Introduction Postpartum is a period where the mother has just finished giving birth to her baby.

It is a period where the normal body of a mother is returning to its normal state. The mother should know how to take care to their babys and how to take care of themselves. The patient cannot do this without the help of a nurse or any medical practitioners. By the help of the nurse it can be guided her by way of clinical teaching, adequate nursing management, and proper medical advice while the patient is still in a lying-in or a hospital. Although proper information would help the patient a lot, rare abnormalities can also threaten the life of the baby or the mother. One of which is the focus of this case study, breech. In almost 7 out of 10 vaginal births, the head is the part of the baby to be born first. During a woman's pregnancy, the fetus moves freely inside the uterus, cushioned out by the amniotic fluid. At 20 weeks' gestation, the midway point in the pregnancy, 7 out of 10 of fetuses are in a breech position. By 34 weeks, only about 3 out of 10 are in a breech position. As the pregnancy progresses towards term (3742 weeks), the growing fetus has less room in which to turn around, and usually remains more in an inverted (head down) position. However, in 1-2 of births, the buttocks or feet present first. In a breech birth, the presenting part of the fetus, or the part that enters the woman's birth canal first, is the buttocks or legs (Encyclopedia of Nursing & Allied Health).

II. Objectives General Objectives: After two days of exposure at the OB WARD in Ospital ng Maynila Medical Center, the student-nurse should be able to apply the theoretical skills and learning, provide a systematic and efficient way of collecting information and will be able to give

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absolute care and medical assistance to the client and be able to learn about the disease and its process.

Specific Objectives: Through the General Objectives we can obtain it by the help of our specific objectives. 1. To provide an accurate, sufficient and reliable physical assessment of the client and thus, make effective nursing interventions

2. To be able to distinguish the different factors, which have caused and that could exacerbate the clients condition through generalized and efficient informationgathering from history taking and physical assessment

3. To be able to create and evaluate the efficacy of a plan of care and nursing interventions related to the disease process.

III. Demographic data Name: Patient A Address: Malate, Manila Age: 36 years old Gender: Female Citizenship: Filipino Occupation: Housewife Religion: Roman Catholic Weight: 88 lbs.
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Height: 411 ft. BMI: underweight (17.8kg/m2) Date and Time of Admission: September 26, 2011, 1:05 am Date Received: September 29, 2011- 8:00 am Source of Information: Patient A Reliability: 100% from the patient 100% from patients medical records

Chief Complaint: Ang sakit na ng tiyan ko! Manganganak na ata ako,as verbalized by the patient.

Admitting Diagnosis: G5 P4 T4 P1 A0 L5 Pregnancy Uterine AOG: 36 weeks and 9 days Breech Presentation

Vital Signs: T: 36.5 RR: 28 PR: 80 BP: 110/80

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IV. History of Present Illness Patient A is from Cavite, but she went to her mother-in-law in Malate, Manila for a month vacation. She didnt expect that she would deliver her fifth baby in Ospital ng Maynila through Breech Presentation. But before she went to Ospital ng Maynila she tried to deliver her baby in the Malate Lying-In but the said Lying-In didnt receive her because the baby is breech. Hindi ako nag-papacheck-up sa Health Center sa Cavite kaya di ko alam na suhi yung anak ko, as verbalized by the patient. But before she was admitted at Ospital ng Maynila, laboratories requested for CBC and Urinalysis. When the laboratory results were released, the doctors requested for blood transfusion because of her low RBC. Patient A delivered spontaneously thereafter. Afterwards, she was transferred to OB ward.

V. Past Medical History 1. Immunization The client does not complete her immunizations which are Hepatitis B, influenza, Tetanus/Diphtheria that rendered by the health center.

2. Past Illness The client doesnt have any medical problem except for fever, cough and common colds a month earlier, but she recovered easily as she said. The client had not experienced any illnesses other than what she stated.

3. Allergies The client had no known allergies. Obstetrical history Patient A has five childrens: 2 boys (including her present baby) - 3days, 14year-old
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3 girls ages 15year-old, 13year-old and 12 year-old. They are all well. If a normal pregnancy, brief: In her second pregnancy, she was induced at 39 weeks and 2 days, underwent a normal vaginal delivery.

In her third pregnancy, she went into spontaneous labor at 37 weeks and had a normal vaginal delivery. In her fourth pregnancy, she was induced at 38 weeks and 6 days, underwent a normal vaginal delivery. If an abnormal pregnancy, full details: In her first pregnancy, she was induced 38 weeks and 6 days, cephalic in labor and had a normal vaginal delivery but she experienced curettage because of the little bit placenta that remain in her. Current pregnancy: LMP Focusing our attention on this pregnancy, the first day of last menstrual period was second week of January. She is certain of the date, because she remembers the day of conception. She was 17 year-old when first menstrual cycle begins. She has a regular, 34 days cycle. By Nageles's rule, her estimated date of delivery is October 16, 2011. Current pregnancy: unexpected The pregnancy was unexpected and was not taking periconceptual folic acid. Current pregnancy: confirmation She had a positive pregnancy test at 7 weeks. She felt quickening at 13 weeks>.

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Current pregnancy: breastfeeding She breastfed her previous children and intends breastfeeding for this baby. Current pregnancy: antenatal care She opted for antenatal care with this hospital. Her antenatal course was <normal until she was admitted to hospital on this occasion. Current pregnancy: pre-admission events Patient A was admitted to hospital 3 days ago. She complained of labor pains. Current pregnancy: hospital events Since coming into hospital, the investigations she is conscious and coherent, labor pains which showed normal to a pre-natal mother. Patient A told me that she is being kept in the hospital for observation. VI. Family Health History

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Patient A stated that she is only 7 year-old when her mother died at aged 45 because her mother was shot by the gun while her father died at the aged of 48 year-old and Patient A dont know why her father died.

Patient A doesnt know the reason why her grandparents died.

VII. GORDONS TYPOLOGY OF HEALTH PATTERN Immediately Before Hospitalization Umiinom ako ng Centrum araw-araw, as verbalized by the client. During Hospitalization Iniinom ko ung gamot na nireseta sa akin ng doctor, as verbalized by the client. Pinahihigop ako ng sabaw para marami daw akong mailabas na gatas sa suso ko, as verbalized by the client. Tatlong beses na lang ako umiihisa isang araw at dalawang beses akong dumudumi sa isang araw, as verbalized by the client. Significance/ Interpretation The client has changed the things she do to her health in order to hasten her recovery. The client is now shifting her diet to a full liquid because it is needed for her lactation. There is a change on the pattern of the clients elimination pattern due to the pain on her episioraphy.

Health Patterns

Health Perception

NutritionalMetabolic Pattern

Kumakain ako ng baboy madalas pero may halong gulay. Kumakain din ako ng isda, as verbalized by the client.

Elimination Pattern Nakakadumi ako ng dalawang beses sa isang araw at nakakaihi ako ng anim na beses sa isang araw. Madami akong inihi kasi malakas akong uminom ng tubig, as verabalized by the client. Activity-Exercise Pattern Naglalakad naman ako palagi sa loob ng bahay namin pero hindi ako gumagawa

Hindi ako makakilos kasi masakit ung tahi ko, as verbalized by the client but the

There is a change in the activity of the client restricts

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ng gawain kasi tamad ako , as verbalized by the client. Sleep-Rest Pattern Sa gabi, hindi ako natutulog kasi naiirita ako pero sa umaga natutulog ako tapos hapon na ung gising ko, as verbalized by the client. Wala akong problema sa pandinig at paningin, as verbalized by the client. Pag masakit tiyan ko, nagwawala ako tapos inaaway ko ung asawa ko as verbalized by the client. Simple lang ako at amadali akong magalit kapag hindi ako sinusunod as verbalized by the client. Kasama ko sa bahay yung pamilya ko at ung mga nangungupahan sa bahay ko, as verbalized by the client. Natataranta ako pag isa sa mga anak ko ay may sakit, as verbalized by the client. Oo, nag-fafamily

client.

her movement because of the pain. The client is exhibiting a good sleep after the delivery than she is pregnant.

Maayos na ung tulog ko. Regular na as verbalized by the client.

CognitivePerceptual Pattern

Yung tahi ko lang ung nararamdaman kong masakit as verbalized by the client.

The client shows signs of distress because of the pain felt on her episioraphy.

Self Perception Pattern

Ganoon pa din, maiinipin at madaling magalit, as verbalized by the client.

The client hasnt changedher view about herself which indicates she knows herself well. The role of the client as a mother, wife and a daughter-inlaw is performed because there is a strong bonding between the family and the client.

Role-Relationship Pattern

Ganoon din, kasama ko ung asawa ko ngayon at tinutulungan kami ng nanay ng asawa ko(biyenan), as verbalized by the client.

Sexually-

Pang limang beses

The client has

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Reproductive Pattern

planning kami. Pag nagsesex kami, pinipigilan niya tapos ilalabas sa labas para di ako mabuntis ,as verbalized by the client.

ko na itong panganganak at siyempre, di muna kami makakapagsex dahil syempre sa tahi ko, as verbalized by the client.

an idea of what family planning is but during hospitalization, the client cannot perform sexual activities because of the pain in her episioraphy. The client has a strong bond in her family even though she is married and she is also helped in times of problems. The client has a strong faith on her religion and has a positive outlook in her life with the help of her religion.

Coping-Stress Tolerance Pattern

Tumatakbo ako sa mga kamag-anak ko pag may proiblema ako kasi sila lang yung makakatulong sa akin e, as verbalized by the client. Mahalaga sa akin ang aking relihiyon dahil ang Diyos lamang ung matatakbuhan natin pag may problema tayo e, as verbalized by the client.

Kamag-anak ko parin ung nandyan para sa akin hanggang ngayon lalo na ngayong nasa ospital ako, as verbalized by the client. Hindi balakid sa paniniwala ko yung panganganak ko ngayon at maganda nga at may anak ulit ako kahit na sobrang hirap ng buhay, as verbalized by the client.

Value-Belief Pattern

VII. Review of Systems General The client stated, Masakit lang yung tahi ko kasi malaki yung tahi. Integumentary System The client answered, "Wala akong mga allergy sa kahit anong pagkain at gamot, lahat kinakain ko," when was asked if she has allergies. Head: The client stated Wala naman akong nararamdamang masakit sa ulo ko.
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Eyes: The client stated Hindi pa naman lumalabo mata ko, wala pa naming nagiging problema. Ears: The client verbalized humihina lang yung pandinig ko kapag may bara. hahaha. Nose/Sinuses: The client stated Wala naman bara yung ilong ko, nakakahinga pa naman ako ng maayos. Throat: The client verbalized Hindi naman ako nahihirapan kapag lumulunok ako, wala naman problema. Respiratory System The client answered, "Wala akong ubo pero hindi ako nakakahinga ng maayos kasi ang init dito pero, wala masyadong problema," when asked if she has cough, difficulty in breathing or chest pain. Cardiovascular System The client said, hinid naman sumasakit yung dibdib ko," when asked if she feels dizzy or any pain in the chest. Gastrointestinal System "Hindi naman ako nakakaramdam ng masakit sa tiyan ko, as verbalized by the client. Genitourinary System The client stated, "Wala naman akong problema sa pag-ihi, maayos naman. Mahapdi lang talaga yung tahi sa kin kasi nga malaki." Musculoskeletal System The client stated, "Hindi ako makatayo at makalakad kasi masakit yung tahi ko. Neurologic System The client said that, Hindi ako nahihilo.

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IX. Physical Assessment C. Head a. Skull and Face Upon inspection, the head is round and normocephalic, without the presence of nodules and edema. The facial features and movements are both symmetric. b. Eyes Upon inspection, the hair of the eyebrows and eyelashes are both even and aligned; the eyelashes slightly outward. The eyelids are intact and close symmetrically. The sclerae are white, the bulbar conjunctivas and corneas are transparent, and the palpebral conjunctivas are shiny and pink. Upon palpation, the lacrimal gland and lacrimal sac do not exhibit edema or any swelling; and upon assessment, the pupils are black and equally round and reactive to light and accommodation (PERRLA) with normal vision. The ocular movements are coordinated and parallel. The client resulted positively with the Hirschberg test.

C. Ears The clients auricles are symmetrical to the face, firm texture and no tenderness. No lesions and nodules at the external ear canal. Tympanic membrane is pearl gray in color. The tuning fork tests result is positive in Rinnes and negative in Webers test. The client also has positive watch tick test and the client can hear sounds correctly. D. Nose and sinuses The patients external nose, upon inspection is symmetric and proportional to the face. The client can breathe freely on nares, pink internal nasal mucosa and intact nasal septum. Upon palpation of the sinuses, there is no tenderness. E. Mouth and Oropharynx The clients lips are symmetrical, dark in color with crusts while the internal lips and buccal mucosa are pink, moist, and elastic and no tenderness. The client has

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incomplete teeth on the upper and the lower part and is wearing dentures. No present gum bleeding and swelling, pink, moist and firm. The tongue is centered, pink and the papillas are raised. Tongue moves freely, and when tongue is raised, there is a prominence of veins at the mouth floor and the frenulum. No inflammation and signs of infection on the salivary ducts, pink soft and hard palates with no nodules and masses, uvula is at the midline and no signs of inflammation, tonsils are pink and no signs of inflammation. The client elicits positive gag reflex. F. Neck The clients neck, upon inspection is centered and head movement is coordinated. The muscle strength of the sternocleidomastiod and the deltoid are equal. No palpable lymph nodes and no visible enlargement of the thyroid and the thyroid ascend when swallowing.

Heart and Central Vessels The heart and central vessels of the patient is auscultated on the aortic,pulmonic,and tricuspid areas and no lift or heave inspected. Full pulsations are heard upon auscultation in all four anatomic sites and quality remains the same in all positions. Bruit in not heard upon auscultation of the carotid artery and jugular veins are not distended. Thorax and Lungs Posterior Thorax The Posterior Thorax of the patient is symmetrical and has the normal shape of 1:2. The patients chest skin and areas are intact. Has a bilateral fremitus. When it is percussed, resonant sound was produced. A diagrammatic excursion measurement is 3-5 cm which means the patient is negative in emphysema. When the chest was

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auscultated, breath sounds are vesicular and bronchovesicular are can be heard. Breathing is quiet, rhythmic and effortless. Anterior Thorax The Anterior Thorax of the patient is full and symmetrical respiratory excursion. Has a bilateral fremitus. When it is percussed, symmetric sound was produced. And when auscultated, a vesicular sound was heard.

X. Anatomy and Physiology

External Anatomy of Female Genetalia

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Internal Anatomy of Female Genetalia

External Parts: Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholin's glands: These glands are located beside the vaginal opening and produce a fluid (mucus) secretion.
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Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect. Hymen: It is a membrane that surrounds or partially covers the

external vaginal opening. It forms part of the vulva, or external genitalia.

Internal Parts: Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall. Cervix: The cervix is the lower end of the uterus. It is located at the top of the vagina and is about one inch long. The cervical canal passes through the cervix, allowing blood from a menstrual period and a baby (fetus) to pass from the womb (uterus) into the vagina. The cervical canal also allows sperm to pass from the vagina into the uterus.
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XI. Laboratory Results COMPLETE BLOOD COUNT

Examination

Reference Value

Result

Analysis and Interpretation

Hematocrit

F: 37-47g%

19.0

Blood loss, Anemia, Dietary deficiency

Hemoglobin

F: 12.0 16.0g/DI

5.5

Blood loss

Blood loss to the RBC F: 4.2 5.4 1.9 client due to her episiorrhaphy 13.9

WBC

5-10

Infection on the episiotomal area Increase in number in

Neutrophils

0.61 0.67

0.72

neutrophils may indicate acute infection or stress.

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URINALYSIS

CHARACTERISTICS

NORMAL FINDINGS

LAB RESULTS

INTERPRETATION AND ANALYSIS

COLOR

Straw, amber, Transparent

Red

Concentrated urine is darker in color. Diluted urine may appear most clear or very pale yellow. It indicates that there may be a mixing of blood in the urine from her episiorrhaphy.

TRANSPARENCY

Clear

Turbid

Turbid (cloudy) urine may be a symptom of a bacterial infection since there is an evident increase of WBC in her hematologic studies.

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XII. Drug Study

Generic Name

Actions

Dosage

Indications

Contraindication

Adverse Effect

Nursing Responsibilities

Brand Name: Methylergo novine Maleate

A partial agonist or antagonist at alpha receptors; as a result, it increases the strength,

1 ampule

>Routine management after delivery of placenta >Treatment of postpartum atony and hemorrhage; subinvolution of the uterus >Uterine stimulation during the second stage of labor following

>Contraindicated with allergy to methylergonovine, hypertension, toxaemia, lactation, pregnancy. >Use cautiously with sepsis, obliterative vascular disease, hepatic or renal impairement.

CNS: Dizziness, headache,

>Give oral drugs after meals with a full glass of water.

CV: dyspnea >Monitor postpartum women for BP changes and amount and character of vaginal bleeding. >Discontinue if signs of toxicity occur.

Generic Name:

duration, and frequency of

Methergine uterine contractions. Drug Class: Oxytocic

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the delivery of the anterior shoulder, under strict medical supervision

Mefenamic Acid

Antiinflammatory, analgesic, and

500 mg q 6 P.O

>Relief of moderate pain. >Treatment of primary dysmenorrhea

>Contraindicated with hypersensitivity to mefenamic acid, aspirin allergy and, as treatment of perioperative pain with coronary artery bypass grafting.

>CNS: fatigue, tiredness, >HEMATOL OGIC: decreased Hgb or HcT >RESPIRA TORY: dyspnea

>Do not take the drug with an empty stomach. >Give with milk or food to decrease the GI upset.

Drug Class: NSAID

antipyreticc activities related to inhibition of prostaglandin synthesis; exact mechanisms of action are not known.

Cefuroxime Bactericidal: Inhibits synthesis Drug Class: of bacterial cell wall, causing cell

1ampule

>Lower respiratory infections caused by S.

>Contraindicated with allergy to cephalosporins or penicillins.

>CNS: Headache, dizziness, .GI:

>Give oral drugs with food to decrease GI upset and enhance absorption.
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Antibiotic

death

Pneumoniae, H. Parainfluenza, H. Influenza

>Use cautiously with pregnancy.

abdominal pain

>Avoid alcohol while taking this drug and for

.Hematolog 3 days after because ic: decreased Hct >Local: Pain severe reactions often occur.

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Ferrous Sulfate

Elevates the serum iron concentration,

1 caplet

>Prevention and treatment of iron deficiency anemias. >Dietary supplement for iron.

>Use cautiously with normal iron balance

>CNS: Dizziness >HEMATOL OGIC: decreased RBC, decreased Hgb and decresed HcT

Confirm that the patient does not have iron deficiency anemia before treatment >Give drugs with meals (avoiding milk, eggs, coffee, tea) if GI discomfort is severe; slowly increase to build up tolerance. >Warn patient that stool may be dark or green. >Arrange for periodic monitoring of Hct and Hgb levels.

Drug Class: Iron

which then helps to form Hgb or trapped in the

preparation reticuloendotheli al cells for storage and eventual conversion to a usable form of iron.

Multivita-

For

500mg

>Provides

>Never take

>Lethargic

>Do not take the

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mins

pharmacological action: multivitamin supplement

the entire fundamental metabolic vitamin.

more than the recommended dose of a multivitamin.

vitamins with an empty stomach. >Take the drug once a day depending on the physicians order.

CoAmoxiclav (amoxicilli n and clavulanate potassium)

>Amoxicillin inhibits transpeptidase, preventing crosslinking of bacterial cell wall and leading to

625mg

>Decrease the removal of methotrexate from the body increasing the risk of toxicity.
>Lower

>Contraindicated in patients with a history of allergic reactions to any penicillin.

>CNS: Headache, dizziness, >GI: abdominal pain >Local: Pain

>Tell patient he may take drug with or without food. >Inform patient that drug lowers resistance to some types of infections. Instruct her to report new signs or symptoms of infection (especially of mouth or rectum). >Advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of
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Pharmacol cell death. ogic >Addition of class: Amin clavulanate (a openicillin beta-lactam) Therapeuti increases drug's c class: Anti- resistance to infective beta-lactamase (an enzyme produced by

respiratory tract infection.

bacteria that may inactivate amoxicillin).

fluids.

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XIII. Nursing Care Plans NURSING DIAGNOSIS Activity Intolerance r/t presence of episiorrhaphy NURSING INTERVENTIONS Independent: 1. Promote comfort measures and provide for relief of pain 2. Ascertain ability

CUES

PLANNING

RATIONALE

EVALUATION

Subjective: Hirap akong kumilos kasi malaki yung tahi ko, as verbalized by the client

Within 8 hours of meticulous nursing intervention, the client will be able to: a. use identified

1. Enhances ability to participate in activities 2. Ascertains any improvement in

Within 8 hours of meticulous nursing intervention, the client was able to: a. use identified techniques to enhance activity tolerance b. participate in necessary/desired activities c. progress to highest level of mobility possible

to stand and move mobility about 3. Monitor vital signs 4. Promote comfort measures and provide relief of pain 3. Evaluates the patients condition 4. Enhances ability to participate in activities

Objective: > sign of distress

techniques to enhance activity tolerance b. participate in necessary/desired activities c. progress to highest level of mobility possible

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CUES

NURSING DIAGNOSIS Pain related to an incision in the perineum

PLANNING

NURSING INTERVENTIONS Independent: 1. Assess clients pain including locations, characteristics, onset/duration, frequency, quality,

RATIONALE

EVALUATION

Subjective: Masakit yung tahi ko sa pwerta, as verbalized by the client

After 2 hours of nursing intervention, the clients pain will be lessen from 6/10 to 3/10

1. To obtain baseline data 2. To evaluate clients response to pain 3. To promote nonpharmacological pain management 4. To distract attention and reduce tension

Goal met. After 2 hours of nursing intervention, the clients pain has lessen from 6/10 to 3/10

Objective: > facial grimace > irritability > pain scale of 6/10

intensity, and precipitating factors 2. Use pain rating scale appropriate for age/condition 3. Provide comfort measures such as touch, repositioning, nurses presence, quiet environment, and calm activities

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4. Instruct the use of relaxation techniques, such as focused breathing and imaging

Dependent: 1. Administer appropriate analgesics as indicated

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XIV. Discharge Plan Medication: -Continue oral medication as prescribed by doctor. -Instruct the patient to continue with follow up medical care -Advise the client not to miss the intake of medications given by her physician upon discharge. Environment and exercise: -Maintain a quite, pleasant environment to promote relaxation -Provide clean and comfortable environment Treatment: -Encourage the patient to take multivitamins -Continue home medications Health Teachings: -Instruct the patient to limit her activity for 24 hours after her discharge -Provide written and oral instructions about activity, diet recommendations, medications, and follow up visits. -General health measures (adequate sleep, proper diet and maintain a clean surrounding). - Promote good nutrition -Promote good hygiene Out Patient: -consult to doctor for any problems and complications encountered

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Diet: -diet as tolerated as much as possible Spiritual: -Supporting religious practices -Assist patient with prayer -Referring patient for spiritual counseling

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