A Nursing Care Plan
In Partial Fulfillment of the
Requirements in NCM 207 – RLE
DELIVERY ROOM ROTATION
Submitted to:
Prof. Kristine Monica Reyes, RN
Clinical Instructor
Submitted by:
Fhey Bernadette M. Beltran
BSN 2L – Group 2 (Subgroup 2)
November 8, 2021
Case Scenario #1
On October 14, 2021, Maria Ana, 35 years old, was admitted due to hypogastric pain with bloody vaginal discharge. Her obstetric history are the following:
LMP was July 10, 2021, delivered a full-term baby in 2000 through NSVD, the next 3 pregnancies were aborted (2010, 2011, and 2012). On October 13,
2021, she had her first USD, the result was single live intrauterine pregnancy at 13 weeks and 3 days (3 months 1 week and 3 days old) AOG, placenta
partially covering the cervical OS, (+) subchorionic hemorrhage inferior to the gestational sac, close cervix, FHT 158 bpm, EDD: April 17, 2022. During her
admission, she was categorized having a high-risk pregnancy and diagnosed with threatened abortion and UTI. On palpation, the uterine contraction was at
10-15 minutes interval, 40-50 seconds with moderate intensity and verbalized a pain of 7/10 pointing at lower abdomen.
PHYSICAL ASSESSMENT

Vital Signs (upon admission)
o BP: 135/90 mmHg
o HR: 76 bpm
o PR: 83 bpm
o RR: 16 cpm
o Temp: 37ºC

General Appearance – appear tired

Abdomen – small engorgement of lower abdomen

Genitourinary – redness of outer vagina, leukorrhea (milky color)
BLOOD CHEMISTRY

Blood Type: A+

WBC: 12.2 x 109 /L (high)
URINALYSIS

Color: Light Yellow

Transparency: Slightly Cloudy

WBC: 42 x 109 /L (high)

RBC: 15 x 109 /L (high)

Epithelial Cells: 21 (high)

Bacteria: 1121 x cfu/ml (high)
THERAPEUTICS

CBR s̅ BRP

PLR 1L @ 120 cc/hr

Ampicillin 1 g/IVTT q6

Metronidazole 500 mg/tab PO q8

Duphaston 10 mg/tab PO q8
CLUSTERING OF CUES
GORDON’S FUNCTIONAL HEALTH PATTERN
Nutritional / Metabolic
CUES
Blood Chemistry

PRIORITY
High Priority
High WBC (12.2 x 109 /L)
Urinalysis
Cognitive / Perceptual

High WBC (42 x 109 /L)

High RBC (15 x 109 /L)

High Epithelial Cells (21)

High Bacteria (1121 x cfu/ml)

Hypogastric Pain

Pain Scale of 7 out of 10 pointing @ lower abdomen

Uterine Contraction @ 10-15 minutes interval, 40-50
High Priority
seconds c̅ moderate intensity.

“Nurse sakit kaayo akong tiyan kanang diring dapit
baba sa akong puson. Murag gina kumot sa kasakit” As
verbalized by the patient.
Activity / Exercise
VS
Medium Priority

BP: 135/90 mmHg

HR: 76 bpm

PR: 83 bpm

RR: 16 cpm
Self-Perception / Self-Concept
Health Perception / Health Management
Elimination
Sexual/Reproductive

Temp: 37ºC

Appears Tired

Small Engorgement of lower abdomen

Redness of outer vagina, leukorrhea

Grimace Face

Guarding behavior at lower abdomen

CBR s̅ BRP

PLR 1L @ 120 cc/hr

Ampicillin 1g/IVTT q6

Metronidazole 500 mg/tab PO q8

Duphaston 10 mg/tab PO q8
Urine
Medium Priority
Low Priority
Low Priority

Color: Light Yellow

Transparency: Slightly Cloudy

Delivered a full-term baby in 2000 through NSVD, the
Low Priority
next 3 pregnancies were aborted (2010, 2011, and
2012).
Role / Relationship

G5P1A3

Mother of 5 children.
Low Priority
Name of the Client: M.A.
Age/Sex: 35/F
Chief Complaint: Hypogastric Pain
Attending Physician: Dr. Garcia
Date /
Cues
Need
Time
O
Subjective:
C
C

O
T
“Nurse sakit
kaayo akong
diring dapit baba
B
sa akong puson.
E
R
Murag gina
kumot sa kasakit
labi na kung
mubusog” As
4
2
Diagnosis
Outcome
Interventions
The patient will
evidenced by pain
hours.
level of pain by below
N
uterine contraction at
lower abdomen,
10-15 minutes
shows lessened
interval lasting to 40-
signs of guarding
50 seconds with
behavior and
moderate intensity,
grimace face within 4
guarding behavior,
– 6 hours after doing
and grimace face.
the nursing
V
E
patient.
P
Rationale:
E
According to the
R
Monitor Vital Signs
of mother every 4
scale of 0-10 at the
T

uterine contraction as verbalize decrease
lower abdomen,
verbalized by the
1
Nursing
Acute Pain related to
interventions.
Bed #: _____
Admitting Diagnosis / Impression: Threatened Abortion and UTI.
Patient
scale of 7 out of 10 at 7 through a pain
I
Room #: _______
Nursing
G
tiyan kanang
O
Ward: __________________
Implementation
Evaluation
1
October 14, 2021 @
1:00 PM
Goal Partially Met:
R: Taking and
The patient was able
Monitoring the Vital
to verbalize
Signs will give nurses
decreased level of
baseline information
pain at the lower
from which they can
abdomen by the pain
compare if the
scale of 4 out of 10.
interventions worked or
Although, patient still
not. Also, VS are
shows guarding
altered when patient is
behavior and
under stress (i.e. pain)

Perform an
Maternal and Child
assessment to the
book of Pillitteri
patient. Determine
grimace face.
2
“Nurse mas arangarang na akong
(2014, p. 397),
the location,
paminaw karon
contractions are
characteristics,
kaysa ganina.
clustered as
onset, duration,
Salamat kaayo.” As
P
involuntary actions
frequency, quality,
verbalized by the
T
that either cause pain
and severity of pain
patient.
or not. These are
via assessment.
0
Objective:
C
2

E
Pain at
hypogastric
1
region.

Facial
Appearance of
@7:00
Tiredness.
am

Grimaced face

Guarding at pain
site.
Vital Signs:

BP: 135/90
mmHg

HR: 76 bpm

PR: 83 bpm

RR: 16 cpm

Temp: 37ºC
A
L
contractions in the
heart, stomach, and
intestine. However,
contractions in the
uterus cause pain
because blood
vessels constrict,
leading to the
decrease of blood
R: The patient
experiencing the pain
is the most reliable
source of information.
Also, this will help
nurses plan effective
pain management
strategies for the
patient.
supply in the uterine
and cervical walls,

Assist patient in
which results in
semi-fowler’s
anoxia to muscle
position or let
fibers. In addition,
patient assume
High WBC (12.2
painful sensations
position of comfort
x 109 /L)
during contractions
Blood Chemistry:

U
3
Urinalysis:
usually happen due
R: Semi-fowler’s

High WBC (42 x
to the stretching of
position helps reduce
109 /L)
the cervix and
abdominal pressure
High RBC (15 x
perineum.
and tension, thereby
Nonetheless, women
reduces pain.
should also take into
However, patient will
consideration that
naturally assume least
painful contractions
painful position for
during the early
relief.
weeks of pregnancy


109 /L)

High Epithelial
Cells (21)

High Bacteria
(1121)
might also be the
Medication:

Duphaston 10
mg/tab PO q8
cause of liver,
kidney, and Bladder
infection and might
be at risk for ectopic
pregnancy. (Villines,
2019)
References:
Demonstrate and
encourage
relaxation
techniques, such as
deep breathing,
visualization, and
abdominal
breathing.
R: Relaxation
Pillitteri, A. (2014).
techniques refocus
Etiology of Pain
attention, reduce
During Labor and
muscle tension,
4
Birth. In Maternal &
promote sense of well-
Child Health Nursing:
being, and control or
Care of the
decrease discomfort.
Childbearing &

Childrearing family
Electronic Fetal
(revised, p. 397).
Villines, Z. (2019.).
Uterus pain in early
pregnancy: Causes
and treatments.
Attach and Monitor
5
Monitoring.
R: This is to monitor
the fetus’ heart rate
during uterine
contractions.
Medical News Today.
Retrieved November

Encourage the
7, 2021, from
mother to increase
https://www.medicaln
oral fluid intake.
ewstoday.com/article
R: Hydration reduces
s/326427.
uterine contractility by
increasing uterine
blood flow and by
decreasing pituitary
secretion of antidiuretic
hormone and oxytocin.
6

Instruct mother to
7
avoid nipple
stimulation.
R: When nipples are
stimulated this triggers
to release oxytocin in
which triggers uterine
contractions.

Give health
teachings to mother
to increase fiber
intake in diet
R: Having sufficient
fiber intake in the body
prevents constipation.
If ever there is a
persistent constipation
then this may cause
irritation of the uterus,
which can lead to
8
excessive uterine
contractions.

Continue IV fluid,
9
PLR 1L @ 120cc/hr
until further orders
by the doctor.
R: Lactated Ringer’s
solution has an
electrolyte
concentration similar to
that of extracellular
fluid. Also, this works
for fluid resuscitation to
avoid dehydration.

Continue
administering
Duphaston until
further instructions
by the doctor.
10
R: Duphaston mimics
the action of
progesterone which
helps reduce the
chance of having
threatened abortion.

Monitor I&O q shift.
11
R: To properly
measure the amount of
fluid intake and output
of the patient, to check
to fluid retention or
fluid overload.
Fhey M. Beltran,St. N
References:
Nwadlike, V. (2018). Does nipple stimulation help to induce labor? Retrieved November 6, 2021 from
https://www.medicalnewstoday.com/articles/322326#overview
Pillitteri, A. (2014). Etiology of Pain During Labor and Birth. In Maternal & Child Health Nursing: Care of the Childbearing & Childrearing family (revised, p.
397).
Villines, Z. (2019.). Uterus pain in early pregnancy: Causes and treatments. Medical News Today. Retrieved November 7, 2021, from
https://www.medicalnewstoday.com/articles/326427.
Wahabi, H. A., Fayed, A. A., Esmaeil, S. A., & Bahkali, K. H. (2018). Progestogen for treating threatened miscarriage. The Cochrane database of
systematic reviews, 8(8), CD005943. https://doi.org/10.1002/14651858.CD005943.pub5
Wayne, G. (2021). Acute Pain Nursing Care Plan. Retrieved November 4, 2021 from https://nurseslabs.com/acute-pain/