PAMANTASAN NG LUNGSOD NG PASIG

A. Jose Street, Kapasigan, Pasig City

COLLEGE OF NURSING

CASE PRESENTATION
NORMAL SPONTANEOUS DELIVER CIL RMLE II

NACILLA, JOSE BRYAN B. S.N.

PROMOTORES DE SALUD
What is normal vaginal delivery?

Normal vaginal birth is the childbirth process which takes place without any form of medical intervention. Nowadays to alleviate the pain and speed up the delivery process medications might be used (you can
choose not to opt for any medical intervention). All in all, a normal delivery is, in other words, a completely natural delivery of a baby by the mother without any medical intervention. During normal/vaginal
delivery the primary focus is on how and in which position will the mother be comfortable delivering the baby. The mother can lead the whole process of labor and delivery. The doctor and attending nurses, aid
her while being alert for any kind of emergencies.

There are three major stages you will undergo during normal childbirth:

1. Labor and effacement of the cervix

2. Pushing & birth of the baby
3. Delivering the placenta

1. Labor and effacement of the cervix

This is the first stage of the normal delivery process and of labor. For the baby to be born, the cervix needs to become malleable, soften and stretch so that the baby can be delivered. This first stage can last for up
to 13 hours for a woman who is delivering a baby for the first time, and for seven to eight hours for a second or third child. Contractions occur which helps to dilate the cervix.

This first stage has three sub-stages:

 Early labor: The cervix of the expectant mother opens to about 4 centimeters. You will probably spend most of the early labor at home. At this stage, the expectant mother can continue to perform her
usual activities, relax often, drink plenty of clear fluids, eat light meals whilst keeping keep track of the contractions. With time the contractions grow stronger and when the expectant mother gets more
frequent and stronger contractions and is not able to talk during contractions, it means she has moved to the stage of active labor.

 Active labor: At this stage, the cervix of the expectant mother may open from 4 to 7 centimeters. This is the stage when the mother should be taken to the hospital. The contractions occur every 3 to 4
minutes and each of them lasts for about 60 seconds. These contractions show that the cervix is opening faster (about 1 centimeter per hour). As the labor progresses, the water may break causing a gush of
fluid. Once the water breaks, the contractions speed up. The expectant mother at this stage needs to relax. She can change positions, receive gentle massages or hot and cold compresses, walk slowly or sit
upright all of which will help. Relaxing in between the contractions is very important as it will help the cervix to widen. The expectant mother can also soak herself in a tub which will ease the discomfort.

 Transitioning to the second stage: The cervix at this stage opens from 7 to 10 cms. This is the most painful and stressful part of the labor for most women as the cervix widens up to its fullest. The
contractions occur every two to three minutes and last for up to 60 to 90 seconds. The mother at this stage may feel a strong urge to push because she feels the pressure in the rectal area and stinging in the
vaginal area, as the baby's head slowly moves down toward the vaginal opening. But she should not push at this stage and wait for her health caregiver to give the go-ahead to start pushing. The health
caregiver will give the signal once the cervix is fully dilated. The expectant mother may feel fatigued, irritated, nauseous and alternately hot or cold. Slow and relaxed breathing is highly effective during
this period.
2. Pushing & birth of the baby

Once the cervix completely widens or dilates the second stage of labor begins. The contractions at this stage continue to be strong, though they often come farther apart.
The frequent contractions help to push the baby down head first through the birth canal. The expectant mother’s health care provider may ask her to push with every contraction. The mother will feel an intense
pressure similar to the urge while undergoing a bowel movement.

The mother may feel highly irritated at this stage and may alternate between wanting to be touched/soothed or being left alone. She will be highly fatigued and may also feel nauseous. The intensity at the end of
the first stage of labor will continue in this pushing phase.

The mother may experience intense pain around the vagina and the surrounding pelvic areas as the baby's head protrudes through the vaginal opening. It is at this stage that the attending doctor may decide to
perform an episiotomy, i.e. an incision made in the area between the vagina and the rectum to widen the vaginal opening so that the baby can emerge smoothly if required. The mother may be asked to push gently
or slowly as the rest of your baby's head and body emerge, till the baby finally emerges into this world.

3. Delivering the placenta

After the birth of the baby, the contractions continue to push out the placenta, a process also known as the afterbirth. The delivery of the placenta can take from a few minutes to a half hour after the baby is born.

The healthcare provider may ask the mother to place the baby on her breast, as this stimulates uterine contractions. Alternatively, the healthcare attendant may gently massage the new mother’s abdomen to help
stimulate placental separation.

Most babies are ready to nurse a few minutes immediately after birth while others may take a little longer. Healthcare providers usually ask the mother to nurse the child as soon as possible after birth, provided the
mother is willing to breastfeed.

Nursing right after birth also helps the uterus to contract and so decrease the amount of bleeding.
What are the risks of normal vaginal delivery?

The risks a mother may face before and during the normal vaginal delivery include:

 rupture of the uterus

 fetal distress (for example reduced oxygen supply to the baby)
 vaginal tear
 tears in the perineum, i.e. the soft tissue between the vulva and the anus
 umbilical cord prolapsed which occurs when the cord comes out before the baby
 if the mother suffers from any infections, it may be passed on from the mother to the child
 the baby is emerging buttocks/feet first (breech position)
 the baby is emerging shoulder first
 there is more than one baby
 the size of the baby is big
 cephalopelvic disproportion (when a baby cannot fit through a pelvis due to the small size of the mother’s pelvis)
 undetected placenta previa, meaning the placenta covers the cervix

The risks a mother may face after a normal vaginal delivery include:

 damage to the pelvic floor due to which the woman may suffer from temporary or chronic pelvic pain
 pelvic organ prolapsed which occurs when the bladder, uterus and/or rectum protrude into the vagina or outside the vaginal opening
 retained placenta
 urinary leakage with sudden coughing, sneezing, or laughing post delivery
 postpartum hemorrhage
 anesthesia (if used) related complications

What to expect during the postpartum recovery period after a normal vaginal delivery?

After a normal delivery, you may face a few issues which will need some care such as:

 Vaginal discharge and bleeding: When bleeding, expect a heavy bright red flow for the first few days after the delivery as it happens during the monthly periods. It then slowly tapers off becoming pink
or brown or yellow or white. You need to immediately call your doctor if you have a fever or are bleeding too much and changing the sanitary pads every hour or you are passing big blood clots.

 Vaginal soreness: If you had a vaginal tear during delivery the wound may hurt for up to six weeks, though if the tearing was severe it could take more time than that to heal. While sitting down it can be
painful, so you can use a pillow or a doughnut cushion that helps you to sit down with any pressure on the perineum.
You can place an ice pad between the sanitary napkin and the wound which will provide some relief from the pain.
Make sure you take your painkillers and stool softeners so that as recommended by your doctor.
  Pain while urinating or having bowel movements: As the tissue around your bladder and urethra may be swollen or bruised, you may find it painful to urinate. Doing Kegel exercises during this period
with doctor’s advice will help. It will tone your pelvic muscles.
Further, you could also have constipation since you could be taking iron supplements which are prescribed by the doctor to get your blood count up. Make sure you take the stool softeners prescribed by
the doctor. Also, drink plenty of water, 8-10 glasses per day to make up for the dehydration breastfeeding may cause, and add high-fiber foods to your regular diet.
If you notice very painful bowel movements you may also have hemorrhoids. To get relief from hemorrhoidsyou can soak the lower part of your body in a tub of warm water. You may also be prescribed
some topical medication by the doctor to apply in the affected area.

 Contractions: Also known as after pains, contractions may occur for a few days immediately after delivery. These contractions are actually good in a way as it means your uterus is shrinking back into
size and the blood vessels are being compressed preventing excessive bleeding. Contractions can especially occur when you are nursing your baby.

 Hair loss: The rise in hormones during pregnancy keeps you from losing your hair. After childbirth, as the hormones return to normal levels it causes the hair to fall out and return to the normal hair fall
and growth cycle. The normal hair loss that was delayed during pregnancy may fall out all at once after delivery.

 Mood changes: After childbirth, it is normal for the new mother to undergo frequent mood changes such as irritation, frustration, anxiety etc. Many new moms also undergo what is known as postpartum
depression. If the depression deepens the mother may need prompt therapeutic help in the form of psychological counseling.

Medio lateral Episiotomy

In a Medio lateral episiotomy, the incision begins in the middle of the vaginal opening and extends down toward the buttocks at a 45-degree angle. The primary advantage of a mediolateral episiotomy is that the
risk for anal muscle tears is much lower. However, there is much more disadvantages associated with this type of episiotomy, including:

 increased blood loss

 more severe pain

 difficult repair

 higher risk of long-term discomfort, especially during sexual intercourse

 risk for infection

 BACKGROUND OF THE STUDY;
INTRODUCTION:

I. Demographic Data:
 Name – Edlyn
 Age – 20years’ old
 Birthplace – Digos, Pangasinan
 Birthday – 1999
 Civil Status – Common law
 Race/ Nationality – Filipino/English
 Religion – Roman Catholic
 Educational Background – College degree undergraduate
 Address – Pasig City
 Occupation of the Parents – N/A
 Usual Source of Income – N/A
 Admission Diagnosis – G1P0 PU 38, 1/7 weeks AOG by CIL
 Final Diagnosis – G1P1 (1001) PUFT CIL via NSD to a live baby boy AS 8|9 BW BL RMLE
 Date Admitted – October 28, 2019
 Time Admitted – N/A
 Height – 157 cm.
 Weight – 64 kg.
 Body Mass Index – 26.0 (above normal – Overweight) (normal 18.5-24.9 | overweight 25-29.9)
II. Information Source and Source of Information:
 All the information and itssources used are all based from the patient’s chart, Nursing Health History, Past/Present
Medical record, Physical assessment including the Vital Sign checking, Medications prescribed by the Physician and
Laboratory/ Clinical data.

III. Chief Complaint:

 Abdominal Pain scale of 9/10 at third trimester (38 weeks AOG).

IV. History of Present Illness (from the start of disease/illness) related to admitting diagnosis:
 The mother experienced episodes of Nausea and Vomiting, Abdominal Pain due to uterine contractions.

V. Past Medical History:

 General state of the health –Good
 Past illnesses – none
 Hospitalizations – prior to pregnancy check-ups
 Injuries/accidents – none
 Surgeries – none
 Immunizations – complete immunization
 Substance abuse – none
 Diet –none
  Sleeping pattern –3 to 4 hours
 Alternative therapy –N/A
 Obstetric/ gynecologic history – none (G1)
 Birth history (of the baby) – G1P1 (1001) PUFT CIL via NSD to alive baby boy AS 8|9 BW BL (RMLE
II)
 Growth and development (of the baby) – Temp: 38.3° 8:30-8:45 am (normalize 37.3° 9:00am), PR:
143bpm, HR: 55cpm, (+) UO and BM, F: NBS, BCG, MGH, Neonatal Jaundice (no exposure to
sunlight) October 28, 2019. || Wt. 3.0kg, Ht. 15.1 inches, HC: 33cm, CC: 35cm, AbdC: 30cm, MAC:
12cm, Apgar 8|9.

VI. Family History: Genogram (3rd generation):

XXX ggf YYY ggm

XX gf YY gm

Xf Ym

XY
  “X” represents the male side (father and grandfather).
 “Y” represents the female side (mother and grandmother); Y is the client.
 “XY” is the baby boy

 Only the client has the condition of NSD RMLE II

VII. Physical Health Assessment:

SKIN
CHARACTERISTICS: NORMAL FINDINGS: ACTUAL INTERPRETA
FINDINGS: TION:
Inspection:
GENERAL COLOR (+) Normal (+) Normal
Normal (-) Pallor (+) Pallor Mild Pallor,
Pallor (-) Jaundice (-) Jaundice Normal
Jaundice (-) Redness (-) Redness
Redness
MOISTURE
Moist (+) Moist (+) Moist Normal
Dry (-) Dryness
Wet/Clammy (-) Clammy skin
Oily (-) Oily skin
TEXTURE
Smooth (-) Scaly skin (+) generalized Normal
Scaly (-) Rough skin smooth skin
Rough
Palpation:
TEMPERATURE (+) Warm (+) Warm Normal
Warm (-) Cool
 Cool
TURGOR
Good (+) Good (+)Good skin turgor Normal
Fair
Poor
EDEMA
No edema (-) Edema (+) Edema Due to
Pitting increase fluid
Non pitting intake thru IV
Pedal R/L
Others:
Petechiae (-) Petechiae (-) Petechiae Normal
Ecchymosis (-) Ecchymosis (-) Ecchymosis
Lesions/ (-) Lesions (-) Lesions
Rashes (-) Rashes (-) Rashes

CONJUNCTIVA
Pinkish (+) Pinkish (+) Pinkish Normal
Pale (-)Pale palpebral
Lesion (-) Lesion conjunctiva
Discharge (-) Discharge
SCLERA
Anicteric (+) Anicteric (+) White, anicteric Normal
Sub icteric (-) Hemorrhages sclera
Icteric
Hemorrhages
CORNEA
Smooth (+) Smooth (+) Smooth and Normal
Clear (+) Clear clear with no
Lesions (-) Lesions opacity nor scratch
Opacity (-) Opacity
Arcus Senilis (-) Arcus Senilis
PUPILS (+) Equal in size,
Equal (+) Equal round and regular Normal
Unequal in shape.
 Diameter (R) 2-4 mm (light) Pupil is 4mm
Diameter (L) 4-8 mm (dark) constricting to
2mm
REACTION TO Pupil equally
ACCOMODATION reactive to light
Uniform (+) Uniform and Normal
Constriction constriction accommodation
Unequal
Constriction
CONVERGENCE (+) Uniform Pupil equally
Uniform convergence reactive to light Normal
Convergence and
Unequal accommodation
Convergence
VISUAL ACUITY
Grossly Normal (+) Grossly normal Can read signages Normal
Wears eye-glasses
Other findings: (+) Blink reflex Normal

NOSE
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
NASOLABIAL (+) Symmetrical (+) Symmetrical Normal
Symmetrical No nasal flaring
Shallow
nasolabial fold
L/R
SEPTUM
Midline (+) Midline (+) Midline Normal
Deviated to L/R (-) Deviation
Perforated (-) Perforation
MUCOSA
Pinkish (+) Pinkish (+) Pinkish nasal Normal
Pale (-) Pale mucosa, no
 Reddish (-) Reddish congestion
DISCHARGE
No discharge (-) Discharge No nasal discharge Normal
Serous
Mucoid
Purulent
Bloody
PATENCY
Both patent (+) Both patent Patent nares with
Obstructed L/R (-) Obstructed L/R good air entry
Masses/ Lesions (-)Masses/ Lesions
GROSS SMELL
Symmetrical (+) Symmetrical (+) Symmetrical Normal
Olfactory
Deficiency L/R
SINUSES No tenderness on
Non-tender Non-tender Frontal and Normal
Tender Maxillary sinuses
EARS
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
EAR PINNAE (+) Symmetrical (+) Symmetrical, Normal
Symmetrical (-) Abnormalities color same as skin,
Gross mobile, firm and
Abnormalities non-tender
EAR CANAL
Normal (+) Normal Left canal clear Normal
Impacted (-) Impacted cerumen Right canal clear
cerumen (-) discharge No discharge
Discharge
Foul smell
Mucoid
Serous
Purulent
GROSS HEARING Acuity good to
Symmetrical (+) Symmetrical whispered voice on Normal
Deafness on L/R (-) Deafness on L/R both L and R side
NECK MOUTH
CHARACTERISTICS: NORMAL ACTUAL INTERPRET
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA FINDINGS: FINDINGS: ATION:
FINDINGS: FINDINGS: TION: Inspection:
Inspection: LIPS
TRACHEA (+) Midline (+) Midline Normal Normal (+) Normal (-) Pallor Normal
Midline (-)Deviation to L/R Pallor (-) Pallor (+) dryness
Deviated to L/R Cyanosis (-) Cyanosis
Palpation: Dryness/ Crack (-) Dryness
CERVICAL LYMPH Non-palpable No cervical Normal Lesions (-) Lesions
NODES Non-Tender lymphadenopathy Swelling (-) Swelling
Non-palpable TONGUE
Palpable Midline (+) Midline (+) Midline Normal
Tender Deviation to L/R (-) Deviation
THYROID GLAND Atrophy (-) Atrophy
Non-palpable Non-palpable Non-palpable Normal Fasciculation (-) Fasciculation
Enlarged Lesions (-) Lesions
RANGE OF MOTION TEETH
Normal (+) Normal Supple, Erect, No Normal Complete (+) Complete (+) Complete Normal
Neck Rigidity (-) Neck rigidity neck rigidity Missing Teeth (-) Missing teeth (-) Missing teeth
Others: Caries (-) Caries (-) Caries
Masses (-) Masses No mass noted no Normal Dentures
Neck vein (-) Neck vein neck vein Braces/ Retainers
engorgement engorgement engorgement GUMS
Pinkish (+) Pinkish (+) Pinkish Normal
Pale
BREAST AND AXILLA Bleeding
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA Tenderness
FINDINGS: FINDINGS: TION: BUCCAL MUCOSA
Inspection: Equally pendulous Pinkish (+) Pinkish Pinkish buccal
SIZE AND SYMMETRY (+) Equal extending from 2nd Normal Pale mucosa Normal
Equal rib down to the 6th Cyanotic
Unequal rib. Stenson’s Duct
SKIN SPEECH Normal
Normal Redness (+) Normal (+) Normal Normal Intact (+) intact (+) Intact
Venous Slurred
prominence Aphasia
 Edema
CONTOUR
Normal (+) Normal (+) Normal Normal
Masses (-) Masses
Dimpling (-) Dimpling
NIPPLE AND AREOLA
Normal (+) Normal Nipples and areola Normal
Inversion are dark
Flattening or
Retraction
Edema
Discharge
Deviation

LUNGS
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
BREATHING (+) Effortless (+) Effortless Normal
PATTERN (-) Hyperventilation
Effortless (-)Use of accessory
(Eupnea) muscles
Hyperventilation
Use of accessory
muscles
SHAPE OF CHEST
Anterior- Normal Normal Normal
Posterior-Lateral
Ratio
AP___L____
Barrel Chest
Funnel
Pigeon
Other
CHEST EXPANSION (+)
Symmetrical (+) Symmetrical Symmetricallung Normal
 Decreased L/R expansion
Percussion:
Resonant (+) Resonant (+) Resonant Normal
Dullness
Hyperresonant
Tympany
Flatness
Vocal/Tactile
Symmetrical (+) Symmetrical (+) Symmetrical Normal
Decreased/
Increased
Breath Sounds
Normal (+) Normal (+) Normal Normal
Abnormal (+) Vesicular (+) Vesicular
Bronchovesicular
Vesicular
Bronchial
Wheezes
Rhonchi
Rales
Pleural Friction
HEART
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
PERICORDIAL AREA (+) Adynamic Adynamic Normal;
Flat precordium precordium; No
Normodynamic (-) Bulging heave, no thrills.
Precordial (-) Tenderness PMI: 5th Intercostal
Hyperdynamic (-) Heave Space (ICS) on the
Precordial (-) Thrill left mid-clavicular
Bulging line
Tenderness
Heave
Thrill
Point of Maximal
Impulse (PMI)
 Apical Beat (AB)
Auscultation:
HEART SOUNDS (+) Distinct heart S1 louder than S2 Normal
Distinct sounds at the apex
Faint S2 louder than S1
S1S2 at base at the base
S1S2 at apex
EXTRA SOUNDS
S3 Normal
S4
Murmur, grade
Best heard at

ABDOMEN
CHARACTERISTICS: NORMAL ACTUAL INTERPRETATI
FINDINGS: FINDINGS: ON:
Inspection:
SKIN
Normal (+) Normal Normal skin with Normal
Dilated vein (-) Dilated veins linea nigra
Scars
Rashes
Striae
Lesion
CONFIGURATION
Flat Normal
Globular
Protr

UMBILICUS
Normal/ Sunken (+) Normal (+) Normal
Bulging Normal/Sunken
Hernia
Palpation:
Normal (+) Normal Flabby, no muscle Normal
Muscle guarding (-) Muscle guarding guarding, Non-
 Direct tenderness (-) Tenderness tender
Rebound
tenderness BACK AND EXTREMITIES
Percussion: CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
Resonant (+) Tympanitic (+) Tympanic Normal FINDINGS: FINDINGS: TION:
Tympanic PERIPHERAL PULSES
Hypertympanic Inspection: (+) Symmetrical Present, Normal
Fluid wave Symmetrical Symmetrical
Shifting dullness Absent
Auscultation: Palpation:
BRUIT (-) Absent (-) Absent Normal Normal Normal
Present Warm
Absent Bounding
BOWEL SOUNDS
Normoactive (+) Normoactive (+) Normoactive Normal
Hyperactive
Hypoactive
Absent

GENITOURINARY
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
LABIA (+) Symmetrical Patient refused Normal
Normal (+) Pinkish genital examination
Symmetrical No discoloration
Asymmetrical
Lesion
Pinkish
Discoloration
Edema
VAGINAL ORIFICE
Normal (+) Normal Patient refused Normal
Discharge (-) Discharge genital examination
Purulent
Bloody
 Foul smelling
INGUINAL
Normal size (+) Normal size Patient refused Normal
Enlarged genital examination
BARTHOLINS GLAND
Normal (+) Normal Patient refused Normal
Swelling genital examination
Discharge
Tenderness
VIII.Gordon’s Functional Pattern (at least 1 month of pre diagnose, underlying cause of current case):

A. Health Perception and Health Management Pattern

Before Confinement During Confinement Nursing Diagnosis
The client’s perception about stages of pregnancy is The prescriptions of the doctor are the priority to Readiness for enhancement, therapeutic regimen
based only on her own and with her family’s idea. use than the herbal medicines. management.

B. Nutritional-Metabolic Pattern
Before Confinement During Confinement Nursing Diagnosis
Normal Diet DAT ordered. Readiness for enhanced nutrition.

C. Elimination Pattern
Before Confinement During Confinement Nursing Diagnosis
Normal elimination. Discomfort in urination. Functional urinary incontinence.

D. Activity-Exercise Pattern
Before Confinement During Confinement Nursing Diagnosis
Normal ROM in doing household chores. Limited ROM, unstable walking and standing, Activity intolerance.
using rails as support.
E. Sleep-Rest Pattern
Before Confinement During Confinement Nursing Diagnosis
6-7 hours regular sleep per day. 3 to 4 hours sleep per day. Disturbed sleep pattern.

F. Cognitive-Perceptual Pattern
Before Confinement During Confinement Nursing Diagnosis
Normal cognition and perception about pregnancy. Normal cognition and perception about NSD Readiness for enhanced knowledge
RMLE II.

G. Self-Perception Self-Concept Pattern

Before Confinement During Confinement Nursing Diagnosis
G1P0 381/7 AOG CIL. G1P1 (1001) PUFT CIL via NSD to a live baby Readiness for enhanced self-concept (from
boy AS 8|9 BW BL (RMLE II). pregnancy up to postnatal care).

H. Role Relationship Pattern

Before Confinement During Confinement Nursing Diagnosis
Seeking help to the mother all the time. Acts Independently only with her partner Readiness for enhanced family process.
I. Sexuality-Reproductive Pattern
Before Confinement During Confinement Nursing Diagnosis
Normal sexual relationship with the partner. Satisfied sexual relationship on both parties. Effective sexuality pattern.

J. Coping-Stress Tolerance Pattern

Before Confinement During Confinement Nursing Diagnosis
The stress-reliever of the client is her leisure such The client’s stress-reliever upon confinement is her Effective coping stress.
as using cellphone gadgets. partner/

K. Value-Belief Pattern
Before Confinement During Confinement Nursing Diagnosis
Prayers before meals and before bedtime sleep.. Prayers using Rosary and bible in the bed. Readiness for enhanced spiritual well-being.
Use prescript drugs by the attending physician.
IX. Anatomy and Physiology: (Normal function only):
 X. Pathophysiology: (Theoretical based/ Client based)
Diagram form:

LEGEND: rectangle – stage title

 XI. Laboratory/ Diagnostic Result: normal values and significance:

HEMATOLOGY

Complete Blood Count

Examination 09/17 09/18 09/19 09/20 Units Normal
Hemoglobin 77 90 98 117 g/L 135 – 180
Hematocrit 0.24 0.29 0.32 0.34 % 40 – 54
RBC Count --- --- --- 3.97 x1012/L 4.5 – 6.0
Platelet 354 --- 130 479 x109/L 150 – 400
Count
WBC Count 17.7 --- 7.6 20.9 x109/L 4.5 – 11.0
Band Cells --- --- --- --- --- 0.00 –
0.05
Neutrophils 0.89 --- 0.53 0.45 0.83 0.35 –
0.65
Lymphocytes 0.05 --- 0.37 0.46 0.13 0.20 –
0.40
Monocytes 0.04 --- 0.05 --- --- 0.02 –
0.08
Eosinophils 0.01 --- 0.05 0.09 --- 0.00 –
0.05
Basophils --- --- --- --- --- 0.00 –
0.01

 Hematocrit is decreased in severe anemias, anemia of pregnancy, acute massive blood loss
 Hemoglobin is decreased in various anemias, pregnancy, severe or prolonged hemorrhage and with excessive fluid intake
 Platelet count is increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperatively; about 50% of patients with unexpected increase of platelet count will be
found to have a malignancy; decreased in thrombocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy.
 WBC Count is increased in patients that have infections
 High neutrophils and low lymphocyte count signifies bacterial infection
 Generic Brand Classifications Indication Contraindication Mode Of Action Actual Dose Usual Dose Side effects Nursing Responsibilities
Name Name

Metronid Flagyl Antibiotic  Acute  Active organic Inhibits growth of 125mg/5mL, 35- Headache,  Observe the 10 Rs before
azole infection disease of the amoebae by binding 50mg/kg/day in Nausea, dry giving the drug.
Antibacterial 2.5mL every 8
with CNS to DNA, resulting in three doses mouth, vomiting,  Instruct to take drug with
hours
Amebicide susceptible  Drug Allergy loss of helical diarrhea food or milk to decrease
anaerobic  Blood dyscrasia structure, strand GI upset
Antiprotozoal bacteria breakage, inhibition  Inform that drug may turn
 Acute of nucleic acid urine brown, don’t be
intestinal synthesis and cell alarmed
amoebiasis death.

Indication: Contraindicated:
Second-generation Body as a Whole:
7.5 grams IV/IM  Report onset of loose
CEFUROX Pharyngitis, * Contraindicated in cephalosporin that 1 tab 500 mg
ZOLTAX ANTIBIOTIC q8hrs Thrombophlebitis (IV stools
IME tonsillitis, patients inhibits cell-wall
site); pain,
infections of the hypersensitive to synthesis, promoting
burning, cellulitis  Absorption of
urinary and drug osmotic instability;
(IM site); cefuroxime is
lower usually bactericidal. enhanced by food.
* Use with caution superinfections,
respiratory tracts
in breast-feeding positive
women and in Coombs'test.  Notify prescriber about
patients with history rashes or
of colitis or renal superinfections
sufficiency.
XII. Problem Lists (actual problem at least 2) (potential problem):

Problem (prioritization) Problem Date Identified Date Resolved

Top 1 Abdominal Pain October 28, 2019

Top 2 Risk for infection related to October 28, 2019

RMLE II

Top 3 Post-Partum Hemorrhage October 28, 2019

XIV. Nursing Care Plan:
Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective: .
AD: G1P0 AOG CIL
FD: G1P1 (1001) PUFT CIL via NSD
to alive baby boy AS 8|9 BW BL
RMLE II
Laboratory:
Hgb: (L) 117
Hct: (L) 0.34
RBC: (H) 3.97
WBC: (H) 20.9
Medicine:
Cepuroxime: 1.5g, 1 dose750 mg.x
3dose for antibacterial infection
Metranidazole: 500mg IV: LD 500mg
every 8hrs x 3dose for antiprotozoal
infection
Ferous Sulfate: to prevent low-blood
level of iron caused by pregnancy
Tranidole + Paracetamol: 1 tab very
6hrs PRN to treat moderate to severe
abdominal pain
-Pale skin, dry lips, unstable walking,
with edema on both feet, with socks,
abdominal pain, Nausea and Vomiting.

Subjective:
Abdominal Pain upon the third
trimester.