ARELLANO UNIVERSITY COLLEGE OF NURSING 2600 Legarda Street , Sampaloc, Manila

CASE STUDY ANALYSIS

Quirino Memorial Medical Center OB-WARD Monday-Tuesday 6am-1pm Feb. 18, 19, & 26, 2013

Presented to: Prof. Hermie Nita Y. Armamento, RN, MAN (Clinical Instructor)

Presented by: Silva, Maria Arceli V. SN AUCN Lvl. 2 Sec. 1

BIOGRAPHICAL DATA Name of Patient: Diana A. Lozano Address: 168 Balant Rd. Tanlazora, Quezon City Date of Birth: December 20, 1995 Age: 20 years old Sex: Female Status: Single Nationality: Filipino Religion: Roman Catholic Occupation: None Educational Attainment: High School Graduate Informant: Patient and Patients Chart Mode of Arrival: Ambulation Date of Admission: February 10, 2013 Type of Delivery: Cesarean Section Date of Delivery: February 10, 2013

CHIEF COMPLAINT Miss Lozano was scheduled for a Cesarean Section at the hospital on February 10, 2013 at Quirino Memorial Medical Center due to postpartum pregnancy. Her AOG is 41 weeks and 4 days according to her LMP=April 25, 2012.

HISTORY OF PRESENT ILLNESS (HPI) Miss Lozano had a Cesarean Section at the hospital on February 10, 2013 at Quirino Memorial Medical Center due to postpartum pregnancy.

PAST HEALTH HISTORY Miss Lozano had her two doses of tetanus toxoid at a Barangay Health Center somewhere in Quezon City . She has no previous hospitalization experience for the past six months. Age 0-10 yrs. Old Medical History (+) Immunization (+) fever, cough and cold as her usual childhood illness (+) Tetanus Toxoid 1 and Tetanus Toxoid 2 Surgical History

11-20 yrs. Old 20-30 yrs. Old

FAMILY HEALTH HISTORY Family Member Father Mother Patient itself Medical History none none none Surgical History

OBSTETRICAL HISTORY Menarche: 12 years old Interval: Regular, 28 days cycle Duration: 5-7 days Amount: 3-4 pads a day, except for the 6th and &th day 1-2pads Signs: none OB Score: G1 P1 (T0 P1 A0 L1)
Gravida Year Where Who delivered the baby
1 2013 QMMC Dr. Pepito Male

Sex

Mode of Delivery
CS

GORDONS 11 FUNCTIONAL HEALTH PATTERNS Before: During: After: 1. .Health PerceptionPatient goes to the Patient is concern Patient can function Health Management health center for about her curettage moderately because of her prenatal check up. procedure thinking that hospital confinement and it may be detrimental condition after surgery. Her to her health. body image changed after the surgical procedure done. 2. Nutritional-Metabolic Prior to During hospitalization, Patients nutritional and Management confinement, the patient is on a strict metabolic status has been patient eats rice, diet. Small amounts are changed due to her bread, vegetables given to patient. confinement. and some meats and fish. 3. Elimination Pattern Bowel: Bowel: Bowel: Patient has 1-2 Patient defecates zero There was a change in the times every other to once a day but not frequency and amount. day, usually in the on a regular basis. morning. Stool is Stool is soft, minimal Bladder: brown in color and in amount and brown There was a change in the well-formed. in color. frequency and amount. Bladder: Patient voids usually 4-6 times a day. Urine is yellow in color. No pain when voiding. Patient is a house wife so she is in charge of the household chores. Bladder: Patient voids 3-4times a day without pain and discomfort. Patients activities in the hospital are ambulation, taking a bath or personal During patients confinement in the hospital, there is a limitation in her activities of daily living and

4. Activity, Leisure, and Recreation Pattern

5. Sleep and Rest Pattern

Sleeps by watching television programs .She usually sleeps at around 11pm to 6am.

hygiene and breastfeeding. Due to the condition and slight pain, patient complains of some difficulty of sleeping and short period of sleeps. Patient present condition is conscience and alert. Can speak and comprehend well.

6. Cognitive Perceptual Pattern

7. Self-Perception /SelfConcept Pattern

Patient is a high school graduate; she can read, speak, write and be understood by others. Patient is a friendly person and a humble and polite.

a disruption in her leisure and recreation pattern. Patients sleep and rest pattern changed when she was admitted. She difficulty sleeping due to present conditional pain plays a big factor for her sleep disturbances. No changes/alterations

8. Role Relationship

Patient is Single mother with the father of the infant as live in with the patients family who works as a construction worker. 9.Sexuality/Reproductive The patient didnt Pattern comment any information about her sexual relationship and satisfaction. 10. .Coping and Stress When patient is Tolerance stressed she goes for a walk. When it comes to problems, she gives time and comes back with a solution. 11. Values- Belief Patients religion is Pattern Roman Catholic. She goes to Sunday mass with her family.

During the times of her confinement she is quiet and shy when speaking. The patients family is supportive to the patient. She is happy with their presence and support.

There is a slight change in her self-perception due to present condition. Normal / No alterations

The patient didnt comment any information about her sexual relationship and satisfaction. The recent hospitalization of the patient was stressful and source of anxiety. However, she feels she will do fine. She follows a therapeutic regimen and her strong faith to God accounts for her fast recovery.

Patient reserved her right of privacy.

Patient accepts present condition with a positive attitude.

Due to her confinement, patient is trusting God that she will be discharge soon and will recover without any complications.

PHYSICAL ASSESSMENT AREA ASSESSED TECHNI QUE USED NORMAL FINDINGS ACTUAL FINDING S ANALY SIS

1.SKIN >Color

>Inspectio n

>Varies from light to deep brown, from ruddy to >The pink to light to light pink, from yellow overtones clients to olive. skin is a light brown. >Keep in mind that some clients have sustannedareas,freckles,or white patches known as vitiligo.The variations are due to different amounts of melanin in certain areas. A generalized loss of pigmentation is seen in albinism. Dark-skinned clients have lighter colored palms,soles,nail beds and lips. Freckle like or dark streaks of pigmentation are also common in the sclera and nail beds of darkskinned clients. >Smooth,withoutlesions.Stretchmarks,healedsca rs,freckles,mole or birthmarks are common findings >Skin is smooth and even.

> Normal

>Uniformity of Color

>Inspectio n

> Normal >The clients skin is generally uniform.(e ven)

>Stretchm arks located on the breast and abdomen

>Lesions

>Inspectio n

>Skin surface may vary from moist to dry depending on the area assessed. Recent activity or warm environment may cause increased moisture.

>Nomal

>Texture

>Palpation

>Moisture

>Palpation

>The clients skin is smooth,no acne,no scars and no lesions.

> Normal

> Normal

>The client skin is smooth and even. >The clients skin has moisture especially in her axillae.

>Temperature

> Palpation

>skin is normally in warm temperature.

> Normal

>Turgor

> Palpation

>Skin can be pinched easily and immediately return to its original position.

> Normal >Edema >Palpation >No edema >The clients skin temperatur e is in the normal range. >When pinched,th e clients skin springs back to its original state. >The client has no edema.

> Normal

SCALP & HAIR >General color and condition

>Inspectio n

>Natural hair color,as opposed to chemically colored hair,varies among clients from pale blond to black to gray or white.The color is determined by the amount of melanin present.

>The clients hair is a natural dark brown and wavy.

> Normal

>Scalp

>Inspectio n& palpation >Inspectio n

>Scalp is clean and dry.Spare dandruff may be visible.No lesions. >The clients scalp is clean and no lesion.

> Normal

>Hair

>Hair is smooth and firm,somewhatelastic.It is shiny,no presence of lice and nits and it should be evenly distributed.

>Distribution of scalp, body, axillae.

>Inspectio n

>Varying amounts of terminal hair cover the scalp, axillary, and body according to normal gender distributions.

>The clients hair is dark brown, wavy ,smooth, firm, it is shiny, no presence of lice, nits and it is evenly distributed. >no

> Normal

presence of dark hair growth on the arms or legs and axillary (shaves axillary)

HEAD AND FACE. >Size & Shape

>Inspectio n

>Head size and shape vary,especially in accord with ethnicity.Usually the head is symmetric,round,erect and in midline. No lesions are visible. The shape of the face varies from round,oval,elongated or square appearance. >Head should be held still and upright. >The head is normally hard and smooth without lessions.

>The clients head is symmetric and no lesions. The client has an slightly round shaped face.

> Normal

>The facial features is symmetric. >Involuntary movement >Inspectio n >The clients head is in upright. >The clients head is smooth and hard without lesions. >The clients facial features are symmetric. >The client has a symmetric facial movement she can smile, frown, raise her both eyebrows > Normal

>Symmetric facial movements.

>Head consistency >Palpation

>we can feel the pulse not tender and no lesion.

> Normal

>Facial features

>No tenderness should be present when palpating. >Inspectio n

> Normal

> Normal

>Facial Movement

>inspectio n

>Hair is evenly distributed, skin intact, Symmetrically aligned , equal movement.

>Equally distributed, curled slightly outward. Borders of chorea are slightly covered.

> Normal

>Temporal artery

>Palpation

>Skin intact, no discharge, no discoloration, lids close symmetrically, approximately 15-20 involuntary blinks per min. bilateral blinking when lids open, no visible sclera above the

cornea and upper and lower Borders of chorea are slightly covered.

and puff her cheeks.

>Sinuses

> Palpation

EYES >eyebrows >Inspectio n

>Bulbar conjunctiva is clear, moist and smooth. Underling structures are clearly visible. Sclera is white. The lower and the upper palpebral conjunctiva are clear and free of swelling or lesion.

>The clients both eyebrows are evenly distributed and is symmetric with each other. >Clients eyelashes is equally distributed and slightly curled outward.

> Normal

>Eyelashes

>Inspectio n

> Normal

>Eyelids

>Inspectio n

>No swelling or redness should be seen. NO drainage should be noted from the punctual when palpating the nasolacrimal duct.

>The clients eyelids have no secretions and they close symmetric ally.

> Normal

> Normal

>Eyeballs are symmetrically aligned in socket without protruding or sinking >Eyeballs >Inspectio n

>The clients eyeballs are well set on both sides in socket. It is not protruding neither sinking.

> Normal

>Conjunctiva and schlera

>Inspectio n

>Transparent, shiny, and smooth, details of the iris is visible. In older people a thin grayish white ring around the margin called arcussenilis may be evident. Client blinks when cornea is being touched indicating that the trigeminal nerve is intact.

>The clients bulbar conjunctiv a is trans parent,

> Normal

>Lacrimal gland

>Inspectio n& palpation >Black in color, equal in size, normally 3-7 mm in diameter, round smooth border, illuminated pupil dilates pupil constricts when looking at near object pupil dilates when looking at a far object.

moist and uniform. Her sclera is white and there is no lesions and swelling. > Normal

>Cornea

>Inspectio n

>The clients cornea is transparent with no opacities. His lens in evident.

> Normal >Pupil(color, shape,size,cap illary light reflex and accommodatio n) >The client can see objects in the periphery.

>Inspectio n

>Peripheral Vission >Inspectio n and palpation

>With normal peripheral vision, the client should see the examiners finger at the same time the examiner sees it. a.Inferior:70 b.Superior:50 c.temporal:90 d.Nasal:60

>The client is able to coordinate his both eyes and he followed the 6 directions correctly >The pupils of the client constricted then an object is moved towards his nose. >The clients lips is color brown .It is smooth and moist without lesion or

> Normal

>Eye movement should be smooth and symmetric throughout the 6 directions >Extraocular movement >Inspectio n and palpation >Visual ACUITY >Constriction of the pupils when an object is moved towards the nose. >The normal vision acuity is 20/20 with or without corrective lenses. This means that the client can distinguish from 20 ft. away.

> Normal

> Normal

swelling.

MOUTH >Lips

>Lips are smooth and moist without lesion or swelling. Pink lips are normal in light skinned clients as are bluish or freckled lips in some dark skinned clients especially those of Mediterranean descent.

.>The clients teeth is color white.

> Normal

>Teeth and gums

>Thirty- two pearly whitish teeth with smooth surfaces and front upper incisors edges. Upper molars should rest directly on the lower molars and the front upper incisors. Some clients normally have only 28 teeth if the four wisdom teeth do not erupt. >Ears are equal in size bilaterally. The auricle aligns with the corner of each eye and within a 10 degree and angle of the vertical position. theskin is smooth with no lesions,lumps.

>The clients auricle is symmetric with each other,it is aligned with the outer canthus and is 10 degrees.the skin is smooth,no lesions lumps and tendeness

> Normal

> Normal

EARS >Auricles

NECK . NAILS >Nail grooming

>Inspectio n

>Nails are clean and manicured.

>Pink tones should be seen.Some longitudinal ridging is normal. >Nail Color >Inspectio n >There is normally a 160 degree angle between the nail base and the skin. >Nails are hard,basically immobile and smooth. > Inspection >Pink tone returns immediate when pressure is released >Nail texture >Palpation >Balch Test/ capillary refill > Palpation

>The clients nails are well rimmed and cleaned. >Pink tones is seen in the clients nails.

> Normal

> Normal

>Curvature

> Normal

> Normal

>The clients nails is hard, and smooth.

> Normal

>When

pressed,the nail returns to its pink tone after pressure has been released. HEART >Murmurs >Auscultat e >Normally no murmurs are heard. However innocent and physiologic mild systolic murmurs may be present in a healthy heart. >The clients normally no murmurs are heard > Normal

ABDOMEN LEGS AND THIGH > Clients legs and thigh are equally and symmetric al

>Inspectio n& Palpation

>Normally the legs and thigh are equally symmetrical and no injuries.

> Normal

DISCHARGE PLAN The patient and significant others will be informed of the 10 Rs in the drug administration: RIGHT: drug, patient, time, route, approach, dose, documentation, drug history, drug to drug and drug to food interaction and drug allergies to ensure patients safety and recovery. Rest: Rest as much as possible after you have your baby. Try to nap when he is asleep. Support your incision with a pillow when you feed him. Use the pillow for support when you cough, sneeze, or laugh. Ask for help with household chores until you feel better. Exercise: Talk to your primary healthcare provider before you start to exercise. He will help find the best exercise plan for you. Start slowly and do more as you get stronger. Do not lift anything heavier than your baby until your primary healthcare provider says it is okay. Wound care: When you are allowed to bathe, carefully wash the incision with soap and water. If you have a bandage, change it any time it gets wet or dirty. You may have thin strips of medical tape on your incision. You can bathe with these medical strips. They will start to peel and fall off in about 2 weeks. Do not pull them off. A hard ridge may form along your incision. The ridge may slowly go down as it heals. It is normal for the area around your incision to be numb after surgery. Feeling should return to the area in about a year. Ice: Ice helps decrease swelling and pain. Use an ice pack or put crushed ice in a plastic bag. Cover the ice pack with a towel and place it on your incision for 15 to 20 minutes every hour for 2 days. Heat: Heat also helps decrease swelling and pain. Use a warm compress or heating pad. Dampen a washcloth or small towel with warm water and place in a plastic bag. Wrap a dry towel around the plastic bag to prevent burns. Place the warm compress or heating pad on your incision for 15 to 20 minutes every hour as long as you need it. Vaginal discharge: You will have vaginal discharge after delivery. The discharge is bright red the first 1 or 2 days after delivery, and then turns pink. The discharge becomes white or yellow by about day 10 after delivery. It is normal to have discharge on and off for 6 weeks after delivery. Use a sanitary pad rather than a tampon. This helps prevent a vaginal infection. The discharge should not have a bad smell. Monthly period: You may start your monthly period 7 to 9 weeks after delivery. Your periods may be different than before you were pregnant. Breastfeeding may start their periods even later. You may not get your period again until you stop breastfeeding. You can get pregnant while you are breastfeeding, even if you do not have a monthly period. Do not have sex: Do not have sex until your primary healthcare provider says it is okay. This is usually about 6 weeks after your C-section. Mood changes: Mood changes are normal after delivery. Hormone changes, tiredness, and anxiety about being a parent can affect your mood. Talk to your primary healthcare provider if you feel depressed or are unable to care for yourself or your baby. Contact your primary healthcare provider if:

You have a fever. You feel depressed. Your incision is swollen, red, or has pus coming from it. You have bad-smelling discharge from your vagina. You have red streaks, swelling, pain, and warmth in one or both of your lower legs. You have questions or concerns about your C-section or how to care for your baby.

Seek care immediately if:

Blood soaks through the bandage on your incision. You soak 1 vaginal pad in 1 hour for 2 hours in a row. Your incision comes apart. You feel like harming yourself or your baby. You have sudden shortness of breath. You have severe abdominal pain.

MEDICATIONS Ordered home medications prescribed by the physician. The patient and significant others will be informed of the 10 Rs in the drug administration: RIGHT: drug, patient, time, route, approach, dose, documentation, drug history, drug to drug and drug to food interaction and drug allergies to ensure patients safety and recovery. Advise patient and significant other (SO) to avoid/ refrain from self-medication. Patient and SO will be aware of each drug dosage, indication, side effects and adverse reaction and report if any of it occurs. The patient will take medications on time and as ordered for safety and faster recovery and be informed about the importance of complying with the medications at home. SO will help the patient to take medications on time.

EXERCISE OR ACTIVITY Inform patient and SO the importance, purpose and benefits of exercise, such as to increase muscle tone and strength, promotion of circulatory and elimination function. Instruct patient to have adequate rest and sleep at least 8 hour/day to avoid exhaustion.

THERAPEUTIC Instruct SO to maintain a home environment that is stress free, which could promote rest and relaxation to patient like proper ventilation, limiting noise, and provision of privacy.

HEALTH TEACHINGS > Instructed her to report to physician any signs of infection > Instructed her to report any case of hemorrhage or abnormal bleeding > Informed her to avoid lifting heavy objects for 1-2 weeks. > Informed her about the importance of perineal cleanliness. > Encouraged client to have warm sitz bath. > Instructed her to increase intake of protein rich foods to promote faster wound healing. > Encouraged client to increase intake of fiber to avoid constipation. > Instructed to promote adequate fluid intake.

Drug Study (DLP) Drug Classifications Brand: Tramadol Therapeutic: Analgesics (centrally acting)

Action Physiologic Mechanism Decreased pain. Pharmacologic Mechanism Binds to muopioid receptors. Inhibits reuptake of serotonin and norepinephrine in the CNS.

Consideration Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk; may cause opioid withdrawal symptoms.

Effects Sweating, dizziness, nausea, vomiting, dry mouth, fatigue, asthenia, somnolence, confusion, constipation, flushing, headache, vertigo, tachycardia, palpitations, miosis, insomnia, orthostatic hypotension, seizures, CNS stimulation e.g. hallucinations. Potentially Fatal: Respiratory depression.

Generic: Metronidazole Brand: Flagyl

Anti-infectives, Anti-protozoals

Disrupts DNA and protein synthesis in susceptible organisms Bactericidal, or amebicidal action

Administer with food or milk to minimize GI irritation. Tablets may be crushed for patients with difficulty swallowing. Instruct patient to take medication exactly as directed

CNS: seizures, dizziness, headache GI: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste,

Generic: Ranitidine Hydrochloride Brand: Zantac

-Anti-ulcer -H2 antagonist -Pregnancy category B

-inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion -has some antibacterial action against H. pylori Therapeutic: Ranitidine blocks histamine H2receptors in the stomach and prevents histaminemediated gastric acid secretion. It

evenly spaced times between dose, even if feeling better. Do not skip doses or double up on missed doses. If a dose is missed, take as soon as remembered if not almost time for next dose. May cause dizziness or lightheadedness. Caution patient or other activities requiring alertness until response to medication is known. Inform patient that medication may cause an unpleasant metallic taste. Inform patient that medication may cause urine to turn dark. Advise patient to consult health care professional if no improvement in a few days or if signs and symptoms of superinfection (black furry overgrowth on tongue; loose or foul-smelling stools develop). History: Allergy to ranitidine, impaired renal or hepatic function, lactation, pregnancy Physical: Skin lesions; orientation, affect; pulse, baseline ECG; liver evaluation, abdominal examination, normal output; CBC, LFTs, renal function tests Administer oral drug with meals and at bedtime. Decrease doses in renal and liver failure. Provide concurrent antacid therapy to relieve pain. Administer IM dose undiluted, deep

vomiting Hematologic: leukopenia Skin: rashes, urticaria CONTRAINDICATIONS hypersensitivity

Headache, dizziness. Rarely hepatitis, thrombocytopaenia, leucopaenia, hypersensitivity, confusion, gynecomastia, impotence, somnolence, vertigo, hallucinations. Potentially Fatal: Anaphylaxis, hypersensitivity reactions.

does not affect pepsin secretion, pentagastrinstimulated factor secretion or serum gastrin.

into large muscle group. Arrange for regular follow-up, including blood tests, to evaluate effects.

Generic: Piperacillin/ Tazobactam Sodium Brand: Zosyn

J01CA12 Piperacillin ; Belongs to the class of penicillins with extended spectrum. Used in the systemic treatment of infections. J01CG02 Tazobactam ; Belongs to the class of betalactamase inhibitors. Used in the systemic treatment of infections.

Piperacillin has an antimicrobial activity against a wide range of gm-ve organisms including K. pneumoniae, P. aeruginosa, Ent erobacteriaceae
and against gm+ve organisms eg E. faecalis and B. fragilis. Tazobactam is a penicillanic acid sulfone derivative with beta-lactamase inhibitory properties. In combination, tazobactam enhances the activity of piperacillin against betalactamaseproducing bacteria. Distribution: Pip eracillin and tazabactam: 30% bound to plasma proteins. Widely distributed into body tissues and fluids. Metabolism: Pip eracillin: metabolised to a desethyl metabolite. Tazobactam: metabolised to a single metabolite that lacks pharmacological and antibacterial activities. Excretion: Half-

Obtain history of hypersensitivity to penicillins, cephalosporins, or other drugs prior to administration. Lab tests: C&S prior to first dose of the drug; start drug pending results. Monitor hematologic status with prolonged therapy (Hct and Hgb, CBC with differential and platelet count). Monitor patient carefully during the first 30 min after initiation of the infusion for signs of hypersensitivity (see Appendix F). Report rash, itching, or other signs of hypersensitivity immediately. Report loose stools or diarrhea as these may indicate pseudomembran ous colitis. Do not breast feed while taking this drug without consulting physician.

Swelling, redness, pain, or soreness at the injection site may occur. Dizziness, trouble sleeping, nausea, vomiting, diarrhea, orheadache may also occur. serious side effects, including: muscle cramps/spasms, swelling of the arms/legs/hands/fee t, easy bruising/bleeding, c hest pain, confusion, new signs of infection (e.g., fever, persistent sore throat), severe abdominal/stomach pain, slow/fast/irregular heartbeat, persistent nausea/vomiting, seizures, extreme tiredness, dark/cloudy urine, change in the amount of urine, yellowing eyes/skin.

life of piperacillin and tazobactam ranges from 0.71.2 hr. Eliminated via kidney by glomerular filtration and tubular secretion. Piperacillin: 68% excreted unchanged in urine.Tazobactam : 80% excreted unchanged urine.