Bulacan State University College of Nursing City of Malolos, Bulacan In partial fulfilment At NCM 102 Case Study: Cesarean

Section Submitted to: All 2nd Level Clinical Instructors Submitted By: Ducducan, Allen B. Dalisay, Ria-Dianne E. David, Leizel Abigael S. De Belen, Mary Ann D.J Dela Cruz, Clarice Mae F. Dela Cruz, Divine Mysterie N. De Leon, Abigael R. Eusebio, Ma. Edilaine N. Eusebio, Ma. Edilyn N. Jeremias, Monique J.

BSN 2E Group2

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Table of Contents I. II. Introduction …………………………………………………………………………………… 1 - 3 Nursing Assessment …………………………………………………………………………… 4 - 15 A. B. C. D. E. F. Personal history Reasons for visit History of past illness History of present illness Family health history Functional health pattern (Gordon’s) a. HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN b. NUTRITION METABOLIC PATTERN c. ELIMINATION PATTERN d. ACTIVITY AND EXERCISE PATTERN e. SLEEP-REST PATTERN f. COGNITIVE –PERCEPTUAL PATTERN g. SELF-PERCEPTION AND SELF-CONCEPT PATTERN h. ROLE-RELATIONSHIP PATTERN i. SEXUALITY-REPRODUCTIVE PATTERN j. COPING-STRESS TOLERANCE PATTERN k. VALUE-BELIEF PATTERN G. Concepts and theories of growth and development III. Anatomy and physiology……………………………………………………………………… 16 – 27

IV. V. VI. VII.

Patient and his illness ……………………………………………………………………………. 28 - 31 Physical assessment ………………………………………………………………………… 32 - 37 Laboratory results……………………………………………………………………………. 38 - 40 Patient and his care……………………………………………………………………………. 41 - 58

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A. Medical Management B. Surgical Management C. Nursing Problem Prioritization D. NCP VIII. Discharge Planning………………………………………………………………………………. 59 IX. Conclusion…………………………………………………………………………………………… 60 X. Bibliography……………………………………………………………………………………….. 61

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colds and cough. She is a high school graduate and her religion is Roman Catholic. She was married and living with her husband for 6 years now. The surgery is relatively safe for mother and the baby.INTRODUCTION This is the case of Ms. and a maternal mortality two to four times greater than that for a vaginal birth. However. psychological complications. intensive care and burdensome financial costs. more than half of women who have cesarean section can give vaginal birth later. both of which are associated with multiple complications. C-sections are most common among women carrying more than one baby. Cesarean section is a surgery to deliver a baby. she do not go to see a doctor instead. After 22 hours of prolonged labor. They already have 2 children. According to her she can consume 2 to 3 pads per day and sometimes she experiences dysmenorrhea. She usually drink softdrinks and eat sour fruits to relief the pain of her dysmenorrhea. including infections. transfusion. Her menarche started when she was 15years old and it usually lasts for 3 days. Cesarean section is one of the life saving emergency obstetric care when complications occur during childbirth. her LMP was last April 4. anesthesia complications. This could cause problems with an attempted vaginal birth later. 4 . 7% of births were delivered via C-section in total. injury to other organs. She told us that whenever she have a typical sickness like flu. According to her. she will take a drug of her choice which she believes can help her to feel good. Her first child was delivered via normal spontaneous delivery and her second child was delivered through cesarean section due to prolonged labor. The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent. Pampanga. An elective cesarean section increases the risk to the infant of premature birth and respiratory distress syndrome. 2011 at exactly 2:15 am in BMCH with initial diagnosis of G2P1 (1001). Apalit. According to the survey in 2003. C-section rate was higher in urban areas than in rural areas by approximately 2-fold. A cesarean section poses documented medical risks to the mother's health. Most C-section are done when unexpected problems happen during delivery. it is major surgery and carries risks. She takes herbal supplements which she believes can help her become healthier. The baby is taken out of the mother’s abdomen. 1979. the doctors decided that she needs to undergo cesarean section. These include health problem. the absences of labor increases the risk of breathing problems and other complications. She had cesarean section last January 20. from Capalangan. She is GTPAL and never experience difficulty in conceiving. Even mature babies. After healing. She was born on January 31. hemorrhage. PU 41 wks AOG. pg. she doesn’t have allergy to any food and drug. 35 years old. not enough room for the baby to go through the vagina and signs of distress in the baby. According to her.2010. She was brought to the hospital last January 19 due to the labor pains. It also takes longer to recover to C-section than from vaginal birth. HY. the position of the baby. Still. the incision may leave a weak spot in the wall of the uterus.

from pregnancy to surgical procedures up to the delivery of the baby. To apply the knowledge we obtained from our Related Learning Experience to an actual hospital setting with an actual patient. KNOWLEDGE: 1. To formulate appropriate nursing care plans applicable to the patient’s condition and render an effective nursing intervention.GENERAL OBJECTIVE: The main purpose of this case is for us to understand the process of Cesarean Section Delivery. Thorough Nursing Health History. 2. ATTITUDE: 1. To show respect to and provide emotional support to the client. 2. To know the different kinds of delivery and understand the physiologic changes that a pregnant woman has to go through. To be able to use our critical thinking in assessing the patient’s condition and interpreting the cues and datas gathered with appropriate nursing care management SKILLS: 1. 3. pg. To be able to establish rapport with the patient and understand the condition she went through and share some of the knowledge that were obtained from academe that will be beneficial to the patient’s general condition and promote wellness. To be able to learn the steps in the care for a post operation mother. To establish an effective nurse-patient relationship. 3. 2. To be able to appreciate the essence of being a woman. 3. This may also help us to know the difference of C-section Delivery to Normal Spontaneous Delivery. Physical Assessment were obtained to render appropriate nursing intervention. 5 .

She also experienced having measles. cough. chicken pox. 1979 PLACE OF BIRTH: Capalangan. pg. H. HISTORY OF PAST ILLNESS: The patient stated that she had vaccination such as BCG. she had a bicycle accident. OPV. The Labor starts at 10:00 am and was described strong. MMR and HEPA B. intense and frequent. When she was still young. Ms.PATIENT’s PROFILE: NAME: Mrs.Y.Y ADDRESS: Capalangan. 6 . at 41 weeks gestation was rushed to the hospital because of labor pains. 2011 TIME OF ADMISSION: 2:15 am TIME OF DISCHARGE: 3:00 pm REASONS FOR VISIT/CHIEF COMPLAINT: Our client. H. Apalit Pampanga OCCUPATION: House wife GENDER: Female RACE: Asian BIRTHDAY: January 31. birth weight of 3. delivered via CS due to prolonged 2nd stage of labor failure in descent with APGAR SCORE of 8. and other common illness like fever. DPT. but hasn’t taken immunization of tetanus toxoid because of not consulting in a clinic for prenatal check-up.4kg DATE OF ADMISSION: January 20. 2011 DATE OF DISCHARGE: January 26. Apalit Pampanga MARITAL STATUS: Married RELIGION: Roman Catholic EDUCATIONAL ATTAINMENT: 4th year High School Graduate HEALTH CARE FINANCING: Husband FINAL DIAGNOSIS: G2P1(1001) PU 41 weeks AOG.

Functional Health Pattern PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION pg. At the time of delivery. H. H.Y. stand and walk beside her bed. a 34 year old gravida 2 para 1 (1001) and her last menstrual period was on the 4th of April. food. She was referred to her ward for her to be comfortable and for her fast recovery. Ms. The client told us that she only had 2 instances of prenatal check up at the third trimester of her pregnancy because of being lazy and because she has no available times to do it. fatigue and shortness of breath. She stated that she doesn’t have any allergies to drugs. she rated the severity of pain on a scale of 1-10 (1 is the lowest and 10 is the highest). She also experienced nausea and vomiting during on the second and third month of her pregnancy. or any environmental factors (dust and smoke). HISTORY OF PRESENT ILLNESS: The patient was admitted in the hospital at 2:15 am of January 20. an increased urge to void. the patient felt that it was the time of her delivery because of painful uterine contractions felt first in lower back & sweep around to the abdomen in a wave so she immediately asked her husband to bring her to the hospital. as 10. birth weight of 3. admitted that her present pregnancy was expected. She presumed that the anesthetic given to her will help in the labor process. she had undergone episiotomy. Prior to hospitalization. The patient delivered her baby boy via primary low segment caesarian section due to prolonged second stage of labor and failure of descent with the APGAR score of 8. She also said that she experienced having urinary tract infection before the first and 2nd pregnancy but cured.colds and flu but easily cured by taking medication and consulting sometimes with her physician. She rated pain at 6. She is Ms. She didn’t experience any major injuries in the past and she had her first hospitalization when she delivered her 1st baby via NSD. mild to severe back ache. 7 . Our patient kept on complaining about the pain. year of 2010. After the delivery. 2011.Y. During her first childbirth. She noticed during her pregnancy that her appetite had change. During the labor process.4 Kg. She had difficulty to sit. (1 is the lowest and 10 is the highest). the patient is referred to the Operating Room. the patient experienced pain and discomfort at her lower abdomen due to surgical incision made by her physician.

Health Perception/ Health Management

.When she was asked to rate her health on a scale of 110( 1 is the lowest and 10 is the highest), her rate was 10. “Hindi naman ako sakitin kaya sa tingin ko malusog naman ako” as verbalized by the client. When she gets sick, she just takes medicine of her choice and consult a doctor sometimes. She takes some herbal medicines which she believes can make her healthier. She told us that she only had her prenatal check up twice. “Tinatamad kasi akong magpablik-balik sa ospital” as verbalized by the client. She’s not in vices until now. She doesn’t encounter any problem in her pregnancy, and her child doesn’t have any abnormalities. Breakfast Januray 18, 2011 1 piece of bread (putok) 1 cup of coffee 2 glass of water 1 piece of fried galungong 1 bowl of pinakbet 1 cup of rice 2 glass of water SNACKS: 1 packed of Mr. Chips 1 bottle softdrinks 8 oz 1 glass of water 1 piece of January 19, 2011 1 cup of coffee 1 piece of pandesal 2 rolls of suman 1 glass of water NPO

Our client told us that she felt some changes in her body after giving birth because of her postsurgical incision. We asked her to rate the pain from 1 to 10, (1 is the lowest, 10 is the highest) she rated it as 6. She’s following the medication prescribed by her physician (cefalexin, cefazolin, discofunal, mefenamic acid, ferrousulfate, nalbuphine, ascorbic acid & bisacodyl) at the right time & dose. With that, she can gain strength that helps her to cope with her situation and to be able to do her activities of daily living.

Nutritional-Metabolic Pattern

Lunch

Dinner

NPO

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galunggong 1 bowl of pinakbet 2 glass of water 2 cup of rice According to patient, her husband is the one responsible for cooking and preparing foods for the family. Our patient stated that she drinks 6-8 glasses of water every day. She loves to eat sweets and spicy foods before. “hindi ako nagtatake ng food supplements” as verbalized by the client. She presumed that she is healthy enough so that she doesn’t take any supplement.

Elimination Pattern

URINE COLOR ODOR FREQUENCY TRANSPAREN CY

January 18, 2011 Yellow Aromatic 8 times (1,800 ml) Clear

January 19, 2011 Yellow Aromatic 5 times (1,000 ml) Clear

URINE COLOR ODOR FREQUENCY

January 20, 2011 None None None

TRANSPARENCY

None

January 21, 2011 dark yellow - The patient has a catheter and urine bag attached to her (2,250 ml) With trace of blood

She consumes 10 glasses of water daily and urinates about 8 times a day. According to client, she perspires not little and not too much. She doesn’t experience any voiding difficulties. She just complains of the discomfort of frequent urination during her pregnancy. FECES January 18, 2011 January 19, 2011

During hospitalization, the client had a Foley catheter inserted to her urethral orifice and it is attached to a urine bag. She felt uncomfortable because of postsurgical procedure and catheter that was inserted to her. FECES COLOR January 20, 2011 Brown-black January 21, 2011 Brownish Yellow

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COLOR ODOR FREQUENCY CONSISTENCY

Brown Foul Once Formed

Brown Foul Once Formed

ODOR FREQUENCY CONSISTENCY

Foul Use of diaper Not formed

Foul Once Formed

Our patient stated that she doesn’t experience any defecation difficulties except constipation. She usually defecates every morning.

As we go in her room, she was defecating; she moves a little and is dependent to her mother-in-law. “Nahihirapan ako dumumi ngayon” as verbalized by the client. Because of pain she felt and limited mobility, our client had difficulty in excreting her waste. She also used diaper upon interview.

Activity – Exercise Pattern

The client’s daily activities are doing household chores with her mother-in-law like cleaning the house, cooking meals sometimes and taking care of her daughter. When she has a free time, She watches television and make herself happy by joining social groups. She makes sure to finish all activities before going to sleep. According to her, she is not exercising every morning. “Madalang lang ako magexercise” as verbalized by our patient. -0- Feeding -0- Bathing -0- Bed mobility -0-Dressing -II- Shopping -0- Grooming -0- General mobility -II- Cooking mobility -II- Home Maintenance

“Hindi ako makahakbang” as verbalized by our patient. During the first day of hospitalization,the patient was not able to walk. She can’t perform what her daily activities until on the 2nd day. Standing, lying flat on bed and sitting on a chair is the common activity she did on the 2nd day. When she wants/needs anything, she move dependently or ask her mother-in-law in favor. The doctor also ordered walking exercise and deep breathing exercise to client. -0- Feeding -II- Bathing -II- Toileting -II- Dressing -II- Grooming -II- General Level 0 – full self care

Level 0 – full self care Level I – requires use of equipment device

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2011 LABOR PROCESS 7:00 am - January 19. she asked “Anu-anu pa ba mga kailangan kong gawen para alagaan si baby?” She is just confused so that she frequently questioned us. she usually wake up at 2 pm. our patient is slightly irritable but responded well to the questions that were asked to her. our patient doesn’t experience any alterations in her senses. According to the client. of sleep . Level I – requires use of equipment device Level II – requires assistance or supervision from another person Level III – is independent and does not participate After giving birth. During the interview process. She also stated that the strange hospital environment added to her sleeping difficulties. of sleep January 18. However. she was able to sleep for 8-10 hours sometimes because at times. 2011 11:00 pm Time of 7 :00 am Awakening Total no. Date January 20. “Sumasakit ang tahi ko kapag nagsasalita” as verbalized by our patient. She doesn’t get enough sleep and rest because she was hungry and the nurses that monitor her vital signs. because of increase frequency of urination.January 21. pg.- Sleep-Rest Pattern Date Time of Sleep January 18. of sleep 8 hours Nap Total no. “Paputol-putol ang tulog ko dito sa Ospital” as verbalized by our patient on the 2nd day. She usually wakes up at 7 am to do household chores and other activities. She also stated that before going to sleep. During hospitalization. She verbalizes and express what she feels upon her situation. She keep on complaining about the pain and discomfort she felt. 11 . She fell asleep after the surgical procedure. She also told us that she’s not using devices that help in her senses. She has no difficulty in learning or absorbing knowledge. she drinks milk and the lights must always be turned off. She doesn’t experience any sleeping difficulties. 2011 30 mins. she’s contented in time of sleep. 2011 1 ½ hours January 19. The patient doesn’t get enough rest during her hospital stay. 2011 6 :00 am .Level II – requires assistance or supervision from another person Level III – is independent and does not participate Cognitive-Perceptual Pattern Our patient has no hearing difficulty and any deviations in her senses. 2011 Time of Sleep LABOR PROCESS Time of Awakening LABOR PROCESS Total no.

were both of them of her husband decides in the financial needs. when she is pregnant. For these. Her eldest is the one she gave birth last 2004 and her 2nd was the one she’s had given birth this January. She told us that her family is the most important people in her life. she is kind to everyone as well to her family.Self-Perception/ Self Concept Pattern Role-Relationship Pattern Our patient is cheerful but she is not that friendly. She also told us that her pregnancy may affect her physical appearance but she doesn’t care about it. During her hospitalization. What’s important is for her to provide the needs of her children and to take good care of them as well. Our patient menarche is when she was 14 years old. After the 2nd child of hers. She told us again that she was very happy to have a new baby. she doesn’t want to get pregnant again because of fear that she might not give them enough of their needs especially now that the life is too hard to live. She belongs to egalitarian type of family. “Gusto ko na ngang umuwi kasi may anak pa akong naiwan sa bahay” as verbalized by the client. Her pregnancy were planned as she said and when we asked her sexual satisfaction from 1-10(1 is the lowest. pg. According to her. Only her older sister is the one who take good care of her daughter at their home. She wants to go home even without the doctor’s order. she takes medicine advised to her by her acquaintances. According to her. 10 is the highest). She doesn’t have any regrets in having her own family. not too heavy and not too little amount of flow but she experienced pain in her lower abdomen before and during times of menstruation. She plays a very important role as mother and she will always maintain good relationship to each member of family. “hindi ko kasundo ang iba kong kapitbahay naming dahil mga chismosa sila” as she verbalized. 2010. When our patient was asked on how she feels after giving birth especially when she undergone surgical procedure. When she was asked what she wants to change in her body. her mense’s duration is about 3-4 days and she consumes 3 pads of napkin a day. she told us that she’s okay. 12 . She doesn’t experienced any miscarriage or abortion before. she will always feel contented. she told us that as long as she’s healthy. Her menses were just right. She is G2P1 patient and doesn’t experience any difficulties of conceiving. She smiled and her rate was 8. She really felt fulfilled when she gave birth to her first child and those feelings doesn’t change upon giving birth to her next child. she and her mother-in-law is the one responsible for taking good care of the infant. According to her. she gets irritable easily. The patient live with her husband together with her daughter. Sexuality-Reproductive Pattern “Gagamit na ako ng contraceptives tulad ng paginom ng pills para hindi na mabuntis” as verbalized by our patient. The closest person to her is her eldest sister who lives also nearby. She told us that she really felt happy for the 2nd time she knew she is pregnant. Her last menstrual period was on April 04.

Coping / Stress Tolerance Pattern 20. She’s relying her problems to God just by striving hard and praying for divine intervention. 13 . She is a roman catholic. hindi na ako naniniwala sa iba at anu anu pa” as she verbalized. 2011. Two of them are normal and reached full term. they see it a blessing from God. She always pray and go to church together with her family. Value – Belief Pattern “Nagprepray ako lagi kay Lord para sa paggaling ko at sa ikabubuti ng pamilya ko” as verbalized by our patient. In times of problem. She doesn’t see that giving birth is a problem rather. She fear of not meeting the needs of her children and family primarily because of their financial situation. According to her. No other problem about her sexuality-reproductive according to the patient. She and her husband usually resolve problems by talking things out. “Bukod sa Diyos. “Iniisip ko ngayon ang babayarin dito sa Ospital” as verbalized by the clientt. she believes that God will be a great help. According to her. She doesn’t change her beliefs and she knows God is always there to help. God and her family is the primary source of her strength to overcome her problems. She doesn’t use any alcohol and other vices to relieve stress when problem is arise. nakikipagtong-its ako sa mga kaibigan ko” as verbalized by our patient. pg. her husband helps them in financial needs. “Tuwing hapon. She also told us that she responded well to situations because of the help of her husband. she is doing this for refreshment and sometimes reading pocketbooks and watching television at afternoon.

Several of her grandparents are can no longer remember by the patient. L. 14 . The client stated that her mother and father-in-law side. side.FAMILY HEALTH ILLNESS HISTORY The patient is the 3rd children of Mrs. she had no diseases present cause of inheritance. 65 years old. 61 years old and Mr. All of these are inherited by their daughter and sons. most of them had DM and Hypertensive. Z. ? ? (stroke) (oldness) Hypertensive ? ? (DM) DM ? ? (?) hypertensive ? ? (? ) hypertensive J ? (oldness) E ? (heart attack) ? ? ? ? (oldness) H A C A ? S P E ? Z G J ? ? N C ? L dered ? ? (?) (heart attack) DM Hypertensive Smokes/ drinks Ocassionally ? DM ? DM ? (?) DM ? ? ? ? smokes/ smokes/ (?) hypertensive drinks drinks hypertensive ocassionally ocassionally 61 ? ? ? (car accident) smokes/ smokes/ (heart attack) drinks occasionally drinks occasionally ? (fetal death) ? A/W ? A/W 52 smokes/drinks drinks ocassionally 61 S 35 Hypertensive S 31 Hypertensive H C 22 Hypertensive C 40 A/W F 36 A/W H 31 A/W E M 25 A/W 27 Hypertensive Smokes and Drinks 28 smokesdrinks Occasional A 6 years old J 2 day old pg..Y. On the Mrs. H.

group. The person values conformity. loyalty. nation or society. By this stage. Conformity means good behavior and is approved. making enough decision about herself and her family and maintaining right way among expectation and rules for the family and society. active maintenance of social order and control. Person is concerned with maintaining expectations and rules of the family.A/W A/W GROWTH AND DEVELOPMENT STAGE PSYCHOSOCIAL Adulthood (25-65 y/o) Generativity vs stagnation PSYCHOSEXUAL GENITAL STAGE (puberty onward) COGNITIVE Formal Operations (11+ years) MORAL Conventional (adolescence and adulthood) DEFINITION By this stage. 15 . The patient is capable of deductive and hypothetical reasoning pg. or become stagnant and inactive. middle aged adults are productive. performing meaningful work. Sense guilt has developed and affects behavior. and raising a family. The patient is in the stage where she gets more mature to handle situation. Physical sexual changes reawaken repressed needs. ANALYSIS The patient is able to seek attention and satisfying relationship within her partner and her family. This stage is energy directed towards full sexual maturity & function & development of skills to cope with the environment. people are able to see relationships and to reason in the abstract. Direct sexual feelings towards others lead to sexual gratification.

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smooth surface inside the labia. curly hairs. these folds are fairly small. It is often torn during the first sexual intercourse pg. The openings to the bladder (the urethra) and the uterus (the vagina) both arise from the vestibule.the mons veneris is a pad of adipose tissue located over the symphysis pubis.ANATOMY AND PHYSIOLOGY: FEMALE REPRODUCTIVE SYSTEM FEMALE EXTERNAL STRUCTURES The structures the female external genitalia are termed the vulva (from the Latin word of covering) Vulva.is the flattened. Perineum. the pubic bone joint. so localized sebaceous cyst may occur here. This is the structure that is sometimes cut (episiotomy) during childbirth to allow for enlargement of the vaginal opening. Arterial blood supply for the clitoris is plentiful. Clitoris.are located just lateral to the urinary meatus. is easily stretched during childbirth to allow for enlargement of the vagina and passage of the fetal head.The labia majora are two folds of adipose tissue covered by loose connective tissue and epithelium that are positioned lateral to the labia minora.a region of the body including the perineal body and the surrounding structures. the labia majora serve as protection for the external genitalia and distal urethra and vagina. Fourchette. The clitoris is sensitive to touch and temperature and is the center of sexual arousal and orgasm in a woman. The alkaline pH of their secretions helps to improve sperm survival into the vagina. The area is abundant with sebaceous glands. Labia Majora. rounded organ of erectile tissue at the forward junction of the labia minora. Perineal muscle/ perineal body. There ducts open to the urethra.is a small (approximately 1-2 cm). It is covered by a triangle of course. Vestibule.Just posterior to the mons veneris spread two hairless folds of connective tissue. Labia Minora. 2 Skene’s glands (paraurethral glands) . The purpose of the mons veneris is to protect the junction of the pubic bone from trauma. after menopause.is a muscular area.is the ridge of tissue formed by the posterior joining of the two labia minora and the labia majora. Mons Veneris. Covered by pubic hair. the prepuce. one on each side. Hymen-is a tough but elastic semicircle of tissue that covers the opening to the vagina in childhood. they atrophy and again become much smaller. It is covered by a fold of skin.is the external genital organs of the female. 18 . Bartholin’s glands (vulvovaginal glands) – are located just lateral to the vaginal opening on both sides. Before menarche. Secretions from both of these glands help to lubricate the external genitalia during coitus. There ducts open to the distal vagina. the labia minora.

Fallopian tubes. serves an important function of constricting the tubal junctions and preventing regurgitation of menstrual blood into the tubes. It is colored as a result of concentrating carotenoids from the diet. Endometrium. the fibers of which are arranged in longitudinal. the isthmus and the cervix Body of the uterus. which is needed to maintain the endometrium. is a temporary endocrine structure in mammals.FEMALE INTERNAL STRUCTURES Ovaries.arise from each upper corner of the uterine body and extend outward and backward until each opens at its distal end. Fimbrae. involved in production of estrogen and progesterone. or the size and shape of almonds. Myometrium. Cervix. pg.is lowest portion of the uterus. pear-shaped organ located in the lower pelvis.“yellow body”. 19 . Their function is to convey the ovum from the ovaries to the uterus and to provide a place for fertilization of the ovum by the sperm.5 cm thick. fluid-filled graafian follicle (an ovum about to be discharged) or a miniature yellow corpus luteum (the structure left behind after the ovum has been discharged) often can be observed on the surface of the ovary. An unruptured. Uterus. transverse. glistening.approximately 4 cm long by 2 cm in diameter and approximately 1. It represents approximately one third of the total uterus size and is approximately 2-5 cm long. Approximately half of it lies above the vagina and half extends into the vagina. approximately 10 cm long in mature woman. Isthmus. as the opening of the fallopian tubes. Fundus.portion of the uterus between the points of attachment of the fallopian tubes. next to an ovary. continues with the endometrium.or muscle layer of the uterus. posterior to the bladder and anterior to the rectum.finger like part or structure. is composed of 3 interwoven layers of smooth muscle. is also affected by hormones. and oblique directions. Corpus luteum.the uppermost part and forms the bulk of the organ. Endocervix. They are grayish white and appear pitted or with minute indentations on the surface.layer of the uterus is the one that is important for menstrual function. muscular.is a short segment between the body and the cervix.is a hollow. consists of 3 divisions: the body or corpus. clear.membrane lining the cervix. secrete mucus to provide a lubricated surface so that spermatozoa can readily pass through the cervix.

20 .pg.

which in a female contain the mammary gland that secretes milk used to feed infants.located anterior to the pectoral muscle and in many women breast tissue extends well into the axilla.BREAST Breast. bile. Milk Ducts. Areola. pg. All of the glands in each lobe produce milk by acinar cells and deliver it to the nipple via a lactiferous duct.are divided by connective tissue partitions into approximately 20 lobes. such as tears. Milk glands. is the upper ventral region of the torso of a primate.the skin surrounding the nipples that are darkly pigmented out to approximately 4 cm Montgomery’s tubercle.sebaceous glands causing the areola to appear rough.a small. tube-shaped part of the body that carries fluids. and breast milk. in left or right sides. 21 .

GASTROINTESTINAL TRACT pg. 22 .

bounded on the outside by the lips and inside by the oropharynx and containing in higher vertebrates the tongue. Gallbladder. spleen.is the final section of the small intestine. also vermix) is a blind-ended tube connected to the cecum (or caecum).A large. reddish-brown.is a hollow system that sits just beneath the liver. muscular organ attached in most vertebrates to the floor of the mouth. the cavity lying at the upper end of the alimentary canal. pg. The neck tapers and connects to the biliary tree via the cystic duct.GASTROINTESTINAL TRACT Abdomen. the colic impression. glandular vertebrate organ located in the upper right portion of the abdominal cavity that secretes bile and is active in the formation of certain blood proteins and in the metabolism of carbohydrates.is the first section of the small intestine.[2]In adults. Pancreas. an aid in chewing and swallowing.The muscular membranous tube for the passage of food from the pharynx to the stomach. and teeth.In human anatomy. forming the right colic flexure (hepatic).The fleshy. and pancreas also called belly.is smaller in caliber than the cecum: It passes upward. gums. In mammals the duodenum may be the principal site for iron absorption.[3] It is divided into three sections: fundus. 23 . body and neck. irregularly shaped gland in vertebrates. Ileum. Esophagus. and somatostatin into the bloodstream. here it bends abruptly forward and to the left. movable. lying behind the stomach that secretes pancreatic juice into the duodenum and insulin. the appendix (or vermiform appendix.The section of the alimentary canal that extends from the mouth and nasal cavities to the larynx. that is the principal organ of taste. from its commencement at the cecum.A long. the gallbladder measures approximately 8 cm in length and 4 cm in diameter when fully distended. opposite the colic valve. fats. and proteins. where it becomes continuous with the esophagus. liver. from which it develops embryologically. this cavity regarded as the source of sounds and speech. Tongue. Pharynx. Mouth. in humans. an important organ of speech. Duodenum. Liver. to the under surface of the right lobe of the liver. where it is lodged in a shallow depression. intestines. on the right of the gall-bladder. and. the gullet. which then joins the common hepatic duct to become the common bile duct. the opening to any cavity or canal in an organ or a bodily part. glucagon.The body opening through which an animal takes in food. Appendix. Ascending colon.The part of the body that lies between the thorax and the pelvis and encloses the stomach. also cecal (or caecal) appendix.

Jejunum. and the gut in others. Sigmoid colon. which. but on account of its freedom of movement it is liable to be displaced into the abdominal cavity. meaning straight intestine) is the final straight portion of the large intestine in some mammals.Transverse colon.is an opening at the opposite end of an animal's digestive tract from the mouth. and normally lies within the pelvis. but it is dilated near its termination. where it curves sharply on itself beneath the lower end of the spleen. and dead or excess gut bacteria and other endosymbionts. such as bones. opposite the confines of the epigastric and umbilical zones. 24 . along the lateral border of the left kidney. pg. The right colic flexure is adjacent to the liver. It forms a loop that averages about 40 cm. Descending colon.(from the Latin rectum intestinum. The change from the duodenum to the jejunum is usually defined as the ligament of Treitz. Anus.passes downward through the left hypochondrium and lumbar regions. may be one or more of: matter which the animal cannot digest. depending on the type of animal. forming the rectal ampulla. The human rectum is about 12 cm long. in length. Rectum. food material after all the nutrients have been extracted. Its function is to control the expulsion of feces. into the left hypochondrium region. passes with a downward convexity from the right hypochondrium region across the abdomen.the longest and most movable part of the colon. unwanted semi-solid matter produced during digestion. terminating in the anus. ingested matter which would be toxic if it remained in the digestive tract. forming the splenic or left colic flexure.lies between the duodenum and the ileum. Its caliber is similar to that of the sigmoid colon at its commencement. for example cellulose or lignin.is the part of the large intestine that is closest to the rectum and anus.

pg. 25 .

In humans. Sacroiliac joint.is a broad. It is located anterior to the urinary bladder and superior to the external genitalia. the sacrum supports the spine and is supported in turn by an ilium on each side. over which the iliacus and psoas major muscles pass. It marks part of the border of the pelvic inlet. Ischial Spine. marks the point of union of the ilium and pubis. the pubic symphysis is intimately close to the clitoris. Sacral Promontory. shallow groove.is a swollen part or broadening of the bone in the frontal portion of the ischium. 26 . In females. the suspensory ligament of the penis attaches to the pubic symphysis. In males. Iliopubic eminence. one on the left and one on the right that often match each other but are highly variable from person to person. the lowest of the three major bones that make up each half of the pelvis. for females it is above the vulva and for males it is above the penis. pg. which are joined together by strong ligaments. Ischial Tuberosity.sacroiliac joint or SI joint is the joint in the bony pelvis between the sacrum and the ilium of the pelvis. levator ani.sacral promontory is the anatomical term for the superior most portion of the sacrum.a thin pointed triangular eminence that projects from the dorsal border of the ischium and gives attachment to the gemellus superior on its external surface and to the coccygeus. weight bearing synovial joint with irregular elevations and depressions that produce interlocking of the two bones. In normal adults it can be moved roughly 2 mm and with 1 degree rotation. The human body has two sacroiliac joints.is the midline cartilaginous joint (secondary cartilaginous) uniting the superior rami of the left and right pubic bones.FEMALE PELVIS Pubic Symphysis. The rectosigmoid junction is at the level of the sacral promontory. and pelvic fascia on its internal surface. This increases for women at the time of child birth. The joint is a strong.

the constricted part of the uterus between the cervix and the body of the uterus d.a yellow grandular mass in the ovary.is a liquid which fills the follicular antrum and surrounds the ovum in an ovarian follicle d. The phase of the monthly female cycle when a developed egg is released from ovary in the fallopian tube for possible fertilization. Ovulation.a small sac. This structure is called primodial or primitive follicles. g. e. hereby maintaining the patency of the uterine cavity. e.an epithelial cell lining follicle such as that of the thyroid. Primary Follicle. formed by an ovarian follicle that has matured and discharged its oocytes.the small conical projection in the center of the areola of each breast. b. Corpus Luteum. Isthmus of the Uterus.the discharge of an ovum from the ovary. Empty follicle.a specialized gland of the female which secretes milk Nipple.are the basic units of the female reproductive biology.Anatomy and Physiology Description: a.the smooth muscle forming the wall of the uterus Mammary Gland. Uterus a.secretes milk for the nourishment of the young Lactiferous ducts. each of which contains an undeveloped egg cell. This structure are periodically initiated to grow and develop and culminating in ovulation of usually a single competent oocytes in human. pg.the part of the uterus above the orifices of the uterine tube b. Follicular cells. Follicular fluid. which in women contains the outlet of milk ducts Areola. Breast a. Ovulation is when an egg released from the ovary and is swept into the fallopian tube toward the uterus.the female reproductive cell. Mature Follicle 1.oocytes are absent from stimulated follicles f.The endometrium function as lining of the uterus preventing adhesion between the opposed walls of the myometrium. h. c. each of which is compose of roughly spherical aggregation of cells found in the ovary. Graafian Follicle.small circular area such as pigmented ring around the nipple.an immature ovarian follicle. They contain single oocytes. Myometrium. Growing follicle 1. Endometrium. 27 . Egg cell. Body of the Uterus c. Ovarian follicles. b. the female gamete 2. Fundus. d. c. At sexual maturity each ovary has large numbers of immature follicles. embedded in the ovary that encloses an ovum.

Broad Ligament of the uterus. pass through a part of broad ligament and through a peritoneal fold and empty to the hypogastric vein.f.the mesentery of the uterus. Uterine tube. h. 28 .is a wide fold of the peritoneum that connects the sides of the uterus to the walls and floor of the pelvis Types of Ligaments: Mesometrium.the part that surrounds the ovary g. for passage of oocytes to the cavity of the uterus and the usual site of fertilization.the part tat surrounds the uterine tube Mesovarium.Either of two veins on each side that arise from the uterine plexus. the largest portion of the broad ligament Mesosalpinx. pg. Uterine vessels.a slender tube extending from the uterus toward the ovary on the same side.

Apalit. Pampanga Pathophysiology Non Modifiable Factors Birth date: January 31. H.Modifiable Factors Name: MRS. 1979 Age: 31 LMP: April 4. 29 . 2011 Address: Capalangan. CIL Religion: Roman Catholic Age: 31 Nationality: Filipino LMP: April 4. Apalit. Pampanga Theories • • • • • Prostaglandin Theory Oxytocin Theory Uterine Stretch Theory Placental Degredation Theory Progesterone Deprivation Theory pg. 2011 AOG: 40 wks AOG Gynecology History: PU 40 wks G2P1. 2010 EDC: January 7.Y Religion: Roman Catholic Nationality: Filipino Status: Married Address: Capalangan. 2010 Status: Married EDC: January 7.

Release of FSH by the anterior pituitary gland Development of the Graafian follicle Production of estrogen (thickening of the endometrium) Release of 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 pg. 30 .

Development of the fetus/ embryo and placental structure until full term Preliminary Signs of Labor Lightening (descent of the fetal head into the pelvis) Braxton Hicks Contraction (false labor) • Begin and remain irregular • First felt abdominally • Pain disappears with ambulation • Do not increase with duration and intensity • Do not achieve cervical dilatation Ripening of the Cervix True Labor Uterine Contraction • Increase in duration and intensity • First felt at the back and radiates to the abdomen • Pain is not relieved no matter what the activity is • Achieve cervical dilatation Average Length of Normal Labor: Primi Multi Client First Stage 12 ½ hr 8 hrs 11 hrs Second Stage 80 mins 30 mins 5 hrs Thrid Stage 10 mins 10 mins 2hrs Show (pink tinge of blood. a mixture of blood and fluid) Rupture of Membranes • First Stage of Labor (Stage of Dilatation) Second stage of Labor • • Fourth stage 2 hrs Latent Phase. dilatation: 4-7 cm Transition Phasecontractions: 60. dilatation: 8. dilatation: 0 to 3 cm Active Phase.contractions: 20-40 seconds.contractions: 40.90 seconds.10 cm pg.60 seconds. 31 .

(Stage of Expulsion) Failed to progress labor Due to Cephalo Pelvic Disproportion Increase risk of fetal distress (Meconium Staining. 32 . Hypoxia) Increase Risk of fetal death Emergent Cesarean Delivery (The incision made on the lower part of the abdomen) Expulsion of the Fetus Third Stage Expulsion of the Placenta (Accompanied by blood loss of approximately 1000-1500 ml) pg.

sitting and walking 3.client’s attitude 8. Areas assessed General appearance 1. 33 . client’s affect/mood.coordinated movement Clean Minor body odor No distress No signs of illness Cooperative responsive Understandable moderate pace Logical sequence makes sense Varies from light to deep brown Actual findings Proportionate unrelaxed and not erect Slightly unkept Slightly has body odor Signs of distress are present Physically ill Cooperative Slightly irritable but responsive because of her physical illness Hard to speak but can deliver organize ideas Makes sense and has sense of reality brown Remarks Normal Due to her post operative condition Due to her labor and hospitalization Due to lochia Due to surgery Due to surgery Normal Deviation from normal Due to post-operative condition Normal Normal pg. palpation. relevance and organization of thoughts Skin and nails 1. we made every effort to recognize and respect the patient’s felling as well as to provide comfort measures and follow appropriate safety precautions. appropriateness of the clients response 9. erect posture. gait standing.Physical assessment Physical examination follows a methodical head to toe format in the cephalocaudal assessment. body built. quality and organization 10. This is done systematically using the techniques of inspection. percussion and auscultation with the use of materials and investment of such as the penlight. During the procedure. tape measure and stetoscope and also the senses. signs of distress in posture or facial expression 6. sphygmomanometer. note body and breath odor 5.overall hygene and grooming 4. skin color Technique Inspection Inspection Inspection Inspection Inspection Inspection Inspection inspection Inspection Inspection Inspection Normal findings Proportionate Relaxed. posture. obvious signs of health or illness 7. height and weight 2. quantity of speech. thermometer.

angle 7. skin moisture 4. no nodules White/light in color. resilient Presence of white hair Normal Normal Normal Normal Due to inadequate time to clean her nails Normal Normal Normal Normal Normal Normal Face 1. fingernail plate/shape to determine curvature. blanch test of capillary refill Head 1. skull (size. inspect lacrimal gland Palpation Tenderness over lacrimal gland Normal pg. no discoloration. nodules 3. 34 . skin temperature 5. skin turgor 6. no nodules Light color.2. silky. smooth Intact nails Prompt return in pink color or usual color Round No masses. no tenderness Evenly distributed(thinness or thickness) silky. lids close symmetrically 15-20 involuntary blinks Hair evenly distributed. shape) 2. facial movements Eyes 1. no tenderness Thinness is evenly distributed. presence of capillaries Sclera appears white No presence of edema Tenderness over lacrimal gland Normal Normal Due to sedation Normal Normal 5. bulbar conjuctiva for color. capillaries sometimes evident Sclera appears white No edema Coordinated No discharge. resilient hair Generally uniform in areas exposed to the sun No moisture in skin folds and axillae Normal range. lids close symmetrically Dull eyes Evenly distributed Transparent. tissue surrounding nails 8. scalp (color. warm Springs back to previous state Slightly dirty smooth Intact epidermis Prompt return in pink color or usual color Round No masses. tenderness) Hair 1. ability to blink 3. masses. uniformity in color 3. texture and presence of lesions Inspection Inspection Inspection Inspection Inspection Coordinated No discharge. eyebrows 4. growth and texture Inspection Palpation Palpation Palpation Inspection Inspection Palpation Palpation Palpation Inspection/palpation Inspection Uniform in color No moisture Uniform in normal range Skin springs back to previous state Convex curvature. no discoloration. skin intact Transparent. eyelids for surface characteristics 2.

firm. 35 . teeth 3. and not tender Mobile. straight. assess near vision Ears 1. auricle for texture elasticity. depth of iris abot 3mm Black. and not tender Normal Nose 1. smooth movement with no discomfort Normal Normal Normal pg. shape. nasal septum Inspection Nasal septum is intact and in the middle Place in the middle Normal Mouth 1. depth of iris abot 3mm Black. auricle for color. moves freely Muscle equal in size. no swelling Coordinated. neck muscle. no discharge Normal 2. moves freely Muscle equal in size. symmetry of size. no lesions. equal in size. position 2. head centered Coordinated Uniform pink in color Normal Pink in color. no discharge Symmetric. pupils 8. swelling 2. head movement Trachea Inspection Inspection Inspection Inspection Inspection Uniform in color 32 adult teeth Pink in color. no lesions. areas of tenderness Inspection Inspection Inspection No shadow of light on iris. tounge movement. straight. outer lips for symmetry of counter color 2. smooth border Able to read newspaper No shadow of light on iris. round. or color and flaring/discharge from nares Inspection Symmetric. smooth border Able to read newspaper Normal Normal Normal Inspection Color same as facial skin Color same as facial skin Normal Inspection Mobile. firm. round.color Neck and lymph nodes 1.6. anterior chamber for transparency and depth 7. equal in size. size.

nipples point at the same directions. no masses or nodules Vertically aligned No tenderness No masses Central placement in midline of neck Gland descend during swallowing but not visible Not palpated smooth and it is not centerally located. slightly unequal in size Unable to excrete milk No edema Oval in shape. similar in color. similar in color. dark brown color. carotid arteries Jugular veins 1. thyroid gland 2.1. swelling or edema 3. equal in size. tenderness and masses Abdomen Palpation Deviation from normal(unable to excrete milk) Deviation from normal normal Inspection Palpation Normal pg. and normally erect No excretion of milk No tenderness. nipples (size. placement Thyroid gland 1. note areas of enlargement. dark brown color. equal in size. position. painless and rise freely with swallowing Symmetry pulses volumes Veins not visible Rounded shape. slightly unequal in size With slightly edema Oval in shape. equal in size Round. No masses or nodules Not able to perform because of surgical incision in abdomen No tenderness No masses Normal Normal Normal Inspection Inspection Inspection Normal Normal Normal 2. jugular veins Breast and axilla 1. 36 . color) 4. size. and normally erect With excretion of milk with tenderness. breast (masses. shape. equal in size Round. smoothness. masses/nodules Carotid arteries 1.lobes are small and smooth Symmetry pulses volumes Veins not visible Rounded shape. temperature. tenderness) Thorax 1. If palpated. spinal alignment 2. areola ( size. discharge) Inspection Inspection Inspection Deviation from normal Normal Normal 5. nipples point at the same directions. symmetry and shape Inspection Inspection Inspection/palpation Central placement in midline of neck Not visible Lobes may not be palpated. shape.

lesions and swelling bones 1. auscultate abdomen for bowel sounds. no swelling Normal Normal Normal Normal Normal Normal Normal pg. smoothness 5. tenderness Upper and lower extremities 1. involuntary movements. rounded(convex). and peritoneal friction 4. tremors. visible peristalsis. scaphoid concave). vascular sounds. symmetry Intact sutures Symmetric movements. muscle size Inspection/auscultation Normal Auscultation Palpation Inspection Normal Normal Normal 2. peristalsis. no evidence of enlargement of liver or spleen. muscle flaccidity.aortic pulsation in thin person at epigastric area Audible bowel sounds. absence of friction No tenderness Equal in size Rounded. observe abdominal movements associated with respiration. muscle tonocity 4. no evidence of enlargement of liver or spleen. symmetric Sutures were intact 3-4 inches surgical incision on lower abdomen (traditional cut) Slightly symmetric movements. 37 . muscle strength Perineum 1.inspect for contour and symmetry Inspection Flat. absence of friction No tenderness Equal in size Scar in left knee due to bicycle accident when she was young No fasciculation Normally Smooth Equal strength in both sides No presence of lesions and swelling No deformities No edema. no swelling Due to surgery 2. Audible bowel sounds. no visible peristalsis. Normal structure 2. or auto pulsations 3. muscle fasciculation and tremors 3.1. spasticity. Edema and tenderness Joints Inspection Inspection Palpation Inspection inspection Inspection palpation No fasciculation Normally Smooth Equal strength in both sides No presence of lesions and swelling No deformities No edema.

or nodules Normal normal assessment 2. normal Due to catheterization pg. or nodules No swelling No tenderness. range of motions 1. 38 . Uneasy movements done with the parts of lower extremities. swelling. crepitating and presence of nodule.1. Upper extremities Inspection palpation No swelling No tenderness.Swelling 2. crepitating. Varies to some degree in accordance with person’s genetic makeup and degree of physical activity. Difficulty in parts of abdomen. swelling. Done different range of motion in the upper extremities. swelling. Lower extremities assessment Varies to some degree in accordance with person’s genetic makeup and degree of physical activity. smoothness of movement. Presence of tenderness. crepitating. Difficulty in parts of abdomen.

>Tell the patient slight discomfort may be felt when skin is punctured DURING: > Collect a venous sample according to the protocol of the laboratory. Hemoglobin 01/20/2011 01/20/2011 measures the amount of oxygen-carrying protein in the bloods 104 g/l 110-165 g/l The result is below normal range Indicates anemia Hematocrit 01/20/2011 01/20/2011 Measures the percentage of red blood cells in a given volume of whole blood Is used to evaluate any type of decrease or increase in the # of RBCs as measured by liter of blood .LABORATORY/DIAGNOSTIC TESTS Diagnostic Laboratory Procedure HEMATOLOGY: Normal Values (unit used in the Hospital) Date Ordered and Date Result Indications or Purpose Gives valuable diagnostic confirmation about hematologic/other body systems.80 x1012/l The result is below normal range Indicates anemia pg.273 l/l . >Handle specimen carefully. prognosis. >Transport time for culture specimen must be minimized.80-5. 39 . response to treatment and recovery. >Explain the procedure to patient >Tell the patient that a blood sample will be taken. Result A Analysis and interpretation of the results Nursing Responsibilities PRIOR: >Verify the doctor’s order.350-.71 x1012/l 3.500 l/l The result is below normal range Indicates anemia RBC 01/20/2011 01/20/2011 3.

2 – 3.5 – 33. date and the procedure.0 pg 26.7 x109/l 5. Granulocyte 01/20/2011 01/20/2011 16.5 pg pg.8 x /l 1. Indicates raised in infection 18.2 x /l The result is within normal range AFTER: > Apply manual pressure/dressing to the punctured site in removal of needle > Monitor punctured site for bleeding and signs of infection >Document the time. 40 .2-6.500 x /l MCH (mean Is a calculation of the average amount of 28.100-. >Inform them that the results will be out as soon as the specimen is interpreted in the laboratory.5 x /l 0.WBC Count 01/20/2011 01/20/2011 maintained at a stable number until the immune system detects the presence of a foreign invader Indicates the amount of lymphocytes participating with macrophages at a site of a local injury.3-0.8 x /l The result is above normal range Indicates infection Monocytes 01/20/2011 01/20/2011 Indicates raised in infection 0.4 x /l 1.0 x109/l The result is above the normal range Indicates infection Lymphocytes 01/20/2011 01/20/2011 1.8 x /l The result is within normal range Platelet Count PCT 01/20/2011 01/20/2011 01/20/2011 01/20/2011 01/20/2011 01/20/2011 Measures clotting potential 295 x109/l 150 – 390 x 109/l The result is within normal range The result is within normal range The result is within normal range .0-10.186 x /l .

3 % 10.7 % 10.5 – 11.0 % The result is above normal range Indicates iron deficiency anemia MCV (mean corpuscular volume) MCHC (mean corpuscular hemoglobin concentration ) RDW (Red cell distribution width) 01/20/2011 01/20/2011 Measures the different sizes and shapes of the red cell MPV (Mean platelet volume) PDW (Platelet distribution width) 01/20/2011 01/20/2011 Reflects the average volume of platelets 6.0 % The result is below the normal range not necessarily indicate disease pg.0 fl The result is within normal range 01/20/2011 01/20/2011 Determine the size of the platelets and may indicate underlying disease such as thrombocytopenia 9.0 – 15. 41 .5 fl 6.0 – 18.corpuscular hemoglobin) oxygen-carrying hemoglobin inside a red blood cell 01/20/2011 01/20/2011 is a measurement of the average size of your RBCs 74 fl 80 – 97 fl The result is below normal range Together with high RDW this indicates iron deficiency anemia 01/20/2011 01/20/2011 is a calculation of the average concentration of hemoglobin inside a red cell 380 g/l 315 – 350 g/l The result is above normal range Indicates spherocytosis 15.

• Check for doctor’s order. mechanism of action Acts directly on Indication Client’s response Nursing responsibilities Oxytoxin Initiation or None • Review doctor’s pg. 42 . • Documentation. B. • Obtain baseline data. Dosage. classification.Medical Management A. Drugs Generic/ Brand name Date ordered/ Date taken/Date changed/ Date discontinue Date ordered: Route of Administration. Frequecy TIV Action. Intravenous fluid Medical Management Date ordered/ Date performed/ Date chnged/ Date discontinued Date ordered: January 20. • Do not administer unless solution is clear and container is undamaged.2011 General Description Indications Client’s response to the treatment Nursing Responsibilities D5LR Treatment for persons needing extra calories who cannot tolerate fluid overload.

• Instruct patient to notfy healthcare professional of the adverse reaction. improvement of uterine contractions to achieve early vaginal delivery for maternal or fetal reasons. pg. Cefazolin Date ordered: Jan. • Monitor and record uterine cotractions. streptococcus.2011 (2:15 am) Date discontinue: Jan. intruterine pressure. genitourinary tract infections. skin and skin structure infections. BP. 20. • Monitor adverse reaction. and other susceptible microorganisms. producing uterine contractions: stimulate milk ejection by the breast.fetal heart rate and blood loss. • Obtain baseline data. gynecological infections. • Obtan specimens for culture and sensitivity before initiating therapy. order.2011 Date discontinue: myofibrils. biliary tract infections.Jan. pre-and post-operative wound and trauma. • Assess patient for infection. 20. Proteus spp. D. • Review doctors order. 43 . Classification: Infections caused by None staphylococcus. 20. E. pneumoniae. • Documentatio.2011 1gram TIV ANST q12 x2 dose Action: Inhibits bacterial cell wall synthesis. coli. thus promoting osmotic instability which eventually leads to bacterial death. Respiratory tract infections. • Observe patient for adverse reaction. heartrate.

44 . • Refrain also alcoholic beverages. • Monitor vital signs after pg. thalamus. It is used mainly as the sodium salt for the relief of pain and inflammation in various conditions: musculoskeletal and joint disorders. • Obtain baseline data. Relief of moderate to severe pain. cut. • Inform the client that the drug may be taken or with food or milk to minimize GI distress. crush or dissolvehe capsule. Nalbuphine Date ordered: Jan. • Monitor hepatic status and function. and other painful coditions.Opthalmic solution. subsequent decrease in prostaglandin result to the analgesic. for preoperatively analgesi. • Documentation.2011 75mg IM now Then q12 Imx2 dose more ANST Inhibits for cyclooxygenase. 2011 5mg TIV q6 PRN for severe pain Binds with opiate receptors in the CNS: ascending pain pathways in lymbic sysems.Diclofenac Date ordered: Jan. hypothalamus. 20. antipyretic and antiinflammatory effects. soft-tissue disorders. • Monitor hematologic status. Relieved pain • Verify the doctor’s order. • Assess patient’s underlying condition before therapy obtain drug history. supplement to balanced anesthesia.periarticular disorders. 20. an enzyme needed for the biosynthesis of prostaglandin. obstretical analgesia. surgical anesthesia. midbrain. • Monitor adverse reaction. • Advise the patient not to chew.

45 . pg. .alteing perception of and emotional response to pain paranteral route. • Assess patient’s and family’s knowledge of drug therapy. • Monitor for possible adverse reactions. • Monitor allergic reaction.

thus promoting osmotic instability which eventually leads to bacterial cell death.2011 500 mg q6 x 1week Inhibits bacterial cell wall synthesis. • Documentation . pharyngitis.Cefalexin Date ordered: Jan. • Inform the patient not to crush the tablets. rheumatic. 46 . 21. tonsillitis and pneumonia). migrain. antipyretic and aninflamatory activities. pg. postoperative and postpartum pain. skin and soft tissue infections. 26. 2011 500mg cap q8 Aspirin. dental. These activities appear to be due to its ability to inhibit cyclooxygenase and also antagonize certain effects of Relief of pain including muscular. • Documentation . respiratory tract infections (including sinusitis.2011 Date discontinue: Jan. Mefenamic acid Date ordered: Jan. 21. • Check for doctor’s order. traumatic.like drug that has analgesic. • Check for doctor’s order. • Assess patient for any signs of infection. fever. pain from rheumatoid arthritis including Relieved of pain relaed to underlying condition. • Monitor for possible drug adverse reactions. 21. 2011 Date discontinue: Jan. and dysmenorrhea. headache. • Obtain baseline data. Cefalexin is used to none treat urinary tract infections. • Obtain baseline data. otitis media. • The drug should be taken with or without food. • Assess patient’s for previous sensitivity reaction to penicillinor other cephalosporins.

Therapy should not exceed 7 days. 2011 OD Provides/replaces elemental iron. • Review for doctor’s order or medication record. carbohydrate metabolism. C. Needed for wound healing.prostaglandins.2011 Date discontinue: Jan. preparation for pg. protein. an essential component in formation of hemoglobin in red blood cell development. 21. antioxidant. 21. Ascorbic acid Date ordered: Jan. still’s disease. • Assess for vit. • Obtain baselne FeSO4 Date ordered: Jan. C defficiency before. Prevention and treatment of irondefficiency anemia. relief of Empty the client’s evaculation in bladder hemorrhoids. • Give between meals for best absorption • Assess nutritional status for inclussion of foods high in vit. Increase vitamin C Bisacodyl Date ordered: Jan. collagen synthesis. • Obtain baseline data. 47 . 2011 BID Enhance body’s natural immune function. during and after treatment. 2011 9:00 am Suppository 2 bisacodyl Increases peristalsis and moor activity of the small intestines by acting directly on Constipation. 21. 26. 26. • Check for doctor’s order. • Assess patient’s and family’s knowledge on drug therapy. lipid synthesis. • Monitor inputoutput ratio. prevention of infection. soft tissue injuries. Decrease feeling of fatigue and weakness.2011 Date discontinue: Jan.

preparation of colon for proctosigmoidoscopy. pre-and-post operative. 48 . • Inform the patient not to C.Date discontinue: Jan. • Monitor frequency and characteristics of stool. May stimulate colonic intramural plexus and promote fluid accumulation in the intestines and colon. barium enema. fluid intake. and DATE DISCONTINUED Date Ordered: GENERAL DESCRIPTION INDICATION/ PURPOSES SPECIFIC FOOD TAKEN CLIENT’S REPSONSE NURSING RESPONSIBILITIES (prior. DATE CHANGED. DIET TYPE OF DIET DATE ORDERED. • Monitor for the adverse reactions. 21. after) Before Be able to NPO NPO dietary state in It is usually on none The client received pg. 2011 the smooth muscles. data: GI status. during. bowel disorder.

January 19. Before: Be able to explain the general principles of the diet to the patient. Help to ease 1 skyflakes 1 bowl of Lugaw Mashed potato Banana Water The diet was taking soft type of food and able to follow the order. serum electrolyte client’s chart who is about to undergo surgery or special diagnostic procedures requiring that the digestive tract be empty or who is unable to tolerate food and fluids by mouth for some reason. the patient.2011 which patient is force to take nothing by mouth over a given period Normally instructed to pre-op patient and patient that have to undergo a certain laboratory examination. nothing per orem and explain the general did not experience principles of the diet to vomiting. 2011 January 22. 2011 Date discontinue: January 21. SOFT DIET Date ordered: January 21.2011 Date discontinue: January 23. FBS. pureed or placed in a sauce for easy swallowing.2011 January 20. During: make sure that patient followed doctor’s ordered Help plan for the patient's continued care After: Observe for restoration of GI function such as passage of flatus and presence of bowel sounds then document findings. Ex. and obtain the patient's cooperation Instruct the client to.2011 soft diet is one where all the food are mashed. and obtain the patient's cooperation pg. This type of diet is Diet can be used for clients who have difficulty in chewing or swallowing. 49 . not eat any foods or drinks.

Provides immediate replenishment of loss nutrients due to diet restrictions or medical/ surgical intervention through oral intake. throat or digestive track surgery as well as after the installation of new dental braces. Instruct client to take easy to digest food like soft food. Before: Be able to explain the general principles of the diet to the patient. and obtain the patient's cooperation Inform client she could eat/drink the food and beverages she desires.2011 Jan 24. Therefore. and it is sometimes recommended to relieve mild intestinal or stomach discomfort. but they must all have a soft texture. During: make sure that patient followed doctor’s order Help plan for the patient's continued care After. and her GI function remains normal and stable all throughout. 50 . Diet as tolerated is a term that indicates that the gastrointestinal tracts is tolerating food and is ready for advancement to the next stage. DAT Diet as Tolerated Date ordered: Jan 22.2011 Jan 23. Assess for GI upset symptoms.2011 Date discontinue: Until discharge of the patient. Rice Water Leafy vegetables Bread (pandesal) Bangus Coffee The diet was well tolerated by the client. difficulty in chewing and/or swallowing due to dental problems or extreme weakness.usually recommended after any type of jaw. this statement is most applicably in regard to the diet after abdominal or gastrointestinal surgery. The patient can eat a wide variety of food groups and types. signifying the patient's tolerance of his diet. During: make sure that patient followed doctor’s order Help plan for the patient's continued care pg.

2011 GENERAL DESCRIPTION INDICATION/PURPOSES CLIENTS RESPONSE NURSING RESPONSIBILITIES (prior. ACTIVITY AND EXERCISE TYPE OF EXERCISE DATE ORDERED. This action is indicated to prepare client start walking. Clients responded to regimen with positivism Prior: none pg. during. ordered movement of the legs. DATE STARTED.After: Assess for GI upset symptoms. after) Walking Exercise A rhythmic. DATE CHANGED & DATE DISCONTINUED Date Ordered: January 21. 51 . D.

creating a vicious cycle. Shallow breathing limits your oxygen intake and adds further stress to your body. During: Advice client to walk around the room After: Assess for any complain or discomfort Deep breathing Exercise Date Ordered: January 21. Pain in the thoracic or abdominal area because of surgery or trauma. 4. Atelectasis. Clients responded to regimen with positivism and affirmation. 3. Sometimes we are not even aware of it. distending the abdomen and exhaling slowly through pursed lips Deep breath as often as possible. Prior: none During: Encourage client to Inhale slowly through the nose. 2. 1. Deep breathing releases tension from the body and clear the mind. Pulmonary embolism.knee and feet that lets the body shift its weight to each leg alternately to initiate movement and travel It would replenish the circulation of the periphery and reoxygenize the leg muscles in preparation for walking Aids in restoring circulation in lower extremities.2011 Deep breathing is a relaxation technique that can be self-taught. improving both physical and mental wellness. immobilized period. and affirmation. Acute respiratory distress. Airway obstruction secondary to bronchospasm or retained secretions. 52 . We tend to breathe shallowly or even hold our hold our breath when we are feeling anxious. Breathing exercises can break this Acute or chronic lung disease. Chronic obstructive lung disease. pg. preferably 5 to 10 times every hour during the postoperative. Pneumonia. Deficit in the central nervous After: Asses for any complain or discomfort. Prevents pooling of blood and createnin of blood clots Helps in readying the leg muscles to reaccomodate body weight after bed rest.

or. 53 . rarely. The importance of good posture cannot be overstated. Stress management and relaxation procedures SURGICAL MANAGEMENT A cesarean section is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterectomy) to deliver one or more babies. system that lead to muscle weakness. High spinal cord injury. chronic. Severe orthopedic abnormalities. Slouching also strains muscles in the neck and back. A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk. It is performed whenever abnormal conditions complicate labor and vaginal delivery. A late-term abortion using Caesarean section procedures is termed a hysterectomy abortion and is very rarely performed. we tend to slouch. or progressive myopathic or neuropathy diseases. which compresses the diaphragm and other organs. It is helpful to sit in a chair with good back support to avoid fatigue that leads to slouching. Acute.cycle. While sitting. pg. such as scoliosis and kyphosis that affects respiratory function. although in recent times it has been also performed upon request for childbirths that could otherwise have been natural. threatening the life or health of the mother or the baby. resulting in shallow breathing. to remove a dead fetus.

and a weaker scar. The second incision opens the uterus. the entire surgical procedure may be performed in less than one hour. The umbilical cord is clamped and cut. From birth through suturing may take 30–40 minutes. a greater risk of abdominal infection. it will be vertical from just below the navel to the top of the pubic bone or. Once the patient has received anesthesia. Once the uterus is opened. In most cases. Some women experience a drop in blood pressure when a regional anesthetic is administered. Because it provides a larger opening than a low transverse incision. The first incision opens the abdomen. The benefits of regional anesthesia include allowing the mother to be awake during the surgery. Infrequently. either a spinal or epidural. is the preferred method of pain relief during a c-section. 54 . NURSING RESPONSIBILITIES PRIOR pg. it is used in the most critical situations such as placenta previa. However. a transverse incision is made. more commonly. it will be a horizontal incision across and above the pubic bone (informally called a "bikini cut"). and allowing early contact between mother and child.Regional anesthesia. the abdomen is washed with an antibacterial solution and a portion of the pubic hair may be shaved. the classic incision causes more bleeding. this can be countered with fluids and/or medications. An epidural is similar to a spinal except that a catheter is inserted so that numbing medications may be administered continuously. avoiding the risks of general anesthesia. The classical incision is vertical. Spinal anesthesia involves inserting a needle into a region between the vertebrae of the lower back and injecting numbing medications. The time from the initial incision to birth is typically five minutes. and the newborn is evaluated. and her uterus and abdomen are stitched closed (surgical staples may be used instead in closing the outermost layer of the abdominal incision). The placenta is removed from the mother. the amniotic sac is ruptured and the baby is delivered.

 PRIORITIZATION DATE IDENTIFIED CUES PROBLEM/ NURSING DIAGNOSIS JUSTIFICATION pg. During and after     Provide instructions on techniques used for cleaning the suture. 55 . Encourage the patient to breastfeed her baby. Explain the purpose of cleaning the suture. Inform the patient and the family of the patient for the procedure to be done. Give pain medications to the patient that do not interfere her breastfeeding. Encouraged to get out of bed and walk around 8.24 hours after surgery to stimulate circulation (thus avoiding the formation of blood clots) and bowel movement.

It is specially seen during our physical assessment Because of difficulty in walking and moving. Ineffective breastfeeding related to previous history of breastfeeding failure as manifested by observable signs of inadequate infant intake Sleep deprivation related to sustained environmental stimulation and discomfort as manifested by irritability January 21. 2011 Our client feels pain whenever she talks. Due to failure in breastfeeding to her first baby.” as verbalized by the client Impaired walking related to pain secondary to surgical incision as manifested by facial grimace when moving and seeing patient always in bed Bowel incontinence related to impaired cognition as secondary to pain due to surgical incision at lower abdomen as manifested by fecal staining at maternal diaper. walk and move because of her operation that’s why during the entire interview. 56 . 2011 “ Sumasakit ang tahi ko kapag Acute pain related to actual tissue nagsasalita. our client feels pain that she finds it hard to breastfeed Because of pain and the nurses who routinely get her vital signs.” as verbalized by the client damage secondary to surgical incision at the lower abdomen as manifested by verbalization of pain scale of 6/10 “ Hindi ako makahakbang.” as verbalized by the client January 21. 2011 “ Nahihirapan akong dumumi dahil sa tahi ko. And also because of her operation. January 21. 2011 “ Walang lumalabas na gatas sa suso ko. we took her condition into consideration.” as verbalized by the client January 21. our client find it hard to defecate that’s why she defecated once in her maternity diaper. our client find it hard to sleep that is why she is so irritable and look restless.” as verbalized by the client ASSESSMENT S: “Hindi ako NURSING DIAGNOSIS PLANNING INTERVENTION -Assist with results of RATIONALE EVALUATION Impaired mobility related LONG TERM GOAL: -for differential diagnosis LONG TERM GOAL: pg.January 21. 2011 “Paputol-putol ang tulog ko dito sa ospital. Our client feels uncomfortable whenever she ambulates. our client becomes unconfident in breastfeeding her newly born baby.

GOAL MET within 45min the client was able to verbalized therapeutic techniques or pain management that may give her comfort. 30min demonstrate some ROM’s that can help her recover with her situation. and identify/develop appropriate devices. -for individualized mobility/walking program.makahakbang kasi sumasakit yung tahi ko. ASSESSMENT Subjective: NURSING DIAGNOSIS PLANNING Long Term goal: INTERVENTION RATIONALE EVALUATION Long Term goal: pg. as individually indicated. O: -seen patient always on bed -grimace face when moving -holding her abdomen when moving -using bedpan when voiding -undergone cesarean section -pain scale: 6/10 to pain secondary to surgical incision as manifested by grimace face when moving and seeing patient always on bed. the patient should learn therapeutic techniques that may provide comfort to her. 57 . 30min assisted the patient to do the ROM’s. -to enhance safety for client and caregivers. -to reduce fatigue. SHORT TERM GOALS: GOAL MET within 30min the client was able to discussed the factors that contribute to the pain she feels. the patient learned therapeutic techniques that may provide comfort to her. -Encourage active and passive exercises. 45min verbalize therapeutic techniques or pain management that may give her comfort. and to guide treatment interventions. After 2hours of nursing intervention. as able. GOAL MET within 30min the client was able to demonstrated some ROM’s that can help her recover with her situation. mobility testing. Advanced levels of exercise. SHORT TERM GOALS: 30min discuss the factors that contribute to the pain she feels.” as verbalized by my patient. 30min assist the patient to do the ROM’s. -Schedule walking/exercise activities interspersed with adequate rest periods. -Consult PT/OT/rehabilitation team. After 2hours of nursing intervention. -Instruct client in safety measures. -to increase stamina/endurance.

 Perform pain assessment each time pain occurs. GOAL MET  After 1 hour the client was able to verbalized methods that provide relief.  Note when pain occurs. Short Term goal:  After 30 minutes the client will be able to follow prescribed pharmacological regimen. Short Term goal: GOAL MET  After 1 hour the client was able to follow prescribed pharmacological regimen.  Review procedures/ expectations and tell client when treatment will hurt. GOAL MET  After 1 hour the client was able to demonstrate the use of relaxation skills and diversional - To maintain acceptable level of pain.the client will be able to minimize verbalization of pain from ( 6/ 10 ) to ( 2/10 ). - To rule out worsening of underlying condition of complications. To reduce concern of the unknown and associated muscle tension. -  After 40 minutes of nursing intervention.  Administer analgesics as indicated to maternal dosage as needed. To medicate prophylactically as appropriate.  After 30 minutes the client will be able to report pain is relieved /controlled.  After 1 hour the client will be able to verbalized methods that provide relief. GOAL MET  After 1 hour the client was able to report pain is relieved /controlled. the client was able to minimize verbalization of pain from ( 6/ 10 ) to ( 2/10 ). 58 .  After 1 hour the client will be able to demonstrate the use of relaxation skills and diversional activities as manifested for  Provide comfort measures.“ Sumasakit ang tahi ko pag nagsasalita” as verbalized by the client.  After 4 hours of nursing intervention. Acute pain related to actual tissue damage as secondary to surgical incision of the lower Objective: abdomen as manifested  Pain scale ( 6/10 ) by verbalization of pain ( 6/10 )  Verbalization of pain  Facial grimace  Touching of abdomen upon interview and irritable. - pg. - To provide non pharmacological pain management.

EVALUATION Long Term Goal: After of Nursing pg.individual situation. ASSESMENT SUBJECTIVE: “Nahihirapan ako dumumi dahil sa tahi ko NURSING DIAGNOSIS PLANNING Bowel Incontinence Long Term Goal: related to impaired cognition as secondary to After 4hours of Nursing INTERVENTION >encouraged client or SO to record times at which incontinence RATIONALE -to note relationship to meals. 59 . activities as manifested for individual situation. activity and client’s behavior.

60 . Encourage warm fluid intake after meals >provide pericare with frequent gentle cleaning and use of emollients. occur. Intervention. -to maintain success of program. GOAL MET the client was able to established maintain as regular of bowel functioning as possible. Short Term Goal: GOAL MET the client wasl able to verbalized understanding of causative/ controlling factors. the client was able to return her changed in normal bowel habits characterized by difficulty to defecate. >take client to the bathroom/place on commode a bedpan at specified intervals taking into consideration individual needs and incontinence pattern. -to enhance coping difficult situation. the client will able to verbalize understanding of causative/ controlling factors.sa tyan” as verbalized by the client. Intervention. Within 1 hour the client will able to establish maintain as regular of bowel functioning as possible. Within 1 hour the client will able to participate in therapeutic regimens to control incontinences. OBJECTIVE: >inability to recognize/inattention to urge to defecate >discomfort because of pain due to surgical incision @ lower abdomen >used of diaper >fecal staining at diapers and at bed >constant dribbling of soft tools >fecal odor on diapers pain due to surgical incision at lower abdomen as manifested by fecal staining at diapers. >Instruct in use of suppositories or stool softeners if indicated. >provide emotional support to client and SO. the client will able to return her changed in normal bowel habits characterized by difficulty to defecate. DISCHARGE SUMMARY: pg. Within 30 min. GOAL MET the client was able to identified individually appropriate interventions. >encourage and instruct client/care giver in providing diet high in fiber and adequate fluids >give stool softener/bulk form as indicate/needed. the client will able to identify individually appropriate interventions. Short Term Goal: Within 30 min. especially when condition in long term -to stimulate timed defecation. GOAL MET the client was able to participate in therapeutic regimens to control incontinences. -to avoid perineal excoriation.

Advice to clean Wound twice a day. clean and in proper attitude to understand the things that she needs to do upon discharge. Out Patient : MGH. Advice also Perineal Care. Encourage Breastfeeding. Hygiene – Can Take a Bath after discharge but should protect her wound so it will not easily get wet and always clean the wound with Betadine . Ascorbic Acid tablet Exercise – She needs to perform likes ROM. Ferrous Sulfate. Mefenamic Acid. B.Cefalexin. Advice to eat healthy Foods. cover it clean gauze. The General Condition of the client upon discharge is neat. pg. METHODS Medication . twice a day and use Binder to easy heal the wound. Walking and ADL Treatment – Continue to take medications. 61 .A. complete medications : Oral meds instructed : Advice follow up after 1 week Diet – Prefer to have Regular Diet or DAT Spirituality – Always go to church and always have a communication with God.

It helps us to know the differences of C. 62 . We learned how to appreciate the effort of the mother just to deliver her baby. physical assessment was obtained to render appropriate nursing intervention.www. It is also important to establish rapport.Conclusion: After we studied the case. we understood the process of cesarean section delivery. As a woman we need to appreciate the essence of it. In formulating appropriate nursing care plans that are applicable to the patient’s condition and rendering an effective nursing intervention. which we also apply in the hospital.html pg.nih. We discovered a lot of new informations on how the C-section happens and the factor that is concerned with it. we learned a lot of things beyond what we already know. Being able to have a case study that is concerned with cesarean section. We need to respect our patient and giving them an emotional support in times of need. Through nursing health history.nlm.gov/medlineplus/cesarean section. BIBLIOGRAPHY: Cesarean definition. We use our critical thinking in assessing the patient’s condition using the knowledge that we obtained in our Related Learning Experience.Section to normal spontaneous delivery. Experiences like this help student nurses like us to grow as a person and to gain more respect to mothers who do their best to deliver their babies alive.

scribd.stress-relief-exercises. 2nd Edition p.wisegeek.com/deep-breathing-exercises.450 p456.childbirth. 450. 22.scribd.com/Ce-Fi/Cesarean-Section. p.92. p.com.com http://www.nursing-nurse.answers.org/section/CSFact.com/drug-study-cefazolin-ancef-172/#more-172 PDD’s Nursing DrugGuide 2nd edition pages: 506.com/doc/16349954/D5LR DIET and EXERCISE http://www.11.html www.html PPD’s Nursing Drug Guide.htm http://www.ph/books?id=odY9mXicPlYC&pg=PA341&lpg=PA341&dq=indication+of+soft+diet&source=bl&ots=z7Ge5YXyT&sig=anvH8kYfkBtQtVNIvXlqRr8BrhE&hl=tl&ei=8AxlTc-tIMKrcZukN4F&sa=X&oi=book_result&ct=result&resnum=10&ved=0CGYQ6AEwCQ#v=onepage&q=indication%20of%20soft%20diet&f=false www. p.com/doc/12250676/Drug-Study http://www. 11. 63 .27 p.93. 502. 93.ph/pregnancy/labourandbirth/labourcomplications/cesarean Growth and development: Source: http://nursingcrib.html pg.www. p.92.com/nursing-notes-reviewer/human-growth-and-development-theories/ Medical and Surgical Management: http://www.babycenter.tpub. 456. p.506 DRUGS: http://www.htm http://books.22.com.com/content/armymedical/md0915/md09150012. 476 IVF http://www. 27. p476.surgeryencyclopedia.google.com/what-is-a-soft-diet.

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