cesarean section 2ndary to fetal distress case presentation

CASE PRESENTATION

BSN Level III – Block 1Adviser: Abayan, Elizabeth RN, MAN

Table of ContentsI. Biographic Data

II. Nursing Health HistoryIII. Physical Assessment

IV. Gordon’s Health Pattern

V. Laboratory/Diagnostic Examination Result

VI. Medications, IV Infusions, Blood Transfusion, Treatments given

VII. Review of Systems

VIII.Anatomy and Physiology

IX. Pathophysiology

X. Prioritized List of Nursing Problems

XI. Nursing Care Plan

XII. Discharge Plan

I. Biographic Data

This is a case of Cesarean delivery. Patient X who is 29 years old, born on Oct. 28,1981. Her weight is 41 kg and height is 5’2”. A Roman Catholic, married, housewife with two children.

II. Nursing Health History

Chief Complaint: Patient x went to the hospital due to labor pain

and seek care for immediate attention.

History of Present Illness:Patient x is a G2P2(2-0-0-2) with regular

prenatal check up. She doesn’t have any history of illness during pregnancy. Prior to admission the patient has no vaginal discharge.


Past History: The patient doesn’t have hypertension,

asthma, DM, and Hepatitis B. During her childhood she had sore eyes, chickenpox and mumps. She is a fully immunized child and has no psychiatric illness. In 2008, she has undergone cesarean delivery for her first baby. She has no allergies at all.


Family History of Illness: Her relatives has history of hypertension

and stroke.

Lifestyle and Activity of Daily Living: Patient x is non alcoholic drinker, non

smoker and not addicted to any drugs. She has poor nutritious food intake and no allergies in any food. She sleeps 10 hours a day, starting from 8 in the evening and awake at 6 in the morning. She takes a nap for 30 minutes every afternoon.


Social Data: She is a college graduate, unemployed and

currently residing in her mother’s house.

Psychological Data: The patient is responsive to voice and touch

and has the ability to carry a conversation and answer questions appropriately. She doesn’t have disabilities regarding reading and writing. The patient can speak Tagalog and some English.

III. GORDON’S FUNCTIONAL HEALTH PATTERNSNutritional Pattern

Patient X is 29 y/o with the height of 5’2” and weight of 41 kg – undernourished

She has a BMI of 17 – underweightThe skin is considered normal

Activity – Exercise PatternBefore admission, the patient served as a fulltime housewife,

she takes care of her child at home and able to do some household chores

During hospitalization, Patient X appears weak and complains about the pain on her incision site. She is able to perform ADL but with assistance in doing activities.

III. GORDON’S FUNCTIONAL HEALTH PATTERNSSleep – Rest Pattern

The patient gets an average sleep of 10 hours every night. She sleeps at around 8 p.m. and wakes up at 6 a.m.

During hospitalization, the patient experiences sleeping disturbances because of the pain on her incision site. She often has disrupted sleep. She wakes up at night and finds it hard to go to sleep again.

Elimination PatternBefore admission, the patient stated that she urinates about 6 -

8 times every day. She usually has bowel movement of 3 times a week, with slightly brownish colored stool.

During hospitalization, Patient X urinates about 3 - 5 times a day with straw-colored urine output. The patient is constipated. There was no pain during urination.

III. GORDON’S FUNCTIONAL HEALTH PATTERNS

Health – Perception/Health Management PatternThe client perceives herself as physically fit personShe takes a bath one to two times a dayShe doesn’t smoke or drink any liquor, she also doesn't use any

harmful drugs

III. GORDON’S FUNCTIONAL HEALTH PATTERNSCognitive – Perceptual Pattern

The patient is responsive to voice and touch. She has the ability to carry a conversation and answer questions properly. She is able to read and write, and a college graduate. It was also observed that she was able to read the signs and posters posted at the hospital ward, and can follow simple instructions and can easily comprehend to questions asked.

There are no complaints regarding reading and writing. The patient can speak Tagalog and a few English.

During hospitalization, Patient X is still responsive to anything and has the ability to use simple sentences in answering questions.

III. GORDON’S FUNCTIONAL HEALTH PATTERNSRole – Relationship Pattern

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

Sexuality – Reproductive PatternThe patient is knowledgeable about sexual functions and sexual

intercourse. But after she undergone Caesarian Section, she was advised not to engage from sexual activity with her husband temporarily until the incision site on her abdomen has healed.

III. GORDON’S FUNCTIONAL HEALTH PATTERNSCoping – Stress Pattern

The patient usually decides for herself or sometimes she consult her familyDuring the interview, she was not attended by her husband due to certain circumstances.

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

IV. Physical Assessment

Vital Signs Findings Norms Interpretation

Temp. 37.4 C 36.5 – 37.5 Afebrile

PR. 88 bpm 60 - 100 Normal

RR 24 cpm 12 - 20 Tachypnea

BP 110/90 mmhg <120/<80 Pre-hypertensive


Weight – 41 kgHeight – 5’2”

Findings Normal Range Interpretation

BMI 17 18 - 25 Underweight

IV. Physical Assessment Body Parts Findings Technique Interpretation Rationale

General Appearance

Conscious, Coherent, slightly fatigue, in pain, reduce activity level irritable

Inspection Abnormal The patient is slightly fatigue, in pain related to surgery.

Head Hair is evenly distributed, symmetrical features and movement, symmetrical eyebrow, intact skin, no discoloration, anicteric sclera/lids close symmetrical, pink palpebral conjunctiva

Inspection, Palpation

Normal


Body Parts Findings Technique Interpretation Rationale

Neck Supple, (-) CLAD (Cervical Lymph Adenopathy), moves without discomfort


Normal

Breast Soft, warm, non-tender, nipples are intact, (-) lesion and redness


Normal

Chest/Lungs (-) retractions, (-) Adventitous breath sounds, Tachypnea

Inspection, Auscultation

Abnormal Rapid respiration because of fatigue caused by the surgery


Abdomen Pfannensteil cut over hypogastric area with scant bloody discharge, dressing and plaster were clean and fully covers the incision site, no foul odor, incision is warm and reddened, bladder not distended, Uterus is 3 cm below the umbilicus

Inspection, light palpation

Abnormal Pfannensteil cut in hypogastric area brings destruction to skin integrity.

Genitals/Rectum Scant lochia, rubra odor similar to menstrual flow, (-) Hemorrhoids

Inspection Normal


Extremities Can move without discomfort, (-) Homan’s sign

Inspection Normal

V. LABORATORY/DIAGNOSTICEXAMINATION RESULTS

RESULT NORMAL RANGE

FINDINGS

WBC 9.8 x 10^9/L 4.0-11.0 Normal

RBC 4.9 x 10^12/L 4.0-6.0 Normal

Hgb 116 g/L 120-180 Decreased

HcT 0.52 % 0.370-0.540 Normal

RESULT NORMAL RANGE

FINDINGS

LYMPHOCYTES 0.310 0.200-0.500 Normal

MONOCYTES 0.022 0.020-0.090 Normal

EOSINOPHILS 0.006 0.000-0.060 Normal

BASOPHILS 0.010 0.000-0.020 Normal

RESULT NORMAL RANGE

FINDINGS

PLATELET 165 x 10^9/L

150-450 Normal

NEUTRO- PHIL

0.510 0.500-0.700 Normal

V. LABORATORY/DIAGNOSTIC EXAMINATION RESULTS

RESULTS FOR BLOOD TYPING

ABO Typing Rh- typing Anti body

screen

A Positive

URINALYSIS

Physical Analysis

Color Light yellow

Transparency Clear



Chemical Analysis Result

Blood (-)

Bilirubin (-)

Ketones (-)

URINALYSIS

Chemical Analysis

Albumin (-)

Glucose (-)

pH 6.0

Specific gravity (-)

Leukocytes (-)


URINALYSIS

VI. MEDICATIONS. IV INFUSIONS, BLOOD TRANSFUSION,TREATMENTS GIVEN

IVF Name:Normal Saline

SolutionOther Name

0.9% NaCl Solution

Frequency: 55-56

gtts/min to run for 6 hours.

Action: Non-

pyrogenic solution for fluid

and electrolyte replenishm

ent. Contains no anti-

microbial agent

Indications: •Source of water and

electrolytes•Use to

replenish fluids

Contraindication:

•Severe hypertensio

n•Pulmonary

edema

Adverse/Side

Effects:•Febrile

response•Infection at the site of infection•Venous

thrombosis/phlebitis•Extravasa

tion•hypervole

mia

Nursing Implications:

•Check for renal function

•Check individual medication before

administration•Store the IVF at

room temp (25°C) to does not adversely affect the product


Drug Name:

Mefenamic Acid

Dosage: 500

mg/capsuleFrequency:

prn

Action: Analgesic

Anti-pyretic

and Anti-Inflammat

ory

Indication: Pain

Reliever

Contraindications:

Contraindicated during lactation with ulcer

and chronic inflammation

, poor platelet

function, kidney and

liver impairment.

Adverse/Side

effect: GI

discomfort, constipation, nausea, vomiting, drowsines

s and dizziness.

Nursing implications:

•Assess patients pain before therapy: Lactation, duration,

and alleviating factors.

•Monitor for possible drug

adverse reactions.•Administer drugs with food or in full

stomach.•Assess patient’s

family and knowledge about

drug therapy.


Genetic Name:

Ketorolac Tromethami

neBrand Name:ToradolDosage

15 mg, IVFrequency:

q6°

Action: Anti-

inflammatory and Analgesi

c. Inhibits

Prostaglandin

Indication: Short term management. of pain

up to 5 days.

Contraindications

: •With

significant renal

impairment.

•During labor and delivery.

•Use cautiously

with impaired

CV conditions

& allergies.

Adverse/Side Effects:

•Headache, dizziness,

insomnia(CNS)•Rash,

sweating, dry mucous

membrane(dermatologic).\

•Dysuria, renal impairment(GU)

•Bleeding, platelet

inhibition with higher doses, bone marrow depression,

menorrhagia(hematologic)

Nursing Implication:

•Assess patient and family

knowledge about drug

administration.•Assess the vital signs (BP, P, R);

cautiously administer to decrease vital

signs.•Assess for renal

impairment, allergies and impaired CV conditions.

•Inform the patient before

administering…



•Dyspnea, bronchospasm (Respiratory).

•Peripheral edema,

anaphylactic shock (others).


the drug that she may experience dizziness and drowsiness.

•Teach the patient to report fever,

rash, itching and swelling of

ankles/fingers after taking the

medications.


GenericName:

CephalexinBrand Name:Cefalin

Dosage:500mg,

PO, capsuleFrequency:

q6°

Action:Bactericidal:

Inhibits synthes

is of bacterial cell wall

causing cell

death.

Indication:Skin and

skin structure infections caused by staphyloco

ccus/ streptococc

us

Contraindications:

•Allergy to cephalosporins/penicillins

•Use cautiously with renal

failure.

Adverse/Side Effects:•Headache, dizziness,

lethargy (CNS)•Nausea, vomiting, diarrhea,

anorexia,abd.pain, flatulence, liver toxicity(GI)•Nephrotoxicity

(GU)•Anaphylaxis

(hypersensitivity)•Superinfections

(others)

Nursing Implications:•Assess the pt

and family knowledge

about the drug administration.

•Assess for cephalosporin/ penicillin allergy

through skin test.

•Assess the renal function before giving a

medication.



•Administer the drug with meals to minimize

adverse reactions.•Administer the drug with small frequent

meals if GI complications occurs.•Inform the pt that she

may experience stomach upset, loss of appetite, nausea and

diarrhea•Instruct the patient to take medication in a

complete course even if she feels better.


GenericName:Ferrous SulfateBrand Name:Rhea

Ferrous Sulfate

Dosage:30mg/day ,

capsule, PO

Frequency:Qd

Actions:Elevates

the serum iron

concentrations which helps form Hgb and

eventually convert to useable form of iron.

Indications:

•Prevention and

treatment of iron

deficiency anemia•Dietary supplement for iron.

Contraindications:

•Allergy to ingredients of ferrous

sulfate•Use

cautiously with normal

iron balance.


•CNS toxicity, coma, and death

(CNS)•GI upset,

nausea, vomiting and constipation

(GI)

Nursing Implications:•Assess the pt

and family knowledge about

the drug administration.

•Obtain baseline assessment of

pt’s iron deficiency before

starting the therapy.•Assess

hypersensitivity to ferrous sulfate.

•Be alert for adverse reaction

VII. Review of SystemsNeurological System

pupil size : 5 mm best verbal response : responsivereaction : PERRLA best motor response : activeeyes open : spontaneously

Integumentary Systemtemperature : warm skin turgor : normalcolor : normal JVD : not distendedskin : unintact skin as evidence by the incision on her abdomen

Respiratory Systemchest : symmetricallungs : equal chest expansionrespirations : no distressbreath sounds : clearcough : absent

VII. Review of SystemsCardiac System

heart sounds : normal

Gastrointestinal Systemabdomen : Pfanneinsteil cut over suprapubic area with scant bloody drainaige; dressing and plaster were clean and fully covers the incision site; no foul odor, incision is warm and softBladder not distended(+) mass tenderness at LLQBowel sounds : Hypoactive

Muscular Systempulses : (+) Homan’s sign : ( - )edema : ( - ) capillary refill : < 3 secondsperipheral calf tenderness : ( - )

VIII. ANATOMY AND PHYSIOLOGY

The Female Reproductive System

Fallopian tube/Oviduct :4 inches long (each

side)transports the mature

ova form the ovaries to the uterus

provide a place for fertilization of the ova by the sperm in it’s outer 3rd or outer half.


Fallopian tube/Oviduct:Interstitial – lies within

the uterine wallIsthmus – tubal ligationAmpulla – where

fertilization usually occurs

Infundibulum - covered by fimbriated cell


Ovaries:Oval, almond sized, dull

white sex glands on either side of the uterus

4 by 2 cm in diameter and 1.5 cm thick

responsible for the production, maturation and discharge of ova and secretion of estrogen and progesterone.


Uterus:hollow, pear-shaped

muscular organ3 x 2 x 1 inches,

weighing 50-60 gramsOrgan of menstruationsite of implantationprovide nourishment to

the products of conception.


Uterus:Perimetrium

(outermost)offers added strenght

and support to the structure.

Myometrium (middle layer)expels fetus during birth

process then contracts around blood vessels to prevent hemorrhage.


Uterus:Endometrium (Inner

layer )vascular and is shed

during menstruation and following delivery.


Divisions of the Uterus:Fundus – upper

rounded, dome-shaped portioncan be palpated to

determine uterine growth during pregnancy


Divisions of the Uterus:Corpus – body of the

uterus.Isthmus forms part of

the lower uterine segmentportion that is cut

when a fetus is delivered by a caesarian section.


Divisions of the Uterus:Cervix – lower

cylindrical portion that represents 1/3 of the total uterus.


Divisions of the Uterus:Vagina – a 3-4 inch

long dilatable canalorgan of

intercourse/copulationpassageway for

menstrual discharges and fetus

Layers of Anterior Abdominal Wall

Skin (functions):Protection: an

anatomical barrier from pathogens and damage

Sensation: nerve endings that react to heat and cold, touch, pressure, vibration, and tissue injury.


Skin (functions):Heat regulation:

increase perfusion and heatloss

Control of evaporation: dry and semi-impermeable barrier to fluid loss

Storage and synthesis: storage center for lipids and water


Skin (functions):Absorption: Oxygen,

nitrogen and carbon dioxide can diffuse into the epidermis in small amounts

Water resistance: so essential nutrients aren't washed out of the body.


FasciaCamper's fascia - fatty

superficial layer.Scarpa's fascia - deep

fibrous layer.

passive structures that transmit mechanical tension generated by muscular activities or external forces throughout the body


Fascia(function) Reduce

friction of muscular force thus allow muscles to glide over each other.


Muscle1. Transversus

abdominus –to stabilize the trunk and maintain internal abdominal pressure.

2. Rectus abdominus –commonly called ‘the six pack’ that move the body between the ribcage and the pelvis.


Muscle3. External oblique

muscles –allow the trunk to twist

4. Internal oblique muscles –flank the rectus abdominus, operate in the opposite way to the external oblique muscles


Fascia transversalisA thin aponeurotic membrane

which lies between the inner surface of the Transversus abdominis and the extraperitoneal fascia.


Fascia transversalisThick and dense in

structure and is joined by fibers from the aponeurosis of the Transversus, but it becomes thin as it ascends to the diaphragm, and blends with the fascia covering the under surface of this muscle.


Peritoneumthe serous

membrane that forms the lining of the abdominal cavity or the coelom

covers most of the intra-abdominal (or coelomic) organ

IX. PATHOPHYSIOLOGY

X. PRIORITIZED LIST OF NURSING PROBLEMS

1. Acute Pain

2. Impaired Skin

3. Constipation

4. Deficient knowledge

XI. NURSING CARE PLANAssessment Diagnosis Planning Interventions Evaluation

Subjective:• “makirot ang hiwa ko sa tiyan, lalo na pag umuupo ako” as stated by the patient.• 8 out 10 pain scale P – with movement Q – stabbing R – throughout the abdomen towards the back S – at abdomen, 8 out of 10 T – with movement

Objective:• V/S: BP – 110/90 mmhg PR – 80 bpm RR – 24 cpm

Acute Pain related to abdominal incision secondary to surgery.

Goal:• Within 30 minutes to 1 hour nursing intervention, the patient will be able to verbalize that the pain is relieved or controlled.

Short Term:• The patient will verbalize pain intensity from 4 – 6 to 3 – 4 intensity pain scale.• Participates in demonstrating techniques to relieve pain.

• Assess clients pain using scale 1 to 10 (rationale: assessment provides objective measurement of the clients perception of pain.• Observe client for non-verbal signs of pain, grimacing and pallor (rationale: observation helps identify discomfort when the client doesn’t ask for help.• Assess location and character of pain each time client reports discomfort (rationale: assessment provides information about the cause of pain.

• After an hour of nursing intervention, the patient was able to verbalize that the pain has lessened

• Goal partially met


Objective: Temp. – 38.2°C• Wound site - dry, scant discharge of blood. - dressing and plaster were clear and fully covers the incision site. - no foul odor - incision site warm and reddened

• S/Sx: - observed evidence of pain - expressive behavior: irritability

• Administer appropriate pain medications ordered (rationale: taking medicines can lessen the pain).• Promote proper position, Low fowler’s position (rationale: reduces intra-abdominal pressure).• Employ non-pharmacologic pain destruction such as music therapy (rationale: to prevent dependence on medicine).• Teach client to eat fresh fruits and vegetable and increase protein and fluid intake in the diet…


(rationale: teaching provides information about the patient needs to make diet decision that will help wound healing).• Encourage ambulation as soon as possible after birth (rationale: ambulation decreases venous stasis & increase platelets).• Encourage adequate rest period (rationale: to prevent fatigue).• Discuss the impact of pain on lifestyle/ independence (rationale: to maximize level of functioning).


Subjective:• “makirot ang hiwa ko sa tiyan,” as stated by the patient.

Objective: • Incision site - reddened - has scanty blood draining - pain in suture site

Impaired Skin Integrity related to surgical incision.

Goal: After 3 – 4 days of nursing intervention the patient will be able to display gradual healing in the incision site.

• Assess the appearance, odor and drainage in the incision site (rationale: for documentation purposes and baseline data for future comparison).• Perform hand hygiene before touching the incision site (rationale: to prevent spread of microorganism).• Keep the area of incision site clean and dry, carefully dress wound/ support incision (rationale: to assist body’s natural process of healing.• Teach the client on proper wound dressing

• After 3 – 4 days of nursing intervention the patient was able to display gradual healing in the incision site.

• Goal partially met.


(rationale: to prevent accumulation of microorganism in the incision site).• Instruct the patient on how to provide optimum nutrition which includes vitamins and increase in protein intake (rationale: To aid in skin and tissue repair).


Subjective: • “hindi pa ako nakakadumi” as stated by the patient.

Objective: • (+) hypoactive bowel sounds• abdominal redness• current medication - ferrous sulfate - Mefenamic Acid

Constipation related to abdominal muscle weakness secondary to Cesarean delivery.

Goal: Within 8 hours of nursing intervention patient will be able to establish and regain normal pattern of bowel function.

• Review surgical history often associated with constipation (rationale: to identify causative /contributing factors).• Record fluid intake and output of the patient (rationale: to evaluate hydration status).• Assess the patient’s medications (rationale: there are medications that can promote constipation; to know if one of her medicine is the cause)• Administer laxatives to the patient as prescribed by the physician (rationale:

• After 8 hours of nursing intervention patient was able to establish and regain normal pattern of bowel function.

• Goal partially met


to aid the non-pharmacologic interventions).• Instruct the patient to increase fluid intake (rationale: to soften stool and for hydration).• Advise the patient to increase in fiber intake by eating green leafy vegetables, cereals, grains and fruits (rationale: by increasing roughage to diet, stool is passed more easily.

XII. DISCHARGED PLAN

MedicineAdvise the patient to take the medicine prescribed by

the doctor.Mefenamic Acid 500 mg as necessary Cephalexin 500 mg/capsule once a day for 7 daysFerrous Sulfate 30 mg/day


ExerciseEncourage Ambulation to the patient to promote fast

healing, avoid strenuous activity to prevent wound dehiscence.


TreatmentGet plenty of rest, adequate rest is important to maintain

progress towards full recovery and to avoid relapse.Drink lots of fluids, especially water, liquids will keep

patient from becoming dehydrated.


HygieneAdvise the patient to take a bath everyday but avoid the

incision site from being wet to prevent on increasing risk of infection and for faster wound healing. Instruct the patient to cover it with clean plastic.

Instruct the patient to clean and dress the incision site everyday with iodine povidone (Betadine) to avoid infection and promote healing.

Others Instruct the patient to go back for hospital visit after a

week for follow up check up.


DietTell the patient to increase protein intake for wound

healing and increase fluid intake and fiber to prevent constipation.

Advise the patient to eat green leafy vegetables (like malunggay) and fruits for lactation.


Sexual and Spiritual Activity Sexual

She can resume coitus as soon as the act is comfortable or her, possibly as early as 1 week after discharge.

Warn the patient to abstain form intercourse if the discharges (lochia) haven’t disappeared yet because it will cause unhygenic intercourse.

Spiritual Tell the patient to continue her daily spiritual activities to

enhance spiritual health.

cesarean section 2ndary to fetal distress case presentation

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