Easter College

DEPARTMENT OF NURSING
Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483
E-mail: [email protected]
Website: www.eastercollege.ph

SECTION&GROUP: BSN-2C1
MEMBERS: MAGCALAS, TIZHA
OYAMA, NUELA
TAYNEC, JEZREEL
SAWATE, SHANNAH

MODULE : September 13-14, 2021 : 2C

Case Study for : NCM 107: CARE OF MOTHER, CHILD AND ADOLESCENT (well client)

INSTRUCTIONS:
Read the case of a patient whom you are to provide nursing care. Take time to analyze and process the
information provided, before answering the activities following each section of your module.
For you to conduct all the requirements for this rotation, we shall follow the schedule below:

Online:
Day 1: 8 AM: Zoom meeting to discuss about the labor process and orientation of the case study
Day 2: 8 AM: Processing of NCP ; 5PM – rotational exam (30 points)

ENDORSEMENT:
Situation: You are on duty at 7-3 shift assigned to Patient Mrs. Dinah L. Ligo at the OB Ward. During
the endorsement, the following data were provided:
o Patient Ligo was admitted at bed #2, G1P0 (1-0-0-0) 39 weeks of gestation
o D5LRS 1L x 16 hours is being infused to your patient. The current level was at 300ml.
o Patient is on DAT diet
o Meds: HNBB 10 mg Oral 1 tab q 1hr; 4pm – patient was given 10 units Oxytocin IM (STAT
order)
● VS: BP – 120/70; PR – 106; RR – 21; Temp – 36.7; SpO2 – 94%; FHT – 141;

HISTORY:
09/14/2021 – 8:40am - Mrs. Dinah L. Ligo, a 29 years old G1P0 (1-0-0-0) mother 39 weeks age of gestation was
brought to the Emergency Room at Baguio General Hospital with chief complaints of active labor pains occurring
every 15 minutes interval. Triage done by ER nurse on duty with hospital number given as O235438. Initial vital
signs taken as follows: BP - 120/80, PR - 106, RR - 22, Temp. 36.5, FHT - 138, SPO2 -92%, weight 62kgs.
Ushered to OB - ER cubicle per wheelchair. Seen and examined by Resident on duty Dr. Pee with dark line
noted in the abdomen, 38cm Fundic height measures from the symphysis pubis to the xyphoid process. Internal
examination revealing 6 cm dilatation of the cervix and 70% effaced. Bag of water still intact, no bleeding and no muscle
cramps. Dr. Pee ordered to admit to labor room to OB ward bed #2 and to secure consent for admission. Intravenous fluid to
insert 1L D5LRS to run for 16 hours, for CBC and urinalysis. Check FHT every 30 minutes. Oral medication to start HNBB 10mg
1 tablet every hour.
At 4pm - since there is a delay in the progress of labor, the OB-Gynecologist, ordered administration of Oxytocin 10
units, IM with BP precautions and monitoring of uterine contractions and advice the nurse to do perineal care PRN before
internal examination

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ACTIVITY 1:
Medical History Chart: based on the case study given, fill in each blank with the corresponding information required.

SAMPLE MEDICAL HISTORY FORM

PATIENT FIRST NAME: Dinah LAST NAME: Ligo

VITALS:

BP: 120/80 T: 36.7 HR/PR: 106 RR: 21 Gravida Para: G1P0 (1-0-0-0) AOG: 39 weeks

CHIEF COMPLAINTS: Active labor pains occurring every 15

minutes interval

PAST MEDICAL HISTORY:

 G1P0 (1-0-0-0)

MEDICATIONS ADMINISTERED:
 HNBB 10 mg Oral 1 tab q 1hr
 4pm – patient was given 10 units Oxytocin IM (STAT order)

ACTIVITY 2:
PHYSICAL EXAMINATION & REVIEW OF SYSTEMS
- Results of the 13 areas of assessment - fill all areas to review HA, positive and negative data )
General Survey Appears in pain, weak, pale, grimacing while holding her abdomen. Patient is awake,
conscious. Appears to be in appropriate and chronological age. The patient is oriented to
three spheres. Complains of active labor pains.

Skin Cold and clammy skin, pale in appearance, good skin turgor, no rashes or any
dermatological conditions.

Head, Eyes, Ears, Nose, Throat Eyes: extraocular motions full, gross visual fields full to confrontation, pale conjunctiva,
sclera non-icteric, pupils’ equal round and reactive to light and accommodation
(PERRLA), fundi is well visualized. No blurring of vision.

Ears: Hearing is normal bilaterally. Tympanic membrane landmarks well visualized.

Nose: No discharge, no obstruction, septum not deviated.

Throat: No dentures noted. Pharynx not injected, no exudates. Uvula moves up in midline.
Normal gag reflex.

Neck Neck supple but thin; no cervical lymphadenopathy, thyromegaly, masses, and carotid
bruits. No jugular vein distention.

Breast Rounded, unequal in size, and asymmetric. Nontender or discharges. No lumps noted.

Respiratory Normal chest shape, RR = 21 cpm, No shortness of breathing. Bilateral vesicular breath
sounds on both lung fields. Symmetrical chest expansion. SPO2: 94% at room air. No
dullness to percussion. No history of upper respiratory tract illness.

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 Cardiovascular No murmurs, no lifts, no heaves. BP: 120/80; PR: 106 bpm. No cardiovascular disorder
indicated. With no episodes of chest pain prior to admission.

Gastrointestinal No bowel movement and vomitus during the shift. No past and present gastrointestinal
disease stated.

Urinary Voided amounting to 90 mL for the whole shift. Without fever, no hematuria, and no
dysuria. No urinary disorder stated.

Genital With dark line noted in the abdomen, 38cm. Fundic height measures from the symphysis
pubis to the xyphoid process. Internal examination revealing 6 cm dilatation of the cervix
and 70% effaced. Bag of water still intact, no bleeding and no muscle cramps. Vagina,
clitoris, and labia are normal. No enlargement or tenderness in inguinal lymph nodes. No
history of sexually transmitted disease. Denies reproductive health disorders.

Peripheral / Vascular Skin cold, clammy and smooth. No clubbing nor cyanosis. No history of claudication,
gangrene, deep vein thrombosis, aneurysm. Capillary refill = 1-2 seconds.

Musculoskeletal Strength not tested; patient moves all extremities. No known musculoskeletal disorders.

Neurologic Awake and alert. Cranial nerves I-XII intact. Sensory: Grossly normal to touch and pin
prick. Cerebellar: no tremor nor dysmetria. Reflexes symmetrical 1+ throughout, no
Babinski sign. There is no history of seizures, syncope, stroke, and memory changes.

Hematologic No known blood or clotting disorders. CBC: to follow.

Endocrine No known diabetes or thyroid disease

Psychiatric Denies history of anxiety, depression, and other mental disorders.

ACTIVITY 3: DIAGNOSTIC STUDIES

PRESCRIBED THERAPEUTIC (MEDICAL/SURGICAL) MANAGEMENT, AND HEALTH PROMOTION PROGRAMS

LABORATORY TEST
Lab test Lab Result Normal values Interpretation Purpose of the Lab test
1. Complete
Blood Count RBC: 4.44 10^6/ul RBC: Female: 4.2- Normal Complete Blood count identifies
(CBC) Hgb: 13.7 g/dl 5.4 million cells/mcL; the total number of blood cells
Hct: 39 % Hgb :Female: 12-16 such as WBCs, RBCs, and
WBC: 10000 10^3/ul g/dL; Hct: Female: platelets as well as hemoglobin,
36-44%; WBC: hematocrit (the percentage of
3,500-10,500 blood consisting of RBCs), and
cells/mcL RBC indices. This is to detect
whether there are current
infection, anemia, and other
blood related diseases.
2. Urinalysis
Color- pale yellow Color – Yellow Normal The urinalysis tests for sugar,
Clarity/ turbidity- cloudy (light/pale to No urinary protein, ketones, bacteria, and
pH- 4 dark/deep amber) infections blood cells to make sure you
Protein: Negative 97 Clarity/turbidity – don't have a condition such as a

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 Glucose: 0.5gm Negative Clear or cloudy. UTI, gestational diabetes, or
pH – 4.5-8. preeclampsia
Protein: 100n
negative
Glucose:<0.5gm
Negative

PROCEDURES PURPOSE OF
DONE: PROCEDURES:

1. Perineal Care An episiotomy is an incision

(cut) that caregivers may
make between the vagina and
the anus to prevent tearing
during delivery. The incision is
sewn back together right after
your baby's birth. Perineal
care will help your perineum
heal faster, feel better, and
help prevent infection.
2. Monitoring of
Uterine Uterine monitoring is based
Contractions on the idea that the frequency
of contractions per hour
increases as a woman gets
closer to delivery. As labor
progresses, contractions get
longer, harder, and stronger.
If the machine measures four
or less contractions per hour,
you're probably not in labor.
3. FHT every 30
minutes Fetal heart rate monitoring
may help detect changes in
the normal heart rate pattern
during labor. If certain
changes are detected, steps
can be taken to help treat the
underlying problem. Fetal
heart rate monitoring also can
help prevent treatments that
are not needed.

REFERENCES Martin, P. (2021, July 17). Retrieved September 14, 2021 from Nurselabs:
https://nurseslabs.com/normal-lab-values-nclex-nursing/

Postpartum Perineal Care (2021, September 8). Retrieved September 14, 2021 from
https://www.drugs.com/cg/postpartum-perineal-care-aftercare-instructions.html

Healthline Editorial Team (2018, December 11). Retrieved September 14, 2021 from
https://www.healthline.com/health/pregnancy/preterm-labor-monitoring-contractions

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COURSE IN THE WARD:
MEDICAL/SURGICAL DIAGNOSIS: Normal Spontaneous Delivery (NSD) (ANALYSIS)

ACTIVITY 4: Read about your patient’s diagnosis using your textbook (Maternal/ Child Health Nursing specify). Focus
on the description of the disease, the etiology or cause, what are the signs and symptoms and why do they occur,
what are the recommended interventions and nursing interventions. Digest the information that you have obtained.
Take time to process and analyze them. Once you are ready, in 500 words or briefly answer the following questions.

Description : Normal Etiology S/Sx (book) S/Sx (patient) Intervention

Spontaneous Delivery
(NSD)
Normal spontaneous When the labor occurs it is  Lightening-baby  Contraction/labor  Provide use of
delivery is the most now the start of the process head descends pain having an comfort to the
common childbirth world of normal spontaneous deeper into the interval of 15 patient by giving
wide. This type of delivery. Labor usually pelvis minutes back/leg rubs
delivery of a mother in begins with the passing of a  Increase in urge to  Taken from  Assess the client
giving birth a child is a woman’s mucous plug. urinate patient 6cm to reposition to
vaginal/natural delivery Wherein as the labor  Cervix dilate dilation 70%
more comfortable
that happens on its own, progresses, strong  Thinning of cervix effaced.
position to at least
without requiring doctors contractions help push the  Back pain lessen the pain
to use tools to help pull baby into the birth canal.  Contractions
the baby out. This occurs This are the 3 stages and
after a pregnant woman signals that SND about to
or the mother goes occur:
through labor or stages
1) Contractions soften and
of labor. During the labor
dilate the cervix until it’s
it opens, or dilates, the
flexible and wide enough for
mother's cervix to at least
the baby to exit the mother’s
10 centimeters.
uterus.
2) The mother must push to
move her baby down her
birth canal until it’s born.
3) The mother pushes out
her placenta, the organ
connecting the mother and
the baby through the
umbilical cord and providing
nutrition and oxygen.

Reference: Cirino, E. (2017, June 4). Spontaneous Vaginal Delivery. Retrieved September 14, 2021 from
Healthline: https://www.healthline.com/health/pregnancy/spontaneous-vaginal-delivery?
fbclid=IwAR2KXjYIo7diBN2EX04gh-wraKvcPPSChapSizG9Pymp3KUifnIwnjGmn1Q

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Activity 5: After reading your textbook or notes on pharmacology and/or obstetric book, answer what are asked on the following
table.

IV THERAPY:

Compute:
D5LRS 1L x 16hrs
COMPUTE: A. HOW MANY DROPS PER MINUTE
1000 ml x 20 gtts
16 hrs x 60 mins

1000 ml x 20 gtts = 20.83~21 drops/minute

960mins

B. HOW MANY ML PER HOUR

1000 ml = 62.5~63 ml/hr
16 hrs

MEDICATIONS

DRUGS Drug classification Health teaching (s/e, management of adverse reaction)

1. HNBB 10 mg Oral 1 tab Antispasmodics 

Substantially reduce period of labor by increasing
q 1hr cervical dilation without causing severe adverse effects.
 Buscopan's action mechanism consists of blocking the
smooth muscle walls' neurotransmission, which means
its blocking of acetylcholine's activity in the receptors in
the digestive and urinary muscle and thus of reducing
spasms and contractions. This relieves the muscles
and reduces the discomfort caused by cramps and
spasms.
2. Oxytocin Oxytocic hormones  During childbirth, oxytocin injections are used to initiate
 4pm – patient was or enhance contractions. Oxytocin can also be used to
given 10 units Oxytocin decrease postpartum haemorrhage.
IM (STAT order)  Oxytocin injection can lead to serious side effects such
as rash, itching, hives, difficulty in breathing, unusual
bleeding, dysuria, swelling of face, legs and throat.
 Nursing intervention:
o Monitor for symptoms of fetal discomfort or
asphyxia, such as reduced heart rate, rhythm,
meconium discharge, or fetal movement
decreases or missing. Report these indications
promptly to the doctor or nursing staff.
o Periodically evaluate maternal blood pressure
and compare with normal readings. Monitor low
blood pressure (hypotension), particularly if the
patient have dizziness, tiredness, etc.
REFERENCES: Hyoscine (2017, November). Retrieved September 14, 20201 from
https://www.medicinesinpregnancy.org/Medicine--pregnancy/Hyoscine/

Hyoscine Butyl Bromide for Management of Prolonged Labor (2017, March 10).
Retrieved September 14, 2021 from National Library of Medicine:
https://clinicaltrials.gov/ct2/show/NCT01854073

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 Oxytocin injection (2016, November 15). Retrieved September 14, 2021 from
National Library of Medicine:
https://medlineplus.gov/druginfo/meds/a682685.html
Oxytocin (n.d.). Retrieved September 15, 2021 from
https://fadavispt.mhmedical.com/content.aspx?
bookid=1873&sectionid=139021017

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 ACTIVITY 6: Applying the nursing process, integrate all the significant findings obtained in the analysis of the case and formulate a nursing care plan for your patient.
Use the given table/format presented.

DATA GOALS/ Expected ACTION/Nursing intervention Rationale RESPONSE/

Outcomes
Evaluation

Subjective Findings: STG: Within an hour of NI Dxtc: Dxtc: STG: fully MET,
the patient will be able to:  The use of charts or drawings within 1 hour of NI
 Pain scale of 8-10 Describe satisfactory pain  Assess for the location of the of the body organs can help the patient was able:
as verbalized by the control at a pain scale level of pain by asking to point to the the patient, and the nurse
patient site that is discomforting determines specific pain Describe satisfactory
2 or 3 and able to engage in
 “masakit tiyan ko  Assess client’s perception of locations.  pain control at a pain
non-pharmacologic measures
every 15 minutes” pain  Client’s perception of and scale level of 2 or 3
to reduce discomfort/pain.
as verbalized by the  Assess the patient’s expression of pain are and able to engage in
patient As manifested/evidenced willingness or ability to influenced by underlying non-pharmacologic
by:  explore a range of problem causing pain, measures to reduce
Objective Findings: techniques to control pain cognitive, and behavioural discomfort/pain.
 Changes in facial and sociocultural factors.
Vital signs are as Txc:
expression As
follows:
 (-) irritability Txc: manifested/evidence
 (-) guarding behaviour  Perform a comprehensive d by: 
 Patient is assessment of pain each
 At ease position  The patient experiencing pain
complaining of time pain occurs. Determine is the most reliable source of  Changes in
active pain labor the location, characteristics, information about their pain. facial expression
occurring 15 onset, duration, frequency,
LTG: Within 1-2 days of NI Thus, assessment of pain by  Non-irritability
minutes interval quality, and severity of pain
the patient will be able to: conducting an interview helps  Cooperative
 (+) facial grimaces via assessment. the nurse in planning optimal behaviour
 (+) guarding Demonstrate use of relaxation  Provide measures to relieve pain management strategies.
behaviour skills and diversional by encouraging the client to  Use pain rating scale
 Irritability and LTG: partially MET,
activities, as indicated, for move slowly or gradual appropriate for age and
tiredness after 3 days of NI the
individual movement. cognition.
 Irritability patient was able:
 Evaluate pain characteristics  Nonpharmacologic methods
As manifested by: and intensity in pain management may Demonstrate use of
Vital signs are as  Provide non- include physical, cognitive-
follows:  Demonstrate proper relaxation skills and
pharmacological pain behavioral strategies, and diversional activities,
 Respirations are 21 breathing exercise management lifestyle pain management.
per minute  Improvement in mood, as indicated, for
 BP is 120/70, Pulse coping mechanism individual
Edx: Edx:
rate is 106 beats per  Ability to perform least
As manifested by:
minute movements   Teach collaborative  Pain medications may include

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 Temperature is  Demonstrate positioning approach for pain patient-controlled analgesia or  Demonstrate
36.7°C. to ease the pain. management based on regional analgesia based on proper breathing
 FHT of 141 client’s understanding about client’s symptomatology and exercise
 SpO2 94% and acceptance of available mechanism of pain as well as  Improvement in
 Weight of 62kgs treatment options tolerance for pain and various mood, coping
analgesics. mechanism
FOCUS/Nursing  Ability to perform
Diagnosis (PE/S): least
movements 
Labor Pain related to  Demonstrate
progressive uterine positioning to
contraction ease the pain.

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COLLABORATION
Activity 7: As a future nurse you should be able to work with your co-nurses and other health care professionals and form a
team sharing knowledge and resources to solve or provide patient care.
 Concepts: referral to primary health care provider to rule out CS or continue with normal delivery of the baby.
 Ex of scenario: Normally, contractions become more frequent, intense and longer as labor progresses, but after
administering oxytocin and HNBB, the contractions becomes less frequent, less intense and shorter in duration. WHAT IS
YOUR RESPONSIBILITY AS A NURSE?

 Explain to the mother what is the purpose of administering HNBB and oxytocin injection in order for the mother to
comprehend and cooperate and also verbalize if there are any side effects of the medicine/drug to her system.

 Assess her vital signs and FHT to have a baseline data in monitoring the progress of labor or any deviation.

 Refer to medical professionals for any deviation from the normal vital signs and expected progress of labor for
possible CS procedure.

ETHICO-MORAL-LEGAL CONCERNS
Activity 8: These principles concern the ethics of caring rather than 'curing' by exploring the everyday interaction between you
as a nurse and the person in your care.
 Concepts: justice, beneficence, nonmaleficence and autonomy
 Example Scenario: Given the numbers of patients that are under your care in the OB ward, some patients can be
annoying and difficult to handle due to their current situation and the pain that they are going through. The nurse decided
to be nicer to other patients who are much nicer than those who are not. What do you think should have been the Nurse’s
reaction?

 The nurse should treat all her patients nicely no matter how they behave because according to the ethical principle
“justice”, as a health provider we need to deliver quality care to our patients equally even if it upsets you. We take
into consideration their present situation as needing care and we are the caregivers who should be the one
understanding them always. Moreover, according to the concept of beneficence doing good for the benefit of our
client and treating well our patients foster and build trust in patient-nurse relationship.

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ACTIVITY 9:
Incorporating all the data that had been presented to you and your readings:
 create a concept map or table on the pathophysiology of the patient’s disease/condition.
 Incorporate the risk factors present in your patient based on his/her history,
 the signs and symptoms presented by your patient as shown on his/her PE and ROS,
 the lab results provided by the various diagnostic exams.
Group all cues together showing how you were able to arrive to a certain nursing diagnosis/es.
 Lastly, include the various medications and or procedures that were given to your patient placing them on their right places
at the map.

CONCEPT TABLE

RISK FACTORS:
SIGNS and SYPMTOMS:
39 weeks AOG, 6 cm cervical
dilation, 38 cm fundic height, Labor pains occurring every 15
70% cervical effacement minutes, uterine contractions,

NORMAL
DELIVERY

LAB RESULTS:
MEDICATION AND OR
Complete Blood Count (CBC) PROCEDURE:
RBC: 3.1-4.44 10^6/ul
Hgb: 9.8-13.7 g/dl MEDICATIONS:
Hct: 28-39 %
HNBB 10 mg Oral 1 tab q 1hr, 10
WBC: 5000- 13000 10^3/ul
units Oxytocin IM (STAT order),
Urinalysis PROCEDURES:
Color: pale yellow
Clarity/turbidity: cloudy Perineal Care, Monitoring of Uterine
pH: 6 Contractions, FHT every 30 minutes
NURSING
DIAGNOSIS:
Labor pain related to labor
and uterine contractions

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Reference: Textbooks /Online resources allowed but should not come from blogs, Wikipedia,

COMMUNICATION
Activity 10: Your shift is about to end, using ISBAR (a patient safety communication structure that aids simplified, effective, structured and anticipated communication between healthcare
personnel). Fill in your end of shift report to help guide the incoming student nurse.

F (FOCUS Nsg Dx) D (DATA) A (ACTION) R (RESPONSE)

Labor pain related to progressive  “masakit tiyan ko every 15 Dx:

uterine contraction minutes” as verbalized by the Patient will demonstrate proper breathing
 Assess for the location of the pain by asking to exercise and have the ability to perform
patient.
point to the site that is discomforting. least movements.
 Pain scale of 8-10 as verbalized  Assess client’s perception of pain
by the patient  Assess the patient’s willingness or ability Demonstrate use of relaxation skills and
 Patient is complaining of active to explore a range of techniques to control pain. diversional activities.
pain labor occurring 15 minutes
interval Tx: Describe satisfactory pain control at a
 (+) facial grimaces pain scale level of 2 or 3
 Perform a comprehensive assessment of
 (+) guarding behaviour
pain each time pain occurs. Determine the Demonstrate positioning to ease the
 Irritability and tiredness location, characteristics, onset, duration, pain.
 Positioning to ease pain frequency, quality, and severity of pain via
assessment.
Vital signs are as follows:  Provide measures to relieve by
 Respirations are 21per minute encouraging the client to move slowly or
 BP is 120/70 gradual movement.
 Evaluate pain characteristics and intensity
 PR is 106 bpm
 Provide non-pharmacological pain
 Temperature: 36.7 management.
 FHT of 141
 SpO2 of 94% Edx:
 Weights of 62 kgs.
 Teach collaborative approach for pain
management based on client’s understanding
about and acceptance of available treatment
options.

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Prepared by:

Jennifer D. Feliciano
Clinical Instructor

Noted by:

Brando Badecao, RN, MAN

Clinical Coordinator

John Michael P. Jarata

DEAN- EC-DON

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