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FAMILY CASE STUDY
_____________
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
IN CHN – RLE 101
_____________
SUBMITTTED TO:
Mr. Donn N. Cariaga,St.N
PRACTICING CLINICAL INSTRUCTOR
Mrs. Bevan B. Balbuena,RN,MN
CLINICAL INSTRUCTOR
SUBMITTED BY:
Jhonna Lyn N. Gallardo,St.N
Roxy Mae A. Melgar,St.N
Roselle Carmi L Lego,St.N
Phil Anthony P. Jimena,St.N
Winston B. Credo,St.N
BSN – 2K
OCTOBER 13, 2009
CRITERIA
CONTENTS
Introduction and objectives 5%
Family developmental task by Duvall 10%
INITIAL DATA BASE 15%
FAMILY COPING INDEX 10%
FAMILY ECOMAP 5%
PRENATAL ASSESSMENT 10%
PROIRITIZING OF PROBLEMS 10%
FAMILY NURSING CARE PLAN 30%
IMPLICATIONS 5%
PROMPTNESS 5%
NEATNESS 5%
FORMAT 5%
TABLE OF CONTENTS
CRITERIA
TABLE OF CONTENTS
INTRODUCTION
INITIAL DATA BASE
FAMILY COPING INDEX
FAMILY ECOMAP
INTRODUCTION
A case study illustrates how a nurse selects a client for health supervision based
on the clinic appointment registry. It also shows how she prepares for a family follow-up.
Note that assessment questions are clearly specified based on review of record done
before a home visit is made is made. This preparation facility the assessment interview
with the family and makes the home visit an efficient method of nurse-family contact.
Community health nursing “nursing for the community’s health”.It’s uniqueness
lies in its emphasis on the health of the population as a whole. Community health
nurses address both the personal and the environmental aspects of health and deal
with community factors which either inhibit or facilitate healthy living. In community
health nursing nurses enter the environment which people live and practice within that
environment, in sharp contrast with the situation where the client nurse’s environment in
a hospital or clinic.
Family definitions are changing as the society changes. Defined as a small group
of people who consider themselves to be bound by ties and who accept the
responsibility for bearing children. It is also an open and developing system of
interacting personalities with a structure and process enacted in relationship among the
individual members regulated by resources and stressors, and existing within the larger
community.
On September 24, 2009, the student nurses of BSN – 2K (group 2) in their first
community rotation assigned at MINIFOREST HEALTH CENTER located in Boulevard,
Davao City. The students were tasked to conduct a home visit to be able to interview
and know better the family whom they chose for their case presentation.
The family belongs to a NON - TRADITIONAL FAMILY specifically the COMMON
LAW which consists of unmarried couple living together; also known in the Phiilippines
as “live – in”.
As the student nurses conducted their home visit, the family seemed to be very
hospitable and cooperative. The family’s willingness to be provided nursing care made
them to decide to have them as client of their case study.
GENERAL OBJECTIVE:
At the end of 5 weeks duty of Community Health Nursing especially in Mini
Forest Health Center, the student nurses will be able to research on their client’s
current and possible health problems, threats and deficits with its respective causative
factors that leads to the deterioration of the family’s health condition to be able to
provide appropriate actions for the family’s betterment through obtaining data, training
the root of current and possible observable disease/s and eventually implement nursing
care.
SPECIFIC OBJECTIVES:
At the end of this case study, the student nurses should be able to:
Choose a family with newborn or a pregnant woman to render
nursing care and be the subject of the case study;
Establish rapport with the family to have a good working
relationship;
obtain demographic data and other pertinent information about the
client as well as the family to support the case study;
State why the family was chosen by the group and how can they be
an attractive and proponent of the study;
Make a comprehensive case study content that contains the
introduction, objectives (general & specific) and present the initial
data base of the client;
present the client’s Family Developmental Task based on Evelyn
Duvall’s theory family development
trace the client’s genogram, family diseases and health conditions
in a diagram format with a corresponding legend
Come up with a family coping index through religious assessment
of the family from the first meeting up to the last meeting of their
home visit;
illustrate the family eco map
present the Prenatal/Newborn Assessment of one of the members
of the chosen family
present the Prenatal/Newborn Assessment of one of the members
of the family
list down 10 problems noted in the family;
prioritize problems based on the Scale for Ranking Health
Conditions and Problems According to Priorities;
select the Top 5 problems in the family;
formulate 5 Family Nursing Care Plans for the family;
objective and subjective cues that give hints about the
client’s problem;
the category of the health and family nursing problem;
general goal of care;
specific objectives of care;
nursing interventions implemented geared towards the
solution of the specified problem;
method of nurse-family contacts;
resources needed for the implementation of nursing
interventions;
evaluation of the impact of the nursing care and
management given towards the family;
Provide implications which would be a summary of how is this case
study would be of a great contribution for nursing practice and
research;
INITIAL DATA BASE
II. Family Data
FAMILY MEMBER’S CHART
FAMILY
MEMBERS
A
G
E
SEX CIVIL
STATUS
POSITION
IN THE
FAMILY
RELATIONSHIP
TO THE
FAMILY
EDUCATIONAL
ATTAINMENT
OCCUPATION
JEFREY
CASIPLE 22 M S HEAD HEAD
CG
(BSMT) DICER
CATHY
BETH
PAROLINOG
21 F S WIFE WIFE
CL
(3ND YEAR) HOUSEWIFE
Ms. Cathy Beth resides in Davao City since birth while Mr. Jefrey was at
Padada, Davao del Sur. When both couple lives together, the family is living at
Governor Salis, Purok-4, Barangay 28-C, Davao City for 1 year. There are only 2
members of the family since they are only starting to build one. Both of them were raise
as Pentecostal religion. The tribe of the husband was Ilonggo while the wife was a pure
Visayan.
Mr. Jeffrey Casiple, the head of the family, a college graduate of BSMT in Holy
Cross of Davao and working as a dicer at PROCTER AND GAMBLE in Bolton, Davao
City to support his family. While Ms. Cathy Beth Parolinog, the wife, a 3rd year college
student at Holy Cross of Davao and a plain housewife who focuses in family issues and
in her pregnancy.
III. Family Characteristics
CRITERIA STATU
S
ADDITIONAL INFORMATION
1.Observable conflicts
between family members
None As the student nurses have visited the family
they have not observed from them any conflicts
within the family.
2.Characteristics of
communication
informal The family calls each other “babes”. They
served are open with each other as what have
also said to us by the wife
3.Interaction patterns
among the members
informal They have time with each other they make
sure that they are going to the Church every
Sunday.
Casiple Family is an extended in terms of its family structure. They are living together
with other relatives on one roof but independent by each other like in budget. Upon
visiting to the family, student nurses have not observed any conflicts within the couple.
And the characteristics of their communication are informal where they call each other
“babes”. They are open to each other in terms of problems and other personal matters
as stated by the wife. The interaction of the family was also informal for as the wife had
also stated to that they make sure that they have time with each other especially during
Sunday which is the day off of the husband. Sunday is the day were the family go to
Church to attend mass.
Family Dietary Habits
MEAL 1 2 3
BREAKFAST rice and fried fish noodles “sinigang”
LUNCH rice, egg and
noodles
“Sinabawang gulay” barbeque
DINNER rice, sardines sardines humba
As shown in the table, the diet of the family is consists of foods with
preservatives, cholesterol, carbohydrates and nutrients. Family usually eats foods with
preservatives such as canned goods and noodles where they buy at the store near their
house and serve it usually during their breakfast and lunch which may compromise
nutritional adequacy and lead to lack of variations in their diet.
They seldom eat foods like vegetables and fruits which gives nutrients for growth
and development of the family especially to Ms. Cathy who is pregnant to help and her
baby to be healthy.
Sleeping Pattern
The couple’s regular hours of retiring is 11:00 pm. And their regular hour for
getting up is at 6:30 am which we find as an unhealthy lifestyle and as a health threat
especially to Ms. Cathy Beth Parolinog who is pregnant. The retiring and getting up
does not depend on the whims of each other.
Monthly Family Income
Mr. Casiple earns ₱265.00 per day wherein he is the dicer at PROCTER AND
GAMBLE located in Bolton, Davao City. While Ms. Parolinog, a plain housewife who
receives ₱1,000.00 per month that was given by her aunt. The total estimated income if
the family is 9,500 pesos a month.
IV. Home and Environment
The house and lot is owned by Parolinog family that is why Mr. Jeffrey Casiple
and Ms. Cathy Beth Parolinog are allowed to live together with their relatives but
provided with different budget and housing needs.
They are just occupying small room in the house where they live. The house was
made of combined cement and wood materials which may result to fire hazard. Some
area in the house may also result of accident such as fall hazard like extra woods
hanging up the stairs. The family’s residence is situated inside which other houses are
at the back situated next to them.
They cook their food using gas stove beside the kitchen sink . The family doesn’t
share eating utensils with each other. There is a common comfort room used for
washing clothes, taking a bath, and peeing or defecating. The waste disposal is a flush
type with a closed drainage system. The drinking water is stored in the refrigerator put
in plastic pitchers and bottles. While food storage facility like their mini cabinet where
they foods is put and covered.
The source of water is Davao City Water District and their electricity’s source is
Davao Light and Power Company. They complain often about mosquitoes at night,
and reports of flies as common household pests. Their garbage is not being segregated
and only placed in big cellophane found at the kitchen; this may be a factor that
contributes to the presence of vectors and pests in their house. One factor also was the
improper drainage system. The student nurses have also observed an open canal on
side of their house with obstructions like garbages which may result to presence of
breeding sites of vectors of diseases.
The student nurses also observed that there were appliances like the TV set with
DVD player, sound system component, refrigerator and computer which owned by her
grandmother.
V. HEALTH AND HEALH SERVICES
ILLNESSES TREATMENT APPLIED
OTC (specify) Herbal (specify) Others (specify)
1. Cough Medicines None none
2. Colds medicines none none
3. Fever medicines none none
As observed in the table, the family encountered most of the common illnesses
which are cough, colds, and fever. These are common in the community which is easily
acquired in having an unusual climate change and unhealthy environment like the
presence of uncovered and obstructions of garbage at the canal. As reported by Ms.
Cathy they usually experience these for couple of weeks. They usually visit the clinic
near their house to have a consultation on what medicines they will take because that
could harm her and the baby.
VIII. Awareness of the Community Organization
The family is aware of the existing organizations in the community and was able
to name those organizations, namely; Barangay Day and Senior Citizen. The family
does not engage their selves to those organizations, but then, they are aware of the
activities conducted by the said organizations.
IX. Environment
As the student nurses interviewed Ms. Cathy Beth Parolinog, she reported that
they have good relationship with their neighbors. And added, that some of them are
fond of gossiping.
She said that the only health facility available in the community is the Health
Center. They use bicycle, motorcycle, and jeep as their way of transportation.
ECOMAP
Legend:
= Ms. Cathy Beth Parolinog
= Mr. Jefrey Casiple
= always
= sometimes
DCLA PADADA
Mall
Church Basketball Court
Neighborhood Work
Ms. Cathy Beth Parolinog and Mr.Jeffrey Casiple were not married.
Jeffrey works as a dicer and regularly goes to work except Sunday. But since Mr. Jefrey
does not have work during Sunday, both of them go to Church together with their
relatives. After attending mass, Mr. Jefrey usually go to the basketball court near to their
house to play basketball together with his friends.
Regularly they go together to their neighbor’s house to socialize since their
neighbors are also their relatives. During salary days, both of them usually go to mall to
shop for those things they will need most especially their basic needs like food or in
DCLA at uyanguren to buy clothes. When both of them want to have a vacation, they
usually decide to go to Padada where Mr. Jefrey lived before, to visit his relatives and
his family.
PRE-NATAL ASSESSMENT
The name of our client is Cathy Beth, a 21 year-old pregnant woman living in
634- 1 Governor Salis, Prk. 4, Brgy. 28- C. She has a weight of 44 kilograms and with a
height of 4 feet and 9.5 inches. She is already 4 months pregnant. In terms of her
pregnancy status her last menstrual period was May 30, 2009. The estimated date of
her confinement is on March 9, 2010. Upon assessment, it revealed that she had
normal vital signs with a blood pressure of 80/70 mmHg, this is normal based on his
previous Bp result. Ms. Cathy has a cardiac rate of 89 beats per minute, pulse rate of 89
beats per minute, respiratory rate of 19 cycles per minute. The age of gestation is 16
weeks and 8 days.
Neurologic System
Neurologic complications and findings were present in our client. She did
experience headache, blurring of vision, and syncope.
Cardiovascular System
There is manifestation of anemia in our client. She has no varicosities and is
negative for edema. Cardiac rate is found to be normal within a range of 89-91 bpm, her
blood pressure is also normal having results of 80/70 mmHg. The fetal heart rate of her
child could not yet be appreciated.
Respiratory System
Our client verbalized that she does not experienced shortness of breathing after
doing certain activities like household chores. When not doing any strenuous work, she
is not experiencing respiratory distress. Upon assessment, presence of colds is noted.
Gastrointestinal System
As far as her appetite and food consumption are concerned, she is having loss of
appetite. She is able to eat 2 to 3 full meals a day and is eating a variety of food each
day but it depends on her budget. Upon assessment of the mouth, she has no dental
complications such as swollen gums and halitosis. She is not experiencing constipation
or other gastrointestinal problems.
Renal System
As we conducted a urine test, the test revealed a negative result of having
glucose and albumin traces which fortunately indicates that she is not in the risk of
having gestational diabetes and pregnancy induced hypertension.
Endocrine System
Our client does not have any family history of any endocrine complications.
Reproductive System
The client verbalized that she does not have any discharges such as vaginal
secretions, blood, and pus. Her genitals were in uniform color with her skin as she
verbalized.
Skin
Upon assessment of the skin we noted that she has fair, white complexion. Her
extremities however had marks of mosquito bites especially on her legs. On her
abdominal area, the presence of LINEA NIGRA was noted; Striae Gavidarum is not yet
evident.
Breast
The client verbalized that her breasts were tender and were free from masses.
She stated that her nipples were darker in color when compared with the color before
pregnancy. Lesions, redness and dimpling on and of her breasts were not noted as she
verbalized
Skeletal System
Our client has no bone deformities and fractures. She has good posture and gait.
She can move about with a full range of motion although limitations are observed due to
the pregnancy.
Nutritional Status
As in terms with our client’s diet, she considers rice as the major source of
carbohydrates. It is always part of her meals. She also has fruits and vegetables along
with her meals sometimes especially banana and also eats a variety of food each day.
She drinks milk everyday especially before she sleeps. She doesn’t prefer meals that
are high in fat and oil. She takes in a lot of water each day and thus she is well
hydrated. Her food intake and selection is according to the capability of her budget.
Lifestyle Habits
Our client has no history of smoking. She is also not an alcoholic. As she got
pregnant, she only walks only when it is necessary like buying items for their food and
other needs in the house every salary day of her husband. She doesn’t do strenuous
activities because she feels fatigue and shortness of breath.
Post Partum Plans
For our client’s first baby, she is planning to provide breastfeeding for she knows the different advantages and benefits of breast milk over formula milk. She also plans to have her child immunized.
ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM
Vagina
The vagina is a muscular, hollow tube that extends from the vaginal opening to
the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is
about three to five inches long in a grown woman. The muscular wall allows the vagina
to expand and contract. The muscular walls are lined with mucous membranes, which
keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the
hymen, partially covers the opening of the vagina. The vagina receives sperm during
sexual intercourse from the penis. The sperm that survive the acidic condition of the
vagina continue on through to the fallopian tubes where fertilization may occur.
The vagina is made up of three layers, an inner mucosal layer, a middle
muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae
that stretch and allow penetration to occur. These also help with stimulation of the
penis. The middle layer has glands that secrete acidic mucus (pH of around 4.0.) that
keeps bacterial growth down. The outer muscular layer is especially important with
delivery of a fetus and placenta.
Purposes of the Vagina
Receives a males erect penis and semen during sexual intercourse.
Pathway through a woman's body for the baby to take during childbirth.
Provides the route for the menstrual blood (menses) from the uterus, to leave the
body.
May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or
female condom.
The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins
with the top end of the vagina. Where they join together forms an almost 90 degree
curve. It is cylindrical or conical in shape and protrudes through the upper anterior
vaginal wall. Approximately half its length is visible with appropriate medical equipment;
the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri",
or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow
the endometrium to be shed. This stretching is believed to be part of the cramping pain
that many women experience. Evidence for this is given by the fact that some women's
cramps subside or disappear after their first vaginal birth because the cervical opening
has widened. The portion projecting into the vagina is referred to as the portio vaginalis
or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide.
It has a convex, elliptical surface and is divided into anterior and posterior lips. The
ectocervix's opening is called the external os. The size and shape of the external os and
the ectocervix varies widely with age, hormonal state, and whether the woman has had
a vaginal birth. In women who have not had a vaginal birth the external os appears as a
small, circular opening. In women who have had a vaginal birth, the ectocervix appears
bulkier and the external os appears wider, more slit-like and gaping. The passageway
between the external os and the uterine cavity is referred to as the endocervical canal. It
varies widely in length and width, along with the cervix overall. Flattened anterior to
posterior, the endocervical canal measures seven to eight mm at its widest in
reproductive-aged women. The endocervical canal terminates at the internal os which is
the opening of the cervix inside the uterine cavity. During childbirth, contractions of the
uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through.
During orgasm, the cervix convulses and the external os dilates.
The uterus is shaped like an upside-down pear, with a thick lining and muscular
walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or
fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build
up until a fertilized egg is implanted, or it is sloughed off during menses.
The uterus contains some of the strongest muscles in the female body. These
muscles are able to expand and contract to accommodate a growing fetus and then
help push the baby out during labor. These muscles also contract rhythmically during an
orgasm in a wave like action. It is thought that this is to help push or guide the sperm up
the uterus to the fallopian tubes where fertilization may be possible.
The uterus is only about three inches long and two inches wide, but during
pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the
fundus and is a landmark for many doctors to track the progress of a pregnancy. The
uterine cavity refers to the fundus of the uterus and the body of the uterus.
Helping support the uterus are ligaments that attach from the body of the uterus to
the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the
growing uterus, but retract after childbirth. In some cases after menopause, they may
lose elasticity and uterine prolapse may occur. This can be fixed with surgery.
Some problems of the uterus include uterine fibroids, pelvic pain (including
endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal
menstrual bleeding, and cancer. It is only after all alternative options have been
considered that surgery is recommended in these cases. This surgery is called
hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal
of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy,
many women begin a form of alternate hormone therapy due to the lack of ovaries and
hormone production.
At the upper corners of the uterus are the fallopian tubes. There are two fallopian
tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a
side of the uterus and connects to an ovary. They are positioned between the ligaments
that support the uterus. The fallopian tubes are about four inches long and about as
wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a
sewing needle. At the other end of each fallopian tube is a fringed area that looks like a
funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not
attached. The ovaries alternately release an egg. When an ovary does ovulate, or
release an egg, it is swept into the lumen of the fallopian tube by the frimbriae.
Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down
the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes
four to five days to travel down the length of the fallopian tube. If enough sperm are
ejaculated during sexual intercourse and there is an oocyte in the fallopian tube,
fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue
down to the uterus and implant itself in the uterine wall where it will grow and develop.
If a zygote doesn't move down to the uterus and implants itself in the fallopian
tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to
be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage
and possible death of the mother.
Mammary glands
Mammary glands are the organs that produce milk for the sustenance of a baby.
These exocrine glands are enlarged and modified sweat glands.
The basic components of the mammary gland are the alveoli (hollow cavities, a
few millimetres large) lined with milk-secreting epithelial cells and surrounded by
myoepithelial cells. These alveoli join up to form groups known as lobules, and each
lobule has a lactiferous duct that drains into openings in the nipple. The myoepithelial
cells can contract, similar to muscle cells, and thereby push the milk from the alveoli
through the lactiferous ducts towards the nipple, where it collects in widenings (sinuses)
of the ducts. A suckling baby essentially squeezes the milk out of these sinuses.
The development of mammary glands is controlled by hormones. The mammary
glands exist in both sexes, but they are rudimentary until puberty when - in response to
ovarian hormones they begin to develop in the female. Estrogen promotes formation,
while testosterone inhibits it. At the time of birth, the baby has lactiferous ducts but no
alveoli. Little branching occurs before puberty when ovarian estrogens stimulate
branching differentiation of the ducts into spherical masses of cells that will become
alveoli. True secretory alveoli only develop in pregnancy, where rising levels of estrogen
and progesterone cause further branching and differentiation of the duct cells, together
with an increase in adipose tissue and a richer blood flow.
Colostrum is secreted in late pregnancy and for the first few days after giving
birth. True milk secretion (lactation) begins a few days later due to a reduction in
circulating progesterone and the presence of the hormone prolactin. The suckling of the
baby causes the release of the hormone oxytocin which stimulates contraction of the
myoepithelial cells.
The cells of mammary glands can easily be induced to grow and multiply by
hormones. If this growth runs out of control, cancer results. Almost all instances of
breast cancer originate in the lobules or ducts of the mammary glands.
PHYSIOLOGY OF LABOR AND DELIVERY
Labor is defined as the sequence of events by which the uterus expels the
products of conception into the vagina and into the outer world. Another definition of
labor is that it is the normal process of coordinated, effective involuntary cervical
effacement and dilatation and descent and delivery of the newborn and placenta. The
term is reserved for pregnancies of more than 20 weeks’ duration.
A primigravida is a woman pregnant for the first time, while a mulitigravida is a
pregnant woman who had more than one previous pregnancy.
Primary and secondary forces work together to achieve birth of the fetus, the
fetal membranes, and the placenta. The primary force is uterine muscular contractions,
which cause the complete effacement and dilatation of the cervix.
The secondary force is the use of abdominal muscles to push during the second
stage of labor. The pushing adds to the primary force after full dilatation.
Each contraction has three phases: (1) increment, the building up of the
contraction (the longest phase); (2) acme or the peak of contraction; and (3) decrement,
or the letting up of the contraction. The terms frequency, duration, and intensity are
used to describe uterine contractions during labor. Frequency refers to the time
between the beginning of one contraction and the beginning of the next contraction.
Duration is measured from the beginning of a contraction to the completion of that
same contraction. Intensity refers o the strength of the contraction during acme.
POSSIBLE CAUSES OF LABOR ONSET
The process of labor usually begins between the 38th and 42nd week of gestation,
when the fetus is mature and ready for birth. The exact cause of labor onset is not
clearly understood. However, some important aspects have been identified:
progesterone relaxes smooth muscle tissue, estrogen stimulates uterine muscle
contractions, and connective tissue loosens to permit the softening, thinning, and
eventual opening of the cervix. Currently, researchers are focusing on several promising
areas of research about labor onset.
PROGESTERONE WITHDRWAL HYPOTHESIS
Progesterone, produced by the placenta, relaxes uterine smooth muscle by
interfering with the conduction of impulses from one cell to the next. During pregnancy,
progesterone exerts a quieting effect and the uterus generally does not have
coordinated contractions. Toward the end of gestation, biochemical changes decrease
the availability of progesterone to myometrial cells and may be associated with an
antiprogestin that inhibits the relaxant effect but allows other progesterone actions such
as lactogenesis. With the decreased availability of progesterone, estrogen is better able
to stimulate contractions.
PROSTAGLANDIN HYPOTHESIS
Although the exact relationship between prostaglandin and the onset of labor is
not yet known, the effect is clinically demonstrated by the successful induction of labor
after vaginal application of prostaglandin E. Preterm labor may be stopped by using an
inhibitor of prostaglandin synthesis.
The amnion and deciduas are the focus of research on the source of
prostaglandins. Once prostaglandin is produced, stimuli for its synthesis may include
rising levels of estrogen, decreased availability of progesterone, and increased levels of
oxytocin, platelet-activating factor, and endothelin-I.
CORTICOTRIN-RELEASING HORMONE
Corticotrin-releasing hormone ha a possible role in labor. It increases during
pregnancy, with a sharp increase at term. Plasma CRH increases prior to preterm labor,
and CRH levels are elevated multiple gestation. CRH is also known to stimulate the
synthesis of prostaglandin F and prostaglandin E by amnion cells.
MYOMETRIAL ACTIVITY
In true labor the muscles of the upper uterine segment shorten and exert a
longitudinal pull on the cervix with each contraction, causing effacement. Effacement is
the drawing up of the internal os and the cervical canal into the sidewalls of the uterus.
The cervix changes progressively from a long, thick structure to one that is tissue paper
thin. In primigravidas, effacement usually occurs before dilatation.
The uterus elongates with each contraction, decreasing the horizontal diameter.
This elongation causes a straightening of the fetal body, pressing the upper portion
against the fundus and thrusting the presenting part down toward the lower uterine
segment and the cervix. The pressure exerted by the fetus is called the fetal axis
pressure. As the uterus elongates, the longitudinal muscle fibers are pulled upward over
the presenting part. This action and the hydrostatic pressure of the fetal membranes
cause cervical dilation. The cervical os and cervical canal widen from less than 1 cm to
approximately 10 cm, allowing birth of the fetus. When the cervix is completely dilated
and retracted up into the lower uterine segment, it can no longer be palpated. At the
same time, the round ligament pulls the fundus forward, aligning the fetus with the bony
pelvis.
MUSCULATURE CHANGES IN THE PELVIC FLOOR
The elevator ani muscle and fascia of the pelvic floor draw the rectum and the
vagina upward and forward with each contraction, along the curve of the pelvic floor. As
the fetal head descends the pelvic floor the pressure of the presenting part causes the
perineal structure, which was once 5 cm in thickness, to thin to less than 1 cm. the anus
everts, exposing the interior rectal wall as the fetal head descends forward.
SIGNS OF LABOR
Preliminary signs of labor
Before labor, the woman often experiences following signs that can signal the onset of
the labor.
Lightening
It is the descent of the fetal presentation part into the pelvis, occurs
approximately 10-14 days before labor begins
For the 1st pregnancy, lightening may occur weeks or days before labor begins.
For subsequent pregnancies, it may not happen ahead of time. For some
women, the changes are obvious. Others may not notice a thing.
Lightening gives the women relief from the diaphragmatic pressure and
shortness of breath she has been experiencing and thus “lightens” her load.
The baby’s new position may give the woman’s lungs more room to expand,
making it easier to breathe. On the other side, increased pressure on the bladder
may send her to the bathroom more often.
In lightening, abdominal pressure increases and this may result in reports of
shooting leg pains from the pressure on the sciatic nerve, increased amounts of vaginal
discharge and, urinary frequency from pressure on the bladder.
Increased in level of activity
This increase in activity is due to an increase in epinephrine release that is
initiated by decrease in progesterone produced by the placenta. This happens
approximately 24-48 hours before labor.
Braxton Hicks Contractions
Braxton Hicks Contractions are uterine contractions occurring prior to the onset
of labor. They are normal and can be demonstrated with fetal monitoring techniques
early in the middle trimester of pregnancy. These innocent contractions can be painful,
regular, and frequent, although they usually are not. Women may be admitted to the
labor unit of a hospital because false contractions so closely simulate true labor.
Cervical Changes
The cervix changes from firm and rigid into soft and dilates so it can stretch and
dilate to allow the passage of the fetus. This softening is called ripening.
Bloody Show
Pink-tinged secretions that begins within 24 to 48 hours. These are cervical
secretions that accumulate in the cervical canal to form a barrier called a mucous plug.
With softening and effacement of the cervix, the mucous plug is often expelled resulting
in a small amount of blood loss from the exposed cervical capillaries.
Rupture of Membranes (ROM)
Rupture of the amniotic membranes before the onset of labor. After the rupture
the onset of labor begins within 24 hours. If membranes rupture and labor does not
begin spontaneously within 12 to 24 hours, labor may be induced to decrease the risk
for infection.
Other signs
Weight loss of 1 to 3 lb due to fluid loss and electrolyte shifts produced by
changes in estrogen and progesterone levels.
Diarrhea, indigestion, or nausea and vomiting just before onset of labor.
Differentiation between the True and False Labor Contractions
FALSE CONTRACTIONS TRUE CONTRACTIONS
Begin and remain irregular Begin irregularly but become regular and
predictable; regular intervals
Felt first abdominally and remain
confined to the abdomen and groin
Felt first in lower back and sweep around
to the abdomen in a wave
Often disappear with ambulation and
sleep
Continue no matter what the woman’s
level of activity
Do not increase in duration, frequency or
intensity
Increase in duration, frequency or
intensity
Do not achieve cervical dilatation Achieve cervical dilatation
The beginning of true labor is marked by increasingly frequent, forceful,
prolonged, and finally, regular uterine contractions. Low backache may precede or
accompany the uterine contractions. Each contraction starts with a gradual buildup of
intensity and a similar dissipation follows the peak.
False labor is defined as a period of fairly regular, painful contractions that are
not accompanied by effacement or dilatation of the cervix and that may either stop,
completely or be followed either promptly or ultimately, by the onset of true labor. False
labor is a form of disordered uterine contractions.
FETAL PRESENTATION AND POSITION
· It is important to document presentation and position because the presentation
of a body part other than the vertex puts the fetus at risk. It implies a proportional
difference between the fetus and pelvis, making a cesarean birth necessary.
· Four methods are used to determine fetal position, presentation and fetal lie: 1.)
combined abdominal inspection and palpation 2.) Vaginal examination 3.)
Auscultation of fetal heart tones and 4.) sonography
Attitude. Attitude describes the degree of flexion the fetus assumes during labor or the
relation of the fetal parts of each other.
· A fetus is in good attitude if it is the complete flexion: the spinal column is
bowed forward; the head is flexed forward so much that chin touches the
sternum. This presents the smallest anteroposterior diameter of the skull to the
pelvis
· A fetus is in moderate flexion if the chin is not touching the chest but is in alert
or “military position. This position causes the next-widest anteroposterior
diameter, the occipital frontal diameter to present to the birth canal.
· The fetus impartial extension presents the “brow: of the head to the birth canal.
If a fetus is in poor flexion, the back is arched, the neck is extended, and the
fetus is I complete extension, presenting the occipitomental diameter of the head
to the birth canal. This is an unusual presentation
Engagement. Engagement refers to the settling of the presenting part of the fetus far
enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis.
· in primipara, nonengagement of the head a t the beginning of labor indicated a
possible complication s such as an abnormal presentation or positron,
abnormality of the fetal head or cephalopelvic disproportion
· in multiparas engagement may or may nit be present at the beginning of the
labor
· a presenting part that is not engaged is said to be “floating”. One that is
descending but has not yet reached the iliac spines can be said to be “dipping”.
· The degree of engagement is assessed by vaginal and cervical examination
Station. Station refers to the relationship of the presenting part of the fetus to the level
of the ischial spines
Station refers to the level of the head in the pelvis. When the most dependent
part of the head is at the level of the ischial spines, the station is referred to as
zero. Levels 1, 2, or 3 cm above or below the level of the spines are referred to
as -1, -2, -3 or +1, +2, +3, respectively. Station 0 is generally considered exact
engagement, indication that the biparietal diameter is the level of the inlet.
Fetal lie. Lie is the relationship between the long axis of the fetal body and the long axis
of the woman’s body.
· 99% of fetuses assume a longitudinal lie. longitudinal lies are further classified
as cephalic and breech.
TYPES OF FETAL PRESENTATION
Fetal presentation denotes the body part that well first contact he cervix or deliver
first. This is determined by fetal lie an the degree of flexion
1. cephalic presentation
a. it means that the head is the body part that first contacts the cervix
b. it is the most frequent type of presentation occurring as often as 95% of
the time
c. Cephalic presentation occurs
when the head is completely
flexed onto the chest; smallest
diameter presents. The
occiput is the presenting part.
This is determined by the
relation of the fetal occiput to
the mother’s right side or left
side. This is expressed as OA (occiput directly anterior), LOA (left occiput
anterior), LOP (left occiput posterior), and so on.
d. the four types of cephalic presentations are vertex brow , face and
mentum
2. breech presentation
a. it means that either the buttocks or feet are the first body parts to contact
the cervix
b. it occurs approximately 3% of births and are affected by fetal attitude
c. Breech presentation is determined by the position of the infant’s sacrum in
relation to the mother’s right or left side. This expressed as SA (sacrum
directly anterior), LSA (left sacrum anterior), LSP (left sacrum posterior),
and so on.
3. shoulder presentation
a. The fetus is lying horizontally in the pelvis so that its long axis is
perpendicular to that of the mother.
b. The presenting part usually becomes one of the shoulders, an iliac crest, a
hand or an elbow
c. Fewer than 1% of fetuses lie transversely. This may be caused by relaxed
abdominal walls from grand multiparity, allowing the uterus to be
unsupported and fall forward.
d. Transverse presentation occurs when the long axis of the fetal body is
perpendicular to that of the mother. One shoulder will occupy the superior
strait, but it will be considerably to the right or left of the midline.
Transverse presentation is designated by relating the infant’s inferior
shoulder and back to the mother’s back or abdominal wall.
TYPES OF CEPHALIC PRESENTATIONS
Type Lie Attitude Description
Vertex Longitudinal Good (full flexion)
The head id sharply flexed, making
the parietal bones or the space
between the fontanelles the vertex)
the presenting part. This is the most
common presentation and allows
the suboccipitobregmatic diameter
to present to the cervix
Brow Longitudinal Moderate (military)
Because the head is only
moderately flexed, the brow or
sinciput becomes the repenting part
Face Longitudinal Poor
The fetus has extended the head to
make the face the presenting part.
From this position, extreme edema
and distortion of the face may
occur. The presenting diameter
(occipitomental) is so wide birth
may be impossible.
Mentum Longitudinal Very poor
The fetus has completely
hyperextend the head to present
the chin. The widest diameter
(occipitomental) is presenting. As a
rule, the fetus cannot enter the
pelvis in this presentation
TYPES OF FETAL POSITION
it is the relationship f the presenting part to the specific quadrant of the woman’s
pelvis
The maternal pelvis is divided into four quadrants according g to the mother’s
right and left: 1.) right anterior 2.) left anterior 3.) right posterior 4.) left posterior
Fetal position refers to the relation of the point of direction to one of the 4
quadrants or to the transverse diameter of the maternal pelvis. The point of
direction may lie in either of the 2 posterior quadrants (right or left posterior), in
either of the 2 anterior quadrants (right or left anterior), or in the direct transverse
diameter (right or left transverse). It may also lie either directly to the front of the
pelvis or directly to the back (direct anterior or direct posterior).
In defining the positions, the following primary abbreviations are used: O for
occiput in the cephalic presentation, M for mentum in the face presentation, Sc
for scapula in transverse presentation, and S for sacrum in breech presentation.
Position is important because it influences the process and efficiency of labor.
typically, a fetus delivers fastest from an ROA or LOA position. Labor is
considerably extended of the position is posterior (ROP or LOP).
PRELIMINARY SIGNS OF LABOR
Lightening Braxton Hicks Contraction
(false labor)
Ripening of the cervix
(descent of the fetal head
into the pelvis)
>begin and remain irregular
>1st felt abdominally
>pain disappears with
ambulation
>do not increase in duration
and intensity
>do not achieve cervical
dilatation
(Goodell’s Sign wherein the
cervix feels softer like
consistency of the earlobe)
TRUE LABOR
Uterine Contractions SHOW Rupture of Membranes
>increase in duration and
intensity
>1st felt at the back &
radiates to the abdomen
>pain is not relieved no
(pink-tinge of blood, a
mixture of blood and fluid)
(rupture of the amniotic
sac)
matter what the activity
>achieve cervical dilatation
FAILED TO PROGRESS LABOR
(due to Large baby)
increase risk for fetal distress
(meconium staining, hypoxia)
I
Increase risk of fetal death
Emergent cesarean delivery
(the incision made on the lower part of the abdomen)
Expulsion of the fetus
Expulsion of the placenta
(accompanied by blood approximately 500-1000 mL)
DEVELOPMENTAL TASK
Stages of family life cycle
Stage- critical family developmental task
Achieved or not achieved
Justification
Family developmental tasks at school-age stage
1. Providing for children’s activity and parents’ privacy
Achieved The family provides the children’s activity in school if there are affairs like joining kids scout, and playing basketball. During this school age period children are fond of playing with their peers after their class session. Parents are letting the child roam the streets and play in the alley.
According to Duvall, encouraging the child’s growth involves letting him go. The child is away from home throughout the school hours, which often include the lunch period as well as morning and afternoon sessions. If he or she is getting normally involved in sports, clubs, and friendship groups, the after-school hours are increasingly given to these interests, so the youngsters come home tired and bedraggled just in time for the evening meal.
2. Keeping financially solvent
Achieved As a family, they focus their financial expenses to their basic needs like food, clothing and school expenses of their son. They are also preparing for the coming of their new angel. Their monthly income is just enough for their daily living.
According to Duvall, the developmental task of school age is that they develop practicing of the use of money. They learn how to buy wisely the things they want most and to stay within their available resources. They learn also the value of saving for postponed satisfactions.
3. Furthering socialization of family members
Achieved Responsibilities have always behind every man’s back. And as a family, everyone must have a new role in performing individual tasks as the level of everyone’s capacity. They make sure that whatever needs of
their child must be well managed and kept in balance. The child must be well-groomed and the wife must be concerned about her husband.
According to Duvall, cooperative efforts in the family like medical preparation, cleaning up, dividing daily responsibilities that would somehow learned the child and to be involved in the household with the parents. In that, the child develops learning and acquire willingness and discipline to his assigned work both in school and home. Thus, he and his family continue their socialization throughout the year.
4. Upgrading communication in the family
Achieved The family has an open communication to each other especially to their school-age child. He can share his own feelings of happiness, sadness, or embarrassment about his experience to a first available family member either his mother or father. The parents also discuss their own problem with each other, but the wife reported having such negative emotion and she just want to be alone. According to Duvall, the child can grow in his ability to cope with simple frustration. Exploring socially acceptable ways of releasing negative emotion effectively. The child gained his skill in sharing his feelings with those who can help him like his parents, teachers, friends, etc.
Establishing ties beyond the immediate family
Achieved Ties between the family plays a great role in maintaining a good working relationship among family members. As a family, they find time with each other by having fun and leisure. They find ways on how to make every moment an unforgettable one despite of the fact that they usually do it at home. Being with an immediate family keeps them stronger and contented. According to Duvall, he explained that a feeling of closeness among
family and relative are achieved over a years of gift-giving vacation sharing and by all means that will help the members of the family maintain the contact with each other. They have a loyalty that bind them together regardless of what any member may or may not do.
6. Developing morally and building family morale
Achieved Parents become especially concerned about the moral development of their child when they are exposed, as school children, to wide variations in the conduct of people outside the family. They teach their son character traits over the years and they will be able to achieve it. The child has full of respect to his parents and other members of his family.
According to Duvall, the morale of families with school children appears to be related to how effectively they are able to cope with community pressures and to give clear interpretation of their own values to their children.
Narrative Genogram
The Parolinog family has a history of Breast Cancer. And only Filipina Parolinog has been suffering from this health problem. All Cathy Beth grandparents died except for her grandmother on the father side. They all died due to old age.
The Casiple family has a history of Hypertension and pulmonary problem (asthma). The brother of Jefrey is the one who is in agony of acquiring a pulmonary problem (asthma). And Jefrey’s mother is the one who has hypertension.
FAMILY COPING INDEX
9 Areas Admission Discharge
Rating
Justification Rating Justification
Physical
Independence
5 The chosen family is well enough to do things and is able to get about as far as possible within their physical abilities. They are not strained by any disability in doing their household chores, caring for others in times of sickness and able to meet their own care. They are receiving resistance when needed without interruption to their own effort.
5 No change in the level of dependence. All of the members can still meet their own personal things to do. They were all able to get as far as possible within their physical abilities. In accordance to household chores, personal care and care for others.
Therapeutic Competence
3 Family carrying out some but not all of the treatments. Ms. Torcende does not drink any medication when she is having a fever but instead she just drinks plenty of water for therapeutic recovery. Live-in partner and child may drink medicine in cases of hyperthermia but they do not know any specific procedures like TSB for recovery.
5 Family able to demonstrate that the members can carry out the prescribed procedures safely and efficiently, with the understanding of the principles involved and with confident and willing attitude. They were able to know the purpose of a medicine, on why is it important to take and are now very confident in taking medications. In cases of Hyperthermia, they were able to perform specific procedures like TSB for immediate relief of a sick member.
.
Knowledge of Health Condition
5 Family knows the salient facts about the disease well enough to take necessary action at proper time as
5 No changes in this area, family still knows the rationale of care and is still able to report signs and symptoms such as dengue rashes.
patient verbalized “ Gkan man na sa lamok ang dengue diba? Mailhan man kung gidengue kay maluya na man. Dalhun na dayon na sa hospital.”
Application of Principles of Personal Hygiene
3 Our client fails to apply some general principles of personal hygiene. They may be able to secure initial immunizations, but fails to clean their yard and drainage passageways. They were able to maintain good personal hygiene like brushing, bathing but as a whole there are incompleteness of necessities in accordance to personal hygiene such as imbalanced family nutrition.
3 Even if we explain to them briefly the immediate need for cleaning their yard and drainage passageways, there is still no improvement. Still no change in this area cause they show partial competence in agreeing to this situation. There is still imbalanced family nutrition because they only depend on their store for canned good. Still there is a need for complete understanding to this situation.
Health Care Attitudes
5 When the family gets seriously ill, they always confine at the UM multi test and diagnostic center to have their check-up. They have the trust in medical professionals to care for themselves in times when they get sick or critically ill. They understand and recognize the need for medical care in illness and for the usual preventive services and follows recommendations that the doctor has
5 No change in this area. Very Competent in doctors for they know that medical professionals know what’s best for their health. They accept every illness and disease calmly and recognize the limits it imposes while doing all possible measures to effect recovery and rehabilitation.
given.
Emotional Competence
5 All members of the family are able to maintain a reasonable degree of emotional calmness. The family makes decisions together. Can control their vices such as smoking and alcohol. They face up to illness realistically and hopefully. The family deals with problems calmly. They prefer to talk about it rather than fight about it because they believe that fighting can never solve any of their problems. They were able to discuss problems with their members even they have differences but understand the part of each member.
5 There were no changes in their emotional competence. They still make decisions together and face problems calmly and as partners. Vices are still minimized or controlled.
Family Living 3 The family cannot eat meals as one. They cannot go to mass together because Mr. Hubert is a Baptist but despite of not spending enough time for God as a whole family, they still try to work things out such as buying groceries for their needs together. The family respects each other and is affectionate to one another such as caring for a sick family member and
3 The family still tries their best to be together. They still respect each other and think for every member’s best possible future. Family gets along but has habits or customs that interfere with their effectiveness or coherence as a family such as Mr. Hubert as a Baptist and waking up late in the morning.
strongly face problems as a whole.
Personal Environment
3 Partially competent in this area because as by evidence, the house was clean but there were dark places that may be a place where rodents and other insects thrive. Not only that, improper garbage disposal is also noted. House may be too small and crowded for the 7 of them but adjustments can be made.
3 They were able to improve this area as evidenced by the partial renovation of their house. 2 family members also transferred to another address to start on their own. There is still no proper garbage segregation.
Use of Community Facilities
5 The family was able to recognize the availability of community facilities such as centers for their own welfare and safety. They use facilities they need appropriately and promptly. They know the things to do, know who will call for help. Feels secure about the community facilities that our government provided to its people. In addition, confident to professionals like teaches, doctors and others.
5 The family continues to consult the center when in serious health condition. They have the knowledge to go on government facilities like centers and hospitals for their check- up.
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