Académique Documents
Professionnel Documents
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School of Nursing
School of Nursing
In
NCENL01
By:
NBA-5
Submitted to:
Clinical instructor
December 2014
TABLE OF CONTENTS
I. Introduction …………………………………………………………………………………………………………………3
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I. INTRODUCTION
A. Brief Introduction
GOALS:
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NSD, using instruments, Dr charting, doing aftercare and
others.
OBJECTIVES:
They enhance his knowledge and skills in the Delivery Room by:
others.
action-response (FDAR).
instruments used.
A. Patient’s Profile
Name: Patient X
Age: 18 y/o
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Gender: Female
Nationality: Filipino
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Diabetes mellitus, and heart diseases. Presently her
she doesn’t have husband, and no one can support except her
2014. She also consults to the near local health unit for
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A. Female Reproductive
System
Vagina
a muscular
Cervix
Uterus
Ovaries
Fallopian tubes
B. Physiology of Pregnancy
a. Uterine Changes
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The length is ranges from 6.5 to 32 cm, the depth
cm thick. The uterine volume can ranges from 2ml to more than
contractions)
b. Cervical Changes
labor—butterlike.
C. Vaginal Changes
d. Breast Changes
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16th week—colostrums (thin, watery, high-protein fluid that
nipples.
e. Integumentary System
f. Respiratory System
hormonal changes.
g. Temperature
h. Cardiovascular System
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rate will become 80 to 90 bpm. Blood pressure decreases in
palpitations.
i. Gatrointestinal System
j. Urinary System
k. Skeletal System.
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separation of symphysis pubis makes the pregnant woman
l. Endocrine System
m. Immune System
roles.
family.
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d. Body image – the way the women appears theirselves.
finds acceptable one week, she may find intolerable the next
week.
following:
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Milestone of fetal growth and development in the mother’s
womb:
and legs are developed genitalia are forming, but sex cant
is now distinguishable.
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Fetal length becomes 10-17 cm, and weighs about 55-120
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Vernix caseosa is fully formed. Creases on the sole of the
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This stage is divided into two phases:
transition.
THIRD STAGE begins right after the birth of the baby and
vaginally.
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First stage of labor is divided into three phases; the
LATENT PHASE
ACTIVE PHASE
TRANSITIONAL PHASE
push.
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Begins with complete dilation of the cervix and ends
the perineum.
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placenta and contracting wall of the uterus that folding
contract.
V. MECHANISMS OF LABOR
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1. DESCENT
the right.
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- in multiparas, this may not occur until dilatation
of the cervix.
2. FLEXION
3. INTERNAL ROTATION
4. EXTENSION
6. EXPULSION
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delivers the anterior shoulder; the head is gently raised
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VI. PRODUCTS OF CONCEPTION
1. FETUS
complications.
2. FETAL MEMBRANE
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The amnion and chorion are separated by the exocelamic
Wharton’s jelly.
4. PLACENTA
5. AMNIOTIC FLUID
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VII. INSTRUMENTATION
Spontaneous Delivery
1. MAYO SCISSOR
episiotomy
cord.
3. TISSUE FORCEP
4. CURETTE
biological tissue or
debris in a biopsy,
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excision or cleaning procedure such as the evacuation of
placenta.
5. METZ SCISSORS
6. MAYO BASIN
the placenta.
7. NEEDLE HOLDER
driver, is a surgical
instrument, similar to
a hemostat, used
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VIII. NEWBORN ASSESSMENT
A. Vital Statistics
B. Vital signs
C. Gastrointestinal System
D. Urinary System
E. Neuromuscular system
light.
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- Rooting reflex. Helps the newborn to find food. When
the mother holds the child and brrush her nipple to the
swallowed.
head usually turn to one side or the other. The arm and
the leg on the side toward which the head turns extend,
F. SENSES
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Hearing – baby girl is very calm in response to a
it.
G. SKIN
H. HEAD
her anterior was diamond ins hape and felt as soft spot.
I. EYES
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purulent discharges and the cornea appears round and
proportionate in size.
J. EARS
K. NOSE
L. MOUTH
intact.
M. NECK
Her neck is short and well flexed. Her can elicited the
N. CHEST
O. ABDOMEN
P. GENITALIA
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Q. ANUS
introduce.
R. BACK
part.
S. EXTREMETIES
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IX. NURSING CARE MANAGEMENT
birth
breasts.
catheterization).
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X. Sample Delivery Room Charting For NSD
Date Focus-Data-Action-Response
Time
2:25 PM >Received from LR ambulatory with ongoing IVF of D5LRS 1l
+10 “U” Oxytocin at 700 cc level, infusing well on the R
hand accomapanied by NOD
>assisted and positioned comfortably lithotomy.
>oxygen inhalation administered at 2-3 lpmp per nasal
cannula.
>right-medio lateral episiotomy done by Clerk Flores
2:28 PM >Delivered an alive baby girl via NSD by Clerck Flores
>oxytocin 10 “U” given IM on the left deltoid.
2:29 PM >cord clamping and cutting done done by clerk Flores
2:31 PM >Placenta out by Schultz presentation done by clerk Flores
>BP taken and recorded as 110/70
>evacuation of blood clots and placental fragments done by
clerk flores
>episiorapphy done by clerk flores used 1 pc vicryl rapide
2.0
>perineal care and betadine swab done by clerk Flores.
>placed adult diaper and secured
>Brought to RR per stretcher accompanied by NOD with
ongoing IVF of D5LRS IL + 10 “U” oxytocin at 400 cc level,
infusing well.
>with minimal lochial discharge
>with firm and contracted uterus
>monitored for possible profuse bleeding
>advised to massage uterus as needed
>encouraged mother to breastfeed per demand and burp then
and after
>instructed to increase fluid intake and to eat food rich
in vit.c, iron and protein
>emphasized importance of drug compliance and daily
perineal care
>advised to report any untoward observation
3:57 PM >transout to ward per wheelchair with ongoing IVF D5LRS Il
+ 10 “U” oxytocin x 28 gtts/min at 300 cc level, infusing
well
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XII. BIBLIOGRAPHY
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