G7P7 (7007) Pregnancy Uterine Full Term Delivered via NSVD

A Case Study Submitted to

The College of Nursing Faculty
Notre Dame of Tacurong College
Tacurong City

Jona Phie D. Montero, RM, RN, MAN

Clinical Instructor

In Partial Fulfillment
Of the Requirements for the Subject
Care of Mother, Child at Risk
or with Problems
(NCM 109 RLE)

by:

GRETCHIANE MAE M. ALO, BSN3

November 28, 2023
 TABLE OF CONTENTS

Page
TITLE PAGE i

TABLE OF CONTENTS ii

CHAPTER I: INTRODUCTION ------------------------------------------------------ 4

a. General Objective ------------------------------------------ 6

b. Specific Objectives ------------------------------------------ 6

CHAPTER II: PATIENT’S DATA --------------------------------------------------- 8

a. Vital Information ------------------------------------------ 8

 Family Background ------------------------------------------ 10

 History of Past & Present Illness ------------------------ 12

 Effects to Self ------------------------------------------ 13

 Effects to Family ------------------------------------------ 13

 Expectation to Self ------------------------------------------ 14

 Family Genogram ------------------------------------------ 16

b. Developmental Data ------------------------------------------ 17

CHAPTER III: PHYSICAL ASSESSMENT --------------------------------------- 25

a. Cephalocaudal Assessment --------------------------------- 25

b. Laboratory and Diagnostic Tests ------------------------ 29

CHAPTER IV: TEXTBOOK DISCUSSION --------------------------------------- 33

a. Complete Diagnosis ------------------------------------------ 33

 b. Anatomy and Physiology --------------------------------- 41

c. Pathophysiology -------------------------------------- 46
d. Symptomatology -------------------------------------- 47
e. Etiology -------------------------------------------------------- 49
 Predisposing Factors ----------------------------- 49
 Precipitating Factors ----------------------------- 50
f. Medical Management ----------------------------- 52
g. Nursing Management -------------------------------------- 56

CHAPTER V: LIST OF DRUGS ------------------------------------------------- 58

a. List of Medication -------------------------------------- 58

b. Drug Study ----------------------------------------------- 59

CHAPTER VI: PRIORITIZED NURSING PROBLEM ---------------------- 83

CHAPTER VII: NURSING CARE PLAN --------------------------------------- 84

CHAPTER VIII: PROGNOSIS ---------------------------------------------------- 87

REFERENCES------------------------------------------------------------------------ 88
 CHAPTER 1

INTRODUCTION

This is a case of a female patient, 40 years old, residing at Kenram,

Isulan, Sultan Kudarat. She was admitted last November 14, 2023 at 7:00 am

in Sultan Kudarat Provincial Hospital, Kenram, Isulan, Sultan Kudarat with

chief complaints of labor pains. She was scheduled for delivery under the

service of Dr. Maganda and diagnosed with G7P6 (7006) Pregnancy Uterine

Full Term Delivered via NSVD.

The World Health Organization (WHO) defined normal birth as

spontaneous in onset, low-risk at the start of labor and remaining so

throughout labor and delivery. The infant is born spontaneously in the vertex

position between 37 and 42 completed weeks of pregnancy. After birth,

mother and infant are in good condition (Funai & Norwitz, 2022). Vaginal

delivery is safest for the fetus and for the mother when the newborn is full-

term at the gestational age of 37 to 42 weeks. Vaginal delivery is preferred

considering the morbidity and the mortality associated with operative

cesarean births has increased over time (Desai & Tsukerman, 2022).

According to the Centers for Disease Control and Prevention (CDC),

there were more than 2.5 million vaginal deliveries in 2020. Vaginal deliveries

account for about 68% of all births in the United States and 80% of births
worldwide. In the year 2013, out of the nearly four million births in the United

States, there were approximately three million were vaginal deliveries.

Further, according to the survey result conducted by the National

Demographic & Health Survey last 2017, Philippines had recorded 13%

caesarean deliveries which indicates that the remaining 87% means births

delivered vaginally. Also, according to Philippine Statistics Authority (PSA), in

2020, of the total number of births in the country, 94.5 percent were attended

by health professionals (physician, midwife, or nurse).

In a special release of PSA 12 last January, 2022, on the average,

SOCCSKSARGEN has 99 live births per month or at most 22 live births per

week or at least 3 babies born per day in in the first quarter of year 2021. The

highest occurrence of births was recorded in South Cotabato while Sultan

Kudarat ranked third. Meanwhile, in 2021 Annual Report of DOH XII, there

were a total of 59, 821 (91.14%) births delivered via NSVD in the region.

Awareness and knowledge of the advantageous and favorable effects

of normal vaginal delivery equips the mother and the family in ensuring the

health and safety of the mother and the newborn. Likewise, knowledge and

mastery of proper nursing management and appropriate interventions help

alleviate patient’s agony and expedite recuperation and restoration physically,

mentally, and emotionally. The chosen case hopes to give researchers first-

hand experience of providing holistic nursing care tailored and anchored on

her specific health needs.

OBJECTIVES OF THE STUDY

General Objective:

Generally, the case study covers vital health information about the

patient’s current condition that will strengthen researcher’s understanding

about the case and eventually be applied and used in clinical settings.

Specific Objectives

Specifically, the study will:

1. Present demographic information about the patient’s:

a) Vital Information

b) Developmental Data

2. Discuss the results of physical assessment cephalocaudally;

3. Discuss textbook discussions of:

 Anatomy and Physiology

 Pathophysiology

 Symptomatology and Etiology

 Medical Management

 Nursing Management

4. Identify the laboratory tests undergone by the patient and interpret

the results;

5. Discuss the medications;

6. Discuss the prioritized nursing diagnosis of patient and enumerate

applicable nursing interventions; and

7. Enumerate references.
 CHAPTER II

PATIENT’S DATA

Vital Information

Patient’s Name: So Sexy

Age: 40 years old

Sex: Female

Birth Date: September 7, 1983

Birth Place: Kenram, Isulan, Tacurong City

Address: Kenram, Isulan, Sultan Kudarat

Occupation: Housekeeping

Tribe: Maguindanaoan

Citizenship: Filipino

Religion: Islam

Educational Attainment: High School Graduate

Civil Status: Married

Husband: Gwapo Mangid

Occupation: Laborer
 Monthly Income: +/- Php 10,000.00

Educational Attainment: High School Graduate

Child: Unangbata (20 yrs old, male)

Ikaduhabata (18, F)

Ikatlobata (16, F)

Ikaapat (13, M)

Ikalima (10, F)

Ikaanom (5, M)

Name of Institution: Sultan Kudarat Provincial Hospital

Date and Time of Admission: November 14, 2023 @ 7:00am

Chief Complaint: Labor Pains

Admitting Diagnosis: G7P6 (7006) Pregnancy Uterine Full Term

Delivered via NSVD.

OB history:

LMP: February 5, 2023

EDC: November 12, 2023

Sources of Data
 Primary Source: Patient through interview

Secondary Source: Patient’s chart

Family Background

So Sexy, married, 40 years old, born on September 7, 1983, is

currently residing at Kenram, Isulan, Sultan Kudarat. She is a Maguindanaoan

and an Islam believer. She is a plain housewife and attends to her maternal

duties at home. Her husband works as a laborer in the market. The husband

decides for the family which means that it is a patriarchal type. The family has

six (6) living children.

According to Mrs. So Sexy, they own a bicycle which her husband uses

as means of transportation on his way to work. He works six days a week and

rests only during Fridays. He earns an average income of Php 200.00- Php

300.00 daily and sometimes, if luck permits, he can earn as much as Php

500.00. It means that the family’s average monthly income is approximately

Php 10,000.00. Such amount shall be used primarily for procurement of their

daily needs like food, bills, and other expenses.

Further interview revealed that the family lives in a two-bedroom

concrete house previously owned by the husband’s parents. The

neighborhood is surrounded by lush African Palm trees. The house’s floor is

cemented with three (3) windows, two (2) doors, and one (1) bed. The house

has a living room and a dirty kitchen. They only have a ceiling fan and a

mobile phone used for communication. The comfort room was constructed

few steps away from the house.

They get their water from a hand-pumped artesian well owned by their

neighbor. It is their source of water which they used primarily for washing,

cleaning, bathing, and even for drinking. They also have chickens and a cat.

Most of the time, leftovers were reheated to be eaten on the next meal. As for

the food, patient has a variety of vegetables planted in their backyard like

horseradish (malunggay), Malabar spinach (alugbati), sweet potato (kamote),

papaya, and lemon grass (tanglad). She also gathers African Palm fruits at a

nearby palm plantation which they use in replacement for firewood. She would

just leave her son on her mother’s house which is a few blocks away from

their home itself whenever she gathers fruits.

Moreover, patient So Sexy admitted that she does not take any

contraceptive pills as it is not practiced in their religion. Thus, it explains why

she got impregnated soon enough. However, upon considering the advice of

the health workers in the hospital and the benefits she could get, patient

decided to try the contraceptive implant because she doesn’t want to get

pregnant soon after her hospital discharge.

History of Past & Present Illness

A day before her hospital admission, the patient felt intermittent pain on

her lower back. Coincidentally, it was also her EDC. A day after and hours

before her confinement, she noticed that her bag of water broke and a gush of

water came out. Upon seeing it, patient informed her mother and together

they called a tricycle to transport them to Sultan Kudarat Provincial Hospital.

Thereafter, she was admitted with chief complaint of labor pains.

Furthermore, So Sexy had religiously availed the prenatal services

from their barangay health center and was so obedient in following the

schedules of prenatal visits as well as the corresponding laboratory tests and

vaccines needed. The patient further claimed that she was only hospitalized

before when she gave birth to her children and when she had an

appendectomy last year.

Generally, So Sexy, along with her family, had never been hospitalized

due to illness. Flu, fever, cough, stomachaches, headaches, toothaches, and

back pains were the illnesses they usually experience. She also seeks

medical help whenever her child got sick and both spouses take over-the-

counter drugs. They also avail massage from a hilot and believe on the latter’s

healing power capacity.

Effects to Self

Anxious of her condition, So Sexy’s motherly love and care prompted

her to immediately went to the hospital. She trusted the hospital’s capacity in

helping her to deliver her second child just like with her son before. She is

also well-aware of her supposed EDC and quite expectant to give birth on that

very day. Moreover, her previous childbirth experience served as her basis in

ascertaining if labor has started.

Considering that her bag of water broke, she immediately decided to

call for her mother to accompany her to the hospital so she could be given

appropriate medical help. Her decision emanated from the fact that she is a

mother and that she has to protect and save not only her life but of the baby

that is yet to be born. Such action proves her being a responsible parent and

her ardent and vehement desire to deliver her baby without suffering too

much complications and risks.

Effects to Family

Upon realizing that her bag of water already broke and that it was a

sign of imminent labor, So Sexy told her mother to accompany her to the

hospital. The prompt action of the mother implies that she also recognizes the

dangers and risks if they disregard the condition.

 In this case, the members of the family should also involve in attending

to the health needs of the patient regardless of the financial liabilities it will

incur. Meanwhile, upon knowing that patient already went to the hospital, the

husband hurried home and took care of their children. The action of the

husband shows his sense of responsibility as the father and as a husband

because he also looks after the welfare of his wife and soon-to-be born baby.

It shows that the family has strong ties and supports each other especially

during trying times.

Expectations to Self

Patient So Sexy looks forward to leave the hospital soonest because

she worries about her children left at home who were calling her asking when

will she come home. She personally attends to the needs of her child. She

believes that she has to resume to her daily routine and childbirth will not

hinder her from doing her responsibilities at home considering the fact that

she is involve primarily in keeping their household.

In fact, she alone attends to her and her baby’s needs in the hospital

while her mother is busy processing her documents. She already assumes

the role of a mother by feeding her baby and eating the right food to enable

her breasts to produce more milk. She also prioritizes her baby over her

hygiene needs.
 So Sexy is very well-aware and expects of this difficult situation to

happen the moment she gives birth in the hospital and all of the

responsibilities awaiting her the moment she goes home. She believes that

she needs to be steadfast and resilient as well because she will be doing

things more than her usual routine and chores before her delivery. She

already expects for sleepless nights and tiring days ahead. All she needs to

do is to manage her time and do her duties both as a mother and a wife

without compromising and prejudicing her health.

Family Genogram
Developmental Data

Developmental tasks are skills or growth responsibilities arising at a

particular time in an individual’s life, the achievement of which will provide a

foundation for the accomplishment of future tasks (Silbert-Flagg, 2022).

A. Psychoanalytic Theory by Sigmund Freud (1856- 1939)

The theory, based on Freud's observations of adults experiencing

mental disturbances, describes adult behavior as being the result of

instinctual drives of a primarily sexual nature (libido). Freud described child

development as being a series of psychosexual stages in which a child's

sexual gratification becomes focused on a particular body part at each

stage.

According to Cherry (2020), Freud’s theory explains that child

development occurs in a series of stages focused on different pleasure

areas of the body. During each stage, the child encounters conflicts that play

a significant role in the course of development. His theory suggested that the

energy of the libido was focused on different erogenous zones at specific

stages. Failure to progress through a stage can result in fixation at that point

in development, which Freud believed could have an influence on adult

behavior.

STAGE TASK JUSTIFICATION REMARKS

 Form a sense of Patient

identity vs role recognizes her

Genital confusion. role as a mother

(Adolescent) Learn who they are and start doing ACHIEVED

and what kind of her motherly

person they will be duties to her

newborn

B. Theory of Psychosocial Development by Erik Erikson (1902- 1996)

The theory stresses the importance of culture and society in

development of the personality. One of the main tenets of his theory,

that a person's social view of self is more important than instinctual drives in

determining behavior, allows for a more optimistic view of the possibilities for

human growth. Erikson looked at actions that lead to mental health, and

describes eight developmental stages covering the entire life span. At each

stage, there is a conflict between two opposing forces. The resolution of each

conflict, or accomplishment of the developmental task of that stage, allows the

individual to go on to the next phase of development.

Erikson's eight-stage theory of psychosocial development describes

growth and change throughout life, focusing on social interaction and conflicts

that arise during different stages of development. The theory described this
process from infancy through death. During each stage, people are faced with

a developmental conflict that impacts later functioning and further growth.

Unlike many other developmental theories, Erik Erikson's psychosocial theory

focuses on development across the entire lifespan. At each stage, children

and adults face a developmental crisis that serves as a major turning point.

STAGE TASK JUSTIFICATION

REMARKS
The Late Relate with other Patient takes

Adolescent people to in care of her child

preparation for and feeds the Achieved

developing future baby whenever

relationships hungry.

C. Cognitive Development Theory by Jean Piaget (1896- 1980)

Piaget defined four stages of cognitive development, within the

stages of growth, then finer units or schemas. To progress from one

period to the next, children reorganize their thinking processes to bring

them closer to adult thinking. Piaget defined four stages of cognitive

development, within the stages of growth, then finer units or schemas.

To progress from one period to the next, children reorganize their

thinking processes to bring them closer to adult thinking.

STAGE TASK JUSTIFICATION REMARKS

Sensorimotor In this stage the Patient had also

Stage (birth to infant focuses on undergone

2 years) physical series of

sensations and on milestones since ACHIEVED

learning to she was a baby.

coordinate his

body.

Preoperational At the beginning of Patient claims

Stage (2 to 7 this stage the child that when she

years) does not use was young, she

operations, so the likes to have

thinking is toys and no one ACHIEVED

influenced by the could use it. It is

way things appear hers.

rather than logical

reasoning.

Concrete A major turning Patient claims ACHIEVED

Operational point in the child's that she already

Stage (7 to 11 cognitive had crushes

years) development when she was

because it marks between this

the beginning of age bracket.

 logical or Shew learns

operational how to like

thought. things base on

her preference.

Formal Solves hypothetic Patient

Operational problems with recognizes the

Stage (12 and scientific reasoning risks of vaginal

up) delivery so she ACHIEVED

decided to give

birth naturally in

the hospital.

D. Moral Development Theory by Lawrence Kohlberg (1927-1987)

It is a theory on the way children gain knowledge of right and wrong or

moral reasoning. Recognizing where a child is developmentally according to

these stages can help identify how children may feel about an illness, such as

whether they think it is fair that they are ill. Recognizing moral reasoning also

helps determine whether children can be depended on to carry out self-care

activities such as administering their own medicine or whether children have

internalized standards of conduct so they do not cheat when away from

external control. Moral stages closely approximate cognitive stages of

development because children must be able to think abstractly (conceptualize

an idea without a concrete picture) before being able to understand how rules

apply even when no one is there to enforce them.

STAGE TASK JUSTIFICATION

REMARKS
Level I It lasts until Patient claims

Preconventional approximately age that she fears

9. Children don’t her parents. She

have a personal obeys them

code of morality. because

Moral decisions deviation from

are shaped by the the rule means ACHIEVED

standards of adults punishment and

and the she doesn’t want

consequences of to be punished.

following or

breaking their

rules.

Level II Conventional She’s living in ACHIEVED

Conventional morality includes harmony with

the society and her parents and

societal roles in it is her duty to

judging the still obey them

 morality of an regardless of her

action. age.

Level III Universal ethical Patient

Postconventiona principal recognizes that

l orientation. women even if it

Follows is a normal

internalized delivery must ACHIEVED

standards of give birth in a

conduct health facility as

mandated by the

law.

E. Bandura's Social Learning Theory

Social learning theory is based on the work of psychologist Albert

Bandura. Bandura believed that the conditioning and reinforcement process

could not sufficiently explain all of human learning. The theory suggests that

observation plays a critical role in learning, but this observation does not

necessarily need to take the form of watching a live model (Cherry, 2020).

STAGE TASK JUSTIFICATION

REMARKS
Observe other Patient observes
Observation ACHIEVED
other pregnant
 people’s behavior. women especially

on what they do.

Following She also visits the

observation, health center for

Imitation assimilation and prenatal checkups ACHIEVED

imitation of the like what others

observed behavior. were doing.

Imitate behavior She believes that

modeled by people prenatal checkup is

perceived as similar for her good and of

Modelling to one’s self. the baby’s. She also ACHIEVED

visits an OB-Gyne

because she

realizes the risks.

CHAPTER III

PHYSICAL ASSESSMENT
Physical Assessment

Patient’s Name: So Sexy Date & Time: Nov. 14, 2023 @ 7:00am

Age: 40 yrs.old Gender: Female Civil Status: Married

Height (m): 1.60m (5”3) Weight (kg): 58kgs BMI (kg/m2): 22.66

General Survey:

Patient lies on the bed, awake, alert, and oriented with the place, time,

and date with an IVF of D5LR 1L regulated at 30 gtts/min hooked on her left

metacarpal vein. She has untied long greasy black hair and wears a dress.

Her skin has blemishes and some marks of keloids noted on her legs.

Perspiration is seen on face too specifically on the ridge of the nose. Further,

her apparent age is evident with her stated age. She chiefly complains pain

and discomfort due to her perineal laceration and hot and humid weather

respectively.

Vital Signs

Body Temp: 36.90 C Pulse Rate: 78 bpm O2sat: 98%

Respiration Rate: 19cpm Blood Pressure: 100/80 mmHg

Pain Scale: 1 2 3 4 5 6 7 8 9 10
P – Precipitating factors: Mediolateral Episiotomy
Q – Quality: Sharp and Aching
 R – Region: Perineum
S – Severity: Moderate-Severe
T – Time: Intermittent

ASSESSMENT OF THE BODY SYSTEMS

SYSTEM ASSESSMENT FINDINGS

I: No nail clubbing, convex curvature shape nails, unclipped

with dirt under nails; Skin has scarring and blemishes, dark

marks (keloids), pale, perspiration on the face noted, linea

Skin and nigra, striae, chloasma and some moles

Nails
P: Skin is warm to touch, Capillary refill after 2sec

P: N/A

A: N/A

I: I: Head is normocephalic; hair is thick, coarse, and black

with some white particles; no lice infestation; facial grimace

noted
Head, Skull
and Face P: No nodule, mass, tenderness, nor lesions.

P: N/A

A: N/A
Eyes, Ears I: Eyes: Pupils equally round, reactive to light and
and Nose
accommodation, pale conjunctiva; darkened areas below the

eyes

Nose: Perspiration and no flaring, bleeding, or discharges

noted on the nose; in the middle of the face

 Ears: Can hear and repeat numbers and letters; earwax

present

P: Ears have no tenderness and pina recoils.

P: N/A

A: N/A

I: No gum bleeding noted; Tongue is pinkish

Jugular veins are not inflamed and no stiffness noted; Neck

can move left to right and right to left with no discomfort;

Mouth,
Oropharynx dental caries noted, dentures present; dry lips
and Neck
P: Trachea is in the midline position, smooth, firm

P: N/A

A: N/A
I: No muscle retraction & symmetrical chest movement upon

breathing; Quiet, unlabored respirations with no use of

accessory, neck, shoulder, or abdominal muscles.

Thorax and P: Normal chest size and shape

Lungs
P: N/A

A: Audible heart sound with a rate of 78bpm; clear breath

sounds; no reports of pain during respiration

Abdomen I: Firm, symmetric, has a scar, globular in shape,

stretchmarks, linea nigra

A: Gurgling sound noted

P: Dull sound noted

 P: Non-tender & without distention

I: Mons pubis is shaved, lochia rubra; patient hasn’t

defecated yet

P: N/A
Genitourinary
P: N/A

A: N/A

I: Symmetrical and appropriate to body size; muscles have

equal strength; Has proper gait and can walk; able to grip

Musculoskele P: No nodule, mass; pain on the perineum

tal
P: N/A

A: N/A

I: Alert and oriented

P: N/A
Neurological
(reflexes) P: Biceps, Triceps, and Quadriceps react when contracted

A: N/A

Laboratory & Diagnostic Tests

Date: November 14, 2023 @ 7:00 am

HEMATOLOGY

Tests Definition NORMAL INTER

RESULT
VALUES PRETATION
RBC A blood test that 4.06 g/L 3.5-5.5g/L Normal

measures red blood

 cells.

a protein in red blood

cells that carries

HGB 100 g/L 130-180 Decreased
oxygen throughout

the body.

Measures the

percentage of red 0.37 –

Hematocrit 32 Decreased
blood cells in blood 0.48

(it carries oxygen)

To determine

infection;

Measure the number 22.35x109 5-10x

WBC count Increased
9
of white blood cells /L 10 /L

(WBCs) in the blood-

infection is present

A type of immune

cell that is made in

Lymphocyte the bone marrow

6 20.0- 40.0 Decreased
s and is found in the

blood and in lymph

tissue.

Neutrophil A type of white blood 94 50-70 Increased

cell that is an
 important part of the

immune system and

helps the body fight

infection.

A type of white blood

cell (leukocytes) that

reside in blood and

Monocytes tissues to find and 1 3.0-12.0 Normal

destroy germs and

eliminate infected

cells

To estimate clotting

Platelet ability; Measure how 356 x 140-

Normal
count many platelets are in 109/L 440x109/L

the blood

Blood Type Blood type is to be B+

documented

because blood may

have to be made

available if a patient

has bleeding; A

method to detect the

possibility of ABO
 and RH

isoimmunization

Result INTERPRETATION

HBsAg (Qualitative) No Hepatitis B surface

Non- Reactive
antigen was found

Specimen Result INTERPRETATION

Rapid Covid-
COVID-19 wasn't
19 Antigen Nasopharyngeal
Negative detected in the body
Test (RAT) swab
system.

LMP: February 5, 2023

Sonogram/ Ultrasound
Date: November 3, 2023 EDC: November 12, 2023

Definition No. of Fetus One

It measures the response of Presentation Cephalic

soundwaves against solid Fetal Heart Rate 147 bpm

objects and a much-used Placenta Location Posterior

tool for fetal health Diagnosis

assessment to: Intrauterine pregnancy, single, alive in

cephalic presentation, 37 weeks and 3 days

 Diagnose pregnancy. age of gestation by ultrasound.

 Confirm the presence, Normohydramnios

size, and location of the

placenta and af.

 Discover complications

in pregnancy.

CHAPTER IV

TEXTBOOK DISCUSSION

Complete Diagnosis

Complete Diagnosis

A. Fertilization: The Beginning of Pregnancy

According to Silbert-Flagg (2022), the union of a single sperm and egg

(fertilization) signals the beginning of pregnancy. The fertilized ovum (zygote)

travels by way of a fallopian tube to the uterus, where implantation takes

place in about 8 days. From implantation to 5 to 8 weeks, the growing

structure is called an embryo. The period after 8 weeks until birth is the fetal

period. Growth of the umbilical cord, amniotic fluid, and amniotic membranes

proceeds in concert with fetal growth. The placenta produces a number of

important hormones: estrogen, progesterone, hPL, and hCG.

 Moreover, fertilization (also referred to as conception and

impregnation) is the union of an ovum and a spermatozoon. This usually

occurs in the outer third of a fallopian tube, termed the ampullar portion.

Further, there are only three documented or positive signs of pregnancy. First

is the demonstration of a fetal heart separate from that of pregnant patient’s

own heartbeat. Although a fetal heartbeat cannot be heard through an

ordinary stethoscope until 18-20 weeks of pregnancy, an echocardiography

can demonstrate a heartbeat as early as 5 weeks. An ultrasound can reveal a

beating fetal heart as early as the sixth or seventh week of pregnancy. The

fetal heart rate ranges between 120 and 160 beats per minute.

Another positive sign is fetal movements felt by an examiner. Fetal

movements may be felt by a pregnant person as early as 16 to 20 weeks of

pregnancy. The last positive sign is the visualization of the fetus by

ultrasound. Ultrasound is the most common method for confirmation of

pregnancy and gives information about the site if implantation and whether a

multiple pregnancy exists.

B. Labor and Birth

Labor is the series of events by which uterine contractions and

abdominal pressure expel a fetus and placenta from the uterus. Regular

contractions cause progressive dilatation of the cervix and create sufficient

muscular uterine force to allow a baby to be pushed out into the extrauterine

world (Silber-Flagg, 2022).

Theories Why Labor Begins

Labor normally begins between 37-42 weeks of pregnancy, when a

fetus is sufficiently mature to adapt to extra-uterine life, yet too large to cause

mechanical difficulty with birth. In some instances, labor begins before a fetus

is mature (preterm birth). In others, labor is delayed until the fetus and the

placenta have both passed beyond the optimal point of birth (post term birth).

Mechanisms (Cardinal Movements) of Labor

1. Descent

Descent is the downward movement of the biparietal diameter of the

fetal head within the pelvic inlet. Full descent occurs when the fetal head

protrudes beyond the dilated cervix and touches the posterior vaginal floor.

Descent occurs because of pressure on the fetus by the uterine fundus which

contracts the abdominal muscles that aids descent.

2. Flexion

As descent is completed and the fetal head touches the pelvic floor, the

head bends forward onto the chest, causing the smallest anteroposterior
diameter to present to the birth canal. Flexion is also aided by abdominal

muscle contraction during pushing.

3. Internal Rotation

As the head flexes at the end of descent, the occiput rotates so the

head is brought into the best relationship to the outlet of the pelvis.

4. Extension

As the occiput of the fetal head is born, the back of the neck stops

beneath the pubic arch and acts as a pivot for the rest of the head. The head

extends, and the foremost parts of the head, the face and chin, are born.

5. External Rotation

After external rotation, the head rotates a final time back to the

diagonal or transverse position of the early part of labor. The anterior shoulder

is born first, assisted perhaps by downward flexion of the infant’s head.

6. Expulsion

Once the shoulders are born, the rest of the baby is born easily and

smoothly because of its smaller size. It is the end of the pelvic division of

labor.
The Stages of Labor

a. The First Stage (about 12 hours to complete) or Effacement Stage

a.1. Latent Phase begins at the onset of regularly perceived uterine

contractions and ends when rapid cervical dilatation begins.

Contractions are mild and short lasting 20 to 40 seconds. Cervical

effacement occurs and the cervix dilates minimally.

a.2. Active Phase begins at 6cm when cervical dilatation occurs more

rapidly and contractions grow stronger, lasting 40 to 60 seconds and

occurs approximately every 3-5 minutes. Show (increased vaginal

secretions) and, perhaps, spontaneous rupture of the membranes

may also occur.

a.3. In Transition Phase, contractions reach their peak of intensity

occurring every 2 to 3 minutes with a duration of 60 to 70 seconds

and a maximum cervical dilatation of 8 to 10cm occurs. Show will

occur as the last of the mucous plug from the cervix is released. The

irresistible urge to push begins.

B. The Second Stage or the Delivery of the Baby

The second stage of labor is the time span from full dilatation and

cervical effacement to the birth of the infant. The fetus begins descent and

the perineum begins to bulge and appear tense. The anus may become
everted, and stool may be expelled. Crowning happens. As the fetal head

is pushed out of the birth canal, it extends and then rotates to bring the

shoulders into the best line with the pelvis. The body of the baby is then

born.

C. The Third Stage or Placental Stage

It begins with the birth of the infant and ends with the delivery of

the placenta. Placenta separates approximately 5 minutes after the

birth of the infant.

c.1. Placental Separation

As the uterus continue to contract, folding and separation of the

placenta occur. As separation is completed, the placenta sinks to the

lower uterine segment or the upper vagina. The placenta has

loosened and is ready to deliver when there is lengthening of the

umbilical cord, a sudden gush of vaginal blood occurs, and the

uterus contracts and feels firm again.

c.2. Placental Expulsion

The placenta delivers either by the natural bearing-down effort

or by gentle pressure on the contracted uterine fundus. Pressure

 should never be applied to a uterus in a noncontracted state

because doing so could cause the uterus to evert accompanied by

massive hemorrhage.

The Components of Labor

a. The Passage refers to the route of fetus must travel from the uterus

through the cervix and vagina to the external perineum.

b. The Passenger is the fetus.

c. The Powers of Labor is the force supplied by the fundus of the uterus

and implemented by uterine contractions which causes cervical

dilatation and then expulsion of the fetus from the uterus.

d. The Psyche refers to the psychological state or feelings a pregnant

person brings into labor.

Preliminary Signs of Labor

a. Lightening

It is the descent of the fetal presenting part into the pelvis that happens

10-14 days before labor begins.

b. Increase in Energy
 This increase in activity is related to a boost in epinephrine release.

c. Slight Loss of Weight

Body fluid is more easily excreted from the body.

d. Backache

An intermittent backache stronger than usual.

e. Braxton Hicks Contractions

f. Ripening of the Cervix

Prostaglandins soften the cervix to allow for shortening and dilatation.

Signs of True Labor

a. Uterine Contractions

Begins at the back and sweep forward across the abdomen similar to

the tightening of a rubber band.

b. Show

The mucous plug that filled the cervical canal during pregnancy is

expelled.

c. Rupture of the Membranes

It is a sudden gush or as a scanty, slow seeping of clear fluid from the

vagina.
 ANATOMY

Female Reproductive Organ

A. External Structure

B. Internal Structure
Mechanism of Labor
Physiology

Structure Location & Description Function

Mons Veneris Over the symphysis pubis, To protect the junction of the
the pubic bone joint pubic bone from trauma.

Labia Minora Posterior to the mons Lubrication during mating

veneris

Labia Majora Positioned lateral to the Protects the external

labia minora genitalia; they shield outlets
of the urethra and vagina.
Hymen Tough but elastic semicircle Covers the opening to the
of tissue vagina during childhood.

Skene Glands Located on each side of the Lubricate the external

urinary meatus genitalia during coitus.

Bartholin Located on each side of the These glands secrete fluid

Gland vaginal opening. that helps lubricate the
vagina.

Perineum Posterior to the fourchette It stretches during childbirth

to allow enlargement of the
vagina and passage of the
fetal head

Uterus Located in the lower pelvis, It receives the ovum from

posterior to the bladder and the fallopian tube; provide a
anterior to the rectum. place for implantation and
nourishment; furnish
protection to a growing
fetus.

Ovaries Located close to and on To produce, mature, and

(female both sides of the uterus in discharge ova.
gonads) the lower abdomen.

Clitoris Small, rounded organ of Center of sexual arousal

erectile tissue and orgasm

Urethra Opening to the bladder Passageway of urine

Urinary It is a muscular sac in the This stores urine, allowing

Bladder pelvis, just above and urination to be infrequent
behind the pubic bone and controlled

Vagina Canal about 10-8 cm long Receives penis during

 going from the cervix to the mating. Pathway through a
outside of the body. woman’s body for the baby
to take during childbirth.

Vulva Surround entrance to the The gate for the uterus or

reproductive tract womb and provides
(encompasses all external protection by opening and
genitalia) closing of the lips of
the vulva

Endometrium The innermost layer of Contains glands that secrete

uterine wall. fluids that bathe the uterine
lining.

Myometrium Smooth muscle in uterine Contracts to help expel the

wall. baby.

Fallopian They arise from each upper Convey the ovum from the
Tubes corner of the uterine body ovaries to the uterus and to
ands extend outward and provide a place for
backward until each open at fertilization of the ovum by
its distal end, next to an the sperm.
ovary.

Cervix Located inside the pelvic Allows fluids to flow inside

cavity, anywhere from 3 to 6 and out of uterus. It's also a
inches inside the vaginal powerful gatekeeper that
canal. can open and close in ways
that make pregnancy and
childbirth possible.
Pathophysiology

Predisposing Factors Precipitating Factors

 Age (21 yrs old)  Lack of knowledge about

 Gender (female) family planning
 Menstruation Cycle  Coitus
 Culture & tradition

Egg Cell + Sperm Cell

Fertilization/ Conception

Implantation
 Zygote
 Morula
 Blastocyst
 Embryo
 Formation of:
 Chorionic Villi
 Placenta
`  Umbilical Cord

Milestones of Fetal Growth &

Development and
Physiologic Changes
 First Trimester (1-12 Weeks) + Signs of
Nausea & Vomiting, Amenorrhea, Pregnancy:
Breast Change
 Demonstration of
 Second Trimester (13- 24 Weeks)
fetal heart
Fetal Movement, Quickening
separate from the
 Third Trimester (25- 40 Weeks)
pregnant patient
Age of Viability, Fetal Presentation
 Fetal movements
felt by an
examiner
 Visualization of the
Symptomatology
Full Term Pregnancy (38-40 Weeks AOG) fetus by UTZ

Factors Labor & Delivery Rationale Remarks

Absence of menstruation. A missed or

Amenorrhea delayed menstruation is one of the most PRESENT

common signs of pregnancy.

This typically occurs at the time of

Slight Bleeding implantation of the fertilized egg but is PRESENT

common in the first 12 weeks of pregnancy

Breast Changes It is the feeling of tenderness, fullness, PRESENT

 tingling, enlargement and darkening or

areola.
(Tender, swollen
Hormonal changes can make the breasts
breasts or nipples)
sore

or even tingly.

The sudden rise of hormones may trigger

Headaches PRESENT
headaches early in pregnancy.

Commonly referred to as "Morning

Nausea/Vomiting Sickness," it can actually occur at any time PRESENT

during the day.

Sudden cravings or developing a dislike of

Food Cravings favorite foods are both common throughout PRESENT

pregnancy

Hormonal changes during pregnancy often

Mood Swings cause sharp mood swings. These can occur PRESENT

as early as a few weeks after conception.

 Lower backaches may be a symptom that

occurs early in pregnancy; however, it is

Backaches common to experience a dull backache PRESENT

throughout an entire pregnancy.

Sense of having to void more often than

Frequent Urination
usual. PRESENT

General feeling of tiredness.

Fatigue PRESENT

Often referred to as a pregnancy line, is

Linea Nigra a linear hyperpigmentation that commonly PRESENT

appears on the abdomen.

Melasma/Chloasma Dark pigment forms on face PRESENT

Stria Gravidarum Stretch marks form on abdomen. PRESENT

Quickening Fetal movement felt by the patient. PRESENT

Etiology

A. Predisposing Factors

Factors Rationale Justification Remarks

 Only females can The patient is
Gender Present
conceive female

Age affects the fertility The patient’s age

of women. is 21 which is

It is the single biggest young and very

Age factor affecting a capable and Present

woman’s chance to productive.

conceive and have a

healthy baby.

Menstrual An episodic uterine The patient Present

Cycle bleeding in response claims that she

to cyclic hormonal has regular

changes. It will bring menstrual flow.

the ovum to maturity

and renew a uterine

tissue bed that will be

necessary for the

ovum’s growth should

it be fertilized. The

length of menstrual

cycle differs but the

average length is 28
 days from the

beginning of one

menstrual flow to the

beginning of the next.

B. Precipitating Factors

Factors Rationale Justification Remarks

A reproductive act As a couple,

in which the male spouses

Coitus reproductive organ engage into Present

enters the female sexual

reproductive tract. intercourse.

Both spouses are The couple’s

Maguindanaoan religious belief

and Islam hinders them

believers. from using

Culture &
contraceptives. Present
tradition
They also

believe that

they have to

procreate.

Lack of Lack of family The couple’s Present

knowledge planning leads to decision not to

 unplanned use any form of

pregnancy. contraceptive

about family and the lack of

planning information led

to patient’s

pregnancy.

Medical Management

Date & Physician’s

Justifications Remarks
Time Order
April 26, Please admit  These are part of

2023 Secure consent routine care.

 For proper and

7:00am Laboratories appropriate Carried out

 CBC management

 Blood Type  The tests are used to

 HBsAg check for diseases and

 UA infections that can

 Platelet affect the health of

Count patient and the unborn.

The results can guide

treatments, which may

help prevent serious

complications.

Start IVF D5LR Lactated Ringer’s Solution

1Lx 30gtts/min is used to treat

dehydration, facilitate the

Started
flow of IV medication

during surgery, and

restore fluid balance.

TPR q hr  For monitoring

It helps in the early

detection of potential life- Carried out

threatening complications

that may arise.

DAT; NPO Diet as tolerated means

once in active that GI tract tolerates food

labor and is ready for

advancement to the next Carried out

stage; Aspiration occurs

when food or liquid is

inhaled into the lungs.

Meds: HNBB An anticholinergic Drug

1amp IVTT x that is effective in reducing

3doses the duration of the first

stage of labor and is not Given &

associated with any Carried out

apparent adverse

maternal or neonatal

outcomes.

Monitor for To make sure everything's

signs of labor going as it should be.

Regular checks can help Carried out

to pick up any potential

issues early.

PPO Post-Partum Order is Carried Out

given to maintain and

 promote patient’s health.

To room Patient care routine and Transferred &

for continued monitoring. Carried Out

DAT Diet as tolerated means

that GI tract tolerates food

and is ready for Carried Out

advancement to the next

stage.

Medicines: Medications are Given

 Oxytocin prescribed with specific

1amp IVTT instructions for a reason,

 Methergine and stopping can have

1amp IVTT serious consequences.

 Mefenamic

Acid 500mg

TID PO

PRN for

pain

 Cefalexin

500mg TID

x 7days

 Ferrous
 1tab x 3mo

Please follow To facilitate treatment

Followed up
up labs

Refer To address untoward

complications properly Referred

and immediately.

Dr. Maganda

Nursing Management

Proper and appropriate nursing management helps patient alleviate

current state. Thus, the following nursing managements would be employed:

Independent:

1. Monitor vital signs to serve as baseline data.

2. Check the pad used for lochia flow and saturation to check for the

occurrence of bleeding.
 3. Inform the signs indicative of possible hemorrhage to detect earliest

signs of bleeding like checking lochia color.

4. Teach the proper way of perineal washing to avoid infection that

microorganisms might cause.

5. Conduct health teaching to patient about the importance of self-care to

maintain hygiene.

6. Advise to change sanitary pads frequently and avoid using pads for

longer periods of time to prevent infection.

7. Advise to wear loose and comfy dress to provide comfort and relief.

8. Encourage to eat nutritious food, soups, and increase fluid intake to

replenish fluid loss during childbirth, revitalize the body, and prevent

constipation.

9. Ask SO for assistance when changing position or in sitting & lying.

10. Utilize time in resting or sleeping as much as possible.

11. Divert attention in activities that can provide leisure and entertainment.

12. Discuss about contraceptives to give patient basic understanding of its

importance and advantages.

13. Teach the proper breastfeeding positions and attachments to ensure

milk flow.

Dependent:
 1. Administer medications in a timely manner while following certain

conditions that will also help and aid in easy absorption of drugs.

Collaborative:

1. Facilitated laboratory requests and followed up pending results.

2. Coordinated with the food department on patient’s diet especially on

NPO order.

CHAPTER V

LIST OF MEDICATIONS

1. Hyoscine N-butylbromide (HnBB) 1amp IVTT q1 x 3 doses

2. Oxytocin 1amp now

3. Methergine 1amp now

4. Terramycin
5. Magnesium Sulfate

6. Phytomenadione

7. Mefenamic Acid 500mg TID PRN for pain

8. Cefalexin 500mg TID x 7 days

9. Ferrous Sulfate 1tab BID x 3mo

 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131

DRUG STUDY
Name of Patient: So Sexy
Date: November 14, 2023
Attending Physician: Dr. Maganda
Diagnosis: G7P6 (7006) Pregnancy Uterine Full Term Delivered via NSVD
 NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING
RESPONSIBILITIES
Generic Name Mechanism of Frequent: Dry mouth GI/GU obstruction 1. Checked/verified
Hyoscine Action (sometimes severe), myasthenia gravis doctor's order to carry
butylbromide Inhibits action of decreased diaphoresis, narrow-angle glaucoma out right
Scopolamine acetylcholine at constipation. paralytic ileus procedure/dose to the
butylbromide post-ganglionic Occasional: Blurred severe ulcerative colitis right patient.
Hyoscyamine (muscarinic) vision, bloated feeling, 2. Performed
receptor sites. urinary hesitancy, handwashing before
Brand Name Therapeutic Effect: drowsiness (with high and after drug
Buscopan Decreases dosage), headache, administration to
SPECIAL
secretions of intolerance to light, loss prevent the spread of
PRECAUTIONS
gastric juices of taste, anxiety, flushing, microorganisms
Classification Reduces motility of insomnia, impotence,  Hyperthyroidism, 3. Monitored patient's
Anticholinergic Drug GI, urinary tracts mental confusion or vital signs to serve as
Antispasmodic Indications excitement, temporary CHF baseline data
Preoperatively to light-headedness (with 4. Checked IV tubing for
reduce secretions parenteral form), local  cardiac arrhythmias patency and problems
block cardiac vagal irritation (with parenteral like clamp or kink to
inhibitory reflexes; form).  prostatic hypertrophy ensure smooth flow of
relief of biliary, Rare: Dizziness, drug.
renal colic; faintness  neuropathy 5. Prepared the
reduce GI motility ADVERSE EFFECT materials to be used
to facilitate  chronic lung disease (syringe & gauze pad)
diagnostic  Overdose: temporary in withdrawing the
procedures;  biliary tract disease. ampule’s content to
MODE OF paralysis of ciliary
reversal of save time and for
ADMINISTRATION
neuromuscular efficiency.
blockade. muscle, pupillary DRUG INTERACTION 6. Withdrawn and
injected slowly over 3-
Route dilation, tachycardia,  DRUG: Antacids 5 minutes to facilitate
infusion and reduce
IVTT palpitations, may decrease discomfort.
7. Raised side rails as a
hot/dry/flushed skin, absorption. precaution because
Dosage some patients
absence of bowel Other become temporarily
1 ampule IVTT x 3
excited or disoriented
doses sounds, anticholinergics and some develop
amnesia or become
hyperthermia, may increase drowsy.
Time: q8 8. Monitored cervix to
increased respiratory effects. check for effacement
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131

DRUG STUDY
Name of Patient: So Sexy
Date: April 26, 2023
Attending Physician: Dr. Maganda
Diagnosis: G2P2 (2002) Pregnancy Uterine Full Term Delivered via NSVD

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

Generic: Directly affects  hypertension,  Hypersensitivity to 1. Verified doctor’s order to

Oxytocin neuroreceptor sites to dysrhythmias, oxytocin. carry out right procedure to

stimulate contraction tachysystole, and  Cephalopelvic the right client

Brand: of the uterus during uterine disproportion 2. Performed hand washing

Syntocinon labor especially hyperstimulation.  Fetal intolerance of before and after drug

toward the end of the  Tachysystole is 6 labor administration to deter

Classification:
pregnancy, helping or more uterine  Anticipated non spread of microorganisms
Oxytoxic drug
expel the baby. It also contractions in a vaginal delivery 3. Monitored vital signs to
 contracts 20-min window. serve as baseline data.

myoepithelial cells in (Hyperstimulation) 4. Reviewed patient's medical

Mode of
Administration the breasts, causing SPECIAL record to be sure there are
PRECAUTION
milk to be expressed Adverse Effects Have tocolytic agents no contraindications to

Route: IVTT from the alveoli into Hypertonicity may and oxygen readily administration.

the ducts so that the occur with tearing of available. 5. Informed patient about the

Dosage: 1 amp baby can obtain it by uterus, increased Caution should be used side effects of the drug for

suckling bleeding, abruption in patients with awareness of such

Time: STAT placentae Fetal coronary disease and occurrence.

bradycardia Low hypertension due to the 6. Maintained patient in lateral

Indication: Apgar score at 5 min, effect of causing arterial recumbent position or sitting

Stimulation of uterine Prolonged IV infusion contraction, which position to promote placental

contractions during of oxytocin with could raise blood perfusion.

third stage of labor excessive fluid pressure or 7. Observed patient after

and control of volume has caused compromise coronary administering the drug for
postpartum bleeding severe water blood flow, or in monitoring and baseline

or hemorrhage. intoxication with patients who have had data.

seizures, coma, death previous cesarean 8. Instructed patient to report

births because of the any unusuality such as

effects on uterine increased bleeding and other

contraction, which adverse effects to render

could compromise immediate action and

scars from previous prevent harm that may

procedures. worsen patient conditions.

9. Checked patient’s status

DRUG INTERACTION before leaving the room to

Drug-drug. Carboprost ensure that patient is safe

tromethamine: Ma and free from risk that may

enhance adverse/toxic cause side effects and

effect of oxytocin. Avoid adverse effects.

 combination 10. Documented all the

procedures done for legal

purposes and continuity of

care.

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131
 DRUG STUDY
Name of Patient: So Sexy
Date: April 26, 2023
Attending Physician: Dr. Maganda
Diagnosis: G2P2 (2002) Pregnancy Uterine Full Term Delivered via NSVD
 NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING
RESPONSIBILITIES
Generic Name Mechanism of FREQUENT: Use of Methergine is 1. Checked/verified doctor's
Action
Methylergonovine contraindicated during order to carry out right
Methylergometrine  Abdominal pain
pregnancy because of its procedure/dose to the right
acts directly on the  Headache
uterotonic effects. patient.
Brand Name smooth muscle of  increased BP

Methergine the uterus and 2. Performed handwashing

increases the tone, before and after drug

Classification DRUG INTERACTION
RARE:
Ergot alkaloids rate, and Methergine may interact administration to prevent the

amplitude of  Dizziness spread of microorganisms

with conivaptan,

rhythmic  Fast, pounding, or

epinephrine, imatinib, 3. Monitored patient's vital
contractions irregular heartbeat or
Mode of isoniazid, nefazodone, signs to serve as baseline
Administration
through binding pulse
zileuton, antibiotics, data.
Route: IVTT
and the resultant  Hives
antidepressants,
4. Obtained patient’s
antagonism of the  light-headedness,
Dosage: 1amp antifungals, cold or allergy
medical history to prevent
dopamine D1 dizziness, or fainting
medicines that contain
Time: STAT hypersensitivity, reactions, or
receptor. Thus, it  Pain or discomfort in
decongestants, heart or
allergies that may harm the
induces a rapid the arms, jaw, back, or
blood pressure
patient.
and sustained neck
medications, hepatitis C

tetanic uterotonic  Pain, tenderness, or 5. Informed patient the side

medications, HIV/AIDS

effect which swelling of the foot or effects of drugs to be

medications, migraine

shortens the third leg administered so patient won’t

headache medicines,
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131

DRUG STUDY
Name of Patient: So Sexy
Date: April 26, 2023
Attending Physician: Dr. Maganda
Diagnosis: G2P2 (2002) Pregnancy Uterine Full Term Delivered via NSVD
 NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING
RESPONSIBILITIES
Generic Name Mechanism of  Stomach pain Contraindicated in patients 1. Checked/verified doctor's
Action
Mefenamic Acid  Nausea & with salicylate order to carry out right
Binds the
vomiting hypersensitivity NSAIDs procedure/dose to the right
prostaglandin
 Heartburn hypersensitivity who patient.
synthtase receptor
Brand Name  Constipation experienced asthma,
2. Performed handwashing
cox - 1 and Cox-2,
Myrefen  Diarrhea urticaria, m other allergic
inhibiting the before and after drug
action  Rash reactions after taking
administration to prevent
Classification
of prostaglandin  Dizziness aspirin on other NSAIDs
Non- steroidal the spread of
synthetase
 Tinnitus
Anti-inflammatory SPECIAL PRECAUTIONS microorganisms.
Drugs  Allergies 3. Monitored patient's vital
Indications
 Helps reduce ADVERSE EFFECT  Pediatric signs to serve as baseline

pain,  Heart attack or  Geriatric data.

MODE OF stroke (chest pain
inflammation,  Breastfeeding 4. Advised patient to take the
ADMINISTRATION
and fever.  shortness of  Drug interaction drug as prescribed by the

 Used to treat breathing

DRUG INTERACTION physician to ensure

mild to  weakness in one

Route  Blood Pressure drug efficacy.
Oral moderate pain, side of the body
 Diuretics (water pills) 5. Advised patient to take
Dosage  slurred (speech)
menstrual  Non-steroidal anti- medication with food
500 mg/ cap
cramps and  Heart failure
inflammatory drugs followed by a full glass of

other (swelling in arms,

Time: TID PO (NSAIDs)\ water or milk to avoid GI
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131

DRUG STUDY
Name of Patient: So Sexy
Date: April 26, 2023
Attending Physician: Dr. Maganda
Diagnosis: G2P2 (2002) Pregnancy Uterine Full Term Delivered via NSVD

CONTRAINDICATIO
NAME DRUG ACTION SIDE EFFECT NURSING RESPONSIBILITIES
N
Generic: Inhibits bacterial cell Diarrhea, nausea, Contraindicated in 1. Verified doctor’s order to carry

Cefalexin wall synthesis, leading vomiting, abdominal patients with known out right procedure, dosage, and

breakdown and pain, headache, and hypersensitivity to medication to the right client.

Brand: eventually cell death. dizziness. cefalexin or other 2. Performed hand washing before

Zelexin members of the and after drug administration to

Indication: cephalosporin class of deter spread of microorganisms

 Respiratory tract antibacterial drugs. 3. Monitored vital signs to serve as

Classification: infections caused Adverse Effects SPECIAL baseline data.
PRECAUTION
Antibiotic by Streptococcus CNS: Headache, Serious allergic 4. Took the health history of the

Cephalosporin pnuemoniae, dizziness, lethargy, reactions can occur client to determine if the patient
(first
generation) group A beta- paresthesia with this medicine. is allergic to the drug.

hemolytic GI: Nausea, Check with your 5. Informed patient about the side
Mode of
Administration streptococci vomiting, diarrhea, doctor right away if effects of the drug for awareness

 Skin and skin anorexia, abdominal you have chest pain, of such occurrence.

Route: PO structure infections pain, flatulence, blistering, peeling, or 6. Gave oral drug with food to

caused by pseudomembranous loose skin, red skin decrease GI upset and enhance

Dosage: 1 tab stephylococcus, colitis, hepatotoxicity lesions, large, hive- absorption.

500mg streptococcus GU: Nephrotoxicity like swelling on the 7. Advised patient to swallow the

 Otitis media Hematology: Bone face, eyelids, lips, tablet whole. Do not break,

Time: TID x 7 caused by S. marrow depression tongue, throat, hands, crush, or chew it results in a

days pnuemoniae, Hypersensitivity: legs, feet, or sex bitter, unpleasant taste and it

Haemophilus Ranging from rash to organs, severe acne may alter the drug’s efficacy.
 influenzae, fever anaphylaxis; or skin rash, sores or 8. Advised patient to report any

streptococcus, serum sickness ulcers on the skin, adverse effects like chest pain or

stephylococcus, reaction trouble breathing or SOB to immediately address the

Moraxella Other: swallowing, or fever or problem.

catarrhalis Susperinfections chills while you are 9. Instructed patient to continue

 Bone infections using this medicine. taking the drug even after feeling

caused by better to ensure drug’s

Escherichia coli, effectiveness and prevent drug

P. mirabilis, tolerance.

Klebsiella DRUG INTERACTION 10. Recorded/documented the

Drug-drug: Laxis procedure performed to provide

(furosemide), Probiotic accurate data in the care of the

Formula, Zinc, client; for legal purposes.

Warfarin, Typhoid

Vaccine, Sodium
picosulfate,

Multivitamins with

Minerals, Metformin,

Cholera vaccine, BCG

 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131

DRUG STUDY
Name of Patient: So Sexy
Date: April 26, 2023
Attending Physician: Dr. Maganda
Diagnosis: G2P2 (2002) Pregnancy Uterine Full Term Delivered via NSVD
 NAME DRUG ACTION SIDE EFFECTS CONTRAINDICATIONS NURSING RESPONSIBILITIES
Generic Name Mechanism of  Headache Primary 1. Checked doctor's order to

Action  Dizziness hemochromatosis, avoid medication error.

Ferrous sulfate
 Nausea hemolytic anemias and
An essential 2. Monitored patient's vital
Brand Name
 Constipation other anemias not to iron
mineral found in signs to serve as baseline
Ferricore  Diarrhea deficiency.
hemoglobin, data.

Classification Anti-  Dark stools

myoglobin and a SPECIAL
3. Performed handwashing
anemics number of PRECAUTIONS
before and after drug
enzymes.
 Peptic ulcer administration to prevent the
Parenteral iron
 Ulcerative colitis or spread of microorganisms
enters the ADVERSE EFFECT regional enteritis
4. Advised patient to take iron
bloodstream and
 Seizure
supplements an hour before
organs of the
 Syncope
MODE OF meals for maximum
reticuloendothelial
 Hypotension
ADMINISTRATION absorption.
system, where iron
 Tachycardia
is separated from DRUG INTERACTION 5. Advised patient not to crush

the dextran the tablet. Alteration can

Route  Tetracycline or
complex and result in rendering the
Antacids
Oral
becomes part of treatment ineffective.
 Fluroquinolones or
Dosage 1 Tab
the body iron penicillin. 6. Advised to take medication

Time OD stores.  Chloramphenicol or with orange juice or vitamin

 CHAPTER VI

LIST OF PRIORITIZED NURSING PROBLEMS

Five (5) prioritized Nursing Diagnosis

1. Acute pain related to perineal laceration secondary to childbirth as

evidenced by patient’s verbalization “Sakit ang tahi ko ma’am kung

maghulag ko. Pati man tiyan ko masakit kay may dugo pa.”

2. Imbalanced nutrition (less than body requirements) related to

insufficient and low hemoglobin as evidenced by hemoglobin level 100

g/L.

3. Deficient fluid volume related to insufficient fluid intake as evidenced

by patient’s dry lip membranes and skin.

4. Impaired comfort related to environmental factors (noise and

temperature) as verbalized by the patient, “Kalain ma’am kay init

kaayo. Grabe gani balhas ko. Di man katulog maayo.”

5. Impaired skin integrity related to alteration in the skin surface as

evidenced by presence of chloasma, linea nigra, stretch marks, and

dark pigmentations on the neck and armpits.

 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131

NURSING CARE PLAN

Name of Patient: So Sexy Diagnosis: G7P6 (7006) Pregnancy Uterine

Area: OB ward Full Term Delivered via NSVD

ASSESSMENT NEEDS NURSING GOALS NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective P Acute pain General 1. Established 1. Generates patient’s

Data A related to After nursing rapport and trust and Goals partially met.

“Sakit ang I perineal interventions, monitored vital cooperation. Patient

tahi ko N laceration patient will be signs. Monitoring VS serves verbalizes, “Ara pa

ma’am kung / secondary to able to as baseline data. man ma’am pero

maghulag D childbirth as experience 2. Assessed pain 2. To determine the medyo nag ok na

ko. Pati man I evidenced by comfort and using pain scale affected area and to basta di lang ko

tiyan ko S patient’s relief. (location, serve as baseline sige hulag” and pain

masakit kay C verbalization, characteristics, & data. scale 4/10.

may dugo O “Sakit ang tahi ko Specific intensity)

pa.” M ma’am kung After 5hrs of 3. Advised patient to 3. Perineal washing Vital Signs:

F maghulag ko. nursing do perineal care prevents infection. T: 36.8 0C

Pati man tiyan ko interventions, and observing

 O masakit kay may patient will be front to back BP: 100/70 mm/Hg

Objective R dugo pa.” able to: washing PR: 76 bpm

Data T Rationale 1. Report technique. RR: 20 cpm

- Facial Unpleasant pain is 4. Advised patient to

expressio sensory and relieved or take medication 4. Certain medications

n of pain emotional controlled; as prescribed by are intended to

(grimace) experience 2. Demonstra the physician. relieve and alleviate

- Sweating associated with te use of 5. Advised patient to pain.

/ actual or potential relaxation avoid strenuous 5. Strenuous activities

diaphore tissue damage, or skills and activities. can aggravate pain.

sis described in diversional 6. Advised patient to

6. Rest promotes
- Needs terms of such activities. rest as much as
comfort and
supports damage; sudden 3. Follow possible.
alleviation.
in moving or slow onset of both 7. Advised patient to

any intensity from pharmacol avoid sudden 7. Sudden movements

Vital Signs: mild to severe ogical and change of may trigger pain.

BP: 100/80 and with a nonpharm position and

mm/Hg duration of less acological exerting too much

Temp: than 3 months. methods effort.

36.90C to relieve 8. Provided

PR: 78 bpm References pain. emotional 8. Support can pacify

RR: 19 cpm Doenges, support. and provides comfort.

Marilynn, et.al. 9. Advised patient to

(2019). Nurse’s wear clean and 9. Wearing loose dress

Pocket Guide comfy dress and can provide comfort.

Diagnoses, avoid tight-fitting

Prioritized one.

Interventions and 10. Checked for

Rationales 15th signs of bleeding 10. To prevent or

Ed. F.A. Davis. and lochia. address if bleeding

occurs.
 Chapter VIII

PROGNOSIS

Prognosis Good Fair Poor Justifications

Patient noticed and experienced pelvic

Onset of Illness pains a day before her hospital

√
admission.

Patient has been staying in the ward

Duration of Illness √
for more than 24hrs already.

Patient looks somewhat tidy. She took

Hygiene √ a bath and able to change her pads

but with unclipped and dirty nails.

Patient’s diet is NPO to prevent gastric

Diet √
irritations and occurrence of aspiration

Patient is 21 years old which means

Age √
that she is capable of bearing a child.

Patient is conscious, alert, and well-

Performance oriented of the time, date, and place.

√
Level She can move and attend to her basic

needs from eating to toileting.

The family shows their support by

Family Support √ looking after the patient and assisting

all throughout.

OVERALL:
 GOOD – 4/7 × 100= 57.14%

FAIR – 3/7 × 100= 42.86%

POOR- 0/7 × 100= 0

REMARKS:

The patient’s prognosis result is good which entails the likelihood of her

fast recovery from her current state. This also shows that patient is doing well

but she also needs to improve and help herself in managing personal hygiene

and grooming. She also needs to follow her diet restriction so that she will

recover soonest.

REFERENCES

Books
Doenges, Moorhouse, & Murr (2019). Nurse’s Pocket Guide Diagnoses,
Prioritized Interventions, and Rationales 15th. iGroup Press Co., Ltd.

Hodgson, Barbara & Kizior, Robert (2014). Saunders Nursing Drug

Handbook 2014. Elsevier, Inc.

Lippincott Williams & Wilkins (2022). Nursing 2022 Drug Handbook 42nd
Ed. Wolters Kluwer.

Pillitteri, Adelle & Silbert-Flagg, JoAnne (2018). Maternal and Child Health
Nursing Care of the Childbearing & Childrearing Family 8th Ed. Wolters
Kluwer.

Silbert-Flagg, JoAnne (2022). Maternal and Child Health Nursing Care of the
Childbearing & Childrearing Family 9th Ed. Wolters Kluwer.

Online Sources

Cherry, Kendra (2020). Child Development Theories and Examples.

Verywellmind.

https://www.verywellmind.com/child-development-theories-2795068

Department of Health 12 (2021). Field Health Services Information System

(FHIS) 2021 Annual Report.

Desai Ninad M. & Alexander Tsukerman (2022). Vaginal Delivery. National

Library of Medicine.

https://www.ncbi.nlm.nih.gov/books/NBK559197/

Funai, Edmund & Erol Norwitz (2022). Labor and delivery: Management of

the normal first stage. UpToDate.

https://www.uptodate.com/contents/labor-and-delivery-management-of-the-

normal-first-stage

Joyce, Martin et.al. (2018). Births: Final Data for 2017

https://pubmed.ncbi.nlm.nih.gov/30707672/

Mohaghegh, Zaynab (2020). The effect of hyoscine n- butylbromide on labor

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https://doi.org/10.1186/s12884-020-2832-3
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020-2832-3

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https://www.intechopen.com/chapters/75511

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https://dhsprogram.com/pubs/pdf/FR347/FR347.pdf

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https://psa.gov.ph/content/registered-live-births-philippines-2020