Room 306 Madox Bermas Devega

Nursing Care Management to a 29
years old Caesarean Section

Patient G1P1 (1001)
In Partial Fulfillment of the Requirements for the
Related Learning Experiences
Submitted by:
Bermas, Benedict James
De Vega, Khatrina Mae
Group 1 - BSN-2
Submitted to:
Ms. Mary Grace Morada-Cu, MAN, RN
February 2020
I. ASSESSMENT
A. General Information
Patient’s initials: MCJ Rm/Wd: Ob-Gyne Ward 3F – Room 306
Date Admitted: February 15, 2020
Age: 29 Sex: Female CS: Married
Nationality: Filipino Religion: Catholic
Educ. Attainment: College Graduate
Occupation: HR Assistant
Admission complaint/s: Not applicable
Admitting or Working Diagnosis: Oligohydramnios
Final Diagnosis: Oligohydramnios
Surgery performed: The patient undergone caesarean delivery (C-section) on
her first child in which she had a longitudinal suture on her lower abdomen.
➢ February 15, 2020

Admitting Vital Signs
Temperature: 36.5C Pulse Rate:75 beats/min
Respiratory rate: 18 Breaths/min: BloodPressure:110/70mmHg
Weight: 47.5 kg Height: 162cm
Arrived on unit by: Wheelchair
Accompanied by: Husband
Allergies: The patient has no allergies.
Medication:
Obimin Plus - A pre- and postnatal supplement to help provide adequate
supply of vitamins, minerals and omega-3 fatty acids, DHA and EPA, during
pregnancy and lactation.

Vital Signs (8:00 AM)
Temperature: 37.2C Pulse Rate: 91 beats/min
Respiratory rate: 20 Breaths/min BloodPressure:110/60mmHg

2
Vital Signs (1:00 PM)
Total Output: urine - FC , 0 stool output

Total Intake: 420 ml

Vital Signs (1:00 PM)

Total Output: urine – 1800 ml, 2 stool output

Total Intake: 1050 ml
Medications:
1. Silgram 750mg/tab BID - Intra-uterine abdominal, gynecologic, and skin
structure infection.
2. Nubain 10mg/tab Q6 - Indicated for the management of moderate to severe
pain and adjunct balanced anesthesia, for operative and postoperative
analgesia.
3. Arcoxia 120mg/tab OD - Responsible for the synthesis of mediators of pain,
inflammation, and fever.
4. Tylenol 325mg/tab TID - Temporarily relives minor aches and pain due to
cold, headache, back ache, minor ache of arthritis, toothache, premenstrual
and menstrual cramp, and temporarily reduces fever
5. Coxidia 200mg/cap BID - Inhibits prostaglandin, synthesis, anti-
inflammatory, analgesic, and antipyretic effects and impending COX-2
6. Natalac 1 capsule BID – A nutritional supplement that increase in lactation
in nursing mothers which promotes breastfeeding
Brief description of the diagnosis/ surgery performed:

Transverse caesarean section under spinal epidural anesthesia
3
B. Nursing History (Based on the Functional Health Pattern by Gordon)
1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
1.1 History of present illness:
The patient undergone caesarean delivery (C-section) on her first child in
which she had a longitudinal suture on her lower abdomen. She was diagnosed
with oligohydramnios and may consider as intra-amnionic infection.
While on the operation, at 2 pm, the patient had been injected with
spinal-epidural anesthesia and hooked with oxygen via nasal canula. She had a
dysfunctional labor prolonged latent phase. She was administered during and
after operation with these medications; oxytocin, Methergine, Plasil, Kettesse
and Paracetamol.
After the operation, the patient experience urinary retention and was
inserted with a foley catheter as manifested by the absence of bladder sensation.
She was given medications to relieve her from the pain of post-partum, and also
to prevent chances of bleeding and to quicken her recovery.
1.2 Past illnesses:

The patient has no significant illnesses that needs to be noted.
1.3 History of illness in the family

The Patient has no significant illnesses from her family that needs to be noted.
2. NUTRITION AND METABOLIC PATTERN

The patient usually consumes bread and coffee during breakfast. It may
be a home cooked meal or from fast food. She usually prefers to have meat with
white bread as her comfort foods.
During her pregnancy, increase consumption of fiber in forms of

vegetables, fruits and wheat products was recommended. The patient is able to
take at least 2-3 liters of water intake a daily. She had Obimin plus, a pre- and
postnatal supplement to help provide adequate supply of vitamins, minerals and
omega-3 fatty acids, DHA and EPA, during pregnancy and lactation.
4
POST OPERATIVE
The patient was ordered to have soft diet. She was prescribed medications and
still has a foley catheter, so she was advised to start with soft diet.
Breakfast: Banana, Boiled Egg, Bread

Lunch: Cooked vegetables, Bread, Sausages, Muffin
Supper: Gelatin, Banana, Soup, Muffin,
Preference: White bread
Drinks: Water
Patient has no trouble on the food given to her and was able to finish the food
with no problem.

The patient was ordered to have soft diet and if tolerated may have full diet once
the foley catheter was removed. Since the patient is recovering well, her appetite
was starting to get back to normal. Every meal that was served to her was fully
consumed.
Breakfast: 1 cup of rice, Chicken, Cooked Vegetables.

Lunch: 1 cup of rice, 2 slices of ham, Banana
Supper: 1 cup of rice, 2 pieces of sausage, Cooked vegetables, Mangoes
Preference: White Bread
Drinks: Water
The patient received various analgesic medication, and was able to finish her
food with no problem, her appetite was starting to get back to normal. Every
meal that was served to her was fully consumed.
3. ELIMINATION PATTERN
3.1 Bladder
The patient verbalized that she doesn’t have any problem with her
pattern of urination. She urinates approximately 2 to 6 in a day. The color of
her urine claimed by the patient is clear to yellowish color.
Post-operative:
After the surgical procedure done to the patient, a foley catheter was inserted
to assist the bladder in draining the urine.
5
Day 1 (Feb 18, 2020) Day 2 (Feb 19, 2020)
Color yellowish Slightly yellowish
Volume 420 ml 1050ml
Frequency Foley catheter inserted 5
Table 1.1 Post-operative bladder elimination
3.2 Bowel
The patient verbalized that she doesn’t have any problem with her
bowel movement. She defecates approximately 1 to 3 in a day. The usual
appearance of her stool is soft to firm brown to black color.
Post-operative:
Day 1 (Feb 18, 2020) Day 2 (Feb19, 2020)
Color N/A brownish
Consistency N/A formed
Frequency 0 1
Table 1.2 Post-operative bowel elimination
3.3 Skin: (condition)

The patient had a skin had minimal lesions on her left leg and arms, she
has a suture in the midline area due to her having her cesarean section incision
there, her overall skin was fair in color, presence of dryness was seen during the
inspection. She had edema on her extremities caused by excess fluids trapped in
her tissues.
4 ACTIVITY EXERCISE PATTERN

The patient only leisure is to enjoy going to mall and do shopping, and
playing badminton before her pregnancy. She does stretch and walking as her
exercise. There were limitations on her physical abilities while she was
pregnant, like lifting heavy and involving in extraneous activities. Also, she can
perform activities of daily living independently. There were no known events
wherein patient experience difficulty of breathing or fatigue while performing
any activities.
5 SLEEP-REST PATTERN
The patient usual bedtime sleep for this month is 9:30 pm. She prefers to
sleep with 2 pillows under her head. Her sleeping hours usually lasts for 7 to 8
hours. The patient verbalizes that she uses her cellphone and surfs the internet
6
before going to sleep as of this month. she has encountered problems with her
sleeping pattern due to her working during the night.
6 COGNITIVE-PERCEPTUAL PATTERN
There was no known deficit on her sensory perception. Patient was
conscious and coherent. She can clearly hear our voice during the interview and
passed to whisper test. The patient had some sight deficit due to her myopia and
astigmatism. She does wears graded eyeglasses. There was no reported deficit
on sensory perception on touch. The patient has the ability to read and write, and
she do recall her memory. She has her own way of learning things.
Patient’s level of consciousness after the surgical procedure was slightly

sedated while post anesthesia care unit. The patient shares that she had no
memories of the procedure. She can only remember the command of the
anesthesiologist to take deep breath and then after that she goes to sleep.
The second day after the surgical procedure, the patient is conscious and
coherent. She was able to recognize all the people around her. There were no
sensory deficits on hearing and touch. Patient was able to see clearly without her
reading glasses.
7 SELF-PERCEPTION PATTERN
The patient is most concerned about the recovery after surgery. The scars
that the possible location of the incision site. The patient is also concerned on
how she will be functioning after the surgery.
The present health goal of the patient is improving her physical shape
after the surgery, she feels that her body has changed significantly after her
doing the c-section. Patient also stated that she is scared on how the scar of her
cesarean section will heal and how will it affect her physically.
The patient verbalized that she was relieved of pain and anxiety after the
surgical procedure. Her fear is still there, but she wants to focus more on the
baby now that she has given birth
7
8 ROLE-RELATIONSHIP PATTERN
8.1 Language spoken
The patient can speak 3 languages namely Filipino, English and dialect
from Northern province.
8.2 Significant person to patient
Persons significant to the patient is her parents, husband and her child.
8.3 Complaints regarding family

There were no complaints regarding the family by the patient. She seemed
to be delighted being around her family during the hospitalization.
8.4 Living with (members of family)

The patient verbalized that she and her husband are living together.
9 SEXUALITY-SEXUAL FUNCTION
The patient has enough knowledge of her sexual functioning, she has
been sexually active and used contraceptives with her partner. After their
marriage, she stated that they had family planning and will primarily focus on
their child for now as it is their first baby.
10 COPING-STRESS MANAGEMENT PATTERN

The patient has the ability to decide on herself when comes to her health.
Also, upon the decision making, she is with her partner for agreeing or
disagreeing upon the decisions. She claims that there was no significant stress
that happened.
The patient manages her stressors through stress eating as it is her way
for coping from stress at work. Patient did not have any major stress this year
other than her work before she was admitted.
11 VALUE BELIEF SYSTEM

The patient was born and raced by a Catholic family. The family
practices the teachings of the Catholic Church. She mentioned before, she
attends Sunday mass and do prayers. The patient believes in one God and
perceived good health is a gift from the Him
8
12. DEVELOPMENTAL TASKS
The patient belongs to Erik Erikson’s Theory of Psychosocial Development;
stage of Intimacy vs Isolation. She belongs to the young-aged adult in which her
relationship focuses more on with her partner – husband. Erikson defined intimate
relationships as those characterized by love, honesty, and closeness. Success at this
stage leads to fulfilling relationships. Failure, on the other hand, can result in feelings of
loneliness and isolation. So, intimacy pertains to good emotional and physical health
wherein a person's perspective now moves from an "I" to a "We. This been proven of
their marriage as they became as one, they have close, deep and lasting romantic
relationships, but they also forge strong relationships with family and friends.
From the Psychosexual Development of Sigmund Freud, the patient is in the

stage of Genital, where sexual pleasures occur. She is matured enough for her sexual
orientation. And based on her sexual activity, she is active with her husband and in
decision after marriage they do had family planning leading to their first-born child.
According to Jean Piaget’s Cognitive Development Theory, the patient belongs

to Formal Operational Stage, she can think critically, logically, rationally, scientifically,
and abstractly, have to take consideration of reasoning and argument. At this stage, she
draws conclusions from thinking. People gain greater awareness and understanding of
their thought processes, they develop what is known as metacognition, or the ability to
think about their thoughts as well as the ideas of others.
Moreover, Lawrence Kohlberg presented Moral Development theory, morality

depends on a person, the patient is at the third level – Post Conventional Morality, it
includes Social Contract or Legalistic and Universal Ethical Principle, which defines as
who follows internalized universal principles of right and justice. It also balances
concern for self with concern for others and the common good. A person acts
independently and in ethical manner regardless of expectations of others.
Lastly, James Fowler introduced the Stages of Faith, the patient belongs to stage
four – Individuative – Reflective Faith. The patient focuses on her personal faith, beliefs
and lifestyle. Some people give up on faith altogether at this point but faith can be
strengthened in this stage as beliefs become explicitly, personally held. There is a strong
reliance on the logic, rational mind and self.
9
C. OB Assessment
Date & Time of Identification: February 15, 2020
Ultrasound Date: Last date: February 15, 2020
LMP: May 29, 2019
Estimated Due Date: March 5, 2020
May = 31 – 29 = 2 Oct = 31
June = 30 Nov = 30
July = 31 Dec = 31
Aug = 31 Jan = 31
Sept = 30 Feb = 15
Total: 262/7 = 37.4
Age of Gestation: 37 weeks 4/7 days
Chief complaint:
(+) Uterine Contracted RPN-Al with HP @ 8-9 weeks
(-) Water vaginal discharge (-) BP elevation
(-) Bloody show (-) excessive weight gain/loss
(+) Good fetal movement (-) maternal illness
Abdominal s/ sx: Abdomen Globular soft
History of present illness:
The patient has no record of present illness.
Past Medical/ Surgical history:
(-) HPN, DM, BA, Allergies, Previous surgery
Medication:
Obimin Plus - A pre- and postnatal supplement to help provide adequate

supply of vitamins, minerals and omega-3 fatty acids, DHA and EPA, during pregnancy
and lactation.
10
Social history:
The patient does not do any kind of vices; smoking, drinking and drugs.
Physical Findings:
The patient is awake, alert not in distress, (-) heart in murmur, lungs CBS
General and Vital signs:

Respiratory rate: 18 Breaths/min: BloodPressure:110/70mmHg
Weight: 47.5 kg Height: 162cm
Conscious and Coherent
Abdominal Fundal Height: 32 cm
Leopold maneuvers
Fetal presentation: Cephalic Presentation

Fetal lie: Not indicated
Fetal attitude: Was not able to determine
Estimated Fetal Weight: 3115 g
Fetal Heart Rate: 140 beats
Pelvic Exam
Date performed: February 15, 2020 – 4:30 PM
Cervix: 1 cm, post med effacement 50%
Station: 3
Amniotic Fluid: (+) BOW
11
D. PHYSICAL ASSESSMENT
Date performed: February 19,2020
HEAD
AREA METHOD OF NORMAL FINDINGS FINDINGS FROM PATIENT INTERPRETATION

ASSESSMENT
Skull Inspection • Generally round, with prominences in the Patient skull is round; no palpable Normocephalic
frontal and occipital area. swelling or tenderness
Palpation • No tenderness noted upon palpation
Scalp Inspection • Lighter in color than the complexion. Patient scalp lighter in (+) Presence of Dandruff
• Can be moist or oily. complexion; no notable lesions
Palpation • No scars noted. seen; no palpable nodule or
• Free from lice, nits and dandruff. swelling, dandruffs were seen
• No lesions should be noted.
• No tenderness or masses on palpation
Hair Inspection • Can be black, brown or burgundy depending on Hair is dyed in dark brown and Normal hair condition
the race. medium length; evenly
• Evenly distributed covers the whole scalp distributed; no signs of hair loss;
• No evidences of Alopecia hair strands are not brittle
• Maybe thick or thin, coarse or smooth.
• Neither brittle nor dry.
12
Face Inspection • Observe the face for shape. Patient face shape is round. (+) Presence of moles
• Inspect for Symmetry. prominent cheek bones;
Palpation • Inspect for the palpebral fissure [There should symmetrical facial movement; no
be bilateral Nasolabial fold] palpable nodules; She has no
• Slight asymmetry in the fold is normal. involuntary movement;
Nasolabial folds were bilateral as
she smiles. There is presence of
moles.
Cheeks Inspection • The normal findings are pinkish and smooth Patient has smooth and pinkish Normal
cheeks with prominent cheekbone
Palpation
Eyebrows Inspection • Symmetrical and in line with each other. Patient has black and plucked (+) Dyed hair
• Maybe black, brown or blond depending on eyebrow. Evenly distributed and
race. symmetrical.
• Evenly distributed.
Eyelashes Inspection • Color dependent on race. Patient eyelashes are black, Normal
• Evenly distributed evenly distributed and turned
• Turned outward outward
Eyelids Inspection • Upper eyelids cover the small portion of the Patient’s upper eyelids covers the Normal
iris, cornea, and sclera when eyes are open. portion of iris, cornea and sclera
• Meets completely when eyes are closed. when opened. Eyelids meets
• Symmetrical completely when closed. There is
presence of symmetry; No ptosis
observed
Lacrimal Inspection • Lacrimal gland is normally non palpable. Patient’s lacrimal gland was Normal
Apparatus • No tenderness on palpation. palpable; no swelling or
Palpation • No regurgitation from the nasolacrimal duct. tenderness upon palpation.
13
Conjunctivae Inspection • Both conjunctivas are pinkish or red in color. Patient’s conjunctiva were Normal
• With presence of many minute capillaries. pinkish and moist. There is no
• Moist presence of lesions and foreign
• No ulcers objects
• No foreign objects
Sclerae Inspection • Sclerae is white in color (anicteric sclera) Patient’s sclera is white, Normal
• No yellowish discoloration (icteric sclera). capillaries are visible
• Some capillaries maybe visible.
Pupils Inspection • Pupillary size ranges from 3 – 7 mm, and are Patient’s pupils are equal, round, Normal
equal in size. reactive to light and
• Equally round. accommodation.
• Constrict briskly/sluggishly when light is
directed to the eye, both directly and
consensual.
Eye Inspection • The eyes can move in all direction The patient was able to move her Normal
Movement eyes in all direction and there
were no noted limitations on
every movement.
Vision Inspection • The normal visual acuity is 20/20 The patient has difficulty on A type of refractive error of
seeing far objects. She wears the eye; Myopia with
eyeglass with grade 175/20 with astigmatism
astigmatism.
Right eye: 175
Left eye: 20
14
EARS

ASSESSMENT
Pinna Inspection • The normal skin color is the same as the facial Patient’s pinna is the same as the (+) Two piercings
skin color of her facial skin. It is
• Symmetrical, parallel, proportional to the size symmetrical and parallel to the size
of the head and the line with outer canthus of of her head. Pinna returns to normal
the eye shape when folded. There are two
piercings present.
External Ear Inspection • The normal findings for the external ear canal Patient external ear canal is clean, Normal
Canal are pinkish, clean with scanty cerumen scanty cerumen. There is no presence
of foreign object or discharge
Hearing Inspection • Normal voice tones are audible Patient was able to hear my voice Normal
• Able to hear whisper during the examination.
15
NOSE

ASSESSMENT
Nose Inspection • Nose in the midline Patient’s nose is in the midline, slight (+) Presence of Pimple
• No Discharges. pointed. There were no discharges marks
• No flaring alae nasi. and no nasal flaring while breathing.
• Both nares are patent. The nasal mucosa is pinkish to red in
• No bone and cartilage deviation noted on color. Good sense of smell.
palpation.
• No tenderness noted on palpation.
• Nasal septum in the mid line and not perforated.
• Good sense of smell
MOUTH / LIPS

ASSESSMENT
Lips Inspection • With visible margin Patient has symmetrical lips which is Normal
• Symmetrical in appearance and movement slightly pinkish. There is no notable
• Pinkish in color lesions and edema.
Gums Inspection • Pinkish in color The patient gums were pinkish, no Normal
• No gum bleeding bleeding was seen. Her gums were
not retracted.
Teeth Inspection • Number The patient’s teeth were not Incomplete teeth and
• Color complete, tooth loss was present. The presence of dental carries
16
• Dental carries color is yellowish. Her teeth incisors and yellowish in color
• Dental fillings have some carries.
Tongue Inspection • Pinkish with white taste buds on the surface. Patient’s tongue is pinkish with white Normal
• No lesions noted. taste buds observed. There is no
• No varicosities on ventral surface notable varicosities and lesions seen.
• Frenulum is thin attaches to the posterior 1/3 of Gag reflex is present. She is able to
the ventral aspect of the tongue. move her tongue in different
• Gag reflex is present direction. Good sense of taste
• Good sense of taste
Tonsil Inspection • Normal findings are pink, smooth Patient’s tonsils are pinkish and no Normal
• No discharge discharge as observed. There is no
presence of inflammation.
NECK

ASSESSMENT
Neck Inspection • The neck is straight. Patient’s neck is straight, (+) Darkening of neck
• No visible mass or lumps. symmetrical with no visible lesions
Palpation • Symmetrical or swelling. There is no presence of
• No jugular venous distension jugular vein distention. The thyroid
gland is palpable. There are
discolorations on neck linings.
17
UPPER EXTREMITIES

ASSESSMENT
Arms Inspection • Both extremities are equal in size. Patient’s both extremities are same (+) Presence of Stage 1
• Have the same contour with prominences of contour but the left arm has stage 1 edema on Right arm
Palpation joints. edema and scar. She has no
• No involuntary movements. involuntary movements and can (+) Presence of scar on
• No edema perform complete range of motion. right arm
• Color is even There is no crepitus noted on joints.
• Temperature is warm and even.
• Has equal contraction and even.
• Can perform complete range of motion.
• No crepitus must be noted on joints.
• Can counter act gravity and resistance on ROM.
CHEST

ASSESSMENT
Anterior Inspection • Symmetrical Patient has symmetrical chest with Normal

• Fair complexion no deformities. Patient is not in
Palpation • No deformities and lesion distress during respiration. There
are no audible abnormal breath
Auscultation
sounds.
18
Posterior Inspection • Symmetrical The patient’s chest is symmetrical, Normal
• Fair complexion no presence of deformities and skin
Palpation • No deformities and lesion lesions. The spine is aligned.
• The spine is aligned
Auscultation
BREAST

ASSESSMENT
Breast Inspection • No lumps or masses are palpable. The patient breasts are enlarged Normal
• No tenderness upon palpation. skin is warm to touch. There is
Palpation breastmilk secretion. There are no
lumps or swelling felt.
ABDOMEN

ASSESSMENT
Abdomen Inspection • The abdomen should be flat, round, scaphoid The patient’s abdomen is flat and (+) Presence of longitudinal
in shape symmetrical. The color of the skin is suture, striae gravidarum,
Palpation • Symmetric contour, the same as the body. There is a and linea nigra
• Same color with the body presence of longitudinal suture, striae
• No lesions gravidarum, and linea nigra.
• Good skin turgor
• No lumps or tenderness
19
GENITALS

ASSESSMENT
Vagina Inspection • The pubic skin must be intact The inspection was not done because (+) Darkening of vaginal
• No lesions the patient refused to but she mentioned lining
• No inflammation that her vaginal lining had darken.
• No swelling
• No discharge
Anus Inspection • The anal skin must be intact The inspection was not done because Patient refused
• The anal sphincter is in good tone the patient refused.
LOWER EXTREMITIES

ASSESSMENT
Lower Inspection • Both extremities are equal in size. The patient’s lower extremities are (+) Presence of Stage 1
extremities • Have the same contour with prominences of symmetric. There is no presence of Edema both in lower
Palpation joints. deformities, and involuntary extremities
• No involuntary movements. movements. Skin is warm to touch.
• No edema Both lower extremities had stage 1
• Color is even edema.
• Temperature is warm and even.
• Has equal contraction and even.
• Can perform complete range of motion.
• No crepitus must be noted on joints.
• Can counter act gravity and resistance on ROM.
20
Drug Study #1
Indication Contraindication
Drug Features Mechanism of Action Adverse Reactions Nursing Responsibilities
Generic Name: Selectively inhibits Short term treatment Contraindicated in • Hypersensitivity • Check medication for appropriate
Etoricoxib cyclo-oxygenase - 2 of moderate pain, patient with reactions include dosage for age of patient.
(Cox-2) which is an symptomatic relief of hypersensitivity. swelling of the face, lips, • Assess patient’s history of
Brand Name: isoform of the enzyme osteoarthritis (OA), tongue or throat which allergic reaction to Arcoxia or for
Arcoxia that has been Rheumatoid arthritis Active peptic ulceration may cause difficulty in previous heart failure, heart
postulated to be (RA) ankylosing or active gastro- breathing or swelling. attack, bypass surgery, angina,
Classification: primarily responsible spondylitis, and the intestinal (GI) bleeding. • Insomnia or increased peripheral arterial disease, or
NSAID (Non-steroidal for the synthesis of pain and signs of anxiety transient ischemic attack.
Inflammatory Drug) mediators of pain, inflammation • Severe increase in blood • Administer after eating meals
inflammation, and associated with acute pressure • Monitor blood pressure regularly
Dosage: 120mg/ fever. gouty arthritis. • Confusion or while taking this medication
Tablet Hallucination • Assess the patient if she/ he
relieves in pain or cramps
Route: Oral
Frequency: Once a
day
21
Drug Study #2
Generic Name: Natalac increases Natural health
Contraindicated in patient Lower blood pressure and • Check medication for
Moringa Oleifera lactation in nursing supplement for nursing
with hypersensitivity slow heart rate because of appropriate dosage for age of
Malunggay Leaf mothers which mothers especially the alkaloids in the plant. patient
promotes breastfeeding. Products containing
those with inadequate • Administer with or without
Brand Name: Natalac lactation. moringa leaf have been Uterine contractions from eating meals
used with apparent safety moringa bark.
• Monitor vital signs for efficacy
Natalac FeFol also for up to 6 months.
Classification:
Cell mutations caused by a • Monitor if lactation has increase
Nutritional helps prevent iron
Products containing chemical isolated from over the course of the therapy.
Supplements deficiency anemia.
moringa seed have been roasted moringa seeds.
used with apparent safety
Dosage: 1 capsule Interference with fertility.
for up to 3 weeks.
Route: Oral Moringa root and root
extracts are possibly
Frequency: BID unsafe when taken by
mouth. The roots contain
Spiro chin, a toxic
substance.
22
Drug Study #3
Generic Name: Inhibits prostaglandin, Celecoxib is used to Hypersensitivity to drug, Dizziness, Drowsiness, • Check medication for
Celecoxib synthesis, anti- treat pain or sulfonamides, or other Headache, Insomnia, appropriate dosage for age of
inflammatory, inflammation caused NSAIDs Fatigue, Peripheral Edema, patient
Brand Name: Coxidia analgesic, and by many conditions Ophthalmic Effects, • Assess patient’s history of
antipyretic effects and such as arthritis, Severe hepatic Tinnitus, Pharyngitis, allergic reaction to the drug
impairment
Classification: impending COX-2 ankylosing Rhinitis, Sinusitis, Nausea, • Monitor complete blood count,
NSAID (Non-steroidal spondylitis, and Diarrhea, Constipation, electrolyte levels, creatinine
History of asthma or
inflammatory drug) menstrual pain. Abdominal Pain, clearance, and occult fecal
urticaria
Dyspepsia, Flatulence, Dry blood test and liver function
Dosage: 200mg/ Serious skin reactions Mouth, GI Bleeding, • Administer after taken meals.
Capsule Menorrhagia, Decreased • Advise patient to immediately
Hemoglobin or Hematocrit, report any adverse reaction to
Route: Oral Eosinophilia, Epistaxis and the medication given
Bruising
Frequency: BID
23
Drug Study #4
Generic Name: Penicillin resistant Intra-uterine abdominal, Contraindicated in Anaphylactic shock, • Check medication for
Sultamicillin Tosylate microorganism and it gynecologic, and skin patient with diarrhea, loose bowel, appropriate dosage for age of
acts sensitive organism structure infection hypersensitivity. nausea, vomiting, patient
Brand Name: during the stage of caused by susceptible epigastric distress, blood • Assess patient’s history of
Silgram active multiplication by rashes With history of clots in the veins of legs, allergic reaction to the drug
cholestatic jaundice or
inhibiting biosynthesis changes in laboratory test • Administer after eating meals
hepatic dysfunction and
Classification: of cell wall values, Throat pain and • Monitor vital signs
Ampicillin sodium mucopeptide. other drug allergies Abdominal pain • Report promptly unexplained
and of the beta- bleeding
lactamase inhibitor • Monitor Urine and Stool
sulbactam pattern and output
Dosage: 750 mg/
Tablet
Route: Oral
Frequency: BID
24
Drug Study #5
Generic Name: Unknown. Nubain is indicated for Contraindicated in Flushing, Nausea, Vomiting, • Check the Doctor’s order
Nalbuphine HCL the management of patient with Stomach Cramps or Gastro- • Check medication for
Binds with Opioid moderate to severe pain hypersensitivity. Intestinal Pain, Spinning appropriate dosage for age
Brand Name: receptors in the CNS, and adjunct balanced Sensation, Dry Mouth, of patient.
altering perception of Significant respiratory Clamminess and Diaphoresis
Nubain anesthesia, for operative • Assess patient’s history of
the emotional response and postoperative depression
allergic reaction or any
Classification: to pain. analgesia
Acute or severe adverse reactions
Opioid Analgesics
bronchial asthma • Administer after eating
meals
Dosage: 100mg/tab GI obstruction includes • Monitor blood pressure
paralytic ileus regularly while taking this
Route: Oral medication
• Reassess the patient’s level
Frequency: q6 of pain at least 15 and 30
minutes after administration
25
Drug Study #6
Generic Name: Thought to produce Temporarily relives Contraindicated in Agitation, Anxiety, Fatigue, • Safe administration
Acetaminophen analgesia by inhibiting minor aches and pain patient with Vomiting, Nausea, Stomach • It can be taken either with or
prostaglandin and other due to cold, headache, hypersensitivity Pain, Loss of Appetite, without food
Brand Name: substances that back ache, minor ache Itchy, Rash, Headache, and • Monitor Vital signs for
Tylenol sensitize pain receptors. of arthritis, toothache, Includes calorie dark urine, gray color stool.
efficacy
undernutrition, acute
Drug may relieve fever premenstrual and • Identify any adverse reaction
Classification: through central action menstrual cramp, and liver failure, liver
to the medication given
Antipyretics in the hypothalamic temporarily reduces problems, sever renal
impairment, • Identify whether patient is
heat-regulating center. fever experiencing tenderness in
Dosage: 1 tablet acetaminophen
overdose the kidneys area
Route: Oral
Frequency: TID
26
Drug Study
Generic Name: A pre- and postnatal Used for Pregnancy Contraindicated in patient Vomiting, Nausea, Stomach • Check medication for
supplement to help complications and with hypersensitivity with Pain, Loss of Appetite, appropriate dosage for age of
Brand Name: Obimin provide adequate deficiencies. intestinal obstruction and Headache, GI bleeding and patient
Plus
supply of vitamins,
acute abdominal pain, allergies • Taken with or without meals
Providing Biotin, also for any allergic
minerals and omega-3 • Monitor vital signs for efficacy
Calcium Carbonate, reactions.
Classification: • Increase oral fluid intake
Nutritional fatty acids, DHA and Calcium Pantothenate,
Supplements EPA, during pregnancy Copper, Folic Acid,
and lactation. Iodine, Iron,
Dosage: 1 capsule Magnesium,
Manganese, Natural
Route: Oral Fish Oil,
Nicotinamide, Omega-
3 Fatty Acids, Vitamin
A, Vitamin B1,
Vitamin B12, Vitamin
B2, Vitamin B6,
Vitamin C, Vitamin D,
Vitamin E and Zinc as
active ingredients
inside your body.
27
Drug Study (during/after delivery)
Generic Name: Thought to produce Temporarily relives Contraindicated in Hematologic: hemolytic • Safe administration
Paracetamol analgesia by inhibiting minor aches and pain patients with anemia, neutropenia, • It can be taken either with or
prostaglandin and other due to cold, headache, hypersensitive to drug. leucopenia, pancytopenia. without food
Classification:
substances that
back ache, minor ache of • Monitor Vital signs for
Antipyretic arthritis, toothache, Use cautiously in Hepatic: Jaundice
sensitize pain receptors. efficacy
patients with long-term
premenstrual and
Metabolic: Hypoglycemia • Identify any adverse reaction
Drug may relieve fever menstrual cramp, and alcohol use because
to the medication given
through central action temporarily reduces therapeutic doses cause
hepatotoxicity
Skin: rash, urticaria. • Identify whether patient is
in the hypothalamic fever experiencing tenderness in the
heat-regulating center. kidneys area
28
Generic Name: Unknown. Treatment of pain of Contraindicated in Peptic ulcers, perforation • Check medication for
Dexketoprofen mild to moderate patient with or gastrointestinal appropriate dosage for age of
Produces anti- intensity like musculo- hypersensitivity. bleeding, sometimes fatal, patient.
Brand Name: inflammatory, skeletal pain, particularly in the elderly, • Assess patient’s history of
Ketesse analgesic, and dysmenorrheal & dental Patients in whom may occur. Nausea, allergic reaction
antipyretic effects, pain. substances with a similar vomiting, diarrhea, • Monitor blood pressure
Classification: possibly by inhibiting action precipitate attacks flatulence, constipation,
regularly while taking this
NSAID (Non- prostaglandin synthesis. of asthma, dyspepsia, abdominal medication
bronchospasm, acute pain,
steroidal melaena, • Assess the patient if she/ he
inflammatory drug) rhinitis, or cause nasal hematemesis, ulcerative
relieves in pain or cramps
polyps, urticaria or stomatitis, exacerbation of
angioneurotic edema. colitis and Crohn's
disease.
29
Generic Name: Its antagonist activity at Used to enhance GI Contraindicated in patient CNS: drowsiness, • Check medication for
Metoclopramide dopamine D2 receptors motility, to treat diabetic with hypersensitivity. extrapyramidal reactions, appropriate dosage for age
in the chemoreceptor gastroparesis, as an anti- restlessness, anxiety, of patient.
Brand Name: Plasil trigger zone (CTZ) in nauseant, and to Metoclopramide should depression, irritability, • Assess patient’s history of
the central nervous facilitate intubation of not be used whenever tardive dyskinesia allergic reaction
stimulation of
Classification: system (CNS)—this the small bowel during • Monitor blood pressure
Anti-emetics action prevents nausea radiologic examination. gastrointestinal motility CV: arrhythmias,
regularly while taking this
and vomiting triggered and in epileptics hypertension, hypotension
medication
by most stimuli. It
GI: constipation, diarrhea, • Assess client for abdominal
increases muscle pain distention, bowel
dry mouth, nausea
contractions in the sound
upper digestive tract. • Assess client for
extrapyramidal reactions
30
Drug Study (during/ after delivery)
Generic Name: Causes potent and To induce or stimulate Contraindicated in CNS: subarachnoid • Assess patient’s history of
Oxytocin selective stimulation of labor patient with hemorrhage, seizures, allergic reaction
uterine and mammary hypersensitivity. coma • Assess client’s uterine
Classification: gland smooth muscles. To reduce postpartum activity or fetal distress
Oxytocics bleeding after expulsion Contraindicated when CV: arrhythmias, occurs
of placenta vaginal delivery isn’t hypertension, hypotension
• Monitor fluid and intake
advised when
GI: vomiting, nausea output
cephalopelvic
• Monitor and record uterine
disproportion is present
GU: Abruptio placenta, contractions, HR, BP,
or when delivery requires
tetanic uterine contraction, intrauterine pressure, FHR,
conversion, transverse lie
postpartum hemorrhage and character of blood loss
Contraindicated in fetal at least every 15 minutes
distress when delivery
isn’t imminent
31
Drug Study (during/ after delivery)
Generic Name: A group of drugs called To prevent and treat Contraindicated in CNS: subarachnoid • Assess patient’s history of
methylergonovine ergot alkaloids. It postpartum hemorrhage patient with hemorrhage, seizures, allergic reaction
maleate affects the smooth caused by uterine atony Hypertension; toxemia; coma • Assess client’s uterine
muscle of a woman's or subinvolution pregnancy; and activity
CV: arrhythmias,
Brand name: uterus, improving the hypersensitivity. • Monitor fluid and intake
Methergine muscle tone as well as For control of uterine hypertension, hypotension
output
hemorrhage in the Caution should be
the strength and timing • Monitor and record uterine
Classification: of uterine contractions. second stage of labor exercised in presence of GI: vomiting, nausea
contractions, HR, BP,
Oxytocics following delivery of the impaired hepatic or renal
GU: Abruptio placenta, intrauterine pressure, FHR,
anterior shoulder. function.
tetanic uterine contraction, and character of blood loss
postpartum hemorrhage at least every 15 minutes
32
Nursing Care Plan #1
Assessment Nursing Diagnosis Planning Intervention Evaluation
Objective cues: Urinary retention related After 8 hours of nursing 1. Assess the patient’s physical After 8 hours of nursing intervention,
Vital signs to caesarean delivery intervention, the patient will be examination (e.g., palpation of the patient was able to:
Temp – 36.7 with spinal-epidural able to: bladder)
PR – 76 bpm anesthesia as evidence by 2. Assess the patient’s level of • Attain sensation and urge to
RR – 20 bpm absence of bladder • Attain sensation and urge to comfortability and pain bladder.
BP – 110/70 mmHg sensation bladder. • Void sufficient amounts with no
3. Monitor the client’s fluid intake and
Fluid intake – 420 ml • Void sufficient amounts with palpable bladder distention
output
Urine output – FC no palpable bladder
4. Assist in treatments to relieve • With the help of food diet, the
Stool output – 0 distention
mechanical obstruction patient’s bowel function will return
• Bowel function will return 5. Administer medication as indicated normally
(+) Foley Catheter normally 6. Assist client to sit upright on bedpan • Foley Catheter was removed
or commode
Patient is on soft diet 7. Encourage to increase in oral fluid
intake and follow the diet
8. Provide privacy
33
Nursing Care Plan #2
Assessment Nursing Diagnosis Planning Intervention Evaluation
Objective cues: Ineffective breastfeeding After 24 hours of nursing 1. Assess the patient knowledge about After 24 hours of nursing intervention,
Vital signs related to inadequate intervention, the patient will be breastfeeding and extent of the patient was be able to:
Temp – 36.7 breastmilk supply as able to: instruction that has been given
PR – 82 bpm manifested by 2. Determine the infant sucking • Verbalize understanding of
RR – 20 bpm insufficient infant weight • Verbalize understanding of problems causative or contributing factors.
BP – 110/70 mmHg gain causative or contributing 3. Review infant’s feeding schedule to • Demonstrate techniques to enhance
factors. note increase demand for feeding breastfeeding experiences (proper
G1P1 • Demonstrate techniques to 4. Monitor and evaluate observable latching and positioning)
enhance breastfeeding signs of inadequate infant intake • Achieve mutually satisfactory
Prescribed with experiences (e.g., sucking, decreased urinary breastfeeding regimen with infant
Natalac (Nutritional • Achieve mutually output and frequency of stools, content after feedings, gaining
Supplement) 1 capsule satisfactory breastfeeding inadequate weight gain) weight appropriately and output
BID regimen with infant content 5. Discuss proper diet for within normal range.
after feedings, gaining breastfeeding mother • Infant’s weight turns into 5.81 lbs
Inadequate infant weight appropriately and 6. Discuss early infant feeding cues • Total Output: 5WD, 3BM
intake and output output within normal range. 7. Demonstrate proper latching
8. Provide emotional support
Infant’s weight: 5.72 9. Provide practices times for infant to
lbs “Lick and Learn”
Intake: Breastfed
Total urine output:
2 WD
Total stool output:
2 BM
34
E. Laboratory Examination and Diagnostic Test
COMPLETE BLOOD COUNT

Date performed: February 17, 2020
EXAMINATION SIGNIFICANCE RESULT NORMAL

VALUE
Hemoglobin It is a protein substance 118 123-153 g/L

found in blood capable of
carrying oxygen and
carbon dioxide. This is a
baseline exam to check
for anemias.
Hematocrit It measures RBC mass 0.34 0.36-0.45
Platelet Platelets are involving in 187 150.00-450.00 x

the clotting formation. 10 ^9/L
RBC Count A person’s red blood cells 3.53 4.10-5.10 x 10

are created in his bone ^9/L
marrow and used to move
oxygen from his lungs to
systemic circulation –
other parts of the body.
WBC Count White blood cells are 23.43 4.00-10.50 x 10

markers for infection and ^10/L
inflammation in the body.
ULTRAROUND
LMP: May 29, 2019 AOG by LMP: 37 weeks, 3/7 days
AOG by Present Scan: 37 weeks. 2/7 days
BIOPHYSICAL PROFILE
General Survey Placenta
No. of fetus: Single Location: Posterior
Presentation: Cephalic Grade: II – III
FHB: 144 bpm Distance to Internal OS: high lying
Gender: Female
Amniotic Fluid Index
2.5 0 Total Amniotic Fluid Index: 4.88 cm
2.53 0
BIOMETRY MEASUREMENT
Biparietal Diameter 9.29 cm
Head Circumference
Occipitofrontal Diameter 11. 0 cm
Abdomen Circumference 33 cm
Femoral lib 7.24 cm
Distal Femoral Epiphysis 0.5 cm
BIOPHYSICAL PROFILE SCORING

Amniotic Fluid 4.88 cm 0
Fetal Tone 1 in 3 min 2
Fetal Breathing 1 in 3 min 2
Fetal Movement 3 in 3 min 2
Total Score: 6/8
36
Ultrasonic EDC: March 5, 2020
EFW: 3115 grams (HADLOCK)
Impression:
Single, Live, Intrauterine pregnancy, Cephalic presentation
37 weeks and 6 days by BPD
37 weeks, 1 day by FL with good cardiac and somatic activity
Oligohydramnios
Sonographic estimated fetal weight appropriate for gestational age
Biophysical profile score: 6/8
OPERATION RECORD
G1P1
Pregnancy where delivered term cephalic-baby girl
37 weeks by Ballard appropriate for gestational age by primary segment transverse
caesarean section under spinal-epidural anesthesia
Dysfunctional labor prolonged latent phase
Oligohydramnios, consider intra-amnionic infection
Medication:
Paracetamol
Ketesse
Plasil
Oxytocin
Methergine
Suture:
Vicryl 0
Vicryl 2.0
Drain:
Foley Catheter
37
F. Definition of Terms and Management
Oligohydramnios - is a condition that causes you to have too little amniotic fluid
during pregnancy. This fluid surrounds your unborn baby in the womb.
Oligohydramnios can happen at any time during the pregnancy. It is most common in
the third trimester.
Amniotic fluid - helps your baby grow and develop normally. The fluid does the
following during pregnancy:
• Protects your baby from injury

• Protects the umbilical cord and keeps it from being pinched
• Helps your baby's lungs develop, and helps him exercise his muscles and
digestive system
• Keeps your baby's temperature regular and protected from infection
• Prevents contractions from starting early
Oligohydramnios is characterized by the following features:
• Diminished amniotic fluid volume (AFV)

• Amniotic fluid volume of less than 500 mL at 32-36 weeks' gestation - Amniotic
fluid volume depends on the gestational age; therefore, the best definition may
be AFI less than the fifth percentile.
• Single deepest pocket (SDP) of less than 2 cm
• Amniotic fluid index (AFI) of less than 5 cm or less than the fifth percentile
Signs and Symptoms
• Less amniotic fluid than expected for the trimester

• Smaller uterus size than expected for the trimester
• Smaller abdomen size than expected for the trimester
• Slow heartbeat of the baby
• Baby is easy to feel when a healthcare provider touches the mother's abdomen
• Fewer movements than usual from the baby
• Amniotic fluid leaking from the mother's vagina
Risk for Oligohydramnios
• Maternal hypertension/preeclampsia
• Maternal diabetes
• Maternal dehydration
• Maternal hypoxia
• Placental issues
Oligohydramnios can cause the following injuries and complications:
• Increased chance of miscarriage or stillbirth

• Compression of fetal organs that can lead to birth asphyxia or hypoxic-ischemic
encephalopathy (HIE)
• Premature birth
• Intrauterine growth restriction
• Cord compression
• Cerebral palsy
• Preterm birth
• Meconium aspiration
38
How is oligohydramnios diagnosed?
• Ultrasound pictures are used to find the amount of amniotic fluid in the womb.
The pictures may also show the baby's size. His kidneys and urinary tract will be
checked. Moving ultrasound pictures are used to check blood flow through
arteries in the baby's kidneys and through the placenta.
• A fetal nonstress test is used to check your baby's movements. Your healthcare
provider may also have you do kick counts. This means counting the number of
times you feel your baby move in an hour.
• A biophysical profile is a test that checks the baby's breathing and movement. It
also checks for the amount of amniotic fluid in the womb.
• Amniocentesis is a procedure used to take a sample of amniotic fluid from the
womb. The fluid contains cells that can be tested for birth defects and other
problems.
How is oligohydramnios treated?
• Delivery may be recommended if your baby is close to being full term.

• An amnioinfusion is a procedure to inject fluid into the womb. The fluid may
help take pressure off the umbilical cord. During labor, your healthcare provider
puts a catheter (thin tube) through your cervix. Fluid is put through the catheter
and into the womb.
Management
• Oral intake of fluids: Some medical professionals may advise women to stay
hydrated if they have oligohydramnios (2). Oral hydration is simplest, but in
some cases, intravenous hydration (through an IV) may be needed.
• Installation of a saline solution into the amniotic sac (amnioinfusion) during
labor. During amnioinfusion, doctors use an intra-amniotic catheter to add more
liquid to the amniotic fluid (2). This may help ‘pad’ the umbilical cord, reducing
the risks of umbilical cord compression, which could cut off oxygen flow to the
baby.
• Bed rest may be needed if you are not ready to deliver. Your healthcare provider
may recommend bed rest for several weeks of your pregnancy.
Source:
Medically reviewed by Drugs.com. Feb 3, 2020. Retrived from

https://www.drugs.com/cg/oligohydramnios.html
American Baby & Child Law Center. 2010-2020. Retrieved from

https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/maternal-medical-
conditions/oligohydramnios/
39

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Nursing Care Management to a 29

years old Caesarean Section

In Partial Fulfillment of the Requirements for the

Related Learning Experiences

Bermas, Benedict James

De Vega, Khatrina Mae

Ms. Mary Grace Morada-Cu, MAN, RN

➢ February 15, 2020

➢ February 17, 2020

➢ February 18, 2020

Total Output: urine - FC , 0 stool output

➢ February 19, 2020

Vital Signs (1:00 PM)

Total Output: urine – 1800 ml, 2 stool output

Brief description of the diagnosis/ surgery performed:

1.2 Past illnesses:

1.3 History of illness in the family

2. NUTRITION AND METABOLIC PATTERN

During her pregnancy, increase consumption of fiber in forms of

Breakfast: Banana, Boiled Egg, Bread

➢ February 19, 2020

Breakfast: 1 cup of rice, Chicken, Cooked Vegetables.

3.3 Skin: (condition)

4 ACTIVITY EXERCISE PATTERN

Patient’s level of consciousness after the surgical procedure was slightly

8.3 Complaints regarding family

8.4 Living with (members of family)

10 COPING-STRESS MANAGEMENT PATTERN

11 VALUE BELIEF SYSTEM

From the Psychosexual Development of Sigmund Freud, the patient is in the

According to Jean Piaget’s Cognitive Development Theory, the patient belongs

Moreover, Lawrence Kohlberg presented Moral Development theory, morality

Date & Time of Identification: February 15, 2020

Ultrasound Date: Last date: February 15, 2020

LMP: May 29, 2019

Estimated Due Date: March 5, 2020

Total: 262/7 = 37.4

Age of Gestation: 37 weeks 4/7 days

(+) Uterine Contracted RPN-Al with HP @ 8-9 weeks

(-) Water vaginal discharge (-) BP elevation

(-) Bloody show (-) excessive weight gain/loss

(+) Good fetal movement (-) maternal illness

Abdominal s/ sx: Abdomen Globular soft

History of present illness:

The patient has no record of present illness.

Past Medical/ Surgical history:

(-) HPN, DM, BA, Allergies, Previous surgery

Obimin Plus - A pre- and postnatal supplement to help provide adequate

General and Vital signs:

Temperature: 36.5C Pulse Rate:75 beats/min

Abdominal Fundal Height: 32 cm

Fetal presentation: Cephalic Presentation

Estimated Fetal Weight: 3115 g

Fetal Heart Rate: 140 beats

Date performed: February 15, 2020 – 4:30 PM

Cervix: 1 cm, post med effacement 50%

Date performed: February 19,2020

AREA METHOD OF NORMAL FINDINGS FINDINGS FROM PATIENT INTERPRETATION

AREA METHOD OF NORMAL FINDINGS FINDINGS FROM PATIENT INTERPRETATION

AREA METHOD OF NORMAL FINDINGS FINDINGS FROM PATIENT INTERPRETATION

AREA METHOD OF NORMAL FINDINGS FINDINGS FROM PATIENT INTERPRETATION

AREA METHOD OF NORMAL FINDINGS FINDINGS FROM PATIENT INTERPRETATION

AREA METHOD OF NORMAL FINDINGS FINDINGS FROM PATIENT INTERPRETATION