BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
S.Y. 2013-2014

A CASE STUDY OF 28 YEARS OLD FEMALE WHO UNDERGONE

CAESARIAN SECTION AND BILATERAL TUBAL LIGATION

SUBMITTED BY: SUBMITTED TO:

GROUP 2B BSN 3-D Rosalinda Bartolome, RN
LEADER: Dela Cruz, Mary Grace C. CLINICAL INSTRUCTOR
MEMBER:
Maluyo, Sarah S.
Masangcay, Milcah Lornel E.
Masangkay, Kriselle Karissha T.
Montales, Michelle D.
Pascual, Rotche M.

Page 1
I. INTRODUCTION

A Caesarian section is a form of childbirth in which a surgical incision is made through a mother’s abdomen and uterus to deliver one or
more babies. It is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk; although in recent times it has been
also performed upon requests for births that would otherwise have been normal.

Caesarian section (CS) is recommended when vaginal delivery might pose a risk to the mother or baby.
Reasons for CS include:
- Precious (high risk) fetus - Failed induction of labor
- Prolonged labor or failureto progress (dystocia - Failed instrumental delivery
- Apparent fetal distress - The baby is too large (macrosomia)
- Apparent maternal distress - Placental problems (placenta previa, placental abruption)
- Complications (pre-eclampsia, active herpes) - Umbilical cord abnormalities
- Catastrophes such as cord prolapse or uterine rupture - Contracted pelvis
- Multiple births - Sexually transmitted infections such as genital herpes
- Abnormal presentation (breech or transverse positions) - Previous caesarian section
- Old Age - Breech Presentation

Bilateral Tubal Ligation is performed at caesarean section for medical reasons and when further pregnancies are deemed inadvisable and
hazardous. It is a surgical procedure which a woman's fallopian tubes are clamped and blocked, or severed and sealed, either method of which prevents
eggs from reaching the uterus for fertilization. Tubal ligation is considered a permanent method of sterilization and birth control.

The prevalence of bilateral tubal ligation at caesarean section accounted for 2.7% of all clients offered family planning methods in the study.
Of the 1,346 clients offered family planning methods during the review period, 78 clients had bilateral tubal ligation. Of the 78 women who had tubal
ligation, 47.4% had the procedure at caesarean section, 46.2% had the procedure through minilaparotomy, while 6.4% had tubal ligation at laparotomy for
ruptured uterus.

In this case of Mrs. L.A., she underwent a low segment transverse Caesarian Section and Bilateral Tubal Ligation to prevent further
complications because her doctor found out that she had Rheumatic Heart Disease. She was admitted last May 13, 2013 (5:30am) at Mary Immaculate
Maternal and General Hospital.

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II. OBJECTIVES

CLIENT – CENTERED:

KNOWLDEGE:

 To develop patient’s awareness about her condition.

 To be able to understand the importance of complying her medications.
 To provide client education appropriate to her condition.

SKILLS:

 To help the patient in motivating her to continue the health care provided by the health care worker.
 To conduct physical assessment and interpret it in order to give the care the patient needed.
 To be able to take care of herself even outside the hospital.

ATTITUDE:

 To be able to comply with treatments to promote recovery.

 To be able to build trust with the hospital personnel.
 To support and encourage the client and her family to ask questions so that information could be clarified.

STUDENT – CENTERED:

KNOWLEDGE:

 To gain knowledge about pharmacologic therapy given to the client who undergone Caesarian Section and Bilateral Tubal Ligation.
 To evaluate outcomes after implementation of nursing care to determine what nursing actions needs to be modified or improve.
 To identify and become familiar with the different diagnostic procedure applicable to our client’s condition.

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 SKILL:

 To do the necessary nursing intervention in hospital for the client.

 To give the known medication as prescribed by the doctor for the client.
 To collect and organize relevant information concerning the client’s current health status.
ATTITUDE:

 To give the proper care and build a genuine nurse-patient relationship conducive to good health.
 To establish appropriate behavior such as honest, reliable, courteous, and open minded.
 To develop our nursing responsibilities in dealing with the client.

III. NURSING HEALTH HISTORY

A. PATIENT’S PROFILE
NAME: Mrs. L.A.
ADDRESS: Sto. Cristo, Malolos, Bulacan
BIRTHDAY: August 29, 1984
AGE: 28 years old
SEX: Female
CIVIL STATUS: Married
RELIGION: Roman Catholic
NATIONALITY: Filipino
EDUCTIONAL ATTAINMENT: College Graduate
SOURCE OF MEDICAL CARE: PhilHealth
ADMISSION DATE: May 13, 2013
TIME: 5:30am
ADMITTING INSTITUTION: Mary Immaculate Maternal and General Hospital

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B. REASON FOR VISIT (CHIEF COMPLAINT)
“Madalas ng humilab ang tiyan ko atska sbi ng doktor pwede na daw ako manganak kahit na anong araw ngayong buwan kasi caesarian
naman ako,” as verbalized by the client.

C. HISTORY OF PRESENT ILLNESS

Prior to admission, our client was assessed by her resident doctor, and found out that she has mild mitral and tricuspid regurgitation that
leads to Rheumatic Heart Disease. The doctor advise her to have Caesarian Section and to prevent further complications, she must undergo Bilateral Tubal
Ligation.

D. HISTORY OF PAST ILLNESS

According to our client, she easily gets tired in every simple thing she does, that’s why she resigned on her work. That time, she didn’t
consult a doctor. “Siguro dahil limang buwan na itong tiyan ko kaya madali akong hingalin”,as verbalized by the client. Last May 6, 2013, she consults her
doctor to check the status of her baby inside her and undergone Ultrasound. The procedure reveals a healthy baby boy but according to her doctor
assessment, Mrs. L.A. had a mild mitral and tricuspid regurgitation. Her past medical history also reveal that she experienced Rheumatic Fever last 2006.
Her resident doctor advised her to undergone Caesarian Section since she was on her term this first or second week of May. The doctor also
told her that she must undergo Bilateral Tubal Ligation to prevent future pregnancy that may cause further complication.

E. FAMILY HISTORY OF ILLNESS

According to Mrs. L.A., her family didn’t have any illnesses except Hypertension of her grandmother.

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 GENOGRAM

Mr. A.C. Mrs. B.C. Mr. J.M.

Mrs. M.M.
? ? ?
?

LEGEND: Mr. J.C. Sr. Mrs. M.C.

52 y/o 47 y/o
- male
A/W A/W
- female

- deceased

- deceased

A/W - Alive & Well

Mrs. L.A.
Mr. J.C.
R.H.D. - Rheumatic 28 y/o
23 y/o
Heart Disease R.H.D.
A/W
? - Unrecall the
cause of death

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F. GORDON’S FUNCTIONAL HEALTH PATTERN

FUNCTIONAL HEALTH PATTERN PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

Health Perception and Health Mrs. L.A. took multivitamins. She used to consult her Our client is strong; she stated that her illness can be
Management doctor every time she got sick. She also told us that cured through complying her medications and enough
vegetables are very important to a human being because rest.
it made our life longer.

Nutritional and Metabolic Pattern
Our client usually prefers to eat vegetables such as cabbage, Our client was ordered NPO last May 13, 2013 at 5:45am in
potato, carrots and kangkong. She doesn’t like to eat fatty preparation for operation. After the operation, 2:00pm in the
foods. When she has wound it heals well. She doesn’t have afternoon she was ordered clear liquid diet when she was fully
any dentures. awake. Then, at 6:30pm, the doctor ordered general liquid diet.
3 Day Dietary Recall
Date Breakfast Lunch Dinner

May 9, 2013 1 serving of ½ cup of rice ½ cup of rice

sopas 1 pc. tortang Small bowl
250ml of talong of pakbet
milk 250ml of 250ml of
water water
250ml of
milk

May 10,2013 2 pcs. of ½ cup of rice ½ cup of rice

bread 1 pc. Fried Smalo bowl
250ml of fish of corned
milk 300ml of beef with
150ml of water potato
water 250ml of
water

May 11,2013 250ml of 1 cup of rice 2 pcs of

milk Small bowl bread

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 of ginisang 250ml of
upo milk.
250ml of
water

Elimination Pattern According to Mrs. L.A., she doesn’t have any difficulties in During hospitalization, she doesn’t have difficulty urinating and
urinating and defecating. She usually urinates 4 to 5 times a defecating.
day and defecates every afternoon after lunch.

Activity and Exercise Pattern Prior to hospitalization, the client easily gets tired when she During Hospitalization, she cannot do some of the activities
does household chores. without supervision from the others.

0 feeding 0 grooming 0 feeding 0 grooming

0 bathing 0 ambulation n/a bathing 1 ambulation
0 toileting 0 cooking 2 toileting n/a cooking
0 bed mobility 2 shopping 0 bed mobility n/a shopping
0 dressing 2 home maintenance 2 dressing n/a home maintenance

Level 0 – full self care Level 0 – full self care

Level 1 – requires use of equipment Level 1 – requires use of equipment
Level 2 – requires assistance or supervision from another Level 2 – requires assistance or supervision from another
person person
Level 3 – requires assistance or supervision from another Level 3 – requires assistance or supervision from another
person or device person or device
Level 4 – dependent or does not participate Level 4 – dependent or does not participate

Sleep and Rest Pattern The patient sleeps at 11pm and wakes around 7am. She She cannot sleep well because the nurses monitoring her vital
usually takes a nap in the afternoon. She doesn’t have signs every 4 hours but she was able to take a nap in the
difficulty falling asleep. Watching her favorite Telenovela is afternoon. She usually sleeps at 8pm then wakes up when
her form of relaxation. nurses took her vital signs.

Cognitive and Perceptual Pattern She does not have problems in vision and hearing. No changes

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Self Perception and Self Concept According to our client, she sees herself as friendly person. She accepts her condition being hospitalized with underlying
Family is her strength. When there are circumstances that disease. She added that she wants to go home as soon as
involving any family members, she was very concern and possible.
make some moves to deal with it.

Role and Relationship Pattern The patient has a nuclear family. When problem arises, she The patient has been doing well on interacting and
and the rest of her family talk about it to solve it. She has a lot communicating with different people around her.
of friends in their neighborhood.

Sexuality and Reproductive Mrs. L.A. menarche starts when she was 14 years old. Her last The client delivered her first and previous baby through
Pattern menstrual period was on August 20, 2012. She engages sexual Caesarian Section. And now she underwent Bilateral Tubal
activity with her husband only. Ligation.

Coping Stress Pattern Watching her favorite Telenovela is her form of relieving The client doesn’t feel alone because her relatives and family
stress. When she feels tense, her husband comforts her. are always visiting her in the hospital.

Value – Belief Pattern Our client is a Roman Catholic. She make sure that every According to her, when she got home going to church the first
Sunday, they must go to church and ask god for guidance. thing she would do.

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IV. GROWTH AND DEVELOPMENT
PSYCHOSOCIAL
(Erik Erickson)
Intimacy vs. Isolation
STAGE (20-30 years old)
Young adults are still eager
DEFINITION to blend their identities with
friends. They want to fit in.
Erikson believes we are
sometimes isolated due to
intimacy. We are afraid of
rejections such as being
turned down or our
partners breaking up with
us. We are familiar with
pain, and to some of us,
rejection is painful; our egos
cannot bear the pain.
ANALYSIS Our client passed this stage.
She was been able to
develop close relationship
with others. In fact, she has
a lot of friends in their
neighborhood.
PSYCHOSEXUAL
(Sigmund Freud)
Genital
(13 years old and above)
This state begins with
puberty, the production of
sexual hormones and
maturation of the
reproductive system. Genital
organs become the major
source of sexual pleasure
and tension. The adolescent
also focuses on relationship
formation and prepares for
more permanent
relationship (e.g. marriage).
A genital sexual pleasure
continues throughout
adulthood into advanced
years.
According to our patient, she
engages sexual activity with
her husband only. She was
fully independent. She can
make decision on her own.
COGNITIVE
(Jean Piaget)
Formal Operation
(11 years old and above)
It marks a movement from an
ability to think and reason
from concrete visible events
to an ability to think
hypothetically; to entertain
what-if possibilities about
the world
The client thinks rationally
and logically. She is able to
solve problem with her
family by communicating to
them and vice versa
MORAL
(Kohlberg)
Post Conventional or Principled
(Stage 5)
Individuals make their own
choices, understanding the
views of other people but make
their own decisions.
Stage 5: Humans Rights and
Social Welfare Morality
 “Promote fundamental
human rights and values”
 “Freely entered social
contract to protect
members’ rights and
ensure the welfare of all”
 Agreements determine
the obligations of
relationships of the
individual.
The patient understand the
different roles of the society and
can distinguish what is right or
wrong based on internalized
rules of conscience rather than
the social law. According to her,
she will follow all the orders of
the doctor.
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V. ANATOMY AND PHYSIOLOGY

REPRODUCTIVE SYSTEM

EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external genital area— or vulva—which runs from the pubic area downward to the
rectum. Two folds of fatty, fleshy tissue surround the entrance to the vagina and the urinary opening: the labia majora, or outer folds, and the labia minora,
or inner folds, located under the labia majora. The clitoris, is a relatively short organ (less than one inch long), shielded by a hood of flesh. When stimulated
sexually, the clitoris can become erect like a man's penis. The hymen, a thin membrane protecting the entrance of the vagina, stretches when you insert a
tampon or have intercourse.

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 INTERNAL REPRODUCTIVE STRUCTURE

The Vagina

The vagina is a muscular, ridged sheath connecting the external genitals to the uterus, where the embryo grows into a fetus during pregnancy. In the
reproductive process, the vagina functions as a two-way street, accepting the penis and sperm during intercourse and roughly nine months later, serving
as the avenue of birth through which the new baby enters the world.

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The Cervix

The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual reproductive functions. After intercourse, sperm
ejaculated in the vagina pass through the cervix, then proceed through the uterus to the fallopian tubes where, if a sperm encounters an ovum (egg),
conception occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly fluctuations in the levels of the two principle
sex hormones, estrogen and progesterone. When estrogen levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to
reach the fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then becomes thin and slippery, offering a much
more friendly environment to sperm as they struggle towards their goal. (This phenomenon is employed by birth control pills, shots and implants. One of
the ways they prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.)

Uterus

The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to
the fallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes
implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an
embryo, develops into a fetus and gestates until childbirth.

Oviducts

The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle
and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of
cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the
endometrium when it reaches the uterus, which signals the beginning of pregnancy.

Ovaries
The ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed
of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, where it travelled
down the oviduct to the uterus, occasionally being fertilised on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human
being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel

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VI. PHYSICAL ASSESSMENT
VITAL SIGNS
BP: 110/80 mmHg
TEMP:
PULSE RATE: 78bpm
RESPIRATORY RATE: 26cpm

PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

General appearance

she has a proportionate

1. Body built in relation to Proportionate and varies (endomorph) body built
Inspection Normal
client’s age, lifestyle & health with lifestyle which is appropriate with
her lifestyle

Relax, erect posture,

2. lient’s posture & gait, Deviation from normal due
Inspection coordinated body Cannot stand perfectly
standing, sitting & walking to the operation performed
movements

. lient’s overall hygiene &

Inspection Neat She is neat and clean. Normal
grooming

No body odor or minor body

4. Body & breath odor Inspection no body odor Normal
odor relative

5. Signs of distress in posture Deviation from normal due

Inspection No distress noted Distress noted
or facial expression to the incision site

6. Obvious signs of health or Inspection Healthy appearance Healthy appearance Normal

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 PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

illness

. lient’s attitude Inspection Cooperative Cooperative Normal

8. lient’s affect/mood;
appropriateness of the Inspection Appropriate to the situation Appropriate to the situation Normal
clients response

Understandable, moderate
9. Quantity of speech, quality
Inspection pace; exhibits thought Understandable Normal
& organization
association

10. Relevance & organization Logical sequence; makes

Inspection has sense of reality Normal
of thoughts sense; has sense of reality.

SKIN

moisture in skin fold and

1. Skin moisture Inspection moisture in skin fold Normal
axillae

Deviation from normal due

2. Skin Texture Inspection smooth Rough at the abdomen to the stretch skin during her
pregnancy.

3. Skin turgor Inspection and palpation Springs back Springs back Normal

Nails

1. Fingernails plate shape to Inspection Convex curvature, angle of Angle of nail plate about 160 Normal

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 PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

determine its curvature & nail plate about 160 degrees. degrees.
angle

Highly vascular and pink in

light skinned clients; dark-
2. Fingernail & toenail bed
Inspection skinned clients may have Pinkish in color Normal
color
brown or black pigmentation
in longitudinal streaks.

She has an intact epidermis

3. Tissues surroundings nails Inspection Intact epidermis. Normal
with no hangnails

4. Fingernail & toenail

Palpation Smooth texture. Smooth nail texture Normal
texture

Prompt return of pink or

5. Blanch test of capillary The color return to the
Palpation usual color (generally less Normal
refill original color in 2 seconds
than 4 seconds.)

Hair

1. Evenness of growth over

Inspection Evenly distributed hair. Her hair is well distributed Normal
the scalp

2. Hair thickness & thinness Palpation Thick/thin hair. has a thick hair Normal

3. Presence of infections or
Inspection Not present. Not present. Normal
infestations

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 PARTS TO BE ASSESSED
4. Texture & oiliness over
the scalp
1. Size, shape, symmetry
2. Nodules or masses and
depressions
1. Facial features
2. Symmetry of the facial
movements
TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
Palpation Silky, resilient hair. Silky, resilient hair. Normal
SKULL
Rounded (normocephalic
and symmetrical, with
Head is symmetrically
Palpation frontal, parietal, and Normal
rounded
occipital prominences);
smooth skull contour.
Smooth, uniform
Palpation consistency; absence of No mass or nodules Normal
nodules or masses.
FACE
Symmetric or slightly Symmetric or slightly
asymmetric facial features; asymmetric facial features;
Inspection palpebral fissures equal in palpebral fissures equal in Normal
size; symmetric nasolabial size; symmetric nasolabial
folds. folds.
Symmetrical facial Facial movements are
Inspection Normal
movements. symmetrical
Eyebrows and Eyelashes
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 PARTS TO BE ASSESSED
1. Evenness of distribution &
direction of curl
1. Surface characteristics &
Inspection and Palpation
ability to blink
1. Bulbar conjunctivas color,
texture and presence of
lesions
2. Palpebral conjunctivas
color, texture & presence of
lesions
TECHNIQUE NORMAL FINDINGS
Hair evenly distributed; skin
intact. Eyebrows
Inspection asymmetrically aligned
equal movement. Eyelashes
curl slightly outward.
Eyelids
Skin intact, no discharge, no
discoloration. Lids close
symmetrically approximately
15-20 involuntary blinks per
minute; bilateral blinking.
When lids open, no open, no
visible sclera above corneas,
and upper and lower borders
of cornea are slightly covered.
CONJUNCTIVA
Transparent; capillaries
Inspection
sometimes evident.
Shiny, smooth, pink or red in
Inspection
color.
ACTUAL FINDINGS REMARKS
Eyebrows and eyelashes are
both evenly distributed,
symmetrical aligned. Normal
Eyelashes curl slightly
outward.
Eyelids skin are intact, no
noted discharge, and no noted
discoloration. Lids close
Normal
symmetrically. Client
exhibited 18 involuntary
blinks per minute.
Transparent, capillaries
evident, no discharge was Normal
noted.
Shiny, smooth and red in
Normal
color.
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 PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

Sclera

Sclera appears white

1. Color & clarity Inspection (yellowish in dark- skinned Sclera appears white Normal
clients).

Cornea

Transparent, shiny and

smooth; details of the iris are
visible. In older people, a
1.Clarity & color Inspection
thin grayish white ring
around the margin, called
arcussenilis, may be evident.
Details of iris are visible.
Transparent, shiny and
Deviation from Normal
smooth. But she has visual of
450/400

Iris

Flat and round and uniform in

1. Shape & color Inspection Flat and round Normal
color.

Pupils

Black in color; equal in size;

1. Color, shape & symmetry
Inspection normally 3-7 mm in diameter; Firm and equal pupils Normal
of size
round, smooth border.

EAR’S AURICLE

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 PARTS TO BE ASSESSED
1. Color & symmetry of size
& position
2. Texture & elasticity &
areas of tenderness
1. Shape, size or color &
flaring or discharge from the
nares
2. Presence of redness,
swelling, growths & pinkish; minimal moist
discharge or nares using the
flashlight
3. Position of nasal septum
4. Test patency of both nasal
septum
TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
Color is same with facial
Color same as facial skin,
skin, symmetrical with each
symmetrical, auricle aligned
Inspection other, auricle aligned with Normal
with outer canthus of eye,
outer canthus of eye, about
about 10cm from vertical.
10 cm vertical
Mobile, firm and not tender, Both pinna recoils after
Palpation pinna recoils after it is being folded. Mobile, firm Normal
folded. and not tender.
Nose
Symmetric and straight
No discharge. Symmetrical
Deviation from normal due
Inspection No discharge or flaring on both sides. Also uniform
to mitral regurgitation.
in color. Nasal flaring noted
Uniform color
Mucosa pink Mucosas are intact and
Inspection Clear, watery discharge Normal
noted inside; no swelling or
No lesions. nodules found.
Nasal septum intact and in Nasal septum is intact and in
Inspection Normal
midline, intact midline
Air moves freely as the client Air moves freely as the client
Inspection Normal
breathes through the nares breathes through each nares
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 PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

5. Tenderness, masses & No tenderness, no lesions

displacement of bone & Palpation Not tender; no lesions noted. No displacement of Normal
cartilage bone & cartilage.

Lips

Uniform pink color Uniform pink color

1. Symmetry of contour color Soft, moist, smooth texture Soft, moist, smooth texture
Inspection and Palpation Normal
& texture Symmetry of contour Symmetry of contour

Ability to purse lips Has the ability to purse lips

Teeth

1. Inspect for color, number 32 adult teeth

& condition & presence of Inspection Smooth, white, shiny tooth She has smooth shiny 32 teeth Normal
dentures enamel

Gums

Pink gums (bluish or dark Pink gums (bluish or dark

patches in dark-skinned patches in dark-skinned
1. Color & condition Inspection clients) clients) Normal

Moist, firm texture to gums Moist, firm texture to gums

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 PARTS TO BE ASSESSED
1. Color & texture of the
mouth floor & frenulum
2. Position, color & texture,
movement & base of the
tongue
1. Skin integrity
2. Abdominal contour
TECHNIQUE NORMAL FINDINGS
TONGUE/FLOOR OF THE MOUTH
Smooth tongue base with
Inspection and Palpation
prominent veins
Central in position
Pink in color (some brown
pigmentation on tongue
borders in darj-skinned
clients); moist; slightly
Inspection and Palpation rough; thin white coating
Smooth, lateral margins, no
lesions
Raised papillae (taste buds)
Moves freely, no tenderness
Abdomen
Unblemished skin, uniform in
color, silver white striae
Inspection
(stretch marks) or surgical
scars.
Inspection Flat, rounded (convex) or
ACTUAL FINDINGS REMARKS
Smooth tongue base with
Normal
prominent veins
Central in position
Pink in color (some brown
pigmentation on tongue
borders in darj-skinned
clients); moist; slightly
rough; thin white coating Normal
Smooth, lateral margins, no
lesions
Raised papillae (taste buds)
Moves freely, no tenderness
She has stretch marks Normal
Convex in shape. Normal
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 PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

scaphoid(concave)

Audible bowel sounds

3. Bowel Sounds Auscultation Hyperactive bowel sounds Normal

VII. PATIENT AND HIS CARE

A. Medical Management
Medical Date Ordered/Date
Management Performed/Date General Description Indication/Purpose Client’s Response to Nursing Responsibilities
treatment Discontinue the Treatment

IVF Date Ordered/ Dextrose 5 Lactated It is use to supply Signs and symptoms of Prior:
Performed: Ringers Solution water and electrolytes dehydration were not  Check the physician’s order for
May 13, 2013 e.g. Calcium, noted such as dry skin. IVF insertion, its drop factor and
D5LR 1L Potassium, and ordered amount.
Date Discontinue: D5LR 1L to run at 30-31 Chloride. During:
Type of Solution ------ gtts./min.  Secure the tube; make sure that
the tube is not dislodging when
the patient moves.
-Hypertonic
 Check for possible complication
such as complication
-Nonpyrogenic,  Observed for the IV site for its
parenteral fluid, appearance.
electrolyte and  Check for its patency.
After:
nutrient replenisher Evaluate the patient’s response to
treatment.

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 B. Drugs
Generic / Brand Date Route of administration, Mechanism of Action Client’s Nursing Resposibilities
Name / Ordered Given Changed Discontinue dosage, frequency Response
Classification
5/13/13 5/13/13 ---- ----
Generic Name: Route of Nalbuphine acts as an - headache PRIOR:
NALBUPHINE Administration: agonist at specific - restlessness  heck the medication’s
HYDROCHLORIDE IV (prn meds.) opioid receptors in the chart to reduce error in
CNS to produce medication administration.
Brand Name: Dosage/Frequency: analgesia, sedation but  Monitor respiratory rate
NUBAINE 10mg IV q8x2doses also acts to cause before and after giving
hallucinations and is an nubain because it causes
Classification: antagonist at respiratorydepression.
Narcotic agonist- µreceptorsIndications:
antagonist analgesic DURING:
- Relief of moderate to  Monitor blood pressure
severe pain. before and after
-Preoperative analgesia, administering the
as a supplement to medication to prevent any
surgical anesthesia, and complication.
for obstetric analgesia  Monitor I and O to
during labor and determine if there is
delivery. excessive fluid loss.

AFTER:
 Evaluates patient’s
appearance.

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 Generic / Brand Date Route of administration, Mechanism of Action Client’s Nursing Resposibilities
Name / Classification Ordered Given Changed Discontinue dosage, frequency Response
5/13/13 5/13/13 ---- ----
Generic Name: Route of A broad-spectrum ---- PRIOR:
Ampicillin Administration: semisynthetic  heck the medication’s chart
Parenteral aminopenicillin, is to reduce error in medication
administration.
Brand Name: highly bactericidal
Ampisan Dosage/Frequency: even at low
DURING:
1g TIV as loading dose concentrations, but  Check IV site carefully for
Classification: then 500mg TIV q6 x 2 is inactivated by signs of thrombosis or drug
Penicillins doses penicillinase. reaction.
Uses
Infections of GU, AFTER:
respiratory, and GI  Evaluates patient’s
tracts and skin and appearance.
soft tissues; also
gonococcal
infections, bacterial
meningitis, otitis
media, sinusitis, and
septicemia and for
prophylaxis of
bacterial
endocarditis. Used
parenterally only for
moderately severe
to severe infections.

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C. Diet
Type of Diet Date General Indication/ Specific Client’s Nursing Responsibilities
Description Purposes foods/fluids Response
taken

NPO 5/13/13 5/13/13 It is an instruction This diet is usually None The client - assess the level of understanding of the
(Nothing Per 5:45 am 2pm meaning to ordered for feels hunger patient.
Orem) withhold oral foods preparation prior and thirst, she - explain the importance of following strictly
and fluids, but for to surgery appears weak. NPO in terms that the client can understand
patient who will specially who will and then evaluate.
undergo surgery, undergo general
the physician will anesthesia to -strictly monitor clients behavior in following
allow small amount prevent aspiration NPO.
of fluid intake for and pneumonia.
oral medication. - instruct the client to continue NPO as
prescribed by the Physician.

Clear Liquid Diet 5/13/13 5/13/13 Clear liquid diet A clear liquid Jelly Ace The patient - Make sure the patient is having the right
2pm 6:30pm Is made up of diet is often used adheres to the intake.
only clear fluids before tests, order without
complains.
and foods that procedures or
turn to clear surgeries that
fluids when they require no food
are at room in your stomach
temperature. or intestines,
such as before
colonoscopy. It
may also be
recommended as
a short-term diet
if you have
certain digestive
problems, such
as nausea,

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 vomiting or
diarrhea, or after
certain types of
surgery.

D. Exercise
Type of Exercises Date Started General Description Indication/purpose Clients Response to the Nursing Responsibilities
Activity

Deep Breathing Exercise May 13, 2013 Breathing that is done by To expel secretion and The client verbalized that Prior:
contracting the promotes lung expansion she practice DBE
diaphragm, a muscle to ease difficulty of whenever she experience Explain to her why she
located horizontally breathing DOB needs to perform
between the chest cavity exercises.
and stomach cavity. Air During:
enters the lungs and the
belly expands during this Observe the patient if she
type of breathing did the exercise properly

Type of Exercises Date Started General Description Indication/purpose Clients Response to the Nursing Responsibilities
Activity

Ambulation May 13, 2013 The act of travelling by To regain strength and The client verbalized that Prior:
foot; is a healthy form of promote good circulation she does walking
exercise. of Blood Explain to her why she
needs to perform
exercises.

During:

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 Assists patient or the
instruct the patient’s
relative to assist the
patient while performing
the exercises.

VIII. NURSING CARE PLAN

Assessment Diagnosis Planning Implementation Rationale Evaluation

S: “ Minsan nahihirapan Ineffective Breathing Short Term Goal:  Encourage slower /  To assist client in Short Term Goal:
akong huminga “, as Pattern related to After 30 minutes of deeper respirations “taking control of the After 30 minutes of
verbalized by the client. underlying disease Nursing Intervention the or use of purse-lip situation. Nursing Intervention the
(Rheumatic Heart client will be able to: technique. client was been able to:
Disease)  Establish a normal  Monitor respirations  To ascertain status and  Established normal
O: and effective and breath sounds, note progress. and effective
 Increased Respiratory respiratory pattern noting the rate and respiratory pattern
Rate. (26cpm) as evidence by the sounds. as evidence by the
 Restlessness absence of nasal  Elevate head of bed  To take advantage of absence of nasal
 Nasal flaring flaring, and or change position gravity decreasing flaring, and
restlessness with every 2 hours. pressure on the restlessness with
Respiratory Rate of diaphragm and Respiratory Rate of
12-20cpm. enhancing ventilation 19cpm.
 Verbalize awareness to different lung  Verbalized
of causative factor. segments. awareness of
 Verbalize causative factor.
understanding of  Verbalized
cause and understanding of
therapeutic cause and
management therapeutic
regimen. management
regimen.

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 Assessment Diagnosis Planning Implementation Rationale Evaluation

S: “mdyo masakit ung tahi Acute Pain related to
ko “, as verbalized by the
client.
O:
 Pain scale of 5 out of
10.
 Facial grimace
 Guarding behavior at
the incision site
Short Term Goal:  Obtain client’s  to rule out worsening of Short Term Goal:
surgical procedure After 30 minutes of assessment of pain underlying After 30 minutes of
Nursing Intervention the including location, condition/development Nursing Intervention the
client will be able to: characteristic, onset, of complications client was been able to:
 Verbalize that the Duration, frequency,  Verbalized that the
pain is lessen. quality, Intensity, pain is lessen.
aggravating factors.
 Follow prescribed  Followed prescribed
pharmacological  Provide comfort pharmacological
 to promote non-
regimen. measures. regimen.
pharmacological
management
 Verbalize non-  Verbalized non-
pharmacological  Instruct/encourage pharmacological
 to distruct attention and
methods that provide use of relaxation methods that provide
reduce tension
relief techniques such as relief
focus breathing,
music therapy

 encourage adequate
 to prevent fatigue
periods

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IX. HEALTH TEACHING

HEALTH TEACHING RATIONALE

1. Explain the importance of ambulation. - To promote good circulation.

2. Explain the importance of deep breathing exercise/ diversional activities. - Deep breathing/ diversional activities help to reduce pain.

3. Explain the importance of splinting. - Splinting reduces the pressure in the abdomen thus reducing pain.

4. Explain not to touch the incision site with bare hands. - To prevent infection.

5. Explain the importance of proper hygiene. - To prevent the spread of microorganism or cross contamination.

6. Explain the importance of maintaining a clean and well ventilated environment. - to reduce the risk of infection and to promote patient’s comfort.

X. DISCHARGE PLANNING
 Medication
o Advice the client to take her medication on time and with regular interval as indicated
o Report any side effects or adverse effect of the medication

 Exercise/Environment
o Provide the client with a clean and well ventilated room to prevent infection
o Deep Breathing Exercises

 Treatments
o Inform client to have a follow up checkup
o Increase fluid intake of 2-3 Liters
o Compliance to the medication

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  Health Teaching
o Ways to prevent infection

 Out Patient
o Report Any Pain or Effect of the medication

 Diet
o Increase fluid intake
o Avoid foods that may cause aspiration

 Spiritual
o Always believe, pray, trust and have faith to God.

XI. CONCLUSION

This case study gave the group more knowledge in making actual management for this kind of condition. Thus, the member of the group have
realized the need of promoting and maintaining optimal health to both the patient and her significant others.
With the proper knowledge about the nature of the disease as well as its preventive measures along with responsibility and sense of will, one can
surely direct herself away from the complications.

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