COLLEGEOF NURSING

A case study submitted in partially fulfillment of the requirements For the RLE

Prepared by: Jeffrey Sibayan Martinez Jheza Loraine Mendoza Bsn 2

I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA 1. Patients Name: C.B. 2. Address:POROC,PURA,TARLAC 3. Age:22 years old 4. Sex: Female 5. Birth Date:October 23,1989 6. Rank in the Family: 10 7. Nationality: Filipino 8. Civil Status: SINGLE 9. Date of Admission: August 16,2012 10. Order of Admission: MEFENAMIC ACIDS,FERROUS SULFATE WITH FOLIC ACID,CEFELEXIN, 11. Attending Physician:Dr.GONZALES
st

B. CHIEF COMPLAINT: Patient B.C.wasadmitted in the OB ward with the chief complaint of MASAKIT ANG PUSON.

C. HISTORY OF PRESENT ILLNESS: Due to postpartum pain the patient is suffering from severe pain. D. PAST HEALTH HISTORY:

Childhood Illnesses: During herchildhood she experienced common colds 4 times in a year. Immunization: According to the patient, she has a complete immunization. Major illness: According to the patient she was not been hospitalized yet. Current Medications:none Allergies: The patient has no allergies.

E. FAMILY ASSESSMENT

NAME

RELATION

AGE

SEX

OCCUPATION

EDUCATIONAL ATTAINMENT HIGH SCHOOL GRADUATE HIGH SCHOOL GRADUATE NONE

J.P. B.C. BABY BOY

LIVE-IN PARTNER LIVE-IN PARTNER 1

ST

27 Y/O 22Y/O NEWBORN

Male Female Male

FACTORY WORKER HOUSE KEEPER NONE

CHILD

F. SYSTEMS REVIEW - Gordons 11 Functional Health Patterns 1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN: Before hospitalization according to B.C. she perceived that she is healthy when she is disease free and does not feel body weakness, fever and headache. Hinder her activity of daily living. She described herself as good. During hospitalization she considered herself as an healthy and completely different from before. She manages her health by following the doctors order and taking enough rest she easily feel weak but very cooperative in therapeutic monitoring. 2. NUTRITIONAL METABOLIC PATTERN

Appetite: According to Ms. B.C. the smell of foods not triggers her appetite.She eats 3 times a day with snack in between meals she eats more vegetable than meat. She has no difficulty in chewing and swallowing. Usual Daily Menu: Food: Rice, Vegetables, Meat, Fish, Fruits Water: 8-9 glasses of water per day Beverage: She usually drinks, softdrinks and tea sometimes Alcohol drinking occasional

3. ELIMINATION PATTERN Bowel habits: According to our patient, she defecates once a day, usually in the morning. And she using Ph care. Color: Brown Odor: Normal odor of stool Consistency:Semi-formed of stool Laxative use if any: The patient is not using laxatives

Bladder: The patient usually urinates 4-5 times a day. Color: Yellowish with transparency of turbid color Odor: Aromatic Alteration if any:none 4. ACTIVITY EXERCISE PATTERN A. Self-Care Ability O O O Others Legend Feeding Bathing IV III Toileting III III Dressing IV O Home Maintenance

Bed Mobility

Grooming

Cooking

O Full self care II Requires use of equipment or device III Requires assistance or supervision from another person IV Requires assistance or supervision from another person and equipment or device V Is dependent and does not participate 5. COGNITIVE PERCEPTUAL PATTERN A.Hearing: hearing impairment negative B.Vision: vision is good C.Sensory Perception: sensory motor positive D.Learning Style: she learns by instruction, reading and hands-on experience. 6. SLEEP REST PATTERN: Usually thepatients regularly sleep 8hour a day. She sleeps at 9:00 PM and wakes up at 8:00 AM. She sleeps together with her husband. She takes a nap in the morning and afternoon because she usually felt drowsiness. 7. SELF PERCEPTION AND SELF CONCEPT PATTERN: According to Ms. B.C., her strength is her family. Whenever there are trials that come in their way they make it a point that they are there for each other. She describes herself as jolly, industrious, and kind to others. 8. ROLE RELATIONSHIP PATTERN: Baby Boy is the 1 child of MS B.C AND MR J.P. Shes mother wake up early doing household chores like cleaning, washing clothes and her partner is going to the factory every morning and go home every nighttime. 9. SEXUALLY REPRODUCTIVE PATTERN: The patient starts her menarche at the age of 11 she consumed one pack of pad every duration of her menstruation she used 34 pads per day for seven days. Patient claims that they are having contact twice a week when she was not yet pregnant and the last time rd that they have contact was in her 4 month of pregnancy. 10. COPING STRESS TOLERANCE PATTERN: According to B.C.sheeats and watch television every time she is stressed whenever there is a fight between her and her partner prior to their lifestyle. 11. VALUE BELIEF PATTERN:
th

The patient is a Catholic influence by her family, though she is not an active church.According to Ms. B.C.they dont believein superstitious beliefs although they are Roman Catholic it doesn't mean that they also follow every beliefs being practices.She only goes to church whenever there is occasion such as Christmas Eve, Holy Friday and weddings. She believes in ghosts and other elementals. She preferred to seek help from health practitioner like the Barangay health worker midwives especially for prenatal check-ups for better result .But for untreated chronic illness; they consult on doctor in the Rural Health Unit. For mild injuries, they go to the nearest manghihilot G. HEREDO FAMILIAL ILLNESS: On the paternal side of our client, his grandfather diagnosed with hypertension and diabetes,while in her maternal side, his grandmother diagnosed anemia 4 years ago. And they have 5children namely children A.,G.J.,M, child J is the father

On the maternal side of our client, her grandfather diagnosed with hypertensionwhile her grandmother was diagnosed with asthma. And they have 10 children namely K.,D.,F.,R.,O.,P.,U.,L.,Y.,B.,. Child Bis the clients mother. H. DEVELOPMENTAL HISTORY Theorist Erickson Age Stage Five: Adolescence 12 To 18 Years Sex Male Patient Description Conflict: Identity vs. Role Confusion This stage could be a book in itself; the teenage years. They are hard on everyone, but especially the child herself. They are aware that they will become a contributor to society (industry) and the search for who they are drives their actions and thoughts. The desire to know what it is they want and believe separate from what they've adopted from their parents is crucial to their self-confidence.

Freud

Latency Period

Male

The resolution of the phallic stage leads to the latency period, which is not a psychosexual stage of development, but a period in which the sexual drive lies dormant. Freud saw latency as a period of unparalleled repression of sexual desires and erogenous impulses. During the latency period, children pour this repressed libidal energy into asexual pursuits such as school, athletics, and same-sex friendships. But soon puberty strikes and the genitals once again become a central focus of libidal energy.

Piaget

Formal operational (11 years and up)

Can think logically about abstract propositions and test hypotheses systematically Becomes concerned with the hypothetical, the future, and ideological problems

Kohlberg

Stage 3. Good Interpersonal Relationships.

Male

At this stage children--who are by now usually entering their teens--see morality as more than simple deals. They believe that people should live up to the expectations of the family and community and behave in "good" ways. Good behavior means having good motives and interpersonal feelings such as love, empathy, trust, and concern for others. Heinz, they typically argue, was right to steal the drug because "He was a good man for wanting to save her," and "His intentions were good, that of saving the life of someone he loves." Even if Heinz doesn't love his wife, these subjects often say, he should steal the drug because "I don't think any husband should sit back and watch his wife die" (Gibbs et al., 1983, pp. 36-42; Kohlberg, 1958b). The sense of identity and outlook on the world are differentiated and the person develops explicit systems of meaning.

Fowler

Stage 4 early adult

Male

I.PHYSICAL ASSESSMENT A. General Survey She looks and appears at her exact age. Her sexual development is appropriate for her gender and age. She wears ordinary clothes such as t-shirt and shorts and duster Sheweights 63 kgs and 55 in height which is appropriate for herage. Her posture seems not to be relaxed. There is no body odor and breath odor. Her body movements are voluntary and coordinated. She interacts and communicates in an appropriate manner with others. She is alert and oriented to time, place, and person. Her speech is clear and her memory is intact. B. Vital Signs: Temperature:

36.5C

Cardiac Rate:88 Respiration:19 C. Regional Exam: 1. Hair: no flakes, shiny and soft and with normal hair distribution upon inspection. Head: normocephalic and no lesions noted upon inspection. Face: no rashes and lesions noted upon inspection. 2. Eyes: pinkish pulp conjunctiva eyebrows symmetrically align and have equal movement. 3. Nose: with no discharges noted upon inspection 4. Ears: symmetrical and no discharges noted upon inspection 5. Mouth and throat: pink mucosal membranes, without lesions, incomplete set of teeth and with dental carries noted upon inspection 6. Neck and lymph nodes: no thyroid enlargement upon palpation and inspection 7. Nails: cut and clean nails and with intact epidermis return to usual color after pressing. 8. Thorax and lungs: theres no wheezing sounds heard upon auscultation 9. Cardiovascular: with regular rate and normal rhythm upon auscultation. 10. Breast and axilla: no lesions, no discharges, and no lymph nodes upon palpation and inspection. 11. Abdomen: elevated abdomen with stretch mark, normal abdominal sound upon IPPA. 12. Extremities: with rashes inspected on both upper and lower extremities. 13. Genitals: bulging with bloody mucous secretion. 14. Rectum and anus: not performed 15. Neurological/cranial nerves: not performed

II.PERSONAL / SOCIAL HISTORY a) b) c) d) e) f) g) h) i) j) k) Habits/Vices: watching television, eating and walking. Caffeine :twice a day Smoking: negative Alcohol:occasional Tea: sometimes Drugs: negative Lifestyle: she and her partner was totally independent living with the mothers parents, they live in a boarding house. Social Affiliation: none th Rank in the family: 10 in the siblings Travel: none Educational attainment: High school graduate

III. ENVIRONMENTAL HISTORY The patient lives in a barangay were there is average number of houses. Family is compliant with regards to the programs of the barangay such as cleanliness and orderliness. Their house is rented. They have their own comfort room and deep well as a source of their water. Their drainage is sealed and it is being cleaned by her partner. IV. PEDIATRIC HISTORY CHIEF COMPLAINT Labor pain ASSESSMENT DIAGNOSIS Pregnancy uterine 41 weeks and 2 day age of gestation cephalic in labor FINAL DIAGNOSIS Pregnancy uterine delivered spontaneously to an a line term cephalic baby boy weight 3.2kg length 48 cm Normal spontaneous delivery with repair of perennial laceration Placenta expelled spontaneously

Intravenous fluid with oxytocin The mother condition at the time the delivered, the mother isconscious a. Maternal and Birth History: b. Mother Bleeding with anesthesia August 16, 2012 3.2 kilograms Normal spontaneous delivery Tarlac Provincial History

c. Neonatal Breast feeding

V. INTRODUCTION Signs and Symptoms of Labor A vaginal delivery occurs after the mother has gone through labor which dilates her cervix, or the opening to the uterus, to 10cm. Labor also moves the baby into the birth canal. Contractions occur during labor to accomplish these tasks, and are different than the practice contractions, or Braxton Hicks, which are felt throughout pregnancy. Labor contractions are intense, and do not go away with rest. As labor progresses, it becomes more difficult to talk through them. The mucous plug, which is formed to protect the uterus from bacteria, may be passed at the onset of labor. Additionally, a woman's water may break, with contractions soon to follow. Stages of Labor Three stages of labor exist, according to the University of Minnesota, signaling an impending delivery. The first stage of labor occurs as contractions work to thin and dilate the cervix to allow the baby to pass through. The second stage begins when complete dilation to 10cm has occurred, and the body changes gears to deliver the baby. During the second stage, pushing occurs. The mother may be coached to push, or she may be instructed to push when she feels the need. The second stage ends with the birth of the baby. The placenta, the organ which provides nourishment for the baby while in the womb, is delivered during the third stage of labor. Contraindications

Several factors can influence the ability of a spontaneous vaginal delivery to occur. According to the American Academy of Family Physicians, these include complete placenta previa, herpes virus with active lesions, previous classic uterine incision and untreated HIV infection. Placenta previa occurs when the placenta forms over the cervix. Attempted vaginal delivery could cause severe hemorrhage, and possible maternal and fetal death. A classic uterine incision is a vertical incision, instead of the customary horizontal one. Classic incisions cut through more of the uterine wall, and increases the risk that the uterus could rupture. With active herpes or untreated HIV, both infections are more readily passed to the baby during a vaginal birth. VI. ANATOMY AND PHYSIOLOGY External

Our overview of the reproductive systems begins at the external genital area or vulva which runs from the pubic area downward to the rectum. Two folds of fatty, fleshy tissue surround the entrance to the vagina and the urinary opening: the labia majora, or outer folds, and the labia minora, or inner folds, located under the labia majora. The clitoris, is relatively short organ (less than 1 inch long), shielded by a hood flesh. When stimulated sexually, the clitoris can become erect like a mans penis. The hymen, a thin membrane protecting the entrance of the vagina, stretches when you insert a tampon or have intercourse.

Internal

Reproduction: In the reproductive process, two kinds of sex cells or gametes are involved. The male sperm, and the female egg or ovum. These two cells meet in the female's reproductive system to create a new individual. The egg is fertilized in the uterine tube and implanted in the uterus. Both the male and female reproductive systems are essential for reproduction. The female needs a male to fertilize her egg, even though she is the one who carries the offspring through pregnancy and childbirth.

Internal Genitals

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. The perimetrium (outermost layer), myometrium (middle layer), endometrium (innermost layer). The endometrium is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the penis. The myometrium layer has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The perimetrium layer is especially important with delivery of a fetus and placenta because of it's muscular walls. Purposes of the Vagina Receives a male's 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, Fem Cap, Nuva Ring, IUD, or female condom. Cervix The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. The location where they meet forms an almost 90 degree angle. 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 portiovaginalis or exocervix. On average, the exocervix 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 exocervix's opening is called the external os. The size and shape of the external os and the exocervix 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 exocervix 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. Uterus 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 and massaged by nurses after the baby is born to help return the uterus to normal size. Massaging helps to stimulate contractions.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 and the cervix may or may not be removed. 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. This is not always necessary and can be monitored with blood analysis. Fallopian Tubes or uterine tubes At the upper corners of the uterus are the fallopian tubes (uterine tubes). There are a total of two uterine tubes. One on each side of the uterus. Each uterine attaches to a side of the uterus and connects to an ovary on the same side of attachment. They are positioned between the ligaments that support the uterus.

Ovaries: Women have an ovary on each side of the uterus. Each month the ovaries release an egg which is then fertilized or sloughed off. They also produce estrogen and progesterone which help with reproductive function. Sometimes 2 eggs are released and if fertilized by sperm, non-identical or fraternal twins (could be two boys, two girls, or a boy and a girl) develop in the uterus. Ovarian cysts form when an egg in the ovary begins to mature and grow but is not released. It can cause pain if it twists and infection and possible death if it bursts. Generally the body will reabsorb these eggs, but if it continues to grow it must be surgically drained or removed. Surgery includes removal of the ovary in many cases. Sometimes this ovarian cyst occurs when a woman is pregnant. Other times it can be brought on due to extreme stress or a predisposed genetic condition. If one ovary is removed, there is still a good chance of becoming pregnant and releasing enough estrogen to help regulate body needs.

Uterine Full Term

Mechanism of labor

VII. PATHOPHYSIOLOGY

Labor Process Pain in the abdominal tract

Pressure

Increment

Uterine contraction

uterine relaxes

Decrement

Effacement

Increase the diameter of the cervical canal filled membranes press against the cervix

Cervical dilation begins

Fluid

Cervical Dilation occur more rapidly

Increase vaginal secretions and perhaps Spontaneous rupture of the membrane

Contractions reach their peak of intensity

Causing maximum dilation

They will rapture as a rule of pull dilation

Sensation in abdomen maybe so intense

Contractions change from the characteristics crescendo-descrescendo

Fetal presenting part as its widest diameter reaches the level of the ischial spine of the pelvis

Downward movement of the biparietal diameter of fetal head until it reaches the pelvic in let

Shortest head diameter passes through the pelvis

Fetal head passes beneath the symphysis pubis

Shoulder rotate internally to fit the pelvis

Expulsion occurs first as the anterior

Then the posterior shoulder passes under the symphysis pubis

After the shoulder delivery rest of the body follows

Folding the separation of the placenta occur

Active bleeding on the maternal surface of the placenta begins and separation

Separation Completed

The placenta sinks to the lower uterine segment of the upper vagina

The placenta is delivered either by the natural bearing down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician

Stage 1 Latent Phase

Beginning with stage 1 of the stages of labor, stage 1 has 3 distinct phases. Dont confuse stages with phases. During phase 1 (latent phase) the cervix is at a dilation of around 1 4 cm. Contractions occur every 15 30 minutes with duration of 15 30 seconds and are of mild intensity. In phase 1 the mother is very chatty and excited to be in labor. Burn off that extra fat that baby left behind!!! The mother and father should be an active part of the care in this phase. Comfort is of the utmost importance, mother should seek assistance with changes in position and walking. Mother should also drink lots of fluids or ice chips. Voiding every 1 2 hours is important at this point. Stage 1 Active Phase In the active phase of stage 1 the cervix is dilated to 4 7 cm. Contractions take place every 3 5 minutes with duration of 30 60 seconds and are of moderate intensity. The mother becomes restless and anxious and because of this may have feelings of helplessness. For this reason it is important to keep the mothersbreathing pattern effective, keep the room as quiet as possible. Mother and father should be kept informed of the progress. Comfort measures used in this phase include back rubs, sacral pressure, support with pillows, and changes in position. Effleurage or Swedish massage should be done by the husband; medical staff can show him what to do. Mother can use ointment for dry lips and continue to drink fluids or ice chips and should void every 1 2 hours. Stage 1 Transition Phase During the transition phase of stage 1 the cervix is dilated to 8 10 cm. Contractions are occurring every 2 3 minutes with duration of 45 90 seconds and are of strong intensity. At this point the mother has become exhausted, is edgy and irritable, and feels out of control. The mother should rest between contractions to conserve energy. Mother should be awakened at beginning of a contraction so she can begin her breathing pattern. Continuing fluid intake or ice chips and voiding every 1 2 hours is important. Stages of Labor: Stage 2 Finally we move on to stage 2, of the stages. During stage 2 dilation of the cervix is complete. The progress of this stage of labor is measured by the changes in fetal station, which means the descent of the babys head through the birth canal. Contractions occur every 2 3 minutes with duration of 60 75 seconds and the intensity continues to be strong. The mother will feel and urge to bear down and the medical staff will assist the mother in her efforts to push. An increase in bloody show will occur. The vital signs of the mother are important to monitor at this point. The babys heart rate will be monitored before, during, and after a contraction. The normal heart rate of a baby is 120 160 beats a minute. Mother should be helped into positions of comfort and that assist in her efforts to push such as side-lying, squatting, kneeling, or lithotomy. The bulging of the mothers perinea area or seeing the babys head are signs the birth is about to occur.

Stages of Labor: Stage 3

At stage 3 of the stages of labor the baby has already been born. Stage 3 is the delivery of the placenta. Contractions will continue until the placenta is born. The placenta separates from the wall and natural removal occurs by uterine

contractions. The birth of the placenta takes place 5 30 minutes

after the birth of the baby. There are two different mechanisms of birth of the placenta that can happen; they are Dirty Duncan or Shiny Schulzes. For Duncans mechanism the margin of the placenta separates, and the dull, red, and rough maternal surface emerges from the vagina first. For Schulzes mechanism the center portion of the placenta separates first, and its shiny fetal surface emerges from the vagina. The mother has her vital signs and uterine fundus location checked. The fundus, at this point, is located 2 fingerbreadths below the umbilicus (belly button). The placenta will be checked for the presence of cotyledons (lobes of placenta), to make sure none of the placenta is missing, including making sure that the placenta membranes are intact. Mother may begin to shiver do to a decrease in body core temperature, provide blankets to warm up. Medical staff should promote baby-mother attachment.

Stages of Labor: Stage 4 Stage 4 extends 1 to 4 hours after delivery. During this time the mothers blood pressure will return to pre-labor level, pulse is decrease than that of the labor pulse. The fundus remains contracted; this is normal and essential. Fundus is midline 1 2 fingerbreadths below the umbilicus (belly button). Lochia is scant and red. (Lochia is a discharge from the vagina after birth to 6 weeks and progresses as follows: mostly blood, followed by a more mucous fluid that contains dried blood, and later a clear-to-yellow discharge.) Checking the mother frequently after birth is important. She is checked first every 15 minutes for 1 hour, then every 30 minutes for an hour, and lastly every hour for 2 hours. Comfort is important at this stage of labor. Give the mother warmed blankets if possible, ice to the perinea area to decrease swelling, teach the mother to massage her uterus to prevent a boggy uterus, the uterus should stay firm. Teach the mother how to breast feed and ask open ended questions to promote conversation about breast

VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS DATE: August 16, 2012 at 7:00pm BLD. TYPE B+ CBC TEST

HEMATOLOGY REPORT

DIAGNOSTIC WBC NEU LYM MONO EOS BASO

RESULT 13.3 11.9 .460 .318 .004 .043 10e3/uL 94.4% 3.11% 2.15% .030% .291%

REFERENCE VALUE 5-10

22-40% 4-8%

RBC

4.18

10e6/uL

F: 4.0-54.5 M: 4.5-5.0

HGB

117g/l

F: 120-160 M: 140-170

HCT

.369L/L

F: 36-47 M: 42-52

MCV MCH

88.3 /L 27.9 pg

MCHC RDW

316. g/L 14.6%

PLT MPV

260. 6.44fL

10e3/uL

150-400

ANTHROPOMETRY

HEIGHT 48 CM WEIGHT 3.2 KG TEMPERATURE 37 C TIME OF DELIVERY 9:47pm

HEAD CIRCUMFERENCE 32CM CHEST CIRCUMFERENCE 33CM ADOMINAL CIRCUMFERENCE30CM NATURE OF DELIVERY: NORMAL SPONTANEOUS DELIVERY

APAGAR SCORING APPERANCE 2PINKK IN COLOR

PULSE RATE 2 ABOVE 100 GRIMACE ACTIVITY LOUD CRY,GRIMACE 2GOOD FLEXION

RESPIRATORY RATE 2 GOOD,LUSTY VIGOROUS CRY

TOTAL SCORE 10

INTERPRETATION 0-3 POOR SEVERELY DEPRESSED NEEDS RECISCITATION 4-6 FAIR MODERALY DEPRESSED NEED SUCTIONING AND OXYGEN 7-10 GOOD HEALTH NEWBORN NEEDS ROUTINE ADMISSION CARE

REFLEXES ASSESS DURING THE POSTPARTUM CARE IRRITATING REFLEX AND SUCKING REFLEX ROUTING RERLEX PLANTAR RESPONSE PALMAR RESPONSE

LMP November 01, 2011 EDC August 08 2012 AOG 41 weeks and 2 days DATE August 16, 2012

POSTPARTUM ORDERED Back to the ob ward Iv fluid to be consume Diet as tolerated Place ice pack over the fundus and massage as order

IX. NURSING CARE PLAN ACUTE PAIN

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Masakityungsugatko

Acute pain related to physical injury as manifested by protective gestures.

STO: After 30 minutes of nursing intervention within the 12hour shift the patient pain will be relieve pain.

Provide comfort measures, quiet environment, and calm activities.

STO: Provide comfort measures, quiet environment and calm activities. Goal partially met after 30 of nursing intervention the pain is controlled as stated by the patient and the pain scale is 4;10.

OBJECTIVE: Weak in appearance - Positioning to avoid pain - Protective gestures - Facial grimace - Pale - Pain scale 6:10 V/S AS FOLLOWS: BP: 120/80 PR: 75 RR: 23 TEMP.: 38.4 -

LTO: After 2 hours of continuous nursing intervention and health teaching the patient will be able to demonstrate use of relaxation skills and diversionalactivity as indicated for individual situation.

Instruct and encourage the patient to deep breathing exercise and use of relaxation technique.

To distract attention and reduce tension. LTO: Goal met, after 2hours nursing intervention and health teaching the pain is relieved. To prevent fatigue.

Encourage adequate rest periods.

Administer analgesics as ordered

To maintain acceptable level of pain.

X. DRUG STUDY ( MEFENAMIC ACID ) Dosage: 500mg PO followed by 250 mg q 6 hours as needed. Do not exceed 1 week of therapy. Indication: relief of moderate pain when therapy will not exceed 1 week. Treatment of primary dysmenorrhea

MECHANISM OF ACTION

SIDE EFFECTS

CONTRAINDICATION Contraindicated with hypersensitivity to mefenamic acid and aspirin allergy.

ADVERSE REACTION

NURSING CONSIDERATION

Anti-inflammatory, analgesic and anti-pyretic activities related to inhibition of prostaglandin synthesis; exact mechanism of action are not known.

CNS: headache, dizziness, insomnia, fatigue, ophthalmic effect. DERMATOLOGIC: rash, pruritus, sweating, dry mucous membrane, stomatitis. GI: nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation, flatulence GU: dysuria, renal impairment. HEMATOLOGIC: bleeding, platelet inhibition with higher dosage, neutropenia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, Agranulocytosis, decreased Hgb or Hct, bone marrow depression RESPIRATORY: dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitis

HISTORY: Allergies, renal, hepatic, CV, GI conditions; pregnancy; lactation PHYSICAL: Skin color and lesions; orientation, reflexes, ophthalmologic and audiometric evaluation, peripheral sensation, P edema, R, adventitious sounds, liver evaluation; CBC, clotting times, LFTs, Renal function test, serum electrolytes, stool guaiac.

Use cautiously with asthma, renal or liver dysfunction, peptic ulcer disease, GI bleeding, hypertension, CHF, pregnancy, lactation.

Interventions: Give with milk or food to decrease GI upset. Arrange for periodic ophthalmologic examinations during long term therapy.

DRUG STUDY (FERROUS SULFATE) DOSAGE: Daily requirements: Men, 10 mg/day PO; Women, 18 mg/day PO; Pregnant and lactating women, 30-60 mg/day PO. Replacement in deficiency states: 90-300 mg/day (6mg/kg/day) PO for approximately 6-10 mo may be required. INDICATIONS: Prevention and treatment of iron deficiency anemias, dietary supplement for iron; Unlabeled use: supplemental use during epoetin therapy to ensure proper hematologic response to epoetin. MECHANISM OF ACTION SIDE EFFECTS CONTRAINDICATION ADVERSE REACTION CNS: Elevates the serum iron concentration, which then helps to form Hgb or trapped in reticuloendothelial cells for storage and eventual conversion to a usable form of iron. Contraindicated with allergy to any ingredient; sulphite allergy; hemochromatosis, hemosiderosis, haemolyticanemias. CNS toxicity, acidosis, coma and death with over dose. NURSING CONSIDERATION Confirm that the patient does have iron deficiency anemia before treatment.

GI: Use cautiously with normal iron balance; peptic ulcer, regional enteritis, ulcerative colitis. GI upset, anorexia, nausea, vomiting, constipation, diarrhea, dark stools, temporary staining of the teeth ( liquid preparations )

Give drug with meals (avoiding milk, eggs, coffee, and tea) if GI discomfort is severe, and slowly increase to build up tolerance.

administer liquid preparations in water or juice to mask the taste and prevent staining of teeth; have the patient drink solution with straw.

Warn patient that stool may be dark or green.

Arrange for periodic monitoring of Hct and Hgb levels.

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY Acute pain related to physical injury XII. ONGOING APPRAISAL The patient shows progressive recovery and is responding well to both medical and nursing intervention.

XIII. DISCHARGE PLAN (HEALTH TEACHING)

Medication: Instruct Ms. B.C.to take all the necessary medicines that the doctors prescribed. Exercise: Encourage to do deep breathing exercises, dangling of feet, and ambulation with rest periods DIET: Eat nutritious foods such as vegetable and citrus fruits Treatment: Instruct to increase oral fluid intake Clinical follow up: Instruct the patient to come of scheduled check up on time. instruct the mother regarding benefits of breast feeding to the infant instruct the mother regarding benefits of the immunization of her newborn

Danger Signs: Instruct the patient to seek medical advice if she is experiencing pain, bleeding regarding condition.

OBJECTIVES GENERAL: The main aims of the case study is to disseminate and impart knowledge and skill to nursing staffs, client nursing student, health provider and intervened individual and of our soundings with regard of the stages of labor its definition cause and effects as well as its management. SPECIFIC: To identify the patient health history that may serve as our base line for our study. To be aware of the pathophysiology , labor process and postpartum care To list down the diagnostic studies intervened to the patient and be able to interpret and understand To classify and the sturdy the drug prescribed to the patient

To formulate precise nursing care plan for the patient to meet his normal levels of functioning To enhance our communication skill To enhance our research skill To developed team work To know the differences and effectives of the different procedure To provide the significance of the study for nursing education nursing research and nursing practice To know exactly what nursing intervention should be done to client suffering from acute pain

SIGNIFICANCE OF THE STUDY NURSING EDUCATION This case study helped the research gain theoretical concept about the precise nature and stages of labor. Knowledge is improved and extended during the interaction of the research to our patient .the collaborate of personnel within the health care team will enhance and benefit the knowledge of care and information about stages of labor or labor process as student nurse we believe that preparation of skill and care come from the knowledge and understand of the dilemma and problem to know the assessment is to know the case that needs to be implemented within the idea of the problem. NURSING PRACTICE This case study has improved the skill of the result of the researchers in providing appropriate care forpatient with after delivery . it take more knowledge and skill to render practice than not knowing the background information in need to apply the action by providing such need to health care in our patient would establish a base line generality of what can be made due to precision and understanding of the causes by processing such information as health advocates provider and team may produce better to client and patient to these cases NURSING RESEARCH This case study will serve as a reference for other student nurses as well as health care professionals in adopting quality facts and information regarding the stages of labor or labor process.This will enhance our understanding and knowledge torendering quality nursing care to patients having it. With the knowledge given within the mass archives of medical research it can be passed on to other health advocate of health care team. This would add on to the helpful facts that can be compromised within the sector of heath personnel and add to the discrepancy of creating much more help for future problems of the same findings.

ACKNOWLEDGEMENT We extend gratitude to the following that made all this things possible. First we want to thank God for giving as strength to endure all the trial and obstacles in facing the challenges in our chosen course. To Mrs.EmylynOng-Unson U.S.RN.,RN our clinical instructor for his being supportive in our case duty by sharing his comments suggestion and advice s. We would not be encouraged to bring out the best in us without your support and encouragement. And Mr. Z for being hospitable and sharing ample time for us to get the information needed in our case study. Thank you for given trust you have given to us we deeply appreciate your coordination. And most of all to our parents for all the support and belief in our capacity and for our financial support. We want to thank this opportunity in behalf of our group to thank them with all our heart and we will always keep in mind to our duties and responsibilities as public health care provider. Finally to all who made this success possible. Thank you and God Bless

Thank you and God Bless

DIABETES MILLITUS TYPE1 INSULIN DEPENDENT DM(IDDM) INSUFFECIENT INSULIN PRODUCTION JUVENILE DIABETES(PUBERTY) S/S POLYURIA POLYPHAGIA EXCESSIVE URINATION EXCESSIVE EATING HYPERGLYCEMIA-DUE TO THE CELL ACTAS OSMOTIC STARVATION WEIGHT LOSS EASY FATIGUE ABILITY GLYCOSURIA BLURRED VISION PARESTHESIA SKIN INFECTION DELAY WOUND HEALING COMPLICATION DIABETES KETOACIDOSIS SEVERE HYPER GLYCERIA WITH ACIDOSIS 300 PLUS MUCOUS LEVEL 70-110 FBS METABOLIC FAT-KETONE 90-180RBS ACIDOSIS CHON AMMONIA-CHO AND CO2 THERAPHY BLOOD GLUCOSE MONITORING INSULIN ADMINATRATION SUBCUNTANEOUS UPPER TIGHT LIPODYSTROPHY INHIBIT INSULIN DIET AND EXERCISE CARBOHYDRATES 60-70% PROTEIN 15-20% FATS 10% EXAMPLE UP TAKE OF GLUCOSE IN THE MUSCLE CELLS IT LOWER COLESTEROL AND TRIGYCERIDES

DIABETES MILLITUS TYPE2 NON INSULIN DEPPENDET DM(NIDDM) INSULIN RESISTANCE ADULT DIABETES 40-65 S/S POLYURIA POLYPHAGIA POLYDIPSIA EXCESSIVE THIRST H20 IS OSOSROTICALLY ATTACHED FROM THE BODY CELL INTRACELLULAR DEHYDRETION COMPLICATION HYPERMOLAR HYPERGLYCEMIC NON KETOTIC COMA HHNK SEVERE HYPERGLYCEMIA WITH NO ACIDOSIS THERAPHY BLOOD GLUCOSE MONITORING ORAL HYPOGLYCEMIC AGENT-OHA DIET AND EXERCISE ADDITION COMPLICATION DIABETEC RETINOPATHY-VISUAL IMPAIRMENT LOSS OF VISION DIABETEC NEUROPATHY-ABNORMAL NERVE FUNCTION STROKE ATHEROSCLEROSIS FOOT CARE WASH TERE FOOT WITH LUKWARM WATER AND SOAP AND PATH DRY