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TABLE OF CONTENTS

I. Introduction

II. Patient’s Profile

III. Physiology of labor

A. Stages of labor

B. Mechanisms of labor

IV. Ideal Nursing Interventions

A. Antepartal period

B. Intrapartal period

C. Postpartal period

D. Newborn CareV. Actual Nursing Interventions

A Antepartal Period



A Antepartal Period

I N T R O D U C T I O N

Having children is essential to the survival of the human species. It can also be a

joyful, emotionally powerful experience. No other experience carries quite the cultural

and personal importance that having a baby does, and it is an experience that humans

have shared since the beginning of time.

The way a child is conceived and born is, essentially, the same as it ever was: A

sperm and an egg meet, and a fetus develops in the mother’s uterus and a baby is born

approximately nine months later. Yet today there are many positive changes in social

attitudes, medical standards, and parenting methods that make rearing children a vastly

different experience from what it was a few generations ago.

Pregnancy brings both psychological and physical changes to a woman and her

partner. Clients are often interested in the changes pregnancy brings, because thesechanges verify the reality and mark the progress of pregnancy.



the. family maintain a state of wellness throughout the pregnancy and into early

parenthood.

PATIENT’S PROFILE

PERSONAL BACKGROUND

My Client is Mrs. x, 20 years of age and a resident of x. Her birthday

falls every May and was born in the year x and a Roman Catholic. She has 4

siblings and was the 4th daughter of Mr. and Mrs. x. Her partners Name is

x, they’ve been together for 10 years but they did not get married.

She was not able to go to school because of poverty. She also has no

working experiences.

x stands 5’3” and weighs 60 kgs. Vital signs were taken during my first

visit which will serve as our baseline data on our study. Results are as

follows:



PAST HEALTH

HISTORY

We might say that x is healthy woman because she didn’t encounter

any serious illnesses. Just like other people, Ritchel only encounters the

common minor illnessnes like for example cough, flu and fever.



HISTORY OFPREGNANCY

This is the third pregnancy of

Ritchel with no history of miscarriage and

abortion (G3P3). She experienced nausea and vomiting and absence of menstruation.

Her last menstrual period was May 10, 2005 and she only had her prenatal check-up

after she was 7 months pregnant, on December 7, 2005 and on a monthly basis

thereafter, she visited the center. However she was only vaccinated twice on

tetanus toxoid (TT2)

Her nutritional intake was quite normal. Ferrous Sulfate was the only

vitamins that she has taken. She made it a habit to exercise every morning like a

simple walking at their area. As she was told, exercise during pregnancy is

important to prevent circulatory status in the lower extremities. It also offered



PHYSIOLOGY OF

LABOR

Labor is an event that follows pregnancy and is considered as the climax of the

entire maternity cycle. During the nine months of gestation certain physiologic and

psychological adaptations gradually have taken place in the pregnant woman, and

simultaneously the growth and the development of the fetus have progressed toward

maturity in preparation for the transition from intra-uterine to extra-uterine life.

By definition, labor refers to the series of processes by which the products of

conception are expelled from the mother’s body. The exact mechanism that initiates

labor is unknown. But there are theories in labor, uterus becomes stretched and

pressure increases, causing physiologic changes that initiate labor, it is known as uterine

stretch theory. As pregnancy progresses, there is a gradual rise in the amount of

circulating oxytocin. As pregnancy advances, progesterone is less effective in controlling

rhythmic uterine contractions that normally occur. There also may be an actual decrease

in the amount of circulating progesterone. There is increased production of prostaglandin

by fetal membranes and uterine dicidua as pregnancy advances. In later pregnancy, the

f t d i d l l f ti l th t i hibit t d ti f th



thickened cell size and with each succeeding contraction becomes thicker and shorter.

Cells of the lower uterine segment become thinner and longer with each contraction.

This mechanism is greatly responsible for the progress of the fetus through the birth

canal.

Before the real labor onset starts, a number of changes would indicate that the

time of labor is approaching. Lightening, is one of the preliminary events of labor, it is the

settling of the fetus in the lower uterine segment. It occurs 2-3 weeks before term in the

primigravida and later, during labor, in the multigravida. Breathing becomes easier asthe fetus falls away from the diaphragm. Lordosis of the spine is increased as the fetus

enters the pelvis and falls forward. Walking may become more difficult; leg cramping

may increase. Urinary frequency occurs because of pressure on the bladder. Vaginal

secretion may increase. Mucous plug is discharged from the cervix along with the small

amount of blood from surrounding capillaries referred to as “show” or “bloody show”.

Cervix become soft and effaced, membranes may rupture occasionally; rupture of the

membranes is the first indication of approaching labor. False labor contraction may

occur. False contractions may begin as early as 3 or 4 weeks before the termination of

pregnancy. They are merely an exaggeration of the intermittent uterine contractions,

which have occurred throughout the entire period of gestation but are now accompanied

by discomfort. They occur at decidedly irregular intervals, are confined chiefly to the

lower part of the abdomen and the groin and do not increase in intensity, frequency and

duration. The discomfort rarely is intensified if the mother walks about and may even be

li d if h i h f t I t l i ti ill l h i th i



During the latent phase the contractions are short, slight, about 10 to 15 minutes

or more apart and may not cause the patient any particular discomforts. She may be

walking about and between contractions comfortably. Contractions are generally mild

and she may experience back pain. There is cervical dilatation of about 1 to 3 cm. The

second phase then follows characterized by moderate contractions that sweeps from the

back to the anterior abdomen. Contractions recur at shortening intervals every 3 to 5

minutes, and become stronger and last longer. Cervical dilatation is about 3 to 7 cm. The

third phase then sets in where there is intense pain accompanied by a completedilatation of the cervix that is from 7 to 10 cm.

As a result of the uterine contractions, two important changes are wrought during

the first stage of labor. These are effacement and dilatation of the cervix.

Effacement is the shortening of the cervical canal from a structure 1 or 2 cm in

length to one in which no canal at all exist. It can simply be defined as the thinning of the

cervix. Dilatation of the cervix on the other hand meant an enlargement of the external

os from an orifice a few millimeters in size to an aperture large enough to permit the

passage of the fetus that is to the diameter of 10 cm.

By the time complete cervical dilatation is accomplished, the second stage of

labor then sets in. This stage is also known as the stage of expulsion that begins with

th l t dil t ti f th i d d ith th d li f th b b C t ti



engagement when the biparietal diameter of the infant’s head is within the pelvic inlet

and is no longer movable. The first requisite for the birth of the infant is descent. This

refers to the downward movement of the fetus that occurs throughout the labor process.

Very early in the process of descent the head becomes so flexed that the chin is in

contact with the sternum and the very smallest anteroposterior diameter is presented to

the pelvis. This mechanism is known as the flexion. When it reaches the pelvic floor, the

occiput is rotated internally and comes to lie beneath the symphysis pubis. After the

occiput emerges from the pelvis, the nape of the neck becomes arrested beneath thepubic arch and acts as a pivotal point for the rest of the head. Extension of the head

ensues, and with it the frontal portion of the head, the face and the chin are born. After

the birth of the head, it remains in the anteroposterior position only a very short time and

shortly will be seen to turn to one or another side of its own accord termed as restitution

or the external rotation. After delivery of the infants head and internal rotation of the

shoulders, the anterior shoulder rest beneath the symphysis pubis. The posterior

shoulder is born, followed by the anterior shoulder and the rest of the body. This phase

is termed as expulsion.



The third stage of labor is known as the placental stage that begins with the

delivery of the baby and terminates with the birth of the placenta. This stage is made up

of 2 phases, namely, the phase of placental separation and the phase of placental

expulsion.

Immediately after the delivery of the baby, the remainder of the amniotic fluid escapes,

after which there is usually a slight flow of blood. The uterus can be felt as a firm globular mass

just below the umbilicus. Shortly thereafter, the uterus relaxes and assumes a discoid shape. With

each subsequent contraction or relaxation the uterus changes from globular to discoid in shape

until the placenta has separated, after which time the globular shape persists. The 3 signs that

suggest that the placenta has separated are: (1) the uterus becomes globular in shape or the

Calkin’s sign, (2) lengthening of the umbilical cord, and (3) sudden gushing of blood.

Extrusion of the placenta then follows after the above signs are manifested. It

may take place by one of the 2 mechanisms. The Schultze’s mechanism refers to the

glistening or the fetal surface and the Duncan’s mechanism that is said to be the

maternal surface and commonly known as the rough and dirty part.



Home Visit and Assessment



IDEAL NURSINGMANAGEMENT

Trimesters of Pregnancy

The 40 weeks of pregnancy are divided into three trimesters. The developing

baby is called an embryo for the first 8 weeks, after which it is called a fetus. All of its

major organs develop in the first trimester. In the mother, nausea and vomiting are



divided into 3 trimesters, the intrapartal stage with its 4 phases, postpartum and the

immediate newborn care.

THE ANTEPARTAL STAGE

FIRST TRIMESTER 1. Breast changes, new sensations: pain, tingling

a. Wear supportive maternity brassiere with pads to absorb discharge may

be worn at night, wash with warm water and keep dry.

2. Urgency and frequency of urination

a. Encourage woman to do Kegel’s exercises.

b. Encourage to void before going to bed.

c. Encourage to void after meals.

d. Instruct the woman to limit fluid intake in the evening.

e. Provide reassurance that this is just a normal process.

f. Wear perineal pad.

g. Refer to physician for pain or burning sensation.

3. Languor and malaise; fatigue (early pregnancy usually)

a. Provide reassurance.

b. Rest as needed.c. Well-balanced diet to prevent anemia.

4. Nausea and vomiting, “morning sickness”



i. Avoid empty or overloaded stomach.

j. Maintain good posture – give stomach ample room.

k. Stop smoking.

l. Avoid fried, odorous, spicy, greasy, or gas-forming foods.

m. Consult physician if intractable vomiting occurs.

5. Ptyalism – may occur starting 2 to 3 weeks after first missed period

Use of astringent mouthwash, chewing gum, support.

6. Psychological dynamics – mood swings, mixed feelingsa. Treatment same as prevention.

b. Both partners need reassurance and support.

c. Support significant other who can reassure woman about her

attractiveness, etc.

d. Improved communication with her partner, family, and others.

SECOND TRIMESTER 1. Pigmentation deepens (striae gravidarum, chloasma, linea nigra, finger nails,

hair, nipples and areolae); acne, oily skin

a. Not preventable.

b. Usually resolved during puerperium.

c. Reassurance given to women and their families about thesemanifestations of pregnant state.

2. Spider nevi – appear during trimesters 2 or 3 over neck, thorax, face, and arms



5. Supine hypotension

a. Side-lying position or semi-sitting posture, with knees slightly flexed.

6. Faintness and, rarely, syncope: may persist throughout pregnancy

a. Moderate exercise, deep breathing, and vigorous leg movement.

b. Avoid sudden change in position and warm crowded areas.

c. Move slowly and deliberately.

d. Keep environment cool.e. Sit down as necessary.

7. Food cravings

a. Satisfy craving unless it interferes with well-balanced diet

8. Heartburn

a. Limit or avoid gas-forming or fatty foods and large meals.

b. Maintain good posture.

c. Keep torso upright.

d. Bend down at knees to reach below the waist.

e. Sips of milk, hot tea, chewing gum for temporary relief.

9. Constipation

a. Instruct the woman to increase fluid intake to at least eight glasses of

water a day. One to two quarts of fluid a day is desirable.

b. Teach the woman that food high in fiber should be eaten daily.

E t t bli h l tt f li i ti



d. Relieve swelling and pain with hot sitz baths, local application of

astringent compresses.

12. Leukorrhea

a. Do not douche.

b. Hygiene, perineal pads, reassurance.

13. Headaches

a. Emotional support; prenatal teaching; conscious relaxation.14. Periodic numbness

a. Maintain good posture.

b. Wear good supportive maternity brassiere.

c. Reassurance that condition will disappear if lifting and carrying baby

does not aggravate it.

15. Joint pain, backache, and pelvic pressure; hypermobility of joints

a. Teach the woman to use good body mechanics-wear comfortable, low-

heeled shoes with good arch support, try the use of a maternity girdle.

b. Instruct the woman in the technique for pelvic rocking exercises.

c. Encourage to take rst periods with her legs elevated.

d. Instruct the woman to dorsoflex the foot while applying pressure to the

knee to straighten the leg for immediate relief of leg cramps.

e. Local heat and back rubs.



3. Psychosocial responses: mood swings, mixed feelings, increased anxiety

a. Reassurance and support from significant other and nurse.

b. Improved communication with partner, family, and others.

4. Gingivitis and epulis

a. Well-balanced diet with adequate protein and fresh fruits and vegetables.

b. Gentle brushing and good dental hygiene; avoid infection.5. Urinary frequency and urgency returns

a. Limit fluid intake before bedtime.

b. Reassurance.

c. Wear perineal pad.

6. Perineal discomfort and pressure

a. Rest, conscious relaxation and good posture.

b. Maternity girdle.

7. Braxton Hicks’ contractions

a. Reassurances, rest, change of position.

b. Practice breathing techniques when contractions are bothersome.

c. Effleurage; rule out labor.

8. Leg cramps

a. Use massage and heat over affected area.

b St t h ff t d l til l



THE INTRAPARTUM STAGE

CONDUCT OF THE FIRST STAGE

1. Anxiety, excitement of onset of labor and fear of the unknown

a. Establish a relationship with the woman or couple.

b. Provide information on the health care facility’s policies and procedures.

c. Inform the woman or couple of maternal status and fetal status and labor

progress.

d. Explain all procedures and equipment used during labor.

e. Answer any questions the woman/couple have.

f. Review the birth plan and make appropriate revisions.

g. Monitor maternal vital signs.

Temperature every 4 hours, unless elevated or membranes

ruptured, then every 2 hours.

Pulse and respirations every hour unless receiving pain

medication, then every 15-30 minutes or as indicated.

Blood pressure every hour unless hypertension or hypotension

exist or woman has received pain medication or anaesthesia.

Then evaluate more frequently based on findings or as



c. Provide ice chips or sips of clear fluids if allowed.

d. Provide mouth care as needed.

3. Injury: contamination, infection, prolapsed cord and abnormal fetal position.

a. Take the woman temperature and record every 2 hours.

b. Maintain asepsis during vaginal examination.

c. Change the pads and linens when wet or soiled.

d. Provide perineal care after voiding and as needed.

e. Discourage the use of perineal pads, because they create a warm, moistand environment for bacteria.

f. Minimize vaginal exams.

g. Observe for fetal tachycardia.

h. Assess complete blood count as indicated.

i. Continue to monitor maternal vital signs, FHR, vaginal secretions, fetal

lie and position using Leopold’s maneuver.

j. Reposition client to left lateral position or other positions as necessary.

k. Provide oxygen by nasal cannula or mask.

4. Pain: increasing intensity and frequency of uterine contractions.

a. Encourage position changes for comfort.

b. Assist the woman with breathing and relaxation techniques as needed.

c. Provide back, leg, and shoulder massage as needed.

d. Provide pain relief as assessing woman’s verbal and nonverbal

i ti



a. Coach woman to reestablish appropriate breathing pattern.

b. Help woman focus attention by doing the breathing with her and making

eye contact.

c. Side-lying position or left lateral position for oxygenation.

d. Encourage using open epiglottis technique when pushing.

2. Physiologic response to contractions; low self-esteem

a. Provide information.

b. Coach woman through contractions giving her verbal and nonverbalapproval and reassurance.

3. Experiences contractions as overwhelming in intensity. Reports ring of fire as

head crowns.

a. Encourage slow gentle pushing.

b. Explain that “blowing away a contraction” facilitates a slower birth of the

head.

c. Coach relaxations of the mouth, throat, and neck to relax pelvic floor.

d. Apply warm compress to perineum to aid relaxation.

THE THIRD AND FOURTH STAGES OF LABOR 1. Delivery of the placenta

a. Assist the mother in delivery of placenta.

b. Massage the uterus immediately but gently.

c. Check for intactness of placenta



a. Dress woman in a clean gown and cover her with a warm blanket. Explain

that tremors are commonly seen after delivery and are not related to

infection. Warm blankets also provide a means of “mothering the mother”.

This helps in restoring her energy so she can move from a focus on

herself to a focus on her baby.

b. Assists the woman onto her bed if transferred from the delivery room to

the recovery room.

c.Raise side rail of bed when transferred.

4. Fluid balance (hydration)

a. Give clear fluids, such as apple juice or tea, and toast can be given unless

the mother’s condition does not allow this.

b. The nurse records the type of fluids and foods taken, the time, the

amount, and the mother’s tolerance of the fluids or foods ingested.

c. In the event of hemorrhage, IV medications are given by the physician.



THE POSTPARTUM STAGE

Immediately after the delivery, or perhaps later, the parents, particularly

the mother may relieve tension by giving way to some emotional displays like laughing,

crying, incessant chattering, and anger. These emotions often are quite unexpected and

shock and embarrass those involved. A calm, accepting, nonjudgmental attitude in the

part of the nurse is very effective in allaying any embarrassment and in helping the

patient to gain control.

Several comfort measures can be employed to restore calm and to help the

mother to relax enough to get some much needed rest and sleep. A soothing backrub,

change of gown and linen, a quiet conversation with the nurse or the husband in which

the patient is allowed to ventilate her feelings, an environment conducive for resting, are

all helpful (Bobac,1989).

The first hour following the delivery is a most critical one for the mother. It is at

this time that the postpartal hemorrhage is most likely to occur as the result of uterine

relaxation. Thus, it is mandatory that the uterus be watched constantly throughout this

period by a competent nurse who keeps her hand more or less constantly on the fundus

d t th li ht t i f di i i hi t ti it t k th t it d



Temperature, Pulse, Respiration

•

A slight rise in the temperature may occur without apparent cause following thedelivery, but in general the mother’s temperature should remain within normal

limits during the puerperium which is below 38 C.

• In the early puerperium, the pulse rate is somewhat slower. The rate is usually

between 60 and 70 but may even become a little slower than this in 1 or 2 days

after the delivery. By the end of the 1st week or 10 days it will return to its normal

rate. On the other hand, a rapid pulse after labor may indicate shock or

hemorrhage.

After-PainsNormally after the delivery of the first chills, the uterine muscle tends to remain in

a state of tonic contraction and retraction. In multiparas a certain amount of the initial

tonicity of the uterine muscle has been lost, and these contractions and retractionscannot be sustained. Consequently, the muscle contracts and relaxes at intervals, and

these contractions give rise to the sensation of pain, the so-called “after-pains”(Reeder,

et. al., 1966).

Several nursing interventions that can be applied in this discomfort would be the

application of ice cap on affected area, administration of analgesics and encourage the

mother of early ambulation.

Nutrition



worries and anxiety-producing situations must be avoided. Especially if she is

breastfeeding, the need for rest is more significant for it will inhibit her milk supply.

Urinary and Intestinal EliminationThe mother should be encouraged to void within the first 6 to 8 hours following

the delivery. It is not prudent, however, to adhere to a designated lapse of time to

indicate when the mother should empty her bladder, but rather on evidence indicating

the degree of bladder distension. It should be kept in mind that there is an increased

urinary output during the early puerperium. Moreover, mothers who have received

intravenous fluids, or who are having them are very likely to develop a full bladder.

Intestinal elimination in the early puerperium may be somewhat a problem

because the bowel tends to remain relaxed. Constipation can be anticipated unless

certain measures are instituted to prevent it. It is common to give a stool softener each

night after the delivery and/or a laxative or mild cathartic on the evening of the 2nd day

following a delivery. If a bowel evacuation has not occurred by the morning of the 3 rd

day, a cleansing enema or a suppository may be prescribed.

BREAST CARE

This routine care is directed to maintain cleanliness and adequate breast support

necessary for the normal function of the breasts and the comfort of the mother.

Precautions should always be exercised to handle the breast gently, and above all to

avoid rough rubbing, massage or pressure on these organs.

The mother who is bottle-feeding her infant should bathe her breasts daily with

mild soap and water; this is done most conveniently at the time of the daily shower or



IMMEDIATE CARE OF THE INFANT

As soon as the infant is born, measures should be taken to promote a clear air

passage before the onset of respiration. As the head is delivered, it is necessary to wipe

the mucus and the fluid from the infant’s nose and mouth before he has the chance to

gasp and aspirate with the first breath. From the moment of delivery the infant should be

kept in the head-down position until his upper respiratory passage is cleared of mucus,

an amniotic fluid, etc. a small rubber bulb syringe, or a soft rubber suction catheter

attached to a mechanical suction or mouth aspirator, should be used promptly to suction

the oropharynx and to remove fluids which may be obstructing the airway.

Assess respiratory status and do Apgar scoring 1 and 5 minutes after delivery of

the baby. Look for meconium staining. Wrap the newborn baby in a warm blanket and

place in heated crib or give to mother and/or father to hold. Avoid excessive exposure as

body temperature is variable. Place infant on side or modified Trendelenburg’s to

facilitate drainage of mucus or blood. Suction mucus as needed with the bulb. The nurse

is to clamp the cord if the physician has not done so. The baby is then identified with

bands.

When the baby is passed to the nursery, another set of care is implemented.

After receiving the baby into the unit, the nurse will check the axillary temperature and

t k th it l t h th i ht l th h d d h t i f



CONTINUING CAREThe daily cleansing of the infant affords the nurse an excellent opportunity for

making the observations that are necessary during the immediate postpartal period.

Several decades ago the daily soap and water and oil baths were replaced with merely

wiping off excess vernix with dry or slightly moist cotton balls. The diaper area was

cleansed as necessary. However, babies do not receive a tub bath until the cord has

separated and until the umbilicus has healed. If the cord is left exposed to the air, some

physicians prefer that the based of the cord be wiped with alcohol daily to encourage

drying further and to discourage the possibility of infection.



ACTUAL NURSING CARE PLANAntepartum Period

CUESNURSING

DIAGNOSISOBJECTIVE INTERVENTION R ATIONALE EVALUATION

Subjective :

“Galisud gyud koug katulog sagabii. Ambutngano pirme ko dili

kumportable” asverbalized byRitchel.

Sleep patterndisturbancerelated to inabilityto maintaincomfort asevidenced by

difficulty in fallingasleep.

At the end of oneday, Ritchelr willreportimprovement insleep rest.

Independent :1. Evaluate use of caffeineand alcoholic beverages.

1. Overindulgenceinterferes with REM(Rapid Eye Movement)sleep.

On the next dayof visit, Ritchelreported to haveslept well inside-lyingposition.

2. Suggest side-lying

position with pillow betweenlegs for support, or placebed board under mattress.

1. Back discomfort may

necessitate changein position, use of multiple pillows /bodypillow, or firmer mattress.

Objectives :1. dark circles

under theeyes

2. constant

yawningirritability

3. Suggest aids to sleep,such as relaxationtechniques/tapes, reading,warm bath, and reduced

activity just before retiring.

3. .Excess anxiety,excitement, physicaldiscomforts, nocturia,and fetal activity all

may contribute tosleeping difficulties.



4. Note reports of positionalbreathing difficulties.Suggest sleeping in a

semi-Fowler’s position.

.4. Use of semi-Fowler’s

position allows thediaphragm to

descend, fosteringoptimal lungexpansion.

5. Encourage participation inregular exercise programduring day to aid in stresscontrol/release of energy.

.5. Exercise at bedtime

may stimulate rather than relax patient andactually interfere withsleep.

6. Drinking a glass of milkmaybe recommended.

1. To reduce sleepinterference fromhunger.

ACTUAL NURSING CARE PLAN( Intrapartum Stage )

CUES NURSING OBJECTIVE INTERVENTION R ATIONALE EVALUATION

CUES NURSING DIAGNOSIS

OBJECTIVE INTERVENTION R ATIONALE EVALUATION



DIAGNOSIS

Subjective :

“Sakit kaayu angakong balat-ang ugmura ko ugkalibangon”, asverbalized byRitchel.

Objectives :

1. Facial grimaces

2. Expressivebehavior – cryingBloody show

Comfort,

Alteration in :Pain related touterinecontractions

At the end of ten

minutes, Ritchelwill verbalizeperceived or actual reductionof pain.

Independent :

1. Provide Ritchel need for physical touch duringcontractions.

1. Provides supportive

reassurance andencouragement andmay aid inmaintainingcontrol/reducing pain.

At the end of ten

minutes, Ritchelverbalizeddecreased in painand discomfort.She was able torelax for a while.

2. Encourage positionchanges like the leftlateral position.

2. To provide comfort bynot occluding thevena cava.

3. Assist the woman withbreathing and relaxation

techniques.

3. To minimize painduring contractions

and to preventhypoxia.

4. Encourage ambulation astolerated if membranesare not yet ruptured andpresenting part is not yetengaged.

4. To control painand stimulate cervicaldilatation and fetaldescent.

5. 5. Provide back, legand shoulder massage asneeded.

5. To minimize pain byimproving bloodcirculation.

ACTUAL NURSNG CARE PLAN( Postpartum Stage )



CUES

NURSING

DIAGNOSISOBJECTIVE INTERVENTION R ATIONALE EVALUATION

Subjective :“sakit akong tahi saakong kinatao” asverbalized byRitchel.

Objectives :

1. gravida 3 para 32. as verbalized by

client3. Facial grimaces

during walking

Alteration incomfort: Painrelated toperinial incisiondone

At the end of theday, client will beable to reduce or eliminatesfactors thatprecipitate pain.

1. instructed the proper perineal care or the

proper way to clean thevagina

2. instructed to do sitz bathor clean the vagina withwarm water.

1.to prevent infection thatprecipitate pain

2. for faster healing of theepisiotomy

3.administer painmedication like aspirin.

4. divert clients attentionlike talking to the client

3. to relieve pain.

4. diverting clients attentionwill help in alleviating thepain of the client.



SUMMARYThe knowledge about Ritchel’s pregnancy was not a shock to her family because this was her 3 rd baby. For

she has 2 daughters she and her partner wanted to have a baby boy but as she was on her labor they found out

that it was again a baby girl. Though they wanted a boy, they accepted and love the new member of their family.

They named the baby “Roxanne”.

It was gathered from the interview and physical assessment that Ritchel had undergone a positive childbearing experience

during this pregnancy. Except for some minor discomforts normally experienced by most pregnant women, it could be said that

Ritchel had a healthy and uncomplicated pregnancy. Her prenatal care included proper nutrition, exercise and adequate rest and self-

care measures which all significantly contributed to the safe passage of her baby and her safety, as well. Being a multigravida, she

reported to have an easy and short labor. Her records at the center showed us that she has no any signs of fetal distress. Inspection of

the neonate did not also show molding which would evidence ineffective bearing down.



REFERRAL

Pediatric primary care involves all the health promotion and disease prevention needs of the child. To obtain the highest level

of wellness attainable, referrals as to immunization/vaccinations had been made as follows:

AGE IMMUNIZATION REMARKS

At birth BCGBCG given at the earliest possible age protectsagainst the possibility of infection from other

family members

6 weeks DPT and OPVAn early start with DPT reduces the chance of pertusis

6 weeks Hepatitis BAn early start of Hepatitis B reduces the chanceof being infected and becoming a carrier

10 weeks DPT and OPVThe extent of protection against polio isincreased the earlier OPV is given



14 weeks DPT and OPV --------

9 months MeaslesAt least 80% of measles can be prevented byimmunization at this stage

Moreover, instructions had been made to immediately contact the pediatrician for any abnormalities observed.

Bibliography

Pilliteri, Adelle. Maternal and Child Health Nursing (3rd Edition ). Lippincott Williams and Wilkins, Inc. 1999.

Taylor. Fundamentals in Nursing (4th Edition ). J.B. Lippincott Company. 2001.



Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition). Addison esley Longman Inc. 1998.

Nettina, Sandra. The Lippincott Manual of Nursing Practice (6th Edition). J.B. Lippincott Company. 1996.

Childcraft. Guide to Parents (Volume 15). World Book – Childcraft International, Inc. 1981.

Timelife. Raising a Happy Child. Time-Life Books, Inc. 1986.

HEALTH TEACHINGS

Name of patient: Ritchel Canaugon



MEDICATION

Instructed the client to take vitamins that’s rich

in iron to revive the blood loss during her labor.

Take mefanamic acid if pain persist, to lessen

the pain that she felt.

EXERCISE

Instruct the patient to do the postpartum

exercise to promote muscle tone.

TREATMENT

Do the proper breast care to have the baby’s

safety when doing breastfeeding.

Instructed to have proper perineal care for fast

healing of the episioraphy.

OUTPATIENT

(check-up)

Instruct the patient to go to the nearest center if

there are any problem that she encounter after

giving birth, like if there is a problem about the

baby’s health or about her episioraphy.



DIET

To eat vegetables that’s high in iron to regain

the blood loss.

To eat foods that is rich in vitamins to have her

energy back.

HEALTH TEACHING

NAME OF PATIENT: x

During our fourth visit to our client, we taught her about proper hygiene, nutritions that she needed and the

post-partum exercise.

We emphasize our teaching to the proper hygiene because as we observed our client, we found out that shedoes not care about herself or to her children. We could see that they have a dirty surroundings. If she continuous

to take for granted about proper hygiene this could affect her health and her children and mostly to her new baby.



We also taught her about the proper nutrition that she should take so that she would regain her energy and

could return to her lifestyle before she got pregnant and also to regain her blood loss.

And lastly we taught her about the 10 post-partum exercise that she could apply after giving birth. We

instructed her on how to do it for ten days and on what exercise it is about.

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