Patient Strawberry CASE Study NCM 107 RLE 0B WARD PDF

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Republic of the PhilippinesTARLAC STATE UNIVERSITYCOLLEGE OF SCIENCEDEPARTMENT OF NURSING Lucinda Campus, Brgy. Ungot, Tarlac City Philippines Tel.: 4931865 Fax: (045) 982-0110 website: tsu.eduAccredited Level 2 status by the Accrediting Agency of Chartered Colleges and Universities inthe Philippine...

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Republic of the Philippines

TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE DEPARTMENT OF NURSING Lucinda Campus, Brgy. Ungot, Tarlac City Philippines Tel.no.: 4931865 Fax: (045) 982-0110 website: www.tsu.edu.ph

Accredited Level 2 status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines, Inc, (AACCUP)

A Case Study about Forceps Delivery in OB Ward presented to the Faculty of the Tarlac State University College of Science, Department of Nursing In Partial Fulfillment of the Requirements of the Subject Care of Mother and Child Submitted by: Manuel, Paolo P. Navero, Simon Peter D. Palencia, Aljon M. Pascual, Kiana Mikaela G. Reyes, Lorenz Eadrian Santos, Janray D. Tabion, Shanelle Anne Tamayo, Angel Tamondong, Bea V. Torres, Jodi Aine Kale Uy, Lejither Paul Valdez, Maria Angelica R. Yaquiten, Rico Submitted to: Prof. Kathleen Gail C. Guevarra September 2021

TABLE OF CONTENTS

I. INTRODUCTION-------------------------------------------------------------------------------------------------------------1-4 II. NURSING PROCESS -----------------------------------------------------------------------------------------------------------5 A. Assessment------------------------------------------------------------------------------------------------------5-21 1. Personal Data 2. Family History of Health and Illness/ (pregnancy) 3. History of Past illness/ (pregnancy) (GTPAL) 4. History of Present illness/ pregnancy 5. Physical Assessment 6. Laboratory and Diagnostic Procedures 7. Anatomy and Physiology 8. Pathophysiology B. Planning---------------------------------------------------------------------------------------------------------22-30 C. Implementation-----------------------------------------------------------------------------------------------31-54 1. Drugs 2. Medical Management 3. Surgical Management 4. Diet 5. Activity/ Exercise 6. Nursing Management D. Evaluation ----------------------------------------------------------------------------------------------------- 55-56 III. CONCLUSION ----------------------------------------------------------------------------------------------------------------57 IV. RECOMMENDATION ------------------------------------------------------------------------------------------------------58 V. REVIEW OF RELATED LITERATURE --------------------------------------------------------------------------------59-60 VI. BIBLIOGRAPHY--------------------------------------------------------------------------------------------------------61-62

Introduction

Many pregnant women can deliver their babies in the hospital normally and without medical assistance. This is called spontaneous vaginal childbirth. However, there are some situations in which a mother may need help during delivery. In these cases, doctors will perform an assisted vaginal delivery, which is sometimes referred to as an operative vaginal delivery. The doctor will use forceps or a vacuum to help get the baby out safely [ CITATION DrM16 \l 1033 ]. Forceps are a medical tool that resemble large salad tongs. During a forceps delivery, your doctor will use this tool to grasp your baby’s head and gently guide your baby out of the birth canal. Forceps are usually used during a contraction when the mother is trying to push the baby out [ CITATION DrM16 \l 1033 ]. In the last three decades, the use of forceps in newborn delivery has gone out of favor among obstetricians. Only about 1.1 percent of vaginal births are currently done with forceps (according to a retrospective cohort involving more than 22 million vaginal deliveries from 2005-2013). Vacuum extraction has also dropped in popularity, but it is still more common than forceps delivery; this could be because vacuum extraction is easier to use than forceps. When compared to the use of forceps, vacuum usage is less likely to result in a successful vaginal delivery (O'Mahony F, et al 2010). Even though forceps are more effective than vacuums, their use is on the decline. Some suggest that this downward tendency is due to a fear of litigation arising from typical forceps delivery problems, such as an increased risk of perineal laceration and baby damage. Others blame a lack of resident training for the decreased use of forceps (Dildi GA, et. al 2016). Forceps-assisted vaginal birth has its advantages. It has the potential to eliminate the need for a cesarean section if used correctly during the second stage of labor arrest. A cesarean section is a more intrusive treatment that comes with a higher risk of complications. Cesarean delivery is linked to a higher risk of postpartum infection (Bailit JL, et. al 2016). Cesarean sections are also linked to a higher chance of repeat cesarean sections, placental abnormalities, and uterine rupture in the long run (Keag OE, et. al 2018). Patients benefit from avoiding these difficulties, which is why many clinicians favor the return of surgical vaginal delivery (Dildi GA, et. al 2016). It is hard to predict what your labor and delivery will be like. But in general, the best thing you can do to have a complication-free delivery is to try to maintain a healthy pregnancy. That means exercising regularly, following your doctor’s recommendations for weight gain and healthy eating, and attending a childbirth class so that you know what to expect from delivery. Being prepared can help you to stay calmer and more relaxed during labor and delivery. If you’ve had more than one child, are older, or have a larger-than-normal baby, you are also at a higher risk of needing forceps [ CITATION DrM16 \l 1033 ].

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International Statistics From 1990 to 2019, this statistic represents the percentage of newborns in the United States that were delivered with forceps or vacuum extraction. Forceps were used to deliver nearly 5% of all newborns in the United States in 1990. The percentage of newborns delivered with forceps has reduced to 0.5 percent as of 2019.

Local Statistics In 2017, a total of 1,700,618 live births were recorded, equating to a crude birth rate (CBR) of 16.2 or 16 births per 1,000 people. Between 2012 and 2017, the number of registered live births decreased substantially. In the last five years, the number of live births has decreased by 5.0 percent, from 1,790,367 in 2012 to 1,700,618 in 2017. Several variables, such as social change or lifestyle choices connected with economic wealth, may have a role in the decline in births. The overall fertility rate has steadily fallen over time, according to the 2017 National Demographic and Health Survey (NDHS), from 4.1 children per woman in 1993 to 2.7 children per woman in 2017. At the moment, the ideal family size is 2.7 children. Many couples may reconsider having children due to the resources required to sustain them. The percentage of married women who use some form of family planning has climbed from 40% in 1993 to 54% in 2017.

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Objectives General We will be able to learn and expand our skills in this profession at the end of this case study, particularly in dealing with clients who have had a typical spontaneous birth. This case study will offer us with enough information to function as a guide. Furthermore, for us to successfully manage and provide postpartum care using the nursing process. Specific 1. Using the 13 areas of evaluation, determine the client's demographic profile, family history, history of past and present illnesses, and physical assessment. 2. Evaluate the client's laboratory and diagnostic results. 3. To examine the female reproductive organ's anatomy and physiology, as well as its pathology. 4. To develop nurse care plans in order to improve the client's condition. 5. Conduct a pharmacological trial in the context of typical spontaneous delivery. 6. To ensure continuity of care through the development of discharge plans.

II. NURSING PROCESS

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A. ASSESSMENT 1. Personal Data a. Demographic Data Name: Patient Strawberry Sex: Female Age: 20 years old Birthdate: January 9, 1996 Address: Rosario, La Union Civil Status: Single Nationality: Filipino Religion: Born Again Christian Chief Complain: Hypogastric Pain Admitting Diagnosis: Acute pain related to hypogastric pain radiating to the back with associated uterine contraction Details of Delivery: 3,010g male was delivered via Forceps delivery APGAR Score: 9/9 Baby’s Weight: 3,010 g Final Diagnosis: G1P1 (1001) Pregnancy Uterine 38 6/7 weeks of gestation cephalic delivered via outlet forceps extraction under CEA due to fetal bradycardia to a live full term baby girl in CA; BW: 3.01kg; BL: 49 cm; AS: 9,9; BS: 39-40 weeks s/p RMLE with repair

b. Environmental Status

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Patient Strawberry lives at the same house with her parents in Rosario, La Union. Their house is made from concrete and heavy materials like metals and was completed 10 years ago. They have two (2) bedrooms where the mother and father share the first bedroom while the other room is for her. They have two (2) large windows located in the kitchen and living room and four (4) average size windows located in each bedroom. The windows are all made of tinted sliding glass. They have fine drainage system that drains through barangay canals. For the water system, they use NAWASA for all the time except for drinking. They bought drinking water at nearby municipal mineral water station. They use electricity as main source of power. They have a three-quarter bathroom that separate the toilet and sink from the shower. The garbage disposal is well-executed as they have five (5) small garbage bins inside their house and one (1) large garbage bin outside. It is being collected every Friday each week by municipal waste management department. They are near supermarkets; they can easily buy foods and other necessities outside. c. Lifestyle The patient is currently a college student, she spends a lot of time after school with her friends. She is not lacking for any needs of food and drink since her parents diligently provide it for her. She eats 3 times a day with balance diet of vegetables and meat. Aside from breakfast, lunch, and dinner, she also enjoys the privilege of eating afternoon snacks. She drinks at least 8 glasses of water or less each day. She likes eating fruits specifically citrus fruits; however, she likes eating street foods and junk foods while at school her lunch is always from fast food store. She is sleeping in a regular routine pattern from 8 pm and waking up 5 am. She rarely does exercise and physical activities, but she helps her mother in daily household chores like washing the dishes and preparing for meals. Their bonding as a family is watching television, she is the only child, and she is very close with her parents. After spending time her parents, she will go up to her room and she spend time talking online with her friends, she loves interacting with other people specially through social media. She loves eating outside and she drink alcohol, but she hates cigarette.

2. Family History of Health Illnesses

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There were no respiratory illnesses or allergies in the family. Her grandfather and grandmother on her father’s side died due to Hypertension, while her grandfather on her mother’s side died due to Diabetes Miletus. Her grandmother is free of any illness or difficulties. Her mother and father have no health issues or history of past illness.

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3. History of Past Illness Patient Strawberry has no record of any past illness. She got vaccinated with Bacillus CalmetteGuerine (BCG) and Hepatitis B at birth, and Pentavalent vaccine, oral polio vaccine, Pneumococcal Vaccination (PCV), and MMR (measles, mumps, and rubella) as follows. She does not have any allergy to food and medication. 4. History of Present Condition Patient Strawberry, the patient, began having problems as soon as her period stopped coming on schedule. The symptoms appear gradually. As a result, the patient had frequent urination and mood changes. Morning sickness affects women during their first and second trimesters. Constipation, back discomfort, leg cramps, vaginal thrush, shortness of breath, and swollen ankles and hands were additional symptoms. Prior to admission, patient Strawberry is a G1P1 and reported hypogastric pain. She stated that the pain is radiating to the back with a pain scale of 7-8/10 with associated uterine contraction that occurs every 30 minutes that lasts for 10 seconds. Thirty minutes after admission the patient reported watery vaginal discharges, amounting more than 1 glass. Physical examination patient was conscious, ambulatory, conversant, afebrile and not in cardiopulmonary distress. Height: 160.02 cm (5ft 3in), prepregnant weight was 49 kgs while present weight is 54 kgs, weight gain of 5 kgs (normal). As for the vital signs, it is recorded as follows: BP - 110/70mmHg CR - 87bpm RR - 20bpm Temp - 36.7 degrees Celsius

5. Physical Assessment a. 13 Areas of Assessment Name: Straw Berry Age: 20 Area of Assessment Findings Social Status Patient Straw Berry is a 20-yearold female, born on January 9, 1996. She is Filipino and resides on Rosario, La union. She is currently enrolled as a college student. Her civil status is currently single, and her religion is Born Again Christian. The patient has a close relationship with her parents and is an only child. Their bond mainly includes watching television. After school, she also loves to spend time with her friends and like every other youth, she in active in social media. Mental Status >General Upon admission, the patient’s Appearance and appearance looks presentable. She Behavior is dressed comfortably, properly groomed, and maintains eye contact when interviewed. However, the patient emits guarding behavior over her abdomen.

Norms Social status is the position one holds in a group or community. It is social support that builds people up during times of stress and often gives them the strength to carry on and even thrive (Cherry, 2020).

Analysis/Interpretation Based on the norm, the patient is able to maintain a normal social lifestyle and status. She gets along with people and is able to build a relationship with others.

Appearance is described as wellgroomed/disheveled, how they are dressed, demeanor in interview, level of eye contact. As appropriate, physical behavior such as restlessness, motor Activity (retardation/over activation) Level of co-operation, any evidence of aggression or hostility. Overfamiliarity, for instance touching interviewer inappropriately (MSE, n.d)

The patient is well groomed and does not exhibit signs of retardation and aggression. Her guarding behavior suggests that she is in pain.

>Level of Consciousness and Orientation

Patient is well-aware and is conscious of the situation. She is literate and is participative on answering questions.

The normal state of consciousness comprises either the state of wakefulness, awareness, or alertness in which most human beings’ function. Being oriented to place and time means that you know who you are, where you are, where you live, and what time it is. When consciousness is decreased, your ability to remain awake, aware, and oriented is impaired (Lights, 2019).

Findings shows that that the patient is within the normal state and is in the right mental capability while interacting with others.

>Speech

The patient is very conversant. She delivers and articulate her words in a soft but audible voice.

Rate ranges from spontaneity with little or no spontaneous utterances to circumstantiality with overinclusion of detail, volume: from low to high, rhythm: monotonous, without variation or inflection; staccato, with frequent pauses between fluent speech, and normal., tone: ranges from low to high (MSE, n.d)

The patient has good communication skills and is able to relay her messages well.

Emotional Status

The patient indicated that she feels anxious during the course of her admission. Grimace are observed when her pain is triggered. She is able to calm down when she is within her family’s presence.

During adulthood, here is some support for the view that people do undertake a sort of emotional audit, reevaluate their priorities, and emerge with a slightly different orientation to emotional regulation and personal interaction in this time period (Lumen, n.d)

Patient’s emotional status appears to be troubled due to her pain. She is able to cope up with the stress through her family.

On assessing the patient’s eyes, the sclera is white, there are no lesions, and palpebral conjunctiva is pink in appearance. She is tearyeyed due to her pain. Patient is

In a normal patient, the sclera is white in color and the palpebral conjunctiva appears pink. (Chandrasekhar, A., n.d). Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the

Eye assessment appears to be normal and patient’s vision is not distorted.

Sensory Perception >Sense of Sight

able to see things clearly without patient can read from 20 ft what a person with normal acuity (20/20 vision) any problems. can read from 50 ft (Shultz et.al., 2016). >Sense of Taste

Buccal mucosa is moist, there are no presence of neck vein engorgement, and there are no anterior neck masses. Patient is able to distinguish different taste of foods.

>Sense of Hearing

External ear is checked for its condition. There are no lesion, excessive cerumen, and presence of swelling. Patient has no trouble on hearing words.

>Sense of Smell

There are no deviations, swellings, and lesion at her external nose structure. Mucous membrane is pinkish-pale in color, and there is no discharge. The patient was able to identify different scents.

Normal tissues of the buccal mucosa appear moist and pink/dark pink. They are soft and pliable on palpation with no discernible indurations (Dental Care, n.d). A person usually identifies the taste of bitter, sweet, sour, and salty. By the use of our sense of taste, we can fix or adjust the taste of our food based on our capacity (Blue, 2018) An adult is classified as having normal hearing ability if their responses indicate they heard noises between 0 and 25 dB across the frequency range (Mroz, 2020).

Nose must be symmetrical and along of the face. Each nostril must be patent and recognize the smell of an object. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances (Shultz et.al, 2016). Tactile receptors identify the sensation

Assessment for ability to distinguish flavors and condition of oral cavity appears to be normal.

Condition of the ear and the hearing acuity of the patient is normal.

Patient was able to identify different aromas presented and there are no abnormalities on the appearance of their nose.

>Tactile

The patient is able to identify and feel stimuli that comes in contact with her skin. However, she gets irritated when someone is touching her.

Motor Stability

Patient was ambulatory despite presence of hypogastric pain. Her extremities have no gross deformities.

Body Temperature

Patient’s temperature was 36.7C and is afebrile.

Respiratory Status

Respiratory rate was 20 breaths per minute. For chest and lungs, there was a symmetrical chest wall expansion and no intercostal retractions and no lagging is noted. Upon auscultation, there are no crackles and wheezes, breath sounds are clear. Blood pressure was recorded at 110/70 mmHg. Cardiac rate is 87bpm. Cardiac examination revealed adynamic precordium, and point of maximal impulse is at

Circulatory Status

of touch and are all over our bodies in our skin. Some are...