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VELEZ COLLEGE – COLLEGE OF NURSING
F. RAMOS STREET, CEBU CITY
PPS GROUND FLOOR
A CRITICAL ANALYSIS REPORT ON L.B.R, 34 YEARS OLD, FEMALE
DIAGNOSED WITH G4P4(4004) PREGNANCY UTERINE TERM371/7 WEEKS AOG BY LMP, CEPHALIC PRESENTATION, DELIVERED SPONTANEOUSLY A LIVE BABY GIRL WITH AS 9,10
BS 40 WEEKS, BW 3100 GRAMS AGA, MULTIPARITY, REPAIR OF SECOND DEGREE LACERATION, POSPARTUMBILATERAL TUBAL LIGATION (MODIFIED POMEROY)

2. SUBMITTED BY
Castro, Janine Angela E.
BSN IV-C
SUBMITTED TO
Ms. Josephine Fajardo
Date:

3. L.B.R, 34 yearsold,female,1st
admissionatCebuVelezGeneral Hospital (CVGH) onFebruary16,2013 at 2:53 PMper private vehicle,accompaniedbyherhusband,due topainful uterinecontractions
associatedwithclearwateryvaginal dischargesnotedmorningPTA.
CASE INTRODUCTION: NORMAL SPONTANEOUS VAGINAL DELIVERY
Pregnancy isthe carrying of one or more offspring,knownasa fetusorembryo,inside the wombof a female.
The periodfromconceptiontobirth. Afterthe eggis fertilizedbyaspermand thenimplantedinthe liningof the uterus, itdevelopsintothe placentaandembryo,andlaterintoafetus.Pregnancy
usuallylasts40 weeks,beginningfromthe firstdayof the woman'slastmenstrual period,andisdividedintothree trimesters,eachlastingthree months.Pregnancyisastate in whicha womancarriesa
fertilizedegginside herbody.
Whengestationhascompleted,itgoesthroughaprocesscalleddelivery,where the developedfetusisexpelledfromthe mother’swomb.
Whengestationhascompleted,itgoesthroughaprocesscalleddelivery,where the developedfetusisexpelledfromthe mother’swomb.There are twooptionsof delivery:
1. Vaginal Deliveryaka Normal SpontaneousVaginal Delivery
 A spontaneousvaginal delivery(SVD) occurswhena pregnantwoman goesintolaborwithoutuse of drugsor techniquestoinduce labor,anddeliversherbabyin
the normal manner,withoutacesareansection.Lacerations(tearingof the tissues) canoccurduringspontaneousvaginal deliveryandmayrequire repair.A mothermaychoose
differentlevelsof painrelief andstillexperienceaspontaneousvaginal delivery.Thisisstill the mostcommontype of deliveryandthatto whichall othermodesof deliveryare
compared.
 Childbirth(alsocalledlabor,birth,partusorparturition) isthe culminationof ahumanpregnancy or gestationperiodwithbirthof one ormore newborn infants
froma woman'suterus.The processof normal humanchildbirthiscategorizedinthree stagesof labor:the shorteningand dilationof the cervix,descentandbirthof the infant,and
birthof the placenta.Insome cases,childbirthisachievedthrough caesareansection,the removal of the neonatethroughasurgical incision inthe abdomen,ratherthanthrough
vaginal birth.
2. Operative Delivery
 CesareanSection -asurgical methodof deliveringthe babyfromthe pregnantmother.A surgical incisionthroughthe mother’sabdomenanduterustodeliverone ormore fetuses.
Thisis usuallydone around9-10thmonth of pregnancyas an emergencyorelectiveprocedureonce the babyismature. Itcouldalso be done as an emergencywhenlifethreatening
complicationstomotherorbabyoccur.
Typesof Incision:ClassicandTransverse orPfannensteil
 ForcepsDelivery - Forcepsare instrumentsdesignedtoaidinthe deliveryof the fetusbyapplyingtractiontothe fetal head.A physicianmayuse forcepstospeedupdeliveryif there
isfetal distressormaternal exhaustion.

4. LABOR
 A series of events by which uterine contractions and abdominal pressure expel the fetus and placenta from the woman’s body. It starts when there’s cervical ovulation
Signs of Labor
Preliminary Signs
 Lightening –descent of the fetal presenting part into the pelvis
 Nesting Behavior –Mother is full of energy in contrast to her feelings during the previous month
 Persistent Backache –progressive and regular uterine contractions
 Weight loss –due to hormonal influence
 Braxton Hicks Contractions –painless, irregular contraction
 Resurgence of the frequency of urination
 Ripening of the cervix
False Contractions True Contractions
Begin and remain irregular Begin irregularly but become regular and predictable
Felt first abdominally and remain confined to the abdomen and groin Felt first in lower back and sweep around to the abdomen in a wave
Often disappear with ambulation and sleep Continue no matter what the woman’s level of activity
Do not increase in duration, frequency, or intensity Increase in duration, frequency, and intensity
Do not achieve cervical dilatation Achieve cervical dilatation
Components of Labor
 PASSAGE - pertains to the woman’s pelvis which should be adequate in size and contour
refers to the route the fetus must travel form the uterus through the cervix and vagina to the external perineum.
 PASSENGER - fluid, blood and mucus which should be appropriate in size and in an advantageous position and presentation.
 POWER - produced by the fundus of the uterus, are implemented by uterine contractions, a process that causes cervical dilatation and then expulsion of the fetus from the uterus.

5.  PSYCHE - is preserved so afterward labor can be viewed as a positive experience.
 POSITION
Stages of Labor
STAGE 1
Dilatation and Effacement – starts from the true labor contractions to the full dilatation and effacement of the cervix
 Effacement
- the processbywhichthe cervix preparesfordelivery.Afterthe babyhasengagedinthe pelvis,itgraduallydropscloserto the cervix; the cervix gradually softens, shortens and
becomes thinner. Phrases like "ripens," or "cervical thinning" refers to effacement.
 Dilatation
- the openingofthe cervix.Dilationisthe processof the cervix openinginpreparationforchildbirth.Dilationismeasuredincentimetresor,lessaccurately, in “fingers” during an
internal (manual) pelvic exam. “Fully dilated” means you're at 10 centimetres and are ready to give birth.
-
Latent Phase – mild contractions; 20-30 mmHg; duration 20-30 seconds; frequency 12-20 mins.
Nursing Management:
 reduce anxiety
 carry out initial assessment
 provide comfort measures
 provide necessary health teachings
 promote bladder care
 proper positioning –L side lying to avoid vena caval compression
Active Phase –contractions become longer and more intense. Most contractions last as long as 45 seconds, and are three minutes apart. The cervix dilates from four to eight centimeters during this
phase.If the bag of watershasnot alreadybroken,the treatingdoctoror midwife,will most likely break them at this time. The contractions during this phase are much more painful than in the early
phase, and expectant mothers may try breathing techniques, massage, pressure or request pain medications.
Nursing Management:
 Continue to monitor uterine contractions; FHT and v/s every 15 minutes  Position the client to Sim’s left

6.  Coach on breathing techniques
 Monitor for the spontaneous or artificial rupturing of the membranes
 Comfort measures
 Administer IV fluids and medications ordered
Transition Phase –contractions occur every two to three minutes. Each contraction can last up to 90 seconds. During this phase, the cervix dilates from eight to ten centimeters. During this phase of
labor,the contractionsare at theirmostintense.The expectant mother may become nauseous, as well as experience shaking, chills, sweats and the urge to push. Once the cervix is fully dilated and
effaced, pushing can begin.
Nursing Management:
 Encourage mother to rest in between contractions
 Monitor FHT and v/s
 Observe for onset of the second stage of labor
 Prepare for the delivery procedure
STAGE 2
Expulsion Phase or Fetal Stage – stage from the full dilatation and effacement of the cervix to the delivery of the baby; contractions same as active phase.
Nursing Management:
 Transfer to the delivery room
 Position client for delivery
 Preparation of the perineum (half-prep)
 Prepare the mother’s and baby’s table
 Teach on effective pushing
Cardinal Movements of Labor
 Engagement
 Descent

7. -Downward movement of the biparietal diameter of the fetal head to within the pelvic inlet
 Flexion
-Head bends forward onto the chest
-Makes the smallest anteroposterior diameter the one presented to the birth canal
 Internal Rotation
-Head flexes as it touches the pelvic floor
-The occiput rotates until it is superior
-Brings the head into the best relationship to the outlet of the pelvis
 Extension
-As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head
*monitor the progress of labor including FHT and vital signs
 External Rotation
-After the head of the infant is born, the head rotates to the diagonal or transverse position
 Expulsion
*Ritgen’s Maneuver
-supporting of the perineum to prevent laceration during the cutting of the perineum or episiotomy
Episiotomy
Incision on the perineum to prevent laceration; facilitate delivery of the baby.

8.  Median or Midline –heals faster but with increased risk for rectal tears.
 Mediolateral –delay wounding healing; for breech presentation; short perineum;
large baby;
Lacerations
First degree - involve the skin of the perineum and the tissue around the opening of the vagina or the outermost layer of the vagina itself
Second degree - go deeper, into the muscles underneath
Third degree - tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter
Fourth degree - goes through the anal sphincter and the tissue underneath it.
STAGE 3
Placental Delivery
 Schultz Placenta:
 shiny and glistening part
 separates from the center then to the edges
 Duncan’s Placenta:
 Raw, red, irregular
 separates from the edges first

9. Stages:
 Separation of the placenta from the uterine wall
 Expulsion from the vagina
Signs of placental Separation
 Uterus becomes firm and globular
 Sudden gush of blood from the vagina
 Umbilical cord lengthens outside the vulva
 Uterine fundusrisesinthe abdomen
STAGE 4
Immediate Postpartum Phase
PUERPERIUM
Phases:
I. Taking- in phase
 Time of reflection.
 2 to 3 days, the woman is passive.
 Physical discomfortsdue toperineal stitches,afterpains,orhemorrhoids;partlyfromheruncertaintyincaringforhernewborn;andpartlyfromthe extreme
exhaustion that follows childbirth.
II. Taking-hold phase
 The woman begins to initiate action.
 3 to 10 days
 The woman begins to express strong interest in taking care of her child.

10. III. Letting- go phase:
 The woman finally redefines her new role.
 10 days to 6 weeks
 Gives up the fantasized image of her child and accepts the real one.
NursingConsiderations:
 Drapes are removed
 Woman’s legs are carefully and simultaneously lowered from the stirrups
 Obtain vital signs every 15 minutes for the 1st
hour
 Palpate fundus for size, consistency, and position
 Observe for the amount and consistency of the lochia
 Perform perineal care
 Apply maternity diaper or perineal pad as order

12. BILATERAL TUBAL LIGATION
It is surgery to block a woman's fallopian tubes. It is a permanent form of birth control. After this procedure, eggs
cannot move from the ovary through the fallopian tubes and eventually to the uterus. Also, sperm cannot reach the
eggin the fallopiantube afteritisreleased by the ovary. Thus, pregnancy is prevented. This procedure is said to have
your "tubes tied."
While you are under anesthesia, one or two small incisions (cuts) are made in the abdomen (usually near the navel),
and a device similartoasmall telescope onaflexibletube (calleda laparoscope) isinserted.Usinginstruments that are
insertedthroughthe laparoscope, the tubes (fallopian tubes) are coagulated (burned), sealed shut with cautery, or a
small clipisplacedonthe tube.The skin incisionisthenclosedwithafewstitches.Youare usually feeling well enough
to go home from the outpatient surgery center in a few hours. Your health care provider may prescribe pain
medications to help you manage the pain, if any.
Most womenreturnto normal activities,includingwork,inafewdays,althoughyoumaybe advisednotto exercise for
several days. You may resume sexual intercourse when you feel ready.
Tubal ligation can also be performed immediately after childbirth through a small incision near the navel or during a
Cesarean delivery.
Risks of Tubal Ligation
No procedure is ever completely free of risks. However, tubal ligation has been performed for many years with successful results and limited complications. If problems do
occur, they may include but are not limited to:
 Infection
 Bleeding
 Allergic skin reactions
 Blood clots
 Blood vessel injury
 Reactions to medication or anesthesia
Minor complications of tubal ligation can include:
 Nausea and vomiting
 Minor infections
 Minor bleeding
 Bruising or a collection of blood at the incision site
 Burns on the skin
 Abnormal or painful scar formation
 Allergic skin reaction to tape, dressings, or latex
 Delayed return of bowel and/or bladder function.

13. Major Tubal Ligation Complications
Possible major complications of tubal ligation include but are not limited to:
 Failure to produce sterility, meaning the operation does not prevent future pregnancy
 Serious bleeding
 Serious infection
 Damage to organs, including the uterus, fallopian tubes, ovaries, bladder, and/or ureters
 Damage to the intestines, including a perforation (a hole) in its lining or a burn injury
 Blood vessel injury
 Blood clots
 Nerve injury
 Hernias, which may include a rupture of the incision or the diaphragm
 Complications from the air placed in the abdomen (stomach), such as air going into a blood vessel or the space outside the lung
 Reactions to medication or anesthesia
Depending on the individual situation, a major tubal ligation complication could lead to a longer stay, a blood transfusion, or a repeat surgery. A surgery such as this could
possibly include immediate major abdominal surgery, a hysterectomy (removal of the uterus), or, in rare instances, placement of a colostomy.
Other major risks, in extreme cases, may lead to permanent disability, paralysis, or loss of life.

14. ANATOMY AND PHYSIOLOGY
THE FEMALE REPRODUCTIVE SYSTEM
The reproductive systemisviewedasthe mostimportantbodysystembecause itsbasicfunctionistoproduce children.The female reproductive systemisacomplicatedsystem
that issimilarandalsodifferent from those of a man’s. Here, we shall examine the external and internal structures of the female reproductive system, the mechanisms that
determine the menstrual cycle, ovulation, and many more.
The External Structures
Mons Veneris: A pad of adipose tissue located over the symphysis pubis, covered with coarse, curly hairs better known as
pubic hairs. The mons veneris protects the pubic bone from trauma.
Labia Minora: “Small lips.” These are two pink, hairless folds of connective tissue located posterior to the mons veneris.
These can be small or could be up to 2 inches each, depending upon the female’s developmental age. They lie within the
labia majora and surround the vaginal opening and the urethra.
Labia Majora: “Large lips.”These are two,larger(thanthe labiaminora),haircovered(afterpuberty) folds of adipose tissue
that enclose and protect the other external structures such as the vaginal orifice and the urethral orifice. The labia majora
contain sweat and oil-secreting glands.
Vestibule: The flattened, smooth surface inside the labia. Both the urethral orifice and vaginal orifice arise from this
structure.
Clitoris:The small (1-2 cm) roundedorganof erectile tissue issynonymoustothe penis.Otherthanerectile tissue, it contains blood vessels and nerves that make it extremely
sensitiveandreactive topleasurable stimuli,thusitisthe centerof sexual arousal and orgasm in a woman. The prepuce, a small fold of skin that covers the clitoris is similar to
the foreskin of a male’s penis.
Skene’sGlandsand Bartholin’s Glands:The pair of Skene’sglandsislocatedlateral tothe urinarymeatusoneachof its sides,withtheirductsopeningtothe urethra.Bartholin’s
glands,alsoknownasthe Vulvovaginal orVestibularglandsare situatedlaterallytothe vaginal openingonbothof itssides.Theirductsopenintothe vagina.Bothglandssecrete
a mucoidsubstance thatlubricatesthe external genetaliaduringcoitus.The alkalinepH of these secretions also helps the sperm survive the acidic environment of the vagina.

15. Perineum: The skin covered muscular area between the vaginal area and the anus. It functions to support the pelvis and helps in constri cting the vaginal, urinary and anal
opening.
Fourchette:A ridge of tissue formedbythe posteriorjoiningof the twolabiaminoraandthe labiamajora.Thisis the structure that is cut during a procedure called episiotomy.
The Internal Structures
Vagina: A hollow,musculomembranouscanal locatedposteriorandanteriorto the rectum; it is lined with mucous. It extends
upward and backward from the vulva to the cervix. The bladder and the urethra are located anterior to the vagina and the
rectum lies posterior to it. Normally, the anterior and posterior walls of the vagina touch each other. This is the organ of
copulationof the woman;itreceivesthe male penisandthe sperm during sexual intercourse. This is also the route of exit for
the menstrual flow and the route of exit for a baby during the end of pregnancy.
Cervix: The lower third portion of the uterus which forms the neck of the uterus and opens into the vagina; connects the
vaginato the uterus. The narrow opening of the cervix is called the os; this allows menstrual blood to flow out of the vagina
duringmenstruation,while during pregnancy, the os closes to help keep the fetus in the uterus until birth. During labor, the
cervix dilates (up to 10 cm) to allow for the fetus to pass through.
Uterus:A hollow,pear-shapedorganmeasuring7.5cm long and3 cm wide.Itis situatedbetweenthe urinary bladder and the
rectum and is suspended in the pelvis by broad ligaments. The upper portion is called the corpus, while the narrow, lower
portionisthe cervix.The uterusservesasthe organ of menstruationandreceivesthe fertilizedovum,maintainsandnourishes
it forit to growto a fetus(duringpregnancy).Rhythmiccontractionsof thisorganhelptoexpel the fetusduringlabor.The wallsof the uterus, about 1.25 cm thick, comprises of
three layers:the endometrium(innermostlayer),the myometrium(large middlelayer),andthe peritoneum(outermostlayer).The endometrium is the layer that is shed at the
endof the menstrual cycle (thusthe onsetof menstruation);whileduringfertilization,thisiswherethe fertilized ovum burrows in for implantation until the end of its growth.
The myometriumisthe muscularlayerof the uterus,whichcontractsto expel the fetusduringlabour.The peritoneumsecretes ablood-like fluidthatpartiallycoversthe uterus.
However small the uterus is before pregnancy, this muscular organ gets stretched out to accommodate the increasing size of the fetus during its growth.
FallopianTubes:Alsoknownas the oviducts.These are twoveryfine tubesthatextendfromthe uterusintothe ovaries(butdonot directly touch the ovaries). These tubes are
responsible forthe transportof the mature egg fromthe ovariestothe uterustoenable fertilization. To be able to receive a mature egg from the ovaries, the distal end of the
tubesexpand(infundibulum)toprojectfinger-likeprojectionsknownasfimbriae veryclose tothe ovaryto“catch” the mature eggthat exitsthe ovary.Once inside the tube,the
eggis transportedalongitslengthbythe wavelikemotionof the cilia,whichline the wallof the tubes,coupledwiththe contractionsof the tubes. Fertilization usually occurs in
the fallopian tube(s).

16. Ovaries:The female gonad,pairedreproductiveglandsof afemale,eachabout the shape of an almond, about 3 cm long. These are analogous to the testes of a male. They lie
behindthe broadligaments,behindandbelowthe fallopiantubes.These produce the female gametes (the ova), and female hormones such as
estrogen and progesterone to initiate and regulate menstrual cycles, as well as facilitate the growth and development of a female during
puberty.The ovariesusuallytake turnsreleasinganeggeverymonth;if the available eggis not fertilized 24 hours after being released from the
ovary,thisgetsexcretedthroughthe menstrual flow.However,if the egggetsfertilized within 24 hours of being released, the ovum undergoes
changes and development to grow into a fetus.
Secondary Structures
Breasts / Mammary Glands: Presentinbothsexesbutonlyfunctional infemales.Theyare a pairof milkproducingglandsthatstay in a dormant,
haltedstage duringinfanthoodandchildhooduntil puberty.The continuationof theirdevelopmentduringpubertyisdue to the rise of estrogen.
The increase of connective tissue aswell asdepositionof fat,accountsforthe increase of breastsize.The mainfunctionof the mammaryglandsistoprovide milk(nourishment)
for the baby,thusthese structuresare onlyimportantduringpregnancyandthe baby’slactationperiod. The breasts are located anterior to the pectoral muscles in the thorax.
Each breast containsonround,darkenedareacalledthe areola,whichsurroundsacentral protrudingnipple. The mammary glands are comprised of 15 to 25 lobes that radiate
aroundthe nipple.Withinthe lobesare the lobulesthatcontainanumberof alveolarglandsthatproduce milkwhenawomanislactating.The milkare then passed through the
lactiferous ducts and out to the nipple. During pregnancy, many changes occur in a woman’s body, including in her breasts. Increased levels of hormones like estrogen,
progesterone (and others), also increase breast vascularity and the permeability and dilatation of the lactiferous ducts.
Amnioticfluid:Amnioticfluidisaclear,slightlyyellowishliquidthatsurroundsthe unbornbaby(fetus) during pregnancy. It is contained in the amniotic sac. The fetus floats in
the amniotic fluid. During pregnancy the amniotic fluid increases in volume as the fetus grows. Amniotic fluid volume is greatest at about 34 weeks into the pregnancy
(gestation),whenitaverages800 ml.Approximately600ml of amnioticfluidsurroundsthe babyatfull term(40 weeksgestation).Thisfluid is constantly circulated by the baby
swallowing and "inhaling" existing fluid and then "exhaling" and urinating out the fluid.Amniotic fluid performs many functions for the fetus, including: allowing the fetus
freedomtomove andenablingthe skeletontodevelopproperly;allowingthe lungstodevelop properly; maintaining a relatively constant temperature around the fetus, thus
protecting the fetus from heat loss; and protecting the fetus from outside injury by cushioning sudden blows or movements.
Placenta: The placenta, Latin for pancake, which is descriptive of its size and appearance at term, arises out of trophoblast tissue. It serves as the fetal lungs, kidneys, and
gastrointestinal tractandas a separate endocrine organthroughoutpregnancy. Its growth parallels that of the fetus, growing from a few identifiable cells at the beginning of
pregnancy to an organ 15 to 20 cm in diameter and 2 to 3 cm in depth at term. It covers about half the surface area of the internal uterus.
For practical purposes, there is no direct exchange of blood between the embryo and the mother during pregnancy. The exchange is carried out only by selective
osmosis through the chorionic villi. However, because the chorionic villi layer is only one cell thick, minute breaks do allow occasional cells to cross. Placenta osmosis is so

17. effectivethatall buta fewsubstancesare able tocross the placentaintothe fetal circulation. Specificmechanismsallowthe nutrientsto cross the placenta. All these processes
are affected by maternal blood pressure and the pH of the fetal and maternal plasma.
To provide enoughbloodfor exchange, the rate of uteroplacental blood flow in pregnancy increases from about 50 ml/min at 10 weeks to 500 to 600 ml/min at term.
No additional maternalarteriesappearafterthe first3 monthsof pregnancy.However,toaccommodate the increasedblood flow, the arteries increase in size. Systematically,
the mother’s heart rate, total cardiac output, and blood volume increase to supply the placenta.
Ovulation
Once pubertyoccurs (usuallyatthe age of 12-14), the ova begin to mature as well. The ovum undergoes many
processessothat itmay reach the state of being“ripe”or mature. Ovulation is the release of a mature egg out
of the ovary. It is released from the follicle (called a graafian follicle) once it is matured and by a hormonal
signal.Ovulationoccursaroundfourteenorfifteendaysfromthe first day of the woman's last menstrual cycle.
When ovulation occurs, the ovum moves into the fallopian tube and becomes available for fertilization. The
remaining cells of the graafian follicle undergoes a series of changes which changes it to a corpus luteum to
produce progesterone that prepares the uterus to receive a fertilized ovum.
The Menstrual Cycle
The menstrual cycle isa seriesof changesa woman'sbodygoesthrough to prepare for a pregnancy. About once a month, the uterus grows a new lining (endometrium) to get
readyfor a fertilizedegg.Whenthere isnofertilizedeggtostart a pregnancy,the uterusshedsitslining.This is the monthly menstrual bleeding (also called menstrual period)
that women have from their early teen years until menopause, around age 50.
Thisepisodicuterinebleedingisbroughtaboutinresponse tocyclichormonal changes. The cycle’s purpose is to bring about an ovum’s maturity and to renew a uterine tissue
bed that will be responsible for the ova’s growth once fertilized.
Many hormones are involved in this cycle:
Estrogen – responsible for developing and maintaining the female reproductive organs and the secondary sex characteristics of the adult female
– play an important role in breast development and in monthly cyclic changes in the uterus
– secreted by the ovaries
– builds up the lining of the uterus

18. Progesterone – secreted by the corpus luteum, the ovarian follicle after the ovum has been released
– the most important hormone for conditioning the endometrium in preparation for implantation of a fertilized ovum
– levelsincrease afteranovaryreleasesanegg (ovulation) at the middle of the cycle; this helps the estrogen keep the lining thick and ready for a fertilized egg
– a drop in progesterone (along with estrogen) causes the lining to break down, thus the beginning of the monthly period
The Phases of the Menstrual Cycle
Proliferative phase – estrogenic, follicular or postmenstrual phase
 Immediatelyafteramenstrual flow,the endometriumisverythin,approximately one cell layer in depth. As the ovaries begin to produce estrogen, the endometrium
beginstoproliferate.Thisgrowthisveryrapidandincreases the thickness of the endometrium approximately eightfold. This increase continues for the 1st
half of the
menstrual cycle, approximately day 5 – day 14.
Secretory phase – progestational, luteal or premenstrual phase
- Afterovulation,the formationof progesterone inthe corpusluteumcausesthe glandsof the uterine endometrium to become twisted in appearance and dilated with
quantitiesof glycogenandmucin.The capillariesof the endometriumincrease inamountuntil the liningtakesonthe appearance of rich,spongy velvet and prepared to
accept and nourish the embryo
Ischemicphase – if fertilization does not occur, the corpus luteum in the ovary begins to regress after 8-10 day. As it regresses, the production of progesterone and estrogen
decreases.Withthe withdrawal of progesterone stimulation,the endometriumof the uterusbeginstodegenerate,approximately day24or 35 of the cycle.The capillary
rupture, with minute hemorrhage, and the endometrium sloughs off.
Menses – menstrual flow
- contains approximately 30-80 ml of blood accompanied by mucus and endometrial shreds (blood from the ruptured capillaries, mucin from the glands, fragments of
endometrial tissue and microscopic, atrophied and unfertilized ovums)
- iron loss during menstrual flow is approximately 11 mg

19. Fertilization
When the mature ovum is released from the ovary, it is only available for 24 hours. Thus, fertilization, the union of an ovum and spermatozoon, must occur pretty quickly,
because after24 hoursthe ovumbecomesnon-functional.Since the spermatozoonis available for 48 hours, the critical time frame for fertilization (time for coitus must occur
for successful fertilization) is 48 hours before, and 24 hours after ovulation.
Once spermenterthe vicinityof the uterus,theytravel uptothe fallopiantube tosearchfora viable mature ovum. It is important to note that when the ovum is released, it is
surroundedbythe zonapellucidaandthe coronaradiata. Before the spermreachthe ovum,however,thesemillionsof spermmustundergocapacitation,aprocessinwhichthe
plasmamembrane of the spermheaddegenaratestoexpose the sperm binding receptor sites. Once capacitation ends, these sperm “attack” the ovum to try and break down
the ovum’sprotective layerof coronaradiata.Outof these millionsof cells,onlyone iscapable of reaching the ovum’s nucleus. As soon as the ovum has been “conquered,” or
penetrated, the chromosomal material of the ovum and spermatozoon fuse to form a zygote.
Implantation
Afterfertilization,the fertilizedeggmigratestothe uterusforcellularmultiplication; this takes about 3 to 4 days. Once the fertilized egg is “ready” it begins to look for a place
withinthe uterine cavityto“settle in,”ortoimplantto.Thisoccurs 8 to 10 days afterfertilization.First, the blastocyst (as the zygote is now called) brushes against the velvety
uterine wall;thisisapposition.Then,the blastocystattachestothe endometrial surface. Lastly, once the blastocyst seems “comfortable,” it settles down into the soft folds of
the endometrium, and burrows deeper until it establishes an effective communication network with the blood system of the endometrium. Once implantation occurs, the
endometrium is then referred to as ‘decidua.’

20. CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION
Patient L.B.R., 34 years old, female, Filipino, married,
RomanCatholic,currently residing in #59 Urgello, Cebu
City was admitted at Cebu Velez General Hospital
(CVGH) for the first time accompanied by her husband
via private vehicle on February 16, 2013 at 2:53 PM.
She was admitted to the Department of Obstetrics and
Gynecologyunderthe servicesof Dr.AmethystYpil with
a case number of 012315 and hospital number of 13-
31460.
Source of Data: Patient and husband
HISTORY OF PRESENT ILLNESS
Last menstrual period was on May 2, 2012; AOG: 37
1/7 weeks
6 months PTA, patient noted a delay in her menses.
This caught her attention since her menses were
regularever since. Consult was sought immediately by
her private obstetrician/sister-in-law (Dr. Amethyst R.
Ypil) in Cebu Doctor’s Hospital. Ultrasound was
performedandresultsof thisstudy then confirmed her
pregnancy.Otherlaboratorystudies also included CBC,
HBsAg and urinalysis which revealed unremarkable
findingsexceptforherurinalysiswhichrevealedpyuria.
Thus, she was given Cefalexin (Cefalin) 500 mg/tab 1
tab 3x a day for 7 days taken with good compliance.
Condition was resolved after compliance of therapy as
claimed. Other medications taken during the course of
pregnancy were Caltrate plus 600 mg (calcium
supplement), Folic acid 5 mg (Vitamin B supplement;
prevent neural tube defects) and Ferrous sulfate (iron
supplement) 1 cap OD PO taken with good compliance.
Patientthenhadregularmonthlyvisits for the first 7
Patient Management
On the first day of care on February 18, 2013,
patient was scheduled for Bilateral Tubal Ligation
in the AM. O2 inhalation at 2 liters per minute
while in the recovery room. She was hooked to
bottle A D5LR 1L at 20 gtts/min. After 2 hours,
patient was then transported to the room.
Ketorolac 30 mg IVx 1 dose only,
Tamadol+Paracetamol (Algesia) 1 tab PO TID,
Nalbuphine 5 mg IV every 4 hours PRN for
breakthroughpain were the medications ordered
all for pain management. Cefalexin (Cefalin) 500
mg/cap 1 cap every8 hours PO for prophylaxis for
infection and Mv+Fe (Beneforte) 1 cap once a day
PO before breakfast as an iron replacement for
blood loss were also ordered. Vital signs were
monitored BP= 100/70 mmHg, PR=80 bpm, RR= 20
cpm, T= 36.7 degrees Celsius per axilla. No other
unusualities noted such as nausea, vomiting,
headache, severe pain.
General survey (2/18/13):
1P> Examinedlying on bed awake, alert, afebrile,
responsive, with clean, dry and intact dressing on
hypogastricareawiththe followingvital signs BP =
100/70 mmHg, PR = 80 bpm RR = 20 cpm T =
36.7 C/axilla
Height = 5’2” Weight = 62 kg
BMI = 24.8
Second day of care on February 19, 2013. Patient
is for discharge. Take home medications included
Cefalexin 500mg/tab 2x a day for 6 more days,
Mefenamic acid 500mg/tab 1 tab every 6 hours as

21. months, every 2 weeks for the 8th
month and every
week for the 9th
month to her private physician as
claimed. No unusual findings were noted.
Morning PTA, patient noted strong, painful uterine
contractions radiating to the lumbar area occurring
every 30-45 minutes with a duration of 30-40 seconds
associated with clear watery vaginal discharges and
occasional blood clots as claimed. This prompted to
seek consult at CVGH and was subsequently admitted.
PAST HEALTH HISTORY
Patient had no problems at birth or childhood as
claimed.She isnon-hypertensive, non-asthmatic, non-
cigarette smoker, non-alcoholic beverage drinker, no
historyof drug abuse.Noknown food or drug allergies.
Her HFD’s include hypertension and asthma on
maternal and paternal sides.
Previous Hospitalizations
First hospitalization was when patient was in
elementary. She was admitted due to Acute
Gastroenteritis at Surigao Hospital, discharged
improved. Second was on March 2005 at Cebu Doctor’s
Hospital for the delivery of her first baby via NSVD, 38
weeks AOG, female, 6.5 lbs. Third was on July 2007 at
Cebu Doctor’s Hospital for the delivery of her second
baby via NSVD, 37 weeks AOG, male, 6.5 lbs. Fourth
was on May 2011 at Cebu Doctor’s Hospital for the
delivery of her third baby via NSVD, 36 weeks AOG,
male, 7.1 lbs, she had a urinary tract infection on the
second trimester and was treated with Cefalexin
(Cefalin) 500 mg/tab 1 tab 3x a day taken with good
compliance as claimed and was then resolved
thereafter.
needed for pain, Iron 1 cap twice a day for 1
month.Followupcheck-upwill be onFebruary 26,
2013.
Physical Examination
Date Performed: February 18, 2013
Place Performed: PPS 105
Time Performed: 1 PM
1st
Day
General appearance:
1P> Seen lying in bed awake, conscious,
responsive, coherent, eupneic, afebrile, with dry
and intact dressing located at hypogastric area,
breasts engorged, uterus two fingerbreadths
belowthe umbilicus,flowof lochiarubra, with the
following vital signs of BP: 100/70mmHg; PR: 80
BPM; RR: 20 CPM; T: 36.7 °C/axilla.
SKIN: brown colored skin; moist; warm; smooth;
has goodskinturgor; no lesions,lumps or any skin
aberrations noted. Striae gravidarum noted. Dry,
clean, intact dressing at the hypogastric area
noted.
SCALP & HAIR: black and evenly distributed hair ;
scalp is clean & dry without visible flakes; no lice
infestations noted
NAILS: transparentwithslightly pale nail beds; no
signsof clubbing noted; nail plate firmly attached
to nail bed, CRT<2secs
HEAD & FACE: normocephalic; no lesions and

22. Prenatal History
Patientstarted her prenatal check-up at 12 weeks AOG
by LMP of May 2, 2012 at Cebu Doctor’s Hospital
attended by Dr. Amethyst Ypil. Patient’s laboratory
studies included CBC, HBsAg and urinalysis which
revealed unremarkable findings except for her
urinalysis which revealed pyuria. Thus, she was given
Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days
taken with good compliance. Condition was resolved
after compliance of therapy as claimed. Other
medicationstakenduringthe course of pregnancywere
Caltrate plus600 mg, Folicacid5mg andFerroussulfate
1 cap OD PO taken with good compliance.
Patientthenhadregularmonthlyvisits for the first 7
months, every 2 weeks for the 8th
month and every
week for the 9th
month to her private physician as
claimed. No unusual findings were noted.
GORDON’S FUNCTIONAL HEALTH PATTERN
A. Health Perception and Health Management
Patient describes health as “Health is wealth”. During
pregnancy, patient rates her health as 7/10 with 10 as
the highest and 1 as the lowest due to restrictions in
work and fatigue especially during the third trimester.
After pregnancy she rates her health 9/10 with 10 as
the highest 1 as the lowest due to relief from fatigue
she had during pregnancy but there are still some
restrictions in her activity for a few days since she
underwent Bilateral Tubal Ligation.
Patientisnon-hypertensive, non-asthmatic. Patient
had complete immunizations. She does not smoke nor
drink. Patient has no known food and drug allergies.
lumps noted; symmetric facial features; TMJ:
mouth opens and closes fully, no swelling,
tenderness and crepitation noted as client opens
and closes mouth
EYES & VISION: : symmetrical, eyebrows and
eyelashes are black and evenly distributed, pink
palpebral conjunctiva, sclera are white, no
discharges noted; can read nameplate at 2 ft
distance, (+) PERRLA), (+) accommodation. (+) six
cardinal gazes
EARS & HEARING:, symmetrical, pinna is
positioned in line with outer canthus of the eye,
no discharges, no lesions, no tenderness upon
palpation, can hear whispered words at 2 feet
distance.
NOSE & SINUSES:nasal septum at midline, patent
nostrils,no discharges, clear frontal and maxillary
Clear frontal and maxillary sinuses on
transillumination test and are non tender to
palpation and percussion. No nasal flaring, no
discharges noted.
MOUTH & PHARYNX: tongue at midline, uvula at
midline, gums and tonsils not inflamed, Lips are
moistand pinkishbrownincolor.Buccal mucosa is
pink, smooth, and moist and without lesions.
Tongue is pink, moist, smooth and symmetrical.
NECK: supple, trachea at midline, no lesions,
nonpalpable lymph nodes, no masses, no
tenderness upon palpation, (+) gag reflex, full

23. Patient claims that she follows health advices as
much as possible. Before pregnancy, patient usually
self-medicates using Phenylephrine HCl + Paracetamol
(Decolgen Forte) for colds, Carbocisteine (Solmux) for
cough and Paracetamol (Biogesic) for fever. During
pregnancypatienttakes Caltrate plus 600 mg, Folic acid
5mg and Ferrous sulfate 1 cap OD PO taken with good
compliance.
Patientdoesn’tuse herbal remedies as claimed Patient
only sees a doctor when there is a need to and for
regular check-ups (prenatal). Patient knows BSE but
doesn’t practice it regulary “usahay ra kung maka
hinumdum” as verbalized.
Environment History
PatientiscurrentlyresidingatUrgello, Cebu for
9 years. Patient claims that this house is owned by her
and herhusband.Patientislivingwithherhusband and
3 children. It is a 3 storey house made up of mixed
materials. It has 6 doors, 6 windows and 5 rooms. They
have separate kitchen, dining room. Type of toilet is
flushedtype.Patient’ssource of electricity is VECO and
MCWD for their water. Their garbage is collected
everydaybya garbage truck. Patientcleans their house
every day. They have a crowding index of 1.
Patientworksas dentist. Her clinic is located in
Colon Street and Club Ultima but she usually stays in
herclinicinColon.She worksfor approximately 7 hours
perday. She is satisfied with her current job because it
isenoughand can sustainherfamily’sneedsasclaimed.
No exposure to chemicals, radiation and toxic
substances in her work place.
Their residence is 50 m away from the main
road. Theirmeansof transportationisthrougha private
ROM
CHEST & LUNGS: chest is symmetrical; no lesions;
equal chestexpansion;regular,relaxed, effortless
and quiet breathing without using of accessory
muscles upon breathing, adventitious breath
sounds; 20cpm
HEART & PERIPHERAL VASCULATURE: Heart rate
is 80 bpm and is strong and regular, strong
peripheral pulses, no murmurs heard. S1and S2
clearly heard, CRT < 2sec (-) Homan’s sign;
BREAST: engorgementnoted,non-tender.(+) milk
noted, nipples are brownish, no purulent
discharges or lesions noted
ABDOMEN: skinsame of the rest of the skin tone,
rounded, lineanigranoted,symmetrical umbilicus
at 2 finger breadths below midline, striae
gravidarum noted. Presence of clean, dry, intact
dressing noted on the hypogastric area
GENITOURINARY: grossly female, minimal lochia
rubra noted on slightly saturated napkin, no
purulent discharges, no lesion, non-tender upon
palpation.
RECTUM: no rashes, hemorrhoids, no lesions
noted.
BACK & EXTREMITIES full ROM noted.
Symmetrical; CRT < 2 seconds, no lesions. No
tenderness noted. (-) Homan’s sign

24. vehicle.Nearestdrugstore is 100m away. Barangay hall
is 200 m away. Fire station is 600 m away. Hospital is
500 m away. Patient stores their medications inside a
box and cleaningsuppliesinside a cabinet. They have a
peaceful neighborhood as claimed. Patient’s last
physical exam was on August 2012 with unremarkable
results except for her urinalysis which revealed pyuria
and wasthenresolvedaftertakingin Cefalexin(Cefalin)
500 mg/tab 1 tab 3x a day for 7 days with good
compliance.
B. Nutritional-Metabolic
Patient’s current weight is 62 kgs, ad 5’2 in height.
BMI is 24.8 which is normal.
Patientissatisfiedaboutherweightasclaimed. Patient
claims that it is easy to gain weight. Patient has a good
appetite and prefers to eat healthy foods such as
vegetables. No cultural or religious influences on diet.
Patient’s diet during hospitalization is a full diet.
24 Hour Diet Recall
5/5 5/5
3/5 3/5
R L
MUSCLE STRENGTH:
R L
* Scale:
5 – Full ROMagainst gravity, full resistance
4 – Full ROMagainst gravity, some resistance
3 – Full ROMwith gravity
2 – Full ROM with gravity eliminated (passive
motion)
1 – Slight Reaction
0 – No Reaction
NEUROLOGIC ASSESSMENT:
 MENTAL STATUS/CEREBRAL FUNCTION:
awake, conscious, responsive, coherent,
oriented to time, place, and people,
speech not slurred, able to speak and can
understand English and Visayan dialect
able to smile and frown, listens and
follows attention
 MOTOR/CEREBELLAR FUNCTION: able to
perform rapid alternating movements,
finger-thumb test, and finger-nose test
 SENSORY FUNCTION: (+) stereognosis,
(jot down notebook) (+) graphesthesia
(letterS),(+) kinesthesia,, able to identify

25. Patient knows the basic food groups (Go, Grow and
Glow). When stressed patient verbalized, “mu kaon ra
man gihapon. Patient shops for food and usually their
helper cooks and prepares it for them. Patient stores
their food inside the refrigerator. Patient claims that
their income is adequate for their food needs.
C. Elimination
Before pregnancy, patient voids 4 times a day and 2
times every night amounting to 1 glass per episode.
Urine is clear and yellow. Patient drinks at least 8
glasses of water a day. Patient claims that she doesn’t
use diureticsandknowshowtodo Kegel’sexercise and
practices it sometimes. Patient defecates every day.
Stool is hard, formed and brown. Patient usually
defecates every morning.
Duringpregnancy,patientclaimsthatshe still voids4
times a day and 2 times every night amounting to 1
glassper episode.Patientstill drinksatleast8 glassesof
water per day. Patient still defecates everyday with
Client’s Diet 24-hour recall Usual Diet
Breakfast Rice, bread,
hotdog, egg,
milk
Juice, bread
Lunch Rice, chicken,
banana, juice
Bought
Dinner Rice,soup, pork Rice,
Vegetables
Snacks Bread
between light, sharp and dull touch
 CRANIAL NERVE TESTING:
 CN I (Olfactory):able to identifysmell
of banana
 CN II (Optic): able to read nameplate
of the student nurse at 2 ft distance
 CN III, IV& VI (Oculomotor,
Trochlear, Abducens):(+) PERRLA and
+ cardinal gaze
 CN V (Trigeminal: able to identify
between light, sharp and dull touch,
able to clench teeth
 CN VII (Facial): able to show teeth,
able to frown, smile, purse lips and
wrinkle forehead when told to do so
 CN VIII(Vestibulocochlear): able to
hearwhisperedwords(baby) at2 feet
distance
 CN IX & X (Glossopharyngeal &
Vagus): able to swallow food, tongue
at midline. (+) gag reflex
 CN XI (Spinal Accessory): able to
shrug shoulders against resistance
 CN XII (Hypoglossal):able toprotrude
tongue and able to move tongue
around when told to do so
2nd day
February 19, 2013
GENERAL APPEARANCE:
4PM> examinedsitting onbed,awake, conscious,
afebrile,eupneic,breastsnontender,uterus three

26. hard, formed, brown stools. Patient doesn’t use any
laxatives and doesn’t have any problems with regards
to defecation. No changes in her elimination pattern
during and before pregnancy.
D. Activity-Exercise
Patientisanactive runner during her teenage years.
Upon awakening, patient will have breakfast, feeds
her children, takes a bath and go to work. Patient is at
work most of the day and arrives home at 5PM. Upon
arriving,patientrestsand eats dinner. On 8PM, patient
washesher face, toothbrushes and then goes to sleep.
Patient sleeps, watches tv during her leisure time
usually 2-3 hours. Patient considered doing household
choresas her form of exercise when she arrives home.
Patient doesn’t have a difficulty in managing their
house. Patientexperiences fatigue during the duration
of her pregnancy because of “bug-at man gud kaayo
akong tiyan” especially on the third trimester as
verbalized. No medical consult was done. Instead,
patientusuallysitsdownanddoesn’tmove aroundthat
much.
Her hospitalizationchangedhernormal activity
patternsince she cannot do her usual routine activities
at home and work.
F. Cognitive Perceptual Pattern
Patient is a college graduate who took up
dentistry,knowshowtospeakandunderstandsEnglish,
Tagalog and Bisaya. Patient is oriented to time, place
and people around her. Patient knows her complete
name, age and birthday. She was able to recall short
term memory such as her 24 hour diet recall; and was
also able to recall long term memory such as her
fingerbreadthsbelowthe umbilicus, with minimal
lochia rubra, with the ff. vital signs of BP:
100/70mmHg; PR: 72 BPM; RR: 20CPM; T: 36.9
°C/axilla.
SKIN: Striae gravidarum noted. Dry, clean, intact
dressing at the hypogastric area still noted.
ABDOMEN: Linea nigra noted, umbilicus at 3
finger breadths below midline, striae gravidarum
noted. Presence of clean, dry, intact dressing
noted on the hypogastric area
GENITOURINARY: grossly female, minimal lochia
rubra noted on slightly saturated napkin
5/5 5/5
5/5 5/5
R L
MUSCLE STRENGTH:
R L
* Scale:
5 – Full ROMagainst gravity, full resistance
4 – Full ROMagainst gravity, some resistance
3 – Full ROMwith gravity
2 – Full ROM with gravity eliminated (passive
motion)
1 – Slight Reaction
0 – No Reaction

27. previous hospitalization. Patient has no visual
problems. Patient is able to identify the smell of a
banana. Patient doesn’t have any hearing problems.
Present condition has not affected her cognition
perception.
G. Sleep-Rest
Patient usually goes to bed at 9PMand wakes up at
6AM. This is her typical pattern during weekdays and
weekends.She doesn’t have any problems in sleeping.
During pregnancy, patient awakens 3 times a night
especiallyduringthe third trimester due to a feeling of
discomfort but can easily put herself back to sleep
again. Patient usually makes up for lost sleep during
weekdays. Before going to sleep, patient washes her
face, brushes her teeth, plays with her children and
prays. She utilizes three pillows, one on the head and
one on eachside.Hersleepingpositionisside lying and
doesn’t use any sleep-inducing drugs such as sleeping
pills. Patient sometimes drinks 1 cup of coffee.
Duringhospitalization,patient uses 1 pillow on
herhead. Patient sleeps around 10PMand wakes up at
7AM. Patient still awakens from time to time because
of a new environment and routine nursing
interventions.
G. Self-Perception and Self-Concept
Patient describes her identity as “typical ra” as
verbalized. Her strength is her family including her
husbandandchildren.She didn’tidentifyanyweakness.
Patient claims that her major accomplishment was to
raise her child with love and care. Patient feels good
and contented with her stable job. Patient thinks that
she isgood. She is withherself.She thinksthatshe has
LABORATORY FINDINGS
1. Complete Blood Count
Purpose:
 A useful screening and diagnostic test
that is often done as part of routine
physical examination. It can provide
valuable information about the blood
and blood-forming tissues, as well as
other body systems. Abnormal results
can indicate the presence of a variety of
conditionssometimesbeforethe patient
experiences symptoms of the disease.
 It is used as a preoperative test to
ensure both adequate oxygen carrying
capacity and hemostasis, to identify
persons who may have infection, to
diagnose anemia, to identify acute and
crhonicillness,bleedingtendencies, and
white blood cell disorders such as
lukemia. It is also used to monitor
treatment for anemia and other blood
related diseases, and to determine the
effects of chemotherapy and radiation
therapy on blood cell production
February 16,
2013 (16:22)
Normal Values
WBC 6.75 k/uL 4.10 – 10.9
NEU 4.75 2.50 – 7.50 %N
LYM 1.36 1.00 – 4.00 %L
MONO .470 6.96%M 2.00 – 11.00 %M
EOS .120 0.00 - .500 %E

28. numbersof goodqualities and strongly agrees that she
can do thingsas mostas otherpeople.Patientfeelsthat
she has much tobe proudof anddoesn’tfeel useless at
all. She strongly agrees that she is a person worth, at
least on an equal plane with others. Patient takes
positive attitude towards herself.
H. Role-Relationship
Patient is the youngest in their family. She is a dentist
and servespeople every day. She describes her role to
her family as important since she was the one who
brought up her child well together with her husband.
Patientconsultsandseekshelpfromherhusbandwhen
problemsoccur. She makesdecisions on her own with
the help of him. Patient describes her family structure
as close. Even with her condition, she still
maintains good relationships to friends and to all the
family members. She claims that her pregnancy didn’t
cause problems to her role but instead she was able to
strengthen her relationship towards her family
especially to her husband.
I. Sexuality-Reproductive
Patient was 13 years old when she had her
menarche. Her LMP was on May 2, 2012. She has a
regular menstrual cycle for 4-5 days and can consume
2-3 sanitary napkins per day (1st
and 2nd
day fully
soaked, 3rd
-5th partially soaked). She sometimes
experiencesdysmenorrheal and is able to tolerate it as
claimed.
Herfirstsexual contact was at the age of 25 with her
husband as her sole sexual partner. Her last sexual
contact was on November 2012. Her pregnancy caused
discomfort and changes in her sexual pattern as
BASO .049 0.00 – 2.00 %B
RBC 4.03 4.00- 5.20
HGB 12.5
12.0 – 16.0
HCT 37.5 36.0 – 46.0
MCV 93.2 80.0 – 100
MCH 31.1 26.0 – 34.0
MCHC 33.3 31.0 – 36.6
RDW 18.0 11.6 – 18.0
PLT 266 k/uL
140 – 440
MPV 8.25 fL 0.00-100
Implication:
Values are within normal limits
2. Urinalysis
2/16/13
PURPOSE:
A general examination of urine to establish
baseline informationorprovide datatoestablish a

29. verbalized, “dali ra ko ma luya karon”. Patient doesn’t
use pills. Her husband uses a condom as a
contraceptive after their first child was born. Recently,
she underwentBilateral Tubal Ligation.It’sherpersonal
choice since “4 na man gud akong anak” as verbalized.
Patientgave birthtoherfirst child on 2005, next was
on 2007, thenon 2011. She deliveredthem via NSVD at
Cebu Doctor’s General Hospital. She had her prenatal
checkups starting at 2 months AOG for the first 2
children and 3 months AOG for the next 2 with regular
visits thereafter.
The patientiscurrentlyG4P4(4004). Both of her
pregnanciesare expectedandplanned.Patient had her
prenatal checkups at Cebu Doctor’s Hopsital. Her first
prenatal checkupwason the thirdmonth of pregnancy,
every month or the first 7 months, every 2 weeks on
the 8th
and every week on the 9th
. During the first pre-
natal check-upwhichwason the 3rd
month,patient had
pyuria and was then resolved with Cefalexin (Cefalin)
500 mg/tab 1 tab 3x a day for 7 days taken with good
compliance.Othermedicationstakenduringthe course
of pregnancy were Caltrate plus 600 mg, Folic acid 5mg
and Ferrous sulfate 1 cap OD PO taken with good
compliance. No other illnesses were noted.
Patient is 37 1/7 weeks AOG. Patient had 4
hoursof labor.She deliveredalive babygirl via NSVD at
Cebu Velez General Hospital. Delivery was assisted by
an obstetrician.
J. Coping-Stress
Patient defines stress as “kapoy”. She claims that
stress had been bad to her but doesn’t affect her
relationship with others. When stressed, patient finds
way to release it such as talking to her husband about
tentative diagnosis and determine whether
furtherstudiesare tobe ordered. The urinalysis is
anothercommontestroutinelytakenin almost all
acute hospitalsasan admissionlabscreening test.
It can easilyreveal renal andsystemic pathologies
Macroscopic Results R.R. Unit
Color Yellow Light
Yellow,
dark
yellow
Transparency Slightly
cloudy
Clear
Chemical Tests
pH 7.0 5.0-8.0
SpecificGravity 1.005 1.001-
1.035
Protein + <10
Glucose - - mg/d
L
Ketone - - mg/d
L
Urobilinogen - - mg/d
L
Leukocyte - - mg/d
L
Bilirubin - - mg/d
L

30. herproblems,staysathome and findstime to relax and
unwind herself. She solves her problems on her own
and sometimes with the help of her husband.
K. Value-Belief
Patient is a Roman Catholic; attends mass on
Sundays regularly. Patient never fails to find time to
seek for guidance. Before and during hospitalization,
patient makes the sign of the cross at night before she
sleeps. Patient doesn’t really believe in superstitious
beliefs such as “magpabuyag”.
Nitrite Negativ
e
- mg/d
L
Ascorbic Acid Negativ
e
- mg/d
L
Microscopic Findings
CONV (/hpf) SI (/uL)
R.R. R.R.
RBC 1-2 0-3/hpf 220/u
L
0-
17/uL
WBC 4-6 0-5/
hpf
28/uL 0-
28/uL
Bacteria Rare None
Mucous
Threads
Few None 0 None
Implications:
 Cloudy urine during gestation is partly
caused as a consequence of hormonal
changesinthe body.Dietarymodifications
together with alterations in hormone
levels are the major reasons for passing
cloudy urine by pregnant women. For
most cases, the causal factor is the food
intake, and prompt results are achieved
after removing the trigger foods. This is
not a subject to worry about.
 Low amounts of protein are not
uncommon, and may simply mean that
your kidneys are working harder than
before pregnancy. Your body may be
fighting a minor infection

31.  Mucus threads in a urinalysis are
consideredtobe normal insmall amounts.
Mucus threads appear long, thin and
wavy-ribbonlike.If there isalarge amount
of themitmay mean there is an irritation,
inflammation, or infection in the urinary
tract. Mucus threads generally have no
clinical significance since they come from
the urethra or vagina.
NURSING CARE PLAN
KEY ISSUES
Methodof Prioritization: Severity
Date Identified: February 18, 2013
1. Acute pain related to surgical incision at
hypogastricregionsecondarytoS/PBilateral Tubal
Ligation (Modified Pomeroy) as manifested by
facial grimacingandcharacterizedby grawing pain
at hypogastric area, limited ROM, and slow
movements lasting for 3-5 minutes with a pain
scale of 7/10, 1 as the lowest and 10 as the
highest,aggravatedbymovementand relieved by
rest and medications.
SB: Painresultsfromthe incision,fromthe stitches
of clamps closing it, and from the gas that
commonly builds up in the mother’s abdomen
after this surgery. Activities such as turning over,
getting out of bed and walking are painful for a
few days.
Independent Interventions:
1. Obtained client’s assessment of
pain using OLDCARTS
R: Assessment provides clues to
underlying cause of pain and
provides a baseline for developing
appropriate pain relief strategies.
2. Observed client’s description of
pain.
R: Pain is a subjective experience
and cannot be felt by others.
3. Monitored vital signs
R: These are usually altered in acute
pain.
4. Provided a quiet, calm and
Desired Outcome:
After the course of
nursing intervention,
client will lessen facial
grimacing in response to
studentnurse’sefforts to
minimize pain such as
teaching the client in
deepbreathing exercises
and providing a calm and
therapeuticenvironment.
No unusualities will be
noted and patient will
verbalize a decrease
severity in pain scale.
Actual Outcome:
After the course of

32. Source:
The Birth Partner:EverythingYouNeedtoKnowto
Help a Woman Through Childbirth 2nd
edition, by
Simpkin, p288
Pain is expected after most operations.
Source:
Merick Manual of Medical Information, 2nd
ed., p.
1540.
comfortable environment
R: Patient’s may decrease ability to
tolerate painful stimuli if
environmental, factors are further
stressing them.
5. Afforded rest and sleep
R: To alleviate pain
6.Monitored for any unusualities
such as fever, profuse vaginal
bleeding,
R: Such unusualities should be
monitored to prevent further
complication.
7. Encouraged to splint incision
during cough and movement
R: stabilizes area, reduces pain and
prevent s damage on incision site
8. Taught on relaxation techniques
such as breathing exercises
R: reduce tension, subsequently
reducing pain.
9. Suggested SO to be at bedside at
all times
R: to provide comfort
10. Instructed the patient to report
pain immediately
R: Relief measures may be
instituted.
nursing intervention:
February 18, 2013
3P> Patient still showed
facial grimacing, Patient
claims that pain is still
noted on hypogastric
area with a pain scale of
6/10 with 10 as the
highest and 1 as the
lowestwiththe following,
no unusualities were
noted.
February 19, 2013
Patient claims that she
doesn’t experience pain
anymore, no facial
grimacing noted, she is
able to ambulate
independently and no
other unusualities were
noted.

33. Date Identified: February 18, 2013
2. Impairedtissue integrityrelatedto break in the
skin and inadequate primary defenses secondary
to S/P Bilateral Tubal Ligation with clean, dry and
intact dressing at hypogastric area.
SB:
Injury to skin and surrounding soft tissue occur
from sharp objects, blunt force, injury, scraping
mechanism or surgical procedures, avulsion, or
puncture wounds.
Source:
Joyce M. Black: Medical Surgical Nursing 7th
Edition, Vol. 2, P 2502.
11. Provided diversional activities
such as talking to the patient.
R: redirectpatientsattentiontopain
12. Assisted in turning to sides and
maintaining proper body position.
R: to conserve energy and lessen
pain felt by patient
Collaborative interventions:
1.Tramadol+Paracetamol (Algesia) 1
tab 3x a day given
R: Provides analgesia, sedation,
suppresses the medullary cough
center to suppress cough reflex
Independent Interventions:
1. Assess the client’s broken tissue
R: to determine the level of damage
sustained by the client
2. Inspect the surrounding skin for
erythema,induration,andlaceration
R: to determine if any type of
infection has occurred yet
3. Inspect skin on a daily basis
R: this is to determine of any
changes has occurred within the
past few days and to determine the
healing rate of the wound
4. Keep the incision site clean and
Desired Outcomes:
Within the course if
nursinginterventions,the
client will be able to
demonstrate behaviors
necessary in healing and
maintaining the integrity
of the incision site.
Actual Outcome:
After the course of
nursing interventions:
February 18, 2013,
The dressing was kept
clean, intact and dry.
Client was able to

34. dry
R: moistareas are breeding grounds
for various microorganisms
5. Assisted in wound dressing
R: this is to prevent aggravating any
painfeltbythe clientandto prevent
any type wound to happen
6. Stimulated the circulation to the
surrounding area
R: to assistthe body’snatural way of
healing
7. Used appropriate barrierdressing,
woundcovering,andskinprotective
agents
R: to protect the wound/or
surrounding areas
8. Removed wet linens promptly
R: moisture potentiates skin
breakdown
9. Encouraged early ambulation or
mobility
R: this is to promote circulation and
reduces risks associated with
immobility
10. Provided optimum nutrition
such as eatingproteinrichfoodslike
organ meats and vegetables
R: to aid inskin/tissuehealingandto
develop behaviors that
are necessary for wound
healing such as sitting on
her own thus promoting
the circulation, was able
to eat nutritious foods
that can facilitate wound
healing such as
vegetables.
February 19, 2013
The dessing was kept
clean, intact and dry.
Client was able to
develop behaviors that
are necessary for wound
healing such as sitting on
her own and ambulating
without assistance thus
promoting the
circulation, was able to
eat nutritious foods that
can facilitate wound
healing such as
vegetables.

35. Date Identified: February 18, 2013
3. Impaired physical mobility related to decrease
strength, pain, and discomfort secondary to S/P
Bilateral Tubal Ligation as manifested by limited
ROM and the need to be supervised when
positioningisneeded,withmuscle strength of 3/5
on lower extremities as of February 18, 2013
SB:
Any special position the individual patient will
need to maintain after surgery is discussed, as in
the importance of maintainingasmuchmobilityas
possible despite restrictions.
Source:
Brunnerand Suddharth’s:Medical Surgical Nursing
10th
Edition, Vol. 1, P 409
maintain general good health.
Independent Interventions:
1.Encouraged participation in self-
care activities like defecating,
voiding and eating, recreational
activities like conversing with SO
and watching tv
R: Enhances self-concept and sense
of independence
2.Identified energy conserving
techniquesfor ADL’s such as placing
personal belongings at bedside
R: limits fatigue, maximizing
participation of the client
3.Provided safety measures such as
maintaining side rails and keeping
pillows at each side
R: to prevent injury that can occur
when immobilized
4.Encouraged adequate intake of
fluid or nutritious food
R: promoted well-being and
maximizes energy production
5.Noted emotional or behavioral
responses to immobility
R: forced immobility heightens
restlessness and irritability
Desired Outcome:
Within the course of
nursing interventions,
patient will be able to
maintain function and
will regainstrengthof her
body parts, and will be
able to perform any type
of activity with only
minimal assistance or
without any type of
assistance.
Actual Outcome:
After the course of
nursing interventions:
February 18, 2013
After 8 hours of nursing
interventionsperformed,
client has minimal
difficulty in moving
various parts of her body
especially near the
incisionsite,asevidenced
by reduced movement
and needs assistance in
positioning and in
movement.
February 19, 2013
After 8 hours of nursing

36. Date Identified: February 18, 2013
4. Risk for infectionrelated to invasive procedure
secondarytoS/P Bilateral Tubal Ligation(Modified
Pomeroy)
Cues:
 presence of incisionapproximately4-5
inches at hypogastric region
 presence of dry, clean and intact
dressing at hypogastric region
SB:
The skin serves as the primary defense against
bacterial invasion. When the skin is incised for a
surgical procedure,this important line of defense
is lost.
Source:
Medical-Surgical Nursing7th
EditionbyJoyce Black,
et al., p. 2503
6.Assisted with activity/progressive
ambulation and therapeutic
exercises
R: physical activityshouldbe started
as soon as possible, usually
progresses slowly according to the
type of activitythat can be tolerated
7. Encouraged and facilitated early
ambulation and other ADLs when
possible.
R: To promote proper circulation to
hasten wound healing
Independent interventions:
1. Performed handwashing before
and after contact with patient.
R: A first line of defense on
nosocomial infection and on cross
contamination
2.Assessed incision site for any
unusualities such as swelling,
redness, discharges
R: Establish comparative baseline
providing opportunity for timely
intervention
3.Kept dressing clean and dry
R: Moisture potentiates further skin
breakdown.
4. Perineal care done twice a day.
R: prevent breakdown of perineal
are
interventions, the client
was alreadyalertandwas
able to move various
parts of the bodywithout
any assistance,evidenced
by standing,sittingonher
own and with muscle
strength of 5/5.
Desired Outcome:
After the course of
nursing intervention, no
signs of infection were
noted. No unusualities
will be noted on incision
site such as swelling,
redness and discharges.
Vital signs will remain
stable, SO and client will
be able to understand
the importance of proper
hygiene and proper
handwashing
Actual outcome:
After the course of
nursing intervention:
February 18-19, 2013

37. The creation of surgical wound disrupts the
integrity of the skin and its protective function.
Source:
Smeltzer,Suzanne.Medical-Surgical Nursing, 11th
ed., p. 546
5. Encouraged patient to verbalize
any unusualities noted
R: to promote optimum healing
through early detection
6. Monitored v/s
R: V/S could vary in times of
infection
7. Monitored the laboratory studies
R: To acquire a comparative data
8. Maintained clean and safe
environment
R: To prevent injury
9. Restricted contact with persons
having infectious disease
R: To reduce exposure to pathogens
10. Taught S.O and patient proper
handwashing.
R: To promote hygiene and prevent
cross-contamination.
Collaborative Interventions:
1.Cefalexin (Cefalin) 500 mg/tab 1
tab every 8 hours
R: Prophylaxis for infection
No signs of infection
were noted such as
swelling, redness and no
unusual discharges were
noted. SO and client
understood the
importance of proper
hygiene and
handwashing, dressing
was kept clean and dry.

38. DISCHARGE PLAN
Health Teachings:
 Encouraged to maintain
proper hygiene by washing
hands before and after
eating and cleaning the
incision, bathing the baby
and changing the diapers.
 Encouraged to clean
perineumfromfrontto back
to prevent infection.
 Instructed to take
medicationatthe righttime,
route and dose.
 Advised to go to physician
for follow up check-up on
February 26, 2013
 Instructed to clean the
breasts with water only to
prevent dryness.
 Advised to always
breastfeed the baby every
2-3 hours or per demand.
Anticipatory Guidance:
 Advised to report for any
signs and symptoms of
bleeding such as pallor,
epistaxis, hematoma,
profuse vaginal bleeding,
melena, hematochezia
 Report to physician for any
signs and symptoms of

39. inflammation and infection
in the incision area such as
swelling, redness, pain,
hematoma.
Spirituality, Saftey, Security:
 Encouraged to continue
attending masses every
Sunday.
 Encouraged to always
reinforce safety such as
wearing seatbelt when in
the car especially and
shouldnotplace the baby in
the front seat.Instead,use a
car seat for the baby.
 Keep away from chemical
exposures and radiation.
 Advised to avoid crowded
areas to prevent from
getting infection.
 Encouraged to never leave
the baby alone or
unattended.
Medications:
 Instructed to comply with
take home medications:
Cefalexin 500 mg/tab 1 tab
2x a day for 6 more days
Mefenamic acid 500mg/tab
1 tab every 6 hours as
needed for pain
Iron 1 cap 2x a day for 1

40. month
Incision Care:
 Instructed to keep site
clean, intact and dry
 Encouragednot to touchthe
incision site with bare
hands.
 Advised to put a dressing in
the incision to prevent
contamination.
 Instructed to wash the site
withwateronlywhentaking
a bath to prevent irritation
Nutrition:
 Advised to eat foods rich in
iron such as liver, clams,
oysters.
 Encouraged to also eat
Vitamin C rich foods such as
oranges, green leafy
vegetables
 Advisednottodrinkcaffeine
and alcohol beverages.
 Encouraged to maintain
proper hydration.
 Encouraged to feed baby
with breast milk only
Environment:
 Instructed to keep their
house clean and well

41. ventilated at all times.
 Advised to keep an
environment conducive for
restand sleepbyminimizing
noise.
 Instructed to keep sharp
objectsawayespeciallyfrom
the baby

42. DRUG STUDY
1. Cefalexin(Cefalin) 500mg/tab 1 tab every8 hours
Classification:Secondgenerationcephalosphorins
Action:Has a beta lactamring whichbindstothe penicillinbindingproteininhibiting
the synthesisof the peptidoglycanlayerwhichweakensthe cell wallcausingcell
lysis
Indication:prophylaxisforinfection
Contraindications:hypersensitivitytopenicillinantibiotics
Adverse effects:pseudomembranouscolitis,candidiasis,foulsmellingvaginal
discharge,urticaria,beefyredtongue
Nursingconsiderations:
 Assessedincisionsiteforredness,swelling,warmth
 Instructedtomaintainproperhygiene suchashandwashing
 Keptthe incisionsite clean,intactanddryalways
 Instructednotto touch the site
 Encouragedto eatproteinrichfoodssuch as organ meats,oystersand
VitaminCrich foodssuch as oranges,greenleafyvegetables
 Monitoredforalterationsinvital signsespeciallythe temperature
2. Tramadol+Paracetamol (Algesia)1tab 3x a day
Classification:OpioidAnalgesic
Action:Actson opioidreceptorsinthe CNStoproduce analgesia, sedation.Also
suppressesmedullarycoughcentertosuppresscoughreflex
I: painrelief
Contraindications:hypersensitivity
Adverse effects:visualdisturbance,anxiety,confusion,nervousness,euphoria,
sleepingdisturbances,respiratoryarrest
Nursingconsiderations:
 Assessedpainscale usingOLDCARTS
 AssistedinADLssuchas positioninginbed
 Instructednotto do strenuousactivitiessuchasliftingheavyobjects
 Instructedtodo splintingwhencoughing
 Instructedtodo diversionalactivitiessuchas watching tv,conversingwith
SO and studentnurse
 Instructedtodo deepbreathingexercises
 Providedcomfortmeasuressuchasbackrub

43. 3. Mv+Fe (Beneforte)1tab 1x a daybefore breakfast
C: Supplement
A: Ironsupportsa healthyimmune systemandis requiredforgrowth.Thismineral
isrequiredforthe productionof healthyredbloodcells,whichcarryoxygento
everycell inyourbody.Ironplaysa role in the productionof adenosine
triphosphate,anessential substance thatsuppliesyourbodywithenergy.
I: post-partummother, bloodloss
Contraindications:hypersensitivity
Adverse effects:toxicity, hypovolemicshock
Nursingconsiderations:
 Take before mealsforbetterabsorptionof drug
 Avoiddrinkingcoffee, tea, colaandalcoholicbeverageswhiletakingiron
 Encouragedto eatiron richfoodssuch as redmeat, egg yolks, organmeats,
greenleafyvegetables
 Encouragedto eatvitaminC richfoodssuch as guava, papaya, oranges,
mangoes, pineapples forbetterabsorption of iron
SUMMARY OF SIGNIFICANT FINDINGS
GORDON’S FUNCTIONAL HEALTH PATTERN
A. Health Perception and Health Management
Before pregnancy,patientusuallyself-medicatesusingPhenylephrineHCl +
Paracetamol (DecolgenForte) forcolds, Carbocisteine(Solmux) forcoughand
Paracetamol (Biogesic) forfever.DuringpregnancypatienttakesCaltrate plus600
mg, Folicacid5mg and Ferroussulfate 1 cap OD POtakenwithgood compliance.
Patient knows BSE but doesn’t practice it regulary “usahay ra kung maka
hinumdum” as verbalized.
Patient’slastphysical exam was on August 2012 with unremarkable results
exceptforherurinalysiswhichrevealedpyuriaandwasthenresolvedaftertakingin
Cefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days with good compliance.
D. Activity-Exercise
Patientexperiencesfatigue duringthe durationof herpregnancybecause of “bug-at
man gud kaayo akong tiyan” especially on the third trimester as verbalized. No

44. medical consult was done. Instead, patient usually sits down and doesn’t move
around that much.
Her hospitalizationchangedhernormal activitypatternsince she cannot do
her usual routine activities at home and work.
G. Sleep-Rest
During pregnancy, patient awakens 3 times a night especially during the third
trimester due to a feeling of discomfort but can easily put herself back to sleep
again.
During hospitalization, patient still awakens from time to time because of a new
environment and routine nursing interventions.
I. Sexuality-Reproductive
Her pregnancy caused discomfort and changes in her sexual pattern as verbalized,
“dali ra ko ma luya karon”. She also uses pills and condom for her husband after
theirfirstchildwasborn forcontraceptives.Recently,she underwentBilateral Tubal
Ligation. It’s her personal choice since “4 na man gud akong anak” as verbalized.
During the first pre-natal check-up which was on the 3rd
month, patient had pyuria
and wasthenresolvedwithCefalexin (Cefalin) 500 mg/tab 1 tab 3x a day for 7 days
taken with good compliance.
PHYSICAL EXAMINATION
Date Performed:February18,2013
Place Performed:PPS105
Time Performed:1PM
1st
Day
SKIN: Striae gravidarumnoted.Dry,clean,intactdressingatthe hypogastricarea
noted.
ABDOMEN: Linea nigra noted, symmetrical umbilicus at 2 finger breadths below
midline, striae gravidarum noted. Presence of clean, dry, intact dressing noted on
the hypogastric area
GENITOURINARY: minimal lochia rubra noted on slightly saturated napkin
5/5 5/5
3/5 3/5
R L
Muscle strength
* Scale:
5 – Full ROMagainst gravity, full resistance
4 – Full ROMagainst gravity, some resistance
3 – Full ROMwith gravity
2 – Full ROMwith gravity eliminated (passive motion)
1 – Slight Reaction
0 – No Reaction

45. 2nd day
February 19, 2013
SKIN: Striae gravidarumnoted.Dry,clean,intactdressingatthe hypogastricarea
still noted.
ABDOMEN: Linea nigra noted, symmetrical umbilicus at 3 finger breadths below
midline, striae gravidarum noted. Presence of clean, dry, intact dressing noted on
the hypogastric area
GENITOURINARY: minimal lochia rubra noted on slightly saturated napkin
5/5 5/5
4/5 4/5
R L
Muscle strength
LABORATORY RESULTS
Macroscopic Results R.R. Unit
Transparency Slightly
cloudy
Clear
Protein + <10
Microscopic Findings
CONV (/hpf) SI (/uL)
R.R. R.R.
Mucous
Threads
Few None 0 None
Implications:
 Cloudyurine duringgestationispartlycausedasa consequence of
hormonal changesinthe body.Dietarymodificationstogetherwith
alterationsinhormone levelsare the majorreasonsforpassingcloudyurine
by pregnantwomen.Formostcases,the causal factor is the foodintake,
and promptresultsare achievedafterremovingthe triggerfoods.Thisisnot
a subjectto worryabout.
 Low amountsof proteinare not uncommon,andmaysimplymeanthat
your kidneysare workingharderthanbefore pregnancy.Your bodymaybe
fightingaminorinfection
 Mucus threadsina urinalysisare consideredtobe normal insmall amounts.
Mucus threadsappearlong,thinand wavy-ribbonlike.If there isalarge
amountof themitmay meanthere isan irritation,inflammation,or
infectioninthe urinarytract.Mucus threadsgenerallyhave noclinical
significance sincetheycome fromthe urethraor vagina.
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