NURSING CASE STUDY:

CAESARIAN SECTION
I. DEMOGRAPHIC DATA
Name:
A.G.M
Gender:
Female
Civil Status: Married
Address:
Bacoor, Cavite
Age:
40 years old
Birthdate:September 26, 1969
Birthplace: Imus, Cavite
Religion:
Roman Catholic
Occupation: Housewife
Diagnosis:
Elderly Gravida, PU 39-40 wks AOG
(Low Lying Placenta Frank Breech)
Operation Performed: Low Transverse Caesarian Section
II. HEALTH HISTORY
Patient A.G.M is a 40 year old female, who is preganant for 40weeks, married
and a mother of two. She is a catholic with faircomplexion, stands 153 cm and
weighs 76 kgs. She was born atDasmarinas, Cavite and second among three
siblings.
Her AOG is 40 weeks. Patient had a previous CS delivery because
she had difficulty on delivering her child.
Patient had no history of asthma, no seizure, no diabetes mellitusand no
hypertension. Patient had complete immunization and had noallergies to either food
or medications.
III. LABORATORY / DIAGNOSTICS
Procedure / Date
Actual
Findings
Normal
Findings
Implications
Nursing
Responsibilities
1. CBC
Pre:
 Check Doctor’s
Procedure / Date
Actual
Findings
Normal
Findings
Implications
Nursing
Responsibilities
Hemoglobin
Hematocrit
WBC
Segmenters
Lymphocytes
Eosinophils
Stab Cells
Platelets
116
0.35
8.0
0.60
0.14
0.02
0.04
320
120 – 140

g/dL

0.30

5 - 10
0.36 - 0.66
0.22 - 0.40
 0.01 - 0.04
0.02 - 0.05
150 –
400x9/L
Decrease
- Indicates
occurrence of
anemia
Increase
- Indicates
hypercoagulatio
n
Normal
Normal
Decrease
- Indicates high
risk for
acquiring
infection
NormalNormalNormal
Order.
 Inform client and
explain the
procedure.
 No need for NPO.
Intra:
 Perform blood
extraction
(venipuncture
technique) using
aseptic
technique.
 Put extracted
blood in
ethyldiamino-
tetracetate
(EDTA) or the
lavender top
vacuum tube.
Post:
 Label the
container
properly and
correctly.
 Send specimen to
the lab
immediately.
 Document the
result to the
chart and inform
Procedure / Date
Actual
Findings
Normal
Findings
Implications
Nursing
Responsibilities
physician that
the result is out.
URINE ANALYSIS
Microscopic Exam
Chemical Exam
Color: Yellow
Albumin: Negative
Transparency: Hazel
Sugar:
Negative
pH: 6.0 (7.35 – 7.45)
Specific Gravity: 1.010 (1.010 – 1.025)
Epithelial Cells: Moderate
IV. INDICATIONS FOR THE PROCEDURE
CAESARIAN SECTION
A Caesarian section is a form of childbirth in which a surgicalincision is made
through a mother’s abdomen and uterus to deliver oneor more babies. It is usually
performed when a vaginal delivery wouldput the baby’s or mother’s life or health at
risk; although in recenttimes it has been also performed upon requests for births that
wouldotherwise have been normal.
Caesarian section (CS) is recommended when vaginal delivery
might pose a risk to the mother or baby. Reasons for CS include:
 Precious (high risk) fetus
 Prolonged labor or failureto progress (dystocia