A CASE STUDY OF A 29-YEAR-OLD FEMALE (PORSTPARTUM) WITH A DIAGNOSIS

OF ANEMIA SECONDARY TO BLOOD LOSS

Maria Reyna – Xavier University Hospital, Inc. – Obstetrics Ward

In Partial Fulfillment of the requirements of NCM 107 RLE – Care of Mother,

Child, Adolescents (Well Clients)

BSN 2 (Block NB) - RLE Group 1

Abigail Dorothy Aguilar
Chariefa Aaliyah Al Ali
Frank Lawrence Alforque
Alyssa Shannen Asira
Beatrice Caxandra Bacas
Shaina Nicole Bitaizar
Shaun Jerico Cabrezos
Johnry Camahalan
Sheehan Mariel Castro
Ma. Jogie Dignos
Samantha Valkyrie Flores
Kristah Dariz Gamolo

Mrs. Ivy R. Go, RN, MAN, DScN

October 12, 2022
 Table of Contents

ACKNOWLEDGEMENT………………………………....................................................1
I. General Objectives................................................................................................3
II. Specific Objectives................................................................................................5
III. Significance of the Study......................................................................................6
IV. Scope and Limitation.........................................................................................12
V. Definition of Terms...............................................................................................14
VI. Introduction.........................................................................................................16
VII. Assessment.........................................................................................................21
VIII. Laboratory Results.............................................................................................26
IX. Pathophysiology.................................................................................................38
a. Narrative Pathophysiology......................................................................38
b. Pathophysiology Schematic Diagram...................................................41
X. Drug Study............................................................................................................42
XI. Nursing Care Management..............................................................................56
a. Nursing Care Plan 1 .................................................................................56
b. Nursing Care Plan 2 .................................................................................60
c. Nursing Care Plan 3 .................................................................................63
d. Nursing Care Plan 4 .................................................................................67
e. Nursing Care Plan 5 .................................................................................69
XII. Discharge Plan...................................................................................................73
XIII. Prognosis.............................................................................................................78
XIV. Conclusion........................................................................................................84
XV. Recommendation.............................................................................................85
XVI. Appendices…………………………………………………………………..……...88
a. Assessment Tool...………………………………………...…….….......……..88
b. Doctor’s Order……………………………………………………...…....……92
c. Nurse’s Notes……………………………………………………….......……...93
d. Consent.....................................................................................................99
XVII. Bibliography………………………………………………………….....…………100
 ACKNOWLEDGEMENT

The RLE group would like to acknowledge the people who had given

their effort to assist the conduction of this case study in any way. The

researchers would like to give special recognition to Xavier University’s clinical

instructor, Dr. Ivy R. Go for her patience, guidance, valuable advice, and

constructive criticism that greatly improved the development and framework

of this study. For teaching us how to handle our patients and perform certain

nursing interventions for straight 2 weeks. She has enlightened us with many

informational topics regarding the processes in the Obstetrics Ward to prepare

us to become competent nurses in the future. The students would like to thank

Dr. Ivy Go for guiding and giving the students advice all throughout their

obstetrics ward clinical duty.

The students would also like to express deep gratitude to the patient and

her family for participating in this case study and for their kind cooperation,

consistent understanding and time contributed to answer the students’

questions. A special thanks to the Maria Reyna Xavier University Hospital for

allowing the students to attend in their prestigious and distinguished institution.

To the nursing staff of Maria Reyna Xavier University Hospital station 2B for their

continuous support, compassion, and guidance that they have shown to the

students during their clinical rotation.

To our Almighty Father, for the guidance and strength that he has given

the students during the duration of their clinical duty. For showering and

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gracing them with His presence and providing them with the spirit and hope

that they need to complete their respective rotations.

The friends who have inspired the group with their enthusiastic

encouragement and useful critiques towards this case study. Also, the family

members of each of the students who were willing to give their support. Lastly,

to the very own group members who individually exhausted their energy,

extended their commitment, and devoted themselves to the case study. This

group was able to observe good teamwork by helping one another and

practiced unison, which developed motivation each member used as an

advantage to complete the work that is crucial to this case study.

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 I. GENERAL OBJECTIVES

At the end of this obstetric case study, the second-year level student nurses

from Block B - RLE Group 1 of academic year 2022 - 2023 should be able to:

Skills

The student nurses should sharpen their abilities to apply appropriate

nursing interventions and medical care towards a postpartum patient. These

include monitoring vital signs, assessing the condition of the patient, managing

the patient’s concerns (pain, discomforts, and the like), as well as learning to

utilize the OB forms. Using the nursing process, student nurses are required to

plan and deliver safe, appropriate, and holistic patient care that would aid

the patient in quick postpartum recovery. Furthermore, they must be able to

execute the 10 rights of medication administration to ensure that no

medication errors would occur. This case study ought to be able to help the

student nurses develop the skills, personality, and way of thinking necessary to

deliver the right nursing care for women and children while making sure that

the Ignatian values of Magis and Cura Personalis are upheld when performing

the duties.

Knowledge

With the help of this case study, the student nurses should be able to

apply the theories, guidelines, and skills learned in maternal and child health

nursing to health promotion, health restoration, health maintenance, and

rehabilitation. Furthermore, it is expected that student nurses will gain a better

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clinical understanding in terms of the concepts on cesarean births and its

implications, postpartum recovery, and postpartum stress. The rationale,

indications, contraindications, adverse effects, and pharmacokinetic and

pharmacodynamic characteristics of the pharmaceuticals in the case study

should be internalized and familiarized by the student nurse. Additionally, the

student nurses must be able to use the nursing process to create three nursing

care plans that will improve their patient’s' care and well-being.

Attitude

This obstetric rotation should assist student nurses in self-development and

character development. When caring for women and children, they must be

able to adhere to the nursing core values executing nursing responsibilities.

They must be able to build trust and rapport with their patients and

communicate effectively. The student nurses must be able to ensure a trusting,

respectful, and collaborative working relationship with the client, support

systems, and all the inter-, intra- multi-disciplinary, and multi-cultural teams

working in Maria Reyna-Xavier University Hospital (MRXUH). They should express

ongoing competence, development, and a willingness to learn to pursue a

lifelong learning in order to stay current on national and global developments

in motherhood and childcare.

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 II. SPECIFIC OBJECTIVES

To be able to achieve the objectives, the student nurses need to perform

certain specific actions to reach their specific general goals or objectives.

Therefore, At the end of this obstetric case study, the student nurses from Block

B - RLE Group 1 of the academic year 2022 - 2023 will be able to:

SKILLS

To achieve the general objectives under the aspect of skills, the student

nurses should be able to:

● Utilize the nursing process to develop three nursing care plans with

incision pain due to the patient’s post-cesarean delivery and

anemia secondary due to acute blood loss.

● Assess the patient regarding the patient’s physical discomfort.

● Develop the communicative and professional qualities necessary

to provide quality nursing care.

KNOWLEDGE

For the general objectives under knowledge to be completed, these

necessary specific objectives should be followed:

● Apply the theories, guidelines, and skills learned in the nursing care

of the patient due to patient’s ncision pain and blood loss as being

concerned with promoting postpartum recovery.

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 ● Become more knowledgeable about the anemia secondary to

blood loss and their causes.

● Increase clinical understanding, internalize and familiarize the

drug study of the case and these are the following: Co-Amoxiclav,

Tramadol, Rexidol Forte Paracetamol, Ketorolac, Celecoxib,

Lactaflow, and Bearse tab.

ATTITUDE

The necessary actions need to be performed such as the following:

● Demonstrate willingness to effectively communicate with the

patient regarding any concerns about patient’s condition.

● Execute the duties and responsibilities for the student nurses to

create a NCP, one open being an admin needed by the patient

with a sense of professionalism.

● To demonstrate the spirit of a real Atenean nurse, magis' heart,

and cura personalis.

● To obtain an attitude that is open to learning and accepting

positive criticism.

III. SIGNIFICANCE OF THE STUDY

This case study will benefit pregnant mothers and postpartum

mothers, to the Patient and Patient’s family, Healthcare

Providers/Professionals, Student nurses, Clinical instructors, Nursing

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Education, Future Researchers who are gathering data in such cases,

Nursing Research, and Nursing Practice.

Pregnant mothers or postpartum mothers

Through a thorough analysis and assessment of the case, it will also

provide the patient with a deeper understanding of the patient’s own

condition that can assist in alleviating the patient’s concerns related to

the patient’s condition. As it offers an analysis of the problem, this case

study may give extra information for treating postpartum and/or Post CS

mother.

To the Patient and Patient’s family

This case study may help the family gain a better understanding

of the patient's condition and serve as a reference for them on how to

provide proper care and spiritual and emotional support. This case study

will also serve as a reference for providing proper care to postpartum

patients and their partners who are planning to produce another child

in the future or to those expecting or planning parents.

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Health Care Providers/Professionals

This case study, which analyzes the condition, may offer extra

guidance for those who care for postpartum patients. Additionally, it will

be used as an additional resource to help them create nursing

interventions that will better manage and care for other patients with

the same problem. These can be used to create nursing and medical

management plans for future postpartum patients using the information

presented.

Nursing Students

This case study will aid nursing students in better understanding by

taking into account and learning from the full course of nursing care

given to postpartum patients, including the interventions and treatments

used. Students that spend time in a hospital will be more equipped to

treat individuals who have the condition with nursing care. Additionally,

it will be used as an additional resource to help them create nursing

interventions that will better manage and care for other patients with

the same problem. The students' performance will be enhanced through

the use of the data as this will assess the student nurse's academic

performance, approach and attitude, clinical abilities, and level of care

provided within the allotted time limit. Furthermore, nursing students may

be given access to this case study as additional teaching and learning

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material for use in the context of nursing education, such as in the

College of Nursing, during class discussions and research projects.

Clinical Instructors

The case study's findings will aid clinical instructors in assessing the

standard of care provided by nursing students as well as their academic

performance, attitude, and abilities in regard to the procedures that

should have been performed in the OB Ward Area with the patient

diagnosed with Anemia secondary to Acute blood loss. The theories,

recommendations, and techniques learned in maternity and child

health nursing, the drug analysis of the case, and the delivery of a variety

of nursing treatments and medical care will all be covered in this study.

The clinical instructor's teaching-learning and evaluating methodologies

would also be developed as a result of the findings in order to improve

the students' knowledge, abilities, and attitudes within the constraints of

the OB Ward procedures. Furthermore, this will help by supplying

pertinent data that can be used in nursing seminars and training sessions

for other licensed nurses about how to care for postpartum patients

Nursing Education

Giving other professional nurses pertinent information that can be

used in nursing seminars and teaching programs about anemia

secondary to acute blood loss will be advantageous. Furthermore,

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nursing students may be given access to this case study as additional

teaching and learning material for use in the context of nursing

education, such as in the College of Nursing, during class discussions and

research projects.

Future Researchers

The material provided could be used as a guide for conducting

more case-related research. By providing basic knowledge and an

overview of the nursing care management of postpartum and/or Post

CS patients, this study will also serve as a platform for further research.

Other readers, particularly those with comparable instances, will learn

about the many nursing care interventions and health education plans

that will assist clients in providing independent care and achieving the

highest level of health.

Nursing Research

The management of postpartum patients with Secondary Anemia

caused by Acute Blood Loss is the subject of previous studies and

research, which this case study complements. Additionally, it will support

the growth of new knowledge and information about the various

evidence-based interventions that nurses use to deliver top-notch care

to patients with secondary anemia. It might also be used as a resource

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by future researchers to help shape the discipline of nursing research,

giving more depth and specifics to other developments in the field of

nursing pertaining to the care of patients with secondary anemia.

Nursing Practice

This case study may be used as a guide to improve the various

nursing interventions and management strategies developed and

applied in the delivery of care to postpartum patients who have

secondary anemia as a result of acute blood loss. Additionally, this will

help determine which nursing interventions and techniques are most

effective in promoting wellness, preventing illness, regaining health, and

rehabilitating postpartum patients with Anemia Secondary to Blood Loss.

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IV. SCOPE AND LIMITATIONS

The scope and limitation of the study is based on the general physical

state and health status of an obstetric patient of Maria Reyna - Xavier

University Hospital (MRXUH).

Scope

- The study's primary subject is Patient J.C.J.A, a 29-year-old

postpartum obstetric patient who was hospitalized at Maria Reyna

Xavier University Hospital Inc. on September 15, 2022, with incision

pain due to cesarean section as a main complaint. This study

includes nursing evaluation information, pathophysiology of the

ailment, a list and individual analysis of each medication the

doctor ordered, nursing care plans, and discharge instructions to

help with the patient's treatment and recovery.

Limitations

- The student nurses were unable to obtain the patient's consent for

the case study since they were able to render care for the patient

in the hospital for three days only. Due to time restrictions, the

student's data collection was limited. The students could only

gather data and carry out processes on the dates of September

19, 20, and 26. The patient and the patient’s family were unsure of

how they would be discharged because of their financial position.

Only after the student nurses had completed their duty were they

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able to select a patient for their case study. The only tasks that the

student nurses could perform were taking vital signs and

administering drugs. The student was also able to get the patient's

laboratory results and follow the doctor's instructions and

directives. The patient's lab and fecalysis results were complete as

well. Since the X-ray and ultrasound were unavailable, the student

nurses' awareness of other important information was constrained.

The available resources acquired provide the foundation for all

information used in and for this OB case study.

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V. DEFINITION OF TERMS

1. Obstetric. Medical processes or procedures as it relates to

childbirth and how the female body must be cared for during.

2. Cesarean. Surgical process of delivering a baby that involves

creating an incision that will act like the exit point of the baby on

the abdominal wall

3. Iron deficiency anemia. A type of anemia that occurs after giving

birth largely due to acute bleeding

4. Infection. The invasion of foreign pathogens in the body in such a

way that affects the homeostasis of the body

5. Perilight. Light therapy used on the perineal area after giving birth

to reduce swelling and inflammation

6. Complete Blood Count (CBC). A blood test used to assess for a

wide range of conditions based on blood composition values.

7. Nulliparous, Term, Singleton, Vertex (NTSV). Is a measure of

survival for babies born at 37 weeks gestation, must be the first

pregnancy, singular baby, and in vertex positioning.

8. Related Learning Experience (RLE). Experiences that provide

opportunity to apply theoretical learnings and develop skills

related to the nursing course.

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9. Body Mass Index (BMI). The ratio of weight and height squared

which is used as a tool to indicate a person’s level of health

10. Pallor skin. Lightness or paleness of the skin that could be a

symptom of illness or disease

11. Cyanosis skin. Blue or purple tint on the skin that is a sign of low

levels of oxygen that could be a symptom of illness

12. Skin purpura. Also known as blood spots as they appear to be

reddish to brown spots on the skin

13. Heme. A component of hemoglobin that functions to bind oxygen

to the red blood cell to be brought to the tissues.

14. Blood loss. Loss of blood through damage to blood vessels

15. Apoferritin. Is a protein that mainly works in binding with and

storing iron

16. Iron-scavenging proteins. A type of iron usually triggered through

lack of iron in ones body. The function is to look for iron within the

body to address the deficiency found

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VI. INTRODUCTION

The birthing process is a physically demanding and emotionally,

cognitively, socially, and culturally significant event because this is a

process that the baby leaves the uterus (Hutchison J., 2022). To the

couple or parents of the baby, it’s one of the magical, memorable, yet

terrifying experiences that they could ever witness. Magical and

memorable because after 9 long months, they can finally hold their

precious baby in their arms; yet terrifying in a sense where it requires a

huge amount of responsibility and tasks for the new parents. Giving birth

is not an easy task because it requires a lot of body functions and

processes. Moreover, the mother needs to endure excruciating pain

before she feels the wave of relief of having her baby in her arms

(Namujju J., Muhindo R., Mselle L., et al, 2018).

Early and active labor, infant birth, and placenta delivery

are the three stages of labor or childbirth. In stage 1: Early and Active

Labor, the mother feels regular, persistent contractions. They dilate,

soften, shorten, and thin the cervix so the baby may enter. Early labor

and active labor make up the longest stage of labor. Early labor dilates

the cervix. Regular, mild contractions are anticipated. As the cervix

opens, pink or crimson vaginal discharge may be seen. This is likely the

pregnant mucus plug. The cervix dilates from 6 to 10 cm during active

labor. In this stage or part of labor, the mother may feel stronger, more

regular, closer contractions. Stage 2 is the baby's birth. As the baby's

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head and body are delivered, the mother must push harder. After the

baby is born, we deliver the placenta. The woman will have mild, closer-

together contractions. Contractions aid placenta delivery. The mother

must push softly to deliver the placenta. The mother also may be given

medicine to promote uterine contractions and minimize bleeding

before or after placenta delivery (Hutchison J., 2021).

However, not all mothers are given the chance to have this type

of delivery due to complications or maybe just because of personal

preference. By definition, a cesarean section (C-section) is used to

deliver a baby through abdominal and uterine incisions. 31.7% of all

births and 25.6% of the NTSV ("low-risk") population experienced

cesarean deliveries in 2019, according to preliminary statistics from the

Centers for Disease Control and Prevention. One of the primary

advantages of having a C-section is the increased safety for both the

mother and the child. For most doctors, a C-section is the safest option

when a vaginal birth poses hazards to the mother or the infant

(Zakerihamidi M., 2015). However, undergoing this procedure involves

some risks like infection, blood loss, blood clot, weakens the uterine wall,

fetal injury, etc. A full recovery from C-section can take between four

and six weeks. In order of occurrence, the most frequent indications for

primary cesarean delivery include labor dystocia, an irregular or

ambiguous (formerly, unsettling) fetal heart rate trace, fetal

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malpresentation, multiple pregnancies, and probable fetal macrosomia

(ACOG, 2014).

To begin a C-section, the mother must first be sedated. Due to the

widespread use of epidurals in planned C-sections, most mothers are

fully conscious throughout the entire process. However, some mothers

undergo the process while unconscious under general anesthesia. An

antiseptic will be used to clean their abdomen, and an oxygen mask

may be placed over their mouth and nose to improve the oxygen supply

to their child. The clinician next wraps a sterile drape around the area of

the incision and over the mother's legs and chest. Finally, the caregivers

cover their bodies with a clean curtain or drape. The mother's skin will be

cut open, and an incision will be made into the abdominal wall by the

obstetrician. The incision made by the doctor could be either vertical or

transverse. Next, the doctor or midwife makes a slashing motion in the

mother's uterine wall that measures between 3 and 4 inches. You can

also make a transverse or vertical cut. Once the incisions are made, the

obstetrician may safely remove the baby. After the placenta has been

removed and the umbilical cord has been cut, the incisions are closed

with stitches or staples. The procedure for an emergency C-section is the

same as any other, but the pace at which the baby is delivered varies.

The average time for a planned C-section delivery is between 10 and 45

minutes. In just a few minutes, the doctor performs an emergency C-

section and removes the baby (Louis H., 2018).

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 Given this strenuous and complicated surgery, there are bound to

be complications that will be experienced by the mother. Severe

maternal morbidity is linked to CS delivery, including obstetric

hemorrhage, hysterectomy, anemia, blood transfusion, and infection.

However, the most common complication that is being experienced by

the mothers is anemia due to blood loss (Acmaz G., Aksoy H., Babayigit

M., et al, 2015). During a vaginal birth, a woman may lose up to 500 mL

of blood, but in a cesarean delivery, the mother may lose up to a liter or

1,000 mL (Morgan J., 2019). Given this amount of lost blood, the mother

is bound to suffer from anemia. When there aren't enough red blood

cells in the blood, a condition known as anemia sets in. The body may

experience this if it is unable to produce enough red blood cells. When

you bleed, your body loses red blood cells faster than it can produce

new ones (Mayo Clinic, 2019).

Anemia is the lack of sufficient red blood cells, which carry oxygen

to the body's tissues. Weakness and fatigue are common symptoms of

anemia. Each kind of anemia has its own root cause. Both short- and

long-term, mild and severe forms of anemia exist. Postpartum anemia or

PA is often the one associated with postpartum mothers. Depression,

cognitive impairment, weariness, decreased work performance,

weakened immunity, and inadequate breast milk are all linked to

anemia in the postpartum period (Butwick A., Escobar G., Li S., et al.,

2018). Serious side effects, including fatigue, headaches, restless legs

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syndrome, and cardiac difficulties, can result from anemia that goes

undiagnosed or untreated. Anemia can also increase the severity of

other chronic illnesses or decrease the effectiveness of therapies for

postpartum mothers. Oral iron supplements, blood transfusions, and

dietary modification rich in iron and electrolytes are often used to treat

postpartum anemia (Mayo Clinic, 2019).

Last 19th and 20th of September, the students of RLE Group 1 from

block NB were exposed to the obstetrics ward of Maria Reyna Xavier

University Hospital. Each of them was assigned to a specific patient,

however a certain case caught their attention; the case of J.C.J.A who

was a 29-year-old postpartum mother. The patient was admitted on Sep

16, 2022, and gave birth to a healthy baby girl the following day,

September 17, 2022 via C-section delivery. The patient was ordered to

have the said delivery due to the fetopelvic disproportion. After the

delivery, the patient was diagnosed with anemia secondary to acute

blood loss. Student nurses were assigned to this particular case, and they

were able to obtain necessary information about the patient and proper

nursing interventions were performed to aid the said patient. The

students of RLE group 1 decided to have this patient case study because

it focuses on the maternal side of the OB ward and a case wherein it is

common or frequently being handled by nurses in the OB ward. Through

this case study, we will be provided with vital information and learn

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 necessary knowledge or interventions that will help in their growth as

student nurses.

VII. ASSESSMENT

A. Narrative Assessment

On September 15, 2022. Patient J.C.J.A is a 29-year-old post-cesarean

female currently residing in Kabulawan Lagonglong Misamis Oriental. The

patient's religion is Pentecostal and is currently married to Mr. J.M.A. Patient

was admitted to Maria Reyna - Xavier University Hospital Inc. with a chief

complaint of labor pain. The patient’s vital signs upon assessment are the

following: heart rate of 79 bpm, respiratory rate of 17 cpm, blood pressure of

110/90 mmHg, temperature of 36.4 degrees Celcius, oxygen saturation of 96%,

and BMI of obese.

Patient J.C.J.A is G3P2. In terms of the patient’s pregnancy, the age of

gestation was 39 weeks and 1 day with a cephalic presentation during the

active phase of labor. In addition, patient J.C.J.A was put into cesarean

section because of cephalopelvic disproportion (CPD). CPD is when the size

of the mother's pelvis and the size of the baby's head do not match up. Thus,

slowing down or stopping vaginal delivery, making it dangerous or impossible.

Correspondingly, on September 17, 2022, at 7:46 AM, patient J.C.J.A

successfully delivered a healthy baby girl via cesarean section. Furthermore,

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the patient takes Celecoxib 200mg, PO.BID for anti-inflammatory, Rexidol Forte

500mg, PO.BID for pain relief, Co-Amoxiclav 1g, PO BID antibiotic to treat

infections, Tramadol 50mg, IV a pain reliever, Ketarolac 30mg, IV for anti-

inflammatory, Bearse tab 50g, PO TID to promote digestion, and Lactaflow

500mg cap, TID for the improvement of breastmilk flow. Furthermore, during

the intervention, the patient was hesitant to do perineal care, irritable with her

catheter, and verbalized bodily discomfort and headache due to the doctor's

order for a soft diet.

Patient J.C.J.A has no history of family illnesses. The patient's obstetric

history is G3P2 (upon admission) and had a total of 8 prenatal visits. Moving on

to gynecologic history, the patient’s last menstrual cycle was on September

17, 2021. Menarche started when the patient was 17 years old, with a menstrual

cycle interval of 28 days. The duration of menstrual flow is 3 days with a

moderate amount of flow and reported menstrual discomfort or

dysmenorrhea. A normal vaginal discharge with a clear and mild odor. The

patient is also sexually active. Furthermore, patient J.C.J.A has no history of

reproductive-related surgery and did not use any reproductive family planning

methods. The patient appears to be in good appearance and is able to

answer all questions. The patient also practiced good hygiene through proper

sanitation and clean clothing as observed when the patient wore a clean and

tidy hospital gown. The patient's hair has no lice/eggs and is black and medium

in length. The patient's speech status is normal. Furthermore, patient J.C.J.A

complains about pain on the incision site, with a pain quality of sharp and

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shooting and radiating at the abdominal area specifically in the incision site.

The patient also verbalized a pain severity of 8-9 on a pain scale with 0 being

the lowest and 10 being the highest. The patient also verbalized pain

frequency every time there is ambulation and a change of position. In

addition, the patient also verbalized a headache located on the forehead

with a frequency of 1-2 times a day. The patient's head and scalp appeared

to be in symmetry (round/egg-like) and has an even distribution, a hair

thickness of 0.22mm per hairline, and semi-oily hair. No lesion was observed.

In terms of the assessment of the patient's eyes and ears, no signs of

edema in the eyelids or sclera were observed. The conjunctiva is in good

condition with a white sclera and pinkish conjunctiva. There are no spots

before the eyes and no presence of diplopia or double vision. In addition, the

patient's ear condition is normal and can hear sounds correctly. Furthermore,

the patient’s nose is also in good condition; it is able to distinguish smells and

has no evidence of epistaxis. In addition, the patient's mouth has dry lips, white

teeth with slightly pale gums, and a slightly pale tongue. There is no presence

of gingival gum hypertrophy and there are no lesions present. The patient also

practiced good mouth hygiene by brushing of teeth.

In terms of the assessment of the neck, lymph nodes, and breast, patient

J.C.J.A. exhibits negative thyroid hypertrophy and no palpable lymph nodes.

The patient has no changes on the areola. It is round and brown in color with

the presence of small Montgomery tubules. Nipples are nearly equal bilaterally

in size. The patient’s breast is also large with a presence of yellowish colostrum.

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The patient could breastfeed the baby 4-13 times a day. Moving on to the

assessment of the abdomen before the delivery, unfortunately, the group was

not able to get the fundal height, pelvic measurement, and results of Leopold’s

Maneuver due to the fact that the patient is post-cesarean. In terms of the

assessment of circulation and respiration, the patient exhibits negative edema

on the ankle and leg. No history of hypertension. The patient verbalized no

numbness or tingling in the extremities. No change in the frequency and

amount of urine. The patient was not assessed for the homan’s sign. The

patient’s blood pressure when lying is 120/80 (right) and 110/80 (left). The group

was unable to get the blood pressure with the patient sitting due to the fact

that the patient is unable to sit. The patient’s heart rate is 97 bpm with a

consistent rhythm. Capillary refill is normal–pink tone returned to blanched nail

beds in less than 2 seconds when pressure is released. The patient’s nails are

clean with pink tones. There is a 160-degree angle between the nail base and

the skin. No cyanosis, pallor, and varicosities were observed. The patient’s

mucous membranes appeared pale red. For the patient’s respiration, it is 17

cpm with a normal depth. Chest goes up and down equally when breathing

in and out. No nasal flaring and abnormal breath sounds were observed. The

patient also exhibits negative cyanosis and clubbing of fingers. The patient

does not have a cough and dyspnea. However, the patient has a history of

asthma. Additionally, the patient is a non-smoker and non-user of respiratory

aids and oxygen.

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 Moving on to the assessment of the patient’s food/fluid intake, patient

J.C.J.A.’s eats 3 times a day with a usual diet of rice, meat, and fish. The last

meal intake was on September 20, 2022 (6:30PM). The patient verbalized no

loss of appetite and no occurrence of nausea and vomiting. There is also no

allergy/food intolerance. The patient exhibits no heartburn and indigestion. No

problems with mastication and swallowing. No use of diuretics. The patient’s

skin is mobile with elasticity. When pinched, it would go back to its original

shape immediately. Recoil is immediate. Mucous membranes are slightly dry.

Lastly, no hernia/masses were palpated. In terms of the patient’s elimination,

the patient defecates at least once a day. The last elimination was on

September 27, 2022. The stool is brown, firm in texture, unpleasant in smell, and

has sausage-like characteristics. The patient has no history of GI bleeding,

hemorrhoids, and constipation. No use of laxatives. The patient’s usual voiding

pattern is 3-4x a day. There is also no verbalized pain, burning, or difficulty in

voiding. No history of kidney/bladder problems.

In terms of activity and rest, unfortunately, the patient’s usual activities,

hobbies, leisure time activities, and limitations imposed by the conditions were

not disclosed by the patient. Talking about sleep, the patient sleeps around 4-

6 hours a day with 1-2x of nap. No use of sleeping aids. However, the patient

has difficulty sleeping due to incision pain. The patient also verbalized that

there is an occurrence of headache and incision pain that would result in sleep

disturbance. Moving on to ego integrity, the patient verbalized stress factors

which include being unable to eat and refusal of catheter. Patient deals with

25
these stress factors by sleeping and resting. The patient also did not disclose

financial concerns and lifestyle information. However, the patient appears

calm, withdrawn, and irritable due to the conditions. Moving on to safety, there

are no reported allergies, sensitivities, arthritis, and unstable joints. No history of

STD, blood transfusion, accidental injuries, fractures, and dislocations. The

patient recently experienced back problems during pregnancy. Lastly, there

are no changes in moles and enlarged nodes.

In terms of social interactions, as mentioned above, the patient is

married and living with family. There is also a reported support system. Patient

verbalized problems on pain, headache, restlessness, hunger, and stress. The

patient is literate with a college degree having Cebuano as a dominant

language. Currently, the patient exhibits an incision site on the symphysis pubis

due to cesarean surgery. During the admission of Patient J.C.J.A. at Maria

Reyna-Xavier University Hospital, the patient underwent CBC and urinalysis.

Results and interpretation would be discussed in the later part of this paper.

VIII. LABORATORY RESULTS

The client has undergone Complete Blood Count and Urinalysis. These

are blood tests that hospitals utilize to determine a client’s current overall

health and well-being. Both especially detect disorders like anemia, leukemia,

and infection. It is composed of tests that cover the different parts of the blood.

Our client is a post-CS mother and possible disorders and illness that could

26
affect these mothers are usually known by the CBC. Additionally, the client has

also lost twice as much blood as in mothers under normal vaginal delivery,

which is indeed quite a lot already, let alone the CS mothers (Morgan, 2018).

Our client also took the urinalysis test, which is a test of a patient’s urine. It

involves the testing of urine’s appearance, contents or presence, and

concentration. The client also has to take this test because of the same reason,

and post-care after CS is a need for delicate care, and the patient might also

need a catheter. And, using a catheter can be quite a risk as it can be a

medium of bacterial infections that could enter the urinary tract of the mother.

Legend:

● * = unit

Table I. Hematology

Hematology

Complete Blood Count

Test Name Results Normal Range Interpretation

WBC 18.3* 4,500 - 11,000 The abnormal

per μl result is visible in

the table since

the WBC count

surpasses the

27
 normal range. It

indicates that the

client may have

an infection that

has caused

inflammation as

its response

(Chen & Deng et

al, 2017). Again,

our client is a

post-CS mother,

which would

require an

incision to deliver

the baby. C-

sections are

generally safe,

but it could also

cause risks for

bacterial

infection. For our

client, bacteria

may have

28
 entered the

incision wound,

and caused

evidence of

infection (Luo,

2017).

RBC 3.61* 4.0 to 5.2 x The RBC count

10*12/L appears to be

lower than the

normal range.

The findings of

the RBC count

then suggest that

the client may be

suffering from low

oxygen levels

(Sampson &

Johnson, 2022).

Additionally, a

diagnosis of iron

deficiency

anemia is very

29
 likely since the

client is a post-CS

mother who lost a

lot of blood

during delivery,

which is roughly

twice the blood

loss in normal

vaginal delivery

(NVD) (Morgan,

2018). It is due to

the need for

incision in the

uterus and the

large amount of

blood pumped to

the uterus during

the CS delivery.

Last indication of

the low RBC is

that the

inflammation

from the incision

30
 wound infection

prevented the

body from using

stored iron, which

would have

produced

enough healthy

RBC (National

Institute of

Diabetes and

Digestive and

Kidney Diseases,

2022).

Hemoglobin 9.8* 11 - 14 The levels of

grams/deciliter hemoglobin is

lower than

normal, which

indicates that

there is a

shortage of iron in

the client’s body,

especially since

31
 the client had lost

twice as much

blood in

comparison to an

NVD (Morgan,

2018). It also

indicates low

oxygen levels,

which is good

evidence on why

the client

reported

complaints of

headache and

nausea (Mayo

Clinic, 2018).

Lastly, it further

indicates the

evidence of iron-

deficiency

anemia (Mayo

Clinic, 2022).

32
Hematocrit 30.2* 33% - 44% The result

appears to be

lower than the

normal range. It

can be

interpreted as the

client suffering

from low supply

of healthy RBC,

as shown in the

low RBC count as

well. And it also

furtherly indicates

evidence of iron-

deficiency

anemia (Young,

2021).

WBC: 80 3.7 - 11.6 The neutrophil

Neutrophils count is also seen

to be abnormal,

wherein it is

above the

33
 normal range.

The increase of

neutrophils,

which focus

directly against

bacterial

infections,

furtherly indicates

evidence of

infection (Witter

et al, 2017). The

incision wound

might have been

infected from

various modes of

contact from

contaminated

hand of

caregiver or the

surgical

instruments,

bioaerosols, and

bodily bacteria

34
 (Johns Hopkins

Medicine, 2019).

WBC: 11* 2-5 The lymphocyte

Lymphocyte count is seen to

be higher than

the normal

range.

According to the

previous

interpretation on

the WBC count, in

general, it was

indicated that

the client has a

bacterial

infection and

resulted in an

inflammatory

response (Chen

& Deng et al,

2017). Hence, the

abnormal result

35
 of the

lymphocyte

count.

WBC: Monocyte 17* 2-5 The result of the

monocyte count

is also seen to be

above the

normal range.

The client's

bacterial

infection had

previously been

linked to an

inflammatory

response. This is

where

monocytes come

into play. They

aid in wound

repair as it

resolves

inflammation

36
 (Kratofil et al,

2016). The client

has an infected

incision wound,

which could

explain why the

monocyte count

is significantly

high as it

responds to it.

RDW 14.9 12%-15% Lastly, the table

shows that RDW

yielded a normal

result. Hence, the

client's blood

cells are similar in

size at most

(MedlinePlus,

n.d.).

37
IX. PATHOPHYSIOLOGY

A. Narrative Pathophysiology

Patient J.C.J.A was diagnosed with anemia secondary to blood loss

after delivery. This diagnosis is normal especially in mothers who underwent

cesarean section because these mothers are bound to lose more blood

because they undergo a surgery to successfully deliver the baby. Despite the

body’s Central Nervous System’s efforts to make up for this loss, it is

unavoidable for the most part due to the inevitable blood loss. The

predisposing factor then is the age of the mother which is 29 and gender. Age

is a predisposing factor because as a human being grows older the

hemoglobin levels tend to be low (Smith D., 2000). Additionally, gender is also

a factor because anemia is a normal occurrence for women because they

experience hormonal imbalances, menstruation, pregnancies, etc. (Christian

P., 2021). The patient also experienced precipitating factors such as the

pregnancy, cesarean delivery, postpartum stress, restlessness, weight, and

J.C.J.A’s GP. The demand for iron increases during pregnancy because of the

increased blood volume. Iron is used by your body to produce additional

blood, which carries oxygen to your baby. Iron deficiency anemia can

develop if a woman does not have adequate iron storage or does not

consume enough iron when pregnant. Additionally, during CS delivery, the

mothers lose more blood because the baby is delivered via CS where a mother

could lose 1,000 mL of blood. The stress, restlessness, or state of the mother can

also affect the hemoglobin levels because it can affect certain mechanisms

38
and the way they perform their respective functions and routines (Beard J.,

Hendricks M., Perez E., et al., 2005). All of these factors then lead us to the very

essence of this pathophysiology which is anemia.

The start of this pathophysiology begins during the rapid, massive acute

blood loss that was due to the horizontal cesarean section of J.C.J.A. As

mentioned above, this occurrence is very normal especially for CS mothers.

Red blood cells contain iron in the blood. Therefore, if you lose blood, you lose

iron. Apoferritin, responsible for the binding and storing of iron, will experience

a lack in available iron to bind with thus forcing iron-scavenging proteins to

target any available sources of Iron in the body. One of the main sources of

iron in the body is the sclera, thus being a main target of these iron-scavenging

proteins. Often the result from this is known as “blue sclera” which is an indicator

of severe iron deficiency and seen as a bluish tint present in the whites of the

eye. (Hassen G., et al., 2017) The lacking iron then acts like an obstacle to heme

production thus also preventing the body from creating ample amounts of

hemoglobin. Hemoglobin serves to pick up oxygen needed by the body and

transport it to various areas along with the blood. Hemoglobin also contains

the pigment necessary to provide the blood with its well-known red color thus

a lack of it causes a fainter color to be seen, which can be observed most on

the skin of anemic patients. (Warner M., Kamran M., 2021)

The CBC results for patient J.C.J.A. reveal that the patient has RBC,

hemoglobin, and hematocrit levels of 3.61, 9.8, and 30.2, respectively. These

39
findings demonstrate that Patient J.C.J.A. has insufficient hemoglobin, which

lowers the patient's ability to produce RBCs in the bone marrow (Braunstein,

2022). When fewer RBCs are released into the peripheral circulation from the

bone marrow, RBC production in the bone marrow decreases. The end effect

of this entire mechanism is an anemia secondary to blood loss, which is the

patient J.C.J.A.'s final diagnosis. To further interpret, a patient's low hemoglobin

indicates poor oxygen delivery to the tissues, thus lowers metabolic activity

and contributes to the patient's feelings of fatigue and irritability. Additionally,

when there is a low RBC count, the blood has a noticeable faint red tint; this is

seen in patients who exhibit pallor, such as pale skin and nail beds as well as

dry lips. Eventually, low hemoglobin results in less oxygen reaching the brain,

which triggers headache and dizziness in the patient (Warner M., Kamran M.,

2021).

40
B. Schematic Diagram

41
 X. DRUG STUDY

This drug study is based on our patient who underwent post-CS, and the following drugs below accommodated the

mother with the intention of attaining health.

Generic Dosage, Classification Indications- Mechanism of Side Effects

Name Timing, Enumerate and Action Nursing
General Class
(Brand and Route underscore Considerations
and Family illustrate
Name) specific
(actual)
& Date indication
Ordered
1 gram tab,- It contains two Adults: - An antibiotic that Common: - Assess bowel

PO BID different - to treat infection on combines - diarrhea, patterns before

medicines called the incision site of the amoxicillin and - thrush, and during

amoxicillin and mother clavulanic acid. It feeling sick treatment.

Co- clavulanic which destroys bacteria - can stain - Report hematuria

Amoxiclav belongs to the - to prevent infection by disrupting the teeth (not or oliguria as high

42
 group of after operative vaginal ability to form cell permanent doses can be

penicillin. delivery walls. Clavulanic and can be nephrotoxic

acid blocks the removed - Monitor Vital signs

chemical defense, when of the patient

known as beta- brushing - observe common

lactamase, that teeth) side effects and

some bacteria immediately assess

have against it and consult to

penicillin. physician if

needed

50 mg, IV- belongs to class - has a specific- inhibits the Common: - Assess the source,

(Intravenous) opiate (narcotic) indication for moderate reuptake of the - location, and

Tramadol 50mg 4-6 analgesics. to severe pain.natural constipation characteristics and

hourly by the Considered a class IVneurotransmitters - feeling of location of pain

intravenous drug by the FDA. norepinephrine warmth - assess the pt.’s

43
route - Due to possible abuse (noradrenaline) - itching level of

and addiction and serotonin, ad - muscle pain consciousness and

potential, limitation to its also binds weekly - loss of pain intensity

use should be for pain opioid receptors strength - overdose will lead

that is refractive to other blocking the - drowsiness to seizures and

pain medication such transmission of pain - feeling cold respiratory

as non-opioid painsignals to the brain. depression

medication.

44
 Generic Dosage, Classification Indications- Mechanism of Side Effects Nursing
Name Timing Enumerate Action Considerations
General Class
(Brand and Route and
and Family illustrate
Name) & underscore
Date specific
Ordered indication
30 mg, IV - A class of - a non-steroidal - inhibits prostaglandin Common: - Blood pressure

(Intravenous) medications anti- synthesis by -headache should be

30 mg every called NSAIDs. It inflammatory competitive blocking -dizziness monitored closely

6 hours, not works by stopping drug and hasof the enzyme -constipation during the

Ketorolac exceeding the body’s antipyretic, cyclooxygenase - mouth sore initiation of NSAID

120 mg in 24 production of a analgesic, and- it is a non-selective - sweating treatment and

hours. substance that anti- COX inhibitor. It is - drowsiness throughout the

causes pain, inflammatory considered a first - diarrhea course of therapy.

fever, and properties generation NSAIDs - in case of

inflammation hypersensitivity, be

45
- it is indicated for sure that

short term emergency

management of equipment is

acute pain (for available

this case the - to maintain

incision pain of serum levels

the mother) that effectively,

requires the administer it every

caliber of pain six hours

management - report any signs

offered by of swelling in the

opioids. ankles, itching,

sore throat, easy

bruising.

46
 200 mg, CAP Class: NSAIDs -used in in - The mechanism of - headache - pt. allergic to or

PO, BID Pharmacologic improving action of celecoxib is - dizziness with a history of

class: postoperative due to selective - insomnia anaphylactic

Cyclooxygenase- pain inhibition of - HTN reactions to

2 inhibitors management incyclooxygenase-2 - peripheral sulfonamides,

Celecoxib parturients under(COX-2), which is edema aspirin, or other

patient- responsible for - pharyngitis NSAIDs may be

controlled prostaglandin - rhinitis allergic to this drug

epidural synthesis, an integral - sinusitis - Watch for

analgesia part of the pain and - abdominal immediately

inflammation pain evaluated signs

pathway. - diarrhea and symptoms of

- heart attack or

hyperchloremia stroke.

- dyspepsia - Drug can cause

47
 -flatulence fluid retention;

- back pain’ monitor pt. with

-dyspnea HTN, edema or HF

- rash - Assess pt. for CV

risk factors before

therapy

- Drug may be

hepatoxic; watch

signs and

symptoms of live

toxicity.

- Monitor pt.’s

renal function

- before starting

therapy, rehydrate

48
 dehydrated pt.

500 mg, tab - psycholeptics ; - Relief of mild to May increase action of Caffeine: -Severe liver

PO BID Belongs to the moderate pain phenylpropanolamine -Tremor damage in large

class of anilide including in increasing heart - difficulty in doses, other drugs

preparations. headache, rate. Competitively sleeping containing

Used to relieve migraine, inhibits clozapine - nervousness paracetamol & ≥3

pain and fever. backache, metabolism. Slight to - restlessness alcoholic drinks

Rexidol Forte muscular aches,moderate increase in - irritability daily.

Paracetamol and etc. serum lithium - anxiety -Limit taking

- headache caffeine-

- ringing in the containing drugs,

49
 ears food (eg,

- fast or irregular chocolate) or

heartbeat beverages (eg,

- rapid coffee, tea, cola).

breathing, -Kidney or liver

frequent problems.

urination & - Discontinue use if

stomach upset new symptoms

-increased BP. occur, symptoms

- Withdrawal & headache

symptoms eg, persists, pain

headache, worsens or lasts for

tiredness & >10 days, fever

decreased worsens or lasts for

alertness >3 days.

50
 Pregnancy &

lactation..

51
 Generic Dosage, Classification Indications- Mechanism of Side Effects Nursing
Name Timing Enumerate Action Considerations
General Class and
and Route and
(Brand Family illustrate
underscore
Name) (actual)
specific
& Date indication
Ordered
50 gram - Bearse tab belongs -indigestion - Bearse Tablet - The most - Avoid taking higher

tab, to a class of and works by common quantity than

Bearse tab
PO,TID digestives. abdominal breaking down side effects recommended dose.

distention due the fat into of bearse

to post smaller pieces; tab - Need doctor's

operative helping in food Diarrhea, consultation in

surgery digestion; soft stools, abdominal cramps,

decreasing the nausea, or blood in stools and

production of vomiting, loose motions- Assess

cholesterol and chest pain, respiratory status.

52
 by dissolving the difficulty in

cholesterol in breathing, -Take it after meals

bile; acting on palpitations and at bedtime

inner lining of may occur.

intestine and Discomfort

allowing gas may occur

bubbles to inside the

come together;. mouth.

LactaFlow 500mg A13A- TONICS: used -supplement LACTA FLOW is Uterine Monitor vital signs of

tab, PO as Tonics that improves a contractions the patient

TID flow of natural from Monitor voiding

breastmilk for supplement moringa pattern of the pt.

lactating that significantly bark Encourage the

mother increases the Cell patient to eat and

breast mutations hydrate. If effects are

53
 milk supply of caused by a evident,

nursing chemical gradually decrease

mothers isolated the dosage and

Moringa from stop

Oleifera Linn roasted

leaves are rich moringa

in seeds.

minerals, Upset

vitamins than stomach,

yogurt, 15 times gas or

more potassium diarrhea

than due to

bananas, and laxative

25 properties

times more iron

54
 than

spinach.

55
 XI. NURSING MANAGEMENT

Nursing care plans were formulated by the students who were assigned to the said case. The patient was experiencing

a lot of ailments or negative health problems after her CS delivery; hence the student nurses addressed all these concerns

and came up with a series of nursing care plans that can aid or alleviate these health concerns. These NCPs are found

in the tables below.

a. Nursing Care Plan 1

ASESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

(CITE SOURCES)

SUBJECTIVE CUES Risk for iron SHORT TERM: INDEPENDENT: -To use the available SHORT TERM:

deficiency At the end of 4 1. Teach aboutenergy to complete At the end of 4

(risk of iron anemia due tohours, the pt will energy conservation. desired activities, hours of nursing

deficiency) blood loss during have less clients and carers interventions, the pt

labor comments may need to develop will have less

56
Verbalized by the regarding dizzy 2. Assess access to the necessary abilities comments

client spells and physical healthy foods that are for task delegation, regarding dizzy

“luya akong pamati appearance rich in prioritization, and spells and physical

murag wakoy will improve. electrolytes (e.g. clustering. The client appearance will

kusog” and spinach, avocadoes, can save energy and improve (normal

“gaka lipon ko kada LONG TERM: broccoli, beans, etc.).feel less worn out with skin color).

maglihok ug At the end of one 3. Health teachingorganization and time

pakalit” week, the lab about the effects ormanagement. LONG TERM:

results of the results of iron - Examine whether At the end of one

OBJECTIVE CUES patient will show deficiency anemia. the patient's ability to week of nursing

that it is back to the acquire food limits interventions,

- Pale Skin normal levels COLLABORATIVE: them from the lab results of the

- Feeling cold and the pt. will feel 1. Inform theconsuming nutrient- patient improved,

- Tiredness more active and physician andrich, calorie- and patient feels

- Hemoglobin: less comments administer balanced meals. more active,

57
9.8 (Low) connected to the medication per - To allow the patient healthy, and free

-RBC: diagnosis is no doctor’s order and the family from dizziness or the

3.62 (Low) longer mentioned 2. Complete Blood members to be like.

Count in order to aware of the health

determine red blood problems. To improve

cells and hemoglobin the knowledge of

levels. both patient and

family to perform

necessary

interventions or

support.

- To help the patient

alleviate and get rid

of the risk of iron

deficiency anemia.

58
 - To monitor the levels

of RBC and

hemoglobin to

provide interventions

if necessary.

59
 b. Nursing Care Plan 2

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE (CITE EVALUATION

SOURCES)

SUBJECTIVE CUES Acute pain related SHORT TERM: INDEPENDENT - Application ofSHORT TERM:

to effects of labor At the end of 41. Apply warm heat reduces pain

(Incision pain) Pain and delivery hours the patientcompress by reducing pain At the end of the 4

verbalized by theprocess of CS will reports 2. Massaging the reflexes and hours’ session the

mother (Cesarean Section satisfactory pain area around the vasodilatation, patient reported

(“Sakit ako samad delivery management at incision site which improves satisfactory pain

tinahian ug mulihok level (for example, (placing fingers 2-3 blood flow to themanagement

ko”) less than 3 to 4 on a inches from the affected region. at a 3 to 4 on a

rating scale of 0 to incision site) - Muscle tissue is rating scale where

OBJECTIVE CUES 10) 3. Provide relaxed during 10 is the highest

cognitive- massage and 1 is the lowest.

60
 - Grimace Face LONG TERM: behavioral therapy treatment, which

- Uncomfortable At the end of 1for pain lessens unpleasant

- Restlessness week, a patient willmanagement. spasms and LONG TERM:

- Pain scale: express total relief (e.g., distractions) contractions.

- Day 1: 8/10 obtain from labor 4. Acknowledge - Nerve At the end of 1

- Day 2: 9/10 pain by the use ofand express compression may weeks, after the

nursing dependent acceptance of the also be lessened by given nursing

and independentpatient's massage. Also interventions, the

intervention. discomfort. enhancing blood patient

flow. was in total level of

COLLABORATIVE -To provide 3 relief obtain from

1. Administer Co- alternatives for the labor paint by the

Amoxiclav 1mg per mother, to distract use of nursing

and comfort the dependent and

61
 tab BID /per mother from the independent

doctor’s order pain. action.

2. Administer - An improved

tramadol50mg, IV nurse-patient

per doctor’s order rapport is

facilitated by

expressing

acceptance of the

patient's suffering.

62
 c. Nursing Care Plan 3

SUBJECTIVE CUES Risk for urinary SHORT TERM: INDEPENDENT: - To be able to SHORT TERM:

tract infection At the end of the 4 1. Perform palpate the urinary

(Not yet voided after and hours session the abdominal bladder via external At the end of the

removing catheter) bladder damage client will take assessment assessment. 4-hour session the

due to the necessary action 2. Assess for risks - Determines the client was able to

“wala pako kaihibladder being to urinate and befactors for UTI nature or urinate atleast

sukad sap agstretched too far able to eliminate 3. Review characteristics of the400mL-500mL

tanggal sa catheter” or too long of the risk of infection medication list bladder.

periods 4. Use of peri bottle. - Some medication LONG TERM:

OBJECTIVE CUES LONG TERM: The patient was can cause urinary

In 2-3 days, thediagnosed with retention After 2-3 days of

- Inability to urinate patient will be ableFetopelvic - A peri bottle allows nursing

- Lower abdominal to urinate without Disproportion you to gently clean interventions the

pain resulting to bulging of your private parts in client was able to

63
- No output after any furtherthe Perineum and those first few days urinate without

catheterization. complications. possible perineal after giving birth. any further

infection. - Drink six to eight complications.

5. Encourage client glasses of water daily

to drink plenty of to maintain regular,

water soft bowel motion and

6. Assess vital signs avoid discomfort of

such as temperature the stitch area in the

and blood pressure perineum.

7. Provide health - Vital signs monitoring

teaching to the client including the patient’s

on drinks or food to temperature help in

avoid (e.g. coffee, the monitoring of

tea, possible infection.

64
spices, alcohol, - Can irritate the

sodas, etc.) urinary tract

8. Encourage the - To stimulate the

patient to void if bladder to void.

possible - To provide

9. Palpation of medications if needed

abdomen to in order to aid the

determine if bladder patient in this health

is full problem.

- To determine if the

COLLABORATIVE patient voided in

previous shifts

1. Ask for doctor’s - To determine if there

advice on what are any abnormalities.

medication to

65
administer to help

the patient urinate.

2. Communicate with

other healthcare

providers regarding

the patient’s intake

and output in other

shifts.

66
 d. Nursing Care Plan 4

ASESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

(CITE SOURCES)

SUBJECTIVE CUES Nausea/Fatigue SHORT TERM: INDEPENDENT: -Vital signs monitoring

due to pain andAt the end of 4 Assess, monitor, and including the SHORT TERM:

Patient verbalizednot being able hours the patient record the patient’s patient’s

“Labad akong ulo to eat should have anvital signs temperature help in The client’s vital

maam” improved Encourage rest and the monitoring of signs stabilized and

condition and not sleep possible infection. had enough rest

OBJECTIVE CUES feel nauseated or -pt. needs and sleep

fatigued. COLLABORATIVE adequate rest and

- Uncomfortable 1. Administer Rexidol sleep to regain

expression LONG TERM: Forte Paracetamol strength back

- Restless The patient will 500mg per tab PO TID - Relief of mild to LONG TERM: After

heal quickly and moderate pain all the nursing

67
- Grimace without further for 7 days according including headache, intervention, the

expression complication. doctor’s order migraine, backache, client was able to

muscular aches, regain strength

menstrual cramps, and normal

arthritis pain, condition.

toothache & pain

associated w/

common cold &

flu.

68
 e. Nursing Care Plan 5

OBJECTIVE CUES: Obesity SHORT TERM: INDEPENDENT: - Once you have

At the end of 4 hours, 1. Encourage pt. to create a recovered from your

- Body Type: Endomorph the Pt. shows verbal light exercise plan (with c-section and no

- Weight: 78 kg understanding of the confirmation from the from longer have any pain,

- Height: 154 cm health teachings, the physician) such as it is usually safe to start

- BMI: 32.9 imparted, and can stationary jogging and low-impact exercises,

Interpretation of BMI: monitor body weight. walking. 2. Encourage pt. to such as swimming,

Obese (normal range: locomotive movements postpartum Pilates,

18.5-24.9) LONG TERM: when at home. yoga, light jogging,

In 3 months, the patient 3. Provide health teaching and low resistance

will lose 2-3 kg after regarding proper diet fit for gym work.

implementation of the pt. - To provide adequate

health teaching and 3. Encourage pt. to create a knowledge and skills

dietary plan and to have a necessary for critical

69
consistent monitoring of well- balanced meal such thinking regarding diet

body weight. as low in fat and sodium. and health so the

Take high fiber individual can make

rich foods such as green healthy food choices

leafy vegetables and fruits. in creating dietary

4. Identify and create plan

weekly goals for the pt. - Dietary plan and

having well- balanced

COLLABORATIVE: meals can speed a

postpartum mother’s

1. Refer patient to a dietitian condition. A nutrient-

or dense diet full of

nutritionist to create a more complex carbs, fiber,

enhanced dietary plan healthy fats and

protein, plus

70
 adequate hydration,

can

help heal your body. A

healthy postpartum

eating plan is the way

to go to stave off

bone loss, replenish

your iron stores, head

off hemorrhoids and

much, much more.

- Setting goals helps

trigger new behaviors,

helps guides the pt.’s

focus and helps pt.

sustain that

71
 momentum in well-

balanced diet.

- A registered dietitian

can assist with making

the best nutrition

choices for the mother

and baby, optimize

nutrition status and

achieve a healthy

weight gain during

pregnancy. After

giving birth, it is a great

time to re- evaluate

the pt.’s nutritional

needs.

72
 XII. DISCHARGE PLAN

After the patient received all the necessary treatments and interventions,

she was ordered for discharge since she was no longer finding difficulty in

doing normal activities. She has also reported that is no longer feeling any

deterioration of her health.

Medications Rationale or Nursing Considerations

Rexidol plus paracetamol500mg, PO, -Rexidol is used to treat mild to

Tid moderate pain.

Bearse tab 50 gram tab, PO,TID -Bearse tab used in digesting of

food.

Co-Amoxiclav 1 gram, PO, BID -Co amoxiclav is an antibiotic and

works by killing bacteria that cause

infections.

Exercise Patient J.C.J.A. is encouraged to do

● The mother should avoid light to moderate activities and to

heavy activities have adequate of sleep, to gain

● The mother should be back strength and have adequate

encouraged to do light supply and quality of milk.

activities only such as

walking.

73
 ● Encourage the woman

to have adequate rest

to fully restore strength

Treatment As symptoms persist, educate the

● Encourage the women client to continue medication per

to continue taking the doctor’s order in order to fully

medication per eliminate the infection and other

physician's order. abnormalities that is happening in

● Advice the woman to the mother’s body.

do a post-operative

check up to make

further assessment and

adjust treatment.

Health Teachings Well-balanced diet is very important

• Eat well balanced diet especially you are feeding your

• Drink fluids to help rid the body baby with your breastmilk, enough

drugs used in surgery. fluid intake can also help client in

• Avoid the use of alcohol regaining strength and the use of

because it may affect the quality of alcohol is strictly prohibited because

breastmilk production. alter the quality of milk production.

74
• Avoid sports or strenuous

activities 4 to 6 weeks as your

surgeon gives you clearance during

your post-operative visits. This is to

avoid any unnecessary

complications.

Outpatient follow-up Post-operative checkups are very

important to know your overall

• Encourage the patient to go to status after the delivery of your

post-operative follow-up baby, and to know what important

appointments to learn about measures needed to maintain

physical health state, have blood health.

and glucose tests performed, and

other things

Diet Proper diet is important in

● Sufficient hydration. In breastfeeding because what you

order to prevent are eating may affect the baby

dehydration, which health and growth. Explain to the

might affect how much client the proper nutrition in

milk you produce, you breastfeeding and foods that can

boost breastfeeding such as protein

75
 must replenish your rich foods, malunggay and any

fluids. green leafy vegetable. Also include

● Sufficient calories. In vitamin C supplements in the diet

order to maintain the such as Ascorbic acid, Kirkland

same caloric intake Vitamin C etc.

when nursing, women

should try to expend an

additional 300–500

calories per day (or 450–

500 calories while

breastfeeding

exclusively).

● Selection of foods. Pick

a variety of lean

proteins, fresh produce,

whole grains, healthy

fats, and lean proteins.

Spirituality Hope may be maintained with the

● Support the patient with aid of faith, and hope can be a

their faith and tradition source of support.

76
● Listen to queries and

concerns without going

to your own stuff.

● Listen to patients'

complaints without

immediately judging

them.

77
 XIII. PROGNOSIS

LEGEND:

Excellent (5) Strong evidence of efficacy and major therapeutic benefit,

strongly recommended; Patient performs exceptionally well, is cooperative

and actively responds to nursing interventions, and is independent.

Very Good (4) Strong or moderate efficacy data, but little therapeutic benefit;

generally recommended. Patient performs well; responds well to nurse

interventions; is largely independent but occasionally needs support.

Fair (3) Insufficient proof of efficacy or benefit does not exceed the risks or

drawbacks (adverse events, costs, etc.).

Poor (2) Moderate evidence against efficacy or for ill result, not generally

advised; Patient performs poorly; does not respond to any nursing intervention;

is dependent on others.

Very Poor (1) Patient does not perform; does not respond to nursing

intervention; is highly dependent on others.

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 Criteria 5 4 3 2 1 Justification

A. Physiologic The patient comprehends

response of the ✓ and actively responds to the

body to the nursing interventions

disease process performed.

B. Relief of the After being rendered by

symptoms ✓ nursing care and medical

associated with management:

the disease ● The patient

condition manifested a pain

scale of 3 over 10 and

will experience a

disappearance of

discomfort due to the

labor and delivery

procedure.

● The patient was able

to urinate without any

further complication;

● The patient shows an

improvement if iron

79
 levels as evidenced

by laboratory results;

● The patient’s vital signs

stabilized and the

patient was able to

regain strength and

return to a normal

condition.

● Patient will lose 2-3 kg

after 3 months by

following the health

teaching and self-

discipline.

C. Performance of The patient is able to

daily living of undertake daily tasks, such

the patient ✓ as eating with a healthy

during appetite, being able to talk

confinement. without any problems, being

able to breastfeed her child,

and being able to walk.

D. Complaint of Patient does not comply

the patient to with regards to the use of

80
 the medication ✓ peri light as well as the

and therapy installation of catheter.

E. Adequacy of ✓ Patient is expected to not

rest periods and have adequate rest and

sleep sleep due to the reason that

the patient’s child is

breastfeeding as well to her

as the patient was attending

to the baby’s needs.

F. Patient’s Significant others

significant demonstrate full

others behavior ✓ cooperation and

regarding the comprehension regarding

health teaching health education, nursing

given by intervention, and medical

healthcare treatment provided.

provider

G. Patient’s The patient demonstrates

perception to comprehensive

the situation comprehension of the

✓ situation by complying with

81
 the nursing actions and

drugs administered.

H. Patient’s social The patient is awake and

interaction cooperative. As a safety

✓ precaution, the patient must

also be monitored for

strange activities and daily

demands.

FORMULA:

[Total number/total number of criteria (40)] x 100 = Total percentage (%)

EXCELLENT (n) 15/40 x 100 37.5%

VERY GOOD (n) 12/40 x 100 30%

FAIR (n) 0/40 x 100 -

POOR (n) 4/40 x 100 10%

VERY POOR (n) 0/40 x 100 -

Total Percentage: 31/40 x 100 = 77.5%

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RATING SCALE:

90% - 100% - Excellent

77% - 89.99% - Very Good

68% - 76.99% - Fair

50% - 67.99% - Poor

50% Below - Very Poor

RESULTS:

Percentage: 77.5%

Rating: Very Good

INTERPRETATION:

Student nurses at Xavier University have put an end to this prognosis

through extensive and comprehensive research and data collection efforts. As

a result, this prognosis has been achieved. With the use of a rating scale that is

expressed in percentages, out of a total possible score of 100%, the result came

out to be 77.5%, which suggests that the patient has achieved a very good

level of success in terms of dealing with health and well-being issues with the

help of nursing interventions and medication rendered to the patient.

83
 XIV. CONCLUSION

The case study of the postpartum patient, J.C.J.A was done to provide

a thorough and efficient evaluation of the patient’s conditions following

childbirth. In the student nurses’ duty assignment at the obstetrics ward in Maria

Reyna Xavier University Hospital, an assessment was done for identification of

the symptoms related to the patient’s condition of concern which is anemia

that resulted from the cesarean section delivery due to fetopelvic

disproportion. Laboratory tests (hematology) that were conducted have

shown some unusual numbers, especially when it came to the complete blood

count which have shown abnormal results in all the components (white blood

cells, red blood cells, hemoglobin, hematocrit, neutrophils) which indicates

that there may be an infection happening within the patient’s system. A

narrative pathophysiology, which was also shown in a diagram was then

created to identify the factors that led to the condition, anemia. A drug study

was then produced to be able to know the functions and uses, with how the

drugs prescribed to the patient work, and how it assists in the recovery of the

patient, along with the important nursing interventions to apply and implement

when it comes to treating the patient with the prescribed medications. A

discharge plan was then developed to enhance and to assist in further

recovery once J.C.J.A is outside the health facility and is back home, without

the assistance of both the student nurses and other healthcare providers. A

nursing care plan was also developed to address the other conditions the

patient has aside from the concern of anemia due to cesarean section for

fetopelvic disproportion and contains specific interventions which is tailored

84
specifically to the patient to address J.C.J.A’s needs. A prognosis was then

utilized to be able to identify and gauge the patient’s performance during the

duration of the admission, which addresses both the patient’s behavior and

interactions within the environment, along with the patient’s body response to

the medication, which resulted in an appropriate (Very Good) rating.

XV. RECOMMENDATION

This case contributed to the student nurses of Block B - RLE Group 1's

knowledge of providing efficient care to a post-cesarean delivery patient. In

the course of this case, several potential areas for further study and practice

were apparent due to some alterations in the clinical rotation setting.

Consequently, this case study's disciplines have made suggestions:

(a) For pregnant, postpartum, and/or post-CS mothers. To help in the

optimization of one’s well-being by applying the health teachings imparted to

them by student nurses and/or nurses. As well as to immediately communicate

any health complications, especially infection or pain issues regarding their

surgical incisions to their doctors, nurses, and/or student nurses.

(b) For student nurses. To provide active support and to improve their

response and recovery aid to post-CS mothers. As well as effectively fulfill their

roles by administering key nursing interventions, including implementing their

postpartum mother care plan with an emphasis on pain relief from abdominal

85
and uterine incisions and physical discomfort. This may include any methods,

treatments, or educational opportunities devised by the student nurses to

optimize the welfare and health of the mother following cesarean delivery.

(c) For clinical instructors. To continue offering their student nurses unfailing

guidance and assistance. Along with continuing to give their student nurses a

high-quality education and preparing them to become competent nurses so

they can deliver patients with safe and high-quality care in the future. Also,

keep carrying out their duties to support students' knowledge acquisition and

assist in the growth of students' attitudes, principles, and professional

competencies.

(d) For healthcare providers/professionals. To continue providing

postpartum patients with high-quality nursing care while implementing

standard nursing practices to maximize patient satisfaction. Also, as the best

strategy to improve patient engagement and communication between nurses

and patients, it is also important for them to keep improving the methods in

which they endorse patients. This is vital, since the key element of safety

practices in the hospital context is efficient nursing communication regarding

care, treatment, and services with their fellow nurses, student nurses, patients,

and families.

86
(e) For future researchers. To utilize and interpret this case study as a as it gives

knowledge and data that can be used for future analysis and research in the

future study of student nurses and researchers.

87
XVI. APPENDICES

A. Assessment Tool

88
89
90
91
 B. Doctor’s Order

DATE ORDERS Rationale or Purpose

09/19/2022 Apply cold compress to Applying cold compress to the

the perineum, twice a perineal area can help ease pain
day good for 15 minutes and reduce swelling.

Use Perilight, twice a day The use of Perilight is to eliminate

good for 15 minutes infection on the pt.’s perineum.

09/19/2022 Doctor ordered a To determine any abnormalities in

Complete Blood Count the pt’s body and to detect wide
(CBC) to the patient. range of disorders anemia,
infection, and leukemia.

09/20/2022 Medication The following medication

administration Celecoxib; for anti-inflammatory,
rexidol forte; for pain relief is
• Celecoxib 200mg, administered since the pt. is
PO BID experiencing pain on the incision
• Rexidol Forte site.
500mg, PO BID
• Bearse tab 50mg, LactaFlow is administered to the pt.
PO TID To enhance breastmilk production.
• Lactaflow 500mg,
PO TID

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 C. Nurse’s Notes

MARIA REYNA-XAVIER UNIVERSITY HOSPITAL

Hayes St., Camaman-an, Cagayan de Oro City

NURSE’S NOTES

PATIENT: Jannien Claire Jabar Aleonar

ROOM: 252

DOCTOR: Dr. Marion G. Abarte

D - DATA (SUBJECTIVE/OBJECTIVE)

A - ACTION (INTERVENTION)

R - RESPONSE (EVALUATION)

DATE TIME PROBLEM DATA - ACTION - RESPONSE

Shift: 1400 - 2200 H

9/19/2022 1400 - Incision pain due D: Pt’s husband reported on pt’s labor

2200 H to post-CS pain. Pt also verbalized, “sakit ako likod

ma’am.” Pt is seen with a grimace face.

Pt also looks uncomfortable and restless.

Pt is a post-CS mother. Pt is observed with

a new incision from cesarean

delivery._______________________________

93
 A: Pt has been admitted. Pt has been

placed in bed comfortably in a semi-

upright position, and the side rail has

been raised and secured. Pt’s vital signs

were taken, HR: 97, RR: 17, BP: 110/90,

Temp: 36.4, O2 Sat: 96%. Pt’s expression

of discomfort had been acknowledged.

Pt has been applied with hot compress.

Pt’s pain site had been massaged.

Doctor’s order for pt has been given,

which included administration of

Mefenamic acid 500mg per tab PO BID

for 3 days. Pt’s first dose for medication

had been administered, while adhering

the different rights to medication

administration._________________________

R: Client reported satisfactory pain

management at a level of 3 to 4 on a

rating scale where 10 is the highest and 1

is the

lowest.________________________________

XUSN

94
9/19/2022 1400 - Risk for Iron D: Pt is a post-CS mother that

2200 H deficiency anemia experienced an excessive amount of

blood loss. Pt is seen with a pale face. Pt

is feeling cold.____________________

A: Pt is given a health teaching on

energy conservation and rest. Health

teaching is composed of educating the

patient the importance of eating iron

rich food like green leafy vegetables

such as malunggay,ampalaya and liver.

Encouraged the patient to take vitamin

C supplements and include Vitamin C

rich fruits and juices._________________

R: Client understood the health

teachings provided. Pt also promises to

adhere to the health teaching, while also

having the reminders and assistance of

the watcher and

nurse._________________________________

XUSN

95
9/19/2022 1400 - Risk for Infection D: Redness on pt’s perineum is visible. Pt

2200 H on perineum has been observed with stitches from

torn perineum._________________________

A: Pt’s vital signs were assessed. Pt’s vital

signs have been monitored for every 2 to

4 hours. Pt’s vital signs were first noted to

be, HR: 97, RR: 17, BP: 110/90, Temp: 36.4,

O2 Sat: 96%. Pt had been advised to use

a peri bottle. Pt has been given

instructions and guidelines on how to use

a peri bottle: While using the restroom, fill

it with warm water and aim the tip at

your nether regions. To ensure that the

liquid flows over the proper area,

squeeze the bottle. Pt has also been

advised to drink plenty of water, and the

advised amount is 11.5 cups (2.7 liters) a

day.

R: Pt has received the information on the

usage of a peri bottle. Pt has been able

to properly use the peri bottle. Pt had

been able to clean the perineum with

ease, without having worsened the risk of

96
 infection on perineum. Pt drinks 2.7 liters

of water a day, with the reminders and

assistance of the watcher and

nurse._________________________________

XUSN

9/19/2022 1400 - Risk for Urinary D: Pt verbalized that “since ge tanggal

2200 H tract infection akong catheter wala pako kaihi.” Pt

underwent urinalysis, with a result of 14.9

RDW, which is considered to be above

normal range in

females._______________________________

A: Pt’s vital signs were assessed.

Medication lists from the doctor's order

were reviewed. Pt is advised to

medication administration on

Methanamine (3g orally 4 times a day).

Pt’s dose of Methenamine was

administered for the day, while adhering

the different rights to medication

administration. Pt was encouraged to

97
 drink plenty of

water._________________________________

R: Pt has been prevented from getting

UTI. Pt was able to take necessary action

to urinate successfully without further

infection.______________________________

XUSN

9/20/2022 1400 - Nausea D:Pt verbalized “labad akong ulo

2200 H maam.” Pt’s uncomfortable expression,

and restless and grimace expression is

evident on the

face.__________________________________

________

A: Pt’s vital signs were assessed and

monitored. Pt is encouraged to have

enough amounts of rest and sleep.

Rexidol Forte Paracetamol 500mg per

Tab PO TID for 7 days has been

administered, while adhering to the

different rights of medication

98
 administration, per physician’s

order.______________________________

R: After all the nursing intervention, the

client was able to regain her strength

and normal condition. Pt also no longer

has any experiences and reports of

headache and

nausea._______________________________

XUSN

D. Consent

Consent was obtained prior to the admission of the patient, however a

copy of it wasn’t obtained by the nursing students.

99
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103