RIVERSIDE COLLEGE INC.

COLLEGE OF NURSING
BSN 2 – A.Y. 2020-2021, 1st SEMESTER

RLE107MCF
RELATED LEARNING EXPERIENCE
CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL-CLIENT)

A CASE STUDY ON CARMEL VASQUEZ (OB-CENTERED)

GROUP 1 – HENDERSON A
Nicole Ann D. Bacolina
Anika Pearl P. Banias
Kiara Therese P. Belarmino
Joyce Gabrielle S. Boncalon
Stephanie L. Caballero
Emma Rose P. Dalmacio
Cheryl Jhone T. Dimson
Catherine Gaile M. Fuentabella
Jessa Mae T. Infante
Alijah Abigail R. Jayme
 TABLE OF CONTENTS

I. OBJECTIVES

II. CASE SCENARIO

III. ANATOMY AND PHYSIOLOGY

IV. NURSING HISTORY (OBSTETRIC DATA)

A. Biographic Data

B. Chief Complaint/s

C. Obstetric Data

V. PHYSICAL ASSESSMENT

A. Baseline Data

B. Overall Appearance of the Patient

C. Hospital Forms

D. Per System Assessment

i. Neurologic

ii. EENT

iii. Respiratory

iv. Cardiovascular

v. Gastrointestinal and Abdominal

 vi. Genitourinary

vii. Musculoskeletal

viii. Integumentary

VI. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS (Results and

its Implications)

A. Blood Test

B. Imaging

VII. NURSING CARE PLAN

VIII. FDAR

IX. DRUG TABULATION (Action and Indication)

X. PREDISCHARGE/DISCHARGE INSTRUCTIONS (HADI)

XI. References and Sources

I. OBJECTIVES

After the analysis of the case scenario, the students of Henderson A:

❖ Will have reviewed the Anatomy and Physiology of the Female internal
reproductive system.
❖ Will be able to identify the objective data of the patient, the vital signs, laboratory
findings, and screenings that were provided in the scenario.
❖ Will be able to state the normal values and interpret the findings with significant
deviation in the laboratory and diagnostic tests and examinations.
❖ Will be able to formulate the nursing care plan according to priority using the
nursing process as the framework of care.
❖ Will be able to identify and chart the medications given to the patient according to
name (generic and brand name), dosage, route of administration, timing or
frequency, content, action, and mechanism of action
❖ Will appreciate the role of the nurse in caring for normal parturient.

II. CASE SCENARIO

On November 16, 2021, at 6:30 AM, Carmel Vasquez, a pregnant 27-year-old, came
in due to labor pains. Her GTPAL was G3P2. An initial IE was done, and it was revealed
that her cervix was 4cm dilated, and her BOW was intact. An assessment was given, and
the following data was taken, such as: The patient's weight was 55 kg. Her vital signs are
as follows: T – 37.2 centigrade, B.P. – 110/70 mmHg, C.R. – 90, and R.R. – 22. Her FH
was at 34cm, and FHB was recorded to be at 140 RLQ. Her LMP was recorded to be on
February 4, 2021. It was revealed that she never had a prenatal checkup.

Upon her admission, Dr. M. Deocampo gave orders for the patient to be admitted
under the service of HC/OB. Her vital signs were to be taken every 4hrs, and her diet was
to be as tolerated. Dr. Deocampo ordered to start patient’s IVF D5Lr 1 L at 20 gtt/min.
The physician then ordered a CBC, Blood Typing, and Urinalysis for the patient. Doctor
ordered her medication: Cefuroxime 500 mg/capsule, I capsule BID. Dr. Deocampo then
ordered to have her progress of labor monitored along with the FHB.
 At 8:30 AM, an IE was done and patient was revealed to be 5 cm dilated, FHB was at
138 bpm. At 9:30 AM, another IE was done and she was revealed to be at a 6-7 cm
dilation, FHB was at 145 bpm. At 11:00 AM, her BOW spontaneously ruptured. Amniotic
fluid appeared to be moderately meconium-stained. FHB was at 145 bpm. Progress of
labor was then noted at 11:20 AM with her cervix dilated at 8-9 cm. At 12:00 PM, the
patient reached full dilation.

At 12:30 PM, she delivered a live female neonate through normal spontaneous vaginal
delivery in cephalic presentation with a second-degree vaginal laceration. Neonate had
an APGAR score of 9/10. At 12:31 PM, oxytocin 1amp IM was administered at the
patient’s right deltoid. Following 12:33 PM, the patient’s placenta was expelled (Schultz
mechanism). Her BP was taken and recorded to be at 120/70 mmHg. The patient’s uterus
was firm and contracted. Her second-degree vaginal laceration was cleansed and
repaired, and diaper was applied. At 2:15 PM, the patient was wheeled out to ward.

Dr. Deocampo then gave postpartum orders. Vital signs were to be monitored Q 15
min X 1 H, 30 min X 1, and hourly until stable. Patient was allowed to have a full diet.
Physician noted to watch out for uterine atony. Regulate present IVF to 30 gtt/min,
discontinue once consumed. Dr. Deocampo then prescribed the following medications:
Oxytocin 10 units IM (given earlier at 12:31 pm), Methylergometrine 1 tablet TID for 6
doses, Multivitamins 1 tablet OD p/o, Mefenamic acid 500 mg, 1 capsule now, then Q4H
PRN for Pain, and continue Cefuroxime 500 mg/capsule, 1 capsule BID. Her voiding was
due at 8:00 PM. The doctor then ordered to have her uterus massaged as needed.

III. ANATOMY AND PHYSIOLOGY

A. Uterus
The uterus, also called the womb, is a pear-
shaped organ with a thick muscular wall. The fundus,
which is at the top of the uterus, the corpus, which is
the main body, and the cervix, which is at the bottom
of the uterus, and the uterine isthmus connects the
body with the cervix and is located on the inferior-
posterior side of the uterus. The isthmus has a thicker
wall and a smaller diameter than the ampulla. Its folded
mucosa serves as a functional storage for sperm. Hegar's sign is a discovery in which the
uterine isthmus becomes more compressible during pregnancy. These parts make up the
uterus. Ligaments in the center of the pelvis, behind the bladder, and in front of the
rectum keep it in place. There are three layers to the uterus's wall. Menstrual bleeding is
caused by the shedding of the endometrium, a thin layer on the inside that responds to
hormones. A muscle wall forms the third layer called myometrium. The uterus has a thin
layer of cells covering the outer and it is called the perimetrium.

The uterus of a non-pregnant woman can vary in size. The average uterine length
in a woman who has never been pregnant is about 7 centimeters. In a woman who is not
pregnant but has previously been pregnant, this grows to about 9 centimeters. The size
and form of the uterus can alter over time and with the number of pregnancies. The size
of a woman's uterus will substantially rise during
pregnancy as the baby grows. The fundal height, or
the distance between the pubic bone and the top of
the uterus, is one way to determine growth. The size
of a pregnant woman's uterus can be affected by a
variety of factors, including fundal height. Women
who are carrying more than one baby, are overweight
or obese, or have specific medical disorders, for
instance, may have a varied fundal height. It's also
crucial to empty your bladder before each
measurement because a full bladder will impact
fundal height measurement. A smaller fundal height
than expected could indicate that the baby is growing slowly or that there is little amniotic
fluid. During pregnancy, amniotic fluid surrounds the unborn baby and is transparent
with a slight yellowish tint. This amniotic fluid is contained in the amniotic sac. A bigger
than expected fundal height, on the other hand, could indicate that the baby is larger than
typical, necessitating additional monitoring. The uterus can apply pressure on the other
organs of a pregnant woman's body as it expands. The uterus, for example, can press
against the bladder nearby, increasing the need to urinate.
 Braxton Hicks contractions, often known as false labor or
practice contractions, prepare the uterus for birth and can begin as
early as the second trimester of a woman's pregnancy and last until
the birth. Braxton Hicks contractions are irregular, and while they
are usually not painful, they can be uncomfortable and become
stronger as the pregnancy progresses. The muscles of the uterus
contract during true labor to help the baby's descent through the
birth canal. True labor contractions begin like a wave and
intensify as they go from the top of the uterus to the cervix. The
uterus will feel tight during the contraction, but the pain will subside
between them, allowing the mother to rest until the next one
begins. Labor contractions, unlike Braxton Hicks, get stronger, more regular, and more
often in the weeks leading up to the birth. The uterus will contract again after the baby is
born to allow the placenta, which feeds the baby during pregnancy, to depart the
woman's body. This is sometimes referred to as the postpartum period. These
contractions are less intense than those experienced during labor. The uterus remains
constricted after the placenta is delivered to help prevent severe bleeding termed as
postpartum hemorrhage. After the birth, the uterus will continue to undergo contractions,
particularly during breastfeeding. This tightening and constricting of the uterus will feel
similar to period cramps and is referred to as afterbirth pains.
B. Vagina

The vagina is a hollow muscular

structure and potential canal. This is often
called the "birth canal". It extends from the
vulva to the uterus, runs upward and
backward parallel to the pelvic brim. It is the
site of sexual intercourse and serves as a
conduit for sperm to reach the egg, as well as
for menstrual flow and the delivery of a baby.
It is supported by pelvic floor muscles and ligaments. The vagina is composed of
vaginal opening, vaginal wall, and hymen. The vaginal opening is where the
menstruation blood flows out of the body. It is found in the urethra and anus. The vaginal
wall contains layers of tissue with many elastic fibers. It does not lie smoothly but falls
into transverse folds called rugae. Rugae allows distention during childbirth. Rugae will
not be visible for grand multipara and to woman who has estrogen deficiency because it
will be stretched. Hymen is found at the distal end of the vagina. It is a thin fold of mucosa.
Most shape of hymen is half-moon that allows the menstrual bleed to leave the vagina.
The vagina has four fornixes: anterior fornix, posterior fornix and two lateral fornixes.
The posterior fornix is the most important. The posterior fornix is the deepest and lies
below the pouch of Douglas; it is located between the lumen and pouch of Douglas. The
posterior fornix is also where the semen goes after intravaginal ejaculation.
 The vagina is composed of inner mucosal layer
and external muscle layer. The four histological layers
of vagina are stratified squamous epithelium, elastic
lamina propria, fibromuscular layer, and adventitia.
The squamous epithelium forms lining of the vagina and
it contains glycogen. After ovulation, the glycogen content
increases. The vagina has high lactic acid because of the
normal flora in the vagina which is the doederlein's
bacilli/lactobacillus that acts on glycogen and converts
them into lactic acid. The elastic lamina propria contain
some lymphocytes and projects papillae into the overlying
epithelium. There are prominent vessels present in the
elastic lamina propria. Fibrous layer comprises the inner
circular smooth fibers and outer longitudinal smooth fibers that is part of external muscle
layer. The adventitia is a strong fibrous layer that provides additional strength to the
vagina.

After giving birth, vagina loosen because it

stretches during birth for the baby to be delivered.
It heals after six weeks after giving birth. The
vaginal wall which is passageway for the infant,
will have changes but it will not be permanent.
During childbirth, the vaginal opening will have
tears and will be stretch and rip. Episiotomy
during labor will leave scar in the perineum in
some mothers but will heal for three to six weeks.
The vagina will still function as how it function
before birth but in some cases, pelvic floor
muscles that supports the vagina will be affected. Injury in pelvic floor muscle is an
indication of bladder dysfunction or uterine prolapse. Vagina will also feel dry when
the mother is lactating because of estrogen deficiency. The superficial mucous
membrane will start to shed after the delivery and will cause vaginal discharge. In the first
few days, the discharge is heavy and reddish then will slowly become taper and watery,
the color will change from pinkish brown to yellowish white.
IV. NURSING HISTORY (OBSTETRIC DATA)

A. Biographic Data

Patient’s Name Carmel Vasquez

Address NA

Age 27-years-old

Birthdate NA

Birth Place NA

Sex Female

Weight 55Kg

Marital Status NA

Nationality NA

Occupation NA

Religion NA

Health Care Financing NA

Source of medical care N.A.

Date and time of admission November 16, 2021, 6:30am

Attending Physician Dr. M. Deocampo – ROD

Source Of Information Primary source: Patient

B. Chief Complaint/s

The patient, Carmel Vasquez, came in due to labor pains.

C. Obstetric Data

The patient, Carmel Vasquez, a 27-year-old female, arrived at the hospital on

November 16, 2021, at 6:30 AM due to labor pains. The patient had a GTPAL of G3P2
(Gravida – 3, Pre-term births – 2). The patient's cervix was dilated at 4 cm after an initial
examination was done by the staff-on-duty at 6:30 AM. Her BOW was also found to be
intact (+). The patient was revealed to have had no prenatal checkup beforehand. Her
vital signs were all normal (T – 37.2 centigrade, B.P. – 110/70 mmHg, C.R. – 90, and
R.R. – 22), and her weight was recorded to be 55 kg. The patient's LMP was on February
04, 2021. Based on her FH of 34 cm, gestational age was estimated to be at 38 weeks
upon admission.

Dr. M. Deocampo – ROD ordered the patient to be admitted under the service of
HC/OB and that her vital signs were to be recorded every 4 hours. The patient's diet was
to be as tolerated. Dr. Deocampo ordered to start IVF D5Lr 1L at 20 gtt/min. The patient
was to undergo CBC, blood typing, and urinalysis and was also prescribed cefuroxime
500 mg/capsule, I capsule BID.

At 8:30 AM, an IE was given, and the cervix was found to be dilated at 5 cm with the
FHB at 138 bpm. At 9:30 AM, cervix dilation was at 6-7 cm with the FHB at 145 beats per
minute. Her bag of water was ruptured at 11 AM with moderate meconium-stained
amniotic fluid. And FHB was recorded to be at 145 beats per minute. At 11:20 PM, an IE
was given, and the cervix was found to be dilated at 8-9 cm. The cervix reached full
dilation at 12:00 PM.

At 12:30 PM, she delivered a live female neonate via NSVD (normal spontaneous
vaginal delivery) in cephalic presentation with a second-degree vaginal laceration. After
the administration of Oxytocin 1amp IM through the right deltoid at 12:31, the placenta
was then delivered via Schultz Mechanism at 12:33 PM. Her blood pressure at that time
was recorded to be at 120/70 mmHg. The patient's uterus was observed to be firm and
contracted. The second-degree vaginal laceration was then repaired and cleansed, and
diaper was applied.

After delivery, the patient was wheeled out to the ward at 2:15 PM. Dr. Deocampo
ordered the patient's vital signs to be monitored Q 15 min X 1 H, 30 min X 1, and hourly
until stable. She was allowed to have a full diet. Her IVF was also to be monitored at 30
 gtt/min, and to discontinue once consumed. The patient's postpartum medications include
methylergometrine 1 tablet O.D. p/o, mefenamic acid 500 mg, 1 capsule now, Q4H PRN
for pain, and cefuroxime 500 mg/capsule, 1 capsule BID; all per physician's orders. The
patient was then expected to void at 8:00 PM.

V. PHYSICAL ASSESSMENT

A. Baseline Data
Height: N/A
Weight: 55kg

VITAL SIGNS
Date/Time BP T P R
11/16/2021 110/70 37.2
90 bpm 22 bpm
6:30 AM mmHg Centigrade
11/16/2021 120/70
N/A N/A N/A
12:33 PM mmHg

B. Overall Appearance of the Patient

The patient was conscious with signs of distress, complaining of labor pains.

C. Hospital Forms/Sheets

LABOR ROOM MONITORING SHEET

NAME: Carmel Vasquez LMP – 02/04/2021 AOG: 38 weeks
AGE: 27 EDC – 11/11/2021
Gravida-Para: G3-P2

Attending Physician: Dr. M. Deocampo

Date TPR FHB Duration/ Remarks

11/16/2021 Frequency
6:30 T-37.2 C 45”/x IE= 4cm
 BP- 110/70 mmHg BOW (+)
CR-90 bpm
RR- 22bpm
6:35 50”/5’
6:38 50”/3’
6:41 65”/3’
6:44 50”/3’
7:17 45”/33’
7:20 75”/3’
7:24 55”/4’
7:28 55”/4’
7:31 70”/3’
8:30 138 bpm 45”/x IE = 5 cm
8:35 50”/5’
8:38 50”/3’
8:41 65”/3’
8:44 50”/3’
9:05 45”/21’
9:08 45”/3’
9:10 55”/2’
9:13 45”/3’
9:16 70”/3’
9:58 60’/x’ IE = 6-7 cm
10:17 45”/19’
10:20 65”/3’
10:24 54”/4’
10:28 67”/4’
10:31 70”/3’
10:40 65”/9’
10:50 50”/10’
10:53 45”/3’
BOW (-) moderate
11:00 145 bpm 60”/x meconium-stained amniotic
fluid
11:05 45”/x IE = 8-9 cm
11:20 60”/15’
11:25 55”/5’
11:45 45”/20’
11:50 70”/5’
11:52 55”/2’
11:56 48”/4’
11:58 60”/2’
 RIVERSIDE COLLEGE INC.
Labor and Delivery Room Record
Patient’s Name: Carmel Vasquez Age: 27
ADMISSION DATA

LMP: 02/04/2021 EDC: 11/11/2021 V/S:

AOG: 38 weeks FH: 34 cm BP – 110/70 mmHg
G-P: G3-P2 FHB: 138 bpm T – 37.2 Centigrade
Wt.: 55kg Location: RLQ P – 90 bpm
IE (Initial): 4 cm BOW: (+) R – 22 bpm

MOTHER'S RECORDS

Time cervix fully dilated: 12:00 PM

Time BOW Ruptured: 11:00 AM Type of Placenta: Schultz Mechanism
Amniotic Fluid Color: Meconium-stained Placenta Out: 12:33 PM
BP: 120/70 mmHg
Date and Time of Birth: T: N/A
11/16/2021 – 12:30 PM P: N/A
Type of Delivery: NSVD R: N/A
Attended by: Dr. M. Deocampo
Medications:
Episiotomy/Laceration: 2nd
degree Oxytocin 10 units IM at 12:31pm
Sex (Baby): Female
Handled by: Dr. M. Deocampo IVF (if any): IVF D5Lr 1L @ 20 gtt/min
Physician: Dr. M. Deocampo

FLOW SHEET
ATTENDING PHYSICIAN
NAME LAST FIRST MIDDLE AGE SEX CIVIL ROOM HOSPITAL
STATUS NO. NO. Dr. M.
Vasquez, Carmel 27 F N/A N/A N/A Deocampo
DATE & TIME T P RR BP REMARKS
11/16/21
6:30 am 37.2 90 22 110/70 VS Q4H and record
Monitor V/S Q 15 min X
12:33 pm N/A N/A N/A 120/70 1 H, 30 min X 1, and
hourly until stable
12:48 pm 37.5 89 21 115/70
1:18 pm 37.3 85 20 110/70
2:18 pm 37.2 80 18 120/70
3:18 pm 37 75 19 110/70
D. Per System Assessment

D1. Neurologic

Psychological state Mentally stable

D2. EENT

NA NA

D3. Respiratory

Before birth at 6:30 PM, the patient's

respiratory rate was at 22 breaths per
minute (rapid breathing due to pregnancy
Respiratory Rate and active phase of labor).

After birth, continuous respiratory rate

monitoring is ordered by the physician.

D4. Cardiovascular

Before birth at 6:30 PM, the blood

pressure of the patient is at
110/70mmHg.

Blood pressure At 12:33 PM, the blood pressure of the

patient is at 120/70mmHg.

After birth, continuous blood pressure

monitoring is ordered by the physician.
Before birth at 6:30 PM, the cardiac rate
of the patient is at 90 bpm.
Cardiac Rate
After birth, continuous cardiac rate
monitoring is ordered by the physician.

D5. Gastrointestinal and Abdominal

Before birth at 6:30 PM, the measured

Fundal Height fundal height of the patient is at 34 cm
(AOG – 38 weeks).
D6. Genitourinary

Before birth at 6:30 PM, the patient was

at 4 cm dilation with an intact BOW.

At 11:20 PM, the patient was at 8-9 cm

dilated cervix.
Internal Examination (IE)
At 12:00 PM, the patient had a fully
dilated cervix.

After birth at 12:33 PM, the patient had a

second-degree vaginal laceration due to
episiotomy.

D7. Musculoskeletal

Body Weight 55kg

D8. Integumentary

Body Temperature 37.2°C

VI. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS (Results and its
Implications)

MOTHER'S CBC RESULT

COMPLETE BLOOD REFERENCE

RESULT INDICATION
COUNT VALUES
Hemoglobin 142 F: 110-150 g/L NORMAL

Hematocrit 0.43 F: 0.38 - 0.47 NORMAL

RBC Count 4.99 F: 4.0-5.5x NORMAL

WBC Count 17.5 F: 5-10x /L -

DIFFERENTIAL REFERENCE
RESULT INDICATION
COUNT VALUES
Neutrophils 0.65 0.50-0.70 NORMAL
Eosinophils 0.02 0-0.05 NORMAL
Basophils 0.00 0-0.01 NORMAL
Lymphocytes 0.14 0.20-0.40 -
Monocytes 0.06 0-0.07 NORMAL
BLOOD TYPE: "A" POSITIVE

REFERENCE
MEASURAND RESULT UNIT INDICATION
RANGE
PHYSICAL PROPERTIES
Color PALE STRAW NORMAL
Transparency HAZY -
pH 6.5 5.0-7.0 NORMAL
Specific Gravity 1.010 1.003-1.030 NORMAL
CHEMICAL TESTS
Sugar NEGATIVE NORMAL
Albumin NEGATIVE NORMAL
MICROSCOPIC EXAMINATION
Pus Cells 0-1 /hpf NORMAL
Red Blood Cells NONE /hpf NORMAL
 Squamous Cells FEW /lpf NORMAL
Bacteria FEW /lpf NORMAL
Mucus Threads FEW /lpf NORMAL
CRYSTALS
Amorphous
FEW /lpf NORMAL
Urates

A total blood count might assist with diagnosing the reason for these signs and
indications. Laboratory results of the patient appear to be normal, and no abnormalities
appear to be present.

Her WBC resulted in 17.5. This is considered normal as its count increases during
pregnancy due to the physiological stress the mother experiences. The patient's
lymphocyte count seems to be below the normal range but is considered normal in this
case. During pregnancy, the reduction of lymphocyte levels in a pregnant woman is a
natural consequence of conception and is a normal body process. When conception
occurs and the embryo is awaiting implantation into the uterus, the body makes
adjustments within itself to allow this to happen without any hurdles. A newly-created
embryo within itself is an alien entity for the human body, so it is natural for the immune
system to observe it as something harmful and reject it. Therefore, the body ends up
suppressing the immune system's response by cutting down the lymphocyte count. This
allows the embryo to be implanted successfully and grow into a fetus.

However, even when the lymphocyte count is reduced during this stage, the body still
keeps the mother well-protected. Other entities, such as neutrophils, are activated, which
temporarily take on the duties of protecting the body from external attacks. And so, the
patient is present to have no underlying problems found in her lab results.
 VII. NCP

A. PROBLEM #1

NURSING EXPECTED
RATIONALE INTERVENTION RATIONALE
DIAGNOSIS OUTCOMES
Independent:
Pain during Independent:
Labor pain 1. Serves as baseline
labor is caused 1. Monitor vital signs
related to foundation of knowledge for
by contractions every 4hrs and
uterine any possible changes on the
of the muscles record.
contraction and condition of the client
of the uterus 2. Monitor uterine
cervical dilation 2. As labor progresses, uterine
and by contractions and
as evidenced by contractions become intense
pressure on progress of labor.
patient’s facial and frequent.
the cervix. 3. Assess the intensity
expression of 3. Provides a baseline in order
It occurs due (scale of 0-10) and
pain to plan and give effective
to the duration of the pain.
care/nursing interventions.
contraction of 4. Provide comfort/
Objective Cues: 4. Promotes relaxation, and Goal was met,
the uterus. helping position of
may enhance coping after 2hrs of
• Facial During these comfort.
abilities. Position changes giving nursing
grimace contractions, 5. Instruct the patient
can also enhance circulation interventions,
• 4cm dilated blood vessels in doing relaxation
and reduce muscle tension. the patient was
cervix constrict, techniques and
5. Educates the patient on how be able to:
• Presence of thereby breathing exercises.
to relax themselves, and ✓ To cope with
uterine reducing the 6. Provide/encourage
allows them to cope with the the
contractions blood supply to use of comfort
increasing labor pain. increasing
the uterine and measures (e.g.,
Breathing exercises can help pain as the
Planning: cervical cells, back/leg rubs,
you relax, because they labor
After 2hrs of resulting in sacral pressure,
make your body feel like it progressed.
giving nursing anoxia to the back rest,
does when you are already
interventions, the muscle fibers. repositioning,
relaxed.
patient will be This pain can and/or shower/hot
6. Promotes relaxation and
able to: be felt as a tub use).
hygiene which will enhance
• Will be able to strong 7. Provide a quiet
feeling of wellbeing and may
cope with the cramping in environment that is
reduce the need or
increasing the abdomen, adequately
analgesia or anesthesia.
pain as the groin, and ventilated, dimly lit,
7. Non-distracting environment
labor back, as well and free of
provides optimal opportunity
progresses. as an achy unnecessary
for rest and relaxation
feeling. personnel.
between contractions.
 B. PROBLEM #2

NURSING EXPECTED
RATIONALE INTERVENTION RATIONALE
DIAGNOSIS OUTCOMES
Dependent:
1. Oxytocin stimulates
contraction
2. Methylergometrine
increases the rate
Dependent: and strength of
1. Administer Oxytocin contractions and the
10 units IM upon stiffness of the uterus
physician’s orders. muscles, which
Risk for uterine 2. Administer effectively helps stop
atony Methylergometrine bleeding.
Uterine atony 1 tablet TID for 6
Objective Cues: refers to the doses upon Independent:
inadequate physician’s orders. 3. Uterine massage right
• G3P2
contraction of after delivery of the Goal is met after 6
• Placental
the corpus Independent: placenta will help hours of
expulsion
uteri 1. Massage uterus. reduce the risk of intervention; the
myometrial 2. Monitor V/S Q 15 atony of the uterus. patient was:
Planning:
cells in min X 1 H, 30 min X 4. Provides a baseline ✓ Consequently,
After 6 hours of
response to 1, and hourly until for any possible free from the
intervention, the
endogenous stable. changes in the risk of uterine
patient will:
oxytocin 3. Educate the patient condition of the atony and
• Be release. Its concerning the patient. Also, a postpartum
consequently presence can medication’s decreased blood hemorrhage.
free from the lead to rationale. pressure could signify
risk for uterine postpartum 4. Emphasize the atony of the uterus.
atony and hemorrhage. importance of 5. Grants apprehension
postpartum continuing of the medication’s
hemorrhage medication after effects
discharge from 6. Increases the
admission. awareness of the
5. Monitor diaper importance of
changes. maintaining
medication
7. Aids us in
differentiating normal
discharges from
abnormal outputs.
 C. PROBLEM #3

NURSING EXPECTED
RATIONALE INTERVENTION RATIONALE
DIAGNOSIS OUTCOMES
Dependent:
Dependent: 1. Mefenamic acid is one
1. Administer Mefenamic acid of the NSAIDS used for
500 mg, 1 capsule now, the relief of pain
Impaired skin then Q4H PRN for Pain following post-
integrity related upon physician’s orders. operations.
to second degree 2. Continue Cefuroxime 500 2. To reduce the
laceration mg/capsule, 1 capsule BID incidence of infections.
as physician ordered. 3. Contributes to the
3. Administer multivitamins 1 wound healing process,
Objective Cues: tablet OD p/o. and reduces risk for
• Normal Goal was met,
4. Monitor V/S Q 15 min X 1 infection.
spontaneous H, 30 min X 1, and hourly 4. Changes could indicate
after 4hrs of
vaginal delivery until stable. abnormal underlying intervention, the
causes such as patient was able
• Second degree to:
Independent: infection and other
vaginal Impaired skin
1. Assess the site of skin complications. ✓ Have their
laceration integrity impairment. skin remain
• G3P2 increases the 2. Inspect and monitor site Independent:
chance of intact as
for color changes, 1. To determine severity
infection, evidenced by
Planning: redness, swelling, warmth, of the impairment.
impaired and pain. 2. Color changes, normal
After 4hrs of
mobility, and 3. Provide tissue care as redness, swelling, healing with
intervention the
decreased needed. warmth, and pain are no signs of
patient will:
function and 4. Monitor patient’s indications for infection. infection, and
✓ Have their skin continence status and 3. Promotes skin integrity
remain intact may result in demonstrate
the loss of limb minimize exposure of skin and faster recovery.
as evidenced proper
impairment site and other 4. Exposure to unhygienic
or, sometimes, areas to moisture from substances may lead to techniques in
by normal
life. incontinence, perspiration, infection or wound care,
healing with no
signs of
or wound drainage. complications in wound and continue
5. Encourage proper recovery. medication
infection, and hygiene. 5. Minimizes risk for
demonstrate after
6. Discuss the relationship infection and enhance
proper between adequate overall health which
discharge.
techniques in nutrition consisting of can help promote faster
wound care, fluids, protein, vitamins B wound healing.
and C, iron, and calories. 6. Nutrition plays a vital
and continue a. Encourage a role in maintaining
medication healthy diet. intact skin and in
after discharge. 7. Educate patient on wound promoting wound
care and demonstrate healing.
techniques that would aid 7. Grants the patient
them in doing so. knowledge and skills in
wound care.
VIII. FDAR

DATA / TIME FOCUS DATA, ACTION AND RESPONSE

DATA:
Objective Cues
• Facial Grimace
• 4cm Dilated Cervix
• Presence of Uterine Contraction

ACTION:
• Monitored and recorded vital
signs every 4hours.
o BP – 110/70 mmHg
o T – 37.2 Centigrade
November 16, 2021 o P – 90 bpm
6:30 AM o R – 22 bpm
• Uterine contraction and progress
of labor monitored.
o IE was done. Cervical
dilation was at 4cm.
• Evaluated the intensity (scale of
0-10) and duration of the pain.
• Provided a quiet environment
that is adequately ventilated,
LABOR PAIN dimly lit, and free of unnecessary
personnel.
• Provided comfort, and aided in
repositioning.
• Coached patient in doing
breathing and relaxation
techniques.

RESPONSE:
• Patient’s comfort level was
improved.
• The patient was able
demonstrate and follow breathing
exercises.
• The patient was able to cope with
the increasing pain.

N.B.
• Ordered by Dr. M. Deocampo:
CBC blood typing and Urinalysis.
• Started the IVF D5Lr 1 L at
20gtt/min. as ordered.
 DATA / TIME FOCUS DATA, ACTION AND RESPONSE
November 16, 2021
12:30 PM DATA:
Objective Cues
• G3P2
• Placental Expulsion

ACTION:
• Assessed VS and recorded Q 15
min X 1 H, 30 min X 1, and
hourly until stabilized.
• Administered oxytocin 10 units
12:31 PM IM as ordered.
• Administered methylergometrine
1 tablet TID for 6 doses upon
physician’s orders.
• Discussed the rationale of the
medication that was given to the
patient.
• Massaged patient’s uterus.
RISK FOR UTERINE
ATONY • Monitored diaper changes

RESPONSE:
• Patient’s uterus was firm and
contracted.
• The patient was cooperative in
taking their medication and
consequently reduced the risk of
uterine atony and postpartum
hemorrhage.

N.B.
• Administered Mefenamic acid
500 mg, 1 capsule Q4H PRN for
pain upon physician’s orders.

12:33 PM • Second degree Vaginal

Laceration repaired and
cleansed. Diaper was then
applied.
 DATA / TIME FOCUS DATA, ACTION AND RESPONSE
November 16, 2021
12:30 PM DATA:
Objective Cues
• Normal spontaneous vaginal
delivery
• Second degree vaginal laceration
• G3P2

ACTION:
• Assessed VS and recorded Q 15
min X 1 H, 30 min X 1, and hourly
until stabilized.
• Administered Mefenamic acid 500
mg, 1 capsule Q4H PRN for pain
upon physician’s orders.
• Continued Cefuroxime 500
mg/capsule, 1 capsule BID as
physician ordered.
• Monitored the patient's continence
and prevented moisture from
incontinence, perspiration, or
wound drainage from reaching the
skin impairment site and
surrounding locations
IMPAIRED SKIN • Inspected and monitored the site
INTEGRITY for color changes, redness,
swelling, warmth and pain.
• Provided tissue care.
• Instructed and demonstrated to the
patient wound care techniques
• Discussed the need of a balanced
diet that includes fluid, protein,
vitamins B and C, iron, and
calories.
• Administered multivitamins 1 tablet
OD p/o.

RESPONSE:
• Patient’s wound was managed.
• Patient’s skin was intact and free
from signs of infection.
• Patient was able to repeat the
demonstrated wound care
techniques.
N.B.
• Administered oxytocin 10 units IM
12:31 PM as ordered.
• Administered methylergometrine 1
tablet TID for 6 doses upon
physician’s orders.
IX. DRUG TABULATION (Action and Indications)

Name of
Content Action/Mechanism of Action Indication
Drug
ACTION: Anti- inflammatory – means
a drug that reduces inflammation like
redness, swelling and pain in the
body.
Oxytocin Stimulation of
MOA: uterine contractions
(Pitocin) Directly affects receptor sites to during third labor
stimulate contraction of the uterus and control of
10 units = 1 Oxytocin during labor especially toward the end
postpartum bleeding
ampoule IM of the pregnancy; helping expel the
baby. Purpose of oxytocin during or hemorrhage after
labor is that oxytocin used to begin or expulsion of the
12:31 PM placenta.
improve contractions. Oxytocin also is
used to reduce bleeding after
childbirth. It also may be used along
with other medications or procedures
to end a pregnancy.

Action/Mechanism of
Name of Drug Content Indication
Action
ACTION: Intramuscular
Methylergometrine For the
(Methergine) prevention and
MOA: Methylergometrine
control of
acts directly on the smooth
1 tablet TID (Three Methylergometrine excessive
muscle of the uterus and
times a day) bleeding
increases the tone, rate, and
following vaginal
amplitude of rhythmic
6 doses child birth.
contractions through binding.

Action/Mechanism of
Name of Drug Content Indication
Action

ACTION: Vitamins, combos PO: Treatment and

Multi-vitamins prevention of vitamin
MOA: deficiencies. Special
Multi-vitamins Absorption: Well-absorbed from formulations are
1 Tablet OD the GI tract after oral available for patients
P/O administration; some processes with needs including
are active, some are passive. prenatal multiple
 Depending on ingredients in the vitamins (with larger
formulation may support doses of folic acid)
metabolic functions as well as Preconception multiple
protein and DNA synthesis. vitamins, multiple
vitamins with iron and
Distribution: widely distributed; multiple vitamins with
cross the placenta and enter fluoride.
breast milk. Fat soluble (A, D, E,
K) are stored in fatty tissues and
the liver.

Action/Mechanism of
Name of Drug Content Indication
Action
ACTION: Non-steroidal anti-
inflammatory drug (NSAID)
Mefenamic Acid
MOA:
(Ponstab, Mefenamic acid binds the
Ponstel) prostaglandin synthetase Prophylaxis for mild
receptors COX-1 and COX-2,
to moderate pain,
500mg Mefenamic Acid inhibiting the action of
prostaglandin synthetase. As treatment for
these receptors have a role as a inflammation
1 capsule Q4H
major mediator of inflammation
(every 4hrs as
and/or a role for prostanoid
needed) signaling in activity dependent
plasticity, the symptoms of pain
are temporarily reduced.

Action/Mechanism of
Name of Drug Content Indication
Action
Cefuroxime ACTION: Antibiotics
(Ceftin, Zinacef) Treatment of
many different
500mg/capsule Cefuroxime MOA: Bind to bacterial cell types of
wall membrane causing cell bacterial
1 capsule BID death infections.
(Twice a day)
X. PREDISCHARGE/DISCHARGE INSTRUCTIONS (HADI)

PLAN
EXPECTED
At the completion of
OUTCOME THE NURSING ACTION
the home care
PATIENT WILL BE DONE
instruction, the patient
ABLE TO:
will be able to:
Teach the patient
how to clean and
perform proper
perineal care and
State the perception of Maintain good breast care.
the importance of hygiene to
Hygiene personal hygiene and prevent/avoid Educate the patient
keeping the complications and and other relatives
environment sanitation. infection. about the
importance of
maintaining home
environment safety
and sanitation.
Have an enough Discourage the
Verbalize the
rest, don’t do patient doing any
understanding of
vigorous activities sexual intercourse
restricted activities, the
Activity dos and don’ts during
such as carrying for 6 months or at
around furniture and least 1 month
predischarge/discharge
also moving heavy letting the uterus of
and enough rest.
objects is prohibited. the patient heal.

The patient will be Educate the

State the importance of
able to maintain and important of
Diet enough and healthy
continue adequate balanced and
diet.
or full diet. healthy diet.
• Instruct the
patient to
strictly comply
with medication
Explain the upon discharge.
understanding of • Encourage
Follow or comply the
abiding prescribed patient and the
Other medication and
medication, importance family to inform
Instructions follow treatment
of follow up checkup the Doctor
plan.
and follow the when pain
treatments plans. occurs.
• Encourage the
patient to
comeback for
follow up
 checkup after 2
weeks.
• Ensure the
patient to know
and understand
the dosage,
route, purpose
and as well as
the possible
side effects of
the
medications.
• Perform uterine
massage to
reduce bleeding
and cramping of
the uterus after
childbirth. As
the uterus
returns to its
non-pregnant
size.

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