RATIONALE

This a study of a 19 year old, female, with iron deficiency anemia who undergone primary low segment transverse cesarean section due to fetal deceleration and gestational hypertension
from Balamban, Cebu.
The researchers preferred Ramona Mercers Conceptualization of Maternal Role Attainment as an organizing framework for nursing practice; the goal is to identify the form and strength of
the relationships between key maternal and infant variables and maternal role attainment as well as other factors that appear to influence the said variables. The model guides the nurse to acquire
competence in care taking task involve in the said theory. The nurse accomplishes the goals by promoting mothers attachment with her infant gaining a sense of harmony, confidence and
competence in how she performs the role. Interventions are provided in order to improve the patients condition or promote comfort when change in the patients condition is not possible.
Mercers theory was based on role theory, knowledge of the infants traits and review of literature to identify variable that influence or are influenced by maternal roles. She defined
maternal role attainment as a process in which the mother achieves competence in the role and integrates the mothering behaviors into her established role set so that she is comfortable with her
identity as a mother.
The researchers opted to use this model since they would like to learn more about it for the reasons that the demands on first time mothers challenge the nurses to be active in anticipatory
socialization and guidance to prepare for the realities of the maternal role. Interventions suggested in Mercers works include promoting parenting groups to highlight maternal needs during the first
months.
The researchers chose the patient as their subject for their case study because she showed enthusiasm despite her unwanted condition at a young age. Through this case, the researchers will
fully comprehend the goal of Mercers theory by applying it to J.Qs case.
Introduction
J.Q. 19 years old, female, Filipino, Roman Catholic, a resident of Balamban, Cebu. Patient is G1P1001 with last menstrual period on July 25,2006
and AOG is 40 weeks by LMP.
Patient was diagnosed with primary low segment transverse cesarean section secondary to fetal deceleration and gestational hypertension; delivered a live baby girl with an APGAR score of 4, 8,
10
, Ballard Score of 38 weeks , birth weight of 3050 grams

CESAREAN BIRTH
Cesarean birth, or birth accomplished through an abdominal incision into the uterus, is one of the oldest types of surgical procedures known. It is a procedure always slightly more
hazardous than vaginal birth. However, when compared with other surgical procedures, it is one of the safest types of surgery and one with few complications.
The word cesarean is derived from the Latin caedore, which means to cut. The term cesarean birth, rather than cesarean delivery, is used to accentuate that this is a birth more a
surgical procedure. A major concern in maternal and child health nursing is the increasing number of cesarean birth being performed annually.
In 1970, only 5.5% of women in the United States had infants born by cesarean birth. Currently, the incidence of primary cesarean birth is 26% (2005). This increased rate results from a
combination of the increasing safety of cesarean birth, the use of fetal monitors (which provide for early detection of fetal problem), and elective cesarean birth chosen by women to prevent
potential urinary or anal incontinence later in life. Its increase may also be related to physicians fears of malpractice suits should a fetus be allowed to be born vaginally and then be discovered to
have suffered anoxia.
Types of Cesarean Delivery
Uterine incisions
Low segment transverse incision made transversely in lower segment of uterus. Incision is made in thinnest portion so blood loss is minimal and uterus is easier to open. Lower segment is area of
least uterine activity. Possibility of later rupture is lessened. Post-operative convalescence is more comfortable. Incidence of post-operative adhesion and danger of intestinal obstruction are
reduced. It is the incision of choice.
Classic vertical incision is made directly into the wall of the body of the uterus; usually done in emergency situations only. It is useful when bladder and lower segment are involved in extensive
adhesion. Classic incision is selected when anterior placenta previa or emergency situation exists. It is also useful when fetus is in a transverse line. There is an increased blood loss with
classic cesarean and increased risk of uterine rupture in subsequent delivery.
Low vertical it is used rarely. It may be extended upward into a classic incision if extra room is needed for delivery. It may extend downward and cause trauma to the cervix, vagina and bladder.
Abdominal incisions
Pfannenstiel it is a horizontal incision rise above the pubic hairline. There is a decreased chance of dehiscence or hernia formation.
Vertical it is a vertical incision made in the midline of the abdomen below the umbilicus to the pubis. It is a quicker procedure to perform and provides better uterine visualization. There is a
greater chance of wound dehiscence and hernia formation.
Indications for Cesarean Delivery
Cephalo-pelvic disproportion
Uterine dysfunction, inability of cervix to dilate
Neoplasm of obstructing birth canal or pelvis
Pregnancy-induced hypertension
Severe diabetes mellitus

Uteroplacental insufficiency and oligohydramnios

Malposition and malpresentation
Complete or partial placenta previa
Abruptio placenta
Prolapse of the umbilical cord
Fetal compromise
Multiple gestation more than three fetuses

Management
NPO (except possible ice chips) during labor.
A blood sample should be typed and screened and available to be crossmatched if needed; a CBC is obtained.
Anesthesia, regional or general, depends on the indication for surgery.
Permit signed/witnessed; informed consent confirmed.
A large bore IV is established, and foley catheter is inserted.
An antacid is administered to reduce gastric acidity and the risk of aspiration pneumonia.
Antibiotics may be given prophylactically.
An abdominal prep is done, and a grounding pad for electrocautery is applied.
Complications
Increase in morbidity and mortality compared with a vaginal birth
Hemorrhage
Paralytic ileus, intestinal obstruction
Pulmonary embolism, thrombophlebitis
Bowel and bladder injury
Respiratory depression of the infant from anesthetic drugs
Possible delay in maternal-infant bonding
Air embolism

GESTATIONAL HYPERTENSION

Gestational hypertension, or GH, is a high blood pressure problem caused by pregnancy. GH may also be called pregnancy-induced hypertension, or PIH. You may have GH if your blood
pressure was normal but began to rise after the 20th week of pregnancy. GH may affect many organs in your body. About five to seven percent of all women get GH during pregnancy. GH can be a
very serious problem to you and your baby if it is not treated. GH usually goes away after you have your baby.
Risk Factors
The cause of GH is not known. You may be at a higher risk to get GH if:
You are less than 20, or older than 35 years old.
You are pregnant with two or more babies.
You had high blood pressure before you became pregnant.
You had GH in another pregnancy, especially if it started early in the pregnancy.
You have a chronic illness such as diabetes and kidney disease
You have a mother or sister who had GH during a pregnancy.
This is your first pregnancy, or the first one with a new partner.
Complications
Gestational hypertension can lead to the following:
Pre-eclampsia is when you have high blood pressure and protein in your urine after the 20th week of pregnancy. Pre-eclampsia is sometimes called toxemia of pregnancy. You may
have mild or very severe (bad) pre-eclampsia. Pre-eclampsia can cause your baby to have a low birth weight or to be born prematurely (too early). It can also cause your baby to be
stillborn (not born alive).
HELLP syndrome may happen if pre-eclampsia is not treated. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. Hemolysis is a problem with your red
blood cells. Special blood tests will check for hemolysis, and for problems with your liver enzymes and platelets. HELLP syndrome can cause liver failure and can be life-threatening
for both you and your baby.
Eclampsia is a life-threatening condition that may happen when pre-eclampsia is not treated. When pre-eclampsia gets worse, you may have seizures (convulsions). If you have
seizures, this may mean you have eclampsia. Eclampsia can damage your brain, liver, and kidneys if it is not treated.
Transient gestational hypertension is high blood pressure that you may get later in your pregnancy. With this type of hypertension, your blood pressure returns to normal by 12 weeks
after delivery.
Chronic gestational hypertension is high blood pressure that you may get later in your pregnancy. This type of hypertension does not return to normal within three months of delivery.
Signs and Symptoms
Being 20 or more weeks pregnant, with a blood pressure that is 140/90 or higher.
Blurry vision, seeing spots or flashing lights, or other vision problems.
Breathing problems.
Decrease in how much urine you are passing or having protein in your urine.
Feeling very sluggish (tired).
Gaining three to five pounds (1.4 kg to 2.3 kg) in one week.

Having very bad pain over your stomach (belly) or under your ribs.
Sudden swelling of your face, hands, or feet.
Swelling of your ankles or feet that does not go away after resting for 12 hours.
Feeling very upset for no known reason.
Very bad headaches.
Vomiting

Diagnostic Exams
Blood and urine tests.
Nonstress test (NST), which tests how your baby's heart rate changes when he moves.
Biophysical profile, which is a test that combines the nonstress test and a special ultrasound of your baby. The ultrasound will show your baby's movement, how his muscles are
working, and the amount of fluid around him. It will also show if your baby's breathing muscles are working.
Electrocardiogram
Ultrasound
Nursing Management
Bedrest at home or in the hospital.
Medications as prescribed to help decrease your blood pressure.

FETAL DECELERATION
Periodic changes:
Periodic changes or fluctuations in fetal heart rate occur in response to contractions and fetal movement and are described in terms of accelerations or decelerations. Periodic changes are
short-term changes in rate rather than baseline; they last from few seconds to 1 or 2 minutes. Four such responses are acceleration, early deceleration, late deceleration and variant deceleration.
Accelerations are temporary normal increases in FHR caused by fetal movement or compression of the umbilical vein during contraction.
Early decelerations are periodic decreases in FHR resulting from pressure on the fetal head during contractions. Parasympathetic stimulation in response to vagal nerve compression brings about
slowing of FHR. Early deceleration follows the pattern of the contraction, beginning when the contraction begins and ending when the contraction ends. However, the waveform of the FHR change

is the inverse of the contraction waveform, with the lowest point of deceleration occurring with the peak of the contraction. In this way, it serves as a mirror image of the contraction. The rate rarely
falls below 100 bpm and it returns quickly to between 120 and 160 beats at the end of the contraction.
Early decelerations normally occur late in labor, when the head has descended fairly low. As such they are viewed as a normal pattern. However, if they occur early in labor, before the head has fully
descended, the head compression causing the waveform change could be the result of cephalopelvic disproportion and is a cause for concern.
Late decelerations are those that are delayed until 30 to 40 seconds after the onset of a contraction and continue beyond the end of the contraction. This is an ominous pattern in labor, because it
suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during uterine contractions. The lowest point of the deceleration occurs near the end of the
contraction instead of its peak. This pattern may occur with marked hypertonia or with abnormal uterine tone caused by the administration of oxytocin. Immediate steps to correct the situation must
be initiated. If oxytocin is being used, stop or slow the rate of administration. Change the womans position from supine to lateral (to relieve pressure on the vena cava and supply more blood to the
uterus). Administer intravenous fluids or oxygen as prescribed. Prepare for possible prompt birth of the infant if the late decelerations persist of if FHR variability becomes abnormal (absent or
decreased).
Prolonged decelerations are decelerations that last longer than 2 to 3 minutes but less than 10 minutes. They generally reflect an isolated occurrence, but they may signify a significant event, such as
cord compression or maternal hypotension. For this reason, they must be reported and documented.
Variable deceleration: The pattern of variable decelerations refers to deceleration that occurs at unpredictable times in relation to contractions. They indicate compression of the cord, which can be
an ominous development in terms of fetal well-being. Cord compression may occur because of a prolapsed cord, but it also may occur because the fetus is lying on the cord. It tends to occur more
frequently after rupture of the membranes than when membranes are intact, or with oligohydramnios (the presence of less that normal amount of amniotic fluid), such as occurs in postterm
pregnancy or with intrauterine growth restriction. Because the pattern this produces is variable, often exhibited as U-, V-, or W-shaped waves, it can be completely missed if monitoring is not
continuous. If this pattern is recognized on the monitor, change the womans position to relieve pressure on the cord. Administer fluids and oxygen as prescribed. If variable decelerations are not
relieved by these measures, amnioinfusion may be prescribed.
IRON DEFICIENCY ANEMIA
Iron deficiency is defined as a decreased total iron body content. Iron deficiency anemia occurs when iron deficiency is sufficiently severe to diminish erythropoiesis and cause the development
of anemia.Its characteristically a microcytic, hypochromic anemia. During childbearing years, an adult female loses an average of 2 mg of iron daily and must absorb a similar quantity of iron in
order to maintain equilibrium. Because the average woman eats less than the average man does, she must be more than twice as efficient in absorbing dietary iron in order to maintain equilibrium
and avoid developing iron deficiency anemia. A woman loses about 500 mg of iron with each pregnancy. During childbearing years, women have a high incidence of iron deficiency anemia because
of iron losses sustained with pregnancies and menses. Symptoms of IDA tend to develop gradually and are similar to symptoms produced by the other types of anemia
Risk factors and etiology:
Insufficient dietary intake of iron
Blood loss
Impaired absorption of iron
Excessive demands for RBC production as a result of hemolysis

Signs and symptoms:

in mild cases, it is usually asymptomatic; in more severe cases, assessment reveals the general manifestation of anemia:
Fatigue
Headache
Dyspnea
Palpitations
Pallor
Stomatitis
Cheilosis
Koilonychias
Pica
Tinnitus
CBC usually results with peripheral blood smear that show microcytic and hypochromic RBCS, haemoglobin level decreased to as low as 6 9 g/dl, reduced mean corpuscular
volume(MCV), mean corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin concentration (MCHC)
Causes:
Hemorrhage
Diet
Malabsorption of iron
Medical management:
Medical care consists of establishing the diagnosis and reason for the iron deficiency. In most patients, the iron deficiency should be treated with oral iron therapy, and the underlying etiology should
be corrected so the deficiency does not recur. The most economical and effective medication in the treatment of iron deficiency anemia is the oral administration of ferrous iron salts. Among the
various iron salts, ferrous sulfate most commonly is used. Packed RBCs are being transfused for patients with either significant acute bleeding or patients in danger of hypoxia and/or coronary
insufficiency.
Nursing interventions:
Promote rest to reduce oxygen demands and provide good oral and skin care.
Diet should me rich in iron such as organ meats, beans and green leafy vegetables
Iron salts change color of stool to dark green or black.

Iron should be paired with Vitamin C rich fluids but not with milk or antacid because this will inhibit absorption

THEORETICAL BACKGROUND
Ramona T. Mercer (Maternal Role Attainment Theory)
A transition is a movement or passage from one position or one concept to another or across between what was and what is to be. It represents an internal process experienced by people
when change occurs. In a classic presentation of what transition entails, Bridges (1994), stated that change is something that happens to people and transition is how they response to change.
Traditionally, it is assumed that the bulk of a womans concern in the post partal period center on the care of her new infant. Based on this, classes in the post partal period have traditionally
focused on teaching how to breast-feed and bathe the infants. Although these acts are concerns for many mothers, they are not necessarily a new mothers chief concern. She has come through a
tremendous psychological experience during pregnancy and the birth of the child. She is in the middle of complete role change. It is only to be expected that some of her attention and interest during
this time will be directed inward as she tries to view herself in these new role.
Maternal role attainment (MRA) is a process in which a mother achieves competence in her role and integrates the mothering behaviors into her established role set, so she is comfortable
with her identity as mother. Age is consistently identified as a variable in MRA. This paper reviews literature on MRA in an exploration of its theoretical foundation and implications for adolescents.
Practice implications include assessment of maternal affect and behavior, education, and follow-up for adolescent mothers.
Maternal role attainment is an interactional and development process occurring during a period of time during which the mother becomes attach to her infant, acquires competence in the
care taking tasks involved in the role. The movement to the personal state in which the mother experiences as sense of harmony, confidence and competence in how she performs the role is the endpoint of the maternal role attainment maternal identity.

Concepts:
Primary Concept-Developmental and interactional process occurs over a period of time
Mother bonds with infant, acquires competence in caretaking tasks, enjoys and expresses joy and pleasure in the role

Maternal Identity-Personal state of harmony, confidence and competence. End point of maternal role attainment.

Process follows 4 stages of acquisition:

Anticipatory: Social and psychological adaptation to role; learning expectations. Fantasizes about the role "What to expect when you are expecting."
Formal: Assumption of role at birth; Behaviors guided by others in social system/ network; "My mother always told me"
Informal: Mother develops own ways of mothering; not conveyed by social system
Personal: Joy of Motherhood; Harmony, confidence, and competence in maternal role; Im ready to have another one"

This theory proposed that the variables of age, perception of the birth experience, early maternal infant separation, social stress, support system, self concept, and personality traits, maternal
illness, child rearing attitudes, infant temperament, infant illness, culture, and socioeconomic level affect the maternal role.
Nurses in post partum situation should recognize that competency in the maternal roles increases with age. Also, the demands on first time mothers challenge the nurse to be active in
anticipatory socialization and guidance to prepare for the realities of the maternal role. Interventions suggested in Mercers works include promoting parenting groups to highlight maternal needs
during the first months.

CONCEPTUAL FRAMEWORK:
4 stages of maternal role attainment

Mothers post partally must pass each stage to attain the maximal role attainment. First, they would be anticipating for the coming of the baby and for the changes of her new role. Then
next, formal stage where the mother would begin to act as what her mother should have done and what she must do as her mother have done. Then the third stage is the informal stage where mother

develops her own mothering technique based on her own instinct and the bonding built by the mother and child. Then lastly the mother gains confidence of her own technique and thus experience
fulfillment in her new role.

REVIEW OF RELATED LITERATURE

ANATOMY AND PHYSIOLOGY
CARDIOVASCULAR SYSTEM

Heart
Location & Size:
Approximately the size of a persons fist, the hollow, cone-shaped heart weighs less than a pound. The heart is located within the bony thorax and is flanked on each side by the lungs. Its
more pointed apex is directed toward the left hip and rests on the diaphragm, approximately at the level of the fifth intercostals space. Its broader posterosuperior aspect, or base, from which the
great vessels of the body emerge, points toward the right shoulder &
Lies beneath the second rib.

Covering & Wall:

The heart is enclosed by a double sac of serous membrane, the pericardium. The thin visceral pericardium or epicardium tightly hugs the external surface of the heart and is actually part
of the heart wall. It is continuous with the heart base with the loosely applied parietal pericardium, which is reinforced on its superficial face by dense connective tissue. This fibrous layer helps
protect the heart and anchors it to surrounding structures, such as the diaphragm and the sternum.
The heart walls are composed of three layers. The outer epicardium (the visceral pericardium described above), the myocardium, and the innermost endocardium. The myocardium consists
of thick bundles of cardiac muscle twisted in ring like arrangements. It is the layer that actually contracts. The myocardium is reinforced internally by a dense, fibrous connective tissue network
called the skeleton of the heart. The endocardium is a thin, glistening sheet of endothelium that lines the heart chambers.
Chambers & Associated Great Vessels:
The heart has four hollow chambers of cavitiestwo atria and two ventricles. The superior atria are primarily receiving chambers. As a rule, they are not important in the pumping
activity of the heart. Blood flows into the atria under low pressure from the veins of the body and then continues on to fill the ventricles. The inferior thick-walled ventricles are the discharging
chambers or actual pumps of the heart. When they contract, blood is propelled
Out of the heart and into the circulation.
The septum that divides the heart longitudinally is referred to as the interventricular or interatrial septum, depending on which chamber it divides and separates.
Although it is a single organ, the heart functions as a double pump. The right side works as the pulmonary circuit pump ( pulmonary circulation) and the left side is responsible for the
systemic circulation.
Valves:
The heart is equipped with four valves, which allow blood to flow in only one direction through the heart chambers. The atrioventricular, or AV, valves are located between the atrial and
ventricular chambers on each side. The AV valves prevent backflow into the atria when the ventricles contract. The left AV valvethe bicuspid or mitral valve consists of two cusps, or flaps, of
endocardium. The right AV valve, the tricuspid valve, has three cusps. Tiny white cords, the chordae tendineaeliterally heart strings, anchor the cusps to the walls of the ventricles. The second
set of valves, the semilunar valves, guards the bases of the two large arteries leaving the ventricular chambers. Thus, they are known as pulmonary and aortic semilunar valves. Each semilunar
valve has three cusps.
Each set of valves operates at a different time. The AV valves are open during heart relaxation and closed when the ventricles are contracting. The semilunar valves are closed during hear
relaxation and are forced open when the ventricles contract.
Cardiac Circulation:
Although the heart chambers are bathed with blood almost continuously, the blood contained in the heart does not nourish the myocardium. The blood supply that oxygenates and nourishes
the heart is provided by the right and left coronary arteries. The coronary arteries branch from the base of the aorta and encircle the heart in the atrioventricular groove at the junction of the atria
and ventricles. The coronary arteries and their major branches (the anterior interventricular and circumflex arteries on the left, and the posterior interventricular and marginal arteries on the right)
are compressed when the ventricles are contracting and fill when the heart is relaxed. The myocardium is drained by the cardiac veins, which empty into a large vessel on the backside of the heart
called the coronary sinus. The coronary sinus, in turn, empties into the right atrium.
Conduction System of the Heart:

Two types of controlling systems act to regulate heart activity. One of these involves the nerves of the autonomic nervous system that act like brakes and accelerators to decrease and
increase the heart rate depending on which division is activated. The second system is the intrinsic conduction system, or nodal system, that is built into the heart tissue.
The intrinsic conduction system is composed of special tissue found nowhere else in the body. This system cause heart muscle depolarization in only one directionfrom the atria to the
ventricles. In addition, it enforces a contraction rate of approximately 75 beats per minute on the heart; thus, the heart beats as a coordinated unit.
One of the most important parts of the intrinsic conduction system is a crescent-shaped node of tissue called the sinoatrial (SA) node, located in the right atrium. Other components include
the atrioventricular (AV) node at the junction the atria and ventricles, the atrioventricular (AV) bundle (bundle of His), and the right and left bundle branches located in the interventricular
septum, and finally the Purkinje fibers, which spread within the muscle of the ventricle walls. Because the SA node has the highest rate of depolarization in the whole system, it starts each heart
beat and sets the pace for the whole heart. Consequently, it is often called the pacemaker.

FETAL CIRCULATION
Since the long and digestive system are not yet functioning in a fetus, all nutrient, excretory, and gas exchanges occur through the placenta. Nutrients and oxygen move form the mothers
blood into the fetal blood, and fetal wastes move in the opposite direction. The umbilical cord contains three blood vessels: one large umbilical vein and two smaller umbilical arteries. The umbilical

vein carries blood rich in nutrients and oxygen to the fetus. The umbilical arteries carry carbon dioxide and debris-laden blood from the fetus to the placenta. As the blood flows superiorly toward
the heart of the fetus, most of it bypasses the immature liver through the ductus venosus and enters the inferior vena cava, which carries the blood to the right atrium of the heart.
Since fetal lungs are nonfunctional and collapsed, two shunts see to it that they are almost entirely bypassed. Some of the blood entering the right atrium is shunted directly into the left
atrium through the foramen ovale, a flap like opening in the interatrial septum. Blood that does manage to enter the right ventricle is pumped out the pulmonary trunk, where it meets a second shunt,
the ductus arteriosus, a short vessel that connects to the aorta and the pulmonary trunk. Because the collapsed lungs are a high-pressure area, blood tends to enter the systemic circulation through the
ductus arteriosus. The aorta carries blood to the tissues of the fetal body and ultimately back to the placenta through the umbilical arteries. At birth, or shortly after, the foramen ovale closes, and the
ductus arteriosus collapses and is converted to fibrous ligamentum arteriosum. As blood stops flowing through umbilical vessels, they become obliterated, and the circulatory pattern becomes that of
an adult.

BLOOD
Composition and Functions
Among all the body tissues, blood is unique: it is the only fluid tissue. Although blood appears to be a thick, homogenous liquid, the microscope reveals it has both solid and liquid
components. Essentially, blood is a complex connective tissue in which living blood cells, the formed elements, are suspended in a nonliving fluid matrix called plasma.
The formed elements of blood compose of a reddish mass which is the erythrocytes, the red blood cells that function in oxygen transport. Another is a thin, whitish layer called the Buffy
coat which is found at the junction of the formed elements and the plasma. This layer contains leukocytes, the white blood cells that act in various ways to protect the body, and the platelets, cell
fragments that function in blood clotting process. Erythrocytes normally accounts for about 45 percent of the total volume of blood sample, the percentage is known as the hematocrit.
Physical Characteristic and Volume:
Blood is a sticky opaque fluid with a characteristic metallic taste. Depending on the amount of oxygen it is carrying the color of the blood varies from scarlet (oxygen-rich) to a dull red
(oxygen-poor). Blood is heavier than water and about five times thicker, or more viscous, largely because of its formed elements. Blood is slightly alkaline, with a pH between 7.35-7.45. Its
temperature is always slightly higher than body temperature.
Blood accounts for approximately 8 percent of body weight, and its volume in healthy males is 5 to 6 liter, approximately 6 quarts.
Plasma
Plasma, which is approximately 90% water, is the liquid part of the blood. Over 100 different substances are dissolved in this straw-colored fluid. Examples of these dissolved substances
include nutrients, metal ions (salts), respiratory gases, hormones, plasma proteins and various wastes and products of cell metabolism.
Plasma proteins are the most abundant solutes in plasma. Except for antibodies and protein-based hormones, most plasma proteins are made by the liver. Albumin contributes to the
osmotic pressure of the blood, which acts to keep water in the bloodstream; clotting proteins helps stem blood loss when a blood vessel is injured; and antibodies help protect the body from
pathogens. Plasma proteins are not taken up by the cells to be used as food fuels or metabolic nutrients, as are other solutes such as glucose, fatty acids and oxygen. The composition of plasma
varies continuously as cells remove or add substances to the blood. The composition of plasma is kept relatively constant by various homeostatic mechanisms of the body. For example, when the
blood proteins drop to undesirable level of blood, the liver is stimulated to make more proteins; when the blood starts to become too acidic or basic both the respiratory system and kidneys are
called into action to restore it to its normal, slightly alkaline pH range of 7.35-7.45. Besides transporting various substances around the body the plasma helps to distribute body heat evenly
throughout the body.

Formed elements
Erythrocyte
Erythrocyte or red blood cells function primarily to ferry oxygen in blood to all cells of the body. They are superb examples of the fit between cell structure and function.
RBCs differ from other blood cells because they are anucleate; that is, they lack a nucleus. They also contain very few organelles. In fact, mature RBCs circulating in the blood are literally
sacs of hemoglobin molecules. Hemoglobin, an iron containing protein, transports the bulk of oxygen that is carried in the blood period. (It also bounds with the small amount of carbon
dioxide). Moreover, because erythrocytes lack mitochondria and make ATP by anaerobic mechanisms, they do not use up any of the oxygen they are transporting, making them very
efficient transporters indeed.
Erythrocytes are small cells shaped like biconcave disks flattened disk with depressed centers. Because of their thinner centers, they look like miniature doughnuts when viewed
with a microscope. Their small size and peculiar shape provide large surface area relative to their volume, making them ideally suited for gas exchange.
Although the erythrocytes numbers are important, it is the amount of hemoglobin in the blood streams at any time that really determines how well the erythrocytes are performing the roles
of oxygen transport. The more hemoglobin molecules the RBCs contains, the more oxygen they will be able to carry. Much more important clinically is the fact that normal blood contains
12-18 g hemoglobin per 100 ml blood. The hemoglobin content is slightly higher in men (13-18g) than in female (12-16g).
A decrease in the oxygen-carrying ability of the blood, whatever the reason, is anemia. Anemia may be the result of (1) a lower than normal number of RBCs or (2) abnormal or
deficient hemoglobin content in the RBCs.
Leukocytes
Although leukocytes or white blood cells, are far less numerous than red blood cells, they are crucial to body defense against disease. On average, there are 4,000 11,000 WBCs
per cubic millimeter, and they account for less than one percent of total blood volume. White blood cells are the only complete cells in the blood; that is, they contain nuclei and the usual
organelles.
Leukocytes form a protective, movable army that helps defend the body against damage by bacteria, viruses, parasites and tumor cells. As such, they have some very special
characteristics. RBC are confined to the blood streams and carry out their functions in the blood, WBC, by contrast, are able to slip into and out of the blood vessels a process called
diapedesis. The circulatory system is simply their means of transportation to areas of the body were their services are needed for inflammatory or immune responses.
In addition, WBC can locate areas of tissue damage and infection in the body by responding to certain chemicals that diffuses from the damage cells. The capability is called
positive chemotaxis. Once they have caught the scent, the WBC moves through the tissue spaces by amoeboid motion. By following diffusion gradient, they pinpoint areas of tissue
damage and rally round in large numbers to destroy foreign substances or dead cells.
Whenever WBC mobilizes for action, the body speeds up their production, and as many as twice the normal number of WBCs may appear in the blood within few hours. A total WBC count
above 11,000 cells /mm3 is referred to as leukocytosis.
WBC is classified into 2 major groups, depending on whether or not they contain visible granules in their cytoplasm. Granulocytes are granule containing WBCs. They have lobe
nuclei, which typically consists of several rounded nuclear areas connected by thin strands of nuclear material. The granules and their cytoplasm stain specifically Wright stain. The
granulocytes include the (1) neutrophils which are multi lobe nucleus and very fine granules that respond to both acidic and basic stain then they are avid phagocyte at site of acute
infection;(2) eosinophils have blue red nucleus that resembles an old fashioned telephone receiver and sport large brick-red cytoplasmic granules their number increases rapidly during
allergies and infection by parasitic worms; and (3) basophils the rarest of the WBCs, contain large histamine- containing granules that stain dark blue. Histamine is an inflammatory
chemical that makes blood vessels leaky and attracts other WBCs to the inflammation site. The second group, agranulocytes, lacks visible cytoplasmic granules. Their nuclei are closer to
the norm that is, they are spherical, oval, or kidney- shaped. The agranulocytes include (1) lymphocytes have a large dark purple nucleus that occupies most of the cell volume. Only
slightly larger than RBCs, lymphocytes tend to take up residents in lymphatic tissues, where they play an important role in the immune response; and (2) monocytes are the largest of the

WBCs except for their more abundant cytoplasm and indented nucleus, they resemble large lymphocytes. When they migrate into the tissues, they change into macrophages with huge
appetite. Macrophages are very important in fighting chronic infections.

Platelets
Platelets are not cells in the strict sense. They are fragments of bizarre multinucleate cells called megakaryocytes which rupture, releasing thousands of anucleate pieces that
quickly seal themselves off from the surrounding fluids. The platelets appear as darkly staining, irregularly shaped bodies scattered among the other blood cells. The normal platelet count in
blood is about 300,000/mm3. Platelets are needed for the clotting process that occurs in plasma when blood vessels are ruptured or broken.

FEMALE REPRODUCTIVE SYSTEM

The Human female reproductive system contains two main parts: the vagina and uterus, which acts as the receptacle for the males sperm, and the ovaries, which produce the females ova.
All of these parts are always internal; the vagina meets the outside at the vulva, which also includes the labia, clitoris, and urethra. The vagina is attached to the uterus through the cervix, while the
uterus is attached to the ovaries via the fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the fallopian tube into the uterus.
If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The
zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and
contractions of the uterus propel the fetus through the birth canal, which is the vagina.
The ova are larger than sperm and are generally all created by birth. Approximately every month, a process of oogenesis matures one ovum to be sent down the fallopian tube attached to its
ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation.

Ovaries
The ovaries are the main reproductive organs of a woman. The two ovaries, which are about the size and shape of almonds, produce female hormones (estrogens and progesterone) and eggs (ova).
All the other female reproductive organs are there to transport, nurture and otherwise meet the needs of the egg or developing fetus.
The ovaries are held in place by various ligaments which anchor them to the uterus and the pelvis. The ovary contains ovarian follicles, in which eggs develop. Once a follicle is mature, it ruptures
and the developing egg is ejected from the ovary into the fallopian tubes. This is called ovulation. Ovulation occurs in the middle of the menstrual cycle and usually takes place every 28 days or so
in a mature female. It takes place from either the right or left ovary at random.
Fallopian tubes
The fallopian tubes are about 10 cm long and begin as funnel-shaped passages next to the ovary. They have a number of finger-like projections known as fimbriae on the end near the ovary. When
an egg is released by the ovary it is caught by one of the fimbriae and transported along the fallopian tube to the uterus. The egg is moved along the fallopian tube by the wafting action of cilia
hairy projections on the surfaces of cells at the entrance of the fallopian tube and the contractions made by the tube. It takes the egg about 5 days to reach the uterus and it is on this journey down
the fallopian tube that fertilization may occur if a sperm penetrates and fuses with the egg. The egg, however, is only usually viable for 24 hours after ovulation, so fertilization usually occurs in the
top one-third of the fallopian tube.
Uterus
the uterus is a hollow cavity about the size of a pear (in women who have never been pregnant) that exists to house a developing fertilized egg. The main part of the uterus (which sits in the pelvic
cavity) is called the body of the uterus, while the rounded region above the entrance of the fallopian tubes is the fundus and its narrow outlet, which protrudes into the vagina, is the cervix.
The thick wall of the uterus is composed of 3 layers. The inner layer is known as the endometrium. If an egg has been fertilized it will burrow into the endometrium, where it will stay for the rest of
its growth. The uterus will expand during a pregnancy to make room for the growing fetus. A part of the wall of the fertilized egg, which has burrowed into the endometrium, develops into the
placenta. If an egg has not been fertilized, the endometrial lining is shed at the end of each menstrual cycle.
The myometrium is the large middle layer of the uterus, which is made up of interlocking groups of muscle. It plays an important role during the birth of a baby, contracting rhythmically to move
the baby out of the body via the birth canal (vagina).
Vagina
The vagina is a fibromuscular tube that extends from the cervix to the vestibule of the vulva. The vagina receives the penis and semen during sexual intercourse and also provides a passageway for
menstrual blood flow to leave the body.

THE CIRCULATORY SYSTEM

Is responsible for transporting materials throughout the entire body. It transports nutrients, water, and oxygen to your billions of body cells and carries away wastes such as carbon dioxide
that body cells produce. It is an amazing highway that travels through your entire body connecting all your body cells.
Group of organs that transport blood and the substances it carries to and from all parts of the body. The circulatory system can be considered as composed of two parts: the systemic
circulation, which serves the body as a whole except for the lungs, and the pulmonary circulation, which carries the blood to and from the lungs. The organs of circulatory system consist of
vessels that carry the blood and a muscular pump, the heart that drives the blood.

Parts of the Circulatory System

the circulatory System is divided into three major parts:
* The Heart
It is an amazing organ. The heart beats about 3 BILLION times during an average lifetime. It is a muscle about the size of your fist. The heart is located in the center of your chest slightly
to the left. Its job is to pump your blood and keep the blood moving throughout your body.
* The Blood Vessels
1. Arteries are blood vessels that carry oxygen rich blood AWAY from the heart. Remember, A A Arteries Away. The main arterial vessel, the aorta, branches into smaller arteries, which in
turn branch repeatedly into still smaller vessels and reach all parts of the body.
2. Capillaries are tiny blood vessels as thin as or thinner than the hairs on your head. Capillaries connect arteries to veins. Food substances (nutrients), oxygen and wastes pass in and out of
your blood through the capillary walls.

3. Veins Blood leaving the tissue capillaries enters converging vessels, the veins, to return to the heart and lungs.
Systemic Circulation
In the systemic circulation, which serves the body except for the lungs, oxygenated blood from the lungs returns to the heart from two pairs of pulmonary veins, a pair from each lung. It
enters the left atrium, which contracts when filled, sending blood into the left ventricle (a large percentage of blood also enters the ventricle passively, without atrial contraction). The bicuspid, or
mitral, valve controls blood flow into the ventricle. Contraction of the powerful ventricle forces the blood under great pressure into the aortic arch and on into the aorta. The coronary arteries stem
from the aortic root and nourish the heart muscle itself. Three major arteries originate from the aortic arch, supplying blood to the head, neck, and arms. The other major arteries originating from the
aorta are the renal arteries, which supply the kidneys; the celiac axis and superior and inferior mesenteric arteries, which supply the intestines, spleen, and liver; and the iliac arteries, which branch
out to the lower trunk and become the femoral and popliteal arteries of the thighs and legs, respectively. The arterial walls are partially composed of fibromuscular tissue, which help to regulate
blood pressure and flow. In addition, a system of shunts allows blood to bypass the capillary beds and helps to regulate body temperature.
At the far end of the network, the capillaries converge to form venules, which in turn form veins. The inferior vena cava returns blood to the heart from the legs and trunk; it is supplied by the iliac
veins from the legs, the hepatic veins from the liver, and the renal veins from the kidneys. The subclavian veins, draining the arms, and the jugular veins, draining the head and neck, join to form the
superior vena cava. The two vena cavae, together with the coronary veins, return blood low in oxygen and high in carbon dioxide to the right atrium of the heart.
Pulmonary Circulation
The pulmonary circulation carries the blood to and from the lungs. In the heart, the blood flows from the right atrium into the right ventricle; the tricuspid valve prevents backflow from
ventricles to atria. The right ventricle contracts to force blood into the lungs through the pulmonary arteries. In the lungs oxygen is picked up and carbon dioxide eliminated, and the oxygenated
blood returns to the heart via the pulmonary veins, thus completing the circuit. In pulmonary circulation, the arteries carry oxygen-poor blood, and the veins bear oxygen-rich blood.

CLIENT in CONTEXT
JQ, 19 years old, female, single, with gravid
uterus of 40 6/7 weeks AOG, by LMP, was
admitted for the 1st time at (CVGH) Cebu
Velez General Hospital last May 7, 2007 at
10:00 pm, per taxi accompanied by her mother
as advised by attending physician for overdue
pregnancy. Received under the services of Dr.
Fe Villamil under the Department of Obstetrics
with a case number of 87440.
GORDONS FUNCTIONAL HEALTH
PATTERNS
1. Health-Management Health-Perception
Patient describes health as the
absence of illness and the ability to do work
and being healthy would make one happy. She
rates her health before pregnancy as 10/10 (10
as the highest and 1 as the lowest) since she
can do all the house chores effectively. She is a
non-smoker, non-alcoholic beverage drinker,
non-diabetic. She is a known asthmatic since
childhood which was diagnosed by a local
physician in the Balamban Health Center. Last
asthma attack was when she was still grade 3.
She uses OTC drugs such as paracetamol
(Biogesic) (classification: antipyretic, action:
inhibits prostaglandin synthesis) 500 mg 1 tab
when having fever. She as no food and drug
allergies. She uses herbal medicines like
limot-limot for cough. During her
pregnancy, her BP was 110-120/80 mmHg and
when she arrived in CVGH, she had a BP of
150/90 mmHg. She doesnt go to annual

PRESENT STATE
Date: May 8, 2007
9:00 pm
Gen. Appearance:
> Seen lying on bed, lethargic, conscious,
coherent and febrile, with breast not engorged,
uterus at 1 fingerbreadth above the umbilicus,
was not able to defecate, urine draining well at
FBC to CDU, with moderate flow of lochia
rubra, presence of dry and intact post C/S
dressing at hypogastric area, (-) homans sign
and feels weak and tired, with venoclysis of
bottle 1 D5LR 1 L + 20 Oxytocin @ 30
gtts/min infusing well @ R arm, with on going
blood transfusion of FWB, B+ piggyback @
20gtts/min on bottle 2 PNSS 1 L off @ L arm.
with the ff v/s:
BP: 130/90 mmHg
PR: 76 bpm
RR: 19 cpm
T: 38C/axilla
PHYSICAL EXAMINATION:
SKIN: brown, no lesions & tenderness,
smooth, good skin turgor, non-pitting edema
NAILS: pale nail beds, CRT < 2 secs.
HEAD: normocephalic, midline with neck, no
deformities, symmetrical facial features, no
lesions & tenderness, with black evenly
distributed hair, no lice nor dandruff
EYES: eyebrows evenly distributed,
symmetrical

INTERVENTIONS

EVALUATION

check-ups and claims that she only visits the

health center when the need arises. HFD
includes asthma on paternal side and HPN on
maternal side. She knows about BSE and
practices it. She is fully immunized and during
pregnancy was given two shots of tetanus
toxoid.

NOSE: nasal septum in midline, no discharges,

on both frontal and maxillary sinuses, no nasal
flaring
EARS: pinna in line wih outer canthus of the
eye, no discharges
MOUTH: pale lips,

During her pregnancy, she rates her

health as 9/10 because her growing belly quite
hinders her in doing activities but she can still
do chores effectively. She then claims that her
health after the delivery of the baby lowered to
6/10. It is because she would have wanted to
have a normal delivery but instead she had a
Caesarian section which placed her at greater
risk.

History of Present Condition

1 day PTA, patients mother advised her to
seek consult to Dr. Villamil because the
pregnancy was already overdue. During the
check-up it was found out that she has
gestational hypertension with a BP of 150/90
mmHg. She was advised for physical profiling
and ultrasound. Patient claimed that the results
were normal as was said to her by the
physician. Dr. Villamil advised her to be
admitted at CVGH.
Noon PTA px went to CUPSCI for her physical
profiling and ultrasound which, px claims that
she doesnt know the results but was told to
seek admission since she was overdue for her

NECK: no lesions nor masses, palpable

thyroid,
CHEST: equal lung expansion, clear breath
sounds on both lung fields, (+) tactile fremitus,
HEART: (+)apical pulse, distince S1 and S2
heart sounds upon auscultation, no heart
murmurs
ABDOMEN: with c/s incision and dressing,
umbilicus in midline, fundus at level of
umbilicus
EXTERNAL GENITALIA AND ANUS:
grossly female, minimal lochia rubra
discharges, with FBC-CDU, perforated anus
UPPER EXTREMITIES: no lesions &
tenderness, no deformities
LOWER EXTREMITIES: no lesions
NEUROLOGIC ASSESSMENT:
CEREBRAL FXN: Asleep
DATE: May 9, 2007
GEN. APPEARANCE:
> Seen sitting on bed, awake, alert, responsive,

delivery.
One hour PTA px went to CVGH per taxi
accompanied by mother where she was
admitted due to a high BP of 150/90 and
overdue of delivery.
Prenatal History
Patients first prenatal check up was done 3
months AOG where she was found to be 3
months pregnant at Cebu Maternity Hospital
by a midwife. Check-up was prompted by
absence of menstruation, vomiting, breast
tenderness and growing of abdomen during the
previous months. Her BP during the first check
up was recorded to be 120/80 mmHg. No
complications were noted. Patient has poor
compliance with her preanatal check-ups, she
claims to have had her prenatal. She was given
(MV)Martam 1 tablet per day, multivitamins
and Calvit, calcium supplement with good
compliance, patient was also prescribed also
with Ferrous Sulfate but she wouldnt take it
since it she claimed it was foul smelling.
Second prenatal check-up was done during 4 th
month AOG at Cebu Maternity Hospital and
the third prenatal check-up was done on the 7 th
month AOG at their health center near their
house. LMP is July 25, 2006 and EDC is May
1, 2007.

2. Nutritional Metabolic Pattern

Before pregnancy, patient eats 4

coherent, febrile and eupneic with breasts not

engorged, uterus at 2 fingerbreadths below the
umbilicus, able to defecate 1x this morning and
voided freely, minimal flow of lochia rubra, (-)
homans sign, feels well rested and better than
last night with IVF @ L arm terminated,
venoclysis of bottle 3 D5LR 1L @ 30gtts/min
infusing well at R arm, with dry and intact
dressing at hypogastric area with ff. v/s:
T: 37.8C/axilla
BP: 160/90 mmHg
PR: 96 bpm
RR: 26cpm
Ht=54
Wt=73.2 kg
IBW=56.3 kg
PHYSICAL EXAMINATION:
SKIN: brown, no lesions & tenderness,
smooth, good skin turgor
NAILS: pale nail beds, CRT < 2 secs.
HEAD: normocephalic, midline with neck, no
deformities, symmetrical facial features, no
lesions & tenderness, with black evenly
distributed hair, no lice nor dandruff
EYES: eyebrows evenly distributed,
symmetrical, anicteric sclera, pale palpebral
conjunctiva, able to read student nurses
nameplate @ 2 ft distance
NOSE: nasal septum in midline, no discharges,

meals and a snack per day. She claims she has

a very good appetite. She eats her breakfast,
around 6:00 am, usually consists of bread,
coffee, rice, fish, meat and vegetables. She eats
again another full meal at around 9:00 am. She
eats lunch, 12:00 noon, and dinner around 7:00
pm, with family. Both meals usually are made
up of 2-3 cups of rice, a serving of vegetables
and a serving of either meat or fish. She eats
snacks usually at around 3:00 pm which
consists of any food available. She claims to
drink 6-7 glasses of fluids a day. She is not a
picky eater. She has no food allergies.
During pregnancy, she claimed to eat a lot
more meals (5-6 meals) which consist of rice
with either fish or meat. She now drinks 10-11
glasses of fluids per day.
Right after pregnancy, she had a general
liquids diet for the first night then liquids for
the next day and full diet thereafter.
She claimed to have no difficulty in eating,
chewing and swallowing. She has incomplete
set of teeth with one missing on the 2 nd lower
left molar. Her present weight is now 73.2 kgs.
Patient is 5 feet and 4 inches tall. Her ideal
body weight is 56.30kgs. She is 130 %
overweight.

(+) transillumination on both frontal and

maxillary sinuses, no nasal flaring
EARS: pinna in line wih outer canthus of the
eye, no discharges, can hear whispered voice
@ 2 ft distance
MOUTH: pale lips, buccal musoca pinkish,
moist with no lesions, tongue in midline and
attached to floor of the mouth by frenulum,
uvula raised when saying ah, incomplete set
of teeth (missing 1 lower left molar), not using
any dentures
NECK: supple, lymph nodes not palpable, no
lesions nor masses, palpable thyroid, full ROM
exercise
CHEST: equal lung expansion, clear breath
sounds on both lung fields, (+) tactile fremitus,
breast is not engorged
HEART: (+)apical pulse, distince S1 and S2
heart sounds upon auscultation, no heart
murmurs

3. Elimination Pattern

ABDOMEN: with c/s incision and dressing,

umbilicus in midline, fundus at level of
umbilicus

Before pregnancy, patient voids 2-3

times per day with clear yellow-colored urine
approximately 120 ml per episode. She claims
to have no difficulty voiding. She defecates 1-2
times per day, usually during morning, of
brown stool of soft consistency before
pregnancy. During pregnancy, she claimed that

EXTERNAL GENITALIA AND ANUS:

grossly female, minimal lochia rubra,
perforated anus
UPPER EXTREMITIES: no lesions &
tenderness, no deformities, full ROM, nonpitting edema
LOWER EXTREMITIES: non-pitting edema,

there is no change in urination but she had

difficulty in moving her bowel. She doesnt
use any laxatives. After pregnancy client was
ablte to defecate once during the course of our
care/
4. Activity Exercise Pattern
Before pregnancy, patient wakes up at
around 4:30 am. She immediately goes to the
bathroom to bathe and use the toilet. She then
takes her breakfast then goes to work at
MEPZA as a tailor. She goes home after work
at around 5 pm, takes her dinner, goes to the
bathroom to bathe before going to sleep. She
sleeps around 9 pm.
During pregnancy, she stopped working when
she was told she was pregnant. She wakes up
at 6 am. She then goes to the bathroom to bath
and use the toilet. She takes her breakfast then
watches TV or does household chores and
takes frequent naps. She only stays home with
no exercise. She sleeps at around 9 pm.
5. Sleep Rest Pattern
Before pregnancy, patient usually
sleeps with an average of 7-8 hours, she sleeps
at around 9:00 pm and wakes up at around
4:30 am. She also had short naps when at
work. Her sleeping aids are 4 pillows on a bed.
She doesnt like any blankets and doesnt use
fans or electric fans. She doesnt use any
sleeping pills. She claims to be well rested
upon waking. She claims to be well rested
upon waking. During pregnancy, she sleeps at
9 pm but wakes up at 6 am. She takes a nap in

no lesions, full ROM

NEUROLOGIC ASSESSMENT:
CEREBRAL FXN: awake, alert, conscious,
responsive, oriented to time, place and person,
long and short term memory intact, able to
convey clear messeages to others
CN TESTING:
I able to smell and identify alcohol with eyes
closed
II able to read students nameplate @ 2 ft
diatance
III, IV, VI (+) PERRLA, (+) cardinal gaze
V able to masticate and blink, can move jaw
from side to side, can clench teeth
VII can perform facial grimaces, able to
frown, smile, raise eyebrows, puff out cheeks
and close eyes tightly
VIII able to hear whispered voice @ 2 ft
distance
IX able to swallow and taste
X (+) gag reflex
XI able to shrug shoulders against resistance
XII able to move tongue side to side and
stick out tongue
CEREBELAR/MOTOR:
(+) finger-nose test, (+) finger-thumb test,
coordinated hand movement
DTR: (+) patellar reflex, (+) biceps reflex
MUSCLE STRENGTH: upper extremities:
5/5, lower extremities: 5/5
SENSORY FXN: (+) stereognosis & (+)
graphestesia
DATE: May 10, 2006

the afternoon for 1-2hrs.

6. Sexual Reproductive Pattern
Patient had her menarche when she
was 12 years old and her thelarche at 11 years
old. She claims that her menstruation is regular
with moderate flow consuming 2-3 pads per
day within 5-7 bleeding days. She doesnt
usually experience dysmenorrheal. Her first
sexual contact was when she was 18 years old
with her boyfriend as her sole sexual partner.
She doesnt use any contraceptives. Her
current obstetrical score is G 1P1001. she
praccices BSE, stating that they were taught
how to do it in school.
Obstetrical History

GEN. APPEARANCE: > seen lying on bed,

awake, alert, responsive, coherent, afebrile,
eupneic breasts not engorged, with clean and
intact dressing, able to void and defecate,
minimal lochia serosa flow, (-) Homans sign,
with ff. v/s:
T: 36.9 C/axilla
BP: 130/70 mmHg
PR: 75 bpm
RR: 20 cpm
EYES: pale palpebral conjunctiva
NAILS: pale nailbeds
ABDOMEN: fundus at 2 fingerbreadths below
umbilicus, with c/s incision and dressing
EXTREMITIES: non-pitting edema
LABORTORY FINDINGS
May 7, 2007 11:13 pm

G1 Bb Girl, 40 6/7 weeks AOG, LSTCS,

CVGH, May 8, 2007, living
7. Cognitive Sensory Pattern
She is a high school graduate of
Bwanoy High School. Patient is oriented to
time, place and person. She has intact short
and long term memory. She can recall her
birthday and of her parents, age of menarche,
and food eaten the day before. She doesnt
wear glasses or contact lenses. She doesnt use
any hearing aids and as no problems with her
sense of hearing, smell and touch. During and
after pregnancy, there was no significant
change in cognitive and sensory.
8. Role Relationship Pattern

WBC
NEU
LYM
MONO
EOS
BASO
RBC
HgB
Hct
MCV
MCH
MCHC
RDW
Plt
MPV

7.08 k/ul
4.37
1.94
0.378
0.330
0.056
3.67 M/ul
8.72 g/dl
27 %
73.5 fl
23.8 pg
32.3 g/dl
16.7 %
339 k/ul
7.82 fl

N Value
4.10 10.9
2.50 7.50
1.00 4\.00
0.100 1.20
0.00 0.500
0.00 0.100
4 5.20
12 16
36 46%
80 100
26 34
31 36
11.6 18
140 440
0.00 100

Patient is a daughter, sister and a

girlfriend. Patient still lives with her parents
and her elder brothers family and claims to
have good relationship with them . they use a
switchboard type of communication. Patient is
the 3 child out of 4 siblings and claims to have
a good relationship and an open
communication among them. She has a lot of
acquaintances and relatives and she maintains
a peaceful relationship with them.
.
Genogram:

Implication:
= Decreased RBC, Hgb, Hct, MCV and MCH
indicates possible anemia due to blood loss
secondary to S/P lower segment transverse
caesarian section
May 7, 2007 11:30 pm
CSF - Serology
HBs Ag.IC = non reactive
May 7, 2007
Crea D

11:51 pm

Crea D = 1.0 mg/dL (0.5-1.3)

Alta = 9 u/L (0 - 41)
May 8, 2007
Urinalysis

9. Self-Perception Self-Concept Pattern

Patient claims that she is a talkative
person and gets along easily. She claimed to be
a strong-willed person and considers her
laziness as her weakness. During pregnancy,
there were instances when she doubted her
capabilities of raising a child and of becoming
a good mother. But even in doubt she tries to
remain strong for herself, her baby and family.
After pregnancy she felt proud that she was
able to go through such experience. She

Color: yellow
Appearance: slightly cloudly
pH: 6.0
specific gravity: 1.021
protein: trace
glucose: negative
reducing substance: negative
RBC: 2-4
WBC: 3-5
Epithelial: 4-6/hpf
Mucus threads: few
Amorphous materials urates: few
Bacteria: few
Heat and acetic acid: trace
Ketones: negative
Blood: negative

claimed that she is not yet contented with her

life.
10. Coping-Stress Tolerance Pattern

Key Issues:

Patients current short term stressor is

her present condition and the condition of her
newly delivered baby. Her long term stressor
includes that of financial nature. She copes
with her problem by sleeping. She also asks
advices from her mother.

May 8, 2007

11. Value Belief Pattern

Patient is a Roman Catholic. She
seldom goes to church because she claimed to
be lazy to go to church. She believes in
traditional health practices and uses herbal
medicines. She has no religious organizations.
Patient prays at night.
Environmental History
Patient lives in Balamban with her
parents, her brother and sister in law, and her
niece. The place is a one storey house made up
of mixed materials owned by the family. It has
2 rooms which serves sleeping quarters. They
different room for kitchen and dining. They
have 5 windows. Electricity is supplied by
CEBECO while water for drinking and
washing is from the well which is checked by
the DOH every once in a while. Garbage
disposal is through scheduled motorized
garbage collector and is put in a sack. Place of
residence is accessible to every public utilities.

1.Acute Pain related to surgical incision

secondary to 1 day status post low segment
transverse cesarean section (LSTCS) as
manifested by facial grimacing, altered
mobility, verbalization of Sakit inig lihok
nako and reporting of gnawing pain located in
the hypogastric area, aggravated by upper body
movement, relieved by rest and sleep with a
pain scale of 8 out of 10 with 10 as the highest.
Scientific Basis:
Because her abdominal muscles are so
lax from having been stretched from
pregnancy, abdominal contents tend to shift
forward and put pressure on the suture line
causing pain and an uncomfortable feeling
often described as falling apart. (Pillitteri.
Maternal and Child Health Nursing 4th ed.
p559)

May 9, 2007
2.Impaired skin integrity related to break in

Independent Interventions:
1. Assessed pain reports, noting
location, intensity and frequency
indicates need for/effectiveness of
interventions and may signal development
or resolution of complications
2. Encouraged verbalization of feelings
can reduce anxiety and fear thereby
reducing perception of intensity of pain
3. Taught to have progressive relaxation,
deep breathing activities and splinting
promotes relaxation and feeling of wellbeing
4. Initiated conversation
refocuses attention, may enhance
coping
5. Repositioned every two hours,
performed passive ROM
promotes relaxation/decreased muscle
tension

Desired Outcome:
Within 6 hours nurse-client interaction, client
will be able to report lessened pain verbally
and in non verbal cues (no more facial
grimacing, guarding behavior and muscle
rigidity) and be able to perform taught skills
like splinting.

Collaborative Interventions:
1. Administered analgesic ketorolac
(Toradol) 30 mg IVTT every 6 hours
NSAID med which inhibits the
prostaglandin synthesis

05/10: Pain scale was noted to be 3 out of 10,

no facial grimacing and able to do activities
with assistance; able to splint incision sight
upon movement and change of position (lying
on bed to sitting), verbalization of arang2x na
dong, di na kaayu grabe

Independent Intervention:

Desired Outcome:

Actual Outcome:
05/08: : Pain scale was noted to be 7 out of 10
(With 10 as the highest and 1 as the lowest),
facial grimacing and altered mobility was still
noted; able to splint incision sight upon
movement and coughing., verbalization of
sakit pajud siya dae
05/09: Pain scale was noted to be 5 out of 10
(With 10 as the highest and 1 as the lowest),
facial grimacing and altered mobility was still
noted; able to splint incision sight upon
movement and coughing.

About 10-15 minute tricycle ride to the market,

church, health center and other facilities. The
place is peaceful but when fiestas are
celebrated, trouble occurs often in the area.

the skin and inadequate primary defenses

secondary to 1 day status post LSTCS as
manifested by 4-inch surgical incision with
clean, dry and intact dressing at hypogastric
area.
Scientific Basis:
Cesarean birth, a birth accomplished
through abdominal surgical procedures known.
Unfortunately, it is a procedure more
hazardous than vaginal birth. A low segment
incision is one made horizontally across the
uterus just over the cervix. (Pillitteri. Maternal
and Child Health Nursing, 4th ed. p 549)

1.

Noted signs and symptoms of

infection
fever, chills, diaphoresis, altered level
of consciousness, and positive blood
cultures may indicate infection
2. Encouraged proper hand washing
techniques to client and SO
a first line of defense against
nosocomial
infection
or
crosscontamination
3. Encouraged to check wound for signs
of inflammation and drainage.
may indicate hematoma formation and
developing infection
4. Encouraged
and
assisted
in
ambulation
promotes wound healing
5. Instructed patient to keep incision dry
and clean
to prevent risk for infection
6. Instructed patient to clean incision
site daily and PRN with PovidoneIodine or other appropriate solutions
and change dressings as needed.
disinfectants reduce accumulation of
microorganisms thus avoiding infection.
Changing dressing reduces accumulation
of microorganisms.
7. Emphasized the importance of having
a diet high in fluid
to prevent constipation, this could
increase pressure in perineal area during
defecation.
Collaborative Interventions:
1. admininstered cefuroxime ( Furocems)
50 mg IVTT every 8 hours

Within the 8 hours of nurse-patient contact,

patient will be able to display timely healing of
wounds without complication and be able to
verbalize feelings of self-esteem brought by
the incision.
Actual Outcome:
After the course of nursing intervention,
patient verbalized ok ra ni ako samad
matabunan raman sad basta lang gud maayo ni,
ok na kaayo.
05/09 05/10: no signs of infection such as
fever, redness, swelling, itchiness, warmth and
pain on incision site were noted; wound was
kept clean and dry.


May 9, 2007
3.Ineffective Peripheral Tissue Perfusion
related to decreased cardiac output secondary
to gestational hypertension as manifested by
increased blood pressure (140/60 mmHg), (+)
non pitting edema on lower extremities and on
the both hands, pale palpebral conjunctiva,
pale lips, pale nail beds, low RBC ( 3.67u/ul),
HGB ( 8.72g/dl) , HCT (27%), MCV (73.5 fl) ,
MCH (23.8 PG)
Scientific Basis:
With hypertension, the cardiac system
can become overwhelmed because the heart is
forced to pump against rising peripheral
resistance. This reduces the blood supply to
organs such as kidney, pancreas, liver, brain
and placenta. Vasospasm in the kidney
increases blood flow resistance. Degenerative
changes develop in kidney glomeruli and this
leads to increased glomerular membrane
permeability, allowing the serum CHON
albumin and globulin to escape. Increased
tubular reabsorption of Na occurs because Na
retains fluid, edema results (Pillitteri.
Maternal and Child Health Nursing, 4 th ed.
p404-405). As the plasma volume increases,
the concentration of hemoglobin and
erythrocytes may decline, giving the woman a
pesudoanemia. (Pillitteri. Maternal and Child
Health Nursing, 4th ed. p220).

Independent Interventions:
1. Identified changes related to systemic
and peripheral circulation
to assess causative factors
2. Assessed and monitored v/s and I and
O q 4H
for baseline data and changed/alteration
of v/s especially blood pressure may
indicate worsening of the conditions
3. Weighed daily.
provides a baseline for comparison
4. Evaluated edematous extremities by
measurement of the diameter of the
extremities daily and changed
position frequently
to reduce tissue pressure and risk of
skin breakdown
5. Encouraged ambulation and foot
dangling for about 15- 30 mins
this enhances venous return
6. Discouraged sitting/standing for long
periods, wearing of constrictive
clothing and crossings of legs
these prevent alteration in blood
circulation
7. Provided with adequate ventilation
and quiet environment by turning on
electric fans
to promote rest periods
8. Encouraged to elevate the head of bed
or position in Semi-Fowlers when
sleeping
to increase gravitational blood flow
Encouraged to use relaxation techniques
such as reading newspaper and taught on

Desired Outcome:
Within the course of nurse-patient interaction,
patient will demonstrate increased tissue
perfusion with the manifestations of BP within
normal levels, absence or decreased edema,
pinkish palpebral conjunctiva, pinkish lips and
nail beds, and complications like shock/coma
will be prevented and demonstrate diet
changes.
Actual Outcome:
After the entire course of nursing interaction
client was able to demonstrate changes in diet.
05/09: pale palpebral conjunctiva, pale lips,
pale nail beds, non-pitting edema on
both legs, BP= 130/170 mmHg, wt=
73.2 kg
05/10: pinkish palpebral conjunctiva, pinkish
nailbeds, BP= 130/80 mmHg, wt= 73.1
kg

the 15 S for stress management

to decrease tension level
9. Elevated edematous extremities
to promote good venous return
10. Instructed patient to have a low-fat,
low-sodium diet
to promote wellness
Collaborative Interventions
1. Administered Furosemide (Lasix) 40
mg /tab one tab single dose
R: Class: loop diuretic
IND: fluid volume excess, oliguria,
MOA: prevents absorption of Na in the
loop of Henle
2. administered nifedipine (Adalat)20
mg /tab 1 tab BID PO
R:
3. administered methyldopa ( Aldonet)
250 mg/tab every 8 hours
R:
May 8, 2007
4.Altered body temperature: hyperthermia
r/t trauma secondary to s/p LSTCS as
evidenced by core body temperature of 38C.
Scientific Basis:
Fever results from an alteration in the
hypothalamic set point. Fever may result from
chills, shivers, and feels cold. During a febrile
episode, WBC production is stimulated.
Increased
temperature
reduces
the
concentration of iron in the blood plasma,
suppressing the growth of bacteria.
(Fundamentals of Nursing, 6th Ed., pg. 623)

Independent Interventions:
1. Monitored core temperature.
R: to evaluate effects or degree of
hyperthermia.
2. Promoted surface cooling by means of
loosing clothing.
R: heat loss by radiation and conduction.
3. Rendered tepid sponge bath every 15
minutes.
R: heat loss by evaporation and
conduction.
4. Promoted client safety and placed pillows
on sides.
R: to assist with measure to reduce body
temperature.

Desired Outcome:
Within 8 hours of nurse-patient interaction,
patient will be able to maintain core
temperature within normal range.
Actual Outcome:
After 8 hours of nurse- patient interaction,
patient was able to:
May 8, 2007:
No change in body temperature,px
remained febrile
May 9,2007:
Temperature changed from 38 to 37.7,
still febrile

5.

6.
7.
8.

Encouraged to drink lots of water and

fluids.
R: to support circulating volume and
tissue perfusion. And also, to prevent
dehydration.
Maintained bedrest.
R: to reduce metabolic demands or oxygen
consumption.
Encouraged to eat a high calorie diet.
R: to meet increased metabolic demands.
Instructed to eat foods rich in Vitamin C
such as guavas, oranges and other citrus
fruits.
R: to strengthen immune system and fight
against infection.

May 10, 2007

Px was afebrile

Collaborative Intervention:
1. Administered antipyretics (Biogesic 500
mg/tab 1 tab every 4 hours) orally.
R: to relieve fever through central action in the
hypothalamic heat-regulating center.
May 8, 2007
5.High risk for infection related to inadequate
primary defenses
Cues: presence of 4 inch surgical incision with
clean dry and intact dressing at hypogastric
area, presence of IV line at both lefta and right
arm, with FBC-CDU. (May 8, 2007)
Scientific Basis:
A postpartal infection can be
devastating to a woman who already has mad
other physical adaptations. (Pllitteri. Maternal
and Child Health Nursin, 4th ed. p 541)

Independent Intervention:
1. Noted signs and symptoms of
infection
fever, chills, diaphoresis, altered level
of consciousness, and positive blood
cultures may indicate infection
2. Encouraged proper hand washing
techniques to client and SO
a first line of defense against
nosocomial
infection
or
crosscontamination
3. Encouraged to check wound for signs
of inflammation and drainage.

Desired Outcome:
Within 8 hours of nursing intervention px will
be able to be free from the signs and symptoms
of infection like swelling, fever, redness, pain
Actual Outcome:
May 8, 2007: px was febrile
May 9, 2007: px was febrile, free from redness
and pain
May 10, 2007: px was free from the signs and
symptoms of infection

 may indicate hematoma formation and

developing infection
4. Encouraged
and
assisted
in
ambulation
promotes wound healing
5. Instructed patient to keep incision dry
and clean
to prevent risk for infection
6. Instructed patient to clean incision
site daily and PRN with PovidoneIodine or other appropriate solutions
and change dressings as needed.
disinfectants reduce accumulation of
microorganisms thus avoiding infection.
Changing dressing reduces accumulation
of microorganisms.
7. Emphasized the importance of having
a diet high in fluid
to prevent constipation, this could
increase pressure in perineal area during
defecation.
Collaborative Interventions:
1. Administered cefuroxime (Furocem)
750 mg IVTT every 8 hours

May 9, 2007
6.Fatigue related to exerted effort during labor
process and sleep deprivation as manifested by
decreased performance of ADLs, drowsiness,
weakness of the body and verbalization of
kapoy ako lawas kay kulang ko ug tulog ug
pahulay unya bag-o pako g operahan
Scientific Basis:
Labor is work. Its process can loom

Independent Interventions:
1. Determined patients level of mobility
to assess causative/contributing factors
2. Assessed for any presence of sleep
disturbances
to assess causative/contributing factors
3. Provided a quiet and minimally
disturbed environment
to assess patient to cope with fatigue

Desired Outcome:
Within 8 hours of nursing intervention, patient
will report improved sense of energy and to
perform her ADLs and participate in desired
activities at level of ability.
Actual Outcome:
05/09: needs assistance in performing ADLs,
with decreased level of activity

as an overwhelming, unendurable experience;

it can cause a woman to deplete her glucose
source. (Pllitteri, Maternal and Child Health
Nursing, 4th ed. p466). Factors that may
influence the amount and severity of fatigue
include persistent pain, sleep disturbance,
impaired physical activity and disease
duration. Pain increases fatigue by requiring
additional physical and emotional energy to
deal with it. Pain may also interfere with sleep,
thereby increase fatigue level. (Smeltzer and
Bare. Medical-Surgical Nursing. 9th edition.
page 1415)

May 8, 2007
7.Impaired Physical Mobility (Partial) r/t
pain or discomfort manifested by limited
ROM, inability to get out of bed without
assistance and verbalization of lisod jud
ilihok kay sakit pa ang tahil
Scientific Basis:

4.

Organized nursing care like telling in

advance the schedule of vital signs
monitoring,
medication
administration and other nursing
procedures
to keep interruptions to a minimum
5. Encouraged to minimize visitors
to keep interruptions to a minimum
6. Encouraged patient to sleep while
baby is sleeping
to cope with fatigue
7. Advised to have a care taker to look
after the baby while she is sleeping
to provide uninterrupted sleep and so as
to provide adequate rest periods

05/10: able to perform ADLs like toileting and

feeding with minimal assistance, reported an
increased energy level by verbalization of
nakatug raman ko unya ok ra man.

Independent Interventions:
1.
Determined
functional
level
of
classification.
R: Assess the functional ability.
2. Placed positioning devices such ass pillows
bet. Bony prominences.
R: To prevent ulcers.
3. Positioned safely on bed.
R: To promote safety.
4. Assisted with the activities of ADL like
going to the comfort room.
R: prevent complications.
5. Encouraged SO to attend to needs.
R: To be able to cater patients immediate
needs.
6. Stayed at the bedside frequently.
R: To ensure safety.
7. Assisted in ambulation
R: to promote wellness

Desired Outcome:
Within 8 hours of nursing interventions,
patient will be able to demonstrate progressive
changes in her mobility as tolerated, and at the
same time SO will be able to provide the
necessary needs of the patient such as bathing
ang going to the CR.
Actual Outcomes:
After 8 hours of nursing interventions the
following were noted:
May 8, 2007:unable to change positions
without assistance
May 9, 2007:able to dangle feet on bed
May 10, 2007:able to move without assistance

May 8, 2007
8.Activity intolerance r/t weakness, pain on
the incision site in the hypogastrium as
manifested by inability to ambulate to the
comfort room, take a shower, change clothes,
comb hair and brush teeth and verbalization of
sakit taga lihok nako
Scientific Basis:
Clients muscle strength, flexibility and
dexterity, balance, coordination and activity
tolerance necessary on performing activities
determine clients physical and cognitive
ability to perform basic hygiene measures for
self-care. (Potter and Perry. Fundamentals of
Nursing. Pg 1067-68)

May 8, 2007
9.Partial self-care deficit in hygiene and
toileting r/t impaired physical mobility as
manifested by inability to take a bath and
toileting unassisted, difficulty in going to the
CR and refuses to perform self Care as
verbalized by Di ko ganahan maligo ug mu
adto sa CR kay sakit inig lakaw.

Independent Interventions:
1.
Encouraged adjustment of activities
and reduced intensity of activities
R: to prevent overexertion
2.
Planned care with rest periods
between activities
R: to reduce fatigue
3.
Encouraged to increase exercise or
activity levels gradually
R: to conserve energy
4.
Assisted with activities of Activities
of Daily Living
R: to protect client from injury
5.
Promoted comfort measures and
provided relief of pain
R: to enhance ability to participate in
activities
6.
Encouraged patient to maintain a
positive attitude and suggested use of
relaxation techniques such as DBE and
visualization.
R: to promote wellness

Independent Interventions:
1. Assessed the degree of assistance needed.
R: To provide assistance to the extent of
clients need.
2. Established contractual partnership with
the client.
R: To assist in dealing with situation.

Desired Outcome:
Within 8 hours of student nurse- client contact,
the patient will
participate in prevention measures and
treatment program.
Actual Outcome:
After 8 hours of student nurse-client contact
the patient was:
May 8, 2007
not able to dress by herself
still needing assistance in eating,
changing positions, and grooming
May 9, 2007
able to sit in bed unassisted
May 10, 2007
able to ambulate without assistance

Desired Outcome:
Within 8 hours of nursing intervention, the
patient will be able to perform self-care
activities within the level of her own ability
and demonstrate techniques to meet self care
needs.

3.
Scientific basis:
Clients muscle strength, flexibility and
dexterity, balance, coordination and activity
tolerance necessary in performing activities
determine clients physical and cognitive
ability to perform basic hygiene measures for
self-care (Potter and Perry: Fundamentals of
Nursing. Pg 1067-68)

May 9, 2007
10.Imbalanced nutrition: more than body
requirements r/t excessive intake in
relationship to metabolic need as manifested
by weight of 73.5Kg with IBW of 55.8Kg and
height of 54. Her present weight is now 73.2
kgs. Patient is 5 feet and 4 inches tall. Her
ideal body weight is 56.30kgs. She is 130 %
overweight.
Scientific Basis:

Encouraged self-care with in patients

capacity.
R: To enhanced feeling of self-worth.
4. Took time for listening to the client.
R: To discover barriers to participation in
regimen.
5. Provided privacy during personal care
activities.
R: To assist in dealing with situation.
6. Materials needed by client should be
placed near her.
R: Reduces need for movement.
7. Encouraged SO to accompany patient all
the time
R: To prevent untoward accidents
1. Provided assistance only when necessary.
R: Prevents dependence
2. Provided positive feedbacks for efforts &
accomplishments.
R: Encourages patient to continue endeavors.
Independent Interventions:
1. Assessed weight, age, body build,
strength, activity/ rest level
R: To provide comparative baseline
2. Determined the ability to chew, swallow
and taste
R: Factors that can affect ingestion and/or
digestion of nutrients.
3. Provided oral hygiene
R: a clean mouth can enhance the taste of food
4. Encouraged adequate nutrition
R: to meet individualized need
5. Emphasized importance of well-balanced,
nutritious diet
R: to promote wellness

Actual Outcome:
After 8 hours of nursing care:
May 8-9, 2007
Patient was not able to demonstrate techniques
to meet self- care needs and was not able to
perform self- care activities within level of
ability independently. She still needed the
assistance to do self- care activities like
perineal care and toileting.
May 10, 2007
Patient was able to demonstrate techniques to
meet self-care needs with minimal assistance.
She was slowly left to perform self-care
activities such as bathing and toileting on her
own.

Desired Outcome:
Within 8 hours of nursing intervention, the
patient will be able to demonstrate behavior
towards progressive weight loss to correct food
choices
Actual outcome:
After 8 hours of nursing intervention, the
patient was able to:
Show signs of understanding health
teachings given
Verbalized understanding of eating
the right foods for better management
kasabot ko na di jud makatabang

6.

Provided information on the proper diet

for disease management such low salt low
fat diet
R: for setting proper guidelines on proper diet
May 9, 2007
11.Sleep deprivation related to acute pain as
manifested by drowsiness, irritability, facial
grimacing and a tired look on the face and
verbalization of sige ko mata-mata sa
kasakit.
SB:
pain and sleep correlate on so many levels.
Chronic pain sufferers experience less deep
sleep, more Arousals and disturbances and less
effective sleep. A poor quality of sleep mixed
with waking pain created a vicious cycle that
affects mood, behavior, energy and safety.
(www.emedicine.com)

May 9, 2007
12.Risk for constipation r/t effects of general
anesthesia secondary to surgery
Cues: px wasnt able to defecate since
childbirth
SB: Constipation is common after surgery and
can range from a minor irritation to a serious
complication. Decrease mobility, decrease oral

Independent Interventions:
1. Encouraged to do deep breathing exercises
to alleviate pain
R: Deep breathing promotes relaxation and
diverts attention.
2. Suggested abstaining from daytime naps.
R: Daytime naps impair ability to sleep at
night.
3. Restrict intake of caffeine-containing
foods or fluids.
R: Caffeine may delay patients falling asleep
and interfere with rapid eye movement sleep,
resulting in patient not feeling well rested.
4. Support continuation of usual bedtime
rituals.
R: Promotes relaxation and readiness for sleep.
5. Recommended quiet activities such as
reading/listening to soothing music
R: to reduce stimulation to promote relaxation.

Independent Interventions:
1. Monitored bowel sounds
R:to note any unusualities
2. Encouraged to eat a diet high in
roughage and emphasized foods such
as fresh fruits and vegetables
R: dietary supplement of fiber can
improve consistency of stool and facilitate

ang mga tambok ug mantikaon na

pagkaon para nako ug maayo ka nako
ang mga pagkaon na daghan ug Vit.
C ug mga proteins para makatabang
sa pag-ayo sa tahi
Patients weight was still 73.5 Kg

Desired Outcome:
Within 8 hours of student nurse-client contact
the patient will be able to afford rest and sleep
and will be able to report improved sense of
energy.
Actual Outcome:
May 9, 2007: px still complained of being tired
by verbalization of kapoy pa kihapon oi
May 10, 2007: px seemed well rested and
verbalized arang2x na dae, di najud ayu sakit,
mada2x na, nakapahuway nako gamay

Desired Outcome:
Within 8 hours of nursing intervention, patient
will be able to defecate once a day
Actual Outcome:
May 9, 2007: px wasnt able to defecate

intake, and opioid analgesics contribute to

difficulty having a bowel movement.
(Medical-Surgical Nursing, (Smeltzer and
Bare. Brunner and Suddarth Vol. 1 10th ed., p.
453

May 9, 2007
13.Noncompliance of regular prenatal
check-ups and prentala meds related to
sedentary lifestyle and financial constrains as
manifested by pre-natal chek-ups only during
the 3rd, 4th, 7th month of pregnancy and failure
to take ferrous sulfate meds due to foul smell.
Scientific Basis:
Compliance with a therapeutic
program may be more difficult for the regimen
can be difficult to remember and the expense
can be a problem. (Smeltzer and Bare. Medical
Surgical Nursing, 10th ed. p 864)

passage through the colon

3. Encouraged intake of fluids
R: adequate intake of fluids is necessary
to prevent hard, dry stools
4. Encouraged ambulation as soon as
possible
R: to promote peristalsis
5. Encouraged activity/exercise w/in
limits of individual ability
R: to promote peristalsis.

Independent Interventions:
1. Assessed availability/use of support
systems and resources

to
determine
reason
for
alteration/disregard of therapeutic regimen
2. Developed therapeutic nurse-client
relationship
to assist client/SO to develop strategies
for dealing effectively with the situation
3. Explained to the client the importance
of medication regimen
to promote understanding
4. Have
client
paraphrase
instruction/information heard
helps validate clients understand and
reveals misconceptions
5. Acknowledged
the
clients
choice/point of view.
to maintain open communication

May 10, 2007: px was able to defecate once

that day with brown formed stool

Desired Outcome:
Within the course of nursing interventions, the
client will adhere to medication regiment and
verbalize accurate knowledge of condition and
understanding of treatment regimen.
Actual Outcome:
After 2 hours of nurse- client interaction, client
verbalized diay noh ,kibaw man ko dae na
dapat jud paprenatal pero layo man gud,pero
sunod mag paprenatal najud ko

DISCHARGE PLAN
Discharge order given by Dr. Fe VIllamil on May 12, 2007 at 1:20 pm
H - advise patient to regularly and meticulously perform incision care
- use mild soap and wash cloth to clean incision
- promptly report ulcerations, redness, cracking of the skin
>advised to follow dietary guidelines
>advised to correctly take medications
>encouraged to maintain a daily exercise which is approved by physician
>encourage family members to aid patient in chores
> instruct patient to do activities in moderation
- reminded about the importance of keeping follow-up appointments on May 16, 2007 with the attending physician.
A- Instructed pt. to report:
>Searing pain/cutting pain which may be indicative of evisceration.
>to physician or caregiver at once for any signs and symptoms of infections like:
*fever *pain *inflammation
*redness/rash *elevation of body temperature

*discharges noted at wound

S- Advise pt:
>to continue praying and have a strong faith in the Lord God
>to continue in attending mass with the family
>encouraged to have anointing of the sick
>restrain/limit activity if wound is not completely healed
>advised SO to never leave patient alone
>advised SO to assist patient in activities
>practice stress management by applying stress management, scheduling of activities, siesta, sounds & song, smile, sensation technique, speak to me and
spirituality
M- Instructed pt:
>To take discharged medications such as:
*cefuroxime (Sharox) 500mg/cap 1 capsule every 12 hours by mouth for four days
*nifedepine (Adalat GHS) 20 mg/tab 1 tablet twice a day by mouth

I-

Instructed pt:
>to inspect the surgical site for:
*redness
*discoloration
*warmth
*swelling
*unusual tenderness
>provide daily wound care and subsequent dressing change to provide a proper environment for wound healing.

N- Advised to:
>eat a balanced diet
>eat foods rich in protein such as meat, poultry and fish for faster wound healing
>eat foods rich in Vit. K such as beans, legumes, green leafy vegetables for faster wound healing
>Vit. A and rich in Iron foods like malunggay, petchay liver & fish for faster wound healing
>eat foods rich in vit. C such as oranges, guavas, lemon to increase resistance against infection
>avoid eating greasy, fatty and salty foods
>take in small frequent feedings
E- Encouraged to:
>ambulate when wound is heated to reduce the incidence of post-operative complications such as:
*atelectasis
*gastrointestinal discomfort
>maintain a clean to order environment.
>maintain a pleasant environment
>maintain a safe and therapeutic environment for recuperation
>maintain a quiet and peaceful environment
>remove all objects that may impede the hallway

SUMMARY OF SIGNIFICANT FINDINGS

May 8, 2007
She is a known asthmatic since childhood
She doesnt go to annual check-ups and claims that she only visits the health center when the need arises
Patient has poor compliance with her preanatal check-ups
patient was prescribed with Ferrous Sulfate but she wouldnt take it since it she claimed it was foul smelling
During pregnancy, she claimed that there is no change in urination but she had difficulty in moving her bowel
HFD includes asthma on paternal side and HPN on maternal side

non-pitting edema
pale nail beds
pale lips
with c/s incision and dressing

May 9, 2007
pale nail beds
pale palpebral conjunctiva
pale lips
non-pitting edema in lower extremities and on both hands
May 10, 2007
pale palpebral conjunctiva
pale nailbeds
fundus at 2 fingerbreadths below umbilicus, with c/s incision and dressing
non-pitting edema