Académique Documents
Professionnel Documents
Culture Documents
CARE STUDY
ON
Submitted to:
In Partial Fulfillment
NCM 501201 – A
Submitted by:
MARIO C. ALUMBRO II
Student
SEPTEMBER 11 , 2008
TABLE OF CONTENTS
PAGES
I. Introduction…………………………………………………………………….. 1
II. General Data……………………………………………………………………. 2
III. History of present Illness………………………………………………………. 3
IV. Past health history……………………………………………………………… 4
V. Nursing Review of Systems…………………………………………………… 4
VI. Family, Personal, Social and Environmental History…………………………. 6
A. Immediate family member
B. Personal and Social History
C. Environmental History
D. Heredo-Familia History
APPENDICES:
BIBLIOGRAPHY
I. INTRODUCTION:
Pregnancy is the carrying of one or more embryos or fetuses by female mammals, including humans,
inside their bodies. In a pregnancy, there can be multiple gestations (e.g., in the case of twins, or
triplets). Human pregnancy is the most studied of all mammalian pregnancies. Human pregnancy lasts
approximately 9 months between the time of the last menstrual cycle and childbirth (38 weeks from
fertilization). The medical term for a pregnant woman is genetalian, just as the medical term for the
potential baby is embryo (early weeks) and then fetus (until birth). A woman who is pregnant for the
first time is known as a primigravida or gravida 1: a woman who has never been pregnant is known
as a gravida 0; similarly, the terms para 0, para 1 and so on are used for the number of times a
In many societies' medical and legal definitions, human pregnancy is somewhat arbitrarily divided
into three trimester periods, as a means to simplify reference to the different stages of fetal
development. The first trimester period carries the highest risk of miscarriage (natural death of
embryo or fetus). During the second trimester the development of the fetus can start to be
monitored and diagnosed. The third trimester marks the beginning of viability, which means the
The study of maternal and child care nursing during the various phases of childbearing includes
the study of anatomic and physiologic adaptations to human reproduction and, the full meaning,
the study of human growth and development and the many interdependent relationships
concerned. Maternal and childcare nursing involves directly personal ministrations to maternity
patients and their newborn infants, or related activities on their behalf during the various phases of
1
Begetting children is a family-affair, thus the nursing care of childbearing patients is
basically a family-centered activity. In most situations today, the maternity patient is usually a
Pain during labor is inevitable. That is why, as future nurses, it is a must for us to know how to
lessen the agony felt by our patients. This study will serve as our guide on what possible
interventions we can render, for them not to be traumatized. Through this, we will be able to
adhere to the different circumstances that women have undergone in relation to childbearing. They
will optimistically know that pain is just a fraction of this meticulous process, and the satisfaction
As you scan and read the content of this study, I sincerely hope you can obtain knowledge and
curiosity out of it. May this be a helpful tool in motivating us on how important nurses are during
those critical times of labor, and even during the postpartum period. May we continuously
remember that we are there not just to administer medications and monitor their general condition,
but we are also there to serve as their teacher, their confidant, and their friend.
Patient name: R. C. J.
Race: Filipino
Sex: Female
2
Civil Status: Married
Sex: Male
Race: Filipino
Occupation: OFW
Prior to admission of the patient in BDH, she was complaining of bloody vaginal
discharges, the baby was noted to be cephalic. And was being consulted and advised for
admission.
She has a history of hypertension at material side, there is not known for allergies in either
food or drugs, She had her menarche at 15 years old from 3-4 days duration with regular intervals.
There was (-) potential spotting (+) dispareunea. Non-smoker and non-alcoholic beverage drinker
3
had previous hospitalization as well due to fever. Her last menstrual period was on November 7,
2007 . Age of gestation is 39 weeks and 4 days and the expected date of confinement is on August
14, 2008.
She had been hospitalized. A history of hypertension and no history of diabetes mellitus
and other diseases. She had her series of pre-natal check up at BDH. OPD from first prenatal
check-up was when 1st month of pregnancy until 9 months. She was able to visit the clinic one-
week prior to her delivery to Dr. Garaygay. It was noted cephalic presentation of the baby.
EDUCATIONAL BACKGROUND:
Patient’s perception to health is the state of an individual being free from any
illnesses and is capable of doing her daily activities without any discomforts. Patient
was
able to do her daily activities but with guidance and limitation. During any illnesses,
she
self-medicate herself with any over-the-counter drugs applicable for that illness. She
Patient experienced fatigue due to delivery. While she was still pregnant, she
had
her exercise by walking. Since the store where she worked at as a saleslady, is only a
walking distance from her house, the morning walk is consider as her daily exercise.
4
NUTRITIONAL METABOLISM
Patient normally eats 3 times a day. Food and fluid consumed by the patient
adequate for her metabolic needs and pattern indicates adequate local nutrient
supply.
Patient had experienced occasional likes and dislikes of food during the first 3 months
of
pregnancy. She had shared that there would times she would ask her husband to bring
her
that food (or fruit) because she feels wanting to eat it.
ELIMINATION
a day and defecate at least once a day. Since voiding is painful, normal urination has
been
altered.
During first contact with the patient, sleepiness is evident. Patient was able to
rest and take naps at free time. She would just wake up if the baby cries or if there is a
visitor or when there is a need for us to perform any needed nursing procedure like
changing IVF and during vital signs taking. Patient’s normal sleep pattern is 6-8 hrs
nightly. Since, a new member of the family has come, it is experienced that her normal
is oriented to time, place, date, and person. She was able to respond coherently yet
she’s
tired.
5
SELF-PERCEPTION AND SELF-CONCEPT
Patient shows concern on the newborn and verbalizes acceptance of the new
role
being a mother. She verbalizes understanding on the proper way of breastfeeding and
was
Patient is married and is very close to her family. Patient show eagerness
during
Fatigue is evident to patient yet she was still able to perform care towards
her
baby. And patient was able to void despite of the burning sensation she might felt.
Hence,
she was able to cope up with the stressful situation she had encountered.
Patient has been married once, it’s expected that his husband was his only
sexual
partner. Pregnancy was never planned but it doesn’t mean they got disappointed.
They
practices Natural Family Planning Method, specifically, condom.
Patient is a Roman Catholic. She is active in church activities like she would
attend masses during Sunday. The couple would baptize their baby soon.
The Patient is living presently in her house with extended family. Her husband is working in Saudi
Arabia as a factory worker. She has no work. Her husband decides in terms of health and finances
6
in the family.
The patient starts her day early by taking a warm bath, cooks breakfast for family. Usually wakes
up at 5:30 in the morning. Her afternoon routine includes doing household chores. Spends her free
time taking a nap or watching T.V. together with her sister or reading about tips in preparing for
her babies arrival. Client usually retire at 9 or 10 pm. Client also keeps a good and clean
environment. She seldom strolls in market unless needed.
ENVORONMENTAL HISTORY
Patient lives in her house. Situated near the street. There are trees around, with lots of
leaves falling at the ground. Water supply runs throughout the town through pipelines and supplies
their home. They also have an electricity line connected. Garbage is collected by the maintenance
of there house.
7
GENERAL HEALTH:
- Patient is slowly regaining strength.
- And is able to ambulate a few meters away
SKIN:
- fair skin
- no presence of rashes
- no presence of lesions
- has good skin turgor
- No signs of abnormalities on I.V. site
HAIR:
- has evenly distributed hair
- shiny black, signifies adequate nutritional intake
NAILS:
- normal nail color
- normal nail growth
- no presence of breaks
HEAD:
- symmetrical
- normocephalic
- no birth defects
EYES:
- Eyebrows free from scaling
- External eye structures are normal, eyes are symmetrical
- conjunctiva is reddish pink in color and is noted normal
- Client gazed at the six cardinal signs
EARS:
- External ear contains some cerumen, with no lesions, exudates or swelling.
- external ears are symmetrical
- firm smooth and free from lesion
- client was able to repeat words clearly following voice test.
8
NOSE:
- No noted pain or tenderness upon palpation
- Without swelling and lesions, deformities/deviations
- Located symmetrically at midline lf the face
- Nostrils are both patent
- Client was able to distinguish common scents
NECK:
- No tenderness noted
- No masses
HEART:
- Heart rate within normal range
FEMALE GENITALS:
NEUROLOGIC SYSTEM:
- Patient was conscious and coherent. Well oriented with time and place. All reflex were
present and noted normal.
Adolescent Self-Identity versus Both primary andIt was during these times
12 – 18 role diffusion secondary sexthat the patient started
years old characteristics develop. development crushes and
They are concerned with puppy loves. The patient
their bodies, their
also started to take notice
appearances and their of her body changes and
physical abilities. Peer worry about her
groups assume a great appearance. She started
importance. Of the
Having her period and at
opposite sex starts. the first, did not want
anybody to know.
Early adult Intimacy versus They are more focused The patients have had no
20 – 40 isolation on reality and usually luck on making their
years old interested in meeting baby due to the fact that
their health needs. her husband had a
problem on his sperm
count. The patient also
had experienced death on
her 1st husband. And
then came her present.
Middle Generativity versus Hair begins to thin and Patient claimed to have
Adult 40 – Stagnation gray hairs appear. Skin an increasing no. of gray
65 years old turgor and moisture hairs, loss of muscle tone
decreases. Metabolism and decreased sexual
slows. Hormonal changes desire. Though she really
take place. longs for at least one
child. And prays for it
every time.
11
EXTERNAL GENITALIA
Mons Verenis
The area above the female's pubic bone, near the top of her pubic hair. The mons is a soft area
which is usually covered in pubic hair, and it is very sensitive to touch and pressure.
Labia Majora
The outer lips of the vagina. The labia majora are the lips closest to the thighs, and are usually
lightly covered in pubic hair. They surround the labia minora, urethral, and vaginal opening.
The clitoral hood is formed by the upper junction of the labia minora. This fold of skin
Clitoris
12
The clitoris is made up of the external shaft and glans and the internal crura. The crura is the root
of the clitoris from which the shaft extends. The glans is the tip of the external clitoris..
Sometimes covered by the clitoral hood, the clitoris becomes erect during stimulation and sexual
arousal. There are many nerve endings in the clitoris, making it very sensitive. In fact, there are
about the same number of nerve endings in the external parts of the clitoris as there are in the head
of the male penis. The glans is particularly sensitive to stimulation. Direct stimulation may be too
intense, and even painful. Gentle, indirect stimulation, however, may be very pleasurable and may
result in orgasm.
Labia Minora
The inner lips of the vagina. They are usually hairless and protrude from between the labia
minora. They meet at the clitoris as an especially sensitive area called the frenulum of the clitoris.
Urethra
The tube through which urine passes from the bladder to leave the body at the urethral opening.
Introitus
The introitus is the opening of the vagina. It is located between the urethral opening and the anus.
The perineum is the smooth area of skin between the introitus and the anus. There are many
nerves in the perineum and it is sensitive to touch. During childbirth, an incision, called an
episiotomy, is sometimes made in the perineum to prevent tearing of the tissues as the baby’s head
Anus
The opening through which feces (human solid wastes) leaves the body.
13
INTERNAL GENITALIA
Vagina
The vagina extends from the vaginal opening to the cervix - the opening to the uterus. The vagina
receives the penis during sexual intercourse, and is the birth canal through which the baby passes
during labor. The average vaginal canal is three inches long, possibly four in women who have
given birth. This may seem short in relation to the penis, but during sexual arousal the cervix will
lift upwards and the fornix (see illustration) may extend upwards into the body as long as
necessary to receive the penis. After intercourse, the contraction of the vagina will allow the
cervix to rest inside the fornix, which in its relaxed state is a bowl-shaped fitting perfect for the
pooling of semen.
At either side of the vaginal opening are the Bartholin's glands, which produce small amounts of
lubricating fluid, apparently to keep the inner labia moist during periods of sexual excitement.
Further within are the hymen glands, which secrete lubricant for the length of the vaginal canal.
Cervix
The cervix is the opening to the uterus. It varies in diameter from 1 to 3 millimeters, depending
14
upon the time in the menstrual cycle the measurement is taken. The cervix is sometimes plugged
with cervical mucous to protect the cervix from infection; during ovulation, this mucous becomes
Uterus
The uterus, or womb, is the main female internal reproductive organ. The inner lining of the uterus
is called the endometrium, which grows and changes during the menstrual cycle to prepare to
receive a fertilized egg, and sheds a layer at the end of every menstrual cycle if fertilization does
not happen. The uterus is lined with powerful muscles to push the child out during labor.
Ovaries
The ovaries are situated on the side of the uterus just below the finger like projections of the
fallopian tubes The ovaries perform two main functions: production of female sex hormones
-estrogen and progesterone, and the production of mature ova, or eggs every month after puberty.
Of the two female hormones produced by the ovaries, estrogen is responsible for development and
maintenance of all secondary sex characters such as breast, shape of the body, and maturity of the
reproductive organs such as vagina, uterus, fallopian tubes, etc. Progesterone is produced after the
ovum has been released. It is essential for maintenance of pregnancy and is responsible for regular
menstruation and maintaining normal menstrual flow. High progesterone levels suppress
menstruation. At birth, the ovaries contain nearly 400,000 ova, and those are all she will ever
have. However, that is far more than she will need, since during an average lifespan she will go
through about 500 menstrual cycles. These premature eggs are formed when baby is growing in
the uterus itself and may be damaged due to x-rays or exposure to toxic substances. After
maturing, the single egg travels down the fallopian tube, a journey of three or four days-- this is
the period during which a woman is fertile and pregnancy may occur. Eggs that are not fertilized
15
are expelled during menstruation along with the inner layer of uterus. Even if there is no damage
to the premature eggs in the uterus, those that are released after the age of thirty-five years are
Fallopian Tube
Fallopian tube is the duct through which the egg must pass to reach the uterus. The tube is about
4” long and hangs freely in the pelvic cavity. They are not directly connected to the ovaries but its
end widens into a wide flower like opening that lies adjacent to the ovary.
MALE FEMALE
tube
16
reproductive tract
Every human being starts out as two separate germ cells, or gamete. The female gamete
is the ovum, and the male gamete is the spermatozoon, or sperm for short. Only a man and a
woman capable of producing these germ cells are involved in fertilization. Though every man is
capable of producing sperm some of them has low production and has weak sperms leading to
17
faster death once it has traveled in the female reproductive tract. Also, there are those that are
not really capable of contributing into fertilization. Thus, such condition enables the man to be
not part of the fertilization. For women, there are some who do not ovulate regularly thus giving
them difficulty to bear a child. As soon as the woman had her menarche, the chance of
conceiving is already with her. Same with men, there are also those who unfortunately cannot
bear a child.
Furthermore, in the diagram, “viable” was clearly indicated due to the above-mentioned reasons.
When the sperm and the ovum meet through sexual contact, thus fertilization occurs. This has
There are some cases wherein pregnancy was not continued due to miscarriage or the
developing fetus was not properly implanted in the uterus but stayed in the fallopian tube
instead. This condition is called the Ectopic pregnancy. For this study, uterine pregnancy will be
focused. The developing fetus would be it he uterus of the mother in about 37-40 weeks or nine
months. From a single cell, it will be developing everyday and changes by week could be
noticed through ultrasound. In the whole gestation, the fetus is totally dependent with the
mother. What the mother has taken in would also go to the developing fetus. Once the fetus
matures and its system is already capable of functioning outside the uterus, hence would result
to birth. Birth is a natural process that cannot be controlled by the mother itself. Only for special
cases wherein the physician would decide to take the baby out when either mother both the
mother and the baby are at risk. But, if the fetus goes out from the mother and has reached its
D. SYMPTOMATOLOGY
18
SIGNS AND
SCIENTIFIC
SYMPTOMS MONTH OCCURRED
BASIS
MANIFESTED
A woman’s statement
3rd month
Quickening that she feels life
cannot be accepted as
any more than a
presumptive sign.
Occasionally, the
movement of gas in
the intestine may
stimulate such a
sensation.
(Pilliterri, 1976; 56)
The patient was admitted last Aug. 9, 2008, 5:25 pm. The patient complaints was labor pain, hypo
gastric pain and vaginal discharges. The rationale for this is to prevent further complication during
labor. The internal examination is fully dilated, fully effaced membrane. The rationale for this is
examining the internal side of the abdomen. The patient vital signs are as follows: T= 36.8 °C/
axilla, PR= 72 bpm, RR= 16 cpm, BP= 110/70 mmHg. The rationale for this is to ensure the
safety of the patient. The internal examination done by Dr. Gian Carlo Garaygay @ IE room,
labor watch done, transported @ delivery and assisted the patient in lithotomy position, baby out
@ 5:03 pm, placental out @ 5:08 pm, assisted in episioraphy repair @ 5:17 pm. The patient’s
present illness prior to admission noted gradual onset of persisting hypogastric pain with
contraction thus sought consult hence admission. The rationale for this is to know when the
21
labor happens.
The patient was discharge last Aug. 11, 2008, 9:00 am. The patient has no take home medications.
The rationale for this is the patient’s vital organ is back to normal.
injection or oral administration. Tetanus toxoid is an active immunization agent prepared from
detoxified tetanus toxin that produces on antigenic response in the body, conferring permanent
immunity to tetanus infection. It is prescribed for primary active immunization against tetanus.
delivery. A median episiotomy was performed on the patient. The incision followed the natural
3. Episiorraphy – the perineal repair was done after the delivery of the placenta.
4. Perilite treatment - is the management and care for one’s disorder by means of electric candles,
5. Intravenous Fluid Therapy - is an efficient and effective method of supplying fluids directly
B. Medications
During Pregnancy
22
The general principle regarding medication use during pregnancy is that all medications cross
the placenta and can potentially harm the fetus. No medication, including over-the-counter
medications and herbal remedies should be used without the express approval of increasing
needs the body requires. The primary care provider. Before any medication is taken, a careful
appraisal of risk versus benefit should be made. Yet, vitamins and other food supplements are
After Delivery
Cefalexin (Cefalin)
Mefenamic Acid (Dolfenal)
C. DIAGNOSTIC PROCEDURES
D. DIET
The patient was give full diet. The regular or full diet contains the essential requirements
our body needs. It is the initial diet prescribed by the physician to a newly admitted postpartum
patient who does necessitate a diet modification. The patient was advised to take foods that are
X. NURSING MANAGEMENT
During my shift, only few procedures were to be implemented. First and foremost, I
23
assessed my patient of her latest condition. Part of this was the taking of vital signs and the
First, I did my aesthetic care. I assisted the patient to carry out oral hygiene and combing
of her hair. I also made some arrangements of their things to achieve a therapeutic environment.
Looking on the patient’s chart, I implemented on the doctor’s orders. One of this is the
administration of medications. I also encouraged the patient to continue self perineal care. I was
not able to perform perilite treatment, but I believe she had undergone the procedure.I also
encourage my patient to ambulate in order for her to achieve defecation. I also did my patient
teaching.
PROBLEMS ENCOUNTERED DURING IMPLEMENTATION OF
NURSING CARE
There were no problems encountered during the implementation of nursing care except on
the administration of oral medication sometimes. This was due to the sleeping pattern of the
particular time would be delayed because she was still asleep. Other than this, there
24
include positioning the patient, deep breathing exercise every 10-15 minutes on her waking hours,
leg exercise every two hours, turning from side to side and early ambulation with assistance from
bed to chair to promote good circulation. Hydration was maintained as she was ordered sips of
water.
The patient was also encouraged some time for rest and sleep to relieve fatigue so she can
gain control, thus improving the chance for early recovery. After delivery, as expected, the patient
was very exhausted. Yet she was still encouraged to ambulate if she could manage. She was
ordered by the doctor to take ferrous sulfate to restore her iron reserves in the body. She was also
encouraged to include fiber in her diet to prevent her from constipation. Also, intake of plenty of
To evaluate good achievement and the effectives of the nursing interventions, the
following were noted on the patient. The patient’s vital signs are stable, re-establishment of fluid
intake and output, performance and effectiveness of deep-breathing and leg exercises, and client
The patient was glad and grateful of the care rendered to her. She complied with all the
instructions given to her. Due to this very good attitude of my patient, her health restored easily
and even didn’t complain of pain even though she repeatedly emphasized her exhaustion during
25
PATIENT TEACHING
As a post operative patient, she was encouraged to do deep breathing exercises, 5-10
deep breaths, let exercises by extending the knees and ankles to prevent circulatory stasis. She was
taught gradual ambulation and sit up on bed for lung expansion. The patient was also taught how
to do breast care, care for newborn, assessment of her incision wound, wound care, how to take
Every procedure done to my patient has a teaching that goes along with it; especially, on
the administration of the medicines. Due to this, she understood further the importance of the
I encouraged her to breastfeed her baby, for it is very advantageous not only to her baby,
but also to her. Since she was a first time mother, I also taught her the feeding and burping
techniques.
Since she made verbalizations about not being able to achieve defecation, I encouraged her
to drink plenty of fluids, and eat foods rich in fiber. Ambulation was also encouraged, yet her
A. CONCLUSION
For a health care provider who participates in maternal care, adequate knowledge of the
anatomy and physiology of the reproductive organs and the development of the newborn child
26
One of the primary goals of nursing care is the safe delivery of the baby. Should
circumstances arise that threaten this goal, the obstetrician has several methods to assist the
delivery and prevent harm to come about to the infant and mother.
The significance of this study therefore is to provide the best of medical and nursing
science to protect the life and health of the mother and the fetus, and to ensure a satisfying and
growth-promoting experience for the woman and her family. Nurses provide essential care to the
woman, and thus, the effectiveness of such nursing care is determined by outcomes for the mother
and family.
B. RECOMMENDATION
This care study is the product of good rapport with the patient. I conclude that even with
very limited time, we could still give out our best to our patients. Even we are not guided by
nursing care plans, we could still give a systematic care to them only if we give our heart to our
job. I know this care study could not reach the best remark, but I believe I have learned many
things in making this possible. I still have many things to improve on, so I recommend to myself
to work harder especially in gathering all the data. It is the most important factor to make this kind
A. NURSING EDUCATION
The study is designed to upgrade the knowledge and skills of the student nurse.
Educational changes have to keep pace with health care reform so that nurses and health carte
27
providers are prepared for this responsibility. Mother and child health recognized as a need for
preventive and restorative care as this is one of the expanding areas in the broadening scope of the
nursing profession. Thus, nursing education includes perceptions of the pregnancy and childbirth
as periods of wellness in the life of a woman and the importance of knowledge in the area of
The study also centers on the primary focus of the first semester of the school year –
Maternal and Child Health Nursing. For about three months, varied discussions were conducted in
the school and in different area assignments. The above data show a brief glimpse of what
Maternal and Child Health is all about. It would give us a direction on what to do when we, in the
future, will be faced with the same circumstances. May this study further increase our knowledge,
for us to give the optimal care that our patients expect from us.
B. NURSING PRACTICE
have learned should then be put into practice. This study is the product of that practice. This is the
Though cases vary from one person to another, commonly, the same procedures are
applied to intra-postpartum patients. So this would be a good guide for us student nurses in order
The utilization of the nursing process (i.e., Nursing Care Plan) is an important
concept of this study that helps and improves the student nurses’ preparation in the clinical area,
28
so he/she can focus his/her care planning and apply principles to practice. Nursing care planning is
essential for individualized care planning because this aids the student to apply theory to practice
and make use of critical thinking skills. Thus, student nurses can emphasize the specific needs of
clients, and the need to delegate care even in the midst of the proliferation of the variety of new
care settings and the diversity of the roles of nurses in the nursing field of practice.
C. NURSING RESEARCH
Care for the childbearing woman and her child does not only end after delivery. It
follows the family from the pregnancy period, through labor and delivery and postpartum period,
tertiary care, thus emphasis on research is placed on health care provision to the mother and child.
As what I have learned, nursing is now a big and a growing profession. Our scope
broadens which was brought about by constant research. Though this study does not employ the
steps in doing research, the data presented are relevant and could be a good ground for further
study. In this way, we could, in actual fact, appreciate the diversity of our profession even more.
So, through constant research, we could become competent nurses in this Information
Era.
29