DRUG STUDY

Name of patient: ___Mrs. MM___________

Name of Drug Specific
Date Dose/ Frequency/ Mechanism of Nursing
Generic Classification Indication (why Contraindication Side Effects
Ordered Route Action Precautions
(Brand) drug is ordered)

Novo Ampicilin Penicillin 500mg/ /p.o An Contraindicated in CNS: lethargy,  Use

 Respiratory
aminopenicillin patient hallucinations, cautiously in
(Ampicili) tract or skin
that inhibits cell- hypersensitive to seizures, anxiety, patients with
and skin-
wall drugs or other confusion, other drug
structure
synthesis during pencillins. agitation, allergies
infection
microorganism depression, because of
multiplication. dizziness, fatigue possible cross-
CV: vein sensitivity and
irritation, in those with
thrombophlebitis. mononucleosis
GI: nausea, because of
vomiting, high risk of
diarrhea, maculopapular
glossitis, rush.
stomatitis,  Before giving
gastritis, drug, ask
abdominal pain, patient about
enterocolitis, allergic
pseudomembran reactions to
ous colitis, black penicillin. A
hairy tongue negative
history of
penicillin
allergy is no
guarantee
against a future
allergic
reaction
 THE INTRAPARTUM STAGE

CONDUCT OF THE FIRST STAGE

1. Anxiety, excitement of onset of labor and fear of the unknown
a. Establish a relationship with the woman or couple.
b. Provide information on the health care facility’s policies and procedures.
c. Inform the woman or couple of maternal status and fetal status and labor
progress.
d. Explain all procedures and equipment used during labor.
e. Answer any questions the woman/couple have.
f. Review the birth plan and make appropriate revisions.
g. Monitor maternal vital signs.
 Temperature every 4 hours, unless elevated or membranes ruptured,
then every 2 hours.
 Pulse and respirations every hour unless receiving pain medication,
then every 15-30 minutes or as indicated.
 Blood pressure every hour unless hypertension or hypotension exist or
woman has received pain medication or anaesthesia. Then evaluate
more frequently based on findings or as indicated.
h. Monitor FHR
 Evaluate once every hour for 15-30 minutes for intermittent monitoring.
 Evaluate the monitor strip at least hourly with continues monitoring.
 Evaluate immediately and after each of the next 5 contractions on
rupture of the membranes.
2. Fluid volume deficit.
a. Explain to woman and support person why oral fluids are restricted or stopped at
this time.
b. Start and maintain an IV infusion.
c. Provide ice chips or sips of clear fluids if allowed.
d. Provide mouth care as needed.
3. Injury: contamination, infection, prolapsed cord and abnormal fetal position.
a. Take the woman temperature and record every 2 hours.
b. Maintain asepsis during vaginal examination.
 c. Change the pads and linens when wet or soiled.
d. Provide perineal care after voiding and as needed.
e. Discourage the use of perineal pads, because they create a warm, moist and
environment for bacteria.
f. Minimize vaginal exams.
g. Observe for fetal tachycardia.
h. Assess complete blood count as indicated.
i. Continue to monitor maternal vital signs, FHR, vaginal secretions, fetal lie and
position using Leopold’s maneuver.
j. Reposition client to left lateral position or other positions as necessary.
k. Provide oxygen by nasal cannula or mask.
4. Pain: increasing intensity and frequency of uterine contractions.
a. Encourage position changes for comfort.
b. Assist the woman with breathing and relaxation techniques as needed.
c. Provide back, leg, and shoulder massage as needed.
d. Provide pain relief as assessing woman’s verbal and nonverbal communication.
e. Assess vital signs, including BP, FHR, frequency and intensity of uterine
contractions.
5. Bladder fullness
a. Encourage the woman to void every two hours at least 100ml.
b. Palpate the lower abdomen and evaluate for a distended bladder.
c. Assist with enabling the woman to void by providing time and privacy, running
the sink water gently, providing the perineal bottle of warm water for the woman
to squirt against her perineum.
d. Catheterize (in and out) when necessary.
e. Monitor intake and output.

THE SECOND STAGE OF LABOR

1. Impaired gas exchange
a. Coach woman to reestablish appropriate breathing pattern.
b. Help woman focus attention by doing the breathing with her and making eye
contact.
c. Side-lying position or left lateral position for oxygenation.
d. Encourage using open epiglottis technique when pushing.
2. Physiologic response to contractions; low self-esteem
 a. Provide information.
b. Coach woman through contractions giving her verbal and nonverbal approval
and reassurance.
3. Experiences contractions as overwhelming in intensity. Reports ring of fire as head
crowns.
a. Encourage slow gentle pushing.
b. Explain that “blowing away a contraction” facilitates a slower birth of the head.
c. Coach relaxations of the mouth, throat, and neck to relax pelvic floor.
d. Apply warm compress to perineum to aid relaxation.

THE THIRD AND FOURTH STAGES OF LABOR

1. Delivery of the placenta
a. Assist the mother in delivery of placenta.
b. Massage the uterus immediately but gently.
c. Check for intactness of placenta
d. Check BP.
e. Administer oxytocin if ordered.
2. Episiotomy and hemmorhoids
a. Suture any tearing.
b. Cleansed vulvar area with sterile water.
c. Ice caps wrapped in gauze may be placed over the episiotomy to numb the area
and minimize the edema.
d. Apply a sterile perineal pad.
e. Remove drapes and place dry linen under buttocks.
f. Reposition delivery table.
g. Lower the mother’s legs simultaneously from the stirrups.
3. Tremors that resemble chilling.
a. Dress woman in a clean gown and cover her with a warm blanket. Explain that
tremors are commonly seen after delivery and are not related to infection. Warm
blankets also provide a means of “mothering the mother”. This helps in restoring
her energy so she can move from a focus on herself to a focus on her baby.
b. Assists the woman onto her bed if transferred from the delivery room to the
recovery room.
c. Raise side rail of bed when transferred.
4. Fluid balance (hydration)
a. Give clear fluids, such as apple juice or tea, and toast can be given unless the
mother’s condition does not allow this.
b. The nurse records the type of fluids and foods taken, the time, the amount, and
the mother’s tolerance of the fluids or foods ingested.
c. In the event of hemorrhage, IV medications are given by the physician.
IV. Ideal Nursing Intervention
Intrapartum Period
Nursing diagnosis: Pain related to labor contractions
Nursing intervention
1. Assess the patient knowledge of the
labor. Process and her current anxiety
level
2.Encourage the support person to
remain with the patient in labor
3.Discuss the techniques of conscious
relaxation
4. Tell the patient to concentrate on an
internal or external focal point
5.Instruct the patient in shallow chest
breathing tell her to take slow, panting
like breaths
Nursing Diagnosis: Anxiety related to process of labor and birth
Rationale
 To plan supportive strategies
 A woman in labor will respond
more readily to supportive
measure offered by a familiar,
caring person.
 During labor, relaxation enables
the patient to use coping
techniques.
 A focal point allows control
thought while breathing.
 Slow breathing avoids
hyperventilation.
 Shallow chest breathing lifts the
diaphragm from the uterus during
contractions, decreasing the
intensity of contraction.
 Nursing intervention
1.Assess the patients knowledge,
experience, and expectation of labor
2. Discuss normal labor progression
with the patient, and explain what to
expect during labor
3. Involve the patient in making
decision about care
4. Share information on labor
progression, vital signs, and the
neonates condition with the patient
5. Interpret environmental sights and
sounds (electronic fetal monitor strip,
fetal monitor sounds, and activities on
unit) for the patient
Nursing Diagnosis: Situational low self-esteem related to inability to use prepared
childbirth method
Rationale
 To learn the precise source of
anxiety and increase the
effectiveness of intervention.
 Increase the patient’s knowledge
about normal progression of
labor and understanding of her
own experience.
 To reduce the sense of
powerlessness that some women
experience during labor.
 To provide reassurance of
normality and increase her sense
of participation.
 To make the environment seem
less threatening.
 Nursing Intervention
1. Encourage the patient and support
person to articulate their expectations
of the labor and delivery experience.
2. Provide ongoing, positive feedback
about the patient behavior.
3. Emphasize realistic goals for
behavior during labor and delivery.
4. Encourage the support person to
express feeling about labor and
delivery.
5. Encourage the patient to take active
role in self-care activities after delivery.
INTRAPARTUM PERIOD
Newborn Care
Nursing Diagnosis: Ineffective airway clearance related to secretions in airway.
Rationale
 Identify and correct
misconceptions early in the
couple’s experience.
 To clear up misconceptions and
increase feelings of self –
esteems.
 Placing unrealistic demands and
the patient can lead to feelings of
inadequacy and poor self-
esteem.
 The patient may misunderstand
how the support person viewed
her behavior during labor.
 To reinforce the patient ability to
care for her and increase self
esteem.
 Nursing Intervention
1. Regularly assess the neonate’s
respiratory status until stable.
2. Monitor vital sign, according to
facility protocol, and report changes
3. Review laboratory result and report
abnormalities.
4. Explain to the parent the reasons for
this intervention.
5. When offering the initial feeding,
observe for suck and swallow reflex,
gag and reflex and color changes.
Have suction equipment available and
ready to use.
Nursing Diagnosis: Ineffective thermoregulation related to heat loss from exposure in
birthing room
Nursing Intervention
1. Monitor the neonate body
temperature after delivery
Rationale
 To evaluate respiratory system
transition to extra uterine life.
 To determine multi system
adjustment to extra uterine
existence.
 Early identification of abnormal
laboratory values reduces the
risk of aspiration.
 To gain parental understanding
and cooperation which
contributes to a positive
outcome.
 Early detection of difficulty may
prevent neonatal morbidity and
mortality.
Rationale
 To obtain a baseline
2. Monitor and record the heart rate,
respiratory and blood pressure after
delivery and routinely. Thereafter until
discharge
3. Place the neonate under a radiant
warmer device, with a temperature
prompt. When his temperature is
stable, transfer a healthy neonate to a
regular open crib. Transfer a sick
neonate to a servo-controlled open
warmer bed or incubator.
4. Provide fluids base on the neonate
age, size, and condition. Monitor intake
and output, and administer parenteral
fluids as ordered.
5. Teach family members about:
- Sign and symptoms of altered body
temperature, such as cool
extremities
- Factors in the home that
contributes to neonatal heat loss
and ways to minimize heat loss.
Nursing Diagnosis: Imbalanced nutrition, less than body requirements, related to poor
sucking reflex.
Nursing intervention
1. Obtain the neonate’s weight at the
same time each day, using the same
scale.
2. If bottle feeding, record the amount
 To help ensure prompt diagnosis
and treatment of conditions that
may affect thermoregulation.
 This measure will help minimize
oxygen consumption and
metabolic rate, cause sweat
gland activity to cease, and
maintain deep body temperature
at appropriate level.
 The neonate may need an
increase in fluids to compensate
for water loss caused by
increase in metabolic rate.
 Careful teaching allows family
members to take an active role in
maintaining the neonate health.
Rationale
 To ensure early recognition of
excessive weight loss.
 To aid in early recognition of
ingested at each feeding. If
breastfeeding, record the number of
minutes the neonate nurses at each
feeding as well as ingestion of any
supplement
3. Regularly assess the neonate-
sucking pattern. Try to correct
ineffective sucking patterns.
4. Provide a preemie nipple or breast
shell, as appropriate.
5. Assess the neonate for neurologic or
other physical causes of ineffective
sucking
Nursing Diagnosis: Readiness for enhanced family coping related to birth of planned
infant.
Nursing Intervention
1. Encourage family members to
express enjoyment and satisfaction in
their role in the family
2. Assist the family members in
copping with changes related to growth
and development
inadequate caloric and fluid
intake.
 To help eliminate ongoing
difficulties.
 The preemie nipples larger hole
and softer texture make it easier
for the neonate to obtain formula.
Breast shell helps draw out an
inverted nipple.
 To identify the need for more
extensive evaluation.
Rationale
 To enhance family dynamics and
strengthens family bonds
 Each transitions stage of G & D
is a stressful life event.
3. Explore with the family members
traditional activities that all family
members will enjoy doing together.
4. Assess measure taken to maintain
open and positive communications
5. Assess measure taken to maintain
safety in the home environment
Nursing Diagnosis: Health-seeking behaviors related to newborn needs.
Nursing Intervention
1. Explain to the parents that their
actions can help promote infant
development. Make it clear, however
that infant maturation isn’t completely
with in their control
2. Explore with the parents ways to
cope with stress cause by the infant’s
 Sharing traditional family
activities increases loyalty,
security and a sense of
belonging for family member
 Healthy communications bridge
the gap between the members of
the family
 Environments that are free from
environmental hazards, both
chemical and physical, assure a
sense of security.
Rationale
 This explanation may decrease
feelings of anxiety and
incompetence and help to
prevent unrealistic expectations.
 To increase their copping skills
behavior
3. Praise the parents for their attempts
to enhanced their interaction with the
infant
4. Provide the parents with the
information on sources of support and
especial infant services
5. Help the parents interpret behavioral
cues from their infant
Nursing Diagnosis: Powerlessness related to duration of labor
Nursing Intervention
1. Discuss effect of fatigue on daily
living and personal goals. Explore with
patient the relationship between fatigue
and the delivery process.
2. Reduce demands placed on patient;
for example, ask one family member to
call at specified times and relay
messages to friends and other family
 To provide positive reinforcement
 To encourage them to continue
to foster their infant’s
development
 To foster healthy parent child
interaction
 For example, help them
recognize when the infant is
awake and alert, and point out to
them that this is a good time to
provide stimulation.
Rationale
 To help increase patient
compliance with the schedule for
activity and rest.
 To reduce physical and
emotional stress.
members.
3. Structure patient environment: for
example, set up daily schedule based
on patient’s needs and desires.
4. Postpone eating when patient is
fatigue.
5. Avoid highly emotional situations.
Nursing Diagnosis: Risk for ineffective breathing pattern related to breathing exercises
Nursing Intervention
1. Assess and record respiratory rate
and depth at least every 4 hours.
2.Ausculate breath sound at least
every 4 hours
3. Assist patient to a comfortable
position, such as by supporting upper
extremities with pillows, providing over-
 This encourages compliance with
treatment regimen.
 To avoid aggravating the
condition.
 Which aggravate patient’s
fatigue.
Rationale
 To detect early signs of
respiratory compromise.
 To detect decreased are
adventitious breath sounds;
report changes.
 These measures promote
comfort, chest expansion, and
ventilation of basilar lung fields.
bed table with a pillow to lean on, and
elevating head of bed.
4. Administer oxygen as ordered.
5.Teach patient about:
-Pursed-lip breathing
-Abdominal breathing
-Performing relaxation techniques
-Taking prescribe medication (ensuring
accuracy of dose and frequency and
monitoring adverse effects)
-Scheduling activities to avoid fatigue
and provide for rest periods.
Nursing Diagnosis: Risk for fluid volume deficit related to prolonged lack of oral intake
and diaphoresis from the effort of labor
Nursing Intervention
1. Monitor vital signs as often as policy
dictates.
2. Asses skin turgor and examine oral
mucous membranes for dryness.
 Supplemental oxygen helps
reduced hypoxemia and relieves
respiratory distress.
 These measures allow patient to
participate in maintaining health
status and improve ventilation.
Rationale
 Decreased blood pressure and
increased pulse rate may be late
signs of fluid volume lose. With
PIH, increased blood pressure
may occur.
 Dehydration can cause dry
mucous membranes; skin
tenting, and dry, cracked lips.
3. Continuously and monitor parenteral
fluids.maintain intake according to
order or protocol (usually 125 to 175
ml/hr.output should approximate intake.
4. Monitor electrolyte values and report
abnormalities.
5. Provide the patient with ice chips or
cool, damp, 4”x 4” gause compress.
 These measures help ensure
adequate hydration.
 Hypernatremia may indicate
dehydration, requiring I. V
volume replacement.
Hypernatremia may be related to
excessive insensible water loss.
 To increase patient comfort and
decrease mouth dryness,
especially if the patient breathes
through her mouth.

V. Actual Nursing Intervention

Intrapartum Period

“Agay! dli na nako makaya ang kasakit.” as verbalized by the patient

S
 Scale – 9
 Expression of Pain
O
 Facial grimace
 Guarding
A Pain related to labor contractions
P At the end of 5 minutes, patient will be able to identify characteristics
of pain and will describe factors that intensify pain, modify behavior to
 decrease pain, express decrease intensity of discomfort, and will
experience satisfaction with her performance during labor and delivery.
1. Assess the patient knowledge of the labor. Process and her
current anxiety level.
2. Encourage the support person to remain with the patient in labor.
3. Discuss the techniques of conscious relaxation.
I
4. Tell the patient to concentrate on an internal or external focal
point.
5. Instruct the patient in shallow chest breathing tell her to take
slow, panting like breaths.
Goals have been met, at the end of 5 minutes patient was able to
identify characteristics of pain and will describe factors that intensify
E pain, modify behavior to decrease pain, express decrease intensity of
discomfort, and will experience satisfaction with her performance during
labor and delivery.

“Medyo nakulbaan na man ko ma’am mahadlok ko ug utong”, as

S
verbalized by the patient.
 Expression of concern about birth
 Expression of fear of unspecified negative outcome
O
 Expression of feelings of helplessness
 Inability to concentrate and understand
A Anxiety related to process of labor and birth
At the end of 5 minutes, patient will be able to make use of available
emotional support, identify positive aspects of her efforts to cope during
P
childbirth, and acquire knowledge about childbirth and will be better
prepared to cope with future births.
I 1. Anxiety related to process of labor and birth.
2. Discuss normal labor progression with the patient, and explain
what to expect during labor.
3. Involve the patient in making decision about care.
4. Share information on labor progression, vital signs, and the
 neonate’s condition with the patient.
5. Interpret environmental sights and sounds (electronic fetal
monitor strip, fetal monitor sounds, and activities on unit) for the
patient.
Goals have been met, at the end of 5 minutes patient was able to
make use of available emotional support, identify positive aspects of her
E
efforts to cope during childbirth, and acquire knowledge about childbirth
and will be better prepared to cope with future births.

“Makaya unta ni nako, una baya ni nako na anak,” as verbalized by

S
the patient.
 Perception of self as unable to deal with events
O
 Expression of self-negating thoughts
Situational low self-esteem related to inability to use prepared
A
childbirth method
At the end of 5 minutes, patient will be able to set realistic goals
for her behavior during labor and delivery, receive adequate emotional
P
and physical support during labor and delivery, and project positive self-
concept through behavior and verbal expression.
1. Encourage the patient and support person to articulate their
expectations of the labor and delivery experience.
2. Provide ongoing, positive feedback about the patient behavior.
3. Emphasize realistic goals for behavior during labor and delivery.
I
4. Encourage the support person to express feeling about labor and
delivery.
5. Encourage the patient to take active role in self-care activities
after delivery.
E Goals have been met, at the end of 5 minutes patient was able to set
 realistic goals for her behavior during labor and delivery, receive
adequate emotional and physical support during labor and delivery, and
project positive self-concept through behavior and verbal expression.

“Gikapoy man gud ko og utonga, wala pa jud ko’y katulog sukad

S
gabi-e”, as verbalized by the patient.
 Apathy
 Expression on lack of control over self-care, current situation,
O and outcome
 Reluctance to express true feelings because of fear of alienating
caregivers
A Powerlessness related to duration of labor
At the end of 10 minutes, patient will be able to acknowledge fears,
P feelings, and concerns about current situation, decrease level of anxiety
by changing response to stressors, and participate in self-care activities.
1. Discuss effect of fatigue on daily living and personal goals.
Explore with patient the relationship between fatigue and the labor
process.
2. Discuss effect of fatigue on daily living and personal goals.
Explore with patient the relationship between fatigue and the labor
I
process.
3. Structure patient environment: for example, set up daily schedule
based on patient’s needs and desires.
4. Postpone eating when patient is fatigue.
5. Avoid highly emotional situations.
E Goals have been met, at the end of 10 minutes patient was able to
acknowledge fears, feelings, and concerns about current situation,
 decrease level of anxiety by changing response to stressors, and
participate in self-care activities.

“Sakit kaayu ang akong balat-ang ug mura ko ug kalibangon”, as

S
verbalized by the patient.

 Facial grimaces
O
 Expressive behavior – crying
 Bloody show

A
Comfort, Alteration in : Pain related to uterine contractions

P At the end of ten minutes, Ritchel will verbalize perceived or actual

reduction of pain.

1. Provide patient need for physical touch during contractions like

back rob.
2. Encourage position changes like the left lateral position.
I 3. Assist the woman with breathing and relaxation techniques.
4. Encourage ambulation as tolerated if membranes are not yet
ruptured and presenting part is not yet engaged.
5. Provide back, leg and shoulder massage as needed.

Goals have been met, at the end of 5 minutes patient was able to
identify characteristics of pain and will describe factors that intensify
E pain, modify behavior to decrease pain, express decrease intensity of
discomfort, and will experience satisfaction with her performance during
labor and delivery.
Newborn Care

S -Not applicable-
 Temperature: 36.4°C
 Cyanotic nail beds
O
 Mild shivering
 Cool skin
Ineffective thermoregulation related to heat loss from exposure in
A
birthing room
At the end of 5 minutes, patient will be able to maintain body
P temperature at normal levels, have warm, dry skin, and maintain heart
rate, and respiratory rate within normal range.
1. Monitor the neonate body temperature after delivery.
2. Monitor and record the heart rate, respiratory and blood pressure
after delivery and routinely. Thereafter until discharge.
3. Place the neonate under a radiant warmer device, with a
temperature prompt. When his temperature is stable, transfer a
healthy neonate to a regular open crib. Transfer a sick neonate to
a servo-controlled open warmer bed or incubator.
I 4. Provide fluids base on the neonate age, size, and condition.
Monitor intake and output, and administer parenteral fluids as
ordered.
5. Teach family members about:
 Sign and symptoms of altered body temperature, such as cool
extremities
 Factors in the home that contributes to neonatal heat loss and ways to
minimize heat loss.
Goals have been met, at the end of 5 minutes patient was able to
E maintain body temperature at normal levels, have warm, dry skin, and
maintain heart rate, and respiratory rate within normal range.
 THE POSTPARTUM STAGE
Immediately after the delivery, or perhaps later, the parents, particularly the
mother may relieve tension by giving way to some emotional displays like laughing, crying,
incessant chattering, and anger. These emotions often are quite unexpected and shock and
embarrass those involved. A calm, accepting, nonjudgmental attitude in the part of the nurse is
very effective in allaying any embarrassment and in helping the patient to gain control.

Several comfort measures can be employed to restore calm and to help the mother to
relax enough to get some much needed rest and sleep. A soothing backrub, change of gown
and linen, a quiet conversation with the nurse or the husband in which the patient is allowed to
ventilate her feelings, an environment conducive for resting, are all helpful (Bobac,1989).

The first hour following the delivery is a most critical one for the mother. It is at this time
that the postpartal hemorrhage is most likely to occur as the result of uterine relaxation. Thus, it
is mandatory that the uterus be watched constantly throughout this period by a competent nurse
who keeps her hand more or less constantly on the fundus and at the slightest sign of
diminishing contraction massages it, to make sure that it does not relapse and balloon with
blood. It is important for the nurse to be alert not only to the condition of the mother’s uterus but
also to any abnormal symptoms related to her general condition. Checking of the maternal vital
signs is usually included in the nursing observations. These signs are checked as often as
necessary until they become stable (Reeder, et. al.,1966).

Certain observations should be made and recorded daily. These would include such
findings as temperature, pulse and respiration; urinary and intestinal elimination; the physical
changes which occur normally in the puerperium. The nurse should take note the changes in
the breasts, the height and consistency of the fundus, the character, the amount and the color of
the lochial discharge and the condition of the episiotomy.

Temperature, Pulse, Respiration

• A slight rise in the temperature may occur without apparent cause following the delivery,
but in general the mother’s temperature should remain within normal limits during the
puerperium which is below 38 C.
 • In the early puerperium, the pulse rate is somewhat slower. The rate is usually between
60 and 70 but may even become a little slower than this in 1 or 2 days after the delivery.
By the end of the 1st week or 10 days it will return to its normal rate. On the other hand, a
rapid pulse after labor may indicate shock or hemorrhage.

After-Pains
Normally after the delivery of the first chills, the uterine muscle tends to remain in a state
of tonic contraction and retraction. In multiparas a certain amount of the initial tonicity of the
uterine muscle has been lost, and these contractions and retractions cannot be sustained.
Consequently, the muscle contracts and relaxes at intervals, and these contractions give rise to
the sensation of pain, the so-called “after-pains”(Reeder, et. al., 1966).
Several nursing interventions that can be applied in this discomfort would be the
application of ice cap on affected area, administration of analgesics and encourage the mother
of early ambulation.

Nutrition
After delivery the mother is given small amounts of easily digested foods, such as milk or
tea and toast, for the first meal if it is not contraindicated. Thereafter she enjoys a normal diet.
The daily diet of the lactating mother should be like that taken during pregnancy, with the
addition of 1,000 calories and amounts of the various nutrients such as protein, calcium, vitamin
A, iron, etc. These increased demands in the diet during lactation can be supplied with the
addition of a pint of milk, 1 serving of vegetables and 1 citrus fruit, an egg and 1 large serving of
meat. Often, these mothers become hungry in between meals. For this reason it is advisable to
see that they receive immediate nourishment consisting of a nourishing beverage or a snack 3
times a day.

Rest and Sleep

The mother in the puerperium should be encouraged to relax and sleep whenever
possible. To accomplish this she must be comfortable and free from any worries and anxiety-
producing situations must be avoided. Especially if she is breastfeeding, the need for rest is
more significant for it will inhibit her milk supply.
Urinary and Intestinal Elimination
The mother should be encouraged to void within the first 6 to 8 hours following the
delivery. It is not prudent, however, to adhere to a designated lapse of time to indicate when the
mother should empty her bladder, but rather on evidence indicating the degree of bladder
distension. It should be kept in mind that there is an increased urinary output during the early
puerperium. Moreover, mothers who have received intravenous fluids, or who are having them
are very likely to develop a full bladder.
Intestinal elimination in the early puerperium may be somewhat a problem because the
bowel tends to remain relaxed. Constipation can be anticipated unless certain measures are
instituted to prevent it. It is common to give a stool softener each night after the delivery and/or
a laxative or mild cathartic on the evening of the 2nd day following a delivery. If a bowel
evacuation has not occurred by the morning of the 3rd day, a cleansing enema or a suppository
may be prescribed.
BREAST CARE
This routine care is directed to maintain cleanliness and adequate breast support
necessary for the normal function of the breasts and the comfort of the mother. Precautions
should always be exercised to handle the breast gently, and above all to avoid rough rubbing,
massage or pressure on these organs.
The mother who is bottle-feeding her infant should bathe her breasts daily with mild soap
and water; this is done most conveniently at the time of the daily shower or bath (Reeder, et. al.,
1966).
Actual Nursing Intervention

Postpartum Period

“sakit akong tahi sa akong kinatao” as verbalized by the patient.

S
 gravida 1 para 1
 as verbalized by client
O
 Facial grimaces during walking

A Alteration in comfort: Pain related to perinial incision done

At the end of 3mins. client will be able to reduce or eliminates factors that
P
precipitate pain.
1. instructed the proper perineal care or the proper way to clean the
vagina
2. instruct to do sitz bath or clean the vagina with warm water
I 3. administer pain medication like aspirin
4. diverts patient attention like talking to her.

Goals have been met, at the end of 5 minutes patient was able to
identify characteristics of pain and will describe factors that intensify
E pain, modify behavior to decrease pain, express decrease intensity of
discomfort, and will experience satisfaction with her performance during
labor and delivery.
 REFERRAL

Pediatric primary care involves all the health promotion and disease prevention needs of
the child. To obtain the highest level of wellness attainable, referrals as to
immunization/vaccinations had been made as follows:

AGE IMMUNIZATION REMARKS

BCG given at the earliest possible age protects

At birth BCG against the possibility of infection from other
family members
An early start with DPT reduces the chance of
6 weeks DPT and OPV
pertusis
An early start of Hepatitis B reduces the chance
6 weeks Hepatitis B
of being infected and becoming a carrier
The extent of protection against polio is
10 weeks DPT and OPV
increased the earlier OPV is given
14 weeks DPT and OPV --------
At least 80% of measles can be prevented by
9 months Measles
immunization at this stage

Moreover, instructions had been made to immediately contact the pediatrician for any
abnormalities observed.
 HEALTH TEACHINGS
Name of patient: _Mrs. MM__

 Instructed the client to take vitamins that’s rich

MEDICATION in iron to revive the blood loss during her labor.

 Take mefanamic acid if pain persist, to lessen

the pain that she felt.

 Instruct the patient to do the postpartum

EXERCISE exercise to promote muscle tone.

 Do the proper breasts care to have the baby’s

TREATMENT safety when doing breastfeeding.

 Instructed to have proper perineal care for fast

healing of the episioraphy.

 Instruct the patient to go to the nearest center if

OUTPATIENT there are any problem that she encounter after

(check-up) giving birth, like if there is a problem about the

baby’s health or about her episioraphy.

 To eat vegetables that’s high in iron to regain

DIET the blood loss.

 To eat foods that is rich in vitamins to have her

energy back.