I.

INTRODUCTION

Cesarean delivery, also known as cesarean section, is a major abdominal surgery involving 2 incisions (cuts): One is an incision through the abdominal wall and the second is an incision involving the uterus to deliver the baby. While at times absolutely necessary, especially in emergencies or for the safety of the mother or the baby, cesarean childbirth is not a procedure to be undertaken lightly by the doctor or the expectant mother. During the surgical delivery, if not an emergency, the woman may be awake but numb from the chest to the legs. Legend has it that the Roman leader Julius Caesar was delivered by this operation and the procedure was named after him. However, Caesar's mother lived many years after his birth, and at that time, the operation most likely caused death in the mother. In addition, no mention is made of this procedure prior to the Middle Ages; therefore, Caesars contribution to the naming of this operation is practically impossible. The most likely origin for the term is in reference to a Roman law created in the 8th century BC that ordered the procedure in the last few weeks of a pregnancy in dying women to save the child's life. (eMedicine Health, 2011) In 2007, the cesarean rate was the highest ever reported in the United States. There were 1.4 million cesarean births in 2007, representing approximately onethird of all births in the United States. Following a decline in the early 1990s, the cesarean rate increased by 53% from 1996 to 2007, from 21% to an all-time high of 32%The cesarean rate rose by 53% from 1996 to 2007, reaching 32%, the

ii highest rate ever reported in the United States. From 1996 to 2007, the cesarean rate increased for mothers in all age and racial and Hispanic origin groups. The pace of the increase accelerated from 2000 to 2007.Cesarean rates also increased for infants at all gestational ages; from 1996 to 2006 preterm infants had the highest rates. Cesarean rates increased for births to mothers in all U.S. states, and by more than 70% in six states from 1996 to 2007.In 2007, nearly one-third (32%) of all births were cesarean deliveries. In 2007, approximately 1.4 million women had a cesarean birth, representing 32% of all births, the highest rate ever recorded in the United States and higher than rates in most other industrialized countries. (Fay Menacker, Dr. P.H.,et al.2010) In 2008, 27.2% of all births were a cesarean delivery, associated with an increased rate of cesarean delivery among Filipino mothers. There has been a gradual increase in cesarean births over the past 30 years. In November of 2005, the Centers for Disease Control and Prevention (CDC) reported the national cesarean birth rate was the highest ever at 29.1%, which is over a quarter of all deliveries. This means that over 1 in 4 women will experience a cesarean birth. The 2008 Philippine Health Statistics report of the DOH lists of cesarean delivery ranged from 25.9% in Ilocos region to 54.6% in Western Mindanao region recourse to caesarean sections. (LEADs Technical Strategy on Maternal and Child Health 2008) Data shows that during the year 2009 there were 332 deliveries at Tagum City. 58.36% of the total number of deliveries is normal spontaneous vaginal delivery

iii and the remaining percentage was of cesarean sections.(Tagum City Health Office, 2009) In Tagum Doctors Hospital there are 165 cesarean deliveries in the year 2010.(Tagum Doctors Hospital Inc.2010) The Group has chosen this Case for us to improve our skills and knowledge pertaining on caring for patients with High Risk Postpartum and to be able to apply our learnings during lectures and demonstrations related to the case chosen.

A. OBJECTIVES a. General objectives This case study is designed to identify health problems or potential threats that could arise in our patient. As student nurses, it is expected from us that we will apply what we have learned from our class lectures in the actual settings.

b. Specific Objectives The specific objectives are enumerated as follows; to establish rapport to gain trust and cooperation. to gather a complete personal data and pertinent information that will serve as our main source of reliable facts and baseline data for completion of our study; to understand the underlying causes of the patients health condition;

iv to trace the pathophysiology of Hypertonic Uterine Dysfunction resulting to Cesarean Section; to be able to learn its medications and treatments; to implement nursing interventions, having the skills of an efficient and effective nurse base on assessment done; and to formulate an effective discharge plan for the continuity of care.

5 II. ASSESSMENT

A. Biographical Data Name Age Sex Civil Status Nationality Birthday Birth Place Occupation Address : Patient X : 20 : Female : Single : Filipino : March 1, 1990 : Davao City : None : Prk.3,Mainit, Nabunturan Compostela Valley Prov Religion Name of Partner Name of Father Educational Attainment Name of Mother Educational Attainment Type of Community Ordinal Rank : Roman Catholic : Mr. X : Mr. A : 2nd yr. college : Mrs. B : High School Graduate : Rural : eldest among the siblings

6 B. Chief Complaint The patient is 20 years old with complaint of pain related to surgical incision during the assessment. C. Obstetric History Patient X is immunized with Diphtheria, Poliomyelitis, and Tetanus Toxoid, Hepa B at Prk. Mainit Health Center. The patient verbalized that she visits at the center every month for check up and to ask for Ferrous Sulfate. At her 7 th month of pregnancy, she had an ultrasound at Tagum Doctors Hospital with Dr. Duterte as her obstetrician. She had her check up every 2 weeks as instructed by her OB. D. Past Medical History Illness Mumps Chickenpox Age 7 years old 14 years old Duration 3 days 1 week Treatment Aniel Isolation and took medicine (Acyclovir) Dengue 10 years old 1 week Admitted to Flores Sr. Clinic for 1 week Gingivitis 20 years old 3 days Confined nabunturan Doctors Hospital Table 1.1 to

7 E. Personal and family History Patient X was raised up in a Christian belief. She came from Nabunturan Compostela Valley Prov. She gave birth to her first baby via cesarian section due to hypertonic uterine contraction. Her grandmother in the maternal side, 72 y/o, diabetic, gave birth to its three offspring via cesarian section due to cephalopelvic disproportion. Her grandfather, died at the age of 57 due to heart disease. Patients mother, 43 y/o, plain housewife, a mother of four, is the youngest among the three siblings. She gave birth to her four offspring via NSVD. Patient Xs grandmother at the paternal side gave birth to her 5 children via NSVD. She is well and alive at the age of 71. Her grandfather died at the age of 65 due to lung cancer. Patients father, 47 y/o, third among the 5 siblings is working as a tricycle driver for more than 20 years and working sideline at APEX Mining Co., She had a past history of kidney disease at the age of 25. One of their sons is diagnosed with Kawasaki Disease at 8 months old and treated immediately.

F. Personal/ Social History Patient X was born on March 1, 1990 at Davao City. She is the eldest among the four siblings of Mr. and Mrs. X. She studied at Davao City taking up vocational course. After she graduated, she met his partner and decided to build their own family. She got pregnant and delivered their first baby via C-section last December 16, 2010.

8 Her partner, 23 y/o, working as a miner at APEX Mining Corporation has a monthly income of 40,000-60,000php per month. According to Patient X, they are planning to get married next year.

G. Genogram

Figure 1.1

10 G. Developmental History Theorist / Theory Erik Erikson Developmental Normal Findings Stages / Task Stage 1 INFANCY Psychosocial (0 to 1 years Theory old) A sense of trust requires a feeling of physical comfort and a minimal amount of fear Trust vs. Mistrust and apprehension about the future. Trust in infancy sets the stage for a lifelong expectation that the world will be a good and pleasant place to live. (Demand Media, 2010) Actual Findings She grew up with her parents. Her parents gave her infants basic needs like food In this stage, the infants primary source of pleasure is sucking and the area of gratification is Justification

and comfort. the mouth She also - A baby is

feels love by very his parents. -TRUSTdependent and can do little for itself. If babies needs properly fulfilled can move onto the next stage but

11 Theorist / Theory Developmental Normal Findings Stages / Task Actual Findings if not fulfilled baby will be mistrustful or over-fulfilled baby will find hard to cope with a world that doesnt meet all his/her demands. Stage 2 Early childhood (18 mos.-3 yrs.) After gaining trust in their caregivers, infants begin to discover that their behavior is their own. They Autonomy vs. shame and doubt start to assert their sense of independence, She gained The second Justification

more control stage of over food choices, toy Eriksons theory of

preferences, psychosocial and clothings selection. She learnt to say NO. development takes place during early childhood and is focused on

12 Theorist / Theory Developmental Normal Findings Stages / Task or autonomy. They realize their will. If infants are restrained too much or punished too harshly, they are likely to develop a sense of shame and doubt. (Demand Media, 2010) Stage 3 Play age (3-5 yrs.) Initiative vs. guilt Initiative versus guilt is Eriksons third stage of development, occurring during the preschool years. As preschool She made up stories with barbie doll, toy During the preschool years, children begin Actual Findings children developing a greater sense of personal control. Justification

phones, and to assert their play bahay- power and bahayan with her control over the world

13 Theorist / Theory Developmental Normal Findings Stages / Task children encounter a widening social world, they are challenged more than when they were infants. Active, purposeful behavior is needed to cope with these challenges. Children are asked to assume responsibility for their bodies, their behavior, their toys, and their pets. Actual Findings friends. through directing play and other social interaction. Justification

14 Theorist / Theory Developmental Normal Findings Stages / Task Developing a sense of responsibility increases initiative. Uncomfortable guilt feelings may arise, though, if the child is irresponsible and is made to feel too anxious. (Demand Media, 2010) Stage 4 School age (612 yrs.) Itinvolves the shift from whimsical play to a desire for Industry vs. Inferiority achievement and completion. She was encouraged by her parents and teachers to join During this stage, often called the Latency, we are capable of learning, Actual Findings Justification

15 Theorist / Theory Developmental Normal Findings Stages / Task A child learns that he receives praise and recognition for doing well in school and Actual Findings curricular activities such as in literacy contest and quiz bee. creating and accomplishing numerous new skills and knowledge, thus Justification

completing tasks Her parents, developing a and also realizes he can fail at these tasks as well. (Demand Media, 2010) teachers, and peers gave her full support. sense of industry. This is also a very social stage of development and if we experience unresolved feelings of inadequacy and inferiority among our

16 Theorist / Theory Developmental Normal Findings Stages / Task Actual Findings peers, we can have serious problems in terms of competence and selfesteem. Up to this stage, according to Erikson, development mostly depends upon what is done to us. From here on out, development depends primarily upon what we do. Stage 5 The adolescent Our patient Adolescence Justification

17 Theorist / Theory Developmental Normal Findings Stages / Task Adolescence (12-18 yrs.old) is newly concerned with Actual Findings found a mutually is a stage at which we are neither a child nor an adult, Justification

how they appear satisfying Identity vs. Confusion to others. Ego identity is the accrued confidence that the inner sameness and continuity prepared in the past are matched by the sameness and continuity of ones meaning for others, wherin adolescents begin to seek their true relationship

and built her life is own family with her partner. definitely getting more complex as we attempt to find our own identity, struggle with social interactions, and grapple with moral issues.

18 Theorist / Theory Developmental Normal Findings Stages / Task identities and a sense of self. The central question of this stage is of course, Who am I?. (Demand Media, 2010) Stage 6 Young adulthood (1835 yrs. Old) which individuals experience during the early adulthood years. Intimacy and Solidarity vs. Isolation At this time, individuals face the developmental task of forming intimate relationships This stage covers the period of early adulthood when people are exploring personal relationships. Actual Findings Justification

19 Theorist / Theory Developmental Normal Findings Stages / Task with others. (Demand Media, 2010) Actual Findings Justification

Table 1.2

20 Theorist / Theory Sigmund Freud Psychosexu al Theory Developmental Stages / Task Oral stage Birth- 1 yr. old Normal Findings During the oral stage, the infant's primary source of interaction occurs through the mouth, so the rooting and sucking reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral The mouth is the primary erogenous zone through which pleasure is derived. The major conflict issue during this stage is the weaning process, during which the child is forced to become less dependent upon Actual Findings A baby is very dependent and can do little for herself. If babys needs properly fulfilled, he/she can move onto the next stage. But if not fulfilled, baby will be mistrustful or over-fulfilled baby will find it hard to cope with a world that Justification

21 Theorist / Theory Developmental Stages / Task Normal Findings stimulation through gratifying activities such as tasting and sucking. Because the infant is entirely dependent upon caretakers (who are responsible for feeding the child), the infant also develops a sense of trust and comfort Actual Findings caretakers. A fixation at this stage can result in problems with dependency or aggression. doesnt meet all of his/her demands. Justification

22 Theorist / Theory Developmental Stages / Task Normal Findings through this oral stimulation. (Kendra Cherry, 2011) Actual Findings Justification

Anal Stage TODDLER 2-3 YERS OLD

During the anal stage, Freud believed that the primary focus of the libido was on controlling bladder and bowel movements. The major

Toddlers attention focused

Toddlers should on control a

the anus and bowel thats the sexual why they

pleasure the elimination.

is should have toilet training to urges control and

-she

learns behaviors.

to eat by her -Caregivers own, washes should hands encourage

conflict at this her stage is toilet

and dresses self-sufficient

23 Theorist / Theory Developmental Stages / Task Normal Findings training--the child has to learn to control his or her bodily needs. Developing this control leads to a sense of accomplishm ent and independenc e. (Kendra Cherry, 2011) Actual Findings herself. behavior, Justification

-In this stage toddlers she started develop sense a of

to play toy. -

autonomy- a of

AUTONOMY sense -

being able to handle many problems on their But caregivers demand much too too own. if

soon, refuse to let children perform tasks which of they

are capable, or ridicule

24 Theorist / Theory Developmental Stages / Task Normal Findings Actual Findings early attempts selfsufficiency; children may instead develop shame and at Justification

doubt about their ability to handle problems. Phallic Stage PRESCHOOLE R During the phallic stage, the primary Childrens focused in genital region and become particularly interested in playing with their genitals Morality and sexuality identification and out figuring what it

4 TO 6 YEARS focus of the OLD libido is on the genitals. Children also discover the differences

means to be girl/boy. According to Freud,

25 Theorist / Theory Developmental Stages / Task Normal Findings between males and females. Freud also believed that boys begin to view their fathers as a rival for the mothers affections. The Oedipus complex describes these feelings of wanting to possess the mother and the desire to replace the She to count numbers, and simple chores sweeping the floor. INITIATIVEActual Findings at this stage. children have sexual began feelings for Justification

speak, the opposite sexed parent at this stage feel

doing and some like hostility same-sex

in

parent. Boys experience castration and suffer envy. -Parents and preschool teachers encourage and support girls penis

26 Theorist / Theory Developmental Stages / Task Normal Findings father. However, the child also fears that he will be punished by the father for these feelings, a fear Freud termed castration anxiety. The term Electra complex has been used to describe a similar set of feelings experienced by young Actual Findings children's efforts, while also helping them make realistic and appropriate choices, children develop initiativeindependenc e in planning and undertaking activities. But if, instead, adults discourage the pursuit of independent activities or Justification

27 Theorist / Theory Developmental Stages / Task Normal Findings girls. Freud, however, believed that girls instead experience penis envy. (Kendra Cherry, 2011) Actual Findings dismiss them as silly and bothersome, children develop guilt about their needs and desires. Justification

Table 1.3

28 Theorist / Theory Jean Piaget Stages / Task Sensori motor Cognitive Development (Birth 2 Recognises self yrs. old) as agent of action and her and begins to act environment intentionally: e.g. through pulls a string to motor and set mobile in reflex motion or shakes actions. a rattle to make a Thought noise. Achieves derives from object sensation permanence: and realises that movement. things continue to The child exist even when learns that no longer present she is to the separate sense.(Atherton J from her S, 2011)) environment given present at a immediately are not people that objects or awareness of infant has no symbols. An language, or images, using environment the representing in competence about herself little Differentiates self from objects Normal Findings Actual Findings During this stage, the child learns During this stage, a child has relatively Justification

29 Theorist / Theory Stages / Task Normal Findings Actual Findings and that aspects of her environment moment. Object permanence is the Justification

-- her parents awareness or favorite toy that objects -- continue to exist even though they may be outside the reach of her senses. and people continue to exist even if they are out of sight. In infants, when a person hides, the infant has no knowledge that they are just out of sight Pre Learns to use She is now better able to Children develop an

operational language and to

30 Theorist / Theory Stages / Task (2-7 yrs. old) represent objects by images and words Normal Findings Actual Findings think about things and events that aren't Thinking is still immediately egocentric: has present. difficulty taking Oriented to the viewpoint of the present, others. Classifies the child has objects by a difficulty single feature: conceptualizi e.g. groups ng time. Her together all the thinking is red blocks influenced by regardless of fantasy -- the shape or all the way she'd square blocks like things to regardless of be -- and she color.(Atherton J assumes that S, 2011) others see situations this stage is viewed The world at thoughts. egocentric Piaget called by what characterized al stage are preoperation the Children in feelings. events, and people, describe them to internal representatio n of the world that allows Justification

31 Theorist / Theory Stages / Task Normal Findings Actual Findings from her viewpoint. She takes in information and then changes it in entirely from the child's own perspective. Thus a child's explanation Justification

her mind to fit to an adult her ideas. can be uninformative . Children who have not passed this stage do not know that the amount, volume or length of an object does not change length when the shape of

32 Theorist / Theory Stages / Task Normal Findings Actual Findings the configuration is changed. Concrete Can think logically The child develops an Children in the concrete Justification

operational about objects and (7 11 yrs. events. Classifies old) objects according to several features and can order them in series along a single dimension such as size. (Atherton J S , 2011)

ability to think operational abstractly and to make rational judgments about concrete or observable phenomena, which in the past he needed to manipulate physically to understand. stage have a better understandin g of time and space. Children at this stage have limits to their abstract thinking, according to Piaget.

Formal

Can think logically She is no

This stage

33 Theorist / Theory Stages / Task operational about abstract (11 yrs and propositions and up) test hypotheses systematically Normal Findings Actual Findings longer requires concrete objects to produces a new kind of thinking that is abstract, Justification

make rational formal, and Becomes judgments. concerned with At her point, the hypothetical, she is the future, and capable of ideological hypothetical problems.(Atherto and n J S, 2011) deductive reasoning. child at this stage can think hypothetically and use logic to solve problems. It is thought that not all individuals observed. A can be to events that no longer tied Thinking is logical.

34 Theorist / Theory Stages / Task Normal Findings Actual Findings reach this level of thinking. Justification

Table 1.4

35 H. Physical Assessment General Survey Upon assessment the patient is lying on bed, weak, pale, and has poor grooming; afraid to move the lower extremities and guarding position noted; responsive when asked kumusta imong gibati maam?, and the patient responded okay-okay naman and is oriented to people, place, and time.

Systems Integumentary (HEENT) Head Inspection

Normal Findings

Actual Findings

Justification head is in with of

-Normocephalic and -Patient's symmetric features, symmetrical facial was

head -The

symmetrical shape and

normocephalic and and

symmetric, the

absence

contour rounded. Softening

symmetrical facial any Facial Normal

problems.

and features. grimace flushed noted. noted. Dry

thinning of the hair.

and implication. face (Patricia lips Dillon,2007) is of in the M.

There

presence Palpation dandruff -absence of lesions, scalp. masses,

-With the absence lesions,

tenderness, bumps, of

36 and dandruffs. masses, bumps,

Relatively soft with and no unexpected She

tenderness. also had facial with

contours or bulges. symmetric In her TMJ it should movements be

smooth, hair in eyebrows

symmetrical motion, evenly distributed with no pain, and skin intact in the eyebrows. ears are

crepitus, or clicking. Ears Inspection -Absence

of -Ears are found in -Both

discharges and any line with the outer normally hearing complications canthus of the functioning. M.

just eye. No hearing (Patricia

like ear ringing and problems detected Dillon,2007) impaired hearing in the both ears. of

ability. Ears should Absence be in line with the discharges. Palpation

outer canthus of the -Without presence -Both eye. -Without of presence swelling

ears

are

masses normally and functioning. No It means normal was indication. M.

of discharges and nodules. the color of the ear tenderness is consistent

with felt by the patient (Patricia

37 the skin color. -Without during palpation. Dillon,2007)

the The ears of the

presence of nodules client are soft and or masses, pliable.

structures should be non-tender with no swelling. It should be soft and pliable, non-tender. Eyes Inspection -Note for clarity and - Sclera is white, -Patient parallel alignment, with shiny cornea, visual has acuity with a of

eyes should clear pupil is round and 20/20 and parallel note bright,

well-

in reactive to light. conditioned eyes. corrective (Patricia M.

alignment, No for

the lenses were used. Dillon,2007)

presence of contact Without presence lenses. The of crusting or

eyelashes have no infestation in the presence of crusting eyelashes. or infestation; note hair of The the

the hair distribution eyelashes is well of the eyelashes distributed. are

present and curving Eyelids

38 outward. Eyelids contact and

note for edema, and without presence lesions, should with in the eyelids of edema. contact The bulbar and

eyeball. palpebral is

The eyeball should conjunctiva have no protrusion clear, without lesions. The blood

minimal vessels,

lacrimal gland and and the sclera is nasolacrimal should nodules, and have duct white and visible. no

lesions, masses,

without presence of swelling, or redness, In

drainage.

conjunctiva (palpebral) it should be glistening, peach minimal vessels smooth, pinkishwith blood visible,

color,

39 bulbar over should conjunctiva the be globes clear,

with few underlying blood vessels and white sclera visible. The pupil is equal in size and has

reaction to light both the eyes. No

impaired vision and the outer canthus of the Palpation eyes were

aligned to the upper part of the ears. Redness swelling absent. must and be -The gland lacrimal and

- The globe of the nasolacrimal duct eye is firm and non- without presence tender. glands nasolacrimal Lacrimal of lesions, masses and and swelling. The ducts bulbar and

40 should palpable, tearing. non palpebral no conjunctiva without presence of masses and

nodules. Nose Inspection -No nasal flaring, no -No flaring and no -The patient has drainage, it should discharge during no difficulty on

be pink in color (it the assessment. depend on the

breathing. (Patricia Dillon,2007) M.

ethnicity) should be intact lesions perforations, with no or no

crusting or polyps, septum midline. No Palpation impaired -Then there is no of located

smelling ability. -Note and patency. Cartilaginous for note

nostrils feeling

for tenderness felt by the patient when we palpate her

portions is should nose.

41 be slightly mobile, no masses, should and be

nares patent. Neck Inspection -Inspect

neck,

it -Upon

the No problems were her found in her neck erect, upon the inspection of palpation. M. the and

should be erect, no inspection lumps, bulges, or neck is

masses. Thyroid not without visible, no masses, presence swelling,

or lumps, bulges, or (Patricia Her Dillon,2007) is not

hypertrophy in mid masses. to lower half of thyroid

anterior neck. Palpation

visible no masses, swelling, or

-cervical nodes are no non-palpable.

any hypertrophy. the there

Trachea is midline -Upon and mobile. Thyroid palpation,

is non-palpable, non are no lumps or tender. bumps. Trachea is midline thyroid palpable. Nails -Pink nail bed, with -As observed the -Changes in nail is and not

42 Inspection glossy appearance, patient's nail bed texture are due to absence hemorrhage, discoloration of color was pinkish. the During of assessment of nail influence of

hormonal changes the during pregnancy. the Normal indication. is (Patricia M.

surrounding tissues texture and clubbing, angle patient's

of nail attachment rough. Her nails Dillon,2007) 160 degrees, nails have convex. Palpation -The firm, nail and curvature convex with

should capillary refill time the of less than 1

longitudinal. Skin Inspection

second. of -During pregnancy and the occurrence of acne skin darkening

Uniform skin color -Presence with slightly darker lesions exposed areas. excessive

are noted on the was normal, this face and upper change is due to the increased of an

extremities.

Skin darkening Is secretion observed in the melanotropin neck underarms. Palpation -skin is warm, & anterior

pituitary

hormone. (Patricia M. Dillon,2007)

43 exposed skin Patient -As palpated, skin elevated has

usually not as soft as skin, the

exposed is warm to touch temperature which elasticity with a temp. of indicates a

decreases with age, 38.5C. Pain and possible sign exposed areas may tenderness have less turgor. noted. not of infection(Patricia M. Dillon,2007) Respiratory Inspection -Chest expansion -No lesions and -Patients have

should be full and scar symmetrical, skin and

was stable respiratory

chest observed on the condition with no hair patients (men) Full be expansion chest. problems chest identified. with (Patricia M.

distribution should consistent patients

with shallow breathing Dillon,2007) gender, patterns and vocal

skin intact with no symmetric scars. straight lateral

Spine fremitus with no without presence curves of

or secretions found. Respiratory rate of the patient is 26 cpm.

deformities.

44 Palpation -Trachea should be -The in midline, no the trachea patient of Patients have

in stable respiratory no condition with no

deformities crepitus, tender,

or midline,

non- deformities noted, problems chest chest excursion identified. (Patricia Dillon,2007) M.

excursion should be symmetrical symmetrical without without lag. lag. (Tactile

Fremitus) should be equal diminished thorax. Percussion -Without of presence -without presence tenderness of Patients have and mid

tenderness stable respiratory

during percussion, it during percussion, condition with no should be without without dullness without dullness problems

and noted and hyper identified. hyper resonance. (Patricia Dillon,2007) -Lungs are clear. Patients have M.

resonance noted. Auscultation -Without

adventitious sound Adventitious

stable respiratory

noted, lungs should sound and cough condition with no be clear to noted during the problems

45 auscultation. No assessment. identified. (Patricia Dillon,2007) maximal -The PMI at was -The the heart patients and pulse M.

crackles, wheezes, or rubs. Cardiovascular system Palpation -Point

impulse is found to detected

be located at the 5thintercostals 5thintercostals

rate was in order the normal which

space at the left with

space at the left midclavicular line. range midclavicular line. (PMI may

Heart rate was 70 means that there be beats per minute. were no

displaced

upward Pulse rate at 98 complications when it comes to her cardiovascular Heart sound (S1 system. the and S2) without (Patricia M.

and laterally in the bpm. latter Auscultation stages of

pregnancy.) Without

presence of extra the presence of Dillon,2007) sounds auscultation. aortic murmurs. upon extra sound, and No without the

presence of aortic Blood

( systolic murmurs murmurs. caused increased volume )

by pressure 120/70. blood

46 Breast Inspection -Increased in size, - No dimpling and and increased sensitivity. latter nodularity, lesions. Tenderness And assessed. Areola and

nipple are darker is than Dark tissue. the breast Become

colostrum areola and nipple even darker during pregnancy. (Patricia M. Dillon, 2007)

secretion in the third noted. trimester. Hyperpigmentation of nipples and

areolar tissue. No dimpling retraction, or no

increase in venous pattern unless

patient is pregnant. Then symmetrical

increased is normal. Nipples have no or

discharges lesions. Palpation -There should

be - Non-tender and -Colostrum in

is the of

absence of masses engorged. Masses produced and lesions. and lesions not late

stage

47 Tenderness should noted. also be absent and Spontaneous also Breast dimpling. discharges should be colostrum noted. pregnancy till the 4 days after

of pregnancy. It is a deep yellow fluid. Spontaneous discharge normal pregnancy lactation (Patricia Dillon,2007) M. is during and

soft and non-tender.

Gastrointestinal system Inspection

- Skin should be -Skin color is the Presence of striae intact, with no same throughout gravidarum abdomen. pregnancy after is

lesions, or masses. the Striae present. If

maybe Striae gravidarum normal because it new, noted. Incision: doesn't disappear directly after birth. of

should be pink; if (REEDA) old,

white/silver. Post CS (vertical giving inverted incision), clean, Presence

Umbilicus

and in midline.

dry, redness,edema, ecchymosis an

dressing on, no and redness, edema,

no indicates no infection.

48 ecchymosis, drainage, approximation. Auscultation -An average bowel Positive bowel -Patient's bowel were to be in no (Patricia no Dillon,2007) M.

sound is found to be sound at a rate of sounds present at a rate of 15 clicks per found

5 to 30 clicks per minute. minute. Without present.

Flatus normal range Last (Nursing Health 2nd

presence of other bowel movement Assessment, extra sound. 1/16/2011 soft stool.

with edition by Patricia M. Dillon) Page ( 836- 839 )

Palpation

No

abdominal The

patients Normal indication. M.

distention. average

In abdomen is firm (Patricia adult, and rounded. Dillon,2007)

contour should be either flat, round, or scaphoid. Genitourinary system Inspection/ Palpation Neurologic -Alert -person should void Patient has voided Patient's every hour at 30 cc 30-50cc per hr. measured foley catheter. per hr. was bladder

functioning

via normally.(Patricia M. Dillon,2007)

and -The patient was - Her memory and

49 Inspection conscious, clear appropriate during conversations. uses conscious and awake. and thinking skills were Her

Oriented intact.

words to people, time, neurologist status and place. Was was able to think functioning; still she

comprehensively and

was able to give and

use correct

appropriate words appropriate during conversations. answer to the

given questions. (Patricia Dillon,2007) M.

Reproductive system Inspection Vaginal discharge

Lochia

Rubra-

a Lochia in

rubra Lochia with a foula smell or a greentinge may indicate not infection. (Patricia M. Dillon, 2007) -Normal findings.

red, distinctly blood- noted

tinged vaginal flow moderate flow. that follows delivery. Foul It lasts from two to noted. four days after smell

Palpation/ Uterus

delivery. -Size

varies -Uterus is firm and Boggy

uterus uterine

according to parity. located above the indicates Pear shaped in umbilicus.

atony which leads to bleeding.

nongravid

woman

50 and more rounded in parous woman. Smooth, mobile, and masses. firm, nontender, without (Patricia Dillon,2007) M.

Table 1.5

51 COURSE IN THE WARD

A. Doctors order

Date 1/14/11

Time 9:50 am

Order May go to room until 4pm Cont. FHT & PO monitoring q FHTB5/min Note & refer for uterine contraction every q 5min Uterine IVF D5LR 1L at 120 cc/hour

11:45 pm 1 am IE

For NST in AM after breakfast

FAT: 148/min

1/15/11

Irregular UC Start oxygen disp D5LR 1L + 10 units oxytocin at 60 gtts/min for 30 min Hook to EFM once with UC every 3-5min Refer EFM result Continuous FHT monitoring q

52 Date Time Order 30min with record please IE 1-2 cm, 20 % 6pm Effued clearAF Start anapialis 1gm IVTT ANST then q 6 IVTT IVF of ff. D5LR 1L @ 120 cc/hr Off oxytocin drip 1/16/11 12:10 pm Dinospostore 500mg/3gl per

6pm

cervical cavad now Continue FHT & POL monitoring q 30min To EFM at 2 pm please refer. 4:34 pm Give nuborn 2.5mg &

promotherine 12.5 mg slow IVTT now 8:15 pm For STAT CS- 2 fetal distress Serve consent & SE Please inform anesthesiologist Please inset PL & attach to urobag

53 Date Time Order Please inform pediatrician

1/16/11

11pm

POST OP ORDER To PAW x2 then to room NPO tempo then gal icuds

shown post op.

Table 1.6

54
B. Nurses Notes

Date/ Shift Time/ D (Data) A (Action) R (Response) 01-13-11 117 03:05 AM D: Admitted this 30 y.o female ambulatory, awake, responsive, NU=38-39 AOG,came in due to labor pain, under the service of Dr.Duterte with orders and carriedout. A: VS taken and recorded; afebrile .Seen and examined by Dr. Leal with orders carried-out.IE done by Dr.Leal 1cm. CBC, BT done. Still for U/A with AC approved with consent signed. DR aware.Dr. Apolinario-pediatrician; aware. R:Needs attended. Transported to labor room per wheel chair. Endorsed to NOD. 311 4:00 PM D: Received from ER per wheel chair a pregnant mother conscious and coherent with AC and consent signed under the service of Dr. Duterte. A: Ushered to room ambulatory.Place on bed on supine position; provided with pillow and blanket.TPR checked and recorded;afebrile.FHT monitored and recorded.

Hooked pt. to LFM. EFM result attached to chart. Monitor

55 progress q labor and uterine contraction. Still for U/A with lab. Request approved attached to chart. 5:10 PM A: urine specimen collected forwarded to lab. 6:00 PM A: Meal served with poor appetite. Encourage pt. to verbalized feelings of discomfort. R: Health teaching imparted on deep breathing exercisees. 9:00 PM A: seen and examined by Dr. Duterte CISC & U/A result received attached to chart, seen by AP. Assisted pt. to IE table, IE done necessary 1-2 cm cervical dilation, continuous monitoring done. R: Encouraged mother to rest at period of times. 9:25 PM D: on IV cannula insertion as ordered by Dr.Duterte, consent served signed by pt. herself.IVF started with # 1D5LR 1L using g.18 IV cannula inserted @ right metacarpal vein @ 120cc/hr with one attempt of insertion. Leaved near pt. & intact. A: Continuous monitoring done. R: Watch &cared for. Watched for any unusualities. 117 D: Received on bed in semi-fowlers position awake,

56 responsive & coherent; not on active labor; with IV of D5LR 1L @120cc/hr infusing well at right metacarpal vein; regulated ell at desired rate,

A: VS taken and recorded; afebrile. I&O monitored & recorded; provided with safe & comfortable environment, needs attended, R: watched &cared for any unusualities not noted, endorsed to next NOD
01-14-11

D: received on bed awake & responsive not in respiratory distress, with IVF # 1 D5LR @ 120cc/hr regulated well. A: VS checked &recorded. EFM done .Breakfast done. Attached to chart; provided safe & quiet environment. R: Health teaching imparted. FHT monitored. 9:45 AM A: seen & examined by AP with orders made & carriedout. Meds prescribed; may go to room until 4PM as ordered. 10 AM A: back to room per wheel chair not in respiratory distress. R: Endorsed to ward OD for continuously care. 10:00 AM D: received from DR

73

57 A: transported via wheel chair & ushered to room 306 & leave pt. comfortably. 311 D: received on bed awake & responsive on diet AT with #2 D5LR @120CC/hr infusing ell; A: VS checked & recorded; transfer to labor room per wheel chair for close monitoring; R: Endorsed to NOD. 4:00PM D: received from ward per wheel chair with IVF # 2 D5LR 1L @120CC/hr infusing well @ right metacarpal vein patent & intact. A: Ushured labor room; on bed; provided with pillow & blanket.TPR checked & recorded; afebrile. Monitor uterine contraction & progress q. FHT monitored & recorded. R: Encourage to verbalize feeling of discomfort. Continuous monitoring done. 6 PM A: meal served with fair appetite. 8:45 PM D: above IVF consumed & followed-up with same IVF D5LR 1L @ 120cc/hr. 10:00 PM D:left on bed, asleep with same IVF going-on & cared for.

58 Endorsed to NOD. 117 D:Received pt. on moderate high back rest not in any form of respiratory distress, awake & responsive with good skin turgor & warm to touch. A: VS checked & recorded. 11:45 PM D: seen and examined by AP.FHT taken & IE done, A: monitor uterine contraction & progress of labor. R: Place on bed comftably, watched closely.VS recorded; afebrile. 6:00 AM A: meds given as ordered, all needs are attended & cared for. R: Endorsed to NOD
01-15-11

D: received on bed with # 3 D5LR 1L @120cc/hr, able to verbalize feeling not in pain. Able to consume meals with good apetite. 9:00 AM D: see and examined by AP with orders made & carriedout. A: IVF D5LR +10 u of oxytocin infusing and regulated. Electron of 6 mggts/microsec. 6 mggts energy after 30 minutes then maintain 42 u gtts.EFM taken and referred to

73

59 AP. R: Attached to chart & endorsed to NOD 311 D: received on bed awake & responsive, laor 1-2 cm cervical dilation with on-going D5LR 1L regulated @ 120cc/hr 2 right metacarpal vein with side drip of oxytocin drip @ 42 gtts/min. D5LR 1L + oxytocin. A: VS, FHT, progress of labor & uterine contraction moitored and recorded. 6:00 PM D: seen and examined by Dr. Duterte with orders made & carried-out. A: Ampicillin 1 gm IVTT q6 as ordered. Oxytocin drip off as ordered place on KSS continuously moitored. R: Left on bed asleep not on respiratory distress. Still ongoing IVF D5LR 1L regulated @ 120cc/hr still patent & intact. Endorsed to next nurse on duty 117 D: received sitting on bed awake, coherent & responsive, not on respiratory distress with IVF D5LR 1L @ 800 CC LEVEL @ 120cc/hr infusing well, not in active labor with 12 cm cervical dilation. A: TPR & FHT taken and recorded, provide with cool and comftable environment. R: Continuously monitored for progress of labor.

60 12:0 MN A: due Ampicillin q given as order advice to lie on left lateral position, watched & cared for. 6:00 AM A: morning care done. Due ampicillin given IVTT as ordered. Left on bed on comftable position. Still on-going IVF still patent & intact. R: Endorsed to next nurse on duty.
01-16-11

D: received on bed in semi-fowlers position, awake with D5LR 1L@ 120cc/hr. Able to go to bathroom without assistance. Able to eat breakfast with good appetite. 8:00 AM A: VS taken & recorded; afebrile .I&O monitored & recorded. FHT taken and recorded. Continuously monitor for progress of labor. 12:00MN A: due meds given and recorded.12:15AM> seen & examined by AP with new orders made & carried-out. Cerveprime inserted by Dr. Duterte intravaginally, IE done with revealing result of 1-2 cm cervical dilatation. FHT, EFM taken & refer to AP. Continuously monitoring on progress of labor. R: Need attended, watched and cared for any unusualities

73

61 not noted. Endorsed to next nurse on duty.

D: received on bed awake and responsive wth IVF PLRN 311 @120 gtts/min. VS checked and recorded. Pain noted within 1-2 min intervals beyond to AP with orders made and carried out. A: Give newborn Nuborn 2.5g+prometherine 15mg via IVTT given at 8:15 pm seen and examined by AP with orders made and carried out. Stat CS, consent proceed AC approved by Dr. Aquino informed by Dr. Nervosa(pedia) informed. Transfer to OR per stretcher and placed to OR table. Attach to monitor. Hooked pulse meter with OR set ranges 99-100% 9:20 pm A: op section started bleeder sponged controlled 9:45pm D: delivered via CS a live baby girl,; A: cord clamped n bet. And cut, suctioned done receive by Dr Nervosa(pedia) 9:50 pm D: placenta delivered bleeders sponged and controlled. Suturing done layer by layer. R: Counting of sponges monitored and needles complete. 11 pm

62 D: operation ended. A: MS placed in the muscle site with binder. Transfer to recovery room to monitor. Attached monitor, hooked pulse operator with doctors order made and carried out with IVF D5LR+15 U oxytocin @ 30 gtts/min. recorded well. 11 pm R: left on recovery room not n respiratory distress. Awake, endorse to NOD.

01-16-11 117

D: receive patient awake and responsive, not in respiratory distress, stat post CS under the service of Dr. Duterte, anesthesiologist Dr. Bagara. With on going IVF of D5LR1L @ 120cc/hr. oxygen at 2-3L via nasal cannula. A: Kept pt.dry and clean, diaper placed; gown changed. VS taken and monitored. With orders made carried out. Left on bed awake. endorsed to NOD D: receive conscious and coherent with general liquid diet

01-17-11
73

with hooked IVF #7 D5LR + 10 u oxytocin, 250cc level @ 120cc/ rate. A: VS checked & recorded. 9:15 visited by Dr. Duterte w/ new orders made and carried out by NOD. 9:50 above IVF consumed and followed-up with #8 D5LR @ 120cc/ rate. 12nn

63 A: VS checked and recorded. 1:30 PM A: Temp rechecked 37C. paracetamol 500mg IVTT given by NOD. 01-18-11 73 D:received on bed conscious, coherent in soft diet with IVF #9 D5LR @ 160cc level @ 120cc/ rate regulated. A: VS checked & recorded with elevated temperature of 38.3C referred to NOD. Swelling of above IV site noted. Check for infiltration not back flow of blood referred to NOD.IVF removed @ KSS bedside. 8:30 AM A: Paracetamol 500 mg PO given as ordered. 9:00 AM D:visited & examined, wound dressing & perineal flushing rechecked by AP. A:Temperature rechecked 38.1C,TSB done. 9:30 AM A: Warm compress done to swollen IV site. 12:00 NN A: due meds given VS checked & recorded. R: Endorsed to NOD. 3:00 PM A: IVF reinserted on other site. Regulated @ same rate

64 .Endorsed to NOD. 01-19-11 117 D: received on bed asleep with IVF # 10 D5LR 1L @ 120cc/. A:VS taken & recorded. Due meds given as ordered. R: Watched & cared for. 73 D: received on bed asleep. With IVF # 10 D5LR 1L @120cc/. 9:00 AM D: seen & examined by AP. A: New orders made and carried out.MGH ordered.

Table 1.7

65 III. LABORATORY EXAMINATIONS

ELECTRIC FETAL MONITORING REPORT Date: 1/13/11 Electric fetal monitoring baseline heart rate fetal 130-142 bpm The baseline fetal heart rate is normally between 120 and 160 beats per minute (110 to 160 at full term). This seems to be the range that the normal, healthy fetus prefers to keep itself well-supplied with oxygen and nutrients. The heart can be faster, but only at a cost of increased energy utilization that is normally not justified. The heart can beat slower, but if the bradycardia is prolonged, it can lead to progressive tissue oxygen debt. http://www.brooksidepress.org/Products/M ilitary_OBGYN/Textbook/LaborandDeliver y/electronic_fetal_heart_monitoring.htm variability good This variability reflects a healthy nervous system, chemoreceptors, baroreceptors and cardiac responsiveness. Prematurity Actual findings Interpretation

66 Electric fetal monitoring decreases variability; therefore, there is little rate fluctuation before 28 weeks. Variability should be normal after 32 weeks. Interpretation of the FHR variability from an external tracing appears to be more reliable when a second-generation fetal monitor is used than when a firstgeneration monitor is used.3 Loss of Actual findings Interpretation

variability may be uncomplicated and may be the result of fetal quiescence (restactivity cycle or behavior state), in which case the variability usually increases spontaneously within 30 to 40 minutes. http://www.aafp.org/afp/990501ap/2487.ht ml periodic More than 2 patt accelerations ern are seen in The baseline rate is interpreted as

changed if the alteration persists for more than 15 minutes. Prematurity, maternal

20min period of anxiety and maternal fever may increase observation. the baseline rate, while fetal maturity decreases the baseline rate.

67 Electric fetal monitoring http://www.aafp.org/afp/990501ap/2487.ht ml uterine contraction one contraction regular is seen intervals that begin before Actual findings Interpretation

the fetus is mature, usually before thedue date of delivery. Contractions are when

measuring22-45 mmhg intensity every 6-7 min.

your abdomen tightens like a fist every 10 minutes backache. http://en.mimi.hu/pregnancy/uterine_contr actions.html or more often. Low, dull

Table 1.8

68 OBSTETRIC ULTRAOUND REPORT Date: 9/15/10 Obstetric ultrasound I. BPD (Biparietal diameter) FETAL BIOMETRY 49.6 mm - 21 W0D The diameter Actual findings Interpretation

between the 2 sides of the head. This is measured after 13

weeks. It increases from about 2.4 cm at 13 weeks to about 9.5 cm at term. Different babies of the same weight can have

different head size, therefore dating in the later part of is

pregnancy

generally considered unreliable. Dating

using the BPD should be done as early as is feasible.

69 Obstetric ultrasound Actual findings Interpretation http://www.obultrasound.net/index. html

HC

(Head

17.4 mm - 19 W6D

It is supposed to be better than the BPD because it

circumference)

compensates for the shape of the fetal

head ( for example a very flat head will give a smaller BPD ). the

However

measurement itself is technically more

difficult to make and carries with it a higher degree measurement of error.

It's use is valuable in fetuses with abnormal head shape.

70 Obstetric ultrasound Actual findings Interpretation http://www.obultrasound.net/omeas ure.html AC (Abdominal 158 mm - 20 W5D The single most

circumference)

important measurement make in to late

pregnancy. It reflects more of fetal size and weight age. measurements useful rather than Serial are in

monitoring growth of the fetus. AC

measurements should not be used for dating a fetus.

http://www.obultrasound.net/index. html

71 Obstetric ultrasound FL (Femur length) Actual findings 33 mm - 19 W6D Interpretation Measures the longest bone in the body and reflects the longitudinal growth of the fetus. Its usefulness is similar to the BPD. It increases from about 1.5 cm at 14 weeks to about 7.8 cm at term. Similar to the BPD, dating using the FL should be done as early as is feasible.

http://www.obultrasound.net/index. html

Table 1.9

72 ULTRAOUND REPORT Date: 1/12/10 Ultrasound report Actual findings BPD (Biparietal diameter) 8.91 = 36wk 0 day cm The diameter between the 2 sides of the head. This is measured after 13 weeks. It increases from about 2.4 cm at 13 weeks to about 9.5 cm at term. Different babies of the same weight can have different head size, therefore dating in the later part of pregnancy is generally considered unreliable. Dating using the BPD should be done as early as is feasible. http://www.ob-ultrasound.net/index.html HC (Head circumference) 32.2 = cm It is supposed to be better than the BPD 36 because it compensates for the shape of the fetal head ( for example a very flat head will give a smaller BPD ). However the measurement itself is technically more difficult to make and carries with it a higher degree of measurement error. It's use is valuable in fetuses with Interpretation

wk & 3 day

73 Ultrasound report Actual findings abnormal head shape. http://www.obultrasound.net/omeasure.html AC (Abdominal circumference) 31.6 cm The single most important measurement to make in late pregnancy. It reflects more of fetal size and weight rather than age. Serial measurements are useful in monitoring growth of the fetus. AC Interpretation

measurements should not be used for dating a fetus.

http://www.ob-ultrasound.net/index.html FL length) (Femur 7.01 cm = 35 wk & 6 day bone in the body and reflects the longitudinal growth of the fetus. Its usefulness is similar to the BPD. It increases from about 1.5 cm at 14 weeks to about 7.8 cm at term. Similar to the BPD, dating using the FL should be done as early as is feasible.

http://www.ob-ultrasound.net/index.html Ultrasound EDC Feb 9 2011 The date that spontaneous onset of

74 Ultrasound report Actual findings labor is expected to occur. http://www.perinatology.com/calculators/ Due-Date.htm Interpretation

Table 1.10 Urinalysis Date: 1/18/11 Urinalysis Normal findings Color: Straw yellow amber color to in Actual findings Yellow Abnormal colors include yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases. Yellow urine may be caused by bilirubin (a bile pigment). http://www.surgeryencyclopedia.com/StWr/Urinalysis.html Reaction: pH range of 5.0 to 8.5 acidic A combination of pH indicators (methyl red and bromthymol blue) react with hydrogen ions (H + ) to produce a color change over a pH range of 5.0 to 8.5. Interpretation

75 Urinalysis Normal findings Actual findings pH measurements are useful in Interpretation

determining metabolic or respiratory disturbances in acid-base balance. http://www.surgeryencyclopedia.com/St -Wr/Urinalysis.html Appearance : Clear Hazy Turbid (cloudy) urine may be caused by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. http://www.surgeryencyclopedia.com/StWr/Urinalysis.html Specific gravity 1.0021.030 1.010 The specific gravity of urine is a measure dissolved of the concentration (substances in of a

solutes

solution), and it reflects the ability of the kidneys to concentrate the urine

(conserve water). Specific gravity is usually measured by determining the

76 Urinalysis Normal findings Actual findings refractive index of a urine sample (refractometry) or by chemical analysis. Specific gravity varies with fluid and solute intake. Interpretation

http://www.surgeryencyclopedia.com/StWr/Urinalysis.html Sugar Negative ( quantitativ e less than 130 mg / day or 30 mg/ dl ) Negativ e The glucose test is used to monitor persons with diabetes. When blood glucose levels rise above 160 mg/dL, the glucose will be detected in urine. Consequently, glycosuria (glucose in the urine) may be the first indicator that diabetes or another hyperglycemic

condition is present. The glucose test may be used to screen newborns for galactosuria and other disorders of carbohydrate metabolism that cause urinary excretion of a sugar other than glucose. http://www.surgeryencyclopedia.com/St -Wr/Urinalysis.html

77 Urinalysis Normal findings Album Negative ( quantitativ e 15- 150 mg / day, less than Actual findings trace Urine protein results always must be interpreted in conjunction with specific gravity. A small amount of protein normally is present in urine and may be detected in concentrated urine. Many false positive with protein alkaline tests urine. occur, The Interpretation

10 mg / dl )

especially

protein test detects mainly albumin. (http://www.medhelp.org/posts/Urology/ Urinalysis-interpretation/show/731397)

Pus Cells

0-4 0-5 / hpf

6-8/hpf

Pus in urine means there is a urinary tract infection which is already

diagnosed for and the number indicates the severity of the infection. Pus cell and bacteria should be absent in urine. Their presence always indicates infection (pyelonephritis, urethratitis,

uretitis, cystitis, etc.). Acute infections are most common cause of increased pus cells and get back to normal after couple of days of treatment. There are

78 Urinalysis Normal findings Actual findings non infective causes of high number of pus cells, like presence of stones or following any surgery on the urinary passage (high number of pus cells may persist for months after prostate surgery even in absence of infection). (http://www.medhelp.org/posts/Urology/ Urinalysis-interpretation/show/731397) Table 1.11 Urinalysis Date: 1/13/11 Urinalysis Normal findings Color: Straw yellow to amber in color Actual findings Yellow Abnormal colors include yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases. Yellow urine may be caused by bilirubin (a bile pigment). http://www.surgeryencyclopedia.com/StWr/Urinalysis.html Interpretation Interpretation

79 Urinalysis Normal findings Reaction: pH range of 5.0 to 8.5 Actual findings acidic A combination of pH indicators (methyl red and bromthymol blue) react with hydrogen ions (H + ) to produce a color change over a pH range of 5.0 to 8.5. pH measurements are useful in determining metabolic or respiratory disturbances in acid-base balance. http://www.surgeryencyclopedia.com/StWr/Urinalysis.html Appearan ce: Clear Hazy Turbid (cloudy) urine may be caused by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. http://www.surgeryencyclopedia.com/StWr/Urinalysis.htm Specific gravity: 1.0021.030 1.015 The specific gravity of urine is a measure of the concentration of dissolved solutes (substances in a solution), and it reflects Interpretation

80 Urinalysis Normal findings Actual findings the ability of the kidneys to concentrate the urine is (conserve usually water). Specific by Interpretation

gravity

measured

determining the refractive index of a urine sample (refractometry) or by chemical analysis. Specific gravity varies with fluid and solute intake.

http://www.surgeryencyclopedia.com/StWr/Urinalysis.html Sugar: Negative (quantitati ve less negative The glucose test is used to monitor persons with diabetes. When blood

glucose levels rise above 160 mg/dL, the glucose will be detected in urine.

than 130 mg / day or 30 mg/ dl )

Consequently, glycosuria (glucose in the urine) may be the first indicator that diabetes or another hyperglycemic

condition is present. The glucose test may be used to screen newborns for galactosuria carbohydrate and other disorders that of

metabolism

cause

urinary excretion of a sugar other than

81 Urinalysis Normal findings Actual findings glucose. http://www.surgeryencyclopedia.com/StWr/Urinalysis.html Album: Negative ( quantitativ e 15- 150 mg / day, less than 10 mg / dl ) negative Urine protein results always must be interpreted in conjunction with specific gravity. A small amount of protein Interpretation

normally is present in urine and may be detected in concentrated urine. Many false positive protein tests occur,

especially with alkaline urine. The protein test detects mainly albumin. (http://www.medhelp.org/posts/Urology/Ur inalysis-interpretation/show/731397)

Pus Cells: 0-4 0-5 / hpf

4-6/hpf

Pus in urine means there is a urinary tract infection which is already diagnosed for and the number indicates the severity of the infection. Pus cell and bacteria should be absent in urine. Their presence always indicates infection (pyelonephritis, urethratitis,

uretitis, cystitis, etc.). Acute infections are

82 Urinalysis Normal findings Actual findings most common cause of increased pus cells and get back to normal after couple of days of treatment. There are non infective causes of high number of pus cells, like presence of stones or following any surgery on the urinary passage (high number of pus cells may persist for months after prostate surgery even in absence of infection). (http://www.medhelp.org/posts/Urology/Ur inalysis-interpretation/show/731397) RBC: 1-2/hpf The blood cell that carries oxygen. Red cells contain hemoglobinand it is the hemoglobin which permits carbon them to Interpretation

transport oxygen (and

dioxide).

Hemoglobin, aside from being a transport molecule, is a pigment. It gives the cell its red color. http://www.medterms.com/script/main/art. asp?articlekey=15489 Table 1.12

83 Hematology Date: 1/17/11 Hematology Normal findings Hemoglobin Mass Concentratio n (hemoglobin ) Female (120-100) Actual findings 106 g/L The hemoglobin molecule fills up the red blood cells. It carries oxygen and gives the blood cell its red color. The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout the body. http://www.webmd.com/a-to-zguides/complete-blood-count-cbc Leucocyte 5-10 21.0 x 10 9/L White blood cells (WBC's) are the ones responsible for the immune system in the body. The white blood cell count rises in cases of infection, steroid use and other conditions. A low white blood cell count can have many causes, which need to be further evaluated by a doctor. http://medicaldictionary.thefreedictionary.com/leucoc Interpretation

84 Hematology Normal findings Actual findings yte Lymphocyte s 0,25-0,40 0.13 Lymphocytes are responsible for immune responses. There are two main types of lymphocytes: B cells and T cells. The B cells make antibodies that attack bacteria and toxins while the T cells attack body cells themselves when they have been taken over by viruses or have become cancerous. Lymphocytes secrete products (lymphokines) that modulate the functional activities of many other types of cells and are often present at sites of chronic inflammation. http://www.medterms.com/script/main/a rt.asp?articlekey=4220 Monocytes 0,02-0,06 0.02 Monocytes later emigrate from blood into the tissues of the body and there differentiate (evolve into) into cells called macrophages which play an important role in killing of some Interpretation

85 Hematology Normal findings Actual findings bacteria, protozoa, and tumor cells, release substances that stimulate other cells of the immune system, and are involved in antigenpresentation. http://www.medterms.com/script/main/a rt.asp?articlekey=4426 Blood type: A, AB, B, O A Individuals have the A antigen on the surface of their RBCs, and blood serum containing IgM antibodies against the B antigen. Therefore, a group A individual can receive blood only from individuals of groups A or O (with A being preferable), and can donate blood to individuals with type A or AB. http://en.wikipedia.org/wiki/Blood_type RH type: Positive and negative positive The Rh factor is written as either positive (present) or negative (absent). Most people are Rh positive. This factor does not affect your health except during pregnancy. A woman is at risk when she has a Interpretation

86 Hematology Normal findings Actual findings negative Rh factor and her partner has a positive Rh factor. This combination can produce a child who is Rh positive. While the mother's and baby's blood systems are separate there are times when the blood from the baby can enter into the mother's system. This can cause the mother to create Interpretation

antibodies against the Rh factor, thus treating an Rh positive baby like an intruder in her body. If this happens the mother is said to be sensitized.

http://pregnancy.about.com/cs/rhfactor/ a/aa050601a.htm Hematocrit: 0.32 Hematocrit is a measure of how much space (volume) the red blood cells take up in the blood. A hematocrit check is often used to test for anemia, which is a decrease in the amount of oxygencarrying substance (hemoglobin) found

87 Hematology Normal findings Actual findings in red blood cells.The hematocrit value may be given as a percentage of red blood cells in a volume of blood. http://www.webmd.com/hwpopup/hematocrit Interpretation

Table 13 Hematology Date: 1/13/11 Hematology Normal findings Hemoglobin Mass Concentratio n (hemoglobin ) Female (120-100) Actual findings 123 g/L The hemoglobin molecule fills up the red blood cells. It carries oxygen and gives the blood cell its red color. The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout the body. http://www.webmd.com/a-to-zguides/complete-blood-count-cbc Leucocyte 5-10 14.0 x 10 White blood cells (WBC's) are the ones Interpretation

88 Hematology Normal findings Actual findings 9/L responsible for the immune system in the body. The white blood cell count rises in cases of infection, steroid use and other conditions. A low white blood cell count can have many causes, which need to be further evaluated by a doctor. http://medicaldictionary.thefreedictionary.com/leucocyt e Lymphocyt es 0,25-0,40 0.12 Lymphocytes are responsible for immune responses. There are two main types of lymphocytes: B cells and T cells. The B cells make antibodies that attack bacteria and toxins while the T cells attack body cells themselves when they have been taken over by viruses or have become cancerous. Lymphocytes secrete products (lymphokines) that modulate the functional activities of many other types of cells and are often present at sites of chronic inflammation. Interpretation

89 Hematology Normal findings Actual findings http://www.medterms.com/script/main/art. asp?articlekey=4220 Monocytes 0,02-0,06 0.01 Monocytes later emigrate from blood into the tissues of the body and there differentiate (evolve into) into cells called macrophages which play an important role in killing of some bacteria, protozoa, and tumor cells, release substances that stimulate other cells of the immune system, and are involved in antigenpresentation. http://www.medterms.com/script/main/art. asp?articlekey=4426 Eosinophils 0,01-0,05 0.03 An absolute eosinophil count is a blood test that measures the number of white blood cells called eosinophils. Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions. http://www.nlm.nih.gov/medlineplus/ency/ article/003649.htm Interpretation

90 Hematology Normal findings Blood type: A, AB, B, O Actual findings A Individuals have the A antigen on the surface of their RBCs, and blood serum containing IgM antibodies against the B antigen. Therefore, a group A individual can receive blood only from individuals of groups A or O (with A being preferable), and can donate blood to individuals with type A or AB. http://en.wikipedia.org/wiki/Blood_type RH type: Positive and negative positive The Rh factor is written as either positive (present) or negative (absent). Most people are Rh positive. This factor does not affect your health except during pregnancy. A woman is at risk when she has a negative Rh factor and her partner has a positive Rh factor. This combination can produce a child who is Rh positive. While the mother's and baby's blood systems are separate there are times when the blood from the baby can enter into the mother's system. This Interpretation

91 Hematology Normal findings Actual findings can cause the mother to create antibodies against the Rh factor, thus treating an Rh positive baby like an intruder in her body. If this happens the mother is said to be sensitized. Interpretation

http://pregnancy.about.com/cs/rhfactor/a/ aa050601a.htm Hematocrit 0.37 Hematocrit is a measure of how much space (volume) the red blood cells take up in the blood. A hematocrit check is often used to test for anemia, which is a decrease in the amount of oxygencarrying substance (hemoglobin) found in red blood cells. The hematocrit value may be given as a percentage of red blood cells in a volume of blood. http://www.webmd.com/hwpopup/hematocrit Table 1.14

92 Blood test

Blood test

Actual results

Interpretation

RH

Positive

the Rh factor is written as either positive (present) or negative (absent). Most people are Rh positive. This factor does not affect your health except during pregnancy.A woman is at risk when she has a negative Rh factor and her partner has a positive Rh factor. This combination can produce a child who is Rh positive. While the mother's and baby's blood systems are separate there are times when the blood from the baby can enter into the mother's system. This can cause the mother to create antibodies against the Rh factor, thus treating an Rh positive baby like an intruder in her body. If this happens the mother is said to be sensitized. http://pregnancy.about.com/cs/rhfactor/a/aa050601 a.htm

Table1.15

93 IV. REVIEW OF ANATOMY AND PHYSIOLOGY

Anatomy and Physiology

Figure 1.2 Vagina: A muscular passageway that leads from the vulva (external genitalia) to the cervix. Cervix: A small hole at the end of the vagina through which sperm passes into the uterus. Also serves as a protective barrier for the uterus. Duringchildbirth, the cervixdi lates (widens) to permit the baby to descend from theuterus into the vagina for birth. Uterus: A hollow organ that houses the baby during pregnancy. During childbirth, the uterine muscles contract to push out the baby. Each month,unless a fetus has been conceived, the uterine wall sheds its lining (see TheMenstrual Cycle and Ovulationbelow). Ovaries: Two organs that produce hormones and store eggs. Each ovary releases one egg per month.

94
Fallopian tubes: Muscular tubes that eggs released from the ovaries must traverse to reach the uterus. The Menstrual Cycle and Ovulation Each month a womans body goes through a menstrual cycle. A woman can become pregnant only during ovulation, a several-day phase in the middle of the menstrual cycle when one of the ovaries releases an egg.

Figure 1.3 If the ovulated egg is fertilized by a mans sperm following sexual intercourse, it will implant in the endometrium, the lining of the uterus that becomes the placenta during pregnancy. The placenta nurtures the fertilized egg as it develops and grows into a baby.

Figure 1.4

95 1st Trimester/ weeks of pregnancy Events

Figure 1.5

The woman's last period before fertilization occurs.

Fertilization occurs. The fertilized egg (zygote) begins to develop into a hollow ball of cells called the blastocyst.

The blastocyst implants in the wall of uterus.The amniotic sac begins to form.

The area that will become the brain and spinal cord (neural tube) begins to develop.

The heart and major blood vessels are developing. The beating heart can be seen during ultrasonography.

The beginnings of arms and legs appear.

Bones and muscles form. The face and neck develop. Brain waves can be detected. The skeleton is formed. Fingers and toes are fully defined.

96
10 The kidneys begin to function. Almost all organs are completely formed. The fetus can move and respond to touch (when prodded through the woman's abdomen). The woman has gained some weight, and her abdomen may be slightly enlarged.

2nd Trimester/ weeks of pregnancy

Events

Figure 1.6 14 The fetus's sex can be identified. The fetus can hear.

16

The fetus's fingers can grasp. The fetus moves more vigorously, so that the mother can feel it. The fetus's body begins to fill out as fat is deposited beneath the skin. Hair appears on the head and skin. Eyebrows and eyelashes are present.

20

The placenta is fully formed.

24

The fetus has a chance of survival outside the uterus. The woman begins to gain weight more rapidly.

97
3rd Trimester/

Events

weeks of pregnancy

Figure 1.7 25 The fetus is active, changing positions often. The lungs continue to mature. The fetus's head moves into position for delivery. On average, the fetus is about 20 inches long and weighs about 7 pounds. The woman's enlarged abdomen causes the navel to bulge. 37-42 Delivery

Breast

Figure 1.8

98 Mammary glands are the organs that produce milk for the sustenance of a baby. These exocrine glands are enlarged and modified sweat glands. The basic components of the mammary gland are the alveoli (hollow cavities, a few millimeters large) lined with milk-secreting epithelial cells and surrounded by myoepithelial cells. These alveoli join up to form groups known as lobules, and each lobule has a lactiferous duct that drains into openings in the nipple. The myoepithelial cells can contract, similar to muscle cells, and thereby push the milk from the alveoli through the lactiferous ducts towards the nipple, where it collects in widenings (sinuses) of the ducts. A suckling baby essentially squeezes the milk out of these sinuses. The development of mammary glands is controlled by hormones. The mammary glands exist in both sexes, but they are rudimentary until puberty when - in response to ovarian hormones - they begin to develop in the female. Estrogen promotes formation, while testosterone inhibits it.

Figure 1.9

99 At the time of birth, the baby has lactiferous ducts but no alveoli. Little branching occurs before puberty when ovarian estrogens stimulate branching differentiation of the ducts into spherical masses of cells that will become alveoli. True secretory alveoli only develop in pregnancy, where rising levels of estrogen and progesterone cause further branching and differentiation of the duct cells, together with an increase in adipose tissue and a richer blood flow. Colostrum is secreted in late pregnancy and for the first few days after giving birth. True milk secretion (lactation) begins a few days later due to a reduction in circulating progesterone and the presence of the hormone prolactin. The suckling of the baby causes the release of the hormone oxytocin which stimulates contraction of the myoepithelial cells. The cells of mammary glands can easily be induced to grow and multiply by hormones. If this growth runs out of control, cancer results. Almost all instances of breast cancer originate in the lobules or ducts of the mammary glands.

100 V. SYMPTOMATOLOGY

Symptoms Pain

Actual findings

Justification The patient may feel pain

because

the

myometrium

becomes tender from constant lack of relaxation and the anoxia of uterine cells that results. Dilation and effacement does not occur

Stay at 2 - 3 cm. doesnt dilate as should. If deceleration in the fetal heart rate (FHR), an

abnormally long first stage of labor, or lack of progress with pushing occurs, cesarean birth may be necessary. Prolonged latent phase.

The

muscle

fibers

of

the

myometrium do not repolarize or relax after a contraction, thereby wiping it clean to accept a new pacemaker stimulus. Fetal early distress occurs

Uterine resting tone is high, decreasing placental perfusion.

101 Anxious and discourage A woman may become frustrated or disappointment with her

breathing exercises for childbirth, because such techniques are ineffective contraction. with this type of

Table 1.16

102 VI. ETIOLOGY

List of Etiology

Actual findings

Effect to the patient / implication

Predisposing Factors: Age

Age affect the surgical risk because it can

cause circulatory function.

decrease and renal

Fortunately

most pregnant women fall within the young

adult age group so they are excellent candidate for surgery.

Failure of the muscle fibers to repolarize

This type of contraction has possibly occur to

our

pt

because fibers of do

the the not

muscle

myometrium

repolarize or relax after a contraction, thereby

103 wiping accept pacemaker They may it clean a to new stimulus. occur

because more than one pacemaker is stimulating the contraction.

Lack

of

relaxation

A danger of hypertonic contractions is that the

between contractions

lack between

of

relaxation contraction

may not allow optimal uterine artery filling; this could lead to fetal

anoxia early in the latent phase of labor

Long first stage of labor

Abnormally first stage of labor or lack of progress

with pushing (second stage arrest) occurs,

cesarean birth may be

104 necessary. Our pt and her support need system to that, the

person understand although

contractions are strong, they are ineffective and not achieving cervical

dilatation.

Precipitating Factors: Fetal Distress

The

most

common

cause of fetal distress is

lack of oxygen to the baby. If fetal monitoring detects a problem with the amount of oxygen that your baby then is an

receiving, emergency

cesarean

may be performed.

Failure to progress in labor

This can occur when the cervix has not dilated

105

completely, labor has slowed down or stopped, or the baby is not in an optimal delivery position. This can be diagnosed correctly once the women is in the second phase (beyond 5 scentimeters dilation), since the first phase of labor (0-4 centimeters dilation) is almost always slow.

Table 1.17

106 VII. Predisposing factors; -Age - Primigravida Release of FSH by the anterior Pitruitary gland PATHOPHYSIOLOGY Precipitating factors; -Failure of the muscle fibers to repolarize -Lack of relaxation between -Long first stage of labor Contractions

Development of the graafian follicle

Production of estrogen ( thickening of the endometruim)

Release of the luteinizing hormone

Ovulation (release of mature ovum from the graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovum and sperm in the ampulla)

Zygote travels from the fallopian tube to the uterus

Implantation

Development of the fetus/embryo & placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening (descent of the fetal the cervix

Braxton Hicks Contraction

Ripening of

107 head into the pelvis) (false labor) (Goodells Sign wherein >begin and remain irregular the cervix feels softer like ST >1 Felt abnormally consistency of the earlobe >Pain disappear with ambulation >Do not increase in duration and Intensity >Do not achieve cervical dilatation

TRUE LABOR

Uterine Contractions SHOW >increase in duration (pink-tinge of blood, Membranes and intensity a mixture of blood and fluid amniotic sac) >1st felt at the back Radiates to the abdomen >pain is not relieved no Matter what the activity >achieve cervical dilatation I IF LEFT UNTREATED: Lack of uterine relaxation May not allow optimal uterine artery filling Fetal anorexia Expulsion of the fetus Increase for fetal distress Fetal death

Rupture of (rupture of the

Failed to progress labor

increase risk for fetal distress (meconium staining, hypoxia)

Increase risk of fetal death

Emergent cesarean delivery(the incision made on the lower part of the abdomen)

Expulsion of the placenta (accompanied by Bloodless approximately 1000-1500 mL)

108 VIII. A. Nursing care plan #1 Assessm ent Nursing Diagnosis Objective criterion Nursing Management/ Rationale Subjectiv e Altered After 4 hrs. of Independent: - monitor vital signs Goal Met: After 4 of Evaluation PLANNING

cues thermoregul giving r/t appropriate

Init kaayo ation akong gibati. As verbalize d by the patient

To obtain baseline hours data. giving

invasion of intervention, microorgani sms. thermoregulati

appropriate

on will return -provide tipid sponge intervention, within normal bath range as TSB helps the thermoregul in ation to

Reference: N.Jayne Klossner

evidenced by:

lowering

body returned and its

Dili na kayo temperature init gibati

normal

akong alcohol cools rapily, range as causing sheviring. (Temp37.4) -remove excess ok akong dili na

Objective cues: -Temp38.5C

&Nancy Hatfield(20

verbalized by

06).Introduc the patient tory -Temp-36.5-

clothings and cover

- Dry lips Maternity & 37.5C noted pediatric -Moisten lips.

These decreases pamati, warmth

and na kaayo ko

109 - Slightly Nursing flushed face noted -Skin warm touch to Lippincott William &Wilkins.pp . 1661. -Flushed skin increases not noted -skin not warm when touch -promote a evaporative cooling. init as

verbalized by the

well patient -moisten

ventilated area

to create flow of air lips. in patients area. One -flushed way of promoting skin noted patient to skin not to not

heat loss. -advise

increase oral intake Additional to

warm

fluids touch. prevent

helps

elevated temperature associated dehydration -maintain bed rest reduces metabolic demands/ consumption. -provide high calorie diet To meet increased oxygen with

110 metabolic demands -educate and advise support system

(family and relatives) when increase

thermoregulation occurs; -do TSB with warm water only -Make sure that luke

armpits and groins are included. teaching the

support system the right way to do TSB will help in insuring the effectiveness of care in case of

increase thermoregulation occurs not only the patient but also other members of the

111 family.

Dependent: Administer per

antipyretics doctors order

-this drug inhibits the that prostaglandin serves as

medication for fever and pain. Collaborative: -Obtain test. to ensure the laboratory

effectiveness of care.

Table 1.18 #2 Assessm ent Nursing Diagnosis Objective Criterion Nursing Management/ Rationale Subjectiv Pain related After 6 of Independent GOAL Evaluatio n

112 e cues to surgical nursing s/t intervention, provide comfort MET: quiet After 6 of and nursing interventi pain

incision Sakit sakit pa akong post CS.

measures,

pain will reduce environment to 2 as calm activities.

evidenced by; Scientific dili bases: na

to promote non- on,

tahi

kayo pharmacological pain reduced to 2 as

sakit akong tahi management Pain Scale of caused by 5 out of the 10 damage position done Objectiv tissue e cue the incision, Guardin the g procedure position itself, closing grimace the wound to pain. and force is any of the -encourage noted and reduce tension. by -grimace to noted breathing not such as -Guarding the patient -encourage use is as verbalized by

evidenced of by; na

relaxation technique; dili

focused kayo sakit akong as

not to distract attention tahi

verbalized by patient the

diversional activities -Guarding such as watching TV. position to distract attention not noted -grimace not noted that -monitor applied color/temp and vital skin

113 during the procedure. signs which are usually altered in acute pain. Reference: Jennifer Heisler, RN, 2010 -increase oral fluid intake to help reduce the body temperature. Dependent Administer analgesics, indicated to maintain as encourage adequate rest period to prevent fatigue

acceptable level of pain.

Table 1.19

114 #3

Assess ment

Nursing Diagnosis

Objective Criterion

Nursing Management/ Rationale

Evaluatio n

Subjecti ve cue None

Risk infection

for Within 6 of care Independent r/t the patient will -established rapport be free

Goal met At 1 pm

inadequate primary

from to gain trust and Has able cooperation -note signs to and verbalize

infection.

Objectiv e cue Fever Chills Weak

defenses secondary to C-section

symptoms of sepsis her such as fever and understan chills. ding to assess prevent factors the risk of infection. to

Scientific basis

contributing

Vital sign BP 120/70 PR 98 RR 26 Temp 38.5

The creation of surgical

that causes infection

wound disrupts integrity the of

-if patient has fever As perform TSB. to lower evidenced the by kabalo na diay ko -stress proper hand unsay

the skin in its protective function.

temperature

115 Exposure deep tissues of washing techniques buhatun dili

body to

to prevent cross para contamination nosocomial infections. -cleanse of magka

pathogens in the environment places the

impeksyo n,as incision patient

sites daily and PRN verbalized with povidone-iodine . or other appropriate solution. to disinfect surgical incision site Health teaching -Instruct client in

patient at risk for of infection the

surgical site, a potentially

lifethreatening complication.

techniques to protect the integrity of skin

Reference Brunner and Suddarths Textbook medicalsurgical nursing 15th of

to

prevent

the

spread of infection -emphasize necessity of taking antibiotics directed. premature as

116 Edition 545 pp. discontinuation of

treatment when client begins to feel well, may result in return of infection Dependent Administer anti-

infective drugs per doctors order. to prevent infection

Table 1.20

117 B. DISCHARGE PLAN Medication Inform the patient and family of the prescribed medication including the name, purpose, schedules, doses and side effects. Instruct the patient not to change any medication that the patient is taking, adding or stopping drugs without consulting the physician. Instruct the patient not to take other over the counter drug without the physicians advised.

Exercise Instruct the patient to maintain all the activities and restrictions that can affect her condition. Encouraged patient to participate in strength conditioning exercise.

Treatment Instruct the family and patient to religiously comply follow up check ups of the patient with the physician to ensure full recovery.

Hygiene Instruct the patient to maintain hygienic measures like taking a bath every day and perform daily oral care. Instruct the client to have perineal care and dress the wound regularly

118 Outpatient Orders Instruct the patient to follow regular medical checkups to monitor her progress and for further management. Provide adequate rest and sleep including calm and quiet environment. Encouraged patient to strictly follow medications and diet.

Diet Instruct client to eat nutritious food to help in the recovery process. Instruct patient to increase fluid intake.

Spiritual Encouraged the patient and the family members to always keep God almighty in their midst and pray for good health and safety. Advised the patient and family to make God as the center of their activity.

119

IX. PHARMACOLOGICAL MANAGEMENT DRUG STUDY #1

DATE/ SHIFT

NAME OF DOSAGE/ DRUG TIME ROUTE

INDICATION

CONTRAINDICATION

MECHANIS M OF ACTION Interferes

SIDE EFFECTS

NURSING RESPONSIBILITIES

1/17/11

GENERIC NAME: Ampicillin

1g IVTT Q 6

Soft

tissue Hypersensi tive to drug

Common side -Assess any history of of allergy -Check IV site carefully for signs of thrombosis or

infection

with cell wall effects synthesis susceptible of ampicillin include

BRAND NAME: Omnipen

organism, preventing bacteria multiplication

nausea, vomiti ng, loss appetite, diarrhea, abdo

of drug reaction. -Do not give IM injections in the

120

CLASSIFI CATION: Anti-biotic

it renders cell

also minal

pain, same site; atrophy

the rash, itching, h can occur. wall eadache, conf usion and -Monitor injection site. -Administer oral

osmotically Drawing:

unstable and dizziness.

burst due to Patients with a drug on an osmotic pressure. history allergic reactions other penicillins should receive ampicillin. Persons who of empty stomach, 1 hr before o 2 hrs to after meals with a full glass of water; do not give with not fruit juice or soft drinks

121

are allergic to the cephalosporin class antibiotics, which are of

related to the penicillins, for example, cefa clor (Ceclor),c ephalexin (Kef lex), and cefprozil ( Cefzil), may or may not be

122

allergic penicillins. Serious

to

but

rare reactions include seizur es, allergic reactions (anaphylaxis), and low severe

platelet or red blood count. Ampicillin can alter the cell

123

normal bacteria in the colon encourage overgrowth of some bacteria such as Clostridium difficilewhich causes inflammation of the colon and

(pseudomemb ranous colitis). Patients who

124

develop signs of pseudomembr anous after colitis starting

ampicillin (diarrhea, feve r, abdominal and

pain,

possibly shock ) contact physician immediately. should their

Table 1.21

125

DRUG STUDY #2

DATE/ SHIFT

NAME OF DOSAGE/ DRUG TIME ROUTE

INDICATION

CONTRA-

MECHANIS

SIDE EFFECTS

NURSING RESPONSIBILITIE S

INDICATIO M N Used in the Hypersensi tivity OF ACTION Inhibits

1/17/11

GENERIC NAME: Ranitidine

50mg

CNS:

-Assess any history of allergy -Assess patient for epigastric or

q 8 hours management IVTT

to Gastric acid Confusion, secretion by blocking the effect histamine on,histamin e dizziness, drowsiness,

of various GI Ranitidine distress such

hallucinations,

BRAND NAME: Aceptin

as dyspepsia.

of headache CV: Arrhythmias GI:

abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. -Nurse should know that it may cause

H2 Altered taste, black tongue, constipation,

CLASSIFI CATION:

Receptors.

dark stools, diarrhea, drug-

126

Gastrointe stinal drugs

induced hepatitis, nausea GU: Decreased

false-positive results for test sulfosalicylic urine protein; with acid.

DRAWING

sperm count, impotence ENDO: Gynecomastia HEMAT:

-Inform patient that it may cause or

drowsiness dizziness.

Agranulocytosis -Inform patient that , Aplastic increased fluid and Anemia, neutropenia, thrombocytope nia LOCAL: Pain at IM site MISC: Hypersensitivity constipation. -Advise patient to report onset of fiber intake may

minimize

127

reactions, vasculitis

black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations health professional promptly. -Inform patient that medication temporarily may cause to car

stools and tongue to appear gray black.

Table 1.22

128

DRUG STUDY #3 DATE/ SHIFT NAME OF DOSAGE/ DRUG TIME ROUTE 1/17/11 GENERIC NAME: Mefenamic acid BRAND NAME: Mefenax 500mg TID Prevention and management of to pain. INDICATION CONTRAMECHANIS SIDE EFFECTS NURSING RESPONSIBILITIE S Cardiovascular Edema; weight - Assess for history of ulceration -Instruct patient to eat meal first before taking the drug. -Advice the patient to avoid sudden to

INDICATIO M N Hypersensi tivity mefenax; OF ACTION Inhibits

to prostaglandi

n synthesis gain; CHF; and affects altered BP; platelet palpitations; chest pain; bradycardia; tachycardia.

moderate GI severe inflammati on

or function.

ulceration

movement

CLASSIFI CATION: Analgesics CNS Headache;

prevent drowsiness. -Advice the patient to calm down.

129

, NSAID.

vertigo; drowsiness;

-Report any signs of urticaria or pupura. -Instruct patient to verbalize feelings

DRAWING

dizziness; insomnia. Dermatologic

such as blurring of visions Rash; urticaria; purpura. EENT Blurred vision; tinnitus; salivation; glossitis. GI

130

Diarrhea; dry mouth; vomiting; abdominal pain; dyspepsia; GI bleeding; nausea; constipation; flatulence. Genitourinary Hematuria; proteinuria; dysuria; renal failure.

131

Hematologic Decreased hematocrit; bleeding; neutropenia; leukopenia; pancytopenia; eosinophilia; thrombocytope nia. Hepatic Mild elevations in LFT results. Respiratory Bronchospasm;

132

laryngeal edema; rhinitis; dyspnea; pharyngitis; hemoptysis; shortness of breath. Miscellaneous Autoimmune hemolytic anemia may occur if used long term.

Table 1.23

133

DRUG STUDY #4 DATE/ SHIFT NAME OF DOSAGE/ DRUG TIME ROUTE 1/17/11 GENERIC NAME: Gentamicin Sulfate BRAND NAME: Orimed 240 mg IVTT q 6 INDICATION CONTRAMECHANIS SIDE EFFECTS NURSING RESPONSIBILITIE S Special Senses: the Ototoxicity -Assess patient for sign and symptom such as

INDICATIO M N Skin and soft Patient tissue infection,abd ominal infection,bact erialsepticem ia. OF ACTION Anti-

with known bacterial hypersensi tivity Orimed inhibits

to protein

(vestibular distu rashes,itcheness. -Determine creatinine optic clearance and CNS: serum drug concentrations at frequent intervals,

synthesis of rbances, bacterial cell impaired and interfere hearing), neuritis.

CLASSIFI CATION: Anti-

with growth bacteria.

the neuromuscular of blockade:

skeletal muscle particularly for

134

infective

weakness, apnea,

patients with impaired renal function, patients

DRAWING

respiratory

paralysis (high receiving high doses);arachno doses or therapy

iditis (intratheca beyond 10 d, l use). CV: patients with fever or extensive burns, edema, obesity.

hypotension or hypertension

. GI: Nausea, -Repeat C&S if vomiting, transient increase improvement does not occur in 35 d; in reevaluate therapy.

AST, ALT, and -Note: Dosages are serum LDH and generally adjusted

135

bilirubin; hepatomegaly, splenomegaly. Hematologic: Increased decreased reticulocyte counts;

to maintain peak serum gentamicin concentrations of 4 10 g/mL, and trough or concentrations of 1 2 g/mL. Peak concentrations above 12 g/mL and

granulocytopeni trough a, thrombocytope nia bleeding tendency), thrombocytope concentrations above 2 g/mL are

(fever, associated with toxicity.

136

nic

purpura, Body Whole:

anemia. as a

Hypersensitivity (rash, pruritus, urticaria, exfoliative dermatitis, eosinophilia, burning sensation skin, fever, joint pains, laryngeal edema, of drug

137

anaphylaxis). Urogenital: Nephrotoxicity: proteinuria, tubular necrosis, or casts cells in

urine, hematuria, rising BUN,

nonprotein nitrogen, serum creatinine; decr easedcreatinine clearance. Othe

138

r: irritation pain IM

Local and

following use;

thrombophlebiti s, abscess,

superinfections, syndrome hypocalcemia (tetany, weakness, hypokalemia, hypomagnese mia). of

Table 1.24

139 X. SYNTHESIS OF CLIENTS CONDITION A. Conclusion

B. Patients Prognosis Criteria Good 3 Family Support Fair 2 Poor 1 The family had supported the client all throughout her pregnancy and they Justification

verbalized that they would try their best to help the patient recover easily. Her partner is very supportive and attends to the patient well enough.

Environment

The

environment

of

the

client is not hazardous to her condition because the surrounding area is free from risks.

140 Financial Could able to supply the needed medication due to sufficient income. Age Cesarian section is most common in this age.

Onset illness Duration illness

of

The

patient

has

no

presence of any illnesses. The patient has no

of

presence of any illnesses.

Compliance to medication

The

patient

has

no

presence of any illnesses.

Table 1.25 Legend: Good- 3pts. Rating: Good- 2.4-3 Computation: Good: 3x7= 21 Fair: 2x0= 0 Poor: 1x0= 0 Fair- 2pts. Fair- 1.7-2.3 Poor- 1pt. Poor- 1-1.6

141 General Prognosis Based on the aforementioned result, the overall prognosis of the client is goo since the client reveals eminence of health and wellness. Therefore, the client achieved a state of good care providence by the health care team as well as the evidences from her family. The family assured that they will support the client financially and emotionally. C. Recommendation Care should be done on the site of incision. It should be dry and clean. Modification of activities, exercise and diet particularly taking of foods which are reach in iron and fibrous fruits for fast recovery. Patient should take home medications as prescribe to continue the care even at home. Discus the signs and symptoms of infection and educate on that to do and when to visit the physician.

142 XI. EVALUATION

Having this case presentation, each member of the group involved to the said study was able to assess properly every single data, thoroughly assessed every system involved regarding the patients condition and mapped out and traced the pathophysiology of Fetal distress resulting to Cesarean Section. On the latter part, the students were able to come up with a nursing care plan that is very helpful in restoring the clients present condition. We were able to gather all possible resources and relevant datas regarding the past and present history of Patient Xs illness. With the data gathered, we are able to identify vital informations such as predisposing and precipitating factors that greatly contribute to Patient Xs present illness The group was able to identify, determine and understand the underlying general health problems of our client. The study improves our skills and knowledge pertaining on caring patients with such changes. Without anticipation, we are looking forward that this output may give additional knowledge to other student nurses in order for them to extend their cognition made upon it and finally improve their service.

143 APPENDICES A Date: 1/13/11 Name : Magno, Neliza Age:20 years old File No.: 11LMP: March

000871 Address: Nabunturan Compostela Valley Prov 12 2010 Physician: Dr. Duterte

OB index: G1P0

ELECTRIC FETAL MONITORING REPORT TYPE OF TEST Intrapartum Prepartum (NST) : YES CST Time started: 12:10 pm Time ended: 12:30 pm

BASELINE FETAL HEART RATE: 130-142 BPM VARIABILITY: GOOD PERIODIC PATTERN: more than 2 accelerations are seen in 20min period of observation. UTERINE CONTRACTION: one contraction is seen measuring 22-45 mmHg intensity every 6-7 min. OTHER INTERPRETATION: Normal Fetal Heart Rate Pattern

Mariebeth P. Juarez M.D., FPOGS, FPSMFM, FPSUOG Perinatologist / OB-GYNE sonologis

144 APPENDICES B

Date: 9/15/10 Name : Magno, Neliza old Prov Age:20 years

File No.: 10-00632 Address: Nabunturan Compostela Valley LMP: March 12 2010 OB index: G1P0

Physician: Dr. Duterte

OBSTETRIC ULTRAOUND REPORT

I.GENERAL SURVEY Fetal number Presentation FHR : singleton : cephalic : 165 BPM

Amniotic fluid index : 8.5 cms Placental grade Fetal sex :I : not seen

FETAL BIOMETRY BPD :49.6 mm HC AC FL : 17.4 mm : 158 mm : 33 mm 21 W0D 19 W6D 20 W5D 19 W6D

145 II.FETAL ANATOMIC SURVEY Lateral ventricles:<1 cm Posterior Fossa: 0.2 cm 4 chamber heart Lungs Stomach Kidney Spine Cord insertion: 3 vessel cord: + Bladder : + Non-biometric parameter TCD : 2.0 cms. :+ :+ :+ :+ :+

Colonic grade: one Distal Femoral Eiphysis:-

OTHERS: Fetal Face not seen due to unfavor fetal position DIAGNOSIS: Pregnancy, uterine, 20 weeks and 3 days by Fetal Biometry. Live, singleton in cephalic in cephalic presentation with good cardiac and somatc activity adequate amniotic fluid volume. Placenta anterior, grade I,no previa. Mariebeth P. Juarez M.D., FPOGS, FPSMFM, FPSUOG Perinatologist / OB-GYNE sonologist

146 APPENDICES C Name : Magno, Neliza 1/12/10 Address: Nabunturan Compostela Valley Prov 2011-0056 LMP: March 12 2010 Physician: Dr. Duterte File No.: Age:20 years old Date:

OB index: G1P0 ULTRAOUND REPORT Transabdominal Biometry: within the enlarged uterus is a single live fetus in cephalic presentation with god cardiac (FHR=130bpm) and somatic activities, with the ff. biometric features

BPD :8.91 cm OTD : 10.9 cm CI HC AC : 82% : 32.2 cm : 31.6 cm

= 36wk 0 day

= 36 wk & 3 day

SEFW : 2767 g (hadlock) FL : 7.01 cm = 35 wk & 6 day

Placenta: anterior, grade III, high lying AFL : 7.9 cm

Ultrasound EDC: Feb 9 2011 Gender : FEMALE

BIOPHYSICAL SCORING:

147 Breathing 2

Movement 2 Tone AFI 2 2 8/8

Impression : single intrauterine pregnancy, cephalic presentation with good cardiac and somatic activity, 36 wk by BPD, 35 6/7 wk by FL, placenta anterior, grade III, high lying normohydramnios, sonographic estimated fetal weight appropriate for gestational age. Loraine C. Suaybaguio Duterte,M.D. OB-GYNE sonologi

148 APPENDICES D

Name : Magno, Neliza Age:20 years old Sex: Female Room no.: 304 Physician: Dr. Duterte

Date: 1/18/11 Hospital No.: 09-011739

Urinalysis

Color: Yellow Appearance: Hazy Sugar: Negative Pus Cells: 6-8/hpf

Reaction: acidic Specific gravity: 1.010 Album: trace

Dr. Oscar Grageda, PSP, APCD Pathologist

149 APPENDICES E

Name : Magno, Neliza Age:20 years old Sex: Female Room no.: 306 Physician: Dr. Duterte

Date: 1/13/11

Urinalysis

Color: Yellow Appearance: Hazy Sugar: Negative Pus Cells: 4-6/hpf RBC: 1-2/hpf

Reaction: acidic Specific gravity: 1.015 Album: negative

Dr. Oscar Grageda, PSP, APCD Pathologist

150 APPENDICES F

Name : Magno, Neliza Age:20 years old Sex: Female Room no.: 306 Physician: Dr. Duterte

Date: 1/17/11 Hospital No.: 09-011739

Hematology

Hemoglobin Mass Concentration (hemoglobin) Female (120-100): 106 g/L Leucocyte not Conc. (5-10): 21.0 x 10 9/L Segmentres (0,55-0,65): 0.82 Myelocytes (0): Juvenile (0-0,001): Stab (0,01-0,05): Lymphocytes (0,25-0,40): 0.13 Monocytes (0,02-0,06): 0.02 Eosinophils (0,01-0,05): 0.03 Basophils (0,0.005): Thrombocyte No. Conc (150-300): ReticulocytenNo. Fraction (0,005-0,.5): Dr. Oscar Grageda, PSP, APCD Pathologist Malaria: Blood type: A RH type: + Bleeding time: Clotting time: Hematocrit: 0.32

151 APPENDICES G

Name : Magno, Neliza Age:20 years old Sex: Female Room no.: 306 Physician: Dr. Duterte

Date: 1/13/11 Hospital No.: 09-011730

Hematology Hemoglobin Mass Concentration (hemoglobin) Female (120-100): 123 g/L Leucocyte not Conc. (5-10): 14.0 x 10 9/L Segmentres (0,55-0,65): 0.87 Myelocytes (0): Juvenile (0-0,001): Stab (0,01-0,05): Lymphocytes (0,25-0,40): 0.12 Monocytes (0,02-0,06): 0.01 Eosinophils (0,01-0,05): 0.03 Basophils (0,0.005): Thrombocyte No. Conc (150-300): ReticulocytenNo. Fraction (0,005-0,.5): Malaria: Blood type: A RH type: + Bleeding time: Clotting time: Hematocrit: 0.37

Dr. Oscar Grageda, PSP, APCD Pathologist

152 APPENDICES H

Name: Magno, Neliza Age: 20 years old Sex: Female Room No.: 306

Requesting physician: Dr. Duterte

Blood test: A RH: POSITIVE

June Lipayban Medical Tech.

153 XII. BIBLIOGRAPHY Web:

AMIR SWEHA, M.D., and TREVOR W. HACKER, M.D. primary care physicians by the American Academy of Family Physicians, 1999; http://www.aafp.org/afp/990501ap/2487.html

CDC/National Center for Health Statistics; by Office of Information Services; http://www.cdc.gov/nchs/data/databriefs/db35.htms

CDC/National Center for Health Statistics; by Office of Information Services;http://www.cdc.gov/nchs/data/databriefs/db35.htms

Cherry,

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Development;

http://psychology.about.com/od/theoriesofpersonality/ss/psychosexualdev _2.htm Demand Media 2010; Erik Erikson And Psychosocial Development: In contrast to Freud's psychosexual stages, Erik Erikson believed we develop in eight psychosocial stages.; http://www.essortment.com/erikerikson-psychosocial-development-50823.html eMedicineHealth,2011(http://www.emedicinehealth.com/cesarean_childbir th/article _em.htm) eMedicine Health; Expert for everyday emergencies By 2011 WebMD, Inc.http://www.emedicinehealth.com/cesarean_childbirth/article_em.htm Fay Menacker, Dr. P.H.,et al.2010;

http://www.cdc.gov/nchs/data/databriefs/db35.htm

154 Jennifer Heisler, RN, About.com Guide; Updated January 23, 2010 About.com Health's Disease and Condition content is reviewed by the Medical Review Board;

http://surgery.about.com/od/aftersurgery/a/SurgeryPain.htm

Johnsons

baby

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by

BabyCenter,L.L.C.2011;http://www.babycenter.com.ph /pregnancy/labourandbirth/labourcomplications/caesarean-rate/s Military Obstetrics & Gynecologyby The Brookside Associates Medical Education Division, 2009 http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/Labor andDelivery/electronic_fetal_heart_monitoring.htm Pregnancy: What is what? Everything you always wanted to know. by mimi.hu http://en.mimi.hu/pregnancy/uterine_contractions.html Victoria E. DeMoranville Mark A. Best; Encyclopedia of Surgery http://www.surgeryencyclopedia.com/St-Wr/Urinalysis.html We brings doctors knowledge to you ; 1996-2011 MedicineNet, Inchttp://www.medterms.com/script/main/art.asp?articlekey=15489 We brings doctors knowledge to you ; 1996-2011 MedicineNet, Inc http://www.medterms.com/script/main/art.asp?articlekey=4426 Book:
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155
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