Nursing Case study nsvd normal spontaneous deliveryDocument Transcript
NORMAL SPONTANEOUS VAGINAL DELIVERY NSVD Nursingcasestudy.blogspot.com
INTRODUCTION Pregnancy, the state of carrying a developing embryo or fetus withinthe female body. This condition can be indicated by positive results on an over-the-counter urine test, and confirmed through a blood test, ultrasound, detection of fetalheartbeat, or an X-ray. Pregnancy lasts for about nine months, measured from thedate of the womans last menstrual period (LMP). It is conventionally divided intothree trimesters, each roughly three months long. When gestation has completed, it goes through a process calleddelivery, where the developed fetus is expelled from the mother’s womb. There aretwo options of delivery: Cesarean section and NSVD or normal spontaneous vaginaldelivery. A cesarean section is a surgical incision through the mother’s abdomen anduterus to deliver one or more fetuses. NSVD or normal spontaneous vaginal deliveryis the delivery of the baby through vaginal route. It can also be called NSD ornormal spontaneous delivery, or SVD or spontaneous vaginal delivery, where themother delivers the baby with effort and force exertion. Normal labor is defined as the gradual subjugation and dilatation ofthe uterine cervix as a result of rhythmic uterine contractions leading to theexpulsion of the products of conception: the delivery of the fetus, membranes,umbilical cord, and placenta. Laboring cannot that be easy; thereby implicating thatthere are processes and stages to be undertaken to achieve spontaneous delivery.Through which, Obstetrics have divided labor into four (4) stages thereby explainingthis continuous process. STAGE 1: It is usually the longest part of labor. It begins with regularuterine contractions and ends with complete cervical dilatation at 10 centimeters.This stage is broken down into three (3) phases: the Early phase, where the
contractions are usually very light and maybe approximately 20 minutes or moreapart from the beginning, gradually becoming closer, possibly up to five minutesapart; the Active phase, where contractions are generally four or five times apart,and may last up to 60 seconds long. Cervix dilates with 4-7 cm and initiates a morerapid dilatation. It is known that to get through active labor, mobility and relaxationsare done to increase contractions; and the Transition phase, where it is definitelyknown as the shortest phase but the hardest, contractions maybe two or three timesapart, lasting up to a minute and a half, about approximately 8-10 cm of cervicaldilatation. Some women will shake and may vomit during this stage, and this isregarded as normal. Most of the time, women would find a comfortable position toacquire complete dilatation. STAGE II: This stage lasts for three or more hours. However, thelength of this stage depends upon the mother’s position (e.g.; upright position yieldsfaster delivery). Once the cervix has completely dilated, the second stage hadbegun. This stage ends with the expulsion of the fetus. STAGE III: This stage focuses on the expulsion of the placenta fromthe mother. Placenta exclusion is much more easier than the delivery of the babybecause it includes no bones, and this is during this stage that the baby is placed ontop of the mother’s womb. STAGE IV: No more expulsions of conception products for this stageas this is generally accepted as POST PARTUM juncture. This phase is from theplacental delivery to full recovery of the mother. Labor and delivery of the fetus entails physiological effects both onthe mother and the fetus. In the cardiovascular system, the mother’s cardiac outputincreases because of the increase in the needed amount of blood in the uterine
area. Blood pressure may also rise due to the effort exerted by the mother in orderexpel the fetus. There could also be a development of leukocytes or a sharp increasein the number of circulating white blood cells possibly as a result of stress and heavyexertion. Increased respiratory may also occur. This happens as a response to theincrease in blood supply in order to increase also the oxygen intake. Braxton Hicks contractions, or also known as false labor or practicecontractions. Braxton Hicks are sporadic uterine contractions that actually start atabout 6 weeks, although one will not feel them that early. Most women start feelingthem during the second or third trimester of pregnancy. True labor is felt in theupper and mid abdomen and leads to the cervical changes that define true labor. With delivery imminent, the mother is usually placed supine with her kneesbent (ie, the dorsal lithotomy position). An episiotomy (an incision continuous withthe vaginal introitus) may be performed at this time. Episiotomy may ease deliveryof the fetal head and allow some control over what may otherwise be anuncontrolled perineal laceration. However, many providers no longer perform routineepisiotomy, since it may increase the risk of rectal injury and are larger than thespontaneous laceration. The labor and birth process is always accompanied by pain. Several optionsfor pain control are available, ranging from intramuscular or intravenous doses ofnarcotics, such as Meperidine (Demerol), to general anesthesia. Regional nerveblocks, such as a pudendal block or local infiltration of the perineal area can also beused. Further options include epidural blocks and spinal anesthetics.
Nursing Health History Nursing health history is the first part and one of the most significant aspectsin case studies. It is a systematic collection of subjective and objective data,ordering and a step-by-step process inculcating detailed information in determiningclient’s history, health status, functional status and coping pattern. These vitalinformations provide a conceptual baseline data utilized in developing nursingdiagnosis, subsequent plans for individualized care and for the nursing processapplication as a whole. In keeping the private life of my patient and in maintaining confidentiality, letme hide for with the pseudonym of Patient P. Patient P was born on December 19, 1992. She was born to parents fromSurigao Del Norte, but she didn’t actually live with them. She was technicallyabandoned to the relatives, but those people could not essentially foster her. Shestayed at the Department of Welfare and Social Development or DSWD and spenther 15 years of existence. Her education was funded mainly by volunteers andcharitable foundations. At the same time, she compensated for it by means ofhelping in chores and accomplishing tasks in the said foundation. She grew up with other abandoned children with questions in her mind. Butto that, she never completely disclosed herself. Patient P is a victim of sexual abuse.She was raped and was unable to resist because of her innocence. She doesn’t talkthat much. Often times, she paces back and forth inside the ward, sits silently onher bed and sometimes quietly stares outside the window. When tried to ask aboutwhat she knows of her family, she could only turn silent, and somehow implies toask the next question to her. But when chance punched, I grasped it and coileddirectly to my point. Unfortunately, hesitancy was felt from the kind of thing that
was wanted to be discussed. The issue was not forced until her watcher, which hasno relation to her, revealed the reason behind her pregnancy. According to Patient P’s watcher, it was on a cold night in September 2007,when Patient P came home from school: Upon nearing the center, a man, which sheidentified as a newcomer to the center, blocked and harassed her brutally. Shestruggled to let go from the ruthless hands of the unaccustomed man. Patient P wasthreatened that if she’d make any noise, she’d get killed. Ill-fatedly, she was heldpowerless to the man, and the crime had happened. Fortunate enough that shewasn’t killed, she thanked the Lord for sparing her life. Although alive, she felt verymuch unfair about her situation. She could only tell, “Kabata pa kaayo nakonahimong inahan, nganong nahitabo man pud ni..” . Patient P conceived the babyand bore it for 9 months. For the first trimester, she couldn’t believe and accept herfate, and sometimes thought of slight curses to the person who did the crime. Butsomehow, she felt a jot of excitement of a having a baby unexpectedly. She evenverbalized, “Wa naman koy mabuhat. Nahitabo nato. Basin makasala pa kogipalaglag nako ang bata.. Wala man siya’y sala.” According to Erik Erikson’s Developmental Task of adolescence, from the ageof 10 to 18 years old, Patient P belonged to the IDENTITY versus ROLECONFUSION, which proposes that the adolescent is newly concerned with how heor she appears to others. Development mostly depends upon what is done to us.From here on out, development depends primarily upon what we do. And whileadolescence is a stage at which we are neither a child nor an adult, life is definitelygetting more complex as we attempt to find our own identity, struggle with socialinteractions, and grapple with moral issues. On June 29, 2008, Patient P complained of extreme abdominal pain. On thesame date was her EDC or expected date of confinement. The age of gestation is 39
weeks by LMP. Her LMP was September 2007, exact date unrecalled. She wasadmitted to Butuan Medical Center at around 2:40am with blood pressure of 140/90mmHg. She was examined by Dr. Bombeo and found out that she was fully dilated.By 2:45am, 5 minutes after her admission, doctor’s orders were carried out: • #1 D5LR I Liter started @ 20 gtts/min • TPR q 4° • NPO • CBC blood typing; hbsAg requested • Labor watch By 2:55am, she was endorsed to DR wheelchair. With the next 5 minutes,she was admitted in the ER accompanied by the staff, positioned on the DR tablewith final preparation done. Around 3:36 am, she delivered an alive, 6 lbs 13 oz and 49 centimeters inlength baby girl with these statistics: • Head Circ: 32 cm • Chest Circ: 30 cm • Abd Circ: 20 cm Extemporaneously, the baby cried with the same breathing time of 3:36am.Patient P’s placenta was expelled spontaneously by 3:47am with blood pressure of130/80. Oxytocin 10 units was infused to IVF; Methergine I amp IVTT; her uteruswas firm and contracted and was admitted to ward via stretcher. During her labor,she was anesthetized with Lidocaine HCl 5cc.
After her delivery, she was admitted to the Ob ward with repairedepisiotomy. Post partum doctor’s orders were as follows which was carried out: • DAT (Diet as Tolerated) • Ice pack over hypogastrium • Perineal care • Oxytocin 10 U infused to IVF and; • Methergine I amp IVTT. • Cephalexin I amp IVTT • Mefenamic Acid 500mg I cap TID • May room in • Breastfeed per demand Patient P’s temperature was monitored until stable. On the following day, June 30, 2008, doctor’s order was to secure HBsAgresult. Patient P’s baby was admitted to NICU because of frequent vomiting andfever. The staff continued to monitor her vital signs and administered prescribedmedications. As a student nurse, I also did my assessment towards my patient’scondition. Upon assessing, I was able to take and record her vital signs: • T = 37.3°c • 82 bpm • 21 cpm • 120/70 mmHg Patient P wasn’t able to take a bath because of her beliefs. Since she has anepisiotomy wound, she is at risk for infection. I made my independent nursinginterventions. I explained to her the importance of proper hygiene to prevent the
occurrence of infection. Emphasis on eating foods rich high protein to promotewound healing was imparted. She verbalized, “Sakit man akong totoy mam.” So, Iencouraged her to let her baby continuously suck to both breasts when receivedback from NICU, that is to relieve her engorgement. Also, I instructed her toincrease fluid intake at least 8 oz per hour to facilitate increase in milk production,and to eat nutritious foods such as fruits and vegetables to nourish her baby well. On July 1, 2008, doctor’s orders were noted: • Continue meds • Repeat hemoglobin • MGH after IE and if hemoglobin is OK By 1:25 pm: • Defer MGH • Secure and transfuse 4 units FWB/wg (fresh whole blood) properly crossmatched • Antamine I amp 10,000 units • BT (blood transfusion) On the same day, I did my Physical assessment to Patient P and a briefhistory about her case. I aided her in securing her blood by persistently going withher to the blood bank. Patient P was advised to take adequate rest in fear ofhypotension due to her low hemoglobin, 59G/L. So, it was me and her watcher whowas always on the go. I continued to administer her medications per prescription: • Cephalexin 500mg I cap TID • Mefenamic Acid 500mg I cap TID July 2, 2008, doctor’s order was to follow up 4 units of blood. Patient P wasreinserted with IV D5LR.
On July 7, 2008, Patient P was transfused with 4 units of fresh whole blood,baby was already on mother’s side, and were about to go home. She was seen withthe health workers facilitating her discharge from the hospital.
PHYSICAL ASSESSMENT Physical examination follows a methodical head to toe format in theCephalocaudal assessment. This is done systematically using the techniques ofinspection, palpation, percussion and auscultation with the use of materials andinvestments such as the penlight, thermometer, sphygmomanometer, tape measureand stethoscope and also the senses. During the procedure, I made every effort torecognize and respect the patient’s feelings as well as to provide comfort measuresand follow appropriate safety precautions.A. General Physical Assessment Patient is a 15 year old female, stands 5’4, with pulse rate of 82 beats preminute, respiratory rate of 21 breathe per minute and a temperature of 37.3 °C. Sheis conscious and coherent upon interaction but answers only the questions she iscomfortable with. Most of the time, she is pacing inside the ward and appearswithdrawn.B. Assessment of the Head Head is round in shape. Hair is long, thick and coarse, straight and evenlydistributed. Scalp is smooth and white in color, minimal lesions were noted. Dandruffand lice were seen.C. Assessment of the Eyes Her eyes are symmetrical, black in color, almond shape. Pupils constrictswhen diverted to light and dilates when she gazes afar, conjunctivas are pink.
Eyelashes are equally distributed and skin around the eyes is intact. The eyesinvoluntarily blink.D. Assessment of the Ears Ears are clean, no ear wax was noted and approximately of the same sizeand shape. Patient can hear normally when spoken softly.E. Assessment of the Nose With narrow nose bridge, there were discharges noted upon inspection. Noswelling of the mucous membrane and presence of nasal hairs were seen.F. Assessment of the Mouth She has a complete set of teeth with minimal dental caries noted. Oralmucosa and gingival are pink in color, moist and there were no lesions norinflammation noted. Tongue is pinkish and is free of swelling and lesions. Lips aresymmetrical, appears pale without bits noted upon observation.J. Assessment of the Neck Lymph nodes noted. Neck has strength that allows movement back and forth,left and right. Patient is able to freely move her neck.
H. Assessment of the Lungs and Thoracic Region No reports of pain during the inhalation and exhalation. Absence ofadventitious sounds upon auscultation. Respiratory rate 21 breathes per minutefrom the normal range of 16-20 breaths per minute.I. Assessment of the Heart Patient has an audible heart sound. PMI is heard between 4th - 5th intercostalsspace. Heart is pumping well with a pulse rate of 82 bpm from the normal rate of60-100 beats per minute.J. Assessment of the Abdomen Abdominal movement as with respiration, presence of peristalsis duringauscultation. Presence of rashes and lesions.K. Assessment of the Upper Extremities Skin: White in color; presence of marks/scars of wounds in the arms, neck and legs. Skin is smooth, moist and soft to touch. Hands: Medium in size with 5 fingernails in each side. Nails are short, small dusty particles are present. Arms: Able to move through active ROM. Able to extend arms in front or push them out to the side.
L. Assessment to the Lower Extremities Size of the feet is undefined with lines on the sole, presence of scars andlesions. Ten fingers are present. Nails are clean and short. Patient is ambulatory.M. Assessment of the Genitourinary With episiotomy dry and intact, urinates 2-4 times a day and has notdefecated yet since her delivery.N. Assessment of the Perineum With episiotomy intact, absence of lesions and swelling.O. Neurological Assessment Behavior – Patient is silent but is conscious and coherent upon interaction. She sits and walks if she wants to. Motor Functioning - Able to move extremities through active ROM. Able to extend arms front and resist active as pushed down/up on his hands. Reflexes - reflexes were present such as the blinking reflex and deep tendon reflex. Sensory Functioning – Patient’s sensory system is intact, she was able to distinguish touch, pain, hot and cold.
ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM EXTERNAL GENITALIA Our overview of the reproductive system begins at the external genital area—or vulva—which runs from the pubic area downward to the rectum. Two folds offatty, fleshy tissue surround the entrance to the vagina and the urinary opening: thelabia majora, or outer folds, and the labia minora, or inner folds, located underthe labia majora. The clitoris, is a relatively short organ (less than one inch long),shielded by a hood of flesh. When stimulated sexually, the clitoris can become erectlike a mans penis. The hymen, a thin membrane protecting the entrance of thevagina, stretches when you insert a tampon or have intercourse.
INTERNAL REPRODUCTIVE STRUCTUREThe Vagina The vagina is a muscular, ridged sheath connecting the external genitals tothe uterus, where the embryo grows into a fetus during pregnancy. In thereproductive process, the vagina functions as a two-way street, accepting the penisand sperm during intercourse and roughly nine months later, serving as the avenueof birth through which the new baby enters the world .The Cervix The vagina ends at the cervix, the lower portion or neck of the uterus. Likethe vagina, the cervix has dual reproductive functions. After intercourse, sperm ejaculated in the vagina pass through the cervix,then proceed through the uterus to the fallopian tubes where, if a spermencounters an ovum (egg), conception occurs. The cervix is lined with mucus, the
quality and quantity of which is governed by monthly fluctuations in the levels of thetwo principle sex hormones, estrogen and progesterone. When estrogen levels are low, the mucus tends to be thick and sparse, whichmakes it difficult for sperm to reach the fallopian tubes. But when an egg is readyfor fertilization and estrogen levels are high the mucus then becomes thin andslippery, offering a much more friendly environment to sperm as they struggletowards their goal. (This phenomenon is employed by birth control pills, shots andimplants. One of the ways they prevent conception is to render the cervical mucusthick, sparse, and hostile to sperm.)Uterus The uterus or womb is the major female reproductive organ of humans. Oneend, the cervix, opens into the vagina; the other is connected on both sides to thefallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its majorfunction is to accept a fertilized ovum which becomes implanted into theendometrium, and derives nourishment from blood vessels which develop exclusivelyfor this purpose. The fertilized ovum becomes an embryo, develops into a fetus andgestates until childbirth.Oviducts The Fallopian tubes or oviducts are two very fine tubes leading from theovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovarys wall rupture, allowing theovum to escape and enter the Fallopian tube. There it travels toward the uterus,pushed along by movements of cilia on the inner lining of the tubes. This trip takeshours or days. If the ovum is fertilized while in the Fallopian tube, then it normally
implants in the endometrium when it reaches the uterus, which signals thebeginning of pregnancy.Ovaries The ovaries are the place inside the female body where ova or eggs areproduced. The process by which the ovum is released is called ovulation. The speedof ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, where it travelled downthe oviduct to the uterus, occasionally being fertilised on its way by an incomingsperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs(cilia) to help the egg cell travel.
DRUG LISTDrug Name and Dose Date Ordered Ordering PhysicianCephalexin 500mg 1 cap June 29, 2008 Dr. Bombeo TIDMefenamic Acid 500mg 1 June 29, 2008 Dr. Bombeo cap TID DRUG STUDY
(ORAL MEDS)GENERIC NAME: CEPHALEXINCLASSIFICATION: Anti-InfectiveACTION: Inhibits DNA synthesis by inhibiting DNA gyrase in susceptible gram negative and gram positive organismsINDICATIONS: Infectious diarrhea, respiratory tract infection, infection on the skin structures, bones and jointsCONTRAINDICATIONS: Hypersensitivity to drug or other fluoroquinolonesADVERSE REACTIONS: • CNS: Headache • CV: Orthostatic Hypotension • EENT: Blurred Vision • GI: Nausea and Vomiting, Diarrhea, constipation • OTHER: TasteINTERACTIONS: Oral anticoagulants: Increased anti-coagulant effectsNURSING CONSIDERATIONS: • Advise Patient not to take drugs with dairy or Caffeinated products • Inform physician if allergies or rashes abruptly develop
GENERIC NAME: MEFENAMIC ACIDCLASSIFICATION: Anti-Inflammatory, AnalgesicACTION: Inhibits reuptake of serotonin norepinephrine CNSINDICATIONS: Moderate to moderately severe painCONTRAINDICATIONS: Hypersensitivity with drugs, acute intoxication with alcohol, physical opioid dependenceADVERSE REACTIONS: • CNS: dizziness • CV: Vasodilation • EENT: visual disturbances • GI: Nausea and Vomiting • GU: urinary retention • SKIN: pruritusNURSING CONSIDERATIONS: • Tell patient that drug works best when taken before pain becomes severe • Recommend abstinence from alcohol when taking medication • Caution patient that drug can cause dependence PROBLEM LIST
Problem # Nursing Diagnosis Date Identified Date Evaluated 1 Risk for infection r/t June 30, 2008 July 1, 2008 traumatized skin tissue 2º to episiotomy 2 Interrupted breast July 1, 2008 July 1, 2008 feeding r/t infant illness 3 Situational Low Self- July 1, 2008 Not Evaluated Esteem r/t perceived failure at life events 2º to rape trauma LEARNING OUTCOMES
For at least four weeks of duty, I have encountered several constraintswith regards to the implementation of interventions. It was not that easy speciallythat what I am dealing with are lives, lives through which if jeopardized, can eitherput me in an obnoxious situation or be blameworthy for any complications. Three days of multi-tasking and time management, the OB-NURSERYward exposure has taught me how to appropriately handle pregnant and postpartum women. The idea of caring for mothers and newborns which is not in mylineage is hard. Hard, because some of the patient’s are uncooperative and noncompliant. It isn’t that smooth to establish an interacting relationship specially thatmost of the patient’s admitted in the institution has a low educational attainment.Therefore, I cannot expect them to fully comprehend the instructions I haveimparted. However, it was a marvelous experience since I was exposed to variouskinds of maternal paragons and procedures which weren’t return demonstrated yet.Fortunately, there is our clinical instructor who persistently supervised us andassisted us to make it through with just minimal errors. Now, let me get this straight. This is my first time to manage anindividual case study. Adding to that is the fear of making a physiologic structure ofmy opted case. One false move and I am screwed. I have learned to thoroughlyassess my patient to comply with the requisites. Also, I have acquainted myself withregards to establishing rapport with my patient to have a trusting relationship. Somepatients do not totally disclose themselves because they may find it privacy invading.I have learned to be patient and control my feelings of anger or annoyance towardsthe patient; to respect and accept their beliefs and values without judging them; tocommunicate with them therapeutically; to be accurate and systematic when itcomes to charting to avoid errors and reprimands. Basically, it’s the feeling ofconfidence you have in yourself that will facilitate accomplishment and error-freeimplementation of nursing care. If you are confident enough to perform the
procedures, then the client will develop trust and confidence to you. The nurse has alot of responsibilities to take in, thus, confidence is a very important factor. The exposure wasn’t centered mainly to rendering care. It was alsofocused to building and developing intrapersonal and interpersonal relationships. Icall it, personal growth. To adjust and adapt with the environment is a humongoustask! It’s not that easy. But mingling with other people helps you identify yourstrength and weaknesses, and it aids in modifying what is somehow negative in ourattitudes. To sum this all up, it was a SUCCESS! Thanks be to GOD. The next time that I’ll render care and perform procedures, I will tryto do my best to attain satisfaction and accomplishment. ACKNOWLEDGEMENT
The materialization of this case study wouldn’t be possible without theaid of the following folks: To the Almighty Father for the strength given in realizing and fulfillingthe duties and the study; to beloved parents who have always been supportive allthroughout the start of the duty until the end, the toils and efforts; to dearcomrades and colleagues who have been extending all out help during the roughscenarios, specially to Miss Sheila Marie Adorador for aiding me in realizing the casestudy; and to my groupmates for the overwhelming support, help andcamaraderie, for being cooperative and indulging, that helped meaugment my learning and somehow sharpened my skills. To our ever lenient but strict clinical instructor, Mr. Paul Ritchie Pelos,for simplifying what used to be incomprehensible, tricky and complicatedconcepts, for assisting us in the various procedures we have performed,and for being kind to us despite our immaturity