MANILA DOCTORS COLLEGE We Nurse the World President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay City 1302

Nursing Process
3rd Floor Manila Doctors Hospital In Parital Fulfillment of the Course Requirement in Nursing Care Management in Related Learning Experience 103

Pregnancy Uterine Delivery by Primary Low Transverse Cesarean Section for Breech Position Preterm, Premature Rupture of Membranes (G1P1)

Submitted to: Prof. Christina Cruz, RN, MAN

Clinical Instructor

Submitted by: BSN III A 01 Group 02

Del Rosario, Katrina Ysabel G. Doria, Milan Lisette C. Ederosas, Toni Faye G. Encabo, Angela Grace P. Espiritu, Vien Paulo C. Estrella Jan Michael D. Gallarin, Ellise Eudore C. Geronimo, Jerico Mark S. Herrmann, Mary Estiffany C. Iligan, Sarah Jane S. Javier, Jebryl T. Jazmines, Nicole Andrean B.

25 August 2010

NURSING PROCESS
I. ASSESSMENT A. General Assessment General Information Patients Initials: CNCR-DC Address: Quezon City Age: 29Y 2M 17D Sex: Female Date of birth: May 26, 1981 Civil Status: Married Occupation : Lawyer Informant: Patient Date of Admission: 08/12/10 3:06PM Order of Admission: Ambulatory No. of Days in the 6 days Hospital:

B. Chief Complaints For STAT caesarean section procedure secondary to sudden gush of watery vaginal discharge without pain and with no bloody show. C. History of Illnesses August 7, 2010 Mrs. DC went to her doctor complaining for painful urination, oliguria and abdominal pain which she had observed and experienced for 2 days. She was diagnosed with UTI and was ordered to take Augmentin 3 times a day for 7 days. August 12, 2010 10:30AM, when the client was busy working at the office, she felt a sudden gush as if urinating, akala ko naihi lang ako bigla, as verbalized by the client. She rushed to the comfort room to urinate. The client checked her pad and saw a clear, odourless, watery vaginal discharge. The client then called her OB-Gyne informing him about the incident, and then described its characteristics. Her OB-Gyne then instructed Mrs. CNCR-DC to see him at his clinic at Fatima. The client was assessed and was informed that her amniotic fluid was already ruptured and that the fetus is in breech position. The client was admitted at Manila Doctors Hospital. She was observed inside the MDH-delivery room. She was given Steroids intravenously for the lung maturity of the fetus. The doctor monitored her uterine contractions, a second dose of Steroids was again given an hour before the procedure, and after having continuous with regular interval of contractions the doctor told her that though the baby was still on preterm (33 weeks AOG) she needed to undergo STAT primary CS by 9:00PM.

D. Past History 1. Childhood Illnesses - German measles (below 10 years old) - Chicken pox (between 10-13 years old) - Mumps (Teen years) 2. Adult Illnesses

Severe Upper Respiratory Tract Infection (not remembered) Polycystic ovarian syndrome; right ovary (2001) Mitral Valve Prolapse (diagnosed: 25 years old- 2006) Urinary Tract Infection (diagnosed: July 2010)

3. Immunization Fully Immunized 4. Previous Immunization - Tetanus Toxoid (TT3) - Hepatitis A and B - Typhoid vaccine 5. Operations Primary Low Transverse Cesarean Section (12 August 2010) 6. Injuries - Fell from the stairs (childhood) 7. Medications Prior to Confinement - Fern C, 500mg (daily) - Augmentin (3x a day for 7 days; for UTI) - Cal-Mag (OD; daily supplement) - Amino 1000 (daily; since pregnancy) 8. Allergies - Allergic to seafoods (not fresh) E. System Reviews- Gordons Eleven Functional Health Patterns *Prior to confinement (during clients pregnancy) A. Health Perception-Health Management Pattern Prior to confinement and during pregnancy, Mrs. DC described her general health as ok lang naman, as verbalized by the client. She seldom gets colds, fever or flu. She regularly takes vitamin C supplement and eats a lot of citrus fruits. The client has never been absent from work even when shes not feeling well. Kaya ko namang magtrabaho kahit masama pakiramdam ko kasi hindi naman ganon kalala ang sakit ko, as verbalized by the client. She performs simple cardio exercises like walking and she strictly follows the diet ordered by her doctor to keep her healthy. If the clients not feeling well, she increases her oral fluid intake, takes paracetamol alone as her immediate drug regimen. If paracetamol is not effective, she immediately consults her physician. She has been a smoker for 15 years but stopped by the time she learned that she was pregnant. She drinks approximately 5 to 6 bottles of alcoholic beverages 4 times a month when she was not yet pregnant. The client is not taking any prohibited drugs. She usually performs self-breast examination and is aware of its importance. She only had a minor injury when she was a child (fell from the stairs) and was never involved in a major accident. She thinks that her UTI had caused her condition (PPROM), though she immediately sought help from her physician, she thinks that her actions were too late.

During confinement, she does not feel body weakness and she is still active, she can still perform activities of daily living, she does walking exercises inside her room and she thinks that her health will be better than before she got pregnant because she can now eat what she want and there are no more diet restrictions for her. She also said that by the time her wound heals she will immediately return to her vigorous exercises and will engage on heavier weight lifting like before.

B. Nutritional Metabolic Pattern Prior to confinement, the clients diet consist of the following: high in protein, high in fiber, low carbohydrates and use of soy milk instead of full cream milk. She had diet restrictions like avoidance of foods rich in fats and sugars because she was prevented from gaining too much weight.The client eats vegetable salad during snack time. Shes taking the following

supplements: Fern C, 500mg (daily), Augmentin, Cal-Mag, and Amino 1000 (daily; since pregnancy). The clients daily fluid intake is approximately 3150mL daily. She gained weight (20 lbs) during pregnancy from 134lbs to 154lbs (weight before delivery). The client has a good appetite. The client eats at least 5 times a day in small portions since she gets full easily. Onte lang kinakaen ko, kasi mabilis ako mabusog pero mayat maya na lang ako may nginunguya as verbalized by Mrs. DC. They do not have a family history of diabetes. She would rarely have skin rashes and has an allergy which is triggered by eating sea foods that are not fresh. Upon admission to the delivery room, the client was ordered to a NPO diet for pre surgical preparation for administration of anesthesia. She had an intravenous fluid line connected to her left metacarpal vein. The clients NPO diet was shifted to clear liquids, general liquids diet on August 13, 2010. At 07:00PM of the same day, she was shifted from clear, general liquids diet to soft diet. At August 15, 2010 her diet was shifted from soft diet to diet as tolerated and her intravenous fluid was discontinued. At present, Mrs. DC is really glad that she is now on DAT. She told us that her appetite will surely increase since she can now eat the foods that were restricted to her before like chocolates but her meal would usually consist of meat and vegetables. She does not have eating problems. She can consume a total of 1,500mL of oral fluid intake daily. She had lost weight (5 lbs), from 154lbs. (before delivery) to 149lbs. (present). C. Elimination Pattern Prior to admission, the client consumes approximately 3150mL of fluids (water, milk and juices) per day. The client urinates at least four 4 times when shes working in the office and at least 5 times at home. She defecates twice a day with characteristics of well formed, brown stool. The client does not use any laxative and she eats foods that are high in fiber. She does not experience any difficulty when urinating or defecating. She only had urination problems when she had a UTI. She described having a painful and frequent urination wherein sometimes she had the urge to urinate but nothing comes out, she also had abdominal pain which is associated to this infection. That time she rated 7/10 for her pain scale. Based on the clients observation, she perspires excessively when shes not able to exercise. Upon admission at the delivery room, a foley catheter was inserted to the client and was removed the following day on August 13, 2010. On the same day, the client had a positive flatus and negative bowel movement. The physician ordered for a rectal suppository (Dulcolax) to be administered to the client. By 07:00PM of August 16, 2010, the client had a positive bowel movement. The client would normally have a urine output of 600 to 1000mL and defecates at least once or twice during our shift (2:00-10:00PM). D. Activity-Exercise Pattern During the clients pregnancy (before admission), she stated that her energy to do required activities is not enough; parang kulang pero pinipilit ko na lang gawin ang trabaho, as verbalized. She performs exercises like walking for approximately 1 hour and weight lifting (5-10lbs dumbbells) just to prevent sagging of her muscle after giving birth to her first child. She does this for at least 3 times a week. She lives an active lifestyle and allocates her spare time on reading and writing (still work related activities) and sometimes she goes out with her husband to watch movies or go shopping. Perceived ability for: 0 Feeding 0 Dressing 0 Cooking 0 Bathing 0 Grooming

0 Shopping 0 Toileting 0 General Mobility 0 Home Maintenance 0 Bed Mobility

During her confinement, the client stated; sa tingin ko mas may energy ako ngayon kasi mas nakakapahinga ako since andito lang naman ako sa hospital, wala ako masyado ginagawa, nakakapagod lang magpa-breast-pump. She is not physically active since she had just undergone an operation and she would immediately feel pain when exerting pressure (coughing and laughing) to her incision site. Her usual activities in the hospital are walking, reading, watching TV, visiting her baby at the NICU and breast-pumping. After surgery, her demonstrated ability were:

0 Feeding 0 Dressing 0 Bathing 0 Grooming

0 Toileting 0 General Mobility 0 Bed Mobility

Functional Level Codes: Level 0: Full self care Level I: Requires use of equipments or device Level II: Requires assistance/ supervision from other person. Level III: Requires assistance/ supervision from other person and equipments or device.

E. Sleep-Rest Pattern Prior to confinement, the client sleeps at least 6 to 12 hours during weekends and 6 to 8 hours during weekdays. She would usually be on bed by 11:00PM and wakes up by 9:00 or 10:00AM on weekends and by 6:00 or 8:00AM on weekdays. The client takes naps during weekends for at least 2 hours. She does not have any sleeping problem. She only wakes up at night for elimination purposes (urinating/defecating) and does not have problems going back to sleep. Her usual preparation before bedtime are drinking soy milk, taking a warm bath and applying coco butter on skin to prevent having stretch marks. The client does not have nightmares and feels well-rested most of the time. She feels lazy though, to rise up in the morning during rainy days Pakiramdam ko kulang tulog ko kapag umuulan, as verbalized by the client. During admission, the clients sleep rest pattern varies since she does not have a schedule to follow. She can sleep and wake-up anytime she wants. But she assures that she gets at least 8 hours of sleep and she feels well rested after having sleep. She does not have any difficulty in sleeping, and whenever shes interrupted, shes able to go back to sleep immediately. F. Cognitive Perception Pattern Prior to admission, the client uses contact lenses with a grade of 475 (left eye) - 450 (right eye). She is near sighted and was diagnosed to have astigmatism. She does not have any hearing difficulties. When it comes to decision making, the client would usually consult her husband. The client learns technical matters by demonstration, while other things through either or both by demonstration and by simply following procedures. She easily learns things that interest her and has difficulty with those that do not which are usually required for her to learn. She noticed during her pregnancy that her mental ability decreased, Mahina ako makapick up ng ideas nung buntis ako, as verbalized by Mrs. DC. During confinement, the client asked her OB-Gyne if hindi po ba ako mabobobo sa anesthesia. She observed that, few days ago after her STAT CS delivery, she was a little bit slow with grasping ideas than before but during the interview she stated that, Ngayon naman bumabalik na ulit yung mabilis kong pag grasp ng ideas pero marami pa akong mga simpleng bagay na hindi alam gawin tulad ng pagpapaligo kay baby, she added. G. Self Perception Pattern Prior to confinement, the client described herself as competitive and sees herself more as a pessimist than an optimist. I expect the worse to happen, as verbalized by Mrs. DC. She usually feels good about herself and stated that, Mas masiyahin ako nung buntis ako. The client is irritable when shes hungry and always craves for chocolates but restricted herself from eating since she needed to maintain her weight to stay healthy during pregnancy. One thing that annoys me, is my boss, she said while laughing. She had been a positive thinker with regards to her pregnancy and hoped that she and her baby would always be in good condition. During admission, according to the patient, she remained the same and still thinks positive about the situation of her newborn baby boy who is premature. The client and her husband still cant perceive themselves as parents because their newborn baby boy was still inside an incubator in the NICU for further nourishment. Even though she still cant feel that

shes already a mother, she goes over the internet to search for information about the how tos of parenting and newborn care, and asks the nurses of the NICU and her Pediatrician for further details. And the thing that she wants to change for herself right now is to lose weight and return from her lean figure again. The client and her husband keep themselves well informed and knowledgeable about parenting and effective newborn care. H. Role-Relationship Pattern Prior to admission, the client and her husband lives in a patrilocality. They have an extended family. According to the client, she is still the bread winner of her family and she still supports them by giving a portion of her salary. As a soon-to-be mom, she and her husband already bought some basic material needs for their baby. They have prepared a room for him and inquired about providing neonatal care beforehand, and proper parenting. At present, there has been no change with the clients role in her family. Even if she is a mother now, she will still support her family. When her husband learned of the incident (PROM), he verbalized Wala lang, normal lang, I was working kasi when it happened but I was a little disappointed when I learned that the baby was inside an incubator. Even though the client had been in contact with their newborn baby boy, they cant still feel the pressure of being parents. The client said, we still cant feel the pressure of becoming mom and dad because hes (baby boy) not yet with us, so parang hindi pa kami ganon na kaexcited kasi wala pa talga siya dito na kasama namin. She now includes her child in their future plans: They are preparing for their babys education, and a house of their own (separated from her husbands parents). I. Sexuality-Reproductive Pattern Mrs. DC had her menarche at the age of 11y/o, presenting in a heavy character. She can consume 4 to 5 pads per day with 7 days duration. She usually experiences dysmenorrhea on the first to second day of her menstruation. Shes been having irregular menstrual period, and after seeking consultation, she was given pills to make her menstrual cycle regular. She was diagnosed of having polycystic ovarian syndrome (PCOS) on her right ovary last 2001 and was treated with pills prescribed to her (cannot recall medications). Her LMP was on Dec. 23, 2009; G1P1. Regarding her sexual relationship, the client verbalized Ok lang naman, Good. They prefer using contraceptives pills than condoms. They tried it (condom) once but the couple did not find it satisfying. The client describes her sexual relationship as satisfying.

J. Coping Stress Tolerance According to Mrs. DC, there has been a significant change in her life the fact that shes going to enter motherhood very soon. She does not have any conflict with her family or friends and if ever she would encounter one, she will not let the day end without getting solution for the problem. Whenever shes having a life crisis, she always finds comfort from her husband and she always consults him first for decision making. She is not taking any drugs or is not drinking alcohol just to solve her problem. She said that before, she tends to smoke a lot when shes in a stressful situation. She can consume 10 sticks per day and would even increase when she is stressed. But since she stopped smoking when she realized shes pregnant, her coping mechanism is drinking avocado shake. Her husband had also been very supportive and caring for her during her pregnancy and until now. She is having worries and anxieties at the moment related to the condition of her child and what might happen. Mrs. DC said, nagaalala lang ako kung magiging mabuting mommy ba ako. Marami pa akong mga simpleng bagay na hindi alam gawin tulad ng pagpapaligo kay baby, medyo natatakot ako baka mapano sya. She admits that she is more worried right now than before and she wanted to get home soon because shes getting bored inside the hospital but shes also sad that their child cant come with them. K. Value-Beliefs Pattern According to Mrs. DC, their religion is important in their life, she believes that God will always be there to for them but she does not leave everything to Him. Naniniwala akong andyan lang Siya lagi, pero may kasabihan ngang nasa Diyos ang awa, nasa tao ang gawa. It has been their family practice to go to mass during Sundays. She is a Roman Catholic and as a devotee, she believes that with a strong faith, love and trust with the Lord, she will be able to cope with her problems or challenges that may come. God can keep her strong. She also said that: No matter how shitty things are, if you have faith, things will work out. She has her own principles in life which she follows. Even she is a lawyer, she said that sometimes you have to break the rules in order to do what is best for you and for your family. She said that rules are rules and principles are principles. During confinement, her hospitalization did not affect her spiritual life. She is still able to pray, the only thing that changed is that she failed to go to Mass last Sunday because she was

confined. Her faith grows even stronger, she believes in Gods power that her child would survive and would live normally.

F. Family Assessment Relation Father-inB.D.C. law Mother-inA.V.D.C law Brother-inS.V.D.C law C.V.D.C Husband Sister-inK.V.D.C law G. Heredo-Familial Illness Name Age 64 y/0 67 y/o 36 y/o 30 y/o 27 y/o Sex M F M M F Occupation Retired Retired Marketing Financial Analyst Medical Student Educational Attainment Post Graduate College College College Still studying

Paternal: Hypertension Maternal: No known maternal familial illness

Developmental History Theorist Age Gender Patient Description Generativity vs. Stagnation Erikson Psychosocial Development 29 years old Mrs. CNCR-DC is a fulltime lawyer and is dedicated to her work. She earns her income, shares it with her family and saves a part of it to prepare for the babys future expenses. She said that she has a good relationship with other people especially with her colawyers and clients, because all of them help each other in resolving the cases of each of their clients. Genital Stage Freud Psychosexual Development 29 years old F The patient is already married to a financial analyst and they live together with her husbands family. As a wife, she is able to help her husband in deciding for their plans and for the good of their relationship. Formal Operations Piaget Cognitive Development 29 years old F . Mrs. CNCR-DC learns through observation. She is good in recalling her past even if it was decades or years ago. The patient understands and is able to respond to situations. Post-Conventional Kohlberg Moral Development 29 years old F She has her own principles in life which she follows. Even she is a lawyer, she said that sometimes you have to break the rules in order to do what is best for you and for your family. She said that rules are rules and principles are principles. Paradoxical-consolidative Fowler Spiritual Development 29 years old She is a Roman Catholic and as a devotee, she believes that with a strong faith, love and trust with the Lord, she will be able to cope with her problems or challenges that may come. God can keep her strong. She also said that: No matter how shitty things are, if you have faith, things will work out.

H. Physical Examination Performed: August 18, 2010 (1700H) Measurements Weight: 67.72 kg Height: 56 BMI: 24.1 kg/m2 IBW: 59.6 kg Vital Signs: Temperature: 36.5 C Pulse Rate: 85 bpm Respiratory Rate: 20 cpm Blood Pressure: 110/90 mmHg Regional Examination: SKIN: NAILS: Inspection: Pink nail bed Visible lunula Nail plate appears smooth and flat Clean and well-trimmed Absence of inflammation and lesions in the nail folds Palpation: Hard and smooth with uniform thickness Nail edges are smooth and rounded Capillary refill within 2 3 seconds Inspection: Fair complexion Absence of lesions Hair evenly distributed Palpation: Smooth, moist and warm to touch Minimal perspiration and oiliness Skin can be easily pinched and returns back to its original position immediately

HEAD and FACE Inspection: Normocephalic Upright and still Proportional to the body Features are symmetric Absence of lesion, dandruff and lice EYES Inspection: Symmetrical Eyebrows and eyelashes evenly distributed Eyelids can open, close and blink Wearing contact lenses Cornea is shiny, transparent and smooth in appearance White sclera Pinkish conjunctivae P.E.R.R.L.A. Palpation: Absence of masses, edema and tenderness No skull deformities

 EARS NOSE

Can read upraised fingers Can follow the six direction of gaze Can assume crossed-eye vision Visual acuity is 475 (left) -450(right) Palpation: No signs of tenderness felt on the lacrimal gland Inspection: Symmetrical Same color as facial skin Absence of discharges, lesion and nodules Palpation: Auricles are firm, mobile and without nodules Can hear the sound equally in both ears(Webers Test) Air conduction heard longer than bone conduction(Rinnes test) Inspection: Proportional to the face Absence of deformity or inflammation Septum in midline Palpation: No tenderness felt on the maxillary and frontal sinuses Right and left nares are patent

MOUTH and PHARYNX Inspection: Lips are dark in color and moist Teeth are yellowish With pasta on all molars Has one decaying tooth Uvula and tongue are in midline Tongue appear dull-red, moist and glistening No difficulty of swallowing No tenderness NECK SPINE Inspection: Spine lies at midline in the anterior posterior direction Curved in lateral position Has proper posture and gait Presence of normal muscle bulk Palpation: No tenderness, masses or nodules felt. Inspection: Proportion to the body Absence of neck vein engorgement Free from edema and erythema Active R.O.M Palpation: No tenderness felt on thyroid gland Lymph nodes non-palpable

THORAX and LUNGS Inspection: No visible pulsation

 HEART

Sternum and manubrium is at the middle Symmetrical lung expansion Palpation: Movement of the thumb symmetrically separates 1-2 inches(chest excursion) Vibrations are symmetrical and felt strongest at the top(tactile fremitus) Percussion: Audible resonant sounds at lung field Flat sounds at the rib cage Auscultation: Vesicular sound over the lung field no adventitious breath sounds heard Inspection: No visible pulsations Palpation: No thrills No exaggerated lifts Vibrations can be felt on the 2nd, 3rd and 4th intercostals space Auscultation: S1 heard at the apex ; S2 heard at the base No extra heart sound heard

BREAST: Inspection: Hyperpigmented areola Smooth and even pigmentation of the breast No cracks on both nipples Palpation: Full breasts

ABDOMEN Inspection: Has abdominal binder With horizontal incision, 3FB above the symphysis pubis No redness, inflammation, pus at the incision site Uterus is 2FB below umbilicus Auscultation: (+) bowel sounds Palpation: No distention of bladder Pain

EXTREMITIES Symmetrical No sign of deformities Positive deep tendon reflex on both knees Negative homans sign GENITALS: Client refused Lochia serosa with moderate amount RECTUM and ANUS Client refused

NEUROLOGIC EXAMINATION A. Mental & Emotional Status Conscious and Coherent Responds easily to questions Able to understand spoken and written words B. Intellectual Function Can recall past events & narrate it verbally Can interpret a certain phrase with relevance

II. PERSONAL/SOCIAL HISTORY a. Habits: Prior to pregnancy, the client drinks alcoholic beverages 4 times a month approximately 5 to 6 bottles. She is a smoker for almost 15 years and only stopped when she learned of her pregnancy. The client also has a habit of nail biting, may she be stressed or not. b. Lifestyle: Active lifestyle Patient was able to maintain her weekly routine of exercise. The patient does 1 hour of walking and weight lifting (5-10lbs). The client works as a lawyer and travels to provinces often for court hearings. c. Social Affiliation: NONE

d. Clients Usual Day like: (During pregnancy) Time 6:00AM 6:15AM 6:30AM 9:30-10:00AM 11:00AM-12:00NN 12:00NN-4:00PM 4:00PM 6:30-7:00PM 7:00-8:00PM 8:00-11:00PM 11:00PM Activity The client wakes up Breakfast Exercise (walking) Travel time to her office Lunch Break Resume of work Snack time Travel time going home Dinner Time for leisure; sometimes the client takes home office works Bed time

e. Travel for the Last 6 months Singapore (11-13 June 2010) Isabella, Quezon Province (every so often when there is a court hearing) f. Educational Attainment: Post graduate (Lawyer Ateneo de Manila University, Quezon City)

III. ENVIRONMENTAL HISTORY The client lives in a quiet and safe village in Quezon City with village security guards. There havent been reposts of crimes within their village. The village garbage collection is twice a week, during Wednesdays and Saturdays. They do not practice garbage segregation. They use purified water for drinking and their water supply comes from NAWASA. IV. OB/GYNE HISTORY Deliveries: G 1 P 1 Operations: 1 LTCS OB Score: T 0 P 1 A 0 L 1 h Menarche: 11 years old

Menstruation: 4 to 5 pads with 7 days duration V. PEDIATRIC HISTORY Not Applicable

Relaxin (Reversal of suppressive effects of estrogen and progesterone)

Genital Tract infection (presence of bacterial proteases, host immune response (interleukin-1, tumor necrosis factor A

Glucocorticoid Production

Amniotic extracellular matrix (collagen) degradation (collagenase activity, imbalance of matrix metalloproteinase or tissue inhibitor of metalloproteinase

Production of Prostaglandin E2 and Prostaglandin F2a

Decreased amniotic collagen content. Altered amniotic collagen structure ( presence of abnormal collagen cross-linking, abnormal collagen triple helical structure)

Programmed amniotic cell death

Membrane Stretch (production of interleukin-8)

PROM
Generalized decreased tensile strength

Localized Defects

VI.

PATHOPHYSIOLOGY Theoretical Based:

Non-modifiable: Age Client Based: Gender Family Hx of HPN

Modifiable: Environment Lifestyle Diet Habits/Vices

Smoking (stopped within __ weeks of pregnancy)

Urinary tract Infection

Cigarette chemicals brew within the bloodstream

Amniotic extracellular matrix (collagen) degradation (collagenase activity, imbalance of matrix metalloproteinase or tissue inhibitor of metalloproteinase

Elevated levels of WBC

Membrane Stretch (production of interleukin-8)

Production of Prostaglandin E2 and Prostaglandin F2a

Glucocorticoid Production

Inflammation of the lung parenchyma

Programmed amniotic cell death

Pain / Inflammation

Decreased amniotic collagen content. Altered amniotic collagen structure (presence of abnormal collagen crosslinking, abnormal collagen triple helical structure)

Lowers the amount of oxygen supply within the bloodstream

PROM

Uterine Irritability

VII.

LABORATORY RESULTS OR FINDINGS Date (08/12/10) Normal Value Color: Straw, amber Transparency: Transparent Result Color: Light Yellow Transparency: Slightly Cloudy Significance Normal

Laboratory Test Physical Examination Specimen: Urine

Slightly cloudy urine is caused by slight elevation of white blood cells Laboratory Test Chemical Analysis Specimen: Urine pH Specific Gravity Glucose Protein Blood Ketone Nitrite Bilirubin Urobilinogen Leukocytes Date (08/12/10) Normal Value Result Significance

4.5 - 8 1.010 1.025 Not present Not present Not present Not present Negative Negative Negative Negative

8.0 1.010 2+ 1+ 4+ 1+ Negative Negative Negative Negative

Normal Normal Abnormal Abnormal Abnormal Abnormal Normal Normal Normal Normal

Presence of glucose in urine indicates abnormal glucose tolerance during pregnancy Presence of protein in urine indicates damaged to glomerular capillaries Presence of blood in urine indicates urinary tract infection or bleeding from the urinary tract Presence of ketone in urine indicates excessive ingested amounts of aspirin Laboratory Test Urine Flow Cytometry Specimen: Urine WBC RBC Epith Cells Bacteria Date (08/12/10) Normal Value Result Significance

0.00 17.00 ul 0.00 11.00 ul 0.00 17.00 ul 0.00 278.00 ul

17.4 ul 217.8 ul 15.9 ul 11.8 ul

Abnormal Abnormal Normal Normal

Slight elevation of WBC is due to urinary tract infection Elevation of RBC is due to excessive bleeding from the urinary tract

Laboratory Test Histopathology Report Specimen: Abdominal Mass

Date (08/12/10)

Histopathologic Diagnosis Anterior Abdominal Wall Mass, Excision: -Angiolipoma with secondary chronic and acute inflammation and hemorrhages

Gross & Microscopic Descriptions Specimen labeled anterior abdominal wall mass consists of a gay brown bean-shaped discrete firm tissue measuring 2x1.2x0.4 cm. Cut section shows brown lobulated cut surfaces. Blocks two all (one). (Dr. MH Diwa) Microscopic examination done

Angiolipoma is a subcutaneous nodule with vascular structure, commonly painful

VIII.

DRUG STUDY

DRUGS

INDICATION

ACTION

SIDE EFFECTS/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

Date Ordered: 08/12/2010 Generic Name: Cefuroxime Brand Name: Zegen Classification: Antibiotics Dosage: 500 mg TID

Treatment of bone and joint infections, bronchitis (and other lower respiratory tract infections), gonorrhea, meningitis, otitis media, peritonitis, pharyngitis, sinusitis, skin infections, surgical infections and UTI.

Bind to bacterial cell wall membrane which causes cell death.

Thrombophlebitis, Pruritus, urticaria, +ve Coombss test, diarrhea, nausea, pseudomembrenous colitis. Decrease in Hb and hematocrit transient increase in liver enzymes, elevation in serum creatinine and BUN. Possible seizure and angiodema.

1. Assess patient for infection at the beginning and during the therapy. 2. Before initiating therapy, obtain a history to determine previous use of and reaction to penicillin or cephalosporins. Person with a negative history of penicillin sensitivity may still have an allergic response. 3. Obtain specimens for culture and sensitivity before initiating the therapy. 4. Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing) Assess patient for renal dysfunction and adjust accordingly.

1. Do not take this medication if you are allergic to cefuroxime, or to similar antibiotics, such as Cefzil, Keflex, Omnicef, and others. 2. Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to. 3. This medication can cause you to have false results with certain medical tests, including urine glucose (sugar) tests. Tell any doctor who treats you that you are using cefuroxime. 4. Should be taken with food.

DRUGS

INDICATION

ACTION

SIDE EFFECTS/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

Date Ordered: 08/12/2010 Generic Name: Mefenamic Acid Brand Name: Dolfenal Classification: Analgesic Dosage: 500mg TID

Relief of pain including muscular, rheumatic, traumatic, dental, post-op and postpartum pain, headache, migraine, fever, dysmenorrhea

Aspirin-like drug that has analgesic, antipyretic, & anti inflammatory activities

PRECAUTION: If rash occurs, administration should be stopped, asthmatics, Hx of liver and kidney disease ADVERSE RXN GI discomfort, diarrhea or constipation, gas pain, nausea, vomiting, drowsiness

1. Assess pt.s pain before therapy. 2. Monitor for possible drug induced adverse reactions. 3. Advice pt. not to take drug for more than 7 days. 4. Advice pt. to report immediately persistence or failure to relieve pain.

1. Advice pt. not to take drug for more than 7 days. 2. Advice pt. to report immediately persistence or failure to relieve pain.

DRUGS

INDICATION

ACTION

SIDE EFFECTS/ADVERSE REACTION

NURSING CONSIDERATION

PATIENT TEACHING

Date Ordered: 08/14/010 Generic Name: Moringa Olifera Brand Name: Natalac Classification: Supplements and adjuvant therapy Dosage: 250mg TID

Food supplement for breastfeeding mothers. Enhances milk letdown, lactation & increases milk volume.

Enhances milk letdown and increases volume of milk production. It is an effective galactogogoue (lactation enhancer).

Sagging of breast, excessive weight gain

1. Encourage frequent breastfeeding or use of breast pump to release milk

1. May be taken with or without food.

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Date Ordered: Generic name: Cefuroxime Sodium Brand name: Kefox Classification: Cephalosporin, second generation Dosage: 1.5g Route: IV

Pre-operative prophylaxis in clients undergoing surgical procedures classified as cleancontaminated or potentially contaminated

Peak serum levels after 1.5 grams IV: 100 mcg/mL. 66100% is excreted unchanged in the urine. It will be prolonged in clients with renal failure

ADVERSE REACTION: GI: nausea, vomiting, diarrhea, gastric pyrosis, abdominal pain

History: Hypersensitivity to cephalosporins, Cross-allergy to penicillin 1. Assess for anemia, renal dysfunction. Reduce dose with renal failure Intervention: 1. For direct intermittent IV administration slowly inject drug over 3 to 5 mins., or give in tubing of other IV solutions.

1. Report lack of response, persistent diarrhea or signs and symptoms of anemia (dizziness, pale skin etc.) immediately.

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Date Ordered: Generic name: Nalbuphine hydrochloride Brand name: Nubain Classification: Opioid agonistantagonist analgesic Dosage: 10 mg q6x4doses Route: IV

Preoperative and postoperative analgesia; supplement to balanced anesthesia; obstetrical analgesia during labor and delivery.

Nubain acts as an agonist at specific opioid receptors in the CNS to produce analgesia and sedation

CVS: Bradycardia, hypertension, hypotension, tachycardia. CNS: dizziness, vertigo; headache; agitation, confusion, depression, faintness, floating feeling, hallucinations, heaviness feeling, hostility, nervousness, numbness, restlessness, seizures.

History: Hyper sensitivity to nubain. Intervention: 1. Store ampules and vials at controlled room temperature (59 to 86F). 2. Protect from excessive light. Store ampules and vials in carton until contents have been used. 3. Do not administer if particulate matter or discoloration noted 4. Ensure oxygen, and resuscitation and intubation equipment are available for use if needed.

1.Taper dosage when discontinuing after prolonged use to avoid withdrawal Symptoms. 2.Keep opioids antagonist and facilities for assisted or controlled respiration readily available in case of respiratory

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Date Ordered: Generic Name: Methylergonovine maleate Brand Name: Methergine Classification: Oxytocic drug Dosage: iTab q4x 6 doses Route: PO

Management and prevention of postpartum and post abortal hemorrhage by producing firm uterine contractions and decreasing uterine bleeding.

Acts directly on the uterine smooth muscle to stimulate the rate,tone, and amplitude of uterine contractions. It induces a rapid, sustained titanic uterotonic effect that shortens the third stage of labor and reduces blood loss. The uterus becomes more sensitive to the drug toward the end of pregnancy.

CV: Hypertension, seizure, hypotension, acute Myocardial infarction, Chest pain. GI: N&V, diarrhea CNS: Dizziness, hallucinations

History: Assessment: 1. Assess fundal tone and nonphasic contractures; massage to check for relaxation or severe cramping. 2. With postpartum bleeding, report frequency,amount,color and any associated S&S. Intervention: 1. Administer Slowly 1 min; check BS for evidence of shock or hypertension after IV administration. 2. Give only solutions that are clear. Discard ampules if discolored

1. Report any Signs or symptoms of ergotism (cold/ numb fingers/toes, N&V, headache, muscle pr chest pain, weakness) or infection 2. Abdinubak cranos nay be experienced; report any severe cramping, head aches or increasing bleeding

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Date Ordered: 08/12/10 Generic Name: Metoclopramide Brand Name: Plasil Classification: Antiemetics / GIT Regulators, Antiflatulents & AntiInflammatories Dosage: 2u IV q4 prn

Disturbances of Metoclopramide, gastrointestinal motility, a dopamine including antagonist, gastroesophageal reflux stimulates and diabetic gastroparesis motility of the (diabetic gastric upper stasis). Nausea and gastrointestinal vomiting of central and tract without peripheral origin stimulating associated with surgery, gastric, biliary or metabolic diseases, pancreatic infectious secretions. Its diseases, migraine headac mode of action is he, or drugs including unclear. It seems cancer chemotherapy. to sensitize tissues to the action of acetylcholine. The effect of metoclopramide on motility is not dependent on intact vagal innervation but it can be abolished by anticholinergic drugs. Metoclopramide increases the tone and amplitude of gastric (especially antral) contractions, relaxes the pyloric sphincter and the duodenum and jejunum, resulting in accelerated gastric emptying and intestinal transit. It increases the resting tone of the lower esophageal sphincter.

Restlessness , drowsiness, fatigue & lassitude. Extrapyramid al symptoms, insomnia, headache, dizziness, nausea, galactorrhea, gynecomasti a, rash including urticaria, bowel disturbances. Increased prolactin levels; gastroparesi s.

1. It is contraindicated patients with a history of hypersensitivity to metoclopramide or any of the components of Plasil. 2. IV injections of metoclopramide should be made slowly over a 1to 2-min period since a transient but intense feeling of anxiety and restlessness, followed by drowsiness, may occur with rapid administration. 3. Extrapyramidal symptoms may occur in patients treated with metoclopramide. These occur more frequently in children and young adults and may occur after a single dose. These most often consist of feelings of restlessness; occasionally, they may include involuntary movements of limbs and facial grimacing; rarely, torticollis, oculogyric crisis, rhythmic protrusion of tongue, bulbar type of speech or trismus. 4. It has additive effects w/ alcohol, sedatives, hypnotics, narcotics or tranquilizer.

1. Patients should be cautioned about engaging in activities requiring mental alertness for a few hours after the drug has been administered. 2. Instruct patient that the most frequent adverse reactions to metoclopramide are restlessness, drowsiness, fatigue and lassitude which occur in approximately 10% of patients. Less frequently, extrapyramidal symptoms, insomnia, headache, dizziness, nausea, galactorrhea, gynecomastia, rash including urticaria, or bowel disturbances may occur.

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Date Ordered: 08/14/10 Generic Name: Bisacodyl Brand Name: Dulcolax Classification: Laxatives/Purgat ives Dosage: 1 supp now

Constipation. Prep for radiography; antepartum & postpartum care; prep for sigmoidoscopy or proctoscopy; colonoscopy; hemor rhoids & anal fissures. All conditions w/c require defacation to be facilitated.

Bisacodyl acts mainly in the large intestine by increasng its motility to effect bowel evacuation. Onset: 6-12 hr (oral). 15-60 min (rectal). Absorption: Minim al from the GI tract (oral, as enteric-coated tablets/suppositori es). Metabolism: Conv erted to bis(phydroxyphenyl)pyr idyl-2-methane by intestinal or bacterial enzymes. Excretion: Faeces ; urine (as glucuronide).

Cramps; faintness; stomach discomfort. Rarely, abdominal discomfort & diarrhea.

1. It is contraindicated to patient with Ileus, intestinal obstruction, acute surgical abdominal conditions; severe dehydration, Appendicitis & acute inflammatory bowel diseases. 2. Do not administer for longer than 1 week without checking with the doctor. Using Dulcolax for a long time may result in loss of normal bowel function. 3. Do not administer additional laxatives or stool softeners with Dulcolax unless directed by the physician. 4. Rectal bleeding or failure to have a bowel movement within 12 hours after use of a laxative may be a sign of a serious condition. Stop use and refer it to physician.

1.Instruct patient to insert suppository well up into the rectum as directed by your doctor or on the package labeling. Retain the suppository for 15 to 20 minutes. 2. Drinking extra fluids while you are using Dulcolax Suppositori es are recommend ed. 3. If the patient miss a dose of Dulcolax Suppositori es and are using it regularly, instruct him/her to use it as soon as possible. If it is almost time for the next dose, skip the missed dose and go back to the regular dosing schedule. Do not use 2 doses at once.

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Tramadol

Moderate to severe acute or chronic pain

Centrally acting opiate receptor agonist that inhibits the uptake of norepinephrine and serotonin, suggesting both opiod and non-opioid mechanisms of pain relief. May produce opioidlike effects, but causes less respiratory depression than morphine

Drowsiness, dizziness, vertigo, fatigue, headache, restlessness, euphoria, confusion, anxiety, palpitations, vasodilatation, nausea, constipation, urinary Retention/frequency.

-Monitor vital signs and assess for orthostatic hypotension or signs of CNS Depression. -Discontinue drug and notify the physician if s/s of hypersensitivity y occur -Assess bowel and bladder function, report urinary Frequency or retention.
NURSING CONSIDERATION

-Inform client that medication may cause CNS depression and/or respiratory depression, particularly when Combined with other CNS depressants.

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D5nm

parenteral maintenance of routine daily fluid And electrolyte requirements with minimal carbohydrate calories from dextrose. Magnesium in the formula may help to prevent magnesium deficiency

Dextrose Injection provides water and electrolyte for maintenance of daily fluid and electrolyte requirements, plus minimal carbohydrate Calories.

Hypersensitivity to any of the components

-Do not administer unless solution is clear and container is undamaged -Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis

IX.

LIST OF PRIORITY PROBLEMS Priority 1 Problems Acute Pain related to surgical trauma secondary to Pregnancy Uterine Delivery by Primary Low Transverse Cesarean Section for Breech Position Preterm, Premature Rupture of Membranes Impaired parent-child attachment Anxiety related to new responsibility Readiness for enhanced knowledge related neonatal care Readiness for enhanced parenting

2 3 4 5

X. XI.

Please see NCP on separate page NURSING CARE PLAN *Please see pages after Discharge Plan ONGOING APPRAISAL Aug. 12: Mrs. DC was seen and examined by Dr. Martinez, her OBG and was diagnosed with a 33 1/7 weeks AOG with breech presentation, PPROM. She was scheduled for STAT primary CS. Her attending anaesthesiologist Dr. B. Ong was informed. Around 1400h, she was already instructed to be on NPO and

her CBC and WBC were extracted in preparation for the procedure. She was admitted to the DR around 1500H, her uterine contractions and the fetal condition were continuously monitored. First dose of steroids was given, the second dose (bethamethasone) was administered on 2000H and she was then scheduled for primary CS the next hour. IVF number 1 D5NR was inserted together with a side drip of D5NM 1L + 100mg tramal + 10 syntocinin + 100mg orudis. Foley catheter was inserted. Other medications given were: Zegen, Cefuroxime, Nubain, Methergin, Plasil. Aug. 13: The patient may have a moderate to high bed rest and should be turned from side to side. At 0600H, D5NM 1L + 100mg tramal + 10 syntocinin + 100mg orudis was given and discontinued and foley catheter was removed at 1400H. 1300H (+) flatus, (-) BM. Her physician ordered her to be on clear liquids and general liquids if tolerated, except for coffee, milk, tea and soft drinks. On 1930H general liquids was shifted to soft diet. Discontinued drugs: Nubain, Methergin. Aug. 14: She was given new orders of medications: Natalac 1 tab TID, Dulcolax rectal suppository STAT. Her soft diet was shifted to diet as tolerated. Plasil was discontinued. Aug. 15: to continue, Natalac 1 tab TID. The client was ordered to ambulate herself. Aug. 17: instructed to do splinting technique (especially during coughing and laughing). Medication to continue: Natalac. Client may go home on August 19. XII. DISHCARGE PLAN XI. Discharge Plan M-edication Follow the prescribed dose and time for home medication (Natalac, 250 mg TID). E-xercise Perform exercises that promote full range of motions to enhance blood circulation in the body and help with weight loss. Avoid overexertion initially and abstain from sexual intercourse until lochia has ceased. Have additional assistance with household chores and self-care to be able to rest and heal. Treatments Have a change with the patients lifestyle. Informed to have follow-up check-ups as scheduled.

Health & Education Have a healthy eating plan. Instruct patient to take medications in a prescribed dose and time. Explain needed dietary modifications such as restricted sodium and saturated fats. Stress the importance of planning rest periods. If the patient has a decreased level of consciousness, discuss specific safety measures. Provide emotional support for the patient and family. Minimize on alcohol intake and smoking especially when taking oral contraceptive pills. Check all medications with your doctor because certain prescription and OTC medications may be inappropriate.

O-pd Follow-up Diet Discuss with the prenatal health care provider the schedule of the following OPD check-up. Adhere to the scheduled appointment for postpartal examination and infants well-baby examination with her physician. Encouraged client to increase intake of fiber to avoid constipation. Instructed to increase oral fluid intake. Instructed to increase intake of nutritious foods such as fruits and vegetables.

Signs and Symptoms

The patient should contact the caregiver if she develops any of the following signs and symptoms: o Sudden persistent or spiking fever o Change in the character of the lochia--Foul smell, return to bright red bleeding, and excessive amount (more than two pads in one hour). o Evidence of mastitis such as breast tenderness, reddened areas, malaise, fever, chills o Evidence of calf pain, tenderness and redness o Evidence of infection in the incision site such as redness, edema, pain or discomfort, discharge or lack of approximation.