Arellano University

Jose Abad Santos Campus

3058 Taft Avenue, Pasay City

CASE PRESENTATION
(Cord Compression Leading to Fetal Distress
and Caesarean Section)

BSN Level III – Block 1

Under Professor Elizabeth Abayan

 TABLE OF CONTENTS
I. Biographic Data

II. Nursing Health History

III. Physical Assessment

IV. Gordon’s Health Pattern

V. Laboratory/Diagnostic Examination Result

VI. Medications and IV Infusions

VII. Review of Systems

VIII. Anatomy and Physiology

IX. Pathophysiology

X. Prioritized List of Nursing Problems

XI. Nursing Care Plan

XII. Discharge Plan

 I. BIOGRAPHIC DATA
Patient Name: Patient X
Age: 29 years old
Birthday: October 29, 1981
Gender: Female
Religion: Roman Catholic
Civil Status: Married
Occupation: Housewife
Address: Lipa, Batangas

II. NURSING HEALTH HISTORY

Chief Complaint:
Patient X, when admitted to the OB ward complained of pain in the hypogastric
area, due to the operative incision made on her caesarean section.

History of Present Illness:

2 hours prior to admission, Patient X felt progressive labor contractions which
made her opt to admission.

Past History:
The patient X doesn’t have hypertension, asthma, diabetes mellitus, and hepatitis
B. She has never been hospitalized due to any illness, only when she had her previous
caesarean delivery for her first baby last 2008. During her childhood she had sore eyes,
chickenpox and mumps. She is a fully immunized child and has no psychiatric illness.
She has no allergies at all.
Family History of Illness:
Patient X’s father has a history of hypertension. Also, her uncle on her mother’s
side died of stroke.

Obstetrical History:
Patient X reported her menarche to occur when she was 12. She is a
G2P2(2-0-0-2). She gave birth to her fist baby by caesarean section, at 37 weeks age of
gestation. During her current pregnancy, she has a regular prenatal check up and doesn’t
have any history of illness during pregnancy. Her second baby was delivered by an
emergency caesarean section at 38 weeks of gestation due to fetal distress secondary to
cord compression.

Lifestyle and Activity of Daily Living:

Patient x is non alcoholic drinker, non smoker and not addicted to any drugs. She
has poor nutritious food intake and no allergies in any food. She sleeps 10 hours a day,
starting from 8 in the evening and awake at 6 in the morning. She takes a nap for 30
minutes every afternoon.

Social Data:
She is a college graduate, unemployed and currently residing in her mother’s
house.

Psychological Data:
The patient is responsive to voice and touch and has the ability to carry a
conversation and answer question appropriately. There are no complaints regarding
reading and writing. The patient can speak Tagalog and some English.
III. GORDON’S FUNCTIONAL
HEALTH PATTERNS
Nutritional Pattern
Patient X is 29 y/o with the height of 5’2” and weight of 41 kg – undernourished
She has a BMI of 17 – underweight
The skin is considered normal

Activity – Exercise Pattern

Before admission, the patient served as a fulltime housewife, she takes care of her
child at home and able to do some household chores
During hospitalization, Patient X appears weak and complains about the pain on
her incision site. She is able to perform ADL but with assistance in doing activities.

Sleep – Rest Pattern

The patient gets an average sleep of 10 hours every night. She sleeps at around 8
p.m. and wakes up at 6 a.m.
During hospitalization, the patient experiences sleeping disturbances because of
the pain on her incision site. She often has disrupted sleep. She wakes up at night
and finds it hard to go to sleep again.

Elimination Pattern
Before admission, the patient stated that she urinates about 6 - 8 times every day.
She usually has bowel movement of 3 times a week, with slightly brownish colored
stool.
During hospitalization, Patient X urinates about 3 - 5 times a day with straw-
colored urine output. There was no pain during urination. The patient has not yet
evacuated her bowels since yesterday.

Health – Perception/Health Management Pattern

The client perceives herself as physically fit person
 She takes a bath one to two times a day
She doesn’t smoke or drink any liquor, she also doesn't use any harmful drugs

Cognitive – Perceptual Pattern

The patient is responsive to voice and touch. She has the ability to carry a
conversation and answer questions properly. She is able to read and write, and a
college graduate. It was also observed that she was able to read the signs and posters
posted at the hospital ward, and can follow simple instructions and can easily
comprehend to questions asked.
There are no complaints regarding reading and writing. The patient can speak
Tagalog and a few English.
During hospitalization, Patient X is still responsive to anything and has the ability
to use simple sentences in answering questions

Role – Relationship Pattern

She lives with her husband and her first child. According to the patient, they have
a good family relationship. She also emphasized that her family is very supportive
to her especially now that she was hospitalized.

Sexuality – Reproductive Pattern

Patient X is currently not sexually active because she has undergone caesarean
section last 3 days.

Coping – Stress Pattern

The patient usually decides for herself or sometimes she consult her family
During the interview, she was not attended by her husband due to certain
circumstances.

Value – Belief Pattern

The patient is Roman Catholic. She attends mass every week with her family.
IV. PHYSICAL ASSESSMENT
(Postoperative and Postpartum Physical Assessment)
Date: September 27, 2010

Vital Signs Normal Range Findings Interpretation

Temperature 36.5 C- 37.5C 37.4 C Afebrile
Pulse Rate 60- 100 bpm 88 bpm Normal
Respiratory Rate 12-20 cpm 24 cpm Tachypnea
Blood Pressure <120;<80 110/90 mmHg Prehypertensive

Weight: 41 kilograms
Height: 5’2”

Normal Range Findings Interpretation

Body Mass Index 18-25 17 Underweight

Body Parts Technique Findings Interpretation

• Conscious
Abnormal: Patient has
• Coherent
an overwhelming
• Slightly fatigued, in
General sustained sense of
Inspection pain
Appearance exhaustion and decrease
• Irritable capacity for physical
• Reduce activity and mental work
level
Head
• Normo-cephalic
• Smooth skull
Inspection
 Skull and contour
Palpation Normal
face • Symmetrical facial
features and
movements
• Black, evenly
 Hair Inspection Normal
distributed
Body Parts Technique Findings Interpretation
• Symmetrically
aligned eyebrows
• Lids close
symmetrically
• No discharges
• Anicteric sclera
Inspection
 Eyes • Pink palpebral Normal
Palpation
conjunctiva
• PERRLA
• Pupil: 5mm, black
• Both eyes are
coordinated
• 20/20 vision
• Symmetrical
• Auricle aligned
with outer canthus
Inspection
 Ears of the eyes Normal
Palpation
• (+) cerumen
• Normal voice tone
audible
• Symmetric
• No discharges/
Inspection
 Nose flaring Normal
Palpation
• Pink nasal mucosa
• Sinuses not tender
• Pink lips
• 32 teeth
• Pink gums
• Tongue pink in
Inspection color with raised
 Mouth Normal
Palpation papillae, moves
freely
• Pink buccal mucosa
• Tonsils are pink
with uvula at center
• Supple
• Muscles equal in
Inspection size and strength
Neck Normal
Palpation • (-) CLAD
• Moves without
discomfort
 Body Parts Technique Findings Interpretation
• Slightly unequal in
size
• Soft, warm, non-
Inspection
Breast tender Normal
Palpation
• Round, dark areola
• Round, everted
nipples, (-) cracks
• Symmetric chest
• Spine vertically
aligned
• Full symmetric
chest expansion
• Bilateral symmetry Crackles are small
Inspection of vocal fremitus sharp sounds heard on
Palpation
Chest • Normal percussion auscultation caused by
Percussion
sounds on posterior excessive fluid within
Auscultation
and anterior chest the airways.
• (-) retraction
• (+) crackles/rales
• (-)gurgles/ronchi
• (-)wheeze
• (-)friction rub
• Soft, tender
• 5 inches pfannenstiel
cut over hypogastric
area
• 15 stitches incision The Pfannenstiel
with scant bloody incision is a type of
discharge
surgical incision made
Inspection • Incision site is warm
in the lower abdomen.
Auscultation and erythematous
Abdomen It is used primarily in
Percussion • Dressing and plaster
are clean and fully women during
Palpation
covered the incision childbirth through the
• No foul odor abdomen, also known
• Hypoactive bowel as cesarean section.
sounds
• Bladder not distended
• Uterus is 3 cm below
umbilicus
• Scant lochia rubra
Genitals/Rectum Inspection Normal
• (-) hemorrhoids
 Body Parts Technique Findings Interpretation
• Can move without
discomfort
Extremities Inspection • (-)Homan’s Sign Normal
• (-) edema

V. LABORATORY/DIAGNOSTIC
EXAMINATION RESULTS
HEMATOLOGY: COMPLETE BLOOD COUNT

BLOOD
RESULT NORMAL FINDINGS
COMPONENT

WBC 9.8 x 109/L 4.0-11.0 Normal

RBC 4.9 x 1012/L 4.0-6.0 Normal

Hgb 116 g/L 120-180 Decreased

Hct 0.52 % 0.370-0.540 Normal

Lymphocytes 0.310 0.200-0.500 Normal

Monocytes 0.022 0.020-0.090 Normal

Eosinophils 0.006 0.000-0.060 Normal

Basophils 0.010 0.000-0.020 Normal

 Neutrophils 0.510 0.500-0.700 Normal

Platelet 165 x 109/L 150-450 Normal

RESULTS FOR BLOOD TYPING

ABO Typing Rh-typing Antibody Screen

A Positive

URINALYSIS

Chemical Analysis Result

Blood (-)
Bilirubin (-)
Ketones (-)

Physical Analysis Result

Color Light yellow
Transparency Clear
Albumin (-)
Glucose (-)
pH 6.0
Specific gravity
Leukocytes (-)
VI. MEDICATIONS AND IV
INFUSIONS
VII. REVIEW OF SYSTEMS
Neurological System
pupil size : 5 mm best verbal response : responsive
reaction : PERRLA best motor response : active
eyes open : spontaneously

Integumentary System
temperature : warm skin turgor : normal
color : normal JVD : not distended
skin : broken skin as evidence by the incision on her
abdomen

Respiratory System
chest : symmetrical
lungs : equal chest expansion
respirations : no distress
breath sounds : clear
cough : absent

Cardiac System
heart sounds : normal

Gastrointestinal System
abdomen : Pfanneinsteil cut over suprapubic area with scant
bloody drainaige; dressing and plaster were clean and
fully covers the incision site; no foul odor, incision
is warm and soft
Bladder not distended
(+) mass tenderness at LLQ
Bowel sounds: normoactive

Muscular System
pulses : (+) Homan’s sign : ( - )
edema : ( - ) capillary refill : < 3 seconds
peripheral calf tenderness : ( - )
VIII. ANATOMY AND PHYSIOLOGY

The Female Reproductive System

Fallopian tube/Oviduct :
o 4 inches long (each side)
o transports the mature ova form the ovaries to the uterus
o provide a place for fertilization of the ova by the sperm in it’s outer 3rd or outer
half.

Parts of Fallopian Tube:

 Interstitial – lies within the uterine wall
 Isthmus – tubal ligation
 Ampulla – where fertilization usually occurs
 Infundibulum - covered by fimbriated cell

Uterus:
o hollow, pear-shaped muscular organ
o 3 x 2 x 1 inches, weighing 50-60 grams
o Organ of menstruation
o site of implantation
o provide nourishment to the products of conception.
Muscular Layers of the Uterus:
 Perimetrium (outermost)
o offers added strenght and support to the structure.
 Myometrium (middle layer)
o expels fetus during birth process then contracts around blood vessels to
prevent hemorrhage.
 Endometrium (Inner layer )
o vascular and is shed during menstruation and following delivery.

Divisions of the Uterus:

 Fundus – upper rounded, dome-shaped portion
o can be palpated to determine uterine growth during pregnancy
 Corpus – body of the uterus.
 Isthmus forms part of the lower uterine segment
o portion that is cut when a fetus is delivered by a caesarian section.
 Cervix – lower cylindrical portion that represents 1/3 of the total uterus.
 Vagina – a 3-4 inch long dilatable canal
o organ of intercourse/copulation
o passageway for menstrual discharges and fetus

Layers of Anterior Abdominal Wall

Skin (functions):
  Protection: an anatomical barrier from pathogens and damage
 Sensation: nerve endings that react to heat and cold, touch, pressure, vibration, and
tissue injury
 Heat regulation: increase perfusion and heatloss
 Control of evaporation: dry and semi-impermeable barrier to fluid loss
 Storage and synthesis: storage center for lipids and water
 Absorption: Oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in
small amounts
 Water resistance: so essential nutrients aren't washed out of the body.

Fascia
o Camper's fascia - fatty superficial layer.
o Scarpa's fascia - deep fibrous layer.
 passive structures that transmit mechanical tension generated by muscular
activities or external forces throughout the body
 (function) reduce friction of muscular force thus allow muscles to glide over each
other.

Muscle
1. Transversus abdominus –to stabilize the trunk and maintain internal abdominal
pressure.
2. Rectus abdominus –commonly called ‘the six pack’ that move the body between
the ribcage and the pelvis.
3. External oblique muscles –allow the trunk to twist
4. Internal oblique muscles –flank the rectus abdominus, operate in the opposite way
to the external oblique muscles

Fascia transversalis

 A thin aponeurotic membrane which lies between the inner surface of

the Transversus abdominis and the extraperitoneal fascia.
 Thick and dense in structure and is joined by fibers from the aponeurosis of the
Transversus, but it becomes thin as it ascends to the diaphragm, and blends with
the fascia covering the under surface of this muscle.

Peritoneum
 the serous membrane that forms the lining of the abdominal cavity or the coelom
 covers most of the intra-abdominal (or coelomic) organ
IX. PATHOPHYSIOLOGY
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 (continued next page)

 PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Contractions Ripening of the Cervix

(descent of the fetal
head into the pelvis)
(false labor) (Goodell’s Sign
>begin and remain irregular wherein the cervix
>1st felt abdominally feels softer like
>pain disappears with consistency of the
ambulation earlobe)
>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
and intensity a mixture of blood and fluid) amniotic sac)
>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 and
Transverse presentation of fetus)

increase risk for fetal distress

when cord is compressed
(meconium staining, hypoxia)

Increase risk of fetal death (continued next page)

 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

(blood loss of patient X: 800mL)
X. PRIORITIZED LIST OF NURSING
PROBLEMS

1. Acute Pain

2. Impaired Skin Integrity

3. Constipation

4. Deficient knowledge
XI. NURSING CARE PLAN
XII. DISCHARGE PLAN

Medication
 Advise the patient to take the medicine prescribed by the doctor.
o Mefenamic Acid 500 mg as necessary
o Cephalexin 500 mg/capsule once a day for 7 days
o Ferrous Sulfate 30 mg/day

Environment
 Instructed patient to stay in calm, quiet environment
 Home environment must be free from slipping or accident hazards

Exercise
 Encourage Ambulation to the patient to promote fast healing, avoid strenuous
activity to prevent wound dehiscence.

Treatment
 Get plenty of rest, adequate rest is important to maintain progress towards full
recovery and to avoid relapse.
 Drink lots of fluids, especially water, liquids will keep patient from becoming
dehydrated.

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

Hygiene
 Advise the patient to take a bath everyday but avoid the incision site from being
wet to prevent on increasing risk of infection and for faster wound healing.
Instruct the patient to cover it with clean plastic.
 Instruct the patient to clean and dress the incision site everyday with iodine
povidone (Betadine) to avoid infection and promote healing.

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
Others
 Instruct the patient to go back for hospital visit after a week for follow up check
up.

Diet
 Tell the patient to increase protein intake for wound healing and increase fluid
intake and fiber to prevent constipation.
 Advise the patient to eat green leafy vegetables (like malunggay) and fruits for
lactation.

Sexual and Spiritual Activity

 Sexual
o She can resume coitus as soon as the act is comfortable or her, possibly as
early as 1 week after discharge.
o Warn the patient to abstain from intercourse if the discharges (lochia)
haven’t disappeared yet because it will cause unhygienic intercourse.
 Spiritual
o Tell the patient to continue her daily spiritual activities to enhance
spiritual health.
 Presented by:
BSN III – Block I

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Bala, Kenneth Masiding, Najmerah
Bastes, Merriam Molino, Joann
Cantila, Arlene Morales, Juan Paolo
Casaul, Bernadette Nepacena, Kristel Joyce
David, Jan Irvil Ocampo, Trisha Joyce
Dulguime, Maria Teresa Olermo, Olivia
Durias, Jemalen Palejaro, Melanie
Ebuenga, Amy Pena, Karen Gill
Estaras, Raquel Perdiz, Hanna Joy
Evangelista, Lovi Rizza Rivas, Jecca
Forlales, Allan John Carlo Rubel, Catherine Ann
Gabay, Christine Joy Sacare, Ana Marie
Galagaran, Jazel Simmons, Michael
Garcia, Karen Luz Vargas, Charmaine Claire
Guzman, Vanessa Jean Villarte, Mark David
Halamani, Rona Liza
Java, Marinela
Lambino, Joanna Jill