VISION MISSION

A premier university in historic Cavite State University shall provide excellent,

Cavite recognized for
Republic of the Philippines equitable and relevant educational
excellence in the development CAVITE STATE UNIVERSITY opportunities in the arts, science and
of morally upright and globally technology through quality instruction and
Don Severino De las Alas Campus relevant research and development activities.
competitive individuals.
Indang, Cavite It shall produce professional, skilled and
morally upright individuals for global
competitiveness.

College of Nursing

CASE PRESENTATION
Postpartum

Presented by:
Trisha Mae B. Pascual
BSN 2-4

Presented to:
Ms. Ailene M. Maclid, RN, LPT, MAN, Phd©

Date:
October 9, 2019

In Partial Fulfillment of the Requirement in NURS 08 for the Degree Bachelor of Science in
Nursing
I.Demographic Data
A. Initials of Client’s Name: M.M. Date of Interview: October 21, 2019
B. Address: Brgy. Alulod, Indang, Cavite Time of Interview: 3:12 pm
C. Age: 23
D. Birth Date: October 4, 1996 Primary Informant: Client
E. Birth Place: Indang, Cavite Secondary Informant: None
F. Gender: Female
G. Civil Status: Single
H. Religion: Born Again
I. Highest Educational Attainment: High School
J. Occupation: None
K. Monthly Income/ Budget: 4K

II. Reason for Seeking Health Care

“minsan ay nakakaranas pa rin ako ng pananakit ng puson dalawang beses kada
lingo” as verbalized by the client. The client stated that she was experiencing after pains or
dicomfot twice every week and rated 6 out of 10 in pain scale that urged the client to seek
health care.

III. History of Present Illness

The client started feeling the after pains or discomfort after the delivery of her 2nd
child with a pain scale of 7 out of 10 4 times a week. 1 week before appearance, the client
experienced after pain once again with a pain scale of 6 out of 10. The client experienced
pain 3 days prior to appearance, “sumakit ulit noong nagpunta ako sa palengke kasama ang
asawa ko” with a pain scale of 6 out of 10 that urged the client to seek for medical
assistance.

IV. Health History

Client M.M. had a mumps chicken pox when she was 7 years old in 2006, her
mother told her to put vinegar with blue powder (tina). The client yearly has a fever with
duration of 3 days and takes 1 dosage of paracetamol in a day. The client has no recorded
injuries, accidents, adult illnesses and has no drug sensitivities and allergic reactions to any
foods, plants and animals. The client is not taking herbal medicines. Client M.M. is a fully
immunized child (FIC). The last tetanus toxoid that was given is on September 9, 2019. The
client did not undergo on any kind of examination.
 V. Pregnancy History
Client M.M., a 23-year-old G2P2 (2002) female with a 4 months old baby girl. The
client stated that she did not have any problems or complications such as spotting or
pregnancy-induced hypertension. The client’s expected date of delivery was on August 28,
2019 and stated that the pregnancy was not planned.

VI. Labor and Birth History

The duration of the client’s labor was 12 hours from 9pm-9am. The position of the
baby inside the uterus was on cephalic presentation and had a normal vaginal delivery.
The client stated that perineal sutures is not present and cannot remember if there is any
analgesia or anesthesia used during delivery.

VII. Infant Data

The newborn is girl and had a weight of 4kg with no congenital anomalies. The
client stated that there is no difficulty at birth such as need for resuscitation. Since birth,
the baby was being breastfeed by the client and still has no plans for formula feed. The
baby had a return visit for physical examination last September 2, 2019 and all findings
were normal. The client stated that her latest concern is when the baby had coughs and
colds last October 14, 2019. The baby is sleeping at spaced intervals every 7am-9am,
1pm-3pm, 9pm-4am and 5am-6:30am.

VIII. Postpartal Course

The client stated that her activity level since the birth was returned back to normal
after 4 weeks. Client M.M. had her lochia for about 2 weeks and stated that she still
experiences intermittent after pains or discomfort twice every week and rated 6 out of 10 in
pain scale. Fatigue, abdominal and breast pain was not verbalized by the client and has no
difficulty in elimination. The client stated that she is having disturbed sleep pattern because
the baby awakens at night. Client M.M. plans to continue work after her 4 month old baby turn
to 2 years old.

Gordon’s Functional Health Assessment

A. Health Perception-Health Management Pattern

The client stated that she asks advices to her mother for her to adjust easily after her
pregnancy state. The client’s last drink of alcohol was on March 2016 before pregnancy. No
usage of tobacco was stated by the client. Client M.M. has no problems with cuts healing.
As stated, the client experiences tinnitus on both ears 10-15 minutes every 2 months. The
client does not perform breast self-examination.
The client is oriented to person, place and time and appears to be well nourished with no
apparent distress. The pupil’s size and reaction are normal on both eyes. Whisper test and
Romberg Test was used to test the hearing, the right and left ear is within normal limits and
the client does not use hearing aids. The sense of touch, smell and taste was within normal
limits as well. The lymph nodes of the clients are not palpable upon palpation. The skin is
dry, warm, smooth with no lesions observed, and has no prominent discolorations. The
client’s hair has an even growth as well as the texture and the thickness. Client has no
unusual body odor. Nails are clean, firm, has a pink tone and in good shape with no
clubbing.

B. Nutritional Metabolic Pattern

The client’s weight is 52kg and a height of 158cm. She has gained weight for about 4kg
in the last 6 months. Good appetite was stated by the client and has low salt diet as
prescribed by a doctor last August 2019 and was able to follow it. The client drinks 6-7
glasses of water every day. She has no problem in nausea, vomiting, swallowing, chewing
and indigestion. Client M.M. describes her lifestyle as active.
The client’s skin appears normal, has a good turgor and no bruises and lesions upon
inspection. The mouth appears pink, soft and moist with no lesions and cracks on the
corners of the mouth. The client has dentures on the lower part of the teeth particularly the
2nd molars on both sides and has minimal dental carries on both molars in upper and lower
teeth. The tongue appears pink, moist and in moderate size. Generally, there was no edema
upon observation. The jugular vein is not distended and gag reflex is intact.

3-Day Diet Recall

October 18, 2019 October 19, 2019 October 20, 2019
(Saturday) (Sunday) (Monday)
Breakfast (7am) 2 pcs pandesal 1 serving of sinigang 2pcs pandesal
with 2 cups rice
Lunch (12am) 1 serving of chicken 1 serving of 1 serving of adobo
tempura with 2 cups sinigang with 2 cups with 2 cups rice
rice rice
Dinner (8pm) 1 serving of 1 serving of 1 pc bangus daing
sinigang with 2 cups sinigang with 2 cups with 2 cups rice
rice rice

C. Elimination Pattern
The client’s usual bowel movement is 3 times a week every morning. As described by
the client, her stool was usually soft and brown. The client had a diarrhea last September 12,
2019 to September 13, 2019 and taken an over-the-counter drug diatabs with 1 dosage per
day. No history of constipation, and incontinence as stated by the client. The usual voiding
pattern was 6-7 times per day. As described by the client, her urine was light yellow with
aromatic odor. The client experiences nocturia with 3 times frequency of urination during the
night. Client M.M. does not experience discomfort during urination and no excessive
perspiration upon observation. No tenderness and masses in the client’s abdomen upon
palpation.
D. Activity -Exercise Pattern
Client M.M. rated bathing, grooming, general mobility, toileting, home maintenance, bed
mobility, dressing and shopping 1 as completely independent. The client considered
household chores as her exercise every day.
The client is not cyanotic upon observation. The carotid, jugular, temporal, radial,
femoral, popliteal, protibial, dorsalis pedis pulses are easily palpable and regular with a
grade of +2. Upon locating the heart’s point of maximal impulse, any abnormal rhythm or
sounds was not heard upon auscultation. The respiratory rate and rhythm is regular and
symmetrical. We had the client walk in place for 3 minutes and minimal shortness of breath
after the activity was observed because the diaphragmatic excursion is lessened but no
dyspnea. The client has a normal range of motion, gait, balance, posture, muscle mass and
strength. No deformities, missing limbs and tremors upon inspection.

Activity Diary/ Recall

Sunday September 8, 2019 Activities
6:00 am woke up
6:30 am -8:00 am household chores
9:00 am watch television and eat breakfast
9:30 am breast feed
10:00 am -11:00 am take a bath
12:00 pm eat lunch
12:30 pm breast feed
1:00pm-3:00pm laundry
4:00pm-5:00pm watch television
5:30 pm breast feed
6:00 pm prepare dinner
7:00 pm eat diner
8:30 pm sleep

E. Sleep-Rest Pattern
The client’s usual sleep habit is 10 hours per night from 9pm – 6am and usually naps in
the afternoon from 2pm-4pm. The client has no difficulty in sleeping and awakens during the
night because of the baby. Yawning during the assessment not observed.

F. Cognitive-Perceptual Pattern
Client M.M. appears alert, and calm and doesn’t experiences numbness or tingling
sensation on any part of the body. The client has no difficulty upon reading a handheld
material with a distance of 2ft. The client has a vision of 20/20 upon using the Snellen chart
and has no history of eyeglass use. The client has no overt signs of pain. The client noticed
that she experiences mood swings frequently than her previous pregnancies.
G. Self-Perception – Self-Concept Pattern
The client rated her anxiety from 5 out of 10 without any signs of anxiety upon
observation. The level of assertiveness and level of control in situations is rated by the client
as 7 out of 10. Client M.M. does not show any unusual body language. The client views
herself as positive and healthy postpartum mother and stated that she currently do not have
any major health concerns.
The client appears calm, shows readiness in answering the questions and does not
hesitate to talk about her postpartum experience with a soft and normal voice quality.

H. Role-Relationship Pattern
The client belongs to a nuclear family type; this includes her husband, 25 years old and
daughter, 2 years old. Client’s family shows good affection towards each other and does not
show any form of dysfunctional family interactions upon observation. She stated that she is
active in terms of social activity that includes interaction with her neighbors and friends.
Client M.M. is unemployed and has a history of employment as an operator of a company.
The client’s support system includes her live-in-partner, neighbors and other members of the
family.

I. Sexuality -Reproductive Pattern

The client had a progestin only injectable at the barangay health center in Alulod,
Indang, Cavite. Client M.M. does not undergo pap smear ever since and has no history of
sexually transmitted disease. She is not experiencing any problems in sexual functioning and
satisfied with her sexual relationship.

J. Coping-Stress Pattern
Client M.M. appears without any signs of stress upon observation and stated that her
primary way to deal with it is through talking with her friends. Usage of cellular phone and
bonding with her children is considered by the client as her stress releasing activity. She
rated her usual handling of stress as average. The client is satisfied with the care that she is
receiving at home and has not experience any traumatic events in the past years. Financial
is the major concern of the client regarding hospitalizations.

K. Value Belief Pattern

The client stated that her religion is a Born Again and has no religious restrictions. The
client believed that eating twin banana during pregnancy will have a bad effect to the baby.
Client M.M. believes that the interview will not interfere with any of her spiritual or religious
practices as well as with her plans in the future.