Case 2

Introduction

Pt JTL 23years old female, married, with educational attainment college and is employed, lives at Inayawan Cebu
City born on October 21,1997 with AOG of 38 1/7 weeks under by DR. Monte falcon with the complaints of having labor
pain with mucoid bloody vaginal discharge associated with crampy hypogastric pain radiating to lumbosacral area, with
uterine contraction every minute. Patient experiencing irregular x5days 3-5pads/day when she is 13years old as
verbalized. She has 5 days antenatal visits with the total weight gain of 23lbs. The patient was conscious, coherent,
cooperative, and besuited but has a noticeable uncomfortable feeling upon her visit to the hospital. While doing the
assessment vital signs was taken, following vital sign of BP: 110/70 HR: 104 RR: 21 Temp: 36.2 O2 stat: 98% Weight:
109lbs. Patient has obstetric history record of G1P0, LMP: 8/1 week/2019, is EDC: May 26, 2020, AOG: 38 1/7 NSVD.

CAUSES OF BLOODY VAGINAL DISCHARGE

Vaginal discharge is most often a normal and regular occurrence. However, there are certain types of discharge that can
indicate an infection. Abnormal discharge may be yellow or green, chunky in consistency, or foul smelling. Brown or
bloody discharge is usually normal, especially when it occurs during or right after your menstrual cycle. A late discharge
at the end of your period can look brown instead of red. You may also experience a small amount of bloody discharge
between periods. This is called spotting. But if the discharge appears outside your labor period then there may be a
problem. It’s best to consult your doctor to know the problem and find an accurate treatment for the discharge.

ANATOMY AND PHYSIOLOGY

Urethral Opening- transmits urine from the bladder to the exterior of the body during urination.

Vestibule- hestriated muscle completely surrounds the urethra and vagina, forming an urethrovaginal sphincter.

Hymen-can serve a protective purpose by helping to prevent things from being pushed into the vagina; sometimes, a
damaged hymen is looked at as an indicator of abuse and incest.

Perineum -the most important task is performed by the muscles and consists in supporting the internal organs (bladder,
uterus and rectum). This region also contributes to urinary and fecal continence, plays an important role in sexual life
and, during the birth, and favors the release of the unborn child.

Labia Majora- to cover and protect the inner, more delicate and sensitive structures of the vulva, such as the labia
minora, clitoris, urinary orifice, and vaginal orifice.

Labia Minora- is to protect any kind of mechanical irritation, infections, and dryness in the extremely sensitive region of
the vulval vestibule with urethral and vaginal openings in between.
Vaginal Entrance- receives the penis during sexual intercourse and also serves as a conduit for menstrual flow from the
uterus.

Glans of clitoris - the clitoris is primarily to mediate sexual arousal. It serves as a locus of pleasurable sensation during
sexual contact. Stimulation of the clitoris may also directly affect blood flow to the other genital organs and, therefore,
both the subjective and objective elements of arousal.

CEPHALO- CAUDAL ASSESSMENT

GENERAL APPEARANCE:

1. The patient is conscious and cooperative but being anxious is visible due to hypogastric pain which is active and
crampy causing pain to be visible to the patients action and gestures.
2. The vital signs of the patient are within normal range the BP is at 110/70 mmHg, weight 109lbs and her oxygen
saturation at 98 percent which is also within the normal range.
3. While having the consultation the patient was troubled caused by the active and crampy hypogastric pain which
radiates to the lumbosacral area and contracts every 30 minutes and also because of the mucoid bloody
discharges.
4. The patient is observed restless and not on her best due to the pain and the uncomfortable feeling caused by
the bloody discharge.
5. The patient was also at the state of active labor.

SKIN

Patient skin is normal, color is slightly pale, has no edema, lesions, or any abrasions. The color of the clients nail when
pinched returns to its pink color each finger every 5 second during the blanched test.

HEAD AND FACE

Patients hair is silky, evenly distributed, and shiny. Scalp is clean, no dandruff, tenderness, and lice. Patients scalp has
normal color which is lighter to her skin color. The patient has good facial movements and has a asymmetric facial form.

EYES

The patients eyes are symmetrically aligned, the iris is perfectly brown and rounds, no dryness of the eyes, and also has
clear conjunctiva and a white and clear sclera which is good and normal.

EARS

Patients ears are also at normal state with good hearing mechanism on both ear. No irritation, blood, no pus, clean and
good with a dry external ear canal which is also good to avoid bacterial and fungal growth.

NOSE

The patients nose has no tenderness upon palpation on its sinuses, no blockage, no nasal flaring, and no cartilage
deviation. Patient sense of smell is also at its state.

MOUTH AND THROAT

Patients lips is symmetrical, pink, smooth, and moist no growths, lumps, or discoloration of the tissue. Teeth is clean
with no decay, white with shiny enamel and smooth surfaces and edges. Gums appear symmetrical, moist and pinkish,
with well-defined margins with no discoloration or bleeding. Oral mucosa appears moist, smooth, shiny and pink. The
tongue is symmetrical, pink, moist, slightly rough from the papillae and free from any lesions. Tonsils appears pink,
symmetrical and normal-size tonsils.

NECK

Patients neck is symmetric trachea is at its central placement. Thyroid glands is not visible during inspection, during
palpation the thyroid nicely slides beneath the finger with no asymmetry or enlargements.

CHEST (POSTERIOR AND LATERAL)

The patients posterior and lateral chest is normal, thorax is asymmetric, chest is also symmetric upon expansion, muscle
development is uniform and spines are a bit aligned no tenderness found.

CHEST (ANTERIOR)

Because of pain felt by the patient breathing process is disturbed, still chest is symmetric during expansion. Bony
prominces tympany on the stomach is observed with spleen Broncho vesicular and vesicular, and also dullness on the
liver is noticed.

HEART

The patient heart is at its normal range. Heart rate is normal with no abnormal sounds.

UPPER EXTREMITIES

Upper extremities are in good condition, no edema or involuntary movements, both are equal in size and same outline.

ABDOMEN

Patients abdomen is normal with no lesions or tenderness observed.

LOWER EXTREMITIES

Patients lower extremities is in normal state with no lesions, tenderness, or skin discoloration, or any involuntary
movement, lower extremities has same outline.

MUSCOSKELETAL

Patients muscles are at its normal state without any lesion, tenderness, or edema. Patients strength is at its best.

LAB AND DIAGNOSTICS

DATE TYPE OF EXAM PATIENTS RESULT NORMAL VALUES SIGNIFICANCE/INTERPRETATION

5/14/2020 CBC WBC-9.70 4.4-11.0 Patients CBC results are within
NEU-60.9 37.0-80.0 its normal state the WBC who
MON- 14.1 0.0-12.0 fights infection is at 9.70, RBC
EOS-0.8 0.0-7.0 who carry oxygen is at 3.95 and
BAS- 0.4 0.0-2.5 other CBC results is at normal
values. If abnormal increases or
RBC- 3.95 4.5-5.1 decreases in cell counts as
HGB- 12.7 12.3-15.3 revealed in a complete blood
HCT- 37.7 35.9-44.6 count may indicate that you
have an underlying medical
MCV- 95 80-96 condition that calls for further
MCH- 32.2 27.5-33.2 evaluation.
 MCHC- 33.8 32.0-36.0
RDW- 11.5 11.6-14.8

PLT-187 150-450
MPV- 7.4 6.0-11.0
5/14/2020 URIALYSIS pH- 6.5 4.5-8 The patients urinalysis results
USG- 1.010 1.003-1.030 are within normal range except
Blood -3+ Negative for the WBC which ranges to 8-
Albumin- 1+ Negative 10 HPF high amount of WBC in
Ketone- 3+ Negative urine can be an indication of
Nitrates-(-) Negative infection, stress, inflammation,
Glucose- Trace Negative trauma, allergy, or certain
Bilirubin- (-) Negative diseases. And also the RBC is
Urobinilogen- Trace to 1 mg/dl high ranges from 50-60 which
normal can also be an indication of
infection. The urine appears
WBC -8-10/HPF 0-5/HPF cloudy caused by blood in the
RBC- 50-60/HPF 0-1/HPF urine.
Bacteria- Negative
moderate
Epithelial Cells- None
rare
Mucus Threads- None
rate

Color –
Dark Yellow Light yellow to
Volume brownish
-60 ml

Transparency CLEAR
Cloudy
5/14/2020 IMMUNOLOGY HBsAg Nonreactive The patients immunology result
(Qualitative) shows that the patient has no
-NonReactive hepatitis B surface antigen
found.
 DRUG STUDIES

Name of Mechanism of Indication Side Nursing Responsibilities

drugs action Effects/Adverse
Effect
*Arrange for culture and
Generic Bactericidal: Respiratory CNS: sensitivity tests of infection
Name Inhibits synthesis Tract infections Headache, before and during therapy if
Cefalexin of bacterial cell caused by dizziness, infection does not resolve.
wall, causing cell Streptococcus lethargy *Give drug with meals; arrange
Brand Name death pneumoniae, group for small, frequent meals if GI
Apo-Cephalex A beta-hemolytic GI: complications occur.
streptococci. Nausea, vomiting, *Refrigerate suspension, discard
Classification diarrhea, anorexia, after 14 days.
Antibitic Skin and skin structure abdominal pain *Instruct patient to take this
infections caused by , flatulence drug with food. Refrigerate
Dosage staphylococcus, suspension; discard any drug
500 mg 1 streptococcus Hypersensitivity: after 14 days.
cap Ranging from rash *Complete the full course of this
To fever to drug even if you feel better.
Route anaphylaxis; *Inform patient that this drug is
Oral Serum sickness prescribed for this particular
infection; do not self-treat any
Frequency Contraindication other infection.
TID Hematologic: *Inform patient that she may
Contraindicated Bone experience these side effects:
Timing With allergy marrowdepression Stomach upset, loss of appetite,
8:00 am, 1:00 Tocephalosporins nausea (take drug with food);
pm or penicillins. diarrhea; headache, dizziness.
6:00 pm *Instruct patient to report
Use cautiously with severe diarrhea with blood, pus,
renalfailure,lactation, or mucus; rash or hives;
pregnancy difficulty breathing; unusual
tiredness, fatigue; unusual
bleeding or bruising.
*Advice patient to avoid alcohol
while taking cephalexin.
 Name of Mechanism of Indication Side Effects/Adverse Nursing Responsibilities
drugs action Effect

Generic Exhibits anti- Adjunctive treatment CNS: Before:

Name inflammatory, to decrease the dizziness, Assess pt’s history of allergic
Celecoxib analgesic, number of adenoma drowsiness, reactionto the drug
andante touscolo rectalpolyps headache, insomnia, Monitor complete blood
Brand Name pyreticaction infamiliala fatigue count,electrolyte levels,
Celebrix due to inhibition denomatouspolyposis CV: Creatinine clearance, and
of the Peripheral edema occult fecal blood test
Classification enzymeCOX-2 EENT: and liver function test results
NSAID (Non- ophthalmic every 6 to 12months
Steroidal effects,tinnitus, During:
Inflammatory Contraindication pharyngitis, Instruct patient to take drug
Drugs) rhinitis,sinusitis with food or milk. -
Hypersensitivity GI: Teach patient to avoid aspirin
Dosage todrug,sulfonamides,or nausea,diarrhea, and other
200 mg/1 cap other NSAIDs constipation, NSAIDs (such as ibuprofen
Severe hepatic abdominal lpain, andnaproxen) during
Route impairment dyspepsia, therapy.
Oral Historyof asthmaor flatulence, dry mouth, After:
urticaria GI bleeding
Frequency Advanced renal GU: Advise patient to immediately
BID disease menorrhagia report bloody stools,
Latepregnancy Hematologic: blooding vomit, or signs or
Timing Breastfeed Decreased symptoms of liver
8:00 AM & hemoglobin or damage (nausea, fatigue,
6:00 PM hematocrit, lethargy, pruritus, yellowing of
eosinophiliing eyes or skin, tenderness on
upper right side of abdomen,
or flu like symptoms).
 Name of drugs Mechanism of Indication Side Nursing Responsibilities
action Effects/Adverse
Effect

Generic Name Stimulant laxatives Used to clean out the GI: Abdominal Instruct pt swallow tablets
Sennosides work by irritating intestine before a Pain, Diarrhea, whole, do not chew.
luminal sensory bowel Intestinal Mucosa
Brand Name nerve endings, examination/surgery. Pigmentation Inform that normal bowel
Senokot there by Sennosides are movements do not always
stimulating colonic known as stimulant. GU: Hematuria , occur daily.
Classification motility and albuminuria , urine
Laxatives reducing colonic metabolite Educate pt that do not use
water absorption. discoloration, in the presence of
Dosage The result Contraindication abdominal pain, nausea,
1 cap increased fluid Hypersensitivity Derma: vomiting.
accumulation in Gastrointestinal Prutitus ,
Route the colon and obstruction Uriticaria Advise pt the other possible
Oral laxative action. perforation means of avoid
Ulcerative Colitis Musculo: constipation.
Frequency Acute Intestinal Finger Clubbing,
Once a day Inflammation. Hypertrophic Instruct pt to take with full
osteoarthropathy glass of water and avoid
Timing straining with bowel
Hours of sleep movements.
 Name of drugs Mechanism of action Indication Side Nursing
Effects/Adverse Responsibilities
Effect
CNS: Before
Generic Name An essential mineral MV+FeSO4 is Seizures, dizziness, Monitor blood studies
Multivitamins + found in hemoglobin prescribed of Headache, syncope of patient
Ferrous Sulfate myoglobin and many postpartum patients Observe proper dosage
enzymes. Enters the to prevent the CV: of medication
Brand Name bloodstream and is occurrence of Hypotension, Note other drugs
Mulvitron transported to the pregnancy induced hypertension, patient is taking to
organs of the anemia and keep her tachycardia avoid possible
Classification reticuloendothelial nutritionally balanced. interactions
Water Soluble system (liver, spleen, GI: Verify the patient’s
vitamins, iron bone marrow) where Nausea, identity
supplements it separated out and constipation, dark
becomes part of iron stools, diarrhea, During
Dosage stores . vomiting Most effectively
1 cap absorbed if
Dermatologic: administered 1 or 2 hrs
Route Contraindication Flushing, urticaria before meal
Oral Take with a full glass of
Hemochromatosis, Respiratory: water/juice
Frequency Hemosiderosis or Cough, dyspnea Do not crush/chew
Once a day Other evidence of iron enteric-coated tablets.
Overload: anemias MS: Inform pt about
Timing not due to iron Arthralgia, myalgia dark,green or black
8:00 am deficiency . stools to aovoid panic

After
Monitor pt’s blood
studies
Inform pt about what
possible adverse effect
that may occur
Assess bowel functions
for
constipation/diarrhea
Document and record.
 NURSING CARE PLAN

Defining Nursing Scientific Goal of Care Intervention Rationale Evaluation

Characteristics Diagnosis Analysis

Subjective Acute Pain Acute Pain is After 8hrs of

Data: an nursing Assess patients To create a After 4 hours
“Sakit man unpleasant intervention vital signs. Ask baseline set of of nursing
gud kayo sensory and pt will be the patient to observations for interventions
akong bat-ang emotional able to; rate the pain the patient. The the patient
“ experience from 0 to 10, 10 point pint demonstrated
arising from Report pain is and describe pain scale is use of
Objective actual or relieved the pain she/ globally relaxation
Data: potential /controlled he is recognized pain skills and
10hrs PTL tissue with the pain experiencing rating tool that diversional
noted onset of damage. scale of 3/10 is both accurate activities as
crampy Sudden or from 9/10 and effective. indicated for
hypogastric slow onset of individual
pain radiating any intensity Verbalized Instruct the To reduce situation .
to lumbosacral from mild to method that patient to avoid abdominal
area severe with provide relief carbonated distention
an beverages and which can
Pain scale of 9 anticipated gas producing worsen pain
out 10 or food.
predictable
end and a Reposition To promote
duration of patient in her optimal patient
less than 6 comfortable/ comfort and
months. preferred reduce anxiety/
position. restlessness
Encourage
pursed lips
breathing and
deep breathing
exercises.

Provide comfort Alterations from

measures, quiet normal maybe
environment sign of
and calm infection.
activities.

Asses the To address the

patients patients
readiness to cognition and
learn, mental status
misconceptions, towards pain
and blocks to management
learning. and help the
patient
overcome
blocks to
learning.
Educate the
patient about To reduce stress
the non and promote
pharmalogical optimal pain
methods for relief without
acute pain such too much
as imagery, dependence on
distraction pharmalogical
techniques, and means.
recommended
exercise and
relaxation
techniques.

Create a daily
weight chart To effectively
and a food and monitor the
fluid chart. patients daily
nutritional
intake and
progress in
weight goal.
Administered
analgesics as To promote non
indicated to pharmacologica
maximum l
dosage as pain
needed. management.

Inform the
patient the
details about To inform the
the prescribed patient of each
medications to prescribed
treat acute drug and to
pain. Ask the ensure that the
patient to patient fully
repeat or understands the
demonstrate purpose,
the self- possible side
administration effects, adverse
details to you. events and self-
administration
Refer the details.
patient to the
dietitian. To provide a
more
specialized care
for the patient
in terms of
nutrition and
diet.
 Post- partal Discharge Plan

Medication Cefalexin (Canelin) 500 mg 1 cap TID P.O

Celecoxib (Coxto) 200mg 1 cap BID P.O
Senna (Senokot Forte) 1 cap OD HS
Moringa (Feralac) 1 cap BID P.O
MV+ Iron (Foralivit) 1 cap OD PO
Instruct patient to take medications on time with the right prescription of her doctor.

Follow up visit and Follow up after 1 week. Instruct patient to contact her healthcare provider in case of
when to report any abnormalities is observed.
immediately

Work Instruct patient to avoid to do heavy lifting of things that can cause straining at least 3
weeks. Encourage mother early ambulation which to promote blood circulation in the
lower extremities.

Diet Encourage mother to eat green leafy vegetables and increase water intake and high in
fiber such as orange, fish, papaya’s etc. to avoid constipation and avoid straining of the
affected part of the mother.

Rest Advise patient to have adequate rest to avoid fatigue, provide calm environment and
avoid strenuous activities.

Exercise Encourage mother to have proper exercise and meditate for calming of the mind and
body, advise also to have kegels exercise to strengthen the muscle of the affected part .

Hygiene Maintain proper hygiene using of pads change it as needed to avoid infection and 3x a
day of perineal washing from front to back to avoid UTI’s ( Urinary Tract Infection )
 Coitus Inform patient that it’s safe as soon as lochia turns to white (alba) and instruct them to
wait at least 6months for another conception.

Contraception Advice patient to use contraceptives before initiating coitus have a 2-3 weeks of
contraceptives pills after birth and it should not be delayed because it might cause her
from getting pregnant again.