UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

Salinas Drive, Lahug, Cebu City 6000

College of Nursing

CARE OF POSTPARTUM MOTHER

(G7P7)

Submitted by:
Bitoon, Jeszel Imee C.
Borinaga Al Gino B.
Codilla, Sherlock Francis
Masayon, Merjuly
BSN IV

INTRODUCTION
Normal Spontaneous Vaginal
Delivery
It is the term used to describe the
delivery through the vagina. It implies
that the birth occurred without the
need for forceps, vacuum, or any other
instrumentation. This term does not
imply that every part of the birth was
without medical care or intervention.

 Lacerations (tearing of the tissues) can

occur during spontaneous vaginal delivery
and may require repair. A mother may
choose different levels of pain relief and still
experience a spontaneous vaginal delivery.
This is still the most common type of
delivery and that to which all other modes
of delivery are compared.

Puerperium

Phases:
I. Taking- in phase
II.Taking-hold phase
III.Letting- go phase

PHYSIOLOGIC CHANGES DURING THE POST-PARTUM PERIOD

Uterus
Involution involves sealing of the site where
the placenta was implanted to prevent
bleeding and return to its prepregnant state
After birth: 1000g
End of first week: 500g
After pains: intermittent cramping most
noticeable with breastfeeding and
multigravida

PHYSIOLOGIC CHANGES DURING THE POST-PARTUM PERIOD

Lochia
-Uterine flow consist of blood, fragments of
deciduous WBCs, mucus and some
bacteria
Vagina
-Soft with few rugae after vaginal delivery
-Hymen permanently torn
-Takes the entire postpartal time to involute

PHYSIOLOGIC CHANGES DURING THE POST-PARTUM PERIOD

Cervix
Soft and malleable after birth
End of 7 days: external os is
narrowed, atrophied and to about
size of the pencil and firm
External os appears slitlike or stellate

Perineum
Develops edema and generalized tenderness
Labia majora and minora remained soften after
birth
Urinary System
Extensive dieresis immediately after birth
Hydronephrosis (increased size of the ureters) for
about 4 weeks after delivery
Urine contains more nitrogen due to increase
muscle activity and breakdown of protein during
involution

Circulatory System
Blood volume is equal to prepregnant
state by the end of 1st and 2nd week of
puerperium
High levels of plasma fibrinogen during
postpartal weeks
Increased number of WBCs (as high as
30,000 cells/mm3)
Varicosities will recede

Gastrointestinal System
Digestion and absorption begin
to be active soon after birth
Bowel sounds are active
Passage of stool may be slow
due to the effect of relaxin

Integumentary System
Stretch marks will appear
reddened after delivery
Chloasma and linea nigra are
barely detachable in 6 weeks
time
Hormonal System
HCG and HPL are negligible
by 24 hours
Progestin, estrone and

Vital Signs Changes

Temperature
Slight increase in temperature during the first 24
hours because of dehydration during labor
Temperature rises for a few hours during the 3rd or
4th postpartum days when the breast fill with milk
Pulse
Usually slightly slower than normal during
postpartal period
End of the first week, pulse rate will return to
normal
Blood Pressure
Decrease in BP can indicate bleeding
Elevation above 140 mmHg systolic during labor or
90 mmHg diastolic may indicate postpartal
pregnancy-induced HPN

Progressive Changes
Lactation
The formation of breast milk (lactation) begins in a
postpartal woman whether or not she plans to
breastfeed
Breast milk forms in response to the decrease
estrogen and progesterone levels that follows the
delivery of the placenta (which stimulates prolactin
production, and consequently, milk production)
Return of menstrual flow
With the delivery of the placenta, the production of
placental estrogen and progesterone ends. The
resulting decrease in hormone concentrations
causes a rise in production of FSH by the pituitary,
which leads with only a slight delay, to the return
of ovulation. This initiated the return of normal
menstrual cycles.

EPISIOTOMY
A surgical Incision of the perineum
used to enlarge the vaginal outlet
It is used to prevent the perineum
from tearing, which can occur with
birth
It helps to release the pressure on
the fetal Head that accompanies
birth

TYPES:
Median/ Midline involves the incision thats
made in the middle of the perineum. It is
advantageous because it is associated with
easier healing, decreased blood loss ,and
decreased postpartum discomfort.
Mediolateral -involves an incision begun at the
midline and then angled to one side away from
the rectum. It is also advantageous because of
the decreased risk of rectal mucosa tears.

LACERATIONS
First degree skin around the vaginal
opening. It requires no medical
treatment and heals within a few
weeks.
Second degree vaginal tissue and
the perineal muscles. It requires
stitches but usually heal within a few
weeks

LACERATIONS
Third degree vaginal tissues, perineal
muscles and the anal sphincter. It
requires surgical repair and usually
heals within 4 to 6 weeks.
Fourth degree perineal muscle, anal
sphincter, and the tissues lining the
rectum. It needs surgical repair and
heals within months.

LACERATIONS
Third degree vaginal tissues, perineal
muscles and the anal sphincter. It
requires surgical repair and usually
heals within 4 to 6 weeks.
Fourth degree perineal muscle, anal
sphincter, and the tissues lining the
rectum. It needs surgical repair and
heals within months.

General Information or Patient's Profile

Name
: Mongaya, Elizabeth

Age
: 36 years old

Sex
: Female

Civil Status
:Married

Address
: Kalunasan, Cebu City

Occupation
: unemployed/housewife

Nationality
: Filipino

Religion
: Roman Catholic

Ward and Bed #

: OB Ward LRU #7

Date and Time of admission: October 1, 2015 12:35am

Admitting Diagnosis
: G7P7 PU del ceph by NSD

Chief Complaints
: post-partal pain

Pertinent Nursing Health History

History of Present Illness

Pregnancy was confirmed by using a pregnancy test.

Prenatal history was done at VCMMC-OPD and started at 3
months age of gestation and regular monthly check- ups
thereafter as advised. Patients LMP was 12/02/2014 and
EDC was on 9/1/2015. She was not given any immnunization
during her pregnancy. She didnt experience any illnesses
during her pregnancy. The obstetrics resident doctor had
prescribed multivitamins + iron, vitamins C, E, and B
complex, and folic acid (C: multivitamins A: nutritional
supplement) 1 capsule once a day after meals taken orally.
All medications were taken with good compliance. She drinks
2 glass of milk (Anmum) a day; one glass in the morning and
another glass at night before retiring to bed, which was also
prescribed.

5 hours PTA, patient felt pain on the

hypogastric area. The pain was
irregular, and was relieved by walking
with a pain scale of 9/10 with 10 as the
highest, mild to moderate contractions.
1 hour PTA, patient then urged her
husband to accompany her to the
hospital due to unbearable pain and the
rupture of bag of water, thus the
admission. She delivered a live baby girl
via normal spontaneous vaginal
delivery.

Previous Hospitalizations

Client claims that she has been hospitalized before at Vicente Sotto
Memorial Medical Center for also delivering her previous children.

Family History

Client claims that her father is a known hypertensive and no one

else in her family has it.

Medical History

Upon asking about previous drug usage, client shakes her head 'no'.
Upon asking about her alcohol intake, she claims that she only
drinks 2-3 glasses of beer occasionally.

Developmental Task:

Patient ME is a 36 year old female,

married and a resident of Calunasan
Cebu, falls under the 7th stage of Erik
Eriksons psychosocial development:
Middle
adulthood,
35-65.
Genarativity vs. self absorption or
stagnation.

During this period of time, adults strive to create or nurture

things that will outlast them; often by having children or
contributing to positive changes that benefits other people.

Contributing to the society and doing things to benefit

future generations are important needs at the generativity
vs. stagnation stage of development stage of development.
Generativity refers to making your mark on the world,
through caring for others, creating things and accepting
things that make the world a better place. Stagnation refers
to the failure to find a way to contribute. These individuals
may feel disconnected or uninvolved with their community
and with society as a whole.

Erikson believed that those who are successful during

this phase will feel that they are contributing to the world
by being active I their home and community. Those who fail
to fail to attain will feel unproductive and uninvolved in the
world.

GORDON'S FUNCTIONAL HEALTH

PATTERNS

Health Perception and

Health Maintenance
Before Hospitalization
Considers herself healthy and strong,
as verbalized.
himsog man jud ko og lawas, dili man
kaayo ko masakiton.. usahay ubhon,
pero pila ra sab ka adlaw, as
verbalized by the patient.

Health Perception and

Health Maintenance
During Hospitalization
Considers her health as luya jud ko
karon kay bag-o pa ko na nganak,
pero pila ra siguro ka adlaw, ma balik
ra akong pamati pareha sauna

takes medications as prescribed

Nutrition and Metabolism

Before Hospitalization
Eats 3x a day with afternoon snacks; for
breakfast, she usually eats rice, vegetables
and fish; for Lunch and Supper, she usually
eats rice, fish (most of the time dried &
salted), vegetables, and sometimes pork
Drinks plenty of water, not so much of soft
drinks.
Drinks alcoholic beverages occasionally

Nutrition and Metabolism

After Hospitalization
On full diet or on DAT
For breakfast, she would usually take meals
served by the dietary department of the hospital
claimed that she does not have any changes in
appetite, kusog man gihapon ko mu kaon karon,
pero usahay ma dugay ko kay mag atiman man
ko sa akong baby, as verbalized

Elimination
During Hospitalization
Urinates at least 5x daily; voids freely;
def
ecates once daily.
After Hospitalization
Urinates at least 3-4x daily; voids
freely; defecation pattern is once
every other day.

Activity and Exercise

During Hospitalization
Claims that she is a housewife
her activities includes washing the clothes,
cleaning the house, and going grocery
shopping at the market
After Hospitalization
Claims that she cannot move that much
because of pain due to episiorraphy,
verbalizes sakit man kaayo akong tahi
kung mag lakaw-lakaw ko, gi tahian man
gud ko pag pa nganak nako
kapoy kaayo akong lawas as verbalized

Cognition and Perception

During Hospitalization
Client claims that she does not have any
memory problems
able to read and write without any
difficulties
After Hospitalization
Client was able to recall her own birthday
and when she gave birth to her recent
childbirth
able to respond to questions without any
difficulty

Sleep and Rest

During Hospitalization
Client claims she used to sleep around 10pm
after watching television and wakes up at
5:30am to prepare breakfast for her family
Seldom take naps during the day.
After Hospitalization
Putol-putol akong katug kay lisud kaayo i katug dire tungod sa ka - banha, ka - alimuot,
ug sa pag huna - huna sa mga prob-lema, sa
akong kahim-tang.. mag mata-mata man sab
ko kay mu hilak man akong anak, kailangan
akong pa totoyon jud as verbalized.

Sexuality and
Reproduction
Client claims that

she got married to her

current husband at the age of 17 and has 7
children with him
she had her menarche when she was just 14
years old
Client has had her 7th child
claims she has used contraceptive methods
such as pills and IUD

Self-Perception and SelfBefore

Hospitalization
Concept

Client claims that she is content with her life

and family even though sometimes there are
financial problems
During Hospitalization
Client claims that she is very happy with her
baby girl and is excited to go home
Expressed concerns about the needs of her
other children while shes in confined in the
hospital

Roles and Relationship

Client claims that she has a good relationship
with her husband, 'usahay mag away mi
bahin sa kwarta, pero ma sulbad ra man
dayon', as verbalized. She claims that she is
very friendly and trustworthy.

Stress Tolerance and

Coping

She stated that whenever he had problems,

she tells her mother and her sister about her
problems
She stated that talking to other patients in the
ward is therapeutic; it is provides diversion
from feeling of boredom, and pain.

Values and Belief

Client claims that she is a catholic and goes to
church with her whole family when she can. She
prays to God before eating and before going to
bed.
Client stated that her child is another gift from
God and is very happy to have the baby.

Female

Male
Mother
Father
Patient
Son
Daughter
Newborn Inf
Hypertensio

(FERTILIZATION)
All spermatozoa that achieve
capacitation reach the ovum
and releases hyaluronidase to
dissolve the ovums layer

Union of a
spermatozoon(23) and
ovum(23)

Peristaltic action
and movements of
the cilia propels
ovum to the tube

Zygote is formed (46

chromosomes)
After ejaculation,
sperm cells travel
by means of
flagella through
the cervix into the
fallopian tube

Implantation (8
to10 days after
fertilization)

Zygote secretes
HCG
Releases
progesterone,
estrogen,
relaxin, inhibin

Keeps corpus
luteum alive for
another 16-20
wks.

Zygote migrates towards the body

of the uterus

Cleavage begins
When it reaches the uterus,
becomes morula(16 to 50 cells)
Continues to multiply and
becomes a blastocyst(the
structure that attaches to the
uterine endometrium

Ovum ruptures
out from the
graafian follicle

Placenta develops
takes over when
corpus luteum
degenerates 16-20
weeks after

Becomes the
embryo until 5 to
8 weeks
Fetus: From 5 to 8
weeks until term

Fetal growth milestones

and development

Fetus becomes mature

to cope with extrauterine
life
Rising fetal cortisol
levels, which reduce
progesterone formation
and increase
prostaglandin formation

Placental age,
which triggers
contractions
at set point

estroge
n

progestero
ne

relaxin
HPL

Fetal membrane production of

prostaglandin, which stimulates
contractions

First stage of labor:

Cervical Dilatation and
Effacement

3
4

Latent
Phase
Uterine muscle
stretching,
which results in
release of
prostaglandin
Pressure on the
cervix which
stimulates the
release of
oxytocin
Oxytocin
stimulation, which
works together
with prostaglandins
to initiate
contractions

Active
Phase
Transitional
Phase
Second stage of labor:
Expulsion Stage

Third Stage:
Placental
Expulsion

NSVD

Dilatation:0-3cm Effacement:
0-40%
Dilatation:4-7cm Effacement:
50-80%
Dilatation:8-10cm Effacement:
90-100%
Cardinal movements of labor:
-Engagement
-Descent
-Flexion
-Internal rotation
-Extension
-External rotation

Vascular
and
edematou
s cervix

ESTRO
GEN

Increased
vascularity

Softening of
cervix
Hegars Sign
Darken to
violet hue

Pressure on veins and

bladder

Uterine
enlarge
ment

Push intestine and

stomach towards the back
Diaphragm
displacement

Striae
gravidarum
Hemorrhoids and
urinary frequency
Slow peristalsis &
emptying time of
stomach

SOB
Heartburn &
constipation

Decrease blood flow on

lower extremities

Hypertrophie
d vaginal
epithelium;
enriched with
glycogen

Butter in
consistenc
y

Ripening of cervix

Rupture of small segments

of the connective layer of
skin

Increase

Increased
fluid between
cells

Increase
activity
Increase
circulation

White
discharges
Deep violet
color

Palmar erythema, stuffy nose, clotting factors, WBCs

Increase saliva formation

Lactobac
illus
acidophil
us
thrives
Chadwicks
sign

Decrease
pH in the
vagina

Sets a new level in the

hypothalamus for
acceptable blood CO2
levels

Allows CO2
to cross
readily

Increased
ventilation

May lead to
respiratory
alkalosis

Endometrial
integrity
2

Increase
PROGESTER
ONE

Slight increase in
body temperature
Response of RAA
system and
aldosterone but also
a potassium sparing

Kidneys excrete
plasma
bicarbonate in
urine
polyuria
Fluid
retention

Breast
development for
lactation
Diameter of ureters
and
bladder
capacity
Inhibit uterine
contractility

Has an effect on
smooth muscle

Less active
intestine

3
RELAXIN

Decrease gastric
motility

Enlarges birth
canal

Softening of cervix and

collagen

Dilatation at delivery

HPL

More glucose to be
available for fetal growth

Antagonist to
insulin

5
30 to 50%
increase in blood
volume
pseudoanemi
a

CO and

HR

Maintain adequate
supply of placenta

Increase Iron
needs

Increase
blood
perfusion

Increase
GFR

Increase filtration
of glucose into
renal tubules but
constant
reabsorption

glycosuri
a

Estrogen
and
progesteron
e

Halts the
production of LH
and FSH
amenorrh
ea

PPG increases the

production of
growth hormones
and melanocyte
stimulating
hormone

Extra
pigmentation:
linea nigra and
melasma

Late in pregnancy,
PPG produces:

Oxytocin to
aid in labor

Prolactin to prepare
for lactation

Acute pain related to episiorraphy secondary to normal spontaneous vaginal delivery as manifested by patient's
guarding behavior and gramaced facial expressions
Significant Findings

Scientific Basis

Expected
Interventions
Actual Outcomes
Outcome
Subjective:
Additional
complications Within 8 hours of 1.Assessed for characteristics of pain Oct. 1,2015 patient
sakit
kaayu
akong associated
with
an nursing
care, (location, onset, duration, characteristics, still complained of
tinahian
episiotomy
may
be client will be able etc.)
pain on incision site
8/10
infection,
blood
loss, to report relief of R: To note degree of impairment & at perinum with a
Objective:
facial perineal discomfort and pain,
precipitating on contributing factors
pain scale of 8/10,
grimacing,
guarding pain that may continue for demonstrate non- 2.Assessed incision site for any swelling, medication for the
behavoir
days or weeks past birth pharmacological discharges and redness.
relief of pain was
including
dyspareunia. methods
to R: This can influence the amount of pain taken
with
good
(Maternal-Newborn
relieve
pain, and presence of known complications, compliance
Nursing 5th edition by Olds, follow prescribed making
pain
more
severe
than Oct.2 client claimed
London
and
Ladewig, pharmacological anticipated.
that pain decreased
p.769)
regimen
3.Observed non-verbal cues such as how and described it as
client walks, sits, facial expressions.
ngul-nguol, with a
R: To evaluate clients response to pain. pain scale of 6/10
4.Monitored vital signs.
Oct. 3, 2015 patient
R: Vital signs are usually altered in acute does not complain of
pain.
pain and verbalized
5.Promoted an environment that is calm mu ngul-ngul sya
and quiet and is conducive for rest and basta dako akong
sleep.
tikang with a pain
R: Rest periods aid in reducing pain and scale of 2/10
prevent fatigue.
6.Encouraged diversional activities like
talking to SO or to other patients.
R: Refocuses attention and may promote
coping activities.
7.Encouraged comfort measures such as
change in position, use of pillows and
back rub
R: To assist client to explore methods for
control of pain.
8.Encouraged
use
of
relaxation
techniques such as deep breathing
R: To assist client on how to alleviate
pain.
Collaborative Interventions:
Administration of Mefenamic Acid 500
mg/tab.
R: Non steroidal anti-inflammatory drug
for relief of pain.

Risk for infection related to episiorraphy secondary to normal spontaneous vaginal delivery as manifested by sutures on perinum site

Significant Findings

Scientific Basis

Expected
Outcome

Interventions

Actual Outcomes

Subjective:
gi tahian man ko pag pa
nganak nako
Objective: presence of
sutures on perinium site

An
episiotomy
is
a
surgical incision of the
perineal body that is
done to protect the
perineum, sphincter and
rectum from lacerations
during
birth
and
to
decrease
duration
of
labor. (Maternal and Child
Nursing by Pilliteri, 4th
edition, p.512)

Within 3 days of
nursing
care,
client
will
participate
in
preventive
measures
for
infection,
maintain optimal
nutrition
and
physical
wellbeing, vmanifest
no
signs
of
infection

1.Encouraged to
change in
position in bed or chair on a
regular schedule.
R: To maintain skin integrity at
optimal level
2.Assessed color, condition of
surrounding skin, any swelling,
redness and discharges.
R: Provides baseline information
about circulation of blood in the
skin and monitor any signs of
infection.
3.Kept bed clothes dry, nonirritating and kept bed wrinklefree.
R: To increase circulation and
alter or eliminate excessive
tissue pressure.
4.Kept episiorraphy clean and
dry.
R: To prevent bacterial growth
and infection.
5.Stressed proper hand washing
to all care-givers including S.O.
R: To reduce risk of crosscontamination.
6.Encouraged optimum nutrition
to aid in healing and to maintain
general good health.
R: Provides a positive nitrogen
balance to aid in healing and to
maintain general good health.
Collaborative Interventions:
1.Perineal care twice a day
R: To clean site and prevent
infection.

Oct. 1-3, 2015 after 3

days
of
nurse-patient
interaction,
the
client
complied
with
health
teachings given to prevent
infection and there were
no signs of infection such
as redness, swelling, pain,
and abnormal discharges
on episiorraphy site

Disturbed sleep pattern related to uncomfortable sleeping environment as manifested by day-time drowsiness, frequent yawning
, and appearing lethargic

Significant Findings

Scientific Basis

Expected Outcome Interventions

Actual Outcomes

Subjective:
Putol-putol akong katug
kay lisud kaayo i - katug
dire tungod sa ka banha, ka - alimuot, ug
sa pag huna - huna sa
mga prob-lema, sa akong
kahim-tang.. mag matamata man sab ko kay mu
hilak man akong anak,
kailangan
akong
pa
totoyon
jud
as
verbalized.
-claims to only sleep for
4-5 hours
-frequent yawning
Objective:
appears
lethargic

After birth, a woman is

paradox. Shes excited.
She has a baby and she
wants to be w/ this
person in her life. She
wants to talk to her
support person about the
experience. At the same
time, she is exhausted so
usually
fills
asleep
instantly. Covering the
woman
w/
a
warm
blanket offering her a
warm drink if shes not
nauseated
from
an
anesthetic, assuring her
that occurrence is normal
and are usually enough to
make the chill transient
and allow her to fall into
sound,
much
needed
sleep. Most women will
then sleep for at least an
hour.
(Maternal
and
Child
Nursing by Adelle Pillitery
p. 597)

Within 8 hours of
nursing care, client
will
be
able
to
identify appropriate
interventions
to
promote sleep and
able to adjust to her
new condition and
will
be
able
to
improve
her
sleep/rest pattern

Oct. 1,2015 patient

wasn't able to sleep
well because of the
need to attend to
her newboard and
because of the pain
she
was
experiencing.
She
was able to take
naps whenever her
baby was sleeping
Oct.2-3, 2015 after
8 hours of nursepatient interaction,
client appears to be
well
rested
and
claims that she was
able to sleep and
take naps while her
baby was also taking
a nap

1.Determine presence of physical

or psychological stressors.
R: To identify factors affecting
sleep.
2.arranged bed to promote an
environment conducive for sleep
R:
To
enhance
environment
conducive for sleep
3.Evaluate for use of medications
and/or other drugs affecting sleep.
R: To identify contributing factors
affecting sleep.
4.Provide calm, quiet environment
and manage controllable sleep
disrupting factors, and provide
comfort measures.
R: To establish optimal sleep
pattern.
5.Scheduled activity.
R: To provide adequate periods for
the patient to sleep.
6. Encouraged the SO to help in
taking care of the baby
R: To conserve energy
7.Encouraged the patient to rest
whenever not attending to her
babys needs.
R: to conserve energy and promote
comfort.

Fatigue related to stress from pregnancy, labor, childbirth and operation secondary to normal spontaneous vaginal delivery
as manifested by non-verbal cues such as drowsiness, weakness, tired appearance and verbalization of kapoy kaayo akong lawas

Significant
Findings

Scientific Basis

Expected
Outcome

Interventions

Actual
Outcomes

Subjective:
kapoy
kaayo
akong lawas as
verbalized
-claims
to
only
sleep
for
4-5
hours
-frequent yawning
Objective:
appears
lethargic/drowsy

Although a woman
needs activity and
movement
after
surgery,
she
also
needs adequate rest.
Many women attempt
to handle their own
and their newborns
needs
immediately
after
surgery,
because
their
excitement over their
baby and their new
role
makes
them
unaware
of
their
underlying
fatigue.
Extreme
fatigue
interferes
with
healing and possibly
increases the risk for
infection.
It
can
eventually
interfere
with bonding.
Source:
(Pillitteri,
Adele. Maternal and
Child Health Nursing.
5th Ed. Volume 1. Page
582)

Within 8 hours of
nursing care, client
will be able to report
improved sense of
energy by having
adequate
rest
periods, absence of
non-verbal
cues
such as drowsiness
and
tired
appearance

1. Noted presence of factors related to

fatigue
R: To identify basis of fatigue.
2.Encouraged several rest periods during
the day
R: During rest, energy is conserved and
levels are replenished. Several shorter
rest periods may be beneficial than one
longer rest period
3.Advised to increase sleep hours.
R: Sleep helps restore energy levels
4.Provided an environment conducive to
relief of fatigue such as quiet environment
and uninterrupted rest periods.
R: Temperature and level of humidity are
known to effect exhaustion and restores
energy needed for activity and cellular
regeneration/tissue healing.
5.Instructed methods to conserve energy
and planned steps of activity before
beginning so that all needed materials are
at hand.
R: To assist patient to cope with fatigue
and manage within individual limits of
ability.
6.Instructed in methods to conserve
energy (to sit instead of standing up).
R: To assist client to cope with fatigue.
7.Recommended to avoid intake of
chocolate and sodas and other foods
containing caffeine.
R: Caffeine may delay patients falling
asleep.

Oct. 3,2015
patient was able
to rest for long
periods of time
and claims that
she has more
energy than on
the first day after
labor

Activity Intolerance secondary to episiorraphy as manifested by perceived pain at the suture site and the verbalization o
f sakit man kaayo akong tahi kung mag lakaw-lakaw ko.

Significant
Findings

Scientific Basis

Expected
Outcome

Interventions

Actual
Outcomes

Subjective:
Claims that she
cannot move that
much because of
pain
due
to
episiorraphy,
verbalizes
sakit
man kaayo akong
tahi
kung
mag
lakaw-lakaw ko, gi
tahian man gud ko
pag
pa
nganak
nako
Objective:
facial
grimacing,
guarding behavoir

Episiotomy sutures
can cause
considerable
discomfort because
the perineum is an
extremely tender
area and the muscles
of the perineum are
involved in many
activities such as
sitting, walking,
stooping, squatting,
bending, urinating
and defecating.
Source:
(Pilliteri.
Maternal and Child
Health Nursing, 5th
ed. p 637.)

Within 8 hours of
nursing care, client
will be able to
accomplish
her
ADL's with some
assisstance

1. Noted reports of discomfort and pain

with its pain scale
R: These may contribute to intolerance of
activity
2. Ascertained ability to stand and move
around the room and the degree of
assistance
R: To determine current status and needs
associated in desired activities
3. Planned care to carefully balance rest
periods with activities.
R: To reduce fatigue.
4. Provided a therapeutic environment,
while acknowledging the situation of the
patient
R: To promote comfort.
5. Instructed to do deep breathing
exercise
R: To relieve pain.
6. Encouraged to verbalize any concerns
and needs for assistance
R: To reduce anxiety and to attend to her
needs
7.Assisted with meeting patients needs.
R: Personal care assistance is part of
nursing care and is essential to promote
the patients safety.

Oct. 3,2015
patient was able
to rest for long
periods of time
and was able to
accomplish her
ADL's
without
any assistance.
She claimed that
the pain in the
perinium
site
decreased.

Name
Generic name: Mefenamic
Acid
Brand name: Ponstel
1 cap 500mg BID PO

Classification
Analgesic; Non-steroidal
anti-inflammatory drug

MECHANISM OF
ACTION
Mefenamic acid
binds the
prostaglandin
synthetase
receptors COX-1
and COX-2,
inhibiting the
action of
prostaglandin
synthetase. As
these receptors
have a role as a
major mediator of
inflammation
and/or a role for
prostanoid
signaling in
activitydependent
plasticity, the
symptoms of pain
are temporarily
reduced.

Indication/
Contraindicatio
n
Indications:
Rheumato
id arthritis
Mild to
moderate
pain
Dental
pain
Postopera
tive pain
Dysmenor
rhoea
Osteoarth
ritis
Menorrha
gia
Contraindicati
ons:
Inflammat
ory
intestinal
diseases
Active
peptic
ulcers
Hypersen
sitivity to
aspirin
(acetylsali
cylic acid)
or other
nonsteroidal
antiinflammat
ory
agents
Renal
failure

Side Effect
-

Bloody nose
Black, tarry
stools
Blood in the
urine or stools
Vomiting blood
Red or purple
spots on the
skin.
Nausea
Fatigue
Yellowing of the
skin or whites of
the eyes
(jaundice)
Excessive
tiredness
Swelling of the
face or body
Blisters
Unexplained
skin rash
Wheezing
Difficulty
breathing
Chest pain
Shortness of
breath
Weakness on
one side of your
body
Slurred speech

Nursing Responsibilities
1.

2.

3.
4.

Assess patients who

develop severe diarrhea and
vomiting for dehydration
and electrolyte imbalance.
Discontinue drug promptly if
diarrhea, dark stools,
hematemesis, ecchymoses,
epistaxis, or rash occur and
do not use again. Contact
physician.
Notify physician if persistent
GI discomfort, sore throat,
fever, or malaise occur.
Lab tests: With long-term
therapy (not recommended)
obtain periodic complete
blood counts, Hct and Hgb,
and kidney function tests.

1. Right Drug
2. Right Patient
3. Right Dose
4. Right Route
5. Right Time & Frequency
6. Right Documentation
7. Right History and Assessment
(Complete patient drug/relevant
history)
8. Drug approach and Right to
Refuse
9. Right Drug-Drug Interaction
and Evaluation
(drug-food
incompatibilities/interaction)
10. Right Education and
Information
(Teach pt about the drug he is
taking)

Drug Data
GENERIC
NAME:
Cefuroxime
BRAND NAME:
Cefuroxime
axetil (ceftin)
Cefuroxime
sodium (Zinacef)
DOSAGE:
500 mg BID PO

Classification

Mechanism of
Action
Bactericidal:
Antibiotic
Inhibits synthesis of
Cephalosporin bacterial cell wall,
(second
causing cell death
generation)

Indication/Contraindic Adverse Effect

ation
INDICATION:
GI
Nausea; vomiting;
Treatment of
diarrhea; anorexia;
infections of lower
abdominal pain or
respiratory tract,
cramps; flatulence;
urinary tract, skin and colitis, including
skin structures;
pseudomembranous
treatment of
colitis.
uncomplicated
Genitourinary
gonorrhea, otitis
Pyuria; renal
media, pharyngitis,
dysfunction; dysuria;
and tonsillitis caused reversible interstitial
by susceptible strains nephritis; hematuria;
of specific
toxic nephropathy.
microorganisms.
Hematologic
CONTRA-INDICATION: Eosinophilia;
Contraindicated in
neutropenia;
patients
lymphocytosis;
hypersensitive to drug leukocytosis;
or other
thrombocytopenia;
cephalosporin.
decreased platelet
Use cautiously in
function; anemia;
patients
aplastic anemia;
hypersensitive to
hemorrhage.
penicillin because of
Hepatic
possibility of crossHepatic dysfunction;
sensitivity with other abnormal LFT results.
beta lactam
Miscellaneous
antibiotics
Hypersensitivity,
including StevensJohnson syndrome,
erythema multiforme,

Nursing Responsibilities
Before:
Assess for previous history
of reactions to
othercephalosporin
orpenicillin. ( Theres
possibility of crosssensitivity with other betalactam antibiotics)
Before giving the first dose,
obtain specimen for culture
and sensitivity test. (To
ensure right drug)
During:
Swallow tablets whole; do
not crush them. Take the
drug with food(Taking the
drug with food can mask
the taste of the medication)
Advise patient to maintain
normal fluid intake while
using this medication. (Fluid
ease swallowing and
facilitate absorption from
gastrointestinal tract)
After:
Be alert for adverse
reaction and drug
interaction(to establish
proper precautionary
measures and management
for possible adverse effects
of the drug)
If GI reactions occur,
monitor pts hydration(To
prevent dehydration)

Name

Classification Mechanism of Action

Indication /Contraindication

Name of
Vitamin A is effective Indications :
Drug: Vitamin Pharmacologi for
treatment
of Vitamin A injection is effective
A
cal drugs :
conditions such as for the treatment of vitamin A
Brand name: retinoid
acne
or
lung deficiency
Aquasol A
diseases,
or
for Contraindications:
Doze: 50,000
treatment
of
eye In
Pregnancy:Safety
of
USP Units (15
problems, wounds, or amounts
exceeding
6,000
mg
dry or wrinkled skin Units of vitamin A daily during
retinol/mL)
not caused by lack of pregnancy has not been
Time: Single
vitamin A has not established at this time. The
dose
been proven.
use of vitamin A in excess of
the recommended dietary
allowance may cause fetal
harm when administered to a
pregnant
woman.
Animal
reproduction studies have
shown
fetal
abnormalities
associated with over-dosage
in
several
species.
Malformations of the central
nervous system, the eye, the
palate, and the urogenital
tract are recorded. Vitamin A
in
excess
of
the
recommended
dietary
allowance is contraindicated
in women who are or may
become pregnant. If vitamin A
is used during pregnancy, or if
the patient becomes pregnant
while taking vitamin A, the
patient should be apprised of
the potential hazard to the
fetus.

Side Effects
Anaphylactic shock
and death have been
reported using the
intravenous
route.
Allergic
reactions
have been reported
rarely
with
administration
of
AQUASOL
AParenteral
including one case of
an
anaphylactoid
type
reaction.
Vitamin A toxicity
can cause growth
retardation, hair loss
and enlarged spleen
and liver in its more
severe form. Vitamin
A overdose can also
cause birth defects
and has been linked
to increased risk of
bone fractures in
some people.

Nursing
Responsibilities
>Teach the family
about the Vitamin A
toxicity
>Caution
pregnant
patient about the
taking of vitamin A
>Teach patient that
over consumption of
vitamin A can cause
nausea,
irritability
and blurred vision.
>Teach patient that
Vitamin A must be
avoided from direct
sunlight exposure
>Instruct
patient/family that if
there is a sign of over
dosage of vitamin A,
it must be reported
immediately to the
physician.

Name
Generic Name:
Multivitamins +
FeSO4
Patients Dose:
1 cap PO OD
Minimum Dose:
125 mg
Maximum Dose:
750 mg
Contents:
Fe sulfate 200 mg,
folic acid 400 mcg,
vit B12 mg, vit
B22 mg, vit B62
mg, vit B1210 mcg,
vit C 100 mg
Availability:
tablets: 150 mg,
300 mg, 500 mg
capsules: 300
mg, 500 mg
syrups:250
mg/5ml
Route/s for
Administration:
PO

Classification
Therapeutic
vitamins and
minerals;
antianemics
Pharmaco
logic:
water-soluble
vitamins; iron
supplements
Pregnancy
Category
Risk:
A

Mechanism of Action
Pharmacodynamics:
Chemical Effects
An essential mineral
found in hemoglobin,
myoglobin, and many
enzymes. Enters the
bloodstream and is
transported to the
organs of the
reticuloendothelial
system (liver, spleen,
bone marrow), where it
is separated out and
becomes part of iron
stores.
Therapeutic Effects:
Prevention/treatment of
iron deficiency
Pharmacokinetics
Absorption:
510% of dietary iron is
absorbed (up to 30% in
deficiency states).
Therapeutically
administered PO iron
may be 60% absorbed
via an active and
passive transport
process. Vitamins well
absorbed following
administration
Distribution:
Remains in the body for
many months. Crosses
the placenta enters
breast milk. Protein
Binding: 90%.
Metabolism &
Excretion:
Mostly recycled: smally
daily losses occurring
via sweat,
desquamation, urine and
bile.
Half-Life:
unknown

Indication/Contraindication
General Indication:
Prevention and treatment of
iron-vitamin and dietary
deficiency anemias. Used in
anemia due to blood loss during
menstruation, infections,
surgery, delivery, intoxications,
parasitosis or other causes and
anemias during pregnancy
Contraindicated in:
Hemochromatosis,
hemosiderosis, or other
evidence of iron overload;
Anemias not due to iron
deficiency; some products
contain alcohol, tartrazine or
sulfites and should be avoided
in patients with known
intolerance or hypersensitivity
Precaution:
Use cautiously in peptic ulcer;
ulcerative colitis or regional
enteritis (condition may be
aggravated); Alcoholism;
Severe hepatic impairment;
Severe renal impairment (oral
products); Pre-existing
cardiovascular dse; significant
allergies or asthma; rheumatoid
arthritis, pregnancy or lactation.
Interaction:
Drug-Drug:
Antacids that contain calcium
makes it harder for the body to
absorb certain ingredients of
the vitamins. Oral iron
supplements decrease
absorption of tetracyclines,
bisphosphonates,
fluoroquinolones,
levothyroxine,
mycophenoalte mofetil, and
penicillamine. Decrease
absorption of and may decrease
effects of levodopa and
methyldopa. Concurrent admin
of H2 antagonists, protonpump inhibitors and
cholestyramine may decrease
absorption of iron.
Drug-Food:
Iron absorption is decreased 3350% by concurrent
administration of food.

Adverse Effect
CNS: seizures,
dizziness,headache, syncope
CV: hypotension,
hypertension, tachycardia
GI: nausea, constipation,
dark stools, diarrhea,
epigastric pain, GI bleeding,
taste disorder, vomiting
Derm: flushing, urticaria
Resp: cough, dyspnea
MS: arthralgia, myalgia
Misc: staining of teeth,
anaphylaxis, sweating
Local: pain at IM site

Nursing Responsibilities
Before:
Monitor blood studies of pt.

Assess for intake of other

multivitamin products within 2

hours, may result to vitamin
overdose.

Observe proper dosage of

medication to prevent overdose
or toxic effect of the drug.
Assess for colostomy or

ileostomy.
Note other drug that the pt are

taking to avoid possible

interactions
Verify pt.s identity

During:
Most effectively absorbed if

administered 1 hour before or 2

hrs after meal.
Take tablets and capsules with

a full glass of water or juice.

Do not crush or chew enteric
coated tablets and do not open
capsules.
Avoid using antacids, coffee,

tea, dairy products, eggs within

1 hr after administration.
Inform pt. about dark, green or

black stools to avoid panic.

After:
Monitor pt.s blood studies

periodically thereafter to
determine the level of
effectiveness.
Inform pt of what the possible

adverse effects that may occur.

Provide brief information about

drug and its indications to be

guided and modify ADL and
prevent any doubts.
Assess bowel function for

constipation or diarrhea.
Advised pt. to notify.
Instruct pt to report

immediately any signs and

symptoms of severe adverse
effects that would arise for
prompt intervention.

Learning Objectives
After 30 minutes of
nursing health
education, client will be
able to:
-demonstrate proper
techniques for
successful, effective,
breastfeeding (time,
position, comfort)
-achieves effective
breastfeeding
-have adequate
information regarding
breastfeeding
-verbalize a safe
alternative route for
feeding infant if
breastfeeding is
ineffective

Learning Content
What is breastfeeding?
Breastfeeding provides optimal nutrition to the baby. It is the preferred
method of feeding a newborn because it provides numerous health
benefits to both mother and child, and it remains the ideal nutritional
source for infants through the first year of life.
What are the benefits of breastfeeding?
Best for babies
Reduces incidence of allergies
Economical
Antibodies
Stool-inoffensive
Temperature always correct and constant
Fresh
Emotional Bonding
Easy once established
Digested easily
Immediately available
Nutritionally balanced
Gastroenteritis greatly reduced
Correct positioning and attachment for breastfeeding positioning
-hands and nipples should be washed before feeding the baby, no soap
should be used
-infants head and body should be straight
-facing the breast with infants' nose opposite/inline with the nipples
-infants' body close to the mothers' body
-supporting the infants whole body, not just the neck and shoulder
Attachment
-chin touching the breast
-mouth wide open
-lower lip turned outward
-more areola below than the mouth
-hold the hand in a C position around the breast with the thumb on top
behind the areola and the fingers against the chest wall, supporting the
underside of the breast
How to help the infant attach/latch on the breast?
-touch the infants' lower lips or the cheek with the nipple of the mother
-wait until the infants' mouth is wide open
-move the infant quickly into breast, aiming the infants' lower lip well
below the nipple
Counsel the mother about feeding problems
-If the child is not feeling well during illness, counsel the mother to
breastfeed more frequently and longer if possible, clear a blocked nose if
it interferes with feeding, expect that the appetite will improve as the
child gets better.
-Nipples often become tender during the first week of nursing, but should
not become sore. Soreness are most often the result of a baby who is not
latched onto the breast properly.
Proper diet for lactating mother
-increase calcium and iron intake
-increase fluid intake of three liters per day
-increase caloric intake, avoid alcohol drinking and smoking
-dont skip meals and have small frequent feedings

Time Frame
1min
5min
10-20min
(cont.)
(cont.)
5min
5min

Resources
Visual Aids
Visual Aids
Visual Aids with
demonstration
Visual Aids with
demonstration
Visual Aids with
demonstration
Visual Aids
Visual Aids

Evaluation
Client responded well with the
health teachings and expressed
improved self-esteem regarding
her understanding of
breastfeeding and its benefits.
Able to do return demonstration
correctly
Able to do return demonstration
correctly
Able to do return demonstration
correctly
Responded well and exhibited
improved self-esteem regarding
feeding problems
Responded well and exhibited
improved self-esteem regarding
proper diet for a lactating
mother

Discharge Plan
M Instructed immediate relatives to facilitate the patient to continue taking the
drugs prescribed to her on the right time and with the right dose to facilitate
continuity of care
-instructed to contact physician if there are any hypersensitivity with the drugs
given
-encouraged to prevent taking over-the-counter drugs without the physicians
advice
E- Encouraged immediate relatives to facilitate passive exercises and stretching
to exercise muscles
-encouraged him not to carry heavy loads and do not force himself too much to
prevent injury
T- encouraged client to have enough rest and instructed to seek physicians
consultation whenever health problems occurs
H- Encouraged and explained to Her the benefits Breastfeeding and proper
hygiene to promote wellness
O Instructed client to come back for scheduled follow up checkup when he is
discharged
D- Advised patient to eat nutritional foods like fruits and vegetables and to eat a
balanced diet
-instructed to limit eating foods high in fat content and with cholesterol
-instructed to avoid salty foods
S Encouraged client to continue his habits in going to church every Sunday and
always seek Gods help and guidance throughout his life