INTRODUCTION
Pregnancy is the state of carrying a developing fetus within the female
body. Pregnancy lasts for about 9 months measured from the womans last
menstrual period and is divided into three trimesters. When gestation has
completed, it goes through a process called delivery, where the developed
fetus is expelled from the mothers womb.
During pregnancy, the fetus may be in cephalic presentation or the
normal position of a baby in which the fetus head are the nearest the birth
canal. There is also an abnormal presentation in which the fetus buttocks or
feet are nearest the birth canal, it is called Breech Presentation.
Normal labor is defined as the gradual subjugation and dilatation of the
uterine cervix as a result of rhythmic rhythmic Uterine Contractions leading
to the expulsion of the products of conception: the delivery of the fetus,
membranes, umbilical cord and placenta.
In the case of our patient, she was not able to complete the said three
trimesters because of certain circumstances that forces the patient to deliver
the products of conception on the 7 th month. It is an emergency case so
there is a need to induce labor and the use of Oxytocin is necessary to help
contract the uterine wall.
We chose this case because we are focusing on the Delivery Room
Cases for our group case and it was our first time to encounter a preterm
delivery of a fetus in a breech position.
Republic of the Philippines
PALAWAN STATE UNIVERSITY
September 1, 2016
College of Nursing and Health Sciences
Tiniguiban Heights, Puerto Princesa City
Name: Pokemon
Ward: Delivery Room
Date: August 25, 2016
PATIENTS ASSESSMENT
I. PATIENTS PROFILE
Name: Pokemon
Age: 18 years old
Gender: Female
Status: Single
Occupation: Housekeeper
Religion: Born Again
Date & Time Admitted: August 25, 2016 @ 4:10 pm
Address: Sta. Monica, Puerto Princesa City Palawan
Educational Attainment: High School Graduate
Attending Physician: Patricia Evelyn P. Palaypayon MD
Chief Complaint: G1P0 Vaginal Bleeding
Discharge Diagnosis: G1P1 (0101) Pregnancy Uterine 29 weeks AOG
Delivered by complete breech extract (NSD)
Using marshall maneuver to a live baby boy
Diet: DAT
II. HEALTH HISTORY
A. PRESENT ILLNESS
A day prior to admission, patient was taking a shower and
suddenly the basin full of water above her fall down and she accidentally
catched the basin full of water to her surprised. She didnt felt anything after
the incident, at 7pm she experienced pain on her lower back and started
bleeding profusely. According to the patient, her stepmother massage her
abdomen. She didnt mind that she was bleeding because she thought it was
just nothing.
30 minutes prior to admission, the patient experienced pain that
she rate 7 out of 10. The bleeding continued she thought that she was on
labor, her husband brought her to Ospital ng Palawan at 10am and were
admitted at ER.
B. PAST HEALTH HISTORY
Patient has no history of hypertension, Diabetes Mellitus, asthma
and PTB. She has allergies to food such as alamang, and seafoods. She has
no allergies to drugs and never been hospitalized as she remembered.
Patient never experienced chicken pox, measles and mumps. She
September 1, 2016
experienced cough that would last for a week and she couldnt remember
the medication that she took that time.
She had her first prenatal at 4 months and second prenatal was at 6
months.
C. FAMILY HISTORY
According to the patient she has two sisters and apparently in a
good health. She emphasized that her father has a high blood pressure, her
mother died at age 32 due to hypertension. The patient is the youngest of
three siblings and there is no history of such diseases.
GENOGRAM
Father:
High Blood
Mother:
High Blood
Deceased
September 1, 2016
Alive and
Well
Alive and
Well
FATHER
SISTERS
MOTHER
PATIENT
Patient
OB/GYNECOLOGIC HISTORY
A. MENSTRUAL HISTORY
Menarche of the patient began when she was 13 years old in a regular
cycle of 5-7 days. She uses two packs of feminine napkins, moderately
soaked in her whole menstrual cycle. Patient sometimes experiences
dysmenorrhea during her first to second days of her menstruation.
B. OBSTETRIC HISTORY
G1P1T0P1A0L1 2016 baby boy via NSD preterm, footling breech @
ONP
LMP February 4, 2016
EDC November 11, 2016
C. ANTHROPOMETRIC MEASURE
Head Circumference 27 cm
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Chest Circumference 23 cm
Abdominal Circumference 22 cm
Body Length 38 cm
Body Weight 1,210 gms
Temperature 36 C
Cardiac rate 157 bpm
Respiration rate 46 cpm
September 1, 2016
GROWTH:
Adolescents are generally in good health, subject neither to disease nor problems of
senescence. Biologically function and physical performance reach their peak from
13-19 years of age, waning after 19.
DEVELOPMENT:
Ms. Pokemon approximately 5 feet and 3 inches weighing 55 kilogram.
THEORY
AGE
Freuds
psychosexual
developmental
theory
(Genital)
Eriksons
Psychosocial
Theory
young adulthood
(ages 18 to 40
yrs)
Puberty and after
CHARACTERISTICS
Energy is directed
toward full sexual
maturity and
development of
skills needed to
cope with the
environment.
Patient is 18 years old.
She has a live in
partner which is also
an 18 years old. She is
not studying due to
lack of financial
support from her
parents, who are now
separated. They are
currently living at the
residence of her father.
She had no job so she
just helps her
stepmother at
household chores.
intimacy vs.
isolation
The patient states that
she and her live in
partner have an
intimate relationship
and they both decide
in terms of decision
making. She usually
does households with
her stepmother.
intimate relationship
with another person
commitment to work
and relationship
Havigursts
Cognitive
developmental
theory
Adolescent
13-18 years old
PRESENTING
CHARACTERISTICS
Developmental
Tasks of
Adolescence:
1. Achieving new
and more mature
relations with agemates of both sexes
Patient lives happily
with her partner even
though they are not
yet married.
She usually does
households with her
stepmother.
2. Achieving a
masculine or
feminine social role
3. Accepting one's
physique and using
the body effectively
4. Achieving
emotional
independence of
parents and other
adults
5. Preparing for
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marriage and family
life preparing for an
economic career
6. Acquiring a set of
values and an
ethical system as a
guide to behavior;
developing an
ideology
7. Desiring and
achieving socially
responsible behavior
DISCHARGE PLAN
Name of patient: Ms. Pokemon
Delivery Room
Age: 18 y/o
Ward:
September 1, 2016
Chief Complaint:
Palaypayon
Nursing
Discharge Instructions
Orders
Medications
Instruct the mother to
adhere medications as
prescribe by the
doctor.
Instruct the right
dosage, route, time
and other special
instruction or
precautions.
Exercise
Treatment
Attending Physician: Dra.
Rationale
To avoid drug toxicity,
to minimize the side
effects of the drugs and
factors that contributes
to it.
TTo minimize the side
effect of the drugs and
factor that contributes
to it.
Instruct the patient to
check medication
label first before
taking.
To avoid making
medication errors thus
preventing adverse
reaction.
Instruct the mother to
walk and advise active
ROM within limits like
flexion, extension, etc.
at extremities.
To regain strength
Advise the mother to
plan leisure activity
that requires minimal
expenditures.
To hasten recovery
Encourage patient to
continue deep
breathing exercise and
instructed the family
for the exercise
needed.
This is to promote
circulation of blood, and
relaxation also.
Instructed the mother
to perform ADLs after
2-3 days.
To provide rest and
promote self-care
activities.
Instruct the mother to
wash perineal area
using tap water and
feminine wash with
antibacterial solution.
To prevent infection and
provide clean perineal
area.
Instruct the mother to
To promote involution
September 1, 2016
have sexual
intercourse after 4
weeks.
state of the perineal
area.
To avoid hemorrhage.
Instructed the mother
to inform the nurse if
heavy bleeding occurs
or the diaper is
soaking with blood.
Instruct the mother to
breastfeed her baby
within 6 months.
To promote the skin to
skin contact, bonding to
the mother and stabilize
immunity of the baby.
Instruct the mother to
give vaccination to
her baby.
To prevent newborn
diseases.
Encourage patients
compliance in
treatment.
Emphasized the
importance of
adequate rest and
sleep
Hygiene
To maintain physiologic
functioning
To maintain internal
equilibrium
Instruct the mother to
clean the babys
umbilical cord after
every bath and keep it
dry.
To avoid infection
Encourage the mother
to change babys
diaper every 4 hrs.
To prevent skin rashes
Encourage the patient
to take a bath and
toothbrush regularly.
It facilitates good
healing and prevents
harboring of
microorganisms that will
cause infection
Teach the client to
perform perineal care.
To avoid infection.
Teach the patient to
have breast care using
cotton with water from
inner to outer portion
and let it dry in the air.
To prevent infection and
clean the breast
properly.
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OPD
Diet
Spirituality
Advise the mother to
go to OPD after 1
week.
For follow up check up.
Encourage the mother
to eat green leafy
vegetables,(kangkong,
malunggay, kamote
tops) seashells, and
increase fluid intake.
To increase lactation
Instructed to eat fruit
foods rich in Vit.C like
orange, grapes,
guava, papaya, and
melon.
To boost immune
system and promote
wound healing.
Advise the mother to
breastfeed her baby
as per demand and
continue
breastfeeding within 6
months. And Instruct
not to give pacifiers
and formula milk.
Breast milk is easy to
digest, contains
antibodies, and helps
brain development,
clean and sterile.
Increase fluid water
intake.
To hydrate the mother.
Encourage the mother
to pray continually for
her good health and
to her baby.
To immense her faith
and strengthen her
belief in God.
Suggest patient to
attend Sunday
service/ mass in
church as to boost
spirit and to prevent
distress.
Spiritual aspect is a part
of holistic care.
September 1, 2016
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