Republic of the Philippines

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
Intramuros, Manila

In Partial Fulfillment in
Maternal and Child Health Nursing II
(Lecture)

Submitted by:
Mary Rose E. Melicor
2014-10525

Submitted to:
Prof. Ronnie M. Tiamson, RN, RM, MAN, MSN
 Table of Contents

Title Page

Introduction

I. General Objectives

II. Demographic Profile

III. Chief Complaint

IV. History of Present Illness

V. Past Medical History

VI. Social History

VII. OB History/Scoring

VIII. Physical Examination

IX. Review of Systems

X. Course in the Ward

XI. Drug Study and Analysis

XII. Laboratory Results and Analysis

XIII. Nursing Care Plan

 INTRODUCTION

A high-risk pregnancy is one that threatens the health or life of the mother or her

fetus. It often requires specialized care from specially trained providers. Some

pregnancies become high risk as they progress, while some women are at increased risk

for complications even before they get pregnant for a variety of reasons. Early and regular

prenatal care helps many women have healthy pregnancies and deliveries without

complications. Risk factors for a high-risk pregnancy can include existing health

conditions, such as high blood pressure, diabetes, or being HIV-positive ; overweight and

obesity. According to the American Congress of Obstetricians and Gynecologists, more

than one-half of all pregnant women in the United States are overweight or obese. Obesity

increases the risk for high blood pressure, preeclampsia, gestational diabetes, stillbirth,

neural tube defects, and cesarean delivery. NICHD researchers have found that obesity

can raise infants' risk of heart problems at birth by 15%. Multiple births. The risk of

complications is higher in women carrying more than one fetus (twins and higher-order

multiples). Common complications include preeclampsia, premature labor, and preterm

birth. More than one-half of all twins and as many as 93% of triplets are born at less than

37 weeks' gestation. Young or old maternal age. Pregnancy in teens and women age 35

or older increases the risk for preeclampsia and gestational high blood pressure. Women

with high-risk pregnancies should receive care from a special team of health care

providers to ensure the best possible outcomes.

Pregnancy that is high risk could often lead to delivering the child via Cesarean

Section for it would be dangerous both for the mother and the baby to force doing the

normal delivery. According to Wikipedia, Cesarean section, also known as C-

section or caesarean delivery, is the use of surgery to deliver one or more babies. A

caesarean section is often necessary when a vaginal delivery would put the baby or
mother at risk. This may include obstructed labour, twin pregnancy, high blood pressure in

the mother, breech birth, or problems with the placenta or umbilical cord. A caesarean

delivery may be performed based upon the shape of the mother's pelvis or history of a

previous C-section. A trial of vaginal birth after C-section may be possible. The World

Health Organization recommends that Caesarean section be performed only when

medically necessary. Some C-sections are performed without a medical reason, upon

request by someone, usually the mother.

In our country, if you’ve delivered you previous via Cesarean Section that would

be the most common indication that you’re going to deliver your current baby via Cesarean

section too (85%). However in this case study that was not the case, the mother have

undergone Cesarean Section not because her previous pregnancy was delivered via

Cesarean Section but because the mother suffers Gestational Diabetes Mellitus (GDM)

thus resulted for the baby to be Large for Gestational Age (LGA). Aside from that the

patient also has Chronic Hypertensive Vascular Disease (CHVD), having the said

condition would be a great risk both for the baby and the mother, thus the medical

professional as well as the mother decided to do a Cesarean Section instead both for the

safety of the mother and the baby.

The student nurse chose the specific patient for this case study for the reason that

it would be a great opportunity to acquire an additional knowledge regarding the patient

who is suffering CHVD and experienced GDM. The specific case would also challenge the

student nurse on how she’s going to build rapport using her communication skills as well

as on how she’s going to make a Nursing Care Plan appropriate for the said patient.
I. General Objective:

The case study aims to gain a wide-ranging knowledge and have full understanding of the

state of the post-partum patient who has undergone two operations. The first operation

was an elective Low Transverse Cesarean Section (LTCS) due to her acquired disease

Chronic Hypertensive Vascular Disease (CHVD) and secondly, a Bilateral Tubal Ligation

(BTL), to promote an environment susceptible for recuperation and to help the patient go

back to her non-pregnant state and her optimal health before child bearing with the help

of a nursing care plans with the application of the nursing process.

Specific Objectives:

 To build a nurse-patient relationship as well as to the patients relative to have an

effective data gathering.

 To apply interpersonal communication skills to be able to collect the veracious

demographic profile and other pertinent data of the patient about her past medical,

family, and psychosocial history.

 Conducting a thorough and effective physical examination to the patient to have a

baseline data to provide an adequate nursing intervention.

 To analyze the medications given to the patient, their classifications, indications,

modes of action, side effects and the nursing considerations that must be

observed.
  To review medical other medical management given to the patient, specifically her

laboratory works-up, and be able to interpret those results on how they are

associated with the patient’s condition.

 To give appropriate health teaching for the patient’s health enhancement and

prevention of further complications.

 To formulate at least one nursing care plan based on the gathered data, the

objective cues and subjective cues gathered, appropriate with the conditions felt

by the patient, to effectively apply it and to be able evaluate the patient’s response

to these nursing care plans.

II. Demographic Data

Name: Patient E Age: 43 years old

Address: Sampaloc, Manila Gender: Female

Birthday: August 10, 1974 Birthplace: Caloocan

Occupation: None Marital Status: Single

No. of Children: 1 Religion: Roman Catholic

Educational Attainment: High School Graduate

Height: 162.56 cm Weight: 87.5 kg BMI: 34.18

Admitting Diagnosis: G5 P4 (T4 P0 A0 L4 M0) pregnancy uterine 38 3/7

weeks age of gestation cephalic in labor and with Chronic Hypertensive

Vascular Disease (CHVD) and Gestational Diabetes Mellitus (GDM)

Source of Information: Patient and chart

Date & Time of Admission: January 12, 2018/ 11:45 AM

III. Chief Complaint:

Labor pain and High blood pressure

IV. History of Present Illness

The patient detailed that she was doing her usual household routine when she

experienced pain in her nape due to her hypertension. She specified that she can bear

it at fist however the pain in her nape was suddenly followed by contractions and thus

that’s where she started to shout for his husband, asking for help and she was then

rushed to the Ospital ng Sampaloc.

V. Past Medical History

The patient acquired illnesses such as chickenpox, mumps and measles during

childhood.

The patient has a family history of Hypertension, Heart Disease, Asthma,

Diabetes and Pulmonary Tuberculosis. The patient has no allergy related to food, drug

and animals. The patient has a Chronic Hypertensive Vascular Disease (CHVD) which

is uncontrolled and experiences Gestational Diabetes Mellitus (GDM) thus her baby is

Large for Gestational Age (LGA)

VI. Social History

The female patient is 43 years and the younger of the two siblings. She has an

older brother. They are only four in the family. Her parents are still alive as well as his

brother who is now has its own family too. She arrived at the hospital accompanied by
 her living partner and they’ve been living together for 21 years. Her lived-in partner is

also the father of her four children. When asked if they’re still planning to have another

baby after their fifth, she stated that her recently delivered baby would be their last for

they already have five children and that’s enough. When I asked the patient about her

lifestyle, she detailed that she’s doing Zumba that’s why it comes to a shock when she

found out that she have a Chronic Hypertensive Vascular Disease (CHVD) however

when I asked her about her eating habits she said that she loves eating sweets and

salty food.

VII. Obstetric-Gynecologic History:

The patient had her first menstrual period when she was 14 years old. She has

an irregular menstrual period that lasts for five to seven days and uses at least five

napkins on the first and second day of her menstruation. She doesn’t experience any

abdominal pain or dysmenorrhea whenever she’s on her monthly period.

Her last menstrual period was on April 18, 2017 based on what she recalls.

The age of gestation before she delivered her baby is 38 3/7 weeks. She experienced

distresses, exhaustion and malaise during the last few weeks prior to her labor due to

her acquired diseases.

The patient’s OB Scoring is G5 P4 (T4 P0 A0 L4 M0); gravida (5), para (4),

term (4), preterm (0), abortion (0), live birth (4) and multigravida is zero.
VIII. Physical Examination

The patient’s skin is color brown, has now skin lesions, but some pigmented

area, due to production of melanocytes during labor that cause some pigmentation on

patient’s face and abdomen. Striae gravidadum is also present on the patient’s

abdomen.

There is a presence of pedal edema nevertheless the patient can still walk and

move freely since a medication have been administered to treat the edema. The nails

are symmetrical and short, it has a good circulation. There is no presence of clubbing

on the fingers.

The patient’s hair is evenly distributed, thick and color black. No lesions on the

scalp, and there is no lice or nits.

The head is normocephalic and smooth, has uniform consistency, no presence

of masses or nodules palpated on the head. The patient’s eyes are even, no

discoloration or presence of edema. Both eyes moved coordinately in unison.

The ears of the patient are symmetric in position and aligned to the outer

canthus of the eyes. Has an even color same with the facial skin. No presence of

tenderness or experiences pain when palpated.

The patient’s nose is symmetric and uniform in color. There is no presence of

obstruction that can hinder the patient’s breathing. No tenderness when palpated, and

no presence of lesions.

The patient’s lips are essentially normal, pale pink in color, the patient’s teeth

are incomplete due to cavity. The patient’s tongue is normal as well.

 There is no inflammation of nodes in the patient’s neck, has a smooth

movement and coordinated.

The patient’s chest is symmetric and there are no signs of difficulty in breathing

when inhaling and expiring.

The abdomen is slightly big however essentially normal, normal in color, but

has an uneven distribution of color due to pigmentation and there is presence of stretch

marks. Linea nigra is still present and visible.

The patient’s breast is symmetrical, has a round shape. There is no

tenderness, nodule or masses during palpation.

The patient’s genitals are slightly dark in color and has a few pubic hairs for it

has been cut due to labor. There is lochia secretions. There is no pubic lice present.

IX. Review of Systems

The patient appears to experience fatigue with no implications of headaches

and dizziness. The patient is coherent and well-oriented but verbalized that she’s

feeling a slight pain due to her suture repair. The patient can already ambulate despite

the fact of having a 1+ pedal edema and with suture due to the operation she’s

undergone.

No skin lesion has been observed on the patient’s skin, except for the presence

of scar in her right arm due to some injury. The patient also has a pigmentation on the

abdomen and striae gravidadum caused by the stretching of the skin in the abdomen

due to conception.
 There is no other verbalized feeling of discomfort aside from the fatigue and

after pain experiences because of the suture repair. The patient stated that she can

hear loud and clear. There are no complications when it comes to the patient’s vision,

there is no presence of cataracts, no blurring or other infections.

The presence of 1+ edema is evident on her lower extremities. The breasts of

the patient are tender and engorge. She doesn’t experience chest pains, but

experiences shortness of breath.

The patient can move comfortably and does not experience any muscle pain,

stiffness or joint pain, however the patient stated feeling of pain and slight difficulty in

moving because of the after effect of the operation she’d undergone.

X. Course in the ward

It was the first day of my duty in the OB ward when I first saw the patient. Like the

old times, our CI oriented us first on what would be our routine job when we are in the

ward. After doing so, our CI started to introduce to the patients that we would be

handling and instructed us on what we’re going to do for the day.

After introducing ourselves to each patients, we then dispersed and went to the

patient assigned to us. The chosen patient of mine for this case study seemed to be

fine when I saw her. Before doing everything that was instructed to me, I started first

by building rapport with my patient, so that it wouldn’t be so hard for us to talk to each

other and thus promote good communication between the two of us, in that way the

patient would also open to me and won’t be ashamed of telling me if it so happen that

I have some sensitive question. It was quite easy for me to build rapport with my patient

for she’s easy to get along with. After some talking, I started to ask her about herself,
questions about her lifestyle, and if she does know that she is Diabetic, for when I

looked at her chart she experienced Gestational Diabetes Mellitus during her

pregnancy with her fifth child. She stated that she’s not aware of it as well as the fact

that she have a Chronic Hypertensive Vascular Disease for she believed that she’s

having a healthy lifestyle for she’s doing Zumba everyday. When I looked at the

patient’s chart, I found out that two operations were performed on her, the first one

was the Low Transverse Cesarean Section (LTCS), followed by a Bilateral Tubal

Ligation (BTL). The reason for her undergoing the LCTS was because the baby was

Large for Gestational Age (LGA) for the reason that the patient suffers Gestational

Diabetes Mellitus (GDM) during her pregnancy. Regarding the Bilateral Tubal Ligation

(BTL), the patient stated that she and her husband both concurred with that decision

for the reason that it was already their fifth baby and would be a hard time to have

another one. After interviewing the patient, I took her vital signs for 4 PM for monitoring,

with the result that I got it is evident that the patient really does suffering from CHVD

for she has a high blood pressure of 130/100mmHg, when I asked her if she’s feeling

dizzy or anything, she answered that she was fine and added that it was really her

normal blood pressure. I bid goodbye to the patient after that and told her that I would

come back to get her vital signs once more for 8 PM monitoring.

After getting out of the patient’s room, I’ve observed her and I saw that despite the

fact of her delivering the baby via Cesarean Section and having a high blood pressure

she can already ambulate however she’s still just walking slowly, because of her suture

repair. Quite some hour have gone thru and I’ve decided to go back to my patient’s

room to get her vital signs once more for 8 PM monitoring. I took her vital signs and

the results slightly improved for her blood pressure deceased from 130/100mmHg to

120/90mmHg after getting her vital signs I already bid goodbye and wished her to have
a great day ahead for her baby and her family, I chatted with her a little after that and

went home after for our duty hours is finished. I asked her if she would still be in the

ward for tomorrow but she answered that she would be discharged already early in

the morning. With that said, I wasn’t able to handle my patient again the next day.
XII. Lab Results with Analysis

BLOOD CHEMISTRY

Name: Patient E Ward: OPD Date: 20-December-17

Age: 43 Sex: F

FBS: 7.83* 4.2-6.4 mmol/L SGOT _________ M up to 37 U/L

BUN _____ 1.7-8.3mmol/L F up to 31 U/L

Creatinine _____ F: 53-106 umol/L SGPT _________ M up to 42 U/L

M: 71-115 umol/L F uo tp 32 U/L

Cholesterol ______ 0.5-0.7 mmol/L OGCT (50 grams) ____ <7.8mmol/L

Triglyceride _______ 0.68-1.72 mmol/L OGTT (75 grams)

Uric Acid ________ F:140-340 umol/L 1st hour ___12.46*__ <5.8mmol/L

M: 200-420 umol/L 2nd hour___9.37____< 10.5mmol/L

ULTRASOUND REPORT

Date: December 21, 2017 Age: 43

Name: Patient E LMP: April 18, 2017

Diagnosis: PU 35 weeks 2 days EDD: January 23, 2018

 SECOND AND THIRD TRIMESTER ULTRASOUND (BPS)

General Survey: Biophysical Score

NUMBER: Singleton FETAL BREATHING: 2

PRESENTATION: Cephalic FETAL MOVEMENT: 2

CARDIAC ACTIVITY: 124 bpm FETAL TONE: 2

PLACENTA: Anterior, Grade III, High Lying AFI: 2

GENDER: male NST: 2

AFI = 16.59cm BPS SCORE 8/8

Fetal Biometry

BPD = 8.64 cm. = 34 weeks 6 day

OFD = 11.50 cm =

HC = 32.24 cm. = 23 weeks 4 days

AC = 36.66 cm. = 23 weeks 0 days

FL = 7.25 cm. = 23 weeks and 3 days

CEREB = 4.94 cm. = 36 weeks 4 days

ESTIMATED FETAL WEIGHT: 3546g (7lb 13oz)

WEIGHT PERCENTILE: >90th percentile

AVERAGE ULTRASONIC AGE: 37 weeks 1 day

Impression:

Pregnancy uterine 37 weeks 1 day by fetal biometry, live, cephalic. Singleton ale

fetus with good cardiac and somatic activities. Estimated fetal with is more than >90th

percentile for established age. Biometric ratios within normal limits

Normohydramnios

Placenta Anteior, Grade III, high lying BPS 8/8

BLOOD CHEMISTRY RESULTS

PATIENT’S NAME: Patient E DATE: October 22, 2017

REFERRED BY: --------- AGE: 43 GENDER: Female

S.I units
Examinations Results Unit Ref. Range
FBS 8.36 mmol/L 4.2-6.4
CHOLESTEROL 4.68 mmol/L 4.0-6.7
TRIGLYCERIDES 3.10 mmol/L 0.70-1.70
 Conventional units
Examinations Results Unit Ref. Range
FBS 150.48 Mg/dL 75.6-115.2
CHOLESTEROL 180.98 Mg/dL 154.7-259.1
TRIGLYCERIDES 274.26 Mg/dL 61.9-150.4

URINALYSIS RESULT

PATIENT’S NAME: Patient E DATE: October 22, 2017

REFERRED BY: --------- AGE: 43 GENDER: Female

ROUTINE ANALYSIS

Color: YELLOW
Transparency: SLIGHTLY TURBID
Volume:
Reaction: 6.0
Specific Gravity: 1.020
Sugar: POSITIVE++
Albumin: TRACE

MICROSCOPIC EXAMINATIONS OF URINE SEDIMENTS

Pure Cells (WBC): 10-15 / hpf Bilirubin: NEGATIVE

Red Blood Cells (RBC): 2-4 / hpf Ketones: NEGATIVE
Epithelial Cells: Few / hpf Urobilinogen: NEGATIVE
Bacteria: Moderate / hpf Nitrate: NEGATIVE
Mucous Threads: Rare / hpf
Amor. Urates Rare / hpf
 HEMATOLOGY PROFILE

PATIENT’S NAME: Patient E DATE: September 17, 2017

REFERRED BY: --------- AGE: 43 GENDER: Female
CBC RESULT UNIT REFERENCE VALUE
Hemoglobin 1.25 g/L 115-155
Hematocrit 0.40 0.36-0.48
White Blood Cells 7.1 10^9/L 4.0-11.0
Red Blood Cells 4.1 10^12/L 4.0-5.0
MCV 93 fL 80-100
MCH 31 Pg 27-31
MCHC 32 % 31-38
Platelet Count 258 10^9/L 150-400

DIFFERENTIAL COUNT

Segmenters (%) 0.69 % 0.50-0.70

Lymphocytes (%) 0.25 % 0.20-0.40
Monocytes (%) 0.04 % 0.02-0.07
Eosinophils (%) 0.02 % 0.00-0.05
Basophils (%) % 0.00-0.01
Stab (%) % 0.00-0.05

HEPATITIS MARKER RESULT

PATIENT’S NAME: Patient E DATE: September 17, 2017

REFERRED BY: --------- AGE: 43 GENDER: Female

EXAMINATIONS RESULT

HBAG Screening NON-REACTIVE EXAMINATION TWICE

Note: if REACTIVE to HBsAG Screening, the patient must undergo Hepatitis B Profile panel for confirmation
 SEROLOGY/IMMUNOOLOGY RESULT

PATIENT’S NAME: Patient E DATE: September 17, 2017

REFERRED BY: --------- AGE: 43 GENDER: Female

EXAMINATIONS RESULT UNIT NORMAL VALUE

RPR Non-reactive
VDRL Non-reactive

HEMATOLOGY

PATIENT’S NAME: Patient E DATE: November 7, 2017

REFERRED BY: --------- AGE: 43 GENDER: Female

Hemoglobin: 12.2 F: 12-14g/dl

M: 14-16g/dl
Hematocrit: 0.36 F: 0.37-0.47
M: 0.40-0.57
WBC Count: 11.3 4.8-10.8 x 10
Segmenters: 84 60-70%
Lymphocytes: 16 30-40%
Blood Types: “O” Rh (+)