Nursing Case Study

2200 OB Ward











Submitted By: Liana Monique San Lorenzo
BSN3-2; RLE Group 2
Submitted to: Ms. Vicencio



October 15, 2013
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NURSING CASE STUDY
ADMISSION DIAGNOSIS:
G2P1 (1001) Pregnancy, Uterine,Term, Cephalic
FINAL DIAGNOSIS:
G2P2 (2002) Pregnancy, Uterine,Term, Cephalic Delivered, Live birth by VSD with right
mediolateral episiotomy and repair

I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1. Clients initials: H. H. M.
2. Gender (Sex): Female
3. Age, Birthdate and Birthplace: 30 y/o, May 11, 1983, Trece Martires City
4. Marital (Civil) Status: Married
5. Race and Nationality: Filipino
6. Religion: Baptist
7. Address and Telephone Number: B41 L40 Pontevedra Tiera Solana,
Buenavista 3, General Trias, Cavite
8. Educational Background: College Graduate
9. Occupation (usual and present): Japanese Interpreter
10. Usual Source of Medical Care: Clinic Physician


B. SOURCE AND RELIABILITY OF INFORMATION
The patient was competent to provide information. She was able to speak clearly
and was conscious, coherent and conversant. The patients chart was also used as a
secondary source of information.

C. CHIEF COMPLAINTS
Biglang sumakit ung tiyan ko.
humihilab na ung pakiramdam ng tyan ko.
Ka-buwanan ko na kasi.
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D. HISTORY OF PRESENT HEALTH
1 week prior to admission, the patient was expecting birth so she had already prepared
all the needed things including money for her delivery.
On the day of the admission, the patient experienced pain in her abdominal region and
started having contractions. She then immediately decided to go to the hospital because
her pregnancy is already in term and she knew she was about to start labor.


E. PAST MEDICAL HISTORY OR PAST HEALTH
The patient has complete immunization. She said she barely gets sick. She recalled that
she had mumps and chickenpox when she was young, and some occasional fever. Last
2009, the patient was hospitalized because of UTI. The patients menarche started
when she was 12 years old, the cycle was regular. Her LMP was on January 23, 2013.
8 Months before admission, the patient had discovered that she is pregnant. The patient
started to suspect that shes pregnant because of several episodes of morning
sickness, she took a pregnancy test and got a positive result and went to her OB-Gyne
to confirm it. She followed her check-up schedules and her doctors health teachings to
have a normal pregnancy.

4 months before the admission, the patient went for an ultrasound and she discovered
that her baby was a girl. She said her current pregnancy was easier than the first. The
patient was taking Ferrous sulfate and Iron supplements as prescribed by her physician.
The patient also did not acquire any sickness during her pregnancy, even fever. Her last
check-up was on September 23, 2013, when she was at 38 weeks AOG which revealed
normal findings.











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F. FAMILY HISTORY (Family tree or genogram)

Paternal Maternal





















Legend:
UA - Unrecalled age
UCD - Unrecalled cause of death
A & W- Alive and Well
- Male - Deceased
- Female - Deceased
- Client

Synthesis:
The genogram presented in the previous page shows three generation of the
patients family. Based on the genogram, the clients family has a history of endocrine
disorders such as Diabetes Mellitus which she can acquire due to genetics. Other
diseases could be inherited due to the uncertainty in the cause of death of her
grandparents.
UA
UCD


UA
UCD
UA
UCD
UA
UCD
60
DM
57
A & W
40
A & W
37
A & W
30
A & W
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The said diseases could be prevented by modification of lifestyle and proper
exercise.

G. SOCIO-ECONOMIC
FAMILY MEMBER /
RELATIONSHIP TO
PATIENT
OCCUPATION /
SOURCE OF INCOME

MONTHLY INCOME
H. H. M.
(Patient)
K. H. M.
(Son)
M. B. H
(Brother).
Japanese Interpreter

N/A

Office Worker
12,000 / Month

N/A

10,000 / Month


The clients family is an extended type. Her husband is a seaman and he is
already 6 months away from home. The salary of her husband was not disclosed. The
patient has been working as a Japanese Interpreter for 17 Years and says that her pay
is enough for her familys needs. Her brother also lives with them and helps in paying
the bills.
H. DEVELOPMENTAL HISTORY
Patient's Age: 30 years old
Developmental Stage: Young Adulthood
Developmental Task: Intimacy vs. Isolation


Relationships are important to person included in the young adults age group. It is the
time where they want to start a family, have lasting friends and a strong family
relationship. Young adults need to form intimate, loving relationships with other people
to make them feel successful and on track. Success leads to strong relationships, while
failure results in loneliness and isolation.

As for the patients case, the patient has a loving husband, whom she loves as well and
she says that she still feels butterflies kinikilig due to her husband. She said that she
was lucky and she loves her son and her soon to be daughter so much. She said she
was also contented with her family and friends.



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I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION
1. ROS AND PE
Date of Examination: ________October 2, 2013___ ______
PHYSICAL SYSTEMS R.O.S. P.E.






a. General/Overall Health Status



Okay naman ako.
Vital signs:
BP: 130/80
Pulse: 88
RR: 21
Temp: 67.7
o
C

Feels and looks
relaxed; cooperative
and purposeful
Speech is in moderate
tone
Client appears to be
her stated chronologic
age
With ongoing D5LR 1L
to run for 8 hours.
inserted at left
metacarpal vein,
infusing well





b. Integument


Wala naman akong
rashes.

Meron akong stretch
marks.
SKIN
Inspection:
Skin is fair in
complexion
(-) rashes on all skin
area
(-) flushing
Moist skin
(-) Edema
Palpation:
skin is warm to touch
Good skin turgor

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HAIR
Inspection:
Shiny Hair
With evenly distributed
hair along the scalp
Good hair distribution
Palpation:
Smooth and silky to
touch

NAILS
Inspection:
Fingernails and toe
nails are clean and
trimmed
Pinkish nails

Palpation:
Nails form 160 angle
at base, hard, smooth
and immobile
(+) smooth cuticles
With good capillary
refill of 2 seconds

c. Head
Hindi naman masakit
ang ulo ko.
Inspection:
Head is round and
symmetrical;
appropriate to the size
of the body
(-) lesions on the scalp
Face is oval and
symmetric
Normocephalic


Palpation:
Smooth and hard skull
Good ROM of TMJ
(-) lumps, masses and
tenderness
(-) head depressions or
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elevations

d. Eyes Hindi naman Malabo
ang mga mata ko.

Inspection:
Visual fields intact
Symmetrical blinking
Conjunctiva and sclera
appear moist and
smooth
(+) PERRLA
No discharges

Palpation:
No drainage noted
when nasolacrimal
duct is palpated
e. Ears Wala ako problema
sa pandinig.
Inspection:
Equal in size bilaterally
Auricles aligned with
the corner of each eye
within a 10-degree
angle of vertical
position
No discharges

Palpation:
Skin smooth
(+) firm cartilages
Recoils easily when
folded
No tophi
No tenderness upon
palpation

f. Nose and Sinuses

Wala naman akong
sipon.
Inspection:
Nose is smooth and
symmetric
Nose has same color
as the face
Client was able to
identify odors
presented (orange and
perfume)
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(+) red glow; frontal
and maxillary sinuses
transilluminate
(-) lesions
(-) epistaxis
(-) nasal flaring
(-) nasal discharge

Palpation:
(-) nasal tenderness

Percussion:
(+) hollow tone on
sinuses

g. Mouth and Throat Wala akong ubo. Inspection:
Lips are pink, smooth
and moist without lesion
or swelling
Buccal mucosa appears
pink, and moist without
exudates
Complete teeth
Gums are pinkish
without redness or
swelling
Tongue is pink with and
moist
Tongue hasno swelling
and lesions
Frenulum in the midline
with visible veins
Midline and symmetric
elevation of the uvula
and soft palate with
phonation
(-) tonsillitis

h. Neck Hindi naman masakit
kapag ginagalaw ko.
Inspection:
No lesions
No enlargement of
lymph nodes.
Full ROM
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Palpation:
Palpable thyroid gland,
goes up when
swallowing
No swelling and
tenderness.

i. Breast and Axillary Okay lang naman. Inspection:
Breast skin pale pink
with pink areola
Prominent Montgomery
tubercles
Nipples everted
bilaterally
Hyperpigmented
nipples and areola
(+)Excretion of
colostrum

Palpation:
No masses or
tenderness palpated
j. Respiratory Hindi naman ako
kinakapos sa hininga.
Inspection:
Chest expansion
symmetric
Scapula are symmetric
and prominent
Sternum in midline and
level with ribs
Palpation:
(-) tenderness
(-) masses

Percussion:
Resonant

Auscultation:
No adventitious sounds
present
Lung sounds are clear
on both lung fields.
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k. Cardiovascular okay naman. Inspection:
(-) jugular vein
distention and non-
visible
(-) varicose veins on
both legs near popliteal
area
(-) abnormal
discoloration of the
palms and soles of the
feet

Palpation:
Carotid pulse equal
bilaterally, 3+
PR = 88 bpm, 3+
BP = 130/80 mm Hg
(+) apical pulse felt at
5
th
ICS LMCL
With good capillary bed
refill of 2 seconds
3+ radial pulses and in
other sites are easy to
palpate

Auscultation:
Heart sound are
rhythmic, regular
beating
Apical heart rate = 85
beats/min, regular rate
and rhythm
(-) extra heart sounds
No splitting of heart
sound, snaps, clicks or
murmurs noted
l. Gastrointestinal medyo masakit ung
tyan ko. Pero kaya ko
pa.
Inspection:
(-) lesions on the
abdominal area
(-) rashes
(-) abdominal
discoloration
Abdomen is globular,
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smooth, no lesion and
no scar noted
Umbilicus in midline
(+) Striae
(+) Linea nigra


Palpation:
No tenderness in any
quadrant
Engaged fetal position

m. Urinary Wala namang nasakit
pag naihi.
Inspection:
Amber colored urine,
clear
(-) hematuria
(-) dysuria
n. Genitalia Wala namang akong
problema.
Patient refused
o. Musculoskeletal

wala naman akong
problema sa pag
galaw ko.
Inspection:
Full ROM of TMJ with
no pain, tenderness,
clicking or crepitus
Patient is ambulatory
Full ROM on
extremities
p. Neurologic Kung minsan
nakakalimot pero
naalala ko rin
Inspection:
Patient is alert and
awake throughout the
course of interview;
relaxed, cooperative
and purposeful;
oriented to time, place
and person
(+) good eye contact

Cranial nerves:
CN I identifies correct
scents
CN II Clear vision
CN III Pupils constrict
to light
CN IV Eyes can
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move freely and
coordinately
CN V full TMJ ROM
CN VI Good bilateral
eye movement
CN VII able to smile,
frown, wrinkle
forehead, show teeth,
puff out cheeks, purse
lips, raise eyebrows
and close eyes against
resistance
CN VIII able to hear
whispers
CN IX no difficulty in
swallowing
CN X (+) Gag reflex
CN XI can shrug his
shoulders against
resistance
CN XII Tongue
moves easily

Performs repetitive
alternating movements
of finger-to-nose at
smooth, good pace
Sensory system:
identifies light touch,
dull and sharp
sensations to forearm
Stereognosis and
graphestesia intact
q. Hematologic Di naman ako pasain Inspection:
Nopresence of
hematomas
r. Endocrine
Di naman ako
pawisin
Inspection:
(-) tremors
(-) ABN hair distribution
(-) diaphoresis
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2. LABORATORY STUDIES/DIAGNOSTICS





3. OTHER ASSESSMENT TOOLS (Scale, Sheet, Grade, Level, etc.)
Date (s) taken Comprehensive Actual
Content/Legend
Actual Result
August 13, 2013
Functional Level Code

Level 0 Full Self Care
Level 1 requires use of
requirements or device
Level 2 requires assistance or
supervision from another person
Level 3- requires assistance or
supervision from another person
or device
Level 4 Is dependent and does
not participate
Feeding Level 0
Bathing Level 0
Toileting Level 0
Bed Mobility Level 0
Dressing Level 0
Grooming Level 0
General Mobility Level 0
Cooking Level 0
Home Maintenance Level 0
Shopping Level 0
The patient was graded as
Level 0 in Functional Level
Code since she can take care
of herself fully prior to
Procedure / Date Indication
Normal Values/
Findings
Actual
Findings
Nursing
Responsibilities/
Implications (Pre, Intra,
Post)

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hospitalization.

J . FUNCTIONAL ASSESMENT (including ADL)
1. Health-Perception-Health Management Pattern
The patient has a good image of her health. She says that she takes care of her
body to be able to work efficiently, and to be able to take care of her son and her future
baby. She makes sure that she eats good food and does every measures needed to
gain a healthy body.
2. Self-esteem, Self concept/Self-perception Pattern
The patient said that she is contented with who she is. She doesnt want to
change anything about herself because she is okay with how she looks like. Though
she said she feels uneasy because she has gained weight in the course of her
pregnancy, she said that she could just burn the excess fats off, and has full confidence
on herself.
3. Activity Rest Pattern
The said that most of her usual activities for the last 9 months are walking around
her village early in the morning she said that it helps her prepare herself for her labor.
During her free time, she reads books about pregnancy and home and living
magazines. She alkso likes watching television shows like Americas Next Top Model
and Arrow.
4. Sleep/Rest Pattern
patient said that she sleeps around 9 pm wakes up around 4:30 pm because she
works in Carmona. She said that even though sometimes she couldnot get an 8 hour
sleep, she said that she feels relaxed and refreshed upon waking up.

5. Nutritional/Elimination
The patient said that she loves vegetables more than meat. She hates fatty meat
and like to buy lean meat from the market. She said that she eats various food during
the course of her pregnancy and has a liking in eating fresh oranges.
The patient has no bowel problems. She says that she is not constipated and she
said that she makes sure that she eats foods high in fiber to keep her colons clean.
Also, there is no problem in the patents urination. She said that her urine is mostly
Page | 15

yellow and clear and no pain is present during urination. She says that she always
drinklots of water because she learned her lesson when she got UTI last 2009.

6. Sexuality and Reproductive Pattern
According to the patient, she is not using any family planning method thats why she
got pregnant. Her menstruation started when she was 12 years old and she said that
she often gets dysmenorrhea. Her LMP was last January 23, 2013. She said that after
her delivery, she would then go to her doctor and ask which birth control method suits
her best, but she said that she prefers oral contraceptives.

7. Interpersonal Relationship
The patient verbalized that she was happy with the relationships she has made. May
it be with her friends or with her close family. She said that she is mostly a happy
person and likes a good laugh. She said that she likes hanging out with her friends,
eating out with her family and likes bonding moments. She also has no problems with
her neighbors and she feels relieved that her neighbors and her are all friends so there
is no conflict.
8. Personal Habits
The client said that she has never smoked but drinks alcohol at parties, when she is
not pregnant. She said that she never even have thought of using illegal drugs and she
said that she values her health too much to engage in those kind of vices.
9. Coping and Stress Management
The patient said that she is the type of person who likes to express her feelings and
vent things out when she is in trouble or sad. Although she also said that it all depends
on the situation. She said that if other people could not help her even if they listen to her
problems, she would then keep the problem to herself; and if the problem is needed to
be said, then she will.
7. Environmental Hazards
The patient said that the place she lives in is safe, has a low crime rate, and are very
much accessible. She resides in a subdivision so there are very few cars passing the
streets. Her only problem was the noise from her neighbors when they use the karaoke.


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II. PROBLEM LIST

A. ACTUAL or ACTIVE
Problem No. Problem Date Identified
Date
Resolved/Remarks

1






2






Impaired Comfort






Anxiety related to
stress of labor





Oct 2, 2013






Oct 2, 2013



Oct 2, 2013
Patients pain was
addressed. But the
pain was only
natural because the
patient is in labor.


Oct 2, 2013
-The patient said
that she somehow
feels scared of what
may happen but she
said that she has full
trust with the
hospital staff.

B. HIGH RISK or POTENTIAL

Problem No. Problem Date Identified
1



2
Risk for Ineffective
breathing pattern related
to breathing exercises
Risk for fluid volume
deficit related to decrease
Oct 2, 2013


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in oral fluid intake and
increase in diaphoresis
during labor.

Oct 2, 2013
























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IV. ANATOMY AND PHYSIOLOGY
REPRODUCTIVE SYSTEM
The female reproductive system is designed to carry out several functions. It produces
the female egg cells necessary for reproduction, called the ova or oocytes. The system
is designed to transport the ova to the site of fertilization.Conception, the fertilization of
an egg by a sperm, normally occurs in the fallopian tubes. The next step for the
fertilized egg is to implant into the walls of the uterus, beginning the initial stages
of pregnancy. If fertilization and/or implantation does not take place, the system is
designed to menstruate (the monthly shedding of the uterine lining). In addition, the
female reproductive system produces female sex hormones that maintain the
reproductive cycle.
The female reproductive anatomy includes parts inside and outside the body.

EXTERNAL
The function of the external female reproductive
structures (the genitals) is twofold: To enable
sperm to enter the body and to protect the
internal genital organs from infectious
organisms. The main external structures of the
female reproductive system include:
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.
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.
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INTERNAL
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
adeveloping 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.
THE MENSTRUAL CYCLE
Females of reproductive age
experience cycles of hormonal
activity that repeat at about one-
month intervals. With every cycle,
a woman's body prepares for a
potential pregnancy, whether or
not that is the woman's intention.
The term menstruation refers to
the periodic shedding of the
uterine lining. (Menstru means
"monthly.'')
The average menstrual cycle
takes about 28 days and occurs in pha ses: the follicular phase, the ovulatory phase
(ovulation), and the luteal phase.
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There are four major hormones (chemicals that stimulate or regulate the activity of cells
or organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing
hormone, estrogen, and progesterone.
Follicular Phase of the Menstrual Cycle
This phase starts on the first day of your period. During the follicular phase of the
menstrual cycle, the following events occur:
Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH), are
released from the brain and travel in the blood to the ovaries.
The hormones stimulate the growth of about 15 to 20 eggs in the ovaries, each in its
own "shell," called a follicle.
These hormones (FSH and LH) also trigger an increase in the production of the female
hormone estrogen.
As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating
hormone. This careful balance of hormones allows the body to limit the number of
follicles that mature.
As the follicular phase progresses, one follicle in one ovary becomes dominant and
continues to mature. This dominant follicle suppresses all of the other follicles in the
group. As a result, they stop growing and die. The dominant follicle continues to
produce estrogen.
Ovulatory Phase of the Menstrual Cycle
The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started.
The ovulatory phase is the midpoint of the menstrual cycle, with the next menstrual
period starting about two weeks later. During this phase, the following events occur:
The rise in estrogen from the dominant follicle triggers a surge in the amount of
luteinizing hormone that is produced by the brain.
This causes the dominant follicle to release its egg from the ovary.
As the egg is released (a process called ovulation), it is captured by finger-like
projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into
the tube.
Also during this phase, there is an increase in the amount and thickness of mucus
produced by the cervix (lower part of the uterus). If a woman were to have intercourse
during this time, the thick mucus captures the man's sperm, nourishes it, and helps it to
move towards the egg for fertilization.
Luteal Phase of the Menstrual Cycle
Page | 24

The luteal phase of the menstrual cycle begins right after ovulation and involves the
following processes:
Once it releases its egg, the empty follicle develops into a new structure called the
corpus luteum.
The corpus luteum secretes the hormone progesterone. Progesterone prepares the
uterus for a fertilized egg to implant.
If intercourse has taken place and a man's sperm has fertilized the egg (a process
called conception), the fertilized egg (embryo) will travel through the fallopian tube to
implant in the uterus. The woman is now considered pregnant.
If the egg is not fertilized, it passes through the uterus. Not needed to support a
pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual
period begins.
How Many Eggs Does a Woman Have?
The vast majority of the eggs within the ovaries steadily die, until they are depleted at
menopause. At birth, there are approximately 1 million eggs; and by the time of puberty,
only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's
reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use
of birth control pills, and in the presence or absence of regular menstrual cycles.

THE FETAL DEVELOPMENT
First trimester (week 1-week 12)

At four weeks:
baby's brain and spinal cord have begun to form.
The heart begins to form.
Arm and leg buds appear.
baby is now an embryo and one-twenty-fifth inch long.
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At eight weeks:
All major organs and external body structures have
begun to form.
Baby's heart beats with a regular rhythm.
The arms and legs grow longer, and fingers and toes
have begun to form.
The sex organs begin to form.
The eyes have moved forward on the face and eyelids
have formed.
The umbilical cord is clearly visible.
At the end of eight weeks, the baby is a fetus and looks
more like a human. It is nearly 1 inch long and weighs
less than one-eighth ounce.

At 12 weeks:
The nerves and muscles begin to work together. The
baby can make a fist.
The external sex organs show if the baby is a boy or girl.
A woman who has an ultrasound in the second trimester
or later might be able to find out the baby's sex.
Eyelids close to protect the developing eyes. They will
not open again until the 28th week.
Head growth has slowed, and the baby is much longer.
Now, at about 3 inches long, the baby weighs almost an
ounce.
Second trimester (week 13-week 28)
Page | 26


At 16 weeks:
Muscle tissue and bone continue to form, creating a
more complete skeleton.
Skin begins to form. You can nearly see through it.
Meconium (mih-KOH-nee-uhm) develops in the baby's
intestinal tract. This will be the baby's first bowel
movement.
The baby makes sucking motions with the mouth
(sucking reflex).
The baby reaches a length of about 4 to 5 inches and
weighs almost 3 ounces.

At 20 weeks:
The baby is more active. The mother might feel slight
fluttering.
The baby is covered by fine, downy hair called lanugo
(luh-NOO-goh) and a waxy coating called vernix. This
protects the forming skin underneath.
Eyebrows, eyelashes, fingernails, and toenails have
formed. The baby can even scratch itself.
Your baby can hear and swallow.
Now halfway through the mothers pregnancy, the baby
is about 6 inches long and weighs about 9 ounces.
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At 24 weeks:
Bone marrow begins to make blood cells.
Taste buds form on the baby's tongue.
Footprints and fingerprints have formed.
Real hair begins to grow on the baby's head.
The lungs are formed, but do not work.
The hand and startle reflex develop.
The baby sleeps and wakes regularly.
If the baby is a boy, his testicles begin to move from the
abdomen into the scrotum. If the baby is a girl, her uterus
and ovaries are in place, and a lifetime supply of eggs
have formed in the ovaries.
The baby stores fat and has gained quite a bit of weight.
Now at about 12 inches long, the baby weighs about 1
pounds.
Third trimester (week 29-week 40)

At 32 weeks:
The baby's bones are fully formed, but still soft.
The baby's kicks and jabs are forceful.
The eyes can open and close and sense changes in
light.
Lungs are not fully formed, but practice "breathing"
movements occur.
The baby's body begins to store vital minerals, such as
iron and calcium.
Lanugo begins to fall off.
The baby is gaining weight quickly, about one-half pound
a week. Now, the baby is about 15 to 17 inches long and
weighs about 4 to 4 pounds.
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At 36 weeks:
The protective waxy coating called vernix gets thicker.
Body fat increases. The baby is getting bigger and bigger
and has less space to move around. Movements are less
forceful, but the mothar can will feel stretches and
wiggles.
The baby is about 16 to 19 inches long and weighs about
6 to 6 pounds.

Weeks 37-40:
By the end of 37 weeks, The baby is considered full
term. The baby's organs are ready to function on their
own.
As the mother nears due date, the baby may turn into a
head-down position for birth. Most babies "present" head
down; At birth, the baby may weigh somewhere between
6 pounds 2 ounces and 9 pounds 2 ounces and be 19 to
21 inches long. Most full-term babies fall within these
ranges. But healthy babies come in many different sizes.
CHANGES THAT OCCURS IN THE MOTHER
Pregnancy is associated with normal physiological changes that assist fetal survival as
well as preparation for labour. It is important to know what 'normal' parameters of
change are in order to diagnose and manage common medical problems of pregnancy,
such as hypertension, gestational diabetes, anaemia and hyperthyroidism.

Pituitary
FSH/LH fall to low levels.
ACTH and melanocyte-stimulating hormone increase.
Prolactin increases.


Thyroid and parathyroid
Thyroxine-binding globulin (TBG) concentrations rise due to increased oestrogen
levels.
T4 and T3 increase over the first half of pregnancy but there is a normal to slightly
decreased amount of free hormone due to increased TBG-binding.
Page | 29

TSH production is stimulated, although in healthy individuals this is not usually
significant. A large rise in TSH is likely to indicate iodine deficiency or subclinical
hypothyroidism.
Serum calcium levels decrease in pregnancy, which stimulates an increase in
parathyroid hormone (PTH).
Colecalciferol (vitamin D3) is converted to its active metabolite, 1,25-
dihydroxycolecalciferol, by placental 1-hydroxylase.

Adrenal and pancreas
Cortisol levels increase in pregnancy, which favours lipogenesis and fat storage.
Insulin response also increases so blood sugar should remain normal or low.
Peripheral insulin resistance may also develop over the course of pregnancy and
gestational diabetes is thought to reflect a pronounced insulin resistance of this
sort.

Cardiovascular system
Progesterone reduces systemic vascular resistance by about 20% early in
pregnancy. Postural hypotension may result.
Diastolic and systolic blood pressure tend to fall during mid pregnancy and then
return to normal by week 36.
Venous return in the inferior vena cava can be compromised in late pregnancy if a
woman lies flat on her back. This is relieved by lying in the left lateral position.
Increased circulating angiotensin II encourages water and sodium retention,
leading to an increased plasma volume (to 50% by 30 weeks) and predisposing to
oedema. This enables increased uterine blood flow to meet growing nutritional and
oxygenation needs of the fetus. It also enables blood loss (average 500 ml) at
delivery to be met without physiological decompensation.
Advise women not to take up unaccustomed, vigorous exercise in pregnancy as
there is a risk of diversion of uterine blood flow to the skeletal muscles.
Blood flow to kidneys, skin and mucosa increases.
Cardiac output increases by 30-50% with 15% increase in heart rate and 25-30%
increased stroke volume. Much of this adjustment occurs prior to 12 weeks of
gestation and so impaired cardiac function is likely to present problematically in
early pregnancy or with the sudden increase in pre-load in the third stage of labour.

Cardiac examination in pregnancy:
Many women have a third heart sound after mid-pregnancy.
Diastolic murmurs should be considered potentially pathological.
Systolic flow murmurs are common.
Page | 30

ECG - left axis deviation is common, sagging ST segments and inversion or
flattening of the T wave in lead III may also occur.

Respiratory system
Tidal volume increases by about 200 ml, increasing vital capacity and decreasing
residual volume. In later stages of pregnancy, splinting of the diaphragm may occur
with some decrease in tidal volume. Respiratory rate does not alter significantly.
Increased oxygen consumption by approximately 20%.
State of compensated respiratory alkalosis - arterial pCO
2
drops, arterial
pO
2
remains unchanged and decrease in bicarbonate prevents pH change. Lower
maternal pCO
2
facilitates oxygen/carbon-dioxide transfer to/from the fetus.
Many women complain of feeling short of breath in pregnancy without explanatory
pathology. The mechanism of this is not fully understood

Alimentary system
Appetite is usually increased, sometimes with specific cravings.
Progesterone causes relaxation of the lower oesophageal sphincter and increased
reflux, making many women prone to heartburn.
Gastrointestinal motility is reduced and transit time is consequently longer. This
allows increased nutrient absorption. Constipation is common.
The gallbladder may dilate and empty less completely. Pregnancy also predisposes
to the precipitation of cholesterol gallstones.
Gums become spongy, friable and prone to bleeding. Good dental care is
important.

Urinary tract
The increased blood volume and cardiac output during pregnancy cause a 50-60%
increase in renal blood flow and glomerular filtration rate (GFR). This causes an
increased excretion and reduced blood levels of urea, creatinine, urate and
bicarbonate.
Mild glycosuria and/or proteinuria may occur because the increase in GFR may
exceed the ability of the renal tubules to reabsorb glucose and protein.
Increased water retention causes a reduction of plasma osmolality.
The smooth muscle of the renal pelvis and ureter become relaxed and dilated,
kidneys increase in length and ureters become longer, more curved and with an
increase in residual urine volume.
Bladder smooth muscle also relaxes, increasing capacity and risk of UTI.
Approximately 5% of pregnant women have bacteriuria, often asymptomatic, and
there is a greater risk of developing pyelonephritis in pregnancy.
Page | 31

Haematological
Dilutional anaemia is caused by the rise in plasma volume. Elevated erythropoietin
levels increase the total red cell mass by the end of the second trimester but
haemoglobin concentrations never reach pre-pregnancy levels.
A modest leukocytosis is observed.
A normal pregnancy creates a demand for about 1000 mg of additional iron. This
equates to 60 mg elemental iron or 300 mg ferrous sulfate per day.
Serum iron falls during pregnancy whilst transferrin and total iron binding capacity
rise.
Levels of some clotting factors (VII, VIII, IX and X) and fibrinogen increase whilst
fibrinolytic activity decreases. These changes protect from haemorrhage at delivery
but also make pregnancy a hypercoagulable state with increased risk of
thromboembolism. See also the separate article on Venous Thromboembolism in
Pregnancy.
One study found that during early pregnancy: antithrombin activity remained
unchanged, protein S activity decreased significantly and there was a potentially
biologically significant increase in protein C activity (see the separate article
onThrombophilia).
[
6
]

Serum alkaline phosphatase increases during pregnancy - due to placental
production.
Serum albumin decreases.

Metabolic
Changes in energy requirements in pregnancy remain controversial - healthy levels
of fat deposition and variation in women's physical activity levels cause uncertainty
as to the recommendations that should be made for this time.
The basal metabolic rate increases slowly over the course of pregnancy, by 15-
20%.
In women with normal BMIs, energy requirement does not increase significantly
during the first trimester, increases by about 350 kcal/day in the second trimester
and 500 kcal/day in the third.
Active energy expenditure tends to fall over pregnancy.
Normal weight gain is approximately 12.5 kg (usually at a rate of 0.5 kg per week
for the final 20 weeks). 5 kg is the fetus, placenta, membranes and amniotic fluid
and the rest is maternal stores of fat and protein and increased intra- and extra-
vascular volume.
Skin
Hyperpigmentation of the umbilicus, nipples, abdominal midline (linea nigra) and
face (chloasma) are common due to the hormonal changes of pregnancy.
Page | 32

Hyperdynamic circulation and high levels of oestrogen may cause spider
naevi andpalmar erythema.
Striae gravidarum ('stretch marks') are common.

Musculoskeletal
Increased ligamental laxity caused by increased levels of relaxin contribute to back
pain and pubic symphysis dysfunction.
Shift in posture with exaggerated lumbar lordosis leading to the typical gait of late
pregnancy.

VI. MEDICAL SURGICAL MANAGEMENT

1. Procedure

Procedure/Date Indications/Analysis Nursing Rsesponsibilities
(PRE, INTRA, POST)


2. Pharmacotherapeutics / Medicine (IV Fluids, Drugs)
Generic name, brand name,
classification, stock
Indication,Dosage,
frequency
Nursing Responsibilities

D5LR 1 L
5% Dextrose in Lactated
Ringer's
Classification:
Hypertonic
Nonpyrogenic
Parenteral fluid
Electrolyte
Nutrient replenisher

Indication:
is useful for daily
maintenance of body fluids
and nutrition, and for
rehydration
Dosage:
31 gtts/min, to run for 8
hours
PRE:
Check Doctorsorder
Verify patient
Assess fluid intake
and output
Check for the
consistency of the IV
fluid, do not administer
unless solution is clear
and container is
undamaged.
Caution must be
exercised in the
administration of
parenteral fluids,
especially those
containing sodium
ions to patients
receiving
corticosteroids or
Page | 33

corticotrophin.
Solution containing
acetate should be
used with caution as
excess
administration may
result in metabolic
alkalosis.
Solution containing
dextrose should be
used with caution in
patients with known
subclinical or overt
diabetes mellitus.
INTRA:
Practice 10 rights in
medication
Observe asepsis
Properly label IV fluid
POST
Discard unused
portion


Generic Name: Cephalexin
Brand Name: Keflex
Classification: first-
generation cephalosporin
Stock: 500 mg
(given postpartum)
Indications:
To fight infection
Dosage:
500 mg
Frequency: q6
PRE:
Check
Doctorsorder
Verify patient
Explain
effects/indication of
medications
Determine history
of hypersensitivity
reactions to
cephalosporins and
penicillin and
history of other
drug allergies befor
e therapy is
initiated.
Page | 34

Lab tests: Evaluate
renal and hepatic
function periodically
in patients receiving
prolonged therapy.
Monitor for
manifestations of
hypersensitivity
(see Signs &
Symptoms,
Appendix F).
Discontinue drug
and report their
appearance
promptly.

INTRA:
Practice 10 rights in
medication
Take with meals
POST:
Take medication for
the full course of
therapy as directed
by physician.
Keep physician
informed if adverse
reactions appear.
Be alert to S&S of
superinfections.The
se symptoms
should be reported
promptly and
appropriate therapy
instituted.
Do not breast feed
while taking this
drug.


Page | 35

Generic Name:
Mefenamic Acid
Brand Name:
Ponstan
Classification:
NSAIDS
Stock:
500 mg
(given postpartum)
Indications:
To relieve pain
Dosage:
500 mg
Frequency:
q6
PRE:
Check Doctorsorder
Verify patient
Explain
effects/indication of
medications
Assess patients who
develop severe
diarrhea and
vomiting for
dehydration and
electrolyte
imbalance.
Lab tests: With long-
term therapy (not
recommended)
obtain periodic
complete blood
counts, Hct and
Hgb, and kidney
function tests.

INTRA:
Observe 10 rights in
giving medication
Take with meals to
avoid GI upset
POST:
Discontinue drug
promptly if diarrhea,
dark stools,
hematemesis,
ecchymoses,
epistaxis, or rash
occur and do not
use again.
Contact physician.
Notify physician if
persistent GI
discomfort, sore
Page | 36

throat, fever, or
malaise occur.
Do not drive or
engage in potentially
hazardous activities
until response to
drug is known. It
may cause dizziness
and drowsiness.
Monitor blood
glucose for loss of
glycemic control if
diabetic.
Do not breast feed
while taking this
drug without
consulting physician.



VII. PROGRESS NOTES
Day No. Existing cues/problems
Interventions Actually Done (Nursing
and Collabaration)
Clients Response
October 2, 2013 The patient was in experiencing the
active stage of labor and has a cervical
dilatgation of 4 cm according to the
physician. The patient feels a bit
anxious about her delivery and
verbalized that she hopes that her
delivery will be happen smoothly. Sheis
also anxious about the babys health
and about what could happen once
shes on the delivery room. Support
and encouragements were given to
boost the patients outlook and make
her feel comfortable

Page | 37

VIII. Discharge Plans
Content Strategy
Compliance
-Medications
-Diet
-Exercise

The patient will be
instructed regarding her
home medications and
teaching her the proper
nutritional diet of a
lactating mother, some
helpful teachings on
alleviating breast pain.

Also an increase in oral
fluid intakewouldbe part of
the teaching instructions to
help her lactation be good.
One-on-one discussion with
patient and relatives about
health teaching plans
Follow up checkup The patient will be having a
follow up checkup
regarding the next step
which is to choose the
proper birth control method
the patient will use.
One-on-one discussion of
the schedule.











Page | 38

IX. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF
CONTACT
Date: October 2, 2013
Problems encountered(actualand resolved)

This is the last interaction with the patient. Before the transfer to the delivery
room, the patient looks relaxed and confident. The patient verbalized that she was
a bit axious in the outcome. But then before the transfer to the DR the patient was
relaxed because of the support of the people around her.




____________________________
Liana Monique San Lorenzo


References:
http://almostadoctor.co.uk/content/systems/obstetrics-and-gynaecology/pregnancy-and-
labour/normal-physiology-pregnancy
http://womenshealth.gov/pregnancy/you-are-pregnant/stages-of-pregnancy.cfm
http://www.webmd.com/sex-relationships/guide/your-guide-female-reproductive-system?page=3
http://psychology.about.com/library/bl_psychosocial_summary.htm