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General Objectives:
The purpose of this study is to enhance and gain knowledge about, to develop communication and nursing skills to provide privacy and maintain
confidentiality of the patient and to apply the right attitude of the student nurses in rendering and giving care to the patient with Post Cesarean and Bilateral
Tubal Ligation, its importance and implication.
Specific Objectives:
To understand the condition of Post Cesarean and Bilateral Tubal Ligation and associate it with the patient through the introduction of the case.
To illustrate the anatomy and physiology of the affected organ or the part of the body.
To discuss the pathophysiology that causes anemia.
To be clinically aware of the clinical manifestation and its complication.
To develop an effective skill on how to plan and manage proper care in patient with Post CSBTL.
To provide the client nursing care plan and discharge plan to assure clients total wellness during her hospitalization up to time of his hospital discharge.
To apply right attitude by respect through providing privacy and maintaining clients confidentiality.
Scope and Delimitations
The study would only focus on Post CSBTL which is indicative to the patients health condition and its underlying nursing care relevant for the patient
confined in Quezon Medical Center.
The study was conducted at Quezon Medical Center (OB-Ward) during the nursing students exposure in the hospital (September 23,24 and 25 2012).
Nursing health history, physical assessment, nursing interventions and health teachings for the patient were included. Its primary focus is the clientwhose
diagnosis was Post CSBTL. The baseline data were gathered from the client, f rom the clients chart, and through the nurse-patient interaction during the
exposure.
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Nursing History:
History of Present Illness:
Masakit ang tahi ko,as verbalized by the patient. She experienced lumbosacral pain before admission. She was brought to Quezon Memorial Center last
September 21, 2012. At 2:00 in the afternoon. She was brought to operating room around 10:30pm.
History of Past Illness:
According to the patient, she didnt experience any severe illness during her childhood. Her common illnesses are cough, colds, and fever. She doesnt had any
drug and food allergies. Her first baby was delivered through cesarean operation due to drained amniotic fluid. Her second baby, died four days after the delivery
due to heart failure and was delivered by cesarean operation. Her third baby was delivered through cesarean operation due to breech presentation of the baby. Her
fourth baby was also delivered through cesarean operation.
Family History:
The patient is the 2
nd
child of 4 siblings. Her father is diabetic. Her mother died while giving birth to her youngest child and was delivered through cesareanoperation.
Her sisters, according to her was in good health condition.
Genogram:
Legend:
-Female -deceased
-Male - deceased
giving birth diabetic
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Personal/Social History:
Alcohol Use: Denies.
Tobacco Use: Denies.
Drug Use: Denies.
Travel History: Denies.
Economic Status: Farming as their means of livelihood.
Religion: Roman Catholic
s
Theoretical Framework
Watsons Caring
Theory:
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Physical Assessment
Date of Assessment: September 25, 2012
General Appearance:
The patient is oriented and conscious. She wears neat clothes exactly for her mesomorph body. Upon assessment, the client is sitting on the chair, with a pulse rate
of 93 beats per minute, respiration rate of 18 breaths per minute, and temperature of 36.0 C.
BODY PART NORMALS FINDINGS ACTUAL FINDINGS INTERPRETATION/ ANALYSIS
A.
HEAD
1. SKULL
Proportional to the size of the body,
round, with prominences in the
frontal area anteriorly and the
occipital area posteriorly
symmetrical in all planes.
Proportional to the size of the body,
symmetrical in all planes.
Normal.
2. SCALP White, clean, free from masses,
lumps, scars, nits, dandruff, and
lesion
White, clean, free from masses,
lumps, scars, nits, and lesions
Normal
3. HAIR Black or whitish, evenly distributed
and covers the whole scalp, thick,
shiny, free from split ends.
Black; evenly distributed, thick. Normal
4. FACE Oblong/oval/square or heart-shaped,
symmetrical, facial expressions that
is dependent on the mood or true
feelings,
Round shape. Symmetrical, free
from wrinkles and scars. No
involuntary muscle movements.
normal
B. EYES Black, symmetrical, thick, can raiseand lower eyebrows symmetrically
Black, symmetrical. Can raise andlower eyebrows.
normal
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and without difficulty, evenly
distributed and parallel with each
other.
C. EARS Pinkish, clean, with scant amount of
cerumen and a few cilia.
Cerumen and a few cilia. Normal
D. NOSE Midline, symmetrical, and patent. Midline, symmetrical, and patent. Normal
E. MOUTH Pinkish, symmetrical lip margin,
well-defined, smooth and moist.
Pale Pallor due to decreased hemoglobin
and hematocrit.
F. NECK Proportional to the size of the body
and head, symmetrical and straight.
Proportional to the size of the body
and head, symmetrical and straight.
Normal
G. RANGE OF MOTION Freely movable with relative ease. PoorRange of Motion. >dueto pain at incision site.
H. MUSCULAR STRENGTH Symmetrical movements and able toresist force applied by the nurse.
Symmetrical movements and able toresist force applied
Normal
I. HEART Regular beats
(60-100 beats per minute).
Regular beats (108 beats per minute) Deviation from normalPatients who are anemic or have low
levels of hemoglobin thus carrying
less oxygen in the blood causing a
higher number of BPM in the heart
rate
J. ABDOMEN
Inspection
Unblemished skin; uniform color.
Flat, rounded; symmetric contour.
With presence of incision at the
abdomen; intact and no drainage
Due to caesarean section delivery
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1. Abdomen skin
2. Contour and Symmetry
Symmetric movements caused by
respiration.
Auscultation Audible bowel sounds (5-30/min);
absence of arterial bruits andfriction rubs.
Audible bowel sounds (10/min). Normal
Palpation No tenderness;
With contracted hard abdomen.
Had incision site. Cannot be palpated due to pain at
incision site.
K. CHEST (THORAX)
Inspection
Chest symmetrical, skin intact, no
tenderness, no masses.
Chest symmetrical. No lumps,
tenderness and masses.
Respiration of 20breaths per minute.
Normal
Palpation Full and symmetric chest expansion.
Symmetric vocal fremitus.
Symmetric and expands. Normal
L. UPPER EXTREMITIES
1. ARMS
Inspection
Skin varies (pinkish, tan, dark
brown), skin is smooth, fine hair
evenly distributed, muscles
symmetrical, length symmetrical.
Edematous, Pale skin, fine muscle,
length symmetrical, fine hair evenly
distributed.
Deviation from normal
Pallor due to less oxygen being
available to the surface tissues
caused by decrease haemoglobin
level
Palpation Warm, dry and elastic, no areas of
tenderness. Muscle appears equal
Warm, dry and no areas of Normal
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with good muscle tone. tenderness.
M. NAILS Nails are transparent, smooth, &
convex with pink nail beds & white
translucent tips.
Five fingers in each hand. As
pressure is applied to the nail bed, it
appears white or blanched & pink
color returns immediately as
pressure is released.
Complete fingers, 5 each hand.
Nails are thick, transparent, &
convex with pale nail beds & whitetranslucent tips.
As pressure is applied to the nailbed,
it appears white and color returns
after 4 seconds.
With deviation from normal
Patients with anemia may exhibit
delayed capillary refill - diminished
blood flow to the periphery and
compensatory vasoconstriction.
N. SHOULDERS, ARMS,
ELBOWS, HANDS & WRISTS
ABDUCTION AND ADDUCTION.
Performs with relative ease. Performs with relative ease. Normal
O. LOWER EXTREMITIES
1. LEGS
Inspection
Skin varies (pinkish, tan, dark
brown), skin is smooth, fine hair
evenly distributed, absence of
varicose veins, muscles symmetrical,
length symmetrical.
Edematous in the lower extremities
Skin is pale. Hair evenly distributed.
Deviation from normal
Due to excess fluid volume the
patient may experience edema
(Medical-Surgical Nursing by
Digiulio p.177)
Pallor due to less oxygen being
available to the surface tissues
caused by decrease haemoglobin
level
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Hematocrit 33.4 M 40-50 vol%
F 30-40 vol%
Normal normal
WBC Count 6,300 5,000-10,000/comm Normal Normal
Name of Test Date Done Actual Result Reference Value
Neutrophils 09/21/12 74
Lymphocytes 26100%
Platelet CountBLOOD TYPE
217,000A +
III-Clinical Discussion of the Case:
>Anatomy and Physiology:
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>EXTERNAL GENITALIA:
Labia minora
Labia majora
Clitoris
>INTERNAL REPRODUCTIVE STRUCTURE:
The Vagina
The Cervix
Uterus
Oviducts (Fallopian Tube)
Ovaries
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Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
S- masakit ang tahi ko as
verbalized by the patientOabdominal pain scale of 9,
10 as the highest and 1 as the
lowest-Guarding behavior noted
-Facial grimace noted- Irritable noted-
Pallor
- Change of sleep pattern-
Restlessness
- Elevated pulse102bpm
- Respiration -24-
Acute pain related to tissue
injury secondary to surgicalintervention
After 2-4 hours of nursing
intervention the person willverbalize relief from pain after
satisfactory measures
Monitor vital signs to
compare to its normalvalue.
Teach specific
relaxation strategy;(rhythmic breathing or
deep breath) Instruct on techniques to
reduce skeletal muscle
tension, which willreduce the intensity of
the pain.
Assess the patientcontractions and
discomfort. Encourage the patient to
stand and walk as muchas possible during first
stage Instruct the patient to
change the position atleast every hour.
Encourage diversionalactivities such as talking
with the significantothers reading and so
on.
EXPECTED
OUTCOME
Goal partially met
At the end of nursing
intervention the patientdemonstrated a partial
relief in pain, from 9down to 5
hindi na masyadongmasakit ang tahi ko asverbalized by the patient
S- nanghihina ako asverbalized by the patient .
Opale palpebral conjunctiva
Fatigue related to inadequatetissue oxygenation secondary
to low hemoglobin count
After 1-3 days of nursingintervention the patient will
participate in activities that
Emphasize the need forrest and sleep period
Advice to avoid over
EXPECTEDOUTCOME
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Adults: 150mg p.o
bid or 300mg dailyh.s
hypersecretoryconditions, such as
zollinger ellisonsyndrome; short-term
therapy for patientsunable to tolerate oral
forms
any of its content,Use cautiously in patients
with hepatic dysfunction.Adjust dosage in patients
with impaired kidneyfunction
Other: burning anditching at injection site,
anaphylaxis
decreasing gastric acid and secretion
Oxytocin,synthetic injection
Adults: initially
1ml ampule in1000ml of d5w
injection
Pitocin To induce orstimulate labor, to
reduce postpartumbleeding after
expulsion of placenta
Contraindicated in patientshypersensitive to drug.
Also contraindicated whenvaginal delivery isnt
advised
Cns: subarachnoidhemorrhage, seizures and
comaCv: hypertension,
increased heart rate,systemic venous return
Use with extreme caution during firstand second stages of labor because
cervical laceration, uterine rupture andmaternal and fetal death
Tramadolhydrochloride
Adults: 50-100mg
p.o q4 to 6 hours,prn maximum
400mg daily
Ultram Moderate tomoderately severe
pain
Contraindicated to patienthypersensitive to drug and
in those with acuteintoxification from alcohol,
hypnotics, centrally actingganalgesics.
Cns: dizziness, vertigo,headache, somnolence
Cv: vasodilationGi:nausea, constipation,
vomiting, dyspepsia
Use cautiously in patients at risk forseizures or respiratory depression; in
increased intracranial pressure
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DISCHARGE
MEDICATIONS
Explain to the patient and family members the importance of taking medicines.
Discuss to the patient and family the dosage, frequency and adverse effects of the drugs.
Encourage to follow the dosages and proper timing of his meds.
ENVIRONMENT
Explain to significant others that the rehabilitation may be prolonged to be able for the family to prepare financial needs
Maintain a quiet, clean and calm environment for easy and good recovery of the Patient.
Provide safety measures to promote safe environment and individual safety
Treatment
Provide warm environment
Advice patient to avoid lifting heavy objects and use of too much force to prevent more serious injury.
Instruct to perform light physical activities
HEALTH TEACHINGS
Instruct the patient to take medications religiously
Improve nutritional status
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