TABLE OF CONTENTS

I. Introduction

II. Objectives
General objectives
Specific objectives

III. Patient’s data

a. Vital Information
b. Family background
c. History of Past illness
d. History of Present illness
e. Effects & Expectations of illness to self & Family
f. Genogram

IV. Physical Assessment & Review Of System

V. Definition Of Terms

VI. Textbook Discussion

a. Complete Diagnosis
b. Anatomy and physiology
c. Etiology and Symptomatology
d. Pathophysiology

VII. Diagnostic Results

VIII. Complete Doctor’s Order

IX. List Of Drug’s

X. Drug study

XI. Priorities Problems

XII. Nursing care plan

XIII. Prognosis

XIV. Bibliography
 I. INTRODUCTION

This is a case of Mrs. Beauty, a 34 years old female patient of

South Cotabato Provincial

Hospital. She was admitted last July 17, 2008 at 10:10 am with a chief
complaint of labor pain and

admitting diagnosed of Pregnancy Uterine Full term, Cephalic In

Labor, Gravida 3, Para 2 (2002)

under admitting physician Dr. Joy L. Vencer.

Pregnancy is a time of enormous change in a woman’s body and

mind. These changes affect

her physical well-being, self-esteem, interactions with others, daily

activities and future plans. She

looks fpr answer to questions that arise during pregnancy from many
different sources. Nurse’s

role is uniquely suited in forming a professional bond with the

pregnant client and to offering

impartial and accurate information that guide her nine-month

journey.

A woman’s body changes dramatically to maintain a variable

pregnancy. The knowledge

and understanding on how these changes occur give the nurse the
ability to assess, make

diagnose, plan, interview and evaluate to ensure that the expected

outcomes are achieved.
 II. OBJECTIVES OF THE STUDY

GENERAL OBJECTIVES:

After a thorough analysis , I will be able to present all the

necessary information about my

client’s case and develop the listener’s in rendering effective care.

SPECIFIC OBJECTIVES:

This case study aims to achieve the following specific objectives:

1. Present correctly the important information regarding patient’s

data.

2. Discuss briefly the result of the assessment done to the patient.

3. Define comprehensively the complete diagnosis of the client.

4. Discuss briefly the anatomy and physiology of woman’s

reproductive organ involved in Normal Spontaneous vaginal
Delivery.

5. Enumerate the symptoms present.

6. Enumerate the predisposing factors and precipitating factors it

thoroughly.

7. Briefly discuss the the laboratory test.

8. Present the Doctors Order.

9. Prioritized possible nursing diagnosis of the patient and

formulate applicable nursing intervention.

10. Present the Drugs ordered by the physician.

11. Reveal computed prognosis clearly based on

criteria given.
 VITAL INFORMATION

PATIENT’S NAME : Mrs. Beauty

AGE : 34 years old

SEX : Female

ADDRESS : Sitio ACFAON,Barangay Bunao

Tupi South

Cotabato

DATE OF BIRTH : April 14,1974

PLACE OF BIRTH : Sitio ACFAON,Barangay Bunao

Tupi south

cotabato

RELIGION : Baptist

CIVIL STATUS : Married

CITIZENSHIP : Filipino

TRIBE : Ilonga

OCCUPATION : Barangay Health Worker

EDUCATIONAL ATTAINMENT : Second Year High School

Level

DATE ADMITTED : July 17, 2008

TIME ADMITTED : 10:10 am

 ADMITTING PHYSICIAN : Dr. Joy L. Vencer

ADMITTING DIAGNOSE DIAGNOSIS : Pregnancy Uterine Full

Term,

Cephalic In Labor,

Gravida 3, Para 2

(2002)

CHIEF COMPLAINTS : “Labor Pain”

POST-OPERATIVE DIAGNOSIS : Normal Spontaneous

Vaginal

Delivery, Cephalic

In Labor

Baby Boy G3P3

BW: 2.6g

PROCEDURE : Normal Spontaneous

Vaginal Delivery

NAME OF INSTITUTION : South Cotabato

Provincial

Hospital

LMP : Oct. 7, 2007

EDC : July, 14, 2008

AOG : 40 Weeks & 4/7

Days

WEIGHT : 65 kgs

HEIGHT : 5’3cm

SPOUSE NAME : Mr. Bean

AGE : 33 Years old

OCCUPATION : Farming
EDUCATIONAL ATTAINMENT : Second Year High

School

RELIGION : Baptist

TRIBE : Ilongo

CHILDREN

NAME AGE SEX

1. Ms. A 9 Female

2. Baby A 2 2 Male

3. Baby A1 NB Male

SOURCE OF INFORMATION

• Patient

• Patient’s chart

• Patient’s husband

SOURCE OF MEDICAL FINANCING

• Philhealth

FAMILY BACKGROUND

Mr. Beauty & Mrs. Beauty reside in Sitio ACFAON, Barangay

Bunao Tupi South Cotabato for 11 years right away after marriage but

Mrs. Beauty resides there for 34 years. Mrs. Beauty is 34 years old and

Mr. Beauty is 33 years old. They got married since Mrs. Beauty is 23

and Mr. Beauty is 22, almost 11 years already. They had 2 chidren, a 9

years old girl which is in grade 3 in Sitio ACFAON Elementary school

and a Baby Boy which is 2 years old and the new born baby boy. They

are both complete in immunization as verbalize by Mrs. Beauty except

for her new born baby boy.

As Mrs. Beauty verbalized, she had no immunization during early

days of her life in their Sitio because she mentioned that “wala pa na

sadto”. Ask for prenatal check up, she said that complete.

As interviewed goes on, she mentioned that she is a BHW for 5

years and her husband is a farmer. They ate 3 times a day and I ask

her on what food they usually ate, she verbalized that “maski ano lng”.

I ask her about any vices she had during her early days, after married

life & during pregnancy, she answered none.

HISTORY OF PAST ILLNESS

As verbalized by Mrs. Beauty, she only experienced nausea &

vomiting as said “dala lang sa pag lihi siguro” during my first month of

pregnancy & sometimes head ache. She had check-up every month at

their Barangay Health Center & given Ferrous Sulfate as serve as her

Vitamin & taken after breakfast. Ask if she hospitalized, she replied

none.

HISTORY OF PRESENT ILLNESS

I ask her 3 days prior to admission on what she feel or

experience, she answer none but only the day upon admission that she

felt pain on her back as rated 8 out of 10 (10 as severe & 1 is not). Due

to pain to her back, as verbalized “ugangan ko nga babae kag hinablos

ko ang nagdala sa akon sa Munisipyo sa RHU kay ang bana ko ara sa

bukid abe” at around 8 am but refered to hospital due to the RHU are

taking general cleaning that time & day & happen that the ambulance
of SCPH is in their Sitio. The ambulance took them to Provincial

Hospital directly to ER and at 9 am she was endorsed to DR. She was

on her third pegnancy and having two full term alive children. Her Last

menstrual period is last Oct. 7, 2007. The EDC is July 14, 2008, AOG 40

wks & 4/7 days.

V/S: BP=120/80 mmHg, CR=95 beats/min, RR=25 breath/min,

BT=36.8.

The attending Physician is Dr. Joy L. Vencer. The admitting

diagnosis is Pregnancy Uterine Full Term, Cephalic In Labor G3P2

(2002). The source of their Medical Financing is PhilHealth.

EFFECTS OF ILLNESS

TO SELF:

As patient verbalized that “ normal man lang ang sakit sang

likod kong magawas na ang bata kay pangatlo ko naman ni nga

anak”..

TO FAMILY:

Husband: As husband verbalized that “parehas lang man tong

una nga pag anak sang misis ko ang batyag nya sadto”.

EXPECTATIONS

TO SELF:

“Tani maka gawas nako dri sa ospital”.

TO FAMILY:

Husband: “Tani maka gawas na kmi dri sa ospital sang misis

ko”

DEVELOPMENT DATA

Erickson’s Psychosocial Development Theory

Erickson envisions life as a sequence of levels of achievement. Each

stage signals a task that must be achieved. The resolution of the task

can be complete, partial or unsuccessful. Erickson believes that the

greater the task achievement, the healthier the personality of the

person; failure to achieve a task influences the person’s ability to

achieve next task.

MIDDLE ADULTHOOD

Stage Age Justification Remarks

Generativity • 34  The pt. is Patient

years old interested in shows
establishing positive
and guiding resolution
her children.
She is
unselfish
with regards
to the
welfare of
her children.

Sigmund Freud Psychosexual Development

He postulated that mind consist roughly of three overlapping

divisions: conscious, subconscious and unconscious.

GENITAL (PUBERTY AND AFTER)

Stage Age Justification Remarks

Relationshi • 34  Mrs. Beauty Patient shows

ps with years old love her positive
opposite husband so resolution.
sex much. She
believe that
even though
they are
poor love
will stay
Developmen forever for Patient shows
t of sexual them. positive
identity;  Now that resolution.
ability to she has
love and already 3
work children, the
more she
do her duty
as a
housewives.

HAVIGHURST’S DEVELOPMENT THEORY

Robert Havighurst believed that learning is basic to life and that

people continue to learn throughout life.

Task Justification Remarks

Adjusting to According to the Achieved successfully
decreasing physical patient decreasing
strength and health physical strength and
health is a normal
process of life.
Adjusting to Our patient was Not Achieved
retirement and intended to retire only successfully
reduced income when she get the age
of retirement.
Establishing Our patient is happy Achieved successfully
satisfactory in terms of her work
physical living as a BHW to their sitio
arrangements and as mother of the
family.
 IV. PHYSICAL ASSESSMENT

Date: July 17, 2008

Time: 10:10 am

The PT. is young adult of South Cotabato Provincial Hospital, lying

on bed with IVF of D5LR @ level of 1000 cc, regulated at 20 gtts/min

hooked @ left metacarpal vein. She is physically ill and weak, fair

complexion, properly dressed, nails are not trimmed specifically at her

toe nails but her hair are fixed and combed well. She is properly

oriented at time and place during the interview and can able to answer

questions at clear and moderate voice. No bad or foul odor noted

during the interview.

VITAL SIGN
Blood Pressure 120/80 mmHg

Temperature 36.8 C

Pulse Rate 95 beats per minute

Respiratory Rate 25 breaths/cycles per minute

HEAD

Inspection:

The patients head is proportional to the patient’s body size and

round in shape. No lesions and deformities, no dandruff was noted on

her scalp. She has a long black hair hat is distributed evenly.

Palpation:

No tenderness noted as well as masses.

FACE

Inspection:

The patient face is symmetric. Her skin is brown in complexion;

some moles and dark pigmentation are noted.

Palpation

There is no masses and tenderness noted.

EYES

Inspection:

The eye is straight and in normal position. Eyebrow is black in

color and evenly distributed eyelids able to close completely.

Eyelashes directed outward and intact. Eyeballs are symmetric and

able to move in six cardinal movements. Pupils are equal in size, round

in shape and reacts to light and accommodation. Conjunctiva is normal

in color. Sclera is normal in color & clear, the cornea is clear and

transparent, iris is black in color. Lacrimal system have enough moist.

NOSE
Inspection:

The external nose is symmetrical and align at the center, mucosa

is moist, nasal septum is intact, straight at the midline, no lesions and

deformities.

Palpation:

There is no tenderness noted.

EARS

Inspection:

External ear is clear, no deformities and lesion noted. She can

hear whispered words within 1 foot apart. Auricle has no deformities.

Palpation:

No tenderness and masses noted.

LIPS AND MOUTH

Inspection

The patient’s lips appear to be pale and dry. The tongue had not

enough moist, mobile, and pink in color and position in the midline. No

dentures noted with incomplete set of teeth (13 in down,14 in up).

Gums and mucosa is pink, had not enough moist and no lesion noted.

Tonsils are not inflamed; uvula is bell in shape, pink in color and at the

midline.

NECK

Inspection

Has coordinated movement and no discomfort. Darkening on

neck noted

Palpation

Lymph nodes at the neck are not palpable.

BREAST

Inspection

Black areola and nipple noted during inspection.

Palpation

Tenderness of breast and small amount of milk discharge noted.

LUNGS

Auscultation

Breathing pattern is fast, irregular rhythm. The respiratory rate

is 25 breath/min.

HEART

Auscultation

Abnormal sounds and fast beats noted with a pulse rate of 25

beats per minute.

ABDOMEN

Inspection

No scars noted upon inspection. Striae membrane seen in whole

part of abdomen. Presence of linia negra seen.

GENITO-URINARY

Pubic hair is evenly distributed, presence of bleeding of small

amount of lochia rubia and bulging of vagina noted.

EXTREMETIES

Inspection

The extremities are proportionate to the trunk, skin is brown in

complexion. Symmetrical on both upper and lower extremities. She

has no difficulties in performing flexion and extension. Muscle has

equal strength, able to grasp properly but dominant hand has more

force than her non dominant hand.

Palpation
 Mild edema noted on both lower extremeties, patient sensation

is present. Pulsation is present at the radial and dorsalis pedis.

SKIN

Inspection

Fair complexion but dry and scaly skin noted, no lesions noted

and hair is evenly distributed.

Palpation

No masses and tenderness noted. Afebrile noted during

palpation.

NAILS

Inspection

Patient nail is pink in color, her finger nails are uncut and not well

trimmed specifically at his toe nails. Capillary refill return within 1

seconds after being pressed.

REVIEW OF SYSTEMS

GENERAL:

The patient is experiencing nausea and vomiting, headache and

weight changes during her state of pregnancy.

SKIN, HAIR, NAILS:

She denies rashies and allergies to any food.

HEAD:

The patient verbalized that “nagasakit ang ulo ko kis-a” She also

said that she doesn't experienced any head injury and she tenderness.

EYES:

The patient denies of having a blurry vission.

NOSE:

She denies of having sinus problem and in term of her sense of

smell during pregnancy.

THROAT:

She denies of having difficulty in swallowing.

RESPIRATORY:

She denies of having fast breathing during pregnancy.

CARDIOVASCULAR:

. The patient said that she has no problems in her heart. She

denies of having a hypertension.

GASTROINTESTINAL:

The patient said that she experienced nausea & vomiting.

REPRODUCTIVE SYSTEM:

She said that she has no problems in urination. And she voids

5-6 times a day. She denies of having frequent urination during

pregnancy.

MUSCULOSKELETAL:

She denies of having problems in moving during her pregnancy.

PSYCHIATRIC:

The patient denies of worrying about spacing of birth.

 V.DEFINITION OF TERMS

VAGINA – is highly distensible musculomembranous canal situated in

front of the rectum and behind the bladder.

- It is tubular, fibromuscular organ lined with mucous membrane

that lies in a transverse fold called Rugae.

- Canal that connect to the external genitalia. It receives the

penis and the sperm ejaculated during sexual intercourse and

serve as an exit passageway for menstrual blood and for the

fetus during childbirth.

- Act as the organ of intercourse and also convey sperm to the

cervix so sperm can meet with the ovum in the fallopian tube. It

expands to serve as birth canal.

UTERUS – pear shaped muscular organ on the top of the vagina.

- it is the site fro menstruation, implantation of a fertilized ovum

and development of the fetus during pregnancy and labor.

- Receive the ovum from the fallopian tube. Furnish protection to

a growing fetus and expel it from the woman’s body

CERVIX - the lower part of the uterus, opens into the vagina and has a

channel that allows sperm to enter that uterus and menstrual

discharge to exit.

FALLOPIAN TUBES – are hollow, cylindrical structures that extend 2-3

inches from the upper edges of the uterus toward the ovaries.

-the end of each tube into a funnel shaped providing a large

opening for the egg to fall when it is unleaned from the ovary.
 - it convey the ovum from the ovaries to the uterus and provide a

place for fertilization of the ovum by sperm.

OVARIES – the ovaries are small, oval shaped glands that are located

on either side of the uterus. The ovaries produce eggs and hormones.

-produce, mature and discharge ova.

VULVA – serves to protect the withdrawal and vaginal opening and is

highly sensitive to touch to increase the female’s pleasure during

sexual intercourse.

MONS PUBIS – fatty tissue and skin is covered with pubis after

puberty.

-protects the symphysis pubis during sexual intercourse.

LABIA – contains sweat and sebaceous glands. After puberty they are

covered with hair.

-protect the vaginal opening. Lubricate the vulva in response to

stimulation.

CLITORIS AND PREPUCE – clitoris is a small, cylindrical mass of

erectile tissue and nerves.

-clitoris like penis is very sensitive to touch, stimulation and

temperature and can become erect.

PERINEUM - short stretch of skin starting at the bottom of the vulva

and extending at the anus.

URETHRA – it is the passage of urine located at the pelvic cavity

above bladder.

ENDOMETRIUM – the innermost layer of uterine wall. Contains gland

that bathe the uterine lining.

VI. TEXTBOOK DISCUSSION

 COMPLETE DIAGNOSIS

PREGNANCY – period of time between fertilization of the ovum

(conception) and birth, during which mammals carry their developing

young in the uterus. The duration of pregnancy in humans is about 280

days, equal to nine calendar months. After the fertilized is implanted in

the uterus, rapid changes occurs in the reproductive organs of mother.

The uterus becomes larger and more flexible, enlargement of the

breasts begins, and alteration of renal function, blood volume and

blood cell count occur. Movement of the fetus and fetal heartbeat can

be detected early in pregnancy.

Reference: www.dictionary.com

HUMAN PREGNANCY – divided into three trimester periods, as means

to simplify reference to the different stages of fetal development. The

first trimester carries the highest risk of miscarriage. During the

second trimester the development of the fetus can start to be

monitored and diagnosed. The third trimester often remarks the

beginning of viability, or the ability of the fetus to survive or without

medical help, outside the mother’s womb.

Reference: Mittenporf R. Williams MA, Berkeley CS Cotter PF. The

length of uncomplicated human gestation, OB Stet Gynesol – 1990

PREGNANCY – pregnancy brings both psychological and physical

changes to the woman and her partner. The physiologic changes of

pregnancy occur gradually but eventually affect all organ systems of

the woman’s body. Psychological changes occur in response not only

to the physiologic alterations that are occurring but also to the

increased responsibility associated with welcoming new and

completely dependent person to the family. The changes occur in

order for the woman to provide oxygen and nutrients for the growing

fetus, as well as extra nutrients for her own increased increased

metabolism during the pregnancy. They ready her body for labor and

birth and for lactation once the baby is born.

Reference: Maternal and Child Health Nursing

Adele Pillitteri

LABOR – is the series of events by which uterine contractions and

abdominal pressure expel the fetus and placenta from the woman’s

body. Regular contractions cause progressive dilatation of the cervix

and sufficient muscular force to allow the baby to be pushed to the

outside.

Reference: Maternal and Child Health Nursing

Adele Pillitteri

THEORIES OF LABOR ONSET

Labor normally begins when a fetus is sufficiently mature to cope with

extrauterine life, yet not too large to cause mechanical difficulties with

birth. In some instances, labor begins before the fetus is mature

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

have both passed beyond the optimal point of birth (postterm birth).

SIGNS OF LABOR

Preliminary Signs

 Lightening

The descent of fetal presenting part into the pelvis occurs

approximately 10 to 14 days before labor begins. These changes the

woman’s abdominal contour as the uterus becomes lower and more

anterior.

 Increase in Level of Activity

 The increase in activity is due to an increase epinephrine release

that is initiated by a decrease in progesterone produced by the

placenta.

 Braxton Hicks Contraction

This is true labor contractions. Contractions that begin irregularly

but become regular and predictable. Felt first in the lower back

and sweep around the abdomen in a wave. Continue no matter

what the woman’s level of activity. Increase in duration,

frequency and intensity and it achieve cervical dilatation.

 Ripening of the Cervix

This is seen only on pelvic examination. Throughout pregnancy,

the cervix feels softer than normal, like the consistency of an

earlobe. At term the cervix becomes still softer. Ripening is an

internal announcement that labor is close at hand.

SIGNS OF TRUE LABOR

 Uterine Contractions

The initiation of effective, productive, involuntary uterine

contractions.

 Show

As the cervix softens and ripens, the mucus plug

that filled the cervical canal during pregnancy is expelled.

 Rupture of membranes

Labor may begin with rupture of membranes, experienced as

either a sudden gush or scanty, slow seeping of clear fluid from

the vagina.

COMPONENTS OF LABOR
  PASSAGE – route the fetus must travel from the uterus through

the cervix and vagina to the external perineum.

 PASSENGER – the fetus

 POWERS OF LABOR – supplied by the fundus of the uterus, are

implemented by uterine contractions, a process that causes

cervical dilatation and then expulsion of the fetus from the

uterus.

 PSYCHE – psychological state or feelings that women bring into

labor with them.

STAGES OF LABOR

FIRST STAGE

THREE PHASES

 LATENT PHASE

Begins at the onset of regularly perceived uterine contractions

and ends when rapid cervical dilatation begins. The cervical dilatation

at this phase is 2-3.

 ACTIVE PHASE

Cervical dilatation occurs more rapidly, going from 4cm to 7cm.

 TRANSITION PHASE

Maximum cervical dilatation of 8 to 10 cm.

SECOND STAGE

The second stage of labor is the period from full dilatation and cervical

effacement to birth of the infant. Contractions change from the

characteristic crescendo-decrescendo pattern to an overwhelming,

uncontrollable urge to push or bear down with contractions as if she

had to move her bowels.

THIRD STAGE

The placental stage begins with the birth of the infant and ends with

the delivery of the placenta. Two separate phases are involved:

placenta; separation and placental expulsion.

ANATOMY AND PHYSIOLOGY

1. Mons veneris / mons pubis – a firm, cushion – like elevation of

adipose tissue over the symphysis pubis covered by curly hair or

pubic hair forming escutcheon. In female, pubic hair tends to be

triangular distribution, while in male, it tends to be diamond –

shaped. It serves to protect the junction of the pubic bone from

trauma.

2. Labia majora – two rounded folds of adipose tissue with overlying skin; they extend

from the mons pubis downward and backward to encircle the vestibule. The outer

surface are covered with hair, where as the inner surface contain sebaceous follicles

which are smooth and moist. Their purpose is mainly to protect the inner delicate

parts of the vulva.

The labia majora are homologous of the scrotum in the male organ. At the same

time, it is the frequent site of varicose vein in the vulva. The arterial blood is supplied by

the internal and external pudendal arteries and a portion of the inferior rectus artery. It

also shared an extensive lymphatic supply with the other structure of vulva, which

facilitates the spread of cancer in female reproductive organ, and obstetric or sexual

trauma may cause hematoma.

 Immediately under the skin is a sheet of dartos muscle, which is

responsible for the wrinkled appearance as well as for their

sensitivity to heat and cold. Ordinarily, these structures are 7 – 8

cm. in width and 1 – 1.5 cm. in thickness.

3. Labia minora - two thin, flat, reddish folds of tissue lying between

the inner surface of the labia majora. Each labium minus consists of

a thin fold of connective tissue which when protected, presents a

moist, reddish appearance, similar to that of mucous membrane.

The structure is covered by stratified squamous epithelium. It

doesn’t contain hair follicle but it contains many sebaceous follicles

and occasionally a few sweat glands.

 Functions:

a. To lubricate and waterproof the vulvar skin.

b. To provide bactericidal secretion.

The labia minora are classed among erectile structures. This

structure is extremely

sensitive and abundantly supplied with several varieties of

nerve endings.

Anteriorly, each divide into 2 parts; the upper pair merges into

the prepuce and

the lower one fuse to form the frenulum. Posteriorly, the labia

minora fuse to form

fourchette. The labia minora increase in size at puberty and

decrease after

menopause due to estrogen level changes.

4. Clitoris - a small, cylindrical highly sensitive erectile organ

corresponding to the male penis. It is made up of erectile tissue

which many large and small venous channels surrounded by large

 amount of involuntary muscle tissue, the ischiocarvernosa facilitate

erection of the organ.

 Functions :

a. Stimulate and elevate levels of sexual tension.

b. Serve as a landmark in locating urethral opening during

catheterization.

The clitoris measures 5 – 6 mm. long and 6 – 8 mm. across. It

has very rich blood

and nerve supplies. It produces smegma, which along with other

vulvar secretion

has a unique odor that may be sexually stimulating to the

male.

5. Vestibule – an almond – shaped area that is enclosed by the labia

minora laterally and extends from the clitoris to the fourchette

antero-posteriorly. The posterior portion of the vestibule between

the fourchette and the vaginal opening is called the fossa

navicularis and is usually observed only in nulliparous women.

The vestibular bulb is located beneath the mucous membrane

of the vestibule on either side which are almond shaped

aggregation of vein 3 – 4 cm. long, 1 – 2 cm. wide and 0.5 – 1

cm. thick. These bulbs lie in close opposition to the ischio-pubic

rami and partially covered by the ischiocavernosus and

constrictor vaginal muscles. These structures are liable to injury

and rupture which may result in a vulvar hematoma or

hemorrhage. It is perforated usually by 6 openings: urethra,

vagina, and bartholin’s gland (2) and paraurethral gland (2).

5.1. Urethral meatus / urethral orifice – although not a true

part, it is considered as part of the reproductive system

 because of its closeness and relationship to the vulva. It is

situated in the middle of the vestibule and serves as an

outlet for urine from the urinary bladder.

5.2. Vulvovaginal / bartholin’s gland – pair of small, pea –

sized glands located within the substances of the labia

majora. They correspond to the bulbourethral of Cowper’s

gland in male. Often, they are sites of infection, abcess and

cyst formation. Usually, the openings are not visible or

palpable. The gland secretes a small amount of clear, viscid

mucus during sexual excitement.

5.3. Paraurethral / skene’s gland – a pair of small glands lying

on each side of the urethra. They produce a small amount of

mucus and are especially susceptible to gonorrheal infection.

It is homologous to male prostate.

5.4. Vaginal orifice / introitus – occupies the lower portion of

the vestibule and varies considerably in size and shape. The

vagina has an abundantly vascular supply. Its upper third is

supplied by the of the vesicovaginal branches uterine

arteries. Its middle third by the inferior vesical arteries. Its

lower third by the middle hemorrhoidal internal pudendal

arteries.

Anteriorly, the vagina is in contact with the bladder and urethra

from which is separated by a connective tissue referred to

vesicovaginal septum. Posteriorly between the lower portion

and the rectum is the rectovaginal septum. Approximately, the

upper ¼ of the vagina is separated from the rectum by the

rectouterine or cul-de-sac of Douglas.

 The vagina varies in length. The anterior and posterior vaginal

walls commonly measure 6 – 8 cm. and 7 – 10 cm. in length,

respectively. The areas around the cervix at the upper end of the

vagina are called fornicles, right and left, anterior and posterior.

The walls are lined with mucous membrane, which falls into

folds, or corrugated formation called rugae. These are referred

to the inner wall of vagina. It is smooth during labor and

parturition. It is not present before menarche and gradually

become obliterated after repeated childbirth and menopause. A

healthy vagina has pH of 4.0 – 6.0.

 Functions:

a. serves as excretory duct of the uterus

b. female organ for copulation

c. part of birth canal

Hymen comprised mainly of connective tissue both elastic and

collagen. Both surfaces are covered by stratified squamous

epithelium. The hymen can be broken through strenous physical

activities or masturbation. After childbirth, especially in

multipara, the remnants of the hymen from several cicatrized

nodules of varying size called myrtiform caruncles.

6. Perineum – the area extending from the fourchette to the anus.

The pelvic and urogenital diaphragm provides most of the support

of the perineum.

6.1.Pelvic diaphragm – consists of the levator ani muscles

which is the principal

muscle that is close to vagina and the coccygeus muscle

posteriorly.
 The levator ani muscles form a broad muscular sling that

originates from the posterior surface of the superior rami of

the pubis, from the inner surface of the ischial spine and

between the 2 sites from the obturator rami.

The pubococcygeus and puborectalis constrict the vagina

and rectum and form an efficient functional rectal sphincter.

Their functions are as follows:

a. play a role in sexual sensory function

b. bladder control

c. control perineal relaxation during labor and in expulsion of the

fetus during birth.

6.2.Urogenital diaphragm – located in the hollow of the pubic

arch and consists of the transverse perineal muscles, constrictor

of urethra and internal and external fascial covering. These

muscles originate at the ischial tuberosities and insert into the

perineal body. The strong muscle fibers provide support to the

anal canal (sphincter muscle) during defication and to the lower

vagina during delivery.

The perineal body is a wedge – shaped between the vaginal and

canal opening which serves as an anchor point for the muscles,

fascia and ligament of the upper and lower pelvic diaphragm.

The perineal body is about 4 cm. wide x 4 cm. deep

and continuous with the septum between the rectum and

vagina. This tissue is flattened and stretched as the fetus

moves through the birth canal.

SYMPTOMATOLOGY
 SYMPTOMS RATIONALE REMARKS
Amenorrhea/Missed A missed menstrual period is Present
period most often the first sign of
pregnancy. Sometimes a
woman who is pregnant may
still experience some
bleeding or spotting around
the time of the expected
period. This small amount of
bleeding that occurs at the
time of the expected
menstrual period happens
when the fertilized egg
attaches to the uterine wall
and is referred to as
implantation bleeding.

Tender, swollen This is due to increasing Present

breast levels of hormones. Feelings
of breast swelling,
tenderness, or pain are also
commonly associated with
early pregnancy. These
symptoms are sometimes
similar to the sensations in
the breasts in the days
before an expected
menstrual period. Women
may also describe a feeling
of heaviness or fullness in the
breasts. These symptoms can
begin in some women as
early as one to two weeks
after conception.

Fatigue and Fatigue and tiredness are Present

tiredness symptoms experienced by
many women in the early
stages of pregnancy. The
cause of this fatigue has not
been fully determined, but it
is believed to be related to
rising levels of the hormone
progesterone. Fatigue is
another symptom that may
be experienced early, in the
first weeks after conception.

Nausea and Nausea and vomiting are also Present

Vomiting common in early pregnancy.
Traditionally referred to as
 "morning sickness," the
nausea and vomiting
associated with early
pregnancy can occur at any
time of the day or night.
Elevations in estrogen that
occur early in pregnancy are
thought to slow the emptying
of the stomach and may be
related to the development
of nausea. Accompanying the
characteristic "morning
sickness" may be cravings
for, or aversions to, specific
foods or even smells. It is not
unusual for a pregnant
woman to change her dietary
preferences, often having no
desire to eat previous
"favorite" foods. In most
women, nausea and vomiting
begin to subside by the
second trimester of
pregnancy

Abdominal bloating Some women may Not present

experience feelings of
abdominal enlargement or
bloating, but there is usually
only a small amount of
weight gain in the first
trimester or pregnancy. In
this early stage of pregnancy
a weight gain of about one
pound per month is typical.
Sometimes women also
experience mild abdominal
cramping during the early
weeks of pregnancy, which
may be similar to the
cramping that occurs prior to
or during the menstrual
period.

Frequent urination A woman in the early stages Present

of pregnancy may feel she
has to urinate frequently,
especially at nighttime, and
she may leak urine with a
cough, sneeze, or laugh. The
increased desire to urinate
may have both physical and
hormonal causes. Once the
embryo has implanted in the
 uterus, it begins to produce
the hormone known as
human chorionic
gonadotrophin (hCG), which
is believed to stimulate
frequent urination. Another
cause of frequent urination
that develops later is the
pressure exerted by the
growing uterus on the
bladder.

Melasma Some women may develop a Not present

(darkening of the so-called "mask of
skin) pregnancy" in the first
trimester, referring to a
darkening of the skin on the
forehead, bridge of the nose,
upper lip, or cheekbones. The
darkened skin is typically
present on both sides of the
face. Doctors refer to this
condition as melasma or
chloasma, and it is more
common in darker-skinned
women than those with
lighter skin. Melasma can
also occur in some conditions
other than pregnancy.
Women who have a family
history of melasma are at
greater risk of developing
this sign of pregnancy.

Striae Gravidarum Skin changes in pregnancy. Present

This is reddish, slightly
depressed streaks. This is the
stretching of abdominal wall
to accommodate the growing
fetus.
Linea Nigra Extra pigmentation that Present
appearson the abdominal
wall, running from the
umbilicus to the symphysis
pubis and separating of
abdomen into a right and left
hemisphere. This is due to
melanocyte-stimulating
hormone secreted by the
pituitary.
 VII. HEMATOLOGY

Complete Blood Count - The complete blood count (CBC) is one of

the most commonly ordered blood tests. The complete blood count is

the calculation of the cellular (formed elements) of blood. These

calculations are generally determined by special machines that

analyze the different components of blood in less than a minute. A

major portion of the complete blood count is the measure of the

concentration of white blood cells, red blood cells, and platelets in the

blood.

Date:July 17, 2008

Time:10:20 am

Laboratory Result NormalValu Indication Nursing

e Responsib

ility
Hemoglobi 116 120-160 Decrease, Instruct the
it may patient to
n mass indicate maintain
anemia. increase
fluid intake
and eat
nutritious
food that
are rich in
iron.
Hematocri 0.33 0.40-0.50 Decrease, Encourage
it may pt. to early
t indicate ambulation
dehydratio to increase
n. blood flow
and
frequent
fluid
intake.
Segmenter 0.85 0.55-0.60 Increase Encourage
may patient to
indicate increase
 bacterial intake of
infection. Vitamin C
rich foods
for tissue
repair. Eat
more fruits
and
vegetables
Lympocyte 0.15 0.35-0.40 Decrease Increase
fluid intake
and eat
nourish
foods
Erythrocyt 0.35 0.36-0.40 Decrease Encourage
rate of red pt. to eat
e V◦ blood cell fruits,
production. green leafy
Fraction vegetables.
Blood type B To know
the
patient’s
blood type
so that in
case of
blood
transfusion
due to
increase
blood loss
upon
delivery.

VIII. COMPLETE DOCTOR’S ORDER

Time and ORDER RATIONALE REMARKS

Date
July 17, *Please admit ~The patient was The
2008 @ admitted for further patient
10:10 am observation and was
management. admitted.
*NPO
~ The patient is not
allowed to eat The
whatever she like. patient
Patient might vomit was
*TPR q 4˚ during delivery and monitored.
high risk for
aspiration
The
 ~TPR of the patient is patient
to determine current was
patient condition and instructed.
to note significant
changes. This is also
for baseline data and
*D5LR 1L x 20 to help physician to
gtts/min further interpret or
diagnose the proper
care for the patient.

IV fluid
~ This is done to was
maintain the fluid and hooked
electrolytes balance
Labs: of the patient as well
CBC, BLD as it will serve as the
TYPING partial for IVTT
medicine and it is
regulated at 20
gtts/min to prevent
toxicity and Laboratory
10:11 am circulatory overload. examinati
Cefalexin 500 g 1 on was
cap * 1 week ordered
~These laboratory
Mefenamic acid 500 examination was
mg 1 cap prn TID ordered by the
physician to
determine and role Medication
Methergine TID *1 out the condition of given.
tab * 3 x day the patient.
Medication
given.
July 18, ~Prevent infection
2008 Medication
@ 7:00 *Monitor TPR q 4˚ given
am ~For relief of mild to
moderate pain

~For prevention of
post partum Pt & V/S
hemorrhage caused monitored
*Continue medicine by uterine atony and as
subinvolution. ordered.
* Refer for problem

~This is done to
*Pls discharge monitor the patient’s Medication
July 19, condition and to note given.
2008 @ any changes to the Monitored
10:00 am *Continue vital sign of the order.
medicines. patient.

Pt. was
~To continue instructed.
 medication to pt
Pt. was
~Tell Physician any instructed.
problems regarding
pt. situation.

~Pt. was discharged

to promote rest and
quiet relaxation.
~For proper
management of
drugs to patient.

IX. LIST OF DRUGS

NAME OF DRUGS DOSAGE

FREQUENCY/TIME

1. CEFALEXIN 500 g

Q 8˚ / 6

10
2. METHERGIN 0.2 mg

Q 8˚ / 6

10

3. MEFENAMIC ACID 500 mg

Q 8˚ / 6

10
XIII.PROGNOSIS
 Prognosis Good Fair Poor Justification
Onset of - Patient experience
Illness ‫׀‬ labor pain 8 hours
prior to admittion.
She suffers
irregular pain. She
do some walking
and rubbing of the
back to relieves
the pain. When she
went to the
hospital , the pain
continous but it
stops sometimes.
Duration of - Patient suffered
Illness labor pain every 1-
1.5 mins., she can
‫׀‬ tolerate the pain
with the use of
depth breathing
exercise after the
contraction to ease
the pain.
Hygiene - Patient cannot do
‫׀‬ personal hygiene
without any
support from
family members
because she is a
little bet weak.
Diet - Patient how to
balance diet, she
‫׀‬ have her meal on
time. She usually
eat fruits and
drinking fruit
juices.
Age - Patient is a 34
years old and she
is on 3rd time of
‫׀‬ delivery. She don’t
have any
complication felt
during pregnancy
but only pain prior
to admission.
Performance - Patient can do
Level work but with
assistance because
she has not totally
‫׀‬ recovered yet from
after giving birth,
her body cannot
support her needs
to do her usual
activities.
 Willingness - Patient shows
to udergo willingness to
undergo treatment for
treatment I the reason that she
want to have a fast
recovery by having
an adequate rest and
follows prescribed
medicines. She noted
all the instructions of
the doctor that to take
a rest to regain
strength.
Family - Families gaves their
support full support to our
patient from onset of
labor, during delivery
and during treatment.
‫׀‬ They provide
patient’s needs in
terms of foods and
clothes. They always
at the patient side to
attain the needs of
the patient.

4/8 3/8 1/8

GOOD - 4/8 x 100 = 50

FAIR - 3/8 x 100 = 37.5

POOR - 1/8 x 100 = 12.5

Remarks:

Patient’s possibility in getting well is good, most of the

criteria have good remarks.

The patient has a good chance in recovering after her treatment for

she diminished her physical

strength.
 XIV. BIBLIOGRAPHY

1. 1995 Springhouse Nursing Drug Handbook

2. 2001-02 Drug Information Handbook For Nursing

3. Nursing Care Plans / Guidelines for Individualizing Patient

Care, 6th Edition / Marilynn E.

Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr

4. Maternal & Child Nursing 2nd Edition / Emily Slone

McKinney,Susan Rowena James,

Sharon Smith Murray, Jean Weiler Ashwill

5. Maternal & Child Health Nursing / Care of the Childbearing &

Childrearing By Adele

Pilliteri

6. Fundamentals of Nursing/Concepts, process, and Practice By

Kozier
7. Mittenporf R. Williams MA, Berkeley CS Cotter PF. The

length of uncomplicated human gestation, OB Stet Gynesol –

1990
 VI. TEXTBOOK DISCUSSION

COMPLETE DIAGNOSIS

PREGNANCY – period of time between fertilization of the ovum

(conception) and birth, during which mammals carry their developing

young in the uterus. The duration of pregnancy in humans is about 280

days, equal to nine calendar months. After the fertilized is implanted in

the uterus, rapid changes occurs in the reproductive organs of mother.

The uterus becomes larger and more flexible, enlargement of the

breasts begins, and alteration of renal function, blood volume and

blood cell count occur. Movement of the fetus and fetal heartbeat can

be detected early in pregnancy.

Reference: www.dictionary.com

HUMAN PREGNANCY – divided into three trimester periods, as means

to simplify reference to the different stages of fetal development. The

first trimester carries the highest risk of miscarriage. During the

second trimester the development of the fetus can start to be

monitored and diagnosed. The third trimester often remarks the

beginning of viability, or the ability of the fetus to survive or without

medical help, outside the mother’s womb.

Reference: Mittenporf R. Williams MA, Berkeley CS Cotter PF. The

length of uncomplicated human gestation, OB Stet Gynesol – 1990

PREGNANCY – pregnancy brings both psychological and physical

changes to the woman and her partner. The physiologic changes of

pregnancy occur gradually but eventually affect all organ systems of

the woman’s body. Psychological changes occur in response not only

to the physiologic alterations that are occurring but also to the

increased responsibility associated with welcoming new and

completely dependent person to the family. The changes occur in

order for the woman to provide oxygen and nutrients for the growing

fetus, as well as extra nutrients for her own increased increased

metabolism during the pregnancy. They ready her body for labor and

birth and for lactation once the baby is born.

Reference: Maternal and Child Health Nursing

Adele Pillitteri

LABOR – is the series of events by which uterine contractions and

abdominal pressure expel the fetus and placenta from the woman’s

body. Regular contractions cause progressive dilatation of the cervix

and sufficient muscular force to allow the baby to be pushed to the

outside.

Reference: Maternal and Child Health Nursing

Adele Pillitteri

THEORIES OF LABOR ONSET

Labor normally begins when a fetus is sufficiently mature to cope with

extrauterine life, yet not too large to cause mechanical difficulties with

birth. In some instances, labor begins before the fetus is mature

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

have both passed beyond the optimal point of birth (postterm birth).

SIGNS OF LABOR

Preliminary Signs

 Lightening

The descent of fetal presenting part into the pelvis occurs

approximately 10 to 14 days before labor begins. These changes the

woman’s abdominal contour as the uterus becomes lower and more

anterior.

 Increase in Level of Activity

The increase in activity is due to an increase epinephrine release

that is initiated by a decrease in progesterone produced by the

placenta.

 Braxton Hicks Contraction

This is true labor contractions. Contractions that begin irregularly

but become regular and predictable. Felt first in the lower back

and sweep around the abdomen in a wave. Continue no matter

what the woman’s level of activity. Increase in duration,

frequency and intensity and it achieve cervical dilatation.

 Ripening of the Cervix

This is seen only on pelvic examination. Throughout pregnancy,

the cervix feels softer than normal, like the consistency of an

earlobe. At term the cervix becomes still softer. Ripening is an

internal announcement that labor is close at hand.

SIGNS OF TRUE LABOR

 Uterine Contractions

The initiation of effective, productive, involuntary uterine

contractions.

 Show

As the cervix softens and ripens, the mucus plug that filled the

cervical canal during pregnancy is expelled.

 Rupture of membranes

Labor may begin with rupture of membranes, experienced as

either a sudden gush or scanty, slow seeping of clear fluid from

the vagina.

COMPONENTS OF LABOR

 PASSAGE – route the fetus must travel from the uterus through

the cervix and vagina to the external perineum.

 PASSENGER – the fetus

 POWERS OF LABOR – supplied by the fundus of the uterus, are

implemented by uterine contractions, a process that causes

cervical dilatation and then expulsion of the fetus from the

uterus.

 PSYCHE – psychological state or feelings that women bring into

labor with them.

STAGES OF LABOR
 FIRST STAGE

THREE PHASES

 LATENT PHASE

Begins at the onset of regularly perceived uterine contractions

and ends when rapid cervical dilatation begins. The cervical dilatation

at this phase is 2-3.

 ACTIVE PHASE

Cervical dilatation occurs more rapidly, going from 4cm to 7cm.

 TRANSITION PHASE

Maximum cervical dilatation of 8 to 10 cm.

SECOND STAGE

The second stage of labor is the period from full dilatation and cervical

effacement to birth of the infant. Contractions change from the

characteristic crescendo-decrescendo pattern to an overwhelming,

uncontrollable urge to push or bear down with contractions as if she

had to move her bowels.

THIRD STAGE

The placental stage begins with the birth of the infant and ends with

the delivery of the placenta. Two separate phases are involved:

placenta; separation and placental expulsion.

ANATOMY AND PHYSIOLOGY

7. Mons veneris / mons pubis – a firm, cushion – like elevation of

adipose tissue over the symphysis pubis covered by curly hair or

pubic hair forming escutcheon. In female, pubic hair tends to be

triangular distribution, while in male, it tends to be diamond –

shaped. It serves to protect the junction of the pubic bone from

trauma.

8. Labia majora – two rounded folds of adipose tissue with overlying skin; they extend

from the mons pubis downward and backward to encircle the vestibule. The outer

surface are covered with hair, where as the inner surface contain sebaceous follicles

which are smooth and moist. Their purpose is mainly to protect the inner delicate

parts of the vulva.

The labia majora are homologous of the scrotum in the male organ. At

the same time, it is the frequent site of varicose vein in the vulva. The arterial

blood is supplied by the internal and external pudendal arteries and a portion

of the inferior rectus artery. It also shared an extensive lymphatic supply with

the other structure of vulva, which facilitates the spread of cancer in female

reproductive organ, and obstetric or sexual trauma may cause hematoma.

Immediately under the skin is a sheet of dartos muscle, which is

responsible for the wrinkled appearance as well as for their

sensitivity to heat and cold. Ordinarily, these structures are 7 – 8

cm. in width and 1 – 1.5 cm. in thickness.

9. Labia minora - two thin, flat, reddish folds of tissue lying between

the inner surface of the labia majora. Each labium minus consists of

a thin fold of connective tissue which when protected, presents a

moist, reddish appearance, similar to that of mucous membrane.

The structure is covered by stratified squamous epithelium. It

doesn’t contain hair follicle but it contains many sebaceous follicles

and occasionally a few sweat glands.

  Functions:

c. To lubricate and waterproof the vulvar skin.

d. To provide bactericidal secretion.

The labia minora are classed among erectile structures. This

structure is extremely

sensitive and abundantly supplied with several varieties of

nerve endings.

Anteriorly, each divide into 2 parts; the upper pair merges into

the prepuce and

the lower one fuse to form the frenulum. Posteriorly, the labia

minora fuse to form

fourchette. The labia minora increase in size at puberty and

decrease after

menopause due to estrogen level changes.

10. Clitoris - a small, cylindrical highly sensitive erectile organ

corresponding to the male penis. It is made up of erectile tissue

which many large and small venous channels surrounded by large

amount of involuntary muscle tissue, the ischiocarvernosa facilitate

erection of the organ.

 Functions :

c. Stimulate and elevate levels of sexual tension.

d. Serve as a landmark in locating urethral opening during

catheterization.

The clitoris measures 5 – 6 mm. long and 6 – 8 mm. across. It

has very rich blood

and nerve supplies. It produces smegma, which along with other

vulvar secretion
 has a unique odor that may be sexually stimulating to the

male.

11. Vestibule – an almond – shaped area that is enclosed by the labia

minora laterally and extends from the clitoris to the fourchette

antero-posteriorly. The posterior portion of the vestibule between

the fourchette and the vaginal opening is called the fossa

navicularis and is usually observed only in nulliparous women.

The vestibular bulb is located beneath the mucous membrane

of the vestibule on either side which are almond shaped

aggregation of vein 3 – 4 cm. long, 1 – 2 cm. wide and 0.5 – 1

cm. thick. These bulbs lie in close opposition to the ischio-pubic

rami and partially covered by the ischiocavernosus and

constrictor vaginal muscles. These structures are liable to injury

and rupture which may result in a vulvar hematoma or

hemorrhage. It is perforated usually by 6 openings: urethra,

vagina, and bartholin’s gland (2) and paraurethral gland (2).

11.1. Urethral meatus / urethral orifice – although not a true

part, it is considered as part of the reproductive system

because of its closeness and relationship to the vulva. It is

situated in the middle of the vestibule and serves as an

outlet for urine from the urinary bladder.

11.2. Vulvovaginal / bartholin’s gland – pair of small, pea –

sized glands located within the substances of the labia

majora. They correspond to the bulbourethral of Cowper’s

gland in male. Often, they are sites of infection, abcess and

cyst formation. Usually, the openings are not visible or

palpable. The gland secretes a small amount of clear, viscid

mucus during sexual excitement.

11.3. Paraurethral / skene’s gland – a pair of small glands

lying on each side of the urethra. They produce a small

amount of mucus and are especially susceptible to

gonorrheal infection. It is homologous to male prostate.

11.4. Vaginal orifice / introitus – occupies the lower portion of

the vestibule and varies considerably in size and shape. The

vagina has an abundantly vascular supply. Its upper third is

supplied by the of the vesicovaginal branches uterine

arteries. Its middle third by the inferior vesical arteries. Its

lower third by the middle hemorrhoidal internal pudendal

arteries.

Anteriorly, the vagina is in contact with the bladder and urethra

from which is separated by a connective tissue referred to

vesicovaginal septum. Posteriorly between the lower portion

and the rectum is the rectovaginal septum. Approximately, the

upper ¼ of the vagina is separated from the rectum by the

rectouterine or cul-de-sac of Douglas.

The vagina varies in length. The anterior and posterior vaginal

walls commonly measure 6 – 8 cm. and 7 – 10 cm. in length,

respectively. The areas around the cervix at the upper end of the

vagina are called fornicles, right and left, anterior and posterior.

The walls are lined with mucous membrane, which falls into

folds, or corrugated formation called rugae. These are referred

to the inner wall of vagina. It is smooth during labor and

parturition. It is not present before menarche and gradually

become obliterated after repeated childbirth and menopause. A

healthy vagina has pH of 4.0 – 6.0.

 Functions:
 d. serves as excretory duct of the uterus

e. female organ for copulation

f. part of birth canal

Hymen comprised mainly of connective tissue both elastic and

collagen. Both surfaces are covered by stratified squamous

epithelium. The hymen can be broken through strenous physical

activities or masturbation. After childbirth, especially in

multipara, the remnants of the hymen from several cicatrized

nodules of varying size called myrtiform caruncles.

12. Perineum – the area extending from the fourchette to the anus.

The pelvic and urogenital diaphragm provides most of the support

of the perineum.

6.1.Pelvic diaphragm – consists of the levator ani muscles

which is the principal

muscle that is close to vagina and the coccygeus muscle

posteriorly.

The levator ani muscles form a broad muscular sling that

originates from the posterior surface of the superior rami of

the pubis, from the inner surface of the ischial spine and

between the 2 sites from the obturator rami.

 3 portion of levator ani muscle:

a. iliococcygeus muscle

b. pubococcygeus muscle

c. puborectalis muscle

The pubococcygeus and puborectalis constrict the vagina

and rectum and form an efficient functional rectal sphincter.

Their functions are as follows:

d. play a role in sexual sensory function

e. bladder control

f. control perineal relaxation during labor and in expulsion of the

fetus during birth.

6.2.Urogenital diaphragm – located in the hollow of the pubic

arch and consists of the transverse perineal muscles, constrictor

of urethra and internal and external fascial covering. These

muscles originate at the ischial tuberosities and insert into the

perineal body. The strong muscle fibers provide support to the

anal canal (sphincter muscle) during defication and to the lower

vagina during delivery.

The perineal body is a wedge – shaped between the vaginal and

canal opening which serves as an anchor point for the muscles,

fascia and ligament of the upper and lower pelvic diaphragm.

The perineal body is about 4 cm. wide x 4 cm. deep

and continuous with the septum between the rectum and

vagina. This tissue is flattened and stretched as the fetus

moves through the birth canal.

SYMPTOMATOLOGY

SYMPTOMS RATIONALE REMARKS

Amenorrhea/Missed A missed menstrual period is Present
period most often the first sign of
pregnancy. Sometimes a
woman who is pregnant may
still experience some
bleeding or spotting around
the time of the expected
period. This small amount of
bleeding that occurs at the
time of the expected
menstrual period happens
when the fertilized egg
attaches to the uterine wall
and is referred to as
implantation bleeding.

Tender, swollen This is due to increasing Present

breast levels of hormones. Feelings
of breast swelling,
tenderness, or pain are also
commonly associated with
early pregnancy. These
symptoms are sometimes
similar to the sensations in
the breasts in the days
before an expected
menstrual period. Women
may also describe a feeling
of heaviness or fullness in the
breasts. These symptoms can
begin in some women as
early as one to two weeks
after conception.

Fatigue and Fatigue and tiredness are Present

tiredness symptoms experienced by
many women in the early
stages of pregnancy. The
cause of this fatigue has not
been fully determined, but it
is believed to be related to
rising levels of the hormone
progesterone. Fatigue is
another symptom that may
be experienced early, in the
first weeks after conception.

Nausea and Nausea and vomiting are also Present

Vomiting common in early pregnancy.
Traditionally referred to as
"morning sickness," the
nausea and vomiting
associated with early
 pregnancy can occur at any
time of the day or night.
Elevations in estrogen that
occur early in pregnancy are
thought to slow the emptying
of the stomach and may be
related to the development
of nausea. Accompanying the
characteristic "morning
sickness" may be cravings
for, or aversions to, specific
foods or even smells. It is not
unusual for a pregnant
woman to change her dietary
preferences, often having no
desire to eat previous
"favorite" foods. In most
women, nausea and vomiting
begin to subside by the
second trimester of
pregnancy

Abdominal bloating Some women may Not present

experience feelings of
abdominal enlargement or
bloating, but there is usually
only a small amount of
weight gain in the first
trimester or pregnancy. In
this early stage of pregnancy
a weight gain of about one
pound per month is typical.
Sometimes women also
experience mild abdominal
cramping during the early
weeks of pregnancy, which
may be similar to the
cramping that occurs prior to
or during the menstrual
period.

Frequent urination A woman in the early stages Present

of pregnancy may feel she
has to urinate frequently,
especially at nighttime, and
she may leak urine with a
cough, sneeze, or laugh. The
increased desire to urinate
may have both physical and
hormonal causes. Once the
embryo has implanted in the
uterus, it begins to produce
the hormone known as
human chorionic
 gonadotrophin (hCG), which
is believed to stimulate
frequent urination. Another
cause of frequent urination
that develops later is the
pressure exerted by the
growing uterus on the
bladder.

Melasma Some women may develop a Not present

(darkening of the so-called "mask of
skin) pregnancy" in the first
trimester, referring to a
darkening of the skin on the
forehead, bridge of the nose,
upper lip, or cheekbones. The
darkened skin is typically
present on both sides of the
face. Doctors refer to this
condition as melasma or
chloasma, and it is more
common in darker-skinned
women than those with
lighter skin. Melasma can
also occur in some conditions
other than pregnancy.
Women who have a family
history of melasma are at
greater risk of developing
this sign of pregnancy.

Striae Gravidarum Skin changes in pregnancy. Present

This is reddish, slightly
depressed streaks. This is the
stretching of abdominal wall
to accommodate the growing
fetus.
Linea Nigra Extra pigmentation that Present
appearson the abdominal
wall, running from the
umbilicus to the symphysis
pubis and separating of
abdomen into a right and left
hemisphere. This is due to
melanocyte-stimulating
hormone secreted by the
pituitary.
 VII. HEMATOLOGY

Complete Blood Count - The complete blood count

(CBC) is one of the most commonly ordered blood tests.

The complete blood count is the calculation of the

cellular (formed elements) of blood. These calculations

are generally determined by special machines that

analyze the different components of blood in less than a

minute. A major portion of the complete blood count is

the measure of the concentration of white blood cells, red

blood cells, and platelets in the blood.

Laboratory Result NormalValu Indication Nursing

e Responsib

ility
Hemoglobi 116 120-160 Decrease Decrease
due to
n mass labor that
causes
blood loss.
Hematocri 0.33 0.40-0.50 Hemorrhag Ensure that
e, Anemia the patient
t undergone
blood
transfusion
Segmenter 0.85 0.55-0.60 Increase Encourage
may patient to
indicate increase
infection. intake of
Vitamin C
rich foods
for tissue
repair. Eat
more fruits
and
vegetables
Lympocyte 0.15 0.35-0.40 Decrease Lymphocyt
e will not
increase
because
segmenter
s is in the
first line of
defense.
Erythrocyt 0.35 0.36-0.40 Decrease No contract
rate of red of auto-
e V◦ blood cell immune
production. reaction.
Fraction
Blood type B To know the
patient’s
blood type so
that in case
of blood
transfusion
 due to
increase
blood loss
upon
delivery.

VII. COMPLETE DOCTOR’S ORDER

Time and ORDER RATIONALE REMARKS

Date
July 17, *Please admit ~The patient was The
2008 @ admitted for further patient
10:10 am observation and was
management. admitted.
*NPO
~ The patient is not
allowed to eat The
whatever she like. patient
Patient might vomit was
*TPR q 4˚ during delivery and monitored.
high risk for
aspiration
The
~TPR of the patient is patient
to determine current was
patient condition and instructed.
to note significant
changes. This is also
for baseline data and
*D5LR 1L x 20 to help physician to
gtts/min further interpret or
diagnose the proper
care for the patient.

IV fluid
~ This is done to was
maintain the fluid and hooked
electrolytes balance
Labs: of the patient as well
CBC, BLD as it will serve as the
TYPING partial for IVTT
medicine and it is
regulated at 20
gtts/min to prevent
toxicity and Laboratory
10:11 am circulatory overload. examinati
Cefalexin 500 g 1 on was
cap * 1 week ordered
~These laboratory
 Mefenamic acid 500 examination was
mg 1 cap prn TID ordered by the
physician to
determine and role Medication
Methergine TID *1 out the condition of given.
tab * 3 x day the patient.
Medication
given.
July 18, ~Prevent infection
2008 Medication
@ 7:00 *Monitor TPR q 4˚ given
am ~For relief of mild to
moderate pain

~For prevention of
post partum Pt & V/S
hemorrhage caused monitored
*Continue medicine by uterine atony and as
subinvolution. ordered.
* Refer for problem

~This is done to
*Pls discharge monitor the patient’s Medication
July 19, condition and to note given.
2008 @ any changes to the Monitored
10:00 am *Continue vital sign of the order.
medicines. patient.

Pt. was
~To continue instructed.
medication to pt
Pt. was
~Tell Physician any instructed.
problems regarding
pt. situation.

~Pt. was discharged

to promote rest and
quiet relaxation.
~For proper
management of
drugs to patient.
 IX. LIST OF DRUGS

NAME OF DRUGS DOSAGE

FREQUENCY/TIME

1. CEFALEXIN 500 g

Q 8˚ / 6

10

2. METHERGIN 0.2 mg

Q 8˚ / 6

10
3. MEFENAMIC ACID 500 mg

Q 8˚ / 6

10
 XI. LIST OF PRIORITIES NURSING PROBLEM

1) RISK FOR DEFICIENT FLUID VOLUME R/T EXCESSIVE FLUID LOSS AS

EVIDENCE BY PT. VERBALIZATION “PIRMI LANG AKO GINA UHAW”.

2) FATIGUE R/T POOR PHYSICAL CONDITION AS EVIDENCED BY PT.

VERBALIZATION “GINAKAPOY AKO, ANG LAWAS KO”.

3) ACTIVITY INTOLERANCE (MILD) R/T IMBALANCE BETWEEN OXYGEN

SUPPLY AND DEMAND AS MANIFESTED BY FAST BREATHING.

4) ANXIETY R/T CHANGE IN HEALTH STATUS AS EVIDENCED BY

EXPRESSED CONCERN REGARDING CHANGE IN LIFE EVENTS.

5) DEFICIENT DIVERSIONAL ACTIVITY R/T ENVIRONMENTAL LACK OF

DIVERSIONAL ACTIVITY AS IN LONG TERM HOSPITALIZATION AS

MANIFESTED BY FACIAL GRIMACE.

PROGNOSIS

Prognosis Good Fair Poor Justification

Onset of - Patient experience
Illness ‫׀‬ labor pain 8 hours
prior to admittion.
She suffers
irregular pain. She
do some walking
and rubbing of the
back to relieves
the pain. When she
went to the
hospital , the pain
continous but it
stops sometimes.
Duration of - Patient suffered
Illness labor pain every 1-
1.5 mins., she can
‫׀‬ tolerate the pain
with the use of
depth breathing
exercise after the
contraction to ease
the pain.
Hygiene - Patient cannot do
‫׀‬ personal hygiene
without any
support from
family members
because she is a
little bet weak.
Diet - Patient how to
balance diet, she
‫׀‬ have her meal on
time. She usually
 eat fruits and
drinking fruit
juices.

Age - Patient is a 34
years old and she
is on 3rd time of
‫׀‬ delivery. She don’t
have any
complication felt
during pregnancy
but only pain prior
to admission.
Performance - Patient can do
Level work but with
assistance because
she has not totally
‫׀‬ recovered yet from
after giving birth,
her body cannot
support her needs
to do her usual
activities.
Willingness - Patient shows
to udergo willingness to
undergo treatment for
treatment I the reason that she
want to have a fast
recovery by having
an adequate rest and
follows prescribed
medicines. She noted
all the instructions of
the doctor that to take
a rest to regain
strength.
Family - Families gaves their
support full support to our
patient from onset of
labor, during delivery
and during treatment.
‫׀‬ They provide
patient’s needs in
terms of foods and
clothes. They always
at the patient side to
attain the needs of
the patient.

4/8 3/8 1/8

GOOD - 4/8 x 100 = 50

FAIR - 3/8 x 100 = 37.5

 POOR - 1/8 x 100 = 12.5

Remarks:

Patient’s possibility in getting well is good, most of the

criteria have good remarks.

The patient has a good chance in recovering after her treatment for

she diminished her physical

strength.
 XIV. BIBLIOGRAPHY

8. 1995 Springhouse Nursing Drug Handbook

9. 2007 Lippincott’s Nursing Drug guide

10. Nursing Care Plans / Guidelines for Individualizing Patient

Care, 6th Edition / Marilynn E.
Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr

11. Maternal & Child Nursing 2nd Edition / Emily Slone

McKinney,Susan Rowena James,
Sharon Smith Murray, Jean Weiler Ashwill

12. Maternal & Child Health Nursing / Care of the

Childbearing & Childrearing By Adele Pilliteri

13. Fundamentals of Nursing/Concepts, process, and Practice

By Kozier