Physical: Atmosphere, pollution, lighting, Signs and Symptoms: Medications:

temperature *Uterine Contractions Watery vaginal o Ferrous Sulfate

Social: Family, partner Admitting Diagnosis: G2P1 (1001) Pregnancy
discharge o Mefenamic Acid
Uterine, 39 weeks, CIL
Cultural: Beliefs, moral values *Bloody show o Oxytocin

Spiritual: Religion  Past Medical Hx: - *Vaginal bleeding

Past surgical procedure: Perineal Support *Cervix effacement
The absence of harmful environment
 History of circumstances: N/A and labor
contributed to a restful hospitalization. While
the support of the patient’s family and partner
made it possible for the patient to seek help.
Activity box:
Having connection with religion and beliefs J.M, 21, Female, Filipino, Roman Catholic  Vital signs
helped the patient to cope during Piaget Formal Operational Patient follows
monitoring
hospitalizations, since it provided comfort. directions (immediate
breastfeeding and  Vaginal bleeding
massaging of uterus monitoring
Erikson Intimacy vs Isolation Maintains relationship  Health teaching
with family and partner
o After childbirth, followed by the delivery of placenta is
the start of the ‘recovery’ stage, which may last for 6 Kohlberg Post-conventional, Patient is committed to
Stage 6 caring for her infant Nursing Diagnosis: Effective breastfeeding
weeks. This involves the normal decrease in size of the
uterus (matris). Regular and strong contractions related to basic breastfeeding knowledge a.e.b.
(paghilab) will be present, which assists in the return of Sustained breastfeeding activity
the normal uterine size.
o Lochia (Vaginal bleeding/Pagdurugo) has 3 stages.
During the 1st stage (first three days), the discharge will Goal: Patient will demonstrate continuous effective
be entirely red. The 2nd stage, (4th to 10th day), the breastfeeding techniques after 1-2 hours of nursing
discharge will become pinkish or brownish in color.
interventions
After that, colorless or white discharge will start up
until the third week after birth.
o For the first 2 days after delivery of placenta, colostrum
(unang gatas) will be secreted. The breasts will become Assess: patient’s knowledge To gather baseline for managing Patient has basic knowledge
full and tender as the milk forms. This is due to the regarding breastfeeding or teaching about breastfeeding
decreased levels of estrogen and progesterone Assess: patient’s demonstration of To know whether she needs No problems with
(hormones na nagpapatigil ng paggatas). The breasts breastfeeding additional support demonstrating breastfeeding
becomes fuller, larger and firmer, may be accompanied Manage any deviation from proper To maintain effective Patient prevent doing mistakes
by pain. “Engorgement” occurs if the breasts become breastfeeding breastfeeding while breastfeeding
overfilled with milk, blood and other fluids, and it will Instruct patient to demonstrate To check for any mistakes Patient demonstrate proper
fade once the infant starts sucking/feeding. proper breastfeeding breastfeeding
Explain further the need to To ensure that the patient Patient initiates effective
breastfeed effectively initiates proper breastfeeding breastfeeding
Maintain the bonding of the mother For continuous breastfeeding No interruption during
and her infant, 24 hours a day breastfeeding

The goal was met: patient is observed to be continuously breastfeeding

her infant, and verbalize understanding of proper breastfeeding. CF:
effective health teaching, patient was cooperative