TAGUM DOCTORSCOLLEGE INC.

Mahogany St. Rabe Subdivision, Tagum city

Bachelor of Science in Nursing

A Case Study on
POST-CESAREAN DELIVERY

In Partial fulfillment of the requirements in Related Learning Experience

Submitted to:
Roselle E. Baniel, RN

Submitted By:
Aala, Moira Heather
Adrales, Mark Wesley
Caspillo, April
Castañeda, Nathalie Rose
Ponting, Aiza
Ramos, Wyeth Aesha
Sanchez, Jeremiah
Seniel, Micome Kathria
Tactaquin, John Ivan
Villarin, Christine

BSN-2

November 2022

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Table of Contents

Title Page

Table of Contents

I. Introduction 3

II. Objectives 6

III. Patient’s Data 8

IV. Family Background/Health History 9

V. Developmental Data 10

VI. Definition of complete diagnosis 15

VII. Physical Assessment 18

VIII. Anatomy and Physiology 23

IX. Etiology and Symptomatology 29

X. Concept Mapping 32

XI. Doctor’s Order 35

XII. Laboratory and Diagnostic Exam 40

XIII. Drug Study 41

XIV. Nursing Care Plan 49

XV. Nursing Theories 56

XVI. Discharge Plan (METHOD) 58

XVII. Recommendation 60

XVIII. References 61

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I. INTRODUCTION
Cesarean delivery (C-section) is used to deliver a baby through surgical incisions
made in the abdomen and uterus. Planning for a C-section might be necessary if there are
certain pregnancy complications. Women who have had a C-section might have another C-
section. Often, however, the need for a first-time C-section isn't clear until after labor starts.
(Mayo Clinic 2022).

According to new research from the World Health Organization (WHO), caesarean
section use continues to rise globally, now accounting for more than 1 in 5 (21%) of all
childbirths. This number is set to continue increasing over the coming decade, with nearly a
third (29%) of all births likely to take place by caesarean section by 2030, the research
finds. (WHO, 2021)

The success rate for Cesarean Section in Philippines is now extremely high given
the recent advances in medical technology and surgeon experience. However, with any
surgery, there is always the possibility of complications, such as infection, bleeding,
numbness, swelling and scar tissue. But if you rest post-op and follow the surgeon's
recovery advice, you can expect to reduce these odds close to zero. (MyMediTravel, 2021)

This case study aims to provide students and readers to nursing research related
and nursing practice related further understanding about Post Ceserean Delivery. In order
to collect data, the students used interview and patient need assessment tool as well as
gathering relevant information in the patient's chart. It also includes the laboratory and
diagnostic results to gather more accurate data. The information from this case study will
also help nursing students understand their important role in the management and care of
patients in a case like this.

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II. OBJECTIVES

General Objectives

The goal of this study is to be able student nurses to understand about Post Ceserean
Delivery and apply the most effective intervention by collecting data that can be used for
future nurses to have basis on similar cases like this.

Specific Objectives
The student nurses would be able to:

• To know the client’s personal data, family profile, past health history, current health
history, and physical assessment.
• To be able to review concepts and theories in NCM 107.

• To review the anatomy and physiology of the affected organs/system and the changes
after the delivery.
• To create a drug study of post cesarean delivery.
• To create a nursing care plan that is effective and could be beneficial to the client.
• To create a post-partum discharge plan for the continuation of care

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III. PATIENT’S ASSESSMENT

A. Biographical Data

Name: Mrs. A
Age: 27 years old
Sex: Female
Civil Status: Married
Nationality: Filipino
Birthday: June 5, 1995
Birthplace: Tagum City
Occupation: Works at Panabo Cooperative
Address: B-5 L9 North eagle 2 San Miguel, Tagum City
Religion: Roman Catholic
Date of Admission: November 6, 2022, at 3:00 PM at Tagum Doctor ‘s Hospital
Admitting Diagnosis: G1P0 38 1/7 weeks AOG by late ultrasound
Admitting Physician: Dr. Evelyn Ross H. Perdido
Discharge Date & Time: November 10, 2022, at 6AM

B. Chief complaint
Mrs. A is a 27years old, admitted to the hospital, presented active labor,
experiencing back ache, labor pains, and uterine contractions. Membranes ruptured; cervix
dilated 8cm.

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IV. FAMILY BACKGROUND/ HEALTH HISTORY

A. Family health history

The patient's mother has hypertension, while her father has a history of asthma

LEGEND:
- Male
- Female
- Asthma
- hypertension
- Patient

B. Client’s health history (past illnesses, present illnesses):

Past Illness:
In 2007, the patient was diagnosed with Dengue fever and was admitted to the
hospital.

Present Illness:
A 27-year-old woman reported experiencing severe uterine contractions and back
ache with membranes ruptured undergoing active labor. The patient has no vices and has a
diverse diet. In this scenario, the admitting diagnosis are the following: G1PD 38 1/7 weeks
by late ultrasound, pregnancy uterine, delivered term, cephalic live birth, delivered by LSCS
under spiral anesthesia/ live bb girl, SGA, BW 2.3, LSCS. Patient’s last menstruation is on
January 27,2022 and her first check-up is on March 24,2022. The patient has no vices and
has a healthy diet. However, the patient was stressed by her work and family matters which
caused the loss of her appetite and affected her pregnancy.

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V. DEVELOPMENTAL DATA

Jean Piaget’s “Theory of Cognitive Development”

Stage Actual Justification
finding
Stage: 4 Formal Achieved The patient demonstrates that she is
Operational capable of conceptual thought and
(11years - Adulthood) expresses concern for her future now that
Involves the ability to she is a mother at last.
think conceptually and
hypothetically.

Robert Havighurst's “Developmental Task Model”

Stage Actual Justification

finding
Early Adulthood Achieved The patient states that she and her partner
(19 – 30 years old) have their own businesses in addition to the
Involves finding an one her family owns, which is enough for
occupation and often meeting their basic needs.
finding a life partner as
well.

Erick Erickson’s “Theory of Psychosocial Development”

Stage Actual Justification

finding
Intimacy vs. Isolation Achieved According to our patient, she developed
(18 – 40 years old) intimate connections with her
Occurs during early family, partner, as well as her newborn.
adulthood when
people explore
personal relationships.

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VI. DEFINITION OF COMPLETE DIAGNOSIS

Final Diagnosis: G1P1 (1001): Pregnancy uterine, delivered term, cephalic, live birth.
Nonreassuring fetal heart rate pattern, delivered by LSCS under spinal anesthesia/live baby
girl, SGA, BW 2.3kl

G1P1 (1001)
Gravidity and parity, and GTPAL are systems used in health assessment to record
woman’s obstetric history. Gravidity and parity (G P) are a basic 2-digit system that only
gives information about the number of pregnancies and births. While 5-digit GTPAL system
provides more comprehensive data on obstetric history briefly. Gravidity refers to the total
number of pregnancies regardless of its outcome. A pregnancy can end in a live birth,
miscarriage, premature birth (before 37 weeks of gestation), or an abortion. Parity refers to
the number births after 20 weeks of gestation. When calculating parity also, you include all
births beyond 20 weeks of gestation whether or not the baby born was alive. (Nurseship,
2022)

GTPAL provides quick overview of the person’s term and preterm pregnancies, abortions,
and number of living children.
G- Gravida: number of total pregnancies (includes current pregnancy and all term, preterm,
therapeutic abortions, and miscarriages)
T- Term: all births gave at full term (i.e.: after completion of 37wks of gestation)
P- Preterm: all births gave preterm. (i.e.: from 20wks to 37wks of gestation)
A- Abortion: include all miscarriages or medical abortions and surgical abortions before
20wks of gestation
L- Living children: total number of living children (here every child [i.e., twins, triplets] counts
individually)

PREGNANCY UTERINE
An intrauterine pregnancy (IUP) occurs when a fertilized egg implants and starts to
develop within the uterus, where it is supposed to be. The uterus is the only place where a
pregnancy can develop and progress to full term. An ultrasound finding of an intrauterine
pregnancy means that the pregnancy is developing in the proper location. (FertilitySmarts,

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2020)
DELIVERED TERM
According to the American College of Obstetricians and Gynecologists (ACOG)
describes pregnancy term as greater than or equal to 37 weeks and 0 days using best
EDD. It is divided into the following categories:
Early-term: 37 weeks and 0 days through 38 weeks and 6 days
Full-term: 39 weeks and 0 days through 40 weeks and 6 days
Late-term: 41 weeks and 0 days through 41 weeks and 6 days
Post-term: greater than or equal to 42 weeks and 0 days

CEPHALIC
Fetal presentation, or how your baby is situated in your womb at birth, is determined
by the body part that's positioned to come out first. (Marple, K., 2022)
Cephalic- head is the presenting part
Breech- butt is the presenting part
Transverse- the baby is lying horizontally
Oblique- the baby is lying diagonally

LIVE BIRTH
Live birth is the complete expulsion or extraction from its mother of a product of
conception, regardless of the duration of the pregnancy, which, after such separation,
breathes or shows any other signs of life, such as beating of the heart, pulsation of the
umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord
has been cut or the placenta is attached; each product of such a birth is considered live-
born. (Glossary, 2022)

NONREASSURING FETAL HEART RATE PATTERN

Nonreassuring signs, which are negative in nature and could indicate possible fetal
distress and health compromise which includes tachycardia, bradycardia, absent variability,
late decelerations, variable decelerations falling to less than 70 bpm for longer than 60
seconds, and prolonged decelerations.

LOWER SEGMENT CESARIAN SECTION (LSCS)

It is the most commonly preferred method wherein a horizontal or transverse incision

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is made on the lower part of the abdomen to deliver the baby. It involves less blood loss
and is easier to repair than other incisions employed for the purpose. (Shourie, S., 2016)

SPINAL ANESTHESIA-
Spinal anesthesia is a form of regional anesthesia that involves the injection of
certain anesthetic drugs into a fluid-filled space in which the spinal cord and the nerves
arising from it are suspended using a fine long needle. The drug then mixes with the fluid,
and acts on the nerve fibers, blocking their activity for a finite time. This renders the portion
of the body below the level of the injection numb and anesthetized while the rest of the
body remains active. (Nair, H., 2020)

SMALL FOR GESTATIONAL AGE (SGA)-

Small for gestational age is a term used to describe babies who are smaller than
number for the number of weeks of pregnancy. These babies have birth weight below the
10th percentile. This means they are smaller than many other babies of the same
gestational age. Many babies normally weigh more than 5 pounds, 13 ounces by the 37th
week of pregnancy. Babies born weighing less than 5 pounds, 8 ounces are considered low
birth weight. (Health Encyclopedia)

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VII. PHYSICAL ASSESSMENT
ASSESS THE PATIENT (Initial/Focus/General): Use BLUE for normal findings and RED
for ABNORMAL FINDINGS
SYSTEM NORMAL FINDINGS ACTUAL FINDINGS

GENERAL Received a 27 years-old

female patient sitting on
bed, conscious, alert, and
responsive.
Current Vital Signs:
TEMP: 36.2mmhg
PULSE: 76BPM(regular)
RR: 19CPM (regular)
BP: 90/60
OXYGEN SAT: 99%
SKIN The skin is uniform in color. Soft,
(INSPECTION AND smooth skin over the entire
Warm skin
PALPATION) body. Skin temperature is within
normal limit.

HEAD, EYES, EARS, No facial asymmetry/muscles of Slightly uncomfortable facial

NOSE, AND THROAT facial expression intact. Ears and expression, Ears and nose
nose without deformity, external are normal.
tenderness or discharge.
NECK Straight and symmetrical with no Supple neck.
visible mass or lumps. No
lesions and cervical lymph nodes
were impalpable.
BREAST The nipples, breast tissue, and Breast is large for
areas around the breast are breastfeeding.
normal in size and shape.
RESPIRATORY Chest wall intact; no tenderness; Clear breath sounds.

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LUNGS no masses. Full and symmetric
(AUSCULTATION) chest expansion.
CARDIOVASCULAR Normal heart size. No pulsation Distinct heart sounds.
HEART upon palpating the aortic and
(AUSCULTATION) pulmonic areas. No lift or
heaves. Heart rate changes from
60-100bpm.

GASTROINTESTINAL The lips are normally Lips are symmetrical and

MOUTH symmetrical, pink, smooth, and dry.
(INSPECTION) moist. Teeth should be clean Teeth are yellowish in color.
with shiny enamel and no decay, Tongue is symmetrical and
white with shiny enamel and slightly rough from papillae.
smooth surfaces and edges.
Oral mucosa should appear
moist, smooth, shiny and pink.
A healthy dorsal tongue is
symmetrical, pink and moist and
slightly rough from papillae.

Abdomen is soft, symmetric and

non-tender without distension,
no visible lesions or scars.
Bikini cut is located from
post cs and is bloated.
ABDOMEN
(INSPECTION AND
PALPATION)
URINARY No pain or burning sensation Urinary retention.

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 while urinating. Normal urine
color ranges from pale yellow to
deep amber.
GENITAL Symmetrical smooth to Bleeding is observed due to
somewhat wrinkled, unbroken, post cs.
slightly pigmented.
PERIPHERAL/VASCULAR No presence of diminished Distal pulses are palpable in
pulses. Normal skin color. all extremities with no
abnormalities.
MUSCULOSKELETAL Symmetry of the joints, muscles, The joints are symmetrical
bones. but aching.
NEUROLOGIC Level of consciousness Level of consciousness

Oriented to time, people, and The patient is oriented to

place. Enable to demonstrate time, people, and place.
emotion appropriate to the She is able to demonstrate
scenario. Enable to comprehend emotion appropriate to the
and speak fluently. scenario, and able to
comprehend and speak
fluently.

Visual recognition
Able to identify familiar objects Visual recognition
by sight near and far (pencil and Able to identify familiar
ball pen). objects by sight near and far
(using pencil and ball pen).
HEMATOLOGIC Normal RBC -4.24
RBC: 4.5-6.5 Monocytes- 0.09
MCV: 80-100 (increased)
PCV/HCT: 0.40-0.52 Platelets (150-450 x103/µl) :
MCH: 27-32 372 (Increased)
Creatinine – 79.5
(Decreased)

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 Segmenters-
0.45(decreased)
HBA1C-4.9%

ENDOCRINE Coordinate body’s metabolism, Pt energy level is normal but

energy level, reproduction, is experiencing pain due to
growth and development, and post cs.
response to injury, stress and
mood.
PSYCHIATRIC Speech: normal tone and volume Pt has a normal tone and
Emotional expression: Normal volume when speaking.
expression of faces connected to Normal expression. Alert,
emotion oriented and coherent.
Thinking and perception: Goal
oriented
Cognitive functions: Alert,
oriented and coherent

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VIII. ANATOMY AND PHYSIOLOGY OF THE AFFECTED SYSTEM/ORGAN

BREASTS
The breasts comprise glandular, connective and fatty tissue. Within these tissues are milk-
producing cells. Tiny openings in the nipple allow milk to flow.

So, when the baby sucks, the nipple is stimulated then the muscular tissue surrounding the
nipple causes it to become erect. When the nipple is stimulated, the brain's pituitary gland
secretes the hormone prolactin, which triggers the breast's milk gland cells to produce milk.
This does not occur until the baby and placenta are delivered.

ABDOMEN
The abdomen (commonly called the belly) is the body space between the thorax (chest)
and pelvis. The diaphragm forms the upper surface of the abdomen. At the level of the
pelvic bones, the abdomen ends and the pelvis begins.

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UTERUS
The uterus or womb is a pear-shaped organ that is found in the pelvis at the top of the
vagina. The uterus in a woman that is not pregnant does not extend above the pubic bone
(Figure 1, 2 & 3).

Figure 1 - Anatomy of the uterus and surrounding organs as seen in a section through the
middle of the body.

Figure 2 - Uterus as seen from in-front.

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Figure 3 - View of the uterus, ovaries, fallopian tubes and round ligament through a
laparoscope.

But as for the pregnant woman at the end of pregnancy, the uterus enlarges to
approximately 40cm (16inch) above the pubic bone. The cervix is found at the lowermost
portion of the uterus and is the opening through which the fetus passes during delivery.
Normally, this opening is closed until late in the pregnancy.

AMNIOTIC SAC
The amniotic sac, or amnion, is a lining (membrane) inside the uterus that contains the
fetus and the fluid that cushions the fetus (amniotic fluid). The amniotic sac is also called
the "bag of waters."

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A thin-walled sac that surrounds the fetus during pregnancy. The sac is filled with liquid
made by the fetus (amniotic fluid) and the membrane that covers the fetal side of the
placenta (amnion). This protects the fetus from injury. It also helps to regulate the
temperature of the fetus.

CERVIX
The cervix connects the body of the uterus to the vagina. And it is about 3 to 4 cm long.
Made up mostly of connective tissue and muscle. It is divided into 2 main parts which are
the endocervix (inner part of the cervix lining) and the ectocervix (outer part of the cervix).

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Part of the lining of the cervix contains glands that make and release mucus. For most of
the menstrual cycle and during pregnancy, the mucus is thick and stops sperm from
entering the uterus. The thick mucus also helps to protect the uterus and the upper female
reproductive organs from harmful bacteria. During childbirth, the cervix widens (dilates),
allowing the baby to pass through the birth canal.

PLACENTA
The placenta is the medium through which material passes from the maternal circulation to
the fetal circulation by passive diffusion or active transport.

The placenta is a temporary organ that connects your baby to your uterus during
pregnancy. The placenta develops shortly after conception and attaches to the wall of your
uterus as it provides the baby with oxygen and nutrients, removes harmful waste and
carbon dioxide, passess immunity and portects your baby. Together, the placenta and
umbilical cord act as your baby's lifeline while in the uterus.

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UMBILICAL CORD
The umbilical cord is considered both the physical and emotional attachment between
mother and fetus. This structure allows for the transfer of oxygen and nutrients from the
maternal circulation into fetal circulation while simultaneously removing waste products
from fetal circulation to be eliminated maternally.

The umbilical cord is a soft, tortuous cord with a smooth outer covering of amnion. It
extends from the umbilicus of the fetus to the center of the placenta. Its length ranges from
50 cm to 60 cm, with a diameter of about 1 cm. The umbilical cord is composed of a
gelatinous ground substance called Wharton's jelly or substantia gelatinea funiculi
umbilicalis. It is composed of mucopolysaccharides from the conjugation of hyaluronic acid
and chondroitin sulfate. As previously mentioned, three vessels comprise the umbilical
cord: two umbilical arteries (carry deoxygenated blood from fetal circulation to the placenta)
and one umbilical vein (carries oxygenated blood from the placenta into the growing fetus).

IX. ETIOLOGY and SYMPTOMATOLOGY

SYMPTOMATOLOGY

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SIGNS/SYMPTOMS ACTUAL FINDINGS Rationale

Fatigue PRESENT: Feeling of Officially, being tired is defined as

tiredness with physical constantly feeling low on energy. Even
appearance upon in the first few weeks of pregnancy,
observation fatigue can set in. As early as one week
after conception, some women start to
feel exhausted during pregnancy. While
fatigue usually improves around the
beginning of the second trimester, it
frequently returns in the third trimester,
though this can vary from pregnancy to
pregnancy as with all symptoms.

Insomnia ABSENT The inability to fall or stay asleep while

pregnant is known as pregnancy
insomnia. It can occur at any time
during your pregnancy and is caused by
a variety of things, including hormonal
changes, worsening pregnancy
symptoms, and, of course, a developing
baby bump.

Loss of appetite ABSENT During pregnancy, it's common to either

lose appetite or develop new food
preferences. This could affect how
much the mother’s weight fluctuates
while pregnant. Food aversions are
frequent, and about 6 in 10 pregnant
women experience one.

Breast changes PRESENT Normal breast tissue in your body

transforms into milk-producing tissue as
a result of pregnancy hormones. As

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 early as the first trimester, this change
takes place. You might feel a tingling in
your breasts at the beginning of your
pregnancy. Your breasts might feel achy
and tender. This is brought on by rising
progesterone levels.

Dizziness PRESENT: common You might experience dizziness or

pregnancy symptoms lightheadedness while pregnant. This
may occur for a few different reasons.
You have lower blood pressure.
Additionally, a growing uterus can press
against and obstruct a major vein that
supplies blood to the heart. Low iron
and low blood sugar can also play a
role. Dizziness can occasionally be
brought on by simply standing up too
quickly after sitting down.

Leg Cramps ABSENT Up to 3 out of 10 pregnant women

experience leg cramps (pain). Although
they typically affect your calf muscles,
they can also affect your thighs or feet.
When your muscles contract tightly
when they shouldn't, you will experience
a cramp. When acid accumulates in
your muscles, this occurs. Most cramps
occur at night. During your second and
third trimesters, they are more
prevalent. Pregnancy-related cramps
have a variety of possible causes,
including changes to your metabolism,
vitamin deficiencies, excessive or
inadequate activity, and changes to your

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 metabolism.

Back Ache PRESENT Back pain or aches are very typical

during pregnancy, especially in the
beginning. Your body's ligaments
naturally soften and stretch during
pregnancy to get you ready for labor.
Back pain may result from this strain on
the joints in your lower back and pelvis.

Abdominal Pain PRESENT Pregnancy frequently causes stomach

or abdominal pains or cramps. Although
they typically aren't a cause for concern,
they could occasionally be an indication
of something more serious that should
be looked into.

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 X. CONCEPT MAPPING

MALE FEMALE

OVULATION
SPERM PRODUCTION

Ejaculation occurs Egg travels to the

through sexual fallopian tube
intercourse

It is now a growing
The fertilized egg called
Fertilization occurs cluster of 100 cells
zygote continues to move
Sperm travels through when the sperm and called blastocyst
down in fallopian tube into
the vagina egg meet the uterus

Week 5: Implantation: The blastocyst

Inside the uterus, the then attaches itself to the
Start of the "embryonic
blastocyst develops into an lining of the uterus (the
period" This is when all the
embryo attach to a placenta endometrium)
baby's major systems and
structures develop.
Hormone level increases.

Week 6:
The baby's brain and spinal cord will
develop from the neural tube.
The heart and other organs also are
starting to form.
Structures necessary to the formation
of the eyes and ears develop.
Small buds appear that soon become
arms
Week 7:
Baby's brain and face are growing.
Depressions that will give rise to nostrils
become visible, and the beginnings of the
retinas form. Lower limb buds that will
become legs appear and the arm buds
that sprouted last week now take on the
shape of paddle small buds appear that
soon become arms

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 Week 10:
Your baby's eyelids are more
developed and begin to close. The
outer ears begin to take shape.
Baby's facial features become more
distinct. At the end of the 10th week
of pregnancy, your baby is no longer
an embryo. It is now a fetus, the
stage of development up until birth.
Week 11 to 14
The baby's eyelids close and will not
reopen until about 28th week.
Baby's face well-formed.
Limbs are long and thin.
Nails appear on the fingers and toes.
Genital appear
Baby's liver is making red blood cells.
The head is very large about half of the
baby's size.
Your little one can now make a fist.
Tooth buds appear for the baby teeth.
Week 23 to25
Bone marrow begins to
make blood cells.
The lower airways of the
baby's lungs develop
The baby's begins to store
fat.
Week 9: Week 8:
Nipples and hair Baby's lower limb buds take on
follicles form. Arms the shape of paddles. Fingers
grow and elbows have begun to form. Small
develop. Baby's toes swellings outlining the future
can be seen. All shell-shaped parts of the baby's
baby's essential ears develop and the eyes
organs have begun to become obvious. The upper lip
grow and nose have formed. The trunk
and neck begin to straighten.
Week 15 to 18
At this stage, baby's skin is almost
transparent. Fine hair called lanugo
develops on baby's head. muscle
tissue and bones keep developing,
and bones become harder. Baby
begins to move and stretch. The
liver and pancreas produce
secretions. Your little one now
makes sucking motions.
Week 22
Lanugo hair covers baby's entire body.
Meconium, baby’s first bowel movement, is
made in the intestinal tract.
Eyebrows and lashes appear.
The baby is more active with increased muscle
development.
The mother can feel the baby moving.
Baby's heartbeat can be heard with a
stethoscope
Nails grow to the end of baby's fingers.
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 Week 26
Eyebrows and eyelashes are well-
formed
All parts of baby's eyes are Week 27 to 30
developed. Baby's brain grows rapidly
Your baby may startle in response The nervous system is developed
to loud noises enough to control some body functions.
Footprints and fingerprints are The baby's eyelids can open and close.
forming. The respiratory system, while
Air sacs form in baby's lungs, but immature, produces surfactant.
lings are still not ready to work
outside the womb

Week 31 to 34
Week 38 to 40
The baby's grows quickly and gains a lot
Fingernails may extend beyond
of fat.
fingertips
Rhythmic breathing occurs, but baby's
Head hair is now coarse and thicker
lings are not fully mature Baby's bones
In your 40th week of pregnancy, it has
are fully developed, but are still soft.
been 38 weeks since conception, and
The baby's body begins storing iron,
your baby could be born any day now
calcium, and phosphorus

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XI. DOCTOR’S ORDER

Date Ordered Doctor’s Order Rationale Remarks

11/07/2022

7:35AM - Schedule for To assess the Done

ultrasound feasibility of NSVD

-Schedule for C- Fetal distress Done

section
4:45PM
- Cefuroxime 1.5g IVTT - To reduce risk of Done
infection

- 1 D5LR 1L 200cc/hr - To replace fluids lost Done

for fast drip, regulate during labor
@30gtts/min.
7:45PM
- Place patient @L - To aid fetal blood Done
lateral position supply

- Fast drip 300ml DLR - To replace fluids lost Done

during labor

- Metoclopramide 1 -Treat nausea and Done

ampule IVTT vomiting

9:30PM - Ranitidine 1 ampule -Reduce stomach Done

IVTT acidity

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- NPO - To avoid aspiration Done
during surgery

- Vs Q15min for Q4 - To monitor patient’s Done

condition

- O2 @2L PRN - To avoid hypoxia Done

-PLR u+ Oxytocin 20u - Strengthen uterine Done

@ 120cc/hr contractions

- TF: D5LR u+Oxytocin - Strengthen uterine Done

10u @120cc/hr contractions

-Keep patient warm - To make patient Done

comfortable and avoid
hypothermia

- I&O hourly - Ensure that patient Done

has proper intake of
fluid and nutrients and
monitor renal function

- Meds: - Prevent infection Done

Cefuroxime 750mg IV
infusion
Q8h
- Treat ulcers of the
Ranitidine 50mg IVT stomach and
q8h intestines.

28
 Relieve moderate to
Ketorolac 30mg IVT severe pain post op
q6h
Pain reliever
Tramadol 50mg slow
IVT q6h

11/08/2022

6:10AM -Patient on DAT Decrease nausea, Done

diarrhea, gas in the
bowel

- Give last dose of Done

Cefuroxime

- D/C Ranitidine Done

- Co-Amoxiclav 1g 1 Treat infections Done

tab q8h

- Senokot 1 tab BID Prevent constipation Done

- Methylergometrine 1 Treatment of migraine Done

tab TID

29
 Used to treat heavy
- Tranexamic Acid bleeding after surgery Done
500mg TID

- Remove catheter Done

@3pm Prevent hard, dry
4:00PM stools.
- Increase oral fluid Done
intake Treat pain or
inflammation
- Celicoxib 200mg Done
1cap BID
Pain reliever
-
Tramadol+Paracetamol Done
1cap Promote healing

- Continue meds Done

11/09/2022

- MGH Done
- Home Meds: Prevent infections of
the surgical incision
Co-Amoxiclav 1g 1tab Done
q8x1 week Treat infections

Cefaroxime 20mg 1cap Done

BIDx7days Relieve pain after
surgery
Tramadol+Paracetamol Done
1tab TID RTCx2 days

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DRA Boost Immune system

ImmunoPro 1cap BID Support wound Done

healing after c-section

Juven Aid 1 sachet in Done

200ml 1tab ODx5days

31
XII. LABORATORY AND DIAGNOSTIC EXAM

32
 XIII. DRUG STUDY

Chief Complaints: Membranes raptured, backache, uterine contractions

DATE NAME DRAWING CLASSIFICATION DOSAGE/ INDICATION MECHANISM SIDE EFFECTS NURSING
TIME/ OF ACTION RESPONSIBILIT
OF DRUG
ROUTE IES

11/9/2022 Generic Therapeutic class: 750mg Serious lower Inhibits cell- CV: Phlebitis, Assess patient
Name: Antibiotics Q8H respiratory tract wall thrombophlebitis for allergy to
Cefuroxime IVTT infection, UTI, synthesis, GI: Diarrhea, penicillin or
Sodium Pharmacologic skin or skin- promoting pseudomembranous cephalosporins
class: structure osmotic colitis, nausea,
Brand Second- infection, bone or instability; anorexia, vomiting. Monitor patient
Name: generation joint infection, usually Hematologic: for signs and
Zinacef cephalosporins septicemia, bactericidal. Hemolytictropenia, symptoms of
meningitis, and (Kluwer, eosinophilia. superinfection
gonorrhoea q8h 2022) Skin: Maculopapular and diarrhea and
for life-threatening and erythematous treat
infections and rashes, urticaria, appropriately
infections caused pain, induration,

33
 by less sterile abscesses, Drug may
susceptible temperature increase INR and
organisms. Obtain elevation, tissue risk for bleeding;
specimen for sloughing at IM monitor patient
culture and injection site.
sensitivity tests Other: anaphylaxis, Look alike-sound
before giving first hypersensitivity like: Don’t
dose. reactions, serum confuse drug
sickness. with other
cephalosporins
that sound alike

DATE NAME DRAWING CLASSIFICATION DOSAGE/ INDICATION MECHANISM SIDE EFFECTS NURSING
TIME/ OF ACTION RESPONSIBILITIES
OF

34
 DRUG ROUTE

11/9/2022 Generic Therapeutic class: 200 mg Celecoxib Thought to CNS: Asses patients for
Name: Nonsteroidal anti- BID works by inhibit Headache, allergic to or with a
Celecoxib inflammatory drug PO reducing prostaglandin dizziness, history of
(NSAID) hormones synthesis, insomnia anaphylactic
Brand that cause impeding CV: HTN, reactions to
Name: Pharmacologic inflammation cyclooxygenase peripheral sulfonamides,
Celebrex class: and pain in 2, to produce edema aspirin, or other
Cyclooxygenase- the body. anti- EENT: NSAIDs may be
2 inhibitors Celebrex is inflammatory, Pharyngitis, allergic to drug,
used to treat analgesic, and rhinitis, sinusitis
pain or antipyretic GI: Abdominal
Watch for signs and
inflammation effects. pain, diarrhea,
symptoms of overt
caused by dyspepsia,
(Kluwer, 2022) and occult bleeding
many flatulence, GI
or rash,
conditions. reflux, nausea
Metabolic:
Instruct patient to
Hyperchloremia
promptly report
Musculoskeletal:
signs of GI bleeding,
Back pain

35
 Respiratory:
Dyspnea, URI Advise patient to
Skin: Erythema immediately report
multiforme, unexpected weight
exfoliative gain, or swelling
dermatitis, SJS,
toxic epidermal
necrolysis rash
Other:
Accidental injury

DATE NAME OF DRAWING CLASSIFICATION DOSAGE/TIME/ROUTE INDICATION MECHANISM SIDE NURSING

DRUG OF ACTION EFFECTS RESPONSIB

36
11/9/2022 Generic Therapeutic 1 gram/ 1 tab Treats lower amoxicillin Hypersensitivity Assess
Name: Class: respiratory tract inhibits to the active pattern bef
Co- Antibiotic OD infection ( bacterial cell substances to during treat
Amoxiclav bronchitis, wall any of penicillin pseudomem
Pharmacologic PO pneumonia, mucopeptide or to any may occur
Brand Class: bronchiolitis ) synthesis. excipients
Name: Aminopenicillins While Report hem
Augmentin beta-lactamase Otitis media Clavulanic History of a oliguria a
inhibitors acid severe doses ca
Sinusitis inactivates a immediate nephrotoxic
wide range hypersensitivity
Skin and skin and beta- reaction to Assess re
structure infection lactam another beta- status
(cellulitis, enzymes lactam agent
erysipelas, found in Observe
furuncles, bacteria History of anaphylaxis
carbuncles, resistant to jaundice/hepatic
abscesses, beta-lactam impairment due
impetigo, infected antibiotics to amoxicillin/
ulcers, infected clavulanic acid
(Kluwer,
burns and others)
2022)
and Urinary Tract

37
 Infection
( infections of
kidneys, ureters,
bladder and
urethra)

38
XIV. NURSING CARE PLAN

Patient’s Name: Mrs. A Room No. 516

Age: 27/ F Diagnosis: G1P1 38 1/7 weeks AOG by late ultrasound

Attending Physician: Dr. Perdido Date: 11/07/22

Chief Complaints: Membranes raptured, backache, uterine contractions

DATE/ CUES NEED NSG. DX. OBJECTIVE NSG. ACTION EVALUATION

TIME/ W/SCIENTIFIC OF CARE
SHIFT BASIS

November Subjective: Physiological Disturbed sleep After 8 hours of Identify After 8 hours of
7, 2022 Subjective:”Di ko needs patterns r/t pain from nursing presence of nursing
7-3pm maka tarong og (Maslow’s lesions s/t post cs intervention, factors known intervention, the
7a tulog, sge rakog Hierarchy of the patient will to interfere with patient will be
kamata tungod sa Needs) be able to: the patient’s able to:
sakit” as verbalized Rationale: sleep
by the patient Pain affects sleep Verbalized the Response to

39
 quality as well as appropriate Assess clients interventions,
Objective: quantity. Pain makes interventions to usual sleep teaching, and
the nervous system promote sleep pattern and action performed
Wound incision more active and compare with
hence, keeps a current sleep
Fatigue and person awake Report of disturbance Would be able to
Restlessness (Nanda, 2016) improved sleep with the
sleep Observe adequate amount
physical signs of sleeping hours
Report of fatigue
increased The patient
sense of well- Listen to client’s shown no sign of
being and report of her any presence of
feeling rested sleep quality weakness or
restlessness

40
Patient’s Name: Mrs. A Room No. 516

Age: 27/ F Diagnosis: G1P1 38 1/7 weeks AOG by late ultrasound

Attending Physician: Dr. Perdido Date: 11/07/22

Chief Complaints: Membranes raptured, backache, uterine contractions

DATE/TIME/SHIFT CUES NEED NSG. DX. OBJECTIVE OF NSG. ACTION EVALUATION

W/SCIENTIFIC BASIS CARE

November 7, Subjective: Safety Self-Care Deficit d/t After 8 hours of Assess barriers to After 8 hours of
2022 ”Maglisod ko Needs wound incisions s/c to nursing participation in nursing
7-3pm mag lihok (Maslow’s post cs intervention, the regimen that can intervention, the
7A tungod sa Hierarchy patient will be limit use of patient will be
akong tahi” of Needs) Rationale: able to: resources or able to:
Related to impaired ability choice of options
Objective: to perform self-care tasks, Perform self- Response to
possibly evidenced care activities Implement interventions,
Wound statements of needs for within own level resources to teachings, and
incision assistance and observed of ability overcome actions

41
 difficulty in in performing barriers performed
Requires help ADLs Identify
from husband (Nanda, 2016) individual areas Instruct client to Attainment or
in standing and of weakness or request progress towards
walking needs assistance when desired outcome
needed
Patient is Identify Modifications of
unable to wash personal Assist and plan of care
her body and resources that incorporate
put on her can provide husband/ family
clothes alone assistance members with
alternative
placements as
necessary

42
Patient’s Name: Mrs. A Room No. 516

Age: 27/ F Diagnosis: G1P1 38 1/7 weeks AOG by late ultrasound

Attending Physician: Dr. Perdido Date: 11/07/22

Chief Complaints: Membranes raptured, backache, uterine contractions

Date/Time/Shift CUES NEED NSG. DX. OBJECTIVE OF CARE NSG. ACTION EVALUATION
W/SCIENTIFIC
BASIS

November 7, Subjective: Safety Risk for After 8 hours of nursing • Assess After 8 hours of
2022 Needs; infection d/t intervention, the patient wound nursing
"namaga ug naga
Maslow's surgical incision will be able to: incision. intervention, the
7-3pm pamula tapos sakit
Hierarchy s/c to post cs goal is met if the
ang samad • Verbalize • Observe skin
of needs patient can:
7A color and
paghuman nako understanding of
nanganak" as Rationale: individual warmth, and • Respond to
verbalized by the causative or risk changes in treatment,
A post- the color and
patient factor (s) teaching,
cesarean odor of
• Identify and action
Objective: wound infection secretions;
interventions to performed
can occur when

43
 bacteria get into prevent or that could be • Attained or
• Wound
the incision reduce the risk of signs of made
incision
wound. infection, such as developing a progress
• Redness
(NANDA,2016) hand hygiene, localized toward the
and swelling
wound infection desired
@ incision
disinfection, and outcome
site • Practice and
keeping surfaces
• Assess emphasize • Modified to
clean.
abdomen constant and the plan of
• Demonstrate
proper hand care
techniques to
hygiene; to
promote safe
minimize
environment
contaminatio
• Achieve timely
n and
healing
infection
• Perform
wound
dressing
• Vs taking
• Monitor the
clients'

44
 visitors for
respiratory
illnesses to
limit
exposures,
thus
reducing
cross-
contaminatio
n.

• Include
information
teaching
about ways
to reduce
potential
infection

45
XV. NURSING THEORIES

Nursing Theory

Self-Care Deficits Theory by Dorothea Orem

Dorothea Orem’s self-care deficits theory defined nursing as “The act of assisting
others in the provision and management of self-care to maintain or improve human
functioning at home level of effectiveness” it focuses on each individual’s ability to perform
self-care defined as “The practice of activities that individuals initiate and perform on their
own behalf in maintaining life, health and well-being.

This is represented by a situation in which the individual is unable to engage on

those self-care actions requiring self-directed and the medical prescription to refrain from
such activity. Rem’s theory is relatively simple but generalizable to apply to a wide variety of
a patients. It explains the terms self-care, nursing system and self-care deficit which are
very essential to students who plan go start their career in nursing.

Moreover, this theory signifies that all patients want to care for themselves, and they
were able to recover more quickly by performing their own self-care as much as they are
able. This theory is particularly used in primary care or other sittings in which patients are
encouraged to be independent. Through this theory greatly influences every patient’s
independence, the definition of self-care cannot be directly applied to those who need
complete care or assistance with self-care activities such as the infant and the ages.

We choose this theory because our patient had recently undergone a cesarean
section, and as we cared for her, we created goals by utilizing the nursing process in her
model to provide care through nursing care plans.

46
XVI. DISCHARGE PLAN

MEDICATION:

• Instruct and encourage the patient to continue to check the list of all medicines to take.
• Take your medicines exactly as prescribed by the physician.
• Call the doctor or nurse if you think you are having a problem with your medicine.
• Take your medicines on time.

MEDICATIONS AS FOLLOWS:

• Tramadol+paracetamol 1 tab,1g,3x a day

• Celecoxib 200 mg, 2x a day
• Amoxicillin-c lavulanic 1 gram, 1 tab

E-XERCISE:

Cesarean section patient it’s usually safe to start low impact exercises such as yoga
walking and gentle jogging.

T-REATMENT:

As directed by your doctor, take your prescription. Incision pain may be relieved by
tramadol, paracetamol (1 tab, 3 times daily), celecoxib (2 times daily), and amoxicillin-C
lavulanic (1 tab, once daily). You can use a heating pad to ease discomfort at the surgery
site in addition to alleviating pain.

H-EALTH EDUCATION:

• Encourage the patient to rest and try to keep everything that she and her baby might
need within reach.
• For the first couple of weeks avoid lifting anything heavier than your baby.
• Emphasize strict compliance of follow-up checkup.

O-UT PATIENT ORDERS

47
-Ensure that the patient will follow the health teachings that given specially the maintenance
drugs prescribed.

D-IET:

• Eat well to promote healing, drink a lot of fluids to stay hydrated, eat and drink properly
to prevent constipation.
• Foods high in iron aid in replacing blood lost after childbirth. Spinach, quinoa, chicken,
ham, turkey, dried apricots, sesame and pumpkin seeds, peanuts, toasted almonds, and
sunflower seeds should all be included in the diet following a C-section.
• Foods that are simple to digest, such as yogurt, paneer, soups, and broths, are
excellent snack options. Constipation, indigestion, gas, and bloating are all prevented by
combining them with fiber-rich meals like ragi, oats, green grams.

S-PIRITUAL

Encourage patient to always pray for the healing process and attend mass every Sunday.

48
XVII. RECOMMENDATIONS

• Get plenty of rest. Cesarean section (C-section) is a major surgical procedure.Just

like with any surgery, your body needs time to heal afterward. After giving birth, plan
on remaining in the hospital for 2 to 4 days. If issues arise, your stay will be
prolonged. Allow your body 6 to 8 weeks to recuperate completely.
• It's simpler to say than to do. If your child is requiring a lot of your attention, it might
be difficult to fall asleep for long periods of time.
• Sleep whenever your baby sleeps, as well-meaning friends and family have
doubtless advised you to do. Whenever your child naps, try to get some rest. When
possible, ask friends and family members to help you with chores and diaper
changes so you may rest. Even a brief period of rest every now and then during the
day can be beneficial.
• Relieve your discomfort. If you are breastfeeding, ask your doctor what painkillers
you are allowed to take.
• Depending on the severity of your pain, your doctor may recommend an over-the-
counter pain reliever such as acetaminophen or ibuprofen (Advil or Motrin; Tylenol).
• You might use a heated pad in addition to painkillers to ease discomfort at the
surgery site.
• Put an emphasis on eating well. In the months following delivery, proper nutrition is
equally as crucial as it was during pregnancy. Even if you are breastfeeding, you
continue to be your baby's main nutrition source. Eating a variety of foods will help
you get stronger and keep your baby healthy.
• Drink plenty of liquids as well, especially water. To increase your milk supply and
prevent constipation, you need to drink more water.
• Take extra care of your baby while your body heals. As far as possible, avoid doing
laborious home tasks. To avoid having to get up frequently, have everything you
need nearby, including meals and diaper-changing supplies.
• Lift only what is necessary to support your infant. Consult your spouse, close friends,
or family members for assistance. Hold your abdomen in place whenever you need
to sneeze or cough to protect the incision site.
• Avoid intensive exercise but stroll slowly whenever you can. Your body will mend
and avoid constipation and blood clots with the movement. Walks are also a
wonderful way to expose your infant to the outdoors.

49
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52