Cesarean Section

Combined Spinal- Epidural

Anesthesia (CSEA)
 General Objective:

This case study is Pulmonary Embolism. The goal of this study is to discuss the nursing intervention and treatment options include medicine
to ensure the effective care to the patient

Specific Objectives
1. To be able to discuss the case and define the problem.
2. To review the Anatomy and Physiology underlying to the problem presented.
3. To be able to identify and analyze the etiology of the problem.
4. To be able to tackle the drugs related and is applicable to the problem.
5. To provide necessary Nursing Care Plan to prioritize the immediate problem of the patient.
6. To know the rationale behind every nursing intervention given for the care of the patient.
7. To be able to explain or discuss the report clearly and to answer the questions correctly
PATIENT’S DEMOGRAPHIC DATA
Patient’s initials: R.C.M
Age: 28
Gender: F
Address: 51 Mendez Compound Labangon Street Cebu City
Birth Date: Feb. 23, 1992
Status: Single
Birth Place: Cebu City Religion: Roman Catholic Citizenship: Filipino

PATIENT’S ACCOMPANIES:
Name of accompanying: Rosie Mendez
Relationship: Mother

PATIENT’S PROBLEM:
Complaints(s): Watery vaginal discharge
Vital Signs: BP: 120/80 HR: 83 RR: 20 Temp: 36.4 O2 Sat: 98%
Weight: 109 lbs
Date/Time of Admission: 2/22/20 12:15 pm Reason for Admission: Watery vaginal discharge Physician: Dr. Jumao-as
Department: OB-Gyne
Caesarean section, also known as C-section, or caesarean delivery, is the surgical
procedure by which one or more babies are delivered through an incision in the
mother's abdomen, often performed because vaginal delivery would put the baby or
mother at risk

Most common reason of having C section:

- Placenta Previa
- Placenta Abruption
- Cephalopelvic disproportion (CPD)
- Tumor
- Fetal distress
- Repeat cesarean
- Birth defects
Combined Spinal- Epidural Anesthesia

A regional anesthesia - is the use of local anesthetics to block sensations of pain from a large
area of the body, such as an arm or leg or the abdomen. Regional anesthesia allows a procedure
to be done on a region of the body without your being unconscious.

This CSEA technique provides rapid onset of dense surgical anesthesia while allowing the ability
to prolong the block with an epidural catheter. In addition, because the block can be
supplemented at any time, the CSE technique allows the initial use of smaller doses of spinal
local anesthetics, which may, in turn, reduce the incidence of high spinal block or prolonged
hypotension. It may also reduce the duration of the postanesthesia care unit (PACU) stay.
Potential problems of the CSE technique for cesarean delivery include an inability to test the
catheter, the possibility of a failed epidural catheter after spinal injection, and the risk of
enhanced spread of previously injected spinal drug after use of the epidural catheter.
Spinal Anesthesia
Spinal anesthesia is often used for genital, urinary tract, or lower body procedures

Regardless of the anaesthetic agent (drug) used, the desired effect is to block the transmission
of afferent nerve signals from peripheral nociceptors. Sensory signals from the site are blocked,
thereby eliminating pain. The degree of neuronal blockade depends on the amount and
concentration of local anaesthetic used and the properties of the axon
The medicine begins on a very quick onset. You will also start to feel that it is difficult to move
your legs, and eventually not be able to move your legs at all.
Epidural Anesthesia
Epidural is a kind of anesthesia. This is a medicine that blocks pain. It can be used for labor and
delivery. It's also used for some kinds of surgery. For an epidural, anesthetic is injected into the
lower spine.
The spinal cord is the main path for pain signals. These signals travel from nerves through the
spinal cord to your brain. The brain registers them as pain. The epidural blocks the nerves that
enter your lower spine.
A thin tube (catheter) is threaded through the needle. The needle is removed. The anesthetic
then goes through the catheter. In some cases, a pump is attached to the catheter. This gives you
a constant dose of anesthetic as long as you need it.
An epidural takes about 20 to 30 minutes to reach full effect. You may not able feel the pain but
you can move your legs.
 ANATOMY AND PHYSIOLOGY
Spinal
In spinal anesthesia, the needle is placed past the dura mater in subarachnoid space and
between lumbar vertebrae. In order to reach this space, the needle must pierce through
several layers of tissue and ligaments which include the supraspinous ligament,
interspinous ligament, and ligamentum flavum. Because the spinal cord (conus
medullaris) is typically at the L1 or L2 level of the spine, the needle should be inserted
below this between L3 and L4 space or L4 and L5 space in order to avoid injury to the
spinal cord.
 Epidural
An epidural is injected into the epidural space, inside the bony
spinal canal but just outside the dura. In contact with the inner
surface of the dura is another membrane called the arachnoid
mater, which contains the cerebrospinal fluid. In adults, the
spinal cord terminates around the level of the disc between L1
and L2, while in neonates it extends to L3 but can reach as low
as L4.[14] Below the spinal cord there is a bundle of nerves
known as the cauda equina or "horse's tail". Hence, lumbar
epidural injections carry a low risk of injuring the spinal cord.
Insertion of an epidural needle involves threading a needle
between the bones, through the ligaments and into the
epidural space without puncturing the layer immediately below
containing CSF under pressure.
DRUG STUDY
Name of drug Mechanism of action Indication/s Side effects/ adverse Nursing responsibilities
reactions
Generic name: Epinephrine Naturally occurring catecholamine • Temporarily relief of Special senses: • Monitor BP, pulse,
obtained from animal adrenal bronchospasm, acute Nasal burning or stinging, respirations and urinary
Brand Name: glands; also prepared asthmatic attack, mucosal dryness of nasal mucosa, output and observe patient
Adrenaline synthetically. Acts directly on both congestion, sneezing, rebound closely following IV
alpha and beta receptors; the hypersensitivity and congestion. Transient administration. Epinephrine
Classifications: autonomic most potent activator of alpha anaphylactic reactions, stinging or burning of eyes, may widen pulse pressure. If
nervous system agent; alpha and receptors. Strengthens myocardial syncope due to heart lacrimation, browache, disturbances in cardiac
beta adrenergic agonist; contractions; increases systolic but block or carotid sinus headache, rebound rhythm occur, withhold
bronchodilator may decrease diastolic blood hypersensitivity, and conjunctival hyperemia, epinephrine and notify the
pressure; increases cardiac rate restore cardiac rhythm in allergy, iritis; with prolonged physician immediately.
Dosage: and cardiac output cardiac arrest. use: melanin like deposits on • Keep physician informed of
1:1000mL • Ophthalmic preparation is lids, conjunctiva, and cornea; any changes in intake output
1 mL used in management of corneal edema; loss of lashes ratio.
simple (open-angle) (reversible); maculopathy • Use cardiac monitor with
glaucoma, generally as an with central scotoma in patients receiving
adjunct to topical miotics aphakic patients (reversible). epinephrine IV. Have full
and oral carbonic crash cart immediately
anhydrase inhibitors. Body as a whole: available.
Nervousness, restlessness, • Check BP repeteadly when
fear, anxiety, tremors, severe epinephrine is administered
headache, cerebrovascular IV during first 5 min.
accident, weakness,
dizziness, syncope, pallor,
sweating.
Name of drug Mechanism of action Indication/s Side effects/ adverse Nursing responsibilities
reactions
Generic name: Competitive inhibition of • Used to prevent ulcer • Constipation -Gastrointestinal agent;
Ranitidine histamine at H2 receptors of while patient is on • Diarrhea antisecretory (H2-receptor
the gastric parietal cells, NPO. • Fatigue antagonist)
Brand Name: which inhibits gastric acid • Headache
Zantac secretion, gastric volume, and • Insomnia -Reduced amount of acid in
hydrogen ion concentration Contraindications: • Muscle pain the stomach that may result
Classifications: are reduced. Does not affect • Hypersensitivity to • Nausea to prevented ulcer incidence.
Gastrointestinal agents; pepsin secretion, pentagastrin ranitidine or any • Vomiting
antisecretory (H2-receptor stimulated intrinsic factor component of the • Agitation -Every 8 hours while patient
antagonist) secretion, or serum gastrin. formulation. • Anemia is on NPO.
• Confusion
Dosage: • Depression -Instruct client to report any
50mg • Easy bruising or adverse reaction to the
bleeding physician or nurse. Tell the
Frequency : patient that antacids may
Q8 ֯ decrease the absorption of
ranitidine
Route:
IVTT while on NPO -Ranitidine can interfere with
the metabolism of alcohol.
Patients taking ranitidine
who drink alcohol may have
elevated blood alcohol levels.
Name of drug Mechanism of action Indication/s Side effects/ Nursing responsibilities
adverse reactions
Generic name: Inhibits the hydrolysis of Indications: Body as a Whole: 1Check pulse before giving drug to bradycardic patients. If below 60/min
acetylcholine by competing with Muscle cramps, or other established parameter, consult physician. Atropine will be
Neostigmine acetylcholine for attachment to -Myasthenia gravis fasciculations ordered to restore heart rate.
acetylcholinesterase at sites of -Muscle relaxant- reversal of non- , twitching, pallor,
Brand Name:
cholinergic transmission. It enhances depolarising muscle relaxant fatigability, -Monitor pulse, respiration, and BP during period of dosage adjustment in
Prostigmin, cholinergic action by facilitating the Contraindications: generalized treatment of myasthenia gravis.
Prostigmin Bromide, transmission of impulses across contraindicated in patients with known weakness, -Report promptly and record accurately the onset of myasthenic
Bloxiverz neuromuscular junctions hypersensitivity to the drug, because of the paralysis, agitation, fear, death. symptoms and drug adverse effects in relation to last dose in order to
presence of the bromide ion, it should not assist physician in determining lowest effective dosage schedule.
be used in patients with a previous history CV: Tightness in chest, bradycardia,
Classifications: of reaction to bromides. It is hypotension, elevated BP. -Reduce possible GI (muscarinic) side effects, which occur especially
contraindicated in patients with peritonitis during early therapy, by giving drug with milk or food. Physician may
Autonomic nervous system agent; prescribe atropine or other anticholinergic agent to suppress side effects
or mechanical obstruction of the intestinal GI: Nausea, vomiting, eructation,
cholinergic epigastric discomfort, abdominal (note: these drugs may mask toxic symptoms of neostigmine).
or urinary tract.
(parasympathomimetic) agent; cramps, diarrhea,
cholinesterase inhibitor -Note time of muscular weakness onset carefully in myasthenic patients.
involuntary or difficult defecation.
It may indicate whether patient is in cholinergic or myasthenic crisis:
Dosage: Weakness that appears approximately 1 h after drug administration
CNS: CNS stimulation.
injectable solution (methylsulfate suggests cholinergic crisis (overdose) and is treated by prompt withdrawal
salt; Bloxiverz) of neostigmine and immediate administration of atropine. Weakness that
Respiratory: Increased salivation and
occurs 3 h or more after drug administration is more likely due to
• 0.5mg/mL bronchial secretions, sneezing, cough,
myasthenic crisis (underdose or drug resistance) and is treated by more
dyspnea, diaphoresis, respiratory
intensive anticholinesterase therapy.
• 1mg/mL depression.
-Record drug effect and duration of action. S&S of myasthenia gravis
tablet (bromide salt; Prostigmin)
Special Senses: Lacrimation, miosis, relieved by neostigmine include lid ptosis; diplopia; drooping facies;
• 15mg blurred vision. difficulty in chewing, swallowing, breathing, or coughing; and weakness of
neck, limbs, and trunk muscles.
Urogenital: Difficult micturition.
-Manifestations of neostigmine overdosage often appear first in muscles
of neck and those involved in chewing and swallowing, with muscles of
shoulder girdle and upper extremities affected next.

-Monitor respiration, maintain airway or assisted ventilation, and give

oxygen as indicated, when used as antidote for tubocurarine or other
nondepolarizing neuromuscular blocking agents (usually preceded by
atropine). Respiratory assistance is continued until recovery of respiration
and neuromuscular transmission is assured.

-Report to physician if patient does not urinate within 1 h after first dose
when used to relieve urinary retention.
Name of drug Mechanism of action
Atropine sulfate Acts by selectively blocking all
muscarinic responses to acetylcholine,
whether excitatory of inhibitory.
Antisecretory action (vagolytic effect)
Dosage: suppresses sweating, lacrimation,
0.4- 0.6 mg PO, IM, IV or salivation, and secretions from nose,
subcutaneously mouth pharynx and bronchi. Blocks vagal
impulses to heart with resulting
decrease in AV conduction time,
increase in heart rate and cardiac
output, and shortened PR interval.
Atropine is potent bronchodilator when
bronchoconstriction has been induced
by parasympathomimetics. Produces
mydriasis (dilation of pupils) and
cycloplegia (paralysis of
accommodation) by blocking response
of iris sphincter muscle and ciliary
muscle of lens to cholinergic stimulation.
Indication/s
Atropine sulfate injections, USP, is
indicated when excessive (or
sometime normal) muscarinic
effects are judged to be .life
threatening or are producing
symptoms sever enough to call of
temporary, reversible muscarinic
blockade.
Contraindications:
Hypersensitivity to belladonna
alkaloids; synechiae; angle; closure
glaucoma parotitis; obstructive
uropathy, e.g., bladder neck
obstruction caused by prostatic
hypertrophy; intestinal atony,
paralytic ileus, obstructive disease
of GI tract, severe ulcerative colitis,
toxic megacolon; tachycardia
secondary to cardiac insufficiency or
thyrotoxicosis; acute hemorrhage
myasthenia gravis. Safety during
pregnancy (category C) or lactation
is not established.
Side effects/ adverse reactions
-Xerostomia; altered taste
perception;
nausea; vomiting; dysphagia;
heartburn, constipation; bloated
feeling; paralytic ileus;
gastroesophageal reflux; urinary
hesitancy and retention;
impotence; blurred vision;
mydriasis; photophobia;
cycloplegia; increase intraocular
pressure; palpitations; bradycardia
(following low doses of atropine);
tachycardia (after higher doses);
headache; flushing; nervousness;
drowsiness; weakness; dizziness;
insomnia; fever; severe allergic
reactions including anaphylaxis,
urticaria and other dermal
manifestations; suppression of
lactation; nasal congestion;
decreased sweating. Complete
anhidrosis cannot occur because
large dose would be required,
producing severe side effects from
parasympathetic paralysis.
Nursing responsibilities
-Monitor patients with Down Syndrome
for anticholinergic crisis. (these patients
may be more sensitive to atropine.
-Monitor for signs of anticholinergic
crisis, which result from overdosage:
fever, tachycardia, difficulty swallowing,
ataxia, reduced urine output,
psychomotor agitation, confusion,
hallucinations.
-Observe for side effects. These
symptoms occur due to drug’s action
on ANS.
-Caution patient that atropine impairs
heat regulation due to direct blockade
of the muscarinic receptors on the
sweat glands.
-Monitor patients routinely for
abdominal distention and auscultate for
bowel sounds due to muscarinic
blockade on the tone and motility of
intestinal smooth muscle.
-Use cautiously with the elderly or very
young.
 Name of the Drug Mechanism Of Action Indication/s Side Effects/Adverse Reactions Nursing Responsibilities
•Butorphanol is a •Relief of moderate to severe pain •Sedation, dizziness, physical Before:
phenanthrene derivative •Nasal spray: Relief of migraine dependence, with or without •Assess for history of hypersensitivity to
Generic Name: with opioid agonist and headache pain and relief of moderate to psychological dependence; dyspnea, butorphanol, physical dependence on a
Butorphenol antagonist properties. It has severe pain confusion, headache, nausea, narcotic, lactation, bronchial asthma,
central analgesic actions and •For preoperative or preanesthetic vomiting, drowsiness, constipation; COPD, increased intracranial pressure,
produces generalized CNS medication, to supplement balanced hallucinations, mental depression, HTN acute MI, ventricular failure, coronary
Brand Name: depression. It also alters anesthesia, and to relieve prepartum and paradoxical CNS excitation insufficiency, hypertension, biliary tract
perception of and response pain (parenteral) (especially in children); rash, syncope, surgery, renal or hepatic impairment
to pain by binding to opiate tinnitus, vertigo, diaphoresis, withdrawal •Physical: Orientation, reflexes, bilateral
Classification: receptors in the CNS. Contraindication/s syndrome. grip strength, affect; pupil size, vision;
Opioid agonist-antagonist analgesic Opiate-dependent patients who have not pulse, auscultation, BP; R, adventitious
Dosage: been detoxified; acute respiratory sounds, normal output; LFTs, renal
2 mg depression; pregnancy. •Potentially Fatal: Respiratory function tests
Route: depression, convulsions.
IM During:
•Ensure that opioid antagonist facilities
Frequency: for assisted or controlled respiration is
readily available during parenteral
administration.
Timing:
After:
•You may experience these side effects:
Dizziness, sedation, drowsiness,
impaired visual acuity (avoid driving,
performing other tasks that requier
alertness); nausea, loss of appetite (lie
quietly, eat frequent small meals).
•Report severe nausea, vomiting,
palpitations, shortness of breath or
difficulty breathing, nasal lesions or
discomfort (nasal spray).
 Name of the Drug Mechanism Of Indication/s Side Effects/Adverse Nursing Responsibilities
Action Reactions

Epidural Local or regional anesthesia •Seizure Before:

administration allows or analgesia for surgical, or •observe 10 rights in drug
Generic Name: action to take place diagnostic procedure •Cardiovascular collapse administration
Bupivacaine at the level of the •Assess for hypersensitivity
spinal nerve roots •Respiratory arrest, •Assess for other
immediately contraindications
Brand Name: adjacent to the site •Low BP, bradycardia,
Marcaine spinal of administration. During:
•Dizziness •administer the right drug
Classification: •explain the importance and
Epidural local anesthetics •Anxiety purpose of the drug

Dosage: •restlessness
5 mg/ml After:
•Monitor blood pressure,
Route: Contraindication/s heart rate, and respiratory
Epidural •Known sensitivity to rate continuously while
bupivacaine patient is receiving this
Frequency: medication
•heart block; severe

Timing: •Hemorrhage

•hypotension and shock

 Name of the Drug Mechanism Of Action Indication/s Side Effects/Adverse Reactions Nursing Responsibilities

Generic Name: Binds to mu-opioid receptors. Moderate to moderately severe Frequent: Before:
Inhibits reuptake of serotonin pain (extended-release
Tramadol and norepinephrine in the CNS. formulations indicated for Nausea • History: Hypersensitivity to
patients who require around- tramadol; pregnancy; acute
Brand Name: the-clock pain management) Occasional: intoxication with alcohol,
opioids, psychotropic drugs
Conzip Vomiting or other centrally acting
analgesics; lactation;
Classification: Rare: seizures; concomitant use
of CNS depressants or
analgesics (centrally acting) Constipation MAOIs; renal or hepatic
Contraindication/s impairment; past or
Dosage: present history of opioid
Suicidal patients, acute addiction.
1 amp alcoholism; head injuries; raised
intracranial pressure; severe During:
Route: renal impairment; lactation.
• Control environment
IVTT (temperature, lighting) if
sweating or CNS effects
occur.
WARNING: Limit use in patients
with past or present history of
addiction to or dependence on
opioids.
 Name of the Drug Mechanism Of Action
Generric Name: ▪ Metoclopramide enhances the motility
of the upper GI tract and increases
Metoclopramide gastric emptying without affecting
gastric, biliary or pancreatic secretions.
Brand Name: It increases duodenal peristalsis which
decreases intestinal transit time, and
Reclomide increases lower oesophageal sphincter
tone. It is also a potent central
Classification: dopamine-receptor antagonist and
may also have serotonin-receptor (5-
GI stimulant, Antiemetic, Dopaminergic HT3) antagonist properties.
blocker
Dosage:
50 mg
Route:
Indication/s
▪ Relief of symptoms of acute and
recurrent diabetic gastroparesis
▪ Short-term therapy (4–12 wk) for
adults with symptomatic
gastroesophageal reflux who fail to
respond to conventional therapy
▪ Parenteral: Prevention of nausea and
vomiting associated with emetogenic
cancer chemotherapy
▪ Prophylaxis of postoperative nausea
and vomiting when nasogastric suction
is undesirable
▪ Single-dose parenteral use: Facilitation
of small-bowel intubation when tube
does not pass the pylorus with
conventional maneuvers
▪ Single-dose parenteral use: Stimulation
of gastric emptying and intestinal
transit of barium when delayed
emptying interferes with radiologic
exam of the stomach or small intestine
▪ Unlabeled uses: Improvement of
lactation (doses of 30–45 mg/day);
treatment of nausea and vomiting of a
variety of etiologies: Emesis during
pregnancy and labor, gastric ulcer,
anorexia nervosa
Contraindication/s
▪ GI haemorrhage, mechanical
obstruction and perforation;
phaeochromocytoma; history of
seizures.
Side Effects/Adverse Reactions
CNS:
drowsiness, extrapyramidal reactions,
restlessness, NEUROLEPTIC MALIGNANT
SYNDROME, anxiety, depression, irritability,
tardive dyskinesia.
CV:
arrhythmias (supraventricular tachycardia,
bradycardia), hypertension, hypotension.
GI:
constipation, diarrhea, dry mouth, nausea.
Endo: gynecomastia.
Hemat:
methemoglobinemia, neutropenia,
leukopenia, agranulocytosis.
Nursing Responsibilities
Before:
• History: Allergy to metoclopramide, GI
hemorrhage, mechanical obstruction
or perforation, pheochromocytoma,
epilepsy, lactation, previously detected
breast cancer
• Physical: Orientation, reflexes, affect;
P, BP; bowel sounds, normal output;
EEG
During:
• Monitor BP carefully during IV
administration.
• Monitor for extrapyramidal reactions,
and consult physician if they occur.
• Monitor diabetic patients, arrange for
alteration in insulin dose or timing if
diabetic control is compromised by
alterations in timing of food absorption
After:
• Advise patient may experience these
side effects: Drowsiness, dizziness (do
not drive or perform other tasks that
require alertness); restlessness,
anxiety, depression, headache,
insomnia (reversible); nausea, diarrhea.
• Report involuntary movement of the
face, eyes, or limbs, severe depression,
severe diarrhea.
 Name of the Drug Mechanism Of Action
Selectively blocks the H1
receptors, diminishing the
Generic Name: effects of histamine on cells of
Promethazine the upper respiratory tract and
eyes and decreasing the
sneezing, mucus production,
Brand Name: itching, and tearing that
Phenegran accompany allergic reactions in
sensitized people to exposed to
Classification: antigens: blocks cholinergic
Antiemetic, antihistamine, sedative, receptors in the vomiting centre
Hypnotic that are believed to mediate
the nausea and vomiting caused
Dosage: by gastric irritation, by input
25mg 1 tab from the vestibular apparatus,
and by input from the
Route: chemoreceptor trigger zone;
PO depresses RAS including the
parts of the brain involved with
weakfullnes.
Frequency:
q4
Timing:
Indication/s
General Indications:
•prevention and treatment of nausea and
vomiting associated with labyrinthtis
•prevention of motion sickness
•short term management of insomnia
•symptomatic relief of perennial and
seasonal allergic rhinitis, allergic,
conjunctivitis, uncomplicated urticaria and
angioedema
•amelioration of allergic reactions to blood
or plasma
•Dermatographism, adjunctive therapy in
anaphylactic reactions
•preoperative, posoperative, or obstetric
sedation
•adjunct to analgesics to control
postoperative pain
•adjunctive IV therapy with reduced
amounts of meperidine or other opioid
analgesics in special surgical conditions.
Contraindication/s
Concentrations
•hypersensitivity to antihistamine or
phenothiazines
•comatose patients
•severe CNS depression
•Bone marrow depression
•vomiting of unknown cause
•concomitant therapy with MAOI's
•Lactation
Side Effects/Adverse Reactions
CNS: dizziness, drowsiness, poor
coordination, confusion, restlessness,
excitation, seizures, tremors, headache,
blurred vision, diplopia, vertigo, tinnitus
CV: hypotension, palpitations, bradycardia,
tachycardia, extrasystoles
Dermatologic: urticaria, rash,
photosensitivity, chills
GI: epigastric distress, nausea, vomiting,
diarrhea, constipation
GU: Urinary frequency, dysuria, urinary
retention, decreased libido, impotence
Hematologic: hemolytic anemia, hypoplastic
anemia, thrombocytopenia, leukopenia,
agranulocytosis, pancytopenia
Local: thickening of bronchial secretions,
chest tightness, dry mouth, nose and throat;
respiratory depression, supression of cough
reflex, potential of aspiration
Other: tingling, heaviness and wetness of
hands
Nursing Responsibilities
Before:
•observe 10 rights in drug administration.
•Assess for hypersensitivity and other
contraindications.
•Reduce dosage for patients with hepatic
impairment
•reduce dosage of barbiturates given
concurrently with promethazine by at least
a half.
•arrange for dosage reduction of opioid
analgesics given concomitantly by one
fourth to one half
During:
•Give iv injections into deep muscle
•Do not administer subq, tissue necrosis
may occur.
•Do not administer intrarterially;
arteriospasm and gangrene of the limb may
result.
•instruct to take drug as prescribed.
After:
•instruct to avoid alcohol
•instruct to avoid driving or engaging in
other dangerous activities of dizziness,
drowsiness or vision changes occur.
•Educate about avoiding prolonged
exposure to the sun, or using of sunscreen
or covering garments
•maintain fluid intake, use precautions
against heatstroke in hot weather
•Report sorethroat, fever, unusual bleeding
or bruising, rash, fever, weakness, tremors,
impaired vision, dark urine, pale stools,
yellowing of the skin or eyes.
Name of drug Mechanism of action Indication/s Side effects/ adverse reactions Nursing responsibilities

Generic name: -inhibits prostaglandin synthesis, Indications: -CNS: -Monitor BP Upon administration.
Ketorolac producing peripherally mediated • Short term management of 1) Drowsiness <90/80 never administer. Refer to a
analgesia pain (not to exceed 5 days 2) Abnormal thinking doctor.
Brand Name: total for all routes combined) 3) Dizziness
Toradol -also has antipyretic and anti- • 4) Euphoria -Patients who have asthma, aspirin
inflammatory properties Contraindications: 5) Headache induced allergy, and nasal polyps are at
Classifications: -hypersensitivity increased risk for developing
Nonsteroidal anti-inflammatory -therapeutic effect: -RESP: hypersensitivity reactions. Assess for
agents, nonopioid analagesics decreased pain -cross-sensitivity with other NSAIDs 1) Asthma rhinitis, asthma, and urticaria.
may exist PRE-or perioperative use 2) dyspnea
Route: -Assess pain (note type, location, and
I.V -known alcohol intolerance use -CV: intensity) prior to and 1-2hr following
Dose cautiously in: 1) Edema administration.
Q 6h 1) History of GI bleeding 2) Pallor
2) Renal impairment (dosage 3) Vasodilation -Ketorolac therapy should always be
Dosage: reduction may be required) given initially by the IM or IM route.
30mg 3) Cardiovascular disease -GI: Oral therapy should be used only as a
1) GI Bleeding continuation of parenteral therapy.
2) Abnormal Taste
3) Diarrhea
4) Dry Mouth
5) Dyspepsia
6) GI pain
7) Nausea

-GU:
1) Oliguria
2) Renal Toxicity
3) Urinary Frequency
NURSING CARE PLAN
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
SUBJECTIVE: Risk for injury related to Orthostatic hypotension, a SHORT TERM: INDEPENDENT
biochemical or regulatory failure to maintain blood
N/A After 4 hours of nursing 1. Review prenatal and intrapartum 1. Presence of risk factors such
functions (e.g. orthostatic pressure assuming an upright
interventions, the patient will be record for factors that predispose as fatigue, uterine over
hypotension or development of posture, is common after general
able to demonstrate behavior to client to complications. distension, general anesthesia,
eclampsia), effects of anesthesia anesthesia for minor surgery and
reduce risk factors and/or excessive blood loss, or prenatal
and abnormal blood profile. may be the major cause of
protect self. thrombophlebitis renders the
OBJECTIVE: postoperative orthostatic
client more susceptible to
intolerance. Maternal
V/S: postoperative complications.
hypotension may cause nausea
and vomiting in the mother, and 2. Elevated BP may indicate
BP:120/80 mmHg
can seriously harm the baby. developing or continuing
HR: 93 bpm hypertension or other
antihypertensive treatment.
RR: 20
2. Monitor BP, pulse, and Hypotension and tachycardia
LONG TERM:
Temp: 36.4 temperature. Note cool clammy skin; may reflect dehydration. Pyrexia
After 3 days of nursing weak, thread pulse; delayed capillary may indicate infection.
O2 sat: 98% interventions, the patient was refill or cyanosis.
able to be free of avoidable 3. Orthostatic hypotension may
complications. occur when changing from
supine to upright position on
initial ambulation it may result
from vasodilation caused by the
heat of the shower of sitz bath.

4. Danger of eclampsia due to

3. Assist client with initial ambulation.
PIH exists for up to 72 hr.
Provide adequate supervision in
postpartum. Although Literature
shower or sitz bath.
suggest the convulsive state has
occurred as late as the 5th day
postpartum.

4. Assess for hyperreflexia, headache,

or visual disturbances. Maintain 1. Reduce venous stasis,
seizure precautions, and provide quiet enhancing venous return and
environment. reducing risk of thrombus
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE

SUBJECTIVE: Acute pain related to Cesarean section is a surgical SHORT TERM: INDEPENDENT
disruption of skin and tissue procedure indicated in
“Masakit yung tahi ko’’ as After 1-2 hours of nursing 1. Assess quality, characteristics 1. To establish baseline data
secondary to cesarean situations in which vaginal
verbalized by the patient. interventions, the patient severity of pain. for comparison in making
section. delivery presents a higher
was able to verbalize evaluation and to assess for
likelihood of adverse
decrease intensity from 8/10 possible internal bleeding.
maternal and/or perinatal
to 3/10
outcomes than normal. 2. Calm environment helps to
Wound disruption is a 2. Provide comfortable decrease the anxiety of the
subcutaneous skin or fascial environment- change bed linens patient and promote
OBJECTIVE:
dehiscence excluding primary and turned on the fan. likelihood of decreasing pain.
Pain scale 8/10 wound infections. LONG TERM:
3. To protect the area of
-Teary eyed After 8 hours of nursing incision to improve comfort.
interventions, the patient will And to initiate non stressful
V/S:
verbalize reduced discomfort 3. Instructed to put pillow on the muscle setting techniques.
BP:110/80 mmHg of pain. abdomen when coughing or
4. To promote circulation,
moving.
PR: 80 bpm prevent venous stasis;
prevent pressure on the
RR: 22 operative site.
4. Provided diversionary activities.
Temp: 37.6 1. Relieves pain felt by the
Initiate ankle pumping, active
lower extremity and walking. patient.

COLLABORATIVE
1. Provide analgesics as per
doctor’s order.
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE

SUBJECTIVE: Risk for infection related Due to an effective cesarean SHORT TERM: INDEPENDENT
inadequate primary defenses section, patient’s skin and
N/A After 4 hours of nursing 1. Inspect dressing and perform 1. Moist from drainage can
secondary to surgical incision. tissue were mechanically
interventions, the patient will wound care. be a source of infection.
interrupted. Thus, the wound
be able to understand
is at risk of developing 2. These are signs of
causative factors, identify
infection. infections.
signs of infection and report 2. Monitor elevated temperature,
them to healthcare provider redness, swelling, increased pain,
OBJECTIVE: accordingly. or purulent drainage ate incisions.

-Dressing dry and intact 3. Encourage fluid intake of 2000

3. Fluid promote diluted
ml to 3000 ml of water per day
V/S: urine and frequent emptying
(unless contraindicated).
of bladder; reducing stasis of
BP:120/80 mmHg
urine, in turn, reduces risk of
HR: 80 bpm bladder infection or UTI.

RR: 19 LONG TERM: 4. These measures reduces

stasis of secretions in the
Temp: 37.3 After 3 days of nursing
4. Encourage coughing and deep lungs and bronchial tree.
interventions, patient will
breathing; consider use of
achieve timely, wound
incentive spirometer.
healing, be free of purulent
1. To provide immediate
drainage or erythema, be
medical intervention.
afebrile and be free for
COLLABORATIVE
infection.
1. Administer antibiotics
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE

SUBJECTIVE: SHORT TERM: INDEPENDENT

‘’I am having infrequent bowel Risk for constipation related Postpartum, slow bowel After 8 hours of nursing 1. Ascertain normal bowel 1. This is to determine the
movements since my delivery ’’ as to post pregnancy secondary movements are often interventions, the patient functioning of the patient, about normal bowel pattern.
verbalized by the patient. to cesarean section. caused by fluctuating will be able to demonstrate how many times a day does she
hormones, or by an in behaviors or lifestyle defecate.
adequate amount of liquid changes to prevent 2. To increase the bulk of the
2. Encourage intake of foods rich in
OBJECTIVE: or fiber in the diet. Some developing problem. stool and facilitate the
fiber such as fruits.
women also experience passage through the colon.
- Absence of bruit sounds
constipation following a
3. To promote moist soft
V/S: cesarean due to medications
3. Promote adequate fluid intake. tool.
included in the epidural.
BP:90/60 mmHg LONG TERM: Suggest drinking warm fluids,
especially in the morning to
HR: 96 bpm After 3 days of nursing
stimulate peristalsis. 4. To stimulate contractions
interventions, the patient
RR: 18 of the intestines and prevent
will be able to maintain 4. Encourage ambulation such as
post-operative
Temp: 36.7 usual pattern of bowel walking within individual limits.
complications.
functioning.
COLLABORATIVE

1. Administer bulk-forming agents

1. To promote defecation.
or stool softeners such as laxatives
as indicated or prescribed by the
physician.
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
SUBJECTIVE: SHORT TERM: INDEPENDENT

‘’ Ang sakit po ’’ as verbalized by the Acute pain related to effects of Cesarean delivery is the surgical After 8 hours of nursing 1. Determine characteristics and 1. Comparing specific
patient. anesthesia as evidenced by procedure by often performed interventions, the patient will location of discomfort. Rate severity characteristics of pain aids in
reports of incision pain. because vaginal delivery would be able to identify and use 0/10 scale. differentiating pain from
put the baby or mother at risk. appropriate interventions to developing complications.
OBJECTIVE: An incision of about 15 cm to (6 manage pain/discomfort.
2. Promotes problem solving,
inches) is then typically made
Pain scale: 7/10 help reduces pain associated
through the mother’s lower
2. Provide information and with anxiety and fear of
- Facial mask of pain abdomen. Many women also
anticipatory guidance regarding unknown and provide sense of
feels post-birth cramps as the
V/S: LONG TERM: causes of discomfort and appropriate control.
uterus shrinks. These sensational
feel similar to menstrual cramps, interventions.
BP:120/80 mmHg After 3 days of nursing 3. Deep breathing enhances
but maybe more intense. interventions, the patient will respiratory effort. Splinting
HR: 96 bpm be able to appear relaxed, able reduces strain and stretching of
3. Initiate deep breathing exercises, incisional area and lessens pain
RR: 19 to sleep/ rest appropriately.
incentive spirometry, and coughing and discomfort associated with
Temp: 36.5 using splinting procedures, as movements of abdominal
appropriate, 30 min after muscles.
administration of analgesics.
4. Reduces severity of headache
by increasing fluid available for
production of CSF and limiting
position shifts of the brain.

4. Encourage bedrest in flat-lying

position, increase fluids, and assist as
needed with client and infant care. 1. Effective for relief of severe
spinal headache. The blood
patch procedure has 90-100%
success rate, creates blood clot,
which produces pressure and
COLLABORATIVE
seals the leak.
1. Assist as needed with saline
injection or administration of ‘’blood
patch’’ over site of Dural puncture.
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
SUBJECTIVE: SHORT TERM: INDEPENDENT

N/A Impaired Urinary elimination Urinary retention is common After 8 hours of nursing 1. Note and record amount, color, 1. Oliguria (Output less than
related to effects of anesthesia complication that arises after a interventions, the patient will concentration of urinary drainage. 30ml/hr.) maybe caused by
as evidenced by increased patient has anesthesia or be able to resume usual/ excess fluid loss, inadequate
OBJECTIVE: bladder filing/distension and surgery. The analgesic drugs optimal voiding patterns fluid replacement, or
amount/frequency of voiding. often disrupt the neural following catheter removal. antidiuretic effects of infused
V/S: circuitry that controls the oxytocin.
BP:110/80 mmHg nerves and muscles in urination
2. Fluids promote hydration and
process. The risk of urinary 2. Provide oral fluid, e.g. 6-8 glasses
HR: 90 bpm renal function, and help
incontinence is higher among per day.
LONG TERM: prevent bladder stasis.
women who have had cesarean
RR: 20
sections than among After 3 days of nursing 3. Client should void within 6-8
Temp: 36.2 nulliparous women who had interventions, the patient will hr. following catheter removal,
vaginal deliveries. be able to empty bladder with yet may have difficulty-
02 sat: 99%
each void. 3. Use methods to facilitate voiding emptying bladder completely.
after catheter removal (e.g. run water
in sink, pour warm water over 4. Performing Kegel exercise
perineum). 100 times/day increases
circulation to perineum, aids in
healing and recovery of tone of
pubococcygeal muscle, and
4. Instruct client to perform Kegel
prevents reduces stress
exercise daily after effects of
incontinence.
anesthesia have subsided.

1. Usually, 3 L of fluid, including

lactated Ringer’s solution is
adequate to replace losses and
maintain renal flow/ urine
COLLABORATIVE
output.
1. Maintain IV infusion for 24 hour.
Following surgery as indicated.
Increase infusion rate if output is 30
ml/hr. or less.
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
SUBJECTIVE: SHORT TERM: INDEPENDENT

‘’ Biglaan lang kasi tong CS ko dapat Situational low self-esteem Self-esteem is another After 4 hours of nursing 1. Determine client’s/couple’s emotional 1. Both members of the couple
normal talaga ako.. kaya di ko related to perceived failure at a parameter related to mental interventions, the patient will be response to cesarean birth. may have a negative emotional
napaghandaan ganitong gastos ee.’’ as life event as evidenced by well-being. Low levels of self- able to verbalize understanding reaction to the surgical
verbalized by the patient. verbalization of negative feelings esteem are associated with of individual factors that intervention. Parents often grieve
about self in situation (e.g. anxiety, depression, and eating precipitated current situation. and feel a sense of missing the
helplessness, shame/guilt). disorders. Pregnant women who anticipated vaginal birth.
OBJECTIVE: reported unplanned pregnancy
2. Cesarean birth maybe viewed
have a higher prevalence of
-Emotionally stressed by the client/ couple as a failure
unsatisfactory self-esteem than
LONG TERM: at a life event, and this may have
-Narrowed focus those having planned it.
negative impact on bonding/
After 2 days of nursing 2. Encourage client/couple to verbalize parenting process.
V/S:
interventions, the patient will be unmet needs and expectations. Provide
BP:120/80 mmHg able to verbalize understanding information regarding the normalcy of 3. Client may alter her perception
of individual factors that such feeling. of cesarean birth experience as
HR: 76 bpm precipitated current situation well as her perception of her own
and express positive self- 3. Emphasize similarities between vaginal wellness or illness. Similar care
RR: 20
appraisal. and cesarean birth. Convey positive conveys the message that
Temp: 36.8 attitude, and manage postpartum care as cesarean birth is necessary
close as possible to care provided to alternative to vaginal delivery.
clients following vaginal birth.

4. Help facilitate positive

adaptation to new role; reduces
feeling of inadequacy.

1. Client who is unable to resolve

4. Assist client/couple in identifying
grief or negative feelings may
coping mechanism and developing new
need further professional help.
coping strategies if needed.

COLLABORATIVE

1. Refer client/couple for professional

counselling if reactions are maladaptive.
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
SUBJECTIVE: SHORT TERM: INDEPENDENT

N/A Risk for impaired fetal gas The placenta serves as the After 4 hours of nursing 1. Note presence of maternal factors 1. Decreased circulating volume
exchange related to altered fetus organ of gas exchange interventions, the patient will that negatively affect placental or vasospasms within the
blood flow to placenta and or throughout intrauterine life. be able to manifest normal circulation and fetal oxygen. placenta decrease oxygen
OBJECTIVE: through umbilical cord. The oxygen delivered to the variability on monitor strip. available for fetal uptake.
fetus is first dependent on
- Restless maternal uterine blood supply,
V/S: modified by placental diffusion 2. Owing to hypoxia, fetal
of oxygen, and finally the distress may transpire; may be
BP:10/80 mmHg product of umbilical venous LONG TERM:
2. Record FHR, note any changes or displayed by reduced variability,
blood flow and oxygen content. After 8 hours of nursing decelerations during and following late decelerations and
HR: 102 bpm
interventions, the patient will contractions. tachycardia followed by
RR: 22 be able to reduce frequency of bradycardia.
Temp: 36.7 late or prolonged variable
3. Narcotics normally reduce
decelerations.
FHR variability and may
3. Monitor fetal response to necessitate administration of
preoperative medications or regional naloxone (Narcan) following
anesthesia. delivery to reverse narcotic-
induced respiratory depression.
4. Optimizes uteroplacental
perfusion, helps prevent
hypotensive response.

4. Give IV fluids bolus prior to initiation

of epidural of spinal anesthesia. 1. Position changes may reduce
pressure on cord.

COLLABORATIVE

1. Help physician with elevation of

vertex, if required.
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE

SUBJECTIVE: SHORT TERM: INDEPENDENT

‘’Namamaga ang tahi ko’’ as Impaired skin/tissue integrity Skin is the body’s first line of After 8 hours of nursing 1. Establish rapport 1. To gain trust with the client.
verbalized by the patient. related to mechanical trauma defense against foreign interventions, the patient will
2. To determine unusual ties
of surgical removal of skin and materials that can be be able to participate in
and report it to physician for
subcutaneous tissue secondary considered as injuring agents. prevention measures and 2. Inspect skin on daily basis and
prompt treatment.
OBJECTIVE: to cesarean section. Once the skin is disrupted, this treatment program and observe for changes and unusual ties.
will put a person at risk since it maintain physical well-being. 3. This will assist body’s natural
- Redness on the incision site may become a good medium 3. Keep the area clean, carefully dress
process of repair.
for bacterial growth. Cesarean wound, support incision, prevent
-swelling on the incision site
section, like any other surgical infection. 4. Maintaining clean, dry skin
V/S: procedures includes invasion provides a barrier to infection.
4. Encourage client to demonstrate
on the side body, specifically LONG TERM: Patting skin dry instead of
BP:120/80 mmHg good skin hygiene, e.g., wash
the skin and subcutaneous rubbing reduce risk of dermal
After 3 days of nursing thoroughly and pat dry carefully after
HR: 96 bpm area. trauma to fragile skin.
interventions, the patient will teaching.
RR: 18 be able to display timely
healing of skin lesions/wounds
Temp: 36.7 without complication. COLLABORATIVE
1. To provide a positive
nitrogen balance to aid healing.
1. Provide optimum nutrition such as
increased protein intake.
 DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
SUBJECTIVE: SHORT TERM: INDEPENDENT

‘’ Diba para lang yan sa mga matataba Deficient knowledge regarding A lack of cognitive information After 4 hours of nursing 1. Appraise knowledge toward the 1. Most patients fail to retain
ang CS?’’ as verbalized by the patient. surgical procedure related to or psychomotor ability needed interventions, the patient will procedure. the information instilled during
incomplete/ inadequate for health restoration, be able to verbalize childbirth classes. Therefore,
information as evidenced by preservation, or health understanding of indications for patients have difficulty to
OBJECTIVE: request for information/ promotion is identified as a cesarean birth remember or understand the
verbalization of concerns and knowledge deficit. Knowledge details during the entire
- Slightly confused misconceptions. plays an influential and process.
-ask questions frequently significant part of a patient’s
2. Stress of the situation can
life and recovery.
-slightly agitated LONG TERM: affect the patient’s ability to
understand information
V/S: After 3 days of nursing 2. Give accurate information in easy to required to make informed
interventions, the patient will understand terms and clarify decisions.
BP:120/80 mmHg be able to recognize as an misconceptions.
HR: 96 bpm alternative childbirth procedure 3. Cesarean birth should be
to achieve the best result viewed as an alternative and
RR: 18 positive in the end. not an abnormal situation to
enhance the maternal and fetal
Temp: 36.7
3. Review indications necessitating safety and well-being.
alternative birth method.
4. Explanation of the logical
reasons why a particular choice
was made is vital in preparation
for the procedure.

5. Having knowledge about the

4. Explain preoperative procedures in possible outcomes prevent
advance, and present rationale as unnecessary anxiety.
appropriate.

5. Further stress anticipated sensation

during delivery and recovery period.
Discharge Planning
DATE FOCUS TIME DAR
Discharge D:with the discharge order form the attending physician Dr. Jumao-as
instructions
A:Activity: Do not do lift anything heavier than your baby for the first 6-8 weeks. Avoid heavy house
cleaning, jogging, most exercises, and any activities that make you breathe hard or strain your muscles.
Diet: Continue taking your prenatal iron and vitamin pills until your postpartum visit.
It is important to eat a well-balanced diet and drink plenty of fluids. Drink two quarts of fluid per day if
you are breastfeeding.
Exercise: You may start mild exercise after two weeks’ rest and recovery after giving birth, but more
strenuous exercise should be delayed for four to six weeks. Begin with easier exercises and increase
them gradually if you are comfortable and it does not cause pain. If you had a Cesarean, do not begin an
exercise program for at least six weeks after delivery and with your physician’s permission.
Hygiene:
Keep your incision open to the air ( do not keep a depressing on it), unless directed otherwise by your
doctor. Keep your incision clean and dry. It is okay to wash it in the shower with warm, soapy water and
pat dry afterward.

Medicine: Take your medicine exactly as instructed. Don’t skip doses. The pt. must know the purpose of
the medication and exact dosage, route, and time to be taken. Take vitamin C D and K

Follow up at RHU on March 3, 2020

Follow the follow up appointment as directed. Have your lab work done as directed