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

The labor and birth process is always accompanied by pain. Several options for pain control are available, ranging from intramuscular or intravenous doses of
narcotics, such as meperidine (Demerol), to general anesthesia. Regional nerve blocks, such as a pudendal block or local infiltration of the perineal area can also be used.
Further options include epidural blocks and spinal anesthetics
2003-2004 statistics. In spite of the poverty, 95% of the women had spontaneous vaginal birth; 83% had blood loss less than 500 ml; 85% of the
babies required no resuscitation effort; 67% of the labors were without fetal distress or meconium staining; and 90% of the babies were of normal birth
weight. Transfers to a hospital after admission occurred 7% of the time, with half taking place before delivery and half after delivery. Neonatal mortality was
4.1 per 1000.
OBJECTIVES
General
The Student involve with the case will be able to perform comprehensive review in the patient’s condition and develop plan of care that would be appropriate for the client.
The student can also apply knowledge in caring for the NSD patient. This case is conducted to acquire knowledge and skills in providing a systematic, rational method of
planning and providing nursing care.
Knowledge:
To know the different diagnostic procedures and proper care applicable for the client.
To formulate a NCP to a patient who undergone Normal Spontaneous Delivery.
To prioritize a nursing care plan for the client
Skills:
To carry out appropriate interventions to meet desired goals and objectives.
To use critical thinking skills in interpreting assessment data that is necessary in identifying actual and potential nursing problems on the client.
To achieve the objectives of health teaching plan.

Attitude:
To collect and organize relevant information concerning the clients current health status through careful observation and skillful assessment
To use therapeutic communication skills to the client to gain cooperation and trust.
To render appropriate nursing care for the post partum patient with respect to her.
XIII. Nursing Assessment
A. Personal History
Demographic Data
1. Name: Patient CV
Address: Meyto Calumpit Bulacan
Age: 25 years old
Date and Place of Birth: July 2, 1985, Pampanga
Sex: Female
Nationality: Filipino
Marital Status: Single (live-in partner)
Occupation: none
Religious Orientation: Roman Catholic
Position in the family: wife/mother
Educational attaintment: college graduate
Health Care Financing/Usual Source: his father’s salary
Date/TIme of Admission: September 06, 2010 8:00am
Date/Time of Delivery: September 06, 2010 8:30am
Date/Time of Discharge: September 09, 2010 01:00pm

Final Diagnosis: Normal Spontaneous Delivery with a GP(TPAL) of G2P1(T1P0A0L1
OBSTETRICAL HISTORY
a. LMP December 06, 2009
b. EDC September 13, 2010
c. AOG 39 1/7 days
GP(TPAL) of G2P1(T2P0A0L1).
B. Chief Complaint or Reasonof Visit
“ Masakit na talaga yung puson ko, humihilab yung tyan ko, pasakit ng pasakit yung hilab.” as verbalized by the patient. The doctor admitted her to the Labor room due to
dilatation of cervix of about 7cm.
C. History of Present Illness
3 hours prior to admission, the patient had a sudden onset of a slight fluid discharges with brownish color. Patient says that she already knew that she’ll soon be giving
birth since this was her second time. When she felt that contractions and intensity are getting worse, she was rushed to the hospital. She was admitted last September 06,
2010 at 8:00 am after the doctor conducted an Internal Examination and found out that she is in the active phase of cervical dilation which is 7cm. and she gave birth at
8:30am.
D. History of Past Illness
The last time she was hospitalized was last August 3, 2007 when she gave birth to her first baby. She was then admitted at the same institution, the Bulacan
Maternity and Children’s Hospital The Patient stated that she had not been given any vaccination of tetanus toxoid. The patient stated that she was not sure if she has
completed the vaccination when she was born. She also stated that when she was young, she had experienced having chicken pox and measles. She also uses over the
counter drug when having fever, cough and colds. She believes in quack doctors too.

GENOGRAM
65 68
(HEART ATTACK) (HEART ATTACK) DIABETIC HYPERTENSIVE
HYPERTENSIVE
SMOKER
50 48 46 42 40 38 35 30 25 20
HEART DISEASE SMOKER HYPERTENSIVE SMOKER ASTHMA
SMOKER
CV NP
NV BV AP CP
LV
DP SP FPLV JV
ND
FP

LEGEND
25
FEMALE PATIENT
MALE DECEASED
0
4 ( ) – CAUSE OF DEATH
4 0
F. FUNCTIONAL HEALTH PATTERN
FUNCTIONAL HEALTH
PATTERN
Prior to Hospitalization During Hospitalization
1. Health Perception/Health
Management Pattern
Her rate for her health on a scale of 1-10 (1 being the lowest, and
10 as the highest) is 10, When the client was asked to descried her
health before, she replied “malusog na malusog naman ako bago
ako manganak.” When ask if she is drinking alcohol, she replied
“dati, noong hindi pa ako nagbubuntis at dalaga pa ako pero
simula noong nagasawa ako nawala na bisyo ko.” She also
believed in quack doctors.
“ok lang din naman, medyo naninibago lang kasi wala na
laman yung tyan ko na malikot na baby, tapos medyo
tumataas nga daw yung bp ko sabi ng mga nurse dito.” As
verbalized by the patient.
2. Nutritional and Metabolic
Pattern
September 3, 2010 Seotember 4, 2010 September 5, 2010
Breakfast
1/2 regular bowl
of Oatmeal.
2 pieces of monay
2 glasses of water
Lunch
1 cup of rice
1 medium size
Breakfast
3 pieces of monay
1 cup of Anmum
drink
1 glass of water
Lunch
2 cups of rice
1 pc leg of chicken
Breakfast
3 pieces of monay
1 glass bear brand
choco choco
Lunch
2 cups of rice
1 medium size
bangus
September 6, 2010 September 7, 2010
Breakfast
None
Lunch
1 Choco tops cup
cake
1 glass of water
Dinner
Breakfast
2 glasses of bear
brand choco choco
Lunch
3 pieces of monay
1 glass of water
MV
CV
RJ

bangus
2 glasses of water
Dinner
2 cups of rice
1 pc of fried
chicken (Leg part)
2 glasses of water
tinola
2 glasses of water
Dinner
1 cup of rice
1 piece fried
chiken(leg part)
2 glasses of water
3 glasses of water
Dinner
2 cups of rice
1 medium size
bangus
2 glasses of water
The patient loves eating fish, chicken and pork. The patient drinks
water a lot.
½ bowl of
Sinigang
½ cup of rice
1 glass of water
3. Elimination Pattern
Output Frequency Amount Characteristics
Urine
Stool
8
2
Approx.
1200ml
Yellowish
with pungent
odor
Formed,
brown and
foul odor
Output Frequency Amount Characteristics
Urine
Stool
5
1
Approx.
800ml
Dark yellow
urine with
pungent odor.
Formed,
brown and
foul odor.
The patient urinate four times a day. It is soft and dark yellow
in color. She voided 5 times from 7am to 3pm with yellowish
color urine on September 7, 2010.
The patient defecates one time on September 7, 2010.
4.Activity/Exercise pattern The patient do the house chores as soon as she wakes up before
she goes to their sari-sari store. She do all the house chores except
doing the laundry.
0 Feeding 0 Grooming
0 Bathing 0 General Mobility
0 Toileting
0 Bed Mobility
0 Dressing
Level 0 – Full self-care
Level I – Requires assistance or supervision from another person
During her first day in the hospital, patient was not able to
move around. When she needs anything, her mother and her
partner assist and help her. “Medyo masakit pa kasi yung tahi
ko.” As verbalized by the patient.
0 Feeding 0 Grooming
I Bathing 0 General Mobility
II Toileting
0 Bed Mobility
0 Dressing
Level 0 – Full self-care

Level II – Requires assistance or supervision from another person
Level III – Requires assistance or supervision from another person
or device
Level IV – Is dependent and does not participate.
Level I – Requires assistance or supervision from another
person
Level II – Requires assistance or supervision from another
person
Level III – Requires assistance or supervision from another
person or device
Level IV – Is dependent and does not participate.
5. Sleep Rest Pattern The patient sleeps twice a day. She sleeps usually at 9pm and
wakes up at 8am. And in order for her to sleep during the night,
lights must be turn off. She takes a nap for 20 minutes usually at
2pm.
During her stay in the hospital, the patient was able to sleep at
least 3 times a day since she is in a private room
6. Cognitive Perceptual
Pattern
The patient doesn’t wear eyeglasses. She watched television and
she easily gain knowledge from it. (e.g. News) She sometimes
forget things and she said “kailangan ko pa balikan yung ginagawa
ko bago ko maalala”
While in the hospital, she participates in the interview and she
responded to the question of the students properly. She also
follows the doctor’s order and hospital policies.
7. Self perception/Self-
concept pattern
She is cheerful and a friendly person. When asked what she
wanted to change in her body, she said she wanted to have slim
figure.
No dramatic changes.
8. Role Relationship pattern The patient and her partner lives with her family together with her
daughter. Whenever she have arguments with her husband, they
settle things down with a small talk.
She can’t take care of her daughter since she’s in the hospital
but she can’t wait to see her too. She has a problem
breastfeeding her newborn baby. “Nahihirapan na talaga ako
magpa-breastfeed simula pa dati. Ngayon, ganito na naman,
parang nawawalan yata ako ng gatas”, as verbalized by the
client.
“Kaya naman naming ibigay ng asawa ko ang
pangangailangan ng mga anak namin,”as verbalized by the
client.
9. Sexuality Reproductive
Pattern
She started having menstrual cycle when she was 11 y/o. She and
her husband engage in coitus almost everyday. She does not use
any artificial family method. Whe
The patient and her partner does not engage to any sexual
intercourse.
10. Coping Stress Tolerance She is short tempered whenever her husband goes out with his
friends to play leisure activities(DOTA). She usually cry to release
her stress when having or facing big problems. She tries to keep
her problems to herself.
“aalis na next next week si Kim, kaya ako lang mag-isa mag-
aalaga sa baby,” as verbalized by the client. She talks to her
partner and cry to release her stress knowing that her partner
will soon go to Canada for a job. She is very emotional.
11. Value Belief Pattern She and her family is a Roman Catholic. She believes in quack
doctor too. They attend the mass every Sunday.
Doesn’t change her belief religiously. The religious effort is
still a part of the patient. She prays for her family especially
her new baby.

G. Growth and development
Psychosocial Psychosexual Cognitive Moral
Stage Young adulthood
18-25 years old
Intimacy vs. isolation
Genital
Puberty onwards
Formal operation
11 years to adulthood
Conventional stage 4: Society-
Maintaining Orientation
Adolescence to adulthood
Definition Young adults seek
companionship and love
with another person or
become isolated from others
Energy in directed toward
full sexual maturity and
function and development
of skills needed to cope with
the environment
Locally solves all kinds of
problem; thinks scientifically;
solves complex problems;
cognitive structure matures.
Right is being good, with the values
and norms of family and society at
large. (“I must follow all rules so there
is order in the society”).
analysis The client exhibits a strong
sense of commitment and
responsibility towards her
partner and children.
The client does not
demonstrate independency
from her parents but able to
make her own decisions.
The client, together with her
partner, face life’s difficulties
with positive point of view.
The client is observed of her values
that were instilled to her.
III. Anatomy and Physiology
FEMALE REPRODUCTIVE SYSTEM

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes.
The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next
step for the fertilized egg is to implant into the walls of the uterus, beginning the intitial stages of pregnancy. If fertilization and/or implantation does not take place, the
system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the
reproductive cycle.
During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no
longer produces these hormones a woman is considered to be men
The female reproductive anatomy includes internal and external structures.
EXTERNAL FEMALE REPRODUCTIVE SYSTEM
The function of the external female reproductive structures (the genital) is
twofold: To enable sperm to enter the body and to protect the internal genital
organs from infectious organisms. The main external structures of the female
reproductive system include:
 Labia majora: The labia majora enclose and protect the other
external reproductive organs. Literally translated as "large lips," the labia
majora are relatively large and fleshy, and are comparable to the scrotum in
males. The labia majora contain sweat and oil-secreting glands. After
puberty, the labia majora are covered with hair.
 Labia minora: Literally translated as "small lips," the labia minora
can be very small or up to 2 inches wide. They lie just inside the labia majora,
and surround the openings to the vagina (the canal that joins the lower part of
the uterus to the outside of the body) and urethra (the tube that carries urine
from the bladder to the outside of the body).
 Bartholin's glands: These glands are located next to the vaginal
opening and produce a fluid (mucus) secretion.
 Clitoris: The two labia minora meet at the clitoris, a small, sensitive
protrusion that is comparable to the penis in males. The clitoris is covered by
a fold of skin, called the prepuce, which is similar to the foreskin at the end of

the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.
 Vagina: The vagina is a muscular passage which forms a part of the female sex organs and which connects the neck of the uterus (called the "cervix") with the
external genitals. The vagina, which is approximately two and one-half to four inches long, has muscular walls which are supplied with numerous blood vessels.
These walls become erect when a woman is aroused as extra blood is pumped into these vessels. The vagina has three functions: as a receptacle for the penis during
love-making; as a outlet for blood during menstruation; and as a passageway for the baby to pass through at birth. According to The Guiness Book of World
Records, a Russian peasant woman who lived in the 18th Century holds the record for the most children born to one mother. She had sixty-nine children within forty
years. She produced sixteen pairs of twins, seven sets of triplets, and four sets of quadruplets!
INTERNAL REPRODUCTIVE SYSTEM
The internal reproductive organs include:
 Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to
the outside of the body. It also is known as the birth canal.
 Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a
developing fetus. The uterus is divided into two parts: the cervix, which is the lower part
that opens into the vagina, and the main body of the uterus, called the corpus. The corpus
can easily expand to hold a developing baby. A channel through the cervix allows sperm
to enter and menstrual blood to exit.
 Ovaries: The ovaries are small, oval-shaped glands that are located on either side
of the uterus. The ovaries produce eggs and hormones.
 Fallopian tubes: These are narrow tubes that are attached to the upper part of the
uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus.
Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes.
The fertilized egg then moves to the uterus, where it implants to the uterine wall.
 Cervix: The cervix is the lower, narrow portion of the uterus where it joins with
the top end of the vagina. It is cylindrical or conical in shape and protrudes through the
upper anterior vaginal wall. Approximately half its length is visible, the remainder lies

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

 Physical Assessment
REMARKSACTUAL FINDINGSNORMAL FINDINGSTECHNIQUEPARTS TO ASSESSED
GENERAL APPEARANCE
Deviation from normalHeight: 5"3
Weight: lbs
Over weight
Proportionate, varies with
lifestyle
Inspection1.Body built , height, and weight in relation
to client's age, lifestyle and health
normalRelaxed, erect posture;
coordinated movements
Relaxed, erect posture;
coordinated movements
Inspection2.Client's posture and gait, standing, sitting,
and waking
normalCleanClean and neatInspection3.Client's overall hygiene and grooming
normalNo body odor or minor
odor relative to work or
exercise; no breath odor
No body odor or minor
odor relative to work or
exercise; no breath odor
Inspection4.Body and breath odor
normalNo stress notedNo distress notedInspection5.Signs of distress in posture or facial
expression
normalHealthy appearanceHealthy appearanceInspection6.Obvious signs of health or illness

normalCooperativeCooperativeInspection7.Client's attitude
normalAppropriate to situationAppropriate to situationInspection8.Client's affect/ mood; appropriateness of
the clients response
normalUnderstandable, moderate
face; exhibits thought
association
Understandable, moderate
face; exhibits thought
association
Inspection9.Quantity of speech, quality and
organization
normalLogical sequence; makes
sense; has sense of reality
Logical sequence; makes
sense; has sense of reality
Inspection10.Relevance and organization of thoughts.
SKIN
normaldeep brown
Uniformity-Generally
uniform except in areas
exposed to sunlight
Color- varies from light to
deep brown; from ruddy
pink to light pink; from
yellow overtones to olive.
Uniformity-Generally
uniform except in areas
exposed to sunlight; areas
of lighter pigmentation
(palms, lips, nail beds) in
dark-skinned people
Inspection1.Skin color and uniformity
normalNo edemaNo edemaInspection2.Presence of edema
normalNo birth marks and skin
lesions
Freckles, some birthmarks,
some flat and raised nevi;
no abrasions or other
lesions
Inspection3.Skin lesions
normalMoisture in skin folds and
the axillae (varies with
environmental temperature
and humidity, body temp.
and activity)
Moisture in skin folds and
the axillae (varies with
environmental temperature
and humidity, body temp.
and activity)
Palpation4.Skin moisture
normalUniform warm
temperature; within
normal range
Uniform; within normal
range
Palpation5.Skin temperature
normalWhen pinched, skin moves
back faster
When pinched, skin
springs back to previous
state
Palpation6.Skin turgor
NAILS
normalConvex curvature ; angleConvex curvature; angleInspection1.Fingernails plate shape to determine its

of nail plate about 180of nail plate about 160curvature and angle.
normalHas a pink fingernail and
toenail bed color
Highly vascular and pink
in light skinned clients;
dark-skinned clients may
brown or black
pigmentation in
longitudinal streaks
Inspection2.Fingernail and toenail bed color.
normalThere is an intact
epidermis
Intact epidermisInspection3.Tissue surroundings nail.
normalsmooth textureSmooth textureInspection4.Fingernail and toenail texture.
normalThe color returns into pink
within 4 seconds
Prompt return of pink or
usual color (generally less
than 4 seconds)
Palpation5.Blanch test of capillary refill.
HAIR & SCALP
normalEvenly distributed hairEvenly distributed hairInspection1.Eveness of growth over the scalp.
normalThick hairThick hairInspection2.Hair thickness or thinness.
normalNo infection or infestationNo infection or infestationInspection3.Presence of infections or infestation.
normalSilky and resilient hairSilky and resilient hairPalpation4.Texture and oiliness over the scalp.
SKULL
normalRounded (normocephalic
and symmetrical, with
frontal, parietal, and
occipital prominence);
smooth skull contour.
Rounded (normocephalic
and symmetrical, with
frontal, parietal, and
occipital prominence);
smooth skull contour.
Inspection1.Size, shape, and symmetry.
normalSmooth, uniform
consistency; absence of
nodules or masses.
Smooth, uniform
consistency; absence of
nodules or masses.
Palpation2.Nodules or masses and depressions
FACE
normalSymmetric or slightly
asymmetric facial features;
palpebral fissures equal in
size; symmetric nasolabial
folds
Symmetric or slightly
asymmetric facial features;
palpebral fissures equal in
size; symmetric nasolabial
folds
Inspection1.Face features
normalSymmetrical facial
movements
Symmetrical facial
movements
Inspection2.Symmetry of the facial movements

EYEBROWS & EYELASHES
normalEqually distributed; curled
slightly outward
Equally distributed; curled
slightly outward
Inspection1.Eveness of distribution and direction of
curl.
EYELIDS
normalSkin intact; no discharge;
no discoloration; lids
close symmetrically;
Aprox.15-20 involuntary
blinks per min.; bilateral
blinking
When lids open, no visible
sclera above corneas, and
upper and lower borders
of cornea are slightly
covered
Skin intact; no discharge;
no discoloration; lids
close symmetrically;
Aprox.15-20 involuntary
blinks per min.; bilateral
blinking
When lids open, no visible
sclera above corneas, and
upper and lower borders
of cornea are slightly
covered
Inspection1.Surface characteristics and ability to blink.
CONJUNCTIVA
normalTransparent; capillaries
sometimes evident
Transparent; capillaries
sometimes evident
Inspection1.Bulbar conjunctiva's color, texture and
presence of lesions.
normalShiny, smooth and pinkShiny, smooth, and pink or
red
Inspection2.Palpebral conjunctiva's color, texture and
presence of lesions.
SCLERA
normalSclera appears whiteSclera appears white
(yellowish in dark skinned
client)
Inspection1.Color and clarity.
CORNEA
normalTransparent, shiny , and
smooth; details of iris are
visible
Transparent, shiny , and
smooth; details of iris are
visible
In older people, a thin,
grayish white ring around
the margin, called arcus
senilis, may be evident.
Inspection1.Clarity and color
IRIS
normalFlat and roundFlat and roundInspection1.Shape and color
PUPILS
normalBlack in color; equal in
size; normally 3-7 mm in
Black in color; equal in
size; normally 3-7 mm in
Inspection1.Color, shape, and symmetry of size.

dm; round, smooth borderdm; round, smooth border
normalPupil constrict when
looking at near object;
pupils dilate when looking
at far object;
Pupil converge when near
object is moved toward the
nose
Pupil constrict when
looking at near object;
pupils dilate when looking
at far object; pupils
converge when near object
is moved toward the nose.
Inspection2.Pupil light reaction and accommodation.
normalequal responseIlluminate pupil constricts
(direct response)
Non illuminated pupil
constricts (consensual
response)
Inspection3.Pupils direct and consensual reaction to
light.
VISUAL ACUITY
normalable to read newsprintAble to read newsprintInspection1.Test near vision.
normalBoth eyes sees in 20/20
vision;
20/20 vision on snellen
chart
Inspection2.Test distant vision
LACRIMAL GLAND, LACRIMAL SAC
AND NASOLACRIMAL DUCT
normalNo edema, tenderness, or
tearing
No edema, tenderness, or
tearing
Palpation1. Presence of edema
EXTRAOCULAR MUSCLES
normalBoth eyes coordinated,
move in unison, with
parallel alignment
Both eyes coordinated,
move in unison, with
parallel alignment
Inspection1. Test each eye for alignment and
coordination.
VISUAL FIELDS
normalWhen looking straight
ahead, client can see
objects in the periphery
When looking straight
ahead, client can see
objects in the periphery
Inspection1. Test for peripheral visual fields.
EAR'S AURICLE
normalSame as the facial skin,
symmetrical
Auricle aligned with outer
canthus of eye, about 10
from vertical
Same as the facial skin,
symmetrical
Auricle aligned with outer
canthus of eye, about 10
from vertical
Inspection1.Color and symmetry of size and position.
normalMobile, firm, and non
tender; pinna-recoils after
Mobile, firm, and non
tender; pinna-recoils after
Palpation2.Texture,elasticity and areas of tenderness.

it is foldedit is folded
EXTERNAL EAR CANAL
normalDistal third contains hair
follicles and glands
wet cerumen in various
shades brown
Distal third contains hair
follicles and glands
Dry cerumen, grayish-tan
color; or stick, wet
cerumen in various shades
brown
Inspection1.Cerumen, skin lesions, pus and blood.
HEARING ACUITY TEST
normalNormal voice tones
audible.
Normal voice tones
audible.
Inspection1. Client's response to normal voice tones.
normalAble to hear ticking in
both ears
Able to hear ticking in
both ears
Inspection2.Perform watch tick test
NOSE
normalSymmetry and straight, no
discharge or flaring,
uniform in color
Symmetry and straight, no
discharge or flaring,
uniform in color
Inspection1.Shape, size or color and flaring or
discharge from the nares.
normalMucosa pink, clear, watery
discharge, no lesions
Mucosa pink, clear, watery
discharge, no lesions
Inspection2.Presence of redness, swelling, growths and
discharge of nares, using the flashlight.
normalNasal septum intact and in
middle
Nasal septum intact and in
middle
Inspection3.Position of nasal septum.
normalAir moves freely as the
client breathes through the
nares.
Air moves freely as the
client breathes through the
nares.
Palpation4.Test patency of both nasal septum.
normalNo tenderness, masses; the
bone and cartilage in midle
No tenderness, masses; the
bone and cartilage in midle
Palpation5.Tenderness, masses and displacement of
bone and cartilage
SINUSES
normalNo tenderNo tenderPalpation1.Presence of tenderness
LIPS
normal Deviation fromPale in color
Soft, moist, smooth
texture, symmetry of
contour, ability to purse
lips
Uniform pink in color
(darker, e.g., bluish hue, in
Mediterranean group and
dark-skinned client)
Soft, moist, smooth
texture, symmetryof
contour, ability to purse
lips
Inspection1. Symmetry of contour, color and texture

BUCCAL MUCOSA
normalUniform pink in color
Moist, smooth, soft,
glistening and elastic
texture (drier oral
Uniform pink in color
(freckled brown
pigmentation in dark-
skinned clients)
Moist, smooth, soft,
glistening and elastic
texture (drier oral mucosa
in elderly due to decreased
salivation)
Inspection1.Color, moisture ,texture, and the presence
of lesions
TEETH
Deviation from normal31 teeth; 16 upper teeth,
15lower teeth
Smooth, white, shiny tooth
enamel
36 teeth;
Smooth, white, shiny tooth
enamel
Inspection1.Inspect for color, number, and condition
and presence of dentures.
GUMS
normalPink gums
Moist, firm texture to
gums
retraction of gums no
Pink gums (bluish or dark
patches in dark-skinned
clients)
Moist, firm texture to
gums
No retraction of gums
(pulling away from the
teeth)
Inspection1. Color and condition
TONGUE/FLOOR OF THE MOUTH
normalPink, Smooth, lateral
margins; no lesions
Pink, Smooth, lateral
margins; no lesions
Inspection1. Color and texture of the mouth floor and
frenulum.
normalCentral in position
Pink in color; moist;
slightly rough; thin white
coating
Smooth, lateral margins;
no lesions; raised papillae
(taste buds) ; raised
papillae (taste buds)
Moves freely, no
tenderness
Central in position
Pink in color (some brown
pigmentation on tongue
borders in dark-skiinned
client's); moist; slightly
rough; thin white coating
Smooth, lateral margins;
no lesions; raised papillae
(taste buds) ; raised
papillae (taste buds)
Moves freely, no
Inspection2. Position, color and texture. movement, and
base of the tongue.

tenderness
PALATES AND UVULA
normalLight pink, smooth, soft
palate
Lighter pink hard palate,
more irregular texture
Light pink, smooth, soft
palate
Lighter pink hard palate,
more irregular texture
Inspection1.Color, shape, texture and the presence of
bony prominences.
normalPositioned in midline of
soft palate
Positioned in midline of
soft palate
Inspection2. Position of the uvula and mobility.
OROPHARYNX AND TONSILS
normalPink and smooth posterior
wall
Pink and smooth posterior
wall
Inspection1.Color and texture.
normalPink and smooth, no
discharge, of normal size
or not visible
Pink and smooth, no
discharge, of normal size
or not visible
Inspection2.Size of the tonsils, color and discharge.
normalpresentpresentInspection and palpation3.Gag reflex
NECK AND LYMPH NODES
normalNot visible on inspectionNot visible on inspectionInspection1.Symmetry and visible mass in the thyroid
gland.
normalNot palpableNot palpablePalpation2.Presence of tenderness or nodules in the
lymph nodes.
normalCentral in position in
midline neck; spaces are
equal on both sides
Central in position in
midline neck; spaces are
equal on both sides
Inspection and palpation3.Placement of the trachea.
normalIf palpitated, lobes are
small, smooth, centrally
located, painless, and rise
freely with swallowing
Lobules may not be
palpitated
If palpitated, lobes are
small, smooth, centrally
located, painless, and rise
freely with swallowing
Palpation4.Smoothness and areas of enlargement,
masses or nodules in the thyroid gland.
POSTERIOR THORAX
normalAnteroposterior to
transverse diameter in ratio
of 1:2
Chest symmetric
Anteroposterior to
transverse diameter in ratio
of 1:2
Chest symmetric
Inspection1.Shape, symmetry, and compare the
diameter of anteroposterior thorax to
transverse diameter.
normalSpine vertically aligned;Spine vertically aligned;Inspection2.Spinal alignment

spinal column is straight,
right and left shoulders
and hips are at the same
height.
spinal column is straight,
right and left shoulders
and hips are at the same
height.
normalQuiet, rhythmic and
effortless respirations
Quiet, rhythmic and
Inspection3.Breathing pattern
normalFull and symmetric chest
expansion (that is, when
the client takes a deep
breath, your thumb
separate 3-5 cm during
deep inspiration)
Full and symmetric chest
expansion (that is, when
the client takes a deep
breath, your thumb
separate 3-5 cm during
deep inspiration)
Palpation4.Respiratory excursion
normalSkin intact, uniform
temperature
Chest wall intact; no
tenderness; no masses
Skin intact, uniform
temperature
Chest wall intact; no
Palpation5.Temperature, tenderness, masses.
normalVibration felt through the
chest wall when the client
speaks
Vibration felt through the
chest wall when the client
speaks
Palpation6.Vocal fremitus
normalExcursion is 3-5 cm
bilaterally
Diaphragm usually slightly
higher in on the right side
Excursion is 3-5 cm
bilaterally in women and
5-6 cm in men
Diaphragm usually slightly
higher in on the right side
Percussion7.Percuss the posterior thorax.
normalVesicular and
bronchovesicular breath
sounds.
Vesicular and
bronchovesicular breath
sounds.
Auscultation8.Auscultate the posterior thorax.
ANTERIOR THORAX
normalQuiet, rhythmic and
Quiet, rhythmic and
Inspection1.Breathing pattern
normalSkin intact, uniform
temperature; no
Skin intact, uniform
temperature; no
Palpation2. Temperature, tenderness, masses.
normalFull symmetric excursion;
thumb normally separate
3-5 cm
Full symmetric excursion;
thumb normally separate3-
5 cm
Palpation3. Respiratory excursion.
normalSame as posteriorSame as posteriorPalpation4. Vocal fremitus.

fremitus; fremitus is
normally decreased over
heart and breast tissue
fremitus; fremitus is
normally decreased over
heart and breast tissue
normalPercussion notes resonate
down to the 6th rib at the
level of the diaphragm but
are flat over areas of heavy
muscles and bone, dull on
areas over the heart and
the liver, and tympanic
over the underlying
stomach.
Percussion notes resonate
down to the 6th rib at the
level of the diaphragm but
are flat over areas of heavy
muscles and bone, dull on
areas over the heart and
the liver, and tympanic
over the underlying
stomach.
Percussion5. Percuss the anterior thorax.
normalBronchial and tubular
breath sounds.
Bronchial and tubular
breath sounds.
Auscultation6.Auscultation of the trachea.
normalBronchovesicular and
vesicular breath sounds
Bronchovesicular and
vesicular breath sounds
Auscultation7. Auscultate the anterior thorax.
BREAST
normalRound, no nodules, no
masses. enlarge
Round, no nodules, no
masses. enlarge
Palpation1. Palpation of breast
normalinspection2. inspection of the nipple
inspection3. inspection of the areola
CAROTID ARTERIES
normalSymmetric pulse volumes;
Full pulsations, thrusting
quality; quality remains
same when client's
breathes, turns head,and
changes from sitting to
supine position; elastic
arterial wall.
Symmetric pulse volumes;
Full pulsations, thrusting
quality; quality remains
same when client's
breathes, turns head,and
changes from sitting to
supine position; elastic
arterial wall.
Palpation1. Pulsation of carotid arteries.
normalNo sound heard on
auscultation
No sound heard on
auscultation
Auscultation2.Auscultation of the carotid arteries.
JUGULAR VEINS
normalVeins not visibleVeins not visible
(indicating right side of
heart is functioning
Inspection1.Visibility of jugular veins

normally)
ABDOMEN
normalWhiter than the facial
color, with striae and
scars, no masses or
nodules, no lesion
Whiter than the facial
color, with striae and
scars, no masses or
nodules, no lesion
Inspection1.Skin integrity.
NormalroundedFlat or roundedInspection2.Abdominal contour
normalNo enlargement of liver or
spleen
No enlargement of liver or
spleen
Inspection3.Enlarged liver or spleen.
NormalAbdomen should be
symmetrical bilateral
Abdomen should be
symmetrical bilateral
Inspection4.Symmetry of contour.
NormalThe abdomen may rise
during inspiration and falls
during expiration
The abdomen may rise
during inspiration and falls
during expiration
Inspection5.Abnominal movements.
NormalNo audible bruit,No audible bruit,Auscultation6.Vascular pattern.
Normalno venous hum or friction
rubs
no venous hum or friction
rubs
Auscultation7.Bowel sounds, vascular sounds and
peritoneal friction rubs.
NormalTympany is predominantly
heard bec. Of the stomach
and intestine; dullness
sound heard over the liver
or distented bladder
Tympany is predominantly
heard bec. Of the stomach
and intestine; dullness
sound heard over the liver
or distented bladder
Percussion8.Percusss abdominal quadrants.
NormalFeel smooth and consistent
softness
Feel smooth and consistent
softness
Palpation9.Light palpation of abdominal quadrants.
Uterus
NormalContracted, firm and roundContracted, firm and roundPalpation1. palpation of the uterus.
Lochia
NormalRedRedInspection1. color of lochia
NormalMinimum lochiaMinimum lochiaInspection2. inspection of amount of lochia
PERINEUM
NormalDry, intact, tender,
discolored and edematous
Dry, intact, tender,
discolored and edematous
Inspection1. inspection of the perineum
MUSCULOSKELETAL
SYSTEM
normalEqual size on both sides of
body
Equal size on both sides of
body
Inspection1.Muscle size, compare the muscles on one
side of the body (arm, thigh, calf) to the same
muscle on the other side.

normalNo contractureNo contractureInspection2.Contructures (shortening) of the muscle
sand tendons.
normalNo tremorsNo tremorsInspection3.Muscle fasciculations and tremors of the
hands and arms when stretched in front of the
body.
normalNormally firmNormally firmPalpation4.Muscle tonicity.
normalEqual strength on each
body side
Equal strength on each
body side
Palpation5.Muscle strength
BONES
normalNo presence of noted
deformities
No deformitiesInspection1.Normal structure.
normalNo tenderness, swelling,
crepitation or nodules
No tenderness, swelling,
Palpation2.Edema and tenderness.
JOINTS
normalNo swellingNo swellingInspection1.Swelling
normalNo tenderness, swelling,
No tenderness, swelling,
Palpation2.Presence of tenderness, smoothness of
movement, swelling , crepitation and
presence of nodules.
RANGE OF MOTION
normalJoint moves smoothlyJoint moves smoothlyInspection1.Upper extrimities.
normalJoint moves smoothlyJoint moves smoothlyInspection2.Lower extrimities.
V. THE PATIENTS AND HIS CARE
A. MEDICAL MANAGEMENT
a. IVT, Blood Transfusion, Nebulization, total parenteral nutrition, NGT, oxygen therapy, etc.
Medical treatment
management
Date ordered/date discontinued General description Indication/purpose Client’s response to the
treatment
Intravenous fluid
(IVF)
Date Ordered: 09/06/2010
Time of infusion: 8:00 a.m.
# of bottle/s: 2 bottles(1000
cc/bottle run for 8 hours : 31
D5LR- Lactated Ringer's and
5% Dextrose Injection is a sterile,
nonpyrogenic solution for fluid
and electrolyte replenishment and
Indicated for parenteral
replenishment of the fluid and
minimal carbohydrates calories as
required by the clinical condition of
The patient is looking well
according to her looks and
grimace regarding to the
treatment. And her energy was

gtts/min.)
Time consumed: 12:00 pm
Date consumed: 09/07/2010
caloric supply in a single dose
container for intravenous
administration. Each 100 mL
contains 5 g Dextrose Hydrous,
USP*; 600 mg Sodium Chloride,
USP (NaCl); 310 mg Sodium
Lactate (C3H5Na03); 30 mg of
Potassium Chloride, USP (KCl);
and 20 mg Calcium Chloride, USP
(CaCl2·2H20).
the patient. It is also use as a
mixing solution for other IV
medication and as an alkalinizing
agent. Classified as a hypertonic
solution, which is a solution with a
lower salt concentration than in
normal cells of the body and the
blood.
replenished. And for the IV fluid,
it is infusing well to the patient’s
body.
b. Drugs
GENERIC/BRAND
NAME
DATE ORDERED,
DATE
TAKEN/GIVEN,
DATE CHANGE,
DATE
DISCONTINUED
ROUTE OF
ADMINISTRATION
GENERAL ACTION,
CLASSIFICATION,
MECHANISM OF
ACTION
INDICATION/
PURPOSE
CLIENT’S
RESPONSE
NURSING
RESPONSIBILITIES
(prior, during, after)
Generic Name:
Cephalexin
Brand Name:
Ceporex, Keftab,
Keflex
Septenber 06, 2010 Oral First-generation
cephalosporin;
inhibits bacterial cell
wall synthesis,
rendering cell wall
osmotically unstable;
uses: removal of gram-
negative bacilli from
the upper and lower
respiratory tracts,
urinary tract, and skin;
treatment of bone
Respiratory tract
infections caused by
streptococci; skin and
skin-structure
methicillin-sensitive
staphylococci and
streptococci; bone
staphylococci or
Proteus mirabilis;
There is no allergic
reaction when she
takes the medication.
Prior to
Administration
- During long-term
therapy, monitor CBC
and liver and kidney
function test results.
Ask patient if allergic
to cephalosporins or
penicillin.
During
Administration
- Tell patient to take

infections and otitis
media.
genitourinary
Escherichia coli, P.
mirabilis, and
Klebsiella species;
Haemophilus
influenzae,
staphylococcal,
streptococcal, and
Moraxella catarrhalis
infections
drug with full glass of
water.
After Administration
- Advise patient to
report severe diarrhea.
• As appropriate,
review all other
significant and life-
threatening adverse
reactions and
interactions,
especially those
related to the drugs
and tests mentioned
above.
Generic Name:
Mefanamic Acid
Brand Name:
ponstan
September 06, 2010 Oral Non-steroidal anti-
inflammatory drug;
Analgesic and
antipyretic activities
related to inhibition of
prostaglandin synthesis
Relief for moderate
postpartum
episiotomy pain when
therapy will not
exceed 1 week.
reaction when she
Prior to
Administration
- Inform patient about
the adverse reaction of
the drug.Tell the
patient that she may
stop the medication if
she is experiencing
ringing in ears;
persistent cramping or
stomach pain;
unresolved nausea and
vomiting; respiratory
difficulty or shortness
of breath; unusual
bruising or
bleeding(mouth,
urine, stool); skin
rash; unusual swelling

of extrimities:chest
pain; or palpations.
During
Administration:
maintain adequate
hydration(2-3 L/day
of fluids) unless
instructed to restrict
fluid intake.
- Instruct the patient
that while taking the
drug, do not use
alcohol, excessive
amounts of vitamin C,
or salicylate-
containing foods,other
prescription or OTC
medications
containing aspirin or
salicylate or other
NSAIDs without
consulting prescriber.
Generic Name:
Ferrous Sulfate
Brand Name:
Magniferon
September 06, 2010 Oral IRON
PREPARATION:
Elevates the serum
iron concentration
which then helps to
form Hgb or trapped in
the reticuloendothlial
cells for storage and
eventual conversion to
a usable form of iron.
Prevention &
treatment of Fe
deficiency & other
nutritional anemias;
anemias due to
hemorrhage,
infections, intestinal
parasitism, prolonged
illness, metabolic
disorders, rapid
growth, menstruation
& lactation.
reaction when she
Prior to
Administration
- Use cautiously with
allergy to ingredient,
normal iron balance,
peptic ulcer, regional
enteritis, ulcerative
colitis, hemolytic
anemias,
hemochromatosis
-Confirm that the
patient have iron
deficiency anemia
During
Administration

- Give drugs with
meals
- Administer liquid
preparations in water
or juice to mask taste
and prevent staining
of teeth
- Warn patient that
stool may be black or
green.
- Arrange for periodic
monitoring of
hematocrit and
Hemoglobin levels
c. Diet
Type of Diet Date started, Date
changed
General Description Indications/Purposes Specific food taken Client response to
the diet
Diet as Tolerated After Delivery
(September 07, 2010)
“Suggested food under
D.A.T.”
BREADS & GRAINS =6-
11 servings each day
 Whole-grain or
enriched breads and
cereals, and rice
 Foods in this
group are a major
source of
thiamin, niacin,
iron, fiber and
zinc; and also a
vital part of a
healthy, balanced
Breakfast
2 glasses of bear brand choco
choco
Lunch
3 pieces of monay
1 glass of water
The patient was
replenished and
regained her energy
as manifested by
increased in body
weight and show
signs of healthy
body.

VEGETABLES =3-5 servings
each day
 All canned, frozen or
cooked vegetables
 Fresh vegetables as
tolerated
 Vegetable juice
FRUITS= 2-4 servings each
day
 Fresh or frozen
fruits processed
without sugar
 Water-packed
canned fruits
 Fruit juices,
unsweetened
MEAT & MEAT
SUBSTITUTES
 Lean tender meats
 Chicken (cooked so it is
tender and cut into
small pieces)
diet.
 Vegetables are
high in certain
nutrients, such as
potassium,
vitamins A and C
and folic acid.
 Fruit are major
sources of
vitamins A and
C, potassium,
folic acid, and
soluble and
insoluble fiber.
Meat is a major source
of protein, iron, niacin,
thiamin, vitamins B6
and B12, folic acid,
magnesium, potassium,
phosphorus and zinc

d. Activity Exercise
Type of Exercise Date Started General Description Indications/purposes Client’s response to the
activity/exercise
 Soft fish and shellfish
(baked, boiled, grilled),
Tofu (soy) mixed in
soup or vegetables
 Eggs (cooked with
minimal fat)
MISCELLANEOUS
 Coffee, tea,
unsweetened or diluted
fruit drinks
 Spices and seasonings,
as tolerated
 Milk as tolerated,
nonfat
 Water

Active range of
motion(AROM)
Walking
May 20, 2010
May 20, 2010
Exercises without any
assistance
Exercises without any
assistance
Exercise is useful in preventing
or treating coronary heart
disease, osteoporosis,
weakness, diabetes, obesity,
and depression. Range of
motion is one aspect of
exercise important for
increasing or maintaining joint
function. Strengthening
exercises provide appropriate
resistance to the muscles to
increase endurance and
strength. The benefits of
exercise not only improve
physical health, but also
enhance emotional well-being.
To prevent circulatory stasis in
the lower extremities
 To lowered cholesterol
level, reduced risk of
osteoporosis, increased
energy level, and
possible reduction in
The client is able to walk
across the room. And can
perform personal hygiene and
toileting.
The patient was practiced her
gait.

the rate of caesarian
birth
B. Surgical Management
An episiotomy is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the
posterior end of thevulva, is performed under local anaesthetic (pudendal anesthesia), and is sutured closed after delivery. It is one of the most common medical procedures
performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in many parts of the world a and assist
childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anesthetic (pudendal anesthesia), and is sutured closed
after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is
still widely practiced in many parts of the world.
Episiotomies were once routinely performed to prevent vaginal tears during delivery. Today, routine episiotomies are not recommended.
However, episiotomies may still be performed when there is a complicated delivery. An episiotomy may be needed if the baby's head or shoulders are too big for the
mother's vaginal opening, or the baby is in a breech position (feet or buttocks coming first) and there is a problem during delivery.
It may also be needed to speed the delivery process if there is concern about the baby's heart rate.

The two most common types of episiotomy are the midline episiotomy and the medio-lateral episiotomy. There has been significant debate about the advantages and
disadvantages of these two types of episiotomy. In the, midline episiotomy is by far more common, while medio-lateral episiotomies are more common in and other parts of
the world.
Midline Episiotomy
A midline episiotomy refers to an episiotomy where the incision of the vaginal opening is directly in the midline, straight down toward the anus. The advantages of a
midline episiotomy include easy repair and improved healing. This type is also less painful and is less likely to result in long-term tenderness or problems with pain during
intercourse. There is often less blood loss with a midline episiotomy. The main disadvantage of a midline episiotomy is the likelihood for this type of incision to extend
(continue tearing) and involve the anal sphincter or the lining of the rectum. When this happens, injury to the sphincter can result in long-term problems, such as fecal
incontinence or the development of a recto-vaginal fistula (a small channel that connects the rectum with the vagina).

Medio-Lateral Episiotomy
A right medio-lateral episiotomy begins at the vaginal opening in the midline with the incision directed toward the right buttocks at a 45-degree angle. The main advantage
of the medio-lateral episiotomy is that it is less likely to extend into or involve the anal sphincter and the rectum. Disadvantages of the medio-lateral episiotomy are
significant and include increased blood loss, increased pain, difficult repair, and an increased risk of long-term discomfort, especially during intercourse.
 Client’s response to operation:
After the procedure, there is no sign of infection. The site is dry, intake, pinkish in color, and there is no pus coming from the wound. The wound site is
healing.
 Nursing responsibilities:
 instruct the woman to cleanse from the front to the back every after voiding and defication
 infra red light focused to the perineum for 15 minutes 2 or 3 times at first 24 hours of delivery to promote fast healing
 explain proper handwashing after perineal care

 encourage to increase fruit juices that are rich in vitamin C to increase resistant against infection
 external antiseptic applied to the episiotomy wound every after perineal care or 2 times a day
  The area of the episiotomy may be uncomfortable or even painful for several days. Several practices can relieve some of the pain. Cold packs can be applied
to the perineal area to reduce swelling and discomfort. Use of a sitz bath can ease the discomfort. This unit circulates warm water over the area. A squirt bottle with water
can be used to clean the area after urination or defecation rather than wiping with tissue. Also, the area should be patted dry rather than wiped. Cleansing pads soaked in
witch hazel (such as the brand Tucks) are very effective for soothing and cleaning the perineum.
C. Nursing Problem Prioritization
DATE IDENTIFIED CUES PROBLEM/ NURSING DIAGNOSIS JUSTIFICATION
September 7, 2010 S: “Medyo masakit pa kasi yung tahi
ko,” as verbalized by the patient
O: Uterus firm and contracted
Minimum lochia
Perineum: tender, discoloured,
edematous
Pain related to tissue trauma as
manifested by verbal report of client.
Pain must be prioritized to promote
comfortability to the client in her post
partum period. Pain must be eliminated
as much as possible.
September 7, 2010 S: “Nahihirapan na talaga ako magpa-
breastfeed simula pa dati. Ngayon,
ganito na naman, parang nawawalan yata
ako ng gatas”, as verbalized by the
client.
O:
Breast enlarged
no sign of oxytocin release
Ineffective breastfeeding related to
previous history of breastfeeding failure
as manifested by verbal report of client.
Breastfeeding must be prioritized to
avoid premature development of the
baby and to avoid future problems that
the patient may encounter if ineffective
breastfeeding is not solved.
September 7, 2010 S: “Kaya naman naming ibigay ng asawa
ko ang pangangailangan ng mga anak
Readiness for enhanced parenting related
to ability to put child’s need first as
Parenting must be prioritized to enhance
the ability of the client to guide her

namin,”as verbalized by the client. manifested by physical and emotional
needs of the children are met.
children.
D. NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “Medyo masakit pa
kasi yung tahi ko.” As
verbalized by the patient.
O:
BP: 140/100 mmHg
Uterus firm and contracted
Minimum lochia
Perineum: tender,
discoloured, edematous
Fully ambulating
Pain r/t tissue trauma as
banifested by verbal
reports of client.
After 1 day of nursing
interventionthe client will
be able to report pain
relief.
Within 2 hrs- will follow
prescribed pharmacologic
regimen
Within 1 hr- will
demonstrate use of
relaxation skills and
diversional activities as
indicated.
 Provide comfort
measures
 Encourage use of
diversional
activities
 Encourage
adequate rest
periods to prevent
fatigue
 Administer
analgesic as
indicated
 Provide for
individualized
physical
theraphy/exercise
 To provide
nonpharmacologic
pain management
intervention he client was
able to report pain relief.
_____- follow prescribed
pharmacologic regimen
_____-will demonstrate
use of relaxation skills and
diversional activities as
indicated.

program that can
be continued by
the patient when
discharged.
S: “Nahihirapan na talaga
ako magpa-breastfeed
simula pa dati. Ngayon,
ganito na naman, parang
nawawalan yata ako ng
gatas”
O:
Breast enlarged
no sign of oxytocin
release
Ineffective breastfeeding
related to previous history
of breastfeeding failure as
manifested by verbal
report of client.
intervention the client will
be able to demonstrate
technique to
improve/enhance
breastfeeding.
Within 1 hr- will assume
responsibility for effective
breastfeeding.
Within 1 hr- will achieve
mutually satisfactory
breastfeeding w/ infant
content after feedings.
 Give emotional
support to mother.
Use 1:1 instruction
with each feeding
during hospital
stay/clinic visit
 Recommend
avoidance or
overuse of
supplemental
feedings and
pacifier (unless
specifically
indicated)
 Restrict use of
breast shields (i.e.
only temporarily to
help draw out the
nipple out), then
place baby directly
on nipple
 Encourage
frequent rest
periods, sharing
households/childca
re duties
 Suggest
abstinence/restricti
on of tobacco,
 Overuse of
supplemental
feedings and
pacifier can lessen
infant’s desire to
breastfeed.
 To limit fatigue
and facilitate
relaxation at
feeding times
 Because they may
affect milk
production/let-
down reflex or be
intervention the client was
able to demonstrate
technique to
improve/enhance
breastfeeding.
____- assumed
responsibility for effective
breastfeeding.
____- achieved mutually
satisfactory breastfeeding
w/ infant content after
feedings.

caffeine, alcohol,
drugs, excess sugar
passed on to
infant.
S: “Kaya naman naming
ibigay ng asawa ko ang
pangangailangan ng mga
anak namin,”as verbalized
by the client.
O:
Needs of her children are
met
Evidence of attachment
Readiness for enhanced
parenting related to ability
to put child’s need first as
manifested by physical
and emotional needs of
the children are met.
After 3 days of nursing
intervention the client will
be able to participate in
learning appropriate
attachment/ parenting
behaviors.
Within 2 hrs: will
verbalize realistic
information and
expectations of parenting
role.
 Create an
environment in
w/c relationships
can be develop and
needs of individual
family members
can be met
 Provide
information,
including time
management,
stress reduction
techniques
 A safe
environment in
w/c individuals
can freely express
their thoughts and
feelings optimizes
learning and
positive
interactions among
family members
enhancing
relationships.
 Learning about
positive parenting
skills,
understanding
growth and
development
expectations, and
ways to reduce
stress and anxiety
promotes
individual’s ability
to deal with
problems that may
arise in the course
of family
relationships.
After 3 days of nursing
intervention the client was
able to participate in
learning appropriate
attachment/ parenting
behaviors.
_____- verbalized realistic
information and
expectations of parenting
role.

VI. Discharge Planning
A. General condition of the patient upon discharge
B. METHODS:
M- Medications:
 Cefalexin 500 mg – q6
 Mefenamic acid 500 mg – q6
 Vitamin B1 B6 B12 – OD
 Magniferron - OD
E >fully ambulatory
T > adherence to therapeutic regimen
H > health teaching given as follows:
- Encourage breastfeeding
- Encourage hand washing
- Emphasize perineal care every after voiding and bowel movement
- Instruct to do core care of the baby daily
- Take a bath daily
- Take home medications on time
- Attend on sessions for check-up
- Avoid lifting heavy objects within six weeks of postpartum
O> Out-patient appointment

- Date: September 15, 2010
- Time: 9 a.m.
- Place: OPD-OB section
D> diet as tolerated
- Encourage to eat green leafy vegetables to increase iron content of the body
- Encourage to eat other nutritious foods like fruits, vegetables, egg, and meat
S> advice may resume sexual activity only after six weeks of postpartum.
CONCLUSION:
The purpose of this case study was to provide a wider knowledge regarding the birth process focusing on the Normal Spontaneous Delivery NSD. This study was
conducted of seven students to prolong their knowledge and skills about the case, for them to visualized deep understanding of their Maternal and Child Nursing MCN.
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