A Case Study of Cesarean Delivery (Breech Presentation)

Submitted by: Corpus. Nichelle Urbano, Mary Ann Ursua, John humprey Villarta, John Harley Ylanan, Narissa Ylanan, Nina Submitted to: Mrs. Rebecca Kagahastian-Dominguez, RN Clinical Instructor

I.

INTRODUCTION

Nursing process is a patient centered, goal oriented method of caring that provides a frame work to the nursing care. The nursing process exists for every problem that the patient has, and for every element of patient care, rather than once for each patient. The nurse's evaluation of care will lead to changes in the implementation of the care and the patient's needs are likely to change during their stay in hospital as their health either improves or deteriorates. Nursing process was used in this case study for a more systematic to care for a client who have undergone a cesarean section birth. Cesarean section is commonly called a c - section. Instead of a vaginal birth, during a c - section, your baby is delivered through your abdomen. It is accomplished through an abdominal incision into the uterus and is one of the oldest types of surgical procedures known. It is a procedure always slightly more hazardous than vaginal birth. However, when compared to other surgical procedures, it is one of the safest types of surgeries and one with few complications. Caesarean delivery is a surgical procedure to remove the baby from the uterus through an abdominal incision. Recovery after a caesarean section takes more time than recovery from a vaginal birth. After a cesarean section is common to remain in the hospital 3 to 4 days and full recovery will take between 4 to 6 weeks. Usually, hospitalization for a vaginal delivery is 2 days, and requires less recovery time as a caesarean birth. Caesarean section is also more costly economically than vaginal birth. Breech birth is the birth of a baby from a breech presentation. In the breech presentation the baby enters the birth canal with the buttocks or feet first as opposed to the normal head first presentation. The bottom-down position, called breech presentation, presents some hazards to the baby during the process of birth, and the mode of delivery (vaginal versus Caesarean) is controversial in the fields of obstetrics and midwifery.

This means that your baby is in a bottom-down position. If this is your first baby, he will probably settle into a head-down position in your pelvis around the eighth month of pregnancy. This is called a vertex or cephalic position. When labor begins, nearly all (96 percent) babies are lying head down in the uterus, but a few (about 3 to 4 percent), will settle into a bottom first, or breech, position.

II.

OBJECTIVES

The significance of the study is for us third year students to apply the principles and concepts that we have learned in the NCM 201 (Maternal and Child Nursing) in our rotation at Ospital ng Sampaloc, with the following learning objectives: 1. Cognitive To be able to review concepts and theories in maternal and child nursing. To be able to describe the development, pathophysiology, medical-surgical management, and nursing care of a client who have undergone a cesarean section birth. To be able to design a Nursing Care Plan for the patient who have undergone cesarean birth. To be able to provide information and heath teachings to the patient in the postpartum period. 2. Psychomotor To be able carry-out hospital routines and the treatment prescribed to the patient. To be able to perform nursing procedures and nursing considerations for a client in the postoperative stage. To be able to implement the nursing care plan. 3. Affective To be able to establish a good working relationship with the patient and hospital staff.

III. PATIENTS PROFILE Demographic Profile: Name : Precy Codillo Age : 27 years old Address : 2432 Legarda St. Sampaloc Manila Name of Spouse : Joseph Codillo, 28 yrs. old Name of Father : Victorino Codillo, 56 yrs. old Name of Mother : Elsa Codillo, 56 yrs. old Nationality : Filipino Occupation : Housewife Educational Attainment: College undergraduate ( I.T) LMP : February 15,2011 EDC : November 22,1011 Admission Date : November 21, 2011 Date of Delivery : November 22, 2011 Discharge Date : November 25, 2011 Surgery Performed : Cesarean Sect

IV. HISTORY OF PAST AND PRESENT ILLNESS The patient stands 153 centimeters and weighs about 58 kilograms. Her AOG is 31 weeks and 1 day, LMP was last February 15,2011 and her EDC was on April 8, 2009. Her OB score is G2P2 (2,0,0,2). She was married at the age of 23 years old.She gave birth to her first child through Normal Spontaneous Delivey, It was on November 21,2011 at around 9:00pm when Precy was admitted and was sent to the OR/DR for an internal examination. The midwife opted for cesarean section for this pregnancy because of the babys presentation(breech presentation).

V.

PHYSICAL ASSESSMENT

BODY PART HEAD Skull

TECHNIQUE USED palpation

FINDINGS proportional to the size of the body, round, with prominences in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently curved scalp is white, clean, free from masses, lumps, nits, dandruff & lesions, with no areas of tenderness upon palpation; hair is black, evenly distributed & covers the whole scalp, thick & shiny oblong shaped, symmetrical, smooth & no involuntary muscle movements eyes are parallel & evenly placed, symmetrical, nonprotruding, with scant amount of secretions, both eyes black & clear; sclera is white & clear; eyebrows are black, symmetrical, thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly distributed & turned outward; upper eyelids cover a small portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding

INTERPRETATION Normal

Scalp/ Hair

inspection palpation

Normal

Face

inspection

Normal

Eyes/ Vision

inspection palpation

Normal

skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent & salmon pink in color; iris are proportional to the size of the eye, round & symmetrical; pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light & accommodation; able to move eyes in full range of direction Ears/ Hearing inspection palpation ears are parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area & clean; ear canal is pinkish, clean, with scant amount of cerumen & a few cilia; able to hear whisper spoken 2 feet away; 2 piercing are found in left ear and 1 piercing in right ear nose is in midline, symmetrical, patent; internal nares are clean, dark pink with few cilia lips are pinkish, symmetrical, lip margin is welldefined, smooth & moist; gums are pinkish, smooth, moist, no swelling, no retraction, no discharge; 32 teeth are present, aligned, with no dental caries; tongue is pinkish, slightly rough on top, smooth along the lateral margins, moist, shiny & freely Normal

Nose

inspection palpation

Normal

Mouth/ Lips

inspection palpation

Normal

movable; cheeks are pinkish, moist & smooth; frenulum is in midline, straight & thin; soft palate is pinkish, smooth & moist; hard palate is slightly pinkish; uvula is at the center, symmetrical & freely movable NECK inspection palpation proportional to the size of the body & head, symmetrical & straight, no palpable lumps, masses or areas of tenderness chest contour is symmetrical, spine is straight, no lumps, no masses, no tender areas, with clear breath sounds no abnormal pulsations, pulsations are palpable & visible in apical area symmetrical, pinkish nipples, no cracks & discharges, uniform in skin color, smooth & intact, no lumps, masses & tenderness presence of horizontal incision on the lower part of the abdomen due to her recent cesarean delivery surgery symmetrical, with visible veins, fine hair evenly distributed, warm, dry & elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft & elastic; nails are transparent, smooth & convex with light pink nail beds & white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands & Normal

THORAX & LUNGS

inspection palpation percussion auscultation

Normal

HEART

inspection palpation percussion auscultation

Normal

BREAST

inspection palpation

Normal

ABDOMEN

inspection auscultation percussion palpation

Normal

UPPER EXTREMITIES

inspection palpation

wrists can be moved in different range of motion with relative ease; c marks of petechial rashes skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips; both legs, knees, ankles, & toes can be moved in different range of motion with relative ease; scar on both patellar; c non pitting bipedal edema

Normal

LOWER EXTREMITIES

inspection palpation

VI.

GORDONS FUNCTIONAL PATTERNS

PATTERN OF HEALTH PERCEPTION & HEALTH MANAGEMENT She does not feel anything wrong in herself, she does not feel weak. Though, she feels pain in her wound from her cesarean incision. She eats a balanced diet of meat, vegetables and fish. She does not exercise but she always does her daily household chores and treats it as her exercise to maintain her physical health. She has no allergy. Her mother has high blood pressure. She was not yet hospitalized until recently she had to undergo cesarean delivery because her child was in breech presentation. NUTRITIONAL - METABOLIC PATTERN She eats vegetables, meat and fish. She drinks coffee and juices. She always drinks soft drinks and eats a lot of salty foods. She does not have any disease that affects her nutritionalmetabolic function.

PATTERN OF ELIMINATION She urinates every day and has a regular bowel movement. She has no diseases on her digestive system, urinary system and has no skin problems. PATTERN OF ACTIVITY & EXERCISE Ever since she got married and when she had her first baby, she just stays at home taking care of her baby and their household chores. She does not do exercise, her main work out is doing the household chores. Twice or thrice a month, she goes to church along with her family. When they have their free time, they spend it by going to Luneta Park.

COGNITIVE - PERCEPTUAL PATTERN She does not have any sensory deficits. She is a college undergraduate(2nd year I.T). She worked as a service crew in a fast-food chain and she was not yet married at that time. She does not have any disease that affects her mental or sensory functions. She feels pain in her wound that she got from her recent surgery regarding her cesarean delivery. In a scale of 1-10, she stated that the pain she feels is at 6. PATTERN OF SLEEP & REST She always sleeps early at night and gets up early in the morning. Sometimes, she takes a nap in the afternoon. She does appear physically rested and relaxed. PATTERN OF SELF PERCEPTION & SELF CONCEPT There was nothing unusual in her appearance, and shes quite comfortable with her appearance. ROLE - RELATIONSHIP PATTERN She is an attentive mother to her child and a responsible wife to her husband. She does not have any problem with her husband for he doesnt have any vices. Family is the most important thing in her life. SEXUALITY - REPRODUCTIVE PATTERN She is satisfied being a woman and a mother to her child. They do not use contraceptives and pills. They had a 4-year interval before they had their second child. She does not have any disease regarding her reproductive system. PATTERN OF COPING & STRESS TOLERANCE Whenever she has problems, she prays and she talks to her husband about it to get an advice or an opinion. She has not had any treatment for emotional distress.

PATTERN OF VALUES & BELIEFS She was born and raised as a roman catholic by her parents. She goes to church at least twice or thrice a month.

VII.

ANATOMY AND PHYSIOLOGY

Vagina The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches long in a grown woman. The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes, which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur. The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the penis. The middle layer has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer muscular layer is especially important with delivery of a fetus and placenta. Purposes of the Vagina

Receives a males erect penis and semen during sexual intercourse. Pathway through a woman's body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body. May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom.

The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened. The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping. The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates. The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses. The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible. The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus.

Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery. Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of ovaries and hormone production. At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg. When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the frimbriae. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes four to five days to travel down the length of the fallopian tube. If enough sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant itself in the uterine wall where it will grow and develop. If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage and possible death of the mother.

VIII.

PATHOPHYSIOLOGY Release of FSH by the anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickening of the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from the graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovum and sperm in the ampulla)

Zygote travels from the fallopian tube to the uterus

Implantation

Development of the fetus/embryo & placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening

Braxton Hicks Contraction

Ripening of the cervix

(descent of the fetal feet into the pelvis)

(false labor) >begin and remain irregular >1st felt abdominally >pain disappears with ambulation >do not increase in duration and intensity >do not achieve cervical dilatation

(Goodells Sign wherein the cervix feels softer like consistency of the earlobe

TRUE LABOR

Uterine Contractions >increase in duration and intensity >1st felt at the back & radiates to the abdomen >pain is not relieved no matter what the activity >achieve cervical dilatation

SHOW (pink-tinge of blood, a mixture of blood and fluid)

Rupture of Membranes (rupture of the amniotic sac)

Failed to progress labor (cervical atrophy)

increase risk for fetal distress (meconium staining, hypoxia)

Increase risk of fetal death

Emergent cesarean delivery (the incision made on the lower part of the abdomen)

Expulsion of the fetus

Expulsion of the placenta (Accompanied by blood)

IX.

LABORATORY PROCEDURES

Procedure / Date 1. CBC

Actual Findings

Normal Findings

Implications

Nursing Responsibilities Pre: Check Doctors Order. Inform client and explain the procedure. No need for NPO.

Hemoglobin

116

120 140 g/dL

Decrease - Indicates occurrence of

0.30 Hematocrit 0.35

anemia Increase - Indicates

5 - 10 WBC Segmenters Lymphocytes 8.0 0.60 0.14 0.36 - 0.66 0.22 - 0.40

hypercoagulation Normal Normal Decrease - Indicates high risk for acquiring

Intra: Perform blood extraction (venipuncture technique) using aseptic technique.

Procedure / Date

Actual Findings

Normal Findings

Implications infection

Nursing Responsibilities Put extracted blood in ethyldiaminotetracetate (EDTA) or the lavender top vacuum tube.

Eosinophils Stab Cells Platelets

0.02 0.04 320

0.01 - 0.04 0.02 - 0.05 150 400x9/L

Normal Normal Normal

Post: Label the container properly and correctly. Send specimen to the lab immediately. Document the result to the chart and inform physician that the result is out.

URINE ANALYSIS

Microscopic Exam Color: Yellow Transparency: Hazy pH: 6.0 (7.35 7.45) Specific Gravity: 1.010 (1.010 1.025) Epithelial Cells: Moderate

Chemical Exam Albumin: Negative Sugar: Negative

X.

NURSING MANAGEMENT

NURSING CARE PLAN

ACTUAL

Assessment
Subjective:
Masakit ung tahi ko as verbalized by patient.

Diagnosis
Acute pain related to disruption of skin, tissue, and muscle Integrity.

Inference
Caesarean delivery is the surgical removal of the infant from the uterus through an incision made in the abdominal wall and the uterus. Size and location of the incision vary, but abdominal and uterine incisions of choice are low and horizontal. Vertical incisions may be necessary for quicker procedures, the presence of adhesions and other complications.

Planning
After 8 hours of nursing interventions ,the patient pain will be relieved or controlled

Intervention
Independent:
-Evaluate pain regularly noting characteristics, location, intensity (0-10 scale). -Identify specific activity limitations. -Recommend planned or progressive exercise.

Rationale
-Provides information about need for or effectiveness of interventions. -Prevents undue strain on Operative site. - Promotes return of normal function and enhances feelings of general well being. -Prevents fatigue and conserves energy for healing. -Provides elements necessary for tissue regeneration or healing.

Evaluation
After 8 hours Of Nursing interventions, the patient pain was relieved or controlled

Objective:
-Facial mask of pain. -Guarding behavior. -Narrowed focus. -V/S taken as follows: T: 37.3 P: 80 R: 18 BP: 110/90

-Schedule adequate rest periods.

-Review importance of nutritious diets and adequate fluid intake.

-Reposition as indicated.

-May relieve pain and enhance circulation. -Improves circulation, reduces muscle tension and anxiety associated with pain. -Relieves muscle and emotional tension.

-Provide additional comfort measures like back rub.

-Encourage use of relaxation technique like deep breathing exercises.

Dependent:
-Administer analgesics or non steroidal antiinflammatory drugs as prescribed. -To relieve mild or moderate pain.

POTENTIAL CUES Subjective: - Patient verbalized hndi pa nalilinisan yung tahi ko ngaung araw na to Objective: - dressing dry and intact - V/S taken as follows: T: 37.3 P: 80 R: 19 BP: 120/90 DIAGNOSIS Risk for infection related inadequate primary defenses secondary to surgical incision INFERENCE Due to an elective cesarean section, patients skin and tissue were mechanically interrupted. Thus, the wound is at risk of developing infection. PLANNING STG: After 4 hours of nursing intervention, patient will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly. LTG: After 2-3 days of nursing intervention, patient will achieve timely wound healing, be free of purulent drainage or erythema, be INTERVENTION Independent: -Monitor vital signs -Inspect dressing and perform wound care RATIONALE EVALUATION Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

-To establish a baseline data -Moist from drainage can be a source of infection

- Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions .- Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).

-These are signs of infection

- Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk

afebrile and be free of infection. - Encourage coughing and deep breathing.

of bladder infection or urinary tract infection (UTI). - These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.

Interdependent: - Administer antibiotics(as prescribed by the physicisian).

-Antibiotics have bactericidal effect that combats pathogens.

XI.

DRUG STUDY

MEFENAMIC ACID Drug Class: Non steroidal anti-inflammatory drug (NSAID) Therapeutic Actions: Anti Inflammatory, analgesic, and antipyretic activities related to inhibition of prostaglandin synthesis; exact mechanism of action are not known. Indications: Relief of moderate pain when therapy will not exceed in 1 week.

Treatment of temporary dysmenorrhea Contraindications & Cautions: Contraindicated with hypersensitivity to mefenamic acid, pregnancy, Lactation.

Use cautiously with asthma, renal or liver dysfunction, peptic ulcer disease, G.i. bleeding hypertension.

FERROUS SULFATE Drug Class: Iron preparation Therapeutic Actions: Elevates the serum iron concentration and is then converted to hemoglobin or trapped in the reticuloendothelial cell for storage and eventual conversion to a usuable form of iron. Indications:
Prevention and treatment of iron deficiency anemia. Dietary supplement for iron

Unlabeled use: supplemental use during epotin therapy to ensure proper hematologic response to epotin.

Contraindications & Cautions: Allergy to any ingredients, sulfate allergy hemochromatosis, hemosiderosis, hemolytic anemis, normal iron balance, peptic ulcer, regional enteritis, ultraterative colitis.

CEFUROXIME Drug Classes: Antibiotic Cephalosporin (2 generation)

nd

Therapeutic Actions: Bactericidal Inhibits synthesis of bacterial cell wall, causing cell death

Indications: Oral cefuroxime Pharyngitis Tonsilitis Otitis Media Lower respiratory Tract infection Urinary tract infection Dermatologic infections including impetigo Treatment of early lyme disease

Contraindications and caution: Allergy to cephalosorins or penicillin renal failure, lactation

XII.

DISCHARGE PLANNING

M Medication Methylgonometrine 1 tab TID Mefenamic Acid 250mg 1 tab q4 hrs Ferrous sulfate 1 tab once a day E Environment Instructed patient to stay in calm, quiet environment Home environment must be free from slipping or accident hazards T Treatment Informed patient to have a follow-up check up after 1- 2 weeks H Health Teachings Informed patient to avoid lifting heavy objects for 1-2 weeks Stressed the importance of perineal cleanliness Encouraged client to have hot sitz bath Instructed patient to increase intake of protein-rich foods to promote faster wound healing Instructed to promote adequate fluid intake Discouraged patient to participate in strenuous activities that might precipitate stress and trauma to the wound Instructed patient to promote breastfeeding O Observable Signs and Symptoms Observe for dehiscence and evisceration Instructed patient to report to physician any signs of infection Instructed patient to report any case of hemorrhage or abnormal bleeding

D Diet Encouraged client to increase intake of fiber to avoid constipation Instructed to increase fluid intake Instructed to increase intake of nutritious foods such as fruits and vegetables.