CEBU INSTITUTE OF TECHNOLOGYUNIVERSITY College Of Nursing

SY: 2011-2012 Cebu Puericulture Center and Maternity House Incorporation

CASE PRESENTATION
Submitted by: GROUP 3 Nunez, Kimberly faith Pasaol, Willow Jed Prajes, Stephanie Quijote, Sherwin Mike Rocafor, Marianne Romero, Stevenson Saeed, Saira Tamayo, Danielle Villamer, Jan Marfie Ybanez, Maria Christina BSN 2- NI Submitted To:

Mrs. Lucelle Valencia

INTRODUCTION

Caesarean section (C-section) is the delivery of a baby through a cut in the mothers lower abdomen and the uterus. It was an operation with many risks, less than a century ago. Today, it is one of the most frequently performed surgeries in the world. Caesarean births are more common than most surgeries (such as gallbladder removal, hysterectomy or tonsillectomy) due to many factors. One factor, of course, is that nearly 50% of the world population are women, and pregnancy is still a very common condition! However, more important is the fact that a Caesarean section may be life saving for the baby, or mother (or both). Caesarean birth is also much safer today than it was a few decades ago. Thus caesarean is not something that should scare you, as the ultimate goal is a healthy mother and healthy baby, regardless of the method of delivery. It is important to know a few things about caesarean section in order to be prepared for a caesarean birth if it does happen to you.

PATIENTS PROFILE Patients Name: Mrs. X Case No.: 074453/11

Name of the Hospital: Cebu Puericulture Center and Maternity House Incorporation Civil Status: Single Address: Logarta Street Cebu City Highest Educational Attainment: College Level Date/Time of Admission: December 4, 2011 @ 9:50 AM Admitting Diagnosis: PUFT Multiferal Pregnancy PATIENTS MEDICAL HISTORY: 1. Immunizations Received: Tetanus Toxoid (TT1, TT2) 2. Allergies: Food: Drugs: Others: 3. 4. 5. 6. 7. 8. Smoking: Drinking: Heredo-Familial Disease: Recent Exposure to communicable disease: Geographical History: Travel for the last: Current Medication List: Dosage 30mg 50mg Route of medication IVTT IVTT PO PO PO Frequency q 6 q 6 BID BID OB x 5 days Last Dose MD Religion: Roman Catholic

Name of medication Ketorolac Tramadol FeSo4 (trinemic) Cefuroxime (Zoltax) Etericoxib (Arcoxia)

500mg 120mg

OBSTETRICAL HISTORY: a) b) c) d) e) f) g) h) i) G1 T P A L Desire Family Size: ( ) 1 (*) 2 ( ) 3 ( ) 4 ( ) more:_________ Menarche at: ( )9 -11 y.o (*)12-14 y.o ( )15-17 y.o ( )others:__________ Menstrual Cycle: ( )28 (*)29 ( )30 ( )31 ( )32 ( )others:__________ Duration: (*) 1-3days ( ) 1-4days ( )1-5days ( )1-6days ( ) 1-8days ( ) 1-10days ( )others____ Specify number of pads used per day: 3 Problems encountered during menstruation: ( none) Dietary history during pregnancy: meat, fruits, vegetables Complications of Pregnancy during the: 1st trimester: nausea and vomiting 2nd trimester:_________________ 3rd trimester:_________________ j) k) l) m) n) Total weight gain: (N/A) Methods of contraception used: (none) Prenatal check-up: (*) Yes ( ) No Where: Clinic Previous Surgery: Date: Where: Post Operative Diagnosis:

How many times: Regular

o) Genito- urinary problems encountered:

History Of previous deliveries: a) b) c) d) e) f) g) Mode of Delivery: C/S Delivered/handled by: Doctor Place of delivery: Hospital Complications after delivery: (none) Perineal laceration/episiotomy: ( ) Yes (*) No Post-partum vital signs: T: 36.4 ; P: 80 ; R : 26 ; BP: 130/80 Final diagnosis: G1P1 Pregnancy uterine delivered pregnancy LSTCS for first twin in footling breech presentation; second twin in transverse lie presentation.

Admission Data: (baseline data) a) Date admitted: 12/04/11 b) Time: 9:50 am c) Mode of admission: Emergency Admission Accompanied by: Sister in- law d) Source of information: Patient, Parents, Family members, Relatives e) Problem/urgent needs on arrival: f) Action taken: g) Admission diagnosis: PUFT Multifetal Pregnancy h) Chief compliant: Vital signs on admission: Temp. 37.0 Pulse rate 80 Respiratory Blood rate pressure 22 120/80 Weight 65kg Height 54 O2 Remarks saturation

PHYSICAL ASSESSMENT (HEAD TO TOE) BODY PARTS Head IPPA ASSESSMENT FINDINGS I y y y y y Hair skull is generally round Scalp is lighter in color than the complexion Oily No scars noted Free from lice, nits, and dandruff REVIEW OF SYSTEMS

Eyes Eyebrows Eyelids Eyeballs Cornea Pupils Iris Eye Function Visual Acuity Peripheral vision Ears Nose and Sinuses

I Black hair, Straight, evenly distributed, fine No parasites, no lesions Smooth and firm scalp I Hair evenly distributed; skin intact I equally distributed I lids close symmetrically, approximately is to 20 involuntary blinks per minute, bilateral blinking. I Parallel eye movement I transparent, shiny and smooth, details of the iris are visible. I black in color, equal in size; normally 3 to 7 mm in diameter, round, smooth border. I iris flat and round. I both eyes coordinated, move in unison, with parallel alignment. I able to read newsprint I when looking straight ahead, client can see objects in the periphery I color same as facial skin, symmetrical, normal alignment I symmetric and straight, no discharge of flaring, uniform color P no tender, no lesions, air moves freely as the client breath through

Mouth Lips Teeth Buccal Mucosa Gums Tongue Hard Palate Soft Palate Oropharynx Uvula and Frenulum Neck Thyroid Carotid Artery and Lymph nodes

the nares. I - Uniform pink color P uniform, smooth, soft, glistening and elastic texture I smooth, white, shiny tooth enamel I moist, firm texture to gums I pink gums I pink color, central position, moves freely; no tenderness P smooth with no palpable nodules I lighter pink hard palate, more irregular texture I light pink smooth I pink and smooth posterior wall I positioned in midline of soft palate I muscles equal in size; head centered I not visible on inspection P lobes may not be palpated P not palpable

Chest Breast

I no deformities I rounded shaped, slightly unequal in size, generally symmetric P no tenderness, masses, nodules or nipple discharge I round or oval and bilaterally the same color varies widely, form light pink to dark brown P no masses, nodules, or nipple discharge I round inverted, and equal in size; similar in color; both nipples point in the same direction. P smooth and soft A Labdab sound is audible in the stethoscope - (-) murmurs I spined vertical aligned P skin intact- uniform temperature

Areola

Nipple

Heart Thorax and Lungs

Abdomen

Genitalia

Upper Extremities Fingernails

I unblemished skin-uniform color, presence of silver white strive P No tenderness; relaxed abdomen with smooth, consistent tension. I there are widely variations; generally kinky in the same menstruating adult, thinner and straighter after menopause I both extremities are equal in size I Round and hard - Lighter color nail bed - Color returns < 2 seconds I highly vascular and pink in lightskinned P prompt return to pink or usual color ( generally less than 2 seconds)

Toenails

ANATOMY AND PHYSIOLOGY

DISCHARGE PLAN
METHODS: Medication: >Instruct the client to continue taking the medication. >Advise the client not to miss in taking the medication. >Instruct the client to report to the physician for any side effects upon taking the medication. Environment: >Maintain quiet and peaceful place for relaxation. >Maintain cleanliness of the surroundings. >Proper disposal of garbage with proper segregation. Treatment: >Instruct the patient to have enough rest. >Instruct the patient to report immediately to the Physician if there is a signs of complications on adverse effects.

Hygiene: >Instruct the patient to take a bath to maintain cleanliness. Observation: >Instruct the patient to report to the physician If there are signs of abnormalities. Diet: >Instruct the patient to eat nutritious foods. >Encourage patient to drink plenty of water. Spiritual: >Encourage the patient to have faith in GOD. >Encourage to pray the holy rosary. >Encourage patient to read bible.

GORDONS HEALTH PATTERN 1. Health Perception Management Pattern Before: - Mrs. X describe her health as healthy, she avoids being exposed to vice and good exercise as a way to keep herself healthy After: - She still defines herself as healthy but worries about being pregnant and how her pregnancy will affect her health. 2. Nutritional Metabolic Pattern Before: - She eats 3 times a day and eats many kinds of foods. She does not have any allergies related to food. After: - She already eats more than the usual, and she also started taking vitamins and supplements that is necessary for the development for the baby as well as the mother. 3. Elimination Pattern Before: - She has regular voiding patterns and her urine is pale yellow. She does not have any discomfort. After: - She experience frequent urination, she never experienced postponing her urination or defecation, but she did not experience any problems in elimination. 4. Activity Exercise Pattern Before:

5.

6.

7.

8.

9.

She always spend her time with her family because of her work, and uses it as an exercise. After: - She already had more time with her family because. She stopped working, and she also advised to rest most of the time because she had difficulty in sitting, standing and other simple routines. Sleep and Rest Before: - She sleeps late because of her work and wakes up early for her work. After: - She already had more time sleeping, she sleeps 8pm and wakes up at 6-8pm. She sometimes experiences disturbance of sleep exercise of her belly but is able to go back to sleep after some time. Cognitive Perceptual Pattern Before: - She doesnt have any problems with her sensual functions like hearing or seeing. After: - The surgery in her abdominal region is still aching but not like in the first days of post-partum. She also experiences sudden headaches, but only wild intensity. Self Concept Pattern - She describes herself as a happy person but she is happier now that she booze a twin. She noticed that her weight has increased and her abdomen is still not going back in place. She relies on her family when problem comes and is already not afraid of giving birth. Role Relationship Pattern - She lives with her partner (not married) and relies only with her husband regarding money. Sexuality Representative Pattern - She began her menstruation at the age of 14 years old. She experienced minor problems during menstruation but was able to overcome the problem; this is her first time to get pregnant and to have a multifocal pregnancy.

10. Coping and Stress Tolerance Pattern

She is a very optimistic person. She never took her pregnancy as a stressing factor, she is happy with her pregnancy; she is also supported by her family during her pregnancy.

11. Values Belief Pattern She is a religious person, she goes to mass every week, and her family and God is her main source of strength and enlightment , and now that she is a mother, her children is her inspiration.