INTRODUCTION Gestational diabetes mellitus (GDM) is a form of diabetes that occurs in pregnant women.

It usually causes only mild symptoms similar to those of early Type 2 diabetes, and is thus often only diagnosed by specific screening in the 24th-28th week of pregnancy; some cases sadly remain undiagnosed. GDM can cause serious complications for the baby and the mother, so early diagnosis and ongoing treatment is important for a good outcome. 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. During the second half of the twenty-first century, physicians began to recognize a form of diabetes that was unique to pregnancy (gestational diabetes). In general, these patients are non-diabetic prior to pregnancy and after delivery. However, hormone changes during pregnancy alter the body's ability to handle sugar metabolism, resulting in a "temporary" diabetic condition during the pregnancy. Gestational diabetes cannot be recognized by symptoms, since the symptoms of diabetes (loss of energy, intense thirst, frequent urination) are common in normal pregnant women. As a result, universal screening for gestational diabetes is recommended during pregnancy. Patients who have gestational diabetes have an increased risk of three complications: large babies, cesarean delivery, and stillbirth. Recognition and treatment of patients with gestational diabetes is designed to minimize these complications, and improve pregnancy outcome for these patients.


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.

C. Scope and Limitations of the Study Our study encompasses the nature, causes, signs and symptoms, and prognosis of gestational diabetes. It focuses not only the nursing care of the client but also proper evaluation of the client-care outcomes were done and important health teachings to the client and significant others were given to promote fast recovery and effective coping. Referrals have also been made to guide the client on what to do after discharge, so as to ensure good client followthrough. Because of some uncontrolled circumstances, this study came across with some limitations. One of which is time constraint, because of it some of the data like the doctor’s order and some of the data in the pharmacologic therapy.


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. History of Present Illness The patient complained of shortness of breath last X, the patient sought consult and was admitted in X at around 10:15 pm by Dr. X. Upon admission, patient was advised for cesarean section due to fetal respiratory distress with fetal heart rate of 100 bpm. The patient is negative to allergies to any food and drug; has no history of asthma, and is positive to diabetes mellitus (DM). The patient received blood transfusion when she had dengue fever in Manila last 2007.


IV. DEVELOPMENTAL DATA A. Developmental Task Theory 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 According to Sigmund Freud, the personality develops in five overlapping stages from birth to adulthood. The libido changes its location of emphasis within the body from one stage to another. A particular body area has special significance to a client at a particular stage. If the individual does not achieve a satisfactory resolution at each stage, the personality becomes fixated at the stage. Fixation is immobilization or inability of the personality to proceed to the next stage because of anxiety. Mrs. KL is married to a seaman husband. Apparently, it’s not that easy to be alone for 9 months because her husband goes home after every contract of


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 Erik Erickson adapts and expands Freud’s theory of development. He envisions life as a sequence of levels of achievement. Each stage signals a task that must achieve. The resolution of the task can be complete, partial, or unsuccessful. He believes that the greater task achievement, the healthier the personality of the person is. Failure to achieve a task influences the person’s ability to achieve the next task. The patient’s ego development outcome is integrity versus despair in late adulthood 60 years to death. As older adults, they can often look back on their lives with happiness and are content, feeling fulfilled with a deep sense that life has meaning and they’ve made a contribution to life, a feeling Erickson calls integrity. The strength comes from a wisdom that the world is very large and they now have a detached concern for the whole of life, accepting death as the completion of life. On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They may fear death as they struggle to find a purpose to their lives, wondering "Was the trip worth it?" The significant relationship is with all of mankind—"my-kind." The assessment was not fully granted with how the patient defined this stage because she was not able to verbalize his concerns as she was having difficulty of speaking. However as through the questions raised to her family, they said that the patient is a very social oriented person, and because she exhibits unselfish actions and happy to have done those acts, therefore, she has attained the tasks for this stage. 5

The health care provider encouraged the significant others to provide love and support to the patient. D. Cognitive Theory According to Piaget, cognitive development refers to the manner in which people learn to think; reason and use language. This involves the person’s intelligence perceptual. This is an orderly sequential process in which a variety of new experiences (stimuli) must exist before intellectual abilities can develop and this represents the progression from illogical to logical thinking from simple to complex. Piaget sees adolescence as the time when cognition achieves its final form, that of formal operational thought. When this stage is reached, adolescents are capable of thinking in terms of possibility – what could be (abstract thought) – rather than being limited to thinking about what already is (concrete thought). This makes it possible for adolescents to use scientific reasoning. Mrs. KL belongs to the Formal Operations Phase in which rational thinking is use and reasoning is deductive and futuristic. She was even attentive to our questions and willing to participate. She was well oriented and cooperates.


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


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. Structure Islets of Langerhans Appearance Lightly staining, large, spherical clusters Darker staining, small, berryPancreatic acini like clusters Function Hormone production and secretion (endocrine pancreas) Digestive enzyme production and secretion (exocrine pancreas)

The pancreas is a dual-function gland, having features of both endocrine and exocrine glands.

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."

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


ducts, called centroacinar cells, secrete a bicarbonate- and salt-rich solution into the small intestine.[6]

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. Sympathetic (adrenergic) Parasympathetic (muscarinic) α2: decreases secretion from beta cells, increases M3[7] increases stimulation from alpha secretion from alpha cells cells and beta cell

Diseases 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.



Definition: Gestational diabetes is a carbohydrate intolerance of variable severity that starts or is first recognized during pregnancy or the inability of the tissues to absorb glucose from the bloodstream during pregnancy due to a lack of the hormone insulin.

Precipitating factors: Insulin resistance due to pregnancy Overweight Have previously given birth to a very large, heavy baby Have previously had baby who was stillborn or born with defect have an excess amount of amniotic fluid (the cushioning fluid within the uterus that surrounds the developing fetus. Age Belong to an ethnic group known to experience States, higher rates of gestational diabetes. (In the United these groups include American Mexican-Americans, Predisposing factors: Genetic disposition

Indians, African-Americans, as well as individuals from Asia, India, or the Pacific Islands) Have a previous diabetes history during of a

gestational pregnancy.


Increase hormone release in the placenta which is HPL

HPL blocks insulin receptor

Increases in direct linear relation to the length of pregnancy.

Insulin release is enhanced in an attempt to maintain glucose homeostasis.

The patient experiences increased hunger due to the excess insulin release as a result of elevated glucose levels or gestational diabetes

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: Laboratory July 16, 2008 Hematology  Clotting Time Bleeding Time 7 minutes and 3-7 minutes 15 seconds 6 minutes and 1-3 minutes .05 seconds Increase Result Normal Range Implication

Prolonged Bleeding Time Prolonged in thrombocytopenia, defective platelet function and aspirin therapy.

Complete Blood Count

      

Total WBC Total RBC Hemoglobin Hematocrit MCV MCH MCHC

9.58X10^9/L 5.0-10x10^9/L 4.27X10^12/L 3.695.90X10^12/L 12.4 g/dL 11.70-14.0 g/dL 39.4% 34.10-44.00% 92.3 Fl 70.00-97.00Fl 29.0pg 26.10-33.30 pg 31.5 g/dL 32.0-35.0 g/dL

      

Normal Normal Normal Normal Normal Normal DECREASE Patient may have severe hypochromic anemia. Normal

Platelet Count

282x10^9/L 150.0390.0x10^9/L 68.1% 55.0-62.0%

Differential Count  Neutrophils Lymphocytes Monocytes Eosinophils

  

24.8% 6.4% 0.6%

20.0-40.0% 4.0-10.0 1.0-6.0%

INCREASE Due to surgery  Normal  Normal  DECREASE Because of stress and use of ACTH medications like epinephrine and thyroxine
 

Basophils 0.1% 0.00-14.5%


July 16,2008 Urinalysis  Color  Appearance  Glucose  Protein  Reaction  Specific Gravity Yellow Clear Negative +1 6.0 ph 1.010

Clear Negative <150 mg/ 24 h

  

Normal Normal Normal

Microscopic  WBC  RBC  Epithelial Cells  Mucous Threads  Urates  Bacteria

0-1 0-1 10-12 Occasional NONE Seen NONE Seen Negative Negative
 

Normal Normal

July 16,2008 Blood Chemistry  Potassium  Na

3.63 meq/L 139.20 meq/L 0.72 meq/L


3.50-5.50 meq/L 135.00-155.00 meq/L 0.70-1.30 meq/L

  

Normal Normal Normal

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 Name of Drug: Cafazolin (Stancep) Date Ordered: July 16, 2008 Dose/ Route: Classification: Anti-infective

Mechanism of Action: Bind to bacterial cell wall membrane, causing cell death Specific Indication: Preoperative prophylaxis Contraindication: Contraindicated in: hypersensitivity to cephalosporins.

Serious hypersensitivity to penicillin. Side Effects: CNS: Seizures GI: Pseudomembranous colitis, diarrhea, nausea, vomiting, cramps. Derm: rashes, pruritus, urticaria Hemat: blood dyscrasias, hemolytic anemia Local: pain at IM site, phlebitis at IV site Misc: allergic reactions including anaphylaxis and serum sickness Nursing Precaution: • Assess for infection (vital signs; appearance of wound; WBC) at the beginning and during the therapy • Before initiating therapy, obtain a history to determine previous use of and reactions to penicillin or cephalosporin. Persons with a negative history of penicillin sensitivity may still have allergic response. • Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing) • Use cautiously in: Renal Impairment: History of GI disease, especially colitis: superinfection

OB: Pregnancy or lactation (half-life shorter and blood levels lower during pregnancy: have been used safely)

Name of Drug: Famotidine Date Ordered: July 16, 2008 Dose/ Route: 20 mg q12 Classification: Antiulcer agents 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 Specific Indication: Treatment and prevention of heartburn Contraindication: Contraindicated in: Hypersensitivity. Cross sensitivity may occur. Some products contain alcohol and should be avoided in patients with known intolerance. Some products contain aspartame and should be avoided in patients with phenylketonuria. Side Effects: CNS: confusion, dizziness, drowsiness, hallucination, headache CV: Arrhythmias GI: Altered taste, black tongue, constipation, diarrhea, druginduced hepatitis, nausea Hemat: Anemia, neutropenia, Local: Pain at IM site. Nursing Precaution:

Assess for epigastric or abdominal pain and frank or occult blood in stool, emesis, or gastric aspirate

Use cautiously in: Renal impairment

Name of Drug: Midazolam Date Ordered: July 16, 2008 Dose/ Route: 1 tab P.O with sips of water Classification: Antianxiety agents Mechanism of Action: Acts as many levels of the CNS to produce generalized CNS depression. Effects may be mediated by GABA, an inhibitory neurotransmitter. Postoperative amnesia. Specific Indication: Preprocedural sedation and anxiolysis in pediatric patients. Contraindication: Contraindicated in: Hypersensitivity. Cross-sensitivity with other benzodiazepines may occur. Shock. Comatose patients or those with preexisting CNS depression. Uncontrolled severe pain. Products containing benzyl alcohol should not be used. Pregnancy. Acute narrow-angle glaucoma. Side Effects: CNS: agitation, drowsiness, excess sedation, headache EENT: blurred vision Resp: Apnea, Laryngospasm, respiratory depression, bronchospasm, coughing CV: Cardiac arrest, arrhymias GI: Hiccups, nausea, vomiting

Derm: rashes Local: Phlebitis at IV site, pain at IM site

Nursing Precaution: • Assess level of sedation and level of consciousness throughout and for 26 hr following administration. • Monitor blood pressure, pulse, and respiration continuously during IV administration. Oxygen and resuscitative equipment should be immediately available.

Name of Drug: Celecoxib (Celebrex) Date Ordered: July 17, 2008 Dose/ Route: 200 mg P.O BID Classification: Nonsteroidal anti-inflammatory drugs Mechanism of Action: Inhibits the enzyme COX-2. This is required for the synthesis of prostaglandin. Has analgesic, anti-inflammatory properties. Decreased pain. Specific Indication: Pain Contraindication: Contraindicated in: Hypersensitivity. Cross sensitivity may exist with other NSAIDS, including aspirin.

OB: Should not be used in late pregnancy (may cause premature closure of the ductus arteriosus) Side Effects: CNS: dizziness, headache, insomnia CV: edema GI: GI bleeding, abdominal pain, diarrhea, dyspepsia, flatulence, nausea Derm: Expoliative dermatitis, rash

Nursing Precaution: • Assess range of motion, degree of swelling, and pain in affected joints before and periodically throughout therapy • Use cautiously in: Cardiovascular disease or risk factors for cardiovascular disease.

Name of Drug: Ferrous Sulfate Date Ordered: July 17, 2008 Dose/ Route: 500 mg 1 tab P.O OD Classification: Antianemics Mechanism of Action: An essential mineral found in hemoglobin, myoglobin, and many enzymes. Parenteral iron enters the bloodstream and organs if the

reticuloendothelial system, where iron is separated out and becomes part of iron stores. Specific Indication: Prevention of iron-deficiency anemia Contraindication: Contraindicated in: Primary hemochromatosis. Hemolytic anemias and other anemias not due to iron deficiency. Side Effects: CNS: seizures, headache, syncope CV: hypotension, tachycardia GI: nausea, constipation, dark stools, diarrhea Derm: flushing, urticaria Local: pain at IM site Nursing Precaution: • Assess nutritional status dietary history to determine possible cause of anemia and need for patient teaching • • Assess bowel function for constipation or diarrhea. Use cautiously in: Peptic Ulcer; Ulcerative Colitis or regional enteritis.

Name of Drug: Metronidazole Date Ordered: July 17, 2008 Dose/ Route: 1 grm supp/ rectum OD Classification: Anti-infective

Mechanism of Action: Disrupts DNA and protein synthesis is susceptible organisms. Specific Indication: Gynecological infections Contraindication: Contraindicated to: Hypersensitivity. First trimester of pregnancy Side Effects: CNS: seizures, dizziness. Headache EENT: tearing GI: abdominal pain, anorexia, nausea, dry mouth Derm: rashes, skin irritation, mild dryness Nursing Precaution: • Assess patient for infection (vital signs; appearance of wound, sputum, urine and stool; WBC) at beginning of and throughout therapy • • • Monitor neurologic status during and after the therapy Monitor intake and output and weigh patient daily. Use cautiously in: History of blood dyscrasias; History of seizure or neurologic problems; severe hepatic impairment.

Name of Drug: Nalbuphine (Nubain) Date Ordered: July 18, 2008

Dose/ Route: IV PRN Classification: Opioid Analgesic Mechanism of Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. On addition, has a partial antagonist property, which may result in opioid withdrawal in physically dependent patients. Thus decreasing pain. Specific Indication: Moderate to severe pain Contraindication: Hypersensivity to nalbuphine or bisulfites. Patients who are physically dependent to opioids and have not been detoxified. Side Effects: CNS effects: Nervousness, depression, restlessness, crying, euphoria, floating, hostility, unusual dreams, confusion, faintness, hallucinations, dysphoria, feeling of heaviness, numbness, tingling, unreality. The incidence of psychotomimetic effects, such as unreality, depersonalization, delusions, dysphoria and hallucinations has been shown to be less than that which occurs with pentazocine. CVD: Hypertension, hypotension, bradycardia, tachycardia, pulmonary edema. GI: Cramps, dyspepsia, bitter taste. Respi: Depression, dyspnea, asthma. Derm: Itching, burning, urticaria.

Nursing Precaution:

Assess type, location, and intensity of pain before 1 hr after IM or 30 min (peak) after IV administration.

Assess blood pressure, pulse, and respiration before and periodically during administration.

Use cautiously in: Rhinitis

NURSING MANAGEMENT IDEAL NURSING INTERVENTION Nursing Diagnosis: Pain Related factors: cervical dilation, muscle hypoxia, uncomfortable position, lack of position change, diaphoresis, full bladder, leaking of amniotic fluid. 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. 2. Monitor for signs of anxiety. Rationale: a moderate amount of anxiety about the pain enhances the ability to cope with it; however, too much anxiety interferes with coping. 3. Monitor vital signs and observe for signs of pain.

Rationale: Frequent physiologic manifestations of pain are increased pulse, respirations, and BP; dilated pupils; and muscle tension. Muscle tension can impede the progress of labor. 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. Rationale: Ambulation provides diversion because the woman focuses on stimuli other than the UCs. Criteria provide for the safety of the mother and the fetus.

5. Use touch (e.g. hold the woman’s hand, rub her back), as appropriate. Rationale: A sensory experience (e.g. backrub) can provide distraction because the woman focuses on the stimulus than the pain. It is common for a woman to want touch during early labor but pull away from touch during transition.

Nursing Diagnosis: Fatigue 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: 1. Note the length of the first stage. 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: Fetal malposition or malpresentation may prolong second stage causing energy depletion. Recognition of the problem allows interventions such as charging the woman’s position. 3. Teach and reinforce correct use of relaxation techniques. 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. Nursing Diagnosis: Ineffective Coping Related factors: stress of labor, worry about potential complications of labor, history of ineffective coping skills, inadequate emotional support, fatigue, lack of confidence. 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. Rationale: What appears to be ineffective coping may merely be a culturally accepted mode of dealing with pain. 3. Assess for factors (e.g. age, lack of partner) that may increase vulnerability to stress. Rationale: For example, women without a support person and adolescent woman may be more vulnerable to stress and less able to remain in control with UCs. 4. Evaluate the efforts of the partner to provide support, and teach or act as a role model as needed. Rationale: Especially in transition, the woman is likely to be calmer when her coach and/or the nurse are calm. Because she may feel dependent and put of control, it is especially important for her to feel that those around her are in control. 5. Provide pharmacologic and nonpharmacologic pain-relief measures. Rationale: Pain is a stressor, and minimizing stressors improves ability to cope.

Nursing Diagnosis: Knowledge deficit related to lack of information Interventions:

1. Determine the client’s ability to learn. Rationale: May not be physically, emotionally, or mentally capable at this time. 2. Be alert to signs of avoidance. Rationale: May need allow the client to suffer the consequences of lack of knowledge before client is ready to accept information. 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

ACTUAL NURSING INTERVENTION S O “Maglisod kog ginhawa sa kasakit” Facial grimaces Guarding Shallow breathing Splinting respirations High risk for Ineffective breathing pattern related to abdominal incision pain. At the end of 5 hours, the patient will be able to maintain effective breathing pattern.



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.


At the end of 5 hours, the patient was able to maintain effective breathing pattern and verbalizes that she had no difficulty in breathing.


“ sakit pa gihapon akong samad” as verbalized by the patient. Facial grimaces Guarding Pain related to cesarian operation (abdominal incision).


At the end of 30 minutes, the patient will verbalizes relief of pain or ability to tolerate pain.


Independent Assess nature of pain ( location, quality, duration). Patient using patient-controlled analgesia PCA may need reinstruction or reminders to “push the button” during the early postoperative phase when they are still under the effects of anesthesia Document patient’s response to pain-relieving measures. - Patients have very individualized pain tolerance levels, and all patients will not be made comfortable with standard doses. Place patient in complete bed rest for 2-3 days. Pain will influence activity thus it is appropriate to have rest for further evaluation and treatment. 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 Analgesic such as mefenamic acid as ordered. At the end of 30 minutes, the patient was able to tolerate pain according to her tolerance and verbalizes that she could managed it.



“wala man ko gipakaun before ko gi operahan” Wound drainage Wound dressing on the incision site (abdominal) NPO High Risk for fluid volume deficit related to wound drainage, blood loss in surgery and NPO status. 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



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) At the end of 8 hours, the patient was able to have an adequate fluid intake through the IV fluids.


“ naa koy samad sa tiyan kay gi cesarean man ko” as verbalized by the patient Wound drainage Wound dressing on the incision site (abdominal) High Risk for Infection related to abdominal incision. At the end of 3 days, patient is free of infection as evidenced by healing wound, free of redness, swelling purulent discharge



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 anti-infective drugs like cefazolin At the end of 3 days, the patient’s wound was free from infection as evidenced by free of redness and purulent discharge in the dressing..


“ wala pa naulian akong samad” Wound drainage Wound dressing on the incision site (abdominal) High risk for altered tissue integrity related to operative wound. At the end of 1 hour, patient has intact wound or free from complications such as dehiscence, evisceration or fistulaization.



Independent Monitor for postoperative bleeding. Intraabdominal,Intraluminal,Incisional - Postopertive bleeding usually shows as increased bloody drainage on dressings and tubes. Assess for wound dressing or cleaning. . - Incisions are usually kept covered to avoid invasion of microorganism thus inhibit further infection. Place patient in complete bed rest for 2-3 days. - Unusual activities may precipitate to an increase metabolic rate thus increasing risk for dehydration. It also increases the wound to heal and avoid the risk of contour. 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 ointment (bactroban) At the end of 1 hour, the patient’s wound displayed healing with no evidenced of complications.

DISCHARGE PLANNING 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 Pilitteri, Adelle. Maternal and Child Health Nursing: Care of Childbirth and Childbearing Family. 4th ed. Lippincott William and Wilkins Company. 2003.  Marlow, Dorothy R. Redding, Barbara A. Pediatric Nursing. 6th ed. Philadelphia .. W.B Saunder’s Company. 1988.  Nursing 2006: Drug Handbook. 26th ed. Philippines . Lippincott William and Wilkins Company. 2006.  Doenges, M.E.,Moorehouse.M.F and Geissler,A.C. Nursing Care Plans: Guidelines for individualizing Patient Care. Philadelphia . F.A. Davis Company. 2002.  Karch, Amy M. Focus on Nursing Pharmacology. Philadelphia : J.B Lippincott Co. 2000.

Kozier, B. et al. Fundamentals of Nursing, 7th edition. New Jersey: Pearson Education, Inc., 2004 pp. 1132-1687: 12611262 www.

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