VELEZ COLLEGE COLLEGE OF NURSING F.

RAMOS STREET, CEBU CITY

PPS GROUND FLOOR A CRITICAL ANALYSIS REPORT ON L.B.R, 34 YEARS OLD, FEMALE DIAGNOSED WITH G4P4(4004) PREGNANCY UTERINE TERM 371/7 WEEKS AOG BY LMP, CEPHALIC PRESENTATION, DELIVERED SPONTANEOUSLY A LIVE BABY GIRL WITH AS 9,10 BS 40 WEEKS, BW 3100 GRAMS AGA, MULTIPARITY, REPAIR OF SECOND DEGREE LACERATION, POSPARTUM BILATERAL TUBAL LIGATION (MODIFIED POMEROY)

SUBMITTED BY Castro, Janine Angela E. BSN IV-C

SUBMITTED TO Ms. Josephine Fajardo Date:

L.B.R, 34 years old, female, 1st admission at Cebu Velez General Hospital (CVGH) on February 16, 2013 at 2:53 PM per private vehicle, accompanied by her husband, due to painful uterine contractions associated with clear watery vaginal discharges noted morning PTA.

CASE INTRODUCTION: NORMAL SPONTANEOUS VAGINAL DELIVERY Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the womb of a female. The period from conception to birth. After the egg is fertilized by a sperm and then implanted in the lining of the uterus, it develops into the placenta and embryo, and later into a fetus. Pregnancy usually lasts 40 weeks, beginning from the first day of the woman's last menstrual period, and is divided into three trimesters, each lasting three months. Pregnancy is a state in which a woman carries a fertilized egg inside her body. When gestation has completed, it goes through a process called delivery, where the developed fetus is expelled from the mothers womb. When gestation has completed, it goes through a process called delivery, where the developed fetus is expelled from the mothers womb. There are two options of delivery: 1. Vaginal Delivery aka Normal Spontaneous Vaginal Delivery A spontaneous vaginal delivery (SVD) occurs when a pregnant woman goes into labor without use of drugs or techniques to induce labor, and delivers her baby in the normal manner, without a cesarean section. Lacerations (tearing of the tissues) can occur during spontaneous vaginal delivery and may require repair. A mother may choose different levels of pain relief and still experience a spontaneous vaginal delivery. This is still the most common type of delivery and that to which all other modes of delivery are compared. Childbirth (also called labor, birth, partus or parturition) is the culmination of a human pregnancy or gestation period with birth of one or more newborn infants from a woman's uterus. The process of normal human childbirth is categorized in three stages of labor: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta. In some cases, childbirth is achieved through caesarean section, the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth.

2. Operative Delivery Cesarean Section -a surgical method of delivering the baby from the pregnant mother. A surgical incision through the mothers abdomen and uterus to deliver one or more fetuses. This is usually done around 9-10th month of pregnancy as an emergency or elective procedure once the baby is mature. It could also be done as an emergency when life threatening complications to mother or baby occur. Types of Incision: Classic and Transverse or Pfannensteil Forceps Delivery - Forceps are instruments designed to aid in the delivery of the fetus by applying traction to the fetal head. A physician may use forceps to speed up delivery if there is fetal distress or maternal exhaustion.

LABOR A series of events by which uterine contractions and abdominal pressure expel the fetus and placenta from the womans body. It starts when theres cervical ovulation

Signs of Labor Preliminary Signs Lightening descent of the fetal presenting part into the pelvis Nesting Behavior Mother is full of energy in contrast to her feelings during the previous month Persistent Backache progressive and regular uterine contractions Weight loss due to hormonal influence Braxton Hicks Contractions painless, irregular contraction Resurgence of the frequency of urination Ripening of the cervix False Contractions Begin and remain irregular Felt first abdominally and remain confined to the abdomen and groin Often disappear with ambulation and sleep Do not increase in duration, frequency, or intensity Do not achieve cervical dilatation Components of Labor PASSAGE - pertains to the womans pelvis which should be adequate in size and contour refers to the route the fetus must travel form the uterus through the cervix and vagina to the external perineum. PASSENGER - fluid, blood and mucus which should be appropriate in size and in an advantageous position and presentation. POWER - produced 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. True Contractions Begin irregularly but become regular and predictable Felt first in lower back and sweep around to the abdomen in a wave Continue no matter what the womans level of activity Increase in duration, frequency, and intensity Achieve cervical dilatation

PSYCHE - is preserved so afterward labor can be viewed as a positive experience. POSITION

Stages of Labor STAGE 1 Dilatation and Effacement starts from the true labor contractions to the full dilatation and effacement of the cervix Effacement the process by which the cervix prepares for delivery. After the baby has engaged in the pelvis, it gradually drops closer to the cervix; the cervix gradually softens, shortens and becomes thinner. Phrases like "ripens," or "cervical thinning" refers to effacement. Dilatation - the opening of the cervix. Dilation is the process of the cervix opening in preparation for childbirth. Dilation is measured in centimetres or, less accurately, in fingers during an internal (manual) pelvic exam. Fully dilated means you're at 10 centimetres and are ready to give birth. Latent Phase mild contractions; 20-30 mmHg; duration 20-30 seconds; frequency 12-20 mins. Nursing Management: reduce anxiety carry out initial assessment provide comfort measures provide necessary health teachings promote bladder care proper positioning L side lying to avoid vena caval compression

Active Phase contractions become longer and more intense. Most contractions last as long as 45 seconds, and are three minutes apart. The cervix dilates from four to eight centimeters during this phase. If the bag of waters has not already broken, the treating doctor or midwife, will most likely break them at this time. The contractions during this phase are much more painful than in the early phase, and expectant mothers may try breathing techniques, massage, pressure or request pain medications. Nursing Management: Continue to monitor uterine contractions; FHT and v/s every 15 minutes Position the client to Sims left

Coach on breathing techniques Monitor for the spontaneous or artificial rupturing of the membranes Comfort measures

Administer IV fluids and medications ordered

Transition Phase contractions occur every two to three minutes. Each contraction can last up to 90 seconds. During this phase, the cervix dilates from eight to ten centimeters. During this phase of labor, the contractions are at their most intense. The expectant mother may become nauseous, as well as experience shaking, chills, sweats and the urge to push. Once the cervix is fully dilated and effaced, pushing can begin.

Nursing Management: Encourage mother to rest in between contractions Monitor FHT and v/s Observe for onset of the second stage of labor Prepare for the delivery procedure

STAGE 2 Expulsion Phase or Fetal Stage stage from the full dilatation and effacement of the cervix to the delivery of the baby; contractions same as active phase.

Nursing Management: Transfer to the delivery room Position client for delivery Preparation of the perineum (half-prep) Prepare the mothers and babys table Teach on effective pushing

Cardinal Movements of Labor Engagement Descent

-Downward movement of the biparietal diameter of the fetal head to within the pelvic inlet Flexion -Head bends forward onto the chest -Makes the smallest anteroposterior diameter the one presented to the birth canal Internal Rotation -Head flexes as it touches the pelvic floor -The occiput rotates until it is superior -Brings the head into the best relationship to the outlet of the pelvis Extension -As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head *monitor the progress of labor including FHT and vital signs External Rotation -After the head of the infant is born, the head rotates to the diagonal or transverse position Expulsion

*Ritgens Maneuver -supporting Episiotomy Incision on the perineum to prevent laceration; facilitate delivery of the baby. of the perineum to prevent laceration during the cutting of the perineum or episiotomy

Median or Midline heals faster but with increased risk for rectal tears. Mediolateral delay wounding healing; for breech presentation; short perineum; large baby;

Lacerations First degree - involve the skin of the perineum and the tissue around the opening of the vagina or the outermost layer of the vagina itself Second degree - go deeper, into the muscles underneath Third degree - tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter Fourth degree - goes through the anal sphincter and the tissue underneath it. STAGE 3 Placental Delivery Schultz Placenta: shiny and glistening part separates from the center then to the edges Duncans Placenta: Raw, red, irregular separates from the edges first

Stages: Separation of the placenta from the uterine wall Expulsion from the vagina

Signs of placental Separation Uterus becomes firm and globular Sudden gush of blood from the vagina Umbilical cord lengthens outside the vulva Uterine fundus rises in the abdomen

STAGE 4 Immediate Postpartum Phase PUERPERIUM Phases: I. Taking- in phase Time of reflection. 2 to 3 days, the woman is passive. Physical discomforts due to perineal stitches, afterpains, or hemorrhoids; partly from her uncertainty in caring for her newborn; and partly from the extreme exhaustion that follows childbirth. Taking-hold phase The woman begins to initiate action. 3 to 10 days The woman begins to express strong interest in taking care of her child.

II.

III.

Letting- go phase: The woman finally redefines her new role. 10 days to 6 weeks Gives up the fantasized image of her child and accepts the real one.

Nursing Considerations: Drapes are removed Womans legs are carefully and simultaneously lowered from the stirrups Obtain vital signs every 15 minutes for the 1st hour Palpate fundus for size, consistency, and position Observe for the amount and consistency of the lochia Perform perineal care Apply maternity diaper or perineal pad as order

BILATERAL TUBAL LIGATION It is surgery to block a woman's fallopian tubes. It is a permanent form of birth control. After this procedure, eggs cannot move from the ovary through the fallopian tubes and eventually to the uterus. Also, sperm cannot reach the egg in the fallopian tube after it is released by the ovary. Thus, pregnancy is prevented. This procedure is said to have your "tubes tied." While you are under anesthesia, one or two small incisions (cuts) are made in the abdomen (usually near the navel), and a device similar to a small telescope on a flexible tube (called a laparoscope) is inserted. Using instruments that are inserted through the laparoscope, the tubes (fallopian tubes) are coagulated (burned), sealed shut with cautery, or a small clip is placed on the tube. The skin incision is then closed with a few stitches. You are usually feeling well enough to go home from the outpatient surgery center in a few hours. Your health care provider may prescribe pain medications to help you manage the pain, if any. Most women return to normal activities, including work, in a few days, although you may be advised not to exercise for several days. You may resume sexual intercourse when you feel ready. Tubal ligation can also be performed immediately after childbirth through a small incision near the navel or during a Cesarean delivery. Risks of Tubal Ligation No procedure is ever completely free of risks. However, tubal ligation has been performed for many years with successful results and limited complications. If problems do occur, they may include but are not limited to:
Infection Bleeding Allergic skin reactions Blood clots Blood vessel injury Reactions to medication or anesthesia

Minor complications of tubal ligation can include:

Nausea and vomiting Minor infections Minor bleeding Bruising or a collection of blood at the incision site Burns on the skin Abnormal or painful scar formation Allergic skin reaction to tape, dressings, or latex Delayed return of bowel and/or bladder function.

Major Tubal Ligation Complications Possible major complications of tubal ligation include but are not limited to:
Failure to produce sterility, meaning the operation does not prevent future pregnancy Serious bleeding Serious infection Damage to organs, including the uterus, fallopian tubes, ovaries, bladder, and/or ureters Damage to the intestines, including a perforation (a hole) in its lining or a burn injury Blood vessel injury Blood clots Nerve injury Hernias, which may include a rupture of the incision or the diaphragm Complications from the air placed in the abdomen (stomach), such as air going into a blood vessel or the space outside the lung Reactions to medication or anesthesia

Depending on the individual situation, a major tubal ligation complication could lead to a longer stay, a blood transfusion, or a repeat surgery. A surgery such as this could possibly include immediate major abdominal surgery, a hysterectomy (removal of the uterus), or, in rare instances, placement of a colostomy. Other major risks, in extreme cases, may lead to permanent disability, paralysis, or loss of life.

ANATOMY AND PHYSIOLOGY

THE FEMALE REPRODUCTIVE SYSTEM The reproductive system is viewed as the most important body system because its basic function is to produce children. The female reproductive system is a complicated system that is similar and also different from those of a mans. Here, we shall examine the external and internal structures of the female reproductive system, the mechanisms that determine the menstrual cycle, ovulation, and many more. The External Structures Mons Veneris: A pad of adipose tissue located over the symphysis pubis, covered with coarse, curly hairs better known as pubic hairs. The mons veneris protects the pubic bone from trauma. Labia Minora: Small lips. These are two pink, hairless folds of connective tissue located posterior to the mons veneris. These can be small or could be up to 2 inches each, depending upon the females developmental age. They lie within the labia majora and surround the vaginal opening and the urethra. Labia Majora: Large lips. These are two, larger (than the labia minora), hair covered (after puberty) folds of adipose tissue that enclose and protect the other external structures such as the vaginal orifice and the urethral orifice. The labia majora contain sweat and oil-secreting glands. Vestibule: The flattened, smooth surface inside the labia. Both the urethral orifice and vaginal orifice arise from this structure. Clitoris: The small (1-2 cm) rounded organ of erectile tissue is synonymous to the penis. Other than erectile tissue, it contains blood vessels and nerves that make it extremely sensitive and reactive to pleasurable stimuli, thus it is the center of sexual arousal and orgasm in a woman. The prepuce, a small fold of skin that covers the clitoris is similar to the foreskin of a males penis. Skenes Glands and Bartholins Glands: The pair of Skenes glands is located lateral to the urinary meatus on each of its sides, with their ducts opening to the urethra. Bartholins glands, also known as the Vulvovaginal or Vestibular glands are situated laterally to the vaginal opening on both of its sides. Their ducts open into the vagina. Both glands secrete a mucoid substance that lubricates the external genetalia during coitus. The alkaline pH of these secretions also helps the sperm survive the acidic environment of the vagina.

Perineum: The skin covered muscular area between the vaginal area and the anus. It functions to support the pelvis and helps in constricting the vaginal, urinary and anal opening. Fourchette: A ridge of tissue formed by the posterior joining of the two labia minora and the labia majora. This is the structure that is cut during a procedure called episiotomy. The Internal Structures Vagina: A hollow, musculomembranous canal located posterior and anterior to the rectum; it is lined with mucous. It extends upward and backward from the vulva to the cervix. The bladder and the urethra are located anterior to the vagina and the rectum lies posterior to it. Normally, the anterior and posterior walls of the vagina touch each other. This is the organ of copulation of the woman; it receives the male penis and the sperm during sexual intercourse. This is also the route of exit for the menstrual flow and the route of exit for a baby during the end of pregnancy. Cervix: The lower third portion of the uterus which forms the neck of the uterus and opens into the vagina; connects the vagina to the uterus. The narrow opening of the cervix is called the os; this allows menstrual blood to flow out of the vagina during menstruation, while during pregnancy, the os closes to help keep the fetus in the uterus until birth. During labor, the cervix dilates (up to 10 cm) to allow for the fetus to pass through. Uterus: A hollow, pear-shaped organ measuring 7.5 cm long and 3 cm wide. It is situated between the urinary bladder and the rectum and is suspended in the pelvis by broad ligaments. The upper portion is called the corpus, while the narrow, lower portion is the cervix. The uterus serves as the organ of menstruation and receives the fertilized ovum, maintains and nourishes it for it to grow to a fetus (during pregnancy). Rhythmic contractions of this organ help to expel the fetus during labor. The walls of the uterus, about 1.25 cm thick, comprises of three layers: the endometrium (innermost layer), the myometrium (large middle layer), and the peritoneum (outermost layer). The endometrium is the layer that is shed at the end of the menstrual cycle (thus the onset of menstruation); while during fertilization, this is where the fertilized ovum burrows in for implantation until the end of its growth. The myometrium is the muscular layer of the uterus, which contracts to expel the fetus during labour. The peritoneum secretes a blood-like fluid that partially covers the uterus. However small the uterus is before pregnancy, this muscular organ gets stretched out to accommodate the increasing size of the fetus during its growth. Fallopian Tubes: Also known as the oviducts. These are two very fine tubes that extend from the uterus into the ovaries (but do not directly touch the ovaries). These tubes are responsible for the transport of the mature egg from the ovaries to the uterus to enable fertilization. To be able to receive a mature egg from the ovaries, the distal end of the tubes expand (infundibulum) to project finger-like projections known as fimbriae very close to the ovary to catch the mature egg that exits the ovary. Once inside the tube, the egg is transported along its length by the wavelike motion of the cilia, which line the wall of the tubes, coupled with the contractions of the tubes. Fertilization usually occurs in the fallopian tube(s).

Ovaries: The female gonad, paired reproductive glands of a female, each about the shape of an almond, about 3 cm long. These are analogous to the testes of a male. They lie behind the broad ligaments, behind and below the fallopian tubes. These produce the female gametes (the ova), and female hormones such as estrogen and progesterone to initiate and regulate menstrual cycles, as well as facilitate the growth and development of a female during puberty. The ovaries usually take turns releasing an egg every month; if the available egg is not fertilized 24 hours after being released from the ovary, this gets excreted through the menstrual flow. However, if the egg gets fertilized within 24 hours of being released, the ovum undergoes changes and development to grow into a fetus. Secondary Structures Breasts / Mammary Glands: Present in both sexes but only functional in females. They are a pair of milk producing glands that stay in a dormant, halted stage during infanthood and childhood until puberty. The continuation of their development during puberty is due to the rise of estrogen. The increase of connective tissue as well as deposition of fat, accounts for the increase of breast size. The main function of the mammary glands is to provide milk (nourishment) for the baby, thus these structures are only important during pregnancy and the babys lactation period. The breasts are located anterior to the pectoral muscles in the thorax. Each breast contains on round, darkened area called the areola, which surrounds a central protruding nipple. The mammary glands are comprised of 15 to 25 lobes that radiate around the nipple. Within the lobes are the lobules that contain a number of alveolar glands that produce milk when a woman is lactating. The milk are then passed through the lactiferous ducts and out to the nipple. During pregnancy, many changes occur in a womans body, including in her breasts. Increased levels of hormones like estrogen, progesterone (and others), also increase breast vascularity and the permeability and dilatation of the lactiferous ducts. Amniotic fluid: Amniotic fluid is a clear, slightly yellowish liquid that surrounds the unborn baby (fetus) during pregnancy. It is contained in the amniotic sac. The fetus floats in the amniotic fluid. During pregnancy the amniotic fluid increases in volume as the fetus grows. Amniotic fluid volume is greatest at about 34 weeks into the pregnancy (gestation), when it averages 800 ml. Approximately 600 ml of amniotic fluid surrounds the baby at full term (40 weeks gestation). This fluid is constantly circulated by the baby swallowing and "inhaling" existing fluid and then "exhaling" and urinating out the fluid.Amniotic fluid performs many functions for the fetus, including: allowing the fetus freedom to move and enabling the skeleton to develop properly; allowing the lungs to develop properly; maintaining a relatively constant temperature around the fetus, thus protecting the fetus from heat loss; and protecting the fetus from outside injury by cushioning sudden blows or movements. Placenta: The placenta, Latin for pancake, which is descriptive of its size and appearance at term, arises out of trophoblast tissue. It serves as the fetal lungs, kidneys, and gastrointestinal tract and as a separate endocrine organ throughout pregnancy. Its growth parallels that of the fetus, growing from a few identifiable cells at the beginning of pregnancy to an organ 15 to 20 cm in diameter and 2 to 3 cm in depth at term. It covers about half the surface area of the internal uterus. For practical purposes, there is no direct exchange of blood between the embryo and the mother during pregnancy. The exchange is carried out only by selective osmosis through the chorionic villi. However, because the chorionic villi layer is only one cell thick, minute breaks do allow occasional cells to cross. Placenta osmosis is so

effective that all but a few substances are able to cross the placenta into the fetal circulation. Specific mechanisms allow the nutrients to cross the placenta. All these processes are affected by maternal blood pressure and the pH of the fetal and maternal plasma. To provide enough blood for exchange, the rate of uteroplacental blood flow in pregnancy increases from about 50 ml/min at 10 weeks to 500 to 600 ml/min at term. No additional maternal arteries appear after the first 3 months of pregnancy. However, to accommodate the increased blood flow, the arteries increase in size. Systematically, the mothers heart rate, total cardiac output, and blood volume increase to supply the placenta. Ovulation Once puberty occurs (usually at the age of 12-14), the ova begin to mature as well. The ovum undergoes many processes so that it may reach the state of being ripe or mature. Ovulation is the release of a mature egg out of the ovary. It is released from the follicle (called a graafian follicle) once it is matured and by a hormonal signal. Ovulation occurs around fourteen or fifteen days from the first day of the woman's last menstrual cycle. When ovulation occurs, the ovum moves into the fallopian tube and becomes available for fertilization. The remaining cells of the graafian follicle undergoes a series of changes which changes it to a corpus luteum to produce progesterone that prepares the uterus to receive a fertilized ovum. The Menstrual Cycle The menstrual cycle is a series of changes a woman's body goes through to prepare for a pregnancy. About once a month, the uterus grows a new lining (endometrium) to get ready for a fertilized egg. When there is no fertilized egg to start a pregnancy, the uterus sheds its lining. This is the monthly menstrual bleeding (also called menstrual period) that women have from their early teen years until menopause, around age 50. This episodic uterine bleeding is brought about in response to cyclic hormonal changes. The cycles purpose is to bring about an ovums maturity and to renew a uterine tissue bed that will be responsible for the ovas growth once fertilized. Many hormones are involved in this cycle: Estrogen responsible for developing and maintaining the female reproductive organs and the secondary sex characteristics of the adult female play an important role in breast development and in monthly cyclic changes in the uterus secreted by the ovaries builds up the lining of the uterus

Progesterone secreted by the corpus luteum, the ovarian follicle after the ovum has been released the most important hormone for conditioning the endometrium in preparation for implantation of a fertilized ovum levels increase after an ovary releases an egg (ovulation) at the middle of the cycle; this helps the estrogen keep the lining thick and ready for a fertilized egg a drop in progesterone (along with estrogen) causes the lining to break down, thus the beginning of the monthly period

The Phases of the Menstrual Cycle Proliferative phase estrogenic, follicular or postmenstrual phase Immediately after a menstrual flow, the endometrium is very thin, approximately one cell layer in depth. As the ovaries begin to produce estrogen, the endometrium begins to proliferate. This growth is very rapid and increases the thickness of the endometrium approximately eightfold. This increase continues for the 1st half of the menstrual cycle, approximately day 5 day 14.

Secretory phase progestational, luteal or premenstrual phase After ovulation, the formation of progesterone in the corpus luteum causes the glands of the uterine endometrium to become twisted in appearance and dilated with quantities of glycogen and mucin. The capillaries of the endometrium increase in amount until the lining takes on the appearance of rich, spongy velvet and prepared to accept and nourish the embryo

Ischemic phase if fertilization does not occur, the corpus luteum in the ovary begins to regress after 8-10 day. As it regresses, the production of progesterone and estrogen decreases. With the withdrawal of progesterone stimulation, the endometrium of the uterus begins to degenerate, approximately day 24 or 35 of the cycle. The capillary rupture, with minute hemorrhage, and the endometrium sloughs off. Menses menstrual flow contains approximately 30-80 ml of blood accompanied by mucus and endometrial shreds (blood from the ruptured capillaries, mucin from the glands, fragments of endometrial tissue and microscopic, atrophied and unfertilized ovums) iron loss during menstrual flow is approximately 11 mg

Fertilization When the mature ovum is released from the ovary, it is only available for 24 hours. Thus, fertilization, the union of an ovum and spermatozoon, must occur pretty quickly, because after 24 hours the ovum becomes non-functional. Since the spermatozoon is available for 48 hours, the critical time frame for fertilization (time for coitus must occur for successful fertilization) is 48 hours before, and 24 hours after ovulation.

Once sperm enter the vicinity of the uterus, they travel up to the fallopian tube to search for a viable mature ovum. It is important to note that when the ovum is released, it is surrounded by the zona pellucida and the corona radiata. Before the sperm reach the ovum, however, these millions of sperm must undergo capacitation, a process in which the plasma membrane of the sperm head degenarates to expose the sperm binding receptor sites. Once capacitation ends, these sperm attack the ovum to try and break down the ovums protective layer of corona radiata. Out of these millions of cells, only one is capable of reaching the ovums nucleus. As soon as the ovum has been conquered, or penetrated, the chromosomal material of the ovum and spermatozoon fuse to form a zygote. Implantation After fertilization, the fertilized egg migrates to the uterus for cellular multiplication; this takes about 3 to 4 days. Once the fertilized egg is ready it begins to look for a place within the uterine cavity to settle in, or to implant to. This occurs 8 to 10 days after fertilization. First, the blastocyst (as the zygote is now called) brushes against the velvety uterine wall; this is apposition. Then, the blastocyst attaches to the endometrial surface. Lastly, once the blastocyst seems comfortable, it settles down into the soft folds of the endometrium, and burrows deeper until it establishes an effective communication network with the blood system of the endometrium. Once implantation occurs, the endometrium is then referred to as decidua.

CLIENT IN CONTEXT Patient L.B.R., 34 years old, female, Filipino, married, Roman Catholic, currently residing in #59 Urgello, Cebu City was admitted at Cebu Velez General Hospital (CVGH) for the first time accompanied by her husband via private vehicle on February 16, 2013 at 2:53 PM. She was admitted to the Department of Obstetrics and Gynecology under the services of Dr. Amethyst Ypil with a case number of 012315 and hospital number of 1331460. Source of Data: Patient and husband HISTORY OF PRESENT ILLNESS Last menstrual period was on May 2, 2012; AOG: 37 1/7 weeks 6 months PTA, patient noted a delay in her menses. This caught her attention since her menses were regular ever since. Consult was sought immediately by her private obstetrician/sister-in-law (Dr. Amethyst R. Ypil) in Cebu Doctors Hospital. Ultrasound was performed and results of this study then confirmed her pregnancy. Other laboratory studies also included CBC, HBsAg and urinalysis which revealed unremarkable findings except for her urinalysis which revealed pyuria. Thus, she was given Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days taken with good compliance. Condition was resolved after compliance of therapy as claimed. Other medications taken during the course of pregnancy were Caltrate plus 600 mg (calcium supplement), Folic acid 5 mg (Vitamin B supplement; prevent neural tube defects) and Ferrous sulfate (iron supplement) 1 cap OD PO taken with good compliance. Patient then had regular monthly visits for the first 7

PRESENT STATE Patient Management On the first day of care on February 18, 2013, patient was scheduled for Bilateral Tubal Ligation in the AM. O2 inhalation at 2 liters per minute while in the recovery room. She was hooked to bottle A D5LR 1L at 20 gtts/min. After 2 hours, patient was then transported to the room. Ketorolac 30 mg IVx 1 dose only, Tamadol+Paracetamol (Algesia) 1 tab PO TID, Nalbuphine 5 mg IV every 4 hours PRN for breakthrough pain were the medications ordered all for pain management. Cefalexin (Cefalin) 500 mg/cap 1 cap every 8 hours PO for prophylaxis for infection and Mv+Fe (Beneforte) 1 cap once a day PO before breakfast as an iron replacement for blood loss were also ordered. Vital signs were monitored BP= 100/70 mmHg, PR=80 bpm, RR= 20 cpm, T= 36.7 degrees Celsius per axilla. No other unusualities noted such as nausea, vomiting, headache, severe pain. General survey (2/18/13): 1P> Examined lying on bed awake, alert, afebrile, responsive, with clean, dry and intact dressing on hypogastric area with the following vital signs BP = 100/70 mmHg, PR = 80 bpm RR = 20 cpm T = 36.7 C/axilla Height = 52 Weight = 62 kg BMI = 24.8 Second day of care on February 19, 2013. Patient is for discharge. Take home medications included Cefalexin 500mg/tab 2x a day for 6 more days, Mefenamic acid 500mg/tab 1 tab every 6 hours as

INTERVENTIONS

EVALUATION

months, every 2 weeks for the 8th month and every week for the 9th month to her private physician as claimed. No unusual findings were noted. Morning PTA, patient noted strong, painful uterine contractions radiating to the lumbar area occurring every 30-45 minutes with a duration of 30-40 seconds associated with clear watery vaginal discharges and occasional blood clots as claimed. This prompted to seek consult at CVGH and was subsequently admitted. PAST HEALTH HISTORY Patient had no problems at birth or childhood as claimed. She is non-hypertensive, non-asthmatic, noncigarette smoker, non-alcoholic beverage drinker, no history of drug abuse. No known food or drug allergies. Her HFDs include hypertension and asthma on maternal and paternal sides. Previous Hospitalizations First hospitalization was when patient was in elementary. She was admitted due to Acute Gastroenteritis at Surigao Hospital, discharged improved. Second was on March 2005 at Cebu Doctors Hospital for the delivery of her first baby via NSVD, 38 weeks AOG, female, 6.5 lbs. Third was on July 2007 at Cebu Doctors Hospital for the delivery of her second baby via NSVD, 37 weeks AOG, male, 6.5 lbs. Fourth was on May 2011 at Cebu Doctors Hospital for the delivery of her third baby via NSVD, 36 weeks AOG, male, 7.1 lbs, she had a urinary tract infection on the second trimester and was treated with Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day taken with good compliance as claimed and was then resolved thereafter.

needed for pain, Iron 1 cap twice a day for 1 month. Follow up check-up will be on February 26, 2013. Physical Examination Date Performed: February 18, 2013 Place Performed: PPS 105 Time Performed: 1 PM 1st Day General appearance: 1P> Seen lying in bed awake, conscious, responsive, coherent, eupneic, afebrile, with dry and intact dressing located at hypogastric area, breasts engorged, uterus two fingerbreadths below the umbilicus, flow of lochia rubra, with the following vital signs of BP: 100/70mmHg; PR: 80 BPM; RR: 20 CPM; T: 36.7 C/axilla. SKIN: brown colored skin; moist; warm; smooth; has good skin turgor; no lesions, lumps or any skin aberrations noted. Striae gravidarum noted. Dry, clean, intact dressing at the hypogastric area noted. SCALP & HAIR: black and evenly distributed hair ; scalp is clean & dry without visible flakes; no lice infestations noted NAILS: transparent with slightly pale nail beds; no signs of clubbing noted; nail plate firmly attached to nail bed, CRT<2secs HEAD & FACE: normocephalic; no lesions and

lumps noted; symmetric facial features; TMJ: Prenatal History mouth opens and closes fully, no swelling, Patient started her prenatal check-up at 12 weeks AOG tenderness and crepitation noted as client opens by LMP of May 2, 2012 at Cebu Doctors Hospital and closes mouth attended by Dr. Amethyst Ypil. Patients laboratory studies included CBC, HBsAg and urinalysis which EYES & VISION: : symmetrical, eyebrows and revealed unremarkable findings except for her eyelashes are black and evenly distributed, pink urinalysis which revealed pyuria. Thus, she was given palpebral conjunctiva, sclera are white, no Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days discharges noted; can read nameplate at 2 ft taken with good compliance. Condition was resolved distance, (+) PERRLA), (+) accommodation. (+) six after compliance of therapy as claimed. Other cardinal gazes medications taken during the course of pregnancy were Caltrate plus 600 mg, Folic acid 5mg and Ferrous sulfate EARS & HEARING:, symmetrical, pinna is 1 cap OD PO taken with good compliance. positioned in line with outer canthus of the eye, Patient then had regular monthly visits for the first 7 no discharges, no lesions, no tenderness upon months, every 2 weeks for the 8th month and every palpation, can hear whispered words at 2 feet week for the 9th month to her private physician as distance. claimed. No unusual findings were noted. NOSE & SINUSES: nasal septum at midline, patent GORDONS FUNCTIONAL HEALTH PATTERN nostrils, no discharges, clear frontal and maxillary Clear frontal and maxillary sinuses on A. Health Perception and Health Management transillumination test and are non tender to Patient describes health as Health is wealth. During palpation and percussion. No nasal flaring, no pregnancy, patient rates her health as 7/10 with 10 as discharges noted. the highest and 1 as the lowest due to restrictions in work and fatigue especially during the third trimester. MOUTH & PHARYNX: tongue at midline, uvula at After pregnancy she rates her health 9/10 with 10 as midline, gums and tonsils not inflamed, Lips are the highest 1 as the lowest due to relief from fatigue moist and pinkish brown in color. Buccal mucosa is she had during pregnancy but there are still some pink, smooth, and moist and without lesions. restrictions in her activity for a few days since she Tongue is pink, moist, smooth and symmetrical. underwent Bilateral Tubal Ligation. Patient is non-hypertensive, non-asthmatic. Patient NECK: supple, trachea at midline, no lesions, had complete immunizations. She does not smoke nor nonpalpable lymph nodes, no masses, no drink. Patient has no known food and drug allergies. tenderness upon palpation, (+) gag reflex, full

Patient claims that she follows health advices as much as possible. Before pregnancy, patient usually self-medicates using Phenylephrine HCl + Paracetamol (Decolgen Forte) for colds, Carbocisteine (Solmux) for cough and Paracetamol (Biogesic) for fever. During pregnancy patient takes Caltrate plus 600 mg, Folic acid 5mg and Ferrous sulfate 1 cap OD PO taken with good compliance. Patient doesnt use herbal remedies as claimed Patient only sees a doctor when there is a need to and for regular check-ups (prenatal). Patient knows BSE but doesnt practice it regulary usahay ra kung maka hinumdum as verbalized. Environment History Patient is currently residing at Urgello, Cebu for 9 years. Patient claims that this house is owned by her and her husband. Patient is living with her husband and 3 children. It is a 3 storey house made up of mixed materials. It has 6 doors, 6 windows and 5 rooms. They have separate kitchen, dining room. Type of toilet is flushed type. Patients source of electricity is VECO and MCWD for their water. Their garbage is collected everyday by a garbage truck. Patient cleans their house every day. They have a crowding index of 1. Patient works as dentist. Her clinic is located in Colon Street and Club Ultima but she usually stays in her clinic in Colon. She works for approximately 7 hours per day. She is satisfied with her current job because it is enough and can sustain her familys needs as claimed. No exposure to chemicals, radiation and toxic substances in her work place. Their residence is 50 m away from the main road. Their means of transportation is through a private

ROM CHEST & LUNGS: chest is symmetrical; no lesions; equal chest expansion; regular, relaxed, effortless and quiet breathing without using of accessory muscles upon breathing, adventitious breath sounds; 20cpm HEART & PERIPHERAL VASCULATURE: Heart rate is 80 bpm and is strong and regular, strong peripheral pulses, no murmurs heard. S1and S2 clearly heard, CRT < 2sec (-) Homans sign; BREAST: engorgement noted, non-tender. (+) milk noted, nipples are brownish, no purulent discharges or lesions noted ABDOMEN: skin same of the rest of the skin tone, rounded, linea nigra noted, symmetrical umbilicus at 2 finger breadths below midline, striae gravidarum noted. Presence of clean, dry, intact dressing noted on the hypogastric area GENITOURINARY: grossly female, minimal lochia rubra noted on slightly saturated napkin, no purulent discharges, no lesion, non-tender upon palpation. RECTUM: no rashes, hemorrhoids, no lesions noted. BACK & EXTREMITIES full ROM noted. Symmetrical; CRT < 2 seconds, no lesions. No tenderness noted. (-) Homans sign

vehicle. Nearest drug store is 100m away. Barangay hall is 200 m away. Fire station is 600 m away. Hospital is 500 m away. Patient stores their medications inside a 5/5 5/5 box and cleaning supplies inside a cabinet. They have a peaceful neighborhood as claimed. Patients last 3/5 3/5 physical exam was on August 2012 with unremarkable results except for her urinalysis which revealed pyuria and was then resolved after taking in Cefalexin (Cefalin) R L 500 mg/tab 1 tab 3x a day for 7 days with good compliance. MUSCLE STRENGTH: R L B. Nutritional-Metabolic * Scale: Patients current weight is 62 kgs, ad 52 in height. 5 Full ROM against gravity, full resistance BMI is 24.8 which is normal. 4 Full ROM against gravity, some resistance 3 Full ROM with gravity Patient is satisfied about her weight as claimed. Patient 2 Full ROM with gravity eliminated (passive claims that it is easy to gain weight. Patient has a good motion) appetite and prefers to eat healthy foods such as 1 Slight Reaction vegetables. No cultural or religious influences on diet. 0 No Reaction Patients diet during hospitalization is a full diet. NEUROLOGIC ASSESSMENT: 24 Hour Diet Recall MENTAL STATUS/CEREBRAL FUNCTION: awake, conscious, responsive, coherent, oriented to time, place, and people, speech not slurred, able to speak and can understand English and Visayan dialect able to smile and frown, listens and follows attention MOTOR/CEREBELLAR FUNCTION: able to perform rapid alternating movements, finger-thumb test, and finger-nose test SENSORY FUNCTION: (+) stereognosis, (jot down notebook) (+) graphesthesia (letter S), (+) kinesthesia,, able to identify

Clients Diet Breakfast

24-hour recall

Usual Diet

between light, sharp and dull touch CRANIAL NERVE TESTING: CN I (Olfactory): able to identify smell of banana CN II (Optic): able to read nameplate of the student nurse at 2 ft distance CN III, IV& VI (Oculomotor, Trochlear, Abducens): (+) PERRLA and + cardinal gaze CN V (Trigeminal: able to identify between light, sharp and dull touch, able to clench teeth CN VII (Facial): able to show teeth, able to frown, smile, purse lips and wrinkle forehead when told to do so CN VIII(Vestibulocochlear): able to hear whispered words (baby) at 2 feet distance CN IX & X (Glossopharyngeal & Vagus): able to swallow food, tongue at midline. (+) gag reflex CN XI (Spinal Accessory): able to shrug shoulders against resistance CN XII (Hypoglossal): able to protrude tongue and able to move tongue around when told to do so 2nd day February 19, 2013 GENERAL APPEARANCE: 4PM> examined sitting on bed, awake, conscious, afebrile, eupneic, breasts nontender, uterus three

Rice, bread, Juice, bread hotdog, egg, milk Rice, chicken, Bought banana, juice Rice, soup, pork Rice, Vegetables

Lunch

Dinner

Snacks

Bread

Patient knows the basic food groups (Go, Grow and Glow). When stressed patient verbalized, mu kaon ra man gihapon. Patient shops for food and usually their helper cooks and prepares it for them. Patient stores their food inside the refrigerator. Patient claims that their income is adequate for their food needs. C. Elimination Before pregnancy, patient voids 4 times a day and 2 times every night amounting to 1 glass per episode. Urine is clear and yellow. Patient drinks at least 8 glasses of water a day. Patient claims that she doesnt use diuretics and knows how to do Kegels exercise and practices it sometimes. Patient defecates every day. Stool is hard, formed and brown. Patient usually defecates every morning. During pregnancy, patient claims that she still voids 4 times a day and 2 times every night amounting to 1 glass per episode. Patient still drinks at least 8 glasses of water per day. Patient still defecates everyday with

hard, formed, brown stools. Patient doesnt use any laxatives and doesnt have any problems with regards to defecation. No changes in her elimination pattern during and before pregnancy. D. Activity-Exercise Patient is an active runner during her teenage years. Upon awakening, patient will have breakfast, feeds her children, takes a bath and go to work. Patient is at work most of the day and arrives home at 5PM. Upon arriving, patient rests and eats dinner. On 8PM, patient washes her face, toothbrushes and then goes to sleep. Patient sleeps, watches tv during her leisure time usually 2-3 hours. Patient considered doing household chores as her form of exercise when she arrives home. Patient doesnt have a difficulty in managing their house. Patient experiences fatigue during the duration of her pregnancy because of bug-at man gud kaayo akong tiyan especially on the third trimester as verbalized. No medical consult was done. Instead, patient usually sits down and doesnt move around that much. Her hospitalization changed her normal activity pattern since she cannot do her usual routine activities at home and work. F. Cognitive Perceptual Pattern Patient is a college graduate who took up dentistry, knows how to speak and understands English, Tagalog and Bisaya. Patient is oriented to time, place and people around her. Patient knows her complete name, age and birthday. She was able to recall short term memory such as her 24 hour diet recall; and was also able to recall long term memory such as her

fingerbreadths below the umbilicus, with minimal lochia rubra, with the ff. vital signs of BP: 100/70mmHg; PR: 72 BPM; RR: 20CPM; T: 36.9 C/axilla. SKIN: Striae gravidarum noted. Dry, clean, intact dressing at the hypogastric area still noted. ABDOMEN: Linea nigra noted, umbilicus at 3 finger breadths below midline, striae gravidarum noted. Presence of clean, dry, intact dressing noted on the hypogastric area GENITOURINARY: grossly female, minimal lochia rubra noted on slightly saturated napkin

5/5 5/5

5/5 5/5

MUSCLE STRENGTH: R L * Scale: 5 Full ROM against gravity, full resistance 4 Full ROM against gravity, some resistance 3 Full ROM with gravity 2 Full ROM with gravity eliminated (passive motion) 1 Slight Reaction 0 No Reaction

previous hospitalization. Patient has no visual LABORATORY FINDINGS problems. Patient is able to identify the smell of a banana. Patient doesnt have any hearing problems. 1. Complete Blood Count Present condition has not affected her cognition Purpose: perception. A useful screening and diagnostic test that is often done as part of routine G. Sleep-Rest physical examination. It can provide Patient usually goes to bed at 9PM and wakes up at valuable information about the blood 6AM. This is her typical pattern during weekdays and and blood-forming tissues, as well as weekends. She doesnt have any problems in sleeping. other body systems. Abnormal results During pregnancy, patient awakens 3 times a night can indicate the presence of a variety of especially during the third trimester due to a feeling of conditions sometimes before the patient discomfort but can easily put herself back to sleep experiences symptoms of the disease. again. Patient usually makes up for lost sleep during It is used as a preoperative test to weekdays. Before going to sleep, patient washes her ensure both adequate oxygen carrying face, brushes her teeth, plays with her children and capacity and hemostasis, to identify prays. She utilizes three pillows, one on the head and persons who may have infection, to one on each side. Her sleeping position is side lying and diagnose anemia, to identify acute and doesnt use any sleep-inducing drugs such as sleeping crhonic illness, bleeding tendencies, and pills. Patient sometimes drinks 1 cup of coffee. white blood cell disorders such as During hospitalization, patient uses 1 pillow on lukemia. It is also used to monitor her head. Patient sleeps around 10PM and wakes up at treatment for anemia and other blood 7AM. Patient still awakens from time to time because related diseases, and to determine the of a new environment and routine nursing effects of chemotherapy and radiation interventions. therapy on blood cell production G. Self-Perception and Self-Concept Patient describes her identity as typical ra as verbalized. Her strength is her family including her husband and children. She didnt identify any weakness. Patient claims that her major accomplishment was to raise her child with love and care. Patient feels good and contented with her stable job. Patient thinks that she is good. She is with herself. She thinks that she has February 16, Normal Values 2013 (16:22) 6.75 k/uL 4.10 10.9 4.75 1.36 .470 6.96%M .120 2.50 7.50 %N 1.00 4.00 %L 2.00 11.00 %M 0.00 - .500 %E

WBC NEU LYM MONO EOS

numbers of good qualities and strongly agrees that she can do things as most as other people. Patient feels that she has much to be proud of and doesnt feel useless at all. She strongly agrees that she is a person worth, at least on an equal plane with others. Patient takes positive attitude towards herself. H. Role-Relationship Patient is the youngest in their family. She is a dentist and serves people every day. She describes her role to her family as important since she was the one who brought up her child well together with her husband. Patient consults and seeks help from her husband when problems occur. She makes decisions on her own with the help of him. Patient describes her family structure as close. Even with her condition, she still maintains good relationships to friends and to all the family members. She claims that her pregnancy didnt cause problems to her role but instead she was able to strengthen her relationship towards her family especially to her husband. I. Sexuality-Reproductive Patient was 13 years old when she had her menarche. Her LMP was on May 2, 2012. She has a regular menstrual cycle for 4-5 days and can consume 2-3 sanitary napkins per day (1st and 2nd day fully soaked, 3rd-5th partially soaked). She sometimes experiences dysmenorrheal and is able to tolerate it as claimed. Her first sexual contact was at the age of 25 with her husband as her sole sexual partner. Her last sexual contact was on November 2012. Her pregnancy caused discomfort and changes in her sexual pattern as

BASO RBC HGB

.049 4.03 12.5

0.00 2.00 %B 4.00- 5.20 12.0 16.0

HCT MCV MCH MCHC RDW PLT

37.5 93.2 31.1 33.3 18.0 266 k/uL

36.0 46.0 80.0 100 26.0 34.0 31.0 36.6 11.6 18.0

140 440 MPV 8.25 fL 0.00-100

Implication: Values are within normal limits 2. Urinalysis 2/16/13 PURPOSE: A general examination of urine to establish baseline information or provide data to establish a

verbalized, dali ra ko ma luya karon. Patient doesnt use pills. Her husband uses a condom as a contraceptive after their first child was born. Recently, she underwent Bilateral Tubal Ligation. Its her personal choice since 4 na man gud akong anak as verbalized. Patient gave birth to her first child on 2005, next was on 2007, then on 2011. She delivered them via NSVD at Cebu Doctors General Hospital. She had her prenatal checkups starting at 2 months AOG for the first 2 children and 3 months AOG for the next 2 with regular visits thereafter. The patient is currently G4P4(4004). Both of her pregnancies are expected and planned. Patient had her prenatal checkups at Cebu Doctors Hopsital. Her first prenatal checkup was on the third month of pregnancy, every month or the first 7 months, every 2 weeks on the 8th and every week on the 9th. During the first prenatal check-up which was on the 3rd month, patient had pyuria and was then resolved with Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days taken with good compliance. Other medications taken during the course of pregnancy were Caltrate plus 600 mg, Folic acid 5mg and Ferrous sulfate 1 cap OD PO taken with good compliance. No other illnesses were noted. Patient is 37 1/7 weeks AOG. Patient had 4 hours of labor. She delivered a live baby girl via NSVD at Cebu Velez General Hospital. Delivery was assisted by an obstetrician. J. Coping-Stress Patient defines stress as kapoy. She claims that stress had been bad to her but doesnt affect her relationship with others. When stressed, patient finds way to release it such as talking to her husband about

tentative diagnosis and determine whether further studies are to be ordered. The urinalysis is another common test routinely taken in almost all acute hospitals as an admission lab screening test. It can easily reveal renal and systemic pathologies

Macroscopic Color

Results Yellow

Transparency

Slightly cloudy

R.R. Light Yellow, dark yellow Clear

Unit

Chemical Tests pH 7.0 Specific Gravity 1.005 Protein Glucose Ketone + -

5.0-8.0 1.0011.035 <10 -

mg/d L mg/d L mg/d L mg/d L mg/d L

Urobilinogen

Leukocyte

Bilirubin

her problems, stays at home and finds time to relax and unwind herself. She solves her problems on her own and sometimes with the help of her husband. K. Value-Belief Patient is a Roman Catholic; attends mass on Sundays regularly. Patient never fails to find time to seek for guidance. Before and during hospitalization, patient makes the sign of the cross at night before she sleeps. Patient doesnt really believe in superstitious beliefs such as magpabuyag.

Nitrite

Negativ e Negativ e

mg/d L mg/d L

Ascorbic Acid

Microscopic Findings CONV (/hpf) R.R. RBC 1-2 0-3/hpf WBC Bacteria Mucous Threads 4-6 Rare Few 0-5/ hpf None None

SI (/uL) 220/u L 28/uL R.R. 017/uL 028/uL None

Implications: Cloudy urine during gestation is partly caused as a consequence of hormonal changes in the body. Dietary modifications together with alterations in hormone levels are the major reasons for passing cloudy urine by pregnant women. For most cases, the causal factor is the food intake, and prompt results are achieved after removing the trigger foods. This is not a subject to worry about. Low amounts of protein are not uncommon, and may simply mean that your kidneys are working harder than before pregnancy. Your body may be fighting a minor infection

 Mucus threads in a urinalysis are considered to be normal in small amounts. Mucus threads appear long, thin and wavy-ribbon like. If there is a large amount of them it may mean there is an irritation, inflammation, or infection in the urinary tract. Mucus threads generally have no clinical significance since they come from the urethra or vagina. NURSING CARE PLAN KEY ISSUES Method of Prioritization: Severity Date Identified: February 18, 2013 1. Acute pain related to surgical incision at hypogastric region secondary to S/P Bilateral Tubal Ligation (Modified Pomeroy) as manifested by facial grimacing and characterized by grawing pain at hypogastric area, limited ROM, and slow movements lasting for 3-5 minutes with a pain scale of 7/10, 1 as the lowest and 10 as the highest, aggravated by movement and relieved by rest and medications. SB: Pain results from the incision, from the stitches of clamps closing it, and from the gas that commonly builds up in the mothers abdomen after this surgery. Activities such as turning over, getting out of bed and walking are painful for a few days.

Independent Interventions: 1. Obtained clients assessment of pain using OLDCARTS R: Assessment provides clues to underlying cause of pain and provides a baseline for developing appropriate pain relief strategies.

Desired Outcome: After the course of nursing intervention, client will lessen facial grimacing in response to student nurses efforts to minimize pain such as teaching the client in 2. Observed clients description of deep breathing exercises pain. and providing a calm and R: Pain is a subjective experience therapeutic environment. and cannot be felt by others. No unusualities will be noted and patient will 3. Monitored vital signs verbalize a decrease R: These are usually altered in acute severity in pain scale. pain. Actual Outcome: 4. Provided a quiet, calm and After the course of

Source: The Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth 2nd edition, by Simpkin, p288

nursing intervention: February 18, 2013 3P> Patient still showed facial grimacing, Patient claims that pain is still Pain is expected after most operations. noted on hypogastric Source: 5. Afforded rest and sleep area with a pain scale of nd Merick Manual of Medical Information, 2 ed., p. R: To alleviate pain 6/10 with 10 as the 1540. highest and 1 as the 6.Monitored for any unusualities lowest with the following, such as fever, profuse vaginal no unusualities were bleeding, noted. R: Such unusualities should be monitored to prevent further February 19, 2013 complication. Patient claims that she doesnt experience pain 7. Encouraged to splint incision anymore, no facial during cough and movement grimacing noted, she is R: stabilizes area, reduces pain and able to ambulate prevent s damage on incision site independently and no other unusualities were 8. Taught on relaxation techniques noted. such as breathing exercises R: reduce tension, subsequently reducing pain. 9. Suggested SO to be at bedside at all times R: to provide comfort 10. Instructed the patient to report pain immediately R: Relief measures may be instituted.

comfortable environment R: Patients may decrease ability to tolerate painful stimuli if environmental, factors are further stressing them.

11. Provided diversional activities such as talking to the patient. R: redirect patients attention to pain 12. Assisted in turning to sides and maintaining proper body position. R: to conserve energy and lessen pain felt by patient Collaborative interventions: 1.Tramadol+Paracetamol (Algesia) 1 tab 3x a day given R: Provides analgesia, sedation, suppresses the medullary cough center to suppress cough reflex Date Identified: February 18, 2013 2. Impaired tissue integrity related to break in the skin and inadequate primary defenses secondary to S/P Bilateral Tubal Ligation with clean, dry and intact dressing at hypogastric area.

Desired Outcomes: Within the course if nursing interventions, the client will be able to demonstrate behaviors SB: 2. Inspect the surrounding skin for necessary in healing and Injury to skin and surrounding soft tissue occur erythema, induration, and laceration maintaining the integrity from sharp objects, blunt force, injury, scraping R: to determine if any type of of the incision site. mechanism or surgical procedures, avulsion, or infection has occurred yet puncture wounds. Actual Outcome: 3. Inspect skin on a daily basis After the course of Source: R: this is to determine of any nursing interventions: Joyce M. Black: Medical Surgical Nursing 7th changes has occurred within the Edition, Vol. 2, P 2502. past few days and to determine the February 18, 2013, healing rate of the wound The dressing was kept clean, intact and dry. 4. Keep the incision site clean and Client was able to

Independent Interventions: 1. Assess the clients broken tissue R: to determine the level of damage sustained by the client

dry develop behaviors that R: moist areas are breeding grounds are necessary for wound for various microorganisms healing such as sitting on her own thus promoting 5. Assisted in wound dressing the circulation, was able R: this is to prevent aggravating any to eat nutritious foods pain felt by the client and to prevent that can facilitate wound any type wound to happen healing such as vegetables. 6. Stimulated the circulation to the surrounding area February 19, 2013 R: to assist the bodys natural way of The dessing was kept healing clean, intact and dry. Client was able to 7. Used appropriate barrier dressing, develop behaviors that wound covering, and skin protective are necessary for wound agents healing such as sitting on R: to protect the wound/or her own and ambulating surrounding areas without assistance thus promoting the 8. Removed wet linens promptly circulation, was able to R: moisture potentiates skin eat nutritious foods that breakdown can facilitate wound healing such as 9. Encouraged early ambulation or vegetables. mobility R: this is to promote circulation and reduces risks associated with immobility 10. Provided optimum nutrition such as eating protein rich foods like organ meats and vegetables R: to aid in skin/tissue healing and to

maintain general good health. Date Identified: February 18, 2013 3. Impaired physical mobility related to decrease strength, pain, and discomfort secondary to S/P Bilateral Tubal Ligation as manifested by limited ROM and the need to be supervised when positioning is needed, with muscle strength of 3/5 on lower extremities as of February 18, 2013 SB: Any special position the individual patient will need to maintain after surgery is discussed, as in the importance of maintaining as much mobility as possible despite restrictions. Source: Brunner and Suddharths: Medical Surgical Nursing 10th Edition, Vol. 1, P 409

Independent Interventions: 1.Encouraged participation in selfcare activities like defecating, voiding and eating, recreational activities like conversing with SO and watching tv R: Enhances self-concept and sense of independence

Desired Outcome: Within the course of nursing interventions, patient will be able to maintain function and will regain strength of her body parts, and will be able to perform any type of activity with only 2.Identified energy conserving minimal assistance or techniques for ADLs such as placing without any type of personal belongings at bedside assistance. R: limits fatigue, maximizing Actual Outcome: participation of the client After the course of nursing interventions: 3.Provided safety measures such as maintaining side rails and keeping February 18, 2013 pillows at each side After 8 hours of nursing R: to prevent injury that can occur interventions performed, when immobilized client has minimal difficulty in moving 4.Encouraged adequate intake of various parts of her body fluid or nutritious food especially near the R: promoted well-being and incision site, as evidenced maximizes energy production by reduced movement and needs assistance in 5.Noted emotional or behavioral positioning and in responses to immobility movement. R: forced immobility heightens restlessness and irritability February 19, 2013 After 8 hours of nursing

6.Assisted with activity/progressive ambulation and therapeutic exercises R: physical activity should be started as soon as possible, usually progresses slowly according to the type of activity that can be tolerated 7. Encouraged and facilitated early ambulation and other ADLs when possible. R: To promote proper circulation to hasten wound healing Date Identified: February 18, 2013 4. Risk for infection related to invasive procedure secondary to S/P Bilateral Tubal Ligation (Modified Pomeroy) Cues: presence of incision approximately 4-5 inches at hypogastric region presence of dry, clean and intact dressing at hypogastric region Independent interventions: 1. Performed handwashing before and after contact with patient. R: A first line of defense on nosocomial infection and on cross contamination

interventions, the client was already alert and was able to move various parts of the body without any assistance, evidenced by standing, sitting on her own and with muscle strength of 5/5.

2.Assessed incision site for any unusualities such as swelling, redness, discharges SB: R: Establish comparative baseline The skin serves as the primary defense against providing opportunity for timely bacterial invasion. When the skin is incised for a intervention surgical procedure, this important line of defense is lost. 3.Kept dressing clean and dry R: Moisture potentiates further skin Source: breakdown. Medical-Surgical Nursing 7th Edition by Joyce Black, 4. Perineal care done twice a day. et al., p. 2503 R: prevent breakdown of perineal are

Desired Outcome: After the course of nursing intervention, no signs of infection were noted. No unusualities will be noted on incision site such as swelling, redness and discharges. Vital signs will remain stable, SO and client will be able to understand the importance of proper hygiene and proper handwashing Actual outcome: After the course nursing intervention: February 18-19, 2013

of

The creation of surgical wound disrupts the 5. Encouraged patient to verbalize integrity of the skin and its protective function. any unusualities noted R: to promote optimum healing Source: through early detection Smeltzer, Suzanne. Medical-Surgical Nursing, 11th ed., p. 546 6. Monitored v/s R: V/S could vary in times of infection 7. Monitored the laboratory studies R: To acquire a comparative data 8. Maintained clean environment R: To prevent injury and safe

No signs of infection were noted such as swelling, redness and no unusual discharges were noted. SO and client understood the importance of proper hygiene and handwashing, dressing was kept clean and dry.

9. Restricted contact with persons having infectious disease R: To reduce exposure to pathogens 10. Taught S.O and patient proper handwashing. R: To promote hygiene and prevent cross-contamination. Collaborative Interventions: 1.Cefalexin (Cefalin) 500 mg/tab 1 tab every 8 hours R: Prophylaxis for infection

DISCHARGE PLAN Health Teachings: Encouraged to maintain proper hygiene by washing hands before and after eating and cleaning the incision, bathing the baby and changing the diapers. Encouraged to clean perineum from front to back to prevent infection. Instructed to take medication at the right time, route and dose. Advised to go to physician for follow up check-up on February 26, 2013 Instructed to clean the breasts with water only to prevent dryness. Advised to always breastfeed the baby every 2-3 hours or per demand. Anticipatory Guidance: Advised to report for any signs and symptoms of bleeding such as pallor, epistaxis, hematoma, profuse vaginal bleeding, melena, hematochezia Report to physician for any signs and symptoms of

inflammation and infection in the incision area such as swelling, redness, pain, hematoma. Spirituality, Saftey, Security: Encouraged to continue attending masses every Sunday. Encouraged to always reinforce safety such as wearing seatbelt when in the car especially and should not place the baby in the front seat. Instead, use a car seat for the baby. Keep away from chemical exposures and radiation. Advised to avoid crowded areas to prevent from getting infection. Encouraged to never leave the baby alone or unattended. Medications: Instructed to comply with take home medications: Cefalexin 500 mg/tab 1 tab 2x a day for 6 more days Mefenamic acid 500mg/tab 1 tab every 6 hours as needed for pain Iron 1 cap 2x a day for 1

month Incision Care: Instructed to keep site clean, intact and dry Encouraged not to touch the incision site with bare hands. Advised to put a dressing in the incision to prevent contamination. Instructed to wash the site with water only when taking a bath to prevent irritation

Nutrition: Advised to eat foods rich in iron such as liver, clams, oysters. Encouraged to also eat Vitamin C rich foods such as oranges, green leafy vegetables Advised not to drink caffeine and alcohol beverages. Encouraged to maintain proper hydration. Encouraged to feed baby with breast milk only Environment: Instructed to keep their house clean and well

ventilated at all times. Advised to keep an environment conducive for rest and sleep by minimizing noise. Instructed to keep sharp objects away especially from the baby

DRUG STUDY

1. Cefalexin (Cefalin) 500 mg/tab 1 tab every 8 hours Classification: Second generation cephalosphorins Action: Has a beta lactam ring which binds to the penicillin binding protein inhibiting the synthesis of the peptidoglycan layer which weakens the cell wall causing cell lysis Indication: prophylaxis for infection Contraindications: hypersensitivity to penicillin antibiotics Adverse effects: pseudomembranous colitis, candidiasis, foul smelling vaginal discharge, urticaria, beefy red tongue Nursing considerations: Assessed incision site for redness, swelling, warmth Instructed to maintain proper hygiene such as handwashing Kept the incision site clean, intact and dry always Instructed not to touch the site Encouraged to eat protein rich foods such as organ meats, oysters and Vitamin C rich foods such as oranges, green leafy vegetables Monitored for alterations in vital signs especially the temperature

2. Tramadol+Paracetamol (Algesia) 1 tab 3x a day Classification: Opioid Analgesic Action: Acts on opioid receptors in the CNS to produce analgesia, sedation. Also suppresses medullary cough center to suppress cough reflex I: pain relief Contraindications: hypersensitivity Adverse effects: visual disturbance, anxiety, confusion, nervousness, euphoria, sleeping disturbances, respiratory arrest Nursing considerations: Assessed pain scale using OLDCARTS Assisted in ADLs such as positioning in bed Instructed not to do strenuous activities such as lifting heavy objects Instructed to do splinting when coughing Instructed to do diversional activities such as watching tv, conversing with SO and student nurse Instructed to do deep breathing exercises Provided comfort measures such as back rub

3. Mv+Fe (Beneforte) 1 tab 1x a day before breakfast C: Supplement A: Iron supports a healthy immune system and is required for growth. This mineral is required for the production of healthy red blood cells, which carry oxygen to every cell in your body. Iron plays a role in the production of adenosine triphosphate, an essential substance that supplies your body with energy. I: post-partum mother, blood loss Contraindications: hypersensitivity Adverse effects: toxicity, hypovolemic shock Nursing considerations: Take before meals for better absorption of drug Avoid drinking coffee, tea, cola and alcoholic beverages while taking iron Encouraged to eat iron rich foods such as red meat, egg yolks, organ meats, green leafy vegetables Encouraged to eat vitamin C rich foods such as guava, papaya, oranges, mangoes, pineapples for better absorption of iron

SUMMARY OF SIGNIFICANT FINDINGS

GORDONS FUNCTIONAL HEALTH PATTERN A. Health Perception and Health Management Before pregnancy, patient usually self-medicates using Phenylephrine HCl + Paracetamol (Decolgen Forte) for colds, Carbocisteine (Solmux) for cough and Paracetamol (Biogesic) for fever. During pregnancy patient takes Caltrate plus 600 mg, Folic acid 5mg and Ferrous sulfate 1 cap OD PO taken with good compliance. Patient knows BSE but doesnt practice it regulary usahay ra kung maka hinumdum as verbalized. Patients last physical exam was on August 2012 with unremarkable results except for her urinalysis which revealed pyuria and was then resolved after taking in Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days with good compliance. D. Activity-Exercise Patient experiences fatigue during the duration of her pregnancy because of bug-at man gud kaayo akong tiyan especially on the third trimester as verbalized. No

medical consult was done. Instead, patient usually sits down and doesnt move around that much. Her hospitalization changed her normal activity pattern since she cannot do her usual routine activities at home and work. G. Sleep-Rest During pregnancy, patient awakens 3 times a night especially during the third trimester due to a feeling of discomfort but can easily put herself back to sleep again. During hospitalization, patient still awakens from time to time because of a new environment and routine nursing interventions. I. Sexuality-Reproductive

1st Day SKIN: Striae gravidarum noted. Dry, clean, intact dressing at the hypogastric area noted. ABDOMEN: Linea nigra noted, symmetrical umbilicus at 2 finger breadths below midline, striae gravidarum noted. Presence of clean, dry, intact dressing noted on the hypogastric area GENITOURINARY: minimal lochia rubra noted on slightly saturated napkin

5/5 3/5 R

5/5 3/5 L

Her pregnancy caused discomfort and changes in her sexual pattern as verbalized, dali ra ko ma luya karon. She also uses pills and condom for her husband after their first child was born for contraceptives. Recently, she underwent Bilateral Tubal Ligation. Its her personal choice since 4 na man gud akong anak as verbalized. During the first pre-natal check-up which was on the 3rd month, patient had pyuria and was then resolved with Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days taken with good compliance. PHYSICAL EXAMINATION Date Performed: February 18, 2013 Place Performed: PPS 105 Time Performed: 1 PM

Muscle strength * Scale: 5 Full ROM against gravity, full resistance 4 Full ROM against gravity, some resistance

3 Full ROM with gravity 2 Full ROM with gravity eliminated (passive motion) 1 Slight Reaction 0 No Reaction

2nd day February 19, 2013 SKIN: Striae gravidarum noted. Dry, clean, intact dressing at the hypogastric area still noted. ABDOMEN: Linea nigra noted, symmetrical umbilicus at 3 finger breadths below midline, striae gravidarum noted. Presence of clean, dry, intact dressing noted on the hypogastric area GENITOURINARY: minimal lochia rubra noted on slightly saturated napkin Mucous Threads Microscopic Findings CONV (/hpf) SI (/uL) R.R. R.R. Few None 0 None

Implications: Cloudy urine during gestation is partly caused as a consequence of hormonal changes in the body. Dietary modifications together with alterations in hormone levels are the major reasons for passing cloudy urine by pregnant women. For most cases, the causal factor is the food intake, and prompt results are achieved after removing the trigger foods. This is not a subject to worry about. Low amounts of protein are not uncommon, and may simply mean that your kidneys are working harder than before pregnancy. Your body may be fighting a minor infection Mucus threads in a urinalysis are considered to be normal in small amounts. Mucus threads appear long, thin and wavy-ribbon like. If there is a large amount of them it may mean there is an irritation, inflammation, or infection in the urinary tract. Mucus threads generally have no clinical significance since they come from the urethra or vagina.

5/5 4/5 R

5/5 4/5 L

Muscle strength LABORATORY RESULTS Macroscopic Transparency Protein Results Slightly cloudy + R.R. Clear <10 Unit