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. (eMedicine Health, 2011)

Many complications of cesarean section delivery are unpredictable and very rare,
but there are some things that make women more likely to have complications. Some
complication includes obesity, large infant size. Emergency complications that
necessitate a C-section which are long labor or surgery, having more than one baby,
allergies to anesthetics, drugs, or latex, maternal inactivity, low maternal blood cell
count, use of an epidural and premature labor. (healthline, 2012)

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 one-third
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 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

2
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 Novemberof 2005, the
Centers for Disease Control and Prevention (CDC) reported the national
cesareanbirth rate was the highest ever at 29.1%, which is over a quarter of all
deliveries. This meansthat 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 regionrecourse to
caesarean sections.(LEADs Technical Strategy on Maternal and Child Health 2008)

Data shows that during the year 2011 there were 332 deliveries at Tagum City.
58.36% of the total number of deliveries is normal spontaneous vaginal delivery and
the remaining percentage was of cesarean sections.(Tagum City Health Office, 2012)
In Tagum Doctors Hospital there are 165 cesarean deliveries in the year 2012.
(Tagum Doctors Hospital Inc.2012)

I choose this Case to improve my skills and knowledge pertaining on caring postoperative patients and to be able to apply my learnings during lectures and
demonstrations related to the case chosen.

3
II.

OBJECTIVES

A. General objectives
This case study is designed to identify health problems or potential threats that
could arise in my patient. As student nurse, it is expected to apply what I have
learned from my class lectures in the actual settings.

B. Specific Objectives
The specific objectives are enumerated as follows;

Gather the bibliography data of the patient;

gather the history of present illness, past medical history, obstetrical

history, family history and socio- economic history of the patient;

trace the developmental task according to Erickson, Freud, and Piaget;

perform physical assessment using the methodical head-to toe format and
identify the chief complaint of the client;

review the diagnostic test or exam and its indication that the client had
gone;

review the anatomy and physiology of the involved organs and systems;

trace the pathophysiology of the disease or illness;

formulate a nursing care plan;

identify the medication that the client is taking;

present conclusions about the client's condition;

present recommendations and discharge plan about the client's condition;

and

Present evaluation regarding this case study.

4
II. ASSESSMENT

A. Biographical Data
Name

: Patient X

Age

: 24 years old

Sex

: Female

Civil Status

: Single

Nationality

: Filipino

Birthday

: March 1, 1990

Birth Place

: Davao City

Occupation

: None

Address

: Prk.3,Mainit, Nabunturan Compostela Valley

Prov

Religion

: Roman Catholic

Name of Partner

: Mr. X

Educational Attainment

: 2nd yr. college

5
B. Chief Complaint
The patient is 24 years old with complaint of pain related to surgical
incision during the assessment. G1 P1 A0 L1
C. Obstetric History
Patient X is immunized with Diphtheria, Poliomyelitis, Tetanus Toxoid, and
Hepa B at Prk. Mainit Health Center. The patient verbalized that she visits at the
center every month for checkup and to ask for Ferrous Sulfate. At her 7th month
of pregnancy, she had an ultrasound at Tagum Doctors Hospital with Dr. Aquino
as her obstetrician. She had her check up every 2 weeks as instructed by her
OB.
D. Past Medical History
Illness
Age
Mumps
7 years old
Chickenpox
14 years old

Duration
3 days
1 week

Dengue

10 years old

1 week

Gingivitis

20 years old

3 days

Treatment
Aniel
Isolation
and
took
medicine
(Acyclovir)
Admitted
to
Flores Sr. Clinic
for 1 week
Confined
to
Nabunturan
Doctors Hospital

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 her 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

6
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.

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
August 26, 2014.
Her partner, 26 y/o, working as a miner at APEX Mining Corporation has a
monthly income of 20,000-40,000php per month. According to Patient X, they are
planning

to

get

married

next

year.

G. Genogram

X, 24

8
H. Developmental History
Theorist /
Developmenta
Theory
l Stages / Task
Erik Erikson Stage 1
INFANCY
Psychosocia (0 to 1 years
l Theory
old)

Trust
Mistrust

Normal
Findings
A sense of trust
requires
a
feeling
of
physical comfort
and a minimal
amount of fear
vs. 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)

Stage 2
Early childhood
(18
mos.-3
yrs.)

After
gaining
trust in their
caregivers,
infants begin to
discover
that
their behavior is
Autonomy vs. their own. They
shame
and start to assert
doubt
their sense of
independence,

Actual
Findings
She
grew
up with her
parents.
Her parents
gave
her
infants
basic needs
like
food
and
comfort.
She
also
feels
love
by
her
parents.
-TRUST-

She gained
more
control over
food
choices, toy
preferences
,
and
clothing
selection.
She learn to

Interpretatio
n
In this stage,
the
infants
primary
source
of
pleasure
is
sucking and
the area of
gratification is
the mouth
- An infant is
very
dependent
and can do
little
for
herself.
If
infants needs
properly
fulfilled
can
move
onto
the next stage
but
if
not
fulfilled infant
will
be
mistrustful or
over-fulfilled
baby will find
hard to cope
with a world
that doesnt
meet
all
his/her
demands.
-ACHIEVEDThe second
stage
of
Eriksons
theory
of
psychosocial
development
takes
place
during early
childhood and
is focused on

9
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
Initiative versus
Play age (3-5 guilt is Eriksons
yrs.)
third stage of
Initiative
vs. development,
guilt
occurring during
the
preschool
years.
As
preschool
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.
Developing
a
sense
of
responsibility
increases

say NO.

children
developing a
greater sense
of
personal
control.
-ACHIEVED-

She made
up stories
with barbie
doll,
toy
phones,
and
play
bahaybahayan
with
her
friends.

During
the
preschool
years,
children begin
to assert their
power
and
control over
the
world
through
directing play
and
other
social
interaction.
-ACHIEVED-

10
initiative.
Uncomfortable
guilt
feelings
may
arise,
though, if the
child
is
irresponsible
and is made to
feel too anxious.
(Demand
Media, 2010)
Stage 4
Itinvolves
the
School age (6- shift
from
12 yrs.)
whimsical play
to a desire for
Industry
vs. achievement
Inferiority
and completion.
A child learns
that he receives
praise
and
recognition for
doing well in
school
and
completing
tasks and also
realizes he can
fail at these
tasks as well.
(Demand
Media, 2010)

She
was
encouraged
by
her
parents and
teachers to
join
curricular
activities
such as in
literacy
contest and
quiz
bee.
Her
parents,
teachers,
and peers
gave her full
support.

During
this
stage, often
called
the
Latency, we
are capable
of
learning,
creating and
accomplishin
g numerous
new skills and
knowledge,
thus
developing a
sense
of
industry.
This is also a
very
social
stage
of
development
and if we
experience
unresolved
feelings
of
inadequacy
and
inferiority
among
our
peers, we can
have serious
problems in
terms
of
competence
and
selfesteem. Up to
this
stage,

11

Stage 5
Adolescence
(12-18 yrs.old)
Identity
Confusion

The adolescent
is
newly
concerned with
how
they
vs. appear
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
identities and a
sense of self.
The
central
question of this
stage
is
of
course,
Who
am
I?.
(Demand
Media, 2010)

At
this
stage she
usually
hangs out
with her girl
friends and
is attracted
to opposite
sex.

according to
Erikson,
development
mostly
depends
upon what is
done to us.
From here on
out,
development
depends
primarily upon
what we do.
-ACHIEVEDAdolescence
is a stage at
which we are
neither a child
nor an adult,
life
is
definitely
getting more
complex
as
we attempt to
find our own
identity,
struggle with
social
interactions,
and grapple
with
moral
issues.
-ACHIEVED-

12
Stage 6
Which
Young
individuals
adulthood (18- experience
35 yrs. Old)
during the early
adulthood
Intimacy
and years. At this
Solidarity
vs. time, individuals
Isolation
face
the
developmental
task of forming
intimate
relationships
with
others. (Deman
d Media, 2010)

My patient
found
a
mutually
satisfying
relationship
and
built
her
own
family with
her partner.

This
stage
covers
the
period
of
early
adulthood
when people
are exploring
personal
relationships.
-ACHIEVED-

13
Theorist /
Developmental
Theory
Stages / Task
Sigmund
Oral stage
Freud
Birth- 1 yr. old
Psychosexu
al Theory

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
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
through this
oral

Actual
Findings
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
caretakers.
A fixation at
this
stage
can result in
problems
with
dependency
or
aggression.

Interpretatio
n
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
doesnt meet
all of his/her
demands.
-ACHIEVED-

14
stimulation.
(Kendra
Cherry,
2011)
Anal Stage
During
the Toddlers
TODDLER 2-3 anal stage, attention
YEARS OLD
Freud
focused on
believed that the anus and
the primary the
sexual
focus of the pleasure is
libido was on the
controlling
elimination.
bladder and
bowel
-she learns
movements.
to eat by her
The
major own, washes
conflict at this her
hands
stage is toilet and dresses
training--the
herself.
child has to -In this stage
learn
to she started
control his or to play toy.
her
bodily needs.
AUTONOMY
Developing
this
control
leads to a
sense
of
accomplishm
ent
and
independenc
e.
(Kendra
Cherry,
2011)

Toddlers
should
control
a
bowel thats
why
they
should have
toilet training
to
control
urges
and
behaviors.
-Caregivers
should
encourage
self-sufficient
behavior,
toddlers
develop
a
sense
of
autonomy- a
sense
of
being able to
handle many
problems on
their
own.
But
if
caregivers
demand too
much
too
soon, refuse
to let children
perform
tasks
of
which
they
are capable,
or
ridicule
early
attempts at
selfsufficiency;
children may
instead

15

Phallic Stage
PRESCHOOLE
R
4 TO 6 YEARS
OLD

During
the
phallic stage,
the primary
focus of the
libido is on
the genitals.
Children also
discover the
differences
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
father.
However, the
child
also
fears that he
will
be
punished by
the father for
these
feelings,
a

Childrens
focused
in
genital
region and
become
particularly
interested in
playing with
their genitals
at this stage.
She began
to
speak,
count
numbers,
and
doing
simple
chores like
sweeping
the floor.
INITIATIVE-

develop
shame and
doubt about
their ability to
handle
problems.
-ACHIEVEDMorality and
sexuality
identification
and figuring
out what it
means to be
girl/boy.
According to
Freud,
children have
sexual
feelings for
the opposite
sexed parent
at this stage
and
feel
some
hostility
in
same-sex
parent. Boys
experience
castration
and
girls
suffer penis
envy.
-Parents and
preschool
teachers
encourage
and support
children's
efforts, while
also helping
them make
realistic and
appropriate
choices,
children
develop

16
fear
Freud
termed
castration
anxiety. The
term Electra
complex has
been used to
describe
a
similar set of
feelings
experienced
by
young
girls. Freud,
however,
believed that
girls instead
experience
penis envy.
(Kendra
Cherry,
2011)

Latency Stage During

this
(6 yr. old to time, sexual
Puberty)
feelings are
suppressed
to
allow
children
to
focus
their
energy
on
other aspects
of life. This is
a time of
learning,
forming
beliefs
and
values,
developing
same-sex
friendships,
engaging in
sports, etc.
This period of
sexual

initiativeindependenc
e in planning
and
undertaking
activities. But
if,
instead,
adults
discourage
the pursuit of
independent
activities or
dismiss them
as silly and
bothersome,
children
develop guilt
about
their
needs
and
desires.
-ACHIEVED-

According to
my patient
as
she
remember at
this age, she
already
learns how
to write, to
count and to
identify
shapes and
colors. She
usually plays
with her girlfriends even
though she
have friends
in
an
opposite
sex. At this
stage
according to

Pt x at this
stage
develops the
same
sex
friendship
where she is
not confused
with
homosexual
relstionship.
She focus on
areas
like
academics,
athletics and
social
interactions.
-ACHIEVED-

17
latency lasts
five to six
years,
until
puberty,
upon which
children
become
capable
of
reproduction,
and
their
sexuality is
re-awakened

patient
x,
she already
knew
her
limitations
and
restrictions
especially
what is right
and wrong.

18
Theorist /
Theory
Jean Piaget
Cognitive
Developmen
t

Stages /
Normal Findings
Task
Sensory Differentiates self
motor
from objects
(Birth 2
yrs. old)
Recognizes self
as agent of action
and begins to act
intentionally: e.g.
pulls a string to
set
mobile
in
motion or shakes
a rattle to make a
noise. Achieves
object
permanence:
realises
that
things continue to
exist even when
no longer present
to
the
sense.(Atherton J
S, 2011))

Actual
Findings
During
this
stage,
the
child learns
about herself
and
her
environment
through
motor
and
reflex
actions.
Thought
derives from
sensation
and
movement.
The
child
learns
that
she
is
separate
from
her
environment
and
that
aspects
of
her
environment
-- her parents
or favorite toy
-- continue to
exist
even
though they
may
be
outside the
reach of her
senses.

Interpretatio
n
During
this
stage, a child
has relatively
little
competence
in
representing
the
environment
using
images,
language, or
symbols. An
infant has no
awareness of
objects
or
people that
are
not
immediately
present at a
given
moment.
Object
permanence
is
the
awareness
that objects
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
-ACHIEVEDPre
Learns to use She is now Children
operational language and to better able to develop an
(2-7
yrs. represent objects think about internal

19
old)

by images
words

and 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
is
together all the thinking
red
blocks influenced by
regardless
of fantasy -- the
she'd
shape or all the way
square
blocks like things to
regardless
of be -- and she
color.(Atherton J assumes that
see
S,
2011) others
situations
from
her
viewpoint.
She takes in
information
and
then
changes it in
her mind to fit
her ideas.

representatio
n of the world
that
allows
them
to
describe
people,
events, and
feelings.
Children
in
the
preoperation
al stage are
characterized
by
what
Piaget called
egocentric
thoughts.
The world at
this stage is
viewed
entirely from
the
child's
own
perspective.
Thus a child's
explanation
to an adult
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
the
configuration
is changed.
Concrete
Can think logically The
child Children
in
operational about objects and develops an the concrete

20
(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)

Formal
operational
(11 yrs and
up)

Can think logically

about
abstract
propositions and
test hypotheses
systematically
Becomes
concerned
with
the hypothetical,
the future, and
ideological
problems.(Atherto
n J S, 2011)

ability to think
abstractly
and to make
rational
judgments
about
concrete or
observable
phenomena,
which in the
past.
She
needed
to
manipulate
physically to
understand.
She is no
longer
requires
concrete
objects
to
make rational
judgments.
At her point,
she
is
capable
of
hypothetical
and
deductive
reasoning.

operational
stage have a
better
understandin
g of time and
space.
Children
at
this
stage
have limits to
their abstract
thinking,
according to
Piaget.
-ACHIEVEDThis
stage
produces a
new kind of
thinking that
is
abstract,
formal, and
logical.
Thinking
is
no longer tied
to events that
can
be
observed. A
child at this
stage
can
think
hypothetically
and use logic
to
solve
problems. It
is
thought
that not all
individuals
reach
this
level
of
thinking.

21
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

Normal Findings

Actual Findings

Integumentary
(HEENT)
Head
Inspection

-Normocephalic
and
symmetric
facial
features,
symmetrical
and
contour rounded.
Softening
and
thinning of the hair.

-Patient's head was

normocephalic
and
symmetric,
symmetrical
facial
features.
Facial
grimace and flushed
face noted. Dry lips
noted.

-absence
of
lesions,
masses,
tenderness, bumps,
and
dandruffs.
Relatively soft with
no
unexpected
contours or bulges.
In her TMJ it should
be
smooth,
symmetrical
motion, with no
pain, crepitus, or
clicking.
-Absence
of
discharges and any
hearing
complications just
like ear ringing and
impaired
hearing
ability. Ears should
be in line with the
outer canthus of
the eye.

-With the absence of

lesions,
masses,
bumps,
and
tenderness. She also
had symmetric facial
movements with hair
in eyebrows evenly
distributed and skin
intact in the eyebrows.

Interpretatio
n
-The head is
symmetrical
in shape and
with
the
absence of
any
problems.
Normal
implication.
(Patricia M.
Dillon,2007)

Palpation

Ears
Inspection

Palpation

-Ears are found in line

with the outer canthus
of the eye. No hearing
problems detected in
the
both
ears.
Absence
of
discharges.

-Both
ears
are normally
functioning.
(Patricia M.
Dillon,2007)

-Both

ears

22

Eyes
Inspection

-Without presence
of discharges and
the color of the ear
is consistent with
the skin color.
-Without
the
presence
of
nodules or masses,
structures should
be non-tender with
no swelling.
It should be soft
and pliable, nontender.
-Note for clarity and
parallel alignment,
eyes should clear
and
bright,
in
parallel alignment,
note
for
the
presence of contact
lenses.
The
eyelashes have no
presence
of
crusting
or
infestation; note the
hair distribution of
the
eyelashes
present and curving
outward.
Eyelids
note for edema,
and lesions, eyelids
should in contact
with the eyeball.
The eyeball should
have no protrusion
without
lesions.
The lacrimal gland
and
nasolacrimal
duct should have
no
nodules,
lesions,
and
masses,
without
presence
of
swelling, redness,

-Without presence of
masses swelling and
nodules.
No
tenderness was felt by
the patient during
palpation. The ears of
the client are soft and
pliable.

- Sclera is white, with

shiny cornea, pupil is
round and reactive to
light. No corrective
lenses were used.
Without presence of
crusting or infestation
in the eyelashes. The
hair of the eyelashes
is well distributed.
Eyelids are contact
and without presence
of edema.
The
bulbar
and
palpebral conjunctiva
is clear, minimal blood
vessels,
and
the
sclera is white and
visible.

are normally
functioning.
It
means
normal
indication.
(Patricia M.
Dillon,2007)

-Patient has
a
visual
acuity
of
20/20
with
wellconditioned
eyes.
(Patricia M.
Dillon,2007)

23

Palpation

or drainage. In
conjunctiva
(palpebral) it should
be
smooth,
glistening, pinkishpeach color, with
minimal
blood
vessels
visible,
bulbar conjunctiva
over the globes
should be 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 eyes were
aligned
to
the
upper part of the
ears. Redness and
swelling must be
absent.
- The globe of the
eye is firm and nontender.
Lacrimal
glands
and
nasolacrimal ducts
should
non
palpable,
no
tearing.

Nose
Inspection

-The lacrimal gland

and nasolacrimal duct
without presence of
lesions, masses and
swelling. The bulbar
and
palpebral
conjunctiva
without
presence of masses
and nodules.
-No nasal flaring, -No flaring and no -The patient
no
drainage,
it discharge during the has
no
should be pink in assessment.
difficulty on
color (it depend on
breathing.
the
ethnicity)
(Patricia M.
should be intact
Dillon,2007)
with no lesions or
perforations,
no
crusting or polyps,
septum
located

24

Palpation

Neck
Inspection

Palpation

Nails
Inspection

Palpation

Skin
Inspection

midline.
No
impaired
smelling ability.
-Note for nostrils
and
note
for
patency.
Cartilaginous
portions is should
be slightly mobile,
no masses, and
nares should be
patent.
-Inspect neck, it
should be erect, no
lumps, bulges, or
masses.
Thyroid
not
visible,
no
masses, swelling,
or hypertrophy in
mid to lower half of
anterior neck.
-cervical nodes are
non-palpable.
Trachea is midline
and mobile. Thyroid
is
non-palpable,
non-tender.
-Pink nail bed, with
glossy appearance,
absence
of
hemorrhage,
discoloration
of
surrounding tissues
and clubbing, angle
of nail attachment
160 degrees, nails
convex.
-The nail should
firm,
and
the
longitudinal.
Uniform skin color
with slightly darker
exposed areas.

-Then there is no
feeling of tenderness
felt by the patient
when we palpate her
nose.

-Upon the inspection

her neck is erect,
without the presence
of lumps, bulges, or
masses. Her thyroid is
not visible no masses,
no swelling, or any
hypertrophy.
-Upon the palpation,
there are no lumps or
bumps. Trachea is
midline and thyroid is
not palpable.

No problems
were found
in her neck
upon
the
inspection
and
palpation.
(Patricia M.
Dillon,2007)

-As
observed
the
patient's nail bed color
was pinkish. During
assessment
the
texture of the patient's
nail is rough. Her nails
have convex curvature
with capillary refill time
of less than 1 second.

-Changes in
nail texture
are due to
the influence
of hormonal
changes
during
pregnancy.
Normal
indication.
(Patricia M.
Dillon,2007)

-Presence of lesions
and excessive acne
are noted on the face
and upper extremities.
Skin darkening Is
observed in the neck

-During
pregnancy
the
occurrence
of
skin
darkening

25
& underarms.

Palpation

-skin
is
warm,
exposed
skin
usually not as soft
as the exposed
skin,
elasticity
decreases
with
age,
exposed
areas may have
less turgor.

-As palpated, skin is

warm to touch with a
temp. of 38.5C. Pain
and tenderness not
noted.

Respiratory
Inspection

-Chest expansion
should be full and
symmetrical, chest
skin
and
hair
distribution (men)
should
be
consistent
with
patients
gender,
skin intact with no
scars.
Spine
straight
without
lateral curves or
deformities.
-Trachea should be
in
midline,
no
deformities
or
crepitus,
nontender,
chest
excursion
should
be
symmetrical
without lag. (Tactile
Fremitus)
should
be
equal
and
diminished
mid
thorax.

-No lesions and scar

was observed on the
patients chest. Full
chest expansion with
shallow
breathing
patterns
and
symmetric
vocal
fremitus
with
no
presence of secretions
found.
Respiratory
rate of the patient is
26 cpm.

Palpation

-The trachea of the

patient in midline, no
deformities
noted,
chest
excursion
symmetrical
without
lag.

was normal,
this change
is due to the
increased
secretion of
melanotropin
an anterior
pituitary
hormone.
(Patricia M.
Dillon,2007)
Patient has
elevated
temperature
which
indicates a
possible sign
of
infection(Patr
icia
M.
Dillon,2007)
-Patients
have stable
respiratory
condition
with
no
problems
identified.
(Patricia M.
Dillon,2007)

Patients
have stable
respiratory
condition
with
no
problems
identified.
(Patricia M.
Dillon,2007)

26
Percussion

-Without presence
of
tenderness
during percussion,
it should be without
dullness
and
without
hyper
resonance noted.

-without presence of
tenderness
during
percussion,
without
dullness noted and
hyper resonance.

Auscultation

-Without
adventitious sound
noted, lungs should
be
clear
to
auscultation.
No
crackles, wheezes,
or rubs.

-Lungs
are
Adventitious
and
cough
during
assessment.

Cardiovascula
r system
Palpation

-Point
maximal
impulse is found to
be located at the
5thintercostals
space at the left
midclavicular line.
(PMI
may
be
displaced upward
and laterally in the
latter stages of
pregnancy.)

-The
PMI
was
detected
at
the
th
5 intercostals space
at
the
left
midclavicular
line.
Heart rate was 70
beats per minute.
Pulse rate at 98 bpm.

clear.
sound
noted
the

Auscultation

Breast
Inspection

Without
the
presence of extra
sounds
upon
auscultation.
No
aortic murmurs.
( systolic murmurs
caused
by
increased
blood
volume )
-Increased in size,
and
nodularity,
increased
sensitivity.
And
latter
colostrum
secretion in the
third
trimester.

Heart sound (S1 and

S2)
without
the
presence of extra
sound, and without the
presence of aortic
murmurs.
Blood
pressure 120/70.
- No dimpling and
lesions. Tenderness
not noted. Dark areola
and nipple noted.

Patients
have stable
respiratory
condition
with
no
problems
identified.
(Patricia M.
Dillon,2007)
Patients
have stable
respiratory
condition
with
no
problems
identified.
(Patricia M.
Dillon,2007)
-The
patients
heart
and
pulse
rate
was in order
with
the
normal range
which means
that
there
were
no
complication
s when it
comes to her
cardiovascul
ar system.
(Patricia M.
Dillon,2007)

- Areola and
nipple
are
darker than
the
breast
tissue.
Become
even darker

27

Palpation

Gastrointestin
al system
Inspection

Hyperpigmentation
of
nipples
and
areolar tissue. No
dimpling
or
retraction,
no
increase in venous
pattern
unless
patient is pregnant.
Then symmetrical
increased
is
normal.
Nipples
have no discharges
or lesions.
-There should be
absence of masses
and
lesions.
Tenderness should
also be absent and
also
dimpling.
Breast should be
soft
and
nontender.

- Skin should be
intact,
with
no
lesions, or masses.
Striae
maybe
present. If new,
should be pink; if
old,
white/silver.
Umbilicus inverted
and in midline.

during
pregnancy.
(Patricia M.
Dillon, 2007)

Non-tender
and
engorged.
Masses
and lesions not noted.
Spontaneous
discharges
of
colostrum noted.

-Skin color is the same

throughout
the
abdomen.
Striae
gravidarum
noted.
Incision: (REEDA)
Post
CS
(vertical
incision),
clean, dry, dressing
on, no redness, no
edema,
no
ecchymosis,
no
drainage,
no
approximation.

-Colostrum is
produced in
the
late
stage
of
pregnancy till
the 4 days
after
pregnancy. It
is a deep
yellow fluid.
Spontaneous
discharge is
normal
during
pregnancy
and lactation
(Patricia M.
Dillon,2007)
Presence of
striae
gravidarum
after
pregnancy is
normal
because
it
doesn't
directly
disappear
after giving
birth.
Presence of
redness,
edema, and

28

Auscultation

-An average bowel

sound is found to
be present at a rate
of 5 to 30 clicks per
minute.
Without
presence of other
extra sound.

Positive bowel sound

at a rate of 15 clicks
per minute. Flatus
present. Last bowel
movement 1/16/2011
with soft stool.

Palpation

No
abdominal
distention.
In
average
adult,
contour should be
either flat, round, or
scaphoid.
-person should void
every hour at 30 cc
per hr.

The
patients
abdomen is firm and
rounded.

Genitourinary
system
Inspection/
Palpation

Neurologic
Inspection

-Alert
and
conscious,
uses
clear
and
appropriate words
during
conversations.

ecchymosis
indicates an
infection.
(Patricia M.
Dillon,2007)
-Patient's
bowel
sounds were
found to be
in
normal
range
(Nursing
Health
Assessment,
2nd edition by
Patricia M.
Dillon)
Page ( 836839 )
Normal
indication.
(Patricia M.
Dillon,2007)

Patient has voided 30- Patient's

50cc per hr. measured bladder was
via foley catheter.
functioning
normally.(Pat
ricia
M.
Dillon,2007)
-The
patient
was Her
conscious and awake. memory and
Oriented to people, thinking skills
time, and place. Was were intact.
able
to
think Her
comprehensively and neurologist
use appropriate words status was
during conversations.
still
functioning;
she was able
to
give
correct and
appropriate
answer
to
the
given

29

Reproductive
system
Inspection
Vaginal
discharge

Palpation/
Uterus

Lochia Rubra- a
red,
distinctly
blood-tinged
vaginal flow that
follows delivery. It
lasts from two to
four days after
delivery.
-Size
varies
according to parity.
Pear shaped in
nongravid woman
and more rounded
in parous woman.
Smooth,
firm,
mobile, nontender,
and
without
masses.

questions.
(Patricia M.
Dillon,2007)
Lochia rubra noted in Lochia with a
a moderate flow.
foul- smell or
Foul smell not noted.
a green-tinge
may indicate
infection.
(Patricia M.
Dillon, 2007)
-Normal
-Uterus is firm and findings.
located above the Boggy uterus
umbilicus.
indicates
uterine atony
which leads
to bleeding.
(Patricia M.
Dillon,2007)

30
COURSE IN THE WARD
A. Doctors order
Date
08/24/14

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

08/25/14

For NST in AM after breakfast

1 am

IE
FAT: 148/min

8am

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
30min with record please

08/26/14

1pm

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

6am

Dinospostore
500mg/3gl
per
cervical cavad now
Continue FHT & POL monitoring
q 30min
To EFM at 2 pm please refer.
Give
nuborn
2.5mg
&
promotherine 12.5 mg slow IVTT
now

31
10:30

08/26/14

12nn

For STAT CS- 2 fetal distress

Serve consent & SE
Please inform anesthesiologist
Please inset PL & attach to
urobag

Please inform pediatrician

POST OP ORDER
To PAW x2 then to room
NPO tempo then gal icuds shown
post op.

32
IV. LABORATORY EXAMINATIONS
ELECTRIC FETAL MONITORING REPORT
Date: 08/26/14
Electric fetal
Actual
Interpretation
monitoring
findings
Baseline fetal 130-142 bpm The baseline fetal heart rate is normally
heart rate

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
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

variability may be uncomplicated and may

be the result of fetal quiescence (rest-

33
activity 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

The

baseline

rate

is

interpreted

as

pattern

accelerations

changed if the alteration persists for more

are seen in

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.
http://www.aafp.org/afp/990501ap/2487.ht
ml

Uterine

one contraction Regular

contraction

is seen

intervals

that

begin

before

the fetus is mature, usually before the

measuring22-45 mmhg

due of delivery. Contractions

intensity every 6-7 min.

your abdomen tightens like a fist every 10

minutes

or

more

often.

are

Low,

when

dull

backache.
http://en.mimi.hu/pregnancy/uterine_contr
actions.html

OBSTETRIC ULTRAOUND REPORT

34
Date: 04/15/14
Obstetric ultrasound
I.
FETAL BIOMETRY
BPD

Actual findings
49.6 mm - 21 W0D

(Biparietal diameter)

Interpretation
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

pregnancy

of
is

generally considered
unreliable.

Dating

using the BPD should

be done as early as is
feasible.
http://www.obultrasound.net/index.
html
HC

(Head

circumference)

17.4 mm - 19 W6D

It is supposed to be
better than the BPD
because

it

compensates for the

shape

of

the fetal

head (for example a

35
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.

Its use is valuable in

fetuses with abnormal
head shape.
http://www.obultrasound.net/omeas
ure.html
AC

(Abdominal

circumference)

158 mm - 20 W5D

The

single

most

important
measurement
make

to

in

late

pregnancy. It reflects
more of fetal size and
weight

rather

age.

than
Serial

measurements
useful

are
in

monitoring growth of
the

fetus.

AC

measurements
should not be used
for dating a fetus.

36
http://www.obultrasound.net/index.
html
FL (Femur length)

33 mm - 19 W6D

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

37
ULTRAOUND REPORT
Date: 08/22/14
Ultrasound report
Actual
Interpretation
findings
BPD
8.91
cm The diameter between the 2 sides of the
(Biparietal
diameter)

head. This is measured after 13 weeks.

36wk 0 day

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

wk & 3 day

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
abnormal head shape.
http://www.obultrasound.net/omeasure.html

AC

31.6 cm

The single most important measurement

(Abdominal

to make in late pregnancy. It reflects

circumference)

more of fetal size and weight rather than

age. Serial measurements are useful in
monitoring growth of

the

fetus.

AC

measurements should not be used for

38
dating a fetus.
http://www.ob-ultrasound.net/index.html
FL

(Femur

length)

7.01 cm = 35

bone in the body and reflects the

wk & 6 day

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

Urinalysis
Date: 08/28/14
Urinalysis
Normal
findings
Color:

Straw

Actual
finding
s
Yellow

Interpretation

Abnormal colors include yellow, brown,

yellow

to

black (gray), red, and green. These

amber

in

pigments may result from medications,

color

dietary sources, or diseases. Yellow

urine may be caused by bilirubin (a bile
pigment).
http://www.surgeryencyclopedia.com/StWr/Urinalysis.html

Reaction:

pH range

acidic

A combination of pH indicators (methyl

of 5.0 to

red and bromthymol blue) react with

8.5

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.

39
http://www.surgeryencyclopedia.com/St
-Wr/Urinalysis.html
Appearanc

Clear

Hazy

e:

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

1.002-

gravity

1.030

1.010

The specific gravity of urine is a

measure

of

the

dissolved

solutes

concentration

of

(substances in

solution), and it reflects the ability of the

kidneys

to

concentrate

the

urine

(conserve water). Specific gravity is

usually measured by 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

Negativ

The glucose test is used to monitor

persons with diabetes. When blood

quantitativ

glucose levels rise above 160 mg/dL,

e less than

the glucose will be detected in urine.

130 mg /

Consequently, glycosuria (glucose in the

day or 30

urine) may be the first indicator that

mg/ dl )

diabetes

or

another

hyperglycemic

40
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
Album

Negative

trace

Urine protein results always must be

interpreted in conjunction with specific

quantitativ

gravity. A small amount of protein

e 15- 150

normally is present in urine and may be

mg / day,

detected in concentrated urine. Many

less

false

than

positive
with

protein

tests

alkaline

occur,

10 mg / dl

especially

urine.

protein test detects mainly albumin.

The

(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
non-infective causes of high number of
pus cells, like presence of stones or

41
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)

Urinalysis
Date: 08/23/14
Urinalysi
Normal
s
findings
Color:
Straw

Actual
findings
Yellow

Interpretation
Abnormal colors include yellow, brown,

yellow to

black (gray), red, and green. These

amber in

pigments may result from medications,

color

dietary sources, or diseases. Yellow

urine may be caused by bilirubin (a bile
pigment).
http://www.surgeryencyclopedia.com/StWr/Urinalysis.html

Reaction:

pH range

acidic

A combination of pH indicators (methyl

of 5.0 to

red and bromthymol blue) react with

8.5

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

42
Appearan

Clear

Hazy

ce:

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

1.002-

gravity:

1.030

1.015

The specific gravity of urine is a measure

of the concentration of dissolved solutes
(substances in a solution), and it reflects
the ability of the kidneys to concentrate
the

urine

gravity

(conserve

is

water).

usually

Specific

measured

by

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

negative

The glucose test is used to monitor

(quantitati

persons

ve

glucose levels rise above 160 mg/dL, the

less

with

will

diabetes.

detected

glucose

mg / day

Consequently, glycosuria (glucose in the

or 30 mg/

urine) may be the first indicator that

dl )

diabetes

another

in

blood

than 130

or

be

When

urine.

hyperglycemic

condition is present. The glucose test

43
may be used to screen newborns for
galactosuria

and

carbohydrate

other

disorders

metabolism

that

of

cause

urinary excretion of a sugar other than

glucose.
http://www.surgeryencyclopedia.com/StWr/Urinalysis.html
Album:

Negative

negative

Urine protein results always must be

interpreted in conjunction with specific

quantitativ

gravity.

e 15- 150

normally is present in urine and may be

mg / day,

detected in concentrated urine. Many

less than

false

10 mg / dl

especially with alkaline urine. The protein

test detects mainly albumin.

small

positive

amount

protein

of

tests

protein

occur,

(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

most common cause of increased pus
cells and get back to normal after couple
of days of treatment. There are noninfective causes of high number of pus
cells, like presence of stones or following
any surgery on the urinary passage (high

44
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 hemoglobin and it is the
hemoglobin

which

transport oxygen (and

permits

them

carbon

to

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

Hematology
Date: 08/27/14
Hematology Normal
findings
Hemoglobi
Female
n

Mass (120-100)

Actual
findings
106 g/L

Interpretation
The hemoglobin molecule fills up the
red blood cells. It carries oxygen and

Concentrati

gives the blood cell its red color. The

on

hemoglobin test measures the amount

(hemoglobi

of hemoglobin in blood and is a good

n)

measure of the blood's ability to carry

oxygen throughout the body.
http://www.webmd.com/a-to-z-

45
guides/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
yte

Lymphocyt

0,25-0,40

0.13

es

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

46
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/a
rt.asp?articlekey=4426
Blood type: A, AB, B, O

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

positive

The Rh factor is written as either

and

positive (present) or negative (absent).

negative

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

47
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
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

Hematology
Date: 08/23/14
Hematology Normal
findings
Hemoglobi Female
n

Mass (120-100)

Actual
Interpretation
findings
123 g/L
The hemoglobin molecule fills up the red
blood cells. It carries oxygen and gives

Concentrati

the

blood

cell

its

red

color.

The

on

hemoglobin test measures the amount of

(hemoglobi

hemoglobin in blood and is a good

n)

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

48
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 0,25-0,40 0.12

Lymphocytes

are

responsible

es

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/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
system,

other
and

cells

of

the immune

are

involved

49
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
Blood type:

A, AB, B, 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

positive

The Rh factor is written as either positive

and

(present) or negative (absent). Most

negative

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

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

50
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/
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/hw-

popup/hematocrit

Blood test
Blood test
RH

Actual
results
Positive

Interpretation
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

51
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

52
V. REVIEW OF 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. During
childbirth, the cervix dilates (widens) to permit the baby to descend from
the

uterus 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 The

Menstrual Cycle and Ovulation below).

Ovaries: Two organs that produce hormones and store eggs. Each ovary
releases one egg per month.
Fallopian tubes: Muscular tubes that eggs released from the ovaries must
traverse to reach the uterus.

53
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.
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.

54
1st Trimester/
weeks of
pregnancy

Events

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.

3
5
6
7
9

10

2nd Trimester/
weeks of

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

55
pregnancy

Events

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.

3rd Trimester/
weeks of
pregnancy

25

Events

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 about20 inches long

56
and weighs about7 pounds. The womans enlarged
abdomen causes the navel to bulge.
37-42

Delivery

Breast

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

57
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.

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.

V.

SYMPTOMATOLOGY

58

Symptoms
Pain

Actual
findings

Justification
The

patient

because

may

feel

the

pain

myometrium

becomes tender from constant

lack of relaxation.
(Adele Pilliteri, Maternal and
child Nursing:.2007,p.591)
Dilation and effacement
does not occur

The

woman

experiencing

hypertonic uterine dysfunction

primary dysfunctional labor, is
often anxious 1st time mother
who

is

having

painful

and

frequent contraction. That are

ineffective in causing cervical
dilatation/ in the latent phase of
1st stage labor and are usually
uncoordinated. The force of the
contraction

may

be

in

the

midsection of the uterus rather

than in the fundus. Therefore,
the uterus is unable to apply
downward pressure to push the
presenting

part

against

the

cervix. ( low dermilk, Perry and

Cashion, 2014
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.

59
Fetal

distress

occurs

early

Uterine resting tone is high,

decreasing placental perfusion.
(Adele

Pilliteri,

Maternal

and

child Nursing:.2007,p.591)

Exhausted

and

A woman may become frustrated

discourage

or

disappointed

with

her

breathing exercises for childbirth,

because such techniques are
ineffective

with

contraction.

this

type

(Adele

Maternal

of

Pilliteri,

and

child

Nursing:.2007,p.591)

VII. ETIOLOGY
List of Etiology

Actual findings

Effect to the patient /

implication

Predisposing Factors:

According to American

Psychological strees

psychological

(Anxiety and fear )

association,

levels

oxytocin

tend

higher

during

stressful

and

to

of
be
both

socially

bonding experiences. (
Maureen

Salamon,

2010)
In

addition,

recent

research from the UIC

group

supports

alternative

an

hypothesis,

60
first

articulated

Porges

in

1998.

posited

that

by
He

oxytocin,

acting in part through

effect on the ANS, might
allow what he termed
immobility without fear.
In other words, oxytocin
may in general protect
the

nervous

system

shutting down in the

face

of

stressful

circumstances
especially
require

those

that

holding

still

rather

than

fighting/

fleeing.

That

includes

even events that may

seem positive from a
societal standpoint such
as birth. (T. DeAngelis,
2008 )
Primigravida

A woman experiencing
hypertonic

uterine

dysfunction

primary

dysfunctional labor, is
often
time
having

an

anxiousfirst

mother

who

painful

is
and

frequent contraction that

are ineffective in causing

61
cervical

dilatation/

effacement to progress.
(Low dermilk, Perry and
Cashion, 2014)
Sexual stimulation

In human, oxytocin is
thought to be release
during hugging, touching
and

orgasm

sexes.

In

in

the

both
brain,

oxytocin is involved in
social recognition and
bonding and may be
involved in the formation
of trust between people
and

generosity.

(J.

Grohol, 2013)
Smoking

Smoking

may

endothelial

cause
changes

which subsequently lead

to vasoconstriction and
rigidity of arteriolar walls.
(Yeo,

Ananth

and

Vintzileos, 2008)

Precipitating Factors:

The

most

common

Fetal Distress

cause of fetal distress is

lack of oxygen to the
baby. If fetal monitoring
detects a problem with

62
the amount of oxygen
that

your

baby

receiving,

then

emergency

is
an

cesarean

may be performed.
Labor induction

Synthetic

oxytocin

indicated

for

initiation/
of

is
the

improvement

uterine contraction,

where this is desirable

and

considered

for

suitable reasons of fetal/

maternal

concern,

in

order to achieve early

vaginal delivery. It is
indicated for induction of
labor,

stimulation/

reinforcement of labor
and

as

adjunctive

therapy

in

management

the
of

incomplete/

inevitable

abortion.

However,

overdosage

or

hypersensitivity

to

oxytocin

may

hyperstimulation
strong/

cause
with

prolonged

(tetanic) contraction of
the uterus (hypertonic
uterine dysfunction). ( D.

63
McAuley,

Pharm.

D.,

2014)

VIII.PATHOPHYSIOLOGY
Predisposing
factors;
-Psychological
stress (anxiety
and fear)
-Primigravida

Precipitating
factors;
-Labor
induction

64
Increase oxytocin enters the blood stream

Goes to myometrium

Binds on the oxytocin receptors in myometrium

Excessive / increased activation of phospholipase C

Provokes the hydrolysis of membrane phospholipids into inositol triphosphate

and other products

Release increase / excessive amount of Ca2+ from intracellular stores,

Protaglandines PGF and PGE and leukotrienes

Signs and Symptoms

-Pain
-Ineffective dilation and effacement
-Prolong latent phase
-Exhausted and discouraged
-Fetal distress occurs early

Hypertonic Uterine Dysfunction

65

If treated:
Both mother and fetus will be free from
complications and risk of death

Medical MGT:

Medical evaluation
to rule out CPD:

Vaginal exam

X-ray pelvimetry

Ultrasonography

IV fluid
administration
Administration of
short-acting
barbiturates
Evaluate labor
progress
Evaluate labor
dysfunction
Surgical

Nursing MGT:
Promote rets to try
to break the pattern
of frequent but
ineffective uterine
contractions.
Administration of
pain medication
such as Demerol/
Morphine as per
order.
Promotion of
relaxation.
Warm shower/ bath
Quiet environment
Minimal
interruptions to
allow long period of
sleep.
Hydrate the patient
with IV or PO fluids
if tolerated.
Assess FHR
Evaluate labor
progress with a
sterile vaginal
exam.
Inform the pt. and it
family of the
progress of labor

If untreated:
Fetal injuries
Deceleration
of fetal heart
Fetal
hypoxia
Fetal
Permanent
damage to
the fetus
Fetal death
Postpartum
hemorrhage

66
intervention:
Cesarean section/
delivery

and explain

67

PLANNING
A. Nursing care plan
#1
Assessm
Needs
ent
Subjectiv Physiologi
e cues cal needs
Init kaayo
akong
gibati.
As
verbalize
d by the
patient

Objective
cues:
-Temp38.5C
- Dry lips
noted
- Slightly
flushed
face
noted
-Skin
warm to
touch

Nursing
Diagnosis
Altered
thermoregulation
r/t invasion of
microorganisms.

Reference:
N.Jayne Klossner
&Nancy
Hatfield(2006).Intr
oductory
Maternity
&
pediatric Nursing
Lippincott William
&Wilkins.pp.
1661.

Planning

Intervention

Evaluation

After 4 hrs. of
giving appropriate
intervention,
thermoregulation
will return within
normal range as
evidenced by:
Dili na kayo init
akong gibati as
verbalized by the
patient
-Temp-36.5-37.5C
-Moisten lips.
-Flushed skin not
noted
-skin not warm
when touch

Independent:
- monitor vital signs
To obtain baseline
data.

Goal Met:
After 4 hours of
giving appropriate
intervention,
thermoregulation
returned to its
normal
range
(Temp- 37.4)
ok
na
akong
pamati, dili na
kaayo ko init as
verbalized by the
patient
-moisten lips.
-flushed skin not
noted
- Skin not warm to
touch.

-provide tipid sponge

bath
TSB helps in lowering
the body temperature and
alcohol cools rapidly,
causing shivering.
-remove
excess
clothings and cover

These
decreases
warmth and increases
evaporative cooling.
-promote a well-ventilated
area
to create flow of air in
patients area. One way
of promoting heat loss.
-advise
patient
to
increase oral intake
Additional fluids helps

68

to
prevent
elevated
temperature associated
with dehydration
-maintain bed rest
reduces metabolic
demands/
oxygen
consumption.
-provide high calorie diet
To
meet
increased
metabolic demands
-educate
and
advise
support system (family
and relatives)
when
increase
thermoregulation occurs;
-do TSB with luke warm
water only
-Make sure that 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 family.
Dependent:

69

- Administer antipyretics
per doctors order
-this drug inhibits the
prostaglandin that serves
as medication for fever
and pain.
Collaborative:
-Obtain laboratory test.

To
ensure
the
effectiveness of care.

#2
Assessme
nt
Subjective
cues

Needs

Nursing
Planning
Diagnosis
Physiologic Pain related to After 6 of nursing
al needs
surgical incision intervention,
pain
s/t post CS.
will reduce to 2 as
Sakit sakit
evidenced by;
pa akong
dili na kayo sakit
tahi
akong
tahi
as
Scientific
bases: Pain is verbalized by the
Scale of 5
caused by the patient
out of 10
damage done -Guarding position
to tissue by the not noted
Objective
incision,
the -grimace not noted
cue
procedure itself,
-Guarding
the closing of
position
the wound and
-grimace
any force that is
applied during

Intervention
Independent
provide
comfort
measures,
quiet
environment and calm
activities.
to promote nonpharmacological
pain
management

Evaluation

GOAL MET:
After 6 of nursing
intervention, pain
reduced to 2 as
evidenced by;
dili na kayo sakit
akong tahi as
verbalized by the
patient
use
of -Guarding position
technique; not noted
focused -grimace not noted

-encourage
relaxation
such
as
breathing
To distract attention
and reduce tension.

70

the procedure.

-encourage
divisional
activities
such
as
watching TV.
To distract attention to
pain.

Reference:
Jennifer Heisler,
RN, 2010

-monitor skin color/temp

and vital signs
Which are usually
altered in acute pain.
encourage adequate rest
period
to prevent fatigue
-increase oral fluid intake
To help reduce the
body temperature.
Dependent
Administer analgesics, as
indicated
To maintain acceptable
level of pain.

Assessme
nt
Subjective
cue
None

Nursing
Planning
Needs
Diagnosis
Physiologic Risk for infection Within 6 of care
al needs
r/t
inadequate the patient will be
primary defenses free from infection.
secondary to C-

Intervention

Evaluation

Independent
Goal met
-established rapport
At 1 pm
to gain trust and Has
able
cooperation
verbalize

to
her

71

Objective
cue
Fever
Chills
Weak
Vital sign
BP 120/70
PR 98
RR 26
Temp 38.5

section
Scientific basis
The creation of
surgical wound
disrupts
the
integrity of the
skin
in
its
protective
function.
Exposure
of
deep
body
tissues
to
pathogens in the
environment
places
the
patient at risk for
infection of the
surgical site, a
potentially
lifethreatening
complication.
Reference
Brunner
and
Suddarths
Textbook
of
medical-surgical
nursing
15thEdition
pp.
545

-note
signs
and
symptoms of sepsis such
as fever and chills.
to assess contributing
factors
that
causes
infection
-if patient has
perform TSB.

to
lower
temperature

understanding to
prevent the risk of
infection.

As evidenced by
kabalo na diay
ko unsay buhatun
fever para dili magka
impeksyon,as
the patient
verbalized.

-stress
proper
hand
washing techniques
To prevent cross
contamination
of
nosocomial infections.
-cleanse incision sites
daily and PRN with
povidone-iodine or other
appropriate solution.
to disinfect surgical
incision site
Health teaching
-Instruct
client
in
techniques to protect the
integrity of skin
to prevent the spread
of infection
-emphasize necessity of
taking
antibiotics
as

72

directed.

premature
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

73
DRUG STUDY #1
DATE/
SHIFT

NAME OF DOSAGE/
DRUG
TIME
ROUTE

INDICATION

08/27/14

GENERIC
NAME:
Ampicillin

Soft
tissue Hypersensi
infection
tive to drug

BRAND
NAME:
Omnipen
CLASSIFI
CATION:
Anti-biotic
Drawing:

1g
IVTT
Q 6

CONTRAINDICATION

MECHANIS
M
OF ACTION

SIDE
EFFECTS

NURSING
RESPONSIBILITIES

Interferes
with cell wall
synthesis of
susceptible
organism,
preventing
bacteria
multiplication
it
also
renders the
cell
wall
osmotically
unstable and
burst due to
osmotic
pressure.

Common side
effects
of
ampicillin
include
nausea, vomiti
ng, loss
of
appetite,
diarrhea, abdo
minal
pain,
rash, itching, h
eadache, conf
usion and
dizziness.
Patients with a
history
of
allergic
reactions
to
other penicillin
should
not
receive
ampicillin.
Persons who
are allergic to
the
cephalosporin
class
of
antibiotics,
which
are

-Assess any history

of allergy
-Check IV site
carefully for signs
of thrombosis or
drug reaction.
-Do not give IM
Injections in the
same site; atrophy
can occur.
-Monitor
injection site.
-Administer oral
drug on an
empty stomach, 1
hr. before o 2 hrs.
after meals with a
full glass of water;
do not give with
fruit juice or soft
drinks

74

related to the
penicillins, for
example,
cefaclor (Cecl
or)
,cephalexin (K
eflex),
and cefprozil (
Cefzil), may or
may not be
allergic
to
penicillins.
Serious
but
rare reactions
include
seizures,
severe allergic
reactions
(anaphylaxis),
and
low
platelet or red
blood
cell
count.
Ampicillin can
alter
the
normal
bacteria in the
colon
and
encourage
overgrowth of
some bacteria

75

such
as Clostridium
difficile which
causes
inflammation
of the colon
(pseudomemb
ranous colitis).
Patients who
develop signs
of
pseudomembr
anous colitis
after starting
ampicillin
(diarrhea, feve
r, abdominal
pain,
and
possibly shock
)
should
contact their
physician
immediately.

76

DRUG STUDY #2
DATE/
SHIFT
08/27/1
4

NAME OF DOSAGE/
DRUG
TIME
ROUTE
GENERIC 50mg
NAME:
q 8 hours
Ranitidine
IVTT
BRAND
NAME:
Aceptin
CLASSIFI
CATION:
Gastrointe
stinal
drugs
DRAWING

INDICATION

CONTRAINDICATI
ON
Used in the Hypersensi
management tivity
to
of various GI Ranitidine
distress such
as
dyspepsia.

MECHANIS
M
OF ACTION
Inhibits
Gastric acid
secretion by
blocking the
effect
of
histamine
on,
histamine
H2
Receptors.

SIDE
EFFECTS

NURSING
RESPONSIBILITIE
S
CNS:
-Assess any history
Confusion,
of allergy
dizziness,
-Assess patient for
drowsiness,
epigastric
or
hallucinations,
abdominal pain and
headache
frank or occult blood
CV:
in the stool, emesis,
Arrhythmias
or gastric aspirate.
GI:
-Nurse should know
Altered taste,
that it may cause
black tongue,
false-positive results
constipation,
for urine protein;
dark stools,
test
with
diarrhea, drug- sulfosalicylic acid.
induced
-Inform patient that
hepatitis,
it
may
cause
nausea
drowsiness
or
GU:
dizziness.
Decreased
-Inform patient that
sperm count,
increased fluid and
impotence
fiber intake may
ENDO:
minimize
Gynecomastia
constipation.
HEMAT:
-Advise patient to
Agranulocytosis report
onset
of
, Aplastic
black, tarry stools;

77

DRUG STUDY #3
DATE/
NAME OF DOSAGE/
SHIFT
DRUG
TIME
ROUTE
08/27/1 GENERIC 500mg TID
4
NAME:
Mefenamic
acid
BRAND
NAME:
Mefenax
CLASSIFI
CATION:
Analgesics
, NSAID.

INDICATION

CONTRAINDICATI
ON
Prevention
Hypersensi
and
tivity
to
management mefenax;
of moderate GI
to
severe inflammati
pain.
on
or
ulceration

MECHANIS
M
OF ACTION
Inhibits
prostaglandi
n synthesis
and affects
platelet
function.

Anemia,
neutropenia,
thrombocytope
nia
LOCAL:
Pain at IM site
MISC:
Hypersensitivity
reactions,
vasculitis

fever, sore throat;

diarrhea; dizziness;
rash; confusion; or
hallucinations
to
health
care
professional
promptly.
-Inform patient that
medication
may
temporarily cause
stools and tongue to
appear gray black.

SIDE
EFFECTS

NURSING
RESPONSIBILITIE
S
- Assess for history
of ulceration
-Instruct patient to
eat meal first before
taking the drug.
-Advice the patient
to avoid sudden
movement
to
prevent drowsiness.
-Advice the patient
to calm down.
-Report any signs of

Cardiovascular
Edema; weight
gain; CHF;
altered BP;
palpitations;
chest pain;
bradycardia;
tachycardia.
CNS
Headache;

78

DRAWING

vertigo;
drowsiness;
dizziness;
insomnia.
Dermatologic
Rash; urticaria;
purpura.
EENT
Blurred vision;
tinnitus;
salivation;
glossitis.
GI
Diarrhea; dry
mouth;
vomiting;
abdominal pain;
dyspepsia; GI
bleeding;
nausea;
constipation;
flatulence.
Genitourinary
Hematuria;
proteinuria;
dysuria; renal

urticaria or pupura.
-Instruct patient to
verbalize
feelings
such as blurring of
visions

79

failure.
Hematologic
Decreased
hematocrit;
bleeding;
neutropenia;
leukopenia;
pancytopenia;
eosinophilia;
thrombocytope
nia.Hepatic
Mild elevations
in LFT results.
Respiratory
Bronchospasm;
laryngeal
edema; rhinitis;
dyspnea;
pharyngitis;
hemoptysis;
shortness of
breath.
Miscellaneous
Autoimmune
hemolytic
anemia may

80

occur if used
long term.

81
XI. SYNTHESIS OF CLIENTS CONDITION
Patients Prognosis
Criteria
Good
3
Family
Support

Fair
2

Poor
1

Environment

Financial

Onset
illness
Duration
illness

of

of

Justification
The family had supported
the client all throughout her
pregnancy
and
they
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.
The environment of the
client is not hazardous to
her condition because the
surrounding area is free
from risks.
Could able to supply the
Needed medication due to
sufficient income.

The
patient
has
no
presence of any illnesses.
The
patient
has
no
presence of any illnesses.

Compliance
to
medication

The
patient
has
no
presence of any illnesses.

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

82
General Prognosis
Based on the aforementioned result, the overall prognosis of the client is
good 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.

83
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 checkups 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
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.

84
XII. EVALUATION
Having this case presentation, I 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.
I was able to gather all possible resources and relevant datas regarding
the past and present history of Patient Xs illness. With the data gathered, I was
able to identify vital informations such as predisposing and precipitating factors
that greatly contribute to Patient Xs present illness
I was able to identify, determine and understand the underlying general
health problems of my client. The study improves my skills and knowledge
pertaining on caring patients with such changes.
Without anticipation, I am 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.

85

XIII. BIBLIOGRAPHY
Book:
Keith Edmonds, Sir John Dewhurst ;Dewhurst's textbook of obstetrics and
gynaecology 7th Edition by Blackwell Publishing, 2002.
Patricia M. Dillon; Nursing Health Assessment: a critical thinking case
studies aroach,; by B. Proud, 2nd edition
Pillitteri, Adele; Maternal and Child Health Nursing: Care of the
Childbearing and Childrearing Family 6th Edition Volume

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, Kendra; Freud's Stages of Psychosexual 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_
childbirth/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
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
bedtime
by
BabyCenter,L.L.C.2011;http://www.babycenter.com.ph
/pregnancy/labourandbirth/labourcomplications/caesarean-rate/s

86
Military Obstetrics & Gynecologyby The Brookside Associates
Medical Education Division,
2009http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/L
aborandDelivery/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,
Inchttp://www.medterms.com/script/main/art.asp?articlekey=4426

87

Curriculum Vitae
PERSONAL DATA
Name

: Julie Pearl Canoy Remitar

Address

: Gemini Village Apokon Tagum City

Date of Birth

: July 23 1991

Place of Birth

: Matina, Davao City

Age

: 23 years old

Religion

: Roman Catholic

Fathers Name

: Josefino C. Remitar

Mothers Name

: Cielito C. Remitar

Educational Background:

Primary School Attended

: S.I.R Elementary School

Secondary School Attended

: Mintal Comprehensive National High School

Recent School Attended

: Tagum Doctors College Inc

88

89

90

91

92