Far Eastern University Institute of Nursing

CASE PRESENTATION RIZAL PROVINCIAL HOSPITAL

Far Eastern University Institute of Nursing Case Presentation Rizal Provincial Hospital
Labor is the physiological process by which a fetus is expelled from the uterus to the outside world. Determining whether a woman is in labor is sometimes difficult as painful uterine contractions alone are not sufficient to establish a diagnosis of labor. Typically, the diagnosis is reserved for uterine contractions which result in cervical dilatation and/or effacement. Bloody show (a small amount of blood with mucous discharge from the cervix) may precede the onset of labor by as much as 72 hours. Occasionally, fetal membranes rupture with egress of amniotic fluid prior to the onset of labor

PERSONAL AND FAMILY PROFILE Name: Mrs. M. L. T. Address: 22 I Subdivision Phase II Barrio Dolores, Taytay Rizal Birthdate: Sept. 6, 1980 Birthplace: No. of Siblings: Age: 28 y/o Nationality: Filipino Religion: Roman Catholic Occupation: SM clerk Marital Status: Married Provisional Diagnosis: G4 P3 NSD due to labor pains Educational Attainment: HS graduate Husbands Name: Jovy Tanate Educational Attainment: 3rd Year college Occupation: Tricycle driver NURSING HISTORY Past Health History:

The client said that she only experienced mild illness such as fever, cough and colds during her childhood years. She added that she didnt experience long term illness or any disease that is severe and need hospital admission. She also said that she didnt undergo any surgeries before. The client said that she had complete immunizations. The client said that she doesnt have any history of allergies, accident, injuries and hospitalization before. History of Present Pregnancy: Rating of the OB score was done. The client said that her Last menstrual Period was March 26, 2008. Computation of AOG reveals that her baby was 44 weeks in her womb. Her EDC was computed and the result was January 2, 2009. History of Present Delivery: The client delivered via NSD, an alive, healthy baby boy attended by Dra. Buluran at exactly 6: 19 in the afternoon of January 28 year 2009. The birth weight of her baby was 2.7 kg. Measurement of the newborns body parts, length and weight were taken accurately. The head circumference of the newborn was 33 cm. The chest circumference was 32 cm. The abdomen circumference was 29 cm. The length of the baby was 53 cm. the weight of the baby was 2.7 kg. Rating of the APGAR score was done. The APGAR score of the baby was 8. The client is experiencing weakness and exhaustion after the delivery. The client also added that she experiences pain and discomfort in some parts of her body specifically in areas that is affected by the delivery. Postpartum vital signs were taken and recorded. Results of her VS are all normal. Activity of the client after the delivery was minimize. History of Past Pregnancy: The client stated that this is her 4th pregnancy and 3rd delivery. All of her pregnancies were delivered through normal spontaneous delivery and it all happened in Rizal Provincial Hospital. The attending physician during her 3 rd delivery was Dra. Buluran. All of her babies after the delivery were normal. She experienced miscarriage during her 1 st pregnancy. Her 1st childs birth weight was 5.12 kg. She forgot the birth weight of her 2 nd child. There are no complications after birth of her 3 babies. Present state of her children is normal. She doesnt have any premature delivery before. She also doesnt experience any postpartal complications after the delivery of her 1st 2 baby. She also doesnt have infection before, during and after the delivery, cervical tear and experienced postpartum hemorrhage on her 1st 2 pregnancy. Family Health History:

I.

Patterns of Functioning A. Psychological Health 1. Coping Pattern The client said that they dont have problems in the family that is too big and last long because when they have a problem, they try to fix it immediately by talking to each other. The client is fond of eating foods and resting when she is stressed. Analysis: Coping Strategies vary among individuals and are often related to the individuals perception of the stressful event. A persons coping strategies often change with a reappraisal of a situation. There is never only one way to cope. There are three approaches to cope with stress and to alter the stressor, adapt to the stressor or avoid the stressor. -Problem-Focused Coping-efforts to improve a situation by making changes or taking some actions -Cognitively-focused Coping-the person attempts to control the meaning of the problem and thus neutralize it. -Emotion-Focused Coping-thoughts and action that relieve emotional distress; it does not improve situations, but the person often feels better -Effective Coping- results in adaptation -Adaptive Coping- helps the person deal effectively with stressful events and minimizes stresses associated with them Interpretation: The client was able to cope with her problems effectively because she knows how to respond and adapt to the problems and stresses that she encounters in life. By means of talking and sharing with each other regarding their present situations and problems, they come up with effective coping strategies that help them in adapting.

2. Interaction Pattern Regarding about the relationship of each family members, the couple said that all the members has a harmonious relationship on each other. The couple expresses their love and affection on each other by kissing and hugging. They spend their time together watching T.V. or sometimes they go out to church or in mall. The client added that she have a harmonious relationship with her family, the people in the school where she works and in their community Analysis: Individuals and groups, through interpersonal relationships, can provide comfort, assistance, encouragement and information. Social support fosters successful coping and promotes satisfying and effective living(Pender, 2002) Social support systems contribute to health by creating an environment (Fundamentals of Nursing-Concept. Process and Practice(7th edition) kozier et. Al. 2002) Peer groups assume great importance provide a sense of belonging, pride, social learning and sexual roles. Fundamentals of Nursing-Concept. Process and Practice(7th edition) kozier et. Al. (pg. 387-388) 3. Cognitive Patterns The client considered a person healthy if the person is free from diseases and that person is physically fit. The client feels sad whenever there is a member of the family who is sick. The client does self-medication whenever she is sick. She doesnt use herbal medicines in medication and also dont believe in quack doctors. She said that shes not sickly person. When we asked how painful the operation she went through from a range of 1-10, she verbalized, 10, sobrang sakit talaga na parang bibigay ka talaga! Lalo na nung humihilab. Ngayon, medyo kumikirot parin. Sariwa pa kasi siya. Mga 3 o 4 na beses siya kumikirot. Then we asked if there is still pain in the affected area, the client verbalized, sumasakit siya lalo na kapag tumatayo ako o gumagalaw Analysis:

Interpretation

4. Self Concept The client sees herself as a happy person and a person who always give smile to others. For her, all the problems in our life can be solved in different ways. She added that you must be a positive thinker for you to surpass all the problems in your life and for you to accomplish all your goals and your dreams. Analysis: A positive self concept is essential to a persons mental and physical health. Individuals with positive self- concept are better able to develop and maintain interpersonal relationship and resist psychological and physical illness. An individual possessing a strong self-concept should be better able to accept or adapt to changes that may occur over life. (Fundamentals of Nursing: Concept, Process, and Practice 7th edition, 2004, page 957). Interpretation: 5. Emotional pattern The couple expresses their love and affection on each other by kissing and hugging. They spend their time together watching T.V. or sometimes they go out to church or in mall. The couple loves their baby so much. They also wanted the best for their newborn. Analysis: Interpretation: B. Socio-cultural Patterns 1. Cultural pattern

The client practices the common Filipino traditions. She celebrate fiesta, Christmas, New Year and other occasions that is held in their place. Analysis: Interpretation:

Significant Relationships Regarding the relationship of each family members, the client said that all the members of the family have a harmonious relationship on each other. The couple respects each other in terms of decision making. Analysis: Relationships include individual relationship, group relationship, interpersonal relationship, social support systems and peer groups. Individuals and groups, through interpersonal and significant relationships, can provide comfort, assistance, encouragement and information. Social support fosters successful coping and promotes satisfying and effective living(Pender, 2002)

2.

Interpretation:

3.

Recreation Patterns

The client considered watching T.V. together with her husband and going out to mall as her past time and leisure activities. The client said that she prefers to spend her time with her family or to perform her duties in work rather than doing some activities that is not important. The client verbalized, Nako, simpleng tao lang ako! Masaya na ako kapag kasama ko ang pamilya ko! Analysis: There are no norms and standards for leisure activities and recreation as long as their satisfied with their leisure and recreational activities Interpretation: 4. Environment pattern

Analysis: Interpretation: 5. Economic Pattern

Analysis: Interpretation:

C. Spiritual Pattern 1. Religious Beliefs and Practices My client considers a person healthy if there is no sign of distress or illness present to a person. The client considers her health as an essential factor of her life meaning if theres no health, then she cannot move with her life. Like her health, she also considers her Religion as the most important element of her life. It helps her when conflicts arise because according to her, it gives her solemnity. The clients religion is Roman Catholic and according to her, shes contented with her religion Analysis: Aspects of Spirituality(Martsolf and Mickley, 1998) -Value(having cherished beliefs and standards) Spiritual Health is the ability to develop ones spiritual nature to its fullest potential, including the ability to discover and articulate ones purpose in life, to learn how to experience love, joy, peace and fulfillment, and how to help ourselves and others to achieve their fullest potential Pender, 2002 Spiritual wellness is a way of living, a lifestyle that views and lives life as purposeful and pleasurable, that seeks out lifesustaining and life enriching options to be chosen freely at every opportunity, and that sinks its roots deeply in spiritual

values and/or specific religious beliefs Pilch, pg 31 (1998) in Fundamentals of Nursing-Concept. Process and Practice(7th edition) kozier et. al. pg. 996 People nurture or enhance their spirituality in many ways. Some focus on development of the inner self or world; other focus on the expression of their spiritual energy with others or the outer world. Fundamentals of Nursing-Concept. Process and Practice(7th edition) kozier et. al. pg 996 Able to fulfill religious obligations -pg 1002

Interpretation:

2. Values and Valuing

Analysis: Value Systems are basic to a way of life, give direction to life and form the basis of behavior, especially behavior that is based on decisions or choices No one set of values is right for everyone Beliefs are chosen a) freely, without outside pressure b) From among alternatives c) After reflecting and considering consequences Chosen beliefs are prized and cherished (Prizing or Valuing) Chosen beliefs are Affirmed to others Incorporated into ones behavior

 Repeated consistently in ones life -Raths, et. al. Values and Teaching, 1978 Interpretation:

II.

Activities of Daily Living (A.D.L.) ADL Before Hospitalization The patient eats well. She eats what is served in the table. She doesnt have food preference During Hospitalization The patient was able to eat well. She eats what is bought by her husband. Interpretation and Analysis I: There is no big change in her diet. A: Hospitalized clients who do not have special needs eat the regular diet a balance diet that supplies the metabolic requirements of a sedentary person. Diet as tolerated (DAT) is ordered when the clients appetite, ability to eat and tolerance to certain foods may change. (Kozier, Fundamentals of Nursing, 1202) I: Normal A: Frequency of Bowel Elimination and urination: The frequency of elimination is

1. Nutrition

2. Elimination

The patient defecates once a day and urinates in 7x a day. Her stool is color brown. She doesnt feel any discomfort or pain when defecating. The

The patients elimination pattern didnt change much.

color of her urine is light yellow. There is no pain or discomfort when she urinates.

highly individual varying from several times per day. The amount eliminated also varies from person to person. Presence of Discomforts and ability to control: normally absent (Kozier, Fundamentals of Nursing, 1250) I: The patient is too weak to have such strenuous activities. A: Regular exercise promotes both physical and emotional health. Physiologic benefits include increased cardiopulmonary function and weight control. Psychologic benefits include relief of tension, a feeling of well being and relaxation. (Fundamental of Nursing seventh edition by Kozier page 114) I: The patient cant do some usual things that she always does before. A: Patients especially the postpartum ones may not totally perform hygiene care due to pain in affected site.

3. Exercise

The patient doesnt do exercise. The patient cannot move freely She considers walking as her because shes still in pain. exercise. Some parts of her body especially those parts near her genitalia are still in pain because of the delivery. Rest and sleep is necessary for faster recovery.

4. Hygiene

The patient takes a bath everyday. Brushes her teeth when wakes up and before she went to sleep.

The patient handle herself with care when shes taking a bath because shes still experiencing pain and she tries to avoid splashing on areas that are affected by the delivery.

(Medical Surgical Nursing, Burke, 660) 5. Sleep and Rest The patient sleeps 7-8 hrs a day. Shes satisfied with the amount and quality of her sleep. The patient sleeps 7-8 hrs a day and shes satisfied with the amount and quality of her sleep. I: The client gets the proper amount of sleep he needs to accomplish his daily activity. A: Rest and sleep restores the bodys level and are essential aspect of stress management. (Fundamental of Nursing seventh edition by Kozier page 1023)

PATHOPHYSIOLOGY

Modifiable Risk Factors

Non-Modifiable Risk Factors

Lifestyle Preparation for labor

Fetal position Psychological factors that can influence pain include fear, Anxiety, worry, expectation of pain, body image and self-efficacy Familial history of diseases Heart disease Asthma Length of labor

PAIN AND DISCOMFORT DURING AND AFTER LABOR

MECHANICAL STIMULI

SKIN, BONE, PERIOSTEUM, JOINT SURFACES AND ARTERIAL WALLS

CHEMICAL MEDIATORS SUCH AS PROSTAGLANDINS, HISTAMINE, BRADYKININ AND SEROTININ SYNTHESIZE THE NOCICEPTORS

PAIN IMPULSE IS TRANSMITTED

SMALL UNMYELINATED C-FIBERS

LARGE MYELINATED A-FIBERS

DORSAL HORN OF THE SPINAL CORD

SOMATOSTATIN, CHOLECYSTOKIN, SUBSTANCE P NERVE SERVE AS NEUROTRANSMITTER AND ASSIST THE PAIN IMPULSE ACROSS THE SYNAPSE BETWEEN THE PERIPHERAL AND SPINAL NERVE

PAIN IMPULSE ASCENDS THE SPINAL CORD TO THE BRAIN CORTEX PAIN IMPULSE ASCENDS THE SPINAL CORD TO THE BRAIN CORTEX

INTERPRETATION OF PAIN

ECOLOGIC MODEL A. HYPOTHESIS The amount of pain and discomfort a patient experiences during contractions can be compounded because there is the presence of fear and anxiety. The length of labor can also affect the satisfaction of woman after the delivery. B. PREDISPOSING FACTORS 1. Host a. Pain perception and expectation every woman can experience pain during labor and it varies among individual b. Past experience 2. Agent a. Mechanical stimuli 3. Environment a.

D. ANALYSIS

E. CONCLUSION AND RECOMMENDATION

PRIORITIZATION PROBLEM Pain r/t strong uterine contractions RANK 1 JUSTIFICATION Pain avoidance belongs to physiologic needs according to Maslows hierarchy of needs. Individuals experience pain by various daily hurts and aches, and occasionally through more serious injuries or illnesses. It needs intervention Activity intolerance belongs to safety and security needs to Maslows hierarchy of needs. If an individual is weak he will have an insufficient energy to complete his desired activities.

Activity intolerance r/t generalized weakness

NURSING CARE PLAN NURSING DIAGNOSIS Acute pain r/t Alteration in comfort ANALYSIS GGOAL AND OBJECTIVES Short term: INTERVENTION >determine pt. acceptable level of pain on a 0 to 10 scale. RATIONALE >to measure the characteristic of the pain, to implement pain management technique. >vital signs are usually altered in acute pain > It includes techniques to improve ventilation and oxygenation. It prevents respiratory complications. > It is a physical activity for the purpose of conditioning the body, improving health and EVALUATION After 1wk of nsg. Intervention, the pt. feels comfortable and free from pain.

Pain is a cardinal symptom of inflammation and is valuable in the Subjective: diagnosis of many disorders and As verbalized by the conditions. pt: medyo masakit yung tiyan ko. Pp. 998 Mosbys pocket dictionary hirap kumilos kasi msakit kaso Pain is an kasuhan ko pati mga unpleasant sensory buto buto and emotional experience arising Possible Objective: from actual/potential -facial grimace tissue damage or -limited range of described in terms motion of such damage; -guarding behavior sudden or slow onset of any 0intensity from mild

After 4 hrs. of nsg intervention the pt. will be able to verbalized level of pain >monitor v/s Long term: After 1wk of nsg. Intervention, the pt. will feel comfortable and free from pain.

> Instruct Client to perform deep breathing exercises

> Show Client X how to exercise his extremities

to severe with an anticipated or predictable end and a duration of less than six months. Reference: Nurse,s pocket Guide by Doenges, Moorhouse and Murr, 10th edition page 388-392.

maintaining fitness >provide quiet environment, calm activities. >promote comfort measure (e.g. back rub, change of position, use of hot/cold compress) >encourage adequate rest. >administer analgesic as ordered by the physician. >promotes relaxation. >to provide nonpharmacological pain management and to ease pain. >to prevent fatigue >to alleviate pain

METHODS Medication Describe the importance of regularly taking of prescribed medications including the potential unpleasant effects of non compliance Instruct the client to continue with follow up medical care Advise the client not to miss the intake of medications given by her physician upon discharge. (Acetaminophen if the fever reoccur and Shincef)

Exercise Have regular exercise Be active on physical activities. Engage with aerobics or any out door sports

Treatment For the follow-up check-up repeat-- CBC Fecalysis

Health Teachings

Explain the underlying disorder and treatment plan. Teach the client the preventive measure on requiring the disease Lifestyle change (proper food preference) general health measures (adequate sleep, proper diet, and maintaining a clean surrounding).

Out Patient Visit the doctor if there are factors that may be an indication of the risk for infection Diet Diet as tolerated except dark color foods Spiritual Nursing actions to help clients meet their spiritual needs include: providing presence supporting religious practices assisting clients with prayer referring client for spiritual counseling