DDDD

REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
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CENTER OF NURSING
A CASE OF AN 18-YEAR OLD G1P0 WOMAN WHO UNDERWENT NSD DUE TO PREMATURE
RUPTURE OF MEMBRANE
A Case Study Presented to the Faculty of Center of Nursing -

College of Allied and Health Studies -
University of Makati
In Partial Fulfillment of the Requirements for

Related Learning Experience in
Care of Mother, Child, Adolescent
(Well Clients)
Submitted by:
Group 4
Macabinta. Nor Ashya

Manzano, Rizza Mae
Marasigan, Pamela Joyce
Matias, Dysheree
Operaña, John
Submitted to:
Prof. Rochel Klath, RN. MAN
DECEMBER 4, 2021
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CENTER OF NURSING
TABLE OF CONTENTS
I. INTRODUCTION
II. OBJECTIVES
III. NURSING HISTORY
IV. GORDON’S FUNCTIONAL HEALTH PATTERN
V. REVIEW OF SYSTEM
VI. PHYSICAL ASSESSMENT
VII. COURSE IN THE WARD
VIII. DIAGNOSTICS AND LABORATORY RESULTS
IX. DIFFERENTIAL DIAGNOSIS
X. ANATOMY AND PHYSIOLOGY
XI. SURGICAL MANAGEMENT
XII. MEDICAL MANAGEMENT
XIII. CONCEPT MAP AND NURSING CARE PLAN
XIV. THEORETICAL FRAMEWORK
XV. NON-PHARMACOLOGIC MANAGEMENT
XVI. PATHOPHYSIOLOGY
XVII. DISCHARGE PLAN
XVIII. EVALUATION
XIX. REFERENCES
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I. INTRODUCTION
According to the National Institute of Child Health and Human Development (2017), the period during
which a fetus grows inside a woman's womb or uterus is referred to as pregnancy. From the last menstrual
cycle through delivery, a pregnancy normally lasts around 40 weeks, or slightly over 9 months. Trimesters
are the terms used by doctors to describe the three stages of pregnancy.
In addition, MentalHealth.net (n.d.) claimed that pregnancy is a unique, exciting, and frequently joyful
moment in a woman's life, as it displays the woman's incredibly creative and caring abilities while also
bridging the gap between the present and the future. Pregnancy comes at a price, but a pregnant woman
must also be a responsible woman in order to best support her future child's health. For all of its needs, the
growing fetus (the word used to identify the baby-to-be throughout early developmental stages) is completely
reliant on its mother's healthy body. As a result, pregnant women must make every effort to be as healthy
and well-nourished as possible.
This is a case study of Mrs. Montecarlos, who is an 18-year-old mother with a GP score of G1P1
who delivered a healthy baby girl at 35 weeks AOG, through Normal Spontaneous Delivery. She was
admitted to Ospital ng Makati last January 27, 2021, at 9:13 am due to pain in her lower abdomen.
As claimed by the University of Rochester Medical Center (n.d.), a pregnancy complication is preterm
premature rupture of the membranes (PPROM). The sac (amniotic membrane) enclosing your baby splits
(ruptures) before week 37 of pregnancy with this disorder. When the sac ruptures, you're more likely to
become infected. You're also more likely to have a baby that is born prematurely.
Moreover, Medina & Hill (2006) said that the rupture of membranes before 37 weeks of pregnancy
is known as preterm premature rupture of membranes. It affects 3% of pregnancies and accounts for one-
third of all premature births. Significant prenatal morbidity, such as respiratory distress syndrome, newborn
infection, umbilical cord prolapse, placental abruption, and fetal mortality, can result. Improved newborn
outcomes need appropriate evaluation and care. Because the digital examination is linked with a shorter
latent time and the risk of undesirable consequences, speculum examination is chosen to evaluate cervical
dilatation. When rupture of membranes occurs at or after 34 weeks of pregnancy, treatment varies based on
gestational age and may entail delivery. Many newborn problems, including intraventricular hemorrhage and
respiratory distress syndrome, can be reduced with corticosteroids, and antibiotics can be used to extend the
latency period.
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Based on March of Dimes (2018), Labor (commonly known as childbirth) is the process through
which your baby emerges from the uterus (womb). When you have regular contractions that force your
cervix to alter, you're in labor. The muscles of your uterus contract and then relax during contractions.
Contractions aid in the expulsion of your baby from your uterus. The cervix, which sits at the top of the vagina
is the entryway to the uterus. Your cervix dilates as labor begins (opens up). However, these are the signs
of labor; (a) You have strong and regular contractions. A contraction occurs when the muscles of your
uterus contract and then release like a fist. Contractions aid in the delivery of your baby. When you're in full-
blown labor, contractions last 30 to 70 seconds and happen every 5 to 10 minutes. You can't walk or talk
during them because they're so powerful. Over time, they grow stronger and closer together; (b) You feel
pain in your belly and lower back. This pain doesn't go away when you move or change positions; (c) You
have a bloody (brownish or reddish) mucus discharge. This is called a bloody show; (d) Your water
breaks. In your uterus, your baby has been developing amniotic fluid (the bag of waters). You may notice a
large surge of water if the water bag bursts. You might only feel a trickle. In addition, these are the signs that
the mother may be close to starting labor; (a) Your baby drops or moves lower into your pelvis. This is
referred to as lightning. It indicates that your baby is preparing to give birth by moving into position. It might
happen a few weeks or even hours before your labor starts; (b) You have an increase in vaginal discharge
that’s clear, pink, or slightly bloody. This is referred to as a show or a bloody show. It might happen a few
days before labor begins or right at the start; (c) At a prenatal checkup, your health care provider tells
you that your cervix has begun to efface (thin) and dilate (open). Your cervix is usually 3.5 to 4 cm long
before childbirth. It's 10 centimeters when completely dilated (open) for labor. Contractions assist open your
cervix once labor begins; (d) You have the nesting instinct. This is when you want to get things organized
in your home to get ready for your baby. You may want to do things like cook meals or get the baby’s clothes
and room ready. Doing these things is fine as long as you’re careful not to overdo them. You need your
energy for labor and birth.
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II. OBJECTIVES
General Objective:
This case study seeks to increase knowledge, improve skills, and understand the patient's
perspective, particularly for nursing students who may be involved in this type of delivery. To offer the
essential nursing care and intervention for a patient with a Premature Rupture of Membrane's well-being
(PROM). We'd have to figure out what nursing difficulties there are, as well as the nursing considerations and
managements that go along with them, in order to promote and maintain the patient's health.
Specific Objectives:
a. Knowledge
● To discuss the pathophysiology of the client's condition.
● To understand the underlying causes of PROM and identify any possible complications.
● To be familiar with the necessary assessments for Premature Rupture of Membrane
(PROM).
● To acquire knowledge regarding the client’s medication and analyze its classifications,
indications, side effects, mode of action, and nursing considerations that should be
observed.
b. Skills
● To formulate a nursing diagnosis, a nursing care plan, and use clinical judgment to set goals.
● To provide quality nursing care and proper interventions for Premature Rupture of
Membrane
● Administer correct medications as ordered and according to client's condition
● To educate the client and give appropriate health teaching to enhance well-being and
prevent further complications.
c. Attitude
● To utilize communication skills to obtain information about the client such as demographic
profile, past medical, psychosocial history and their family as well.
● To build rapport with the client and her significant other to promote trust and a good nurse-
patient interaction.
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III. NURSING HISTORY
Name of Patient: Carmelita Montecarlos

Address: Blk. 88 Lot 9 Amorseco St., West Rembo, Makati City.
Age: 18 y/o
Birthdate: October 28, 2002
Gender: Female
Height: 162.56 cm
Weight: 54 kg
BMI: 20.3 (Normal Weight)
Nationality: Filipino
Religion: Catholic
Civil Status: Married
Date of Admission: January 27, 2021
Hospital: Ospital ng Makati
Informant: Juanito Alfonso (Patient’s husband)
Chief Complaint (CC): Pain in the lower abdomen
Admitting Diagnosis: Premature Rupture of Membrane
Present Illness:
As reported by the patient, she began experiencing discomfort in her lower abdomen on January 23,
2021, and it extended from the lower abdomen to the lumbar area. She was 35 weeks pregnant when she
was admitted to the hospital at 6 a.m. She gave birth to a baby girl at 9:13 a.m. after being admitted to the
delivery room for a Normal Spontaneous Delivery (NSD). She is a primigravida, or G1P0.
Past Illness:
The patient claimed to have had all of her childhood vaccinations, including BGC, DTap, Measles,
MMR, Hepatitis B, Varicella, and Polio. She had her first menstrual cycle when she was in the sixth or twelfth
grade. Although she cannot recall when she had her first dosage of tetanus toxoid, she can recall receiving
her second dose on January 18, 2021. She mentioned that she visits the center on a regular basis for her
monthly check-up. Her water bag broke on January 23, 2021, and she went to the barangay center, where
she was told it was a natural occurrence. When she felt discomfort in her lower abdomen on January 27,
2021, she decided to go to the OB Emergency Room at the Ospital ng Makati (OSMak).
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IV. GORDON’S FUNCTIONAL HEALTH PATTERN
Functional Health Prior to During Hospitalization Interpretation and

Pattern Hospitalization Analysis
I. Health Perception The patient sees herself The patient is confident There are no changes
Health Management as a healthy individual that she is healthy with regards to the
Pattern as she rarely has illness despite being in pain as patient’s attitude
and is always able to she was able to deliver towards her health.
manage her problems her baby normally and
preventing stress. She without any
also prefers consuming complication. And she is
fresh and healthy foods eating normally hoping
and she doesn’t engage to regain strength.
in any vices.
Furthermore, she
doesn’t fail to visit their
barangay hall for her
prenatal check-ups.
II. Nutritional and The patient’s diet The patient experienced Prior to hospitalization,
Metabolic Pattern consists of nutritious decreased appetite due the patient is already
vegetables and fruits to her recent delivery conscious with her diet
and a balanced amount however she is and consumes healthy
of calories. She drinks determined and hoping foods and it continues
7-8 glasses of water a to regain her strength until now that she gave
day. She sometimes that’s why she eats her birth.
consumes fast food and food and is trying to
sweets but only in the return slowly to her
right amount. usual diet.
III. Elimination Pattern Bowel: Bowel: Bowel: The frequency

and volume of bowel
The patient defecates 1- The patient defecates movements have
2 times each day, most once every day, most changed.
often in the morning and often in the afternoon.
afternoon. The stool is The stool is either well- Bladder: The frequency
well-formed and brown formed and soft, and and volume of urination
in hue. brown in hue. have changed
Bladder: Bladder:
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Patients urinate 6-8 Patients urinate 2-4

times each day. Urine is times each day. Urine is
a light yellow hue. When a light yellow hue. When
voiding, there is no voiding, there’s still no
discomfort. discomfort.
IV. Activity and Because the patient is a In the hospital, patients' During the entire
Exercise Pattern stay-at-home mother, activities include admission of the patient
she is constantly in ambulation, deep to the hospital, her daily
control of domestic breathing and coughing routines are restricted
responsibilities. exercises, bathing, and and her leisure and
Watching her favorite personal hygiene. recreation activities are
television and baking disrupted.
pastries would be two of The patient reports no
her favorite pastimes. history of Dyspnea or
fatigue.
V. Sleep-Rest Pattern The patient stated that During the patient’s stay The patient's sleep and
she was able to sleep for in the hospital, she had rest patterns changed
enough time as her trouble sleeping after she was admitted
husband provides a because of perineal pain to the hospital. Due to
peaceful and quiet due to labor and her current state, she is
environment for her delivery. unable to sleep, and
while she’s asleep pain and discomfort are
the key causes of her
sleep troubles.
VI. Cognitive - Patient has completed During the times of her There are no changes
Perceptual Pattern high school. She is able confinement, she still or alterations.
to read and write. She is manages to
able to communicate communicate with the
and be understood by nurses despite the pain
others. she is enduring.
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VII. Self-Perception Patient is a cheerful Though in pain, the Although the patient had
Self-Concept Pattern individual who is kind patient still manages to been in pain and
and easy to get along appear calm and difficulties due to her
with. She enjoys positive about her new recent labor, this does
spending time with both role as a mother. not appear to detract
her friend and her family. from her general feeling
She considers herself to of physical wellbeing.
be a whole person as
long as she is well,
complete, and
surrounded by her
family.
VIII. Role - The patient is a married The patient's family is There are no
Relationship Pattern woman. She is currently supportive of her. She alterations.
residing in Makati appreciates their
together with her presence and
husband. She views her assistance. The patient
primary role at this stage mentioned that she and
of her life as being a wife her spouse and parents
and a future mother. were really close.
She has close They are now taking
relationships with her turns caring for her while
parents and despite she is in the hospital.
living far apart, they Her friends came to see
have managed to her once to catch up and
maintain good harmony cheer her up for being a
between all of their new mother.
family members. She
has little spare time to
socialize with friends.
IX. Sexuality - The patient stated that The patient is concerned The patient is having an
Reproductive she is sexually active. with sexual intercourse anxiety of conceiving
The patient had her because of her again because of the
menarche at 13 years condition. She is difficult experience of
old and usually somehow afraid of birth
experiences cramps and conceiving a child again
headaches the week because of what she’d
before her cycle. She is been through in giving
currently in her first birth.
pregnancy.
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X. Coping - Stress The patient stated that According to the patient, The patient remains
Tolerance Pattern when she is stressed, Her recent health positive, stating that
she usually has a condition made her a having his husband by
conversation with her little bit stressed but her side helps her cope
husband as he was her again her husband is her by providing support.
primary support. She primary means of
also engages in support during this time.
activities to relieve
stress like playing piano
and eating ice cream
while having a walk.
XI. Value - Belief Patient claimed that God The patient said that a She stated that this is
Pattern is her source of strength relationship with God is just a challenge to her
and meaning very essential and with life and she will get
her present condition through it with God’s
and with the previous grace.
decisions that she made,
she feels like she needs
to consult and
communicate well to
God. She is faithful to
God so she knows that
she will overcome what
she is experiencing right
now.
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V. REVIEW OF SYSTEM
System Subjective and Objective Cues Interpretation and Analysis
Mons pubis Subjective: Normal

“Noong hindi pa ako buntis once
every two weeks ako nagshi- Expected:
shave” Skin is smooth and Clean.
Regularly distributed female
Objective: pubic hair.
No rashes, lesions, or lice are
present
Skin smooth and clean
Pubic hair is regularly distributed
Labia majora Subjective: Normal

“Medyo uncomfortable ako banda
sa ari ko dahil bagong paanak Expected:
ako, medyo mahapdi. Vagial and labial soreness should
resolve within a few weeks after
Objective: the NSD.
Soreness and minimal redness
No rashes, lesions, or tears
Symmetrical
Labia minora Subjective: Normal

“Medyo uncomfortable ako banda
sa ari ko dahil bagong paanak Expected:
ako, medyo mahapdi.
During labor and delivery, you
Objective: may have vaginal tears, and the
Soreness, stretched, tears, and labia minora (but not majora) may
minimal redness stretch or tear somewhat. Tears in
the vaginal and labial areas
No rashes normally heal in seven to ten
days.
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Vagial and labial soreness should
resolve within a few weeks after
the NSD.
Clitoris Subjective: Normal

“Wala naman ako naramdam na
pagbabago” Expected:
Length 2 cm or less; diameter 0.5
Objective: cm.
Not enlarged
No enlargement, atrophy,
No abrasion and swelling inflammation, or adhesions.
Length: 1 cm
Diameter: 0.5 cm
Urethral orifice Subjective: Normal

“Mahapdi kapag umiihi ako”
Expected:
Objective: Shortly after giving birth, it's not
unusual to experience
Swollen constipation or difficulty urinating.
For the following several weeks,
Close to vagina and in the midline the tissue around your bladder
and urethra may be swollen or
bruised, making urination difficult.
Slit or irregular opening, close to

or in vaginal introitus, usually
midline.
Vaginal Opening Subjective: Normal

“Nafefeel ko na namamaga kasi
medyo mahapdi siya” Expected:
The vaginal area may seem
Objective: looser, softer, and 'open.' It might
Bruised and Swollen also appear bruised or swollen.
This is typical, and the swelling
Loose, softer, and more ‘open’ and openness should begin to
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subside within a few days of your
baby's birth. Your vaginal tissue
will most likely not restore to its
pre-birth form, but this should not
be an issue.
Breast Subjective: Normal

“Napansin ko nag increase yung
size, siguro kasi may gatas na at Expected:
may lumalabas na rin na gatas Estrogen and progesterone levels
talaga” drop dramatically after a kid is
born. Colostrum is diluted by extra
Objective: fluid during the third or fourth day
Loose and milk is leaking after birth, making it appear
considerably whiter. Your breasts
No abnormal discharge, foul- may begin to leak milk at this time.
smelling, rashes, or lesions
No abnormal discharge, rashes,
or foul-smelling.
Reference: Female Genitalia - Mosby’s Guide to Physical Examination, 7th Edition. (2015). Retrieved
November 7, 2021, from Doctorlib.info website: https://doctorlib.info/medical/handbook/14.html
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VI. PHYSICAL ASSESSMENT
General Survey: Normal Spontaneous Delivery
Temperature: 37.1 C Heart Rate: 88 Respiratory Rate: 19

Blood Pressure: 110/80 Height: 162.56 cm Weight: 54 kg
Diet: Mediterranean diet Contraptions: N/A
Neuro Vital Signs

Eyes: 4 Verbal: 5 Motor: 6 Total: 15 / 15
Date of Interview: January 27, 2021

Time of interview: 11:00 AM
Organ/System Technique Actual Findings Interpretation and

Analysis
Head Inspection and Palpation The head is shaped like Normal

a sphere. The hair is
long, thick, straight, and
spread evenly. The
scalp is white in tone and
smooth.
Eyes Inspection Her almond-shaped Normal

eyes are symmetrical
and brown in tone. When
her focus is directed to
light, her pupils constrict
and dilate, and her
conjunctiva are pink.
Ears Inspection Ears are clean, there is Normal

no ear wax, and the ears
are about the same size
and shape. When
spoken gently, the
patient can hear
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properly.
Nose Inspection We've noticed nasal Normal

hairs, a small nose
bridge, no discharges,
no enlargement of the
mucus membrane, and
the existence of nasal
hairs.
Mouth Inspection A patient has a full set of Normal

teeth with only little
dental cavities. The
gingival and oral mucosa
is pink in color, moist,
and there are no lesions
or inflammation present.
The tongue is reddish in
color and has no
swelling or lesions. Lips
are symmetrical, with a
pinkish core and a
brownish line along the
lip lining.
Neck Inspection and Palpation Half inches in size lymph Normal

nodes have been
identified. Neck strength
enables the back-and-
forth, left-and-right
motions. The patient is
able to move her neck
freely.
Lungs and Thoracic Inspection, Auscultation, There have been no Normal

Region Percussion and reports of discomfort
Palpation during inhaling or
exhaling. On
auscultation, there are
no aberrant noises. The
respiratory rate is normal
at 19 beats per minute.
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Heart Auscultation There is an audible Normal
cardiac sound in the
patient. Between the 4th
and 5th intercostal
spaces, the Point of
Maximal Impulse may be
heard. The heart is
beating well, with a pulse
rate of 88 beats per
minute, which is higher
than the typical rate of
60-100 beats per
minute.
Abdomen Inspection, Auscultation, Peristalsis is present Normal

Percussion and during auscultation, and
Palpation there is an abdominal
movement similar to
breathing. There are no
lesions, rashes, or
discoloration on the skin,
edema, or tenderness.
Upper Extremities Inspection and Palpation Skin - Brown in colors, Normal

no presence of wounds,
skin is smooth, moist,
warm, and soft to touch.
Hands - Medium in size

with 5 fingernails on
each side. Nails are
short and medium in
length.
Arms - Able to move

through an active range
of motion (ROM). Able to
extend arms in front or
push them out to the
side.
Lower Extremities Inspection and Palpation The feet are undefined in Normal
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size, with no blemishes
or scars. The fingernails
are neat and short.
There are ten fingers.
The patient is mobile or
ambulatory.
Genitourinary Inspection With episiotomy dry and Normal

intact, urinates 2-4 times
a day and has not
defecated yet since her
delivery.
Perineum Inspection With episiotomy intact, Normal

presence of slight
swelling.
Neurological Inspection and Palpation Behavior - During the Normal

Assessment interaction, the patient is
able to speak in a
conscious and coherent
manner.
Motor functioning -
Active ROM allows the
patient to move her
extremities. As she
pushed down/up his
hands, she was able to
stretch her arms in front
and resist activity.
Reflexes - The blinking

reflex and the deep
tendon reflex were both
presents.
Sensory functioning -
The patient’s sensory
system is intact, she was
able to distinguish touch
pain, hot and cold.
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VII. COURSE IN THE WARD
Date Doctor’s Nursing Responsibilities Patient Reaction/

Order Evaluation
January 27, 2021 Monitor Vital signs The nurse is expected to take Patient is following
the temperature, pulse rate, instructions and stated that
respiration rate and the blood she is somehow at ease for
pressure of the patient. the result of her assessment
in Vital signs.
January 27, 2021 Administer the

prescribed medications: The nurse is responsible for Patient will feel relieved and
interpreting the prescription satisfied at the same time.
Cephalexin 500 mg 1 accurately, recording that the The medication will bring
cap TID drug has been given and comfort to the client and the
Mefenamic Acid 500 mg observing the patient’s evaluation about the effects
1 cap TID response. needs to be documented.
Prior to administration the

nurse must know the reason References:
for, action and usual dosage of
Themes, U. F. O. (2016,
the drug; this should enableOctober 8). The role of
him or her to recognize and nurses in drug
question mistakes in
administration. Nurse Key.
prescribing. https://nursekey.com/the-
role-of-nurses-in-drug-
Observations should be made administration/
for therapeutic and adverse
effects.
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January 27, 2021 Provide Assess the client’s need for the
Having no pain is
nonpharmacologic and administration of a PRN pain
characterized by 0 (zero)
pharmacologic pain medication (e.g., oral, topical,
and 10 is the worst possible
relief subcutaneous, IM, IV) pain. Reactions and sudden
changes were observed
Administer and document during the intervention.
pharmacological pain Feelings of the patient were
management needed by the documented and observed.
client.
Administer pharmacological References:

measures for pain Burke, A. (n.d.).
management. Pharmacological Pain
Management: NCLEX-RN
[Review of Pharmacological
Administer controlled Pain Management: NCLEX-
substances within regulatory RN]. Registerednursing.org.
guidelines (e.g., witness, https://www.registerednursi
waste). ng.org/nclex/pharmacologic
al-pain-management/
Evaluate and document the
client's use and response to
pain medications.
Several non-pharmacological
analgesic resources/methods
used in postpartum woman
care in the immediate
postpartum period were
assessed in this systematic
review. Of these, only TENS
and cryotherapy presented
well-established data
regarding the significant effect
on the reduction of
abdominal/pelvic pain in
postpartum women.
January 27, 2021 Instruct to follow and The nurse shall provide the Patients are asked to keep a
have a balanced diet client the proper nutrients she daily food diary in which they
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needs with the help of the other record what and how much
healthcare providers. The they have eaten, when and
nurse should also encourage where the food was
the patient to follow and consumed, and the context
consume the meal planned for in which the food was
her. consumed.
Additionally, patients may

be asked to keep a record of
their daily physical activities.
References:
Institute of Medicine (US)
Subcommittee on Military
Weight Management.
(2019). Weight-Loss and
Maintenance Strategies.
Nih.gov; National
Academies Press (US).
https://www.ncbi.nlm.nih.go
v/books/NBK221839/
January 29, 2021 Assist the patient prior Health teaching should be The patient’s overall
to her discharge discussed. The nurse assigned experience was
will inform the client on things documented as well as the
she needs to do. Provide information regarding her
answers and educate the client situation. The instructions
to avoid misleading made by the healthcare
information.Evaluate the provider were written and
overall experience of the verbally given to the client.
patient and document what is
needed to be documented.
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VIII. DIAGNOSTICS AND LABORATORY RESULTS
TEST NAME OBSERVED RESULT NORMAL VALUES INTERPRETATION

AND ANALYSIS
Hemoglobin 10.1g/dL 11.7-15.7g/dL A hemoglobin test

measures the levels of
hemoglobin in your
blood. Hemoglobin is a
protein in your red blood
cells that carries oxygen
from your lungs to the
rest of your body. If your
hemoglobin levels are
abnormal, it may be a
sign that you have a
blood disorder.
https://medlineplus.gov/l
ab-tests/hemoglobin-
test/
Mean cell volume 87fL 80-90fL Normal
White cell volume 8.2x10/L 3.5-11x10/L Normal
Platelet count 140x10/L 150-440X10/L A platelet count is a lab

test to measure how
many platelets you have
in your blood. Platelets
are parts of the blood
that help the blood clot.
They are smaller than
red or white blood cells.
https://www.mountsinai.
org/health-
library/tests/platelet-
count
Sodium 135 mmol/L Normal
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Potassium 6.1 mmol/L Normal
Urea 6.1 mmol/L Normal
Creatinine 73 umol/L Normal
Urinalysis
LABORATORY TEST OBSERVED RESULT NORMAL FINDINGS INTERPRETATION

AND ANALYSIS
Color Pale yellow Pale yellow Normal
Acid(pH) 6pH 4.5-8 pH Normal
Concentration 650mOsm/mg 500-850 mOsm/kg Normal
Protein 80 mg/d <150 mg/d Normal
Glucose 70 mg/d <130 mg/d Normal
Ketones None None Normal
Bilirubin Negative Negative Normal
Human Chorionic Gonadotropin (HCG)
LABORATORY TEST OBSERVED RESULT NORMAL FINDINGS INTERPRETATION

AND ANALYSIS
HCG 3,000mlU/mL 7-8 weeks The human chorionic

7,650-229,000 gonadotropin (hCG) test
mlU/mL is done to check for the
hormone hCG in blood
or urine. Some hCG
tests measure the exact
amount. Some just
check to see if the
hormone is present.
HCG is made by the
22
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CENTER OF NURSING
placenta during
pregnancy. The test can
be used to see if a
woman is pregnant. Or
it can be done as part of
a screening test for birth
defects.
During the early weeks

of a normal pregnancy,
hCG levels double
every 2 days low or
slowly increasing hCG
in the blood suggest an
early abnormal
pregnancy such as
miscarriage and
pregnancy defects.
https://www.uofmhealth.
org/health-
library/hw42062
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IX. DIFFERENTIAL DIAGNOSIS
Signs & Disease 1 Disease 2 Disease 3 Disease 4

Symptoms
S&S1
S&S2
S&S3
S&S4
S&S5
S&S6
***Place at least two (2) to four (4) different diagnoses similar or related to the case.
**Put narrative discussion of the parameter set on the table.
*Use APA format for proper citation of references.
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X. ANATOMY AND PHYSIOLOGY
FEMALE REPRODUCTIVE SYSTEM
The female reproductive system is made up of organs that aids in several functions such as
reproduction, pregnancy, and childbirth. It produces female sex hormones such as estrogen and
progesterone, which maintain the reproductive cycle. The female reproductive anatomy is divided into both
external and internal structures. The external reproductive structures of a female are responsible for the
protection of the internal genital organs from infectious organisms and enable sperm to enter the body as
well.
External Reproductive Structure
Labia majora: Also known as the “large lips”, it encloses and protects the rest of external reproductive
organs. This is also the part where hair growth occurs during puberty, which contains sweat and oil-secreting
glands.
Labia minora: Coined as “small lips”, it lies inside the labia majora and comes in a variety of shapes and
sizes. It surrounds the opening to the vagina and the urethra as well. This part of the female structure can be
easily irritated and swollen, which makes it delicate.
Bartholin’s glands: Located on both sides of the vaginal opening, these glands are responsible for
producing fluid (mucus) secretion.
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CENTER OF NURSING
Clitoris: A small sensitive protrusion that is covered by a fold of skin called the prepuce, which is comparable
to the foreskin at the end of the penis. Along with that, the clitoris is very sensitive to stimulation and may
become erect as well.
Internal Reproductive Structure
Vagina: Also known as the birth canal, the vagina connects the lower part of the uterus which is the cervix,
to the outside of the body.
Uterus: A hollow, pear-shaped organ where a fetus develops. It is divided into the cervix and corpus. The
cervix is located in the lower part, along with the opening of the vagina, while the corpus is the main body of
the uterus and the part that expands for the development of a fetus.
Ovaries: Located on either side of the uterus, the ovaries are small, oval-shaped glands that are responsible
for egg cell production as well as hormones.
Fallopian tubes: It is where the fertilization of an egg cell by a sperm occurs. The fallopian tubes are narrow
tubes attached to the upper part of the uterus. It serves as the pathway that allows the traveling of eggs from
the ovaries to the uterus.
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XI. SURGICAL MANAGEMENT
Procedure done or to be done Nursing Responsibilities Interpretation and analysis
Pre-operation: Pre-operation:
1. Monitor vital signs ● Perform Hand hygiene ● To prevent the spread of
2. Start an IV line and put on PPEs microorganisms
3. Shave pubic hair
4. Obtain consent form ● Check and verify the ● Check the physician’s
physician's order. order to make sure that
the procedure is
● Assess the patient, the appropriate to the
knowledge and ability of condition of the patient.
the patient to understand
the procedure. ● It is important to know if
the client has understood
● Secure the privacy of the and can comprehend
patient. each procedure that will
be done to her.
● Assess vital signs
● Ensuring privacy can
● Gather all the materials promote more effective
that are needed for the communication between
skin preparation and physician and patient,
operation. which is essential for
quality of care, enhanced
● Secure consent form autonomy, and
every diagnostic test and preventing economic
procedures was well harm, embarrassment,
explained to the patient and discrimination
(Gostin, 2001; NBAC,
● Placement of IV line and 1999; Pritts, 2002).
infusion of IV fluids.
● Vital signs provide a
baseline about the
patient’s condition.
● To conserve time and
ensure that all of the
tools required for each
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CENTER OF NURSING
procedure are complete
and clean.
● The main purpose of the

informed consent
process is to protect the
patient. A consent form is
a legal document that
ensures an ongoing
communication process
between you and your
health care provider.
Intra-operative: Intra-operative
1. Monitor vital signs ● Perform Hand hygiene ● To prevent the spread of

2. Skin preparation and put on PPEs microorganisms
3. Induction of anesthesia:
- Regional ● Check and verify the ● Check the physician’s
(Epidural physician's order. order to make sure that
Anesthesia) the procedure is
4. Place lithotomy leggings ● Continuous monitoring of appropriate to the
5. Semi-fowler positioning monitor vital signs condition of the patient.
6. Draping
7. Normal spontaneous ● Proceed with the skin ● allow for timely detection
vaginal delivery preparation. Identify the of clinical deterioration in
8. Mild episiotomy parts that are in need of patients
9. Delivery of infant shaving and skin prep.
10. Delivery of placenta ● to reduce the number of
11. Episiotomy repair ● Apply lithotomy leggings microorganisms on the
skin's surface that may
● Position the patient into cause infection.
a semi fowler's position.
Ask the patient if she’s ● Semi Fowler's position is
comfortable with her the preferred position
position. during childbirth to
improve the comfort of
● Secure privacy and the mother. This position
properly drape the helps in improving the
patient. lung expansion.
advances, the gravid
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● Assist the surgeon all uterus exerts pressure on
throughout the process. the diaphragm, causes
Make sure to identify and breathing difficulty and
give the correct tool that shortness of breath.
is asked. Strictly practice
the sterile technique all ● Other healthcare
throughout the providers working
procedure. together can improve the
patient's experience and
● Perform the EINC. assist them improve their
condition. It is critical to
● Discard all the use sterile techniques
contaminated during surgeries to avoid
materials.Remove all the patient contracting
PPEs. Perform hand microorganisms from the
washing. environment.
● Document all the ● Essential Intrapartum

procedures that have and newborn care is a
been done to the patient. package of evidence-
based practices
● Assess and monitor the recommended by the
condition of the patient DOH, Philippine health
and the baby. insurance and world
health as the standard of
● Carry out doctor’s order care in all births by
for postoperative care. skilled attendants in all
setting.
● To avoid cross-
contamination and
microorganism
transmission.
● Proper documentation of
medical records
promotes patients' and
physicians' best interests
for many reasons.
Recording all relevant
data of a patient's care
helps physicians monitor
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CENTER OF NURSING
what's been done, and
curtails the risk of
mistakes scrambling into
the treatment process.
● Ensure that the condition

of the patient is normal
and without complication.
Post-operative: Post-operative:
1. Monitoring recovery ● In the recovery room
carefully monitor the
patient V/S, bleeding, if
still on anesthetics, and
monitor for any signs of
nausea and vomiting, as
well as the risk for
infection, make sure to
keep the patient
comfortable at all times.
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31
XII. MEDICAL MANAGEMENT
DRUG STUDY
NAME: _Manzano, Rizza Mae C. and Marasigan, Pamela Joyce T._______ YEAR/GROUP: _II-B BSN Group 4
CONCEPT: ____________________________________________________ AREA: __________________ DATE: __________________
SIDE EFFECTS/ NURSING

DRUG NAME MECHANISM OF ACTION INDICATION CONTRAINDICATION
ADVERSE REACTION CONSIDERATION
Cephalexin is a first Cephalexin is indicated for Common side effects: ● Cephalin Before:
Generic name:
generation cephalosporin the treatment of certain ● diarrhea capsules are
Cephalexin ● Determine
antibiotic which contains infections that are caused ● nausea/vomiti contraindicate
beta lactam and by susceptible bacteria. ng d for patients history of
Brand name: hypersensitivity
dihydrothiazide. These infections include ● indigestion, with known
● Keflex reactions to
Cephalosporins exert the following: stomach pain hypersensitivi
● Biocef cephalosporins
bactericidal activity by ● respiratory tract ● vaginal itching ty to
● Zartan and penicillin
interfering with later infections or discharge cephalexin or
● Panixine and history of
stages of bacterial cell ● otitis media other
● Daxbia other drug
wall synthesis by ● skin and skin Severe side effects: members of
inactivating one or more structure ● allergic cephalosporin allergies before
Group name: Antibiotic, therapy is
penicillin-binding proteins infections reaction class of
Cephalosporin initiated
and inhibiting cross- ● bone infections ● severe skin antibacterial
linking of peptidoglycan ● genitourinary tract reaction drugs ● Lab tests:
Form: evaluate renal
structure. Unlike infections ● severe ● Contraindicat
● Capsule and hepatic
penicillins, ● uncomplicated stomach pain ed with allergy
● Tablet function
cephalosporins are more cystitis (diarrhea is to
● Reconstitution periodically in
resistant to the action of ● streptococcal watery or cephalosporin
beta lactamase. It inhibits pharyngitis bloody) s or patients
Route: Oral receiving
bacterial cell wall ● cellulitis and ● unusual penicillins
synthesis that leads to mastitis tiredness, ● Use prolonged
Dosage & Frequency: therapy
breakdown and contribute ● renal impairment feeling light- cautiously
● Capsule: 250 mg; ● Monitor for
to bacterial cell lysis or ● hepatic headed or with renal
500 mg manifestations
cell death. impairment short of breath failure,
● Tablet: 250 mg: ● easy bruising, lactation and of
500 mg unusual pregnancy hypersensitivity
● Reconstitution: Reference: bleeding,
125 mg/5 mL: 250 purple or red During:
mg/5 mL RxList. Cephalexin: Generic, spots under ● Arrange for
uses, side effects, dosages,
the skin culture and
interactions, warnings.
● seizure sensitivity tests
RxList. Retrieved November
● pale skin, cold of infection
27, 2021, from hands, and before and
https://www.rxlist.com/consu
feet during therapy if
mer_cephalexin_keflex/drug
● yellow skin the infection
s-condition.htm.
and dark- does not resolve
colored urine ● Give drug with
● fever, meals, arrange
weakness for small,
● pain on the frequent meals if
side or lower GI complications
back occur
● Refrigerate
Adverse Reactions: suspension,
● Hypersensitivit discard after 14
y reactions days
● Clostridium
difficile- After:
associated Educate and instruct the
diarrhea client to do the following:
● Direct ● Take this drug
Coombs’ Test with food.
Seroconversio Refrigerate
n suspension;
● Seizure discard any drug
Potential after 14 days
● Complete the
full course of
33
● Effect on this drug even if
Prothrombin you feel better
Activity ● Educate client
● Development that this drug is
of Drug-resist prescribed for
this particular
Drug interaction: infection; do not
There may be an self-treat any
interaction between other infection
cephalexin and any of ● Tell the client
the following: about the side
● BCG effects: upset
● Cholera stomach, loss of
vaccine appetite, nausea
● Metformin (take the drug
● Multivitamins with food);
with minerals diarrhea;
● Sodium headache,
picosulfate dizziness
● Typhoid ● Instruct them to
vaccine report severe
● Warfarin diarrhea with
● Zinc blood, pus or
mucus; rash or
hives; difficulty
breathing;
unusual
tiredness,
fatigue; unusual
bleeding or
bruising
● Avoid alcohol
while taking
cephalexin
34
NAME: _Macabinta, Nor Ashya K., Matias, Dysheree, Operana, John_____ YEAR/GROUP: _II-B BSN Group 4
CONCEPT: ____________________________________________________ AREA: __________________ DATE: January 27, 2021
MECHANISM OF SIDE EFFECTS/ NURSING

DRUG NAME INDICATION CONTRAINDICATION
ACTION ADVERSE REACTION CONSIDERATION
Generic Name: Mefenamic acid binds the Upset stomach, nausea, Before:
Mefenamic acid prostaglandin synthetase For the treatment of heartburn, dizziness, NSAIDs may cause an ● Check and verify
receptors COX-1 and rheumatoid arthritis, drowsiness, diarrhea, and increased risk of serious the physician’s
Brand name: COX-2, inhibiting the osteoarthritis, headache may occur. This cardiovascular thrombotic order.
Mefenamic, Ponstel action of prostaglandin dysmenorrhea, and mild medication may raise your events, myocardial ● Assess pain score.
synthetase. As these to moderate pain, blood pressure. infarction, and stroke, ● Assess for history
of allergies to
receptors have a role as a inflammation, and fever. which can be fatal. This
NSAIDs.
Dosage, Route and major mediator of Serious side effects risk may increase ● Educate patient
Frequency: inflammation and/or a include: with duration of use. regarding desired
For the treatment of role for prostanoid ● fainting, Patients with and adverse
dysmenorrhea. signaling in activity- ● persistent/severe cardiovascular disease or effects.
● Oral dosage dependent plasticity, the headache risk factors for ● Inform patient that
- Adult and symptoms of pain are ● hearing changes cardiovascular disease long-term use of the
Adolescent temporarily reduced. (e.g., ringing in the may be at greater risk. medicine may
females >= 14 ears) cause liver
years ● fast/pounding NSAIDs cause an damage.
Initially, 500 mg heartbeat increased risk of serious
PO at the onset ● mental/mood gastrointestinal adverse During:
of menses changes events including ● Give drug with food,
milk or antacids.
followed by 250 ● stomach pain bleeding, ulceration, and
● Do not increase or
mg every 6 hours Reference: ● difficult/painful perforation of the stomach double the dose,
as needed for no https://go.drugbank.com swallowing or intestines, which can be follow exactly as
longer than 2 to 3 /drugs/DB00784 ● vision changes fatal. prescribed and
days. ● symptoms of heart These events can occur at indicated.
failure (such as any time during use and ● Administer drug
For the treatment of mild swelling without warning with full glass of
pain and moderate pain. ankles/feet, symptoms. water.
● Oral dosage unusual tiredness, ● Do not break, chew
35
- Adults and unusual/sudden Elderly patients are at or crush capsule
Adolescents >= weight gain) greater risk for serious and tablet.
14 years gastrointestinal events. ● Do not administer
Initially, 500 mg with anticoagulants
PO followed by Known hypersensitivity and other drugs
250 mg every 6 (e.g., anaphylactic that cause GI
upset.
hours as needed reactions and serious skin
for no longer than reactions) to mefenamic
After:
7 days. acid or any components of ● Document
the drug product. accordingly.
For migraine prophylaxis†. ● Monitor for adverse
● Oral dosage History of asthma, effects.
- Adults urticaria, or other allergic- ● Instruct
500 mg PO 3 type reactions after taking discontinuation of
times daily. aspirin or other NSAIDs. medication if
Clinical practice Severe, sometimes fatal, adverse effect
guidelines anaphylactic reactions to occurs.
classify NSAIDs have been ● Assess for
occurrence of GI
mefenamic acid reported in such patients.
ulcers after taking.
as possibly
effective for In the setting of coronary
migraine artery bypass graft
prophylaxis. (CABG) surgery
Adults
1250 mg/day PO.
Elderly
1250 mg/day PO.
Adolescents
>= 14 years: 1250 mg/day
PO.
36
< 14 years: Safety and
efficacy have not been
established.
Children
Safety and efficacy have
not been established.
Classification:
central nervous system
agent; analgesic; nsaid;
antipyretic
37
XIII. CONCEPT MAP AND NURSING CARE PLAN
NURSING CARE PLAN
NAME: _Manzano, Rizza Mae C. and Marasigan, Pamela Joyce T._______ YEAR/GROUP: _II-B BSN Group 4
CONCEPT: ____________________________________________________ AREA: __________________ DATE: __________________
Assessment Nursing Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective cue: Acute pain related to Episiotomy is a Short term goal: Monitor the patient's To obtain baseline Short term goal:
“Masakit yung tahi surgical incision surgical incision of After 4 hours of vital signs and skin data After 4 hours of
ko sa pwerta” as secondary to the perineum made nursing intervention, color nursing intervention,
verbalized by the episiotomy. to prevent tearing of the patient will be the patient was able
patient the perineum and able to: Determine client’s One client may not to:
release pressure on ● experience acceptable level of be 100% pain-free ● experience
Objective cues: the fetal head during pain within pain and pain control but may feel that “3” d pain
- Pain Scale: childbirth. tolerable goals is a manageable within
9/10 (Varghese, levels level of discomfort, tolerable
- Facial Champaneria, ● report pain while another may levels
Grimace Kapoor, et al., 2016) scale of require medications ● reported
- Discomfort 7/10 or for pain at the same pain scale
- Irritable The International below level because the of 7/10 or
- Pupil Association for the After 2 hours of experience is below
Dilation Study of Pain (IASP) nursing intervention, subjective GOAL MET
- Guarding defined pain as “an the patient will be
Behavior unpleasant sensory able to: Work with the client As the timely After 2 hours of
and emotional ● no longer to prevent pain. Use intervention is more nursing intervention,
Vital Signs: experience demonstrat flow sheets to likely to be the patient was
T: 36.7 associated with e grimace document pain, successful in being able to:
R: 16 bpm actual or potential upon therapeutic alleviating pain ● no longer
P: 83 bpm tissue damage, or movement interventions, demonstrat
BP: 130/100 described in terms of ● demonstrat response, and ed grimace
such damage.” e comfort length of time before upon
38
Another great and ease pain recurs. Instruct movement
definition of pain is client to report pain ● demonstrat
from Margo Long term goal: as soon as it begins, ed comfort
McCaffery, a nurse The patient will view and ease
expert on pain, who the process of labor Assess the To obtain baseline GOAL MET
defined it as “pain is and delivery as a episiotomy wound data and facilitate
whatever the person positive and joyful for abnormal prompt treatment Long term goal:
says it is and exists experience discharge and signs The patient viewed
whenever the of infection the process of labor
person says it does.” and delivery as a
Pain is a subjective positive and joyful
Acknowledge the experience and experience
patient’s pain cannot be felt by GOAL MET
experience and others
convey acceptance
of the patient’s
response
To relieve the
Place the patient in a pressure on the
comfortable side- episiotomy site
lying position
Instruct patient to
perform deep
breathing exercises -
administer
To facilitate
Provide or promote relaxation or reduce
nonpharmacological the level of pain or
pain management: discomfort without
quiet environment, using analgesics or
calm activities, back pain killer
rub, change of
position, use of heat
or cold compress,
watching televisions,
deep breathing
39
exercises, etc.
Assess the client’s Provides a baseline

knowledge of and for intervention and
expectation about teaching, provides
pain management an opportunity to
allay common fears
and misconceptions,
or to address
expected side
effects of analgesics
Mefenamic acid
500mg/tab 1 tab PO, As the doctor’s
then 250mg/tab 1 ordered and to
tab q6 PO for 3 days maintain an
as ordered acceptable level of
pain
Discuss with
significant other(s)
ways in which they
can assist clients Family
with pain members/SOs may
management provide assistance
by transporting the
client to prevent
walking long
distances, or by
taking on the client’s
strenuous chores,
supporting timely
pain control,
encouraging eating
nutritious meals to
enhance wellness,
Identify specific and providing gentle
signs/symptoms and massage to reduce
40
changes to pain muscle tension
characteristics
requiring medical Provides an
follow-up opportunity to modify
pain management
regimen and allows
for timely
interventions for
developing
complications
41
NAME: _Macabinta, Nor Ashya K., Matias, Dysheree, Operana, John_____ YEAR/GROUP: _II-B BSN Group 4
CONCEPT: ____________________________________________________ AREA: __________________ DATE: January 27, 2021
Assessment Nursing Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective: Disturbed sleeping Due to pain in the Short term goal: Independent: Short term goal:
“Hindi ako makatulog, pattern related to pain perineum, normal After 3 hours of nursing Assess past patterns To provide After 3 hours of nursing
sobrang sakit talaga ng and discomfort on bodily relaxation is intervention the client will: of sleep comparative intervention, the client was
pwerta ko” as stated by perineum secondary to hampered, resulting baseline able to:
the client. labor and delivery. in sleep deprivation ● report a lowered Position client in a
or inability to sleep level of discomfort comfortable position To alleviate ● report a lowered level
Objective: for long periods of and verbalized a discomfort of discomfort and
– 2 hours of time. The pain and pain level of (5 out Provide comfort verbalized a pain level
sleep per day discomfort made it of 10). measures (touch, of (5 out of 10).
– Frequent difficult for the ● achieve at least 5-6 quiet environment, To distract ● achieved at least 5-6
yawning mother to sleep. hours of sleep per dim light, light music) attention on pain, hours of sleep per
during day. reduce tension day.
daytime ● Show signs of and to promote ● show signs of
– Pain scale: 8- decreased yawning Provide a quiet and non- decreased yawning
10 during daytime. peaceful pharmacological during daytime.
– Difficulty ● show signs of environment during pain management ● show signs of
falling and decreased irritability. sleep periods decreased irritability
staying ● report decreased To help in ● report decreased
asleep due to body malaise. Encourage the client providing better body malaise.
pain to express concerns sleep/rest
– Irritable Long term goal: when unable to GOAL MET
– overall body After 3 days of nursing sleep
malaise intervention, the client To be able to
will: Provide a warm bath address concerns Long term goal:
before the client and promote After 3 days of nursing
Vital Signs:  Be able to goes to sleep relaxation intervention, the client was
T: 36.7 reestablish and able to:
R: 16 bpm maintain a Vasodilation of the
P: 83 bpm normal sleeping Expose perineum on veins provide a  reestablish and
BP: 130/100 pattern. penlight bid for 15 sleepy, lazy effect maintain a
42
 achieve 7-8 mins. causing the client normal sleeping
hours of sleep to fall right to sleep pattern.
per day. Dependent:  achieved 7-8
 report absence Prescribe sedatives To provide comfort hours of sleep
of body malaise (Valium) as ordered per day.
and yawning.  report absence of
 report no body malaise and
irritability To induce sleep yawning.
 report further  report no
alleviation of irritability
pain level to 3  report further
out 10. alleviation of pain
level to 3 out 10.
GOAL MET
43
CONCEPT MAP
44
Medical Diagnosis/Chief Complaint: Pain in the lower Abdomen. “Hindi ako makakilos ng
Patient’s Initials: C. M. A maayos dahil sa sakit, parang period cramps ang kirot niya” as verbalized by the patient.
Age: 18 y/o Gender: Female Basis of Prioritization: Maslow’s Hierarchy of Needs
Category: Level I Room No: Date Admitted: Student Nurse/s:

January 27, 2021 Macabinta. Nor Ashya
Manzano, Rizza Mae
Marasigan, Pamela Joyce
Matias, Dysheree
Operaña, John
45
City of Makati
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CENTER OF NURSING
XIV. THEORETICAL FRAMEWORK
Intrapartum Nursing: Integrating Rubin’s Framework With Social Support Theory
Intrapartum nursing care is all about assisting moms throughout childbirth. Both professional and
consumer-oriented study has recently focused on the possible significance of labor support in enhancing
labor and birth outcomes. Previously, for decades, there has been little written on the theoretical
underpinnings of the distinct specialism of intrapartum nursing care. As a result, practical intrapartum nurses
may believe that nursing theory has no importance for them or is irrelevant to their work. Nursing theory, on
the other hand, should aid in the improvement of nursing practice (Chinn & Kramer, 1999). Reva Rubin's
publications and social support theory, among other things, provide a very robust theoretical underpinning
for nurses' care of women in childbirth.
Rubin's theory describes the psychological environment of the laboring woman, directing the support
mechanisms that can help her cope with the challenges of labor, improve delivery outcomes, boost her self-
esteem and identity, and lay the groundwork for her role shift to motherhood. Rubin validated or hinted a lot
about the necessity for nurses to offer supportive care to women in labor while discussing the growth of
mothers' emotions, conduct, and self-view during and after birth. The majority of social support activities
taken by nurses during labor are focused on two of Rubin's four components of pregnancy work: seeking
safe passage and giving of oneself. The safe passage refers to the mother's knowledge and care-seeking
activities in order to guarantee that she and her infant both survive pregnancy and delivery in good health.
The mother's usual fears and concerns about prospective and real hazards or risks exhibit themselves in this
work. The desire and capacity of the mother to make personal sacrifices (time, suffering, etc.) for the kid is
referred to as giving of oneself (Rubin, 1975a).
46
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CENTER OF NURSING
XV. NON-PHARMACOLOGIC MANAGEMENT
Doctor’s Order Nurse Response Interpretation and Analysis
Monitor patient’s vital signs The vital signs of the mother will The mother’s vital signs will be
be checked to make sure that checked straight after birth. Also,
they are within normal range. check pulse and blood pressure
at least once every hour, and the
temperature at least once in the
first six hours.
Reference:
Postnatal care module: 5.

routine postnatal care for
the mother. Postnatal Care
Module: 5. Routine
Postnatal Care for the
Mother: View as single
page. (n.d.). Retrieved
December 2, 2021, from
https://www.open.edu/ope
nlearncreate/mod/ouconte
nt/view.php?id=339&printa
ble=1.
Request for laboratory tests The nurse will carry out the This can evaluate the overall
(Urinalysis and CBC) Doctor's order for the laboratory health or well-being of the client.
tests needed. It aids in detecting infection early,
which will help avoid serious
infections that might occur
Reference
Complete blood count

(CBC) - understand the
Test & Your Results.
Testing.com. (2021,
November 9). Retrieved
47
City of Makati
_____________________________________________________________________________________
CENTER OF NURSING
https://www.testing.com/te
sts/complete-blood-count-
cbc/.
Urinalysis - understand the

Test & Your Results.
Testing.com. (2021,
November 9). Retrieved
https://www.testing.com/te
sts/urinalysis/.
Postpartum massage The nurse will provide massage Providing postpartum massage
to the client and educate the to mothers help promote better
patient’s significant others sleep, improve milk production,
regarding the intervention as hormone regulation, and reduces
well. swelling, anxiety and depression.
Reference
Crider, C. (2020, May 20).

Postpartum massage can
help recovery after birth.
Healthline. Retrieved
https://www.healthline.com
/health/postpartum-
massage#benefits.
Kegel Exercises The nurse will educate and assist During the postpartum period, it
the client on the benefits of Kegel can help heal perineal tissues
Exercises and how it is that were stretched during
performed. vaginal birth.
Reference
Kegel exercises during

and after pregnancy.
Pampers. (n.d.). Retrieved
https://www.pampers.com/
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en-us/pregnancy/prenatal-
health-and-
wellness/article/kegel-
exercises.
Sitz bath The client will be assisted in Sitz baths improve blood flow to
having a sitz bath in which the the perineal area. It aids in
patient will sit on the toilet, with a reducing swelling and promotes
bag filled with warm or cold water healing. It relaxes muscles and
and let the water flow into the soothes soreness.
perineum.
Reference
Sharon, M. (2020, April

23). 5 benefits of A sitz
bath after birth. What to
Expect. Retrieved
https://www.whattoexpect.
com/first-year/postpartum-
health-and-care/sitz-bath-
postpartum/.
Provide a well-balanced diet The nurse will collaborate with a Proper postpartum nutrition is
nutritionist and/or dietician in vital for the overall health of the
order to plan the appropriate diet mother. It is important to have a
as needed by the client. proper diet, hydrate often and
take supplements.
Reference
Carrasco, A. (2021, June

25). Your complete guide
to postpartum nutrition:
Healing foods & more.
mindbodygreen. Retrieved
https://www.mindbodygree
n.com/articles/postpartum-
nutrition-guide.
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XVI. PATHOPHYSIOLOGY
Theoretical-Based
Diagram 1. Theoretical-based Pathophysiology
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The first diagram depicts a pathophysiology of premature rupture of membrane. This condition may
occur due to various causes; multipregnancies, cervical incompetence, antepartum bleeding, history of
PPROM preterm birth, Cigarette smoking, urinary and sexually transmitted infection, polyhydramnious and
low socioeconomic status influencing the activation of inflammatory cascade disrupting proteins of amnions
which weaken the amniotic membrane causing it to rupture. Consequently, amniotic fluid leaks through the
cervix resulting in oligohydramnios causing lack of amniotic fluid to support fetal development and descent
of the umbilical cord below the cervix. Furthermore, the fetus will be exposed to the vaginal flora influencing
the activation of the innate immune system which then causes the presence of neutrophils degrading
placenta. With these, multiple complications can occur like cord prolapse, hypoplastic fetal lungs, fetal facial
anomalies, placenta abruption and certain infections such as chorioamnionitis endometritis and fetal
infection. The stress from complications activates fetal and maternal hypothalamic pituitary adrenal axis and
inflammatory cascade influencing the release of prostaglandin causing regular contractions and cervical
changes leading to preterm birth.
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Patient-Based
Diagram 2. Patient-based pathophysiology.
The second diagram exhibits a pathophysiology based on the patient’s case. The case study
presents a primigravida patient who is in her 35th week of gestation. While currently on preterm pregnancy,
she was reported to have premature rupture of membrane as evidence by sudden gush of fluid from vagina
due to non-modifiable factors which are polyhydramnios and cervical incompetence. Consequently,
premature rupture of membrane is associated with oligohydramnios and exposure of the fetus to vaginal flora
which is influenced by the loss of amniotic fluid and rupture of amniotic sac. Due to these, complications like
cord prolapse, placenta abruption, chorioamnionitis and fetal infection occurs leading to increased risk of fetal
death and prematurity. Therefore, preterm birth is necessary. Thus, normal vaginal delivery was performed
on the patient.
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XVII. DISCHARGE PLAN
Medication ● Educate the patient and her family about the proper
storage and use of the medications prescribed by the
physician.
● Discuss the possible side effects, the signs when to call
for help and what to do if the medication was not taken
according to its instruction.
● Make sure that the patient verbalized understanding
regarding the medications.
● Encourage the client to not skip the prescribed
medications and take it according to its purpose.
Health Teaching/Hygiene ● Encourage the patient to practice good personal hygiene

by demonstrating ways to lessen the infection and other
possible illnesses.
● Advise to take a warm bath.
● Advise the patient to rest as much as possible.
● Let the patient know that it is important to know when to
call the doctor if the pain gets severe or constant.
● Tell the patient to get plenty of sleep and manage her
stress since it can also cause abdominal pain.
Observable Signs and Symptoms ● Inform the patient to seek for professional help if she
experiences:
- Vaginal bleeding
- Severe headache
- Sudden swelling
- Vision problems
- Fever (over 37.5 °C)
- Constant and severe pain or cramping
● Symptoms of Urinary tract infection includes:
- Pain or discomfort when urinating
- A need to urinate often (on its own this is
common in a normal pregnancy)
- Urine that smells bad, is cloudy or bloody
Treatment ● Advise patient to take the prescribed medication when

painful crampings are experienced.
● Teach some deep breathing exercises.
● Heating pads or hot water bottles may also provide relief
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to the patient.
● Educate the patient for possible risks so that she can
avoid and be aware ahead of time.
● To reduce or eliminate round ligament pain, advise client
to practice getting up slowly when sitting or lying down.
● If a sneeze or cough comes on, advise her to bend and
flex her hips as this can help to reduce the pressure on
the ligaments.
● Inform her to provide a pillow for comfort and support.
● Daily stretching is also an effective method for reducing
round ligament pain.
Exercise/Environment ● Encourage the patient to do gentle stretching or any

exercise that will test her mobility.
● Advise to not force herself on activities that will require a
lot of strength.
● Educate the patient about the importance of having a
clean environment.
● Maintaining a clean and safe home is one of the best ways
to prevent any health risks. That's why it’s important to
advise the patient to ensure optimal care in her
environment.
Diet/Nutrition ● Inform the patient to be conscious of what they eat and

drink.
● Tell the patient to sip water or other clear fluids when she
experiences vomiting and diarrhea.
● Encourage to start eating small amounts of foods that
are easy to digest before eating solid ones.
● Advise the client to increase the amount of fiber in her
diet. Increasing fluid intake may also help.
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XVIII. EVALUATION
The case is about “AN 18-YEAR OLD G1P0 WOMAN WHO UNDERWENT NSD DUE TO
PREMATURE RUPTURE OF MEMBRANE”, we conducted to make a certain nursing care plant to our client
with this case by gathering all the necessary data given in the scenario, certain problems and needs of the
client with this case are identified.
A nursing care plan was established to improve our client's health condition and to maintain the
standards of nursing for the client’s safety. We provide the SMART health teaching that promotes
understanding to both readers and for the client's knowledge.
We, group 4 in the OB ward started this paper with minimum knowledge about the case since we
are in a virtual simulation and clinical duty at the OB ward. Despite the difficulties and minimal knowledge
regarding the case, we tried our best to complete this case study.
During the process of making this case study, we conducted a virtual meeting via google meet, our
clinical instructor gave us the case up us the group member divided it into parts, we were able able to analyze
and provide the necessary data from accredited sources, skills, books and internet websites and included it
to our references, with all the reliable information which enlighten our knowledge and help us learned
beforehand. We were able to determine and promote SMART when it comes to importance, etiology, signs
and symptoms, risk factors, pathophysiology, treatment, and management of our case.
Promoting the SMART which stands for Specific, Measurable, Attainable, and Relevant in making
this case study with all the guidance of our clinical instructor and to all the student nurses members
participation in this case study, we concluded that the objectives of this paper are met.
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XIX. REFERENCES
About Pregnancy. (2017, January 31). Retrieved from National Institute of Child Health and Human
Development: https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo
Belly pain in pregnancy: Care instructions. MyHealth.Alberta.ca Government of Alberta Personal

Health Portal. (n.d.). Retrieved December 3, 2021, from
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abq3222.
Carrasco, A. (2021, June 25). Your complete guide to postpartum nutrition: Healing foods & more.
mindbodygreen. Retrieved December 2, 2021, from
https://www.mindbodygreen.com/articles/postpartum-nutrition-guide.
Complete blood count (CBC) - understand the Test & Your Results. Testing.com. (2021, November
9). Retrieved December 2, 2021, from https://www.testing.com/tests/complete-blood-count-cbc/.
Contractions and Signs of Labor. (2018, December). Retrieved from March of Dimes:
https://www.marchofdimes.org/pregnancy/contractions-and-signs-of-lab
Crider, C. (2020, May 20). Postpartum massage can help recovery after birth. Healthline. Retrieved
December 2, 2021, from https://www.healthline.com/health/postpartum-massage#benefits.
de Bellefonds, C. (2021, April 6). Vaginal and Labia Changes During Pregnancy. Retrieved from
What to expect: https://www.whattoexpect.com/pregnancy/symptoms-and-solutions/labia-changes-
during-pregnancy-and-childbirth/
Female reproductive system: Structure & Function. Cleveland Clinic. (n.d.). Retrieved November
30, 2021, from https://my.clevelandclinic.org/health/articles/9118-female-reproductive-system.
Holland, K. (2018, May 24). Understanding the Vaginal Introitus. Retrieved from Healthline:
https://www.healthline.com/health/introitus
Introduction to Pregnancy. (n.d.). Retrieved from MentalHelp.net:

https://www.mentalhelp.net/pregnancy/
Kegel exercises during and after pregnancy. Pampers. (n.d.). Retrieved December 2, 2021, from
https://www.pampers.com/en-us/pregnancy/prenatal-health-and-wellness/article/kegel-exercises.
56
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CENTER OF NURSING
Marcin, A. (2020, August 28). Postpartum cramps: Causes and how to get relief. Healthline.
Retrieved December 3, 2021, from https://www.healthline.com/health/postpartum-cramps#see-a-
doctor.
McDermott, A. (2015, June 18). Abdominal pain during pregnancy: Causes and treatment.
Healthline. Retrieved December 3, 2021, from https://www.healthline.com/health/pregnancy/gas-
pain-during-pregnancy.
MediLexicon International. (n.d.). Female reproductive organ anatomy, parts, and function. Medical
News Today. Retrieved November 30, 2021, from
https://www.medicalnewstoday.com/articles/female-reproductive-organ-anatomy.
Medina, T., & Hill, A. (2006). Preterm Premature Rupture of Membranes: Diagnosis and
Management. American Family Physician, 659-664.Neuman, A. (2020, March 17). Postpartum
Recovery Tips for Treating Your Vagina After Birth. Retrieved from The Bump:
://www.thebump.com/a/the-truth-about-postpartum-recovery-from-vaginal-delivery
Preterm Premature Rupture of Membranes (PPROM). (n.d.). Retrieved from University of

Rochester Medical Center:
https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P0249
6
Rubin, R. (1975a). Maternal tasks in pregnancy. MaternalChild Nursing Journal, 4(3), 143-153.
Sharon, M. (2020, April 23). 5 benefits of A sitz bath after birth. What to Expect. Retrieved
December 2, 2021, from https://www.whattoexpect.com/first-year/postpartum-health-and-care/sitz-
bath-postpartum/
Stomach (abdominal) pain or cramps in pregnancy. Tommy's. Together, for every baby. (n.d.).
Retrieved December 3, 2021, from https://www.tommys.org/pregnancy-information/pregnancy-
symptom-checker/stomach-abdominal-pain-or-cramps-pregnancy.
Urinalysis - understand the Test & Your Results. Testing.com. (2021, November 9). Retrieved
December 2, 2021, from https://www.testing.com/tests/urinalysis/.
Vagina changes after childbirth. (2018, October 23). Retrieved from NHS: https://www.nhs.uk/live-
well/sexual-health/vagina-changes-after-childbirth/
57
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Walls, M. (2020, July 24). Breasts After Breastfeeding: How They Change and What You Can Do.
Retrieved from Healthline: https://www.healthline.com/health/breastfeeding/breasts-after-
breastfeeding
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REPUBLIC of the PHILIPPINES

A Case Study Presented to the Faculty of Center of Nursing -

In Partial Fulfillment of the Requirements for

Macabinta. Nor Ashya

III. NURSING HISTORY

Name of Patient: Carmelita Montecarlos

IV. GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Prior to During Hospitalization Interpretation and

III. Elimination Pattern Bowel: Bowel: Bowel: The frequency

Patients urinate 6-8 Patients urinate 2-4

System Subjective and Objective Cues Interpretation and Analysis

Mons pubis Subjective: Normal

Skin smooth and clean

Pubic hair is regularly distributed

Labia majora Subjective: Normal

No rashes, lesions, or tears

Labia minora Subjective: Normal

Clitoris Subjective: Normal

Urethral orifice Subjective: Normal

Slit or irregular opening, close to

Vaginal Opening Subjective: Normal

Breast Subjective: Normal

VI. PHYSICAL ASSESSMENT

General Survey: Normal Spontaneous Delivery

Temperature: 37.1 C Heart Rate: 88 Respiratory Rate: 19

Neuro Vital Signs

Date of Interview: January 27, 2021

Organ/System Technique Actual Findings Interpretation and

Head Inspection and Palpation The head is shaped like Normal

Eyes Inspection Her almond-shaped Normal

Ears Inspection Ears are clean, there is Normal

Nose Inspection We've noticed nasal Normal

Mouth Inspection A patient has a full set of Normal

Neck Inspection and Palpation Half inches in size lymph Normal

Lungs and Thoracic Inspection, Auscultation, There have been no Normal

Abdomen Inspection, Auscultation, Peristalsis is present Normal

Upper Extremities Inspection and Palpation Skin - Brown in colors, Normal

Hands - Medium in size

Arms - Able to move

Genitourinary Inspection With episiotomy dry and Normal

Perineum Inspection With episiotomy intact, Normal

Neurological Inspection and Palpation Behavior - During the Normal

Reflexes - The blinking

VII. COURSE IN THE WARD

Date Doctor’s Nursing Responsibilities Patient Reaction/

January 27, 2021 Administer the

Prior to administration the

Administer pharmacological References:

Additionally, patients may

VIII. DIAGNOSTICS AND LABORATORY RESULTS

TEST NAME OBSERVED RESULT NORMAL VALUES INTERPRETATION

Hemoglobin 10.1g/dL 11.7-15.7g/dL A hemoglobin test

Mean cell volume 87fL 80-90fL Normal

White cell volume 8.2x10/L 3.5-11x10/L Normal

Platelet count 140x10/L 150-440X10/L A platelet count is a lab

Sodium 135 mmol/L Normal

Urea 6.1 mmol/L Normal

Creatinine 73 umol/L Normal

LABORATORY TEST OBSERVED RESULT NORMAL FINDINGS INTERPRETATION

CONCEPT: __________________________________ AREA: DATE: January 27, 2021

CONCEPT: __________________________________ AREA: DATE: January 27, 2021