We, sophomore BSN students of Arellano University Pasay, would like

to express our
appreciation and gratitude to these persons for the great support by
providing us the
information we needed in order to make this case presentation
knowledgeable and
presentable.

We would like to thank our clinical instructor Mrs. Loida Oca for
allowing us to handle a
patient in OB Ward regarding our case presentation and also for guiding we
in getting
information and letting us to interviewed the patient. We acknowledge her
advises while doing
it and sharing her experiences and knowledge at Caloocan Medical Center.

We also appreciate the help of Mr. August Manzon and our beloved
Dean Arlene Blaise
T. Cortez for letting us to have this kind of presentation to enhance our skills,
experiences and
knowledge, and also our family in guiding us while doing this presentation.

Especially to the family who participate while doing this presentation,

we appreaciate
their trust for giving the information regarding their status in their family.

The most prestigious creator, our God, thanks for guiding us, giving us
knowledge and
keeping us together.

INTRODUCTION

Pregnancy is the development of one or more offspring, known as an embryo

or fetus, in a woman's uterus. It is the common name for gestation in
humans.

Childbirth usually occurs about 38 weeks after conception. In women

who have a menstrual cycle length of four weeks, this is approximately
40 weeks from the start of the last normal menstrual period (LNMP).
Health authorities recommend that women not artificially begin
delivery with labor induction or caesarean section before 39 weeks as
this amount of time is considered "full term" for the child to develop.
Conception can be achieved through sexual intercourse or assisted
reproductive technology.

An embryo is the developing offspring during the first 8 weeks

following conception, and subsequently the term fetus is used until
birth.

NORMAL SPONTANEOUS DELIVERY

It involves the birth of a baby and delivery of the placenta from the
uterus and through the cervix and the birth canal (vagina). This
process results from contractions of the uterus during labor. Most
women deliver 38 to 40 weeks after becoming pregnant (conception).
In some vaginal deliveries, additional assistance is used to assist
vaginal delivery by using forceps or vacuum extraction applied to the
baby's head.

In combination with hormonal changes, the regular muscular

contractions of the uterus in labor cause the cervix to soften, thin out,
and open (dilate) so that the baby may travel from the uterus through
the bony pelvis to the vaginal opening. The average labor lasts 12 to
14 hours for a woman having her first baby (nulliparous) and about 6
to 8 hours for subsequent babies (Beers).

Spontaneous vaginal delivery is the expected outcome for most pregnancies.

Assisted vaginal delivery may occur when the second stage of labor is
prolonged or when the baby appears to be in distress and delivery time
needs to go faster.

ASSESSM
ENT

DIAGNOSI
S

PLANNI
NG

INTERVENTI
ON

RATIONA
LE

EVALUATI
ON

Subjective:
Natatakot
ako baka
hindi ko
magampan
an ang mga
responsibili
dad ko
bilang
nanay dahil
wala akong
sapat na
kaalaman
sa
pagaalaga
ng bata.

Anxiety
related to
role
function/sta
tus

Within 2-3
hours
patient
will be
able to
recognize
proper
newborn
care

Objective:
BP: 110/80

TR: 37.7
RR: 20 bpm
PR: 88 bpm
Poor eye
contact,
increased
wariness

ASSESSMEN

DIAGNOS

Identify
clients
perceptio
n of the
threat
represent
ed by the
situation
Establish
a
therapeut
ic
relationsh
ip,
conveying
empathy
and
unconditi
onal
positive
regard
Do health
teaching
about
newborn
care

Assist in
developin
g skills

Review
strategies
, such as
roleplaying,
use of
visual
aids

PLANNIN INTERVENT

To identify
the
problem
from the
patients
point of
view
To
establish
trust and
cooperatio
n
To have a
broad
discussion
of the
problem
To
eliminate
negative
self-talk
Useful for
being
prepared
for dealing
with
anxietyprovoking
situations

RATIONAL

Goal
met.

Client
was
able
to
demo
nstrat
e
prope
r
newb
orn
care
and
expre
ss
feelin
gs to
provo
ke
anxiet
y
situati
ons

EVALUATI

IS

Subjective:

Knowledg
e deficit
related to
child care
specificall
y breast
feeding
technique
s

After 1
hour of
nursing
interventi
on, the
patient
will be
able to
know and
demonstr
ate
different
breastfee
ding
technique
s

Hindi ako
marunong
magpasuso
as verbalized
by the
patient.
Objective:

Enlarge
d
breast

Enlarge
d
areola

Breastf
eeding
while
lying
down
without
elevatin
g the
babys
head.

ION

Do
health
teaching
about
proper
positioni
ng of the
baby
while
breast
feeding.

Provide
positive
reinforce
ment
and
avoid
negative.

Demonst
rate
different
breastfee
ding
techniqu
e.

State
advantag
es of
breastfee
ding.

Provide
written
informati
on/guidel
ines for
client to
refer to
as
necessar
y.

ON

In
order
for the
patient
to gain
knowle
dge
about
breast
feeding
techniq
ues

Encour
ages
continu
ation
of
effort.

For the
patient
to see
the
differe
nt
techniq
ues
and
easy to
remem
ber.

For the
mother
to
acquire
.

Reinfor
ces
learnin
g
proces
s.

After 1
hour of
nursing
intervention,
the patient
was able to
demonstrate
different
breastfeedin
g
techniques
and
identified
the
importance
of breast
feeding.

GOAL MET

ASSESSM
ENT

DIAGNO
SIS

Subjective Alteratio
n in
Masakit
comfort:
ang tahi
Pain
ko as
related
verbalized
to
by the
incision
patient.
site
Objective

Grim
ace

Pain
Scale
:7

PLANNI
NG

INTERVENTI
ON

Within 8
hours of
nursing
intervent
ion the
patient
pain
scale will
decrease
from
pain
scale 7
to pain
scale 3

Independent:

Monitor
vital
signs

Assess
the
incision
site.

V/S:
BP:
130/100

RR: 33
PR: 120

Ask the
patient
to
verbaliz
e her
feelings
.
Encour
age the
patient
to wash
the
perineu
m
regularl
y.

Dependent:

Admini
ster
analges
ic
drugs
as
order
by the

RATIONALE

To know
the
patients
condition
if it is
affected
by pain.

To check
for
infection
and
proper
suture of
the
perineu
m.

To know
the
patients
feeling
regardin
g pain
and it
can help
her to
destruct
from
pain.

To
maintain
hygiene
and
avoid
infection
in
perineal
area.

EVALUATI
ON
After 8
hours of
nursing
interventio
n, the
patients
pain scale
decrease
from pain
scale 7 to
pain scale
to 3.
GOAL MET

doctor.

ASSESSM
ENT

DIAGNO
SIS

PLANNIN INTERVENTIO
G
N

RATIONALE

EVALUATI
ON

Subjective:
hindi na
po ako
makatulog
sa tuwing
nagigising
ang anak
ko sa
madaling
araw.

Sleep
pattern
disturba
nce
related
to
parentinfant
interacti
on.

Within 68 hours
patient
will be
knowledg
eable and
will report
improved
sleep

Observe
parentinfant
interaction
provision of
emotional
support

Assess
clients
usual sleep
patterns
and
compare
with current
sleep
disturbance
.

Objective:

Yawni
-ng

Sleep
y

Eyes
are
tired

Manage
environmen
t for
hospitalized
client:

Turn on
music or
quiet
environmen
t as client
prefers.

4.
Avoidance
of daytime
napping as
appropriate
for age and
situation
being
active
during day
and more
passive in
evening.

Lack of
knowled
ge of
infant
cues or
problem
relation
ship
may
create
tension
interferi
ng with
sleep.

to
ascertai
n
intensit
y and
duration
of
problem
s

to
enhance
relaxati
on.

Help in
promoti
on of
normal
sleep
wake
patterns
.

After 6
hours
patient
reported
that her
sleep
pattern
improved
and she
avoid to
nap at
noon.
GOAL WAS
MET

III. Patterns of Functioning /Gordons Functional Health

Pattern

PARAMETER

PATIENTS
RESPONSE

INTERPRETATIO
N

ANALYSIS

Health Perception
Pattern

Yes, I always go
here in Caloocan
City Medical Center
to have my prenatal check-up. I
was injected of
tetanus toxoid 1
last May 1and the
second dose was
last June

Patient is
knowledgeable
about pre-natal
check-up.

Patient has a
good health
perception.

I eat 3 times a day

breakfast, lunch,
dinner and snack
(merienda). I
usually eat in the
morning
particularly rice,
bread and
sometimes with
coffee.

Patient nutrition
is compliant and
she eats
additional food
between
afternoon and
evening such as
banana cue,
biscuit and coffee
or water.

Nutrition status is
efficient.

She verbalized
that she defecate
normally.

Elimination
pattern is good

Nutrition Pattern

At lunch usually
eat rice and fish,
and at the evening
rice ad fish or
meat.

Elimination
Pattern

I defecate this
morning

She has the right

dose of Tetanus
Toxoid.

Activity and
Exercise Pattern

I can stand, sit

and walk for fast
recovery and the
doctor also told me
that I will avoid
lying in bed.

The patient is
following
instruction of her
physician and her
activities and
exercise can lead
to fast recovery.

Sleep and Rest

Pattern

Sometimes when
my baby wakes up
early morning (3
am) I cant sleep
again. Also when
my bed mates
baby are crying.

Patient verbalized Sleep disturbance

sometimes she
due to parenthad a hard time
infant interaction
to go back to
sleep when baby
wake up at early
morning.

Cognitive and
Perceptual
Pattern

I dont know how

is the proper way
to breastfeed my
baby and while Im
doing this I can feel
my nipples is
hurts

The patient is
lack of knowledge
about
breastfeeding
technique.

Knowledge deficit
related to
breastfeeding
techniques.

Self Perception
and Self Concept
Pattern

I am scared
maybe I cant
perform my
responsibilities of
being a mom
because I dont

The patient is
scared of her
responsibility to
her child because
she has no

Anxiety

Activity and
exercise of the
patient is good.

have enough
experience to take
care of a child.

experience about
being a mother.

Role and
Relationship
Pattern

My husband has a
decent job and I
know he can
support us and
able to take care of
me and my baby.
As a matter of fact
we are so happy to
finally to have
baby to start a
family

The patient
Good relationship
expresses trust to and parental role.
her husband. Joy
and fulfilment of
having a new
baby.

Sexuality and
Reproductive
Pattern

December 18 2013

Patient is
knowledgeable
about her last
menstrual period.

Effective
Sexuality and
reproductive
pattern.

She usually
relieving herself
from stress by
doing
interpersonal
communicating

Effective coping
pattern

Gravida =1
Para = 1
Term = 1
Pre-term = 0
Abortion = 0
Living = 1

Coping Stress
Pattern

To lessen stress
here in hospital I
just talked to my
husband and
bedmate about
things and
sometimes I played

Values and Belief

Pattern

with my baby

with the people

around her to
gain relaxation.

I am Catholic
and every
Sunday we are
going to church
and every night
here in hospital I
pray that my
baby will have a
good health and
protect us from
danger.

She has a strong

belief and respect
to her religion.

Good religiosity

XII.Discharge Plan
Medication

Co-amoxiclav 625 g Every 12 hours, after meals

Mefenamic Acid 500mg Every 6 hours followed by 250 mg every 6

hours as needed.

Ferrous Sulfate 300 to 325 mg of regular-release ferrous sulfate.

Exercise and environment

Maintain a quiet and pleasant environment to promote relaxation

Have a exercise every morning either walking or simply doing

household chores

Avoid always lying in bed to have a fast recovery.

Treatment

Continue home medication and encourage to take multi-vitamins

Health Teaching
have a health teaching on her about :

New born care such as bathing, cleaning the umbilicus and changing
the babys diaper.

Proper breastfeeding technique and positioning.

Nutrition must be given to her baby and also herself.

Out-patient (follow-up consultation)

Follow up consultation is after 2 weeks.

Diet

Limit consumption of high-fiber foods such as white bread, white rice,

pasta, meat, fruits without skins, eggs, canned fruits and canned
vegetables and fruit juice without pulp.

Sexual activity or Spirituality

We recommend that wait until 6 weeks before having intercourse to

your husband to completely heal your stitches.