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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
2009 : April 24. and her EDC was on April 8. HISTORY OF PAST AND PRESENT ILLNESS The patient stands 153 centimeters and weighs about 83 kilograms. because she had a difficulty in delivering the child due to her age and the lack of knowledge. She was already married at the age of 16 years old. 2009 : LTCS II Educational Attainment: High School Graduate . V. FAMILY HISTORY Unremarkable. CSFP : Mambo Bontes : Muh Ret : Malah Ret : Filipino : Housewife : April 22. 3.0.2). 2008. Her OB score is G2P1 (2. 1991 : AMB Bldg.To be able to implement the nursing care plan. 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. III. She was only 17 years old when she gave birth to her first child through Cesarean Section (Low Segment Transverse). Her AOG is 43 weeks. : Patient Sik Ret Bontes : 18 years old : February 29. 2009.0. Saguin. Brgy. LMP was last November 1. Affective To be able to establish a good working relationship with the patient and hospital staff.
She said she loss her appetite since her onset of labor. All in all. 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. usually morning and in the afternoon. The patient opted for another cesarean section for this pregnancy. Stool is brown in color and well-formed. No pain when voiding.Patient goes to the Health Management health center once upon when she got pregnant. Urine is yellow in color. Bladder: Patient voids usually 6-8 times a day. She eats bread instead of rice. the patient is on diet as tolerated. She also loves condiments like “patis”. Gordon’s Level of Functioning Pattern Before 1. She basically loves eating whatever she likes. and soy sauce. . Bowel: There was a change in the frequency and amount. Stool is soft. Bladder: There was a change in the frequency and amount. PHYSICAL ASSESSMENT Present Patient is concern about her second cesarean section thinking that it may be detrimental to her health. During hospitalization.It was on April 22. Interpretation Patient cannot function normally anymore like before because of her hospital confinement and condition. Her body image changed after the surgical procedure done. She eats fruits like apples and oranges. minimal in amount and brown in color. Bowel: Patient defecates 1-2 times a day.Health Perception. vinegar. Bladder: Patient voids 3-4 times a day without pain and discomfort. Patient’s nutritional and metabolic status has been changed due to her confinement. patient loves eating instant foods and fatty foods like fries and burgers.Elimination Pattern Prior to confinement. NutritionalMetabolic Management 3. she thinks she is in a healthy state. Bowel: Patient defecates once a day but not on a regular basis. 2. VI.
Patient has been married for 3 years. and Recreation Pattern 5. She can speak and be understood by others. She is married with 1 child.Sleep and Rest Pattern 6. No changes/ alterations.Cognitive – Perceptual Pattern 7. Tagalog. Patient’s sleep and rest pattern changed when she was admitted. When patient is stressed. Sexuality/ Reproductive Pattern 10. During patient’s confinement in the hospital. She cannot put himself to sleep anymore due to present condition and pain plays a big factor for her sleep disturbances.Coping and Stress Tolerance Patient is a housewife so she is always in charge of the household chores. She considers himself as holistic human being as long as she is healthy. During the times of her confinement. She is happy with their presence and support. there is a limitation in her activities of daily living and a disruption in her leisure and recreation pattern. She usually sleeps at around 11pm to 6am. . She feels rested when sleeping and thinks that her energy is sufficient for her activities. complete. She can read and write. Patient reserved her right to privacy. she loves to socialize with his friends in their neighborhoods. she is positive that she will be ok after confinement. Patient is a high school graduate. deep breathing and coughing exercise. Patient can understand English. Patient reserved her right to privacy. Due to her uncomfortable condition and pain. she doesn’t think that she is a holistic person anymore.perceptual pattern. There is a slight change in her selfperception due to present condition. However. The patient’s family is supportive to the patient. and his family is always there. The recent hospitalization of the patient was stressful Normal/ No alterations. Patient puts herself to sleep by watching television programs. she sings in the karaoke and eats Patient’s activities in the hospital are ambulation. Role Relationship 9.4.Activity. patient complains of difficulty of sleeping and short period of sleeps. taking a bath or personal hygiene. Patient’s present condition is not a hindrance to her cognitive. Patient accepts present condition with a positive attitude. and Kapampangan. Patient is a friendly person. Self-Perception / Self-Concept Pattern 8. Leisure. She has 5 siblings. Her leisure time would include playing with her firstbornand watching television.
ANATOMY AND PHYSIOLOGY Vagina The vagina is a muscular. She follows a therapeutic regimen and her strong faith to God accounts for her fast recovery. The vagina is made up of three layers. A thin sheet of tissue with one or more holes in it. she lets herself think immediately for a solution. a middle muscularis layer. It is situated between the urinary bladder and the rectum. patient is trusting God that she will be discharge soon and will recover without any complications. The inner layer is made of vaginal rugae that stretch and allow . and source of anxiety. which keep it protected and moist. and an outer fibrous layer. When it comes to problems. called the hymen. Due to her confinement. The muscular walls are lined with mucous membranes. she is positive that she will be able to cope up with current condition. VII. partially covers the opening of the vagina. It is about three to five inches long in a grown woman.Belief Pattern comfort foods like burgers. The muscular wall allows the vagina to expand and contract. 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. hollow tube that extends from the vaginal opening to the cervix of the uterus. She has a strong faith to God and goes to mass every Sunday with her family.11. However. an inner mucosal layer. fries.Values. and her favorite sizzling sisig. Patient is a Roman Catholic.
. the cervix stretches open slightly to allow the endometrium to be shed. The ectocervix's opening is called the external os. These also help with stimulation of the penis. circular opening. It is occasionally called "cervix uteri". The size and shape of the external os and the ectocervix varies widely with age.) that keeps bacterial growth down. Approximately half its length is visible with appropriate medical equipment. The middle layer has glands that secrete an acidic mucus (pH of around 4. contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. Pathway through a woman's body for the baby to take during childbirth. It has a convex. and whether the woman has had a vaginal birth. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. the ectocervix is three cm long and two and a half cm wide.0. The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. the remainder lies above the vagina beyond view. During orgasm. to leave the body. On average.penetration to occur. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity. elliptical surface and is divided into anterior and posterior lips. FemCap. Purposes of the Vagina • • • • Receives a males erect penis and semen during sexual intercourse. such as a diaphragm. This stretching is believed to be part of the cramping pain that many women experience. the ectocervix appears bulkier and the external os appears wider. narrow portion of the uterus where it joins with the top end of the vagina. In women who have had a vaginal birth. Provides the route for the menstrual blood (menses) from the uterus. During menstruation. the cervix convulses and the external os dilates. In women who have not had a vaginal birth the external os appears as a small. more slit-like and gaping. Where they join together forms an almost 90 degree curve. 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. Nuva Ring. During childbirth. or "neck of the uterus". or female condom. May hold forms of birth control. The passageway between the external os and the uterine cavity is referred to as the endocervical canal. hormonal state. Flattened anterior to posterior. The outer muscular layer is especially important with delivery of a fetus and placenta. along with the cervix overall. The cervix (from Latin "neck") is the lower. the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. It varies widely in length and width.
but during pregnancy it changes rapidly and dramatically. The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. The uterine cavity refers to the fundus of the uterus and the body of the uterus. There are two fallopian tubes. In some cases after menopause. or it is sloughed off during menses. it is swept into the lumen of the fallopian tube by the frimbriae. pelvic relaxation (or prolapse). Some problems of the uterus include uterine fibroids. It is only after all alternative options have been considered that surgery is recommended in these cases. also called the uterine tubes or the oviducts. Once the egg is in the fallopian tube. The uterus contains some of the strongest muscles in the female body. adenomyosis). Within each tube is a tiny passageway no wider than a sewing needle. This surgery is called hysterectomy. At the upper corners of the uterus are the fallopian tubes. They are positioned between the ligaments that support the uterus. many women begin a form of alternate hormone therapy due to the lack of ovaries and hormone production. they may lose elasticity and uterine prolapse may occur. At the other end of each fallopian tube is a fringed area that looks like a funnel. Each fallopian tube attaches to a side of the uterus and connects to an ovary. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. or release an egg. or fertilized egg. tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus.The uterus is shaped like an upside-down pear. called the infundibulum. After a hysterectomy. Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. to implant and grow. This fringed area. The ovaries alternately release an egg. takes four to five days to . pelvic pain (including endometriosis. it is hollow to allow a blastocyte. heavy or abnormal menstrual bleeding. and cancer. but retract after childbirth. with a thick lining and muscular walls. The uterus is only about three inches long and two inches wide. The oocyte. Located near the floor of the pelvic cavity. or developing egg cell. but is not attached. When an ovary does ovulate. 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. Hysterectomy is the removal of the uterus. Once performed it is irreversible. lies close to the ovary. This can be fixed with surgery. 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 also allows for the inner lining of the uterus to build up until a fertilized egg is implanted. and may include the removal of one or both of the ovaries. During pregnancy the ligaments prolapse due to the growing uterus.
At the time of birth. similar to muscle cells. a few millimetres large) lined with milk-secreting epithelial cells and surrounded by myoepithelial cells. the pregnancy will need to be terminated to prevent permanent damage to the fallopian tube. The basic components of the mammary gland are the alveoli (hollow cavities. the baby has lactiferous ducts but no alveoli. These exocrine glands are enlarged and modified sweat glands. while testosterone inhibits it. Little branching occurs before puberty when ovarian estrogens stimulate branching differentiation of the ducts into spherical . it is called a ectopic or tubal pregnancy. will continue down to the uterus and implant itself in the uterine wall where it will grow and develop. If enough sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube. The mammary glands exist in both sexes. A suckling baby essentially squeezes the milk out of these sinuses. and each lobule has a lactiferous duct that drains into openings in the nipple. If a zygote doesn't move down to the uterus and implants itself in the fallopian tube. or fertilized egg. After fertilization occurs. but they are rudimentary until puberty when . possible hemorrhage and possible death of the mother. and thereby push the milk from the alveoli through the lactiferous ducts towards the nipple. the zygote. Mammary glands are the organs that produce milk for the sustenance of a baby. Estrogen promotes formation. The development of mammary glands is controlled by hormones.in response to ovarian hormones they begin to develop in the female.travel down the length of the fallopian tube. The myoepithelial cells can contract. These alveoli join up to form groups known as lobules. where it collects in widenings (sinuses) of the ducts. fertilization will occur. If this occurs.
where rising levels of estrogen and progesterone cause further branching and differentiation of the duct cells. VIII. Colostrum is secreted in late pregnancy and for the first few days after giving birth. Almost all instances of breast cancer originate in the lobules or ducts of the mammary glands. together with an increase in adipose tissue and a richer blood flow. The cells of mammary glands can easily be induced to grow and multiply by hormones. True secretory alveoli only develop in pregnancy. If this growth runs out of control. 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 . True milk secretion (lactation) begins a few days later due to a reduction in circulating progesterone and the presence of the hormone prolactin.masses of cells that will become alveoli. cancer results. The suckling of the baby causes the release of the hormone oxytocin which stimulates contraction of the myoepithelial cells.
a mixture of blood and fluid) Rupture of Membranes (rupture of the amniotic sac) Failed to progress labor (due to previous cesarean birth. cervical atrophy) increase risk for fetal distress (meconium staining.PRELIMINARY SIGNS OF LABOR Lightening (descent of the fetal head into the pelvis) Braxton Hicks Contraction Ripening of the cervix (false labor) (Goodell’s 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. cervical arrest. hypoxia) Increase risk of fetal death .
0 (Normal: 7.010-1. 2009 Date Performed: April 22.0 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 5.2 Epithelial Cells: Moderate Result Normal Values 4.35-7.4 WBC 10.1 Increase HgB 116 Decrease Hct 0.45) Specific Gravity: 1.5 – 6.010 (Normal: 1.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.025) Pus Cells: 0. 2009 Microscopic Exam Color: Yellow Transparency: Hazel Rection pH: 6.35 Increase Platelet 320 Normal . LABORATORY PROCEDURES Urine Analysis Date Ordered: April 22.
86 0. severity of pain. patient will verbalize decrease intensity of pain from 8/10 to 3/10.14 0. P – After 1-2hr of nursing intervention. conscious and coherent.DIFFERENTIAL COUNTING Neutrophils 0. I– – – – – – Established rapport. Dressed wound as indicated. O– – – – – – – – – – – – – received patient awake on bed. infusing well.05 – 0.20 – 0.” as verbalized by the patient. Assessed quality.40 Decrease X. 2008 S – “Sobrang sakit. characteristics. with ongoing D5LRS 1L x 30gtts/min. Provided comfortable environment – changed bed linens and turned on the fan. 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. . Monitored vital signs.70 Increase Indicates infection or inflammation Indicates high risk for acquiring infection Lymphocytes 0. COURSE IN THE WARD April 22. hooked on the left hand.6 A – Acute pain r/t disruption of skin and tissue secondary to cesarean section.
. Instructed patient to do deep breathing and coughing exercise. Administer analgesic as per doctor’s order. Patient verbalized pain decreased from a scale of 8/10 – 3/20 as evidenced by (-) facial grimace (-) guarding behavior. E – Goal met. Needs attended. Provided diversionary activities. Frequent small talks with significant others.– – – – – – – Instructed to put pillow on the abdomen when coughing or moving. Due meds given. Instructed patient to ambulate. Endorsed.
or purulent drainage at incisions .XI.Rising WBC indicates body’s efforts to combat pathogens. Thus.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. as evidenced by normal vital signs and absence of purulent drainage from wounds. patient’s skin and tissue were mechanically interrupted. identify signs of infection and report them to health care provider accordingly. Washing between procedures .000 mm3 -these are signs of infection EVALUATION Patient is expected to be free of infection. and tubes. swelling. be free of purulent drainage or erythema. PLANNING STG: After 4 hours of nursing intervention. Redness. be afebrile and be free of infection.dressing dry and intact -V/S taken as follows: T: 37.Monitor Elevated temperature. patient will achieve timely wound healing. the wound is at risk of developing infection. patient will be able to understand causative factors. INTERVENTION Independent -Monitor vital signs -Inspect dressing and perform wound care . NURSING CARE PLAN Post-operative NCP CUES Subjective: – none Objective: . normal values: 4000 to 11. . LTG: After 2-3 days of nursing intervention.Wash hands and teach other caregivers to wash hands before contact with patient and between -Friction and running water effectively remove microorganisms from hands.Monitor white blood count (WB RATIONALE -To establish a baseline data -Moist from drainage can be a source of infection . increased pain. incisions.
including pneumonia.Encourage coughing and deep breathing. in turn.These measures reduce stasis of secretions in the lungs and bronchial tree.procedures with patient.Fluids promote diluted urine and frequent emptying of bladder. consider use of incentive spirometer. reduces risk of bladder infection or urinary tract infection (UTI). . When stasis occurs. Independent: – Administe r antibiotics . reducing stasis of urine.Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). pathogens can cause upper respiratory infections. . reduces the risk of transmitting pathogens from one area of the body to another . -Antibiotics have bactericidal effect that combats pathogens .
CUES NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION .
since she has had cesarean.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 8º of nursing interventions. the patient was able to identify measures to prevent infection as manifested by client’s verbalization of: “Iinom ako ng maraming tubig at kakain ng prutas para makadumi ako. the patient will be able to demonstrate behaviors or lifestyle changes to prevent developing problem INDEPENDENT INTERVENTIONS: • Ascertain normal bowel functioning of the patient. especially in the morning to stimulate peristalsis Encourage ambulation such as walking within individual limits However. the patient will be able to maintain usual pattern of bowel functioning • Promote adequate fluid intake. 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.” • • • To stimulate contractions of the intestines and prevent post operative complications To avoid stress on the cesarean incision/ wound COLLABORATIVE: . also encourage adequate rest periods • After 8º of nursing interventions. Suggest drinking of warm fluids.
• Administer bulkforming agents or stool softeners such as laxatives as indicated or prescribed by the physician • To promote defecation .
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.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.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 .