RELATED LEARNING EXPERIENCE WORKBOOK OBSTETRIC NURSING

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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018

UNIVERSITY OF THE VISAYAS

COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014

Tel. No.: (032) 346-9292

RELATED LEARNING EXPERIENCE WORKBOOK

OBSTETRIC NURSING

Name of Student: _________________________________________

Level: __________________________________________________

Note: To be submitted with clearance at the end of the semester

Rev. 5 05-03-2018

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ACKNOWLEDGEMENT

This obstetrical manual is a fruition of the collective efforts of the members of the faculty

of the University of the Visayas College of Nursing. From its inception, formation, verification,

validation and final furnishing of the output, the support and dedication of the faculty members

was unwavering. The authors would like to extend their deep gratitude and appreciation to the

efforts of all the people involved in creating this manual. We hope this manual would provide

better understanding and learning for student nurses in their related learning experience

exposure and enhance their skills using the different nursing theories in their journey towards

competency building.

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Table of Contents

Content Page

Related Learning Experience Monitoring Sheet 4

Related Learning Experience Attitudinal Scale 5

Patient Centered Nurse’s Record 6

Patient’s Data Profile 7

Head-to-toe Assessment 9

Nursing Systems Review 12

Interpretation of Patient’s Laboratory/ Diagnostic Results 19

Anatomy and Physiology 20

Obstetrical Management 21

Outline of Nursing Management 22

Drug Study 23

Nursing Care Plan 24

Summary Performance Evaluation Achieving Obstetrical Care Competency 25

Glossary 28

References 30

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RELATED LEARNING EXPERIENCE MONITORING SHEET

Name of Student: ________________________ Level: ________________________

Area: Obstetrical Ward____________________ Date Covered: __________________

AREAS OF EVALUATION GRADE TOTAL WEIGHT COMMENTS

ATTENDANCE 5%

1. Attendance

PROGRESSIVE ASSESSMENT 20%

1. Pre-test

DEPORTMENT 5%

1. RLE Attitudinal Scale

PRACTICAL ASSESSMENT 70%

1. PCNR (30%)

2. RLE Evaluative Record (5%)

3. Group Case Study Conference

(10%)

4. Individual Case Conference (10%)

5. Nursing Procedures (10%)

6. Reflection Journal (5%)

Total

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RELATED LEARNING EXPERIENCE ATTITUDINAL SCALE


Area: _________________________________ Date Covered: __________________

Degree of Performance and Quality Classification:

5- Excellent

4- Above Average

3- Average

2- Needs improvement

1- Poor

AREAS TO BE ASSESSED RATING

1. Shows positive attitude towards role required in the area. 5 4 3 2 1

2. Accepts responsibility to pursue goals in the care of the client. 5 4 3 2 1

3. Demonstrates ability to establish rapport with clients. 5 4 3 2 1

4. Self- directed, motivated and willing to assume task/s assigned. 5 4 3 2 1

5. Requests for assistance when needed and is willing to correct

deficiencies.

5 4 3 2 1

6. Seeks feedback of work accomplished from supervisors and

instructors.

5 4 3 2 1

7. Initiates nursing actions under the supervision of the Clinical

Instructor.

5 4 3 2 1

8. Demonstrates caring and compassionate attitude in client

management.

5 4 3 2 1

9. Accepts values of others without imposing own value system. 5 4 3 2 1

10. Demonstrates respect of clients, supervisors, and peers. 5 4 3 2 1

TOTAL POINTS: _____________________

EQUIVALENT GRADE: _____________________

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UNIVERSITY OF THE VISAYAS COLLEGE OF NURSING

Gov. M. Cuenco Ave., Banilad, Mandaue City 6014

Tel. No.: (032) 346-9292

PATIENT CENTERED NURSE’S RECORD


Area: _________________________________ Date Covered: __________________

AREAS OF ASSESSMENT POINTS ACTUAL

SCORE

EQ GRADE

I. Patient Data Record, Head-to-toe

Assessment, and Interpretation of patient’s

laboratory/ diagnostic procedures

30

II. Anatomy and Physiology 10

III. Complications of Pregnancy 10

III. Obstetrical Management 10

IV. Nursing Management according to Goals of

Care

10

V. Drug Study 10

VI. Nursing Care Plan 20

100

Total Points

Average Grade

Signature of Clinical Instructor: ________________________________________

Signature over Printed Name of Clinical Instructor

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PATIENT’S DATA PROFILE

A. Demographic Profile: (Fill in the basic information needed) 10 pts.

Name of Patient:(Initials only) ____________ Date/Time Assessed: ______________

Date of Birth: _________ Age: _________ Gender:___________

Height: ___________ Weight: ____________

Date & Time Admitted: ___________________________________

Chief Complaint/s: ______________________________________________________

Admitting Diagnosis/ Impression: __________________________________________

Final Diagnosis: ________________________________________________________

Attending Physician: ____________________________________________________

Vital Signs: (Upon Assessment)

Temperature: ___________ PR: _________ RR: __________ BP: ____________

Pain Rating Scale: _______

B. Gynecological and Obstetric History:

Menstrual History:

1. Age of Menarche: _______

2. Last Menstrual Period (LMP): _____________________

3. Menstrual Cycle: ( ) Short: < 28 days ( ) Mid: 28-32days ( ) Long: >32days

( ) Regular ( ) Irregular

4. Duration of menses: ________ days

5. Menstrual Flow ( ) Heavy ( ) Moderate ( ) Light

6. Do you have dysmennorhea during menses? ( ) Yes ( ) No

7. Does bleeding or spotting occur between periods? ( ) Yes ( ) No

Obstetric History:

Gravida: ____ Term: ____ Para: ____ Abortion: ____ Living: ____

Record of Pregnancies

Date of

Delivery

Type of Delivery Duration of

Pregnancy

Place of Delivery

C. Current Obstetrical Data:

Age of Gestation (AOG):____________

Estimated Date of Confinement (EDC):___________________

Prenatal Visit AOG Date of Visit Place

1st

2nd

3rd

4th

5th

6th

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Medications Taken: ______________________________________________________

______________________________________________________

______________________________________________________

TT Vaccination: ______________________________________________________

______________________________________________________

D. Family History:

( ) Cancer: _________ ( ) Diabetes ( ) Heart Disease

( ) Hypertension ( ) Asthma ( ) Epilepsy

( ) Others: __________________________________________________________

If yes to any, list affected members: ______________________________________

______________________________________

E. Past Medical/ Surgical History:

( ) Arthritis ( ) Kidney Disease ( ) Asthma

( ) Diabetes ( ) Gall Stones ( ) Emphysema

( ) STI’s: ____________ ( ) Liver Disease ( ) Bronchitis

( ) Lung disease including Hepatitis ( ) Tuberculosis

( ) Gastrointestinal disease ( ) Epilepsy ( ) Eating Disorder

( ) High Blood Pressure ( ) Blood transfusions ( ) Surgeries: ______________

( ) Heart Disease ( ) Thyroid Disease ________________

F. Social History:

Do you smoke? ( ) No ( ) Yes; ______________ No. of packs/day_________

Do you drink alcoholic beverages: ( ) No ( ) Yes; Amount consumed_________

Substance abuse: ( ) No ( ) Yes; Frequency___________

Number of sexual partners: _______

Exercise: ( ) No ( ) Yes

G. Current Medications:

Note: If taking maintenance medications

Medication Dose Frequency

H. History of Food and Drug Allergies:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

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HEAD-TO-TOE ASSESSMENT

Name of Patient: (Initials only )_________________________ Date /Time Assessed: ______________

Areas to be Assessed Subjective Cue(s)

Findings

Head, Scalp and Hair

Inspect size, shape and contour

Observe scalp

Palpate the head

Face

Inspect face for symmetry

Palpate TMJ

Percuss the sinuses

Listen for temporal artery bruits

Instruct to make faces

Perform touch sensation test

Perform taste test (if needed)

Eyebrows and Eyelashes

Inspect for symmetry and shape

Inspect conjunctiva

Palpate lacrimal apparatus

Eyes

Perform Snellen Test

Inspect sclerae

Perform 6 cardinal fields of gaze

Perform accommodation test

Perform corneal reflex test

Perform pupillary reflex test

Do opthalmoscope exam (if available)

Ears

Inspect for shape and symmetry

Palpate external auricle

Inspect auditory meatus (ear canal)

Do whisper test

Perform Rinne Test and Webber Test (if hearing problem is detected)

Otoscopic exam (if applicable)

Nose

Inspect shape and symmetry

Inspect nostrils one at a time

Palpate nasal bridge

Use modified otoscope to inspect inside of nose

Percuss sinuses

Perform olfaction test ( if pt. complains of smelling problems

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Mouth and Throat Inspect features of lips Palpate TMJ while pt. opens and closes mouth Inspect oral mucosa

Inspect hard and soft palate

Inspect tonsils and give appropriate grading

Inspect teeth

Palpate side of tongue

Instruct to move tongue with resistance

Neck Inspect neck ( symmetry and presence of

bulges)

Use penlight to check bulges of neck

Palpate carotids one at a time

Auscultate for bruits

Palpate the thyroid

Palpate the lymph nodes in proper order

Check accessory muscles of neck and shoulders

Thorax (Respi.) Inspect quality of respiration Inspect for symmetry and deformity

Move to back and palpate spinous processes

( spine)

Palpate for lung expansion

Perform tactile fremitus

Percuss and check diaphragmatic excursion

Auscultate for breath sounds in correct order

Move to anterior chest and observe for shape and symmetry

Palpate for lung expansion

Perform tactile fremitus test

Percuss chest

Auscultate for breath sounds

Thorax (Cardio.) Inspect apical pulse Palpate apical pulse

Palpate sternoclavicular area, aortic area, pulmonic area, left ventricular area

Auscultate heart right 2nd ICS, left sternal border, 2nd to 5th ICS and apex using diaphragm

Repeat same process using bell

Upper Extremities Inspect hand and arms Do capillary refill test

Palpate radial and brachial pulses

Check sensory function of arm ( touch, pain,

temperature , vibration and position)

Touch discrimation ( steriognosis, graphesthesia, 2pt discrimation, extinction)

Motor function by deep tendon reflex ( biceps, triceps, brachial radialis)

Cerebellar function of arm ( RAM, finger touch, finger to finger localization, finger to nose test)

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Abdomen Inspect abdomen from rib to symphysis pubis.

Assess bulges (use penlight)

Auscultate abdomen starting at RLQ, LLQ, LUQ

and RUQ

Auscultate for vascular sounds using bell ( aorta, renal, iliac and femoral)

Percuss starting at RUQ moving in counter

clockwise direction

Percuss liver

Percuss stomach at LUQ

Percuss for spleen (turn pt. to right side)

Percuss bladder

Perform light palpation starting RLQ in clockwise manner

Perform deep palpation

Palpate bladder

Palpate kidneys using bimanual technique

Test abdominal superficial reflex

Lower extremities Inspect legs Flex legs and dorsiflex foot

Palpate peripheral pulses ( femoral, popliteal, posterior tibialis, dorsalis pedis,)

Palpate for edema (if present)

Perform sensory test ( light touch, pain,

temperature, vibration and position)

Check DTR (patellar, achilles)

Babinski reflex

Cerebellar test (heel –shin test, gait, tandem

walk, Romberg’s test)

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NURSING SYSTEMS REVIEW (10 pts)

Name of Patient:_________________________ Date/Time Assessed:______________ (Place an “X” on the findings of your assessment, briefly justify with a narrative discussion, place subjective cues (if applicable), and identify a nursing diagnosis according to the findings of your assessment.)

CARDIOVASCULAR SYSTEM Narrative discussion of cardiovascular system findings: A. Bulging of neck veins ( ) Present ( ) Absent B. Quality of carotid pulsation during palpation (Compare both sides) Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry: ( ) Symmetrical ( ) Asymmetrical C. Capillary refill time: Nail color: ( ) Pinkish ( ) Pale ( ) Cyanotic Upper extremity (Right): ( ) Immediate to 2 sec. ( ) More than 2 sec. Upper extremity (Left): ( ) Immediate to 2 sec. ( ) More than 2 sec. D. Quality of peripheral pulsation: Brachial Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical Radial Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical E. Quality of peripheral pulsation: Femoral Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical Posterior tibialis Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry: : ( ) Symmetrical ( ) Asymmetrical Popliteal Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical Dorsalis Pedis Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic

Subjective Cues

Nursing Diagnosis

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Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical F. Quality of Apical pulsation (clavicular, subclavicular, apex sites) Clavicular Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Apical Heart Rate (PMI): ___________Bpm ( ) Regular ( ) Bounding ( ) Tachycardic Subclavicular Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Apical Heart Rate (PMI): ___________Bpm ( ) Regular ( ) Bounding ( ) Tachycardic Apex sites Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Apical Heart Rate (PMI): ___________Bpm ( ) Regular ( ) Bounding ( ) Tachycardic Quality of apical pulsation during auscultation (R- Subclavicular, L- Subclavicular, L-2nd - 5th ICS, Apex) Heart sounds: ( ) Regular ( ) Adventitious a. ______Gallops b. ______Murmurs

G.Others Heart Palpitations, increase heart rate ( ) Present ( ) Absent PMIshifts about1.5cm to the left ( ) Present ( ) Absent Blood Physiologic dilutional anemia/ pseudoanemia ( ) Present ( ) Absent physiologic anemia of pregnancy ( ) Present ( ) Absent pulmonic and apical systolic murmurs ( ) Present ( ) Absent supinehypotension, fainting spells ( ) Present ( ) Absent ankleedema ( ) Present ( ) Absent varicosisities ( ) Present ( ) Absent Blood pressure: 1st trimester: ______________ mmHg 2nd and 3rd Trimester: __________mmHg Headache ( ) Present ( ) Absent

RESPIRATORY SYSTEM Narrative discussion of respiratory system findings: A. Observe for quality of respiration: ( ) Eupneic ( ) Dyspneic ( ) Shortness of breath B. Check respiratory rate: __________ cpm C. Observe for anterior view and AP view of chest (Check ratio)

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( ) Normal ( ) Pectus Excavatum ( ) Pectus Carinatum D. Perform tactile fremitus (Posterior) ( ) Regular ( ) Increased Vibration ( ) Diminished Vibration E. Lung Expansion: ( ) Regular/ Symmetrical ( ) Asymmetrical F. Percuss sound @ lung field ( ) Resonant ( ) Dull ( ) Flat ( ) Tympanic G. Auscultate breath sounds (Posterior and Anterior): ( ) Clear ( ) Adventitious ( ) Wheezing ( ) Crackles ( ) Others: ___________ H. Check presence of cough: ( ) None ( ) Present ( ) Productive ( ) Non-productive I. Other changes: Slight hyperventilcation (SOB): ( ) Present ( ) Absent Nasal congestion ( ) Present ( ) Absent change in voice ( ) Present ( ) Absent epistaxis ( ) Present ( ) Absent edema of nasal mucosa ( ) Present ( ) Absent

Subjective Cues

Nursing Diagnosis

MUSCULOSKELETAL SYSTEM Narrative discussion of musculoskeletal system findings:

A. Mobility: ( ) Ambulatory ( ) Ambulates with assistance or with assistive device ( ) Not ambulatory Observe for gait: ( ) Effortless ( ) Spastic ( ) Waddling ( ) Zigzagging Observe for posture: ( ) Erect ( ) Scoliotic ( ) Lordotic ( ) Stooping B. Presence of musculoskeletal deformity: ( ) None ( ) Present Specify: _____________________ C. Presence of any orthopedic devices: ( ) Cast ( ) Traction ( ) Prosthesis ( ) Others: ________ D. Muscle tone/ strength (Tardieu Scale): ( ) No resistance through passive movement ( ) Slight resistance through passive movements ( ) Presence of clonus at certain angles ( ) Rigid limb and joint E. Range of motion: ( ) Full ( ) Partial F. Presence of pain: ( ) Absent ( ) Present only during ambulation ( ) Present: ________ Pain score ( ) Sprain ( ) Strain ( ) Fracture G. Postural changes

Subjective Cues

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Lumbosacral curve ( ) Present ( ) Absent Back pains and cramps ( ) Present ( ) Absent Waddling gait ofpregnancy ( ) Present ( ) Absent

Nursing Diagnosis

SENSORY PERCEPTION Narrative discussion of sensory perception findings:

Eyes A. Eyebrows and Eyelids ( ) No structural aberration/ Symmetrical ( ) Drooping of Eyelids ( ) Right ( ) Left ( ) Both B. Conjunctiva ( ) Pinkish ( ) Reddish ( ) Pale C. Sclera ( ) White ( ) Reddish ( ) Yellowish D. Visual Acuity ( ) Normal ( ) Far Sighted ( ) Near Sighted E. Six Cardinal fields of gaze ( ) Normal/ symmetrical ( ) Assymetrical F. Cover/ uncover: ( ) Stable ( ) Unstable G. Corneal reflex: ( ) Aligned ( ) Not aligned/ Not centered H. Pupillary reflex: ( ) PERRLA ( ) non PERRLA Ears

A. External ear: ( ) Symmetrical ( ) Non-symmetrical B. Ear canal: ( ) Patent ( ) Excessive cerumen C. Whisper test: ( ) Receptive ( ) Has difficulty hearing ( ) Non-receptive Weber’s test: ( ) Lateralization ( ) No lateralization Rinne’s test: ( ) + ( ) – Nose A. External structure: ( ) Regular/ symmetrical ( ) Obvious deformity B. Nostrils: ( ) Patent and intact ( ) Obstructive ( ) Excessive secretions C. Sense of smell: ( ) Intact ( ) Has difficulty ( ) Absent

Subjective Cues

Nursing Diagnosis

INTEGUMENTARY SYSTEM Narrative discussion of integumentary system findings:

A. Skin integrity: ( ) Intact ( ) Lesions/ Ulcerations Location: ___________________ ( ) Rashes Location: ___________________ ( ) Bruising Location: ___________________ B. Skin Color: ( ) Regular ( ) Discoloration ( ) Erythema ( ) Cyanosis ( ) Pallor ( )Jaundice ( ) Hyperpigmentation Location: ___________________ Skin Temperature: ( ) Regular ( ) Warm to touch ( ) Cold and clammy C. Skin pinch: ( ) Normal ( ) Delayed

D. Edema: ( ) Absent ( ) Present:

Subjective Cues

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( ) Non-pitting ( ) Pitting: ( ) +1 ( ) +2 ( ) +3 ( ) +4 E. Others Hyperactive sweat and sebaceous glands Palmar erythema and angiomas Hair and nails- grow faster but becomes thinner and softer

Nursing Diagnosis

GASTROINTESTINAL SYSTEM Narrative discussion of gastrointestinal system findings:

A. Appetite: ( ) Normal ( ) Loss of appetite B. Oral Mucosa: ( ) Pinkish ( ) Pale ( ) Bleeding noted C. Teeth: ( ) Well embedded ( ) Incomplete/ Dental Caries noted D. Bowel Sound: ( ) Normal: 5-15 per minute

( ) Hypoactive: <5 per minute ( ) Hyperactive: >15 per minute ( ) Absent

E. Bowel Movement: ( ) Regular Frequency (Last 24 hours):________ ( ) Loose bowel movement ( ) Constipated

F. Abdominal Pain: ( ) Absent ( ) Present Location:____________________ Rebound tenderness: ( )+ ( )- Board-like abdomen: ( )+ ( )- G. Vomiting: ( ) Absent ( ) Present Frequency (within 24 hours):____________ H. Other Changes: Heartburn (pyrosis) and flatulence: ( ) Present ( ) Absent Low appetite: ( ) Present ( ) Absent Constipation: ( ) Present ( ) Absent Epulis of pregnancy: ( ) Present ( ) Absent Ptyalism: ( ) Present ( ) Absent Hemorrhoids: ( ) Present ( ) Absent Pica: ( ) Present ( ) Absent I.Metabolic Chnages: Edema: ( ) Present ( ) Absent Increased body tempareature ( ) Present ( ) Absent Weight gain: ( ) Present ( ) Absent Fatigue: ( ) Present ( ) Absent

Subjective Cues

Nursing Diagnosis

ENDOCRINE SYSTEM Narrative discussion of endocrinal system findings:

Increase BMR

Slight hyperplasia of the thyroid

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Increase milk production

Increase HCG: (+) pregnancy tests

Gestational diabetes

Subjective Cues

Nursing Diagnosis

NEUROLOGIC SYSTEM Narrative discussion of neurological system findings:

A. Level of consciousness: ( ) Fully conscious ( ) Lethargic ( ) Stuporous ( ) Comatose B. Coherence: ( ) Coherence ( ) Incoherent C. Orientation: ( ) Oriented ( ) Disoriented D. Mood and affect: ( ) Appropriate ( ) Inappropriate ( ) Flat E. Cerebellar Function (Upper Extremity): Rapid Alternating Movement: ( ) Coordinated ( ) Uncoordinated

Finger to nose: ( ) Coordinated ( ) Uncoordinated Finger-thumb: ( ) Coordinated ( ) Uncoordinated Alternating touch to nose: ( ) Coordinated ( ) Uncoordinated F. Cerebellar function (Lower extremity): Heel-shin test: ( ) Coordinated ( ) Uncoordinated Gait: ( ) Coordinated ( ) Uncoordinated G. Balance: Tandem walk: ( ) Well balanced ( ) Imbalanced Romberg’s test: ( ) Coordinated ( ) Uncoordinated H. Deep tendon reflex:

Site +1 +2 +3 +4

Brachial

Tricep

Patellar

I. Babinski Reflex: ( )+ ( )-

Subjective Cues

Nursing Diagnosis

LYMPHATIC SYSTEM Narrative discussion of Lymphatic system findings:

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Tonsils: ( ) +1 ( ) +2 ( ) +3 ( ) +4

Lymph Nodes +1 +2 +3 +4

Pre auricular

Post auricular

Occipital

Sub mental

Sub mandibular

Lymph Nodes +1 +2 +3 +4

Tonsillar

Superficial Cervical

Deep Cervical Chain

Posterior Cervical

Supraclavicular

Subjective Cues

Nursing Diagnosis

GENITO-URINARY SYSTEM Narrative discussion of genitourinary system findings:

A. Discharges: ( ) Absent ( ) Present Color: ( ) Bright red ( ) Dark red ( ) Brown/Pinkish ( ) White/ pale yellow

Amount: ( ) Heavy ( ) Moderate ( ) Light Odor: ( ) present ( ) absent

B. Pain/ Itching in genitalia: ( ) Absent ( ) Present C. Bladder: ( ) Normal ( ) Distended ( ) Incontinent D. Urination:

Pain: ( ) present ( ) absent Color: ( ) Amber ( ) Tea colored ( ) Blood tinged ( ) Cloudy ( ) Clear Odor: ( ) present ( ) absent

Frequency: ___________ times ______________mL Glycosuria: ( ) Present ( ) Absent

Lactosuria: ( ) Present ( ) Absent

Subjective Cues

Nursing Diagnosis

REPRODUCTIVE SYSTEM Narrative discussion of reproductive system findings:

A. ANTENATAL

a. Uterine Changes (Hegar’s) b. Braxton Hick’s Contractions c. Amenorrhea d. Cervical changes (Goodel’s)

e. Leucorrhea f. Changes in the breasts

Subjective Cues

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B. INTRANATAL C. POSTNATAL

a. Breast: ( ) Normal ( ) Engorged b. Uterus: ( ) Normal ( ) Contracted ( ) Fundal Height: ____

Nursing Diagnosis

COPING PATTERN

Any recent changes in patient’s life (job, death, major surgeries, recent abuse, others)?

Identify issues in self image if there is any.

Coping techniques employed in dealing with stress?

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INTERPRETATION OF CLIENT’S LABORATORY/DIAGNOSTIC RESULTS (Identify and list down all laboratory/ diagnostic results done to patient and fill out indications of such results)

Laboratory Date

Performed

Actual Result Normal Value

(Reference)

Significance of the

Result

Diagnostic

Procedures

Date

Performed

Actual Result Normal Value

(Reference)

Significance of the

Result

Reference:

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ANATOMY AND PHYSIOLOGY (10 pts) (Label and explain the functions of the affected organ or body part.)

Reference:

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COMPLICATIONS OF PREGNANCY (10 pts)

Reference:

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OBSTETRICAL MANAGEMENT (10 pts) (Write the definition and nursing responsibilities for any ideal/actual management) 20 pts.

IDEAL MANAGEMENT ACTUAL MANAGEMENT a. Laboratory Examinations

b. Diagnostic Procedures

c. Treatment

d. Medication

e. Diet

f. Activity/ Exercise

g. Referral

(Note: Please provide additional pages if needed) References:

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OUTLINE OF NURSING MANAGEMENT (10 pts)

(Give at least five (5) ideal Nursing Management according to Priority Goals of Care)

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DRUG STUDY (10 pts)

Name of Patient: (Initials only)______________________________________ (Write all the drugs/ medications presently prescribed)

Name of drug Generic and Brand name

Date ordered

Dose, frequency,

route and time

Specific Indication

Classification Mechanism of action Side Effects Nursing Responsibilities

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Tel. No.: (032) 346-9292

NURSING CARE PLAN (20 pts)

Name of Patient: (Initials only) _______________________________________ (Make a nursing care plan from the identified priority nursing problems)

Assessment Nursing Diagnosis Client Goal Nursing Intervention Rationale Outcome Criteria Actual Evaluation S: O:

Scientific Basis:

Reference:

Independent:

Dependent:

Collaborative:

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SUMMARY PERFORMANCE EVALUATION ACHIEVING

OBSTETRICAL CARE COMPETENCY (In accordance with PRC Board of Nursing Memorandum No. 01 Series 2009)

POSTPARTUM COMPETENCIES Desired Rating

1st RLE 2nd RLE 3rd RLE

I. Safe and Quality Nursing Care

1. Obtain obstetrical and delivery history like problems encountered and managements performed.

2

2. Monitor vital signs and well being` 1

3. Conducts P.E. during postpartum period.

a. Breast Inspect for redness, amount of breast milk

secretions. Palpate for presence of warmth and tenderness.

2

2

b. Uterus Palpate the uterus to check for signs of uterine

atony Massage uterus upon the first sign of uterine

relaxation. Assess for uterine evolution.

2

2

1

c. Bladder Palpate the bladder immediately after the delivery.

If with catheter, check if patient has voided after 6-8 hours from the time the catheter was removed.

2

2

d. Bowel Assess for presence of constipation. Assess for factors that delays bowel movement such

as presence of episiotomy.

1 2

e. Lochia Assess for amount, color and odor. Assess the number of pads used in 4 hours. Assess Lochia:

Every 15 minutes for the first hour Every 30 minutes for the next 2 hours Every 4 hours for the next 24 hours

Every 8 hours until the patient is discharged

2 1 1

f. Homan’s sign 2

g. Episiotomy 2

II. Management of Resources and Environment

1. Utilizes available resources in the unit to manage

patient’s problem like hypo/hyperthermia, keeping uterus firm and well contracted and early ambulation.

2

2. Emphasize the importance of breast milk for the child’s development.

2

III. Health Education

1. Breast Cleanse using plain water only Encourage early breast feeding Teaches different breast feeding positions Teaches to include the whole areola during breast

feeding

2

2. Uterus Teach the patient the normal position of the fundus

postpartum

1

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Assist the patient in palpating her normally contracted fundus and to immediately inform

should there be any signs of uterine relaxation to the medical staff.

2

3. Bladder Educate the patient the importance of urinating 4-6

hours after delivery and prior to palpation of fundal height.

Teach the patient how to promote urination: Soak the hands on tepid/ cold water Let the patient hear running water

Pour warm water over the perineum. Refer to physician if all conservative measures to promote urination fails.

2

2

4. Bowel Educate about the importance of high fiber diet Teach how to increase fluid intake

Use of stool softeners if conservative measures fail

2 1

1

5. Lochia Educate importance of perineal hygiene, amount,

color and odor of lochial discharges to the patient.

2

IV. LEGAL RESPONSIBILITIES

1. Secure informed consent in all procedures 2

2. Document all the assessment/ abnormalities noticed and interventions done during postpartum period.

2

3. Consider legalities of actions in performing both independent

2

V. ETHICO-MORAL RESPONSIBILITY

1. Respect the religious, culture, and ethnic practices of the patient and family.

2

2. Promote empathy and practice patient advocate role in performing postpartum care.

2

3. Ensures safety, privacy, and confidentiality. 2

VI. PERSONAL/ PROFESSIONAL DEVELOPMENT

1. Updates oneself to the latest trends and development in postpartum care.

2

2. Projects professional image of an obstetrical nurse 2

3. Accepts criticism & recommendations 1

4. Perform functions according to standards of care. 2

VII. QUALITY IMPROVEMENT

1. Identifies deviation of practice from standards. 1

2. Recommends corrective & preventive measures for the identified deviations.

2

VIII. RESEARCH

1. Identifies researchable problems related to postpartum

care.

2

2. Initiates a research study on an identified researchable problems

1

3. Participate as a member of a research team in the conduction of a research study.

2

IX. RECORDS MANAGEMENT

1. Document accurately a relevant data about the postpartum client.

2

2. Maintain an organized system of filing and keeping records of the client.

2

X. COMMUNICATION

1. Utilize all forms of communication verbal, non-verbal, and devices appropriately.

2

2. Observe and apply the principles of communication e.g. Listening to the client’s and families queries attentively.

2

XI. COLLABORATION & TEAMWORK

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1. Function effectively as a team player in caring for a postpartum patient/s.

2

2. Establish collaborative relationship with members of the health team and family members.

2

TOTAL 80

When graded RLE’s were performed (Specify academic year and semester):

First Graded RLE: Academic Year________________ 1st Sem._____ 2nd Sem._____ Summer_______

Clinical Instructor: Name_______________________ Signature_______________________________

License Number_______________ Validity:________________________________

Second Graded RLE: Academic Year______________ 1st Sem._____ 2nd Sem._____ Summer_______


License Number_______________ Validity: ________________________________

Third Graded RLE: Academic Year_______________ 1st Sem._____ 2nd Sem._____ Summer_______


License Number_______________ Validity: ________________________________

Verified True and Correct: ______________________ License Number: _________________________

(Signature over printed name)

Clinical Coordinator Validity: __________________________________

Academic year graduated: ______________________

_______________________________________ License Number: _________________________

Dean Validity:________________________________

Signature over printed name

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GLOSSARY

Abdomen - belly, tummy

Amniotic fluid - liquid surrounding the fetus in the womb

Amniocentesis - minimal surgical procedure using a very thin needle to get a sample of amniotic fluid for

genetical or biochemical analysis

Alphafetoprotein - a protein produced by all developing babies and present in the mother´s blood. An

increased level may indicate fetal abnormalities (spina bifida…)

Breech - fetus lying in the womb upside down (buttocks down)

Cardiovascular: relating to the heart and blood vessels

Cervix - the neck of the womb, opens during labor to allow the fetus to leave the mother´s body

Contraction - cramp of the uterine muscle leading to the hardening or tightening of the stomach

Diagnostic: of, relating to, or used in diagnosis : used to help identify a disease, illness, or problem.

Dilatation- widening of the neck of the womb (cervix) during labour

Drug: a medicine or other substance which has a physiological effect when ingested or otherwise

introduced into the body

Edema - swelling, commonly in fingers or ankles during late pregnancy

Effacement of the cervix - shortening of the neck of the womb at the beginning of labor

EFM - electronic fetal monitoring (= cardiotocography), monitoring of fetal heart and uterine activity

Engagement - dropping of the fetal head or buttocks into the pelvis a short time before the baby's due

date

Embryo - the unborn baby during the first 8 weeks in the womb

Enema - lavage of lower part of bowel with warm water prior to delivery

Episiotomy - cut of perineum to enlarge the vaginal opening and prevent perineal tearing

Femur - fetal thigh

Fetus - the unborn baby in the womb from week 9 until birth

Fundus - the bottom or base of anything, e.g. the uterus

Gestation - the period of development of the unborn baby from conception until birth

Humerus - fetal arm

Hypertension - high blood pressure (hypotension = low blood pressure)

Induction of labor - artificial triggering of uterine contractions by cervical massage, breaking of water,

medication

Integumentary: comprises the skin and its appendages acting to protect the body from various kinds of

damage, such as loss of water or abrasion from outside. The integumentary system includes hair,

scales, feathers, hooves, and nails.

Laboratory: is a facility that provides controlled conditions in which scientific or technological research,

experiments, and measurement may be performed.

Lochia: the normal discharge from the uterus after childbirth

Myometrium - uterine muscle (the major part of the womb)

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Neurologic: relating to the anatomy, functions, and organic disorders of nerves and the nervous system

Normohydramnios - normal amount of amniotic fluid

Nursing: Nursing encompasses autonomous and collaborative care of individuals of all ages, families,

groups and communities, sick or well and in all settings

Obstetrics - branch of medical science which deals with pregnancy, labor and childbirth

Oligohydramnios - decreased amount of amniotic fluid

Pelvic floor - a hammock of muscles which supports the bowel, bladder and womb

Perineum - part of the female body between vagina and anus

Phenylketonuria - metabolic disease which, when untreated, can harm the development of the baby's

brain

Placenta - the organ which joins the mother with her unborn baby in the womb and which helps the

mother to protect the fetus against the environment

Polyhydramnios - increased amount of amniotic fluid

Pre-eclampsia - serious disease developing mostly in late pregnancy characterised by high blood

pressure, protein in the urine and general swelling

Premature labor - labor which starts between the 24th - 37th weeks of gestation

PROM - premature rupture of membranes (before 37th week or more than 24 hours before the onset of

labor)

Puerperium - time period of six weeks after childbirth necessary for a woman's organism to fully recover

Respiratory: relating to or affecting respiration or the organs of respiration.

Rhesus factor - specific protein on the surface of red blood cells determining rhesus factor positivity

(present) or negativity (absent)

ROM - rupture of membranes, occurs before onset of labor or during the labor

Rubella - german measles, a viral infectious disease which can cause fetal birth defects if acquired during

the first three months of pregnancy

Sensory/ Perception: occurs in organisms capable of performing neurophysiological processing of the

stimuli in their environment, and covers the processes commonly called "the senses": hearing, vision,

taste, smell and so on

Toxoplasmosis - parasitic infectious disease, which, if acquired during the first four months of pregnancy,

can cause serious fetal defects. Parasites are transmitted by certain animals or via raw meat

Trimester - any period of three months during pregnancy

Umbilical cord - the rope of three blood vessels which link the fetus to the placenta; all nutrients for and

waste products from the fetus pass through the umbilical cord

Uterus - womb, the best incubator in the world (the organ carrying and protecting the unborn baby)

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References

Emily Slone McKinney, S. R. (2017).Maternal-Child Nursing - E-Book. Canada: Elsevier Health Sciences.

M. Christine Neff, M. S. (2008).Introduction to Maternal and Child Health Nursing. Michigan: Lippincott

Williams & Wilkins.

Marcia L London, P. W.(2016).Maternal & Child Nursing Care. Canada: Pearson Education.

Mosby. (2009).Mosby's Medical Dictionary, 9th edition. Elsevier.

Pillitteri, A. (2006). Maternal and Child Health Nursing: Philippine. Chicago: Lippincott Williams & Wilkins.

Pillitteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family.

Chicago: Lippincott Williams & Wilkins.

Documents

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