Saint Louis University

Baguio City
School of Nursing
S.Y 2017-2018

ERCP

SUBMITTED BY:
CARULLO, Ira Christopher C.
BSN-III C1

SUBMITTED TO:
Ronald Paul Valera
Clinical Instructor

Discussion of the Case
A. Demographic Data
The patient, Female, Filipino, Single but with
partner, born on August 22, 1985, Roman
Catholic, currently residing in Baguio City). She
has 1 child born on July 21, 2013 in the same
institution she has consulted in. The patient is a
housewife while her partner is a construction
worker.
B. History
Present Illness: Patient was brought into ER with
her sister with complaints of unbearable labor
pains and active contractions. With an OB score
of G2P1 (1001) the patient is in the latent phase
of labor with. No other threatening symptoms
assessed such as elevated blood pressure,
dizziness and seizures. Her LMP was at June 25,
2018.
Past Illness: the patient claims that her first
child was delivered through normal
spontaneous vaginal delivery.
Family History of Illnesses: no family history of
abortions, hypertension, arthritis, & CVD.
Saint Louis University
Baguio City
School of Nursing
S.Y 2017-2018
Nursing Care Plan
A. Assessment/Cues
S> “ang sakit pero nakakaya ko pa naman at
nakakalakad pa naman ako”. Patient exhibits
arching back when contraction episodes occur.
Patient also grimaces when contractions are
occurring. Claims to have 8/10 pain scale.
O> with stabbing pains, radiating from the
abdominal area to the lumbo-sacral area, during
contractions. However, still able to
communicate properly and smile in between
contractions.
B. Nursing Diagnosis
Acute pain related to contractions and
dilatation of tissues evidenced by verbal reports
“ang sakit sakit na” and narrowed focus during
contractions
C. Explanation of the problem
Stretching of the peritoneum
overlying the uterus
Stretching of cervix during dilatation
Stretching of the ligaments
Extensive Learning Insight
Some patient will adhere to the health teachings given if
they are not distracted by the discomfort that they are
experiencing. In my case, I have given appropriate
health teachings and I have also facilitated the
discomfort the patient is feeling. It is impossible for the
patient to adhere if she is experiencing discomfort.
Furthermore, the care rendered must also be optimal
and health teachings must be instructed to facilitate the
whole delivery process.
Facilitating factors that helped in the implementation of
health teaching and optimal care include the staff who
helped out, the patient herself, and my prior
knowledge. These 3 helped in the process of rendering
optimal care since it was just a simple recall of what I
needed to ay to the patient, the staff aided and added
critical points and the patient was very conducive and
adherent to the managements presented.
 Saint Louis University
Baguio City
School of Nursing
S.Y 2017-2018

Compression of nerve ganglia in the

cervix

There is hypoxia of contracted

myometrium

Labor pains

D. Objective
In 30 minutes of nursing interventions, the
patient will be able to:
a. Exhibit proper breathing techniques
b. Restate proper bearing down techniques
c. Report discomfort is minimized
d. Appear relaxed/resting between
contractions
E. Implementation/interventions
 Taught proper breathing techniques such as
pursed lip breathing and breathing in
through the nose and breathing out through
the mouth.
 Instructed bearing down techniques such as
exerting pressure on the pelvic floor rather
than exerting pressure on her head.
 Instructed with comfort measures such as
 Saint Louis University
Baguio City
School of Nursing
S.Y 2017-2018

sacral pressure, repositioning

 Engaged patient in conversation to assess
sensorium
 Encouraged patient to void when feeling the
need.
F. Brief evaluation
 Fully met if patient is able to achieve 4-5/5
objectives
 Partially met if patient is able to achieve 3/5
objectives
 Not met if patient is able to achieve 2 or less
than 2 objectives
Patient was able to achieve 5/5 objectives given.
A simple test of recall was done to assess if the
information given to the patient was retained.
She was able to recall all the information she
needed to be used in the delivery room while
enduring labor pains.
References
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2008). Nurse's Pocket Guide Diagnoses, Prioritized interventions and Rationales edition 11. Philadelphia: Davis Company.
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2010). Nursing Care Plans. Phladelphia, PA: F.A. Davis Company.
Pillitteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing & Childbearing Family (Edition 6). Philadelphia, PA 19106: LIppincott Williams & Wilkins.
Priscilla Lemone, Karen Burke. (2014). Medical- Surgical Nursing: Critical Thinking in Patient Care 5th Edition. Pearson.