Arellano University

Jose Abad Santos Campus 3058 Taft Avenue, Pasay City

CASE PRESENTATION
(Cord Compression Leading to Fetal Distress and Caesarean Section)

BSN Level III – Block 1 Under Professor Elizabeth Abayan

TABLE OF CONTENTS
I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. Biographic Data Nursing Health History Physical Assessment Gordon’s Health Pattern Laboratory/Diagnostic Examination Result Medications and IV Infusions Review of Systems Anatomy and Physiology Pathophysiology Prioritized List of Nursing Problems Nursing Care Plan Discharge Plan

I. BIOGRAPHIC DATA
Patient Name: Age: Birthday: Gender: Religion: Civil Status: Occupation: Address: Patient X 29 years old October 29, 1981 Female Roman Catholic Married Housewife Lipa, Batangas

II. NURSING HEALTH HISTORY
Chief Complaint:
Patient X, when admitted to the OB ward complained of pain in the hypogastric area, due to the operative incision made on her caesarean section.

History of Present Illness:
2 hours prior to admission, Patient X felt progressive labor contractions which made her opt to admission.

Past History:
The patient X doesn’t have hypertension, asthma, diabetes mellitus, and hepatitis B. She has never been hospitalized due to any illness, only when she had her previous caesarean delivery for her first baby last 2008. During her childhood she had sore eyes, chickenpox and mumps. She is a fully immunized child and has no psychiatric illness. She has no allergies at all.

Family History of Illness:
Patient X’s father has a history of hypertension. Also, her uncle on her mother’s side died of stroke.

Obstetrical History:
Patient X reported her menarche to occur when she was 12. She is a G2P2(2-0-0-2). She gave birth to her fist baby by caesarean section, at 37 weeks age of gestation. During her current pregnancy, she has a regular prenatal check up and doesn’t have any history of illness during pregnancy. Her second baby was delivered by an emergency caesarean section at 38 weeks of gestation due to fetal distress secondary to cord compression.

Lifestyle and Activity of Daily Living:
Patient x is non alcoholic drinker, non smoker and not addicted to any drugs. She has poor nutritious food intake and no allergies in any food. She sleeps 10 hours a day, starting from 8 in the evening and awake at 6 in the morning. She takes a nap for 30 minutes every afternoon.

Social Data:
She is a college graduate, unemployed and currently residing in her mother’s house.

Psychological Data:
The patient is responsive to voice and touch and has the ability to carry a conversation and answer question appropriately. There are no complaints regarding reading and writing. The patient can speak Tagalog and some English.

III. GORDON’S FUNCTIONAL HEALTH PATTERNS
Nutritional Pattern
Patient X is 29 y/o with the height of 5’2” and weight of 41 kg – undernourished She has a BMI of 17 – underweight The skin is considered normal

Activity – Exercise Pattern
Before admission, the patient served as a fulltime housewife, she takes care of her child at home and able to do some household chores During hospitalization, Patient X appears weak and complains about the pain on her incision site. She is able to perform ADL but with assistance in doing activities.

Sleep – Rest Pattern
The patient gets an average sleep of 10 hours every night. She sleeps at around 8 p.m. and wakes up at 6 a.m. During hospitalization, the patient experiences sleeping disturbances because of the pain on her incision site. She often has disrupted sleep. She wakes up at night and finds it hard to go to sleep again.

Elimination Pattern
Before admission, the patient stated that she urinates about 6 - 8 times every day. She usually has bowel movement of 3 times a week, with slightly brownish colored stool. During hospitalization, Patient X urinates about 3 - 5 times a day with strawcolored urine output. There was no pain during urination. The patient has not yet evacuated her bowels since yesterday.

Health – Perception/Health Management Pattern
The client perceives herself as physically fit person

She takes a bath one to two times a day She doesn’t smoke or drink any liquor, she also doesn't use any harmful drugs

Cognitive – Perceptual Pattern
The patient is responsive to voice and touch. She has the ability to carry a conversation and answer questions properly. She is able to read and write, and a college graduate. It was also observed that she was able to read the signs and posters posted at the hospital ward, and can follow simple instructions and can easily comprehend to questions asked. There are no complaints regarding reading and writing. The patient can speak Tagalog and a few English. During hospitalization, Patient X is still responsive to anything and has the ability to use simple sentences in answering questions

Role – Relationship Pattern
She lives with her husband and her first child. According to the patient, they have a good family relationship. She also emphasized that her family is very supportive to her especially now that she was hospitalized.

Sexuality – Reproductive Pattern
Patient X is currently not sexually active because she has undergone caesarean section last 3 days.

Coping – Stress Pattern
The patient usually decides for herself or sometimes she consult her family During the interview, she was not attended by her husband due to certain circumstances.

Value – Belief Pattern
The patient is Roman Catholic. She attends mass every week with her family.

IV. PHYSICAL ASSESSMENT
(Postoperative and Postpartum Physical Assessment)
Date: September 27, 2010 Vital Signs Temperature Pulse Rate Respiratory Rate Blood Pressure Weight: 41 kilograms Height: 5’2” Body Mass Index Normal Range 18-25 Findings 17 Interpretation Underweight Normal Range 36.5 C- 37.5C 60- 100 bpm 12-20 cpm <120;<80 Findings 37.4 C 88 bpm 24 cpm 110/90 mmHg Interpretation Afebrile Normal Tachypnea Prehypertensive

Body Parts

Technique
• • • • • • • • •

Findings
Conscious Coherent Slightly fatigued, in pain Irritable Reduce activity level Normo-cephalic Smooth skull contour Symmetrical facial features and movements Black, evenly distributed

Interpretation
Abnormal: Patient has an overwhelming sustained sense of exhaustion and decrease capacity for physical and mental work

General Appearance

Inspection

Head Inspection Palpation

 Skull and face

Normal

 Hair

Inspection

Normal

Body Parts

Technique
• • • • • • • • • • •

Findings
Symmetrically aligned eyebrows Lids close symmetrically No discharges Anicteric sclera Pink palpebral conjunctiva PERRLA Pupil: 5mm, black Both eyes are coordinated 20/20 vision Symmetrical Auricle aligned with outer canthus of the eyes (+) cerumen Normal voice tone audible Symmetric No discharges/ flaring Pink nasal mucosa Sinuses not tender Pink lips 32 teeth Pink gums Tongue pink in color with raised papillae, moves freely Pink buccal mucosa Tonsils are pink with uvula at center Supple Muscles equal in size and strength (-) CLAD Moves without discomfort

Interpretation

 Eyes

Inspection Palpation

Normal

 Ears

Inspection Palpation

Normal

• • • • • • • • • •

 Nose

Inspection Palpation

Normal

 Mouth

Inspection Palpation

Normal

• • • • • •

Neck

Inspection Palpation

Normal

Body Parts

Technique
• • • • • • • Inspection Palpation Percussion Auscultation • • • • • • •
• • •

Findings
Slightly unequal in size Soft, warm, nontender Round, dark areola Round, everted nipples, (-) cracks Symmetric chest Spine vertically aligned Full symmetric chest expansion Bilateral symmetry of vocal fremitus Normal percussion sounds on posterior and anterior chest (-) retraction (+) crackles/rales (-)gurgles/ronchi (-)wheeze (-)friction rub
Soft, tender 5 inches pfannenstiel cut over hypogastric area 15 stitches incision with scant bloody discharge Incision site is warm and erythematous Dressing and plaster are clean and fully covered the incision No foul odor Hypoactive bowel sounds Bladder not distended Uterus is 3 cm below umbilicus

Interpretation

Breast

Inspection Palpation

Normal

Chest

Crackles are small sharp sounds heard on auscultation caused by excessive fluid within the airways.

Abdomen

Inspection Auscultation Percussion Palpation

• • • • • •

The Pfannenstiel incision is a type of surgical incision made in the lower abdomen. It is used primarily in women during childbirth through the abdomen, also known as cesarean section.

Genitals/Rectum

Inspection

• •

Scant lochia rubra (-) hemorrhoids

Normal

Body Parts
Extremities

Technique
• Inspection • •

Findings
Can move without discomfort (-)Homan’s Sign (-) edema

Interpretation
Normal

V. LABORATORY/DIAGNOSTIC EXAMINATION RESULTS
HEMATOLOGY: COMPLETE BLOOD COUNT BLOOD COMPONENT WBC

RESULT

NORMAL

FINDINGS

9.8 x 109/L

4.0-11.0

Normal

RBC

4.9 x 1012/L

4.0-6.0

Normal

Hgb

116 g/L

120-180

Decreased

Hct

0.52 %

0.370-0.540

Normal

Lymphocytes

0.310

0.200-0.500

Normal

Monocytes

0.022

0.020-0.090

Normal

Eosinophils

0.006

0.000-0.060

Normal

Basophils

0.010

0.000-0.020

Normal

Neutrophils

0.510

0.500-0.700

Normal

Platelet

165 x 109/L

150-450

Normal

RESULTS FOR BLOOD TYPING ABO Typing A URINALYSIS Chemical Analysis Blood Bilirubin Ketones Physical Analysis Color Transparency Albumin Glucose pH Specific gravity Leukocytes Result (-) (-) (-) Result Light yellow Clear (-) (-) 6.0 (-) Rh-typing Antibody Screen Positive

VI. MEDICATIONS AND IV INFUSIONS

VII. REVIEW OF SYSTEMS
Neurological System
pupil size reaction eyes open : 5 mm best verbal response : responsive : PERRLA best motor response : active : spontaneously

Integumentary System
temperature : warm skin turgor : normal color : normal JVD : not distended skin : broken skin as evidence by the incision on her abdomen

Respiratory System
chest lungs respirations breath sounds cough : symmetrical : equal chest expansion : no distress : clear : absent

Cardiac System
heart sounds : normal

Gastrointestinal System
abdomen is : Pfanneinsteil cut over suprapubic area with scant bloody drainaige; dressing and plaster were clean and fully covers the incision site; no foul odor, incision warm and soft Bladder not distended (+) mass tenderness at LLQ Bowel sounds: normoactive

Muscular System
pulses : (+) Homan’s sign : ( - ) edema : ( - ) capillary refill : < 3 seconds peripheral calf tenderness : ( - )

VIII. ANATOMY AND PHYSIOLOGY The Female Reproductive System

Fallopian tube/Oviduct :
o 4 inches long (each side) o transports the mature ova form the ovaries to the uterus o provide a place for fertilization of the ova by the sperm in it’s outer 3rd or outer half.

Parts of Fallopian Tube:
    Interstitial – lies within the uterine wall Isthmus – tubal ligation Ampulla – where fertilization usually occurs Infundibulum - covered by fimbriated cell

Uterus:
o o o o o hollow, pear-shaped muscular organ 3 x 2 x 1 inches, weighing 50-60 grams Organ of menstruation site of implantation provide nourishment to the products of conception.

Muscular Layers of the Uterus:
 Perimetrium (outermost) o offers added strenght and support to the structure.  Myometrium (middle layer) o expels fetus during birth process then contracts around blood vessels to prevent hemorrhage.  Endometrium (Inner layer ) o vascular and is shed during menstruation and following delivery.

Divisions of the Uterus:
 Fundus – upper rounded, dome-shaped portion o can be palpated to determine uterine growth during pregnancy  Corpus – body of the uterus.  Isthmus forms part of the lower uterine segment o portion that is cut when a fetus is delivered by a caesarian section.  Cervix – lower cylindrical portion that represents 1/3 of the total uterus.  Vagina – a 3-4 inch long dilatable canal o organ of intercourse/copulation o passageway for menstrual discharges and fetus

Layers of Anterior Abdominal Wall

Skin (functions):

 Protection: an anatomical barrier from pathogens and damage  Sensation: nerve endings that react to heat and cold, touch, pressure, vibration, and tissue injury  Heat regulation: increase perfusion and heatloss  Control of evaporation: dry and semi-impermeable barrier to fluid loss  Storage and synthesis: storage center for lipids and water  Absorption: Oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in small amounts  Water resistance: so essential nutrients aren't washed out of the body.

Fascia
o Camper's fascia - fatty superficial layer. o Scarpa's fascia - deep fibrous layer.  passive structures that transmit mechanical tension generated by muscular activities or external forces throughout the body  (function) reduce friction of muscular force thus allow muscles to glide over each other.

Muscle
1. Transversus abdominus –to stabilize the trunk and maintain internal abdominal pressure. 2. Rectus abdominus –commonly called ‘the six pack’ that move the body between the ribcage and the pelvis. 3. External oblique muscles –allow the trunk to twist 4. Internal oblique muscles –flank the rectus abdominus, operate in the opposite way to the external oblique muscles

Fascia transversalis
 A thin aponeurotic membrane which lies between the inner surface of the Transversus abdominis and the extraperitoneal fascia.  Thick and dense in structure and is joined by fibers from the aponeurosis of the Transversus, but it becomes thin as it ascends to the diaphragm, and blends with the fascia covering the under surface of this muscle.

Peritoneum
 the serous membrane that forms the lining of the abdominal cavity or the coelom  covers most of the intra-abdominal (or coelomic) organ

IX. PATHOPHYSIOLOGY
PHYSIOLOGY OF CESAREAN DELIVERY
Release of FSH by the anterior pituitary gland Development of the graafian follicle Production of estrogen (thickening of the endometrium) Release of the luteinizing hormone Ovulation (release of mature ovum from the graafian follicle) Ovum travels into the fallopian tube Fertilization (union of the ovum and sperm in the ampulla) Zygote travels from the fallopian tube to the uterus Implantation Development of the fetus/embryo & placental structure until full term PRELIMINARY SIGNS OF LABOR (continued next page)

PRELIMINARY SIGNS OF LABOR

Lightening (descent of the fetal head into the pelvis)

Braxton Hicks Contractions (false labor) >begin and remain irregular >1st felt abdominally >pain disappears with ambulation >do not increase in duration and intensity >do not achieve cervical dilatation

Ripening of the Cervix (Goodell’s Sign wherein the cervix feels softer like consistency of the earlobe)

TRUE LABOR

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

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

Rupture of Membranes (rupture of the amniotic sac)

Failed to progress labor (due to previous cesarean birth and Transverse presentation of fetus) increase risk for fetal distress when cord is compressed (meconium staining, hypoxia) Increase risk of fetal death (continued next page)

Increase risk of fetal death Emergent cesarean delivery (the incision made on the lower part of the abdomen) Expulsion of the fetus Expulsion of the placenta (blood loss of patient X: 800mL)

X. PRIORITIZED LIST OF NURSING PROBLEMS

1. Acute Pain
2.

Impaired Skin Integrity

3. Constipation 4. Deficient knowledge

XI. NURSING CARE PLAN

XII. DISCHARGE PLAN
Medication  Advise the patient to take the medicine prescribed by the doctor. o Mefenamic Acid 500 mg as necessary o Cephalexin 500 mg/capsule once a day for 7 days o Ferrous Sulfate 30 mg/day Environment  Instructed patient to stay in calm, quiet environment  Home environment must be free from slipping or accident hazards Exercise  Encourage Ambulation to the patient to promote fast healing, avoid strenuous activity to prevent wound dehiscence. Treatment  Get plenty of rest, adequate rest is important to maintain progress towards full recovery and to avoid relapse.  Drink lots of fluids, especially water, liquids will keep patient from becoming dehydrated. 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 Hygiene  Advise the patient to take a bath everyday but avoid the incision site from being wet to prevent on increasing risk of infection and for faster wound healing. Instruct the patient to cover it with clean plastic.  Instruct the patient to clean and dress the incision site everyday with iodine povidone (Betadine) to avoid infection and promote healing. 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

Others  Instruct the patient to go back for hospital visit after a week for follow up check up. Diet  Tell the patient to increase protein intake for wound healing and increase fluid intake and fiber to prevent constipation.  Advise the patient to eat green leafy vegetables (like malunggay) and fruits for lactation. Sexual and Spiritual Activity  Sexual o She can resume coitus as soon as the act is comfortable or her, possibly as early as 1 week after discharge. o Warn the patient to abstain from intercourse if the discharges (lochia) haven’t disappeared yet because it will cause unhygienic intercourse.  Spiritual o Tell the patient to continue her daily spiritual activities to enhance spiritual health.

Presented by:
BSN III – Block I

Ameril, Hayma Amodo, Rosemarie Astibe, Shiela Marie Bala, Kenneth Bastes, Merriam Cantila, Arlene Casaul, Bernadette David, Jan Irvil Dulguime, Maria Teresa Durias, Jemalen Ebuenga, Amy Estaras, Raquel Evangelista, Lovi Rizza Forlales, Allan John Carlo Gabay, Christine Joy Galagaran, Jazel Garcia, Karen Luz Guzman, Vanessa Jean Halamani, Rona Liza Java, Marinela Lambino, Joanna Jill

Lariosa, Reymond Roy Macrohon, Girlie Jane Manansala, Ma. April Masiding, Najmerah Molino, Joann Morales, Juan Paolo Nepacena, Kristel Joyce Ocampo, Trisha Joyce Olermo, Olivia Palejaro, Melanie Pena, Karen Gill Perdiz, Hanna Joy Rivas, Jecca Rubel, Catherine Ann Sacare, Ana Marie Simmons, Michael Vargas, Charmaine Claire Villarte, Mark David

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