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A Case study on

Cesarean Section Delivery

In Partial Fulfillment of the Course Requirements in

Medical Nursing

Submitted to the Faculty of Cebu Doctors’ University


College of Nursing

Submitted by:
Perez, Diana U.
BSN IV-D
TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Nursing Assessment
1. Personal History
1.1. Patient’s profile
1.2. Family and individual information
1.3. Level of growth and development
1.3.1. Normal development at particular stage
1.3.2. The ill person at particular stage of patient
2. Diagnostic Results
3. Present profile of Functional Health Patterns
4. Pathophysiology and Rationale
4.1.Normal anatomy and physiology of female reproductive
system
4.2. Schematic drawing to show pathophysiology of
Cesarean Section Delivery
4.3. Disease process and its effect on different
organ/system
4.4. Comparative chart to show the classical signs and
symptoms of the disease and the actual manifestation of the
patient with rationale.
IV. Nursing Intervention
1. Care guide of patient with bipolar I disorder
2. Actual patient care:
2.1. Brunswick lens model
2.2. Nursing care plan
2.3. SOAPIE charting
2.4. Health teaching plan
2.5. Drug therapeutic record
V. Evaluation and recommendation
VI. Evaluation and implication of this case study to:
1. Nursing practice
2. Nursing education
3. Nursing research
VII. Bibliography
I. INTRODUCTION

Pregnancy is the gestational process, comprising the growth and development within

a woman of a new individual from conception through the embryonic and fetal periods to

birth. It lasts approximately 266 days (38 weeks) from the day of fertilization but it is

clinically considered to last 280 days (40 weeks; 10 lunar months;91/3 calendar months)

from the first day of the last menstrual period. Because pregnancy changes a woman’s

normal hormone patterns, one of the first signs of pregnancy is a missed menstrual

period.

The first few months of pregnancy are the most critical for the developing infant,

because during this period the infant’s brain, arms, legs, and internal organs are form. For

this reason, a pregnant woman should be especially careful about taking any kind of

medication except on the advice of a physician who knows that she is pregnant. Pregnant

women should avoid x rays, smoking and alcohol consumption.

Delivery, the process by which the baby is expelled from the uterus through the

birth canal and into the world, begins with irregular contractions of the uterus that occur

every 20 to 30 minutes. As labor progresses, the contractions increase in frequency and

severity. The usual length of labor for a first-time mother is about 13 to 14 hours, and

about 8 or 9 hours in a woman who has given birth previously. Wide variations exist,

however, in the duration of labor.

Cesarean delivery is defined as the delivery of a fetus through a surgical

incision through the abdominal wall (laparotomy) and uterine wall (hysterotomy). The

words cesarean and section are both derived from verbs that mean to cut. Cesarean
section is one of the most common procedures done on the OR/DR. everyone seems to be

pretty familiar with it, us included. However, encountering a cesarean section procedure

and participating in it as student nurses is an entirely different experience.

The student nurse chose this for her case study out of curiosity of how or why

many post partum patients would experience complications days after and as to how

closely the patient should be monitored time to time to rule out those possible

complications. It also serves as knowledge experience for her to utilize if she encounters

patients with similar conditions. We all know that fatality is a big possibility if post

partum patients are uncared. Therefore, it is important that student nurse knows exactly

on how much care is to be rendered for such patients. Close monitoring of mothers

should be done in order to rule out possibility for complications to occur for mothers at

this time are more prone to life threatening complications. The care mother receives

during this period influence her health for the rest of her life.
II. OBJECTIVES:
General Objectives:
After 2 days of student-nurse client interaction, the student-nurse will be
able to gain adequate knowledge, attitude and skills in caring for a patient who undergone
Cesarean Section towards optimum level of functioning.
Specific Objectives:
After 8 hours of student- nurse and patient interaction, the student- nurse
will be able to:
1. reinforce a thorough assessment of the patient
2. state the normal level of growth and development of the patient
3. discuss the anatomy and physiology of the organs or systems involved
4. explain the physiology of Cesarean Section delivery
5. formulate a comprehensive nursing care plan for the post partum patient
6. implement the formulated nursing care plan
7. impart health teaching related to the care of the post partum patient
8. evaluate the effectiveness of the nursing care implemented

After 8 hours of student-nurse and patient interaction, the patient and significant
others will be able to:
1. establish a trusting relationship with the student nurse
2. discuss relevant history and information about self
3. get involved in the planning of case management with the student nurse
4. cooperate with the nursing students in the implementation of care measures
5. show skills in the management of post partum
6. verbalize feelings about the student nurse and patient interaction
III. NURSING ASSESSMENT
1. Personal History
1.1 Patient’s Profile
Name: Mrs. Tagalog, Chanel
Age: 28 years old
Sex: Female
Civil status: Married
Religion: Roman Catholic
Date of Admission: April 12, 2010
Room No. OB 1
Complaints: irregular contractions
Impression/Diagnosis: Pregnancy Uterine Full term, incomplete
breech presentation, delivered via primary cesarean section a live male
neonate
Physician: Dr. Yu
1.2 Family and Individual Information, Social and Health History:
A case of 28-year-old female, Mrs. Tagalog, Chanel, Roman Catholic and
married, was admitted at Cebu Doctor’s University Hospital for the first time.
One week prior to admission, patient had onset of irregular uterine contractions.
Patient tolerated condition; noted passage of vaginal discharge, consulted at labor room,
internal exam was 1 cm cervical dilatation, 50% effacement, NST reactive. Patient was
sent home advised.
Morning prior to admission, patient came in for prenatal check-up at CDUH-
OPD, internal exam was 1-2 cm, 50% effacement, -3 station. Patient noted irregular
contractions, negative vaginal discharges, good perception of fetal movement. Patient
was then advised admission.
LMP: July 222009
EDC: April 29 2010
AOG: 38 6/7 weeks
1.3 Level of Growth and Development
1.3.1 Normal Development during Young Adult
A. Physical Development
Young Adult: 20-40 years
Psychosocial

Intimacy vs Isolation
The young adults face a number of new experiences and changes
in lifestyle as they progress toward maturity. Choices must be made about
education and employment, about whether to marry or remain single, about
starting a home, and about rearing children. Social responsibilities include
forming new friendships and assuming some community activities. Many
people choose to remain single, perhaps to pursue an education and then to
have the freedom to pursue their chosen vocation.

 is in the genital stage in which energy is directed toward attaining a


mature sexual relationship, according to Freud’s theory.

 has the following developmental tasks:


- selecting a mate
- learning to live with a partner
- managing home
- starting a family
- rearing children
- finding a congenial social group

Physical Development
People in their early 20’s are in their prime physical years. The
musculoskeletal system is well developed and coordinated. This is the period
when athletic endeavors reach their peak. All other systems pf the body are
also functioning at peek efficiency. Weight and muscle mass may change as
a result of diet and exercise. In addition, extensive physical and
psychosocial changes occur in pregnant and lactating women.

Cognitive Development
Piaget believes that cognitive structures are complete during the
formal operations period. From that time, formal operations (for example,
generating hypotheses) characterize thinking throughout adulthood and are
applied to more areas. Egocentrism continues to decline; however, these
changes do not involve a change in the structure of thought, only a change in
its content and stability. Researchers in the field pf psychology have
suggested that Piaget’s formal operational stage is not the last stage of
human development. Some have proposed a concept of post-formal thought,
sometimes called the problem finding stage and is characterized by “creative
thought in the form of discovered problems, relativistic thinking, the formation
of generic problems, raising of general questions from ill-defined
problems, use of intuition, insight and hunches, and the development of
significant scientific thought”. Post-formal thinkers possess an understanding
of the temporary or relative nature of knowledge and are able to comprehend
and balance arguments created by both logic and emotion.

Moral Development
Young adults who have mastered the previous stages of Kohlberg’s
theory. This time, the person is able to separate self from the expectations
and rules of others and to define morality in terms of personal principles.
When individuals perceive a conflict with society’s rules or laws, they judge
according to their own principles. Men often use an “ethic of justice” and
define moral problems in terms of rules and rights. Women, by contrast, often
define moral problems in terms of obligation to care and to avoid hurt.
Spiritual Development
The individual, according to Fowler, enters the individuating-
reflective period sometime after 18 years of age. In this period, the individual
focuses on reality. The religious teaching that the young adult had as a child
may now be accepted or redefined.

1.3.2. The ill person at particular stage of patient

Traditionally, it is assumed that the bulk of a woman’s concern in


the postpartal period center on the care of her new infant. Based on this, classes
in the postpartal period have traditionally focused on teaching how to breast-feed
and bathe infants. Although these acts are concerns for many mothers, they are
not necessarily a new mother’s chief concern. She ahs come through a
tremendous psychological experience during pregnancy and the birth of a child.
She is in the middle of a complete role change. It is only to be expected that
some of her attention and interest during this time will be directed inward as she
tries to view herself in this new role. Typical issues identified by postpartal
women include their partner, and their children; coping with emotional tension
and sibling jealousy’ and fatigue.
2. Diagnostic Results
DATE: April 12, 2010
Complete Blood Count

Diagnostic Tests Normal Values Patient’s Results Significance

Hemoglobin 12.3 – 15.3 g/L 12.6g/L Normal

Hematocrit 35.9 – 44.6 % 37.3% Normal


↑ = acute
WBC count 4.4 – 11.0 10^3/uL 13.38 10^3/uL infection

Neutrophil 40.0 – 70 % 82% ↑ = infection

Basophil 0.00 – 1 % 0% Normal

Eosinophil 0.00 – 5% 2% Normal

Lymphocyte 20.0 – 40.0 % 12% ↓ = infection

Monocyte 0-6% 5% Normal

Red Cell count 4.5 – 5.10 106/uL 4.3 10^6/uL ↓ = after


hemorrhage

MCV 80.0 – 96.0 fL 93.5 fL Normal

MCH 27.5 – 33.2 pg 31.6 pg Normal

MCHC 33.4 – 35.5 g/L 35 g/L Normal


9.40 fL
MPV 5.9 – 9.90 fL Normal

RDW 14.0 – 18.0 % 13.1 % ↓ = hypochromic


anemia
Platelet 140.0 – 440 103/ 199 10^3/uL Normal
uL

3. PHYSICAL ASSESSMENT (IPPA)

BODY PART
I P P A

HEAD:
Smooth, evenly Oily, shiny
Hair distributed short,
black hair
No presence of No lesions,
Scalp dandruff lumps
Presence of Warm, no
Forehead pimples, tenderness
absence of
wrinkles

EYES:

Hair evenly
Brows distributed,
symmetrically
aligned
Slightly curved
Lashes upward

Conjunctiva Pinkish, moist

Sclerae White and clear


Iris Round, black,
uniform

Equally round,
reactive to light
and
Pupils accommodation,
equal reaction of
both sides
Without
Visual Acuity eyeglasses, can
read
Peripheral Can see the
Vision objects at
periphery
Centrally located; Symmetrical;
NOSE nasal septum firm and not
intact painful
Frontal and
maxillary Not visible Not tender
sinuses

MOUTH:

Lips dry Slightly smooth

Gums Pinkish, moist tenderness

Teeth No dentures Hard


used, 28 ivory
colored

Hard Palate Whitish tenderness


tenderness
Soft Palate Pinkish

Uvula Midline
Tonsils Not inflamed,
pink

Tongue Pinkish Not tender

Symmetrically
EARS: aligned with eye Not painful,
level, presence free of lumps
of cerumen

NECK: Midline, Carotid pulse:


symmetrical 82 bpm

Lymph nodes Not enlarged

Central
Trachea placement in the movable
midline of the
neck

Goes up and
Thyroid Gland Not enlarged, down when
not visible patient
swallows
Rises and falls Resonant Broncho-
CHEST: during inhalation No masses sound heard vesicular
and exhalation, upon sound heard
20 bpm, equal percussion
chest expansion

Chest Moves the


excursion thumb
separately

Regular and
normal rate
Heart and rhythm
= 84 bpm,
no murmurs

Normal
breath
Lungs Equal lung Equal chest Resonant sound 20
expansion excursion sound bpm, no
crackles /
wheezes

Soft, smooth,
warm to touch, Bowel
Presence of kidney and Resonance sounds = 15
Abdomen striae and of spleen not to dullness bowel
linea negra palpable, liver sounds per
if not enlarged minute

EXTREMITIES
Arms
Upper Brown in color PR = 88 bpm reacted BP = 110/70
Extremities and able to Temp = 36.9 when hit by
move Warm, no hammer
lesions, strong
Legs
Lower Brown in color, Tibial and reactive to
Extremities able to walk but dorsalis pedis percussion
slowly, pain pulse are hammer
upon standing palpable
and moving

SKIN Fair in color, dry, Smooth, warm,


perspiration good skin
present, turgor
absence of
lesions

4. Present profile of Functional Health Patterns

• Health Perception/Health Management Pattern


Before the delivery, she describes her health as poor. Since being pregnant is
very hard have a lot of changes. One thing that is really difficult to bear is the
pain in the abdominal area upon contractions and also the difficulty in walking
and in getting up. After delivery, she then described her health as fair since there
is already lesser pain. There is no mobility nor sensory defect but she’s
complaining about fatigue and sleep disturbance, the pain felt in the perineum.
Good nutrition is required to keep her healthy and also medications &
supplements are given as her treatment for her to take. She expected to feel well
and was able to follow the prescribe instruction by the doctor and nurses.

• Nutritional - Metabolic Pattern


She eats meals three times a day at the right time and sometimes eats snacks.
She drinks milk every night before going to sleep. Her usual fluid intake was
around 7-9 glasses of water a day. Before the delivery the patient has a good
appetite. She eats a lot since she knows that it is needed for her health and for
the health of her baby inside. After the delivery, she loosed weight. She is
currently taking some supplements for her health. She does not have any eating
disorders or disability and she even drinks milk every meal. She also doesn’t
have any allergies to any food or even medications.

• Elimination Pattern
Before the delivery, she has no problems in voiding since there is no pain felt.
After the delivery, she feels pain at times. She said that she has no problems in
voiding but has fear in defecating because of her suture. She is currently using
maternity napkin. Although there’s the presence of pain, she’s not using any
assistive devices when urinating and defecating.

• Activity/Exercise Pattern
Before the delivery, the patient does a lot walking. Her usual activities are
cleaning, cooking, watching television or dvds and sometimes read books or
even listening to music. She does ante-partum exercises since she knows that it
could help in a faster delivery. After the delivery, she feels pain upon standing or
moving and especially when exerting a lot of effort that’s why she is being
assisted by her husband in what ever she does. She also said that she’ll be
doing some exercises in order to regain her body figure.

• Cognitive/Perceptual Pattern
She doesn’t have deficits in sensory perception before and after
the delivery. Patient is oriented with the time, place and of the persons in the
hospital. She is also aware of her current condition. She doesn’t have any
glasses and can read and write very well.
• Sleep/Rest Pattern

The patient experiences disturbance in her sleep before and after the delivery.
She used to sleep early that usually ranges 7-8 hours but it has changed. After
the delivery and now with the new baby around she sleeps only 2-3 hours since
the baby always cry which keeps her awake and feel worried and also, she
constantly monitors her baby.

• Self-perception Pattern

Before the delivery and even after she has delivered, she is most concerned with
her baby. She is also concerned about getting better and be back at her normal
non-pregnant state. She is also concerned about her supply of breastmilk for
baby. She is aware of her health condition and knows that she needs to rest in
order to recover She is excited to go home together with the baby.

• Role-Relationship Pattern
The patient said that her role now has changed. Before her attention centers
towards her common-law husband in taking good care and now a new phase
in her life is to begin and that is to become a good mother. She speaks and
understands English, Filipino and Cebuano dialect. She is communicative and
coherent. She is living together with her common law husband. She doesn’t
have any problems dealing with her relatives. In terms of decision-making,
role discipline and finances she and her husband both decide.

• Sexual Reproductive Pattern


She and her partner decided to have child spacing. Their ideal no. of children
is 2 or 3 only. For now, she is not sexually active due to the vaginal tears and
that they both have decided to focus on caring about their first baby.
• Coping-Stress Tolerance Pattern
She doesn’t feel so much stress because she knows that her family and
partner is there to support her all throughout.

• Value-Belief System

Patient is a Roman Catholic and her family. They go to church every Sunday
at Punta Princesa and during other special occasions together. God is their
source of strength in all their upcomings and problems in life. They pray
together to God for guidance and safety.

V. PATHOPHYSIOLOGY AND RATIONALE


5.1 NORMAL ANATOMY AND PHYSIOLOGY
EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external

genital area— or vulva—which runs from the pubic area downward to the

rectum. Two folds of fatty, fleshy tissue surround the entrance to the

vagina and the urinary opening: the labia majora, or outer folds, and the

labia minora, or inner folds, located under the labia majora. The clitoris,

is a relatively short organ (less than one inch long), shielded by a hood of

flesh. When stimulated sexually, the clitoris can become erect like a
man's penis. The hymen, a thin membrane protecting the entrance of the

vagina, stretches when you insert a tampon or have intercourse.

INTERNAL REPRODUCTIVE STRUCTURE

Vagina

The vagina is a muscular, ridged sheath connecting the external genitals

to the uterus, where the embryo grows into a fetus during pregnancy. In

the reproductive process, the vagina functions as a two-way street,

accepting the penis and sperm during intercourse and roughly nine
months later, serving as the avenue of birth through which the new baby

enters the world.

The Cervix

The vagina ends at the cervix, the lower portion or neck of the uterus.

Like the vagina, the cervix has dual reproductive functions. After

intercourse, sperm ejaculated in the vagina pass through the cervix, then

proceed through the uterus to the fallopian tubes where, if a sperm

encounters an ovum (egg), conception occurs. The cervix is lined with

mucus, the quality and quantity of which is governed by monthly

fluctuations in the levels of the two principle sex hormones, estrogen and

progesterone. When estrogen levels are low, the mucus tends to be thick

and sparse, which makes it difficult for sperm to reach the fallopian tubes.

But when an egg is ready for fertilization and estrogen levels are high the

mucus then becomes thin and slippery, offering a much friendlier

environment to sperm as they struggle towards their goal. (This

phenomenon is employed by birth control pills, shots and implants. One of

the ways they prevent conception is to render the cervical mucus thick,

sparse, and hostile to sperm.)

Uterus

The uterus or womb is the major female reproductive organ of humans.

One end, the cervix, opens into the vagina; the other is connected on

both sides to the fallopian tubes. The uterus mostly consists of muscle,
known as myometrium. Its major function is to accept a fertilized ovum

which becomes implanted into the endometrium, and derives

nourishment from blood vessels which develop exclusively for this

purpose. The fertilized ovum becomes an embryo, develops into a fetus

and gestates until childbirth.

Oviducts

The Fallopian tubes or oviducts are two very fine tubes leading from the

ovaries of female mammals into the uterus. On maturity of an ovum, the

follicle and the ovary's wall rupture, allowing the ovum to escape and

enter the Fallopian tube. There it travels toward the uterus, pushed along

by movements of cilia on the inner lining of the tubes. This trip takes

hours or days. If the ovum is fertilized while in the Fallopian tube, then it

normally implants in the endometrium when it reaches the uterus, which

signals the beginning of pregnancy.

Ovaries

The ovaries are the place inside the female body where ova or eggs are

produced. The process by which the ovum is released is called ovulation.

The speed of ovulation is periodic and impacts directly to the length of a

cycle. After ovulation, the ovum is captured by the oviduct, where it

traveled down the oviduct to the uterus, occasionally being fertilized on

its way by an incoming sperm, leading to pregnancy and the eventual


birth of a new human being. The Fallopian tubes are often called the

oviducts and they have small hairs (cilia) to help the egg cell travel.

Mammary Glands
These are the organs for milk production and are located in the breasts. A rise in
estrogen at puberty produces a marked increased in size from increased
connective tissue and deposition of fat in girls and a transient increase in boys.
Its glandular tissue is necessary for successful breast-feeding, remains
undeveloped until a first pregnancy begins. During pregnancy, she experiences a
feeling of fullness, tenderness or tingling in her breasts because of the increased
stimulation of breast tissue high estrogen level in the body. As pregnancy
progresses, breast size increases because of hyperplasia of mammary alveoli
and fat deposits. Early in pregnancy, breast begins readying themselves for the
secretion of milk. And of the 16th week, colostrum, the thin, watery, high-protein
fluid that is the precursor of breast milk, can be expelled from nipples.

SYSTEMIC CHANGES

Integumentary System
As the uterus increases in size, the abdominal wall must stretch to
accommodate it. This stretching can cause rupture and atrophy of small
segments of the connective layer of the skin. This leads to (striae gravidarum)
pink or reddish streaks appearing on the sides of abdominal wall and
sometimeson thighs. During weeks after birth, striae gravidarum lighten to a
silvery-white color, and, although permanent, become barely noticeable. A
narrow,brown line (linea nigra) may form, running from umbilicus to the
symphysis pubis and separating the abdomen into right and left hemispheres.
Darkened areas may appear on face as well, particularly on the cheeks, and
across nose, known as melasma or mask of pregnancy. Vascular spiders (small,
fiery red branching spots) are sometimes seen on the skin of pregnant women,
particularly on thighs as a result from increased level of estrogen. They may fade
but not completely disappear after pregnancy. The activity of sweat glands
increases and is manifested in an increase in perspiration.

Respiratory System
During pregnancy most women worry about stuffiness of the
nasopharynx or shortness of breath. As the uterus enlarges during pregnancy, a
great deal of pressure is pull on the diaphragm and, ultimately, on the lungs. The
diaphragm may be displaces by as much as 4cm upward. This crowding of chest
cavity causes an acute sensation of shortness of breath late in pregnancy, until
lightening relieves the pressure. Residual volume is decreased up to 20% as the
woman draws in extra volume to increase effectiveness of air exchange. 20% is
increased in total oxygen consumption.

Cardiovascular System
The total circulatory blood volume of the woman’s body increases by at
least 30% during pregnancy. Blood loss of about 300-400mL in a normal vaginal
birth. The increase in blood volume occurs gradually, beginning at the end of first
trimester. Because plasma volume increases faster than RBC production does,
concentration of hemoglobin and erythrocytes declines, leading to pseudoanemia
in early pregnancy. In order for the body to compensate, there is more production
of RBC’s by 2nd trimester. Since fetus requires 350-400mg of iron to grow and
mother’s circulatory RBC mass require an additional 400mg of iron, a total of
800mg is in need. And because iron absorption may be impaired during
pregnancy as a result of decrease gastric acidity, additional iron is often
prescribed during pregnancy to prevent true anemia. During the 3 rd trimester,
blood flow to the lower extremities is impaired by the pressure of the expanding
fetus/uterus on veins and arteries, rectum and legs. Blood pressure doesn’t
normally rise because of the increase heart action takes care of the greater
amount of circulating blood. In most women, blood pressure actually decreases
slightly during the 2nd trimester because of the lower peripheral resistance to
circulation as the placenta expands rapidly.

Gastrointestinal System
As the uterus increases in size, it tends to push the stomach and
intestines toward the back and sides of the abdomen. At about the midpoint of
pregnancy, this pressure may be sufficient to slow intestinal peristalsis and the
emptying time of the stomach, leading to heartburn, constipation and flatulence.
Pressure from the uterus on veins returning from the lower extremities can lead
to hemorrhoids. At least 50% women experience some nausea and vomiting
early in pregnancy. More frequent in women who smoke cigarettes. Known as
morning sickness, nausea and vomiting begin to be noticed at the same time
levels of hcg and progesterone begin to rise.

Urinary System
Water is retained during pregnancy to aid the increase in blood volume
and to serve as a ready source of nutrients to the fetus. Because nutrients can
pass to the fetus only when dissolved in or carried by fluid. During pregnancy, a
woman’s kidneys must excrete not only the waste product of her body but also
those of the growing fetus. Also, must be able to excrete additional fluid and
manage the demands of increased renal blood flow. Urinary output gradually
increases by about 60-80%. The specific gravity decreases. The glomerular
filtration rate and renal plasma flow begin to increase in early pregnancy to meet
the increased needs of the circulatory system. A pregnant woman may notice
an increase in urinary frequency during the first 3 months of pregnancy, until
the uterus rises out of the pelvis and relieves pressure on the bladder.
Frequency of urination may return at the end of pregnancy, as lightening
occurs and fetal head exerts renewed pressure on the bladder.
Skeletal System
As pregnancy advance, there is a gradual softening of the woman’s
pelvic ligaments and joints to created pliability and to facilitate passage of the
baby through the pelvis at birth. This softening is probably caused by the
influence of both the ovarian hormone relaxin and placental progesterone. A wide
separation of the symphysis pubis, as much as 3-4mm by 32 weeks of
pregnancy, may occur. Making women walk with difficulty because of pain.
To change her center of gravity and make ambulation easier, a pregnant woman
tends to stand straighter and taller than usual. “pride of pregnancy”, standing this
way, with shoulders back and abdomen forward, creates a lordosis leading to
backache.

Endocrine System

Gland Changes Effect

Thyroid - slight enlargement - ↑ basal metabolic rate


- ↑ thyroid hormone - ↑ oxygen consumption
production

Parathyroid - slight enlargement - better utilization of calcium


- ↑ parathyroid hormone and vitamin D
production

Pancreas - early in pregnancy, ↓insulin - additional glucose is


production because of heavy available for fetal growth
fetal demand for glucose
- after 1st trimester, ↑ insulin
production because of insulin
antagonist properties of
estrogen, progesterone and
HPL

Pituitary - FSH & LH decreased - anovulation


Gland - Prolactin ↑ -breast prepared for
-melanocyte stimulating lactation
hormone ↑ - ↑ skin pigment
- human growth hormone ↑

Placenta - estrogen and progesterone -uterine and breast


produced engorgement, fat deposits,
- relaxin ↑ ↑ blood coagulation, Na&
H20 retention
- softening of cervix and
collagen of joints, ↑ glucose
available for fetus, ↓
utilization of protein for
energy, ↑ protein

5.2 Schematic Drawing


PHYSIOLOGY OF CESAREAN DELIVERY
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 (false labor) (Goodell’s
Sign wherein
head into the pelvis) >begin and remain irregular the cervix
feels softer like
>1st felt abdominally consistency of
the earlobe
>pain disappears with ambu-
lation
>do not increase in duration
and intensity
>do not achieve cervical
dilatation
TRUE LABOR

Uterine Contractions SHOW Rupture


of Membranes
>increase in duration (pink-tinge of blood, (rupture of
the amniotic sac)
and intensity a mixture of blood and fluid)
>1st felt at the back &
radiates to the abdomen
>pain is not relieved no
matter what the activity
>achieve cervical dila-
tation

Failed to progress labor


(due to previous cesarean birth, cervical arrest,
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
5.3 Disease / Condition Process
UTERUS
The most obvious alteration in the woman’s body during pregnancy is the
increase in size of the uterus to accommodate the growing fetus.

AMENORRHEA
Amenorrhea occurs with pregnancy because of the suppression of follicle
stimulating hormone by rising estrogen levels. In a healthy woman who has
menstruated previously, the absence of menstruation strongly suggests that
impregnation has occurred.

CERVICAL CHANGES
Softening of the cervix in pregnancy is marked. This softening is so marked it is
rated as a probable diagnostic signs of pregnancy.

VAGINA
An increase in the vascularity of the vagina, beginning early in pregnancy,
parallels the vascular changes in the uterus. The resulting increase in circulation
changes the color of the vaginal walls from the normal light pink to violet.

OVARY
Ovulation stops with pregnancy because of the active feedback mechanism of
estrogen and progesterone produced by the corpus luteum early in pregnancy
and by the placents later in pregnancy.

BREASTS
As the pregnancy progresses breast size increases because of hyperplasia of
the mammary alveoli and fat deposits. The vascularity of the breast increases
and the areola of the nipples darkened.
5.4 Comparative Chart

Classical Clinical Rationale


1. Abdominal pain manifested - sign of uterine contraction
- felt first in lower back and
sweep around the
abdomen in wave Source: Maternal & Child
Health Ng., 4th ed. by Adele
Pilliteri p.468
2. nausea and manifested - due to hormonal changes
vomiting - morning sickness - due to intense discomfort
felt during the transition
phase

Source: Maternal & Child


health Ng., 4th ed. by Adele
Pilliteri p. 485
3. extreme tiredness manifested - a woman is generally tired
(fatigue) - patient was fatigue after from labor processes
giving birth
Source: Maternal & Child
Health Ng., 4th ed. by Adele
Pilliteri, p.487
4. constipation manifested - the gastrointestinal system
- pt. not able to void after becomes fairly inactive
first 24 hours from delivery during labor. This is probably
due to the shunting of blood
to non life-sustaining organs
and also to pressure on
stomach & intensive from the
contracting uterus
Source: Maternal & Child
Health Ng., 4th ed. Adele
Pilliteri, p. 487
5. diarrhea not manifested - some women experience a
loose bowel movement as
contractions grow strong

Source: Maternal & Child


Health Ng., 4th ed. by Adele
Pilliteri p. 487
6. pain manifested - uterine contractions cause
pain. Pain also results from
incision in the mid-lower
abdomen

- from sutures, uterine pain


or after pains and breast
tenderness

Source: Maternal & Child


Health Ng., 4th ed, Adele
Pilliteri, pp. 521-522
V. NURSING INTERVENTIONS
1. CARE GUIDE OF PATIENT

A. Provide pain relief


Pain from uterine contractions can be intense, but you can assure the woman
that this type of discomfort is normal and rarely lasts longer than three days. If
necessary, either Ibuprofen, which is anti-inflammatory properties, or a common
analgesics such as acetaminophen is effective for relief. As with any abdominal
pain, heat to the abdomen should be avoided, because if could cause relaxation
of the uterus and subsequent uterine bleeding.
B. Enhance family functioning and bonding
Increase woman’s self-esteem and allowing her to view herself as a new mother
NEEDS / OBJECTIVE
and her new
PROBLEMS infant as part SCIENTIFIC
NURSING ofBASIS
their family.
/
Teaching NURSING
OF new mothers is important, but
RATIONALE
DIAGNOSIS SIGNIFICANCE CARE ACTIONS
CUESit is also important to explore what they already know about child care and what
- promotes
they think would be a sensible solution to a problem. relaxation,
Measures to refocuses
relieve and attention &
C. Relieve muscular aches
control pain: enhance
A woman may need a mild analgesic such as acetaminophen for the pain. A
capabilities
1. provide
backrub is effective for relieving
Pain is anan aching back or shoulders. Carefully assess a
comfort
woman who states that she unpleasant
has pain on standing. measures -reduces
sensory (back rub,etc.) muscle/ joint
I. Physiologic experience stiffness;
Overload arising from
D. Administer Cold and Hot Therapy returns organs
a. Altered actual or to normal
Comfort Applying an ice or cold reduces edema and the possibility of hematoma
potential position
(Pain) tissue
formation, thereby reducing pain and promoting healing and comfort.
2.assist in ROMHeat and
damage. It - pt. may
CUES: cold have been known as mayeffective
be ways to help relieve the exercises &
pain of labor. women
encourage experience a
- facial
Alteredwarm fromincisional,
who become exertion ofor laborAfter
find 8a hours
cool washcloth
early to the forehead
decreased
grimace may be ambulation
comfort: pain of holistic ability to
comforting.
- pain occurs inflammation
related to nursing care, tolerate
every 5-10 or infection.
bikini line he patient will painful stimuli
minutes, Because of
incision in the be able to:
located at the surgical
mid-lower
mid-lower incision 3. eliminate
abdomen 1. report that additional
- minimizes
abdomen, conducted by pain is stressor pain
lasting for 2-3 the surgery, relieved and
minutes, the patient controlled by
characterized may verbalization
as stabbing, experience of the patient - to promote
aggravated by pain and vasodilation
movement, discomfort. 4. discourage
relieved by and muscles pt. to wear snug
walking, of the fitting - to minimize
treated with perineum are underwear
stressors
analgesics involved in
- pain scale of many 5. apply ice
packs wrapped - to reduce
7/10 where 10 activities.
in towel pain
is the highest
Source:
Maternal & Child 6. provide a
Health Nursing. calm, quiet
environment

7. administer
analgesics as
prescribed
NEEDS / SCIENTIFIC OBJECTIVE
NURSING NURSING
PROBLEMS BASIS / OF RATIONALE
DIAGNOSIS SIGNIFICANCE CARE ACTIONS
CUES

Measures to
achieve - helps regain
optimal amount energy
of sleep:
- Lack of
1. encourage knowledge of
period of rest infant problem
may create
2. Observe tension
patient-infant interfering with
interaction / sleep.
After birth, a provision of
woman is a emotional - Over
II. paradox. She support. indulgence
Psychological is excited. She interferes with
deficit has a baby and REM sleep
Disturbed want to hold 3. Evaluate
Sleep pattern: and be with 2. achieve use of caffeine - To aid in
a. Disturbed this new stress control /
frequent optimal and alcoholic
sleep pattern person in her release of
awakenings amounts of beverages.
during night life. She wants sleep as energy.
CUES: related to pain to talk to her
- restlessness evidenced by 4. increase day
in the incision support person rested time physical - Structured
- change in about the sleep routine
site and appearance, activities as
activity level experience, based on adult
attending the verbalization of indicated
- 2-4 hours of needs of the their child, their schedules may
feeling rested
sleep baby future. At the not meet
and 5. Note
- frequent same time, she improvement mother’s sleep child’s needs
awakenings is so of sleep wake pattern
during night exhausted in pattern - awakening
- frequent most cases during a sleep
yawning and falls cycle may
asleep cause her to
- agitation
6. reduce feel poorly
- mood rested
alteration environmental
Source: distractions
Maternal & Child and sleep
Health Nursing.
interruptions
- in order to
relieve pain

7. Administer
pain
medications as
ordered
NEEDS / SCIENTIFIC OBJECTIVE
NURSING NURSING
PROBLEMS BASIS / OF RATIONALE
DIAGNOSIS SIGNIFICANCE CARE ACTIONS
CUES

1. prevents
cross
Measures to contamination
reduce the risk
for infection:
Infection 1. perform or 2.reduce risk
occurs when promoted for bacterial
an organism meticulous growth
invades a hand washing
b. Risk for susceptible by care givers
infection host. Break in
the 2. maintain 3. early
Risk for
CUES: integument, strict aseptic identification or
infection the body’s first treatment may
- incision in the related to techniques
mid-lower line of defense with wound prevent sepsis
presence of allows invasion 3. identify and
abdomen care
incision in the by pathogens, participated in
- disruption of
skin surface
mid-lower open wound, behaviors to
3. inspect 4.self care
abdomen traumatic reduce risk for activities may
- wound wound site,
surgery can be infection provide
exposed to noting signs of
bacteria sites for local protection
- destruction of infection either inflammation
skin layer trauma or
- elevated invasive 4. review
WBC procedures. individual’s
nutritional 5.helps
needs, prevent
Source: appropriate infection
Maternal & exercises and
Child Health
Nursing.
needs for rest

5. administer
antibiotics as
indicated
CLASSIFICATION
DRUGS /
/ MECHANISM SIDE EFFECTS/
DOSE/
INDICATIONS & PRINCIPLE TREATMENT EVALUATION
FREQUENC
CONTRAINDICATIO OF CARE
Y/ ROUTE
NS

Amoxicillin C: Penicillin, Side Effects: - store at a - check for - there are


(Novamox) Antibiotic - mild diarrhea, temperature rash,diarrhea, already no
500 mg / Mechanism: nausea & of not nausea and signs of
cap TID - rapidly absorbed by vomiting, exceeding vomiting,and infection
(8am -1pm the gastrointestinal headache, 25° C other signs of
-6pm) tract after oral generalized rash - give without allergic
p.o. administration and is regards to reaction
stable in the Indications: meal
presence of gastric - treatment of
acid; diffuses readily infections caused by
into most body pathogenic gram
tissues and fluids positive and gram –
except for the negative bacteria
cerebrospinal fluids; that are sensitive to
inhibits bacterial cell amoxicillin
wall synthesis
Contraindications:
- hypersensitivity to
any penicillin

Mefenamic C: NSAIDs Side effects: - use drugs - administer - pain was


acid (Anti- inflammatory) - CNS: headache, only as drug with reduced
(Revalan) Analgesics dizziness, insomnia, suggested food or after
500 g/ cap tiredness - do not meals if GI
q 6h x 4 Therapeutic Action: - Dermatologic: rash, exceed upset occurs
doses - its exact sweating dosage - provide
(8am – 2pm mechanism of - GI: nausea & comfort
-8pm – 2am) action is not known vomiting, GI pain, measures to
p.o dyspepsia reduce
- Hematologic: inflammation
bleeding,leukopenia - advise
- Respiratory: patient to
dyspnea report any
discomfort or
Indications: pain felt
- relief of moderate - provide
pain when therapy will frequent small
not exceed 1 week meals if GI
- treatment of primary upset is
dysmenorrheal severe
OBJECTIVES CONTENT METHODOLOGY EVALUATION
General:
After 8 hours of student
nurse-patient and significant
others interaction, patient and
significant others will be able to
acquire adequate knowledge,
attitude and skills about caring
postpartum patient
Specific:
After 45 minutes of student
nurse-patient and significant
others interaction, patient and
significant others will be able
to:

1.1 Define the following terms


1.1 breast feeding • Breast feeding – nursing and Informal Discussion Patient and significant

feeding of baby with breast others were able to

milk define breast feeding


1.2 lactation and lactation
• Lactation – process of milk
production results from the
In the patient’s own level of
interplay of hormones,
understanding
instinctive reflexes and
learned behavior of mother
and newborn

2. Enumerate the importance Importance: Informal Patient and significant


of breastfeeding essential for the survival of Discussion others were able to
infant enumerate the
• promotes self care, mother will importance of breast
learn the importance of feeding.
cleanliness and how to care for
her breast when nursing
• superior source of nutrition
• provides maternal antibodies to
infection
• Prevents infant against
hypercholestoramia

3. Cite the advantages of Advantages: Informal Patient and significant


breastfeeding Best for babies Discussion others were able to cite
Reduce incidence of allergies the different advantages.

Economical
Antibodies
Stool inoffensive
Temperature always idea;

Fresh milk

• Emotional bonding b/w child


V. EVALUATION AND RECOMMENDATION

Prognosis

Based on the patient’s assessment, she is not experiencing any


complications after the obstetrical procedure (Cesarean Delivery);
therefore there is no prognosis or simply she is good. She complies with
the treatment, medications, and management regimen instructed by the
doctors and nurses.

Recommendation

The most important goal for the patient who undergone Cesarean
Delivery is to achieve full recovery and rule out the possible occurrence of
infection and abscess.
Below are listed recommendations for the patient are as follows:
1. Compliance and maintenance of the medications being prescribed by
the physician.
2. Bed rest if the patient feels pain and fatigue.
3. Nutritious foods are provided for the patient to eat.
4. Patient must be restricted to physical activities causing stress.
5. Promoting good personal hygiene and stressing careful hand washing.
6. Abstain from alcohol after recovery.
7. Environmental sanitation.
8. Deep breathing exercise if pain if felt.
9. Heat and cold application on the affected site.
10. Ambulation is encouraged.
11. Encourage adequate rest
12. Follow up consultation or check-up at clinics or hospital

VI. EVALUATION AND IMPLICATION OF THE CASE STUDY


Nursing Practice

Studying the case ofMrs. TagalogJulie gave the student the


opportunity to enhance the student’s knowledge, attitude, and skills in
rendering therapeutic nursing care for post partum patients. It has
provided new ideas that focus on dedication to study.
This case study though not that perfect can serve as a basis and
reference for the never-ending discovery for better interventions of
students, professionals and family of the affected member.

Nursing Education

This study has been very helpful in making me understand the


extents of this condition. It has aided me to relate the theories, discoveries
and other facts written in textbooks, to the actual situation. Through these
observations, students have gained new set of ideas which will be of great
help in caring for patients with the same cases

Nursing Research

This can be utilized as reference for future research studies. This


will also provide additional knowledge to the students for relating real life
situations.

VII. BIBLIOGRAPHY

Kozier, Barbara et.al. Fundamentals of Nursing Concepts, Process and


Practice, 7th editions, Pearson Education Inc., 2004

Marieb, Elaine N. et.al. Essentials of Human Anatomy and Physiology, 6th


edition, Addison Wesley Longman Inc., 2000
Pilliteri, Adele. Maternal and Child Health Nursing; 4th edition, Lippincott
Williams and Wilkins

Potter, Patricia and Perry, Anne Griffin. Fundamentals of Nursing. 6th ed.
St. Louis, Missouri: Mosby 2005

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