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Republic of the Philippines

STI COLLEGE DAVAO CITY


COLLEGE OF NURSING

A CASE PRESENTATION
ON Incompetent cervix
Presented to the Faculty of
STI COLLEGE OF NURSING
In Partial Fulfillment
of Requirements of the Subject
NCM 102 R.L.E.

Presented by:
Jill Abellanosa
Ronald Ferdi R Onde
Nor aiza Udtang

BSN 2
INTRODUCTION

The relationship between the measurements of the fetal head and the diameters of the maternal
pelvis. The birth passage includes the maternal bony pelvis, beginning at the pelvic inlet and ending
at the pelvic outlet. A narrowed diameter in these areas can result in CPD if the fetus is larger than
the pelvic diameters. Labor is prolonged in the presence of CPD. Membrane rupture can result
from the force of the unequally distributed contractions being exerted on the fetal membranes.
In obstructed labor, in which the fetus cannot descend, uterine rupture can occur. With delayed
descent, necrosis of maternal soft tissues can result form pressure exerted by the fetal head.
Eventually, necrosis can cause fistulas from the vagina to other nearby structures. Difficult, forceps-
assisted births can also result in damage to maternal soft tissue.
SIGNS & SYMPTOMS Prolonged labor, Cervical dilation and effacement are slow, Engagement of
the presenting part is delayed, Adequacy of the maternal pelvis small for size of fetus.

Importance of the case study


In the part of the client
This case will inform the client of what her condition is all about. It will also lessen the burden of the
client increasing her awareness about the whole course of treatments. And also, the client will be
able to familiarize herself about the importance taking care of her own self through the use of
medical regimens.

In the part of the student


The student will gain more information and knowledge about the disease and will lead to a certain
new facts about the said condition, such as cause of disease, path physiology, manifestations,
related factors as well as the proper nursing care management and medical regimens to be
rendered. This acquired information may also help the students on how to properly manage and
care for patients with the same state.

On the side of the College of Nursing


This study could be a used as a guide for the students and it can be source of facts and information
to students of different colleges and especially to the students of College of Nursing.

On the side of nursing profession


This study will serve as a basis in gathering facts and sets of information with regards to pre-
eclampsia.

OBJECTIVES
GENERAL OBJECTIVES

Client Centered

•To assess the health of the patient


•To develop, implement, and evaluate plans for health promotion

Nurse Centered

•To apply the nursing process in the care of the pregnant patient base on the community

SPECIFIC OBJECTIVES

Client-Centered

•Discuss indications for and management of pregnant clients


•Discuss nursing implications for medications commonly prescribed for pregnant
•Describe nursing care for the client
•Use the nursing process to provide individualized care for clients who has experienced pre-
eclampsia.
•Support client and family, and encourage them to ask questions so that information could be
clarified and understood

Nurse-Centered

•Identify major risk factors influencing the said condition.


•Identify the risk factor contributing to the occurrence of the disease.
•Learn the path physiology and manifestations of pre-eclampsia.
•Identify and describe nursing measure to promote awareness in the condition

II. NURSING PROCESS


A. Assessment Data

1. Personal Data
a. Demographic Data

Name:
Age: 24
Sex: Female
Civil Status: Married
Occupation: None
Religious Affiliation: Roman Catholic
Address: Km.9 Upper del Carmen Sasa Davao city
Date of Birth:
Place of Birth: Davao City
Nationality: Filipino
Usual Source of Medical Care: Sasa Health Center
Date and Time of visitation: Feb 17, 2011/10:00 am

Vital signs on admission:

Temp:
BP:
PR:
RR:

2. Environmental Status
The family is composed of three members living within the house. An Nuclear family. According to the
patient, their house was made from concrete materials and has two rooms. They were able to clean
the house on a regular basis. Nawasa is the primary source of drinking. Transportation available in
the family is a tricycle. The location of their house is not easily accessible to hospitals. She did not
report any problems regarding her environment which interfered to her pregnancy.

3. Lifestyle

The patient usually wakes up five in the morning preparing the food. Hobbies and/or recreational
activities exercise. The patient does not smoke and drink alcoholic beverages.

HEALTH HISTORY

PAST HEALTH HISTORY

She has completed all her immunizations and including two shots of tetanus toxoid during her
prenatal visits. She has an allergy. She was been hospitalized before. She has taken prescribed
ferrous sulfate regularly at home.

PRESENT HISTORY

AREAS OF ASSESSMENT
Social Status

Mrs. Perales, 24 years of age, a graduate and lives in Davao City together with his husband.
According to her, she has a good relationship with her family. She talks to her family and able to
interact with other patient.

Interpretation:
The client was able to manage to interact with others. She was cooperative during the interview.

Emotional Status
No comment………….ok?
Interpretation:
Client was able to cope with problems because her family was there to support and comfort her
emotionally.

Mental State
a. General Appearance and Behavior
Patient’s appearance is appropriate with age, oriented, awake, coherent, normal, and symmetrical
facial features. She was wearing maternity dress and was properly groomed. She was responsive
and eye contact was established during the interview.

b. Level of Consciousness
Mrs. Perales was conscious and coherent. She was responsive during the interview.

c. Orientation
The client stated properly the date, place and time. She can identify things or names being asked
and able to answer all questions asked.

d. Speech
The client speaks Tagalog and English and also Bisaya. She is able to read and speaks clearly and
utter words that easily to understand.

BODY TEMPERATURE
Here’s a table showing the body temperature of the client:

DATE TIME TEMPERATURE INTERPRETATION


February 17, 2011 10:30 am 36.5 NORMAL

RESPIRATORY STATUS

DATE TIME RESPIRATORY INTERPRETATION


February 17, 2011 10:30 am 18 NORMAL

CIRCULATORY STATUS

DATE TIME PULSE RATE/BP INTERPRETATION


February 17, 2011 10:30 am 79 NORMAL
100/80
NUTRITIONAL STATUS

Mrs. Perales typical intake of rice is about 2 cups with viand fish of vegetables Lunch
foods are usually noddles paired with rice. During dinner she eats either a meat paired
with rice or a combination. She takes ferrous sulfate every day. She drinks an average of
8-10 glasses a day.
Interpretation
Mrs. Perales can still eat food which is regular or standard diet.

ELIMINATION STATUS
Dark brown stool is normal because patient is taking ferrous sulfate.

SENSORY PERCEPTION

Vision
Mrs .Perales said that she was able to see far and near objects without difficulty. Her eyes
moved smoothly and symmetrically when asked to follow the finger of the student during
the examination. The cornea is moist and shiny. Her pupils were found to be black, round
and equal in diameter, and dilates normally. Client’s eyes constricts as are action to the
light during the examination. The conjunctivas were found to be normal during the
assessment.
Hearing
The external ears match the skin color of the client and were positioned centrally in
proportion with the head. The external ears were elastic and cool to touch. There were no
found obstructions in the ear canals. She has no dry cerumen observed. The patient was
able to hear clear sounds in both ears in response to the voice whisper test with a distance
of about one foot away.
Smell
The patient’s external nose was located symmetrically in the midline of the face. The
nostrils are patent. The nasal mucosa was observed to be red and with no deviations and
no discharges. The patient was able to smell and distinguish different odors as the client
identifies odors such as of the alcohol and perfume.

Taste
The tongue is in the middle of the mouth. Buccal mucosa was found to be normal. Her
tongue is pink and moist.
Touch
She was able to perceive light touch, superficial pain and temperature accurately.

.
STATE OF REST AND PHYSICAL COMFORT

Before hospitalization, she regularly sleeps for about 10 hours and does not take a nap in the
afternoon. After the surgery, Ms.Perales said that she can feel pain on her surgical site that
disturbs her sleeping, she also state that he noisy environment of the hospital is another
reason.

REPRODUCTIVE STATE
Mrs. Perales had her menarche when she was 14 years old. She has a regular 28 days
menstrual cycle. Her menstrual period last 7 days, 2nd and 3rd day is commonly has the
heaviest menstrual discharge. She consumes 5 pads of sanitary napkin a day during
menses. Mrs. Perales is 36 weeks pregnant;

ANATOMY AND PHYSIOLOGY

REPRODUCTIVE SYSTEM

The female reproductive system produces gametes may unite with a male gamete
to form the first cell of the offspring. The female reproductive system also provides protection
and nutrition to the developing offspring. The most essential organ is the ovary which carries
the ova. The uterus, the fallopian tubes and the vulva are accessory organs.

Evaluation
Through assessment and data gathering, certain problems and needs of the
client. Problems urinary elimination, imbalanced nutrition less than body requirement and
impaired parenting/child attachment. Nursing care plan was established to improve client’s
status . Information and health teachings were imparted which led to increase client’s
awareness and knowledge with regards to her condition. which may help the group handle
properly this kind of condition that the student may possibly encounter again.

lll. Conclusion
From the above nursing problems perceived and presented through prioritization and analysis
of the gathered data and proper assessment. Through the use of client focus nursing interventions
and by following to nursing standards, the perceived problems were managed well. Truly, a clinical
eye which is sensitive to client’s need for care was established. Loyalty was observed in aiding the
client’s needs, managing and taking a lead on advocating client’s interest and creating ways on how
to ensure a quality of care.

lV. Recommendation
The following are recommended for the client to easily manage her self being pregnant.
• Encouraged her to begin using birth control immediately after the delivery.
• Encouraged her to take her prescribed medication on right time and dosage.
• Instructed to increase intake of food rich in iron like liver, green leafy vegetables and etc.
• Encouraged to increase intake of food rich in protein and Vit. C.
• Instructed to have adequate rest and try to lower known stresses in life.