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For more than a century, obstetricians have been aware that patients with
pre-existing diabetes who became pregnant worsened clinically. Blood sugar
values of these diabetic patients were very unpredictable. Prior to the invention of
insulin, patients with diabetes were advised by their physicians not to conceive.
There was a significant risk of maternal death from diabetes if patients attempted
pregnancy. After the invention of insulin, the risk of maternal death dropped
dramatically in the era before World War II, but diabetic patients continued to
have a much higher risk of both fetal death and fetal birth defects.
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B. Objectives of the Study
The case study is made for us student to have an understanding about the
case of the patient. Where we can identify the patient’s major cause of illness
and to provide intervention to the identified problems that will improve to the
health status of the patient. And by this, we will expand our nursing skills and
able to impart knowledge to the readers.
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Patient’s Profile
Name of Patient: X
Sex: Female
Age X
Religion: Roman Catholic
Civil Status: Married
Income: Refused
Nationality: Filipino
Date Adm. July 15,2008
Time: 10:15 pm
Informant: Patient
LMP: October 30, 2008
AOG: 36-37 weeks
Physician: Dr. Paano-Go
Temperature:36.3’C
Pulse Rate:83 bpm.
Resp.Rate: 15 cpm
Bp: 120/80
Height:152.4cm
Weight: 68kg.
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IV. DEVELOPMENTAL DATA
Robert Havighurst believes that learning is basic to life and that people
continue to learn throughout life. He describes growth and development as
occurring during six stages, each associated with six to ten tasks to be learned.
According to Havighurst each individual will develop a task and this task
arises at about certain period in life of individual. Successful achievement of
which leads to his happenings and to success with later tasks, while failure leads
to unhappiness in the individual, disapproval of society, and difficulty with later
task.
Mrs. KL belongs to adulthood. In this stage the tasks are (1) rearing
children, (2) managing a home, (3) taking on civic responsibilities, (4) finding a
congenial social group.
On Mrs. KL developmental task, fortunately she had just delivered her first
baby. She has more responsibility now compared before. Our patient is a college
teacher and been socially active in some social activities. But her focus now is
more on her family.
B. Psychosexual Theory
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the ship. Though there was trust but it’s not that easy to be alone but of course
its work and have to bear with it to support their children in the future.
The health care provider’s role is to provide appropriate opportunities for
the person to relate with and allow verbalization of feelings and concerns.
Significant others were encouraged to respond to the needs of the patient and to
talk to him and touch therapy as often.
C. Psychosocial Theory
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The health care provider encouraged the significant others to provide love
and support to the patient.
D. Cognitive Theory
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ANATOMY AND PHYSILOGY
Pancreas
The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is
both exocrine (secreting pancreatic juice containing digestive enzymes) and endocrine
(producing several important hormones, including insulin, glucagon, and somatostatin). It
also produces digestive enzymes that pass into the small intestine. These enzymes help in
the further breakdown of the carbohydrates, protein, and fat in the chyme.
1: Head of pancreas
2: Uncinate process of pancreas
3: Pancreatic notch
4: Body of pancreas
5: Anterior surface of pancreas
6: Inferior surface of pancreas
7: Superior margin of pancreas
8: Anterior margin of pancreas
9: Inferior margin of pancreas
10: Omental tuber
11: Tail of pancreas
12: Duodenum
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Histology
Under a microscope, stained sections of the pancreas reveal two different types of
parenchymal tissue. Lightly staining clusters of cells are called islets of Langerhans,
which produce hormones that underlie the endocrine functions of the pancreas. Darker
staining cells form acini connected to ducts. Acinar cells belong to the exocrine pancreas
and secrete digestive enzymes into the gut via a system of ducts.
Function
The pancreas is a dual-function gland, having features of both endocrine and exocrine
glands.
Endocrine
The part of the pancreas with endocrine function is made up of a million cell clusters
called islets of Langerhans. There are four main cell types in the islets. They are
relatively difficult to distinguish using standard staining techniques, but they can be
classified by their secretion: α cells secrete glucagon, β cells secrete insulin, δ cells
secrete somatostatin, and PP cells secrete pancreatic polypeptide.
The islets are a compact collection of endocrine cells arranged in clusters and cords and
are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by
layers of endocrine cells in direct contact with vessels, and most endocrine cells are in
direct contact with blood vessels, by either cytoplasmic processes or by direct apposition.
According to the volume The Body, by Alan E. Nourse, the islets are "busily
manufacturing their hormone and generally disregarding the pancreatic cells all around
them, as though they were located in some completely different part of the body."
Exocrine
In contrast to the endocrine pancreas, which secretes hormones into the blood, the
exocrine pancreas produces digestive enzymes and an alkaline fluid, and secretes them
into the small intestine through a system of exocrine ducts. Digestive enzymes include
trypsin, chymotrypsin, pancreatic lipase, and pancreatic amylase, and are produced and
secreted by acinar cells of the exocrine pancreas. Specific cells that line the pancreatic
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ducts, called centroacinar cells, secrete a bicarbonate- and salt-rich solution into the small
intestine.[6]
Regulation
The pancreas receives regulatory innervation via hormones in the blood and through the
autonomic nervous system. These two inputs regulate the secretory activity of the
pancreas.
Because the pancreas is a storage depot for digestive enzymes, injury to the pancreas is
potentially very dangerous. A puncture of the pancreas generally requires prompt and
experienced medical intervention.
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PATHOPHYSIOLOGY
Precipitating factors:
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Increase hormone release in the placenta which is HPL
This insulin release further decreases insulin receptors due to elevated hormonal
levels.
Thus the vicious cycle of excess appetite with weight gain occurs. Few other
symptoms mark this condition.
MEDICAL MANAGEMENT
LABORATORY RESULTS:
Hematology
Clotting Time 7 minutes and 3-7 minutes Increase
15 seconds
Normal
Basophils
0.1%
0.00-14.5%
July 16,2008
Urinalysis
Color Yellow
Appearance Clear Clear Normal
Glucose Negative Negative Normal
Protein +1 <150 mg/ 24 h Normal
Reaction 6.0 ph
Specific Gravity 1.010
Microscopic
WBC
RBC 0-1
Epithelial Cells 0-1
Mucous 10-12
Threads
Urates Occasional
Bacteria
NONE Seen Negative Normal
NONE Seen Negative Normal
July 16,2008
Blood Chemistry
Potassium 3.63 meq/L 3.50-5.50 Normal
Na 139.20 meq/L meq/L Normal
135.00-155.00
Creatinine 0.72 meq/L meq/L Normal
0.70-1.30
meq/L
Ultrasound Result:
Impression: Single, live, intrauterine pregnancy in present cephalic
presentation of about 38 weeks AOG by composite fl, BPD, HC and AC.
Placenta Anterior, with a Grannum grade of about III normohydramios.
Biophysical score of 6/8.
DRUG STUDY
Dose/ Route:
Classification: Anti-infective
Mechanism of Action: Bind to bacterial cell wall membrane, causing cell death
Nursing Precaution:
Mechanism of Action: Inhibits the action of histamine at the H2- receptor site
located primarily in gastric parietal cells, resulting in inhibition of gastric acid
secretion
Nursing Precaution:
• Assess for epigastric or abdominal pain and frank or occult blood in stool,
emesis, or gastric aspirate
Nursing Precaution:
Mechanism of Action: Inhibits the enzyme COX-2. This is required for the
synthesis of prostaglandin. Has analgesic, anti-inflammatory properties.
Decreased pain.
Nursing Precaution:
Classification: Antianemics
Nursing Precaution:
Classification: Anti-infective
Mechanism of Action: Disrupts DNA and protein synthesis is susceptible
organisms.
Nursing Precaution:
Nursing Precaution:
• Assess type, location, and intensity of pain before 1 hr after IM or 30 min
(peak) after IV administration.
NURSING MANAGEMENT
Interventions:
1. Assess the mount and type of preparation for childbirth has/ had (e.g., classes)
Rationale: Research indicates that preparation for childbirth reduces the need
for analgesia during labor.
Rationale: a moderate amount of anxiety about the pain enhances the ability to
cope with it; however, too much anxiety interferes with coping.
4. Encourage ambulation, if the following criteria are met; in latent or active first
stage, has not had an analgesic, membranes are intact, no vaginal bleeding, and
no fetal distress.
5. Use touch (e.g. hold the woman’s hand, rub her back), as appropriate.
Related factors: sleep deprivation before labor, prolonged first and/ or second
stage, overwhelming physical and emotional demands of labor, unrelieved pain,
prolonged NPO status.
Interventions:
Rationale: A woman who has experienced a long or difficult first stage may be
too exhausted to push effectively in the second stage.
2. Monitor fetal presentation, position, and station, and monitor the length of the
second stage.
Rationale: Muscle tension increased fatigue; it may also impede fetal descent
and prolong second stage. Because of the intensity of second stage, the couple
may nor remember what they have learned about relaxation techniquesm or they
may not able to concentrate well enough to perform them.
4. Support, or show the partner how to support the woman’s back and shoulders
during bearing-down efforts (or support her body in other positions, as needed).
Rationale: The woman may be too tires to raise her back and shoulders from the
bed without help, so this enables her to assume position most effective for
pushing.
Interventions:
1. Assess maternal and family stressors, use of coping skills, ability to accept
help with coping, and existing support systems.
Rationale: Effective coping requires the ability to identify and solve problems
and adapt to change. Labor and birth is a situational crisis that calls for increased
coping and adaptation.
2. Assess cultural background and observe the mother’s verbal and nonverbal
response to pain.
3. Assess for factors (e.g. age, lack of partner) that may increase vulnerability to
stress.
4. Evaluate the efforts of the partner to provide support, and teach or act as a
role model as needed.
Interventions:
1. Determine the client’s ability to learn.
Rationale: May not be physically, emotionally, or mentally capable at this time.
3. Assess the level of the client’s capabilities and the possibilities of the situation
Rationale: May need to help the significant others or caregivers to learn
4. Provide positive reinforcement
Rationale: Encourage continuations of efforts
5. Determine client’s most urgent need from both client and nurse viewpoint
Rationale: Identifies starting point
O Facial grimaces
Guarding
Shallow breathing
Splinting respirations
A High risk for Ineffective breathing pattern related to abdominal incision
pain.
P At the end of 5 hours, the patient will be able to maintain effective
breathing pattern.
I Independent
Assess rate and depth respirations. Teach deep slow breathing
exercises.
Respirations are typically shallow, because the least amount of
excursion is least painful when abdominal incision is present. Also,
the higher the incision, the more breathing is affected.
Encourage patient to assume position and change them
regularly. Allow client to stand, walk or sit on a chair if not
contraindicated
Position changes promote comfort, reduce muscle tension, relieved
pressure and promote least straint . Encourage husband to
massage back area, using pressure tolerated by the client.
Back massage aids in muscle relaxation. Pressure helps to
counteract
some of pain.
Dependent
Administer supplemental Oxygen as ordered.
O Facial grimaces
Guarding
Dependent
Administer Analgesic such as mefenamic acid as ordered.
E At the end of 30 minutes, the patient was able to tolerate pain
according to her tolerance and verbalizes that she could managed it.
O Wound drainage
Wound dressing on the incision site (abdominal)
NPO
A High Risk for fluid volume deficit related to wound drainage, blood
loss in surgery and NPO status.
P At the end of 8 hours, patient maintains normal fluid volume balance
as evidenced by stable BP and heart rate and by urine output at least
30ml/hour
I Independent
Monitor for postoperative bleeding.
Intraabdominal, Intraluminal, Incisional
- Postopertive bleeding usually shows as increased bloody
drainage on dressings and tubes.
Assess hydration status. Monitor IV fluids closely and provide
oral fluids as indicated.
- Oral fluids are usually restricted until peristalsis returns and
patient is at risk for electrolyte imbalance if not monitored.
Place patient in complete bed rest for 2-3 days.
- Unusual activities may precipitate to an increase metabolic
rate thus increasing risk for dehydration.
Apply Heat or cold compresses as ordered,
Hot moist comressess have penetrating effect. The warmth
rushes blood to the affected area to promote healing. Cold
compresses may reduce local edema and promote some numbing,
thereby promoting comfort.
Dependent
Administer parenteral fluids as indicated to replace fluid loss.
Administer medications as indicated. ( folic acid and ferrous sulfate)
E At the end of 8 hours, the patient was able to have an adequate fluid
intake through the IV fluids.
O Wound drainage
Wound dressing on the incision site (abdominal)
A High risk for altered tissue integrity related to operative wound.
Health Teachings
Medications
Commonly, the patient is prescribed for 3 drugs at the postpartum period.
These are antibiotics (cefalexin, ferrous sulfate and mefenamic acid). It is
important that the patient takes these medications accordingly.
For cefalexin, it is an antibiotic to combat possible infection that might
originate at the wound site (in the perineal area or in the wounded area inside).
Since it is an antibiotic, then the patient must take this according to prescribed
dosage, timing and therapy period (usually 1 week, but not more than 10 days).
A patient must not miss or skip a medication because doing so can result to
resistant strain of bacteria (usually staphylococcus aureus). Resistant strains are
those that can not be treated anymore with the same generation of antibiotic, but
requires a higher generation.
For ferrous sulfate, this is a supplement to be taken once a day to prevent
iron-deficiency anemia. During childbirth, blood loss is unavoidable. Thus, the
blood lost must be replaced. Ferrous sulfate is an iron source to increase the
hemoglobin in the blood (increasing the oxygen capacity of the blood). It is
recommended that this drug be taken either 2 hours after meal or 1 hour before
meal, because this drug is best absorbed in an empty stomach. Also, iron reacts
to milk. Thus, the drug must not be taken with milk or any dairy products. This
drug is also best absorbed in an acidic environment. Hence, it must be taken in
adjunct with vitamin C.
For mefenamic acid, this drug is taken as analgesic or pain reliever. It is a
GI irritant. Thus, it must be taken immediately after meal.
Exercise
Instruct the woman in postpartum exercise for the immediate and later
postpartum period.
A. Immediate postpartum exercises can be performed in bed:
• Toe stretch (tightens calf muscles) – while lying on your back, keep
your legs straight and point your toes away from you, then pull your
legs toward you and point your toes toward your chest. Repeat 10
times.
• Kegel exercise (tightens vaginal muscles) – contract vaginal muscles
as if stopping stream of urine. Do 15 per day, increasing 15 more each
week to a maximum of 40 per week. Once conditioned, patient can do
4 to 5 Kegel’s per day for maintenance.
• Abdominal breathing – lie on back, knees bent, hands on belly, feet
flat. Suck in your belly, trying to pull your navel towards your spine.
Hold 5 seconds; release. When you can do 10 (this can take a week),
add a head lift. Suck in your belly, and then hold it as you lift head
toward chest, counting slowly to 4. Lower head for 4 slow counts;
release belly.
• Arm circle – stand with feet approximately 12 inches apart, arm at
sides. Keeping arms at sides, draw large circles with your shoulders by
moving them forward, up, and back, and finish with a press down. Do
10 to 20 repetitions. Next, extend both arms as you reach forward, up,
back, and down. Move slowly, breath deeply for 5 to 10 repetitions.
• Short walk – start with 5 minutes at first, then increase 5 minutes per
day as desired.
B. Exercise for the later postpartum period can be done after the first
postpartum visit (1 to 2 weeks postpartum):
• Bicycle (tightens thighs, stomach, and waist) – lie on your back on the
floor, arms at sides, palms down. Begin rotating your legs as if you
were riding a bicycle, bringing the knees all the way in toward the chest
and stretching the legs out as long and straight as possible. Breathe
deeply and evenly. Do not exercise at a moderate speed and do not
tire yourself.
• Buttocks exercise (tightens buttocks) – lie on your stomach and keep
your legs straight. Raise your legs in the air, and then repeat with your
right leg (feel the contraction in your buttocks). Keep your hip on the
floor. Repeat 10 times.
• Twist (tightens waist) – stand with legs wide apart. Hold your arms at
your sides, shoulder level, palms down. Twist your body from side to
front and back again. Feel the twist in your waist.
Treatment
Teach the woman to perform perineal care – warm water over the
perineum after each voiding and after each bowel movement several times a day
to promote comfort, cleanliness and healing. Teach the woman to apply perineal
pads by touching the outside only, thus keeping clean the portion that will touch
her perineum.
Inform the woman that intercourse may be resumed when perineal and
uterine wounds have healed and when vaginal bleeding has stopped.
Counsel the woman to rest for at least 30 minutes after she arrives home
from hospital and to rest several times during the day for the first few weeks.
Advise the woman to confine her activities to one floor if possible and to
avoid stair climbing as much as possible for the first several days at home.
Out-patient
Advise woman that healing occurs within 2-4 weeks; however, evaluation
by the health care provider during the follow-up visit is necessary.
For breastfeeding mothers, alert them that uterine cramping may occur,
especially in multiparous women, because of the release of oxytocin. Teach the
mother to provide for adequate rest and to avoid tension, fatigue, and a stressful
environment, which can inhibit letdown reflex and make breast milk less available
at feeding. Also, advise the woman to avoid taking medications and drugs
without provider approval, because many substances pass into the breast milk
and may affect milk production or the infant.
Review methods of contraception. Sexual arousal may cause milk to leak
from breasts. Breastfeeding is not a reliable method of contraception.
Inform the woman that menstruation usually returns within 4 to 8 weeks if
bottle-feeding; if breast-feeding, menstruation usually returns within 4 months,
but may return between 12-18 months postpartum. Nursing mothers may ovulate
even if experiencing amenorrhea, so a form of contraception should be used if
pregnancy is to be avoided.
Counsel the woman to provide quiet times for herself at home, and to help
her establish realistic goals for resuming her own interest and activities.
Encourage the couple to provide times to reestablish their own relationship and
to renew their social interests and relationship.
Diet
It is recommended that the patient eats nutritious foods, with a balanced
diet. Instruct the breast-feeding woman to add between 500 and 750 additional
calories daily for milk production. Inform her that she needs also 2-3 quarts of
liquid per day; 20 grams more protein than before pregnancy; and additional
calcium, phosphorus, vitamins D, A, C, E, B, and B2; and additional niacin, zinc
and iodine.
Aside from vitamins and supplements, it is suggested that the mother eats
more green leafy vegetables (petchay, kangkong, etc) because these are good
sources of iron for the replenishment of blood loss during child delivery. This is to
prevent iron-deficiency anemia.
The mother is also encouraged to eat fruits because these are rich in
vitamin C, and so with foods high in protein. The injury at the perineal area
(laceration, episiotomy) sustained during the childbirth process needs to be
healed soon to prevent infection. Vitamin C and protein promotes cell reparation
or cell regeneration at the injured site. Protein is also the source of antibodies in
the body that can fight possible infection.
Referral
The patient upon discharge from the hospital will be referred to a local
health center nearest to the patient's residence for follow up check up. She will
be given a referral slip by her OB doctor at JRB Hospital so that she can avail of
the services in the local health center. The patient is advised to report to the X
one week after discharge for a postnatal check up. The patient is also advised to
go back to the health center two weeks after delivery for the first immunization of
her infant.
BIBLIOGRAPHY