Post Cs Na Revised Na Toh

8/6/2019 Post Cs Na Revised Na Toh

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Arellano University

College Of Nursing

Legarda, Manila

CASE STUDY

POST CESAREAN SECTION

SUBMITTED BY:

BSN III-12

GROUP 48

LIMUCO, JANNA ZENNA

MANTALA, MICHELLE

MARTINEZ, MARK KEVIN

MARZO, AYESHA CLAIRE

MURILLO, ROSE ANN

NAPULE, CHARLOTTE

NUGUID, GLACIE LYNNE

REAGO, JESTORI

REMOLLO, KEVIN

VILLARANTE, JHUNNAR


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I. INTRODUCTIONCesarean birth, birth accomplished through an abdominal incision into the uterus, is one

of the oldest typed of surgical procedure known. Unfortunately, it is a procedure always more

hazardous than vaginal birth. Fortunately, when compared with other surgical procedures, it

is one of the safest types of surgeries and one with few complications.

The word cesarean is derived from the Latin caedore which means to cut. At one

time, there was a popular belief that Julius Caesar was delivered by a cesarean birth and that

procedure was named for him. However, because Caesar was born before antibiotics and

sterile surgical techniques, it seems likely that his mother would have survived the said

procedure. Currently, cesarean birth is used most often prophylactic measures, to alleviate

problems of birth for conditions such as cephalopelvic disproportion, cervical cerclage,

placenta previa, umbilical cord prolapsed, fetal distress, transverse fetal lie, etc. It is

generally contraindicated when there is a documented dead fetus.

You might need to have a planned cesarean delivery if a patient condition is in

Cephalopelvic disproportion (CPD), Previous cesarean birth, Multiple pregnancy, Placenta

previa, Transverse lie, or Breech presentation. In a Cephalopelvic disproportion (CPD), thebabys head or body is too large to pass safely through the mothers pelvis, or the mothers

pelvis is too small to deliver a normal-sized baby. In Previous cesarean birth,although it is

possible to have a vaginal birth after a previous cesarean, it is not an option for all women.

Factors that can affect whether a cesarean is needed include the type of uterine incision used

in the previous cesarean and the risk of rupturing the uterus with a vaginal birth. In Multiple

pregnancy, although twins can often be delivered vaginally, two or more babies might

require a cesarean delivery. In Placenta previa, a cesarean delivery is done if the placenta is

attached too low in the uterine wall and blocks the babys exit through the cervix. A mother

also underwent a cesarean delivery if the baby is in a Transverse Lie presentation because

the baby is in a horizontal or sideways position in the uterus. In this condition, a cesarean

delivery is always used. And for Breech presentation or Breech birth, the baby is


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positioned to deliver feet or bottom first. If your doctor determines that the baby cant be

turned through abdominal manipulation, you will need to have a cesarean delivery.

The term cesarean birth rather than cesarean delivery is generally used to accentuate that

this is a birth more than surgical procedure. A major concern in maternal and child health

nursing is the increasing number of cesarean births being performed annually.

In South East Asian countries, Overall 27% of women had a caesarean section, with rates

varying from 19% to 35% between countries and 12% to 39% between hospitals within

countries. The most common indications for caesarean were previous caesarean (7.0%),

cephalopelvic disproportion (6.3%), malpresentation (4.7%) and fetal distress (3.3%).

Neonatal resuscitation rates ranged from 7% to 60% between countries. Prophylactic

antibiotics were almost universally given but variations in timing occurred between countries

and between hospitals within countries.

There are two types of Cesarean Birth: scheduled and emergency. In the first instance,

there is time for thorough preparation, some women may have even taken a child preparation

class specifically for cesarean birth. Scheduling cesarean birth this freely also resulted in

preterm births. A physical indication for cesarean birth such as transverse presentation,

genital herpes, cephalopelvic disproportion, or avoidance of post-procedure stress

incontinence, must be documented before a cesarean procedure can be performed. Cesarean

birth reduces the transfer of HIV from mother to newborn (Read et al. 2001). With new

surgical techniques, particularly a low cervical incision, once a cesarean, always a cesarean

no longer applies. Most of women who have had cesarean birth, after 10 years are eligible to

give birth vaginally in subsequent pregnancies if the circumstances are otherwise are

appropriate for vaginal birth. About 60% of woman todat have vaginal birth after a cesarean

birth (VBAC). VBACs are the most successful if there is an interval greater than 19 months

between the cesarean and the VBAC (Huonget Al., 2002). Emergency cesarean births are

done for reasons such as placenta previa, abruption placentae, fetal distress or failure to

progress in labor. An emergency cesarean birth carries with it the risk of all emergency

surgery: a woman may not be a prime candidate for anesthesia and who is psychologically


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unprepared for the experience. In addition, the woman may have a fluid electrolyte

imbalance and be both physically and emotionally exhausted form a long labor.

II. OBJECTIVES

General objective:

We, BSN 3 Group 48 of Arellano University College of Nursing aims to develop our

skills in performing assessment procedures and the necessary intervention for quality client care

of patient with post cesarean client, to enhance our knowledge in understanding the procedure

and identify specific treatment and last and foremost is for us to be able to give knowledge about

cesarean.

Specific objectives:

At the end of the presentation our group will be able:

y To describe indications of cesarean birth.y Formulate diagnosis related to Cesarean birth.y Establish outcomes that meet the needs of woman requiring cesarean birth.y Plan appropriate nursing care to ensure family centered care.y Evaluate outcomes for achievement and effectiveness of nursing care.

III.THEORETICAL FOUNDATION

D o r o t h e a O r e m ' s S e l f - C a r e T h e o r y

This theory composed of three related theories including self care, self care agency, and

therapeutic self care demand. In Self care theory, an individualinitiate and perform his/her own

activities to maintain life, health and well being. In Self care agency, a multidimensional

concept in nursing theory includes motivation, decision-making, energy, and knowledge

necessary to perform self-care actions. In Therapeutic self care demand, "totality of self care


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actions to be performed for some duration in order to meet self care requisites by using valid

methods and related sets of operations and actions".

A Self care requisite is anaction directed towards provision of self care. There are 3 categories

of self care requisites are: 1) The Universal, which includes developmental and health deviation;

2) the Universal self-care requisites associates with life processes and the maintenance of the

integrity of human structure and functioning and activity of daily living (ADL). These requisites

identify maintenance of sufficient intake of air, water, and food. Also provision of care

associated with elimination process, balances between activity and rest between solitude and

social interaction, prevention of hazards to human life well-being and promotion of human

functioning and lastly; 3) the Developmental self care requisites associates with developmental

processes/derives from a condition or associates with an event and this also includes healthdeviation self-care that requires condition of illness, or disease. It also seeks and secures

appropriate medical assistance, being aware of and attending to the effects and results of

pathologic conditions, effectively carrying out medically prescribed measures, modifies self

concept in accepting oneself as being in a particular state of health and in specific forms of

health care and learning to live with effects of pathologic conditions.

Dorothea Orems theory encompasses that patient is requiring nursing care. It is needed if there

is a problem that prevents a person from reaching their optimal health. Restoring, promoting and

maintaining health are the goals of Dorothea Orems Self-care Model, these include the interventions

and teachings design to return a person to or sustain a level of optimal health and well being, It is when

an adult is incapable or limited in the provision of continuous effective self-care. In this case, the

patient has ineffective health continuance because of the procedure she had undergone and due to

the incision she had have the nurses role in helping the client to achieve or maintain a level of

optimal health and wellness to act as an advocate, redirector, support person and teach and to

provide an environment conducive to therapeutic ddevelpoment.


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IV. NURSING HISTORY

A. Biographical Data

Patient Name: A. M.

Address: Delpan ST., Barangay Kasilawan, Makati City

Date of Birth: April 13, 1981

Place of Birth: Pangasinan City

Age: 25 years old

Nationality: Filipino

Educational Attainment: BS Electrical and Communications Engineering

Religion: Roman Catholic

Data of Admission: August 24, 2006

Mode of arrival: Ambulatory

B. Chief Complaint

Noong pag-ihi ko may sumabay na dugo as verbalized by the patient.

C. History of present Illness

Two days prior to admission, patient experienced bloody vaginal discharge upon

urinating. The bloody vaginal discharge she noted prompted her to go to the hospital and

subsequently admitted. (delte breast changes. Eklabu)


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Pain experienced:

Location is in right and lower left quadrant of abdomen specifically on the incision site.

Radiation localized pain. Quality is recurrent and throbbing pain. Aggravating Factor is during

activity. Alleviating factor was medications. Time usually lasts for 1-2 hours

D. History of Past Illness

On the 1st

trimester of her pregnancy, she experienced discomforts like breast changes,

urinary frequency, fatigue, nausea and vomiting. Urinary frequency accompanied by leg cramps

was also experienced in the 2nd

and 3rd

trimester. The patient had her Urinary tract Infection

when she was in her 7th

month of pregnancy and her Physician prescribed her a Cefalexin as

treatment for the said illness. And She have had undergone a procedure of dilatation and

curettage due to her miscarriage. And had no allergies to any food and medications.

E. Family Health History

Patients father was noted to be hypertensive.

F. Social History

Work Environment: She works at MDS, a web design company located at The Fort Strip.

Home Environment: Resides in 2 bedrooms, 1 bathroom concrete house.

Education: A degree holder of Bachelor of Science in Electrical and Communications

Engineering.

Role Relationship: Wife and daughter.

Childhood Immunization: Patient had completed childhood immunization.

G. Obstetrical History

Menarche: 14 years old.

Monthly cycle duration: 3-5 days, 2-3 pads moderately soaked.


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Last Menstrual Period: November 19, 2005

Age of Gestation: 40 weeks and 2 days (via LMP)

: 38 weeks and 4 days (via pelvic ultrasound)

Expected Date of Confinement: September 2, 2006

OB Score: G2 P1 (T1 P0 A1 L1 M0)


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V. ANATOMY AND PHYSIOLOGY


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ANATOMY

The pelvic girdle is the place where the lower limbs attach to the body. The right and left

coxae, or hip bones, join each other anteriorly and the sacrum posteriorly, to form a ring of bone

called the pelvic girdle and the coccyx. The sacrum and the coccyx form part of the pelvis but

are also part of the axial skeleton. Each coxa formed by the three bones fused to one another to

form a single bone. The ilium is the most superior, the ischium is the inferior and the pubis is the

anterior and inferior. An iliac crest can be seen alongthe superior margin of each ilium and an

anterior iliac spine, an important hip landmark, is located at the anterior end of the iliac crest.

The coxae join each other anteriorly at the pubic symphysis and join the sacrum posteriorly at the

sacro ilac joints. The acetabulum is the socket of the hip joint. The obturator foramen is the large

hole in each coxa that is closed off by muscles and other structures.


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PHYSIOLOGY

The organs of the reproductive systems are concerned with the general process of

reproduction, and each is adapted for specialized tasks. These organs are unique in that their

functions are not necessary for the survival of each individual. Instead, their functions are vital to

the continuation of the human species. In providing maternity gynecologic health care to women,

you will find that it is vital to your career as a practical nurse and to the patient that you will

require a greater depth and breadth of knowledge of the female anatomy and physiology than

usual. The female reproductive system consists of internal organs and external organs. The

internal organs are located in the pelvic cavity and are supported by the pelvic floor. The external

organs are located from the lower margin of the pubis to the perineum. The appearance of the

external genitals varies greatly from woman to woman, since age, heredity, race, and the number

of children a woman has borne determines the size, shape, and color.


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VI. PATHOPHYSIOLOGY

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Predisposing Factors:

y Occupationy History of Abortiony UTI during her 7th month of pregnancy

Physiologic Factors:

y Presumptive signs: breasts changes,urinary frequency, fatigue, nausea and

vomiting on the 1st

trimester and leg

cramps on her 2nd

and 3rd

trimester.

y LMP: November 19 , 2005 and her EDC:September 2, 2006

y Pelvic Ultrasound

TRUE LABOR

During Transition Phase the

presenting part was at

station -1

(+) bloody vaginal discharge

Arrest in Cervical

Dilatation

The Presenting part was still

above the ischial spine and

has not crowned yet

Immediate Low Transverse

Cesarean Section

Low Segment Incision on

the Abdomen

Expulsion of Fetus

Expulsion of Placenta accompanied

by blood loss of800 cc

Acute Pain r/t surgical incision

(PS: 5/10)

Activity Intolerance as

manifested by Weakness and

discomfort

Swelling or discharges on the

surgical incision site


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VII. GORDONS FUNCTIONAL PATTERN

BEFOREHOSPITALIZATION

DURINGHOSPITALIZATION

ANALYSIS

HEALTHPERCEPTION/HE

ALTHMANAGEMENT

PATTERN

-The patient had completeimmunizations and had

undergone laboratory anddiagnostic procedures of

ultrasound and urinalysis. Sheregularly intakes

multivitamins and Iron (caltrate and honorate). And

throughout the preganancy,she had completed the pre-

natal check up.

-parang hindi ko kaya nahindi ako kakain ng ganon

katagal, paano akolalakas? As verbalized by

the patient..

Konek?

-The patient was anxious

about her condition and howwill she able to recover easily

if shes under NPO.

- Early and consistentprenatal care is essential to

the health and health of herbaby.

(maternal &child healthnursing vol.1,p595)

NUTRITIONAL-METABOLIC

PATTERN

-The patient eats usual foodssuch as sinigang and adobo

and she has ability inswallowing and chewing

foods and feeds herself. Shestaking regular meals.

-The patient was underNPO and being given by

an IVF of D5LR 1L to runfor 8 hours at 32 gtts/ min

as ordered. And she lossblood about 800 cc on the

operation.

-There is a change in the dietmodification of the patient

because the patient is a postCS she must be in NPO since

her peristalsis movement isnot yet returning to normal.

Theres a risk in deficientfluid volume.

-a pregnant woman shouldeat a sufficient diet to allow

for the growth of fetus andalso provide for the need of

her on growing baby.(maternal and child nursing

vol.1,p657)-most women have a IVF line

before the surgery with afluid .it helps to ensure that a

woman is fully hydrated.(maternal &child health

nursing vol.1,p657)

-The patient had a regular

bowel movement. Her lastmenstrual period was last

-The patient was

catheterized her urine isbloody in color and has an

-There is a change in the

urine pattern because thepatient had been catheterized


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ELIMINATIONPATTERN

November 19, 2005. Duration

of her menstrual period was3- 5 days, 2-3 pads,

moderately soaked.Transfer the mens eke k sa

sexual ekek.

-Nung pag-ihi ko maysumabay na dugo as

verbalized by the patient.

output of 400cc per/hr.

The patient undergonewater glycerine enema

prior to the procedure.

-di ko naman masyadong

nararamdaman nalumalabas yoong ihi ko

pero nakikita ko maylaman naman yoong bag

as verbalized by thepatient.

and the patients elimination

was also changed becausewater glycerine enema was

administered to the client dueto her condition.

-before the hospitalization

patient had a normalelimination pattern, can void

freely but when she gothospitalized her sensation of

voiding become altered.

Not approrioate. Sensation

eklabu.

ACTIVITY-EXERCISE

PATTERN

-The patient is able to feed,bathe and groom herself. She

has sufficient energy fordesired and/or required

activity. She is in full range ofmotion. And practices active

exercises.

Delete feeding churva.

-The patient was not ableto do things independently

and became dependent.She had a difficult time

moving around the bed tochange position due to the

pain

- the patient uses her fullrange of motion and have

active exercise before shehospitalized and become

altered when she got into thehospital because of pain and

weakness due to theprocedure.

-People often define theirhealth and physical fitness by

their activity because mentalwell-being and the

effectiveness of bodyfunction depend largely on

their mobility status.(fundamentals of nursing

vol.2, p1106)

SLEEP AND

REST PATTERN

-She had a normal sleep and

rest pattern.

Not applicable yung normal

-She experienced

difficulty in sleeping asshe experienced pain.

-Due to the procedure that

the client had undergone, shewas having difficulty, since

she cannot move freely andthe presence of incision in

her abdomen and the pain init, made her difficult to sleep.


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COGNITIVEPERCEPTUAL

PATTERN

-Before the hospitalization,the patient experienced

discomforts like breastchanges, urinary frequency

nausea and vomiting. Andurinary frequency

accompanied by leg crampson the 2nd and 3rd trimester of

pregnancy.

Not applicable.what was the

perceptiot the s/sn abou

- Patient was then askedhow she felt after the

operation and sheverbalized

nararamdaman ko yoongsakit ng tahi and kung i-

rarate ko yoong sakit mga5/10. She also added

medyo nauuhaw ako naparang natutuyo

lalamunan ko siguro dahilsa pagod tsaka sa tagal ng

operasyon and paranghindi ko kaya na hindi ako

kakain ng ganoon katagal,

paano ako lalakas?

-The patients cognitiveperceptual pattern changed

due to the patients conditionand maybe due to knowledge

deficit.

-According to Piaget stage ofCognitive development-

formal operational- theperson can solve hypothetical

problems with scientificreasoning understand s

causality and can deal withthe past present and future.

(maternal &child health

nursing vol.2,p801)

SELF

PERCEPTIONPATTERN-SELF

CONCEPTPATTERN

-The patient believes that herneeds for intimacy and

affection are being met. Shefeels good most of the time.

-The patient is concernwith her current health

condition and how shewill be getting well and

her present health goal isto eat to be able to get

well.

-

-Herself perception is mainlyfocused on her health

condition.

ROLE

RELATIONSHIP

-She is living with herhusband and a family oriented

person. She isnt a member ofany organization.

-Patient AM had moderate

self esteem with closerelationship with the member

of her family.

-She was a mom now, andtrying to adjust on things

like taking care of hernewborn, etc.

--throughout life peopleunder go numerous role

changes.(fundamentals of nursing

vol.2,p1006)

SEXUALITY-REPRODUCTIVE

-Her first menstrual periodwas when she was 14 yearsold and her Last Menstrual

Period was last November 19,2005. And have had

undergone D&C due tomiscarriage on her first

pregnancy.

-She had delivered a livefull term baby girl. - according to Freud stages ofpsychosexual a persondevelops sexual maturity and

learns to establishsatisfactory relationship with

the opposite sex.(maternal &child health

nursing vol.2,p803)


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- She was married to hishusband on March 2005.

-She got pregnant to her first

baby but unluckilyexperienced miscarriage due

to week fetal heart tone.

-Later on she had an OBhistory of gravida 2, parity 1,

and abortion 1.

-And lastly became pregnantto a 40 weeks and 2/7 days

baby girl.

STRESS

TOLERANCEPATTERN

-She is coping well in every

problems encountered withthe help of her husband and

faith to God.

-She is stressed and has

worries and fears.

-She became stressful

because of her condition.

VALUE BELIEF

PATTERN

-She is a Roman Catholic and

goes to church regularly, it iswhere she gets her courage in

every circumstances thatcomes along her way.

??????? - religion may be considered

a system of belief, practicesand ethical values about

divine or superhuman poweror power of worshipped as

the creators and rulers of theuniverse.

(fundamentals of nursingvol.1,p315)

Relate before and during.


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VIII. PHYSICAL ASSESSMENT

General Survey: The patient is conscious and coherent upon examination, weighs for 64kg and

stands 53. The client dont have body odor nor breath odor. The client is relaxed every time we

speak to her.

Vital Signs:

BP: 130/80 mmHg

PR: 92 bpm

RR: 20 cpm

TEMP: 37.6

y P (Precipitating Factor) Aggravated by activityy Q(Quality) Localized, recurrent and throbbing qualityy R(Radiating) Right and Lower left quadrant of the abdomen specifically

on the site of incision

y S (Severity) 5/10y T (Time or Onset) Onset of pain is gradual, usually lasts for 1-2 hours

BODY

PART

FINDINGS ANALYSIS NURSING ALERT

Head Normocephalic withsmooth, black and

evenly distributed hairand small traces of

dandruff on the scalp

Normal no signs ofasymmetry and deformities.

????

Face Symmetrical eyebrows,eyelids, eyelashes,pupils and eyeballs are

normally aligned

No deviations likeincreased facial hair, moonface.

Eyes Smooth clear cornea

and lens, (+) reflexes,whitish sclera, pinkish

conjunctivae, intact and

No signs of trauma or

abration that results toopaque appearance of the

eye. Positive reflexes


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normal lacrimal

apparatus.

means no neurological

impairment of the cranialnerves.

Ears Symmetrical,(-)

discharges and waxytexture and normal

hearing acuity

Normal, no signs of

congenital abnormality likelow set ears (Trisomy 21)

Nose Normally deviated with

patent nostril, nontender sinuses, pinkish

turbinates, moist andpinkish nasal mucosa

with (-) discharge

Pt. is not experiencing

DOB, nasal flaring and noabnormal discharge.

(-) lesions like polypsNasal septum intact at the

middle.

Mouth Lips were slightly dry

and pink in color,

symmetrical and withno lesions.Slightly yellowish

complete set of teethpinkish gums and

buccal mucosa, tonsilswith midline tongue

and uvula

No signs of cyanosis, no

mucosal cysts or tumor.

Slightly yellowish teethindicates the pt. have notperforming good oral

hygiene the past days afterthe surgery

Lung Symmetrical lung

expansion and resonantrespiratory sounds

Indicates healthy lung and

normal lung sounds

Heart Apical Heart soundheard at the 5th

intercostals space, leftmid clavicular line with

(-) murmur

Apical sound is normallyheard on that part because

the apex of the heart isnormally located there nad

absence of murmursindicates the pt. has no

heart problem

Abdomen Presence of linea nigra

and striae gravidarum.Low segment Incision

due to CS delivery with

extreme swelling and ordischarge.

Umbilicus is stretched

during pregnancy to suchextent that by the 28

thweek.

Extrapigmentation

generally appears on theabdominal wall. A narrowbrown like linea nigra may

form running from theumbilicus to the symphisis

pubis.Reference: Maternal and

Childs Health 6th edition


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vol. 1 Adele Pilliteri page

234Lower segment incision is

one made horizontallyacross the abdomen just

over the symphysis pubisand also horizontally across

the uterus just over thecervix

Reference: Maternal andChilds Health 6

thedition

vol. 1 Adele Pilliteri page661

Skin Smooth, warm and withgood turgor

No signs of pallor,cyanosis, jaundice and

erythema. Warm skin may

indicate risk for infectiondue to surgical incision.

Nails Nail beds pink, intact

with soft texture 1-2sec. of capillary refill.

No signs of infection or

injuries on the nailsandpoor circulating problem.


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IX. Laboratory Examination

Examination Results

Pelvic Examination

Impression: Single live intrauterine pregnancy

in cephalic presentation of about 38 weeks and4/7 days age of gestation based on biparietaldiameter, fetal lie and abdominal

circumference with normal placentallocalization and amniotic fluid volume.

Sonographic fetal weight is appropriate forgestational age.

X. Medical/Surgical Management

I. Management:

A. Transfer to postpartum ward when stableB. Vital Signs q15 minutes for 1 hour, then q4 hoursC. Monitor intakes and outputs every 4 hours for 24 hoursD. Activity:

1. Bed rest2. Supine for 8 hours after spinal anesthetic3. Incentive Spirometry every 1 hour while awake

E. Standard Diet1.

Nothing by mouth for 8 hours after cesarean section

2. Sips of water after 8 hour window3. Advance to clear liquids as tolerated4. Advance to Regular diet when flatus or Bowel Movement


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F. Early Solid Diet Protocol1. Solid food within 8 hours of C-Section2. Well tolerated3. Resulted in faster bowel function return4. Shortened hospital stay by 24 hours5. Patolia (2001) Obstet Gynecol 98:113-6

G. Intravenous fluids1. D5LR OR D51/2NS at 125 cc/hour2.

Foley to gravity

3. Urine outputa. Foley Catheter in place:


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Name of Drug Mechanism of

Action

Indication Contraindicatio

n

Adverse Reactio

Generic Name:

CefuroximeSodium

Brand Name:Zegen

Drug

Classification:Anti- Effectives

Second

generationcephalosporins

that inhibits cellwall synthesis,

promotingosmotic

instability,usually

bacteracidal

Skin structuringinfections cause by

streptococcuspneumonia and

S.pyogenes,haemophilus

influenzastaphylococcus

aureus, E.coli.

Use cautiously inpatients

hypersensitive topenicillin

because ofpossibility of

cross sensitivitywith other beta

lactamantibiotics.

CV:phlebitis,

thrombophlebitis

GI: pseudo membranoscolitis, nausea, anorexi

vomiting, diarrhea

HEMA: Transient neuteosinophilia, hemolitic

anemia andthrombocytopenia

SKIN: Maculopapular erythematous rashes,

urticaria, pain,in duratisterile abcesses, temp.

elevation, sloughing IMinjection site

OTHER:

Hypersensitivity reactioserum sickness, anaphy


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Name of

Drug

Dosage Indication Contraindication Adverse React

Demerol Injection-10mg/ml,

12mg/ml,

100mg/ml

Syrup-

50mg/ml

Tablets-

500mg, 100mg

moderate tosevere pain

preoperativeanalgesia

adjunct toanesthesia

obstetricanalgesia

contraindicated topatients

hypersensitive to

the drug and in

those who have

received MAO

inhibitors within

the past 14 days.

Avoid use inpatients with end

stage renal

disease.

CNS: physicaldependence, se

CV: hypotensio

bradycardia

GI: constipatio

mouth, nausea

GU: urine reten


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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE

Subjective:

Nararamdaman

ko yoong sakit ng tahi

ko as verbalized by

the patient.

Objective:

y Pain scale of5/10

y Difficulty inmovingwithout

assistance

y Surgicalincision

y FacialGrimace

Acute pain related

to surgical incision

secondary to

cesarean section as

manifested by pain

scale of5/10 and

difficulty moving

without assistance

Inference: Since the

patient had

undergone delivery

via low transverse

caesarean section,she has incision on

the lower quadrant

of her abdomen

which causes pain.

Short Term:

-After 30 minutes to

1 hour ofnursing

intervention the

patients pain scale

of5/10 will decrease

to 2/10.

Long Term:

-After 2 days of

nursing intervention,

the patient will be

able to move freely

with less discomfortand without

assistance.

INDEPENDENT:

y Providecomfort

measures such

as

repositioning

to supine

position, use of

heat packs,

quiet

environment,

and calm

activities.

y Instruct orencourage use

of relaxation

techniques

such as focused

breathing,

listening to

music and

socialization.

yIn

struct theclient on how

to do deep

breathing

exercise

y Teach the

y To avdirect

press

the in

site a

prom

pharm

c pain

mana

y To disatten

reduc

tensio

y It willthe pa


25/30

patient on how

to do coughing

exercise and

instruct the

client not to lift

heavy objects

or do straneous

activities. n/a

y Encouragedadequate rest

periods.

y Check for foulsmelling

discharge and

swelling on the

site

y Evaluates clientresponse to

analgesics and

assists altering

drug regimen

based on

patients

needs.

DEPENDENT:

y Administeranalgesics

(Mefenamic

y To avaccide

remo

the su

and b

on

th

y To prefatigu

y To heearly

detec

infect

other

comp

y To maaccep

level

y Increaand

decredosag

in self

mana

of pai


26/30

References sa ifernce at rationale.

acid), as

needed.

Collaborative:

y Providephysicaltherapy/

exercise

program based

on clients

ability.

N/A

-use of abdominal

binder

y Promactiveand e

sense

contr


27/30


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28 | P a g e

DISCHARGE PLAN

MEDICATION:

Take home medication as prescribed by the physicians.E- Exercise

Encouraged early ambulation (walking )T Treatment

Explain to the patient how she will take care of her situation toward the treatmentshe had undergone.

H- Health Teaching

Informed patient to avoid lifting heavy objects for one to two weeks. Stressed the importance of perineal cleanliness. Instructed patient to increase intake of protein-rich foods to promote faster wound

healing.

Instructed to promote adequate fluid intake. Discouraged patient to participate in strenuous activities that might precipitate

stress and trauma to the wound.

Instructed patient to promote wound healing/ breast feeding Contact physician for

Temperature > 100.4 Systolic Blood Pressure 140 mmHg Diastolic Blood Pressure >90 mmHg or 130 or 32 or


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O- OPD follow-up

Informed patient to have a follow-up check up. Instructed the patient to report to physician any signs of infection.

D- Diet

Encouraged client to increase intake of fiber to avoid constipation. Instructed to increase fluid intake. Instructed to increase intake of nutritious food such as fruits and vegetables.

S- Sex

3-4 weeks or if the client dont feel pain nor discomforts.

BUBBLES

B- Breast Encourage the client to breastfeed 15 mins. Each breast. Instruct the client to check her nipples or signs of sores or cracks which may lead to

discomfort.

U- Uterus Instructed the patient that distended uterus is normal. B- Bladder Encouraged patient to increased fluid intake. Instruct the client that day by day her uterus will go back into its normal position.B- Bowel


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Encouraged patient to increased fiber intake to avoid constipation.L- Lochia

Check for cervical secretions characteristics, amount, color, and odor.S- Sex

3-4 weeks or if the client dont feel pain nor discomforts.H- Hygiene

Regularly wound cleaning/ dressing.E- Exercise

Encouraged early ambulation (walking )

Post Cs Na Revised Na Toh

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