Saint Louis UniversityCollege of Nursing

FOOTLING BREECHPresentation

A Case Study

A Case Presentation Presented to the FacultyOf the College of Nursing

In Partial FulfillmentOf the Requirements for the Course

NCM 103

Submitted by:

BELMONTE, Mary AbigailCORTEZ, Kristin Bernadette

ESBERTO, HelenFAGYAN, Jones

OWEK, Yelloh RaizaTIDACYAO, Gretsin

BSN III-E2

Submitted to:Ma’am Katrina May Ramos, RN

Clinical Instructor

May 8, 2009

NURSING ASSESSMENT

A. Patient’s Profile

Name: Espiloy, Deborah ValmonteAge: 31 years oldGender: FemaleCivil Status: MarriedBirthday: October 22, 1978Birthplace: Bacnotan, La UnionEducational Attainment: High school graduateAddress: Calautit, Bacnotan La UnionOccupation: HousewifeReligion: Roman CatholicCultural Affiliation: IlocanoNationality: FilipinoLatest Hospitalization: No Previous RecordAdmitting Physician: Helen H. BalagotAttending Physician: Dr. Aguilar, Dr. Cababa, Dr. Escobar Date and Time Admitted: May 4, 2010, 3:45amWard: OB-Gyne wardFinal Diagnosis: G4P3 (3013) PU 36 6/7 weeks AOG delivered by Cesarean section to live baby girl Chief Complaint: Hypogastric pain

B. Present Illness

I. HEALTH HISTORY

History of Present Illness

One hour prior to admission, patient complained of a lumbosacral pain with associated uterine contractions noted at 5-10 minutes interval, 60 seconds duration, mild to moderate in intensity with associated bloody vaginal discharge. Persistence of symptoms prompted patient for consultation hence the admission. She stated that her expected date of delivery that was revealed in the ultrasound is in June 10-17, 2010.

Internal examination revealed that the patient’s baby is a footling-breech position, so patient undergone a certain procedure which is cesarean section.

Past Medical History

Patient had no history of Hypertension, Diabetes Mellitus, asthma and PTB. There is no history of surgery, accident and trauma. She has no allergies to food and drugs and she had been hospitalized three times in ITRMC for delivery of her first two children and management of abortion in her second pregnancy. She had a multiple gestation during her second pregnancy in which the developing fetuses were aborted unwantedly in her third month of pregnancy.

Prenatal History

Patient is cognizant of pregnancy at 5 weeks AOG through amenorrhea from previous regular menstrual cycle. Pregnancy test was done at home 12 weeks AOG revealing a positive result. She claims that the pregnancy was unplanned but wanted without attempts of abortion. Subsequent prenatal check-ups were done monthly until 28 weeks then, every two weeks until 36 weeks AOG and weekly thereafter. Patient was prescribed with Calciumade 1 cap OD, Fumarade 1 tab OD. Quickening was felt last 6 months AOG. Ultrasound was first done in the OB clinic at 12 weeks AOG, which revealed a live singleton intrauterine female fetus with good somatic and limbal activity. No exposure to viral exanthematous diseases such as measles, chicken pox during the entire duration of pregnancy. No history of alcohol and cigarette intake.

Family HistoryThe patient has a family history of Diabetes Mellitus, Hypertension, asthma, Cardiovascular

Diseases, twinning and other congenital anomalies.

CAD DM HPN Cancer Asthma PTB Gastric Ulcer

Others

Father side

X √ √ Cancer of the

Bladder

X X X X

Mother side

X √ √ Colon cancer

X X X X

OB/Gynecologic HistoryA. Menstrual History

Menarche of the patient began when she was 12 years old in a regular cycle of 5-7 days. She uses two packs of feminine napkins, moderately soaked in her whole menstrual cycle. Patient sometimes experiences dysmenorrhea during her first to second days of her menstruation. Patient is not yet in a menopausal stage.

B. Obstetric HistoryG1- 2005, LFT baby boy via NSD at ITRMC; no complicationsG2 - 2006, LFT twins; spontaneous abortionG3 - 2007, LFT baby boy via NSD at ITRMC; no complicationsG4 - 2010, LFT baby girl via CS at ITRMC; no complications

C. Gynecological HistoryThere were no previous surgical procedures done and previous gynecological problems

experienced by the patient. She does not experience any postcoital bleeding. She verbalized that her vaginal discharges is whitish in color, not foul smelling and is just little in amount. She doesn’t also experiences vaginal itching.

D. Contraceptive HistoryPatient and her husband don’t use artificial methods of contraception but verbalized that

they use Withdrawal method as their natural family planning method. They’ve agreed to the method and use it ever since they got married.

E. Sexual HistoryFirst sexual intercourse happened when she was 25 years old. She claimed that her only

sexual partner was her husband. She and her husband are sexually active. There were no sexually transmitted infections experienced by the patient.

Social and Environmental Background

The patient is a housewife living with her husband and children in their house with two rooms and 5 occupants. Source of water for drinking purposes comes from a commercial refilling station. Water for domestic purposes comes from the deep well. Garbage is collected regularly. Patient is a non-smoker and non alcoholic beverage drinker. Toilet is flush type and no history of travel.

THIRTEEN AREAS OF ASSESSMENT

I. PSYCHOLOGICAL

The patient is a female, 31 y/o, married, Ilocano, a full time housewife and a mother to 3 children in the family. She is Roman Catholic and stated that she doesn’t have any practices or beliefs that would affect her health.

Patient stated that she enjoys her role as mother to her children and as wife to her husband; organization was mentioned where she belongs; she mostly enjoys bonding with her family, and watching TV as her activities.II. MENTAL AND EMOTIONAL STATUS

During the interview, the patient is fully conscious, oriented to time, place and person. She is a high school graduate; able to understand, comprehend and follow directions during the assessment. She understand that she underwent caesarean section due to the findings during her internal examination that her baby’s position is in footling breech position. This was her first time of experiencing such major operation and the patient stated that as she reacted that her situation is really difficult, especially that she is in pain.

Whenever the patient is stressed, or tired after doing her household chores the patient admitted that she would just watch TV for her to relax. She admitted that as a mother and a wife, she fears of losing her loved ones, especially that she has a history of losing their second baby which happened to be twins at 3 months age of gestation, at year 2006. According to the patient, she was able to cope and accepted everything after the said incident for about 3 months. III. ENVIRONMENT STATUS

Due to the said condition of the patient, she has the risk of having infection, considering that there is the presence of wound; abdominal binder is noted also. During assessment, she was observed that she always guide the affected area and with minimal facial grimaces when moving is noted. No side rails is noted when she was transferred to the ward for further monitoring and assessment. IV. SENSORY STATUS

The patient doesn’t have any eye- related problems; she has good ability in distinguishing voice; no problems in sense of taste; able to differentiate odors. At present, she has problem in sense of feeling because of the pain she is experiencing. On the other hand, the patient has the good ability to understand and initiate speech.V. MOTOR STATUS

At present, the patient has limited movement and always possess guarding behaviour in the abdominal area, especially when moving. When walking, moving, or sitting, the patient moves very slowly; but able to move all extremities. When moving, the patient needs minimal assistance specially when moving out from bed to go to the comfort room. The patient can still perform her common activities of daily living, such as eating, combing of hair and breastfeeding her baby.VI. NUTRITIONAL STATUS

The patient usually eats three times a day. Sample menu is rice, fish, hotdog, egg and vegetables. She usually have her snacks such as fruits (oranges, banana) mostly in the morning. The patient has a medium body built. She has smooth and warm to touch skin. No religious dietary restrictions that was mentioned by the patient.

The patient is a good water drinker and does not prefer any soft drinks; patient admitted that she is not measuring her everyday water intake She is not choosing any food to eat as long as she believes that it is a nutritious food.VII. ELIMINATION STATUS

The patient usually voids 5-8 times in a day, since she is a water drinker. Her regular bowel movement is once a day, every morning. During hospital stay, she was not able to practice her regular bowel movement.VIII. FLUID AND ELECTROLYTE STATUS

The client eats three times a day, with good appetite and eats any type of food as she desired, most especially fish and vegetables. There’s no contraindicated food for her before and during her pregnancy.

She is a good drinker of water so amount is barely noted. Sometimes, she also drinks her milk twice a day. She has a good skin turgor; with moist mucous membrane. During assessment, the patient is taking mefenamic acid 500mg 1 tab, for her pain reliever and Coamoxiclav 6 mg x BID, as anti-inflammatory,analgesic,and antipyretic.

Over all medications given to the patient were the following: Ketorolac 15 mg IV q 6 hours x 6 doses for her pain reliever; Nalbuphine 5 mg IV q 4 hours x 6 doses for her sedation before surgery,

and supplement to balance anesthesia; Ampicillin 2 mg IV q 6 hours for her antibiotic; Mefenamic acid 500mg 1 tab and Coamoxiclav 6 mg x BID.IX. CIRCULATORY STATUS

Patient’s regular pulse rate is ranging from 68- 90 BPM, +2, regular. After the surgery, during assessment, pulse rate increased to 108 BPM. Blood pressure is ranging from 130-110/80 mmHg, at left arm, lying.

X. TEMPERATURE STATUS

Patient’s body temperature is in normal limit, 36.6 °C, axillary.

XI. INTEGUMENTARY STATUS

Skin is warm to touch; with brownish skin color; with good capillary refill of 2-3 seconds. Incision in the abdominal area is with intact dressing, not fully soaked with blood.Normally, patient is perspiring due to weather.Habits such as smoking, drinking alcohol beverages was denied by the client.

XII. COMFORT AND REST

Before hospital confinement, patient usually sleeps 9-10 in the evening and wakes up 6-6:30 in the morning. The patient admitted that her sleep is only disturbed every time she wakes up to go to the comfort room. During hospital stay, still the patient manifest sleep disturbance due to monitoring of vital signs, and every time she breastfeeds her baby. During assessment, the client is experiencing abdominal pain due to her condition, rated as 7 out of 10, characterized as squeezing pain, radiating in the abdominal area, localized in the incision site, aggravated when moving. XIII. RESPIRATORY STATUS

Patient’s respiratory rate is from 20-22 cycles per minute in regular interval, no use of accessory muscles noted; with absence of dryness in lips. She is acyanotic and does not experience difficulty breathing.

NURSING DIAGNOSIS AND PRIORITIZATION

Prioritized problem

Prioritization according to

Maslow’s hierarchy of need

Classification Justification

1.Acute pain related to surgical incision

Physiologic need

Actual problem Acute pain is the 1st prioritized problem according to Maslow’s hierarchy of needs. It is the primary problem since pain is an actual problem, after cesarean birth pain is intense from the uterine or abdominal incision that disturbs a person’s normal functioning.

Avoidance allows the person to be more comfortable active and to assure a greater role in directing the patient’s own care.

2. Impaired skin integrity related to tissue trauma secondary to cesarean section delivery

Physiologic need Actual problem Impaired skin integrity is the 2nd

prioritized problem. Skin integrity is defined as impaired altered epidermis and dermis.The skin serves as the primary line of defense against bacterial invasion. When skin is incised for a surgical procedure the important line of defense is loss.

3. Sleep disturbance related to multiple factors (pain, time of voiding, vital signs taking)

Physiologic need Actual problem Sleep disturbs pattern is the more explicit definition of difficulty falling asleep or staying asleep. It is the 3rd

prioritized problem because it will provide sufficient energy to perform activities of daily living, it will enhance the client’s feeling of well- being or improving the quality the clients sleep. It will reduce stress of the patient.

4 .Risk for deficient fluid volume related to blood loss

Physiologic need Potential problem Risk for deficient fluid volume is the 4th prioritized problem. There is a deficient fluid volume because of the blood loss from surgery.

This is a risk wherein there is a heavy bleeding for postpartum woman.

5. Risk for infection related to inadequate primary defenses

Physiologic need Potential problem Risk for infection is the last prioritized problem. At increased risk for being invaded by pathogenic organisms.

After cesarean birth is performed hours after the membrane ruptured a woman’s risk for infection is higher.

PATHOPHYSIOLOGY

PHYSIOLOGY OF PREGNANCY and CESAREAN DELIVERY IN

FOOTLING BREECH PRESENTATION

Release of FSH bythe anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickeningof the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum fromthe graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovumand sperm in the ampulla)

Zygote travels from the fallopian tubeto the uterus

Implantation

Development of the fetus/embryo &placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Contraction Ripening of the cervix(descent of the fetal (false labor) (Goodell’s Sign whereinhead into the pelvis) >begin and remain irregular the cervix feels softer like

>1st felt abdominally consistency of the earlobe >pain disappears with ambu-

lation >do not increase in duration

and intensity >do not achieve cervical

dilatation

TRUE LABOR

Uterine Contractions SHOW Rupture of Membranes>increase in duration (pink-tinge of blood, (rupture of the amniotic sac) and intensity a mixture of blood and fluid)>1st felt at the back & radiates to the abdomen>pain is not relieved no matter what the activity>achieve cervical dila- tation

Failed to progress labor(due to footling breech presentation)

increase risk for fetal distress(meconium staining, hypoxia)

Increase risk of fetal death

Emergent cesarean delivery(the incision made on the lower part of the abdomen)

Delivery of the fetus

Delivery of the placenta

Breech presentation occurs in 3-4% of all deliveries. The occurrence of breech presentation decreases with advancing gestational age. Breech presentation occurs in 25% of births that occur before 28 weeks’ gestation, in 7% of births that occur at 32 weeks, and 1-3% of births that occur at term.

Predisposing factors- Enlarged uterine cavity as in hydramnios and multiple pregnancy.

References:

A. Books

Black, Joyce and Hawks, Jane - Medical-Surgical Nursing: Client Management for Possible

Outcomes, 7th Edition, 2005, Elsevier PTE Ltd., Singapore

Black, Joyce and Hawks, Jane - Medical-Surgical Nursing: Client Management for Possible

Outcomes, 6th Edition, 2001, Philippines

MIMS Annual Philippines, 19th Edition, 2007-2008

Rosal Maria Isabel – PPD’s Nursing Drug Guide, 2nd Edition, 2007-2008

Philippines Moms and Babies: A Health Guide Publication, 2000

Doenges, Moorhouse, Murr – Nurse’s Pocket Guide, 11th Edition, 2007

Doenges, Moorhouse, Murr – Nurse’s Care Plans: Guidelines for Individualizing Patiet Care 6th

Edition

Porth, Carol M. – Pathophysiology: Concepts of Altered Health States 6th Edition

Suddarth, Brunner – Textbook of Medical Surgical Nursing 5th Edition

Kozier, Erb, Berman, Snyder – Fundamentals of Nursing: Concepts, Process and Practice 7th

Edition

Dell, Bantam – The Bantam Medical Dictionary, 2004

Tortora, Derrickson – Principles of Anatomy and Physiology 11th Edition, 2006

Karch, Amy M. – Lippincott’s Nursing Drug Guide, 2009