Case Study (nsd - Primi) 1r376l

Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY Cabanatuan City College of Nursing

A CASE STUDY ON NORMAL SPONTANEOUS DELIVERY Manuel V. Gallego Cabanatuan City General Hospital (Delivery Room)

Presented By: Payra, Divina May L. (Head Nursing) Gallardo, Khristine Bernadette Reyes, Deane Carmina C. San Pedro, Kimberly Tajorda, Jandaria Tarah Mae Villamia, Lyka C. NEUST SN’14

NORMAL SPONTANEOUS DELIVERY (Case Study) Presented By: Payra, Divina May L. (Head Nursing) Gallardo, Khristine Bernadette Reyes, Deane Carmina C. San Pedro, Kimberly Tajorda, JandariaTarah Mae Villamia, Lyka C. NEUST SN’14

I.

Introduction

II.

Objectives

III.

Client’s Profile

IV.

History

V.

Activities of Daily Living

VI.

Physical Assessment

VII.

Case Discussion I. Normal Spontaneous Vaginal Delivery - Definition - Purpose - Complications - Course of the Procedure II. Episiotomy

VIII.

Anatomy

IX.

Physiology

X.

Management

XI.

Diagnostic Procedure

XII.

Drug Study

XIII.

Nursing Care Plan

I.

INTRODUCTION

Pregnancy is the state of carrying a developing embryo or fetus within the female body. This condition can be indicated by positive results on an over-the-counter urine test, and confirmed through a blood test, ultrasound, detection of fetal heartbeat, or an X-ray. Pregnancy lasts for about nine months, measured from the date of the woman's last menstrual period (LMP). It is conventionally divided into three trimesters, each roughly three months long. When gestation has completed, it goes through a process called delivery, where the developed fetus is expelled from the mother’s womb. There are two options of delivery: Cesarean section and NSVD or normal spontaneous vaginal delivery. A cesarean section is a surgical incision through the mother’s abdomen and uterus to deliver one or more fetuses. NSVD or normal spontaneous vaginal delivery is the delivery of the baby through vaginal route. It can also be called NSD or normal spontaneous delivery, or SVD or spontaneous vaginal delivery, where the mother delivers the baby with effort and force exertion. Labor and delivery of the fetus entails physiological effects both on the mother and the fetus. In the cardiovascular system, the mother’s cardiac output increases because of the increase in the needed amount of blood in the uterine area. Blood pressure may also rise due to the effort exerted by the mother in order expel the fetus. There could also be a development of leukocytes or a sharp increase in the number of circulating white blood cells possibly as a result of stress and heavy exertion. Increased respiratory may also occur. This happens as a response to the increase in blood supply in order to increase also the oxygen intake. Normal labor is defined as the gradual subjugation and dilatation of the uterine cervix as a result of rhythmic uterine contractions leading to the expulsion of the products of conception: the delivery of the fetus, membranes, umbilical cord, and placenta. Laboring cannot that be easy; thereby implicating that there are processes and stages to be undertaken to achieve spontaneous delivery. Through which, Obstetrics have divided labor into four (4) stages thereby explaining this continuous process. Braxton Hicks contractions, or also known as false labor or practice contractions. Braxton Hicks are sporadic uterine contractions that actually start at about 6 weeks, although one will not feel them that early. Most women start feeling them during the second or third trimester of pregnancy. True labor is felt in the upper and mid abdomen and leads to the cervical changes that define true labor. With delivery imminent, the mother is usually placed supine with her knees bent (ie, the dorsal lithotomy position). An episiotomy (an incision continuous with the vaginal introitus) may be performed at this time. Episiotomy may ease delivery of the fetal head and allow some control over what may otherwise be an uncontrolled perineal laceration. However, many providers no longer perform routine episiotomy, since it may increase the risk of rectal injury and are larger than the spontaneous laceration. The labor and birth process is always accompanied by pain. Several options for pain control are available, ranging from intramuscular or intravenous doses of narcotics to general anesthesia and regional nerve blocks. Further options include epidural blocks and spinal anesthetics.

II.

OBJECTIVES

General Objectives This study aimed to broaden the student’s knowledge for Normal Spontaneous Vaginal Delivery by obtaining sufficient information which could serve as a guide for student nurses who will be focusing on the same case and it is also designed to enhance skills and attitudes in the application of nursing process and management of the procedure. Specific Objectives  To gain enough knowledge and understand the entire course of the procedure.  To know the client’s personal data, her family profile, past health history, current medical history, and physical assessment.  To review the anatomy and physiology of the female reproductive system.  To discuss the purpose of the procedure and its possible complication.  To correlate the results of the diagnostic procedures to its normal values.  To formulate the drug study  To develop an effective nursing care plan in which the client may benefit.

III.

Client’s Profile Name: Mrs. ACDC Age: 15 Civil Status: Live-in Address: Purok 2, San Isidro, Cabanatuan City Birthday: December 22, 1997 Nationality: Filipino Religion: Born again Date of ission: December 2, 2013 Time of ission: 9:20 PM itting Physician: Dr. Atuan itting Diagnosis: G1P0 PU 41 2/weeks AOG in labor Final Diagnosis: G1P1 PU 41 2/weeks AOG in labor itting Vital Signs: PR: 70 RR: 22 BP: 100/70 FHB: 148bpm LMP: February 16, 2013 EDC: November 13 – December 18 , 2013 AOG: 41 3/7 weeks I.E.: 4 - 5

IV.

History  History of past illnesses The patient has no known allergy to any foods or drugs and has no history of hypertension, diabetes mellitus or asthma. 

History of family illnesses There was no known familial disease in their family



Current Medical History Few hours prior to ission on December 2, 2013, patient X complained of moderate lumbosacral pain. She was rushed by her partner and her parents to MVGCCGH. Upon arrival to the Emergency Room at 9:20 pm she was assessed with a globularly enlarged abdomen and a 4 – 5cm cervical dilatation examined by Dr. Bataclan. Fetal heart beat 148 beats/min. D5 LRS 1 liter for 41 – 42 drops/min and NPO was instructed, with previous lab attached to chart (CBC, Blood Typing, HBSAg, U/A , UTZ) After ission she was transferred at the Delivery Room (DR) per stretcher. Patient x had an on and off moderate uterine contraction. After an hour she was placed on the DR table, perineal preparation and draping done. At 11:10 pm she gave birth to an alive baby girl via Normal Spontaneous Delivery followed by expulsion of the placenta at 11:15 pm. BP was taken and revealed 100/80mmHg. 1 amp of Methyl Ergometrine Maleate was given via IV push as stat dose. Episiorrhapy was done under local anesthesia at 11:30 pm. Patient is the transferred at the Ward Down with a latest BP of 100/80mmHg; patient conscious; with slight vaginal bleeding and well contracted uterus.

V.

Proposed Activities of Daily Living During Pregnancy

Activities

Bathing

Hygiene

Breast Hygiene

Perineal Hygiene

Rest and Sleep

When I asked patient ACDC about her bathing practices she said that she take a bath every morning as refreshment and avoids taking a bath in the afternoon. The patient stated that she did not know how to clean her breast so she only washes it when taking a bath. She stated that she clean her genitals every time she takes a bath and voiding She has a regular sleep pattern during the first to second trimester of her pregnancy but becomes irregular when her pregnancy reached late 3rd trimester because of lumbosacral pain since it was her first pregnancy.

Elimination

The patient stated that she voids frequently and defecate regular in the morning during her last month of pregnancy.

Nutrition

According to her, does not know what the foods to avoid are and what the foods needs to take for her pregnancy are.

VI.

Physical Assessment During the completion of cephalo-caudal examination, we made every effort to recognize and respect the patient’s feelings as well as to provide comfort measures and follow appropriate safety precautions. Assessed Areas General Appearance Head and Scalp Eyes Ears Nose

Mouth Neck Breast

Abdomen Uterus Perineum

Extremities

Findings Conscious and coherent Symmetrical and in normal contour Hair is evenly distributed Eyes are symmetrical, brown in color With pinkish conjunctivas No edema of the eyelids Symmetrical Ears are clean No deviation noted No discharges seen Oral mucosa and gingival are pink in color, moist and there were no lesions nor inflammation noted No cracked corners in the mouth is seen No palpable lymph nodes Slightly increase in size Areolar area is darkened Full and firm as palpated No palpable nodule or lump Striae Gravidarum and Linea Nigra is seen No distended bowel from constipation No distended bladder from retention With well contracted uterus Post episiorrhapy with suture lines noted No edema noted; Good skin turgor is noted Filling of nail bed is under 3 seconds No varicosities seen at the lower extremities

VII. I.

CASE DISCUSSION Definition

Spontaneous vaginal delivery involves the birth of a baby and delivery of the placenta from the uterus and through the cervix and the birth canal (vagina). This process results from contractions of the uterus during labor. Most women deliver 38 to 40 weeks after becoming pregnant (conception). In some vaginal deliveries, additional assistance is employed to assist vaginal delivery by using forceps or vacuum extraction applied to the baby's head. In combination with hormonal changes, the regular muscular contractions of the uterus in labor cause the cervix to soften, thin (efface), and open (dilate) so that the baby may travel from the uterus through the bony pelvis to the vaginal opening. The average labor lasts 12 to 14 hours for a woman having her first baby (nulliparous) and about 6 to 8 hours for subsequent babies (Beers). Labor occurs in 3 stages. The first stage begins with regular contractions that effect cervical dilation and ends when the cervix dilates to 10 cm. The second stage ends with the baby's birth. The third stage ends with delivery of the placenta, which usually separates from the uterine wall within 5 minutes after delivery. Assisted vaginal delivery can usually occur when the cervix is fully dilated and the baby's head is visible (crowns). Spontaneous vaginal delivery is the expected outcome for most pregnancies. Assisted vaginal delivery may occur when the second stage of labor is prolonged or when the baby appears to be in distress and delivery time needs to be accelerated. Stages of labor STAGE 1: It is usually the longest part of labor. It begins with regular uterine contractions and ends with complete cervical dilatation at 10 centimeters This stage is broken down into three (3) phases: the Early phase, where the contractions are usually very light and maybe approximately 20 minutes or more apart from the beginning, gradually becoming closer, possibly up to five minutes apart; the Active phase, where contractions are generally four or five times apart, and may last up to 60 seconds long. Cervix dilates with 4-7 cm and initiates a more rapid dilatation. It is known that to get through active labor, mobility and relaxations are done to increase contractions; and the Transition phase, where it is definitely known as the shortest phase but the hardest, contractions maybe two or three times apart, lasting up to a minute and a half, about approximately 8-10 cm of cervical dilatation. Some women will shake and may vomit during this stage, and this is regarded as normal. Most of the time, women would find a comfortable position to acquire complete dilatation.

STAGE II: This stage lasts for three or more hours. However, the length of this stage depends upon the mother’s position (e.g.; upright position yields faster delivery). Once the cervix has completely dilated, the second stage had begun. This stage ends with the expulsion of the fetus. STAGE III: This stage focuses on the expulsion of the placenta from the mother. Placenta exclusion is much more easier than the delivery of the baby because it includes no bones, and this is during this stage that the baby is placed on top of the mother’s womb. STAGE IV: No more expulsions of conception products for this stage as this is generally accepted as POST PARTUM juncture. This phase is from the placental delivery to full recovery of the mother.   

  

 

A nulliparous woman (nullipara) has not given birth previously (regardless of outcome). A primagravida is in her first pregnancy. A primiparous woman has given birth once. The term 'primip' is often used interchangeably with primagravida, although technically incorrect as a woman does not become primiparous until she has delivered her baby. A multigravida has been pregnant more than once. A multiparous woman (multipara) has given birth more than once. A grand multipara is a woman who has already delivered five or more infants who have achieved a gestational age of 24 weeks or more, and such women are traditionally considered to be at higher risk than the average in subsequent pregnancies. A grand multigravida has been pregnant five times or more. A great grand multipara has delivered seven or more infants beyond 24 weeks' gestation.

Relationship of gravidity and parity to risk in pregnancy Obstetric histories should always record parity, gravidity and outcomes of all previous pregnancies as:   

Outcomes of previous pregnancies give some indication of the likely outcome and degree of risk with the current pregnancy. The number of previous pregnancies and deliveries will also influence the risks associated with the current pregnancy. What is considered normal labor varies according to parity:  Normal labor in a primagravida is significantly different to normal labor in multiparous women, as physiologically the uterus is a less efficient organ, contractions may be dyscoordinate or hypotonic. The average first stage in a primagravida is significantly slower than in a multip (primarily due to the rate of

cervical dilation)- so progress is expected to be slower but delay longer than expected should prompt augmentation in managed labour. Interestingly, grand multips have a longer latent phase of labour than either nulliparous or lower-parity multiparous women but then begin to dilate more rapidly. After 6 cm dilation, partogram curves for lower parity multips and grand multips are indistinguishable. Progress of labour does not appear to continue to improve with additional child-bearing.



Risks associated with Nulliparity/Primagravidae  Higher risk of developing pre-eclampsia (relative risk 2.91 with confidence interval 1.286.61).  Delayed first stage of labor, though this could be considered normal in a primagravida.  Dystocia (or difficult labor) was diagnosed in 37% primagravidae in one Danish study. Management Provide: 

Good antenatal care with particular vigilance to early warning signs of pre-eclamptic toxaemia (PET). NICE recommends nullips with uncomplicated pregnancies should have 10 routine antenatal appointments (versus 7 in parous women). Good antenatal and parenting education during labor and pain control (if desired) are especially important in a first pregnancy as anxiety levels are likely to be high. Where there is delay in the first stage of labor in a primagravida, active management with artificial rupture of membranes and/or oxytocin to augment labor. The second stage of labor can be allowed to continue for longer than the traditional time associated with multips, as long as fetal monitoring is satisfactory and there is ongoing fetal descent.

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 



Purpose

Vaginal delivery proceeds if the maternal pelvis can accommodate the baby's presenting part, usually the head. The pelvis ordinarily widens and softens during labor to allow age of the baby's head. The decision to proceed with a vaginal delivery may be affected by the obstetrical history of previous labors, types of deliveries and estimated infant weight and status of mother and baby. Forceps or vacuum extraction delivery is needed in any condition threatening the mother or fetus that is relieved by delivery. Some maternal indications include pulmonary injury or compromise heart disease, intrapartum infection, exhaustion,

certain neurological conditions or prolonged second stage of labor (from full cervical dilatation of 10 cm to fetal delivery). Some fetal indications for operative delivery include umbilical cord prolapsed, premature separation of the placenta, or a non-reassuring fetal heart rate pattern.



Possible Complications

Complications of assisted or spontaneous vaginal delivery affecting the mother include excessive bleeding (hemorrhage), inability to urinate (urine retention), loss of bladder control (urinary incontinence), bruising (hematoma) of the perineum, varying degrees of tearing (laceration) of the perineum, and infection. Pressure on the nerve supplying the genitalia (pudendal nerve) may lead to decreased sensation in this area and/or sexual dysfunction. II.

Episiotomy

An episiotomy is minor surgery that widens the opening of the vagina during childbirth. It is a cut to the perineum -- the skin and muscles between the vaginal opening and anus. There are some risks to having an episiotomy. Because of the risks, episiotomies are not as common as they used to be. The risks include:    

The cut may tear and become larger during the delivery. The tear may reach into the muscle around the rectum, or even into the rectum itself. There may be more blood loss. The cut and the stitches may get infected. Sex may be painful for the first few months after birth.

Sometimes, an episiotomy can be helpful even with the risks. Times when an episiotomy is often performed include:    

If you are pushing as the baby’s head is close to coming out, and you tear up toward the urethral area If labor is stressful for the baby and the pushing phase needs to be shortened to decrease problems for the baby If the baby's head or shoulders are too big for the mother's vaginal opening If the baby is in a breech position (feet or buttocks coming first) and there is a problem during delivery



If instruments (forceps or vacuum extractor) are needed to help get the baby out

Not every woman will need an episiotomy during childbirth. Many women get through childbirth without tearing on their own, and without needing a cut. Episiotomies don't heal better than tears. They often take longer to heal since the cut is usually deeper than a natural tear. In both cases, the cut or tear must be stitched and properly cared for after childbirth. Just before your baby is born, and as the head is about to crown, your doctor or midwife will give you a shot to numb the area (if you haven’t already had an epidural). Next, a small incision (cut) is made. There are two types of cuts: median and medio-lateral.  

The median incision is the most common type. It is a straight cut in the middle of the perineum. The medio-lateral incision is made at an angle. It is less likely to tear through to the anus, but it takes longer to heal than the median cut.

Your doctor will then deliver the baby through the enlarged opening.  

Next, your doctor will deliver the placenta (afterbirth). The cut will be stitched closed.

You can do things to strengthen your body for labor that may lower your chances of needing an episiotomy.   

Practice Kegel exercises. Perform perineal massage during the 4 - 6 weeks before birth. Practice the techniques you learned in childbirth class to control your breathing and your urge to push.

Keep in mind, even if you do these things, you may still need an episiotomy. Your doctor or midwife will decide if you should have one based on what happens during your labor.

III.

ANATOMY OF THE FEMALE REPRODUCTIVE SYSTEM

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

INTERNAL REPRODUCTIVE STRUCTURE The Vagina The vagina is a muscular, ridged sheath connecting the external genitals to the uterus, where the embryo grows into a fetus during pregnancy. In the reproductive process, the vagina functions as a two-way street, accepting the penis and sperm during intercourse and roughly nine months later, serving as the avenue of birth through which the new baby enters the world. The Cervix The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual reproductive functions. After intercourse, sperm ejaculated in the vagina through the cervix, and then proceed through the uterus to the fallopian tubes where, if a sperm encounters an ovum (egg), conception occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly fluctuations in the levels of the two principle sex hormones, estrogen and progesterone. When estrogen levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to reach the fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then becomes thin and slippery, offering a much friendlier environment to sperm as they struggle towards their goal. (This phenomenon is

employed by birth control pills, shots and implants. One of the ways they prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.) The Uterus The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. The Oviducts The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy. The Ovaries The ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilized on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel.

IV.

PHYSIOLOGY

Primary follicle in ovary containing immature ovum

Follicle stimulating hormone from anterior pituitary gland Follicle matures

Secretes progesterone (and estrogen) which any subsequent pregnancy

Corpus luteum formed in ovary

Secrets human chorionic Gonadotrophin

Ovulation: Ovum release

Ovum fertilised

Ovum not fertilised

Embeds in uterine wall

menstruation

Pregnancy New cycle begin

(www.eurocytology.eu)

V.

MANAGEMENT

CARE DURING THE FIRST STAGE OF LABOR 

     

Assessing the start of labor  One of the most important aspects of management of labor. Signs of the start of labor are: o Painful contraction with a certain regularity o Effacement and/or dilatation of the cervix o Leakage of amniotic fluid o Bloody discharge Position and movement during the first stage of labor Vaginal examination Monitor the progress of labor Prevention of prolonged labor Intravenous infusion of oxytocin Intramuscular oxytocin istration

CARE DURING THE SECOND STAGE OF LABOR      

Physiological background The onset of the second stage The onset of pushing during second stage Maternal position during the second stage Care of the perineum Perineal tear and episiotomy

CARE DURING THIRD STAGE OF LABOR      

Prophylactic use of oxytocin Controlled cord traction Active versus expected management of the third stage Timing of the cord clamping Immediate care of the newborn Care of the mother immediately after the delivery of the placenta

VI.

DIAGNOSTIC PROCEDURES DECEMBER 2, 2013

URINALYSIS MICROSCOPIC COLOR

YELLOW

TRANSPARENCY

TURBID

REACTION SPECIFIC GRAVITY PROTEIN GLUCOSE OTHERS MICROSCOPIC RED BLOOD CELLS WHITE BLOOD CELLS EPITHELIAL CELLS SQUAMOUS RENAL

MUCUS THREADS CRYSTALS

RARE AMORPHOUS URATE S/PO4 CALCIUM OXALATE URIC ACID TRIPLE PHOSPHATE CAST FINE GRANULAR COARSE GRANULAR WBC

5.0 1.020 NEGATIVE NEGATIVE

0.2 15.20 MODERATE

RARE

/HPF /HPF

BACTERIA OTHERS PREGNANCY TEST

NAME ADDRESS

Ms. ACDC CABANATUAN CITY

DATE AGE 15

SEX F

12-2-13 WARD

OPD

HEMATOLOGY Normal Values

Hematocrit Hemoglobin Red blood cells White blood cells Platelet count Blood type

0.37 118

“ B”

Male 0.40 – 0.52 g/L 140 – 170 g/L 12 x 10 /L 4.5 – 6.2 X 10 12 /L X 10 12/L 5. 0 -10. 0 X 10 12/L X10 9/ L 150 – 350 x 10 9 RH: POSITIVE

Female 0.35 – 0.47 125- 155 g/L 4.25 – 5.4 x 10 12/L

DIFFERENTIAL COUNT SEGMENTERS STAB LYMPHO EOSIN MONO BASO NORMAL : 0.58 – 0.65 0.03 – 0.05 0.21 – 0.30 0.02 – 0.04 0.04 – 0.08 0.00 – 0.01 PATIENT : 0 0 Malarial Smear: _________ Bleeding Time: ______________ N.V. 2 – 4 mins RBC: 98 mg / dl Clotting Time: _______________ N.V. 2 – 4 mins OTHERS: _____________________________________________________________________________

Name : Ms. ACDC Age :

Date : 10/ 16/13 Gender : ROUTINE URINALYSIS

Color Dark Yellow Transparency Slightly Turbid

Glucose Protein PH Specific Gravity

Ketone Bile Nitrite Urobilinogen

Negative Negative 7.0 1.005

CAST

Pus cells/hpf RBC/hpf

Epithelial Cells Mucus Threads Yeast Cells

2-5 0-3

FEW

CRYSTALS Amorphous urates Amorphous PO4 Ca oxalate Uric Acid Pregnancy Test Cast

FEW

OTHERS Bacteria

+1

FEW

OBSTETRICAL ULTRASOUND REPORT Patient’s Name: Ms. ACDC Address: Cabanatuan City

Age: 15 Referred by: CCGH

Date: November 18, 2013

Ultrasound Findings:

Biophysical Profile Scoring (Manning):

Fetal Number Single Fetal Lie/ Presentation Cephalic Placental Location Anterior Grade II Amniotic Fluid Adequate Fetal Movements Positive Cardiac Activity Positive Sex Baby Girl

Amniotic Fluid Volume Fetal Breathing Movements Fetal Tone Fetal Movements Total Score

Ultrasound Measurements: CRL CRL Weeks BPD 85.93 mm BPD Weeks 34 weeks 3 days EFBW 2894.36g Average Gestational Age EDC

FL FL Weeks AC AC Weeks HC HC Weeks

73.74 mm 37 weeks 5 days 312.52 mm 35 weeks 0 day

35 weeks 5 days 12-18-2013 (40 weeks)

Notes: Single visible intrauterine pregnancy in cephalic presentation.

Name: Ms. ACDC Address:

Age: 15 Birthday:

Gender: F Status: Requested By: DR. J. Date/Time Released: DURAN 9/4/2013

OBSTETRICAL ULTRASOUND REPORT FETUS: Number = Single Presentation = Cephalic BPD = 66 mm BPD WEEKS = 26 weeks and 4 days FL = 52 mm FL Weeks = 27 weeks and 3 days AC = 78 mm x 68 mm EFW = 0.92 kg AVERAGE GESTATIONAL AGE = 26 weeks and 3 days FHR = 141 bpm GENDER = AMNIOTIC FLUID INDEX = Adequate (140mm) Average EDD = December 4, 2013 LMP = ?

PLACENTA: Location = Anterior Grade = I BIOPHYSICAL SCORE: Breathing Movement: Body Movement = Muscle Movement = Amniotic Fluid Volume = Total Score =

IMPRESSION: Single, live, intrauterine pregnancy with an AOG of 26 weeks and 3 days Based on ultrasound Normohydramnios Name: Ms. ACDC

Date: 10/02/13 Gender: Female SPECIAL TESTS

Hepatitis B Surface Antigen – NONREACTIVE

The date shows that the hematocrit level of our client is normal which is 0.37 within the normal range of 0.35 – 0.47; hematocrit blood test determines the proportion of red blood cells (RBC) in the blood. It is recorded as the percentage of volume of red blood cells in the

blood sample; it should be noted that pregnant women have extra fluid, which dilutes the blood, decreasing the hematocrit; with the low hematocrit level, iron deficiency is by far the most common cause of anemia in pregnancy, Iron deficiency anemia during pregnancy is linked to an increased of preterm delivery and low birth weight. Its also associated with a higher risk of stillbirth or newborn death, so it something to take seriously; encourage women to take control of their health. The blood test will identify the level of hemoglobin, which is the oxygen-carrying power of your red blood cells; our client had a result of 118 which is low in the normal range; a lot of pregnant women experience low hemoglobin during the term. In fact this condition is one of the most common problems during pregnancy. At the time of pregnancy, the volume of blood increases considerably but it also tends to decrease levels of hemoglobin and the concentration of red blood cell in the body. This can result in women suffering from anemia; higher risk of premature birth is an additional concern related to the effect of maternal iron deficiency on infant health; preterm infants are likely to have more perinatal complications, to be growth-stunted, and to have low stores of iron and other nutrients. A WBC count is a blood test to measure the number of white blood cells (WBC’s). WBC counts, especially neutrophils, increase naturally during pregnancy. During active labor there may be another normal increase, even in the absence of infection; pregnancy is typically considered a hypercoagulable state--- meaning that most pregnant women clot more readily than normal and are predisposed to deep -vein thrombosis or other clot-related conditions. During pregnancy there is an increase in certain factors in the clotting cascade due to normal adaptation The platelet count was measured at approximately monthly intervals during the course of 44 normal pregnancies. There was no evidence of any fall in the platelet count during pregnancy. Any significant change in the platelet count in pregnant women in unlikely to be the result of a normal pregnancy ; Most pregnant women have normal numbers of platelets but about eight per cent have slight drop in their platelet count. HBSAG result is non reactive, means that she does not have Hepatitis B according to the test. The test you had was to determine whether there is Hepatitis virus in your body. However, you can get your blood screened from time to time if you suspect yourself. The client should undergo screening to determine whether she needs Hepatitis B vaccine or whether she has immunity against Hepatitis B.

VII.

DRUG STUDY

Drug Name

Therapeutic Indication Action Generic Name: Bactericidal:  Respiratory tract Cephalexin Inhibits infections caused by synthesis of Streptococcus Brand Name: bacterial cell pneumoniae, group A Keflex wall, causing beta-hemolytic cell death. streptococci Classification:  Skin and skin structure Anti-infective infections caused by staphylococcus, streptococcus  Otitis media caused by S. pneumoniae, Haemophilus influenzae, streptococcus, staphylococcus, Moraxella catarrhalis  GU infections caused by Escherichia coli, P. mirabilis, Klebsiella

Adverse Effect CNS: Headache, dizziness, lethargy, paresthesias GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembranous colitis, hepatotoxicity GU: Nephrotoxicity Hematologic: Bone marrow depression Hypersensitivity: Ranging from rash to fever to anaphylaxis; serum sickness reaction

Contraindications 

Contraindicated with allergy to cephalosporins or penicillins.  Use cautiously with renal failure, lactation, pregnancy.

Nursing Consideration  

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  







History: Penicillin or cephalosporin allergy, pregnancy, or lactation Physical: Renal function tests, respiratory status, skin status; culture and sensitivity tests of infected area Arrange for culture and sensitivity tests of infection before and during therapy if infection does not resolve. Give drug with meals; arrange for small, frequent meals if GI complications occur. Complete the full course of this drug even if you feel better. This drug is prescribed for this particular infection; do not self-treat any other infection. You may experience these side effects: Stomach upset, loss of appetite, nausea (take drug with food); diarrhea; headache, dizziness. Report severe diarrhea with blood, pus, or mucus; rash or hives; difficulty breathing; unusual tiredness, fatigue; unusual bleeding or bruising. Avoid alcohol while taking cephalexin.

Name of Drug

Therapeutic Action

Generic Name: Aspirin like drug Mefenamic Acid that has analgesic Brand Name: antipyretic and Ponstan antiinflammatory Classification: activities Antiinflammatory; Analgesic.

Indication

Adverse Effect

Contraindication Nursing Consideration

Moderate to moderately severe pain. Relief of pain including muscular, rheumatic, traumatic, dental, postoperative and postpartum pain, headache, migraine, fever and dysmenorrhea, pain from rheumatoid arthritis including Still’s disease, soft tissue injuries. Therapy should not exceed 7 days.

CNS: Dizziness CV: Vasodilation EENT: Visual disturbances GI: Nausea and Vomiting GU: Urinary retention SKIN: Pruritus

Pregnancy and Lactation. Hypersensitivity with drugs, acute intoxication with alcohol, physical opioid dependence Kidney or liver impairment. Children less than 14 years old.

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Tell patient that drug works best when taken before pain becomes severe Recommend abstinence from alcohol when taking medication Caution patient that drug can cause dependence Tell patient to report occurrence of drug induced adverse reactions. Advise patient to immediately report persistence or failure to relieve pain.

VIII.

NURSING CARE PLAN

Assessment

Diagnosis

Subjective: “Palaging gutom ang baby ko kaya iyak ng iyak.” As verbalized by the patient

Breastfeeding, (STG) (Independent) ineffective r/t After 8 hours of nursing  Explain the unsatisfactory feeding intervention, the baby benefits of process will be able to stop breast feeding, crying and will show the mechanism satisfactory response to involve lactation, breast feeding process the proper breast care and (LTG) most especially After a couple of the proper months of nursing breast feeding intervention, the baby position. will gain weight and will  Assist the breast receive adequate feeding process amount of milk supply. as needed  Increase fluid intake  Discuss the importance of adequate nutrition during lactation

Objective:  The baby doesn’t respond to other comfort measures given by the mother

Planning

Nursing Intervention

Rationale 

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To promote breast feeding because milk contains all the necessary nutrients a baby needs for the first 6 months of life To promote bonding between mother and child Brest feeding delays ovulation and therefore the possibility of another pregnancy Brest feeding helps stop bleeding after delivery

Evaluation The mother understands the importance and benefits of breast feeding and demonstrates proper breast feeding technique. (The goal was completely met)

Assessment

Diagnosis

Subjective: “Sumasakt yung tahi paminsan minsan.” As verbalized by the client.

Acute vaginal pain After 8 hours of nursing related to right medio care, the client will be lateral episiotomy as able to: evidenced by facial  Express grimacing. alleviation of pain from scale of 6 to 2  To know different techniques in alleviating pain  Comfortably fall asleep

Objective:  Facial grimace  Pain scale of 6  Slowed movement V/S taken as follows:  T: 37.3  RR: 21  PR: 96  BP: 100/80

Planning

Nursing Intervention    

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Provide rapport with the patient Monitor vital signs Provide a therapeutic environment Encourage verbalization of feelings Encourage to do diversional activities Encourage rest and sleep

Rationale 

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To gain trust and full cooperation during the pain alleviation period Vital sings altered during acute pain To aid alleviation of pain To assist in evaluation To alleviate pain To assist in alleviation of pain

Evaluation After 8 hour of nursing care, the client:  Expressed alleviation of pain from scale of 6 to 3  Knew different techniques in alleviating pain  Comfortably feel asleep