COMPETENCE APPRAISAL

The Post-operative Mother

By:Busa, Ana Marie V.

BSN IV-A

To:

Ms. Rowena Ang RNThere are a wide range of surgical procedures that have been developed to treat the various conditions in Obstetrics. Some common surgical procedures that are performed include:

Episiotomy. A surgical incision made in the perineum (the area between the vagina and anus) to expand the opening of the vagina to prevent tearing during delivery.

Colporrhaphy. Surgical repair of the vagina may be necessary after childbirth, sexual assault, or other injuries.

Cervical cerclage . The cervix is stitched closed to prevent a miscarriage or premature birth.

Salpingostomy. An incision is made in the fallopian tube, often to excise an ectopic pregnancy.

Salpingectomy. One or both fallopian tubes are removed in this procedure. It may be used to treat ruptured or bleeding fallopian tubes (as a result of ectopic pregnancy), infection, or cancer.

Tubal ligation. A permanent form of birth control in which a woman's fallopian tubes are surgically cut or blocked off to prevent pregnancy.

Cesarean Section . A surgical procedure in which incisions are made through the woman's abdomen and uterus to deliver her baby.

A cesarean birth, also known as C-section, happens through an incision in the abdominal wall and uterus rather than through the vagina. Some C-sections are planned due to pregnancy complications or because you've had a previous C-section. But, in many cases, the need for a first-time C-section doesn't become obvious until labor has already started. Knowing what to expect during the procedure and recovery can help the mother prepare.

Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Some indications for Caesarean delivery are:

Complete placenta previa Cephalopelvic disproportion Placental abruption Active genital herpes

Umbilical cord prolapse Failure to progress in labor Nonreassuring fetal status Previous classical incision on the uterus Benign and malignant tumors Cervical cerclage Breech presentation Previous cesarean birth Preeclampsia

In the case of Mrs. Precy Ardani, 31 years old from Pasar Staff house Isabel, Leyte, she was admitted to Ormoc Sugarcane Planters Association-Farmers Medical Center last November 8, 2010 with diagnosis of Severe Preeclampsia.

Preeclampsia is a condition of pregnancy marked by high blood pressure and excess protein in your urine after 20 weeks of pregnancy. Preeclampsia often causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious, even fatal complications for both mother and baby. The women at risk for preeclampsia are primiparas younger than age 20 years or older than 40 years, women who have had five or more pregnancies, women of color, women with a multiple pregnancy, women with hydramnios and women with underlying disease such as heart disease, diabetes with vessel or renal involvement and essential hypertension. The condition may be associated with poor calcium or magnesium intake.

A woman has passed from mild to Severe Preeclampsia when her blood pressure has risen to 160mmHg systolic and 110mmHg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic pressure is 30mmHg above the prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample, or more than 5g in a 24 hours sample, and extensive edema are also present.

The hypertension, albuminuria and edema of preeclampsia, usually arise 32 weeks into a first pregnancy, and are often accompanied by headache and disruptions of vision. Preeclampsia seems to originate from an implantation abnormality that affects

placental blood vessels. The resulting placental ischemia may be severe enough to produce placental infarcts.

Complications of hypertension are the third leading cause of pregnancy-related deaths, superseded only by hemorrhage and embolism. Preeclampsia is associated with increased risks of placental abruption, acute renal failure, cerebrovascular and cardiovascular complications, disseminated intravascular coagulation, and maternal death.

Mrs. Precy Ardani was born on a Filipino on January 21, 1979 at Kitaotao, Bukidnon. She is the youngest child of Mr. & Mrs. Macalam. Mrs. Ardani together with her husband lives in Pasar Staff House, Isabel Leyte.

Four days prior to admission, Mrs. Ardani had an elevated BP of 160/110 was detected during her prenatal and was prescribed by Methyldopa, 250g 1tablet TID by Dr. Larrazabal, BP was managed and she was sent home. Mr. Ardani reported that there was no history of elevated BP during the past months of her pregnancy. Although she felt uncomfortable and unable to walk weeks before delivery due to pitting edema grade 4, she doesn’t have any other manifestations of Preeclampsia when she was at home. Came November 8, 2011 when there was positive watery/bloody discharge, she felt heaviness at her nape, she was then rushed and admitted to the Ormoc Sugarcane Planters Association - Farmers Medical Center at 7:43 pm. Upon arrival at the hospital, Mrs. Ardani had an internal examination with one of the resident doctors and resulted that her cervix was 1-2 cm dilated and 60-70% effaced, the staff reached Dr. Gardenia Larrazabal through the phone and decided to induce the labor with oxytoxin. Hours after induction of oxytocin, Mrs. Ardani’s condition worsened and her BP unmanageable so Dr. Gardenia Larrazabal opted for a delivery of the baby via cesarean section. On November 9, 2010 at 1:27 a Primary Low Cervical Transverse Cesarean Section was performed by Dr. G. Larrazabal, the operation ended at 2.25 with safe delivery of the baby.

Pathophysiology of Severe Pre-eclampsia

Vascular damage Hypertension↓Intravascular Volume

↑Extravascular Fluid

Predisposing Factors:Maternal Age (very young or advanced maternal age)

History of HypertensionFamilial history of Preeclampsia

Multiple GestationPrimigravida

Women with history of diabetes or kidney disease.

Precipitating Factors:High Sodium diet

High cholesterol dietStressful lifestyle

ObesityAbnormal placental development

Sedentary lifestyleImmune Malaptation

Decreased levels of vasodilating prostaglandins

Vasospasm

Platelet Aggregation

Signs:BP of 160/110 or higher in 2 occasions in at least 6hrs apart while at rest.preoteinuria≥5 g/L in 24hrsoliguria ≤500 mL in 24hrscerebral or visual disturbancepulmonary edema/cyanosisepigastric or RUQ pain↑hepatic enzymesThrombocytoperiaFetal growth restrictionGeneralized edema

Symptoms:HeadacheBlurred vision/scotomataDyspneaHyperreflexiaNausea & VomitingIrritabilityEmotional tensionDizziness

Surgical Management:Cesarean Section

Nursing Management:Bed restHigh-protein, moderate-sodium dietDaily weigh and daily evaluationof worsening edema.Monitor BP q4hMonitor I&O q4hMonitor FHT qhAssist in ADLsAssess reflexesDiscuss mode of childbirthPosition on the sideProvide comfort measures as neededEncourage family members to stay with the expectant mother as long as possible throughout labor and childbirth.

Medical Management:AnticonvulsantsCorticosteroidsIVF TherapyAntihypertensives

Nursing Assessment(Post operative)

Name of patient: Mrs. Precy Ardani Gender: Female Room #: 109

Age: 31 years old Physician: Dr. G. LarrazabalCase #: 105122 Complaints: Labor PainsImpression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of induction

BodyPart

PHYSIOLOGIC

I P P AHead

Hair

Scalp

Forehead

Face

Symmetrical, normocephalic and in midline of the body, no lesions

Black, coarse and curly, evenly distributed, shoulder level, no parasites or dandruff

White, no dandruff

Smooth, symmetrical, no lesion, no rashes

Round in shape, no deformities, brown colored skin, dry skin turgor, pale, chloasma

Without masses

Thin and coarse

Absence of nodules, non tender

No tenderness, warm, temporal pulse: 148 bpm

No lumps, no tenderness, non pitting edema

Eyebrow

Eyelash

Eyelids

Conjunctiva

Sclera

Pupils

Muscle Balance

Nose

Fontal sinuses

Maxillary Sinuses

Mouth

Lips

Gums

present

Evenly distributed, black in color, parallel

Slightly curved outward and evenly distributed

Skin is intact with no discoloration, able to open and close

Palpebral: light pink color, no inflammation, Bulbar: pale pink, moist, no accumulation of secretions.

White, anicteric, moist, small veins are visible

Brisk constriction, round, regular, smooth border, black and equal in size in both eyes.

Round, reactive to light and accommodation.

Located in the midline of the face, slight nasal stuffiness and swelling, no masses, no bleeding.

No swelling

No swelling, glows on each side is equal

30 adult teeth, 2 molars missing, 1 black

Dry, proportional to the face, presence of cracks and peelings

Light pink, no retraction, swelling or bleeding

present

No masses

No lump, no secretions

No pain

No pain

Tender, rough

No masses

Uvula

Tonsils

Tongue

Teeth

Hard palate

Soft palate

EarsExternal

Neck

Lymph nodes

Trachea

Thyroid

ThoraxChest Anterior

Lungs

Breast

Located at the midline, not inflamed, pink

Not inflamed, light pink

Dark pink, no ulceration

Yellowish in color

Located anteriorly with ruggae

Posteriorly located, moist, no lesions, no ulcerations

Equal in size bilaterally, no scars, no lesions, good skin turgor, evenly distributed skin color, no swelling

No scars, no lesions, nodeformities, full ROM without complaints

Not inflammed

Stays on center

Rises during swallowing

Symmetrical, elliptical shape and brown in color, freckles present, moles present, RR:28 breaths/min

Supple, symmetrical in size, darker pigment than

Resistant

Intact to gums

Hard

Flexible, without masses

Carotid pulse: 120 bpm, no palpable masses, non tender

Non tender, palpable

No pain

No pain

No lump, equal expansion

Unpalpable nodes

Dull sound on bony prominence; resonant on intercostals spaces.

Clear lung sounds on both fields.

Heart

Chest Posterior

Lungs

Abdomen

ExtremitiesUpper

Biceps Reflex

Lower

Patellar Reflex

skin on nipple and dark brown on areola, veins dilated

Spine aligned vertically, no patches, no retractions

Striae present, rotund abdomen, flabby, linia nigra present, freckles present, Pfannensteil incision at lower segment of abdomen present.

Equal muscle tone, poor skin turgor, presence of IVF line of D5NM 1L @ 30 gtts/min at the left dorsum of her hand, freckles present, presence of scars, warm to touch, nails clipped, non pitting edema

Warm to touch, poor skin turgor, bipedal edema, non pitting grade 4, weakness

No pulsation palpable over aortic and pulmonic

Warm to touch, equal expansion

Tender and moderately painful

Pulse rate: 120bpm axillary temp: 38°CNo pain, tenderness or nodules, full ROM

Equal strength

No pain, ROM impairedPulse rate: 120bpm

Equal strength

Dull sound on bony prominence; resonant on intercostals spaces.

Dull sounds on kidneys liver

Heart rate: 124 bpm

Vesicular and bronchovesicular breath sounds heard

Clear lung sounds on both fields.

Bowel sounds: 5/min, no bruits

Diagnostic results

Name of patient: Mrs. Precy Ardani Sex: Female Room #: 109 Age: 31 years old Physician: Dr. G. LarrazabalCase #: 105122 Complaints: Labor PainsImpression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of inductionInstitution: Ormoc Sugarcane Planters Association-Farmers Medical Center

Diagnostic Test Normal Value Patient’s Result Significance

HEMATOLOGIC

EXAM:

Date: Nov. 8, 2010

WBC

Neutrophils

Lymphocytes

Monocytes

Eosinophils

5 – 10 x 10^9/L

35-80%

15-50%

0-13 %

7.8x10^9/L

63.7%

26.9%

7.9%

Normal

Normal

Normal

Normal

Basophils

RBC

HGB

HCT

PLT

MCV

MCH

MCHC

RDW

0-3%

0-2%

4.8-5 x 10^12/L

11.5-16.5 g/dL

35-55%

150-450x10^9g/L

80-100fl

27-32 pq

32-36%

11-15%

1.2%

0.3%

4.1x10^12/L

12.7g/dL

38.8%

171x10^9g/L

94fl

32.7pq

32.7%

12%

Normal

Normal

Slight Decrease

Normal

Normal

Normal

Normal

Slight increase

Normal

Normal

Functional Health Pattern (post-operative)

Health Perception/Health ManagementAfter the operation the patient was more comfortable or

assured that her health was in better condition, and yet she still worries with regards to the next pregnancy if there is any. But verbalizes she wouldn’t have any more children because she can no longer take the pain during the birth process.

Cognitive/PerceptualAfter the operation the patient has no problem in her

hearing, seeing things clearly; she is well oriented time to time by asking some question about her health, place and person. The patient can still perform activities of daily living and there were no changes in her mental status.

Nutritional and MetabolicAfter the operation, the patient was on soft diet and is

still able to eat 3 meals a day. She doesn’t have any problems regarding on the foods being served to her.

Elimination PatternAfter the operation the patient was inserted with a folly

bag catheter and patient’s urine output of 420 mL per shift. The patient defecates for 1-2 times a day.

Sexuality and Reproduction Sexual activity has not yet resumed due to post-operative wound.

Activity and ExerciseAfter the operation, the patient is trying her best to do

some walking at the side of the bed. But she knows where her limits are, and if she feels pain she just rests for a while.

Roles and RelationshipThe patient is married, and a mother of 1 child, and she

has a good relationship with her husband, children, relatives and friends, upon hospitalization some of her relatives and family were there even if they live very far.

Values and BeliefAs a devout Roman Catholic, she prays and read the

scripture most especially thanking God for relieving them from complications.

Coping and StressAfter the operation the patient was able to cope with

the discomfort of post-operative wound. The patient can still cope up to her situation because the support given by her husband, family, relatives and friends. She had a positive outlook of her situation even before and after the operation.

Nursing Care Plans(post operative)

Name of patient: Mrs. Precy Ardani Sex: Female Room #: 109 Age: 31 years old Physician: Dr. G. LarrazabalCase #: 105122 Complaints: Labor PainsImpression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of induction

Needs/ Problems/ Cues

Nursing Diagnosis

Scientific Basis Objectives Nursing

Interventions Rationale Evaluation

Physiologic Overload:1. Altered comfort: Acute Pain

Objective:-Seen patient on bed, conscious, coherent & aware of time

Altered Comfort: Acute Pain related to surgical incision secondary to Primary low cervical transverse cesarean

The woman’s physiologic concern for the first few days after cesarean birth may be dominated by pain at the incision

After 8 hours of nurse- patient interaction, the patient will be able to:

1. experience

1. Measures to decrease pain intensity:

a. keep patient at rest in semi- fowler’s position.

a. Gravity localizes inflammatory exudates into lower abdomen or pelvis relieving

place and date; occasional facial grimaces; presence of wound in the lower segment of abdomen.-Pain started after surgery; located at the hypogastric region of the abdomen or incision site with duration of 30 sec - 1 min characterized by cramping and stinging pain. It is aggravated by frequent movement and relieved by repositioning or sleeping. It is treated by Algesia (37.5/325mg) BID, with pain range of 6 in a 1-10 scale.

Subjective:“Sakit ang tahi sa ako pus-on”

2. Fluid Volume Excess

Objective:

section

Fluid volume excess related to changes in

site and pain resulting from intestinal gas.

Source:Maternity & women’s health careBy: Lowdernill; Perry p1015-1020

Elevated BP damages the institial

increased comfort concerning pain as evidenced by lowered pain intensity from 6/10 to 3/10.

2. Stabilize fluid volume as evidenced

b. provide additional comfort measures such as touch, repositioning & quiet environment.

c. instruct patient to use relaxation techniques such as deep breathing exercises.

d. instruct the use of binders.

e. encourage adequate rest periods.

f. encourage expression of feelings towards pain.

g. Place icebags on abdomen periodically during initial 24-48hr as prescribed.

h. Administer Algesia BID.

2. Measures to stabilize fluid volume:

abdominal tension which is accumulated by supine position.

b. to alleviate pain by promoting non-pharmacologic pain managemen.

c. provides relaxation and good circulation.

d. to reduce pain when moving.

e. to prevent fatigue.

f. to minimize pain.

g. soothes /relieves pain through desensitation of nerve endings.

h. to relieve pain.

-bipedal non-pitting edema Grade 4-weight gain of 54kgs to 82.3 kgs for 9 months-immobility due to edema.

Subjective:“grabe ang paghupong sa akong bitiis”

3. Risk for infection

Objective:-Presence of surgical wound-presence of perineal pad

Subjective:“Delikado magkaimpeksyon tungod sa

regulatory mechanisms and water retention secondary to Pregnancy induced Hypertension

Risk for infection related inadequate primary defenses secondary to surgical incision

lining of the small vessels. Because of the initial damage, fibrin accumulates in the vessels, local edema develops and intravascular clotting may occur.

Medical-Surgical Nursing 7th edition volume 2 by: Black, Hawks p. 1494-1495\

The skin is the first line of defense against bacterial invasion. When the skin is incised for a surgical procedure as in cesarean birth, this important line of defense is automatically lost. In addition, if cesarean birth is

by balanced I/O and decreased signs of edema.

3. be free of infection.

a. auscultate breath sounds.

b. measure circumference of extremeties.

c. restrict sodium and fluid intake as indicated.

d. Weigh daily on a regular schedule.

e. elevate edematous extremeties.

f. promote early ambulation.

g. administer Furosemide OD 8am.

3. Measures to decrease incidence of infection:

a. perform wound care.

b. Monitor white blood count (WBC).

c. Monitor Elevated temperature, Redness, swelling,

a. check for presence of congestion.

b. to create baseline data for comparison.

c. to decrease fluid retention.

d. provides comparative baseline.

e. to reduce tissue pressure.

f. to facilitate increase of circulation

g. to remove excess fluids.

a. Moist from drainage can be a source of infection.

b. Rising WBC indicates body’s efforts to combat pathogens;

c. these are signs of infection

samad.” performed after the membrane have been ruptured for hours, the woman’s risk for infection doubles.

Source: Maternal-Neonatal Nursing by Lippincott p.370

increased pain, or purulent drainage at incisions

d. Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient.

e. provide high calorie diet.

f. Administer Metronidazole TID.

g. Encourage fluid intake of 2000 ml to 3000 ml of water per day

d. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another

e. To compensate metabolic needs.

f. to prevent infection

g. Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).

Health Teaching Plan

Name of patient: Mrs. Precy Ardani Sex: Female Room #: 109 Age: 31 years old Physician: Dr. G. LarrazabalCase #: 105122 Complaints: Labor PainsImpression/Diagnosis: Pregnancy Uterine Full Term, Severe Preeclampsia-- failure of induction

Objectives Content Methodology TimeAllotmen

t

Source Evaluation

General Objectives:After 3 days of student nurse- patient and significant others

interaction, the patient and significant others will be able to gain appropriate knowledge, skills and positive attitude towards management of patient who underwent Primary low cervical transverse cesarean section.

Specific Objectives:After 45 minutes of student nurse-patient and significant others interaction the patient and significant others will be able to:

1. define wound care into his own level of understanding

2. state the signs and infection of symptoms of infection

1. definition wound care: most client return from surgery with a sutured covered by a dressing, wounds are inspected regularly to ensure that they are clean dry and intact, excessive drainage may indicate hemorrhage , infection or an open woundwound care involves removal of debris such as foreign material, excess slough, necrotic tissue, bacteria and other microorganism

2. signs and symptoms:-wound warm to touch (heat)-redness-swelling-pain in wound site

Visual Aids/ pictures/ discussion

Visual Aids/ discussion

10 mins

5 mins

Kozier,Fundamentals of Nursing, chapter 5, page 861

Kozier,Fundamentals of Nursing, chapter 6, page 946

After 45 minutes of student nurse-patient and significant others interaction the patient and significant others was able to:

1. define wound care into his own level of understanding

2. state the signs and infection of symptoms of infection

3.identify the primary intervention of wound infection

4. recognize the materials needed for wound care

5.demonstrate wound care and cleansing

-fever-loss of function-Body malaise

3. Interventions:keep wound clean and dry, use surgical aseptic technique when changing dressingadequate nutritionappropriate incision support and avoidance of strainavoid wound exposure to avoid microorganism to enter wound site

4. Materials:clean watermild soap antimicrobial solutiongauzeNormal Saline Solution or Isotonic Solution

5. demonstration:-Use solution such as Isotonic or Normal Saline Solution to clean and irrigate s. If Antimicrobial solutions are used make sure that they are diluted well.

-When possible, warm the solution to the body temperature before use, this prevents lowering of wound temperature which allows healing process.

-Place the patient in a safe position (high

Visual Aids and discussion

Visual Aids and discussion

demonstration / return demo

5 minutes

5 minutes

20 minutes

Kozier,Fundamentals of Nursing, chapter 6, page 946

Kozier,Fundamentals of Nursing, chapter 6, page 946

Kozier,Fundamentals of Nursing, chapter 5, page 880

3. identify the primary intervention of wound infection

4. recognize the materials needed for wound care

5. demonstrate wound care and cleansing

fowlers or side lying) note the level of consciousness.

-Put patient align in bed use gauze squares, avoid using cotton balls, clean the superficial non infected wound by irrigating then with normal saline solution.

-To retain wound moisture, avoids dry after cleaning.

-Hold sponge with sterile gloves after cleaning.

-Clean the wound from inward to outward direction to prevent cross contamination.

-Keep the gauze duamp, remoisten the skin of saline for optimal healing.