123 OB Final Edited

8/3/2019 123 OB Final Edited

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Liceo de Cagayan UniversityPelaez Blvd. RN,Carmen, Cagayan de Oro City

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENTSIN NCM501201 RELATED LEARNING EXPERIENCE

Submitted to:

Mrs. Florabelle Uliarte, RNClinical Instructor

Submitted by:

Alcordo, Vincent JuliusBacan, Marjorie Jane

Balabaran, SandraBalagot, Julie MaeBrown, Jackilou

Cahatol, Ma. Lourdes

Cordero, ClaireDela, Maria Laarnie

Dimaporo, MahaGaid, Karl Alexander


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I. INTRODUCTION

The greatest embarking journey the woman will ever take in their life is

pregnancy. Pregnancy is one of the miracles of life. It is so amazing how a person

emerges from another person, quite similar in genetic make-up but a totally different

individual with a unique personality and a distinct characteristic. A mother undergoes

pain in giving life to another person which only shows that each of them is created with

the great love felt for one another. Truly, the Creator made this life perfect, a bit of pain

and suffering, but with a basket full of love.

Childbearing is a no easy task. It is one of the complex processes that all women

who want to have a child should undergo and it encompasses a lot of problems and

complications. It has different stages, phases, and periods, each of which has a whole

new experience to offer to each conceiving mother.

The pregnancy is divided into 3 periods Anterpartum, Intrapartum, and

Postpartum period. Antepartum is the period of time from the fertilization up to the time

the labor begins. Intrapartum, the period of actual birthing process is divided into 4

stages. The 1st stage (Dilatation), 2nd stage (Delivery), 3rd stage (Placental and 4thstage (Recovery). Postpartum period refers to the 6-week period after childbirth.

The students are required to provide nursing interventions to their assigned

patients and compare those interventions to what they learned in school and in

textbooks in order for them to understand real situations and able to compare the

positive and negative corners of these type of actual situations.


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Objectives of the Study:

The study centers in promoting Maternal and Child Nursing Care which include the

organized series of steps of the nursing process to ensure quality and consistency.

Thus, the study aims to:

Assess thoroughly the patient to formulate the proper nursing diagnoses

Plan appropriate nursing care

Implement interventions as to the continual of care after delivery

Impart health teachings to the mother well as to other members of the family.

Scope and Limitation of the study

As far as the study was conducted, the above objectives have been puts into

application. Nevertheless, the study has set its own limitation that will particularly apply

within our 1 hour care and stay at patients house. This involves the following:

Conducting an interview during the early stage of labor( Latent Phase)

Monitoring patients condition as to the progress of true labor contractions

Assist patient during stages of labor

Implementing possible nursing actions to the mother and the neonate during post

partum stage.


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II. PATIENTS PROFILE

Name: Alma Tomloan

Age: 28 yrs. oldGender: Female

Status: Married

Address: V.castro Street, Carmen, Cdo

Nationality: Filipino

Religion: Born again

Place of Birth: Malaybalay, Bukidnon

Date of Birth: November 23, 1978

Last Menstrual Period December 6, 2007

Name of Husband: Joseph Tomloan

Occupation: Tricycle driver

Income: Php 1400/week

Temperature: 36.0C

Pulse Rate: 95 bpm

Respiratory: 27 cpm

Blood Pressure: 90/60 mmHg

Height: 49

Weight: 54 kg

Baby Boy

Weight: 2.8 kgs.

Head circumference: 34 cm

Chest circumference: 32 cm

Abdominal circumference: 30 cm

Length: 55 cm

Temperature: 36.7 C


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III. STAGES OF LABOR / PHYSIOLOGY OF LABOR

A. First Stage of Labor (Stage of Cervical Dilation)

Begins with the first true labor contractions and ends with complete

effacement and dilation of the cervix (10 cm dilation).

The first stage of labor averages about 13.3 hours for a nulli Para

and

about 7.5 hours for a multipara.

1. Latent phase (early): Dilates from 0 to 4 cm.

Contractions are usually every 5 to 20 minuteslasting 20 to 40 seconds,

and of mild intensity.

The contractions progress to about every 5 minutes and establish a

regular pattern.

1. Active phase: Dilates from 4 to 7 cm.

Contractions are usually every 2 to 5 minutes; lasting 30 to 50

seconds and of mild to moderate intensity.

After reaching the active phase, dilation averages 1.2 cm per

hour in the nullipara and 1.5 cm per hour in the multipara.

2. Transitional phase: Dilates from 8 to 10 cm.

Contractions are every 2 to 3 minutes, lasting 50 to 60 seconds

and of moderate to strong intensity. Some contractions may last

up to 90 seconds.

B. Second Stage of labor (Stage of Expulsion).

Begins with complete dilation and ends with birth of the baby.

The second stage may last from 1 to 1 hours in the nullipara and from20 to 45 minutes in the multipara.

C. Third stage of labor, (Placental Stage)

Begins with delivery of the baby and ends with separation and delivery of

the placenta.


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The third stage may last from a few minutes up to 30 minutes.

D. Fourth Stage

Last from delivery of the placenta until the postpartum condition of the woman

has become stabilized (usually 1 hour after delivery).

THEORIES OF LABOR

Uterine stretch theory uterus becomes stretched and pressure

increase, causing physiologic change initiating labor.

Oxytocin effect theory as pregnancy progresses, there is a gradual rise

in the amount of circulating Oxytocin.

Progesterone depletion theory as pregnancy advances, progesterone

is less effective in controlling rhythmic uterine contractions that occur.

Production of Prostaglandins increased production of prostaglandin by

fetal membranes and uterine deciduas as pregnancy progresses.

Fetal production of Cortisol in later pregnancy, the fetus produces

increased level of cortisol that inhibits progesterone from the placenta.

MECHANISMS OF LABOR

The mechanism of labor refers to the sequencing of events related to posturing and

positioning that allows the baby to find the easiest way out. For the most part the fetus

is a passive respondent in the process of labor, while the mother provides the uterine

forces and structural configuration of the passageway through which the passenger

must travel. For a normal mechanism of labor to occur, both the fetal an maternal

factors must be harmonious. An understanding of these factors is essential for the

obstetrician to appropriately intervene if the mechanism deviates from the normal.

The following definitions must be mastered to be able to discuss and understand

the mechanism of labor.


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Attitude this refers to the posturing of the joints and relation of fetal parts to

one another. The normal fetal attitude when labor begins is with all joints in

flexion.

Lie this refers to the longitudinal axis of the fetus in relation to the mothers

longitudinal axis; i.e., transverse, oblique, or longitudinal.

Presentation this describes that part on the fetus lying over the inlet of the

pelvis or at the cervical os.

Position this describes the relation of the point of reference to one of the eight

octanes of the pelvic inlet (e.g., LOT: the occiput is transverse and to the left).

Engagement this occurs when the biparietal diameter is at or below the inlet of

the true pelvis.

Station this reference of the presenting part to the level of the ischial spines

measured in plus or minus centimeters.

The single most important determinant to the mechanism of labor is probably pelvic

configuration. Their classification of the pelvis into four major types (gynecoid, android,

anthropoid, and platypelloid) helps the student understand the possible difficulties that

may arise in a laboring patient. A quote that should be remembered is No two pelvises

are exactly the same, just as no two faces are the same.

The narrowest part of the fetus attempts to align itself with the narrowest pelvicdimension which means the occiput generally tends to rotate to the most ample portion

of the pelvis. The mechanical steps the baby undergoes can be arbitrarily divided, and

clinically they are usually broken down into six or eight steps for ease of discussion.

The following six divisions of labor are easy to use:

Flexion and engagement this occurs at various times before the forces of

labor begin

Descent this occurs as a result of active forces of labor.

Internal rotation this occurs as a result of impingement of the presenting part

on the bony and soft tissues of the pelvis.

Extension this is the mechanism by which the head normally negotiates the

pelvic curve.


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External rotation this is the spontaneous realignment of the head with the

shoulders.

Expulsion this is anterior and then posterior shoulders, followed by trunk and

lower extremities in rapid succession.

The above mechanisms of labor should become second nature to the practitioner

and indeed does become such by careful observation. Those patients who have

undeliverable or uncorrectable problems should be unhesitatingly delivered by the

abdominal route because inappropriate operative vaginal intervention may lead to

damage to both mother and fetus. Some of the undeliverable situations include

persistent mentum posterior, persistent brow presentation, some types of breech

presentations, and shoulder presentation

Differentiation between True and False Labor Contractions

True Contractions False Contractions

Begin irregular but become

regular and predictable.

Felt first from lower back

groin to abdomen in a wave

Continue no mailer what

the womans activity

Increase in duration,

frequency and intensity

Achieve cervical dilatation

Begin and remain irregular

Fell first abdominally and

remain confined to the

abdomen and groin

Often disappear with

ambulation and sleep.

Do not increase in duration,

frequency, or intensity

Do not achieve cervical

dilatation


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First Trimester

During the first trimester, the pregnant can expect a host of pregnancy symptoms

including breast changes, tiredness, nausea and vomiting, frequent urination and many

more. At the end of the first trimester, the uterus will have grown into the size of a

grapefruit, while the baby inside is the size of a cherry. The baby will grow from being a

mass of cells to having a heartbeat, reflexes and the ability to move its tiny limbs. Now

is the time to start prenatal careand a nutritious, healthy diet. Regularexercise will keep

the baby safe and ready for a healthier birth.

Second Trimester

Throughout the second trimester, the body will grow more scatterbrained and the

belly will start to show the baby growing inside the body. The body will experience
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pregnancy discomforts such as sleeping problems and notice Braxton Hicks

contractions. During the second trimester, the baby will grow hair all over its body and

the senses will begin to develop. At the end of the second trimester, the baby will

measure about 10 inches (25 cm) and will frequently practice their kicking movements.

Third Trimester

The third trimesterbrings many changes to the body; the pregnant will need to

urinate frequently and the body belly looks like its ready to explode. Now is the time to

start taking childbirth and breastfeeding classes. The finishing touches are being placed

on the baby, and the partner is looking forward to delivery day! Dont forget to include

the patients partner and prepare him for the responsibility offatherhood.

IV. PHYSIOLOGY OF LABOR
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MATURED FETUS

UTERINE MUSCLE CONTRACTIONS

Stimulates Posterior PituitaryGLAND to secrete Oxytocin

Increase level of OXYTOCIN raiseuterine muscle Calcium levels

Release of PROSTAGLANDINstored in the uterine Decidua,

umbilical cord and amnion

Stimulates BIOCHEMICALCHANGES in the uterine wall

LIGHTENING-10 to 14 days before

labor begins- Uterus becomes lower

and more anterior-abdominal pressure

increases-increase vaginal

discharge-urinary frequency frompressure in the bladder

Through this MYOMETRIUM iscapable of contraction

Stimulates UTERINECONTRACTION

INCREASE LEVEL OF ACTIVITY

- due to an increase of epinephrine release initiated by an increasein progesterone produced by the placenta


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BRAXTON HICKS CONTRACTIONS

- strong contractions

RIPENING OF THE CERVIX

- butter-soft and softer- internal announcement that labor

is close at hand.

SHOW- mucus plug is expelled

RUPTURE OF THE MEMBRANES- sudden gush or scanty

- slow seeping of clear fluid from the vagina

BLOODY SHOW

CERVICAL EFFACEMENT- thinning and shortening or obliteration of the

cervix that occur before dilatation begins.

DESCENT- full descent occurs when the fetal extrudesbeyond the dilated cervix and touches the

posterior vaginal floor


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FLEXION- pressure from the pelvic floor causes the fetal

head to bend forward onto the chest

INTERNAL ROTATION-the head flexes as it touches the pelvic floor andthe occiput rotates until it is superior, or just below

the symphisis pubis, bringing the head into thebest diameter for the of the pelvis.

EXTENSION- as the occiput is born, the back of the neck stopsbeneath the pubic arch and acts as a pivot for therest of the head. The head thus extends, and theforemost parts of the head, the face and the chin

are born.

EXTERNAL ROTATION- The head rotates back to the diagonal or

transverse position of the early part of labor almostimmediately after the head of the infant is born.

The after coming shoulders are thus brought intoan anteroposterior position, which is best for

entering the outlet. The anterior shoulder is bornfirst, a assisted perhaps by downward flexion of

the infants head.

EXPULSION-immediately after external rotation, the anteriorshoulder appears under the symphisis pubis and

the perineum soon becomes distended by theposterior shoulder, gentle but firm pressure

downward traction of the head is done to deliverthe anterior shoulder then the head is raised to

deliver the posterior shoulder, then the bodyfollows without difficulty.


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EENT:[ ] Impaired vision [ ] blind[ ] pain redden [ ] drainage[ ] gums [] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality [x] no problem

RESP:

[ ] Asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [ ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, pulse blood[ ] breath sounds, comfort [ x] no problem

CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ x] edema [ ] fatigue[ ] irregular [ ] bradycardia [ ] mur mur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort[ ] no problem

GASTROINTESTINAL TRACT:

[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain[ ] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [x] no problem

GENITO URINARY AND GYNE[ ] pain [ ] urine [ ] color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ ] nocturia[ ] assess urine frequency, control, color, odor, comfort[ ] gyne bleeding [ ] discharge [ x] no problem

NEURO:[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC, strength[ ] grip, gait, coordination, speech [x ] no problem

MUSCULOSKELETAL and SKIN:

[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ x ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] flushed[ ] atrophy [x ] pain [ ] ecchymosis [ ] diaphoretic moist[ ] assess mobility, motion gait, alignment, joint function[ ] skin color, texture, turgor, integrity [ ] no problem

V. Nursing Assessment (System Review and Nursing Assessment)

Name: Alma TomloanBP: 90/60 mmHg Temperature: 36.O C PR: 95 bpm RR: 27 cpmWeight: 54 kg Height: 49 cm

No problem

No problem

Ankle edema

Back pain

No problem


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SUBJECTIVE OBJECTIVECOMMUNICATION Comments[ ]Hearing Loss[ ]Visual changes[x]Denied

[ ] glasses [ ] languages[ ] contact lens [ ] hearing aideR 3-4mm L 3-4mmPupil size: 3-4mm [ ]speech difficultiesReaction: PERRLA

OXYGINATION Comments[ ]Dyspnea[ ]Smoking History________________[ ]Cough[ ]Sputum[ x]Denied

Respiratory: [x] Regular []irregularDescription: RR is within normal range

R: right lung is symmetric to the left lungL: left lung is symmetric to the right lung

CIRCULATION Comments

[x]Back Pain[ ]Leg Pain[ ]Numbness of the

Extremities[ ]Denied

Heart Rhythm: [x] regular [] irregularAnkle Edema present in both foot

Pulse Car Rad DP FemR + + + + N.OL + + + + N.OComments: All pulse sites are palpable

NUTRITION CommentsDiet: DAT[ ]N [ ]VCharacter[ ]Recent change in

Weight, appetite[ ]Swallowing

Difficulty[x ] denied

[x]dentures []none

Full partial with patientUpper [] [x] []Lower [] [x] []

ELIMINATIONUsual bowel pattern [ ]urinaryfrequencyOnce adays 2 3 times aday

[ ]Constipation [ ]urgencyRemedy [ ]dysuria

[ ]hematuriaDate of last BM: [ ]incontinenceSetember 7, 2010 [ ]polyuria

[ ]diarrhea [ ]foly in placeCharacter [ ]denied

Comments: the bowel sound Bowel sounds:Is in normal sound

AbdominalDistension

Present[]yes[x]noUrine (color, consistency odor) yellowish in color

MGT. OF HEALTH & ILLNESS[ ]alcohol [x ]deniedDili ko gainom ug makahubog nga ilimnon[x]SBE Last Pap Smear: NONELMP: December 17, 2009

Briefly describe the patients ability to followtreatments (diet, meds., etc.) for chroni9c healthproblems ( if present)

The patient did not experience any chronicproblem.

Wala man ko problemsa ako panan-an as

verbalized by thepatient.

wala man koproblema sa akong

paginhawa. Asverbalized by the

patient

sakit akong likodinig hapon asverbalized by the

patient

wala man ko

problema sa akongpagkaon as verbalizedby the patient.


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Skin integrity Comments[ ]Dry[ ]itching[ ]other[ ]denied

[ ]dry [ ]cold [ ]pale[ ]flushed [ ]warm[ ]moist [ ] cyanotic

Rashes, ulcers, decubitus (describe size,

location, drainage) No found any impaired skinintegrity.

Activity/safety Comments[ ]convulsion[ ]dizziness[ ]limited motion of joints[ ]ambulate[ ]Bathe self[ ]Other[x]denied

[ ] LOC and orientation: patient is well orientedwith time and date.Gait: [ ]Walker [ ]cane [ ]other

[ ]steady [ ]unsteady_______[ ]sensory and motor losses in face orextremities: NONE[ ] ROM limitations

Comfort/sleep/awake:[x ] pain (location, Comments

frequencyremedies)[ ] nocturia[ ]sleep difficulties[ ]denied

[ ]facial grimace

[ ]guarding[ ]other signs of pain[ ]side rail release form signed (60+ tears)

Coping:Occupation: housewifeMembers of household: 5Most supportive person: husband

Observed non-verbal behavior: the patient wasconscious and coherent

The person and her phone number that can bereached any time: none

wala man koproblema sa akongpanit as verbalized by

the patient

Sakit akong likod padulongsa akong tiyanas verbalized

by the patient

wala ko problema sapaglihok2xas

verbalizedby the patient


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VI. IDEAL NURSING MANAGEMENT

Nursing Diagnosis:

Antepartum period

Health-seeking behaviors related to guidelines for nutrition and activity

during pregnancy.

Imbalanced nutrition, less than body requirements, related to inadequate

intake of calories.

Fatigue related to increased physiologic demands of pregnancy and

inadequate nutritional intake.

Intrapartum period

Powerlessness related to duration of labor.

Anxiety related to stress of labor.

Pain related to labor contractions.

Postpartum period

Risk for infection (uterine) related to lochia.

Risk for impaired urinary elimination or constipation related to loss of

bladder and bowel sensation after childbirth.

Fluid volume deficit related to vaginal bleeding and lack of oral intake.

Newborn

Ineffective airway clearance related to mucus in airway.

Ineffective thermoregulation related to heat loss from exposure in birthing

room.

Imbalanced nutrition, less than body requirements, related to sucking

reflex.


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INTERVENTION

Antepartum period

Perform initial assessment, including vital signs, height and weight

measurement, history and physical examination.

Assess clients knowledge about guidelines for healthy pregnancy and

antepartal care.

Explain with the client the increased nutritional needs during pregnancy.

Provide information about a well-balanced diet, including food selections,

such as fresh fruits and vegetables, calcium sources, and high protein

foods, fluid intake, and prenatal vitamin supplementation.

Monitor weight at every visit and compare with the baseline data.

Intrapartum period

Provide clear liquids and ice chips as allowed.

Evaluate urine for ketones and glucose

Administer IV fluids as indicated.

Inform the woman/ couple of maternal status and fetal status and laborprogress.

Explain all procedures and equipment used during labor.

Monitor maternal vital signs. Remember the individual patient condition is

used to determine frequency of vital signs and FHR assessment.

Encourage ambulation as tolerated regardless of membrane status as

long as presenting part is engaged.

Encourage diversional activities, such as reading, talking, watching TV,

playing cards, and listening to music.

Effleurage, light massage over abdomen with fingertips; can be used with

slow chest and modified-paced breathing; start at pubic bone and move

hands slowly upsides of abdomen in wide circular sweep; during exhaling,

move fingertips down center of abdomen.


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Encourage a warm shower. Laboring woman can sit in the chair in the

shower with the water running continuously over her lower back.

Encourage relaxation techniques

Provide comfort measures:

Give back rubs.

Assist woman to change position. Walking, squatting, semi-sitting,

kneeling, standing, side-lying, or sitting on the toilet are positions

that help to accommodate the descending fetus and relieve pain of

uterine contractions.

Reposition external monitors as needed.

Postpartum period

Monitoring for Hypotension and Bleeding

Monitor vital signs every 4 hours during the first 24 hours.

Increased respiratory rate greater than 24 breaths per minutes may

be caused by increase blood loss, pulmonary edema or pulmonary

embolus.

Increased pulse greater than 100 beats per minute may be present

with increase blood loss, fever, or pain.

Decrease in blood pressure 15-20mmHg below baseline pressures

may indicate decrease fluid volume or increase blood loss.

Assess the woman for light-headedness and dizziness when sitting upright

or before ambulating.

Evaluate orthostatic blood pressures.

Have the woman lie in bed if symptoms exist.

Assess vaginal discharge for clots and amount.

Encourage food and drink as tolerated.

Encouraging Bladder Emptying

Observe for the womans first void within 6-8 hours after delivery.


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Palpate the abdomen for bladder distension if the woman cannot void or if

she complains of fullness after voiding.

Uterine displacement from the midline suggests bladder distension

Frequent voiding of small amounts of urine suggests urinary

retention with overflow.

Promoting Proper Bowel Function

Teach the woman that bowel activity is sluggish because of decreased

abdominal muscle tone, decreased solid food intake during labor, and

prelabor diarrhea.

Review the womans dietary intake.

Encourage daily, adequate amounts of fresh fruit, vegetables, fiber, and at

least 8 glasses of water.

Encourage frequent ambulation.

Administer stool softeners as indicated.

Preventing Infection

Observe for elevated temperature above 38 degree Celsius (100.4 F).

Evaluate perineum for redness, ecchymosis, edema, discharge (color,

amount, odor) and approximation of the skin

Assess for pain, burning, and frequency on urination.

Reducing fatigue

Provide a quiet and minimally disturbed environment.

Organize nursing care to keep interruptions to a minimum.

Encourage the woman to sleep while the baby is sleeping, specifically to

nap or lie down and get off her feet at least 30 minutes per day.

Minimizing Pain

Instruct the woman to apply ice packs to the perineal area for the first 24

hours for perineal trauma or edema.

Instruct the woman to contract her buttocks before sitting to reduce

perinea discomfort.


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Assess gestational age using a tool as the Ballard scoring system.

Monitor closely for respiratory or cardiac complications.

Position infant to allow easy ventilation, paying careful attention to

maintaining body alignment and facilitating hand-to-mouth

positioning.

Protect the infant from infection by following scrupulous hand

washing policy, minimizing infants contact with unsterile

equipment, and minimizing the number of people who come in

contact with the infant.

Post mature Infant

Be alert for the physical appearance of a postmature infant.

Determine the gestational age by physical examination.

Measure weight, length, and head circumference.

Determine blood sugar.

Assess for aphyxia neonatorum by Apgar score and blood gas

analysis.

Be alert for meconium aspiration.

Provide supportive treatment for meconium aspiration.

Provide psychological support to the parents


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VII. ACTUAL NURSING INTERVENTION

FIRST VISIT

Date: Sept 6 ,2010

During our first visit, we were shocked of what we saw because we did notexpect the type of environment we would encounter. We introduced ourselves so

that the patient will feel comfortable and to promote cooperation. We gatheredthe necessary data in order to complete our patients profile. At this time, AOGwas already 35 weeks; vital signs were as follows;

Temperature: 35.8 CelsiusPulse: 95 bpmRespiration: 21 cpmBlood Pressure: 90/60 mmHg.

Fetal heartbeat: 143 bpm and was audible at the left lower quadrant

And health teachings were imparted, such as doing antepartal excercises and

eating foods which are low in sodium to prevent or reduce edema.

SECOND VISIT

September 17, 2010

The second time we visited our patient; she was more cooperative and answeredour questions promptly. We did our routine assessment the data gathered wereas follows;

Temperature: 36 CelsiusPulse rate: 76 bpmRespiration rate: 23 cpmBlood pressure: 100/70 mmHgFetal heartbeat: 135 bpm and audible at the right lower quadrant

We also brought fruits and gave the vitamin supplements to provide the nutrientsthat the patient and her child needs.


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THIRD VISIT

September 25, 2010

On our third visit, the patient still had not give birth despite it was already past theEDC (expected date if confinement) which was due on the 24 th of September. Weobtained her vital signs and readings are as follows:

Temperature: 36.5 CelsiusPulse rate: 70 bpmRespiration rate: 18 cpmBlood pressure: 100/70 mmHgFetal heart beat: 142 bpm and audible at the right lower quadrantWe also brought her fruits and vitamins also

FOURTH VISIT

September 29, 2010

In our fourth visit, the patient was already gave birth, last September 28,2010.She delivered a healthy baby boy. As part of the health care team, werendered health teachings about nutritional foods and demonstrated thepostpartum exercises. We offered foods like fresh fruits and gave ironsupplement. Also, we do our assessment to our patient and as well as thenewborn. We then took the vital signs and readings are as follow:

Temperature: 36.9 CelsiusPulse rate: 80 bpmRespiration: 20cpmBlood pressure: 100/90 mmHg


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VIII.SUMMARY

For the entire visits of our client, we were able to monitor our clients

pregnancy stage. During each visits, our client has met the expected events such

as the different psychological and physiological changes of her pregnancy. And

based on the data that we gathered we found out that our clients adaptation to

pregnancy are normal based on the different psychological and physiological

changes of pregnancy, as well as, the growth and development of the fetus

inside her womb.

The results of the assessment of Alma also show a healthy and positive

remark of each stage. Comparing it with what we gathered from the stages of

fetal development and changes of pregnancy, it shows that the need of our client

was met. She showed a positive resolution to us because we approach our client

fairly well and we have handled her with care.

She showed us positive characteristics in dealing with the changes that

she undergone. Her nutritional needs are not provided fairly well because of

poverty. And that all those factors mention above are helping our client a lot in

dealing with the changes that is happening rapidly in her life during pregnancy

stage.


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IX. DOCUMENTATIONS


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X. HEALTH TEACHINGS

Medication Advice patient to continue taking ferrous sulfate, for iron

supplement, 500mg 1 tab/day.

Environment Instructed patient to stay in calm, quiet environment

Home environment must be free from slipping or accident

hazards

Treatment Informed patient to visit ob-gyne if possible for further check-up

and to facilitate her fast recovery and to secure the wellness of

the infantHealth

teachings

Instructed patient to promote breastfeeding and frequent cleaning

of breast using clean water and avoid using of bath soap and

alcohol, to avoid irritation of breast

Instructed patient to avoid lifting heavy objects for 1-2 weeks

Diet Encouraged client to increase intake of fiber to avoid constipation

Instructed to increase fluid intake

Instructed to increase intake of nutritious foods such as fruits and

vegetables


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XI. BIBLIOGRAPHY

Pillitteri, Adele: Maternal and Child Health Nursing. Cesarean Birth

Vol.1.4th edition. Pg 540-542, 557-560 Lippincot Williams and Collins, 2003

Nursing 2005 Drug Handbook 6th edition. Lippincott Williams and

Wilkins 2006

Doenges, Marilyn E. et.al: Nurses Pocket Guide: Diagnoses,

Interventions, and Rationales. 9th edition pp. 278-279, 472-477, 576-578 F.A.

Davis Company Philadelphia, 2004

Adele Pilitteri: Maternal and Child Health Nursing. Volume 1.3rd

edition, pp. 524-530, 533-539. Lippincott Williams and Wilkins , Inc.


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TABLE OF CONTENTS

I. Introduction

II. Patient Profile

III. Stages of Labor/Physiology of Labor

IV. Ideal Nursing Care Plan

Antepartal Period

Intrapatal Period

Postpartum PeriodV. Actual Nursing Care Plan

Antepartal period

Postpartum Period

New born Care

VI. Health Teachings (REFERRALS)

VII. Summary

VIII. Documentations

XI. Drug Study

X. Bibliography


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Documents

123 OB Final Edited