Davao Doctors College, Inc.

General Malvar St., Davao City Nursing Program

CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS),

A Case Study Presented to the Nursing Clinical Instructors of

Davao Doctors College, Inc.

In Partial Fulfillment of the Requirements in

NRG203: Care of Mother, Child, And Adolescent (Well Clients)

Sabturan, Enjie
Saguiguit, Prince Philip
Sta. Maria, Thea
Tapon, Sheilamae
Tayong, Leila Bianca
Velarde, Jam Chelzea
Velasquez, Danica Joy
Venenoso, Yvonne Dane
Young, Jinky

Oct 11, 2021

 INTRODUCTION

Introduce the case:

The postpartum period is both a happy and crucial period for a woman and her entire family.
The early postpartum days are the most stressful period for a mother, who must deal with
demands from her newborn baby and her own care needs, while coping with physiological and
psychological changes. In a survey conducted in the United States, about 42% of women were
found to suffer from physical and psychological distress because of their perceived inability to
care for their newborn. (BMC, 2019).

In the Philippines, the major causes of maternal death are complications during pregnancy,
delivery, and the postpartum period (ie, pregnancy-induced hypertension, postpartum
hemorrhage, and puerperal infection). This indicates that many maternal deaths occur not only
during pregnancy and delivery, but also during the postpartum period. In fact, approximately
two-thirds of all maternal deaths occur during the postpartum period. In one study, the utilization
of healthcare services in pregnant and postpartum women in the Philippines was observed to be
95.8% and 62.3%, respectively. (Yamashita, Reyes, Concel, et at., 2017).

In the Davao Region, after three years of partnership between DOH Region XI, Korea
International Cooperation Agency (KOICA) and the World Health Organization (WHO), the
collaborative project closes with improved maternal and newborn health (MNH) outcomes. From
baseline figures in 2014, maternal deaths have decreased by 53% and infant deaths have
decreased by 32% in the whole Davao Region in 2017. Meanwhile, the maternal deaths were
reduced by 41% and infant deaths by 12% in the 10 project sites from 2014 to 2017. (WHO,
2018).

Why there is a compelling need to study the case:

In accordance with the 2020 National Health Goals, postpartal period is extremely important
because it is a crucial time for parent-child bonding and high risk for developing uterine
hemorrhage. (Souza & Gulmezoglu, 2013) stated that protecting a woman’s health at this period
takes place which is vital in order to preserve her future childbearing function and to ensure she
is physically and emotionally capable of integrating her child into the family.
There is a compelling need to study this case since the physical care a woman receives during
the postpartal period can influence her future health. The physical care of the postpartum
mother involves providing comfort and relief from any discomfort from delivery, such as the use
of sitz baths and cool compresses to soothe the perineal area. Mothers may often experience
temporary difficulty in passing stool in the early postpartum period. This can be addressed with
the use of stool softeners and encouraging fluid intake and a high-fiber diet. The emotional
support she receives can influence the emotional health of her child and family so much that it
can be felt into the next generation (Newton, 2012).

Brief overview of the subject (patient being studied) of the study:

This study presents the case of Flordiliza, 29 years old, a factory worker, 40 weeks of Age of
Gestation (AOG), a primigravida and was expecting to deliver on October 11, 2020. She was
admitted last October 10, 2021, due to labor pain and with admitting diagnosis of G1P0
pregnancy, cephalic in presentation and labor. Flordiliza delivered to a full-term baby boy via
NSVD. The baby is 2,200 grams with an APGAR score of 8 after 1 minute and 9 after 5
minutes. No difficulties at birth were noted and no resuscitation was needed. No Congenital
anomalies were noted. After 5 days, Flordiliza’s doctor ordered that she may go home but her
baby will stay in the hospital for monitoring and treatment of neonatal sepsis.
 PATIENT’S PROFILE
This section contains the patient’s important health information to allow ease of data retrieval as
necessary. The patient’s complete profile includes the following components: Biographic Data,
Clinical Data, Past Health, Present Health History, and Family History.

i. Biographic Data
The patient's basic information is shown in the table below.

ii. Clinical Data

Clinical data contains information on health determinants, health measurements, and health
status, as well as care delivery documents. These records are kept in various databases across
the healthcare system.
i. Past Health History
Patient Flordeliza, has been hospitalized at Davao Doctors Hospital 8 years ago due to
appendectomy. There are no documented foods, drugs, or environmental allergies.

ii. Menstrual History

She had her menarche at 12 years of age. Patient reports she had a regular
menstruation 28 days cycle lasting 3-5 days with moderate to heavy flow. Patient states she
experiences mild menstrual cramps during her first to second day of menstruation and no
history of bleeding between periods.

Iii. Pregnancy History

Patient states that this is her first pregnancy with a presenting diagnosis of Gravida 1
Para 0 and the estimated time of delivery was on October 11, 2021. Reports she had poor
prenatal check-up and poor compliance with prescribed medicines such as Ferrous Sulfate.
Patient states that this pregnancy was not planned yet she is thankful since there were no
problems or complications arise during labor.
iv. Present Health History
Patient Flordeliza delivered to a full-term baby boy via NSVD with an APGAR score of 8.
She is experiencing afterpain, restlessness, and exhaustion after childbirth. Patient is passive
and dependent on the healthcare provider to attend to her needs and make decisions for her
as she wants to rest and regain her physical strength. She talks about her pregnancy as she
asks some questions about her delivery. The patient begins to initiate action such as
performing self-care, cuddles her baby while breastfeeding, yet feels insecure about her
ability to take care of her baby as she tries her best after some time of being dependent. She
redefines her role and gave up the role of being childless. Few hours following childbirth, her
husband reported that his wife was showing overwhelming sadness, bursting into tears and
feeling down. She is experiencing anorexia, and sleep disturbance. Also, she is worried
about her baby’s weight.

During the second day, patient complained of pain on the incision site. Skin around the
episiorrhaphy appears red with a small amount of seropurulent drainage. A moderate lochia
rubra was observed. Patient had also reported of hard, tender, and shiny over the entire
breast. No presence of redness, fever, and cracked nipples.
v. Family History

Genogram

HEALTH ASSESSMENT
The patient has a dark-colored complexion. Mask of pregnancy is still visible on the face.
Excessive pigment on the face and neck is evident (Chloasma). The patient’s abdomen has
striae gravidarum and appears, reddened and Linea Nigra.There were no visible pulsations on
the aortic and pulmonic areas.Patient’s head is rounded; normocephalic and symmetrical. The
sclera appears white. Patient’s pupils are brown and equal in size. The palpebral conjunctiva is
pale. Patient’s nose has no presence of discharges of any kind, nasal flaring is not noted. She
has a normal alignment of pinna. The neck muscles are equal in size. Upon Inspection, the
patient's breast is hard, larger, and more erectile with the presence of breast milk leakage.
Fundus is 1 cm above the umbilicus and. No leg pain and varicosities noted. Capillary refill
actively returns to its normal color in less than 2 seconds. Patient has no pelvic girdle pain or
back pain. Extremities have a good range of motion. Patient’s chest is symmetrical. Upon
inspection, the patient is not using any accessory muscles when breathing. Patient’s perineum
is edematous with ecchymosis patches from ruptured capillaries. There is an increased steady
flow of bright red blood and clots from the vagina. There is also a saturation period.

Patient’s skin is warm to touch. The skull has no nodules or masses and depressions.
No palpable nodules. Thyroid is not palpable in the neck. Breast is hard upon palpation.
Patient’s pulse is palpable with a pulse rate of 85 beats per minute. Patient’s cervix feels soft
and malleable, vagina feels soft with little rugae.

The patient looks healthy. She has normal vital signs after her normal vaginal delivery.
Her vital signs are as follows: BP 120/80, pulse 85 bpm, T-36.3 degrees celsius. Lungs have
normal breath sounds without dyspnea. Clear to auscultation in all lobes. No signs of crackles,
wheezing, stridor. There is no presence of heaves or lifts.

REVIEW OF ANATOMY & PHYSIOLOGY

The postpartum period is also referred to as the puerperium which commences after
birth of the baby, and marks the end of pregnancy. The puerperium is the period of about 6
weeks, when we give special attention to the changes occurring in the mother’s body. These
changes primarily include the return of the maternal organs to around pre-pregnant sizes and
functions, endocrine changes as the placenta is lost, and the onset of lactation.

REPRODUCTIVE SYSTEM
Involution is the process wherein the reproductive system of a pregnant woman is
gradually returning to its normal state. The uterus, cervix, and vagina are the areas of a
pregnant woman's reproductive system that are affected by involution. The uterus returns to its
pre-pregnant state in just 6 weeks. The reduction in muscle mass and fiber size in uterus
involution is not just stimulated by the large changes in the hormones that were supporting
pregnancy but also the loss of mechanical stimulation. There is catabolism of the muscle as its
mass reduces and the extracellular matrix is remodeled by metalloproteinases. Coordinated
apoptosis and proliferation results in the myometrium returning to its non-pregnant state. The
endometrium regenerates in 3–6 weeks, and menstruation can occur within this time.

There will be a vaginal discharge during the postpartum period, which is known as the
lochia. Lochi refers to the vaginal discharge produced by the uterus, cervix, and vagina. It starts
out red and lasts 1 to 4 days, consisting of blood, decidua fragments, endometrial tissues, and
mucus. The lochia then turns yellowish or pale brown over the course of 5 to 9 days, and is
mostly made up of blood, mucus, and leukocytes. Finally, the lochia is white and largely mucus,
and it can linger anywhere from 10 to 14 days. The lochia might last up to 5 weeks after
delivery. The presence of crimson lochia for more than a week could indicate uterine
subinvolution. The presence of an offensive odor or large pieces of tissue or blood clots in
lochia or the absence of lochia might be a sign of infection.

The cervix must be repaired during the postpartum period to prevent infection and
hemorrhage. By the second week after delivery, the internal os of the cervix should have closed,
although the external os may stay open for several weeks. Given the cervix's significant
collagenous content, metalloproteinases and collagenases, followed by extracellular matrix
protein synthesis, together with cells of the immune and inflammatory systems, play a major
part in the cervix's restoration.

During the first few weeks of the puerperium, the vagina and vulva will be edematous
and swollen, but they will return to their normal state. Each pregnancy causes the vaginal walls
to thin gradually, increasing the chance of genital prolapse as you become older. Tears and
episiotomies will heal in 2–3 weeks, depending on their size, but they must be kept clean and
dry, and the mother must be reassured about the healing process. Most women's pelvic pain
goes away after 6 weeks. Tears and episiotomies, as well as the trauma to the vagina after
delivery, are likely to cause pain during intercourse in the initial weeks and months of
puerperium.

LACTATION
Breast changes can be expected during and after pregnancy, whether or not a woman
breastfeeds. Common symptoms after giving birth include engorged breasts, which refers to a
feeling of fullness and sore or leaking nipples. Color of the breast, size, and stretch marks are
also the changes that will occur during the postpartum period of a mother. The major
physiological event of the puerperium is the establishment of lactation. It is important to
appreciate the structure and cellular components of the lactating breast in order to fully
understand the physiology of lactation.

During labor, when the placenta is removed, it causes a considerable decline in

progesterone, estrogen, and human placental lactogen, as well as a rise in prolactin, cortisol,
and insulin. The tactile stimulation of the nipple-areolar complex with suckling of the nipple,
stimulating nerve terminals and subsequent release from the anterior pituitary regulated by the
brain, causes prolactin concentration to rise fast. Prolactin promotes ductal development,
epithelial cell proliferation, and milk production and secretion in the mammary gland. Milk
proteins are bundled into secretory vesicles within the alveoli, and milk is released into the
lumen of the alveoli through exocytosis and budding. The secretion from the breasts called
colostrum increases after childbirth. Colostrum is the first milk produced by mothers during the
first 4 days postpartum. It is rich in protein, vitamins and immunoglobulins, and other humoral
factors and provides an immunological defense to the newborn.

The release of the hormone oxytocin, which is involved in the milk ejection or let down
reflex, is the second important mechanism for healthy lactation. Oxytocin is released in a
similar manner to prolactin, however it is governed by a different neuroendocrinological system.
Suckling causes afferent signals to be sent to the hypothalamus, which causes the posterior
pituitary gland to produce oxytocin in a pulsatile manner. The contractile myoepithelial cells in
the alveolus are stimulated by oxytocin, which travels via the bloodstream. Milk is forced into the
ducts from the alveolar lumens and out via the nipple as a result of the contraction. Oxytocin
can also be released in response to various sensory inputs including hearing a baby cry. It also
has a psychological effect, which includes inducing a state of calm, and reducing stress and
anxiety. It may also enhance feelings of affection between mother and child, which is an
important factor in bonding.

PATHOPHYSIOLOGY

i. Definition of Diagnosis
Diabetes mellitus is a disease that influences how the body utilizes blood sugar
(glucose). Glucose is necessary for health because it is a primary energy source for the cells
that build muscles and tissues. It is also the brain's primary source of fuel. Diabetes mellitus is
an endocrine disorder in which the pancreas cannot provide sufficient insulin to regulate body
glucose levels. The disease affects 3% to 5% of all pregnancies and is the most usually seen
medical condition in pregnancy (Bradley, Duprey, & Castorino, 2016). It increases as more and
more obese adolescents develop type 2 diabetes (Klingensmith, Pyle, Nadeau, et al., 2016).

Heart disease defines a range of conditions that affect the heart. Heart diseases involve
blood vessel diseases, such as coronary artery disease, heart rhythm problems (arrhythmias),
heart defects you are born with (congenital heart defects), heart valve disease, disease of the
heart muscle, and heart infection. The most frequent type of heart disease is coronary artery
disease (CAD), which affects the blood flow to the heart. Reduced blood flow can cause a heart
attack. Usually, heart disease is not diagnosed until a person encounters signs or symptoms of
a heart attack, heart failure, or arrhythmia.

ii. Etiology

ETIOLOGY PRESENT JUSTIFICATION

DIABETE MELLITUS

Overweight, obesity, People are more likely to develop type 2

and physical diabetes if they are not physically active and
inactivity are overweight or obese. Excess weight
seldom causes insulin resistance and is
prevalent in people with type 2 diabetes.
 The area of body fat also makes a
difference. Extra belly fat is associated with
insulin resistance, type 2 diabetes, and
heart and blood vessel disease.

Insulin resistance Type 2 diabetes typically begins with insulin

resistance, a condition in which muscle,
liver, and fat cells do not use insulin well. As
a result, the body requires more insulin to
help glucose enter cells. At first, the
pancreas produces more insulin to keep up
with the added requirement. Over time, the
pancreas cannot make sufficient insulin, and
blood glucose levels rise.

Genes and family Specific genes may be more likely to

history acquire type 2 diabetes. The disease tends
to spread in families and happens more
often in racial/ethnic groups. Genes also can
enhance the opportunity of type 2 diabetes
by increasing a person’s tendency to
become overweight or obese.

HEART DISEASE

Unhealthy lifestyle Genetic factors can increase the risk of

choices increased heart disease, and unhealthy
lifestyle choices play a significant role.
Some unhealthy lifestyle decisions that can
contribute to heart disease include a
sedentary lifestyle, not getting enough
physical exercise, eating an unhealthy diet
high in fat proteins, trans fats, sugary foods,
sodium, etc.

Depression and heart Studies have explained that people with

disease depression develop heart disease at higher
 rates than the general population.
Depression can lead to several changes in
the body that can increase the risk of
acquiring heart disease or having a heart
attack. Too much stress, constantly feeling
sad, or both may elevate the blood
pressure.

Link between heart The National Institute of Diabetes and

disease and type 2 Digestive and Kidney measures that people
diabetes with type 2 diabetes — particularly those
who reached middle age — are twice as
likely to have heart disease or undergo a
stroke than people who do not have
diabetes. Adults with diabetes tend to have
heart attacks at a younger age. They are
more likely to encounter multiple heart
attacks if they have insulin resistance or
high blood glucose levels.

iii. Symptomatology

SIGNS/SYMPTOMS PRESENT JUSTIFICATION

DIABETES MELLITUS

TYPE 1 Increased thirst, frequent urination, bed-

wetting in children who previously didn't wet
the bed during the night, extreme hunger,
unintended weight loss, irritability and other
mood changes, fatigue and weakness, and
blurred vision

TYPE 2 Increased thirst, frequent urination, bed-

wetting in children who previously didn't wet
the bed during the night, extreme hunger,
 unintended weight loss, irritability and other
mood changes, fatigue and weakness,
blurred vision, slow-healing sores, frequent
infections, numbness or tingling in the hands
or feet, and areas of darkened skin, usually
in the armpits and neck

HEART DISEASE

Symptoms of heart Coronary artery disease symptoms may be

disease in your blood different for men and women. For example,
vessels men are more likely to have chest pain.
Women are more likely to have other
symptoms and chest discomfort, such as
shortness of breath, nausea, and extreme
fatigue. Signs and symptoms can include
chest pain, chest tightness, chest pressure
and chest discomfort (angina), shortness of
breath, pain, numbness, weakness or
coldness in your legs or arms if the blood
vessels in those parts of your body are
narrowed, pain in the neck, jaw, throat,
upper abdomen or back.

Heart disease The heart may beat too fast, too slowly, or
symptoms caused by irregularly. Heart arrhythmia signs and
abnormal heartbeats symptoms can include: fluttering in the
(heart arrhythmias) chest, racing heartbeat (tachycardia), slow
heartbeat (bradycardia), chest pain or
discomfort, shortness of breath,
lightheadedness, dizziness, and fainting
(syncope) or near fainting.

Heart disease People born with severe heart defects

symptoms caused by (congenital heart defects) usually are
heart defects noticed soon after birth. Less severe
 congenital heart defects are often not
diagnosed until later in childhood or during
adulthood—signs and symptoms of
congenital heart defects that usually are not
immediately life-threatening (Mayo Clinic,
2018).

iv. Schematic Diagram

v. Narrative
People are more likely to develop type 2 diabetes if they are not physically active and
are overweight or obese. Insulin resistance is a condition in which muscle, liver, and fat cells do
not use insulin well. As a result, the body requires more insulin to help glucose enter cells. The
disease tends to spread in families and happens more often in racial/ethnic groups.

Genetic factors can increase the risk of increased heart disease, and unhealthy lifestyle
choices play a significant role. Studies have explained that people with depression develop
heart disease at higher rates than the general population. Moreover, adults with diabetes tend to
have heart attacks at a younger age. They are more likely to encounter multiple heart attacks if
they have insulin resistance or high blood glucose levels.

COURSE IN THE WARD/TREATMENT/INTERVENTIONS

i. Medical Management

1) Doctor’s Progress Notes

PROGRESS NOTES DOCTOR’S ORDER RATIONALE

Dr. Liza Dela Cuesta

DAT ● Diet as tolerated is indicated for patients in

Date/Time relation to surgery. Once a surgical procedure
October 10, 2021 is complete, individuals are given only liquids,
@ 1:00 AM such as water and foods that she can tolerate.
 (Wickham, 2011)

IVF: D5LR 1L @ 120 ● This is used for blood loss and to restore fluid
cc/hr volume as to provide an open line for
emergency medication. (Silbert-Flagg &
Pillitteri, 2018)

Hook to EFM ● A woman who is worried something will

happen to her child during labor can find it
reassuring to listen to the regular beeping
sound of an undistressed fetal heartbeat from
a fetal heart transducer. Aside from that, this
would also allow the nurses to monitor the
status of the fetus. (Silbert-Flagg & Pillitteri,
2018)

Monitor progress of ● To detect labor that is becoming abnormal or

labor prolonged. (Silbert-Flagg & Pillitteri, 2018)

FHT q hourly ● A fetus is subjected to extreme pressure by

uterine contractions and passage through the
birth canal, so it is important to ascertain the
FHR remains within normal limits despite
these pressures. (Silbert-Flagg & Pillitteri,
2018)

VS q4H ● Continuous assessment of the vital signs

provides a baseline for future comparison and
evidence of the patient’s status. (Silbert-Flagg
& Pillitteri, 2018)
 Clinical Laboratories:

CBC ● To help physicians evaluate the overall health

of a patient and to detect any sort of patient’s
disorder, such as leukemia or anemia, which is
often due to lower red blood cells. (Doctors,
2021)

Blood typing ● Blood type is documented because blood may

have to be made available if a woman has
bleeding during pregnancy and to detect the
possibility of ABO and Rh isoimmunization.
(Silbert-Flagg & Pillitteri, 2018)

Urinalysis ● To analyze the specimen for appearance,

presence of glucose, specific gravity, and
microscopic analysis. (Silbert-Flagg & Pillitteri,
2018)

HBsAg ● To determine whether a woman is protected

against diseases such as rubella, hepatitis B
and C virus, and varicella (chickenpox).
(Silbert-Flagg & Pillitteri, 2018)

COVID-RAT ● It is essential to avoid admission of patients

with undetected coronavirus disease and to
exclude COVID-19 in critical areas such as
hospital general wards. (Teichgräber &
Neumann, 2021)

Postpartum Order:

Date/Time To recovery room ● Women after birth are transferred to a

October 11, 2021 recovery room where they remain for the
@ 6:00 AM length of their hospital stay. (Silbert-Flagg &
Pillitteri, 2018)

DAT ● Diet as tolerated is indicated for patients in

relation to surgery. Once a surgical procedure
is complete, individuals are given only liquids,
such as water and foods that she can tolerate.
(Wickham, 2011)

Insert IVF of PNSS 1L ● Because oxytocin can elevate BP by causing

and incorporate 20 vasoconstriction, it may be safer to allow the
units of oxytocin to fluid to remain behind for a time since oxytocin
run @ 40 drops/min has a short duration of action, approximately 1
hour, so piggybacking the solution to a
maintenance IV solution such as Ringer’s
lactate allows for accurate and safe dosing.
(Silbert-Flagg & Pillitteri, 2018)

Secure packed Red ● Blood transfusion to replace blood loss with

blood cell, 1 unit and postpartal hemorrhage is often necessary. In
transfuse after proper most agencies, blood typing and cross-
cross-matching matching is done when a woman is admitted
to the labor service so blood can be rapidly
cross-matched. (Silbert-Flagg & Pillitteri, 2018)

Insert Foley catheter ● If the woman still hasn’t been able to void by 4
and attached to Uro- to 8 hours after birth, and bladder distention is
bag present, she will need to be catheterized to
relieve bladder pressure. (Silbert-Flagg &
 Pillitteri, 2018)

Manual removal of ● If bimanual compression and administration of

retained placental uterotonics (drugs to contract the uterus) are
fragments not effective at stopping uterine bleeding, the
woman may be returned to the birthing room,
so that her uterine cavity can be explored
manually. (Silbert-Flagg & Pillitteri, 2018)

O2 inhalation @ 2LPM ● If the woman is experiencing respiratory

via nasal cannula distress from decreasing blood volume,
administering O2 inhalation via nasal cannulas
will provide a concentration of approximately
50%, with an oxygen flow of 4 L/min. (Silbert-
Flagg & Pillitteri, 2018)

Carboprost ● This is used to treat excessive bleeding after

tromethamine childbirth and patients with poor uterine
intramuscular STAT contraction, which could impede the delivery of
the placenta. (Silbert-Flagg & Pillitteri, 2018)

Clinical Laboratories:
CBC STAT ● Postpartum CBC should be performed when
indicated according to risk factors for
excessive blood loss or patients' complaints.
(Dar & Sheiner, 2006)

ABO and RH/blood ● Blood typing is important sto monitor the shifts
type in fluid and electrolytes that occur, and to
 detect the possibility of ABO and Rh
isoimmunization. (Silbert-Flagg & Pillitteri,
2018)

HBsAg ● To determine whether a woman is protected

against diseases such as rubella, hepatitis B
and C virus, and varicella (chickenpox).
(Silbert-Flagg & Pillitteri, 2018)

CBR without BRP ● Complete bed rest without bathroom privileges

is necessary as this may appear to stop the
vaginal bleeding, and prevent vaginal blood
collection and reappearance of bleeding.
(Silbert-Flagg & Pillitteri, 2018)

Medications:

Sultamicillin 750 mg ● Treatment of susceptible infections particularly

tab BID x 7 days PO in settings where women are at higher risk of
puerperal infectious morbidities. (Silbert-Flagg
& Pillitteri, 2018)

Fe SO4 (Feosol) 300 ● This is administered because iron stores tend

mg BID to remain low after childbirth, especially if
there is significant blood loss during the
delivery and additional iron is not consumed in
sufficient quantities. (GENEVA, 2016)
Ascorbic Acid (Cecon) ● Iron is absorbed best with an accompanying
500 mg OD acid medium, so ascorbic acid may also be
prescribed to increase absorption. (Silbert-
Flagg & Pillitteri, 2018)

Ranitidine (Zantac) 150 ● This is administered to neutralize the level of

mg tab BID PO acid in stomach contents and is necessary
because the woman will be expected to be
lying on her back after childbirth due to fatigue
and perineal pain making esophageal reflux
and aspiration highly possible. (Silbert-Flagg &
Pillitteri, 2018)

Metoclopramide ● Nausea and vomiting are common side effects

(Plasil) 10 mg tab PRN of anesthesia, so an antiemetic such as
for vomiting PO metoclopramide (Reglan) may be
administered to counteract nausea. (Silbert-
Flagg & Pillitteri, 2018)

Oxytocin (Syntocinon) ● Administration of oxytocin or uterotonics may

10 “u” incorporate to be necessary to initiate uterine tone and halt
present IVF the bleeding caused by uterine atony or a
retained placental fragment. (Silbert-Flagg &
Pillitteri, 2018)

Methylgometrine ● This is used to increase uterine contraction to

(Methergin) 1-tab TID x aid for the delivery of the placenta and to
3 days PO guard against hemorrhage. (Silbert-Flagg &
Pillitteri, 2018)

Ketorolac (Toradol) 10 ● Ketorolac decreases pain scores and opioid

 mg q 6 hours PO use after childbirth when administered in
scheduled doses during the first 24 hours’
post-surgery. (Williams & Wu, 2019)

Postpartum Order:
Date/Time
Hot sitz bath ● They are especially recommended for women
October 12, 2021
who have recently given birth vaginally as the
@ 6:00 am
temperature of the water used in a sitz bath
increases blood flow to the perineal area and
promotes faster healing. (Kay, MD, 2019)

Due to void 10:55 AM ● To check and assess carefully for the

presence of edema, which is caused by the
pressure of birth. (Silbert-Flagg & Pillitteri,
2018)

Insert Foley catheter ● Because the bladder was handled and

displaced during surgery, its tone or ability to
sense filling may be inadequate to initiate
voiding, so to ensure good urine drainage, a
Foley catheter is inserted. (Silbert-Flagg &
Pillitteri, 2018)

May give Ketorolac IV ● For women with IBD, Ketorolac should be

now and PRN for considered for pain management in the
severe pain (1PM) postpartum period, to optimize pain control
and allow for reducing opioid use. (Johnson &
Rekawek, 2021)

MGH Order:
Date/Time Internal Examination ● An internal examination prior to discharge is
October 13, 2021 prior to discharge performed to be certain involution is complete,
@ 6:00 AM the ligaments and the pelvic muscle supports
 have returned to functional alignment, and any
lacerations sustained during birth have healed.
(Silbert-Flagg & Pillitteri, 2018)

To come back after 1 ● To ensure herself and her healthcare provider

week with CBC that she is in good health and has no residual
laboratory results at problems from her pregnancy or signs of
OPD postpartum depression. (Silbert-Flagg &
Pillitteri, 2018)

Take home meds:

Sultamicilliin 750 mg ● Continuous treatment of susceptible infections
cap BID x 2 days more particularly in settings where women are at
higher risk of puerperal infectious morbidities
(Silbert-Flagg & Pillitteri, 2018)

Mefenamic acid 500 ● This medication is used for the relief of acute
mg cap q6 PRN for postpartum pain. (Cunha, DO, FACOEP,
pain 2021)

Ferrous sulfate 300 mg ● This is administered because iron stores tend

tab OD x 1 month to remain low for several months after
childbirth, especially if there is significant blood
loss during the delivery and additional iron is
not consumed in sufficient quantities.
(GENEVA, 2016)

2) Laboratory/Diagnostics Examination (tubular)

PROCEDURE PURPOSE NORMAL RANGE RESULT NURSING

MANAGEMENT
CBC (Complete A complete blood Hemoglobin: 120- Hemoglobin: 100.00 PRE-PROCEDURE:
Blood Count) count, including 140
Hematocrit: 0.30 1. Provide privacy.
hemoglobin or
Hematocrit: 0.37-
hematocrit and red Erythrocytes: 4.0 2. Explain the
0.45
Date Required: cell index to procedure and purpose.
determine the Erythrocytes: Leukocytes: 6.08
10/10/21 1:03 am 4.5-
presence of anemia, 5.0 3. Inform the patient
Thrombocytes: 179.00
Draw date & time: a white blood cell about the discomfort
10/10/21 1:03 am count to determine Leukocytes: 5.0- · Neutrophil: 0.52 felt when the skin is
infection, and a 10.0 punctured.
platelet count to · Lymphocytes: 0.30
Thrombocytes: 140- 4. Ask the patient about
estimate clotting
440 · Monocytes: 0.09 her maintenance
ability.
medications.
· Neutrophil: 0.55- · Eosinophils: 0.08
0.65 5. Encourage the
· Basophils: 0.01
patient to avoid stress
· Lymphocytes:
Absolute Neutrophil: as this will affect the
0.35-0.45
3.16 results.

·Monocytes:0.06-
Absolute Lymphocytes: INTRA-PROCEDURE
0.12
1.82
6. Perform hand
· Eosinophils:
Absolute Monocytes: washing.
0.02-0.04
0.55
7. Clean the area
· Basophils: 0-0.02
Absolute Eosinophils: before inserting the

Absolute 0.49 needle.

Neutrophil: 1.8-7.8
Absolute Basophils: 8. Apply direct pressure
Absolute 0.06 and gauze over the

Lymphocytes: 1.0- puncture site and put

MCV: 87.34 adhesive bandage to
4.8
stop the bleeding.
MCH: 28.6
Absolute
 Monocytes: 0.0- MCHC: 327.5 POST-PROCEDURE
0.80
RDW: 12.60 9. Send the blood to the
Absolute laboratory.
MPW: 10.10
Eosinophils: 0.0- 10. Evaluate the result.
0.45

Absolute Basophils: Result: Decreased

0.0-0.20 hemoglobin,
hematocrit, and
MCV: 80-97
erythrocytes may
MCH: 27.0-31.2 indicate anemia.
However, a mild
MCHC: 318-354
anemia is normal

RDW: 11.5-14.5 especially when the

MPV: 2-20 patient is pregnant.

Urinalysis A urinalysis is Physical Physical Examination PRE-PROCEDURE:

performed to test for examination:
Date Required: Color: Yellow 1. Explain the
proteinuria,
10/10/21 1:03 am Color - Yellow procedure and purpose.
glycosuria, and Character: Cloudy
Draw date & time: pyuria. All three of Character - Clear INTRA-PROCEDURE:
these can be done Reaction: 5.5
10/10/21 1:03 am
by means of test Reaction - 5.00 - 2. Assist patient to
Specific Gravity: 1.015
strips or microscopic 7.00 collect urine and
examination of the instruct the patient to
Specific gravity -
urine. void directly into a
1.005 - 1.025 Chemical Examination clean, dry container

Chemical Albumin: Negative and avoid having feces,

examination: discharges, or anything

Sugar: Negative that might contaminate

Albumin - the urine.
 NEGATIVE 3. Cover the cup tightly
to avoid being
Sugar – NEGATIVE Urine Flow Cytometry
contaminated and send

WBC: 52 it to the lab.

Urine Flow RBC: 3 POST-PROCEDURE

Cytometry
Epithelial Cells: 41 4. It should be tested in

WBC: 0-17 an hour.

Cast: 0 5. Report any abnormal
RBC: 0-11 findings and keep a
Bacteria: 271
record of the results in
Epithelial Cells: 0-
Result: Increased WBC your nursing records.
17
& Epithelial cells. The
Cast: 0-1 stress that comes
Bacteria: 0-278 during pregnancy may
cause the increase of
WBC. On the other
hand, increased
epithelial cells may
indicate urinary tract
infection (UTI).

To detect the SARS-COV-2 Result: SARS-COV-2

COVID-19 Test PRE-PROCEDURE:
presence of viral VIRAL RNA – Not VIRAL RNA – Not

Date collected: proteins (antigens) Detected Detected 1.Wears proper

10/04/21 8:40 pm expressed by the personal protective
COVID-19 virus. equipment and has
Date received:
appropriate infection
10/04/21 8:51 pm
control procedures.

Report date:
2.Obtain necessary
10/04/21 10 pm
information
 3. Explain the
procedure and purpose.

INTRA-PROCEDURE:

4. Perform hand
hygiene

5. Open the sampling

kit and remove the
swab from the
container being careful
not to touch the soft
end with your hand.

6.Insert a sterile swab

into the nostril of the
patient and then rotate
the swab 3-4 times
against the
nasopharyngeal
surface. Withdraw the
swab from the nasal
cavity.

POST-PROCEDURE

7.Interpret the result.

Hepatitis B Antigen These tests Result:

<0.13 – PRE-PROCEDURE:
HBsAg (Qualitative determine whether a NONREACTIVE - no
NONREACTIVE
woman is protected hepatitis B surface 1. Provide privacy.
against rubella if >0.13 - REACTIVE antigen was found.
exposure should 2. Explain the
occur during
procedure and purpose.
pregnancy and
whether a newborn 3. Inform patient about
will have a chance of side effects of a blood
developing hepatitis draw include discomfort
B. HBsAg testing or stinging when the
may be repeated at needle is inserted as
about 36 weeks. well as temporary
Antibodies for throbbing and bruising.
varicella
(chickenpox) may 4.Ask the patient if
also be assessed. a there are any
vaccine against medication he/she is
these diseases can taking, including both
then be offered in prescription and over-
the postpartum the-counter drugs.
period.
INTRA-PROCEDURE

5. Perform hand

washing.

6. Clean the area

before inserting the
needle.

7. An appropriate vein
is located, often on the
arm or hand.

8. A tourniquet may be
tied around the upper
arm to increase blood
flow.
 9. A small needle is
inserted into a vein and
blood is drawn into an
attached vial.

10. Collecting blood

often takes less than
five minutes. Once the
blood sample is
collected, a bandage or
piece of gauze is
applied to the puncture
site.

POST-PROCEDURE:

11. Send the blood to

the laboratory.

12. Evaluate the result.

Blood Typing Result: “O” Rh

Blood type is There are four main PRE-PROCEDURE:
POSITIVE
documented
blood groups. 1. Explain the
because blood may
procedure and purpose.
have to be made •A
available if a woman 2. Perform hand
has bleeding during A+; A-
washing.
pregnancy and to
•B
detect 3. Inform patient about
the possibility of Rh B+; B- the discomfort felt when
isoimmunization. the skin is punctured.
• AB
INTRA-PROCEDURE:
 AB+; AB- 4. Wrap a band around
the patient arm to see
•O
veins.
O+; O
5. Clean the injection
site to avoid infection.

6. Draw the blood and

get

a gauze to use for

stopping the bleeding.

POST-PROCEDURE:

7. Send the sample to

the lab and tell the
patient to wait since it
will only take minutes.

8. Give the results to

the patient.

3) Drug Study

4) Surgical Management

SURGICAL PROCEDURE INDICATION RESULT NURSING MANAGEMENT

Mediolateral Episiotomy Episiotomy is a planned Skin around the ● Apply sterile pad following
surgical incision made on episiorrhaphy is red thorough perineal flushing
the perineum and and draining a small ● Maintain perineal hygiene
posterior vaginal wall amount of ● Check for bleeding and urine
during late second stage seropurulent output
of labor in order to widen drainage. ● Change sanitary pads every
 the introits and straighten A moderate lochia 4 hours to help prevent
the lower end of the birth rubra was observed. infection
canal. This is done in an ● Encourage use of Sitz bath-
attempt to prevent tearing provide comfort, promotes
of the underlying muscle healing, reduces incidence
and fascia as the head is of infection
born. ● Use stool softener and
encourage a high fiber diet

NURSING MANAGEMENT
i. Nursing Care Plan

ii. Nurse’s Notes

iii. Clinical Reasoning Questions

iv. Discharge Plan

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