2 K Final Case Manuscript

G2P2 (2002) PREGNANCY UTERINE TERM CEPHALIC
DELIVERED LIVE BIRTH VIA LOW TRANSVERSE

CESAREAN SECTION WITH PRE-ECLAMPSIA
A Case Study Presented to the
College of Nursing St. Jude College Dasmariñas Cavite, Inc.
Dasmariñas Cavite, Philippines
In Partial Fulfillment of the requirements for
Care of the Mother, Child & Adolescent (Acute & Chronic)
Presented by:
Claros, Leonila C.
Enrique, Christel Joy S.
Operiano, Kristine A.
Palag, Angelica F.
Pancipane, Maribeth B.
Rocete, Hanna Jane
Shackleton, Angeline L.
Presented to:
Ms. Baby Frecy De La Cruz, RN, MAN
Ms. Novelyn Calarde, RN
Mr. Justine E. Bañez, RN
BSN LEVEL II
TEAM K
BATCH 2025
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TABLE OF CONTENTS
I. Introduction ………………………………………………………………………….…3
A. Background of the study…………………………………………………......3

B. Biographical Data………...………………………………………………… ..5
C. Genogram……………...………………………………………………………6
D. History of past illness……..………………………………………………….7
E. History of present illness….…………………………………………………7
II. Assessment……………………………………………………………….……..8
A. Vital Signs…………………………………………………………………....8
B. Physical Assessment…………………………………………………….…9
C. Gordons Functional Pattern of Assessment………...………...………..16
D. Laboratory and Diagnostic Examination……………………………….28
III. Anatomy and Physiology…………………………………………………..38
IV. Pathophysiology……………………………………….…………………….52
V. Drug Study………………………………………………….………………….55
VI. Nursing Care Plan……………………………………….………………………
A. Prioritization……………………………………………………….…….61
B. Nursing Care Plan………………………………………………..……..70
VII. Discharge Plan………………..…………………………………………….92
VIII. References……………………..……………………………………………96
IX. Consent Letter……………………………………………………………..99
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I. INTRODUCTION
A. BACKGROUND OF THE STUDY
Pregnancy is the period in which an egg cell is fertilized by a sperm to form a

new cell, called the zygote, that eventually develops into a new human organism,
to be born. The average human pregnancy lasts 38 weeks from conception and 40
weeks from the day of the last menstrual period (LMP). Pregnancy can be single
or multiple. The latter refers to the conception of two or more fetuses at the same
time or the conception of one zygote that divides into two or more independent
zygotes at a very early stage of development and produces two fetuses.
Pregnancy is divided into three trimesters, each with its own significant
developments and changes. During the first trimester, which lasts for the first 12
weeks, the fetus is conceived and goes through various stages of embryonic life.
All the fetal organs are formed during this time, and the fetus is referred to as an
embryo. The second trimester, from week 13 to week 28, is characterized by the
growth and shaping of the organs. Morning sickness typically diminishes during
this period, although some mothers may experience back pain, leg cramps, or
constipation. A notable event in the second trimester is "quickening," when the
mother can feel the first movements of the fetus. In the third trimester, from week
29 to week 40, the baby grows and develops rapidly. The mother may experience
breathlessness as the expanding uterus takes up a significant portion of the
abdomen, pressing against the diaphragm and reducing the space in the chest
cavity. Some common discomforts during this period include hemorrhoids,
varicose veins, urinary incontinence, and difficulty sleeping (Thomas, L., M.D,
2020).
There are two primary types of delivery in pregnancy: vaginal delivery and
cesarean section (C-section). Vaginal delivery, the most common and natural
method of childbirth, involves the baby being born through the birth canal. This
process relies on contractions to gradually dilate the cervix and assist in pushing
the baby out. Vaginal delivery is typically the preferred option when there are no
complications or risks that would necessitate a C-section. On the other hand, a C-
section is a surgical
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procedure where the baby is delivered through an incision made in the mother's
abdomen and uterus (Poinier, A., 2022). It may be planned in advance or
performed as an emergency procedure if there are specific complications that
make vaginal delivery unsafe or challenging. Some factors that may lead to a C-
section include fetal distress, breech presentation, multiple pregnancies, certain
maternal health conditions, or a history of previous C-sections. The decision
regarding the type of delivery is made by healthcare professionals who carefully
assess the health and safety of both the mother and the baby. The choice between
vaginal delivery and C-section will depend on various factors specific to each
individual pregnancy and any potential risks involved.
Preeclampsia is a serious pregnancy complication characterized by high blood

pressure and damage to organs, most commonly the liver and kidneys. It typically
develops after the 20th week of pregnancy and is usually accompanied by signs
such as protein in the urine (proteinuria) and swelling in the hands, face, or feet
(edema). Preeclampsia can affect both the mother and the unborn baby, and if left
untreated, it can lead to serious complications, including premature birth, low birth
weight, and even maternal and fetal mortality (August P., & Sibai, B., 2020).
Factors such as a history of high blood pressure, obesity, diabetes, and certain
autoimmune disorders increase the risk of developing preeclampsia. Symptoms of
pre-eclampsia may include severe headaches, vision changes, abdominal pain,
and decreased urine output.
Managing preeclampsia often involves close monitoring of blood pressure,

urine tests to detect protein levels and frequent prenatal visits. In more severe
cases or when the health of the mother or baby is at risk, early delivery of the baby
may be necessary. Medications to lower blood pressure and prevent seizures
(eclampsia) may also be prescribed. Preeclampsia can be a life-threatening
condition, so early detection, proper management, and medical intervention are
crucial in ensuring the best possible outcomes for both the mother and the baby
(Lindberg, S., 2020).
In conclusion the objective of this study for the student nurses is to expand our
knowledge, understanding, and management of pre-eclampsia. This objective
goes beyond completing course requirements and emphasizes the value of
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becoming knowledgeable about illness processes, risk factors, and treatment
options. Additionally, the results obtained. Thought this analysis, it aims to
contribute to the understanding of effective strategies for pre-eclampsia
management and their impact on maternal and fetal outcomes.
B. BIOGRAPHICAL DATA
A. Patient’s Name R.B
B. Address: Barangay Salawag, Dasmarinas City, Cavite
C. Age 39-year-old
D. Birthdate May 6, 1994
E. Birthplace Dasmarinas, Cavite
F. Gender Female
G Civil Status Married
H. Religion Roman Catholic
I. Highest Educational Attainment Bachelor’s Degree
J. Nationality Filipino
K. Occupation Nurse
L. Primary Informant Patient R.B
M. Secondary Informant Partner
N. Other Sources Patient’s Chart
O. Date and Time Admitted May 8, 2023| 8:00 PM
P. LMP : August 11, 2022
Q. Admitting Diagnosis G2P1 (1001) PU 36 3/7 weeks AOG CNIL,

Preeclampsia with Severe Features S/P CS /
x Preeclampsia
R. Final Diagnosis G2P2 (2002) PU Term, Cephalic term
Delivered Live Birth (Female: BW 2560g; BL
47cm; AS 9,9) Via Low Transverse Cesarean
Section II, S/P Preeclampsia with Severe
Features
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C. GENOGRAM
Analysis:
Patient R.B is 39 years old, female, she is married with her partner J.B 41 years
old. According to Patient R.B her partner does not have any medical problems or
history of any medical problem running in the family. Patient R.B is a First born in her
family. Her mother is E.C, 63 years old and was diagnosed with hypertension at 36
years old. According to Paula J. Williams, (2020), Having a family history of
hypertension, particularly in first-degree relatives (such as parents or siblings),
increases the likelihood of developing preeclampsia. This suggests a genetic
predisposition to hypertension, which may contribute to the development of
preeclampsia during pregnancy.
The genogram clearly shows that Hypertension runs in the patient's Maternal
Side. According to Andrea Kattah (2018), A family history of hypertension or other risk
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factors does not guarantee that a woman will develop preeclampsia. However,
healthcare providers may take these factors into consideration when assessing a
woman's risk profile and implementing appropriate monitoring and preventive
measures during pregnancy.
D. HISTORY OF PAST ILLNESS

Patient R.B is a 39-year-old woman with a significant family history of
hypertension on her maternal sides. Patient R.B received complete immunizations and
did not have any hospital admissions or surgeries related to medical illness. Prior to
her pregnancy, she also received 4 doses of the tetanus toxoid vaccine to protect her
and the fetus against the life-threatening bacterial infection, tetanus. Additionally, she
stated that she had a history of pre-eclampsia during 5 months of the present
pregnancy, and she somehow anticipated it due to her family history of hypertension.
Patient R.B have a past surgery, or any history of procedures undergone in the past.
E. HISTORY OF PRESENT ILLNESS

Patient R.B was admitted to Pagamutan ng Dasmariñas City Cavite on May 8,
2023, at 8:00 AM in the morning. She came to the emergency room with a chief
complaint of previous cesarean section and for admission, a cesarean section was
performed to prevent further complication. At the time of admission, she was
diagnosed with G2P2 pregnancy, uterine term with 38 weeks of gestation, cephalic in
labor, and severe preeclampsia features through maintenance.
She was transferred to the delivery room/ operating room on May 9, 2023 at
2:00 P.M, she was given 2 ampules of HNBB through IV as ordered. And she hooked
a side drip of D5LR 1L. The induction of spinal anesthesia started at 2:30 PM on the
same day, following the abdominal preparation and insertion of indwelling foley
catheter.
The final diagnosis for Patient R.B was G2P2 pregnancy, uterine term, cephalic
delivered via low transverse cesarean section. She experienced arrest in cervical
dilation and cephalopelvic disproportion, indicating that the baby was not progressing
naturally, and the uterine contractions were insufficient to facilitate labor. The patient
experienced difficulties in labor due to cephalopelvic disproportion. During the
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procedure, a live baby girl weighing 2.5 kg was delivered. Following the delivery, she
was informed of her high risk of developing hypertension and was advised to maintain
a healthy diet and lifestyle such as low saturated fats, low salt, medications and regular
physical exercise.
II. GENERAL PHYSICAL ASSESSMENT

A. VITAL SIGNS
Patient R.B is a 39-year-old female. Upon assessment, the patient temperature
36.2, a Blood pressure 160/100, a pulse rate 85 bmp, a respiratory rate of 20 cpm, an
oxygen saturation 99%, and the pain scale of 9 out of 10. After the operation, the vital
signs are normal with ongoing 1 liter of D5LR with remaining 850cc to run for 10cc/hr
that located to left metacarpal vein and decreased pain level from 9 out 10 to 4 out of
10.
VITAL SIGNS
VITAL SIGNS PRE-OP POST-OP
( May 8, 2023) (May 9, 2023)
Temperature
36.2 36.7
Blood Pressure
160/100 mm/Hg 130/80 mm/Hg
Pulse Rate
85 beats per minute 89 beats per minute
Respiratory Rate
20 cycles per minute 18 cycles per minute
O2 Saturation
99% 99%
Height
5’3 ft 5’3 ft
Weight
79 kg 70.2 kg
Pain scale
Provoking Factor Back Pain Abdominal Pain

Quality Mild Cramping Mild Cramping
Radiation Lower back Abdominal Pain
Severity 9/10 4/10
Time Recurring Pain Recurring Pain
Fetal Heart Tone
146 beats per minute none
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B. REVIEW OF SYSTEM – PHYSICAL EXAMINATION
POST-OPERATIVE ASSESSMENT
SYSTEM FINDINGS NORMAL FINDINGS ANALYSIS
During pregnancy,
there are several
changes that can
occur in a woman's
skin that do not
involve lesion
masses or nodules.
One such change is
the darkening of the
skin, specifically in
Patient has a light areas such as the
skin all over the underarm, groin, and
body. under the breasts.
This is known as
Presence of striae "chloasma" or
at hypogastric and "melasma" and is
iliac regions. Stretchmarks, linea caused by an
nigra, and varicose increase in melanin
When her skin veins are common in production, triggered
was pinched it pregnancy. Skin by hormonal
returned to its should have good changes in the body.
normal state turgor, no This darkening of the
immediately, her discoloration, no skin is more common
SKIN skin was observed lesions, rashes, and in women with darker
to be without the edema, as stated by skin tones. During
presence of Berman et al. (20 pregnancy, there can
bruises. be changes in the
skin's turgor, or the
Pitting edema ability of the skin to
grade 2 were return to its normal
observed on the position after being
patient’s pinched or pulled.
extremities. One change that can
occur is an increase
in skin hydration and
elasticity due to the
hormonal changes
that occur during
pregnancy. This can
result in the skin
appearing more
plump and hydrated.
(Bolognia, J. L.,
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Schaffer, J. V.,
Cerroni, L. (2018).
Dermatology.
Elsevier.)
Normal Findings the

Client’s hair and
Evenly scalp is healthy as
distributed of Hair should be
evidence of no hair
hair, Thick hair, evenly distributed,
loss, no head lice in
Silky resilient thick, resilient, no
hair follicles, no
hair, No infection and no
scalp lesions and no
infection or infestations. Upon
dryness. Head
infestation, mild palpating the entire
features are
HEAD dandruff neck, enlarged
symmetrical and
lymph nodes should
have no signs of
No masses not be palpable. As
deformities.
noted upon stated by Berman et
Fundamentals of
palpation of al. (2008)
nursing; 4th edition
head and neck
by Porter Perry Page
660-662
Patient said she During pregnancy, it

was able to see is normal for a
far and near woman's eyes to
objects without have no discharge,
difficulty. be symmetrical, have
Sclera should be
white in color and equal eyebrows and
Her eyes
the palpebral eyelashes, and have
moved white sclera (the
conjunctiva appears
smoothly and
pink. As stated by whites of the eyes
symmetrically.
Chandrasekhar and black pupils.
Normal vision is These characteristics
Cornea is moist
20/20 according to indicate that the eyes
EYES and shiny , her
Dr. Mckinney. are healthy and
pupils are black
functioning normally.
round and
(American Academy
equal in
of Ophthalmology.
diameter, and
(2020). Eye health
dilates
normally. and pregnancy.)
The nose is Nasal septum is

The patient’s
symmetrical. and intact. Indicated that
external nose
intact. (-) swelling of the patient is normal.
NOSE was located
mucous membrane Nose is symmetric
symmetrically in
with no lesions and
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the midline of (-) discharge ( masses together with
the face. Bertman et.al.2018) the sinuses, It is
important to note that
Nostril are every woman
patent, The experiences
nasal mucosa pregnancy
was observed differently, and Page
to red and no 14 nasal and sinus
deviations and changes can vary.
no discharge. Some women may
not experience any
The patient was changes in their
able to smell nose and sinuses,
and distinguish while others may
different odors experience more
as the client severe symptoms.
identifies odors (American College of
such as alcohol Obstetricians and
and perfume Gynecologists 2020).
A healthy
antepartum mother
should be free of any
Her tongue is visible abnormalities
pink and moist. or lesions, such as
erythema, exudates,
The tongue is in Soft, moist, smooth or ulcerations. The
the middle of texture. oropharynx should
the mouth. also be free of any
The tongue should masses or masses,
Buccal mucosa be in cent Uniform
and there should be
was found to be in pink color no significant
pale. (darker, e.g., bluish deviation of the uvula
central position,
Lips are or other structures. A
pink in color.
uniform in color, study by D. A. West
Smooth, intact
pink in color, & D. D. Mealey
MOUTH AND dentures.
soft, moist, published in
TEETH
symmetric in American Journal of
32 adult teeth;
contour. Obstetrics and
Smooth, white,
Gynecology in 1996,
shiny tooth enamel.
Teeth are 32 for suggest that
According to
adult , slightly pregnant women
Berman et al., 2018
yellowish in should be advised to
color, with pinks maintain good oral
gums , moist no hygiene, including
lesions regular tooth
brushing and
flossing, in order to
prevent oral
Page 11 of 99
infections and
inflammation, which
may lead to adverse
pregnancy
outcomes. (West &
Mealey, 1996)
Chest
Normal respiration
movements are
rates for an adult
equal.
person at rest range
Crackles and from 12 to 20
any breaths per minute
CHEST AND
unnecessary (Cleveland Cliic,
LUNGS
sounds are 2019) Respiration
absent, and no should be quiet,
complaint noted rhythmic, and
in terms of effortless (Berman
breathing in any et al. 2008
position
According to
American Pregnancy
Association that
Skin uniform in Growth and
color (same in enlargement –
appearance as Around weeks 6-8,
skin of your breasts will get
abdomen or bigger and continue
Your nipples will
back) to grow throughout
become larger and your pregnancy.
more pronounced.
No tenderness, Expect to go up a
They may also
masses, bra cup size or two.
change shape. Your
nodules Your breasts may
nipples and areola feel itchy as the skin
may continue to
BREAST Areola and stretches and
darken significantly
nipples are Darkening of nipples
(Whelan, 2017).
slightly and areolas (the skin
brownish in around your nipples)
color. due to hormones that
affect the
Breast are firm pigmentation of the
skin. (Breast
Changes During
Pregnancy. (2020,
April 27).
Page 12 of 99
Normal findings in
the abdomen of an
antepartum mother
include the presence
of striae gravidarum,
which are stretch
marks that
commonly appear on
the abdomen,
breasts, thighs, and
hips during
Stretchmarks and pregnancy. These
Linea nigra is a marks are caused by
physiological form the stretching of the
of hyper skin as the abdomen
Stretchmarks
pigmentation enlarges. Another
and Linea nigra
commonly seen in normal finding is the
is present.
the first trimester of Linea nigra, which is
ABDOMEN pregnancy (Roh,
Abdomen is not a dark line that runs
tender, no 2018). vertically down the
masses noted center of the
No tenderness;
abdomen. It is
relaxed abdomen
caused by an
with smooth,
increase in melanin
consistent tension
production and
typically disappears
after delivery.
(American College of
Obstetricians and
Gynecologists.
(2018). Physical
examination in
pregnancy.
Obstetrics &
Gynecology, 131(1),
e1-e18)
High vascular and During pregnancy,

Nails are pink in light-skinned the extra fluid in the
medium in clients. body and the
length and pressure from the
pinkish. Prompt return of growing uterus can
pink or usual color cause swelling (or
EXTREMETIES
Presence of in (less than 2 "edema") in the
both legs seconds) as stated ankles and feet. The
edema by Berman et al., swelling tends to get
2008 worse as a woman's
due date nears,
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particularly near the
end of the day and
during hotter weather
as stated by
(kidshealth.org
January 2021).
Vaginal
discharge is According to According to
evident with Schaeffer, J. (2019), (Cleveland Clinic
slightly pink in discharge is present 2021), it is normal
color. at pregnancy and symptom during late
became more pregnancy when a
The external notable as
GENITAL small amount of
genitalia is pregnancy continue, blood and mucus is
pinkish and free it will became heavy released from the
from pus and after delivery. vagina.
lesions
Rectum has Hemorrhoids is

common during
(-) lesions According to Peri, C. pregnancy however,
(2020), a swollen patient K.A, shows
(-) swelling vein causes no sign and
Hemorrhoid in the symptoms of
(-) pain rectum. Getting them
hemorrhoids (e.g.,
during pregnancy is
RECTUM Increased itching or irritation in
normal, especially in
pigmentation anal region, pain or
the third trimester.
due to discomfort, swelling
pregnancy around anus, and
bleeding).
Patient actively The patient was

answers the interviewed to gather
entire questions data about her
and oriented, According to demographic data,
alert and think thriveap.com (2016), history of past and
critically and patients should be present illness, and
can handle the alert and oriented to data about
situation Fully person, place, and genogram. By that,
awake, erect time with normal her cognitive or
posture, speech. Memory thinking skills were
appropriate should be normal tested. It proves that
facial and thought process she is oriented and
NEURO- expression, is intact. alert. Upon
awake, alert answering the
LOGICAL interview, the patient
and oriented to
time and place did not stutter, and
she can talk normally
Page 14 of 99
and it shows the
willingness during
Behavior- She interview.
can response to
simple According to a study
commands published in the
Journal of Obstetrics
and Gynecology
Research (JOGRR)
Motor in 2016, neurological
Functioning- disorders are
She can relatively common
alternately during pregnancy,
supine and with a prevalence of
pronate hands around 2-3%. These
at rapid pace disorders can include
Page 23 headaches,
Able to extend seizures, and stroke,
arms front and which can have a
resist active as significant impact on
pushed maternal and fetal
down/up on his outcomes if left
hand untreated. (Nasr, A.,
& Nasr, A. (2016).
Neurological
Reflexes- disorders in
Reflexes were pregnancy. Journal
present such as of Obstetrics and
the blinking Gynecology
reflex and deep
tendon reflex.
Sensory
functioning-
Patient R, she
could recall the
information
given early in
the interview.
Page 15 of 99
C. GORDON’S FUNCTIONAL ASSESSMENT
GORDON’S BEFORE DURING ANALYSIS

ASSESSMENT PREGNANCY PREGNANCY
Health “Kumakain naman “Noong ang The patient stated
Perception po ako ng mga bubuntis ako, that she was able
Health gulay at prutas, kompleto naman to eat healthy food.
Management Nakakapag ako sa checkup at it's generally
pacheck up din kumakain din ako expected that
kapag sa tingin ko ng mga gulay at medical
kelangan ko at prutas” practitioners, as
may As verbalized by healthcare
nararamdaman the patient. professionals,
ako, kailangan ko would have
din kasi alagaan knowledge about
ang sarili ko lalo the importance of a
na isa din akong healthy diet and its
nurse” impact on overall
As verbalized by health. Medical
the patient practitioners are
individuals with
their own choices
and preferences.
According to
National Institute of
health (2021),
while they may
have knowledge
about healthy
eating, it doesn't
guarantee that
every medical
practitioner strictly
follows a healthy
Page 16 of 99
diet. Personal
circumstances,
individual choices,
and lifestyle factors
can influence their
dietary habits, just
like any other
person.
Nutritional “Wala namang “Noong nag As patient stated

Metabolic pinag babawalan bubuntis ako she avoids or limit
Pattern sakin kainin, pero ganon padin certain foods that
minsan naiwas din naman mga can contribute to
ako sa mga iniisawan kong her condition.
pagkain na puro pagkain, pero According to
saturated fats and napansin ko Medical News
mga red meat, madalas talaga Today (2022),
natikim naman ako ako kumain nung Instead of focusing
minsan pero onti nag bubuntis, on what to avoid,
lang dahil nga parang lagi akong it's also essential to
ayon hypertensive gutom” emphasize the
na talaga ako dati As verbalized by consumption of
pa, more on gulay, the patient. heart-healthy
isda at mga prutas foods. A balanced
ang madalas ko na diet that includes
kinakain” fruits, vegetables,
As verbalized by whole grains, lean
the patient. proteins, and low-
fat dairy products
can help manage
hypertension.
Additionally,
incorporating
Page 17 of 99
physical activity
into the routine,
maintaining a
healthy weight, and
managing stress
are all beneficial for
controlling blood
pressure levels.
Elimination “Nakakaihi naman “dahil nga buntis As patient stated,

Pattern ako ng maayos, ako, madala ako she don’t see any
normal naman ang umuhi kumpara sa problem with her
kulay, hindi rin normal nap ag ihi, urine, she does not
masakit pag naihi. alam ko namang experience any
Sa pag dumi okay normal yon diba discomfort when
din naman, wala pag nag bubuntis, urinating and also
naman akong sap ag dudumi she has a normal
napapansin na ganon padin bowel movement. A
problema” naman normal healthy elimination
As verbalized by lang din” pattern can vary
the patient. As verbalized by among individuals,
the patient” but generally, it
involves regular
and effortless
bowel movements
with well-formed
stools.
According to MUSC
health (2019),
Maintaining a
healthy elimination
pattern is
Page 18 of 99
influenced by
various factors,
including diet,
hydration, physical
activity, stress
levels, and
individual
differences. Eating
a diet rich in fiber,
drinking enough
water, engaging in
regular exercise,
managing stress,
and prioritizing
good digestive
health practices
can all contribute to
promoting healthy
bowel movements
Activity- “Dahil nga busy “Ganon padin As verbalized by
Exercise ako dati kasi naman noong nag the patient before
Pattern madalas asa work bubuntis ako, nag and during her
ako, hindi ako lalakad lakad lang pregnancy, she
nakakapag din ako sa labas, doesn’t have any
exercise, syempre kelangan time to do
nakakapag lakad din diba pag nag exercises, the only
lakad lang ako pag bubuntis na physical activity
may pupuntahan nakakapag lakad that she can do is
sa labas at lakad” walking. A healthy
syempre pag nag As verbalized by exercise pattern
wowork the patient. typically involves a
nakakagalaw balanced
galaw din ako don” combination of
Page 19 of 99
As verbalized by cardiovascular
the patient exercise, strength
training, and
flexibility exercises.
According to
BioMed Central
(2022),
Management:
Maintaining a
healthy weight is
important for
managing
hypertension.
Walking can
contribute to weight
loss or weight
maintenance when
combined with a
balanced diet. It
burns calories and
helps improve body
composition.
Sleep- Rest “Minsan napupuyat “Yung nag As patient stated,

Pattern din ako dati kasi bubuntis ako there are times that
minsan naduty minsan paputol she sleeps late
talaga ako sa work putol tulog ko, because of her
ko ng gabi, pero pero nakakatulog work. Sleeping late
may times din na padin naman ng on a regular basis
maaga ako mahimbing” may potentially
nakakatulog at As verbalized by contribute to the
mahimbing lalo na the patient development or
pag pagod” worsening of
Page 20 of 99
As verbalized by hypertension,
the patient. although it is just
one factor among
many that can
influence blood
pressure levels.
According to
Center for disease
Control and
prevention (2021),
Insomnia is linked
to high blood
pressure and heart
disease. Over time,
poor sleep can also
lead to unhealthy
habits that can hurt
the heart, including
higher stress
levels, less
motivation to be
physically active,
and unhealthy food
choices
Cognitive “Para sakin mabilis “Katulad lang ng As patient stated,
Perception naman ako dati, ganon padin she can quickly
Pattern makaintindi pag nung nagbubuntis understand and
may sinasabi sakin ako, pero may interpret
o pinapaliwanag, times na nagiging information.
may times na pag emotional yung
mahirap talaga perception ko or According to KL
yung concept na yung response ko Robert (2022), Our
gusto ko malaman sa ibang bagay” perception is
Page 21 of 99
medyo natatagalan As verbalized by influenced by how
lalo na pag the patient we interpret the
mahirap, pero information we
normal lang receive. Cognitive
naman yon, hindi perception patterns
naman kasi tayo can involve
perfect” individual
As verbalized by differences in
the patient. interpreting and
assigning meaning
to sensory input,
events, or
situations. This can
be influenced by
factors such as
past experiences,
beliefs, biases, and
cultural
backgrounds.
Self-Perception “Minsan “Alam ko na talaga As the patient
Self-Concept/ nalulungkot din na kahit pa sa stated, she feels
Pattern ako, kasi hindi susunod na sad about her
naman ganito yung magbubuntis pa appearance
itsura ko dati, hindi ulit ako, ganito na because after
pa ako ganito naman giving birth her
kataba, alam ko mangyayari, sanay body does not look
naman na normal naman nako, the same as before
lang na magbago minsan hindi ko na pregnancy.
kapag naging lang din siya According to
nanay na pero naiisip” Gonsalez JS
siguro namimiss As verbalized by (2020), Pregnancy
ko lang yung sarili the patient. and childbirth bring
ko dati” As about significant
Page 22 of 99
verbalized by the changes in a
patient woman's body,
such as weight
gain, stretch marks,
changes in breast
size and shape,
and a softer
abdomen. These
physical changes
may challenge a
person's body
image and
contribute to
feelings of
dissatisfaction or
self-consciousness.
.
Role “Okay naman kami “Noong nag With this statement,
Relationship ng partner ko, bubuntis ako, mas her relationship
Pattern kasal kami, lalo niya akong with her partner
nagtutulungan iniintindi, siya lagi shows a healthy
kaming dalawa sa yung nandyan relationship, as
lahat ng bagay at para alagaan ako they show support
lagi namin iniintindi at siya din yung to each other, has
ang isa’t isa” nag babantay good
As verbalized by sakin palagi” communication and
the patient. As verbalized by care for each other
the patient. through sickness
and health.
According to
Timothy Legg
(2018), Effective
Page 23 of 99
communication is
essential for
healthy role
relationships. It
involves expressing
thoughts, feelings,
and needs openly
and honestly, while
actively listening to
others. Clear and
respectful
communication
helps establish
understanding,
resolve conflicts,
and build trust.
Sexually “Nag pipills ako “Matagal pa As the patient
Reproductive dati, pero tinigil ko siguro kung gusto stated, she stops
din, kasi medyo naming sundan using contraceptive
matanda naman yung anak namin, and would like to
na yung unang pero baka hindi na plan to use one in
anak namin kaya din kasi hirap ako the future because
okay lang pag nag bubuntis it was not easy for
masundan uli kaya baka her during
since namiss din gumamit uli ako ng pregnancy.
talaga naming mag contraceptive” According to
alaga ng baby” As verbalized by Healthline (2019),
As verbalized by the patient. Complications
the patient during pregnancy
can have long-
lasting emotional
and physical
effects. The mother
Page 24 of 99
may have
experienced
postpartum
complications,
physical health
issues, or ongoing
emotional
challenges after the
previous
pregnancy. These
effects may
influence her
decision to
prioritize her own
well-being and not
pursue another
pregnancy.
Coping Stress “Minsan di naman “During ng pag As the patient
Tolerance natin maiwasan bubuntis ko, stated, she was
Pattern mastress lalo na minsan irritable always stressed
dati nag wowork ako at mabilis before in her work
din ako, pero mainis, parang as a nurse,
kinakaya naman, mas nastress ako, however, taking a
pag stress ako siguro dala nga ng break from her
nakikipag bonding nag bubuntis ako work, made her
lang ako duon sa kaya ganon, dati realize that she
isa kong anak” iniisip ko na after feels stressed more
As verbalized by ko manganak when she is just
the patient. parang gusto ko staying at home
na agad mag work and she wants to
uli, pakiramdam ko work again after
parang mas lalo her recovery.
akong mai-istress
Page 25 of 99
kapag na sa According to Steve
bahay ako palagi ” Maron (2016),
As verbalized by Work can be
the patient. closely tied to an
individual's sense
of identity and
purpose. In times of
stress, leaning into
work may provide a
sense of purpose
and fulfillment,
allowing individuals
to focus on their
professional roles
and responsibilities
as a way to cope
with stress in other
areas of their lives.
Values-Belief “Katoliko talaga “After ko As patient stated,
Pattern kami, pati pamilya manganak nag her religion is
ko at asawa ko, pasalamat talaga catholic, she does
nakakapag simba ako sa panginoon not often attend
kami pero bibihira dahil kinaya ko at church but
lang, kasi busy din ng baby ko, lalo sometimes when
kami, pareho na hindi naging their family is not
kaming may work madali ang pag busy, they attend to
e, pero syempre bubuntis ko, hindi it, she was not also
malakas padin kami pinabayaan active to any
pananalig naming ng panginoon” church activities.
sa panginoon” As As verbalized by For her, as long as
verbalized by the the patient. they believe in God
patient. and she is kind, it is
enough.
Page 26 of 99
According to family
doctor (2021),
Spiritual beliefs
often promote a
positive attitude,
hope, and
optimism. Believing
in a higher purpose
or divine
intervention can
instill confidence
and a belief in the
possibility of
healing and
recovery. This
positive mindset
can have a
psychological and
physiological
impact on health,
potentially
influencing the
recovery process.
Page 27 of 99
D. DIAGNOSTIC AND LABORATORY FINDINGS
PARAMETERS REMARKS RESULT NORMAL INTERPRETATION

RANGE
COMPLETE BLOOD COUNT
Hemoglobin L 11.4 12.015.0 (F); The Patient’s

14- 18(M) g/dl hemoglobin is low.
Low hemoglobin
typically indicates
anemia. In
pregnancy, mild
anemia is normal
due to the increased
blood volume.
Hemoglobin
changes from early
to mid or late
pregnancy were
inversely associated
with birth weight,
placental weight,
and placental ratio
(Jwa, et. al., 2015).
Hematocrit L 27.7 35-49(F) The hematocrit
;40-54(M)% result is relatively
low. During
pregnancy, the
hematocrit value
normally decreases-
the fluid in the blood
(plasma) increases,
making red blood
cells less
concentrated.
Hematocrit levels
that are too high or
too low can be a
sign of a blood
disorder,
dehydration, or
other medical
conditions that
affect your blood
(Marshall S., &
William, G., 2017).
RBC L 3.23 4.05.40(F); The Red Blood Cells
4.6- (RBC) Count of
6.0(M)x106/uL patient R.B is low. A
Page 28 of 99
low RBC count
during pregnancy
can indicate
anemia. According
to the American
Society of
Hematology, mild
anemia is normal
during pregnancy
due to an increase
in blood volume.
More severe
anemia, however,
can put the baby at
higher risk for
anemia later in
infancy.
WBC H 12.4 4.5 – 10.0 The White Blood
x103/uL Cells (WBC) of the
patient is high. WBC
count during
pregnancy is
significantly high
due to neutrophil
leukocytosis.
Usually, a high white
blood cell count
means that the body
is defending itself
from an illness or
disease and is
under stress.
However, during
pregnancy, it is
normal to have a
high white blood cell
count reading
(Sruthi, M., 2022).
PLATELET CT 239 150 – 450 x 10 The patient’s
9/L Platelet Count is
normal. In
pregnancy, a normal
platelet count
generally remains
within the range of
150,000 to 450,000
platelets per
microliter of blood,
similar to the non-
pregnant
Page 29 of 99
population.
However, some
women may
experience a mild
decrease in platelet
count due to
physiological
changes, such as
dilutional effects
from increased
blood volume,
without it
necessarily
indicating a
pathological
condition.
MCV 94 80 – 100 fL The patient’s MCV
is normal. MCV is an
unreliable marker of
iron deficiency in
pregnancy.
Stimulation of
erythropoiesis leads
to a physiologic
increase in MCV
during gestation that
counterbalances the
microcytosis of iron
deficiency. A low
MCV, defined as an
MCV <80 fL, is
highly sensitive, but
not specific, for iron-
deficiency anemia
(Achebe, M., 2017).
MCH H 37 27 - 31 pg The MCH result is
relatively high. MCH
is a calculation of
the average amount
of hemoglobin
contained in each of
a person’s red blood
cells. According to
One Care Media,
abnormally high or
low levels of MCH,
as determined by
blood testing, can
be an indication of a
number of problems
Page 30 of 99
in the body, ranging
from nutrient
deficiencies to
chronic diseases.
MCHC 35 33 - 37 g/dl Patient R.B’s MCHC
result is normal. In
women not
supplemented with
iron, mean
corpuscular Hb
(MCH) falls from late
in the second
trimester, with a
further significant
decrease
postpartum, and
mean corpuscular
Hb concentration
(MCHC) falls
gradually until the
end of third trimester
(Morton, A., 2021).
RDW-CV H 15.9 11.5-14.5 % The RDW-CV result
is high. RDW level
was significantly
higher in women
with preeclampsia
compared to
controls. Similarly,
women with severe
preeclampsia had
significantly higher
RDW than those
with the mild form
(Adam, I., & Malik,
E., 2019).
DIFFERENTIAL COUNT
NEUTROPHILS H 80 50 - 70 % The patient’s
neutrophils are high.
The cause of
increased
neutrophils and
WBCs in maternal
blood is most
probably due to this
altered maternal
inflammation.
Activated
neutrophils and
Page 31 of 99
WBCs secondary to
the endothelial
dysfunction in
preeclampsia may
be responsible for
the increased first
trimester levels of
WBC and
neutrophils (Orgul,
G., et. al., 2019).
LYMPHOCYTES L 16 18 - 42 % Lymphocytes
results of patient
R.B are low. Total
lymphocyte counts
are consistently
reduced during
pregnancy, primarily
due to fewer
circulating cytotoxic
lymphocytes
capable of directly
recognizing and
targeting fetal
antigens (Hove, C.,
et. al., 2020).
EOSINOPHILS 3 1-3% Eosinophils result is
normal. Eosinophil
counts are low
during pregnancy,
reaching their nadir
around delivery.
Thus, pregnant
women may have
falsely low numbers
of eosinophils in
response to
parasitic infection
(Kim., Y. & Nutman,
T., 2017).
MONOCYTES 7 2 - 11 % The monocytes
result is normal.
Monocytes are short
lived cells that
mature in the
circulation and
invade into tissues
upon an
inflammatory
stimulus and
develop into
Page 32 of 99
macrophages.
Macrophage are
abundantly present
in the endometrium
and play a role in
implantation and
placentation in
normal pregnancy
(Faas, M., et. al.,
2014).
URINALYSIS
MACROSCOPIC:
NORMAL ACTUAL
TEST INTERPRETATION
FINDINGS FINDINGS
The urine color, as
shown on the result, is
Yellow (Light/Pale dark yellow, which is
Color to Dark/Deep DK YELLOW normal. Since the urine
Amber) color in pregnancy can
change from light
yellow to dark yellow.
The transparency is
hazy, which can
indicate vaginal
discharge or
dehydration.
Cloudiness may be
caused by excessive
Transparency Clear/Transparent HAZY cellular material or
protein in the urine or
may develop from
crystallization or
precipitation of salts
upon standing at room
temperature or in the
refrigerator.
The reaction is alkaline
with a PH level of 7.0.
Reaction - ALKALINE
According to
Healthwise, some
foods (such as citrus
fruit and dairy products)
and medicines (such as
PH 4.5 – 8 7 antacids) can affect
urine pH. A high
(alkaline) pH can be
caused by severe
vomiting, a kidney
Page 33 of 99
disease, some urinary
tract infections, and
asthma. A low (acidic)
pH may be caused by
severe lung disease
(emphysema),
uncontrolled diabetes,
aspirin overdose,
severe diarrhea,
dehydration, starvation,
drinking too much
alcohol, or drinking
antifreeze (ethylene
glycol).
The Specific Gravity is
within the normal
range. A very high
specific gravity means
very concentrated
urine, which may be
caused by not drinking
enough fluid, loss (of
too much fluid
(excessive vomiting,
sweating, or diarrhea),
Sp. Gravity: 1.005 – 1.030 1.030
or substances (such as
sugar or protein) in the
urine. Very low specific
gravity means dilute
urine, which may be
caused by drinking too
much fluid, severe
kidney disease, or the
use of diuretics
(Husney, A., et. al.,
2022).
There is a trace of
albumin in the urine.
Protein in the urine may
mean that kidney
damage (such as
caused by high blood
Albumin None TRACE pressure or diabetes),
an infection, cancer,
systemic lupus
erythematosus (SLE),
or glomerulonephritis is
present.
Page 34 of 99
Protein in the urine may
also mean that heart
failure, leukemia,
poison (lead or mercury
poisoning), or
preeclampsia (if
pregnant) is present
((Husney, A., et. al.,
2022).
There is no sugar in the
Patient’s urine.
Too much glucose in

the urine may be
caused by uncontrolled
diabetes, an adrenal
gland problem, liver
damage, brain injury,
Sugar None NEGATIVE certain types of
poisoning, and some
types of kidney
diseases. Healthy
pregnant women can
have glucose in their
urine, which is normal
during pregnancy
2022).
MICROSCOPIC:
NORMAL ACTUAL
TEST INTERPRETATION
FINDINGS FINDINGS
Patient R.B’s number
of pus cells in the urine
is normal.
In the case of pregnant

women, the urinary
tract undergoes
physiological and
anatomical changes
Pus cells: 0 – 5/hpf 2 – 5/hpf
that result in the
development of
bacteria which are
either symptomatic or
asymptomatic. It is
noted that a
physiological increase
in plasma volume due
to the fetus in the womb
Page 35 of 99
during pregnancy
causes a decrease in
the urine concentration.
Certain conditions
during pregnancy also
cause the development
of glucosuria in
pregnant women,
which is one of the
significant reasons for
bacterial growth in the
urine (Garg, P., n.d).
The RBC result in the
urine is higher than
normal which may
indicate various health
problems.
According to Husney,
A., 2022, Red blood
cells in the urine may
be caused by kidney or
RBC 2 – 5/hpf 5 – 10/hpf
bladder injury, kidney
stones, a urinary tract
infection (UTI),
inflammation of the
kidneys
(glomerulonephritis), a
kidney or bladder
tumor, or systemic
lupus erythematosus
(SLE).
There are few epithelial
cells in the findings,
which is normal.
While it is normal to
have a few epithelial
cells in the urine, a
large number can
indicate several
Epithelial Cells None to Few FEW
problems and can be a
cause of concern. A
large number of cells
can be a sign of urinary
tract infection, yeast
infection, kidney
disease, liver disease
and certain types of
cancer. If you are
Page 36 of 99
pregnant, read on to
learn about epithelial
cells, their normal
range in the urine
during pregnancy, and
more (Arora, M., 2020).
Few mucus threads are
found in the patient’s
urine. It’s common to
find mucus in the urine.
It is typically thin, fluid,
and transparent, or it
Mucus Threads Few FEW may be cloudy white, or
off-white. While these
colors usually
represent normal
discharge, yellowish
mucus can signal a
health problem.
There are no bacteria
found in the Patient’s
urine.
Bacteria in the urine

mean a urinary tract
infection (UTI). Yeast
Bacteria None NONE
cells or parasites (such
as the parasite that
causes trichomoniasis)
can mean an infection
of the urinary tract
2022).
SEROLOGY
TEST NAME: RESULT INTERPRETATION
HbsAg NON – REACTIVE Patient R.B’s results in serology

(screening): are non-reactive in both Hepatitis
B Virus and Syphilis.
V D R L: NON - REACTIVE
Page 37 of 99
III. ANATOMY AND PHYSIOLOGY
A. THE REPRODUCTIVE SYSTEM
UTERUS
The uterus is a hollow muscular organ located

in the female pelvis between the bladder and
rectum. The ovaries produce eggs that travel
through the fallopian tubes. Once the egg has left
the ovary it can be fertilized and implant itself in
the lining of the uterus. The main function of the
uterus is to nourish the developing fetus prior to
birth. The three layers of the uterus (endometrium,
myometrium, and perimetrium) become clearly
defined over the course of pregnancy. The uterus grows at a
steady, predictable rate during pregnancy, with its expansion first
becoming detectable at approximately 5 weeks gestation. The uterine shape
changes from the nonpregnant pear shape to a ball or sphere in the first trimester
and then expands to an elongated cylinder. Growth of the uterus is due to two
processes: (1) estrogen- and progesterone-induced hyperplasia of uterine smooth
muscle cells within the myometrium during early pregnancy and (2) hypertrophy of
the uterine muscles later in pregnancy. The muscles increase their content of actin,
myosin, sarcoplasmic reticulum, and mitochondria, which collectively serve as the
machinery used to contract the muscles during labor and birth, as described in the
Anatomy and Physiology During Labor and Birth chapter. The myometrium thus
has both properties of contractility and elasticity. Contractility allows for
lengthening and shortening, whereas elasticity refers to the ability to stretch.
Fallopian Tube
The fallopian tubes serve as the

pathway of the egg cells towards the uterus. It is a
smooth, hollow tunnel that is divided into four
parts: the interstitial, which is 1 cm in length; the
isthmus, which is2 cm in length; the ampulla,
Page 38 of 99
which is 5 cm in length; and the infundibular, which is 2 cm long and shaped like a
funnel. The funnel has small hairs called the fimbria that propel the ovum into the
fallopian tube. The fallopian tube is lined with mucous membrane, and underneath
is the connective tissue and the muscle layer. The muscle layer is responsible for
the peristaltic movements that propel the ovum forward. The distal ends of the
fallopian tubes are open, making a pathway for conception to occur.
Ovaries
The ovaries are approximately 4 cm

long by 2 cm in diameter and
approximately 1.5 cm thick, or the
size and shape of almonds. They
are grayish white and appear pitted,
or with minute indentations on the surface. An unruptured, glistening, clear, fluid-
filled graafian follicle (an ovum about to be discharged) or a miniature yellow corpus
luteum (the structure left behind after the ovum has been discharged) often can be
observed on the surface of an ovary. Ovaries are located close to and on both sides
of the uterus in the lower abdomen. It is difficult to locate them by abdominal
palpation because they are situated so low in the abdomen. If an abnormality is
present, such as an enlarging ovarian cyst, the resulting tenderness may be evident
on lower-left or lower-right abdominal palpation. The function of the two ovaries (the
female gonads) is to produce, mature, and discharge ova (the egg cells). In the
process, the ovaries produce estrogen and progesterone and initiate and regulate
menstrual cycles. If the ovaries are removed before puberty (or are nonfunctional),
the resulting absence of estrogen prevents breasts from maturing at puberty; in
addition, pubic hair distribution assumes a more male pattern than normal.
Page 39 of 99
Vagina and Vulva
Pregnancy hormones
prepare the vagina for stretching
during labor and birth by causing the
vaginal mucosa to thicken, the
connective tissue to loosen, the
smooth muscle to hypertrophy, and
the vaginal vault to lengthen. The
increased vascularity of the vagina
and other pelvic viscera result in a
marked increase in sensitivity. The increased sensitivity may lead to a high degree
of sexual interest and arousal, especially during the second trimester of pregnancy.
External structures of the perineum are enlarged during pregnancy because of an
increase in vasculature, hypertrophy of the perineal body, and deposition of fat.
Stages of Menstrual Cycle
During each menstrual cycle, an egg

develops and is released
from the ovaries. The lining of the
uterus builds up. If a pregnancy doesn’t
happen, the uterine lining sheds during a
menstrual period. Then cycle starts again.
The menstrual cycle is divided into four
phases:
• menstrual phase
• follicular phase
• ovulation phase
• luteal phase
Page 40 of 99
1. Menstrual phase
The menstrual phase is the first stage of the menstrual cycle. It’s also when
you get your period. This phase starts when an egg from the previous cycle isn’t
fertilized. Because pregnancy hasn’t taken place, levels of the hormones estrogen
and progesterone drop. The thickened lining of your uterus, which would support a
pregnancy, is no longer needed, so it sheds through your vagina. During your period,
you release a combination of blood, mucus, and tissue from your uterus
2. Follicular phase
The follicular phase starts on the first day of your period (so there is some
overlap with the menstrual phase) and ends when you ovulate. It starts when the
hypothalamus signals your pituitary gland to release follicle stimulating This hormone
stimulates your ovaries to produce around 5 to 20 small sacs called follicles. Each
follicle contains an immature egg. Only the healthiest egg will eventually mature. (On
rare occasions, a female may have two eggs mature.)
The rest of the follicles will be reabsorbed into your body. The maturing follicle
sets off a surge in estrogen that thickens the lining of your uterus. This creates a
nutrient-rich environment for an embryo to grow. The average follicular phase Trusted
Source lasts for about 16 days. It can range from 11 to 27 days, depending on your
cycle.
3. Ovulation phase
Rising estrogen levels during the follicular phase trigger your pituitary gland to
release luteinizing hormone (LH). This is what starts the process of ovulation.
Ovulation is when your ovary releases a mature egg. The egg travels down the
fallopian tube toward the uterus to be fertilized by sperm. The ovulation phase is the
time during your menstrual cycle when you can get pregnant.
4. Luteal phase
After the follicle releases its egg, it changes into the corpus luteum. This
structure releases hormones, mainly progesterone and some estrogen. The rise in
hormones keeps your uterine lining thick and ready for a fertilized egg to implant. If
you do get pregnant, your body will produce human chorionic gonadotropin (hCG).
Page 41 of 99
This is the hormone pregnancy tests detect. It helps maintain the corpus luteum and
keeps the uterine lining thick.
Anatomy of the Cervix
The cervix is the lower portion of the uterus, an organ of the female reproductive
tract. It connects the vagina with the main body of the uterus, acting as a gateway
between them. The cervix is composed of two regions namely the ectocervix and
the endocervical canal.
1. The ectocervix is the portion of the cervix that

projects into the vagina. It is lined by stratified squamous
non-keratinized epithelium. The opening in the
ectocervix, the external os, marks the transition from the
ectocervix to the endocervical canal.
2. The endocervical canal (or endocervix) is the more

proximal, and ‘inner’ part of the cervix. It is lined by a mucus-secreting simple
columnar epithelium. The endocervical canal ends, and the uterine cavity begins,
at a narrowing called the internal os.
The cervix performs two main functions:
1. It facilitates the passage of sperm into the uterine cavity. This is achieved via
dilation of the external and internal os.
2. Maintains sterility of the upper female reproductive tract. The cervix, and all
structures superior to it, are sterile. This ultimately protects the uterine cavity and
the upper genital tract by preventing bacterial invasion. This environment is
maintained by the frequent shedding of the endometrium, thick cervical mucus and
a narrow external os.
Physiology of Cervical Dilation:
Cervical dilation is the process by which the cervix opens during labor and
allows the baby to pass through the birth canal. Dilation occurs due to the contraction
of uterine muscles and the pressure exerted by the baby's head.
Page 42 of 99
During early labor, the cervix starts to efface, which means it thins out and
becomes softer. This allows the cervix to stretch and open. As labor progresses, the
uterine contractions become more intense and frequent, leading to further cervical
dilation.
Anatomy of Pelvis
The pelvis is a bony structure located at the base of the spine and consists of
several bones:
• Sacrum: The sacrum is a

triangular bone located at the back of
the pelvis, formed by the fusion of
five sacral vertebrae. It connects
the spine to the pelvis.
• Coccyx: Also known as

the tailbone, the coccyx is a small, triangular bone located at the bottom of
the sacrum.
• Ilium: The ilium is the largest and most superiorly positioned bone of the
pelvis. It forms the upper part of the hip bone.
• Ischium: The ischium is the lower and posterior part of the hip bone. It forms
the sit bones that you can feel when sitting.
• Pubis: The pubis is the anterior and inferior part of the hip bone. It joins the
ischium at the pubic symphysis, a cartilaginous joint in the midline of the
pelvis.
B. ANATOMY OF HEART
The heart is a fist-sized organ located in the center of the chest. It is the
primary organ of the circulatory system, which is responsible for pumping blood
throughout the body. The heart is made up of four chambers: two atria and two
ventricles. The atria receive blood from the body, and the ventricles pump blood to
the lungs and the rest of the body. The heart is a muscle, and it contracts and
relaxes rhythmically to pump blood.
Page 43 of 99
The anatomy of the heart can be described as follows:
• Chambers: The heart is divided into four chambers: two atria and two
ventricles. The right atrium receives deoxygenated blood returning from the body
through the superior and inferior vena cava. The right ventricle pumps this blood to
the lungs for oxygenation. The oxygenated blood from the lungs enters the left
atrium and then flows into the left ventricle, which pumps it out to the rest of the
body.
• Valves: The heart has four valves that ensure the one-way flow of blood. The
tricuspid valve separates the right atrium from the right ventricle, while the mitral (or
bicuspid) valve separates the left atrium from the left ventricle. The pulmonary valve
is located between the right ventricle and the pulmonary artery, and the aortic valve
is found between the left ventricle and the aorta. These valves open and close in a
coordinated manner, allowing blood to flow forward while preventing backward flow.
• Coronary Arteries: The heart has its own blood supply

through the coronary arteries. The right coronary
artery and the left coronary artery branch out into
smaller vessels that supply oxygenated blood to the
heart muscle itself, ensuring its proper functioning.
• Septum: The heart is divided into right and left

halves by a muscular wall called the septum. It
prevents the mixing of oxygenated and
deoxygenated blood. The interatrial septum
separates the atria, while the interventricular septum
separates the ventricles.
• Electrical Conduction System: The heart has a specialized electrical

conduction system that coordinates its rhythmic contractions. The sinoatrial (SA)
node, located in the right atrium, generates electrical impulses that regulate the
heart's beating. These impulses travel through the atria, causing them to contract.
Then, they pass through the atrioventricular (AV) node and travel down the bundle of
His and its branches, stimulating the ventricles to contract and pump blood.
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• Pericardium: The heart is surrounded by a double-layered sac called the
pericardium. The outer layer, the fibrous pericardium, provides protection and
anchors the heart to surrounding structures. The inner layer, the serous pericardium,
consists of two layers: the visceral layer (epicardium), which is closely attached to the
heart, and the parietal layer, which lines the fibrous pericardium.
C. ANATOMY OF THE BLOOD
Blood is a vital fluid that circulates throughout the human body, delivering
essential substances and performing various functions necessary for life. It is
composed of a liquid called plasma and several different types of cells, including red
blood cells, white blood cells, and platelets.
Blood helps maintain homeostatis in several ways:
1. Transport of Oxygen and Nutrients: Blood carries oxygen from the lungs to the
body's tissues and organs, ensuring an adequate supply for cellular respiration.
It also transports nutrients, such as glucose, amino acids, and fatty acids,
derived from the digestive system to the cells, providing them with the
necessary energy and building blocks.
2. Removal of Waste Products: Blood removes waste products, including carbon

dioxide, generated by cellular metabolism. Carbon dioxide is transported from
the cells to the lungs, where it is exhaled. Other waste products, such as urea
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from the breakdown of proteins, are carried by blood to the kidneys for filtration
and elimination in the form of urine.
3. Regulation of pH Balance: Blood helps regulate the body's pH level,

maintaining it within a narrow range for optimal functioning. It contains buffers
that can bind to or release hydrogen ions to keep the blood pH stable. This is
crucial for proper enzyme function, maintenance of cellular processes, and
overall metabolic balance.
4. Temperature Regulation: Blood helps regulate body temperature. When the

body is too hot, blood vessels dilate, allowing increased blood flow to the skin's
surface, which promotes heat loss through radiation and sweating. Conversely,
when the body is too cold, blood vessels constrict, reducing blood flow to the
skin and conserving heat.
5. Immune Response: Blood contains white blood cells, which are essential
components of the immune system. These cells help identify and destroy
pathogens, such as bacteria and viruses, to protect the body against infections.
They also participate in inflammation and immune responses to maintain the
body's defense mechanisms.
6. Clotting and Hemostasis: When a blood vessel is injured, platelets in the blood
form a clot to prevent excessive bleeding. This process, known as hemostasis,
involves platelet aggregation and the activation of clotting factors to seal the
damaged blood vessel, promoting healing and preventing further blood loss.
PHYSIOLOGY OF THE BLOOD:
Red Blood Cells primarily deliver oxygen from the lungs to the tissues of the
body, Red blood cells can transfer The elements of blood Flasma some carbon dioxide
back to the lungs for elimination after giving up the oxygen Reticulocytes, which are
red blood cells that are still in the process of forming, are often released at the same
pace as old RBCs. To maintain the normal RBC count when RBC depletion occurs,
the bone marrow boosts reticulocyte.
White Blood Cells are responsible for defending the body against infection.
When an injury or illness occurs, these cells circulate through the bloodstream and
tissues and attack any foreign organisms that enter the body.
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Plasma takes nutrients hormones, and
proteins to the different parts of the body. It also
carries away the waste products of cell metabolism
from various tissues to the organs responsible for
detoxifying and excreting them. Additionally, plasma
aids in immunity, blood coagulation, blood pressure
regulation, blood volume maintenance, and pH
balance in the body in addition to serving as the
vehicle for the transportation of blood cells through
blood vessels.
Platelets stop bleeding During injury, it clumps and forms a plug in the
damaged area of a tom blood vessel to stop blood loss.
D. ANATOMY OF LIVER
The liver is the largest internal organ in the human body and is located in the
upper right quadrant of the abdomen, just below the diaphragm. It plays a crucial role
in numerous metabolic processes and is involved in digestion, detoxification, storage
of nutrients, and the production of bile.
The anatomy of the liver can be described as follows:
• Lobes: The liver is divided into two main lobes, the larger right lobe and the
smaller left lobe. These lobes are further divided into smaller lobes or lobules.
• Hepatic Lobules: The hepatic lobules are the functional units of the liver. They
are roughly hexagonal in shape and consist of plates of liver cells called hepatocytes.
The lobules are arranged around a central vein, and radiating from the central vein
are hepatic cords composed of hepatocytes.
• Hepatic Portal System: The liver receives blood from two major sources: the
hepatic artery, which carries oxygenated blood, and the portal vein, which carries
nutrient-rich blood from the digestive organs. The portal vein brings blood to the liver
for processing and detoxification before it is distributed throughout the body.
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• Bile Ducts: The liver produces bile, a
greenish-yellow fluid that aids in the digestion
and absorption of fats. Bile is transported from the
hepatocytes through small bile canaliculi that
merge to form larger bile ducts. These ducts join
together outside the liver to form the common
hepatic duct, which then combines with the cystic
duct from the gallbladder to form the common bile
duct. The common bile duct delivers bile into the
duodenum, the first part of the small intestine.
• Gallbladder: The gallbladder is a small, pear-shaped organ located beneath

the liver. It stores and concentrates bile produced by the liver. When stimulated by
the presence of fatty foods, the gallbladder contracts and releases bile into the
common bile duct for digestion.
• Blood Supply: The liver has a unique dual blood supply. In addition to the
hepatic artery and the portal vein mentioned earlier, the liver is drained by the hepatic
veins. These veins collect the filtered and detoxified blood from the liver and ultimately
drain into the inferior vena cava, returning blood to the heart.
E. ANATOMY OF KIDNEY
The kidneys are a pair of bean-shaped organs located in the back of the
abdomen, on either side of the spine. They play a crucial role in maintaining the body's
internal balance by filtering waste products from the blood, regulating fluid and
electrolyte balance, and producing urine.
The anatomy of the kidneys can be described as follows:
• Renal Cortex: The outer region of the kidney is known as the renal cortex. It
appears gra nular and contains millions of tiny filtering units called nephrons. The
renal cortex is responsible for the filtration of blood and the initial processing of urine.
• Renal Medulla: The renal medulla is the inner region of the kidney, consisting
of cone-shaped structures called renal pyramids. The medulla contains tubules that
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collect the filtered fluid (urine)
from the nephrons and
transport it towards the renal
pelvis.
• Renal Pelvis: The

renal pelvis is a funnel-shaped
structure located at the
innermost part of the kidney. It
collects urine from the renal
pyramids and funnels it into
the ureter, which carries urine
to the bladder for storage.
• Nephrons: Nephrons are the functional units of the kidney and perform the
primary functions of filtration and urine production. Each kidney contains millions of
nephrons. Each nephron consists of a renal corpuscle (composed of the glomerulus
and Bowman's capsule) and a renal tubule. The glomerulus is a network of tiny blood
vessels where blood is filtered. Bowman's capsule surrounds the glomerulus and
collects the filtered fluid. The renal tubule processes the filtered fluid, reabsorbing
essential substances back into the bloodstream and concentrating waste products to
form urine.
• Renal Artery and Vein: The kidneys receive their blood supply through the
renal arteries, which branch off from the abdominal aorta. The renal arteries deliver
oxygenated blood to the kidneys, which is then filtered and processed. The filtered
blood is returned to circulation through the renal veins, which join the inferior vena
cava.
• Ureters: The ureters are narrow tubes that connect each kidney to the bladder.
They transport urine from the kidneys to the bladder by peristaltic contractions of
smooth muscles in their walls.
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E. SKIN
The skin is the body’s largest

organ, made of water, protein, fats
and minerals. Your skin protects
your body from germs and
regulates body temperature.
Nerves in the skin help you feel
sensations like hot and cold.
Three layers of tissue make up the skin:
• Epidermis, the top layer.

• Dermis, the middle layer.
• Hypodermis, the bottom or fatty layer.
Layers of the Abdomen
Incision and closure of the

abdominal wall is among the most
frequently performed surgical
procedures. The abdominal
wall is defined cranially by
the xiphoid process of the
sternum and the costal margins
and caudally by the iliac and
pubic bones of the pelvis. It extends
to the lumbar spine, which joins the thorax and pelvis and is a point of attachment for
some abdominal wall structures.
The integrity of the anterior abdominal wall is primarily dependent upon the abdominal
muscles and their conjoined tendons. These muscles assist with respiration and
control the expulsive efforts of urination, defecation, coughing, and parturition. They
also work with the back muscles to flex and extend the trunk at the hips, rotate the
trunk at the waist, and protect viscera by becoming rigid.
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The contour of the abdomen is dependent upon age, muscle mass, muscle tone,
obesity, intra-abdominal pathology, parity, and posture. These factors may
significantly alter topography and become a major obstacle to proper incision
selection and placement. Knowledge of the layered structure of the abdominal wall
permits efficient and safe entry into the peritoneal cavity.
There are nine layers to the abdominal wall:

• Skin
• subcutaneous tissue
• superficial fascia
• external oblique muscle
• internal oblique muscle
• transversus abdominis muscle
• transversalis fascia
• preperitoneal adipose and areolar tissue, and
• peritoneum.
An abdominal incision and a uterine incision are both
parts of a C-section. The doctor will create an incision
in the uterus after the abdominal incision. The most
frequent incisions are low transverse ones. The
majority of incisions are lower-segment ones. The
lower, extended region of the uterine body is cut
down transversely, and the bladder reflection is
separated from the uterus. Only few aberrant
presentations and very big fetuses require a vertical
lower-segment incision.
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IV. PATHOPHYSIOLOGY
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V. DRUG STUDY
DRUG NAME MECHANISIM INDICATION/ SIDE ADVERSE NURSING

ACTION CONTRAINDICATION EFFECTS EFFECT RESPONSIBILITIES
Generic Name: Acts by • Nausea • Hypotension • Assess for
Hyoscine-N- inhibiting It is indicated to • Weakness • Anaphylactic eye pain
Butylbromide cholinergic mother H.B to relief • Headache Reactions • Assess for
transmission in spasms in the • Dry mouth • Constipation urinary
Brand Name: the abdomino- gastrointestinal tract • Dry skin • Blurred hesitancy
Buscopan pelvic such as the stomach, • shortness Vision • Assess for
parasympathetic intestines, or bladder. of breath • Dizziness constipation
Route: ganglia, thus • Irritability • Monitor urine
IV relieving spasm Contraindication: output
in the smooth HNBB is • Encourage
Dosage: muscles contraindicated to patient to
5 mg gastrointestinal, hypersensitivity to the void.
biliary, urinary said drug contents. • Monitor BP
Frequency: tract and female Due to the possibility for possible
female genital for adverse hypertension.
3x doses every 2 organs, anticholinergic HNBB • For pregnant
hours especially the cannot affects, be women,
cervico-uterine administered monitor
Classification: plexus and parenterally to the cervical
anticholinergic aiding cervical person with effacement
dilatation. tachycardia and dilatation
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DRUG NAME MECHANISM OF INDICATION / SIDE EFFECTS ADVERSE DRUG NURSING
ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
DRUG: Oxytocin Action: Indication: Hypotension Postpartum Assess baselines for
Oxytocin Oxytocin is Nausea Vomiting hemorrhage vital signs and history
BRAND: Pitocin increases the administered Tachycardia of allergies.
sodium immediately in the Constipation Anaphylactoid
permeability of postpartum period to Increased pulse reactions Inform the pt about the
ROUTE: IM, IV uterine prevent excessive Rashes Water intoxication purpose of
Nasal irritation administering the drug
myofibrils, bleeding by helping
DOSAGE: Seizures Asphyxia and discuss possible
indirectly the uterus contract. side effects.
uterine rupture
stimulating the
IM: 10 units contraction of Contraindication:
immediately after Raise side rails.
the uterine Hypersensitivity to
delivery.
smooth muscle. oxytocin. Monitor vital signs and
IV: 10 units in D5LR uterine contractions.
1L at 41-42 gtts/min Therapeutic
to consume for 8 Effects: Maintain careful I&O;
hours if no profuse Stimulates be alert to potential
bleeding uterine water intoxication.
contractions Check for blood loss.
CLASSIFICATION: Monitor vital signs and

Uterine smooth uterine contractions.
WOF for changes that
muscle stimulant.
may indicate
(Oxytocic agent) hemorrhage.
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DRUG NAME MECHANISM INDICATION / SIDE ADVERSE DRUG NURSING
OF ACTION CONTRAINDICATION EFFECTS REACTION RESPONSIBILITIES
GENERIC NAME: Action: Indication: Nausea Severe watery Inform the pt about
Cefuroxime Binds to Cephalosporins are usually Vomiting diarrhea the purpose of
bacterial cell considered safe during pregnancy. Mild Nephrotoxicity administering the
BRAND: Ceftin membranes, Minor lower urinary tract infections diarrhea Pseudomembranous drug and discuss
inhibits cell are frequent during pregnancy and Chills colitis possible side effects.
wall synthesis cefuroxime is a first-line treatment. Headache Anaphylaxis
ROUTE: PO, IV Temperature Seizures Give oral drugs with
Therapeutic Contraindication: elevation food to decrease GI
DOSAGE: 500mg Effects: History of hypersensitivity Vaginal upset and enhance
candidiasis absorption.
Bactericidal Anaphylactic reaction to
FREQUENCY: BID, cefotaxime, cephalosporins. Have vitamin K
TAKE 1 tab, 2x a available in case
day for 7 days hypoprothrombinemia
occurs. Discontinue if
CLASSIFICATION: hypersensitivity
Cephalosporin reaction occurs.
Monitor I&O for

nephrotoxicity. Be
alert for
superinfection (e.g.
fever, vomiting,
diarrhea)
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DRUG NAME MECHANISM OF INDICATION / SIDE ADVERSE NURSING
ACTION CONTRAINDICATION EFFECTS DRUG RESPONSIBILITIES
REACTION
DRUG: Action: Indication: Diarrhea Chest pain Assess patients who

Mefenamic Acid It works by Mefenamic is used for the Constipation Trouble develop severe diarrhea
stopping the relief of pain Dizziness breathing and vomiting for
BRAND: body's production Indigestion Slurred speech dehydration and
of a substance Contraindication: Reduced urine Light electrolyte imbalance.
that causes pain, Hypersensitivity to output headedness
ROUTE: PO fever, and mefenamic acid Fever when suddenly Give with meals, food,
inflammation getting up from or milk to minimize GI
DOSAGE: 500mg Patients who have a lying or sitting adverse effects.
Therapeutic experienced asthma, position
Effects: urticaria, or allergic-type Advised the pt to not
FREQUENCY: TID Mefenamic acid reactions after taking use drug for a period
is used to treat aspirin or other NSAIDs exceeding 1 week.
CLASSIFICATION: mild to moderate
nonsteroidal anti- pain. Notify physician if
inflammatory drug persistent GI discomfort,
(NSAID) sore throat, fever, or
malaise occur.
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REACTION
DRUG: Action: Indication: Loss of Stomach Advise to take medication

Ferrous Sulfate Essential To prevent iron appetite cramps between meals with
component in the deficiency anemia and Constipation Nausea orange juice or vitamin C
BRAND: Slow-Fe formation of Hgb, help build up the body’s Black or Diarrhea supplement
myoglobin, iron supply green stool Fever Severe
enzymes. Dizziness hypotension Instruct to remain upright
ROUTE: PO Promotes effective Contraindication: Vomiting Heartburn for at least 30 minutes
erythropoiesis and Hypersensitivity to iron Chest pain Anorexia after administration
DOSAGE: 1 tablet transport, and salts. Headache
(300mg) utilization of Advise patient that the
oxygen. Hemolytic anemia drug has side effects
such as stools that may
FREQUENCY: OD Therapeutic become dark green or
Effects: Prevents black and that this
CLASSIFICATION: iron deficiency. change is harmless.
Enzymatic mineral
Instruct patient to follow a
diet high in iron such as
dark leafy greens,lean
red meats, and fortified
cereals.
Instruct the patient to

increase water intake if
constipation occurs.
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REACTION
DRUG: Amlodipine Action: Inhibits Indication: Headache Chest Pain Advise the patient to
calcium movement Treatment for Flushing Bradycardia keep the side rails up
BRAND: Norvasc across cardiac and hypertension. Light- Peripheral and notify the nurse if
vascular smooth headedness edema the dizziness prolongs.
muscle cell Contraindication: Dizziness Pulmonary
ROUTE: PO membranes during Hypersensitivity to Nausea
edema Monitor VS, especially
depolarization. amlodipine or its Shortness of
DOSAGE: components breath Syncope blood pressure.
10mg / 1Tab Therapeutic Effects: Thrombosis
Dilates coronary WOF signs and
arteries, and symptoms of
FREQUENCY: OD peripheral tachycardia. (e.g SOB,
arteries/arterioles. Fatigue, Rapid
CLASSIFICATION: Decreases total heartbeat) Notify the
Calcium channel peripheral vascular physician if s/sx were
blocker resistance and B/P by displayed.
vasodilation.
Advise the patient to

take medication after
meals to reduce GI
upset.
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VI. NURSING CARE PLAN
A. PRIORITIZATION
NURSING DIAGNOSIS RANK JUSTIFICATION
Acute pain related to low 1st Maslow's hierarchy begins with physiological needs, which are the
transverse cesarean section as basic requirements for survival. Acute pain resulting from a low
(High Priority) transverse cesarean section can significantly impact a woman's
evidenced by (+) Facial Grimace
physiological well-being. Pain can affect her ability to rest, sleep,
& pain scale of 9/10
eat, and recover properly. Addressing and managing the acute
pain becomes crucial to ensure her physiological needs for comfort
and healing are met.
According to the National Library of Medicine, a low transverse

cesarean section incision is associated with less pain compared to
other types of incisions.
Decreased Cardiac Output 2nd Maslow's hierarchy begins with physiological needs, which are the
related to Decreased Venous basic requirements for survival. Decreased cardiac output due to
Return Secondary to Severe (High Priority) decreased venous return in severe pre-eclampsia can significantly
Pre-eclampsia as evidenced by impact a woman's physiological well-being. It can lead to
altered BP and Edema. inadequate blood supply to vital organs, including the brain, heart,
and kidneys, compromising their function. Addressing and
managing decreased cardiac output is crucial to ensure the
woman's physiological needs for oxygenation and organ perfusion
are met, reducing the risk of complications.
According to Amy Dixon, When the resistance against which the
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heart must pump blood increases, such as in conditions like
hypertension, the heart has to work harder to overcome this
resistance, leading to decreased cardiac output. It is characterized
by high blood pressure and damage to organs such as the liver and
kidneys.
Increased Fluid Volume related 3rd Maslow's hierarchy begins with physiological needs, which are the
to Narrowing of the blood basic requirements for survival. Increased fluid volume resulting
vessels due to severe (Medium Priority) from the narrowing of blood vessels in severe preeclampsia can
preeclampsia lead to fluid retention and compromised organ function. Addressing
and managing increased fluid volume is crucial to ensure proper
fluid balance, adequate oxygenation, and organ perfusion, thereby
meeting the physiological needs of the woman and reducing the
risk of complications.
According to Anna Curran RN, imbalanced fluid volume is a

nursing diagnosis related to shifting of fluid to interstitial space
from intravascular space and hormonal changes in pregnancy
secondary to preeclampsia. Narrowing of the blood vessels due to
severe preeclampsia can cause a decrease in blood flow to the
placenta, which can lead to decreased oxygen supply and nutrients
to the fetus.
Risk for Bleeding related to 4th Maslow's hierarchy begins with physiological needs, which are the
Post- Operative Surgical basic requirements for survival. In the context of the risk for
Incision as evidenced by Low (Medium Priority) bleeding from a post-operative surgical incision, addressing this
Transverse Cesarean Section II risk is crucial to ensure the patient's physiological well-being.
Controlling bleeding is necessary to maintain proper blood volume,
circulation, and oxygenation, which are essential for the body's
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overall functioning and survival.
According to The Healthline Editorial Team, A low transverse

Cesarean section is a surgical procedure that involves making a
horizontal incision in the lower part of the uterus. This type of
incision is less likely to cause bleeding than other types of
incisions. However, there are still risks associated with this
procedure. Some of these risks include infection, blood loss, and
injury to other organs.
Risk for Progression to 5th Maslow's hierarchy begins with physiological needs, which are the
Eclampsia related to drastic basic requirements for survival. It should be prioritized as it
decrease in the cardiac output (Medium Priority) addresses physiological well-being. Drastic decrease in cardiac
as evidence by altered BP output and alterations in blood pressure are critical indicators of
cardiovascular compromise in preeclampsia.
According to Horsager-Boehrer (2021), Severe preeclampsia does

increase the risk of developing eclampsia in subsequent
pregnancies, although the exact risk varies from individual to
individual. Eclampsia is a serious complication of preeclampsia
characterized by the onset of seizures or convulsions.
Impaired skin integrity related 6th In Maslow’s Hierarchy safety needs. Impaired skin integrity can
to low transverse surgical lead to an increased risk of infection and delay in wound healing,
(Medium Priority)
incision secondary to cesarean which can compromise the woman's safety and well-being. Proper
birth as evidenced by patient's wound care, infection prevention measures, and monitoring for
verbalization of concerns about signs of complications are crucial to address the safety needs
appearance and pain around the
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incision area associated with the low transverse surgical incision.
According to the National Library of Medicine (2017), Surgical site

infection (SSI) is one of the most common complications following
cesarean section, and has an incidence of 3%–15%. It places
physical and emotional burdens on the mother herself and a
significant financial burden on the health care system. Moreover,
SSI is associated with a maternal mortality rate of up to 3%. With
the global increase in cesarean section rate, it is expected that the
occurrence of SSI will increase in parallel, hence its clinical
significance.
Risk for infection related to 7th In Maslow’s Hierarchy safety needs. The risk for infection in the
incision site secondary to incision site poses a threat to the woman's safety. Infections can
cesarean birth (Medium Priority) lead to systemic complications, such as sepsis, and prolong the
recovery process. Implementing proper aseptic techniques during
and after the cesarean birth, ensuring proper wound care, and
monitoring for signs of infection are essential to address the safety
needs associated with the risk for infection.
According to Jennifer Huizen, Post-cesarean wound infections are

common and can occur in up to 12% of women who have had a
cesarean delivery. Risk of infection after a C-section, including
obesity, and had a previous C-section, also improper wound care.
Risk for Maternal Injury related 8th In Maslow’s Hierarchy safety needs. Hypertensive crisis poses a
to Hypertensive Crisis due to serious threat to the woman's safety. It is crucial to monitor blood
Severe Preeclampsia (Medium Priority) pressure closely, administer appropriate medications, and provide
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necessary interventions to stabilize blood pressure and prevent
further complications. Addressing the risk for maternal injury in the
context of severe preeclampsia supports the woman's safety and
reduces the potential harm associated with hypertensive crisis.
According to Gibran Khalil (2017), preeclampsia complicates about

5% of all pregnancies worldwide and is one of the leading causes
of maternal and fetal morbidity and even mortality. Preeclampsia
usually presents during pregnancy; however, it may sometimes
manifest in the postpartum period in a previously normotensive
woman.
Risk for caregiver role strain as 9th In Maslow’s Hierarchy safety needs. Hypertensive crisis poses a
evidenced by patient’s serious threat to the woman's safety. It is crucial to monitor blood
verbalization of going back to (Medium Priority) pressure closely, administer appropriate medications, and provide
work after recover from necessary interventions to stabilize blood pressure and prevent
cesarean birth further complications. Addressing the risk for maternal injury in the
context of severe preeclampsia supports the woman's safety and
reduces the potential harm associated with hypertensive crisis.
According to Gil Wayne (2023), Caregiver role strain denotes the

stress of caregiving on the caregiver's bodily and emotional health,
as well as its impacts on the caregiver's and care receiver's family
and social system. With inadequate access to health care for many
people, most diseases are diagnosed and managed in the
outpatient setting and more caregiving is being provided by people
who aren’t health care professionals.
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Constipation related to Surgical 10th In Maslow’s Hierarchy safety needs In the context of constipation
Procedure as evidenced by related to a surgical procedure, there may be concerns about
absence of stool (Medium Priority) potential complications, such as bowel obstruction or discomfort
caused by straining during defecation. Addressing constipation
through appropriate interventions, such as stool softeners, dietary
modifications, and adequate hydration, can help ensure the
patient's safety and prevent further complications.
According to Cleveland Clinic (2019), When bowel motions

become less frequent and feces become harder to evacuate, this
is referred to as constipation. It usually happens as a result of a
change in food or routine, or from a lack of fiber.
Readiness for enhanced 11th Maslow’s Hierarchy self-actualization refers to the realization of
Parenting related to Desire to one's full potential and personal growth. Parents who desire to
Enhance Child Maintenance (Low Priority) enhance child maintenance aim to provide the best possible care
for their child and contribute to their overall development. They may
set goals for their child's education, emotional well-being, and
personal growth. By actively engaging in activities that support
their child's development, parents can experience a sense of
fulfillment and self-actualization in their parenting journey.
According to Kathy Slattengren, Every child is different and every

parent is a unique individual. It's important to recognize that good
parenting can look different from family to family. Here are 3 ways
to improve parenting:
1. Spend quality time with each child.
2. Set limits/boundaries.
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3. Be a good role model.
Readiness for Enhanced Coping 12th Maslow’s Hierarchy self-actualization refers to the realization of
related to the Patient’s Desire to one's full potential and personal growth. While the desire to
Maintain Normal Blood (Low Priority) maintain normal blood pressure may not be directly connected to
Pressure Level Secondary to self-actualization, effectively coping with severe hypertension can
Severe Hypertension contribute to the patient's overall growth and well-being. By
embracing a proactive approach to their health, seeking
knowledge, making informed decisions, and actively participating
in their care, the patient can enhance their coping skills, achieve a
sense of control, and experience personal growth in their journey
toward managing their hypertension.
According to Anna Curran RN, The nursing care plan for this
diagnosis includes identifying stressors and coping mechanisms,
providing education on hypertension management, and monitoring
blood pressure levels regularly.
Readiness to Enhanced 13th Maslow’s Hierarchy Self-actualization refers to the realization of

Knowledge as evidenced by one's full potential and personal growth. By seeking knowledge on
asking questions in how to (Low Priority) how to improve their baby's health, parents are actively engaging
Improve her baby’s health in self-actualization. They are demonstrating their commitment to
personal growth and development as caregivers, taking proactive
steps to provide the best care for their child, and making informed
decisions that align with their values and goals as parents.
According to Claire McCarthy, MD, In improving the baby's health.
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There are many ways to do so. Here are some tips:
1. Breastfeed your baby if possible. It provides the best

nutrition for your baby and helps protect against infections
and illnesses.
2. Don’t respond to every cry with a feed. Babies cry for all
sorts of reasons, not just hunger.
3. Don’t overfeed your baby. It’s natural to want a baby to finish
a bottle or a bowl of food, but it’s important not to force them
to eat more than they want.
4. Give healthy solid food when your baby is ready for it.
5. Start family meals early.
6. Get your baby moving by doing tummy time and other
activities.
Readiness for Enhanced Self- 14th In Maslow’s Hierarchy self-actualization Readiness for enhanced
care as evidenced by Patient’s self-care aligns with self-actualization as it involves the patient's
expressing concerns about (Low Priority) willingness to take responsibility for their own well-being and
Self-care and strategies to engage in activities that promote personal growth. By expressing
improve Personal care concerns and seeking strategies to improve personal care, the
patient is taking proactive steps towards self-actualization, striving
to become the best version of themselves and actively contributing
to their own health and well-being.
According to the Betterhelp Editorial Team, Self-care for moms

and your personal well-being is important too. Here are some
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self-care tips for mothers:
● Get moving: Physical activity promotes improved

physical and mental health.
● Eat a balanced diet.
● Get adequate sleep.
● Stay hydrated.
● Make time for ‘me’ time.
Readiness for Enhancing 15th In Maslow’s Hierarchy self-actualization. Readiness for enhancing
Disturbed Body Image related to disturbed body image during pregnancy reflects the individual's
Pregnancy as evidenced by (Low Priority) desire for personal growth and self-acceptance. By actively
Changes in Appearance seeking ways to enhance body image and promoting self-
actualization, individuals work towards embracing their changing
bodies, accepting themselves during pregnancy, and fostering a
positive self-image.
According to Harley Therapy, problems related to body image

during pregnancy can affect the health of the mother and fetus;
thus, it is essential for health professionals to detect potential
disorders as soon as possible. Get honest about how you really
feel. It’s not uncommon to secretly be very uncomfortable with
your expanding body, but feel shame over admitting it.
1. Acute pain related to low transverse cesarean section
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Acute pain Short-Term Independent Independent Short-Term

Patient verbalized, related to low After 2 hours of 1.) Established 1.) Relationships characterized by After 2 hours of
“Sobrang sakit ng transverse nursing Rapport. trust and rapport contribute to better nursing intervention,
tahi ko, natatakot at cesarean section intervention, the care experiences. They can also the goal was MET as
nahihirapan akong as evidenced by patient’s pain will 2.) Provided a alleviate anxiety and distress and the pain scale rating
gumalaw.” verbal reports of be reduced from comfortable enhance patients' involvement in of 9/10 is reduced to
incisional pain 9/10 to 4/10. environment to the decisions about their care. 4/10.
Objective: patient.
- (+) Facial Grimace Long-Term 2.) Patients are more likely to Long-Term
- Patient verbal After 1 week of 3.) Monitored vital recover faster and have better After 1 week of
complaint of pain nursing signs. health outcomes if they are nursing intervention,
with a 9/10 pain intervention: comfortable; a bad environment the goal was MET.
scale 4.) Assessed quality, slows healing. The client showed
- the client will characteristics and relief from pain as
show relief from severity of pain. 3.) Vital signs help medical evidenced by
pain. professionals understand a patient's absence of facial
5.)Schedule adequate general state of health. grimace, pain and
- the client will not rest periods. absence of elevated
complain about 4.) The nurse can assess the vital signs.
pain. 6.) Encourage use of effectiveness of interventions
relaxation techniques intended to lessen pain by
like deep breathing quantifying the intensity of the pain.
exercises.
5.) Prevents fatigue and conserves
Dependent energy for healing.
7.) Administer
analgesics or non- 6.) Reduces tension in the muscles
steroidal anti- and the mind.
inflammatory drugs as
prescribed by the Dependent
physician. 7.) To relieve mild to moderate pain.
2. Decreased Cardiac related to decreased venous return
Page 70 of 99
Subjective Decreased Short-Term Independent Independent Short-Term

Patient Cardiac Output After 3 hours of 1.) Established 1.) Relationships After 3 hours of
verbalized, related to nursing interventions, Rapport. characterized by trust and nursing intervention,
“Sobrang decreased the patient will display rapport contribute to better the goal was MET,
nanghihina at venous return hemodynamic stability 2.) Monitored and care experiences. They can the patient had
nahihilo ako secondary to as evidenced by blood assessed vital signs. also alleviate anxiety and displayed
minsan.” severe pressure within the distress and enhance hemodynamic
preeclampsia normal range. 3.) Assessed the patients' involvement in stability (blood
Objective: as evidenced by patient’s general decisions about their care. pressure within
- Weight gain altered BP and Long-Term physical condition. closer range).
edema After 3 days of nursing 2.) Vital signs help medical
- Edema interventions, the 4.) Schedule professionals understand a Long-Term
patient will adequate rest patient's general state of After 3 days of
- Variations in BP demonstrate periods. health. nursing
reading techniques to lessen interventions, the
the pressure on the 5.) Determined 3.) To determine the goal was MET, the
- Restlessness
heart (such as stress baseline vital presence of abnormality. patient was able to
management, a signs/hemodynamic demonstrate
therapeutic parameters including 4.) Prevents fatigue and activities that reduce
medication regimen, peripheral pulses. conserves energy for workload of the heart
and a schedule of healing. (such as stress
balanced activity and 6.) Reviewed signs of management, a
rest). impending 5.) Provide opportunities to therapeutic
failure/shock. track changes. medication regimen,
and a schedule of
7.) Elevated 6.) To prevent hypovolemic balanced activity and
edematous shock. rest).
extremities and avoid
restrictive clothing. 7.) To promote comfort.
Page 71 of 99
8.) Monitored intake 8.) To determine fluid
and output. balance.
Dependent
9.) Administered anti-
hypertensive
medications as
prescribed.
3. Increase Fluid Volume related to Narrowing of the Blood Vessels
Subjective Increase Fluid Short-Term Independent: Independent: Short-Term

“Sobrang sakit ng Volume related After 5 hours of
ulo ko, tapos to Narrowing of After 5 hours of 1. Established 1. It promotes good communication nursing
namamaga pa the Blood nursing Rapport and improves the overall patient interventions, the
yung pa yung Vessels due to interventions, the experience. goal was MET, the
kaliwang legs ko.” Severe patient will be able 2. Monitored patient was able to
as verbalized by Preeclampsia to demonstrate Blood Pressure 2. Regular blood pressure monitoring demonstrate
the patient. efficient fluid intake helps identify individuals with techniques efficiently
and output 3. Assessed for hypertension (high blood pressure). on fluid intake and
Objective: edema, output.
Long-Term proteinuria, and 3. Edema can be an indication of an
• Increased After 3 days of weight gain. imbalance in the body's fluid levels. Long-Term
BP: 160/100 nursing After 3 days
interventions, the 4. Advised to 4. Excessive sodium intake can lead
of nursing
patient will be able limit sodium to fluid retention, which can
interventions, the
Page 72 of 99
• (+) Edema to maintain intake and take contribute to edema, increased blood goal was MET, the
in Left adequate fluid calcium, volume, and strain on the patient was able to
Lower Leg volume as magnesium, and cardiovascular system. maintain the
• Low evidenced by potassium adequate fluid
Hematocrit blood pressure supplements. 5. It provides valuable information volume as evidenced
Level: 27.7 within normal about the amount of fluid being by blood pressure
limits. 5. Monitored consumed and the amount being within normal limits.
intake and excreted through urine, feces,
output. perspiration, or other sources.
Dependent
1. They work by reducing blood
Dependent volume and decreasing the
resistance in blood vessels,
1. Administered leading to a decrease in blood
diuretics pressure.
medications.
Page 73 of 99
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Short Term: Independent: Independent: Short Term:
Subjective Data: Risk for bleeding After 1 hour of GOAL MET
related to post- nursing intervention 1. Established ➢ To build trust and therapeutic
“Kapag naupo o operative surgical the patient will be rapport with relationship for effective After 1 hour of nursing
hihiga ako, nag incision as able to the client communication and intervention the patient
durugo ako” as evidenced low a. identifies and 2. Regularly collaboration was able to
verbalized by the transverse inspected ➢ It allows for early detection of
understand risk
patient Cesarian section any signs of active bleeding, a. identifies and
that may contribute the incision site for
II excessive drainage, or verbalized
to excessive any signs of active
Objective Data: bleeding, hematoma formation. Prompt understanding of the risk
bleeding increased identification and intervention that may contribute to
drainage, or can prevent further
(+) low transverse b. demonstrates excessive bleeding
hematoma complications related to
incision site due to proper wound
formation. Assess bleeding and ensure timely b. demonstrates proper
cesarean section
control and the color, amount, treatment. wound control and
pressure in and consistency of ➢ Documentation provides a
pressure in handling
lochia (vaginal baseline for comparison and
handling incision incision that may lead to
discharge) to enables healthcare providers
that may lead to to monitor the progression of bleeding
detect any
bleeding healing, identify trends, and
abnormal Long Term:
bleeding. make informed decisions
Long Term:
regarding the patient's care.
3. Documented any
➢ helps reduce pressure on After 1-2 days of
After 1-2 days of significant
the implementation of
implementation changes in
incision site and improves nursing care the client
of nursing care bleeding or
venous return, thus was able to performed
the client will be incision site
promoting optimal blood flow
able to perform appearance. actions that reduces
and reducing the risk of
actions that 4. Elevated the head bleeding
bleeding such as limiting
of bed ➢ helps enhance physical activity as
5. Encouraged circulation, preventing blood tolerated by the patient
Ambulation and
Page 74 of 99
reduces bleeding Leg Exercises pooling and reducing the risk and scratching the
such as limiting 6. Provided of deep vein thrombosis incision site
physical activity Nutritional Support (DVT) or blood clot formation.
Collaborative Collaborative:
➢ Supports pt’s wellbeing
and overall healing process
7. Collaborated to a
dietitian and
physician
5. Risk for Progression to Eclampsia Related to drastic decrease in the cardiac output
Subjective: Risk for Short-Term Independent Independent Short-Term

Progression to 1. Monitored vital signs. 1. It helps identify any After nursing
Patient said Eclampsia After 8 hours of Regularly assessing changes or trends that intervention, the
that she had Related to nursing intervention: vital signs such as may indicate worsening goal was MET
the history of drastic blood pressure, cardiac output and the - The patient’s
severe pre- decrease in the The patient will heart rate, potential for eclamptic blood pressure
eclampsia on cardiac output maintain stable respiratory rate, and seizures. decreased from
her past as evidence by blood pressure oxygen saturation. 2. It can detect early 160/100 to 130/90.
pregnancy. altered BP. within the signs of neurological - The patient
target range 2. Monitored neurologic changes that may remained free from
Objective: status: Frequent precede eclamptic any signs of
- Increased The patient neurological seizures. eclampsia such as
maternal age demonstrates no assessments, 3. It helps optimize seizures and
signs or symptoms including level of blood flow, reduce the convulsions.
of eclampsia, such workload on the heart,
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- Agitated, as seizures or consciousness, and promote adequate - The patient
restless and convulsions. pupillary response, tissue perfusion. remained
Irritated and presence of any monitored and
The patient neurological deficits Dependent assessed in blood
- Vital signs receives ongoing 1. It helps control pressure, cardiac
shows monitoring and 3. Encouraged the blood pressure and output, and other
increased Blood assessment of patient to remain on prevent further decrease relevant
pressure blood pressure, bed rest, in a semi- in cardiac output, parameters.
160/100 cardiac output, and Fowler's position or reducing the risk of
other relevant on the left side. eclamptic seizures
parameters. Dependent. 2. Helps detect any Long-Term
1. Timely administration abnormalities or trends
of prescribed that may indicate After 1-2 days of
Long term medications, such as worsening cardiac nursing
After 1-2 days of antihypertensive function or potential intervention, the
nursing medications complications. goal partially MET,
intervention, the 2. Regularly 3. Empowers the patient the patient was able
patient will: assessed laboratory values, and their family to to verbalize and
such as complete blood recognize warning signs demonstrate the
- The patient and count, renal function, and seek importance of
their family liver function, medications,
demonstrate and importance of
understanding of coagulation profile seeking medical
the signs and 3. Provide education about attention and ways
symptoms of the signs and symptoms to reduce the risk of
eclampsia and the of eclampsia and the having occurrence
importance of importance of adhering to of eclampsia.
seeking immediate the prescribed
medical at tention if medication regimen
they occur.
Page 76 of 99
6. Impaired skin related to low transverse surgical incision
Subjective: Impaired skin Short-Term Independent Independent Short-Term

integrity related 1. Established Rapport 1. To achieve a good nurse-client
“Nakirot yung to low After 4 hours of 2. Monitored Vital signs. relationship After 4 hours of
tahi ko pag transverse nursing 3. Discuss to patients 2. Changes in vital signs may be nursing
gumagalaw surgical incision intervention, the the following signs of used for rough estimate of pain interventions, the
ako” as secondary to patient's pain infection; redness, 3. To impart to the patient when goal was MET as the
verbalized by cesarean birth level is expected swelling, and the wound becomes infected patient verbalized a
the patient. as evidenced to decrease to a increased pain. and when to seek medical care. decreased level of
by patient's tolerable level, 4. Instruct the patient to 4. To reduce pain especially pain and did not
Objective: verbalization of and there should use supportive when moving display any
• (+) Facial concerns about be no signs of materials such as 5. May relief pain and enhance discomfort or signs
grimace appearance facial grimace. binder. circulation of facial grimace.
• Patient and pain 5. Reposition as 6. Relieves muscle and emotional
reported around the Long-Term indicated. tension, which can also Long-Term
pain with incision area After 3 days of 6. Encouraged the promote the healing of surgical After 3 days of
the pain nursing patient to perform wounds. nursing
scale of intervention, the deep breathing and interventions, the
9/10 patient will be coughing exercises Dependent goal was MET as the
• Discomfort able to verbalize to prevent respiratory
1. Analgesics are used to relieve patient achieved
• Protective a decreased pain complications and or manage pain, thereby timely wound
gesture to scale and improve circulation. improving comfort, function, healing, remained
avoid pain achieve timely and overall well-being. free from infection,
in incision wound healing, Dependent Effective pain management and was able to
site leading to 4. Administered promotes early recovery, move without
freedom from analgesic medication prevents complications, requiring much
infection. as ordered by reduces anxiety and stress, assistance from
physician and enhances the patient's others.
overall satisfaction.
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7. Risk for infection related to post operative surgical incision
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

Subjective Data: Risk for infection After 30 mins of ➢ To build trust and
related to post nursing intervention 1. Established rapport therapeutic GOAL MET
“Kahit second operative surgical the patient will be able with relationship for After 30 mins of nursing
time na ako na- incision to verbalize the client effective intervention the patient was
cs, hindi parin understanding of 2. Promoted proper communication and able to verbalized
siguro maiwasan surgical site infection hand hygiene collaboration understanding of surgical
na magka 3. Encouraged ➢ Proper hand
prevention measures site infection prevention
infection tahi ko” Ambulation and hygiene is essential
and verbalize measures and verbalize
as verbalized by Early Mobilization in preventing the
adherence to spread of adherence to prescribed
the prescribed 4. Educated pt on interventions.
patient microorganisms
interventions. Incision Site Care and reducing the
5. Encouraged the risk of surgical site
Objective Data: patient to consume Long Term:
Long Term: infection.
a well-balanced diet ➢ Improved blood
(+) low transverse that includes foods flow enhances the After 2-3 days of nursing
incision site due to After 2-3 days of rich in protein, delivery of oxygen intervention, the patient
cesarean section nursing intervention, vitamins, and and nutrients to the demonstrates no signs or
the patient will minerals. incision site, symptoms of
demonstrate no signs 6. Addressed any
or symptoms of facilitating wound surgical site infection, with
dietary restrictions healing and
surgical site infection, the incision site showing
or modifications reducing the risk of
with the incision site signs of healing and no
based on the
showing signs of infection. evidence of infection.
patient's individual
healing and no needs. ➢ Proper care of
evidence of infection. the
7. Educated pt and
incision site is
their significant crucial in
preventing
infection.
Page 78 of 99
others about the ➢ Adequate
importance of nutrition plays a
maintaining a vital role in
clean environment supporting the
by ensuring that immune system
the patient's bed and promoting
linens, clothing, wound healing.
and other personal ➢ Keeping the
items are regularly patient's
cleaned and immediate
properly sanitized. environment
clean and free
from potential
Collaborative sources of
infection is
essential
8. Referred to a
dietitian and
physician Collaborative:
➢ This collaborative
effort contributes
to reducing the
risk of surgical
site infection.
Page 79 of 99
8. Risk for maternal Injury related to hypertensive crisis
Subjective Risk maternal Short-Term Independent Independent Short-Term

“ Pag nagalaw injury related to After 8 hours of 1. Monitored 1. Frequent monitoring of blood After nursing
ako parang hypertensive nursing blood pressure. pressure helps identify the severity intervention, the
nasakit yung ulo crisis due to intervention: 2. Maintained a of hypertension and allows for goal was MET, the
ko” Severe - The patient's calm and quiet timely intervention in case of a patient Blood
Preeclampsia blood pressure is environment hypertensive crisis. pressure decreased
controlled within 3. Implemented 2. A calm environment promotes as evidenced by:
Objective: the target range seizure relaxation and can help prevent from 160/100 to
- An absence of precautions stress or anxiety, which can 130/90.
-Increased BP seizures or 4. Monitored exacerbate hypertension and - The patient
160/100 eclamptic urine output and increase the risk of a hypertensive remains free from
episodes assess forcrisis. seizures or
(+) Weakness - Maintain a stable proteinuria 3. Seizures are a potential eclamptic episodes
neurologic status 5. Provided complication of severe - The patient has no
-Client looks
Long-Term emotional preeclampsia. Implementing new or worsening
anxious, restless
After 1-2 days of support and seizure precautions, such as signs of neurologic
and irritable.
nursing education. padding the bed and maintaining a dysfunction such as
intervention: safe environment, helps protect the severe headaches,
1. The patient and patient from injury during a seizure visual disturbances,
their family episode. hyperreflexia, or
demonstrate 4. Monitoring urine output and changes in level of
understanding of Dependent. assessing for proteinuria helps consciousness.
the condition, its 1. Administered evaluate kidney function and
potential antihypertensive identifies any worsening renal
complications. medications as involvement, which is a potential
prescribed complication of severe Long-Term
preeclampsia. After 1-2 days of
nursing
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5. Emotional support and education intervention, the
help reduce anxiety and empower goal was MET, the
the patient to understand the patient and the
condition and actively participate in family was able to
their care. This can promote demonstrate
adherence to the treatment plan understanding of
and improve overall outcomes. the condition, its
. potential
Dependent: complications, and
1. Antihypertensive medications the importance of
are given to lower blood pressure self-management
and reduce the risk of strategies,
complications associated with indicating improved
hypertension, including a knowledge and
hypertensive crisis. reduced risk of
maternal injury.
Page 81 of 99
9. Risk for caregiver role strain as evidenced by patient’s verbalization of going back to work after recover from cesarean
birth
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

Subjective Data: Risk for caregiverAfter 1-2 hours of
role strain as nursing intervention, 1. Established rapport ➢ It creates an open and GOAL MET
“Balak ko nga evidenced by the patient will be able with the client supportive environment
agad bumalik sa patient’s to: 2. Encouraged the where the patient feels After 1-2 hours of
trabaho ko eh, verbalization of patient to delegate comfortable discussing nursing intervention, the
dahil ayun ang going back to a) Express an tasks and seek their concerns and patient was able to:
nakasanayan ko” work after recover understanding of support from seeking guidance, a) Expressed an
” as verbalized by from cesarean the importance of significant others increasing the understanding of the
the patient birth taking care of her and family members effectiveness of importance of taking
child, especially 3. Educated pt the subsequent care of her child,
after birth importance of interventions.
especially after birth
b) Express more selfcare to the ➢ It reduces the patient's
b) Expressed more
patient. Encourage burden, allowing them to
realistic realistic
them to allocate focus on their own
understanding and understanding and
time for rest, recovery, bonding with
expectation in expectation in
relaxation, and the infant, and adjusting
motherhood motherhood
activities that to their new role as a
promote their parent
Long Term: wellbeing. ➢ By allocating time
After 2 days of nursing Long Term:
4. Provided education for rest, relaxation,
intervention, the on postpartum and engaging in GOAL MET
patient will be able to recovery activities they enjoy,
5. Educated pt on the the patient After 2 days of nursing
a) Report and importance of can recharge, reduce intervention, the patient
improve well- building relationship stress levels, and was able to:
being with the infant a) Report and improved
prevent caregiver role
wellbeing
Page 82 of 99
6. Encouraged strain. It allows them b) Discussed
continuous to set realistic different approach to
breastfeeding ➢ expectations and handle current situation
Collaborative: make informed decisions c) established a support
about their readiness to system or utilize available
7. Collaboration with return to work. It resources to assist with
the healthcare team, promotes emotional childcare responsibilities
connection, facilitates the as evidenced by pt’s
including
infant's verbalization of
physicians, delegating task to
therapists, and significant other
Collaborative:
social workers
➢ allows for a
comprehensive
assessment of the
patient's needs and the
development of an
individualized care plan.
10. Constipation related to surgical procedure as evidenced by absence of stool
Subjective Constipation Short-Term Independent Independent Short-Term

Patient verbalized related to After 6 hours of After 6 hours of
“Hindi pa din ako surgical nursing 1. Established 1. It helps build trust, nursing interventions,
nakakadumi, mag procedure as interventions, the Rapport promote effective the goal was MET, the
dalawang araw na evidenced by patient will relieve communication, and patient was able to
simula nung constipation and relieve constipation
Page 83 of 99
nanganak ako. absence of prevent enhance the overall patient and was able to
Nahihirapan pa din stool complications 2. Performed experience. prevent complications
ako.” associated with abdominal associated with
constipation, such assessment, 2. Abdominal assessment constipation, such as
as bowel assessed abdomen allows medical bowel obstruction.
Objective: obstruction. for swelling, professionals to detect and
tenderness or pain. identify abnormalities or Long-Term
Long-Term changes in the abdomen. After 1-2 days of
After 1-2 days of 3. Monitored nursing interventions,
nursing patient’s intake and 3. Help assess the the goal was met, the
interventions, the output. patient’s fluid balance. patient was able to
patient will have eliminate bowel
good and regular 4. Encouraged to 4. Increasing fluid intake movements regularly.
bowel movements. increase fluid intake helps prevent dehydration.
for hydration. Maintaining proper
hydration levels ensures
5. Advised to eat optimal bowel function.
fiber rich foods.
5. Fiber adds bulk to the
Dependent stool, making it easier to
pass through the
1. Administered intestines.
laxative
medications or Dependent
other prescribed
medications as 1. Laxative medications can
ordered by the help initiate or enhance the
physician. natural contraction of the
intestinal muscles, facilitating
the movement of stool
through the digestive tract.
Page 84 of 99
11. Readiness For Enhance Parenting
Subjective Data: Readiness for SHORT-TERM INDEPENDENT SHORT-TERM

Enhanced 1. Showed typical -To know the
“Gusto kong Parenting After 8 hours of newborn typical newborn GOAL MET After 8
mapabuti ang anak related to Desire nursing characteristics: characteristics and hours of nursing
ko, dahil gusto ko to Enhance intervention, the Point out state traits know the common intervention the
maibigay yung best Child patient will be able such as quiet cues and what they patient was able to:
para sa kanya” as Maintenance to: awareness and cues correspond with.
verbalized by the - Parents improve to feeding readiness. -Participating in - Parents were able
patient. responsibility for infant care makes to improve
emotional and 2. Encouraged them appreciate responsibility for
Objective Data: physical care and participation of and embrace being emotional and
well being of the patients in care a parent as a role. physical care and
(+) desire of the new family behaviors such as well being of the
mother to learn member. diapering, -To know how to new family member.
(+) patient show breastfeeding and care for the infant.
positivity towards the LONG-TERM bathing. LONG-TERM
newborn care
After 1 week of 3. Education: Infant GOAL MET
nursing care After 1 week of
intervention, the nursing intervention
patient will be able the patient was able
to: to:
-Emotional
attachment -Patient was able to
confident in infant have emotional
care. attachment and
confidence in infant
care.
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12. Readiness For Enhance Coping
Subjective Readiness for SHORT-TERM INDEPENDENT INDEPENDENT: SHORT-TERM:

Data: Enhanced Coping 1. Assessed -To gain a general GOAL MET
The patient related to the The patient general health understanding of the After 4 hours of
expressed their Patient’s Desire to should be at status. patient’s well-being and nursing intervention,
desire for greater Maintain Normal ease, and well- overall health. the patient was able
comfort and Blood Pressure level rested after 2.Monitored vital to feel at ease, and
relaxation. Secondary to receiving nursing signs. -To provide information well-rested.
Severe care for four about potential disorders,
The patient Hypertension, as hours. 3.Provided a aid in evaluating the The patient was able
wants to improve evidenced by pleasant and well patient’s physical health, to identify potential
complaint verbalization to ease -The patient will environment. and demonstrate the stressors and
resolution, and tension, and verbalize healing process. employed effective
alleviate alleviate understanding of 4.Encouraged coping behaviors.
hypertension. hypertension. potential expression of -To promote rest and
stressors and feelings and healing. LONG-TERM:
Objective Data: employ effective assess the GOAL MET
coping behaviors. patient’s -It can provide a support
BP: stressors. system for the patient and The patient was able
-160/100 mmHg LONG-TERM a baseline of information to remain composed
(+) Edema After 2 days of Dependent: for the nurse to curate a throughout the shift
nursing more effective program. with enough rest. The
intervention, The Administered anti- blood pressure was
patient should hypertensive -To alleviate hypertension decreased from
remain composed drugs as ordered. and prevent complications. 160/100 mmHg to
with enough rest 130/80 mmHg.
and the blood
pressure must
lessen.
Page 86 of 99
13. Readiness For Enhance Knowledge
Subjective Readiness to SHORT-TERM INDEPENDENT ➢ Conveying SHORT-TERM

Data: Enhance GOAL: 1. Provided an respect is
Knowledge as After 8 hours of atmosphere of respect, especially GOAL MET
“Patient Evidenced by nursing intervention openness, trust, and important when After 8 hours of
expresses desire Asking the patient will be collaboration. providing nursing intervention,
and willingness Questions on able to: education to the patient was able
to enhance How to -The patient will be 2. Defined and specify patients with to:
learning” Improve her able to verbalize desired blood pressure different values -The patient was able
and her understanding on the limits. and beliefs to verbalize
Objective Data: Baby’s Health changes that occur about health understanding on the
in the pregnancy 3. Described and illness. changes that occur in
Action congruent state. hypertension and its the pregnancy state.
with verbal effect on the heart, ➢ Provided a
expression -The patient will be blood vessels, kidney, basis for -The patient was able
able to recognize the and brain. understanding to recognize the need
need for medications blood pressure for medications and
and understand 4. Explored reactions elevation and understand
treatments. and feelings about describes the treatments.
changes. commonly used
LONG-TERM medical terms. LONG-TERM
GOAL: 5. Assisted patients in GOAL MET
-After 2-3 days of identifying the risk ➢ Assessments After 2-3 days of
nursing intervention factors that can be assist the nurse nursing intervention,
the patient will be modified, e.g,. Obesity, in the patient was able
able to: a diet in sodium, understanding to:
saturated fat, and how the learner
Page 87 of 99
-Patient will be able cholesterol sedentary may respond to -Patient was able to
to demonstrate how lifestyle, smoking, the information demonstrate how to
to incorporate new alcohol consumption, and how incorporate new
health regimens into and stress lifestyle. successful the health regimens into
lifestyle. patient may be lifestyle.
with the
expected
changes.
➢ Understanding
that high blood
pressure can
occur without
symptoms is
that the center
allows patients
to continue
treatment, even
when it feels
good.
➢ Risk factors that

have been
shown to
contribute to
hypertension
and
cardiovascular
and renal
disease.
Page 88 of 99
14. Readiness For Self-Care
Subjective Data: Readiness for SHORT-TERM INDEPENDENT INDEPENDENT: SHORT-TERM

“Noon ay mahilig Enhanced Self- GOAL: 1. Encouraged the 1. The patient may only GOAL MET
akong mag-ayos ng care as After 30 minutes patient to have a need help with some after 30 minutes of
sarili ko pero ngayon evidenced by of nursing schedule for self-care self-care measures. nursing
sa tingin ko ay hindi Patients intervention, the activities. Self-care items related intervention, the
ko na magagawa dahil Expressing patient will be 2. Provided to eating, bathing, patient was able to
dalawa na ang anak Concerns able to know therapeutic grooming, dressing, gain knowledge on
ko at ako lang ang about Self-care techniques on interventions, such toileting, bladder and how she can
nag aasikaso sa and Strategies how she can as modifications or bowel management. manage her time
kanila dahil nasa to Improve maximize her adaptations to on herself and
trabaho ang asawa Personal care time for her personal care tasks 2. Helping the patient verbalized the
ko” as verbalized by children and for or routines; with setting realistic importance of self-
the patient. herself. individualize goals, it will reduce care.
interventions to frustration.
Objective Data: LONG-TERM developmental LONG-TERM
GOAL: needs. 3. Patients may require GOAL MET
Messy hair and skin After 2 days of 3. Provided frequent help in determining the After 2 days of
noted nursing encouragement, safe limits of trying to nursing
intervention, the along with prompting be independent versus intervention, the
Inability to complete patient will be and assistance as asking for assistance patient was able to
basic activities of daily able to perform needed. when necessary. verbalize the
living techniques on 4. Identified patient’s techniques that
how she can preferences for 4.The patient will be she does to
maximize her clothing, food, and eager to submit himself maximize her time
time for herself personal care items; or herself to the for her children
and for her offer and honor treatment regimen that and for herself.
children. patient choice when supports his or her
possible. individual preferences.
Page 89 of 99
15. Readiness For Body Image
Subjective Readiness for SHORT-TERM INDEPENDENT SHORT-TERM

Data: Enhancing GOAL: > Acknowledge, and > Acceptance of this GOAL MET
“ Ngayong Disturbed body After 8 hours of accept the expression feeling as a normal After 8 hours of
nagbuntis ako image related nursing intervention of feeling frustration. response to what has nursing interventions
ang daming to pregnancy the patient will be Note withdrawn occurred. It is not the pt. Was able to
nagbago sakin, as evidenced able to verbalize behavior and use of helpful or possible to verbalized
lalo na sa by changes in -acceptance of self denial. push patients ready to acceptance of self in
physical appearance. in situation, relief of > Be realistic and deal with situations. situation relief
appearance anxiety and positive during Denial may be anxiety and
ko”as verbalized adaptation to treatments in health prolonged and be an adaptation to altered
by pt. altered body image teaching and setting adaptive mechanism body image and was
and will be able to goals within limitation because the patient is able verbalized
Objective Data: verbalize not ready to cope with understanding body
-Feeling of understanding of > Provide hope within personal problems. changes.
helplessness body changes parameters > Enhance trust and
and LONG-TERM of individual rapport between LONG-TERM
hopelessness GOAL: situation, do not give patient and nurse GOAL MET
After 2-3 days of false reassurance > Promotes positive After 2-3 days the
-Conscious on nursing > Encourage family attitude and provides patient was able to
her look intervention, the interaction with each opportunity to set goals recognized and
patient will be able other and with the and plan for future incorporated body
-Anxiety to rehabilitation team. based on reality image into self-
Recognize and > Words of concept in an
incorporate body DEPENDENT encouragement can accurate manner
image change into > Provide resources, support development without negating self-
self concept in such as a list of of positive coping esteem and was able
accurate manner support groups. behaviors. to acknowledge self
without negating as an individual who
Page 90 of 99
self esteem, and >Patient may benefit has responsibility for
will be able to from exchanging self.
acknowledge self feelings and thoughts
as an individual COLLABORATIVE with people going
who has > Involve a specialist through the same
responsibility to in the care hardship.
self
> Specialists, such as

psychologist or nurse
can facilitate the
transitioning process
and promote
confidence
Page 91 of 99
VII. DISCHARGE PLAN
A. Health Teaching
Preeclampsia Management:
• Educated patient about preeclampsia, its symptoms, and potential
complications.
• Adequate rest is crucial for managing preeclampsia. Reduce your workload,
prioritize sleep, and practice relaxation techniques to manage stress levels.
• Drink plenty of water to stay hydrated, as dehydration can worsen symptoms
of preeclampsia. Avoid excessive caffeine and sugary beverages.
Incision Care:
• Explained the proper care of the cesarean incision, including keeping the area
clean and dry.
• Instructed the patient on how to identify signs of infection, such as redness,
swelling, or discharge from the incision site.
Breastfeeding:
• Provided guidance on breastfeeding techniques and proper positioning to
promote successful breastfeeding.
• Discussed strategies for managing breastfeeding positions that may be more
comfortable after cesarean section, such as side-lying or using pillows for
support.
Postpartum Care:
• Provided information on the postpartum contraception options and options for
family planning.
• Educated the patient about the importance of adequate rest and self-care
during the postpartum period.
Follow-up and Monitoring:
• Scheduled follow-up appointments with the healthcare provider to monitor
incision healing and overall postpartum recovery.
• Emphasized the importance of attending postoperative follow-up appointments
and providing information on what to expect during these visits.
Page 92 of 99
B. Anticipatory Guidance & Teachings
• Advised the patient to report any signs and symptoms of the possible infection,
especially at the site of the incisions for any pain ( sharp, aching, throbbing, or
burning in nature inflammation/infection on the incision site).
• When cleaning the breast, use water to clean your nipples when you have a
shower. Do not use soap on your nipples. Keep your nipples clean and dry.
• Fever of 38C or higher.
• Discussed contraception options suitable for the patient’s needs and
preferences.
• Educate the patient to report if there are alarming signs like persistent heavy
bleeding.
• Note that lochia or the vaginal discharge after delivery is normal and is not
menstruation. This will last for 10 days. Report immediately if there are signs of
infection or hemorrhage such as blurred vision, pale clammy skin, and notice
that lochia has a foul-smelling odor, or the bleeding increases or gets lighter
and then suddenly gets heavy again
Lochia Rubra
• Day 1-3
• Bright red in color
Lochia Serosa
• Day 3 to Day 10
• Pinkish or brownish in color
Lochia Alba
• Day 10 until 3rd week up to 6th
week postpartum
• White in color
C. Environment
• To keep the minimal risk of illness and harm, make sure your house is clean
and safe.
• Keep a calm environment for relaxing as an element of recuperation and
healing.
Page 93 of 99
D. Spirituality
• Allow self to be open, communicate with the family member and allow them to
offer practical and emotional support.
• Allow yourself to have free time and spend time on hobbies.
• Spend time with significant others together with a newborn baby.
E. Medication
• Mefenamic Acid - 500mg every 6 hours per oral to treat mild to moderate pain
and dysmenorrhea (menstrual cramps)
• Ferrous Sulfate - per oral once daily to treat and prevent iron deficiency
anemia.
• Cefuroxime - This medication is for bacterial infection, prescribed by the
physician and should be taken exactly as prescribed and complete the entire
course of treatment to prevent bacterial resistance.
• Amlodipine - is a calcium channel blocker used to treat high blood pressure
(hypertension).
• Advised the patient to not self-medicate with other antibiotics.
• Take medicine on time as prescribed by the physician.
F. Exercise
• Educated the patient about the importance of saturated fats in managing
blood pressure.
• Before beginning any postnatal treatment, always seek medical advice for
workout healing.
• Generally speaking, you can begin light activities like walking as soon as you
feel comfortable after giving birth.
• Avoid/limit heavy lifting and stairs.
• Emphasized the inclusion of a variety of foods from all food groups, including
fruits, vegetables, lean proteins, whole grains, and healthy fats.
• Encouraged the patient to follow a regular meal schedule with consistent
timings to help stabilize hypertension.
Page 94 of 99
G. Nutrition and Diet
• Stay hydrated all day. A well-hydrated body has a regulated body temperature,
it keeps bones lubricated, prevents infections, delivers nutrients to cells, and
keeps the organs in functioning properly.
• Breastfeeding mothers should continue taking prenatal vitamins. This will help
the lactating mother to provide sufficient nutrients needed for her baby and her
body.
• Lessen or avoid caffeine intake. This will improve the iron content of the breast
milk.
• Limit or avoid alcohol. Alcohol consumption could lead to shortened
breastfeeding duration due to decreased milk production.
Page 95 of 99
VIII. REFERENCES
National Library of Medicine (2020). Lower-Segment Transverse Cesarean Section.

Retrieved from. Lower-Segment Transverse Cesarean Section - PMC (nih.gov)
Huizen, J., (2019). What causes post-cesarean wound infection ?. Retrieved by. Post-
cesarean wound infection: Causes and treatment (medicalnewstoday.com)
The Healthline Editorial Team (2017). Cesarean Section Complications. Retrieved

from. Labor and Delivery: Complications of Cesarean Section (healthline.com)
Dixon, A., (2017). Blood pressure. Retrieved from. How Do Automatic Blood Pressure
Monitors Work? | Healthfully
Curran, A., (2022). Preeclampsia. Retrieved from. Preeclampsia Nursing Diagnosis

and Care Plans - NurseStudy.Net
Curran, A., (2022). Readiness for Enhanced Coping. Retrieved from. Readiness for
Enhanced Coping Nursing Diagnosis and Nursing Care Plans - NurseStudy.Net
McCarthy, C., (2020). 6 ways to help keep your baby at a healthy weight. Retrieved
from. 6 ways to help keep your baby at a healthy weight - Harvard Health
Betterhelp Editorial Team (2023). Why Self Care is Important For Moms. Retrieved
from. Why Self Care Is Important For Moms | BetterHelp
Harley Therapy (2018). Ways to Improve Body Image During Pregnancy. Retrieved
from. 10 Ways to Improve Body Image During Pregnancy (and feel more
neutral) (summerinnanen.com)
Slattengren, K., (2021). Ways to Improve Parenting Skills. Retrieved from. 3 Ways to
Improve Parenting Skills - wikiHow Life
Anemia and Pregnancy. American Society of Hematology. Retrieved from:

https://www.hematology.org/education/patients/anemia/pregnancy
Manurung, H., Sunarno, I., & Usman, A., (2020). Hematology Profile in Severe
Preeclampsia at the Mother and Child Hospital of Makassar City. International
Conference on Women and Societal Perspective on Quality of Life, 630-633.
August, P. & Sibai, B., (2020). Preeclampsia: Clinical Features and Diagnosis. Up To
Date. Retrieved from: https://www.uptodate.com/contents/preeclampsia-
Page 96 of 99
clinical-features-and-
diagnosis#:~:text=Generalized%20edema%20in%20preeclampsia%20may,th
e%20mother%20and%2For%20fetus
Jwa, S., Fujiwara, T., Yamanobe, Y., et. al., (2015). Changes in Maternal Hemoglobin
During Pregnancy and Birth Outcomes. BMC Pregnancy Childbirth, 15-80.
Sruthi, M., (2022). What Does High White Blood Cell Count Mean When Pregnant.
Retrieved from.
https://www.medicinenet.com/high_white_blood_cell_count_in_pregnancy/arti
cle.htm
Achebe, M., & Gafter-Gvili, A., (2017). How I Treat Anemia in Pregnancy: Iron,
Cobalamin, and Folate. Retrieved from.
https://ashpublications.org/blood/article/129/8/940/36329/How-I-treat-anemia-
in-pregnancy-iron-cobalamin-and
Morton, A., (2021). Hematological Normal Ranges in Pregnancy. Maternal Medical

Health and Disorders in Pregnancy, Volume 8.
Orgul, G., et. al., (2019). First trimester complete blood cell indices in early and late
onset preeclampsia, 112 - 117. Retrieved from.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637787/#:~:text=The%20cau
se%20of%20increased%20neutrophils,levels%20of%20WBC%20and%20neu
trophils
Kim, Y., & Nutman, T., (2017). Eosonophilia. Immigrant Medicine. Retrieved from.
https://www.sciencedirect.com/topics/immunology-and-
microbiology/eosinophil-
count#:~:text=Eosinophil%20counts%20are%20low%20during,in%20respons
e%20to%20parasitic%20infection
Horsager-Boehrer, R., (2021). Pulmonary Embolism in Pregnancy: Know

the Symptoms, Risks of Blood Clots. UT Southwestern Medical Center.
Retrieve from: http://utswmed.org/medblog/pulmonary-embolism-pregnancy/
Zuarez-Easton, S., Zafran, N., Garmi, G., & Salim, R. (2017, February 17).
Postcesarean wound infection: prevalence, impact, prevention, and
Page 97 of 99
management challenges. PubMed Central (PMC). Retrieve
from: https://doi.org/10.2147/IJWH.S98876
Khalil, G. (n.d.). Preeclampsia: Pathophysiology and the Maternal-Fetal Risk.

Retrieved From:http://clinmedjournals.org/articles/jhm/journal-of-hypertension-
and-management-jhm-3-024.php?jid=jhm
BSN, R.N., G. W. (2017, April 6). Caregiver Role Strain & Family Caregiver Support
Systems Nursing Care Plan. Nurseslabs. https://nurseslabs.com/caregiver-
role-strain/
C. (n.d.). Constipation; Symptoms, Causes, Treatment & Prevention. Cleveland Clinic.

https://my.clevelandclinic.org/health/diseases/4059-constipation
Page 98 of 99
XI. CONSENT FORM
Respected Sir/Ma'am,
We are Student nurses from level 2 of St. Jude College

Dasmariñas, Cavite. We would like to interview you regarding your pregnancy journey
as how it was before, during and after your delivery, you can tell us about your
experiences, and we also would be asking you questions related to our study.
This interview will be recorded as part of our documentation and

all data recorded from you will be enclosed in private. This interview is conducted as
part of our partial fulfilment of our Maternal and Child Nursing 2 (NCM 109) Subject
and will be used for our Case Study. Parts of our Case provides solutions to potential
problems, risks, and unexpected circumstances a mother and child could endeavor.
Thank you for your cooperation with our interview and we look forward to helping you
educate and avoid potential risk problems.
Sincerely,
Group 2-K
St. Jude College of Dasmariñas City, Cavite
Page 99 of 99

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G2P2 (2002) PREGNANCY UTERINE TERM CEPHALIC

DELIVERED LIVE BIRTH VIA LOW TRANSVERSE

A Case Study Presented to the

College of Nursing St. Jude College Dasmariñas Cavite, Inc.

Dasmariñas Cavite, Philippines

In Partial Fulfillment of the requirements for

Care of the Mother, Child & Adolescent (Acute & Chronic)

Enrique, Christel Joy S.

Rocete, Hanna Jane

Ms. Baby Frecy De La Cruz, RN, MAN

Ms. Novelyn Calarde, RN

Mr. Justine E. Bañez, RN

A. Background of the study…………………………………………………......3

D. Laboratory and Diagnostic Examination……………………………….28

III. Anatomy and Physiology…………………………………………………..38

VI. Nursing Care Plan……………………………………….………………………

VII. Discharge Plan………………..…………………………………………….92

IX. Consent Letter……………………………………………………………..99

A. BACKGROUND OF THE STUDY

Pregnancy is the period in which an egg cell is fertilized by a sperm to form a

Preeclampsia is a serious pregnancy complication characterized by high blood

Managing preeclampsia often involves close monitoring of blood pressure,

A. Patient’s Name R.B

B. Address: Barangay Salawag, Dasmarinas City, Cavite

D. Birthdate May 6, 1994

E. Birthplace Dasmarinas, Cavite

G Civil Status Married

H. Religion Roman Catholic

I. Highest Educational Attainment Bachelor’s Degree

L. Primary Informant Patient R.B

M. Secondary Informant Partner

N. Other Sources Patient’s Chart

O. Date and Time Admitted May 8, 2023| 8:00 PM

P. LMP : August 11, 2022

Q. Admitting Diagnosis G2P1 (1001) PU 36 3/7 weeks AOG CNIL,

D. HISTORY OF PAST ILLNESS

E. HISTORY OF PRESENT ILLNESS

II. GENERAL PHYSICAL ASSESSMENT

Provoking Factor Back Pain Abdominal Pain

SYSTEM FINDINGS NORMAL FINDINGS ANALYSIS

Normal Findings the

Patient said she During pregnancy, it

The nose is Nasal septum is

High vascular and During pregnancy,

Rectum has Hemorrhoids is

Patient actively The patient was

GORDON’S BEFORE DURING ANALYSIS

Nutritional “Wala namang “Noong nag As patient stated

Elimination “Nakakaihi naman “dahil nga buntis As patient stated,

Sleep- Rest “Minsan napupuyat “Yung nag As patient stated,

PARAMETERS REMARKS RESULT NORMAL INTERPRETATION

COMPLETE BLOOD COUNT

Hemoglobin L 11.4 12.015.0 (F); The Patient’s

Too much glucose in

In the case of pregnant

Bacteria in the urine

TEST NAME: RESULT INTERPRETATION

HbsAg NON – REACTIVE Patient R.B’s results in serology