In Partial Fulfillment of the Requirements for

the Related Learning Experience NCM 107

CASE STUDY ABOUT

NORMAL SPONTANEOUS VAGINAL DELIVERY:
A TWENTY-THREE-YEAR-OLD MOTHER

Submitted by:

Group No. 2 BSN 2 /Section C

Casimiro, Gail Anne Elyse D.

De Guzman, Carolyn M.
Esteban, Reymart T.
Gatchalian, Aine Jermaine
Jundarino, Dianne C.
Macadadaya, Norhaynie W.
Mamayog, Bai Haidee R.
Manuel, Andrea Kaye C.
Mazo, Donnabelle F.
Sefuentes, Rosa Camila M.

CLINICAL INSTRUCTOR
Ms. Rosario Ignacio

Clinical Area:
Mandaluyong City Medical Center - DR Ward

Inclusive RLE duty dates:

Month: November, December, January Dates: 6-8 & 13-15, 4-6 &11-13, 8-
10 & 15-1

Mary Chiles College

667 Gastambide St., Sampaloc, Manila
CASE STUDY

I. LEARNING OUTCOMES
At the end of the case presentation, the student is expected to:

1. Integrate relevant principles of social, physical, natural and health sciences and humanities
in the care of clients with teenage pregnancy.
2. Utilize the nursing process to promote safe quality care.
a. Obtains assessment data.
1. Nursing history
2. Physical assessment
3. Diagnostic and treatment procedures
b. Relates data with each other to determine patterns, recurring themes, or processes.
c. Interprets data gathered.
d. States nursing diagnosis/nursing problems.
e. Sets priorities among a list of conditions or problems.
f. Specifies goals, objectives and expected outcomes of care.
g. Implements interventions.
h. Evaluates outcomes.

3. Adapt the nursing core values (caring) and the institutional core values (competence,
compassion, discipline)

4. OBJECTIVES OF THE CASE STUDY

a. General
b. Specific

II. INTRODUCTION & CASE ABSTRACT

CASE ABSTRACT

1ST paragraph (OVERVIEW OF THE CASE-The case and details about the case. Short definition,
Incidence (WHO, LOCAL,DOH , prevalence, risk factors/etiology, signs and symptoms can be
discussed in brief manner. - DE GUZMAN

Patient J.L. is a 23-year-old primigravida, who was admitted in Mandaluyong City Medical Center
on December 4, 2023, due to experiencing pressure on her groin and pain on her lower back, thus she
was immediately sent to the delivery room ward. Upon arriving, the patient is 4 cm dilated, longitudinal
lie, with cephalic presentation. At (insert time of delivery) am on December 4, 2023, she gave birth to a
male baby who has a normal birth weight and height for his gestational age. After birth, the patient
immediately tried breastfeeding but found it difficult due to her inadequate knowledge.

Patient J.L express her anxiety and concerns about her 1st time breastfeeding. She doesn't have
knowledge on how should she going to

Mary Chiles College

667 Gastambide St., Sampaloc, Manila
 2nd paragraph - Theoretical framework (2 -3 nursing theory) - MACADADAYA

erik erikson - developmental

virginia peplau - nursing need theory? (about independence keme ng pasyente pero di ko sure)

Mary Chiles College

667 Gastambide St., Sampaloc, Manila
III. NURSING HEALTH HISTORY

A. Biographic Data
The student nurse must fill up the following boxes with relevant information as needed.

Patient’s Initial: J.L. Gender: Female Age: 23

Date of Birth: Religion: Christian Marital status: Single

April 13, 2000
Educational Attainment: College No. of days in hospital: 3 days
Place of Birth:
San Jose, Occupation: Factory worker Travel hx(for the last 6 mos): N/A
Mandaluyong
City
Citizenship: Filipino Source of Information: Patient

B. MODE OF
ADMISSION
ambulatory / stretcher / brought in by Boyfriend
wheelchair others (specify) unaccompanied

C. CLASSIFICATION

service / health insurance

/ pay / others (Social
Welfare Assistance
(SWA))

D. Diagnosis:
Admitting diagnosis: Gravida 1, Para 0, 39 1/7 weeks AOG, Longitudinal lie, Cephalic presentation,

Final diagnosis: Normal Spontaneous Vaginal Delivery

● 39 weeks by Ballard Score
● Cephalic, APGAR Score of 8, baby boy
● Birth weight: 3 kg
● Birth Height: 50.3 cm
● By Normal Spontaneous Vaginal Delivery with right mediolateral episiotomy and 2nd degree
repair under local anesthesia (Lidocaine)

Mary Chiles College

667 Gastambide St., Sampaloc, Manila
E. HISTORY OF PRESENT HEALTH / ILLNESS - CASIMIRO

1. Chief complaint
Patient J.L. 23-year-old female complains of feeling pressure on her groin and pain on her lower
back, thus she was admitted. She was experiencing regular contractions every 6 minutes and upon
checking, she was 4 centimeters dilated.

F. HISTORY OF PRESENT HEALTH HISTORY

2. Symptom analysis:
On December 4, 2023, patient J.L., 23 years old, was admitted to Mandaluyong City Medical Center
(MCMC) due to feeling pressure on her groin and lower back pain. Patient states, “Sobrang sakit. Parang
pinipisil nang sobra tapos may nakadagan na mabigat”, when describing the symptom characteristics. The
patient described the severity of pain as an 8 over 10. The symptom started gradually at 6 am that same
morning which usually lasts about 1 minute with a 6 minutes interval. The symptoms are better when the
patient applies deep breathing exercises, and the pain is worse when another contraction occurs.

G. HISTORY OF PAST HEALTH HISTORY

Non-stated
Childhood illness(es)
Complete Immunization
Childhood/adult immunization(s)
[Vaccines]
BCG, HEPA B, OPV, PCV, PENTA-HIB, IPV, MCV

AstraZeneca 1st and 2nd dose

Tricycle accident
Accidents and Injuries Lip injury

Previous Non-stated
hospitalization:

Medical: Non-stated

Non-stated
Surgery:
No order for blood transfusion
Blood transfusion:

Mary Chiles College

667 Gastambide St., Sampaloc, Manila
 Medication(s) prior to confinement Vitamins:
Multivitamins (Enervon) 1 tab OD
Folic acid 1 tab OD

H. PERSONAL AND SOCIAL HISTORY

1. Emotional problem Patient J.L. usually gets stressed due to her work as a factory worker and
eats the food of her choice as a
coping mechanism in relieving her stress. As this is her first time experiencing labor and birth,
she felt nervous but very excited to meet her first child.

2. Allergies (food, medication, environment, use of tobacco) Does not have any known allergies
and does not smoke.

3. Use of alcohol occasionally (before pregnancy) Occasionally drinks alcohol.

4. Use of illicit drugs None-stated

5. Others:
I. Familial Tendency / HISTORY
Relation Name Age Gender Educatio Occupatio Diseases/Disorder
nal n
Attainme
nt
1. Partner A.G. 29 M College Service crew Unknown

2. Father C.L. 63 M High school Business Heart problem

owner

3. Mother L.L. 57 F High school OFW Hypertension

4. Sibling D.L. 13 M Elementary Student None

Mary Chiles College

667 Gastambide St., Sampaloc, Manila
 J. GENOGRAM (Heredo-Familial disease) - MACADADAYA

? ? 6 5

2
Partn Patie

LEGEND: D pa totally done

Newb

M
Hea
F
Hy

K. OB History
1. MATERNAL NURSING
a. MENSTRUAL CYCLE /History
i. 1st Menarche : 12 years old
ii. LMP : March 17, 2023
iii. Regularity : Regular
iv. Period starts every : 7th day
v. Duration of bleeding : 5 days

b. Obstetrical History
i. GTPAL : G1 T0 P0 A0 L0

c. No. of pre-natal visits

ii. 1st trimester (monthly) : 0 times 0
iii. 2nd trimester (twice monthly) : 3 times 3
iv. 3rd trimester (4 times a month) : 3 times 3

d. Risk Factors (Age, Gynecologic history, underlying medical

conditions, TORCH infection, Teratogenic Drugs, substance
abuse : None

2.POST-PARTUM ASSESSMENT
a. Assess maternal status.
i. Mode of deliver : Normal
 Spontaneous Vaginal Delivery
ii. Characteristics of labor /duration : Labor pains, 6 or
7 hours,
iii. Complications : None
iv. Vital signs
● Blood pressure : 110/70
● Pulse rate : 67 bpm
● O2 Sat : 97
● Respiratory Rate : 23
● Temperature. : 35.1C
v. Fundic height
a. After birth (at umbilicus)
:
b. Day 1 (first 12 hours) one finger above umbilicus
:
c. Descends by one finger breath daily until Day 10
:
d. Day 10 behind symphysis pubis, non-palpable
:
vi. Blood loss in labor : N/A
vii. Bladder elimination : 60 mL/hr
viii. Contraptions (IV, IC) if any : IVF of LRS 0
CASIMIRO
POST-PARTUM
FINDINGS
ASSESSMENT
(BUBBLES – HE)
a. Breast

b. Uterus
(not distended to kasi ni-straight catheter siya during labor)
c. Bladder distention

d. Bowel movement

e. Lochia

f. Episiotomy

g. Sanitation and
Surroundings

h. Homan’s signs
kumalma after manganak (from crying)
i. Emotional kaba BAGO manganak (keep here muna)
status is
“distressed”

L. Immunization History
VACCINE 1STDOSE (DATE) 2NDDOSE (DATE) 3RD DOSE(DATE) Adverse Reaction

M. ENVIRONMENTAL HISTORY: (Provide a complete description of the living condition of the client.
This may include the living space relevant to the family size, neighbourhood, and ventilation ratio,
presence of pollution or hazard, if any.)

The client lived with his parents at a home where they slept in the living room as they couldn't
sleep in the bedroom. They had an adequate amount of space for three people, were well-
 ventilated, and they were far enough away from the town to prevent them from being exposed to
any pollution.

3 members in the house (2 parents and client), adequate living space for three people, “hindi komportable
sa kwarto kaya sa sala natutulog”

okay lang yung neighborhood, walang problems sa basura at kanal, hindi rin crowded, looban sila kaya di
exposed sa pollution t

well ventilated ang bahay, no pets

IV. FUNCTIONAL HEALTH ASSESSMENT – Evaluates the effects of the mind, body and environment in
relation to a person’s ability to perform the tasks of daily living

GORDON’S 11 FUNCTIONAL HEALTH PATTERNS -

Date/
BEFORE DURING ANALYSIS/
FUNCTIONAL
HOSPITALIZATI HOSPITALIZATI INTERPRETATI
HEALTH
ON ON ON
PATTERNS

1. Health Perception / Health ”parang hindi kasi

Management - kinakain ko lahat ng
CASIMIRO gusto ko kainin,
chichirya, juice, street
foods”

lmay balance diet,

balance and kainin,
vegetables lang ang
kinakain”

insert medications

all checkups
attendended

january 11, 2024 -

schedules checkup
talaga

none

“nagtatanong ano
 pwede inumin o
gawin, umiinom agad
ng biogesic kapag
feeling na
magkakalagnat kasi
effective daw -
madalas di na
tumutuloy yung
lagnat”

no colds, no coughs,
no fever

Ang ginagawa kolang

po ay mahilig din po
kasi ako sa gulay,
ang ginagawa ko
lang po…

Talagang gamot
pagmagkakaroon.

NPO since admission

2. Nutritional and Metabolic - Client was put - is not fed by solid
Pattern on NPO upon foods during labor but
further water can be drink
(include 3 days Diet assessment
recall) during - she still taking
- ESTEBAN admission persulfate prescribed
from the doctor
- Eat 3 to 4
times a day - Not having eaten
with high fluid since the baby was
intake delivered⁰00⁰

- She eats - She lost a lot of

everything and weight because she
her meals couldn't eat due to
consist mostly pregnancy
of street foods,
junk foods, - She was placed on a
meat (pork straight catheter to
and chicken) urinate due to
products and distended bladder
more and help her bring
vegetables the baby out after
removing the urine
 - She takes
persulfate and
multivitamins
(enervon)
every morning
and before go
to bed

3. Elimination Pattern - - Defecates 1-2 - No defecation due to

times per incis
ESTEBAN
week and 2
times a day, - Voids times a day,
soft stool and amber urine
light yellow in
color - painful due to labor
because of the
- Urinates 1-2 contractions
times a day ,
yellowish urine

- No pain during
urination
4. Activity - Exercise Pattern - - she had - There is no
simple exercise pattern
ESTEBAN
exercises due to pregnancy A
such as
walking

- No signs of
difficulty in
breathing

- Her hobbies
before are
watching tv

5. Sleep - Rest Pattern -
JUNDARINO
- Had no sign
of evidence
of a cough
Client has a normal She only sleeps for a few
sleeping pattern. hours because she is
Sleeps 7-8 hours a constantly awakened by
night, has no trouble her baby’s cries and
sleeping. Normally worries for his safety
sleeps around 9-10 whenever she’s asleep.
pm and wakes up at
7-8 in the morning.
 Client has a normal The client can
6. Cognitive and sense of taste, smell, communicate and make
Perceptual sight, pain decisions for herself. Client
Pattern - perception, hearing has no trouble speaking or
JUNDARINO and touch. She can in formulating words before
also communicate, speaking. She also
speak and decide for verbalized, “Masakit yung
herself. She can also tahi, parang tinutusok-
recall past events tusok”.
without any problem.
7. Self-Perception / Self- She verbalized that The client is worried about
Concept Pattern - she is comfortable her body after pregnancy
JUNDARINO with her body, and due to stretch marks, skin
does not have any discoloration, and dark
body issues despite spots that could be
losing weight during apparent on her skin after
pregnancy. The client giving birth.
slouches sometimes
but stands straight
without any problem.
The client states that She was anxious because
8. Role- Relationships Pattern she relies on her she was going to give birth
- MAMAYOG partner and also her and her partner was not
family who provide around. After giving birth
her emotional she was happy because
support system, and she had a successful
stated that she had a normal delivery of her
good relationship baby.
with them.
9. Sexuality – Reproductive Had her menarche at The client states that she is
Pattern - MAMAYOG 11 years old. Her planning to get a family
cycle duration is 30 planning.
days and the duration
of her menstrual flow
is 5 days. She had
dysmenorrhea when
she still had her
menstrual cycle but
not frequently. Also
she is sexually
active.
She was stressed The client is stressed
10. Coping/Stress Tolerance - because of the because, after giving birth,
MAMAYOG nervousness who she doesn't have family
might be she will not beside her. especially her
be a good mother to partner who Additionally,
her child the way she she experiences boredom
 cope to this stressor due to a lack of social
is to eat activities. The only thing
she does is bond with her
child.

11. Values and beliefs - The client is a During hospitalization she

MAMAYOG christian .She states prays everyday and
that they pray consistently seeks
everyday about their guidance, healing and
health, emotionally safety for her family. This
and physically. could be her source of
Especially her emotional support and a
pregnancy. way for her to cope with her
current situation.

V. PHYSICAL ASSESSMENT

a. General Survey - GATCHALIAN

Postur Body Odor
Body Built: Ectomorph Grooming/Hygiene e& and Breath
The patient is well groomed, neat, Gait: Odor:
and clean Erect There is no
postur sign of
e and body odor,
coordi the smell of
nated Lochia is
move present,
ment and there is
no sign of
breath
odor.

Signs of Distress: No signs of distress Obvious Signs of Illness(es): Pain

Orientation: Level of Affect: tired and Mood: Anxious

Conscious about time, date, and Consciousn overwhelmed and irritability
places. ess: Alert

Quantity & Quality of Speech: The patient pronounces words Organization of thoughts: The
at a moderate pace that are loud,clear, and understandable. thoughts of the patient organized
have a sense of reality.
 b. Anthropometric Measurement*
● For Neonates
Head circumference: Chest Circumference: Abdominal circumference:
32 cm 34 cm 31 cm

● For Adult

Height: Weight: IBW/BMI:

* You may provide additional measurements (i.e. tricep skin fold, abdominal girth, etc.)

b. Vital Signs (include date)

Temperature Pulse Rate: Respiratory Rate: Blood Pressure:

: 110/70
36.3

c. Physical Examination (include date) - DONNABELLE

NORMAL ACTUAL ANALYSIS &

Organ Assessed TECHNIQUE USED
FINDINGS FINDINGS INTERPRETATI
ON
SKIN / Inspection Varies from light Presence of Chloasma and
INTEGUMENTARY to deep brown; chloasma on discoloration are
- Color from ruddy pink to the neck, and normally seen during
light pink, from discoloration on pregnancy caused
yellow to inner thighs. by hormonal
overtones to olive changes.
- Turgor Palpation - When pinched, - Good Client’s skin turgor is
skin springs back elasticity, skin in normal state, as it
- Continui to its previous return to original rapidly returns to its
ty & state. contour upon original shape after
Texture - Smooth, even, released less than 1-2
and firm - Smooth, even, seconds of release,
and firm which indicates good
skin elasticity and
hydration.
- Presence of Inspection Freckles, some Presence of Hormonal changes
rashes, sores, birthmarks, some striae in pregnancy can
lesions, flat and raised gravidarum. affect skin resulting
excessive nevi; no in striae gravidarum.
 dryness, abrasions or This happens when
bruising, other lesions. skin is stretched and
scars, wounds broken in places.
Inspection Rounded No head Client’s head has no
HEAD – Skull Palpation (normocephalic deformities, deformities, lumps,
and symmetric lumps, or and tenderness
with frontal, tenderness. observed, aligned
parietal, and with a normal
occipital expectation of a
prominences) healthy skull.
smooth skull
contour
Inspection Smooth, clean, - Scalp is Findings indicate
- Scalp and free of smooth, clean, that the client's scalp
dandruff, flaking, and free of is free from dandruff,
or scaling dandruff, flaking flaking, and scaling,
or scaling. as normally seen in
normal and healthy
scalp.
Inspection Healthy, firm hair, - Hair is long, Hair of the client is
- Hair evenly distributed black, and healthy and firm,
evenly with color black that
distributed. is evenly distributed,
which falls within the
normal range.
Feeling of Headache, Inspection No feeling of - No feeling of Client reported that
vertigo & syncope headache, headache, she doesn’t feel any
vertigo, and vertigo, and headache, vertigo
syncope. syncope and syncope during
assessment. This
indicates normal
which aligns in a
typical healthy state.
Inspection Symmetric or - Face is slightly Having an
FACE - Symmetry slightly asymmetrical asymmetrical face
asymmetrical with no and no involuntary
facial involuntary movement
features; movements. emphasizes a
palpebral normal condition of
fissures equal in facial structures.
size, symmetric
nasolabial
folds.
- Symmetrical
facial movements
Inspection Symmetrical - Symmetrical Symmetrical
EYES - Symmetry appearance of eyes
 indicates a healthy
ocular condition
without apparent
misalignment.

Inspection Visual acuity of - Acuity of 20/20 20/20 visual acuity

- Visual Acuity 20/20 in both eyes in both eyes indicates normal range
of clarity and
sharpness of vision.
The client can see at a
distance and within
close range.
- Periphe Inspection When looking Client can see The client can see and
straight ahead, the objects in her detect objects within
ral
client can see periphery when the defined
vision objects in the looking straight. parameters. This
periphery. indicates a healthy
range of vision.
- Pupill Inspection Pupils constrict Brisk and equal Pupillary light reflex
when looking near reaction to involves adjustments in
ary
objects. Pupils changes in light. pupil size with changes
reflex dilate when looking in light levels. Client’s
at far objects. pupillary reflex reacts
to light consensually.
Inspection Color is white Color is white,
- Sclera (darker or yellowish displaying a
and with small smooth texture
brown macules in without
dark-skinned irregularities.
clients)
Inspection Transparent and Transparent and
- Conjunctiva smooth membrane smooth
membrane.
Change in vision, Inspection No changes in No changes in
pain, discharge, vision, pain, vision, pain,
sensitivity to discharge, discharge,
sensitivity to light sensitivity to light.
li
g
h
t
Inspection Pinna recoils after it Pinna recoils after
EARS - Auricles folded. it is folded.

Palpation Firm and not tender Firm and not

● texture tender

Inspection Symmetrical Symmetrical

● symmetry
 Discharg Inspection No discharge No discharge
e (if present)
Pain, discharge, change Inspection No pain, discharge, No pain,
change in hearing, discharge,
in hearing, tinnitus
tinnitus change in
hearing, tinnitus
NOSE AND SINUSES Inspection Moist, pinkish, and Moist, pinkish,
without signs of and without signs
- Internal mucosa
inflammation or of inflammation or
abnormalities abnormalities.
Epistaxis, obstruction, Inspection No epistaxis, No epistaxis,
obstruction, pain, obstruction, pain,
pain, discharge,
discharge, snoring discharge,
snoring snoring
MOUTH AND THROAT Inspection - Lips is pink and - Lip is
uniform in color. dry and
- Lips & gums
Soft, moist, smooth dehydrat
texture. Ability to ed.
purse lips. - Gums is
- Pink gums (bluish pink,
or brown patches in moist,
dark-skinned and have
client), moist, and a firm
firm texture texture.
Inspection 32 adult teeth, Complete set of
- Teeth smooth, white, teeth with no
shiny tooth enamel dama
Inspection Moist and pinkish Moist and pinkish
- Mucus lining
Inspection Pinkish, and not Pinkish, and not
- Tonsils visibly swollen or visibly swollen or
inflamed inflamed.
Sore throat, bleeding Inspection No sore throat, No sore throat,
gums, dysphagia, bleeding gums, bleeding gums,
altered taste, lesions dysphagia, altered dysphagia,
taste, and lesions. altered taste, and
lesions.
Inspection Able to move the Able to move the
NECK - Movement neck in all neck in all
directions without directions without
discomfort and discomfort and
restrictions. restriction.
- Lymph Palpation No masses, nodes, No masses,
lumps, masses, nodes, lumps,
nodes/
swelling, or bulges masses, swelling,
masses or bulges.

Inspection No pain and No pain and

Pain.Stiffness stiffness stiffness.
CHEST & LUNGS Inspection Symmetrical Symmetrical
- Symmetry
- Shape & Inspection Regular shape and Regular shape
symmetrical and symmetrical
movement
movement during movement during
breathing breathing.
Auscultation Clear and equal Clear and equal
- Breath sounds breath sounds breath sounds
heard in all lung heard in all lung
fields. fields.
Inspection No difficulty of No difficulty of
DOB breathing breathing

BREAST Inspection Rounded shape, Rounded shape,

- Size, symmetry slightly unequal slightly
& shape size. asymmetrical,
with presence of
discoloration
around areola.
Palpation No palpable No palpable
- Any mass/lesions masses or lesions masses or lesions

Inspection No discharge Has a milk

- Discharge discharge

HEART/ Cardiovascular Auscultation No murmurs are No murmurs are

- Abnormal heard. heard.
heart
sounds
Inspection No chest No chest
Palpitations, chest pain, deformities deformities

ABDOMEN/GIT Inspection Flat, rounded, or Abdomen is

scaphoid globular, with
-
symmetric
Shape/symmetry movements
caused by
respirations.
- Skin Inspection No pigmentation, Presence of striae
striae, scars, gravidarum and
lesions, rashes, linea nigra are
dilated veins, and observed.
turgor.
- Unblemished skin
and uniform in
color.
Auscultation Audible bowel Audible bowel
- Bowel sound sound, and irregular sound, and
gurgling noises. irregular gurgling
noises.
- Tenderness of Percussion No tenderness, No tenderness,
relax abdomen with relax abdomen
 liver and smooth, consistent with smooth,
tension. consistent
spleen
tension.
- Eating Inspection Absence of eating Absence of eating
disorders, disorders, disorders,
abdominal abdominal pain, abdominal pain,
pain, change change in stool, change in stool,
ascites ascites.
in stool,
ascites
URINARY- changes Inspection No changes in
in urinary pattern, urinary pattern,
nocturia, dysuria, nocturia, dysuria,
urgency, hesitancy urgency, hesitancy

EXTREMITIES Inspection Symmetrical Symmetrical

- Symmetry
Inspection Able to move Limitation in
- Mobility (ROM) without discomfort movement and
and limitation. with discomfort
due to episiotomy.
Inspection Move freely and Move in
- Muscle tone have muscles discomfort after
return to their birth.
original relaxed
state.
Palpation Warm to touch Warm to touch
- Skin temperature

- Limitation or Inspection Absence of Limited

pain with limitation or pain movement due
movement in movement, to episiotomy.
,gait, joint gait, joint
swelling, muscle swelling, muscle
weakness weakness
GENITAL & Inspection No lesions, pain,
REPRODUCTIVE and
-
Lesions,disch
arge s,odors,
pain
- Menstrual Inspection Regular Regular
Hx menstrual menstrual
(woman) period cycle period cycle.
RECTUM/ANUS Inspection Absence of pain
Pain, swelling and swelling
NEUROLOGIC Inspection Fully conscious, Fully
ASSESSMENT responds to conscious,
-Level of questions responds to
consciousness quickly. questions
Makes eye quickly. Makes
contact, eye contact,
expresses expresses
feelings with feelings with
response to the response to
situation. the situation.
- Seizures, Inspection Absence of Absence of
paralysis, seizures, seizures,
paresthesia paralysis, and paralysis, and
paresthesia paresthesia.

VI. Developmental milestone (For Pediatric ward/NICU)

VII. A. CASE DISCUSSION (LEVEL 2 to 4)

1. Anatomy and Physiology: - GATCHALIAN

The female reproductive system functions to produce gametes and reproductive hormones, just like the male
reproductive system; however, it also has the additional task of supporting the developing fetus and delivering it to
the outside world. Unlike its male counterpart, the female reproductive system is located primarily inside the pelvic
cavity. Recall that the ovaries are the female gonads. The gamete they produce is called an oocyte.The female
reproductive system produces hormones and makes it possible to get pregnant and give birth. It includes two
ovaries, two fallopian tubes, and the uterus. It also includes the cervix, the vagina, and the vulva.The ovaries store
and release eggs (ova). After puberty, about once a month, the lining of the uterus thickens. Then an ovary
releases an egg. This is called ovulation.

The egg then enters the fallopian tube. This tube leads to the uterus. A pregnancy can occur if the egg is fertilized
by sperm and attaches to, or implants in, the lining of the uterus. The uterus is where the fertilized egg will grow
during a pregnancy. If the egg isn't fertilized, or if a fertilized egg doesn't implant, the uterus sheds its lining. This
shedding is the menstrual period. The most superficial layer is the serous membrane, or perimetrium, which
consists of epithelial tissue that covers the exterior portion of the uterus. The middle layer, or myometrium, is a
thick layer of smooth muscle responsible for uterine contractions. Most of the uterus is myometrial tissue, and the
muscle fibers run horizontally, vertically, and diagonally, allowing the powerful contractions that occur during labor.

The first stage starts when labor begins and ends with full cervical dilation and effacement. The second stage
commences with complete cervical dilation and ends with the delivery of the fetus. The third stage initiates after the
fetus is delivered and ends when the placenta is delivered.Labor is the process through which a fetus and placenta
are delivered from the uterus through the vagina. Human labor is divided into three stages. The first stage is further
divided into two phases. Successful labor involves three factors: maternal efforts and uterine contractions, fetal
characteristics, and pelvic anatomy.This triad is classically referred to as the passenger, power, and passage.
Clinicians typically use multiple modalities to monitor labor. Serial cervical examinations are used to determine
cervical dilation, effacement, and fetal position, also known as the station. Fetal heart monitoring is employed nearly
continuously to assess fetal well-being throughout labor. Cardiotocography is used to monitor the frequency and
adequacy of contractions. Medical professionals use the information they obtain from monitoring and cervical
exams to determine the patient's stage of labor and monitor labor progression.

2. LABORATORY AND DIAGNOSTIC EXAM - MANUEL

Date performed:

Nursi
Date/ Nor Clinical
1st Result 2nd Result ng
LABORAT mal Significan
Nursi
ORY Valu ce
ng
TEST es
Responsibiliti
es

Urinalysis:
 X-ray:
Ultrasound:
MRI:
CT Scan:
Bone Scan:
2D Echo:
ECG:
EEG:
VIII- Drug study - SEFUENTES

D
at Drug(s) Indicati Mechanism Side Nursing
e on of Action Effect(s responsibilities
(Gener )&
al) Advers
e
Effect(s
)

Brand Name: Based from drug

Generic effects (side and
Name: adverse)
Classification:
Dose:
Route:
Preparation
Frequency:
Date
Ordered:
Reference/s

X: Nursing Care Plan - CASIMIRO, JUNDARINO

Date Assessment Nursing Planning Interventi Rational Evaluatio

diagnoses on e n
 Subjective Ineffective
breastfeedi
ng

Objective

XI. Discharge Plan - SEFUENTES

Medication

Exercise

Treatment

Health Education

OPD Follow-up

Diet

Spiritual

XII: Implication of the case to the following areas - MAMAYOG, ESTEBAN

a. Nursing research
b. Nursing education
c. Nursing practice

XIII : Bibliography (APA format