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General Objectives: The purpose of this study is to enhance and gain knowledge about, to develop communication and nursing

g skills to provide privacy and maintain confidentiality of the patient and to apply the right attitude of the student nurses in rendering and giving care to the patient with Post Cesarean and Bilateral Tubal Ligation, its importance and implication. Specific Objectives: To understand the condition of Post Cesarean and Bilateral Tubal Ligation and associate it with the patient through the introduction of the case. To illustrate the anatomy and physiology of the affected organ or the part of the body. To discuss the pathophysiology that causes anemia. To be clinically aware of the clinical manifestation and its complication. To develop an effective skill on how to plan and manage proper care in patient with Post CSBTL. To provide the client nursing care plan and discharge plan to assure clients total wellness during her hospitalization up to time of his hospital discharge. To apply right attitude by respect through providing privacy and maintaining clients confidentiality. Scope and Delimitations The study would only focus on Post CSBTL which is indicative to the patients health condition and its underlying nursing care relevant for the patient confined in Quezon Medical Center. The study was conducted at Quezon Medical Center (OB-Ward) during the nursing students exposure in the hospital (September 23,24 and 25 2012). Nursing health history, physical assessment, nursing interventions and health teachings for the patient were included. Its primary focus is the client whose diagnosis was Post CSBTL. The baseline data were gathered from the client, from the clients chart, and through the nurse-patient interaction during the exposure.

Nursing History: History of Present Illness: Masakit ang tahi ko,as verbalized by the patient. She experienced lumbosacral pain before admission. She was brought to Quezon Memorial Center last September 21, 2012. At 2:00 in the afternoon. She was brought to operating room around 10:30pm. History of Past Illness: According to the patient, she didnt experience any severe illness during her childhood. Her common illnesses are cough, colds, and fever. She doesnt had any drug and food allergies. Her first baby was delivered through cesarean operation due to drained amniotic fluid. Her second baby, died four days after the delivery due to heart failure and was delivered by cesarean operation. Her third baby was delivered through cesarean operation due to breech presentation of the baby. Her fourth baby was also delivered through cesarean operation. Family History: The patient is the 2nd child of 4 siblings. Her father is diabetic. Her mother died while giving birth to her youngest child and was delivered through cesarean operation. Her sisters, according to her was in good health condition. Genogram: Legend:

-Female

-deceased

giving birth

diabetic

-Male

- deceased

Personal/Social History: Alcohol Use: Denies. Tobacco Use: Denies. Drug Use: Denies. Travel History: Denies. Economic Status: Farming as their means of livelihood. Religion: Roman Catholic s Theoretical Framework

Watsons Caring Theory:

Physical Assessment Date of Assessment: September 25, 2012 General Appearance: The patient is oriented and conscious. She wears neat clothes exactly for her mesomorph body. Upon assessment, the client is sitting on the chair, with a pulse rate of 93 beats per minute, respiration rate of 18 breaths per minute, and temperature of 36.0 C. BODY PART A. HEAD 1. SKULL NORMALS FINDINGS Proportional to the size of the body, round, with prominences in the frontal area anteriorly and the occipital area posteriorly symmetrical in all planes. White, clean, free from masses, lumps, scars, nits, dandruff, and lesion Black or whitish, evenly distributed and covers the whole scalp, thick, shiny, free from split ends. Oblong/oval/square or heart-shaped, symmetrical, facial expressions that is dependent on the mood or true feelings, B. EYES Black, symmetrical, thick, can raise and lower eyebrows symmetrically Black, symmetrical. Can raise and lower eyebrows. normal ACTUAL FINDINGS Proportional to the size of the body, symmetrical in all planes. INTERPRETATION/ ANALYSIS Normal.

2. SCALP 3. HAIR 4. FACE

White, clean, free from masses, lumps, scars, nits, and lesions Black; evenly distributed, thick. Round shape. Symmetrical, free from wrinkles and scars. No involuntary muscle movements.

Normal Normal normal

and without difficulty, evenly distributed and parallel with each other. C. EARS D. NOSE E. MOUTH F. NECK G. RANGE OF MOTION H. MUSCULAR STRENGTH Pinkish, clean, with scant amount of cerumen and a few cilia. Midline, symmetrical, and patent. Pinkish, symmetrical lip margin, well-defined, smooth and moist. Proportional to the size of the body and head, symmetrical and straight. Freely movable with relative ease. Symmetrical movements and able to resist force applied by the nurse. I. HEART Regular beats (60-100 beats per minute). Proportional to the size of the body and head, symmetrical and straight. Poor Range of Motion. Symmetrical movements and able to resist force applied Regular beats (108 beats per minute) Deviation from normal Patients who are anemic or have low levels of hemoglobin thus carrying less oxygen in the blood causing a higher number of BPM in the heart rate Due to caesarean section delivery >due to pain at incision site. Normal Midline, symmetrical, and patent. Pale Normal Pallor due to decreased hemoglobin and hematocrit. Normal Cerumen and a few cilia. Normal

J. ABDOMEN Inspection

Unblemished skin; uniform color. Flat, rounded; symmetric contour.

With presence of incision at the abdomen; intact and no drainage

1. Abdomen skin 2. Contour and Symmetry Auscultation

Symmetric movements caused by respiration. Audible bowel sounds (5-30/min); absence of arterial bruits and friction rubs. Audible bowel sounds (10/min). Normal

Palpation

No tenderness; With contracted hard abdomen.

Had incision site.

Cannot be palpated due to pain at incision site.

K. CHEST (THORAX) Inspection

Chest symmetrical, skin intact, no tenderness, no masses.

Chest symmetrical. No lumps, tenderness and masses. Respiration of 20breaths per minute.

Normal

Palpation L. UPPER EXTREMITIES 1. ARMS Inspection

Full and symmetric chest expansion. Symmetric vocal fremitus. Skin varies (pinkish, tan, dark brown), skin is smooth, fine hair evenly distributed, muscles symmetrical, length symmetrical.

Symmetric and expands. Edematous, Pale skin, fine muscle, length symmetrical, fine hair evenly distributed.

Normal Deviation from normal Pallor due to less oxygen being available to the surface tissues caused by decrease haemoglobin level Normal

Palpation

Warm, dry and elastic, no areas of tenderness. Muscle appears equal

Warm, dry and no areas of

with good muscle tone. M. NAILS Nails are transparent, smooth, & convex with pink nail beds & white translucent tips. Five fingers in each hand. As pressure is applied to the nail bed, it appears white or blanched & pink color returns immediately as pressure is released. N. SHOULDERS, ARMS, ELBOWS, HANDS & WRISTS ABDUCTION AND ADDUCTION. O. LOWER EXTREMITIES 1. LEGS Inspection Skin varies (pinkish, tan, dark brown), skin is smooth, fine hair evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical. Performs with relative ease.

tenderness. Complete fingers, 5 each hand. Nails are thick, transparent, & convex with pale nail beds & white translucent tips. As pressure is applied to the nailbed, it appears white and color returns after 4 seconds. Performs with relative ease. Normal With deviation from normal Patients with anemia may exhibit delayed capillary refill - diminished blood flow to the periphery and compensatory vasoconstriction.

Edematous in the lower extremities Skin is pale. Hair evenly distributed.

Deviation from normal Due to excess fluid volume the patient may experience edema (Medical-Surgical Nursing by Digiulio p.177) Pallor due to less oxygen being available to the surface tissues caused by decrease haemoglobin level

Palpation

Muscles appear equal, warm & with good muscle tone.

Muscles appear equal, warm & with good muscle tone. Five toes in each foot. Sole and dorsal surface is smooth. With pale nail beds.

Normal

2. TOES Inspection

Five toes in each foot: sole and dorsal surface is smooth:

Deviation from normal Pale, whitish nail beds may indicate a low red blood Normal Normal

P. LEGS, KNEES, ANKLES, TOES ADDUCTION AND ABDUCTION. Q. PERINEUM

Performs with relative ease. No excoriation, swelling and no foul smell

Performs with relative ease. No excoriation and no swelling. With bleeding.

Laboratory Tests and Results: CBC(Complete Blood Count) Name of Test Hemoglobin Hematocrit 21 F 30-40 vol% Date Done 09/24/12 Actual Result 7 Reference Value M 14.0-18.0gm/dL F 12.0-15gm/dL M 40-50 vol% Indication decrease Interpretation anemia

decrease

anemia

Name of Test Hemoglobin

Date Done 09/21/12

Actual Result 11.3

Reference Value M 14.0-18.0gm/dL F 12.015gm/dL

Indication decrease

Interpretation anemia

Hematocrit

33.4

M 40-50 vol% F 30-40 vol%

Normal

normal

WBC Count Name of Test Neutrophils Lymphocytes Platelet Count BLOOD TYPE

6,300 Date Done 09/21/12

5,000-10,000/comm Actual Result 74 26 100% 217,000 A +

Normal

Normal Reference Value

III-Clinical Discussion of the Case: >Anatomy and Physiology:

>EXTERNAL GENITALIA: Labia minora Labia majora Clitoris >INTERNAL REPRODUCTIVE STRUCTURE: The Vagina The Cervix Uterus Oviducts (Fallopian Tube) Ovaries

PATHOPHYSIOLOGY

RISK FACTORS: BLOOD LOSS INADEQUATE RBC PRODUCATION OR INCREASE RBC DESTRUCTION NUTRITIONAL DEFICIENCY AGE AND HEALTH STATUS

HYPOTENSION AND PERIPHERAL CONSTRICTION OF THE VESSEL

COOL AND CLAMMY SKIN

DECREASED LOC AND OLIGURIA

BLOOD LOSS

BLODD VOLUME DECREASE

RBC / HEMOGLOBIN

BONES

STIMULATES ERYTHROPOIETIN RELEASE IN THE BONE MARROW

INCREASED ERYTHROPOIETIN ACTIVITY

MAY LEAD TO BONE PAIN

OXYGEN CARRYING CAPACITY OF THE BLOOD TISSUE HYPOXIA

BRAIN

CEREBRAL HYPOXIA MAY CAUSE ANGINA, FATIGUE, DYSPNEA ON EXERTION AND NIGHT

HEADACHE, DIZZINESS AND DIM

HEART

COMPENSATORY MECHANISM OF THE BODY HEART FAILURE IN SEVERE ANEMIA IN ATTEMPT TO CARDIAC OUTPUT AND TISSUE PERFUSION PALLOR OF THE SKIN, MUCOUS MEMBRANE, CONJUNCTIVA AND NAIL BED

CARDIAC AND RESPIRATION RATE

I.

Nursing process a. Long term objective

The study aims to influence the clients behavior and health and to express a clear precise meaning of diagnosis and aims to restore the patients normal activities of daily living and to prevent of further complication that might be life threatening, through collaborative management of the physician. b. Prioritized list nursing problem

Ranking

Problem

Justification

Acute pain related to tissue injury secondary to surgical intervention

We prioritized this diagnosis because pain should be attend to first, since the pain is intolerable for the patient and interventions are to render

We put this as the second because the underlying 2 Fatigue related to inadequate tissue oxygenation secondary to low hemoglobin count factor that contribute to the fatigue is due to low hemoglobin which should be correct through undergoing blood transfusion Disturbed body image related to effect of pregnancy and presence of incision. 3

We considered this as the least because we should give ample time for the patient to accept the changes she had

Nursing Care Plan ASSESSMENT S- masakit ang tahi ko as verbalized by the patient O abdominal pain scale of 9, 10 as the highest and 1 as the lowest -Guarding behavior noted -Facial grimace noted - Irritable noted - Pallor - Change of sleep pattern - Restlessness - Elevated pulse 102bpm - Respiration -24 DIAGNOSIS Acute pain related to tissue injury secondary to surgical intervention PLANNING After 2-4 hours of nursing intervention the person will verbalize relief from pain after satisfactory measures INTERVENTION Monitor vital signs to compare to its normal value. Teach specific relaxation strategy ;(rhythmic breathing or deep breath) Instruct on techniques to reduce skeletal muscle tension, which will reduce the intensity of the pain. Assess the patient contractions and discomfort. Encourage the patient to stand and walk as much as possible during first stage Instruct the patient to change the position at least every hour. Encourage diversional activities such as talking with the significant others reading and so on. Emphasize the need for rest and sleep period Advice to avoid over EVALUATION EXPECTED OUTCOME Goal partially met At the end of nursing intervention the patient demonstrated a partial relief in pain, from 9 down to 5 hindi na masyadong masakit ang tahi ko as verbalized by the patient

S- nanghihina ako as verbalized by the patient . O pale palpebral conjunctiva

Fatigue related to inadequate tissue oxygenation secondary to low hemoglobin count

After 1-3 days of nursing intervention the patient will participate in activities that

EXPECTED OUTCOME

Poor capillary refill -hgb 7gm/dl - hct 21%

stimulates and balance.

exertion. Encourage to eat food that are rich in iron. Encourage increase fluid intake COLLABORATIVE INTERVENTION Blood transfusion as ordered

Goal partially met. At the end of nursing interventions the patient demonstrated partial participation in activities that will stimulates balance and, physical domains.

LONG TERM S naiilang ako, kasi ang taba ko at may tahi pa ako sa tiyan as verbalized by the patient. affect noted Not looking at body part Not touching at body part

Disturbed body image related to effect of pregnancy and presence of incision.

After 1-2 weeks of nursing intervention the patient will able to verbalized and demonstrate acceptance of appearance.

Encourage to do light exercise.

EXPECTED OUTCOME Goal partially met. At the end of nursing intervention the patient demonstrated a willingness and ability to resume self-care and acceptance of appearance.

Drug Study Drug name Cefuroxime sodium Adults1.5g iv 3060mins before surgery ;in lengthy operations,750mg iv or im every 8hrs. Ketorolac tromethamine Im: adults less than 65 years of age 60mg Iv: adults less than 65 years of age 30mg Bisacodyl Adults and children age 12 and older: 10 -15 mg p.o in evening or before breakfast Diphenylmethane derivative Classification Second generation cephalosporin Indication Peri-operative pervention Ci and caution interaction -contraindicated in patients hypersensitive to drug or other cephalosporin -use cautiously in patients hypersensitive to penicilin because of possibility to cross-sensitivity with other beta-lactam antibiotics Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent gi bleeding or perforation Adverse effect Gi: diarrhea,nausea, vomiting Skin: Maculopapular and erythematous rashes, urticaria, pain, tissue sloughing at i.m injection site Cns: headache, dizziness, drowsiness, sedation Nursing intervention -alert: tablets and suspension arent bioequivalent and cant be substituted miligram-for-miligram -monitor patient for signs and symptoms of super infection

Nsaid

Short-term management of moderately severe, acute pain for singledose treatment

Correct hypovolemia beforegiving, Oral therapy is only indicatedas a continuation of i.m therapy in 5 days, dont give drug epidurally or intrathecally because of alcohol content

Preparation for childbirth, surgery,

Ranitidine hydrochloride

H2-receptor antagonist

Interactable duodenal ulcer; pathologic

Contraindicated to patients hypersensitive to drug or its components and in those with rectal bleeding, gastroenteritis, intestinal obstruction, abdominal pain,nausea, vomiting and other symptoms of appendicitis Contraindicated in patients hypersensitive to drug or

Cns: dizziness, faintness, muscle weakness with excessive use Gi: abdominal cramps, burning sensation in rectum with suppositories, nausea, vomiting and diarrhea Cns: vertigo, malaise Hepatic: jaundice

Give drug at times that dont interfere with scheduled activities or sleep. Soft formed stools are usually produced 15 to 60 minutes after rectal use

Competitively inhibits action of h2 at receptor sites of parietal cells,

Adults: 150mg p.o bid or 300mg daily h.s

Oxytocin, synthetic injection Adults: initially 1ml ampule in 1000ml of d5w injection

Pitocin

hypersecretory conditions, such as zollinger ellison syndrome; short-term therapy for patients unable to tolerate oral forms To induce or stimulate labor, to reduce postpartum bleeding after expulsion of placenta

any of its content, Use cautiously in patients with hepatic dysfunction. Adjust dosage in patients with impaired kidney function Contraindicated in patients hypersensitive to drug. Also contraindicated when vaginal delivery isnt advised

Other: burning and itching at injection site, anaphylaxis

decreasing gastric acid and secretion

Cns: subarachnoid hemorrhage, seizures and coma Cv: hypertension, increased heart rate, systemic venous return

Use with extreme caution during first and second stages of labor because cervical laceration, uterine rupture and maternal and fetal death

Tramadol hydrochloride Adults: 50-100mg p.o q4 to 6 hours, prn maximum 400mg daily

Ultram

Moderate to moderately severe pain

Contraindicated to patient hypersensitive to drug and in those with acute intoxification from alcohol, hypnotics, centrally actingg analgesics.

Cns: dizziness, vertigo, headache, somnolence Cv: vasodilation Gi:nausea, constipation, vomiting, dyspepsia

Use cautiously in patients at risk for seizures or respiratory depression; in increased intracranial pressure

DISCHARGE MEDICATIONS Explain to the patient and family members the importance of taking medicines. Discuss to the patient and family the dosage, frequency and adverse effects of the drugs. Encourage to follow the dosages and proper timing of his meds.

ENVIRONMENT Explain to significant others that the rehabilitation may be prolonged to be able for the family to prepare financial needs Maintain a quiet, clean and calm environment for easy and good recovery of the Patient. Provide safety measures to promote safe environment and individual safety Treatment Provide warm environment Advice patient to avoid lifting heavy objects and use of too much force to prevent more serious injury. Instruct to perform light physical activities

HEALTH TEACHINGS Instruct the patient to take medications religiously Improve nutritional status

Importance of proper hygiene for comfort

OUT-PATIENT CHECK-UP DIET Eat five or more servings of vegetables and fruit daily. Eat foods rich in Iron like liver and green leafy vegetables Have supplement of iron and drink it with vitamin C to hasten the absorption Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin turgor. Avoid use of alcohol The patient could avail his medication from government hospitals that he could get some benefits. He will also be able to avail the services offered by the barangay health center and and at the Botika ng barangay. Instruct patient to seek regular medical check-up