COMPETENCE APPRAISAL

The Post-operative Mother

By: Busa, Ana Marie V. BSN IV-A To: Ms. Rowena Ang RN

There are a wide range of surgical procedures that have been developed to treat the various conditions in Obstetrics. Some common surgical procedures that are performed include: y Episiotomy. A surgical incision made in the perineum (the area between the vagina and anus) to expand the opening of the vagina to prevent tearing during delivery. y Colporrhaphy. Surgical repair of the vagina may be necessary after childbirth, sexual assault, or other injuries. y Cervical cerclage . The cervix is stitched closed to prevent a miscarriage or premature birth. y Salpingostomy. An incision is made in the fallopian tube, often to excise an ectopic pregnancy. y Salpingectomy. One or both fallopian tubes are removed in this procedure. It may be used to treat ruptured or bleeding fallopian tubes (as a result of ectopic pregnancy), infection, or cancer. y Tubal ligation. A permanent form of birth control in which a woman's fallopian tubes are surgically cut or blocked off to prevent pregnancy. y Cesarean Section . A surgical procedure in which incisions are made through the woman's abdomen and uterus to deliver her baby. A cesarean birth, also known as C-section, happens through an incision in the abdominal wall and uterus rather than through the vagina. Some C-sections are planned due to pregnancy complications or because you've had a previous C-section. But, in many cases, the need for a first-time C-section doesn't become obvious until labor has already started. Knowing what to expect during the procedure and recovery can help the mother prepare. Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Some indications for Caesarean delivery are: y Complete placenta previa y Cephalopelvic disproportion y Placental abruption y Active genital herpes y Umbilical cord prolapse y Failure to progress in labor y Nonreassuring fetal status y Previous classical incision on the uterus

y y y y y

Benign and malignant tumors Cervical cerclage Breech presentation Previous cesarean birth Preeclampsia

In the case of Mrs. Precy Ardani, 31 years old from Pasar Staff house Isabel, Leyte, she was admitted to Ormoc Sugarcane Planters Association-Farmers Medical Center last November 8, 2010 with diagnosis of Severe Preeclampsia. Preeclampsia is a condition of pregnancy marked by high blood pressure and excess protein in your urine after 20 weeks of pregnancy. Preeclampsia often causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious, even fatal complications for both mother and baby. The women at risk for preeclampsia are primiparas younger than age 20 years or older than 40 years, women who have had five or more pregnancies, women of color, women with a multiple pregnancy, women with hydramnios and women with underlying disease such as heart disease, diabetes with vessel or renal involvement and essential hypertension. The condition may be associated with poor calcium or magnesium intake. A woman has passed from mild to Severe Preeclampsia when her blood pressure has risen to 160mmHg systolic and 110mmHg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic pressure is 30mmHg above the prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample, or more than 5g in a 24 hours sample, and extensive edema are also present. The hypertension, albuminuria and edema of preeclampsia, usually arise 32 weeks into a first pregnancy, and are often accompanied by headache and disruptions of vision. Preeclampsia seems to originate from an implantation abnormality that affects placental blood vessels. The resulting placental ischemia may be severe enough to produce placental infarcts. Complications of hypertension are the third leading cause of pregnancyrelated deaths, superseded only by hemorrhage and embolism. Preeclampsia is associated with increased risks of placental abruption, acute renal failure, cerebrovascular and cardiovascular complications, disseminated intravascular coagulation, and maternal death.

Mrs. Precy Ardani was born on a Filipino on January 21, 1979 at Kitaotao, Bukidnon. She is the youngest child of Mr. & Mrs. Macalam. Mrs. Ardani together with her husband lives in Pasar Staff House, Isabel Leyte. Four days prior to admission, Mrs. Ardani had an elevated BP of 160/110 was detected during her prenatal and was prescribed by Methyldopa, 250g 1tablet TID by Dr. Larrazabal, BP was managed and she was sent home. Mr. Ardani reported that there was no history of elevated BP during the past months of her pregnancy. Although she felt uncomfortable and unable to walk weeks before delivery due to pitting edema grade 4, she doesnt have any other manifestations of Preeclampsia when she was at home. Came November 8, 2011 when there was positive watery/bloody discharge, she felt heaviness at her nape, she was then rushed and admitted to the Ormoc Sugarcane Planters Association - Farmers Medical Center at 7:43 pm. Upon arrival at the hospital, Mrs. Ardani had an internal examination with one of the resident doctors and resulted that her cervix was 1-2 cm dilated and 60-70% effaced, the staff reached Dr. Gardenia Larrazabal through the phone and decided to induce the labor with oxytoxin. Hours after induction of oxytocin, Mrs. Ardanis condition worsened and her BP unmanageable so Dr. Gardenia Larrazabal opted for a delivery of the baby via cesarean section. On November 9, 2010 at 1:27 a Primary Low Cervical Transverse Cesarean Section was performed by Dr. G. Larrazabal, the operation ended at 2.25 with safe delivery of the baby.

Pathophysiology of Severe Pre-eclampsia

Predisposing Factors:  Maternal Age (very young or advanced maternal age)  History of Hypertension  Familial history of Preeclampsia  Multiple Gestation  Primigravida  Women with history of diabetes or kidney disease.

    

Precipitating Factors: High Sodium diet High cholesterol diet Stressful lifestyle Obesity Abnormal placental development

 

Sedentary lifestyle Immune Malaptation

Decreased levels of vasodilating prostaglandins

Vasospasm

Vascular damage Platelet Aggregation

Hypertension Intravascular Volume Extravascular Fluid

Low platelet count

Fibrin deposits

Microangiopathic Hemolytic anemia

Decreased uteroplancental perfusion Placental Ischemia

Decreased hepatic perfusion

Obstructed blood flow with liver distention

Decreased renal perfusion

Signs:  BP of 160/110 or higher in 2 occasions in at least 6hrs apart while at rest.  preoteinuria 5 g/L in 24hrs  oliguria 500 mL in 24hrs  cerebral or visual disturbance  pulmonary edema/cyanosis  epigastric or RUQ pain  hepatic enzymes  Thrombocytoperia  Fetal growth restriction  Generalized edema

Symptoms:  Headache  Blurred vision/scotomata  Dyspnea  Hyperreflexia  Nausea & Vomiting  Irritability  Emotional tension  Dizziness

Nursing Management:  Bed rest  High-protein, moderate-sodium diet  Daily weigh and daily evaluationof worsening edema.  Monitor BP q4h  Monitor I&O q4h  Monitor FHT qh  Assist in ADLs  Assess reflexes  Discuss mode of childbirth  Position on the side  Provide comfort measures as needed  Encourage family members to stay with the expectant mother as long as possible throughout labor and childbirth.

Medical Management:  Anticonvulsants  Corticosteroids  IVF Therapy  Antihypertensives

Surgical Management:  Cesarean Section

Nursing Assessment (Post operative) Name of patient: Mrs. Precy Ardani Gender: Female Room #: 109 Age: 31 years old Physician: Dr. G. Larrazabal Case #: 105122 Complaints: Labor Pains Impression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of induction

Body Part Head

PHYSIOLOGIC I Symmetrical, normocephalic and in midline of the body, no lesions P Without masses P A

Hair

Black, coarse and curly, evenly distributed, shoulder level, no parasites or dandruff White, no dandruff

Thin and coarse

Scalp

Absence of nodules, non tender No tenderness, warm, temporal pulse: 148 bpm No lumps, no tenderness, non pitting edema present

Forehead

Smooth, symmetrical, no lesion, no rashes

Face

Round in shape, no deformities, brown colored skin, dry skin turgor, pale, chloasma present Evenly distributed, black in color, parallel Slightly curved outward and evenly distributed Skin is intact with no discoloration, able to open and close Palpebral: light pink color,

Eyebrow

No masses

Eyelash

Eyelids

Conjunctiva

no inflammation, Bulbar: pale pink, moist, no accumulation of secretions. Sclera White, anicteric, moist, small veins are visible Brisk constriction, round, regular, smooth border, black and equal in size in both eyes. Round, reactive to light and accommodation. Located in the midline of the face, slight nasal stuffiness and swelling, no masses, no bleeding. No swelling No swelling, glows on each side is equal 30 adult teeth, 2 molars missing, 1 black Dry, proportional to the face, presence of cracks and peelings Light pink, no retraction, swelling or bleeding Located at the midline, not inflamed, pink Not inflamed, light pink Dark pink, no ulceration Yellowish in color Located anteriorly with ruggae Resistant Intact to gums Hard Tender, rough No pain No pain No lump, no secretions

Pupils

Muscle Balance

Nose

Fontal sinuses Maxillary Sinuses Mouth

Lips

Gums

No masses

Uvula

Tonsils Tongue Teeth Hard palate

Soft palate

Posteriorly located, moist, no lesions, no ulcerations Equal in size bilaterally, no scars, no lesions, good skin turgor, evenly distributed skin color, no swelling No scars, no lesions, no deformities, full ROM without complaints Not inflammed Flexible, without masses

Ears External

Neck

Carotid pulse: 120 bpm, no palpable masses, non tender Non tender, palpable No pain No pain No lump, equal expansion

Lymph nodes

Trachea Thyroid Thorax Chest Anterior

Stays on center Rises during swallowing Symmetrical, elliptical shape and brown in color, freckles present, moles present, RR:28 breaths/min

Lungs

Dull sound on bony prominence; resonant on intercostals spaces. Supple, symmetrical in size, darker pigment than skin on nipple and dark brown on areola, veins dilated Unpalpable nodes Clear lung sounds on both fields.

Breast

Heart

No pulsation palpable over aortic and pulmonic Spine aligned vertically, no patches, no retractions Warm to touch, equal expansion Dull sound on bony prominence; resonant on intercostals spaces.

Heart rate: 124 bpm

Chest Posterior

Vesicular and bronchovesicular breath sounds heard

Lungs

Clear lung sounds on both fields. Striae present, rotund abdomen, flabby, linia nigra present, freckles present, Pfannensteil incision at lower segment of abdomen present. Equal muscle tone, poor skin turgor, presence of IVF line of D5NM 1L @ 30 gtts/min at the left dorsum of her hand, freckles present, presence of scars, warm to touch, nails clipped, non pitting edema Tender and moderately painful Dull sounds on kidneys liver Bowel sounds: 5/min, no bruits

Abdomen

Extremities Upper

Pulse rate: 120bpm axillary temp: 38C No pain, tenderness or nodules, full ROM

Biceps Reflex Lower Warm to touch, poor skin turgor, bipedal edema, non pitting grade 4, weakness

Equal strength No pain, ROM impaired Pulse rate: 120bpm

Patellar Reflex

Equal strength

Diagnostic results Name of patient: Mrs. Precy Ardani Sex: Female Room #: 109 Age: 31 years old Physician: Dr. G. Larrazabal Case #: 105122 Complaints: Labor Pains Impression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of induction Institution: Ormoc Sugarcane Planters Association-Farmers Medical Center
Diagnostic Test HEMATOLOGIC EXAM: Date: Nov. 8, 2010 WBC Neutrophils Lymphocytes Monocytes Eosinophils Basophils RBC HGB HCT PLT MCV MCH MCHC 5 10 x 10^9/L 35-80% 15-50% 0-13 % 0-3% 0-2% 4.8-5 x 10^12/L 11.5-16.5 g/dL 35-55% 150-450x10^9g/L 80-100fl 27-32 pq 32-36% 7.8x10^9/L 63.7% 26.9% 7.9% 1.2% 0.3% 4.1x10^12/L 12.7g/dL 38.8% 171x10^9g/L 94fl 32.7pq 32.7% Normal Normal Normal Normal Normal Normal Slight Decrease Normal Normal Normal Normal Slight increase Normal Normal Value Patient s Result Significance

RDW

11-15%

12%

Normal

Functional Health Pattern (post-operative) Health Perception/Health Management After the operation the patient was more comfortable or assured that her health was in better condition, and yet she still worries with regards to the next pregnancy if there is any. But verbalizes she wouldnt have any more children because she can no longer take the pain during the birth process. Cognitive/Perceptual After the operation the patient has no problem in her hearing, seeing things clearly; she is well oriented time to time by asking some question about her health, place and person. The patient can still perform activities of daily living and there were no changes in her mental status. Nutritional and Metabolic After the operation, the patient was on soft diet and is still able to eat 3 meals a day. She doesnt have any problems regarding on the foods being served to her. Elimination Pattern After the operation the patient was inserted with a folly bag catheter and patients urine output of 420 mL per shift. The patient defecates for 1-2 times a day. Sexuality and Reproduction Sexual activity has not yet resumed due to post-operative wound. Activity and Exercise After the operation, the patient is trying her best to do some walking at the side of the bed. But she knows where her limits are, and if she feels pain she just rests for a while. Roles and Relationship

The patient is married, and a mother of 1 child, and she has a good relationship with her husband, children, relatives and friends, upon hospitalization some of her relatives and family were there even if they live very far.

Values and Belief As a devout Roman Catholic, she prays and read the scripture most especially thanking God for relieving them from complications. Coping and Stress After the operation the patient was able to cope with the discomfort of post-operative wound. The patient can still cope up to her situation because the support given by her husband, family, relatives and friends. She had a positive outlook of her situation even before and after the operation.

Nursing Care Plans (post operative) Name of patient: Mrs. Precy Ardani Sex: Female Room #: 109 Age: 31 years old Physician: Dr. G. Larrazabal Case #: 105122 Complaints: Labor Pains Impression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of induction
Needs/ Problems/ Cues Physiologic Overload: 1. Altered comfort: Acute Pain Objective: -Seen patient on bed, conscious, coherent & aware of time place and date; occasional facial grimaces; presence of wound in the lower segment of abdomen. -Pain started after surgery; located at the hypogastric region of the abdomen or incision site with duration of 30 sec - 1 min characterized by cramping and stinging pain. It is aggravated by frequent movement and relieved by repositioning or sleeping. It is treated by Algesia Nursing Diagnosis Altered Comfort: Acute Pain related to surgical incision secondary to Primary low cervical transverse cesarean section Scientific Basis The woman s physiologic concern for the first few days after cesarean birth may be dominated by pain at the incision site and pain resulting from intestinal gas. Source: Maternity & women s health care By: Lowdernill; Perry p10151020 Objectives After 8 hours of nursepatient interaction, the patient will be able to: 1. experience increased comfort concerning pain as evidenced by lowered pain intensity from 6/10 to 3/10. Nursing Interventions 1. Measures to decrease pain intensity: a. keep patient at rest in semifowler s position. a. Gravity localizes inflammatory exudates into lower abdomen or pelvis relieving abdominal tension which is accumulated by supine position. b. to alleviate pain by promoting nonpharmacologic pain managemen. Rationale
Evaluation

b. provide additional comfort measures such as touch, repositioning & quiet environment. c. instruct patient to use relaxation techniques such as deep breathing exercises. d. instruct the use of binders.

c. provides relaxation and good circulation.

d. to reduce pain when moving.

(37.5/325mg) BID, with pain range of 6 in a 110 scale. Subjective: Sakit ang tahi sa ako pus-on

e. encourage adequate rest periods. f. encourage expression of feelings towards pain. g. Place icebags on abdomen periodically during initial 2448hr as prescribed. h. Administer Algesia BID.

e. to prevent fatigue.

f. to minimize pain.

g. soothes /relieves pain through desensitation of nerve endings. h. to relieve pain.

2. Fluid Volume Excess Objective: -bipedal nonpitting edema Grade 4 -weight gain of 54kgs to 82.3 kgs for 9 months -immobility due to edema. Subjective: grabe ang paghupong sa akong bitiis

Fluid volume excess related to changes in regulatory mechanisms and water retention secondary to Pregnancy induced Hypertension

Elevated BP damages the institial lining of the small vessels. Because of the initial damage, fibrin accumulates in the vessels, local edema develops and intravascular clotting may occur. MedicalSurgical th Nursing 7 edition volume 2 by: Black, Hawks p. 14941495\

2. Stabilize fluid volume as evidenced by balanced I/O and decreased signs of edema.

2. Measures to stabilize fluid volume: a. auscultate breath sounds. a. check for presence of congestion. b. to create baseline data for comparison. c. to decrease fluid retention.

b. measure circumference of extremeties. c. restrict sodium and fluid intake as indicated. d. Weigh daily on a regular schedule. e. elevate edematous extremeties. f. promote early ambulation.

d. provides comparative baseline. e. to reduce tissue pressure.

f. to facilitate increase of circulation g. to remove excess fluids.

g. administer Furosemide OD 8am.

3. Risk for infection Objective: -Presence of surgical wound -presence of perineal pad

Risk for infection related inadequate primary defenses secondary to surgical incision

Subjective: Delikado magkaimpeksyon tungod sa samad.

The skin is the first line of defense against bacterial invasion. When the skin is incised for a surgical procedure as in cesarean birth, this important line of defense is automatically lost. In addition, if cesarean birth is performed after the membrane have been ruptured for hours, the woman s risk for infection doubles. Source: MaternalNeonatal Nursing by Lippincott p.370

3. be free of infection.

3. Measures to decrease incidence of infection: a. perform wound care. a. Moist from drainage can be a source of infection. b. Rising WBC indicates body s efforts to combat pathogens;

b. Monitor white blood count (WBC).

c. Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions d. Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient.

c. these are signs of infection

d. Friction and running water effectively remove microorganism s from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another e. To compensate metabolic needs. f. to prevent infection

e. provide high calorie diet.

f. Administer Metronidazole TID.

g. Encourage fluid intake of 2000 ml to 3000 ml of water per day

g. Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).

Health Teaching Plan Name of patient: Mrs. Precy Ardani Sex: Female Room #: 109 Age: 31 years old Physician: Dr. G. Larrazabal Case #: 105122 Complaints: Labor Pains Impression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of induction
Objectives General Objectives: After 3 days of student nursepatient and significant others interaction, the patient and significant others will be able to gain appropriate knowledge, skills and positive attitude towards management of patient who underwent Primary low cervical transverse cesarean section. Specific Objectives: After 45 minutes of student nursepatient and significant others interaction the patient and significant others will be able to: 1. define wound care into his own level of understanding Content Methodology Time Allotment Source Evaluation

After 45 minutes of student nurse-patient and significant others interaction the patient and significant others was able to:

1. definition wound care: most client return from surgery with a sutured covered by a dressing, wounds are inspected regularly to ensure that they are clean dry and intact, excessive

Visual Aids/ pictures/ discussion

10 mins

Kozier, Fundamentals of Nursing, chapter 5, page 861

1. define wound care into his own level of understanding

drainage may indicate hemorrhage , infection or an open wound wound care involves removal of debris such as foreign material, excess slough, necrotic tissue, bacteria and other microorganism
2. state the signs and infection of symptoms of infection

2. signs and symptoms: -wound warm to touch (heat) -redness -swelling -pain in wound site -fever -loss of function -Body malaise 3. Interventions: keep wound clean and dry, use surgical aseptic technique when changing dressing adequate nutrition appropriate incision support and avoidance of strain avoid wound exposure to avoid microorganism to enter wound site 4. Materials: clean water mild soap antimicrobial solution gauze Normal Saline Solution or Isotonic Solution 5. demonstration: -Use solution such as Isotonic or Normal Saline Solution to clean and irrigate s. If Antimicrobial solutions

Visual Aids/ discussion

5 mins

Kozier, Fundamentals of Nursing, chapter 6, page 946

2. state the signs and infection of symptoms of infection

3.identify the primary intervention of wound infection

Visual Aids and discussion

5 minutes

Kozier, Fundamentals of Nursing, chapter 6, page 946

3. identify the primary intervention of wound infection

4. recognize the materials needed for wound care

Visual Aids and discussion

5 minutes

Kozier, Fundamentals of Nursing, chapter 6, page 946

4. recognize the materials needed for wound care

5.demonstrate wound care and cleansing

demonstration / return demo

20 minutes

Kozier, Fundamentals of Nursing, chapter 5, page 880

5. demonstrate wound care and cleansing

are used make sure that they are diluted well. -When possible, warm the solution to the body temperature before use, this prevents lowering of wound temperature which allows healing process. -Place the patient in a safe position (high fowlers or side lying) note the level of consciousness. -Put patient align in bed use gauze squares, avoid using cotton balls, clean the superficial non infected wound by irrigating then with normal saline solution. -To retain wound moisture, avoids dry after cleaning. -Hold sponge with sterile gloves after cleaning. -Clean the wound from inward to outward direction to prevent cross contamination. -Keep the gauze duamp, remoisten the skin of saline for optimal healing.