I.

INTRODUCTION

Nursing process is a patient centered, goal oriented method of caring that provides a frame work to the nursing care. The nursing process exists for every problem that the patient has, and for every element of patient care, rather than once for each patient. The nurse's evaluation of care will lead to changes in the implementation of the care and the patient's needs are likely to change during their stay in hospital as their health either improves or deteriorates. Nursing process was used in this case study for a more systematic to care for a client who have undergone a cesarean section birth. 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. There has been a gradual increase in cesarean births over the past 30 years. In November of 2005, the Centers for Disease Control and Prevention (CDC) reported the national cesarean birth rate was the highest ever at 29.1%, which is over a quarter of all deliveries. This means that over 1 in 4 women will experience a cesarean birth. II. OBJECTIVES

The significance of the study is for us third year students to apply the principles and concepts that we have learned in the NCM 101 (Maternal and Child Nursing) in our rotation at Porac District Hospital, with the following learning objectives: 1. Cognitive To be able to review concepts and theories in maternal and child nursing. To be able to describe the development, pathophysiology, medical-surgical management, and nursing care of a client who have undergone a cesarean section birth. To be able to design a Nursing Care Plan for the patient who have undergone cesarean birth. To be able to provide information and heath teachings to the patient in the postpartum period. 2. Psychomotor To be able carry-out hospital routines and the treatment prescribed to the patient. To be able to perform nursing procedures and nursing considerations for a client in the preoperative and postoperative stages

To be able to implement the nursing care plan. 3. Affective To be able to establish a good working relationship with the patient and hospital staff. III. NURSING ASSESSMENT

Demographic Profile: Name Age Birthday Address Name of Spouse Name of Father Name of Mother Nationality Occupation Admission Date Discharge Date Surgery Performed IV. FAMILY HISTORY Unremarkable. V. HISTORY OF PAST AND PRESENT ILLNESS The patient stands 153 centimeters and weighs about 83 kilograms. Her AOG is 43 weeks, LMP was last November 1, 2008, and her EDC was on April 8, 2009. Her OB score is G2P1 (2,0,0,2). She was already married at the age of 16 years old. She was only 17 years old when she gave birth to her first child through Cesarean Section (Low Segment Transverse), because she had a difficulty in delivering the child due to her age and the lack of knowledge. : Patient Sik Ret Bontes : 18 years old : February 29, 1991 : AMB Bldg, Brgy. Saguin, CSFP : Mambo Bontes : Muh Ret : Malah Ret : Filipino : Housewife : April 22, 2009 : April 24, 2009 : LTCS II

Educational Attainment: High School Graduate

It was on April 22, 2008 at around 8:00am when Patient Sik Ret Bontes was admitted at the Ob-ward of Porac District Hospital and was sent to the OR/DR for an internal examination and was told that her pregnancy was already over due. The patient opted for another cesarean section for this pregnancy. VI. PHYSICAL ASSESSMENT Present Patient is concern about her second cesarean section thinking that it may be detrimental to her health. Interpretation Patient cannot function normally anymore like before because of her hospital confinement and condition. Her body image changed after the surgical procedure done. Patients nutritional and metabolic status has been changed due to her confinement. Gordons Level of Functioning Pattern Before 1.Health Perception- Patient goes to the Health Management health center once upon when she got pregnant. All in all, she thinks she is in a healthy state.

2. NutritionalMetabolic Management

3.Elimination Pattern

Prior to confinement, patient loves eating instant foods and fatty foods like fries and burgers. She also loves condiments like patis, vinegar, and soy sauce. She basically loves eating whatever she likes. Bowel: Patient defecates 1-2 times a day, usually morning and in the afternoon. Stool is brown in color and well-formed.

During hospitalization, the patient is on diet as tolerated. She eats fruits like apples and oranges. She eats bread instead of rice. She said she loss her appetite since her onset of labor. Bowel: Patient defecates once a day but not on a regular basis. Stool is soft, minimal in amount and brown in color.

Bowel: There was a change in the frequency and amount.

Bladder: Patient voids usually 6-8 times a day. Urine is yellow in color. No pain when voiding. Bladder: Patient voids 3-4 times a day without pain and discomfort. Bladder: There was a change in the frequency and amount.

4.Activity, Leisure, and Recreation Pattern

5.Sleep and Rest Pattern

6.Cognitive Perceptual Pattern

7. Self-Perception / Self-Concept Pattern

8. Role Relationship

9. Sexuality/ Reproductive Pattern 10.Coping and Stress Tolerance

Patient is a housewife so she is always in charge of the household chores. Her leisure time would include playing with her firstbornand watching television. Patient puts herself to sleep by watching television programs. She usually sleeps at around 11pm to 6am. She feels rested when sleeping and thinks that her energy is sufficient for her activities. Patient is a high school graduate. She can read and write. She can speak and be understood by others. Patient is a friendly person; she loves to socialize with his friends in their neighborhoods. She considers himself as holistic human being as long as she is healthy, complete, and his family is always there. Patient can understand English, Tagalog, and Kapampangan. She has 5 siblings. She is married with 1 child. Patient has been married for 3 years. When patient is stressed, she sings in the karaoke and eats

Patients activities in the hospital are ambulation, deep breathing and coughing exercise, taking a bath or personal hygiene. Due to her uncomfortable condition and pain, patient complains of difficulty of sleeping and short period of sleeps.

Patients present condition is not a hindrance to her cognitive- perceptual pattern. During the times of her confinement, she doesnt think that she is a holistic person anymore. However, she is positive that she will be ok after confinement.

During patients confinement in the hospital, there is a limitation in her activities of daily living and a disruption in her leisure and recreation pattern. Patients sleep and rest pattern changed when she was admitted. She cannot put himself to sleep anymore due to present condition and pain plays a big factor for her sleep disturbances. No changes/ alterations.

There is a slight change in her selfperception due to present condition.

The patients family is supportive to the patient. She is happy with their presence and support. Patient reserved her right to privacy. The recent hospitalization of the patient was stressful

Normal/ No alterations.

Patient reserved her right to privacy. Patient accepts present condition with a positive attitude.

11.Values- Belief Pattern

comfort foods like burgers, fries, and her favorite sizzling sisig. When it comes to problems, she lets herself think immediately for a solution. Patient is a Roman Catholic. She has a strong faith to God and goes to mass every Sunday with her family.

and source of anxiety. However, she is positive that she will be able to cope up with current condition.

She follows a therapeutic regimen and her strong faith to God accounts for her fast recovery.

Due to her confinement, patient is trusting God that she will be discharge soon and will recover without any complications.

VII.

ANATOMY AND PHYSIOLOGY

Vagina The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches long in a grown woman. The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes, which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur. The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow

penetration to occur. These also help with stimulation of the penis. The middle layer has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer muscular layer is especially important with delivery of a fetus and placenta. Purposes of the Vagina Receives a males erect penis and semen during sexual intercourse. Pathway through a woman's body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body. May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom. The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened. The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping. The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates.

The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses. The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible. The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus. Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery. Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of ovaries and hormone production. At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg. When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the frimbriae. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes four to five days to

travel down the length of the fallopian tube. If enough sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant itself in the uterine wall where it will grow and develop. If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage and possible death of the mother.

Mammary glands are the organs that produce milk for the sustenance of a baby. These exocrine glands are enlarged and modified sweat glands. The basic components of the mammary gland are the alveoli (hollow cavities, a few millimetres large) lined with milk-secreting epithelial cells and surrounded by myoepithelial cells. These alveoli join up to form groups known as lobules, and each lobule has a lactiferous duct that drains into openings in the nipple. The myoepithelial cells can contract, similar to muscle cells, and thereby push the milk from the alveoli through the lactiferous ducts towards the nipple, where it collects in widenings (sinuses) of the ducts. A suckling baby essentially squeezes the milk out of these sinuses. The development of mammary glands is controlled by hormones. The mammary glands exist in both sexes, but they are rudimentary until puberty when - in response to ovarian hormones they begin to develop in the female. Estrogen promotes formation, while testosterone inhibits it. At the time of birth, the baby has lactiferous ducts but no alveoli. Little branching occurs before puberty when ovarian estrogens stimulate branching differentiation of the ducts into spherical

masses of cells that will become alveoli. True secretory alveoli only develop in pregnancy, where rising levels of estrogen and progesterone cause further branching and differentiation of the duct cells, together with an increase in adipose tissue and a richer blood flow. Colostrum is secreted in late pregnancy and for the first few days after giving birth. True milk secretion (lactation) begins a few days later due to a reduction in circulating progesterone and the presence of the hormone prolactin. The suckling of the baby causes the release of the hormone oxytocin which stimulates contraction of the myoepithelial cells. The cells of mammary glands can easily be induced to grow and multiply by hormones. If this growth runs out of control, cancer results. Almost all instances of breast cancer originate in the lobules or ducts of the mammary glands. VIII. PATHOPHYSIOLOGY Release of FSH by the anterior pituitary gland Development of the graafian follicle Production of estrogen (thickening of the endometrium) Release of the luteinizing hormone Ovulation (release of mature ovum from the graafian follicle) Ovum travels into the fallopian tube Fertilization (union of the ovum and sperm in the ampulla) Zygote travels from the fallopian tube to the uterus Implantation Development of the fetus/embryo & placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening (descent of the fetal head into the pelvis)

Braxton Hicks Contraction Ripening of the cervix (false labor) (Goodells Sign wherein >begin and remain irregular the cervix feels softer like >1st felt abdominally consistency of the earlobe >pain disappears with ambulation >do not increase in duration and intensity >do not achieve cervical dilatation

TRUE LABOR

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

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

Rupture of Membranes (rupture of the amniotic sac)

Failed to progress labor (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 (accompanied by blood approximately 500-1000 mL) IX. LABORATORY PROCEDURES

Urine Analysis Date Ordered: April 22, 2009 Date Performed: April 22, 2009 Microscopic Exam Color: Yellow Transparency: Hazel Rection pH: 6.0 (Normal: 7.35-7.45) Specific Gravity: 1.010 (Normal: 1.010-1.025) Pus Cells: 0.2 Epithelial Cells: Moderate Result Normal Values 4.5 6.0 x 10/L 5 10 x 10/L 120 140 g/dl 0.30 150 400 x 09/L Interpretatio n Normal Indicates presence of infection Indicates occurrence of anemia Indicates hyper coagulation Significance Chemical Exam Albumin: Negative Sugar: Negative

RBC

5.4

WBC

10.1

Increase

HgB

116

Decrease

Hct

0.35

Increase

Platelet

320

Normal

DIFFERENTIAL COUNTING Neutrophils 0.86 0.05 0.70 Increase Indicates infection or inflammation Indicates high risk for acquiring infection

Lymphocytes

0.14

0.20 0.40

Decrease

X.

COURSE IN THE WARD

April 22, 2008 S Sobrang sakit, as verbalized by the patient. O received patient awake on bed, conscious and coherent, with ongoing D5LRS 1L x 30gtts/min, hooked on the left hand, infusing well. Pain scale= 8/10 Teary eyed (+) guarding behavior (+) facial grimace Irritable Pale palpebral conjunctiva Skin warm to touch BP= 110/80 PR= 80 RR= 22 T= 37.6

A Acute pain r/t disruption of skin and tissue secondary to cesarean section. P After 1-2hr of nursing intervention, patient will verbalize decrease intensity of pain from 8/10 to 3/10. I Established rapport. Monitored vital signs. Assessed quality, characteristics, severity of pain. Dressed wound as indicated. Provided comfortable environment changed bed linens and turned on the fan.

Instructed to put pillow on the abdomen when coughing or moving. Instructed patient to do deep breathing and coughing exercise. Instructed patient to ambulate. Provided diversionary activities. Administer analgesic as per doctors order. Due meds given. Needs attended.

E Goal met. Patient verbalized pain decreased from a scale of 8/10 3/20 as evidenced by (-) facial grimace (-) guarding behavior. Frequent small talks with significant others. Endorsed.

XI.

NURSING CARE PLAN

Post-operative NCP CUES Subjective: none Objective: - dressing dry and intact -V/S taken as follows: T: 37.3 P: 80 R: 19 BP: 120/80 DIAGNOSIS Risk for infection related inadequate primary defenses secondary to surgical incision INFERENCE Due to an elective cesarean section, patients skin and tissue were mechanically interrupted. Thus, the wound is at risk of developing infection. PLANNING STG: After 4 hours of nursing intervention, patient will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly. LTG: After 2-3 days of nursing intervention, patient will achieve timely wound healing, be free of purulent drainage or erythema, be afebrile and be free of infection. INTERVENTION Independent -Monitor vital signs -Inspect dressing and perform wound care - Monitor white blood count (WB RATIONALE -To establish a baseline data -Moist from drainage can be a source of infection - Rising WBC indicates bodys efforts to combat pathogens; normal values: 4000 to 11,000 mm3 -these are signs of infection EVALUATION Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

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

-Friction and running water effectively remove microorganisms from hands. Washing between procedures

procedures with patient.

reduces the risk of transmitting pathogens from one area of the body to another - 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). - These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia. -Antibiotics have bactericidal effect that combats pathogens

- Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).

- Encourage coughing and deep breathing; consider use of incentive spirometer.

Independent: Administe r antibiotics

CUES

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Objective Cues: Patient has not yet eliminated since delivery Absence of bruit sounds Normal pattern of bowel has not yet returned

Risk for constipation r/t post pregnancy 2 cesarean section

Short Term Goal: Within 8 of nursing interventions, the patient will be able to demonstrate behaviors or lifestyle changes to prevent developing problem

INDEPENDENT INTERVENTIONS: Ascertain normal bowel functioning of the patient, about how many times a day does she defecate Encourage intake of foods rich in fiber such as fruits

This is to determine the normal bowel pattern To increase the bulk of the stool and facilitate the passage through the colon To promote moist soft stool

Long Term Goal: Within 3 days of nursing interventions, the patient will be able to maintain usual pattern of bowel functioning

Promote adequate fluid intake. Suggest drinking of warm fluids, especially in the morning to stimulate peristalsis Encourage ambulation such as walking within individual limits However, since she has had cesarean, also encourage adequate rest periods

After 8 of nursing interventions, the patient was able to identify measures to prevent infection as manifested by clients verbalization of: Iinom ako ng maraming tubig at kakain ng prutas para makadumi ako.

To stimulate contractions of the intestines and prevent post operative complications To avoid stress on the cesarean incision/ wound

COLLABORATIVE:

Administer bulkforming agents or stool softeners such as laxatives as indicated or prescribed by the physician

To promote defecation

XII.

DISCHARGE PLANNING

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