I.

INTRODUCTION

This is a case of Patient CV, a 25 year old female from Meyto Calumpit Bulacan, who was admitted at the Bulacan Maternity & Childrens Hospital last September 06, 2010 at 8:00am with a chief complain of labor pain with a diagnosis of Normal Spontaneous Delivery with an ob score of G2P1(T1P0A0L1). A Normal spontaneous delivery (NSD) occurs when a pregnant woman goes into labor without use of drugs or techniques to induce labor, and delivers her baby in the normal manner, without a cesarean section. There are three stages of normal human birth these are First stage, second stage and third stage. The first stage of labor starts classically when the effaced cervix is 3 cm dilated. The second stage begins when the cervix is fully dilated, and ends when the baby is finally delivered. In the third stage, the uterus expels the placenta (afterbirth). Maternal blood loss is limited by the compression of the spiral arteries of the uterus as they pass though the lattice-like uterine muscles of the upper segment. Normal blood loss is less than 600 mL. The placenta is usually delivered within 15 minutes of the baby being born. The post-partal period, or the puerperum, refers to the 6-week period after childbirth. This is a time for maternal changes that are retrogressive (involution of the uterus and vagina) and progressive (lactation, return of menstrual cycle and beginning of parental role). Protecting a womans health as these changes occur is important for preserving her future childbearing function for ensuring that she is physically well enough to incorporate her new child into the family. This period is popularly termed the fourth trimester of pregnancy. The labor and birth process is always accompanied by pain. Several options for pain control are available, ranging from intramuscular or intravenous doses of narcotics, such as meperidine (Demerol), to general anesthesia. Regional nerve blocks, such as a pudendal block or local infiltration of the perineal area can also be used. Further options include epidural blocks and spinal anesthetics

2003-2004 statistics. In spite of the poverty, 95% of the women had spontaneous vaginal birth; 83% had blood loss less than 500 ml; 85% of the babies required no resuscitation effort; 67% of the labors were without fetal distress or meconium staining; and 90% of the babies were of normal birth weight. Transfers to a hospital after admission occurred 7% of the time, with half taking place before delivery and half after delivery. Neonatal mortality was 4.1 per 1000.

OBJECTIVES General The Student involve with the case will be able to perform comprehensive review in the patients condition and develop plan of care that would be appropriate for the client. The student can also apply knowledge in caring for the NSD patient. This case is conducted to acquire knowledge and skills in providing a systematic, rational method of planning and providing nursing care. Knowledge: To know the different diagnostic procedures and proper care applicable for the client. To formulate a NCP to a patient who undergone Normal Spontaneous Delivery. To prioritize a nursing care plan for the client

Skills: To carry out appropriate interventions to meet desired goals and objectives. To use critical thinking skills in interpreting assessment data that is necessary in identifying actual and potential nursing problems on the client. To achieve the objectives of health teaching plan.

Attitude: To collect and organize relevant information concerning the clients current health status through careful observation and skillful assessment To use therapeutic communication skills to the client to gain cooperation and trust. To render appropriate nursing care for the post partum patient with respect to her.

II.

Nursing Assessment

A. Personal History Demographic Data 1. Name: Patient CV

Address: Meyto Calumpit Bulacan

Age: 25 years old Date and Place of Birth: July 2, 1985, Pampanga Sex: Female Nationality: Filipino Marital Status: Single (live-in partner) Occupation: none Religious Orientation: Roman Catholic Position in the family: wife/mother Educational attaintment: college graduate Health Care Financing/Usual Source: his fathers salary Date/TIme of Admission: September 06, 2010 8:00am Date/Time of Delivery: September 06, 2010 8:30am Date/Time of Discharge: September 09, 2010 01:00pm Final Diagnosis: Normal Spontaneous Delivery with a GP(TPAL) of G2P1(T1P0A0L1

OBSTETRICAL HISTORY a. LMP b. EDC c. AOG GP(TPAL) of G2P1(T2P0A0L1).

December 06, 2009 September 13, 2010 39 1/7 days

B. Chief Complaint or Reason of Visit Masakit na talaga yung puson ko, humihilab yung tyan ko, pasakit ng pasakit yung hilab. as verbalized by the patient. The doctor admitted her to the Labor room due to dilatation of cervix of about 7cm.

C. History of Present Illness 3 hours prior to admission, the patient had a sudden onset of a slight fluid discharges with brownish color. Patient says that she already knew that shell soon be giving birth since this was her second time. When she felt that contractions and intensity are getting worse, she was rushed to the hospital. She was admitted last September 06, 2010 at 8:00 am after the doctor conducted an Internal Examination and found out that she is in the active phase of cervical dilation which is 7cm. and she gave birth at 8:30am. D. History of Past Illness The last time she was hospitalized was last August 3, 2007 when she gave birth to her first baby. She was then admitted at the same institution, the Bulacan Maternity and Childrens Hospital The Patient stated that she had not been given any vaccination of tetanus toxoid. The patient stated that she was not sure if she has completed the vaccination when she was born. She also stated that when she was young, she had experienced having chicken pox and measles. She also uses over the counter drug when having fever, cough and colds. She believes in quack doctors too.

GENOGRAM

CV

LV

NP

FP

(HEART ATTACK)

(HEART ATTACK)

65 DIABETIC HYPERTENSIVE SMOKER

68 HYPERTENSIVE

NV

BV

ND

LV

AP

DP

SP

FP

CP

JV

50 48 HEART DISEASE SMOKER

46 HYPERTENSIVE

42

40 SMOKER

38

35

30

25 ASTHMA SMOKER

20

CV 25

LEGEND

FEMALE

PATIENT

RJ 4 4

MV 0

MALE

DECEASED ( ) CAUSE OF DEATH

F. FUNCTIONAL HEALTH PATTERN

FUNCTIONAL HEALTH Prior to Hospitalization PATTERN 1. Health Perception/Health Her rate for her health on a scale of 1-10 (1 being the lowest, and Management Pattern 10 as the highest) is 10, When the client was asked to descried her health before, she replied malusog na malusog naman ako bago ako manganak. When ask if she is drinking alcohol, she replied dati, noong hindi pa ako nagbubuntis at dalaga pa ako pero simula noong nagasawa ako nawala na bisyo ko. She also believed in quack doctors. 2. Nutritional and Metabolic September 3, 2010 Seotember 4, 2010 September 5, 2010 Pattern Breakfast Breakfast Breakfast 1/2 regular bowl 3 pieces of monay 3 pieces of monay of Oatmeal. 1 cup of Anmum 1 glass bear brand 2 pieces of monay drink choco choco 2 glasses of water 1 glass of water Lunch 2 cups of rice Lunch Lunch 1 cup of rice 2 cups of rice 1 medium size 1 medium size 1 pc leg of chicken bangus bangus tinola 3 glasses of water 2 glasses of water 2 glasses of water Dinner 2 cups of rice Dinner Dinner 2 cups of rice 1 cup of rice 1 medium size 1 pc of fried 1 piece fried bangus chicken (Leg part) chiken(leg part) 2 glasses of water 2 glasses of water 2 glasses of water

During Hospitalization ok lang din naman, medyo naninibago lang kasi wala na laman yung tyan ko na malikot na baby, tapos medyo tumataas nga daw yung bp ko sabi ng mga nurse dito. As verbalized by the patient.

September 6, 2010 Breakfast None

September 7, 2010 Breakfast 2 glasses of bear brand choco choco Lunch Lunch 1 Choco tops cup 3 pieces of monay cake 1 glass of water 1 glass of water Dinner bowl of Sinigang cup of rice 1 glass of water

The patient loves eating fish, chicken and pork. The patient drinks water a lot. Output Frequency Amount Characteristics

Output Urine

Frequency 5

Amount Approx. 800ml

Characteristics Dark yellow urine with pungent odor. Formed,

3. Elimination Pattern

Stool

Urine

Approx. 1200ml

Yellowish with pungent odor

brown and foul odor.

Stool

Formed, brown and foul odor

The patient urinate four times a day. It is soft and dark yellow in color. She voided 5 times from 7am to 3pm with yellowish color urine on September 7, 2010. The patient defecates one time on September 7, 2010.

4.Activity/Exercise pattern

The patient do the house chores as soon as she wakes up before During her first day in the hospital, patient was not able to she goes to their sari-sari store. She do all the house chores except move around. When she needs anything, her mother and her doing the laundry. partner assist and help her. Medyo masakit pa kasi yung tahi ko. As verbalized by the patient. 0 Feeding 0 Grooming 0 Bathing 0 General Mobility 0 Feeding 0 Grooming 0 Toileting I Bathing 0 General Mobility 0 Bed Mobility II Toileting 0 Dressing 0 Bed Mobility 0 Dressing Level 0 Full self-care Level I Requires assistance or supervision from another person Level 0 Full self-care Level II Requires assistance or supervision from another person Level I Requires assistance or supervision from another Level III Requires assistance or supervision from another person person or device Level II Requires assistance or supervision from another Level IV Is dependent and does not participate. person Level III Requires assistance or supervision from another person or device Level IV Is dependent and does not participate. 5. Sleep Rest Pattern The patient sleeps twice a day. She sleeps usually at 9pm and During her stay in the hospital, the patient was able to sleep at wakes up at 8am. And in order for her to sleep during the night, least 3 times a day since she is in a private room lights must be turn off. She takes a nap for 20 minutes usually at 2pm. 6. Cognitive Perceptual The patient doesnt wear eyeglasses. She watched television and While in the hospital, she participates in the interview and she Pattern she easily gain knowledge from it. (e.g. News) She sometimes responded to the question of the students properly. She also forget things and she said kailangan ko pa balikan yung ginagawa follows the doctors order and hospital policies.

ko bago ko maalala 7. Self perception/Self- She is cheerful and a friendly person. When asked what she concept pattern wanted to change in her body, she said she wanted to have slim figure. 8. Role Relationship pattern The patient and her partner lives with her family together with her daughter. Whenever she have arguments with her husband, they settle things down with a small talk.

No dramatic changes.

She cant take care of her daughter since shes in the hospital but she cant wait to see her too. She has a problem breastfeeding her newborn baby. Nahihirapan na talaga ako magpa-breastfeed simula pa dati. Ngayon, ganito na naman, parang nawawalan yata ako ng gatas, as verbalized by the client.

Kaya naman naming ibigay ng asawa ko ang pangangailangan ng mga anak namin,as verbalized by the client. 9. Sexuality Reproductive She started having menstrual cycle when she was 11 y/o. She and The patient and her partner does not engage to any sexual Pattern her husband engage in coitus almost everyday. She does not use intercourse. any artificial family method. Whe 10. Coping Stress Tolerance She is short tempered whenever her husband goes out with his aalis na next next week si Kim, kaya ako lang mag-isa magfriends to play leisure activities(DOTA). She usually cry to release aalaga sa baby, as verbalized by the client. She talks to her her stress when having or facing big problems. She tries to keep partner and cry to release her stress knowing that her partner her problems to herself. will soon go to Canada for a job. She is very emotional. 11. Value Belief Pattern She and her family is a Roman Catholic. She believes in quack Doesnt change her belief religiously. The religious effort is doctor too. They attend the mass every Sunday. still a part of the patient. She prays for her family especially her new baby.

G. Growth and development

Stage

Psychosocial Young adulthood 18-25 years old Intimacy vs. isolation Young adults seek companionship and love with another person or become isolated from others The client exhibits a strong sense of commitment and responsibility towards her partner and children.

Psychosexual Genital Puberty onwards

Cognitive Formal operation 11 years to adulthood

Moral Conventional stage 4: SocietyMaintaining Orientation Adolescence to adulthood

Definition

analysis

Energy in directed toward full sexual maturity and function and development of skills needed to cope with the environment The client does not demonstrate independency from her parents but able to make her own decisions.

Locally solves all kinds of problem; thinks scientifically; solves complex problems; cognitive structure matures. The client, together with her partner, face lifes difficulties with positive point of view.

Right is being good, with the values and norms of family and society at large. (I must follow all rules so there is order in the society). The client is observed of her values that were instilled to her.

III. Anatomy and Physiology FEMALE REPRODUCTIVE SYSTEM The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next step for the fertilized egg is to implant into the walls of the uterus, beginning the intitial stages of pregnancy. If fertilization and/or implantation does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be men The female reproductive anatomy includes internal and external structures.

EXTERNAL FEMALE REPRODUCTIVE SYSTEM The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include: Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholin's glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect. Vagina: The vagina is a muscular passage which forms a part of the female sex organs and which connects the neck of the uterus (called the "cervix") with the external genitals. The vagina, which is approximately two and one-half to four inches long, has muscular walls which are supplied with numerous blood vessels. These walls become erect when a woman is aroused as extra blood is pumped into these vessels. The vagina has three functions: as a receptacle for the penis during love-making; as a outlet for blood during menstruation; and as a passageway for the baby to pass through at birth. According to The Guiness Book of World Records, a Russian peasant woman who lived in the 18th Century holds the record for the most children born to one mother. She had sixty-nine children within forty years. She produced sixteen pairs of twins, seven sets of triplets, and four sets of quadruplets!

INTERNAL REPRODUCTIVE SYSTEM The internal reproductive organs include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.

Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall. Cervix: The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible, the remainder lies above the vagina beyond view. The vagina has a thick layer outside and it is the opening where baby comes out during delivery. The cervix is also called the neck of the uterus.

MAMMARY GLAND A mammary gland is an organ in mammals that produces milk for the sustenance of young offspring. It is an exocrine gland that is an enlarged and modified sweat gland, and gives mammals their name. The mammary glands of domestic mammals that have more than two breasts are called dugs. Nipple: is a structure from which a fluid emanates. More specifically, it is the projection on the breasts or udder of a mammal by which breast milk is delivered to a mother's young. In this sense, it is often called a teat, especially when referring to non-humans. The rubber mouthpiece of a baby bottle or pacifier may also be referred to as a "nipple" or a "teat". Lobule: a small part of a lobe in the breast. A breast lobule is a gland that makes milk. Duct: a milk duct carries breast milk from the lobes to the nipple. Areola: the darker skin of the breast which is around the nipple in a circular area.

Physical Assessment

PARTS TO ASSESSED GENERAL APPEARANCE 1.Body built , height, and weight in relation to client's age, lifestyle and health

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Inspection

Proportionate, varies with lifestyle

Height: 5"3 Weight: lbs Over weight Relaxed, erect posture; coordinated movements Clean No body odor or minor odor relative to work or exercise; no breath odor No stress noted Healthy appearance Cooperative Appropriate to situation Understandable, moderate face; exhibits thought association Logical sequence; makes sense; has sense of reality deep brown Uniformity-Generally uniform except in areas exposed to sunlight

Deviation from normal

2.Client's posture and gait, standing, sitting, and waking 3.Client's overall hygiene and grooming 4.Body and breath odor

Inspection Inspection Inspection

5.Signs of distress in posture or facial expression 6.Obvious signs of health or illness 7.Client's attitude 8.Client's affect/ mood; appropriateness of the clients response 9.Quantity of speech, quality and organization 10.Relevance and organization of thoughts. SKIN 1.Skin color and uniformity

Inspection Inspection Inspection Inspection Inspection

Relaxed, erect posture; coordinated movements Clean and neat No body odor or minor odor relative to work or exercise; no breath odor No distress noted Healthy appearance Cooperative Appropriate to situation Understandable, moderate face; exhibits thought association Logical sequence; makes sense; has sense of reality Color- varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. Uniformity-Generally uniform except in areas exposed to sunlight; areas of lighter pigmentation (palms, lips, nail beds) in

normal normal normal

normal normal normal normal normal

Inspection

normal

Inspection

normal

2.Presence of edema 3.Skin lesions

Inspection Inspection

dark-skinned people No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temp. and activity) Uniform; within normal range When pinched, skin springs back to previous state Convex curvature; angle of nail plate about 160 Highly vascular and pink in light skinned clients; dark-skinned clients may brown or black pigmentation in longitudinal streaks Intact epidermis Smooth texture Prompt return of pink or usual color (generally less than 4 seconds) Evenly distributed hair

No edema No birth marks and skin lesions

normal normal

4.Skin moisture

Palpation

Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temp. and activity) Uniform warm temperature; within normal range When pinched, skin moves back faster

normal

5.Skin temperature

Palpation

normal

6.Skin turgor

Palpation

normal

NAILS 1.Fingernails plate shape to determine its curvature and angle. 2.Fingernail and toenail bed color.

Inspection Inspection

Convex curvature ; angle of nail plate about 180 Has a pink fingernail and toenail bed color

normal normal

3.Tissue surroundings nail. 4.Fingernail and toenail texture. 5.Blanch test of capillary refill.

Inspection Inspection Palpation

There is an intact epidermis smooth texture The color returns into pink within 4 seconds

normal normal normal

HAIR & SCALP 1.Eveness of growth over the scalp.

Inspection

Evenly distributed hair

normal

2.Hair thickness or thinness. 3.Presence of infections or infestation. 4.Texture and oiliness over the scalp. SKULL 1.Size, shape, and symmetry.

Inspection Inspection Palpation Inspection

Thick hair No infection or infestation Silky and resilient hair Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominence); smooth skull contour. Smooth, uniform consistency; absence of nodules or masses.

Thick hair No infection or infestation Silky and resilient hair Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominence); smooth skull contour. Smooth, uniform consistency; absence of nodules or masses.

normal normal normal normal

2.Nodules or masses and depressions

Palpation

normal

FACE 1.Face features Inspection Symmetric or slightly Symmetric or slightly asymmetric facial features; asymmetric facial features; palpebral fissures equal in palpebral fissures equal in size; symmetric nasolabial size; symmetric nasolabial folds folds Symmetrical facial Symmetrical facial movements movements Equally distributed; curled slightly outward Skin intact; no discharge; no discoloration; lids close symmetrically; Aprox.15-20 involuntary blinks per min.; bilateral blinking When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered Transparent; capillaries Equally distributed; curled slightly outward Skin intact; no discharge; no discoloration; lids close symmetrically; Aprox.15-20 involuntary blinks per min.; bilateral blinking When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered Transparent; capillaries normal

2.Symmetry of the facial movements EYEBROWS & EYELASHES 1.Eveness of distribution and direction of curl. EYELIDS 1.Surface characteristics and ability to blink.

Inspection

normal

Inspection

normal

Inspection

normal

CONJUNCTIVA 1.Bulbar conjunctiva's color, texture and

Inspection

normal

presence of lesions. 2.Palpebral conjunctiva's color, texture and presence of lesions. SCLERA 1.Color and clarity.

Inspection

sometimes evident Shiny, smooth, and pink or red Sclera appears white (yellowish in dark skinned client) Transparent, shiny , and smooth; details of iris are visible In older people, a thin, grayish white ring around the margin, called arcus senilis, may be evident. Flat and round Black in color; equal in size; normally 3-7 mm in dm; round, smooth border Pupil constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward the nose. Illuminate pupil constricts (direct response) Non illuminated pupil constricts (consensual response) Able to read newsprint 20/20 vision on snellen chart

sometimes evident Shiny, smooth and pink

normal

Inspection

Sclera appears white

normal

CORNEA 1.Clarity and color

Inspection

Transparent, shiny , and smooth; details of iris are visible

normal

IRIS 1.Shape and color PUPILS 1.Color, shape, and symmetry of size. Inspection Inspection Flat and round Black in color; equal in size; normally 3-7 mm in dm; round, smooth border Pupil constrict when looking at near object; pupils dilate when looking at far object; Pupil converge when near object is moved toward the nose equal response normal normal

2.Pupil light reaction and accommodation.

Inspection

normal

3.Pupils direct and consensual reaction to light.

Inspection

normal

VISUAL ACUITY 1.Test near vision. 2.Test distant vision

Inspection Inspection

able to read newsprint Both eyes sees in 20/20 vision;

normal normal

LACRIMAL GLAND, LACRIMAL SAC AND NASOLACRIMAL DUCT 1. Presence of edema EXTRAOCULAR MUSCLES 1. Test each eye for alignment and coordination. VISUAL FIELDS 1. Test for peripheral visual fields.

Palpation

No edema, tenderness, or tearing Both eyes coordinated, move in unison, with parallel alignment When looking straight ahead, client can see objects in the periphery Same as the facial skin, symmetrical Auricle aligned with outer canthus of eye, about 10 from vertical Mobile, firm, and non tender; pinna-recoils after it is folded Distal third contains hair follicles and glands Dry cerumen, grayish-tan color; or stick, wet cerumen in various shades brown Normal voice tones audible. Able to hear ticking in both ears

No edema, tenderness, or tearing Both eyes coordinated, move in unison, with parallel alignment When looking straight ahead, client can see objects in the periphery Same as the facial skin, symmetrical Auricle aligned with outer canthus of eye, about 10 from vertical Mobile, firm, and non tender; pinna-recoils after it is folded Distal third contains hair follicles and glands wet cerumen in various shades brown

normal

Inspection

normal

Inspection

normal

EAR'S AURICLE 1.Color and symmetry of size and position. Inspection normal

2.Texture,elasticity and areas of tenderness.

Palpation

normal

EXTERNAL EAR CANAL 1.Cerumen, skin lesions, pus and blood.

Inspection

normal

HEARING ACUITY TEST 1. Client's response to normal voice tones. 2.Perform watch tick test NOSE 1.Shape, size or color and flaring or discharge from the nares.

Inspection Inspection

Normal voice tones audible. Able to hear ticking in both ears

normal normal

Inspection

Symmetry and straight, no Symmetry and straight, no discharge or flaring, discharge or flaring,

normal

2.Presence of redness, swelling, growths and discharge of nares, using the flashlight. 3.Position of nasal septum. 4.Test patency of both nasal septum.

Inspection Inspection Palpation

5.Tenderness, masses and displacement of bone and cartilage SINUSES 1.Presence of tenderness LIPS 1. Symmetry of contour, color and texture

Palpation

uniform in color uniform in color Mucosa pink, clear, watery Mucosa pink, clear, watery discharge, no lesions discharge, no lesions Nasal septum intact and in Nasal septum intact and in middle middle Air moves freely as the Air moves freely as the client breathes through the client breathes through the nares. nares. No tenderness, masses; the No tenderness, masses; the bone and cartilage in midle bone and cartilage in midle No tender Uniform pink in color (darker, e.g., bluish hue, in Mediterranean group and dark-skinned client) Soft, moist, smooth texture, symmetryof contour, ability to purse lips Uniform pink in color (freckled brown pigmentation in darkskinned clients) Moist, smooth, soft, glistening and elastic texture (drier oral mucosa in elderly due to decreased salivation) 36 teeth; Smooth, white, shiny tooth enamel No tender Pale in color Soft, moist, smooth texture, symmetry of contour, ability to purse lips

normal normal normal

normal

Palpation Inspection

normal normal Deviation from

BUCCAL MUCOSA 1.Color, moisture ,texture, and the presence of lesions

Inspection

Uniform pink in color Moist, smooth, soft, glistening and elastic texture (drier oral

normal

TEETH 1.Inspect for color, number, and condition and presence of dentures.

Inspection

31 teeth; 16 upper teeth, 15lower teeth Smooth, white, shiny tooth enamel

Deviation from normal

GUMS

1. Color and condition

Inspection

Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums No retraction of gums (pulling away from the teeth) Pink, Smooth, lateral margins; no lesions Central in position Pink in color (some brown pigmentation on tongue borders in dark-skiinned client's); moist; slightly rough; thin white coating Smooth, lateral margins; no lesions; raised papillae (taste buds) ; raised papillae (taste buds) Moves freely, no tenderness

Pink gums Moist, firm texture to gums retraction of gums no

normal

TONGUE/FLOOR OF THE MOUTH 1. Color and texture of the mouth floor and frenulum. 2. Position, color and texture. movement, and base of the tongue.

Inspection Inspection

Pink, Smooth, lateral margins; no lesions Central in position Pink in color; moist; slightly rough; thin white coating Smooth, lateral margins; no lesions; raised papillae (taste buds) ; raised papillae (taste buds) Moves freely, no tenderness

normal normal

PALATES AND UVULA 1.Color, shape, texture and the presence of bony prominences.

Inspection

2. Position of the uvula and mobility. OROPHARYNX AND TONSILS 1.Color and texture.

Inspection

Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture Positioned in midline of soft palate Pink and smooth posterior wall

Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture Positioned in midline of soft palate Pink and smooth posterior wall

normal

normal

Inspection

normal

2.Size of the tonsils, color and discharge.

Inspection

Pink and smooth, no discharge, of normal size or not visible present Not visible on inspection Not palpable Central in position in midline neck; spaces are equal on both sides Lobules may not be palpitated If palpitated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing

Pink and smooth, no discharge, of normal size or not visible present Not visible on inspection Not palpable Central in position in midline neck; spaces are equal on both sides If palpitated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing

normal

3.Gag reflex NECK AND LYMPH NODES 1.Symmetry and visible mass in the thyroid gland. 2.Presence of tenderness or nodules in the lymph nodes. 3.Placement of the trachea.

Inspection and palpation Inspection Palpation Inspection and palpation

normal normal normal normal

4.Smoothness and areas of enlargement, masses or nodules in the thyroid gland.

Palpation

normal

POSTERIOR THORAX 1.Shape, symmetry, and compare the diameter of anteroposterior thorax to transverse diameter. 2.Spinal alignment

Inspection

Inspection

3.Breathing pattern 4.Respiratory excursion

Inspection Palpation

Anteroposterior to Anteroposterior to transverse diameter in ratio transverse diameter in ratio of 1:2 of 1:2 Chest symmetric Chest symmetric Spine vertically aligned; Spine vertically aligned; spinal column is straight, spinal column is straight, right and left shoulders right and left shoulders and hips are at the same and hips are at the same height. height. Quiet, rhythmic and Quiet, rhythmic and effortless respirations effortless respirations Full and symmetric chest Full and symmetric chest expansion (that is, when expansion (that is, when the client takes a deep the client takes a deep breath, your thumb breath, your thumb separate 3-5 cm during separate 3-5 cm during deep inspiration) deep inspiration)

normal

normal

normal normal

5.Temperature, tenderness, masses.

Palpation

6.Vocal fremitus

Palpation

7.Percuss the posterior thorax.

Percussion

8.Auscultate the posterior thorax.

Auscultation

Skin intact, uniform Skin intact, uniform temperature temperature Chest wall intact; no Chest wall intact; no tenderness; no masses tenderness; no masses Vibration felt through the Vibration felt through the chest wall when the client chest wall when the client speaks speaks Excursion is 3-5 cm Excursion is 3-5 cm bilaterally in women and bilaterally 5-6 cm in men Diaphragm usually slightly Diaphragm usually slightly higher in on the right side higher in on the right side Vesicular and Vesicular and bronchovesicular breath bronchovesicular breath sounds. sounds. Quiet, rhythmic and effortless respirations Skin intact, uniform temperature; no tenderness; no masses Quiet, rhythmic and effortless respirations Skin intact, uniform temperature; no tenderness; no masses

normal

normal

normal

normal

ANTERIOR THORAX 1.Breathing pattern 2. Temperature, tenderness, masses.

Inspection Palpation

normal normal

3. Respiratory excursion.

Palpation

4. Vocal fremitus.

Palpation

5. Percuss the anterior thorax.

Percussion

Full symmetric excursion; Full symmetric excursion; thumb normally separate3- thumb normally separate 5 cm 3-5 cm Same as posterior Same as posterior fremitus; fremitus is fremitus; fremitus is normally decreased over normally decreased over heart and breast tissue heart and breast tissue Percussion notes resonate Percussion notes resonate down to the 6th rib at the down to the 6th rib at the level of the diaphragm but level of the diaphragm but are flat over areas of heavy are flat over areas of heavy muscles and bone, dull on muscles and bone, dull on areas over the heart and areas over the heart and the liver, and tympanic the liver, and tympanic over the underlying over the underlying stomach. stomach.

normal

normal

normal

6.Auscultation of the trachea. 7. Auscultate the anterior thorax. BREAST 1. Palpation of breast 2. inspection of the nipple 3. inspection of the areola CAROTID ARTERIES 1. Pulsation of carotid arteries.

Auscultation Auscultation

Bronchial and tubular breath sounds. Bronchovesicular and vesicular breath sounds Round, no nodules, no masses. enlarge

Bronchial and tubular breath sounds. Bronchovesicular and vesicular breath sounds Round, no nodules, no masses. enlarge

normal normal

Palpation inspection inspection Palpation

normal normal

2.Auscultation of the carotid arteries. JUGULAR VEINS 1.Visibility of jugular veins

Auscultation

Symmetric pulse volumes; Full pulsations, thrusting quality; quality remains same when client's breathes, turns head,and changes from sitting to supine position; elastic arterial wall. No sound heard on auscultation

Symmetric pulse volumes; Full pulsations, thrusting quality; quality remains same when client's breathes, turns head,and changes from sitting to supine position; elastic arterial wall. No sound heard on auscultation

normal

normal

Inspection

Veins not visible (indicating right side of heart is functioning normally) Whiter than the facial color, with striae and scars, no masses or nodules, no lesion Flat or rounded No enlargement of liver or spleen Abdomen should be symmetrical bilateral The abdomen may rise

Veins not visible

normal

ABDOMEN 1.Skin integrity. Inspection Whiter than the facial color, with striae and scars, no masses or nodules, no lesion rounded No enlargement of liver or spleen Abdomen should be symmetrical bilateral The abdomen may rise normal

2.Abdominal contour 3.Enlarged liver or spleen. 4.Symmetry of contour. 5.Abnominal movements.

Inspection Inspection Inspection Inspection

Normal normal Normal Normal

6.Vascular pattern. 7.Bowel sounds, vascular sounds and peritoneal friction rubs. 8.Percusss abdominal quadrants.

Auscultation Auscultation Percussion

9.Light palpation of abdominal quadrants. Uterus 1. palpation of the uterus. Lochia 1. color of lochia 2. inspection of amount of lochia PERINEUM 1. inspection of the perineum MUSCULOSKELETAL SYSTEM 1.Muscle size, compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side. 2.Contructures (shortening) of the muscle sand tendons. 3.Muscle fasciculations and tremors of the hands and arms when stretched in front of the body. 4.Muscle tonicity. 5.Muscle strength

Palpation

during inspiration and falls during inspiration and falls during expiration during expiration No audible bruit, No audible bruit, no venous hum or friction no venous hum or friction rubs rubs Tympany is predominantly Tympany is predominantly heard bec. Of the stomach heard bec. Of the stomach and intestine; dullness and intestine; dullness sound heard over the liver sound heard over the liver or distented bladder or distented bladder Feel smooth and consistent Feel smooth and consistent softness softness Contracted, firm and round Contracted, firm and round Red Minimum lochia Dry, intact, tender, discolored and edematous Red Minimum lochia Dry, intact, tender, discolored and edematous

Normal Normal Normal

Normal

Palpation Inspection Inspection Inspection

Normal Normal Normal Normal

Inspection

Equal size on both sides of body No contracture No tremors

Equal size on both sides of body No contracture No tremors

normal

Inspection Inspection

normal normal

Palpation Palpation

Normally firm Equal strength on each body side

Normally firm Equal strength on each body side

normal normal

BONES 1.Normal structure.

Inspection

No deformities

No presence of noted deformities

normal

2.Edema and tenderness. JOINTS 1.Swelling 2.Presence of tenderness, smoothness of movement, swelling , crepitation and presence of nodules. RANGE OF MOTION 1.Upper extrimities. 2.Lower extrimities.

Palpation

No tenderness, swelling, crepitation or nodules No swelling No tenderness, swelling, crepitation or nodules

No tenderness, swelling, crepitation or nodules No swelling No tenderness, swelling, crepitation or nodules

normal

Inspection Palpation

normal normal

Inspection Inspection

Joint moves smoothly Joint moves smoothly

Joint moves smoothly Joint moves smoothly

normal normal

V. THE PATIENTS AND HIS CARE A. MEDICAL MANAGEMENT a. IVT, Blood Transfusion, Nebulization, total parenteral nutrition, NGT, oxygen therapy, etc. Medical treatment Date ordered/date discontinued General description management Intravenous fluid (IVF) Date Ordered: 09/06/2010 Time of infusion: 8:00 a.m. # of bottle/s: 2 bottles(1000 cc/bottle run for 8 hours : 31 gtts/min.) Time consumed: 12:00 pm Date consumed: 09/07/2010 D5LRLactated Ringer's and

Indication/purpose

Clients response to the treatment

Indicated for parenteral replenishment of the fluid and minimal carbohydrates calories as required by the clinical condition of the patient. It is also use as a mixing solution for other IV medication and as an alkalinizing agent. Classified as a hypertonic solution, which is a solution with a lower salt concentration than in normal cells of the body and the blood.

The patient is looking well according to her looks and grimace regarding to the treatment. And her energy was replenished. And for the IV fluid, it is infusing well to the patients body.

5% Dextrose Injection is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration. Each 100 mL contains 5 g Dextrose Hydrous, USP*; 600 mg Sodium Chloride, USP (NaCl); 310 mg Sodium Lactate (C3H5Na03); 30 mg of Potassium Chloride, USP (KCl);

and 20 mg Calcium Chloride, USP (CaCl22H20).

b. Drugs GENERIC/BRAND NAME DATE ORDERED, DATE TAKEN/GIVEN, DATE CHANGE, DATE DISCONTINUED Septenber 06, 2010 ROUTE OF ADMINISTRATION GENERAL ACTION, CLASSIFICATION, MECHANISM OF ACTION INDICATION/ PURPOSE CLIENTS RESPONSE NURSING RESPONSIBILITIES (prior, during, after)

Generic Name: Cephalexin Brand Name: Ceporex, Keftab, Keflex

Oral

First-generation cephalosporin; inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable; uses: removal of gramnegative bacilli from the upper and lower respiratory tracts, urinary tract, and skin; treatment of bone infections and otitis media.

Respiratory tract infections caused by streptococci; skin and skin-structure infections caused by methicillin-sensitive staphylococci and streptococci; bone infections caused by methicillin-sensitive staphylococci or Proteus mirabilis; genitourinary infections caused by Escherichia coli, P. mirabilis, and Klebsiella species; Haemophilus influenzae, methicillin-sensitive staphylococcal, streptococcal, and Moraxella catarrhalis

There is no allergic reaction when she takes the medication.

Prior to Administration - During long-term therapy, monitor CBC and liver and kidney function test results. Ask patient if allergic to cephalosporins or penicillin. During Administration - Tell patient to take drug with full glass of water. After Administration - Advise patient to report severe diarrhea. As appropriate, review all other significant and lifethreatening adverse reactions and interactions,

infections

especially those related to the drugs and tests mentioned above.

Generic Name: Mefanamic Acid

September 06, 2010

Oral

Non-steroidal antiinflammatory drug; Analgesic and antipyretic activities related to inhibition of prostaglandin synthesis

Brand Name: ponstan

Relief for moderate postpartum episiotomy pain when therapy will not exceed 1 week.

There is no allergic reaction when she takes the medication.

Prior to Administration - Inform patient about the adverse reaction of the drug.Tell the patient that she may stop the medication if she is experiencing ringing in ears; persistent cramping or stomach pain; unresolved nausea and vomiting; respiratory difficulty or shortness of breath; unusual bruising or bleeding(mouth, urine, stool); skin rash; unusual swelling of extrimities:chest pain; or palpations. During Administration: maintain adequate hydration(2-3 L/day of fluids) unless instructed to restrict fluid intake. After Administration

Generic Name: Ferrous Sulfate Brand Name: Magniferon

September 06, 2010

Oral

IRON PREPARATION:

Prevention & treatment of Fe deficiency & other Elevates the serum nutritional anemias; iron concentration anemias due to which then helps to hemorrhage, form Hgb or trapped in infections, intestinal the reticuloendothlial parasitism, prolonged cells for storage and illness, metabolic eventual conversion to disorders, rapid a usable form of iron. growth, menstruation & lactation.

There is no allergic reaction when she takes the medication.

- Instruct the patient that while taking the drug, do not use alcohol, excessive amounts of vitamin C, or salicylatecontaining foods,other prescription or OTC medications containing aspirin or salicylate or other NSAIDs without consulting prescriber. Prior to Administration - Use cautiously with allergy to ingredient, normal iron balance, peptic ulcer, regional enteritis, ulcerative colitis, hemolytic anemias, hemochromatosis -Confirm that the patient have iron deficiency anemia During Administration - Give drugs with meals - Administer liquid preparations in water or juice to mask taste and prevent staining of teeth After Administration - Warn patient that stool may be black or

green. - Arrange for periodic monitoring of hematocrit and Hemoglobin levels

c. Diet Type of Diet Date started, Date changed Diet as Tolerated After Delivery (September 07, 2010) Suggested food under D.A.T. BREADS & GRAINS =611 servings each day Whole-grain or enriched breads and cereals, and rice Foods in this General Description Indications/Purposes Specific food taken Client response to the diet Breakfast The patient was 2 glasses of bear brand choco group are a major replenished and choco Lunch source of regained her energy 3 pieces of monay thiamin, niacin, as manifested by 1 glass of water iron, fiber and increased in body zinc; and also a vital part of a healthy, balanced diet. VEGETABLES =3-5 servings each day All canned, frozen or cooked vegetables Fresh vegetables as tolerated Vegetables are high in certain nutrients, such as potassium, vitamins A and C weight and show signs of healthy body.

Vegetable juice

and folic acid.

FRUITS= 2-4 servings each day Fresh or frozen fruits processed without sugar Water-packed canned fruits Fruit juices, unsweetened

Fruit are major sources of vitamins A and C, potassium, folic acid, and soluble and insoluble fiber.

Meat is a major source MEAT & MEAT SUBSTITUTES Lean tender meats Chicken (cooked so it is tender and cut into small pieces) Soft fish and shellfish (baked, boiled, grilled), Tofu (soy) mixed in soup or vegetables Eggs (cooked with minimal fat) of protein, iron, niacin, thiamin, vitamins B6 and B12, folic acid, magnesium, potassium, phosphorus and zinc

MISCELLANEOUS Coffee, tea, unsweetened or diluted fruit drinks Spices and seasonings, as tolerated Milk as tolerated, nonfat Water

d. Activity Exercise Type of Exercise Date Started General Description Indications/purposes Clients response to the activity/exercise Active range of motion(AROM) May 20, 2010 Exercises without any assistance Exercise is useful in preventing The client is able to walk or treating coronary heart disease, osteoporosis, weakness, diabetes, obesity, and depression. Range of motion is one aspect of exercise important for increasing or maintaining joint function. Strengthening across the room. And can perform personal hygiene and toileting.

exercises provide appropriate resistance to the muscles to increase endurance and strength. The benefits of Walking May 20, 2010 Exercises without any assistance exercise not only improve physical health, but also enhance emotional well-being. The patient was practiced her gait.

To prevent circulatory stasis in the lower extremities To lowered cholesterol level, reduced risk of osteoporosis, increased energy level, and possible reduction in the rate of caesarian birth

B. Surgical Management An episiotomy is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the posterior end of thevulva, is performed under local anaesthetic (pudendal anesthesia), and is sutured closed after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in many parts of the world a and assist childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anesthetic (pudendal anesthesia), and is sutured closed

after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in many parts of the world. Episiotomies were once routinely performed to prevent vaginal tears during delivery. Today, routine episiotomies are not recommended. However, episiotomies may still be performed when there is a complicated delivery. An episiotomy may be needed if the baby's head or shoulders are too big for the mother's vaginal opening, or the baby is in a breech position (feet or buttocks coming first) and there is a problem during delivery. It may also be needed to speed the delivery process if there is concern about the baby's heart rate.

The two most common types of episiotomy are the midline episiotomy and the medio-lateral episiotomy. There has been significant debate about the advantages and disadvantages of these two types of episiotomy. In the, midline episiotomy is by far more common, while medio-lateral episiotomies are more common in and other parts of the world.

Midline Episiotomy A midline episiotomy refers to an episiotomy where the incision of the vaginal opening is directly in the midline, straight down toward the anus. The advantages of a midline episiotomy include easy repair and improved healing. This type is also less painful and is less likely to result in long-term tenderness or problems with pain during intercourse. There is often less blood loss with a midline episiotomy. The main disadvantage of a midline episiotomy is the likelihood for this type of incision to extend (continue tearing) and involve the anal sphincter or the lining of the rectum. When this happens, injury to the sphincter can result in long-term problems, such as fecal incontinence or the development of a recto-vaginal fistula (a small channel that connects the rectum with the vagina).

Medio-Lateral Episiotomy A right medio-lateral episiotomy begins at the vaginal opening in the midline with the incision directed toward the right buttocks at a 45-degree angle. The main advantage of the medio-lateral episiotomy is that it is less likely to extend into or involve the anal sphincter and the rectum. Disadvantages of the medio-lateral episiotomy are significant and include increased blood loss, increased pain, difficult repair, and an increased risk of long-term discomfort, especially during intercourse.

Clients response to operation: After the procedure, there is no sign of infection. The site is dry, intake, pinkish in color, and there is no pus coming from the wound. The wound site is

healing.

Nursing responsibilities:

instruct the woman to cleanse from the front to the back every after voiding and defication infra red light focused to the perineum for 15 minutes 2 or 3 times at first 24 hours of delivery to promote fast healing explain proper handwashing after perineal care encourage to increase fruit juices that are rich in vitamin C to increase resistant against infection external antiseptic applied to the episiotomy wound every after perineal care or 2 times a day

The area of the episiotomy may be uncomfortable or even painful for several days. Several practices can relieve some of the pain. Cold packs can be applied to the perineal area to reduce swelling and discomfort. Use of a sitz bath can ease the discomfort. This unit circulates warm water over the area. A squirt bottle with water can be used to clean the area after urination or defecation rather than wiping with tissue. Also, the area should be patted dry rather than wiped. Cleansing pads soaked in witch hazel (such as the brand Tucks) are very effective for soothing and cleaning the perineum. C. Nursing Problem Prioritization

DATE IDENTIFIED September 7, 2010

CUES S: Medyo masakit pa kasi yung tahi ko, as verbalized by the patient O: Uterus firm and contracted Minimum lochia Perineum: tender, discoloured, edematous S: Nahihirapan na talaga ako magpabreastfeed simula pa dati. Ngayon, ganito na naman, parang nawawalan yata ako ng gatas, as verbalized by the client.

PROBLEM/ NURSING DIAGNOSIS Pain related to tissue trauma as manifested by verbal report of client.

JUSTIFICATION Pain must be prioritized to promote comfortability to the client in her post partum period. Pain must be eliminated as much as possible.

September 7, 2010

Ineffective breastfeeding related to previous history of breastfeeding failure as manifested by verbal report of client.

Breastfeeding must be prioritized to avoid premature development of the baby and to avoid future problems that the patient may encounter if ineffective breastfeeding is not solved.

O: Breast enlarged no sign of oxytocin release S: Kaya naman naming ibigay ng asawa ko ang pangangailangan ng mga anak namin,as verbalized by the client.

September 7, 2010

Readiness for enhanced parenting related Parenting must be prioritized to enhance to ability to put childs need first as the ability of the client to guide her manifested by physical and emotional children. needs of the children are met.

D. NURSING CARE PLAN

ASSESSMENT S: Medyo masakit pa kasi yung tahi ko. As verbalized by the patient. O: BP: 140/100 mmHg Uterus firm and contracted Minimum lochia Perineum: tender, discoloured, edematous Fully ambulating

DIAGNOSIS Pain r/t tissue trauma as banifested by verbal reports of client.

PLANNING After 1 day of nursing interventionthe client will be able to report pain relief. Within 2 hrs- will follow prescribed pharmacologic regimen Within 1 hr- will demonstrate use of relaxation skills and diversional activities as indicated.

INTERVENTION Provide comfort measures

RATIONALE To provide nonpharmacologic pain management

EVALUATION After 1 day of nursing intervention he client was able to report pain relief. _____- follow prescribed pharmacologic regimen _____-will demonstrate use of relaxation skills and diversional activities as indicated.

Encourage use of diversional activities

Encourage adequate rest periods to prevent fatigue

 Administer analgesic as indicated

S: Nahihirapan na talaga ako magpa-breastfeed simula pa dati. Ngayon, ganito na naman, parang nawawalan yata ako ng gatas O: Breast enlarged no sign of oxytocin release

Ineffective breastfeeding related to previous history of breastfeeding failure as manifested by verbal report of client.

After 1 day of nursing intervention the client will be able to demonstrate technique to improve/enhance breastfeeding. Within 1 hr- will assume responsibility for effective breastfeeding. Within 1 hr- will achieve mutually satisfactory breastfeeding w/ infant content after feedings.

Provide for individualized physical theraphy/exercise program that can be continued by the patient when discharged. Give emotional support to mother. Use 1:1 instruction with each feeding during hospital stay/clinic visit Recommend avoidance or overuse of supplemental feedings and pacifier (unless specifically indicated) Restrict use of breast shields (i.e. only temporarily to help draw out the nipple out), then place baby directly on nipple Encourage frequent rest periods, sharing

After 1 day of nursing intervention the client was able to demonstrate technique to improve/enhance breastfeeding. Overuse of supplemental feedings and pacifier can lessen infants desire to breastfeed. ____- assumed responsibility for effective breastfeeding. ____- achieved mutually satisfactory breastfeeding w/ infant content after feedings.

To limit fatigue and facilitate relaxation at

households/childca re duties Suggest abstinence/restricti on of tobacco, caffeine, alcohol, drugs, excess sugar S: Kaya naman naming ibigay ng asawa ko ang pangangailangan ng mga anak namin,as verbalized by the client. Readiness for enhanced parenting related to ability to put childs need first as manifested by physical and emotional needs of the children are met. After 3 days of nursing intervention the client will be able to participate in learning appropriate attachment/ parenting behaviors. Within 2 hrs: will verbalize realistic information and expectations of parenting role. Provide information, including time management, stress reduction techniques Create an environment in w/c relationships can be develop and needs of individual family members can be met

feeding times Because they may affect milk production/letdown reflex or be passed on to infant. A safe environment in w/c individuals can freely express their thoughts and feelings optimizes learning and positive interactions among family members enhancing relationships. Learning about positive parenting skills, understanding growth and development expectations, and ways to reduce stress and anxiety promotes individuals ability to deal with problems that may arise in the course of family relationships. After 3 days of nursing intervention the client was able to participate in learning appropriate attachment/ parenting behaviors. _____- verbalized realistic information and expectations of parenting role.

O: Needs of her children are met Evidence of attachment

VI. Discharge Planning A. General condition of the patient upon discharge B. METHODS: M- Medications: Cefalexin 500 mg q6 Mefenamic acid 500 mg q6 Vitamin B1 B6 B12 OD Magniferron - OD

E >fully ambulatory T > adherence to therapeutic regimen H > health teaching given as follows: Encourage breastfeeding Encourage hand washing Emphasize perineal care every after voiding and bowel movement Instruct to do core care of the baby daily Take a bath daily Take home medications on time Attend on sessions for check-up

Avoid lifting heavy objects within six weeks of postpartum

O> Out-patient appointment Date: September 15, 2010 Time: 9 a.m. Place: OPD-OB section

D> diet as tolerated Encourage to eat green leafy vegetables to increase iron content of the body Encourage to eat other nutritious foods like fruits, vegetables, egg, and meat

S> advice may resume sexual activity only after six weeks of postpartum.

CONCLUSION: The purpose of this case study was to provide a wider knowledge regarding the birth process focusing on the Normal Spontaneous Delivery NSD. This study was conducted of seven students to prolong their knowledge and skills about the case, for them to visualized deep understanding of their Maternal and Child Nursing MCN.