ARELLANO UNIVERSITY
COLLEGE OF NURSING
2600 LEGARDA ST, SAMP. MANILA
SUBJECT: INP DATE:
NAME:Nicole Jane Z. Cuenco CI:Ma’am Violy Dunca
ACTIVITY: I CASE STUDY
CASE SCENARIO:
CASE: 8
CITA, G4P2 ( 2 TERM LIVING, 1 ABORTION ) WAS ADMITTED AT 1 PM TODAY DUE TO LABOR
PAINS. THE CERVIX WAS 3 CM, CEPHALIC, INTACT BOW. FHT= 144/MIN, BP=120/80, PR=
80/MIN, T= 36.5 C. SHE LIVES IN REMOTE VILLAGE, 5 HOURS AWAY FROM THE HEALTH FACILITY.
AT 6 PM, CONTRACTIONS WERE MODERATE, 3 IN 10 MIN. IE SHOWED CERVIX 4 CM DILATED.
FHT= 148/MIN. VITAL SIGNS REMAINED THE SAME. SHE VOIDED URINE SPONTANEOUSLY. AT 10
PM, YOUR IE SHOWED 6 CM DILATED CERVIX, WITH SPONTANEOUS RUPTURE OF MEMBRANES
WITH CLEAR AMNIOTIC FLUID. FHT= 150BPM, VS SAME. AT 12 AM, ANOTHER IE DONE SHOWED
8CM DILATED CERVIX, MECONIUM STAINED FLUID. BP=110/70, PR=92/MIN, T= 37.5 C, FHT=
140/MIN.
A. DEMOGRAPHIC DATA
Cita, lives in remote village
B. HEALTH HISTORY
G4P2 ( 2 TERM LIVING, 1 ABORTION )
C. PHYSICAL ASSESSMENT
As patient Cita admitted she complained of labor pains as the following assessment her
cervix was 3cm, cephalic intact bow, the FHT=144/min, as follows her vital sings
BP=120/80, PR= 80/MIN, T= 36.5 C.
D. PATHOPHYSIOLOGY – CONCEPT MAPPING
Pathophysiology of Pain
Stimuli
Nerve fibers
(nocireceptors)
Transduction(provokes
an electrical activity )
A-Delta Fibers C Fibers
(Large myelinated) (Small unmyelinated)
Spinal Cord
(Substanntial Gelatinosa)
MIDBRAIN
(Thalamus)
Cerebral Cortex
(Center for interpretation of pain )
Response
Involuntary Response
(Sympathetic &Parasympathetic) Voluntary Response
(Behavioral& Emotional )
PATHOPHYSIOLOGY
It is mostly caused by PATIENT NAME:
stimulation of mechanical ASSESSMENT
CITA
receptors in the uterus Patient complains of labor pains, her
and cervix, which cervix was 3cm, cephalic intact
respond to stretch from bow, the FHT=144/min, vital sings
uterine BP=120/80, PR= 80/MIN, T= 36.5 C.
contractions. Pain is also NURSING DIAGNOSIS
caused by activation of
chemoreceptors in the 1. Acute pain r/t
uterus that are stimulated labor contractions
by the release of AEB complain of
neurotransmitters in labor pain
response to uterine 2. Fatigue r/t
contractions. discomfort/pai
n AEB MEDICATIONS:
verbalization of NONE
MEDICAL DIAGNOSIS
pain
MEDICAL/SURGICAL
MANAGEMENT SIGN AND SYMPTOMS:
Baby drops
Cervix dilates.
RISK FACTORS Spontaneous rupture of
Pregnant woman membranes with clear amniotic fluid
Vaginal discharge
EXPECTED OUTCOMES
NURSING INTERVENTION
- Patient was able to make an
informed decision regarding pain - Assess pain, noting location, intensity (scale of 0-10)
control options she would like to duration
use - -Monitor skin color and temperature and vital signs
- Verbalized nonpharmacological - Determine client’s acceptable level of pain and pain
regimen control goals.
- Verbalized pain is - Provide comfort measures like back rub, helping
relieved/controlled position of comfort
- Demonstrate use of relaxation - Suggest use of relaxation technique and deep breathing
skills and diversional activities, as exercise.
indicated - Encourage diversional activities and relaxation
techniques
- Provide pharmacologic as prescribe.
E. LABORATORY
EXAMINATION NORMAL VALUES FINDINGS ANALYSIS NURSING ALERT
F. DRUG STUDY
DRUG MECHANISM INDICATIONS CONTRA- ADVERSE NURSING
ORDER OF ACTION INDICATION EFFECTS RESPONSIBILITY
S
G. NCP (2)
ASSESSMEN NURSING PLANNING INTERVENTION RATIONAL EVALUATIO
T DIAGNOSI E N
S
Subjective: Acute pain r/t After nursing - Assess - Allows the After nursing
Labor pain as labor intervention the current nurse to intervention the
contractions knowledge develop an
verbalized by as evidence by
patient will individualized
patient was
of obstetric
the patient the able to: pain control teaching plan able to:
-Make an measures for the patient - Make an
Objective : informed decision - informed decision
regarding pain regarding pain
cervix was control options
- Assess pain, -Provide control options
3cm, cephalic noting information
she would like to she would like to
location,
intact bow, the use to aid in use
intensity
FHT=144/min (scale of 0- determining
, as follows -Verbalize 10) duration choice or -Verbalized
her vital sings nonpharmacologic effectiveness nonpharmacologic
al regimen al regimen
BP=120/80, PR= of
80/MIN, T= 36.5 intervention
C. -Demonstrate -Demonstrate
use of relaxation use of relaxation
skills and -Which are skills and
diversional actually diversional
- -Monitor
activities, as
skin color altered in activities, as
indicated acute pain indicated
and
temperature
-Verbalize pain is -Verbalized pain
and vital -Varies with
relieved/controlled is
signs individual relieved/controlled
and situation
- Determine
client’s
acceptable -Promote
level of pain
relaxation,
and pain
control refocuses
goals. attention and
may enhance
- Provide coping
comfort abilities
measures
like back -To distract
rub, helping attention and
position of reduce
comfort
tension
- Suggest use
of relaxation
technique
and deep
breathing
exercise.
Encourage
diversional
activities
and
relaxation
techniques
ASSESSME NURSING PLANNING INTERVENTI RATIONA EVALUATION
NT DIAGNOSIS ON LE
Subjective Fatigue r/t After nursing -Assess degree Fatigue may After nursing
Cues : intervention the of fatigue. interfere with intervention the
discomfort/ the client’s
Patient patient will able to: patient was able to:
complains pain pain AEB physical and
during labor verbalizatio Use techniques
psychological
Used techniques
abilities to
n of pain to conserve maximally to conserve
energy participate in energy
Objective labor process
Cues: between contrac between contrac
and to master
vital sings tions. and carry tions.
BP=120/80, out self-care a
PR= 80/MIN, Report sense of nd infant care Reported sense
T= 36.5 C. after delivery.
control. of control.
-Provide
Appear reinforcem Appeared
moderately ent for moderately
relaxed. desired relaxed.
behaviors
-Keep client
informed of the
progress labor
- Maximizes
opportunitie
s for rest.
- Promotes
Plan care to limit
relaxation,
interruptions
enhances
the sense of
control, and
may
- Provide
strengthen
comfort
coping.
measures.
- The patient
will need
properly
balanced
intake of
-Promote
carbohydrat
sufficient
es, proteins,
nutritional
vitamins,
intake.
and minerals
to provide
energy
resources.
H. DISCHARGE PLANNING
M-edication – as physician’s ordered
E-nvironment/Exercises- Keep the patient at rest.
T-reatment- Use of analgesics for pain if indicated,
H-ealth teaching - Activity restriction, Signs and symptoms of infection, provide
health teachings about nutritional food and wound care.
O- Complete follow up check-up and consult the physician if complication
persists
D-eit- Diet as Tolerated
Encourage to eat proper balanced intake of carbohydrates, proteins, vitamins, and
minerals to provide energy resources.
I. REFERENCES
Maternal and Child Health Nursing
