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    A Case Study of G2 P1 (2023) of 35 2/7 Weeks Aog by Normal Spontaneously Vaginal Delivery To A Live Baby Girl

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    Mikes Castro
    The document presents a case study of a 22 year old pregnant woman admitted for normal spontaneous vaginal delivery, including her medical history and assessments, laboratory results showing anemia, ultrasound findings consistent with a 28 week gestation, treatment with oxytocin and antibiotics, and a nursing care plan and sample charting documenting her care and delivery.

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    A Case Study of G2 P1 (2023) of 35 2/7 Weeks Aog by Normal Spontaneously Vaginal Delivery To A Live Baby Girl

    Uploaded by

    Mikes Castro
    55 views19 pages
    The document presents a case study of a 22 year old pregnant woman admitted for normal spontaneous vaginal delivery, including her medical history and assessments, laboratory results showing anemia, ultrasound findings consistent with a 28 week gestation, treatment with oxytocin and antibiotics, and a nursing care plan and sample charting documenting her care and delivery.

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    The document presents a case study of a 22 year old pregnant woman admitted for normal spontaneous vaginal delivery, including her medical history and assessments, laboratory results showing anemia, ultrasound findings consistent with a 28 week gestation, treatment with oxytocin and antibiotics, and a nursing care plan and sample charting documenting her care and delivery.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    55 views19 pages

    A Case Study of G2 P1 (2023) of 35 2/7 Weeks Aog by Normal Spontaneously Vaginal Delivery To A Live Baby Girl

    Uploaded by

    Mikes Castro
    The document presents a case study of a 22 year old pregnant woman admitted for normal spontaneous vaginal delivery, including her medical history and assessments, laboratory results showing anemia, ultrasound findings consistent with a 28 week gestation, treatment with oxytocin and antibiotics, and a nursing care plan and sample charting documenting her care and delivery.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 19

    A CASE STUDY OF G2 P1 (2023) OF 35 2/7 WEEKS

    AOG BY NORMAL SPONTANEOUSLY VAGINAL

    DELIVERY TO A LIVE BABY GIRL

    Piolo Amiel H. Launico


    Michael Christian Dionisio
    AGENDA
    • Clinical Scenario / Actual Case with Patients Profile
    Primary goals
    • Definition of Disease / Clinical Situation
    • Pathophysiology / Physiology
    • Assessment
    I. Physical Assessment
    II. System Assessment
    III. Laboratories
    IV. Diagnostic Procedures

    • Treatment
    • Drug Study
    • NCP (Nursing Care Plan)
    • Sample Charting (FDAR)
    Clinical Scenario / Actual Case with Patients Profile
    3

    DEMOGRAPHIC PROFILE
    Name: Bolante, Regine
    Age: 22 years old
    Weight: 51 kg
    Address: Brgy. San Cristobal, S.P.C.
    Gender: Female
    Marital Status: Married
    Date of Admission: March 12, 2023
    Time of Admission: 5:45 am
    DEFINITION OF DISEASE / 4

    CLINICAL SITUATION

    How pregnant women feel?


    In the first trimester, tiredness and morning sickness can make many women feel worn out and mentally fuzzy. But even a
    well-rested pregnant women may have trouble concentrating and periods of forgetfulness. Thinking about the baby plays a
    role, as do hormonal changes
    5

    “ GIVING BIRTH IS AN INCREDIBLE

    ”
    ACT OF NATURE AND POWER.
    Michelle Obama
    PATHOPHYSIOLOGY / 6

    PHYSIOLOGY
    Pathophysiology of Normal Spontaneous Vaginal Delivery

    Human egg cell meets


    Fetal Development Stages of Labor
    the human sperm cell
    Process of Labor
    NSD

    Implantation
    Decidua Fetal
    Fertilization
    Membranes
    Zygote

    Blastocyst Formation of
    Process of Throphoblast
    Implantation Chorionic Villi
    7

    ASSESSMENT

    GENERAL VITAL SIGNS HEAD AND NECK BODY AND DIAGNOSTIC


    EXAMINATION ASSESSMENT UPPER/LOWER
    • Conscious and - Facial symmetry EXTREMITIES
    coherent Blood Pressure: - No deformity noted Normally proportion
    • Ambulatory 100/60 mmHg - No nasal infection No signs of Essentially Normal
    • Active labor Pulse Rate: - No infection in eye abnormalities for NSD
    90 bpm - Area Paleness in No signs of difficulty
    Temperature: look in range of motion
    36.7 ˚C
    Respiratory Rate:
    20 bpm
    8

    SYSTEMS ASSESSMENT
    SYSTEMS   ASSESSMENT RESULTS
    Integumentary x Pale in appearance
    Genitourinary x Clear, pale-yellow urine
    Neurologic   Cooperative in internal
    examination
        Severely anxious
      Oriented to time, place, and
     
    person
        Conscious and Coherent
    LABORATORIES ( MARCH 12,2023)
    9

    Test Result Normal Value Clinical Significance


    Red Blood Cells (RBC) 2.91 3.80 -5.10 10^12/L Below Normal

    Hemoglobin (HGB) 88 g/dL 138-172 d/dL Below Normal

    Hematocrit (HCT) 25.6% 36% - 48% Below Normal

    White Blood Cells (WBC) 21.74 x10^9/L 4.5 – 11.0 x10^9/L Above Normal

    Lymphocytes (LYM%) 18.6 % 20 % - 40 % Below Normal

    Granulocytes 75.8 % 36.9 % - 44.6 % Above Normal


    (Gran %)
    URINE ANALYSIS ( MARCH 12,2023)
    10

    Physical Microscopic
    Color: YELLOW Pus Cells: 8-10 / hpf

    Transparency: Slightly Yellow RBC: 1-3 / hpf


    Specific Gravity : 1.005 Bacteria: FEW

    pH : 7.00 Epithelial Cells: Few

    CHEM EXAM Amorphous: Rare

    Albumin - “Negative” Urates: Rare

    Glucose – “Negative” Mucus Thread: FEW


    DIAGNOSTIC PROCEDURES
    • Transvaginal Ultrasound
    Transvaginal ultrasound revealed a cephalic presentation
    and lateral placenta location, grade II. The amniotic fluid
    volume is normal at 14.47cm, and the baby's estimated
    weight is 3300 grams (2lbs, 2 oz). The mean sac diameter
    was used to determine the patient's gestational age, and she
    was found to be 28 weeks and 5 days pregnant.
    • Fetal Ultrasound
    The fetal ultrasound revealed the gestation sac was in
    normal section.
    12

    TREATMENT (DRUG STUDY)

    Oxytocin (Pitocin, Syntocinon, Syntometrine)


    Cefuroxime (Apo-Cefuroxime, Ceftin, Zinacef)
    TREATMENT (PRE NATAL-MEDICATION)
    • Generic: Ferrous Sulfate Brand: Hemarate FA
    Classification: Anti-anemic
    Indication:
    • To prevent iron deficiency on the recommended daily
    allowance. To replace iron deficiency states. To treat
    iron deficiency in patient who have an intolerance to
    oral iron, have had unsatisfactory response to oral iron
    or who has have non-dialysis-dependent chronic kidney
    disease. To provide iron supplement during the
    pregnancy.
    TREATMENT
    14
    (PRE NATAL-MEDICATION)

    Generic: Calcium Brand Name: Caltrate 600+D3


    Indication:
    Calcium supplementation during pregnancy for women with deficient
    dietary calcium intake offers modest benefit in terms of preventing
    preeclampsia and preterm births and improving maternal and infant bone
    health.
    15

    NURSING CARE PLAN (NCP)


    GO A L S A ND I N T E RV E N T I ON S   16
    OU T C O M E
    A S S E S S M E NT D I AG N O S I S E VA L U AT I O N

    Assessed the vital signs of the patient. The patient does not
    Continued uterine Laboring patient To deliver the   experience any head
    contraction Fetus successfully. Performed internal examination (IE) ache, visual disturbances
    and does not show any
    Assisted the patient everything she needed to
    Irritability swelling on the face nor
    go to the comfort room ex. Putting on
    diapers. hands.
    V/S taken as
    follows Established rapport.

    Teach the patient the proper way of


    T: 36.7 mmHg breathing.
    P: 90bpm
    Massaged
    R: 20bpm
    the abdomen to help the placenta detach.
    BP: 100/60
    17

    SAMPLE CHARTING (FDAR)


    FOCUS DATA ACTION RESPONSE
    March 12, 2023 • 22 y/o G2P2 Mother, ex Fully Altered. Evaluated and Recorded.
    V.s. Taken and recorded 18
     
    In Labor Admission for Admission Secured

    BOW Ruptured 5:52 am


    Placed at DR Table
     
    Perineal Care Done
     
    Baby out 5:55 am
     
    Placenta out 5:58 am
     
    Oxy given (IM)
     
    IVF given
     

    March 13, 2023 Vs Taken and Recorded Signed and Endorsed


    Afebrile  
    Continuity of Care Vs Monitored q4
    Conscious  
    Monitored for any untoward s/sx.
    Coherent

    Pale Blessing

    Well Contracted Uterus


     
    THANK YOU

    Presented By:
    Piolo Amiel H. Launico
    Michael Christian Dionisio

    BSN 2 B Group 11:

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