A Case Presentation in

ASSIGNED AREA: OB
CONCEPT: “CARE OF FAMILY AND FAMILY HEALTH”
 2
GENERAL AND SPECIFIC
OBJECTIVES
 GENERAL OBJECTIVES
After 1 to 2 hours of case presentation with a concept of Care of Family and Family Heath,
the student nurses will be able to gain knowledge about the health and well-being of the patient,
enhance the skills in improving and identifying the problems and show positive attitude to the
patient as well as towards other people.
 3
GENERAL AND SPECIFIC
OBJECTIVES
 SPECIFIC OBJECTIVES
1. Have an overview of the Demographic data including patient's name, age, date of birth and
others.
2. Discuss the patient’s present medical history that includes the chief complaint and admitting
diagnosis, past health history, family heath history and psychosocial history will be followed.
3. Discuss the physical assessment of the patient based from the assessment findings.
4. Explain the anatomy and physiology of the affected organ system according to the diagnosis
of the patient and provide a brief discussion on its function.
 4
GENERAL AND SPECIFIC
OBJECTIVES
 SPECIFIC OBJECTIVES
5. Explain the pathophysiology to trace the disease process of the patient’s diagnosed condition.
6. Identify five nursing problem and provide its justification for each problem.
7. Formulate a nursing care plan based on the assessment findings of the patient.
8. Discuss the discharge planning of the patient using the METHODS.
9. Have a further readings about the news and updates related to the diagnosis or management of
the patient.
 5
DEMOGRAPHIC DATA

A 23 year old female patient was born on December 11, 1995, single status, lives in Sanciangko
Street Pahina, Cebu City. She is a Roman Catholic and Filipino by birth. Patient is currently
working as a cashier at McDonald's. As part of physical assessment, her weight is 58kg with a
height of 5ft. The patient was admitted last September 16, 2019 at 7:40pm with a chief of
complaint of hypogastric pain. Admitting Diagnosis was Gravida 1 para 0, pregnancy uterine 39
weeks age of gestation, delivered cephalic a live birth male neonate in active phase of labor.
 6
HISTORY OF PRESENT ILLNESS

Patient T, Q.J., a 23-year old Filipina, born on December 11, 1995, from Mambaling, Cebu
City, was admitted last September 16, 2019 at 7:40pm. Her chief complaint was hypogastric pain
radiating to the lumbosacral area, admitted by Dr. Justimbaste with a diagnosis of G1P0
pregnancy uterine 39 3/7 weeks AOG, cephalic, in active phase of labor. Four days prior to
admission, the patient went for the subsequent prenatal care at SWU Medical Center - RHU
Clinic. Seen and examined, internal examination revealed 1cm cervical dilation. She was advised
to come to SWU Medical Center anytime there are already signs of true labor. One hour prior to
admission, the patient complained of hypogastric pain radiating to the lumbosacral area with a
pain scale of 8 out of 10 along with bladder vaginal discharge. Due to this, she was prompted to
be admitted.
 7
PAST HEALTH HISTORY

The patient had not been hospitalized and has not had any obstetric history prior to
current admission. She was not diagnosed of any chronic illness. She cannot recall her past
immunizations and had no known allergies.
 8
PSYCHOLOGICAL HISTORY

 Lifestyle
The patient woke up at 5:30 am in the morning and started her morning routine by preparing
breakfast for her and her partner. After eating, she did some quick household chores such as
washing the dishes and sweeping the floor. After which, she prepared herself for work and headed
to her workplace. After work, she immediately went home and rested for a while before she
prepares for dinner. After dinner, she watched TV shows, checked her social media accounts or
sometimes do some laundry. After she had done all the household chores, she then went to sleep.
 9
PSYCHOLOGICAL HISTORY

 Relationship with family and peers

The patient had a good relationship with her friends and family. She had no problem
communicating and interacting with them. The patient verbalized that she usually spent her free
time together with her family.
 Vices and Addictions
The patient had a history of smoking. She frequently smoked when she was still single but
later on, she gradually stopped her habit in smoking because her partner told her so. The patient
also drank alcohol occasionally with her partner and friends. The patient had no history of taking
illegal drugs.
 10
PSYCHOSOCIAL HISTORY

 Employment History
The patient first worked as a waitress in a restaurant but she quit and looked for another.
Recently, she works as a cashier in a fast-food restaurant but currently, she just had her maternity
leave.
 Current Stage in Erick Erickson’s Psychosocial History.
The patient’s current stage in Erick Erickson’s Psychosocial history is the stage of Intimacy
and Isolation. The patient already developed her sense of self in adolescence and is also ready to
share her life with others especially to her partner. The patient had an intimate relationship with
her SO, bearing their first child. They are living on the same house together but are not married
yet.
 11
FAMILY HISTORY

Based on the genogram, the patient’s parents are both alive. Her mother is anemic and her
father is hypertensive. The patient is the 3rd child and the only female among her siblings. She is
not diagnosed with any chronic illnesses. The patient has four male siblings and all are healthy
and with no chronic illnesses too.
12
 13
PHYSICAL ASSESSMENT/EXAMINATION

 Patient’s vital signs are assessed with a temperature of 36℃, pulse rate of 108 bpm,
respiration of 20 cpm, blood pressure of 110/70 mmHg, an oxygen saturation of 99%,
and a pain score of 8/10.

GENERAL SURVEY
 A female patient, 23 years old, born on December 11, 1995, has a weight of 58kg and a
height of 5ft. Patient’s body within normal limits, was well-groomed and seems happy.
 14
NEUROLOGICAL
 Patient is alert, awake and was well oriented with person, place, time, and event. Patient responds to touch and
voice, eye sight is 20/20 and does not need eyeglasses, pupils are equal, round, reactive to light and accomodates.
Pupil size before light is 5mm, after light, pupils constricted to 2mm. Patient had unaided hearing, hand grip and
foot pushes are +5 and are equal. Patient’s cranial nerves were assessed. In cranial I, patient can correctly identify
3 odors from alcohol, perfume, and coffee. In cranial II, patient’s optic disc appeared yellowish-pink and are
round with clearly defined edges. In cranial III, IV, and VI, lower edges of her lids met bottom edges of irises,
pupils dilated when light is removed and both eyes converge towards the pencil at same level and distance. In
cranial V, patient can clench teeth tightly. In cranial VII, patient can correctly identify all tasted and symmetrical
facial movement was observed. In cranial VIII, patient have equal hearing at both ears. In cranial IX, when patient
spoke, her uvula and soft palate moved straight up. In cranial X, patient’s voice is slightly weak. In cranial XI,
patient can lift shoulders against downward pressure. Lastly, in cranial XII, smooth tongue movement was
observed.
 15
PAIN (COLDSPA)

Patient complained about intermittent pain located at the hypogastric area radiating towards
the lumbosacral area. Patient rated the severity of pain as 8 out of 10, on a pain scale where 1 is
the lowest and 10 is the highest. No other symptoms occurred along with the pain. As the patient
stated, the pain began at September 16, 2019 around 6pm with the duration of 5-10 minutes and
recurs every often as 5 minutes.
 16
REVIEW OF SYSTEMS

 CARDIOVASCULAR
Patient's skin and mucus membranes were pale, left and right radial pulses were palpable,
apical radial pulses were also palpable, carotid pulses were noted as thrill, and capillary refill
returned at approximately 2 seconds. Jugular neck veins, edema, and calf tenderness were not
visible. Irregular, strong heart rhythms were assessed. Patient was infused with D5LR at 30
gtts/min. located at the right arm, digital vein. Erythema was assessed at the IV site.
 RESPIRATORY
Patient's respirations were regular and symmetrical and lung sounds were clear. Patient had no
cough. Oxygen was from room air with a pulse oxygen at 99%.
 17

 GASTROINTESTINAL
Patient's GI system showed regular function, with no masses or any abnormalities. Continence
was normal, a medium size (3cm) brown stool. Bowel sounds were normoactive. Patient was
capable of self-feeding with diet as tolerated.
 GENITOURINARY
Patient was female, in postpartum state. Urine was continent with a clear light yellow color.
IV intake at 1000ml (1L) with a urine output at 1200ml, which was above the input.
 18

 MUSCULOSKELETAL
Patient was independent, does not need further assistance, for she can turn herself, sits, stands,
and walks independently. No presence of contractures and amputation. Has a risk for falls,
particularly side rails. Temperature at 36.0℃ with normal CMST.
 INTEGUMENTARY
Skin was intact, pale in color with a 1 second time turgor. It was warm to touch but dry. No
presence of wound dressing and pressure ulcers.
 19

 PSYCHOSOCIAL
Patient was cooperative and attentive, without any signs of discomfort. She spoke Visayan
language (mother tongue) and felt at ease. No presence of restraints.
 GENERAL SUMMARY OF PHYSICAL 20
ASSESSMENT/EXAMINATION
FINDINGS
Based on the assessment of the patient, she was active and responsive to the different
questions and interviews that were asked to her. She delivered a healthy baby boy via NSVD.
After experiencing chills around 3pm on Aug 27,2019, she felt better after an hour and became
well-oriented as well as her senses. The patient was well-groomed and can walk and sit
independently as she managed to change her maternity dress on her own. The patient's vital signs
became normal. Furthermore, the patient fed herself with teeth intact. Even though the patient
experienced pain on her breast, she managed the pain well through relief measures and is
improving, including her health status.
 21
ANATOMY AND PHYSIOLOGY
 22
 Placenta- The placenta acts to provide oxygen and nutrients to the fetus, whilst removing carbon dioxide and
other waste products. It metabolizes a number of substances and can release metabolic products into maternal
and/or fetal circulations.
 Umbilical Cord- The umbilical cord carries oxygenated blood and nutrients from the placenta to the fetus
through the abdomen, where the navel forms. It also carries deoxygenated blood and waste products from the
fetus to the placenta.
 Uterus-functions in nurturing the fertilized ovum that develops into the fetus and holding it till the baby is mature
enough for birth.
 Vagina- The vagina is a muscular canal lined with nerves and mucus membranes. It connects the uterus and
cervix to the outside of the body, allowing for menstruation, intercourse, and childbirth.
 Cervix- The cervix thins, softens, relaxes and dilates in response to uterine contractions, allowing the cervix to
easily pass over the presenting fetal part during labor.
 23

PATHOPHYSIOLOG
Y
 24
Embryonic development
begins during second week
continues through the
eight week

3 Stages
Fetal Development is from
the 9th week to birth
1st Stage- increase in cell number and with
elaboration of cell products
2nd Stage- morphogenesis/ includes mass cell
movement Newborn baby via vaginal
delivery
3rd Stage- differentiation or maturation of physiologic
processes

NSVD is a method of childbirth most health experts recommend for women whose babies have reached full
term. A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors to
use tools to help pull the baby out. This occur after a pregnant woman goes through labor. Labor opens or
dilates her cervix at least 10 cm.
Labor usually begins with the passing of a woman’s mucous plug. This is a clot of mucous that protects the
uterus from bacteria during pregnancy. Soon after, a woman’s water may break. This is also called the rupture
of membranes. The water might not have break until labor is established, even right before delivery. As labor
progresses, strong contractions help the baby to be pushed into the birth canal.
 25
PROBLEM PRIORITIZATION

 Risk for Infection related to episiotomy secondary to post NSVD as evidenced by above
normal body temperature - patient had just undergone episiotomy during normal vaginal
delivery, and experiencing pyrexia, diaphoresis, rapid short breathing
 Acute pain related to impaired skin integrity secondary to medial episiotomy as
evidenced by verbal reports of pain - patient reported sharp pain in the episiotomy site
medial in the perineal area with a pain scale of 8/10.
 Discomfort related to primary breast engorgement as evidenced by breast tenderness -
the mother was not able to breastfeed the baby frequently because she was experiencing
pyrexia
 26
PROBLEM PRIORITIZATION

 Risk for altered Parent- Infant attachment related to interrupted bonding process -
mother was experiencing pyrexia intermittently so the baby was not able to have a bonding
with her mother.
 Health-seeking behaviors related to client's desire to return to prepregnant weight and
appearances - patient stated wanting to return to her prepregnant body and appearance and the
dresses she used to wear.
 27
FDAR
 28
NURSING CARE PLAN
 29
NURSING CARE PLAN
 30
DRUG STUDY
 HEMATOLOGY
HEMATOLOGY PT. RESULT NORMAL VALUES SIGNIFICANCE
WBC 13.5 H 10^3/mm^3 4.40-11.00 The pt. excreted more WBC comparing
to the range of normal values.
RBC 3.83 10/mm^3 4.50-5.10
HGB 12.2 g/dL 12.30-15.30
HCT 36.2% 35.90-44..60
MCV 95 mm^0 80-96.00
MCH 31.9 pg 27.50-33.20
MCHC 33.7 g/dL 32.00-36.00

RDW 15.1% 11.60-14.80

PLT 256 10^3/mm^3 150-450
MPV 6.7 mm^3
NEU 80.0 37.0-80.0
LYM 11.3 10.0-50.0
EOS 0.9 0.0-7.0
MON 7.4 0.0-12.0
BAS 0.4 0.0-2.5
 URINE ANALYSIS
MACROSCOPIC EXAMINATION
Color: Yellow (Normal: yellow) Transparency: Hazy (Normal: clear)
Volume: 30 mL Specific gravity: 1.015 (Normal:1.005-1.025)

CHEMICAL EXAMINATION PT. RESULT NORMAL VALUES

Albumin 1+
pH 7.0 4.5-8.0
Ketone 2+
Blood 4+
Glucose Not done

Nitrite Not done

Bilirubin Not done

Urobilinogen normal

MICROSCOPIC EXAMINATION
WBC = 0-3/HPF Epithelial cells: Rare
RBC = TNTC/HPF Bacteria: Few
Remarks: TNTC (Too many to Count)
 33

DISCHARGE
PLANNING