Professional Documents
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Case-Study Final
Case-Study Final
Presented to:
Ms. Myrrha Taganas, RN
Faculty of the College of Nursing
The College of Maasin
Presented by:
Sanchez, Hennie Vee G.
Maldo, Micah Joyce P.
BSN- II LEVINE
March, 2021
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
INTRODUCTION
A case of a 25-year-old woman, Mrs. B who was brought to the hospital by her mother
in law and reports that she has been in labor for 8 hours and that her membranes ruptured 3
hours ago. Upon arrival at the hospital, she had a strong contraction lasting 45 seconds and is
showing signs of labor. A quick check to detect signs/symptoms of life-threatening complications
have been completed and, finding none, quickly proceeded to physical examination to
determine whether birth is imminent. Although Mrs. B is not pushing, and has a bulging, thin
perineum.
EPIDEMIOLOGY
Normal labor is defined as the gradual subjugation and dilatation of the uterine
cervix as a result of rhythmic uterine contractions leading to the expulsion of the products
of conception: the delivery of the fetus, membranes, umbilical cord, and placenta.
Laboring cannot that be easy; thereby implicating that there are processes and stages to
be undertaken to achieve spontaneous delivery. Through which, Obstetrics have divided
labor into four (4) stages thereby explaining this continuous process.
General Objectives:
This study aimed to broaden the student’s knowledge for Normal Spontaneous
Vaginal Delivery by obtaining sufficient information which could serve as a guide for
student nurses who will be focusing on the same case and it is also designed to enhance
skills and attitudes in the application of nursing process and management of the
procedure.
Specific Objectives:
After thoroughly discussed the case presented, the nursing students shall be able to:
To gain enough knowledge and understand the entire course of the procedure.
To know the client’s personal data, her family profile, past health history, current
medical history, and physical assessment.
To review the anatomy and physiology of the female reproductive system.
To discuss the purpose of the procedure and its possible complication.
To correlate the results of the diagnostic procedures to its normal values.
To develop an effective nursing care plan in which the client may benefit
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
Questions:
1. What history will you include in your assessment of Mrs. B and why?
- Past obstetric history. It is important to know how many pregnancies the patient has
gone through/lost. Patients often forget about miscarriages and ectopic pregnancies,
and may also not mention previous pregnancies from another husband or boyfriend.
Mrs. B.’s antenatal records should be quickly checked for history of present pregnancy,
as well as obstetric and medical histories, with particular attention to problems and
treatments
2. What physical examination will you include in your assessment of Mrs. B and
why?
-You should perform the following elements of examination to guide further assessment
and help individualize care provision. Some findings may help determine stage/phase of
labor, or may indicate a special need/condition that requires additional care or a life-
threatening complication that requires immediate attention
-Mrs. B.’s respirations, blood pressure, temperature and pulse should be measured to
ensure normalcy/normal progress, and detect abnormal signs/symptoms.
Abdominal examination including assessment of:
Surface of abdomen for presence of scars, which might indicate a previous C-section
or other uterine surgery
Uterine shape, which may indicate lie and/or uterine abnormality
Fundal height, which will helps confirm gestational age or indicate size-date
discrepancy
Fetal parts and movement,which may indicate multiple pregnancy
3. What laboratory tests will you include in your assessment of Mrs. B and why?
- A urinalysis and a CBC test because urinalysis is important to rule out a urinary tract
infection. Pregnant women are prone to urinary tract infections due to the progesterone
effect on the smooth muscle of the ureters and a complete blood count to identify and
prevent problems, a CBC may be done before pregnancy, if possible, at the beginning
of pregnancy, and one or more times during pregnancy. The first baseline results can
be compared to later values to look for changes that could indicate a health issue.
4. Based on these findings, what is Mrs. X's diagnosis (problem/need) and why?
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
- Mrs. B. has reached the second stage of labor, indicated by full dilation of the cervix
5. Based on your diagnosis (problem/need identification), what is your plan of care for
Mrs. B and why?
- Mrs. B. must not be left alone. She should receive on going assessment (e.g.,
maternal pulse and contractions every30 minutes, fetal heartrate every 5minutes) to
ensure that any problems or abnormalities in the condition of mother or baby or
progress of labor are detected early for immediate attention.
She should receive on going supportive care:
A supportive, encouraging atmosphere that is respectful of Mrs. B’s wishes should be
established to provide emotional support.
Mrs. B. should be made comfortable and encouraged to adopt a position for pushing
that is comfortable for her and aids in the descent of the fetus: semi-sitting/reclining,
squatting, hands and knees or lying on side.
Mrs. B. should been courage to follow her own tendency to push: the intensity of her
contractions should regulate her efforts to push. She should be encouraged not to
6. Based on these findings, what is your continuing plan of care for Mrs. B and why?
Immediate new born care should be provided:
Thoroughly dry baby and cover in clean, warm cloth.
Clamp/tie and cut cord.
Assess uterine tone and if necessary massage the uterus through the abdomen until
firmly contracted (Mrs. B. should also be shown how to massage her fundus to maintain
the contraction)
Examine the vagina and perineum for lacerations or tears.
Mrs. B. should be made comfortable (e.g., cleanse perineum, change bed linens).
She and the baby should receive ongoing assessment every 15minutes for first 2
hours following birth (e.g., mother: blood pressure, pulse, fundus [for firmness], and
vaginal bleeding; newborn: respiration, warmth, color to ensure that any problems or
abnormalities in the condition of mother or baby are detected early for immediate
attention
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
B. Chief Complaint:
Few hours prior to admission on the hospital the patient was already in labor for 8
hours that her membranes ruptured 3 hours ago. Upon arrival she was assessed
with bulging in her perineum
C. History of Present Illness:
N/A
D. Past History
The patient has no known allergy to any foods or drugs and has no history of
hypertension, diabetes mellitus or asthma
E. Family History
There was no known familial disease in their family
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
Patient is 25 yrs. Old, female and married. She was in labor for 8 hours and that her
membranes ruptures 3 hours ago before she was admitted in to the hospital. She had a
strong contraction lasting for 45 seconds and there is a bulging in her perineum which is
possibly cause by the pressure during her prolonged labor
Patient has complete meals (breakfast, lunch, and dinner) and has fluid intake of 8-10
glasses /day. She eats meats, vegetables and fruits.
C. Elimination Pattern
Bladder Habits:
Bowel Habits:
D. Activity-Exercise Pattern
During pregnancy the patient do exercise which can reduce backaches, constipation,
bloating and swelling. Boost your mood and energy levels. Help you sleep better.
E. Sleep-Rest Pattern
She has a good sleep-wake cycle. She usually sleeps 6-8 hours
F. Cognitive-Perceptual Pattern
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
She has no deficit in her sensory perception (hearing and sight) and she’s able to read
and write. She can hear and answer questions being asked. She is aware of the
conversation. She can see people that surrounds her.
According to her significant others, patient is a good mother and daughter. She is not a
smoker and doesn’t drink. She wants to reach her goals later on.
Patient is very responsible. She always said that she wants to attain her goals or
dreams for her family
I. Sexually-reproductive pattern
She said that, whenever she has a problem she shares it to the family and solve the
problems by herself and of course, listens to the advices of her family
K. Value-belief pattern
She is a roman catholic. She attended masses together with the family every Sunday.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
DEVELOPMENTAL TASK
DEFINITION OF TERMS
1.
Normal Spontaneous Vaginal Delivery (NSVD)
A normal spontaneous vaginal delivery (NSVD) occurs when a pregnant female goes
into labor without the use of drugs or techniques to induce labor, and delivers her baby
in the normal manner, without forceps, vacuum extraction, or a cesarean section.
2.
Normal Spontaneous Vaginal Delivery (NSVD)
Vaginal delivery is the method of childbirth most health experts recommend for women
whose babies have reached full term. Compared to other methods of childbirth, such as
a cesarean delivery and induced labor, it’s the simplest kind of delivery process. A
spontaneous vaginal delivery is a vaginal delivery that happens on its own, without
requiring doctors to use tools to help pull the baby out. This occurs after a pregnant
woman goes through labor. Labor opens, or dilates, her cervix to at least 10
centimeters.
3.
Normal Spontaneous Vaginal Delivery (NSVD)
Normal spontaneous vaginal delivery is when a woman goes into labor without the aid
of any labor inducing drugs or methods, and is able to deliver the baby without requiring
a doctor’s aid through cesarean section, vacuum extraction, or with forceps, this is
known as a normal spontaneous vaginal delivery (NSVD).
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
ETIOLOGY
During labor, the role of the cervix must change from maintaining the pregnancy (by keeping the
uterus closed) to facilitating delivery of the baby (by dilating, or opening, enough to allow the
baby through). The fundamental changes that occur near the end of the pregnancy result in a
softening of the cervical tissue and thinning of the cervix, both of which help prepare the cervix.
True, active labor is considered to be underway when the cervix is dilated 3 centimeters or
more. Eventually, the cervical canal must open until the cervical opening itself has reached 10
centimeters in diameter and the baby is able to pass into the birth canal. As the baby enters the
vagina, your skin and muscles stretch. The labia and perineum (the area between the vagina
and the rectum) eventually reach a point of maximum stretching. At this point, the skin may feel
like it’s burning. Some childbirth educators call this the ring of fire because of the burning
sensation felt as the mother’s tissues stretch around the baby’s head. At this time, your
healthcare provider may decide to perform an episiotomy.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
SYMPTOMALOGY
SYMPTOMS RATIONALE ACTUAL
Strong contractions These contractions cause ✔
the upper part of the uterus
to tighten and thicken while
the cervix and lower
portion of the uterus
stretch and relax, helping
the baby pass from inside
the uterus and into the
birth canal for delivery.
Fully dilated cervix The cervix has ✔
opened completely in
preparation for childbirth.
increased pressure in
the region.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
CONCEPT MAP
RISK FACTORS
Predisposing Factor: Bulging perineum.
Protrusion in the perineal area during the
second stage of labor. It is
the characteristic sign of impending birth and is
caused by increased pressure in the region
Precipitating Factors: Strong contractions
lasting 45 seconds. The periodic tightening
and relaxing of the uterine muscle. LABORATORY/DIAGNOSTIC
TEST
MEDICAL MANAGEMENT
LABORATO INDICATIONS REFERENCE ACTUAL SIGNIFICANCE NURSING
RY/ VALUE FINDINGS OF THE CONSIDERATIONS
DIAGNOSTI FINDINGS
C TEST
Complete To identify and Hemoglobin: n/a Measures the Pre-procedure:
blood prevent 11.5-13.0 (13.5) numbers of - educate the patient
count problems, g/dl different types about the importance
(CBC) a CBC may of cells that of the test.
- is a set of be done before Platelets: make up your - Explain that slight
medical pregnancy, if 150,000 to blood to check discomfort may be felt
laboratory possible, at the 450,000 platelets for anemia, when the skin is
tests that beginning per microliter of infection and punctured.
provide of pregnancy, blood your blood- - Encourage to avoid
information and one or clotting ability. stress if possible.
about the more White blood cell:
cells in a times during 9,000-15,000 During/Intra-
person's pregnancy. cells per microliter procedure:
blood. The first - Apply manual
baseline pressure and
results can be dressings over
compared to puncture site.
later values to - Tell the patient to
look for relax.
changes that
could indicate Post-procedure:
a health issue. - Monitor the puncture
site for oozing or
hematoma formation.
- Instruct to resume
normal activities and
diet.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
Crystals:
negative or
none.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
DRUG STUDY
DRUG MODE OF INDICATI CONTRAIN- SIDE EFFECTS/ NURSING
NAME ACTION ONS DICATIONS ADVERSE INTERVENTIONS
EFFECTS
Generic Name: Agonist of kappa - Analgesia Hypersensitivity to CNS - Question medical history
opioid receptors nalbuphine. Severe Effects: Nervousness, in Precautions
nalbuphine and partial respiratory depression,
antagonist of mu depression, acute restlessness, crying, - Obtain vital signs before
Brand Name: medication.
opioid receptors or severe bronchial euphoria, floating,
Nubain within CNS, asthma, GI hostility, unusual - Monitor for change in res
inhibiting obstruction dreams, confusion, B/P, rate/quality of pulse.
Therapeutic
ascending pain including paralytic faintness,
Class: - Monitor daily pattern of b
pathways. ileus. Cautions: hallucinations,
Opioid partial Therapeutic Hepatic/renal dysphoria, feeling of activity, stool consistency.
agonist. Effect: Alters impairment, heaviness, numbness,
- Initiate deep breathing, c
pain perception, respiratory tingling, unreality. The
Pharmacologic emotional exercises, particularly in p
depression, recent incidence of
class: pulmonary impairment
response to MI, recent biliary psychotomimetic
pain. tract impairment, effects, such as - Assess for clinical impro
Opioid
pancreatitis, unreality, record onset of relief of pa
analgesic.
hypovolemia, head depersonalization,
Actual Dose, trauma, increased delusions, dysphoria - Consult physician if pain
Timing and intracranial and hallucinations has not adequate.
Route: pressure (ICP), been shown to be less
pregnancy, pts than that which occurs
For IV push, suspected of being with pentazocine.
administer opioid dependent,
each 10 mg obesity, thyroid Cardiovascular: Hyper
over 3–5 min. dysfunction, tension, hypotension,
prostatic bradycardia,
hyperplasia, tachycardia.
urinary stricture,
adrenal Gastrointestinal: Cra
insufficiency, mps, dyspepsia, bitter
cardiovascular taste.
disease, elderly
pts, debilitated pts. Respiratory: Depressi
on, dyspnea, asthma.
Dermatologic: Itching,
burning, urticaria.
Miscellaneous: Speec
h difficulty, urinary
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
Allergic
Reactions: Anaphylacti
c/anaphylactoid and
other serious
hypersensitivity
reactions have been
reported following the
use of nalbuphine and
may require immediate,
supportive medical
treatment. These
reactions may include
shock, respiratory
distress, respiratory
arrest, bradycardia,
cardiac arrest,
hypotension, or
laryngeal edema. Some
of these allergic
reactions may be life-
threatening. Other
allergic-type reactions
reported include stridor,
bronchospasm,
wheezing, edema, rash,
pruritus, nausea,
vomiting, diaphoresis,
weakness, and
shakiness.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
in fetal distress,
hydramnios,
partial placental
previa,
predisposition to
uterine rupture
during stages
of labor.
9. Teach patient
pain control options
9. Providing
available, giving the
information
pros and cons of
allows the
each
patient to
make
informed
decision
regarding pain
control
10. Provide teaching
between uterine
contractions. 10. The
patient is more
attentive and
can better
internalize
information
when not in
pain.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
6. Encourage use of
Source: relaxation 6. Enables the
Doenges, M. techniques. client to obtain
E., maximum benefit
Moorhouse, from rest
M. F., & Murr, periods; prevents
A. C. (2008). muscle fatigue
Nurse's and improves
pocket guide: uterine blood
Diagnoses, flow.
prioritized 7. Assess support
interventions, systems available 7. The
and to the client or assistance and
rationales. couple. caring of
Philadelphia, significant
Pensylvennia: others, including
F.A. Davis caregivers, are
Company. extremely
important during
this time of
uncertainty and
8. Provide massage stress.
and backrubs for
patient to reduce 8. This aids in
anxiety. reduction in
anxiety.
9. Interact with
patient in a peaceful 9. The nurse or
manner. health care
provider can
transmit his or
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
3. Provide positive
reinforcement and 3. Positive
encouragement to reinforcement and
patient and support encouragement
persons as they provide the patient
apply and support
nonpharmacolgic person a sense of
techniques learned control and self-
in childbirth confidence.
classes. Assist with
techniques as
necessary.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
4. Assess anxiety
level and
4. Allows for
implement
clearly intervention
measures to
to decrease
reduce anxiety as
anxiety levels.
needed.
High levels of
anxiety can
increase the
perception of pain,
and decrease
comprehension of
verbal instruction.
7. Initiate 7. These
teaching/reinforcing nonpharmacologic
of comfort measures
nonpharmacologic work by providing
comfort measures diversion during
that can be used uterine
during labor if contractions.
needed. Assist with
implementation of
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
these measures as
needed.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
S Subjective cues
• “I don’t feel any pain anymore.”
• “I want to go home.”
O Objective cues
• Continue your prenatal vitamins as long as you are breast feeding or for 30days after
delivery.
• Balance activities with adequate rest periods and stay hydrated all day long.
• Eat healthy meals. Maintain a healthy diet to promote healing. Increase your intake of
whole grains, vegetables, fruits, and protein.
• Exercise. Your doctor will let you know when it’s okay to exercise. The activity should
not be strenuous.
O Observable signs/ symptoms (cues for seeking prompt management)
• A red or swollen leg that feels warm or painful when you touch it
• A bad headache that doesn’t get better after taking medication, or a bad headache that
affects your vision
• At every meal, fill half your plate with fruits and vegetables. The other half should
include whole grains like brown rice, whole-grain bread, or oatmeal.
• Foods like beans, seafood, lean meats, eggs, and soy products are rich in protein, which
help your body recover from childbirth. Aim for five servings each day, or seven if
you’re breastfeeding.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
JOURNAL READING 1
External cephalic version (ECV) is a method commonly used to manipulate the fetus
abdominally to a cephalic presentation. The purpose of this audit was to evaluate all ECV
procedures over a one‐year period in our unit, to analyse subsequent pregnancy
outcomes and compare these with previous audits.
Design
This was a retrospective audit, analysing all ECV procedures performed in the year 2017.
Methods
Data queries were used to extract all patients with a non‐cephalic fetus at the routine
36 weeks’ scan, and a second query extracted all breech deliveries.
Results
250 fetuses were breech at the routine 36 weeks’ scan. From these, 110 ECV procedures
were attempted. 34.6% were successful and 86% of these patients had a vaginal delivery.
From those procedures that failed, all patients delivered by caesarean section. A greater
success rate was seen in multiparous compared with nulliparous patients (51% versus
26%). When compared with the results from previous audits, there had been an overall
increase in ECV procedures; however, the success rate had fallen compared to the
previous year.
Conclusion
The results show that antenatal detection of breech presentation is extremely high in our
unit and can be explained by the routine 36 weeks’ scan. ECV remains one of the principal
methods to reduce the incidence of breech presentation, thereby potentially avoiding
caesarean section and its sequelae. Further audit would need to be carried out looking at
the factors associated with failure in terms of case selection and operator experience.
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
JOURNAL READING 2
Mode of Vaginal Delivery: A Modifiable Intrapartum Risk Factor for Obstetric Anal
Sphincter Injury
Source: https://www.hindawi.com/journals/ogi/2015/679470/
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
REFERENCES
https://nyepartners.com/nsvdserv/
https://www.healthline.com/health/pregnancy/spontaneous-vaginal-delivery#Should-
you-have-a-spontaneous-vaginal-delivery?
https://courses.lumenlearning.com/boundless-ap/chapter/birth-parturition/
THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”
College of Nursing & Allied Health Sciences
Maasin City, Southern Leyte
1. Nursing Practice
Knowledge, skills and attitude should always be present on the practice of the
nursing profession. In carrying out the nursing actions & interventions, the
underlying principles and standards must always be observed to provide total
patient care. The nursing care plans in this presentation will aid the learners in
the care of the patients.
2. Nursing Education
This presentation will help future students gain knowledge about the case – Beta
thalassemia major and provide them insight on how to care and manage patients
with this disease. This case presentation will also encourage health teaching to
caregivers and other health care professionals.
3. Nursing Research
In the field of research, this case presentation will encourage effective therapeutic
management for patients undergoing normal spontaneous vaginal delivery. It will
also give more insights to future researchers about the normal spontaneous
vaginal delivery and its nursing management.