocational responsibilities have been minimalized since her pregnancy due to the reason that her husband doesn’t want her to experience overworking so, her husband does
most of the household chores. The patient does not have any existing disease that can be affected.

C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications,
habits, birth and developmental history, nutrition- for pedia)
The patient's medical record reveals a clean slate with no prior instances of hospitalization, injuries, trauma, or any previous medical procedures undergone. As a child, the patient received
the full course of childhood immunizations, establishing a well-documented vaccination history. There is no documented history of major illnesses in the patient's recent past. Importantly,
there are no recorded allergies or intolerances to medications in her medical profile. During her early stages of development, the patient was initially breastfed, though this practice was
discontinued at the age of six months. Following this period, her dietary regimen transitioned to a mixed feeding approach, combining both breastmilk and other milk-based products,
ensuring a diversified and balanced nutritional intake.
FAMILY HISTORY WITH GENOGRAM
Acquired Diseases: Heredo- familial Diseases:
Hypercholesterolemia Diabetes
Kidney Disease Heart Diseases
Tuberculosis Hypertension
Alcoholism Cancer
Drug Addiction Asthma
Hepatitis A Epilepsy
B Mental Illness

C Rheuma/Arthritis
Others (pls. specify) Others (pls. specify)

D. PATIENT’S PERCEPTION OF:

1. Present Illness
“Masakit igira miyag-contract ago paganay akn aya mbawata” as verbalized by the patient.

2. Hospital Environment
“Okay lang” The patient stated that briefly that she was fine with the hospital.

E. SUMMARY OF INTERACTION
The patient exhibited a high level of cooperation throughout the examination, willingly and comprehensively responding to all inquiries posed. This cooperative demeanor not
only facilitated the thorough monitoring of her vital signs but also enabled a comprehensive and unhindered physical assessment. No impediments or obstacles were
encountered during the process, contributing to a smooth and effective evaluation.
 Physical Examination

Name: Patient X Date: October 17, 2023

Chief Complaint: Labor pain Height: 1.6 m Weight: 58 kg
Vital Signs: Temp: 36.8˚C PR: 79bpm RR: 19cpm BP: 110/80 O2Sat: 97% Pain Score: 8 BMI: 36.3 (Obese Class II)

Upon initial assessment, the patient presented as awake, conscious, and fully oriented in terms of time, place, person, and overall situation. The patient had
an ongoing intravenous fluid (IVF) infusion of Lactate Ringer's solution at a rate of 14 drops per minute, administered via the left metacarpal vein. The
intravenous line was found to be patent and infusing smoothly, with 800 milliliters of the solution remaining to be administered. A thorough neurological
evaluation revealed that the patient possessed a Glasgow Coma Scale (GCS) score of 15/15, indicative of her excellent cognitive function. This score was
GENERAL broken down into the following categories: Eye Opening (E) 4, Motor Response (M) 6, and Verbal Response (V) 5. In terms of attire, the patient was
dressed in a blue gown and a malong, providing comfort and modesty during her hospital stay. Her initial vital signs were as follows: Blood Pressure (BP)
at 110/80mmHg, Respiratory Rate (RR) at 19 breaths per minute, Pulse Rate (PR) at 79 beats per minute, Oxygen Saturation (O2Sat) at 97%, and body
temperature at 36.8˚C. The patient also reported a pain score of 8, suggesting the presence of discomfort or pain, which will require further evaluation and
management.

Head Examination: The patient's head exhibited normocephalic proportions and symmetry, with a normal distribution of black hair, free from tenderness,
bruises, masses, or palpable lesions. The circumference of the head appeared circular with no deformities or soft areas, ensuring the absence of any
irregularities. Facial features presented symmetrical, and facial nerves demonstrated their intact functionality.
Eye Examination: The patient's eyebrows displayed a natural black color without any abnormalities observed in the external eye structures. The sclera, the
white part of the eyes, exhibited a healthy white hue, and the conjunctiva appeared pink, indicating the absence of any notable eye issues. Pupils were
assessed using the PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) approach, revealing equal, round pupils that responded
HEENT appropriately to both light and accommodation. No other ocular abnormalities were detected.
Ear Examination: The patient's ears displayed a normal shape without any visible lesions or abnormalities. Hearing capability was assessed and found to
be proper in both ears, indicating the absence of auditory issues.
Nose Examination: The patient's nasal passages were clear, with no visible lesions, masses, or other abnormalities. The sense of smell was intact,
indicating no olfactory concerns.
Throat Examination: A comprehensive examination of the throat revealed no deformities, lesions, or masses. There was no tenderness, swelling, or pain
observed, and the interior of the mouth appeared free from abnormalities. The tongue exhibited a healthy pink color and retained its motor control.
Additionally, the carotid pulse was palpable, suggesting proper blood flow in the neck region.

The patient's skin exhibited a consistent and healthy brown color throughout all extremities, highlighting the absence of any significant variations or
discolorations. Hair distribution was symmetrical, and there were no signs of injuries, abnormalities, lesions, or wounds observed upon thorough
examination. The skin's turgor was found to be well-preserved, indicating good hydration and elasticity, and it was warm to the touch, indicative of proper
INTEGUMENTARY circulation. Furthermore, capillary refill, a crucial measure of circulatory health, was assessed and found to be intact, signifying that blood was flowing
appropriately to the peripheral areas of the body. It is worth noting that a G22 cannula had been thoughtfully inserted into the patient's left metacarpal
vein, providing a reliable means of intravenous access for various medical interventions and treatments as needed. This detail underscores the attentiveness
to the patient's medical care and overall well-being.
 The patient's cardiovascular parameters were meticulously assessed, revealing a pulse rate of 79 beats per minute and a blood pressure reading of 110/80
mmHg. These vital signs are well within the normal range, indicative of the patient's overall cardiovascular stability and health. Pulses were examined at
various anatomical locations, including the apical, radial, and carotid sites, and in all instances, they were palpable, confirming the presence of adequate
blood circulation. Furthermore, the capillary refill time was measured and found to be within the expected range, taking only 3 seconds for the color to
return, further supporting the patient's circulatory well-being. The physical examination extended to the assessment of the patient's chest, where various
CARDIOVASCULAR
aspects were considered. Chest expansions were observed to be well, indicating a normal range of respiratory movement. Additionally, upon auscultation,
no murmurs were detected, and the patient's heartbeat exhibited a regular rhythm, contributing to a reassuring cardiac assessment. In summary, the
comprehensive cardiovascular evaluation demonstrated that the patient's heart and circulatory system are functioning well within healthy parameters, with
no signs of edema, tenderness, or deformities noted. This thorough assessment underlines the patient's current cardiovascular stability and overall well-
being.

The patient's respiratory health was assessed with care and attention. A respiratory rate of 19 breaths per minute and an oxygen saturation level of 97%
were recorded, reflecting the patient's stable and efficient respiratory function. The regularity of the patient's respiration further reinforced the absence of
any immediate concerns. Auscultation of the patient's lungs revealed a reassuring absence of wheezing or crackles, indicating clear and unobstructed air
passages. This clear breath sound, combined with the absence of coughing and the lack of any respiratory treatment attachments, suggested that the patient
RESPIRATORY
was comfortably breathing room air without any immediate respiratory distress. Moreover, there were no nasal issues noted, and the patient exhibited
normal and unhindered breathing patterns. The process of inhaling and exhaling was observed to be smooth and without any difficulties, reaffirming the
patient's optimal respiratory function. In summation, the patient's respiratory assessment demonstrated the absence of any immediate issues, with stable
respiratory rates, clear lung sounds, and an efficient oxygen saturation level, collectively indicating a reassuring state of respiratory health.

A comprehensive evaluation of the patient's overall health and condition included an examination of various aspects, yielding noteworthy observations.
Oral Health: The patient's oral health was found to be satisfactory, with a complete set of teeth. This dental examination is a vital aspect of overall health,
ensuring the patient's ability to maintain proper nutrition and oral hygiene.
Abdominal Assessment: The patient's abdomen presented as distended, which is consistent with a 37-week gestational age, marking a critical stage of
pregnancy. This abdominal presentation aligns with the expected changes during late-term pregnancy. The skin covering the abdomen appeared normal,
with no discernible discoloration or unusual abnormalities, further reinforcing the patient's overall skin health.
Fetal Heart Monitoring: Remarkably, fetal heart sounds were distinctly audible in the right lower quadrant, indicating the presence and well-being of the
developing fetus. This is a crucial aspect of maternal health and prenatal care.
GASTROINTESTINAL Gastrointestinal Evaluation: The examination extended to the gastrointestinal system, where bowel sounds were noted as present, indicating active gut
motility and a normally functioning digestive system. No significant abnormalities or concerns were observed in this regard. The patient's report of a
bowel movement around 5 am in the morning, characterized by yellowish-brown stool with a somewhat firm yet soft consistency, provides valuable
insights into the patient's gastrointestinal health and regularity.
Nutritional Independence: Notably, the patient exhibited the ability to eat independently, underscoring a level of self-sufficiency in their daily activities
and well-being.
In summary, this comprehensive assessment not only confirms the patient's well-maintained oral and skin health but also offers critical insights into the
patient's pregnancy status, fetal health, gastrointestinal function, and nutritional independence. These observations collectively contribute to the patient's
overall health profile and the successful monitoring of their well-being."
 The patient was found to be awake and alert, demonstrating full consciousness and an admirable orientation to time, place, and person. This state of
alertness not only fosters effective communication but also underscores the patient's cognitive clarity. The patient's eyesight was impressive, as there was
no requirement for aids, affirming good visual acuity. Pupillary examination revealed that the pupils were equal, round, and responsive to both light and
accommodation, further emphasizing the integrity of the patient's visual system. Furthermore, the ears exhibited no hearing impairments, with the patient's
NEUROLOGICAL
auditory senses remaining fully intact. The cranial nerves were assessed and found to be entirely intact, denoting a complete and unimpaired neural
network. The patient did experience abdominal pain, which was attributed to the ongoing labor process. This is a common and expected occurrence
during childbirth and, in this context, it signifies progress in the labor process. Importantly, no additional abnormalities or complications were noted,
indicating that the patient's labor was proceeding within normal parameters.

The patient's musculoskeletal evaluation revealed impressive muscle strength, scoring a perfect 5/5, indicating optimal strength and control. This robust
muscle strength enabled the patient to exhibit full gripping capabilities with both hands, showcasing excellent dexterity. The patient's ability to perform
Activities of Daily Living (ADL) independently is a testament to their functional independence and self-sufficiency. Importantly, the absence of any
fractures or musculoskeletal injuries further highlights the patient's physical well-being and the absence of acute pain or discomfort. The patient's capacity
MUSCULOSKELETAL
to independently turn in bed, sit without assistance, stand, and walk unaided is a testament to their physical mobility and autonomy. In summary, the
patient's musculoskeletal examination underscores an impressive level of muscle strength, manual dexterity, and functional independence in performing
daily activities. The absence of fractures or injuries, combined with the patient's ability to move, sit, stand, and walk independently, collectively contribute
to a positive outlook for their overall physical well-being.

The patient's medical history and personal details provide a comprehensive picture of her unique health and life circumstances. Circumcision Status: The
patient's history includes circumcision, a common surgical procedure typically performed on males. This detail can have implications for aspects of her
healthcare, such as urological considerations and hygiene practices. Marital Status: The patient is currently married, which is an important aspect of her
social and personal life. Marital status can often influence a patient's support system, decision-making, and emotional well-being, all of which are
REPRODUCTIVE
significant factors in her overall health and healthcare. Pregnancy: Perhaps one of the most significant and exciting aspects of the patient's current health
status is her pregnancy, as she is in her 37th week of gestation. This marks a pivotal and often highly anticipated moment in her life. Pregnancy brings
with it a unique set of healthcare considerations, including prenatal care, monitoring, and preparation for childbirth. It's a remarkable and transformative
experience in the life of the patient, one that will soon lead to the arrival of a new member of her family.

The patient's urinary and gastrointestinal functions were reviewed as part of a holistic health assessment, with a focus on their regularity and
characteristics. Urinary Function: The patient reported experiencing normal urination, a vital aspect of waste elimination and fluid balance within the
body. According to the patient, she typically urinates 2-3 times a day. Adequate and regular urinary frequency is a reassuring sign of proper hydration and
EXCRETORY kidney function, which are essential for maintaining overall health.
Gastrointestinal Function: The patient also provided insights into her bowel habits, stating that she defecates once a day. This regularity is a positive
indicator of healthy gastrointestinal functioning, as well as digestive and dietary habits. Furthermore, the description of her stool as 'firm and smooth' is
indicative of a well-formed and properly hydrated stool consistency, which is considered a healthy standard.
 NURSING ASSESSMENT II

Name: PATIENT XX Sex: FEMALE

Admitting Chief Complaint: LABOR PAINS Age: 27 YEARS OLD
Impression/Diagnosis: G1P0 PREGNANCY UTERINE 37 3/7 WEEKS AOG BY LMP; CEPHALIC IN LABOR Inclusive Dates of Care: 1 DAY
Date/Time of Admission: OCTOBER 17, 2023 AT 12:10 AM Allergies: NONE
Diet: NO PARTICULAR DIET
Type of Operation (if any): NONE

CLINICAL APPRAISAL
NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL
DAY 1 DAY 2

1.ACTIVITIES- REST The patient's activities are

The patient continues to perform
a. Activities currently restricted, and she
The patient typically remains in her Activities of Daily Living
b. Rest relies on support from her
her residence, engaging in (ADLs), including walking and
c. Sleeping pattern significant other (SO) when it
occasional household tasks. Her urinating, albeit with the
comes to mobility, such as when
sleep routine is consistent, as she assistance of her husband.
she needs to access the restroom.
retires at 9 PM and awakens at 5 However, she is experiencing
Unfortunately, the patient has
AM to observe morning prayers, restlessness and has been unable
been unable to achieve restful
ensuring she maintains a full 8 to attain restful sleep due to the
sleep, primarily because of the
hours of sleep during the night. discomfort associated with labor
persistent contractions she is
pain.
experiencing.
The patient follows a regular
2.NUTRITIONAL- METABOLIC eating routine, having three
a. Typical intake(food, fluid) meals daily, typically consisting
b. Diet of rice, meat, and vegetables. In
c. Diet restrictions The patient's diet is exclusively
the morning, she enjoys a cup of The patient's dietary choices are
d. Weight based on the offerings provided
e. Medications/supplement
black coffee. The patient limited to what the hospital
by the hospital, which primarily
food maintains a balanced diet and provides, including meals like
consist of items like fried
does not adhere to any specific fried chicken and rice. Her
chicken and rice. Her current
dietary restrictions. Her current current weight is 62 kilograms.
weight is 62 kilograms.
weight is 62 kilograms, and she
does not require any additional or
supplemental medications at this
time.
The patient has a regular urinary The patient currently experiences The patient's current urinary
3. ELIMINATION pattern, typically urinating at a lower frequency of urination, pattern involves urinating twice a
a. Urine (frequency, color,
 transparency)
b. Bowel (frequency, color, least four times a day. The urine
consistency) appears clear and is of a pale
yellow color, which is indicative
of proper hydration and normal
kidney function. In terms of
bowel movements, the patient
has one daily occurrence, and the
stool is characterized by a firm
consistency and a dark brown
color, which is generally
considered a healthy appearance
of stool. This regularity in bowel
habits suggests normal
gastrointestinal functioning.
The patient maintains a positive
4. EGO INTEGRITY self-perception and effectively
a. Perception of self manages life's challenges, thanks
b. Coping Mechanism in part to the strong support of
c. Support System
her family, particularly her
d. Mood/Affect
husband. When confronted with
difficulties, she expresses her
resilience by sharing uplifting
and wise words with her family,
offering encouragement and
fostering a sense of hope to help
them navigate through tough
times.
The patient is in good mental
5. NEURO-SENSORY health and maintains orientation
a. Mental state to time, location, and individuals.
b. Condition of five senses: While most of the patient's senses
(sight, hearing, smell, taste,
are fully intact and functional,
touch)
there is an exception with the
sense of vision. The patient
experiences blurred vision in the
right eye.
typically voiding twice a day.
The urine appears clear and is of
a yellow color, indicating good
hydration and normal renal
function. However, the patient
has not had a bowel movement
since admission, which may be a
point of concern. Monitoring and
assessing the patient's
gastrointestinal function and
bowel movements should be a
priority to ensure normal
intestinal motility and overall
well-being.
The patient maintains a positive
self-perception and effectively
manages life's challenges, thanks
in part to the strong support of
her family, particularly her
husband. When confronted with
difficulties, she expresses her
resilience by sharing uplifting
and wise words with her family,
offering encouragement and
fostering a sense of hope to help
them navigate through tough
times.
The patient's mental state is
sound, but they are restless and
irritable because of severe pain.
While the patient's sensory
faculties are generally intact and
fully functional, an exception
exists with their vision.
Specifically, the patient
experiences blurred vision in
day, with the urine appearing
clear and yellow, which is
typically indicative of good
hydration and normal renal
function. However, the patient
has not had a bowel movement
since admission. Monitoring the
patient's bowel movements and
assessing their gastrointestinal
function is essential to ensure
normal intestinal motility and
overall well-being. This situation
should be carefully monitored
and addressed as needed to
support the patient's digestive
health.
The patient maintains a positive
self-perception and effectively
manages life's challenges, thanks
in part to the strong support of
her family, particularly her
husband. When confronted with
difficulties, she expresses her
resilience by sharing uplifting
and wise words with her family,
offering encouragement and
fostering a sense of hope to help
them navigate through tough
times.
The patient is in good mental
health and demonstrates clear
orientation to time, location, and
individuals. She is conscious and
responsive, answering questions
appropriately. The patient's
sensory faculties are fully
functional, except for her sense
of sight. She experiences blurred
 their right eye. vision in her right eye.

6. OXYGENATION BP: 110/80 mmHg BP: 110/80 mmHg

a. Vital signs HR: 79 bpm HR: 82 bpm
At the time of this incident, the
Temperature RR: 20 cpm RR: 19 cpm
patient's vital signs had not been
Respiratory rate T: 36.8 oC T: 36.1 oC
assessed. The significant other
Heart rate No unusual or abnormal lung No unusual or abnormal lung
Blood pressure (SO) mentioned that they lack the
sounds were detected during the sounds were detected during the
b. Lung sounds necessary skills and equipment to
process of auscultation. The process of auscultation. The
c. History of Respiratory perform vital sign measurements.
patient also has no known history patient also has no known
Problems of respiratory issues. history of respiratory issues.

7. PAIN-COMFORT
a. Pain (location, onset, The patient has conveyed that
The patient has informed that she
character, intensity, The patient has shared that, when she encounters labor pain
undergoes labor pain when
duration, experiencing labor pain, she specifically during contractions,
experiencing contractions, with a
associated symptoms, employs relaxation techniques rating the intensity as 8 out of 10
aggravation) pain score of 8/10. To alleviate
and practices breathing exercises on the pain scale. To address the
b. Comfort this discomfort, she chooses to
to cope with the discomfort. pain, she adopts a squatting
measures/Alleviation adopt a squatting position.
position.
c. Medications

The patient has reported a daily

8. HYGIENE AND ACTIVITIES The patient continues to engage The patient continues to engage
self-care routine that includes
OF DAILY LIVING in her Activities of Daily Living in her Activities of Daily Living
bathing, nail trimming, and
(ADLs), such as walking and (ADLs), such as walking and
regular teeth brushing. She is
urinating, although she requires urinating, although she requires
proficient in performing her daily
assistance from her husband to assistance from her husband to
activities with ease and
do so. do so.
competence.

9. SEXUALITY

a. female (menarche, menstrual

cycle, civil status, number of
children, reproductive
status)
b. male (circumcision, civil
status, number of children)
The patient experienced her
menarche (the onset of
menstruation) at the age of 18,
and she is currently pregnant
with her first child.
The patient experienced her
menarche (the onset of
menstruation) at the age of 18,
and she is currently pregnant
with her first child.
The patient experienced her
menarche (the onset of
menstruation) at the age of 18,
and she is currently pregnant
with her first child.
 LABORATORY AND DIAGNOSTIC PROCEDURES

DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

October 17, 2022 HEMATOLOGY
Complete Blood Count
WBC 7.5 x10^9/L 5.0-10.0  Leukocytosis may be caused by bacterial
RBC 3.72 x10^9/L 4.0-5.5 infection suspected in the lungs.
Hemoglobin 9.27 L 14.0-18.0  Altered hemoglobin may be caused by onset the
of medication.
Hematocrit 0.35 L 0.40-0.50  Altered hematocrit may be caused by onset the
of medication.
Differential Count
Neutrophils 73 % H 50-70  High neutrophils try to neutralize the WBC.
Lymphocytes 19 % L 20-40  Low lymphocytes indicate bacterial infection.
Monocyte 6%H 1-5  Monocytosis indicates chronic infection.
Eosinophil 2% 0-5
Basophil 0% 0.01

Red Indices
MCV 92.92 80-96  A low MCH value typically indicates the
MCH 24.92 L 27-31 presence of iron deficiency anemia.
MCHC 26.82 L 33-36  A low result in an MCHC blood test may
indicate iron-deficiency anemia.
Platelet
Platelet Count 222.40 140-340

Blood Typing
Blood Typing O
Rh Positive

October 17, 2022 SGPT

Blood Urea Nitrogen 3.00 mg/Dl L 10 – 50  A low BUN value may be caused by a diet very
Creatinine 0.50 mg/dL 0.6 – 1.3 low in protein, by malnutrition, or by severe
LDH 278.00 u/dL 225 - 450 liver damage.

ELECTROLYTES
NA 141.1 mmol/dL 135 – 155  Hypokalemia refers to a lower-than-normal
K 2.96 mmol/Dl L 3.5 – 5.3 potassium level in your bloodstream.
SGPT/ALT 41.00 IU H Up to 31  It may indicate liver injury or damage.
SGOT/AST 19.00 U/L Up to 30
 SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED

October 17, 2023 1L Plain Lactated Ringer’s Solution 30 gtts/min 8 hrs October 17, 2023
1:00 AM 9:00 AM

October 17, 2023 1L Plain Lactated Ringer’s Solution 10 gtts/min Until consumed October 17, 2023
9:00 AM with 10mL of Oxytocin Not yet consumed as of
3:00 PM
 SUMMARY OF MEDICATION

MEDICATIONS
DATE Remarks
(dosage, frequency, route)

October 17, 2023 Hyoscine N-Butylbromide 1AP + 4cc Sterie Water q1h x 3 doses All given and administered
(12:20AM, 1:20AM, 3:30AM)

Hyoscine N-Butylbromide 1AP + 4cc Sterie Water q1h x 3 doses 5AM and 6AM given and administered
(5AM, 6AM, 7AM)

Ampicillin 2g 1 LA q6h 8AM was given and administered

(8AM, 2PM)

DRUG STUDY
 Prescribed and Mechanism Adverse
BRAND NAME;
Recommended dosage; of Action Reaction
GENERIC NAME; Indication Contraindication Nursing Responsibilities
frequency; route of;
CLASSIFICATION
administration
Generic Name: The usual oral dose The mechanisms of action A penicillin-type Principen may Nausea,  Confirm the prescription and ensure
Ampicillin range of Principen for of ampicillin are antibiotic used to treat interact with vomiting, that it is correctly written, including
most infections is 250 interference with cell wall many different types of allopurinol, stomach pain, the patient's name, medication name,
to 500 mg 4 times daily synthesis by attachment to infections caused by methotrexate, sulfa diarrhea, vaginal dose, route of administration, and
Brand Name: for 7-14 days. To treat penicillin-binding proteins bacteria, such as ear drugs, or tetracycline itching or frequency.
Principen gonorrhea, a single 3.5 (PBPs), inhibition of cell infections, bladder antibiotics. Tell your discharge,  Check the medication label for
g dose is administered wall peptidoglycan infections, pneumonia, doctor all headache, accuracy and verify that it is
along with probenecid. synthesis and inactivation gonorrhea, and E. coli medications you are mouth/tongue ampicillin and not another
Drug Class: of inhibitors to autolytic or salmonella infection. taking. sores, thrush medication.
Penicillins, Amino enzymes. Principen is available in (white patches  Ensure that the medication is within
generic form. inside your its expiration date and has not been
mouth or throat), compromised.
Principen should be or swollen, black,  Inform the patient about the purpose
used only when or "hairy" tongue. of ampicillin, the expected duration
prescribed during of therapy, and the importance of
pregnancy. This completing the full course of
medication passes into antibiotics.
breast milk. Consult  Prepare ampicillin according to the
your doctor before healthcare facility's policies and
breastfeeding. procedures, which may include
dilution or reconstitution if the
medication is in powdered form.
 Administer the correct dosage and
use the appropriate route (e.g., oral,
intravenous, intramuscular) based on
the physician's order.
 Administer intravenous ampicillin
slowly, following a specific rate and
duration to prevent adverse
reactions.
 Administer oral ampicillin with
adequate fluid, as recommended, to
ensure proper absorption.
 DRUG STUDY

Prescribed and
BRAND NAME;
Recommended dosage; Mechanism Adverse
GENERIC NAME; Indication Contraindication Nursing Responsibilities
frequency; route of; of Action Reaction
CLASSIFICATION
administration
Generic Name: Oral Gastrointestinal An anticholinergic agent is Hyoscine butylbromide Patients who have Achyarrhythmias,  Conduct a thorough patient
Hyoscine tract spasm, used for abdominal pain is indicated in acute demonstrated prior hypotension, assessment to confirm the indication
Butylbromide Genitourinary spasm and spasms in organs spasm, as in renal or hypersensitivity to increased intra- for Hyoscine Butylbromide and
contain smooth-muscle biliary colic, in Hyoscine-N- ocular pressure, assess the patient's medical history,
Adult: fibers. It binds to radiology for butylbromide or any drowsiness, allergies, and any contraindications.
Brand Name: As hyoscine muscarinic receptors, differential diagnosis of other component of confusional  Confirm the prescription and ensure
Buscopan butylbromide: 20 mg 4 blocking them (thanks to obstruction and to the product; states, visual that it is correctly written, including
times daily. its nitrogen atom), and reduce spasm and pain myasthenia gravis, hallucinations, the patient's name, medication name,
thereby rendering them in pyelography, and in mechanical stenosis blurred vision, dose, route of administration, and
Drug Class: Child: As hyoscine inaccessible to Ach. other diagnostic in the gastrointestinal eye pain, frequency.
Belladonna Alkaloid butylbromide: 6-11 procedures where tract, paralytical or idiosyncratic  Check the medication label for
years 10 mg tid; ≥12 spasm may be a obstructive ileus, reactions (e.g. accuracy and verify that it is
years Same as adult problem (e.g. megacolon. agitation, Hyoscine Butylbromide and not
dose. gastroduodenal delusion, acute another medication.
endoscopy). toxic psychosis),  Inform the patient about the purpose
epileptic of Hyoscine Butylbromide, how it
seizures.. works, and the expected relief from
gastrointestinal cramps and spasms.
 Discuss potential side effects.
 Prepare Hyoscine Butylbromide
according to the healthcare facility's
policies and procedures. Ensure the
correct dosage and route of
administration.
 Administer Hyoscine Butylbromide
according to the physician's order,
which may involve oral or
intramuscular administration.
 Administer the medication using
proper aseptic technique for
intramuscular injections, selecting
the appropriate injection site.
 ANATOMY AND PHYSIOLOGY

ACTUAL FEMALE REPRODUCTIVE ORGANS

NORMAL FEMALE REPRODUCTIVE ORGANS
(DURING LABOR AND DELIVERY)

The female reproductive system consists of a complex set of organs responsible for the The physiology of the female reproductive organs during the delivery of a baby is a complex
production of ova (eggs), fertilization, gestation, childbirth, and lactation. Here is an overview and highly coordinated process. It involves various stages, hormonal changes, and
of the anatomy and physiology of the female reproductive organs: physiological responses. Here's an overview of the key physiological events during childbirth:

1.Ovaries. The ovaries are a pair of almond-sized organs located in the lower abdomen, one on 1. Onset of Labor. Labor typically begins with the onset of regular uterine contractions,
each side of the uterus. They are held in place by ligaments. Ovaries produce ova (eggs) and often referred to as "labor pains." These contractions are the result of complex hormonal
 release one mature egg during the menstrual cycle in a process known as ovulation. They interactions and signaling within the body.
also secrete female sex hormones, including estrogen and progesterone. 2. Uterine Contractions. Uterine contractions are the primary physiological force driving the
2.Fallopian Tubes. There are two fallopian tubes, one connected to each ovary. These tubes baby's descent and eventual birth. These contractions are caused by the release of the
extend from the ovaries toward the uterus, where they open into the uterine cavity. The hormone oxytocin, which stimulates the uterine muscles to contract.
fallopian tubes are the site of fertilization. Sperm travel through these tubes to meet an egg 3. Cervical Changes. As labor progresses, the cervix undergoes a series of physiological
released during ovulation. Fertilization occurs if a sperm successfully penetrates the egg here. changes:
3.Uterus. The uterus, or womb, is a pear-shaped organ located in the pelvis, between the i. Effacement: The cervix thins out and shortens as a result of uterine contractions and
bladder and the rectum. It consists of the fundus (top), body (main portion), and cervix pressure from the baby's head.
(lower part). The uterus serves as the site for the implantation of a fertilized embryo and the ii. Dilation: The cervix opens (dilates) to allow the passage of the baby. Full dilation
development of a pregnancy. It undergoes changes during the menstrual cycle and pregnancy (typically 10 centimeters) is necessary for the baby to exit the uterus.
to support fetal development. 4. Descending and Engaging of the Fetal Head. The baby's head descends into the birth
4.Cervix. The cervix is the narrow, lower portion of the uterus that connects to the vagina. The canal, also known as the vagina. This process is facilitated by the mother's pushing efforts,
cervix secretes mucus that changes in consistency throughout the menstrual cycle. It also the elasticity of the vaginal walls, and the pressure exerted by uterine contractions.
dilates during labor to allow the passage of the baby. 5. Fetal Presentation and Position. The baby's head typically presents first in a head-down
5.Vagina. The vagina is a muscular tube connecting the cervix to the external genitalia. position, with the back of the head facing the mother's spine (occiput anterior). However,
Physiology: The vagina serves as a birth canal during childbirth and a passageway for various fetal positions are possible and can affect the course of delivery.
menstrual flow. It also accommodates sexual intercourse. 6. Crowning and Birth. Crowning is the stage when the baby's head becomes visible at the
6.External Genitalia. The external genitalia include the mons pubis (fatty area over the pubic vaginal opening. It is a pivotal moment during childbirth, and the baby's head is carefully
bone), labia majora and minora (folds of skin), clitoris (sensitive organ), and vaginal and guided through the birth canal. After the head is born, the rest of the baby's body follows.
urethral openings. These structures protect the internal reproductive organs, provide sensory 7. Placental Delivery. Following the baby's birth, the placenta (afterbirth) must be delivered.
stimulation during sexual activity, and play a role in childbirth. The uterus continues to contract, helping to separate the placenta from the uterine wall. The
7.Mammary Glands. The mammary glands are located in the breasts. These glands produce placenta is then expelled through the vagina.
milk for breastfeeding during and after pregnancy. Prolactin, a hormone produced by the 8. Postpartum Period. After the baby is born and the placenta is delivered, the uterus
anterior pituitary gland, stimulates milk production. continues to contract to control bleeding and aid in uterine involution, which is the process
8.Menstrual Cycle. The menstrual cycle is a monthly series of changes in the female of the uterus returning to its pre-pregnancy size.
reproductive system controlled by hormonal fluctuations. It includes menstruation, ovulation,
and the preparation of the uterine lining for potential pregnancy. Throughout labor and delivery, the female reproductive organs, including the uterus, cervix,
and vagina, work in coordination to facilitate the safe passage of the baby from the uterus to the
The female reproductive system is intricately regulated by a complex interplay of hormones, outside world. The process is driven by hormonal changes, muscular contractions, and
including those produced by the ovaries, pituitary gland, and hypothalamus. This system allows physiological adaptations that allow for the successful birth of the baby.
for the formation of ova, pregnancy, and the nourishment of offspring through breastfeeding.
PATHOPHYSIOLOGY (NORMAL SPONTANEOUS VAGINAL DELIVERY)

Jack Frost, 2009. Retrieved from

https://www.slideshare.net/davejaymanriquez/normal-
spontaneous-vaginal-delivery-presentation.
 MEDICAL MANAGEMENT

IDEAL ACTUAL
Medical interventions for labor and delivery are used when necessary to ensure the safety and October 26, 2022
well-being of both the mother and the baby. The choice of interventions depends on the Managements:
specific circumstances of each pregnancy and labor. Here are some ideal medical interventions  Monitored contractions
that can be considered during labor and delivery when medically indicated:  Iv fluid administered
 Monitored V/S every 1 hour
1. Early Induction: Early induction refers to the medical practice of initiating or  Monitored I&O every shift
stimulating labor before it begins spontaneously. This can be done for various medical  Monitored FHT
reasons, such as maternal or fetal health concerns, but it typically takes place prior to the  Monitored CTG
natural onset of labor.  Requested for CBC, HBSAG, and UA
2. Induction by Artificial Rupture of Membranes: This induction method involves the
deliberate breaking of the amniotic sac (the membranes) surrounding the fetus inside the Medications:
uterus. This procedure is performed to trigger or accelerate labor when there are medical  Ampicillin q6h
indications for doing so.  HNBB q1h
3. Induction with Pitocin: Pitocin is a synthetic form of oxytocin, a hormone that naturally
stimulates uterine contractions. Induction with Pitocin involves administering this
medication to induce or enhance labor when the natural contractions are insufficient or
when there are medical reasons for expediting the birthing process.
4. IV Fluids: Intravenous (IV) fluids are administered through a vein and are used during
labor to provide hydration and maintain the patient's electrolyte balance. This is
important to ensure the well-being of both the mother and the fetus throughout the
birthing process.
5. Epidural and Anesthesia: An epidural is a form of regional anesthesia used during labor
to relieve pain in the lower part of the body while allowing the patient to remain alert and
mobile. General anesthesia may also be considered in some situations. These methods are
employed to manage pain and discomfort during labor and childbirth.
6. Movement Restrictions: Movement restrictions refer to limitations placed on a laboring
patient's ability to move around during labor and childbirth. These restrictions may be
imposed due to certain medical conditions or interventions that require the patient to
remain in a specific position or location. Continuous Electronic Fetal Monitoring (EFM):
7. Continuous Electronic Fetal Monitoring (EFM) is a medical procedure that involves
the continuous monitoring of the fetus's heart rate and uterine contractions during labor.
This monitoring is typically achieved through the use of electronic sensors placed on the
mother's abdomen. Continuous EFM is employed to assess the well-being of the fetus
and detect any potential signs of distress during labor.
 NURSING MANAGEMENT

IDEAL ACTUAL
Nursing management for Normal Spontaneous Vaginal Delivery (NSVD) focuses on providing Actual nursing management for Normal Spontaneous Vaginal Delivery (NSVD) involves a
comprehensive care to the mother and baby before, during, and after childbirth. Here's an series of specific actions and interventions during labor and childbirth. Here is an actual
overview of the ideal nursing management for NSVD: nursing management done for the NSVD patient:

Before Labor 1. Admission and Initial Assessment

1. Assessment and Education  The nurse admits the laboring mother to the labor and delivery unit.
 Assess the mother's medical history, current health, and pregnancy progress.  Obtain a detailed history, including prenatal care, medical history, and any
 Provide comprehensive prenatal education on what to expect during labor, pain complications.
management options, and the labor process.  Assess vital signs, fetal heart rate, and uterine contractions.
2. Labor Preparation  Check cervical dilation, effacement, station, and cervical status.
 Ensure that the labor and delivery room is ready with necessary supplies and  Review the birth plan and discuss the mother's preferences for labor and delivery.
equipment. 2. Continuous Monitoring
 Review the mother's birth plan, if she has one, and discuss her preferences.  Continuously monitor maternal vital signs, fetal heart rate, and uterine
3. Support and Comfort contractions.
 Offer emotional support to alleviate any anxiety or concerns.  Record and document labor progression, including cervical changes and fetal well-
 Encourage the mother to rest and conserve energy if early labor is lengthy. being.
3. Pain Management
During Labor  Offer pain relief options, including breathing techniques, relaxation exercises, and
1. Monitoring positioning changes.
 Continuously monitor the mother's vital signs, fetal heart rate, and uterine  Administer pharmacological pain relief, if requested and approved by the
contractions. healthcare provider.
 Assess cervical dilation, effacement, and fetal descent. 4. Emotional Support
2. Pain Management  Provide emotional support, reassurance, and encouragement throughout labor.
 Provide various pain relief options, such as breathing techniques, relaxation  Promote effective communication and involve the mother in decision-making.
methods, hydrotherapy, or pharmacological pain relief as per the mother's
preference. 5. Position Changes and Mobility
 Administer pain relief medications or epidural anesthesia, if requested and  Encourage the mother to change positions, walk, or use a birthing ball to promote
approved by the healthcare provider. comfort and fetal descent.
3. Position Changes and Mobility  Assist with position changes to facilitate labor progression.
 Encourage the mother to change positions and move around to promote 6. Pushing and Delivery
comfort and progression.  Guide the mother on when and how to push when the cervix is fully dilated.
 Assist with position changes that help facilitate fetal descent.  Assist the healthcare provider during the actual delivery of the baby.
4. Emotional Support 7. Immediate Post-Delivery Care
 Offer reassurance and emotional support and validate the mother's feelings and  Place the baby on the mother's chest for skin-to-skin contact.
experiences.  Assess the newborn's Apgar scores and provide initial care and warmth.
 Maintain clear and effective communication to keep the mother informed  Administer prophylactic eye ointment and vitamin K as required.
about the labor progress. 8. Delivery of the Placenta
5. Guidance and Education  Assist the healthcare provider with the delivery of the placenta.
 Educate the mother about the stages of labor and the need for patience, as labor  Ensure the placenta is complete and intact.
can be a lengthy process. 9. Perineal Care
 Provide guidance on pushing techniques when the cervix is fully dilated.  Provide perineal care for any tears or episiotomy.
 Administer pain relief as needed.
After Delivery 10. Breastfeeding Initiation
 SURGICAL MANAGEMENT

IDEAL ACTUAL
It's important to clarify that Normal Spontaneous Vaginal Delivery (NSVD) is typically a non- A Mid-Lateral Episiotomy is a surgical incision made during childbirth. It differs from a
surgical process. It refers to the natural process of childbirth where a baby is born through the traditional mediolateral episiotomy in terms of the direction of the incision. Here's a closer look
vaginal canal without the need for surgical intervention. However, in some cases, at what a mid-lateral episiotomy is and when it may be performed:
complications may arise during labor or delivery, requiring surgical interventions. Here are a
few scenarios where surgical management may be necessary during or after a vaginal delivery: Direction of the Incision
In a mid-lateral episiotomy, the incision is made diagonally, extending from the vaginal
1. Episiotomy Repair. An episiotomy is a surgical incision made in the perineum (the area opening towards the side or angle between the vagina and the rectum (perineum). It's typically
between the vagina and the anus) to widen the vaginal opening during childbirth. After a made at an angle of approximately 45 degrees to the midline of the body. This is in contrast to
NSVD, surgical repair of the episiotomy may be needed to close the incision. This is a a mediolateral episiotomy, where the incision is made more towards the midline.
routine and typically uncomplicated surgical procedure performed by a healthcare provider.
2. Repair of Vaginal or Perineal Tears. In some cases, women may experience tears in the Indications
vaginal or perineal tissues during childbirth. Depending on the severity of the tear, surgical A mid-lateral episiotomy is considered when there is a need to widen the vaginal opening
repair (also known as suturing) may be necessary to facilitate healing and prevent during childbirth to allow for the passage of the baby's head while minimizing potential trauma
complications. to the anal sphincter muscles. It may be recommended in specific cases where a mediolateral
3. Vacuum Extraction or Forceps Delivery. In cases where there is difficulty with fetal episiotomy is deemed inappropriate or when a healthcare provider believes it may be a better
descent, vacuum extraction or forceps delivery may be employed. These are instrumental option for the individual mother.
procedures in which a healthcare provider uses a vacuum device or forceps to assist in
safely guiding the baby through the birth canal. Rationale
4. Manual Removal of the Placenta. In rare situations, the placenta may not be expelled The primary goal of a mid-lateral episiotomy is to reduce the risk of severe perineal tears,
naturally after childbirth. In such cases, a healthcare provider may need to manually especially tears that involve the anal sphincter. By making a controlled incision at an angle,
remove the placenta via a surgical procedure. healthcare providers aim to create a controlled pathway for the baby's head to pass through,
5. Repair of Uterine Rupture. Uterine rupture is a rare but serious complication during labor reducing the risk of extensive perineal tearing. Minimizing damage to the anal sphincter
that may require surgical repair. This occurs when the uterine wall tears, often necessitating muscles can help prevent long-term complications, such as fecal incontinence, which may
a cesarean section. occur with severe perineal tears.

It's essential to emphasize that surgical interventions are typically reserved for situations where
complications arise during the process of a NSVD. The vast majority of vaginal deliveries do
not require surgical management. The goal is to promote the safe and natural progression of
labor and childbirth, and surgical interventions are used only when necessary to ensure the
health and well-being of the mother and baby. Decisions regarding surgical management are
made by healthcare providers based on the specific circumstances of each case.
Procedure
 A mid-lateral episiotomy is typically performed by a healthcare provider (such as an
obstetrician or midwife) during the second stage of labor, just before the baby's head is
delivered.
 Local anesthesia is administered to numb the perineal area.
 A controlled incision is made at the appropriate angle using surgical scissors.
 Following the baby's birth, the episiotomy is repaired with sutures.

The decision to perform an episiotomy is made by the healthcare provider after careful
consideration of the potential benefits and risks, as well as in consultation with the laboring
mother. The preference for a mid-lateral episiotomy versus other types of episiotomies, or no
episiotomy at all, will depend on the unique situation and the healthcare provider's judgment.
 DISCHARGE PLAN

NAME: Patient XX DATE OF DISCHARGE: ____________________

CONDITION UPON DISCHARGE ___________ NATURE: Home per request ( ) Discharge against medical advice ( )

 Pain Management: If the mother is experiencing pain or discomfort, provide guidance on the use of over-the-counter pain relievers, such as acetaminophen
or ibuprofen, as recommended by her healthcare provider. Ensure she knows the appropriate dosage and timing.
1. MEDICATIONS  Iron and Calcium Supplements: If prescribed, remind the mother to continue taking iron and calcium supplements as instructed to aid in recovery and
maintain her nutritional status.
 Prenatal Vitamins: Discuss the importance of continuing prenatal vitamins, especially if she plans to breastfeed.

 Advise the mother on the importance of gradually resuming physical activity. Recommend starting with gentle postpartum exercises, such as pelvic floor
2. EXERCISE exercises, Kegels, and walking. Encourage her to consult with her healthcare provider before starting more strenuous exercise routines.
 Stress the importance of listening to her body and not overexerting herself in the early postpartum period.

 Emphasize the importance of a well-balanced diet to support her postpartum recovery and breastfeeding (if applicable). Encourage her to consume a variety
3. DIET of nutritious foods, including lean proteins, fruits, vegetables, whole grains, and dairy products.
 If the mother is breastfeeding, advise her on maintaining proper hydration and consuming extra calories to support milk production.

 Perineal Care: Provide instructions on proper perineal care to prevent infection and promote healing. Discuss the use of warm water and mild soap for
cleansing, patting dry instead of rubbing, and using prescribed medications (if any).
 Breast Care: If the mother is breastfeeding, offer guidance on breast care and breastfeeding techniques, including latching and positioning, and how to
address common breastfeeding challenges.
 Emotional Well-being: Discuss postpartum emotional well-being and the signs of postpartum depression. Encourage the mother to seek help if she
4. HEALTH TEACHING
experiences persistent feelings of sadness, anxiety, or mood swings.
 Birth Control: If the mother wishes to resume sexual activity and is not ready for another pregnancy, discuss contraceptive options and offer a referral to a
family planning clinic.
 Postpartum Recovery: Inform the mother about typical postpartum changes, such as vaginal bleeding (lochia), uterine contractions, and episiotomy or tear
healing.
5. SCHEDULE FOR THE  Schedule the mother's postpartum follow-up appointment, typically within six weeks after delivery, to assess her physical recovery, discuss any concerns,
NEXT VISIT and address contraception. Remind her of the date, time, and location of the appointment and provide contact information in case of questions or issues.

NURSING CARE PLAN (LATENT PHASE OF LABOR)

NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Cue: Risk for Deficient After the 8 hours of Within 8 hours of our duty, my interventions are: My interventions are done to: After 8 hours of
“Masakit igira Fluid Volume nursing intervention, nursing interventions,
miyag-contract ago relating to loss of Independent
paganay akn aya fluid as evidenced by  The client will maintain  Assessment: Conduct a thorough assessment of  This helps in the early  The client maintained
mbawata. loss of fluids through a fluid intake of at least the laboring mother's fluid balance by monitoring identification of fluid deficits, a fluid intake of at
Diyokawan normal routes, one glass of selected vital signs, urine output, and signs of dehydration, allowing for timely intervention least one glass of
akodn.” forceful contractions, beverage every hour as such as dry mucous membranes or poor skin and prevention of complications. selected beverage
and separation of the tolerated. turgor. every hour as
placenta.  The client will  Oral Hydration: Encourage the laboring mother to  It helps maintain hydration, tolerated.
verbalize the absence of drink fluids orally if she is able to tolerate them. provides comfort, and prevents  The client verbalized
Objective Cues: frequent thirst. Clear liquids and ice chips are typically allowed dehydration, which can negatively the absence of
 Loss of fluids  The client will during labor to help maintain hydration. affect maternal well-being and frequent thirst.
through normal demonstrate adequate uterine contractions.  The client
routes hydration (e.g., moist  Intravenous (IV) Fluid Administration:  IV fluids rapidly restore and demonstrated
 Forceful mucous membranes, Administer IV fluids if the laboring mother is maintain fluid balance, ensuring adequate hydration
contractions yellow/amber urine of unable to maintain adequate hydration orally. This maternal hydration and supporting (e.g., moist mucous
 Separation of appropriate amount, is often the case if she has had a long labor, uterine blood flow, which is membranes,
the placenta absence of thirst, significant vomiting, or other complications. critical for fetal oxygenation. yellow/amber urine of
 Tachycardia afebrile, stable vital  Monitor Fetal Well-being: Monitor the fetal heart  Deficient fluid volume in the an appropriate
 Prolonged labor signs/FHR). rate and uterine contractions to ensure the baby's mother can affect uterine blood amount, absence of
 Increased thirst well-being, as deficient fluid volume can affect flow, potentially compromising thirst, afebrile, stable
 Concentrated uterine blood flow. fetal oxygen supply. Monitoring vital signs/FHR).
urine helps detect any signs of fetal
distress early.
 Positioning and Mobility: Encourage the laboring  Mobility and position changes can
mother to change positions and move around as enhance comfort, reduce the risk
Vital Signs: tolerated to improve blood circulation and of edema, and promote maternal
 Temp: 36.8˚C potentially reduce fluid retention. well-being.
 PR: 79bpm  Promote Relaxation: Use relaxation techniques  Lowering stress levels helps
 RR: 19cpm and non-pharmacological pain management preserve maternal hydration and
 BP: 110/80 strategies to minimize stress and anxiety, which overall well-being during labor.
 O2Sat: 97% can reduce the risk of dehydration due to
 Pain Score: 8 excessive sweating.
Collaborative
 Collaborate with Obstetric Team: Communication  Effective collaboration ensures
with the obstetric team is essential to ensure they
are informed about the mother's fluid status and
any interventions being implemented.
 Consult a Lactation Consultant: If breastfeeding is  Proper breastfeeding support
planned post-delivery, consulting a lactation
consultant is important to provide guidance on
proper breastfeeding techniques and promote
maternal hydration, as breastfeeding can be
demanding.
 Collaborate with Pediatric Team: If there are
concerns about the baby's well-being due to the
mother's fluid volume deficit, collaboration with
the pediatric team ensures prompt assessment and
care for the newborn.
Dependent
 IV Fluids: Administering IV fluids, such as
normal saline or lactated Ringer's solution, is
indicated when the mother's fluid deficit is
significant and oral intake is insufficient.
 Medications: Medications may be prescribed by
the healthcare provider to address specific causes
of fluid loss, such as antiemetics to control
vomiting or antibiotics for infections.
that the laboring mother's care is
coordinated, with a focus on both
maternal and fetal well-being.
contributes to the mother's
hydration and the successful
establishment of breastfeeding.
 This collaboration guarantees the
health and safety of both the
mother and the newborn.
 This helps restore fluid balance
rapidly and maintain hydration,
especially if there is a concern for
dehydration due to prolonged
labor or excessive fluid loss.
 These medications treat the
underlying causes of fluid loss and
contribute to maintaining maternal
well-being.
 NURSING CARE PLAN (ACTIVE PHASE OF LABOR)

NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Cue: Anxiety relating to After the 8 hours of Within 8 hours of our duty, My interventions are done to: After 8 hours of
“Masakit igira threat to self and/or nursing intervention, my interventions are: nursing interventions,
miyag-contract ago fetus as evidenced by
paganay akn aya increased tension,  The client will use Independent  The client used
mbawata. fearful, restlessness, breathing and  Emotional Support and  Anxiety during labor is common and may be exacerbated breathing and
Diyokawan and sympathetic relaxation techniques Communication by the unfamiliarity of the process. Providing emotional relaxation techniques
akodn.” stimulation effectively. support and effective communication helps to reduce stress effectively.
 The client will and anxiety by making the mother feel cared for and  The client cooperated
cooperate with informed. with necessary
necessary preparations  Health Education  Educating the laboring mother about the stages of labor, preparations for a
Objective Cues: for a rapid delivery. pain management options, and what to expect can rapid delivery.
 Increased  The client will follow empower her and reduce anxiety stemming from fear of  The client followed
tension directions and/or the unknown. directions and/or
 Fearful actively participate in  Relaxation Techniques  Teaching relaxation techniques such as deep breathing, actively participated
 Restlessness the delivery process. guided imagery, and progressive muscle relaxation helps in the delivery
 Sympathetic the mother to cope with the physical and emotional stress process.
stimulation of labor.
 Position Changes and  Encouraging the laboring mother to change positions and
Mobility Supportive move around can provide comfort, reduce anxiety, and
Environment promote the progress of labor.
Vital Signs:
 Temp: 36.8˚C Collaborative
 PR: 79bpm  Collaboration with  In cases where the laboring mother has a history of mental
 RR: 19cpm Mental Health health issues or severe anxiety, collaborating with a mental
 BP: 110/80 Professionals health professional can ensure that her psychological needs
 O2Sat: 97% are met during labor.
 Pain Score: 8  Collaboration with  For mothers considering regional anesthesia, collaboration
Anesthesia Team with the anesthesia team can provide pain relief, which
may reduce anxiety associated with pain during labor.
 Consultation with Social  When anxiety is related to external factors such as
Work or Counseling personal stressors, financial concerns, or relationship
Services issues, involving social workers or counselors can provide
additional emotional support and resources.

Dependent
 Pharmacological  When anxiety becomes severe and interferes with labor
Interventions progress, the healthcare provider may order medications
such as anxiolytics or sedatives to help the mother relax.
 NURSING CARE PLAN (AUGMENTED PHASE OF LABOR)

NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Cue: Postpartum pain After the 8 hours of Within 8 hours of our duty, My interventions are done to: After 8 hours of
“Masakit igira relating to slow nursing intervention, my interventions are: nursing interventions,
miyag-contract ago progress of labor as
paganay akn aya evidenced by facial  The client will Independent  The client verbalized
mbawata. grimacing, verbalize a reduced or  Pain Assessment and  Regularly assessing and reassessing pain is essential for a reduced or tolerable
Diyokawan restlessness, and tolerable level of pain. Reassessment understanding the severity and type of pain the mother is level of pain.
akodn.” verbalization of pain  The client will display experiencing, allowing for more targeted interventions.  The client displayed a
a relaxed facial and  Emotional Support and  Providing emotional support and comfort measures, such relaxed facial and
body appearance Comfort Measures as a calm presence, soothing touch, and a supportive body appearance
between contractions. Position Changes environment, can help the laboring mother cope with pain between contractions.
Objective Cues: The client will be able and reduce anxiety. The client was able to
 Verbalizations to utilize techniques to  Encouraging the laboring  It can relieve pressure on specific areas, alleviate pain, and utilize techniques to
of pain and handle contractions. mother to change potentially enhance labor progress. handle contractions.
discomfort  The client will positions frequently.  Teaching and encouraging the use of deep breathing,  The client
 Facial demonstrate the ability  Breathing and Relaxation guided imagery, and progressive muscle relaxation demonstrated the
grimacing to listen and respond to Techniques techniques can help manage pain and reduce the ability to listen and
 Narrowed focus questions and perception of pain. respond to questions
 Anxiety instructions. and instructions.
 Restlessness Collaborative
 Irritability  Collaboration with  Close collaboration with the obstetric team is vital to
 Tachycardia Obstetric Team discuss and plan interventions for pain management, such
 Tachypnea as the use of epidural anesthesia or other medical
 Changes in BP interventions, when necessary.
 Collaboration with  In cases where epidural anesthesia is deemed appropriate,
Anesthesia Team collaboration with the anesthesia team is crucial to
administer pain relief safely and effectively.
Vital Signs:  Consultation with a  If pharmacological pain management is used, collaboration
 Temp: 36.8˚C Lactation Consultant with a lactation consultant can provide guidance on
 PR: 79bpm breastfeeding techniques and potential implications for the
 RR: 19cpm newborn.
 BP: 110/80
 O2Sat: 97% Dependent
 Pain Score: 8  Pharmacological  In some cases, pain relief through pharmacological means
Interventions may be necessary. The healthcare provider may prescribe
analgesics, opioids, or epidural anesthesia to address
severe pain when other methods are inadequate.