INTRODUCTION

Gestational diabetes mellitus (GDM) is a form of diabetes that occurs in

pregnant women. It usually causes only mild symptoms similar to those of early
Type 2 diabetes, and is thus often only diagnosed by specific screening in the
24th-28th week of pregnancy; some cases sadly remain undiagnosed. GDM can
cause serious complications for the baby and the mother, so early diagnosis and
ongoing treatment is important for a good outcome.

For more than a century, obstetricians have been aware that patients with
pre-existing diabetes who became pregnant worsened clinically. Blood sugar
values of these diabetic patients were very unpredictable. Prior to the invention of
insulin, patients with diabetes were advised by their physicians not to conceive.
There was a significant risk of maternal death from diabetes if patients attempted
pregnancy. After the invention of insulin, the risk of maternal death dropped
dramatically in the era before World War II, but diabetic patients continued to
have a much higher risk of both fetal death and fetal birth defects.

During the second half of the twenty-first century, physicians began to

recognize a form of diabetes that was unique to pregnancy (gestational
diabetes). In general, these patients are non-diabetic prior to pregnancy and after
delivery. However, hormone changes during pregnancy alter the body's ability to
handle sugar metabolism, resulting in a "temporary" diabetic condition during the
pregnancy. Gestational diabetes cannot be recognized by symptoms, since the
symptoms of diabetes (loss of energy, intense thirst, frequent urination) are
common in normal pregnant women. As a result, universal screening for
gestational diabetes is recommended during pregnancy.

Patients who have gestational diabetes have an increased risk of three

complications: large babies, cesarean delivery, and stillbirth. Recognition and
treatment of patients with gestational diabetes is designed to minimize these
complications, and improve pregnancy outcome for these patients.

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B. Objectives of the Study

The case study is made for us student to have an understanding about the
case of the patient. Where we can identify the patient’s major cause of illness
and to provide intervention to the identified problems that will improve to the
health status of the patient. And by this, we will expand our nursing skills and
able to impart knowledge to the readers.

C. Scope and Limitations of the Study

Our study encompasses the nature, causes, signs and symptoms,

and prognosis of gestational diabetes. It focuses not only the nursing care of the
client but also proper evaluation of the client-care outcomes were done and
important health teachings to the client and significant others were given to
promote fast recovery and effective coping. Referrals have also been made to
guide the client on what to do after discharge, so as to ensure good client follow-
through.
Because of some uncontrolled circumstances, this study came across with
some limitations. One of which is time constraint, because of it some of the data
like the doctor’s order and some of the data in the pharmacologic therapy.

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Patient’s Profile

Name of Patient: X
Sex: Female
Age X
Religion: Roman Catholic
Civil Status: Married
Income: Refused
Nationality: Filipino
Date Adm. July 15,2008
Time: 10:15 pm
Informant: Patient
LMP: October 30, 2008
AOG: 36-37 weeks
Physician: Dr. Paano-Go
Temperature:36.3’C
Pulse Rate:83 bpm.
Resp.Rate: 15 cpm
Bp: 120/80
Height:152.4cm
Weight: 68kg.

History of Present Illness

The patient complained of shortness of breath last X, the patient sought
consult and was admitted in X at around 10:15 pm by Dr. X. Upon admission,
patient was advised for cesarean section due to fetal respiratory distress with
fetal heart rate of 100 bpm.
The patient is negative to allergies to any food and drug; has no history of
asthma, and is positive to diabetes mellitus (DM). The patient received blood
transfusion when she had dengue fever in Manila last 2007.

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IV. DEVELOPMENTAL DATA

A. Developmental Task Theory

Robert Havighurst believes that learning is basic to life and that people
continue to learn throughout life. He describes growth and development as
occurring during six stages, each associated with six to ten tasks to be learned.
According to Havighurst each individual will develop a task and this task
arises at about certain period in life of individual. Successful achievement of
which leads to his happenings and to success with later tasks, while failure leads
to unhappiness in the individual, disapproval of society, and difficulty with later
task.
Mrs. KL belongs to adulthood. In this stage the tasks are (1) rearing
children, (2) managing a home, (3) taking on civic responsibilities, (4) finding a
congenial social group.
On Mrs. KL developmental task, fortunately she had just delivered her first
baby. She has more responsibility now compared before. Our patient is a college
teacher and been socially active in some social activities. But her focus now is
more on her family.

B. Psychosexual Theory

According to Sigmund Freud, the personality develops in five overlapping

stages from birth to adulthood. The libido changes its location of emphasis within
the body from one stage to another. A particular body area has special
significance to a client at a particular stage.
If the individual does not achieve a satisfactory resolution at each stage,
the personality becomes fixated at the stage. Fixation is immobilization or
inability of the personality to proceed to the next stage because of anxiety.
Mrs. KL is married to a seaman husband. Apparently, it’s not that easy to
be alone for 9 months because her husband goes home after every contract of

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the ship. Though there was trust but it’s not that easy to be alone but of course
its work and have to bear with it to support their children in the future.
The health care provider’s role is to provide appropriate opportunities for
the person to relate with and allow verbalization of feelings and concerns.
Significant others were encouraged to respond to the needs of the patient and to
talk to him and touch therapy as often.

C. Psychosocial Theory

Erik Erickson adapts and expands Freud’s theory of development. He

envisions life as a sequence of levels of achievement. Each stage signals a task
that must achieve. The resolution of the task can be complete, partial, or
unsuccessful. He believes that the greater task achievement, the healthier the
personality of the person is. Failure to achieve a task influences the person’s
ability to achieve the next task.
The patient’s ego development outcome is integrity versus despair in late
adulthood 60 years to death. As older adults, they can often look back on their
lives with happiness and are content, feeling fulfilled with a deep sense that life
has meaning and they’ve made a contribution to life, a feeling Erickson calls
integrity. The strength comes from a wisdom that the world is very large and they
now have a detached concern for the whole of life, accepting death as the
completion of life.
On the other hand, some adults may reach this stage and despair at their
experiences and perceived failures. They may fear death as they struggle to find
a purpose to their lives, wondering "Was the trip worth it?"
The significant relationship is with all of mankind—"my-kind." The
assessment was not fully granted with how the patient defined this stage
because she was not able to verbalize his concerns as she was having difficulty
of speaking. However as through the questions raised to her family, they said
that the patient is a very social oriented person, and because she exhibits
unselfish actions and happy to have done those acts, therefore, she has attained
the tasks for this stage.

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 The health care provider encouraged the significant others to provide love
and support to the patient.

D. Cognitive Theory

According to Piaget, cognitive development refers to the manner in which

people learn to think; reason and use language. This involves the person’s
intelligence perceptual. This is an orderly sequential process in which a variety of
new experiences (stimuli) must exist before intellectual abilities can develop and
this represents the progression from illogical to logical thinking from simple to
complex.
Piaget sees adolescence as the time when cognition achieves its final
form, that of formal operational thought. When this stage is reached, adolescents
are capable of thinking in terms of possibility – what could be (abstract thought) –
rather than being limited to thinking about what already is (concrete thought).
This makes it possible for adolescents to use scientific reasoning.
Mrs. KL belongs to the Formal Operations Phase in which rational thinking
is use and reasoning is deductive and futuristic. She was even attentive to our
questions and willing to participate. She was well oriented and cooperates.

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ANATOMY AND PHYSILOGY

Pancreas
The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is
both exocrine (secreting pancreatic juice containing digestive enzymes) and endocrine
(producing several important hormones, including insulin, glucagon, and somatostatin). It
also produces digestive enzymes that pass into the small intestine. These enzymes help in
the further breakdown of the carbohydrates, protein, and fat in the chyme.

1: Head of pancreas
2: Uncinate process of pancreas
3: Pancreatic notch
4: Body of pancreas
5: Anterior surface of pancreas
6: Inferior surface of pancreas
7: Superior margin of pancreas
8: Anterior margin of pancreas
9: Inferior margin of pancreas
10: Omental tuber
11: Tail of pancreas
12: Duodenum

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Histology

Under a microscope, stained sections of the pancreas reveal two different types of
parenchymal tissue. Lightly staining clusters of cells are called islets of Langerhans,
which produce hormones that underlie the endocrine functions of the pancreas. Darker
staining cells form acini connected to ducts. Acinar cells belong to the exocrine pancreas
and secrete digestive enzymes into the gut via a system of ducts.

Structure Appearance Function

Islets of Lightly staining, large, Hormone production and secretion
Langerhans spherical clusters (endocrine pancreas)
Darker staining, small, berry- Digestive enzyme production and
Pancreatic acini
like clusters secretion (exocrine pancreas)

Function

The pancreas is a dual-function gland, having features of both endocrine and exocrine
glands.

Endocrine

The part of the pancreas with endocrine function is made up of a million cell clusters
called islets of Langerhans. There are four main cell types in the islets. They are
relatively difficult to distinguish using standard staining techniques, but they can be
classified by their secretion: α cells secrete glucagon, β cells secrete insulin, δ cells
secrete somatostatin, and PP cells secrete pancreatic polypeptide.

The islets are a compact collection of endocrine cells arranged in clusters and cords and
are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by
layers of endocrine cells in direct contact with vessels, and most endocrine cells are in
direct contact with blood vessels, by either cytoplasmic processes or by direct apposition.
According to the volume The Body, by Alan E. Nourse, the islets are "busily
manufacturing their hormone and generally disregarding the pancreatic cells all around
them, as though they were located in some completely different part of the body."

Exocrine

In contrast to the endocrine pancreas, which secretes hormones into the blood, the
exocrine pancreas produces digestive enzymes and an alkaline fluid, and secretes them
into the small intestine through a system of exocrine ducts. Digestive enzymes include
trypsin, chymotrypsin, pancreatic lipase, and pancreatic amylase, and are produced and
secreted by acinar cells of the exocrine pancreas. Specific cells that line the pancreatic

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ducts, called centroacinar cells, secrete a bicarbonate- and salt-rich solution into the small
intestine.[6]

Regulation

The pancreas receives regulatory innervation via hormones in the blood and through the
autonomic nervous system. These two inputs regulate the secretory activity of the
pancreas.

Sympathetic (adrenergic) Parasympathetic (muscarinic)

α2: decreases secretion from beta cells, increases M3[7] increases stimulation from alpha
secretion from alpha cells cells and beta cell

Diseases of the pancreas

Because the pancreas is a storage depot for digestive enzymes, injury to the pancreas is
potentially very dangerous. A puncture of the pancreas generally requires prompt and
experienced medical intervention.

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PATHOPHYSIOLOGY

Definition: Gestational diabetes is a carbohydrate intolerance of variable

severity that starts or is first recognized during pregnancy or the inability of
the tissues to absorb glucose from the bloodstream during pregnancy due
to a lack of the hormone insulin.

Precipitating factors:

Insulin resistance due to pregnancy

Overweight Predisposing factors:

Have previously given birth to a very Genetic disposition

large, heavy baby
Belong to an ethnic group known to
Have previously had baby who was
experience higher rates of
stillborn or born with defect
gestational diabetes. (In the United
have an excess amount of
States, these groups include
amniotic fluid (the cushioning
Mexican-Americans, American
fluid within the uterus that
Indians, African-Americans, as well
surrounds the developing fetus.
as individuals from Asia, India, or the
Pacific Islands)
Age

Have a previous history of

gestational diabetes during a
pregnancy.

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 Increase hormone release in the placenta which is HPL

HPL blocks insulin receptor

Increases in direct linear relation to the length of pregnancy.

Insulin release is enhanced in an attempt to maintain glucose homeostasis.

The patient experiences increased hunger due to the excess insulin release as a
result of elevated glucose levels or gestational diabetes

This insulin release further decreases insulin receptors due to elevated hormonal
levels.

Thus the vicious cycle of excess appetite with weight gain occurs. Few other
symptoms mark this condition.

MEDICAL MANAGEMENT

LABORATORY RESULTS:

Laboratory Result Normal Implication

Range
July 16, 2008

Hematology
 Clotting Time 7 minutes and 3-7 minutes  Increase
15 seconds

 Bleeding Time 6 minutes and 1-3 minutes  Prolonged

.05 seconds Bleeding Time
Prolonged in
thrombocytopenia,
defective platelet
function and aspirin
therapy.
Complete Blood
Count
  Total WBC 9.58X10^9/L 5.0-10x10^9/L  Normal
 Total RBC 4.27X10^12/L 3.69-  Normal
5.90X10^12/L
 Hemoglobin 12.4 g/dL 11.70-14.0  Normal
g/dL
 Hematocrit 39.4%  Normal
34.10-44.00%
 MCV 92.3 Fl  Normal
70.00-97.00Fl
 MCH 29.0pg  Normal
26.10-33.30 pg
 MCHC 31.5 g/dL  DECREASE
32.0-35.0 g/dL Patient may have
severe
hypochromic
anemia.

 Platelet Count 282x10^9/L  Normal

150.0-
Differential Count 390.0x10^9/L
 Neutrophils
68.1%  INCREASE
55.0-62.0% Due to surgery
 Lymphocytes  Normal
 Monocytes 24.8%  Normal
 Eosinophils 6.4% 20.0-40.0%  DECREASE
0.6% 4.0-10.0 Because of stress
1.0-6.0% and use of ACTH
medications like
epinephrine and
thyroxine

 Normal
 Basophils
0.1%
0.00-14.5%
July 16,2008

Urinalysis
 Color Yellow
 Appearance Clear Clear  Normal
 Glucose Negative Negative  Normal
 Protein +1 <150 mg/ 24 h  Normal
 Reaction 6.0 ph
 Specific Gravity 1.010
 Microscopic
 WBC
 RBC 0-1
 Epithelial Cells 0-1
 Mucous 10-12
Threads
 Urates Occasional
 Bacteria
NONE Seen Negative  Normal
NONE Seen Negative  Normal
July 16,2008

Blood Chemistry
 Potassium 3.63 meq/L 3.50-5.50  Normal
 Na 139.20 meq/L meq/L  Normal
135.00-155.00
 Creatinine 0.72 meq/L meq/L  Normal
0.70-1.30
meq/L

Ultrasound Result:
Impression: Single, live, intrauterine pregnancy in present cephalic
presentation of about 38 weeks AOG by composite fl, BPD, HC and AC.
Placenta Anterior, with a Grannum grade of about III normohydramios.
Biophysical score of 6/8.

DRUG STUDY

Name of Drug: Cafazolin (Stancep)

Date Ordered: July 16, 2008

Dose/ Route:

Classification: Anti-infective
Mechanism of Action: Bind to bacterial cell wall membrane, causing cell death

Specific Indication: Preoperative prophylaxis

Contraindication: Contraindicated in: hypersensitivity to cephalosporins.

Serious hypersensitivity to penicillin.

Side Effects: CNS: Seizures

GI: Pseudomembranous colitis, diarrhea, nausea, vomiting,
cramps.
Derm: rashes, pruritus, urticaria
Hemat: blood dyscrasias, hemolytic anemia
Local: pain at IM site, phlebitis at IV site
Misc: allergic reactions including anaphylaxis and serum
sickness superinfection

Nursing Precaution:

• Assess for infection (vital signs; appearance of wound; WBC) at the

beginning and during the therapy

• Before initiating therapy, obtain a history to determine previous use of and

reactions to penicillin or cephalosporin. Persons with a negative history of
penicillin sensitivity may still have allergic response.

• Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,

laryngeal edema, wheezing)

• Use cautiously in: Renal Impairment: History of GI disease, especially

colitis:
 • OB: Pregnancy or lactation (half-life shorter and blood levels lower during
pregnancy: have been used safely)

Name of Drug: Famotidine

Date Ordered: July 16, 2008

Dose/ Route: 20 mg q12

Classification: Antiulcer agents

Mechanism of Action: Inhibits the action of histamine at the H2- receptor site
located primarily in gastric parietal cells, resulting in inhibition of gastric acid
secretion

Specific Indication: Treatment and prevention of heartburn

Contraindication: Contraindicated in: Hypersensitivity. Cross sensitivity may

occur. Some products contain alcohol and should be avoided in patients with
known intolerance. Some products contain aspartame and should be avoided in
patients with phenylketonuria.
Side Effects: CNS: confusion, dizziness, drowsiness, hallucination, headache
CV: Arrhythmias
GI: Altered taste, black tongue, constipation, diarrhea, drug-
induced hepatitis, nausea
Hemat: Anemia, neutropenia,
Local: Pain at IM site.

Nursing Precaution:
 • Assess for epigastric or abdominal pain and frank or occult blood in stool,
emesis, or gastric aspirate

• Use cautiously in: Renal impairment

Name of Drug: Midazolam

Date Ordered: July 16, 2008

Dose/ Route: 1 tab P.O with sips of water

Classification: Antianxiety agents

Mechanism of Action: Acts as many levels of the CNS to produce generalized

CNS depression. Effects may be mediated by GABA, an inhibitory
neurotransmitter. Postoperative amnesia.

Specific Indication: Preprocedural sedation and anxiolysis in pediatric patients.

Contraindication: Contraindicated in: Hypersensitivity. Cross-sensitivity with

other benzodiazepines may occur. Shock. Comatose patients or those with pre-
existing CNS depression. Uncontrolled severe pain. Products containing benzyl
alcohol should not be used. Pregnancy. Acute narrow-angle glaucoma.

Side Effects: CNS: agitation, drowsiness, excess sedation, headache

EENT: blurred vision
Resp: Apnea, Laryngospasm, respiratory depression,
bronchospasm, coughing
CV: Cardiac arrest, arrhymias
GI: Hiccups, nausea, vomiting
 Derm: rashes
Local: Phlebitis at IV site, pain at IM site

Nursing Precaution:

• Assess level of sedation and level of consciousness throughout and for 2-

6 hr following administration.

• Monitor blood pressure, pulse, and respiration continuously during IV

administration. Oxygen and resuscitative equipment should be
immediately available.

Name of Drug: Celecoxib (Celebrex)

Date Ordered: July 17, 2008

Dose/ Route: 200 mg P.O BID

Classification: Nonsteroidal anti-inflammatory drugs

Mechanism of Action: Inhibits the enzyme COX-2. This is required for the
synthesis of prostaglandin. Has analgesic, anti-inflammatory properties.
Decreased pain.

Specific Indication: Pain

Contraindication: Contraindicated in: Hypersensitivity. Cross sensitivity may

exist with other NSAIDS, including aspirin.
OB: Should not be used in late pregnancy (may cause premature closure of the
ductus arteriosus)

Side Effects: CNS: dizziness, headache, insomnia

CV: edema
GI: GI bleeding, abdominal pain, diarrhea, dyspepsia, flatulence,
nausea
Derm: Expoliative dermatitis, rash

Nursing Precaution:

• Assess range of motion, degree of swelling, and pain in affected joints

before and periodically throughout therapy

• Use cautiously in: Cardiovascular disease or risk factors for cardiovascular

disease.

Name of Drug: Ferrous Sulfate

Date Ordered: July 17, 2008

Dose/ Route: 500 mg 1 tab P.O OD

Classification: Antianemics

Mechanism of Action: An essential mineral found in hemoglobin, myoglobin,

and many enzymes. Parenteral iron enters the bloodstream and organs if the
reticuloendothelial system, where iron is separated out and becomes part of iron
stores.

Specific Indication: Prevention of iron-deficiency anemia

Contraindication: Contraindicated in: Primary hemochromatosis. Hemolytic

anemias and other anemias not due to iron deficiency.

Side Effects: CNS: seizures, headache, syncope

CV: hypotension, tachycardia
GI: nausea, constipation, dark stools, diarrhea
Derm: flushing, urticaria
Local: pain at IM site

Nursing Precaution:

• Assess nutritional status dietary history to determine possible cause of

anemia and need for patient teaching

• Assess bowel function for constipation or diarrhea.

• Use cautiously in: Peptic Ulcer; Ulcerative Colitis or regional enteritis.

Name of Drug: Metronidazole

Date Ordered: July 17, 2008

Dose/ Route: 1 grm supp/ rectum OD

Classification: Anti-infective
Mechanism of Action: Disrupts DNA and protein synthesis is susceptible
organisms.

Specific Indication: Gynecological infections

Contraindication: Contraindicated to: Hypersensitivity. First trimester of

pregnancy

Side Effects: CNS: seizures, dizziness. Headache

EENT: tearing
GI: abdominal pain, anorexia, nausea, dry mouth
Derm: rashes, skin irritation, mild dryness

Nursing Precaution:

• Assess patient for infection (vital signs; appearance of wound, sputum,

urine and stool; WBC) at beginning of and throughout therapy

• Monitor neurologic status during and after the therapy

• Monitor intake and output and weigh patient daily.

• Use cautiously in: History of blood dyscrasias; History of seizure or

neurologic problems; severe hepatic impairment.

Name of Drug: Nalbuphine (Nubain)

Date Ordered: July 18, 2008

 Dose/ Route: IV PRN

Classification: Opioid Analgesic

Mechanism of Action: Binds to opiate receptors in the CNS. Alters the

perception of and response to painful stimuli while producing generalized CNS
depression. On addition, has a partial antagonist property, which may result in
opioid withdrawal in physically dependent patients. Thus decreasing pain.

Specific Indication: Moderate to severe pain

Contraindication: Hypersensivity to nalbuphine or bisulfites. Patients who are

physically dependent to opioids and have not been detoxified.

Side Effects: CNS effects: Nervousness, depression, restlessness, crying,

euphoria, floating, hostility, unusual dreams, confusion, faintness,
hallucinations, dysphoria, feeling of heaviness, numbness, tingling,
unreality. The incidence of psychotomimetic effects, such as
unreality, depersonalization, delusions, dysphoria and
hallucinations has been shown to be less than that which occurs
with pentazocine.
CVD: Hypertension, hypotension, bradycardia, tachycardia,
pulmonary edema.
GI: Cramps, dyspepsia, bitter taste.
Respi: Depression, dyspnea, asthma.
Derm: Itching, burning, urticaria.

Nursing Precaution:
 • Assess type, location, and intensity of pain before 1 hr after IM or 30 min
(peak) after IV administration.

• Assess blood pressure, pulse, and respiration before and periodically

during administration.

• Use cautiously in: Rhinitis

NURSING MANAGEMENT

IDEAL NURSING INTERVENTION

Nursing Diagnosis: Pain

Related factors: cervical dilation, muscle hypoxia, uncomfortable position, lack

of position change, diaphoresis, full bladder, leaking of amniotic fluid.

Interventions:

1. Assess the mount and type of preparation for childbirth has/ had (e.g., classes)

Rationale: Research indicates that preparation for childbirth reduces the need
for analgesia during labor.

2. Monitor for signs of anxiety.

Rationale: a moderate amount of anxiety about the pain enhances the ability to
cope with it; however, too much anxiety interferes with coping.

3. Monitor vital signs and observe for signs of pain.

Rationale: Frequent physiologic manifestations of pain are increased pulse,
respirations, and BP; dilated pupils; and muscle tension. Muscle tension can
impede the progress of labor.

4. Encourage ambulation, if the following criteria are met; in latent or active first
stage, has not had an analgesic, membranes are intact, no vaginal bleeding, and
no fetal distress.

Rationale: Ambulation provides diversion because the woman focuses on stimuli

other than the UCs. Criteria provide for the safety of the mother and the fetus.

5. Use touch (e.g. hold the woman’s hand, rub her back), as appropriate.

Rationale: A sensory experience (e.g. backrub) can provide distraction because

the woman focuses on the stimulus than the pain. It is common for a woman to
want touch during early labor but pull away from touch during transition.

Nursing Diagnosis: Fatigue

Related factors: sleep deprivation before labor, prolonged first and/ or second
stage, overwhelming physical and emotional demands of labor, unrelieved pain,
prolonged NPO status.

Interventions:

1. Note the length of the first stage.

Rationale: A woman who has experienced a long or difficult first stage may be
too exhausted to push effectively in the second stage.
2. Monitor fetal presentation, position, and station, and monitor the length of the
second stage.

Rationale: Fetal malposition or malpresentation may prolong second stage

causing energy depletion. Recognition of the problem allows interventions such
as charging the woman’s position.

3. Teach and reinforce correct use of relaxation techniques.

Rationale: Muscle tension increased fatigue; it may also impede fetal descent
and prolong second stage. Because of the intensity of second stage, the couple
may nor remember what they have learned about relaxation techniquesm or they
may not able to concentrate well enough to perform them.

4. Support, or show the partner how to support the woman’s back and shoulders
during bearing-down efforts (or support her body in other positions, as needed).

Rationale: The woman may be too tires to raise her back and shoulders from the
bed without help, so this enables her to assume position most effective for
pushing.

Nursing Diagnosis: Ineffective Coping

Related factors: stress of labor, worry about potential complications of labor,

history of ineffective coping skills, inadequate emotional support, fatigue, lack of
confidence.

Interventions:

1. Assess maternal and family stressors, use of coping skills, ability to accept
help with coping, and existing support systems.
Rationale: Effective coping requires the ability to identify and solve problems
and adapt to change. Labor and birth is a situational crisis that calls for increased
coping and adaptation.

2. Assess cultural background and observe the mother’s verbal and nonverbal
response to pain.

Rationale: What appears to be ineffective coping may merely be a culturally

accepted mode of dealing with pain.

3. Assess for factors (e.g. age, lack of partner) that may increase vulnerability to
stress.

Rationale: For example, women without a support person and adolescent

woman may be more vulnerable to stress and less able to remain in control with
UCs.

4. Evaluate the efforts of the partner to provide support, and teach or act as a
role model as needed.

Rationale: Especially in transition, the woman is likely to be calmer when her

coach and/or the nurse are calm. Because she may feel dependent and put of
control, it is especially important for her to feel that those around her are in
control.

5. Provide pharmacologic and nonpharmacologic pain-relief measures.

Rationale: Pain is a stressor, and minimizing stressors improves ability to cope.

Nursing Diagnosis: Knowledge deficit related to lack of information

Interventions:
1. Determine the client’s ability to learn.
Rationale: May not be physically, emotionally, or mentally capable at this time.

2. Be alert to signs of avoidance.

Rationale: May need allow the client to suffer the consequences of lack of
knowledge before client is ready to accept information.

3. Assess the level of the client’s capabilities and the possibilities of the situation
Rationale: May need to help the significant others or caregivers to learn
4. Provide positive reinforcement
Rationale: Encourage continuations of efforts

5. Determine client’s most urgent need from both client and nurse viewpoint
Rationale: Identifies starting point

ACTUAL NURSING INTERVENTION

S “Maglisod kog ginhawa sa kasakit”

O Facial grimaces
Guarding
Shallow breathing
Splinting respirations
A High risk for Ineffective breathing pattern related to abdominal incision
pain.
P At the end of 5 hours, the patient will be able to maintain effective
breathing pattern.
I Independent
Assess rate and depth respirations. Teach deep slow breathing
exercises.
Respirations are typically shallow, because the least amount of
excursion is least painful when abdominal incision is present. Also,
the higher the incision, the more breathing is affected.
Encourage patient to assume position and change them
regularly. Allow client to stand, walk or sit on a chair if not
contraindicated
Position changes promote comfort, reduce muscle tension, relieved
pressure and promote least straint . Encourage husband to
massage back area, using pressure tolerated by the client.
Back massage aids in muscle relaxation. Pressure helps to
counteract
some of pain.

Dependent
Administer supplemental Oxygen as ordered.

E At the end of 5 hours, the patient was able to maintain effective

breathing pattern and verbalizes that she had no difficulty in
breathing.

S “ sakit pa gihapon akong samad” as verbalized by the patient.

O Facial grimaces
Guarding

A Pain related to cesarian operation (abdominal incision).

P At the end of 30 minutes, the patient will verbalizes relief of pain or

ability to tolerate pain.
I Independent
Assess nature of pain ( location, quality, duration).
Patient using patient-controlled analgesia PCA may need
reinstruction or reminders to “push the button” during the early
postoperative phase when they are still under the effects of
anesthesia
Document patient’s response to pain-relieving measures.
- Patients have very individualized pain tolerance levels, and
all patients will not be made comfortable with standard doses.
Place patient in complete bed rest for 2-3 days.
Pain will influence activity thus it is appropriate to have rest for
further evaluation and treatment.
Apply Heat or cold compresses as ordered,
Hot moist comressess have penetrating effect. The warmth
rushes blood to the affected area to promote healing. Cold
compresses may reduce local edema and promote some numbing,
thereby promoting comfort.

Dependent
Administer Analgesic such as mefenamic acid as ordered.
E At the end of 30 minutes, the patient was able to tolerate pain
according to her tolerance and verbalizes that she could managed it.

S “wala man ko gipakaun before ko gi operahan”

O Wound drainage
Wound dressing on the incision site (abdominal)
NPO
A High Risk for fluid volume deficit related to wound drainage, blood
loss in surgery and NPO status.
P At the end of 8 hours, patient maintains normal fluid volume balance
as evidenced by stable BP and heart rate and by urine output at least
30ml/hour
I Independent
Monitor for postoperative bleeding.
Intraabdominal, Intraluminal, Incisional
- Postopertive bleeding usually shows as increased bloody
drainage on dressings and tubes.
Assess hydration status. Monitor IV fluids closely and provide
oral fluids as indicated.
- Oral fluids are usually restricted until peristalsis returns and
patient is at risk for electrolyte imbalance if not monitored.
Place patient in complete bed rest for 2-3 days.
- Unusual activities may precipitate to an increase metabolic
rate thus increasing risk for dehydration.
Apply Heat or cold compresses as ordered,
Hot moist comressess have penetrating effect. The warmth
rushes blood to the affected area to promote healing. Cold
compresses may reduce local edema and promote some numbing,
thereby promoting comfort.
Dependent
Administer parenteral fluids as indicated to replace fluid loss.
Administer medications as indicated. ( folic acid and ferrous sulfate)
E At the end of 8 hours, the patient was able to have an adequate fluid
intake through the IV fluids.

S “ naa koy samad sa tiyan kay gi cesarean man ko” as verbalized by

the patient
O Wound drainage
Wound dressing on the incision site (abdominal)
A High Risk for Infection related to abdominal incision.

P At the end of 3 days, patient is free of infection as evidenced by

healing wound, free of redness, swelling purulent discharge
I Independent
Monitor for postoperative bleeding.
Intraabdominal, Intraluminal, Incisional
- Postopertive bleeding usually shows as increased bloody
drainage on dressings and tubes.
Assess hydration status. Monitor IV fluids closely and provide
oral fluids as indicated.
- Oral fluids are usually restricted until peristalsis returns and
patient is at risk for electrolyte imbalance if not monitored.
Place patient in complete bed rest for 2-3 days.
- Unusual activities may precipitate to an increase metabolic
rate thus increasing risk for dehydration.
Apply Heat or cold compresses as ordered,
Hot moist comressess have penetrating effect. The warmth
rushes blood to the affected area to promote healing. Cold
compresses may reduce local edema and promote some numbing,
thereby promoting comfort.
Dependent
Administer anti-infective drugs like cefazolin
E At the end of 3 days, the patient’s wound was free from infection as
evidenced by free of redness and purulent discharge in the dressing..

S “ wala pa naulian akong samad”

O Wound drainage
Wound dressing on the incision site (abdominal)
A High risk for altered tissue integrity related to operative wound.

P At the end of 1 hour, patient has intact wound or free from

complications such as dehiscence, evisceration or fistulaization.
I Independent
Monitor for postoperative bleeding.
Intraabdominal,Intraluminal,Incisional
- Postopertive bleeding usually shows as increased
bloody drainage on dressings and tubes.
Assess for wound dressing or cleaning. .
- Incisions are usually kept covered to avoid invasion of
microorganism thus inhibit further infection.
Place patient in complete bed rest for 2-3 days.
- Unusual activities may precipitate to an increase
metabolic rate thus increasing risk for dehydration. It also
increases the wound to heal and avoid the risk of contour.
Apply Heat or cold compresses as ordered,
Hot moist comressess have penetrating effect. The warmth
rushes blood to the affected area to promote healing. Cold
compresses may reduce local edema and promote some numbing,
thereby promoting comfort.
Dependent
Administer ointment (bactroban)
E At the end of 1 hour, the patient’s wound displayed healing with no
evidenced of complications.
DISCHARGE PLANNING

Health Teachings

Medications
Commonly, the patient is prescribed for 3 drugs at the postpartum period.
These are antibiotics (cefalexin, ferrous sulfate and mefenamic acid). It is
important that the patient takes these medications accordingly.
For cefalexin, it is an antibiotic to combat possible infection that might
originate at the wound site (in the perineal area or in the wounded area inside).
Since it is an antibiotic, then the patient must take this according to prescribed
dosage, timing and therapy period (usually 1 week, but not more than 10 days).
A patient must not miss or skip a medication because doing so can result to
resistant strain of bacteria (usually staphylococcus aureus). Resistant strains are
those that can not be treated anymore with the same generation of antibiotic, but
requires a higher generation.
For ferrous sulfate, this is a supplement to be taken once a day to prevent
iron-deficiency anemia. During childbirth, blood loss is unavoidable. Thus, the
blood lost must be replaced. Ferrous sulfate is an iron source to increase the
hemoglobin in the blood (increasing the oxygen capacity of the blood). It is
recommended that this drug be taken either 2 hours after meal or 1 hour before
meal, because this drug is best absorbed in an empty stomach. Also, iron reacts
to milk. Thus, the drug must not be taken with milk or any dairy products. This
drug is also best absorbed in an acidic environment. Hence, it must be taken in
adjunct with vitamin C.
For mefenamic acid, this drug is taken as analgesic or pain reliever. It is a
GI irritant. Thus, it must be taken immediately after meal.

Exercise
 Instruct the woman in postpartum exercise for the immediate and later
postpartum period.
A. Immediate postpartum exercises can be performed in bed:
• Toe stretch (tightens calf muscles) – while lying on your back, keep
your legs straight and point your toes away from you, then pull your
legs toward you and point your toes toward your chest. Repeat 10
times.
• Kegel exercise (tightens vaginal muscles) – contract vaginal muscles
as if stopping stream of urine. Do 15 per day, increasing 15 more each
week to a maximum of 40 per week. Once conditioned, patient can do
4 to 5 Kegel’s per day for maintenance.
• Abdominal breathing – lie on back, knees bent, hands on belly, feet
flat. Suck in your belly, trying to pull your navel towards your spine.
Hold 5 seconds; release. When you can do 10 (this can take a week),
add a head lift. Suck in your belly, and then hold it as you lift head
toward chest, counting slowly to 4. Lower head for 4 slow counts;
release belly.
• Arm circle – stand with feet approximately 12 inches apart, arm at
sides. Keeping arms at sides, draw large circles with your shoulders by
moving them forward, up, and back, and finish with a press down. Do
10 to 20 repetitions. Next, extend both arms as you reach forward, up,
back, and down. Move slowly, breath deeply for 5 to 10 repetitions.
• Short walk – start with 5 minutes at first, then increase 5 minutes per
day as desired.
B. Exercise for the later postpartum period can be done after the first
postpartum visit (1 to 2 weeks postpartum):
• Bicycle (tightens thighs, stomach, and waist) – lie on your back on the
floor, arms at sides, palms down. Begin rotating your legs as if you
were riding a bicycle, bringing the knees all the way in toward the chest
and stretching the legs out as long and straight as possible. Breathe
 deeply and evenly. Do not exercise at a moderate speed and do not
tire yourself.
• Buttocks exercise (tightens buttocks) – lie on your stomach and keep
your legs straight. Raise your legs in the air, and then repeat with your
right leg (feel the contraction in your buttocks). Keep your hip on the
floor. Repeat 10 times.
• Twist (tightens waist) – stand with legs wide apart. Hold your arms at
your sides, shoulder level, palms down. Twist your body from side to
front and back again. Feel the twist in your waist.

Treatment
Teach the woman to perform perineal care – warm water over the
perineum after each voiding and after each bowel movement several times a day
to promote comfort, cleanliness and healing. Teach the woman to apply perineal
pads by touching the outside only, thus keeping clean the portion that will touch
her perineum.
Inform the woman that intercourse may be resumed when perineal and
uterine wounds have healed and when vaginal bleeding has stopped.
Counsel the woman to rest for at least 30 minutes after she arrives home
from hospital and to rest several times during the day for the first few weeks.
Advise the woman to confine her activities to one floor if possible and to
avoid stair climbing as much as possible for the first several days at home.

Out-patient
Advise woman that healing occurs within 2-4 weeks; however, evaluation
by the health care provider during the follow-up visit is necessary.
For breastfeeding mothers, alert them that uterine cramping may occur,
especially in multiparous women, because of the release of oxytocin. Teach the
mother to provide for adequate rest and to avoid tension, fatigue, and a stressful
environment, which can inhibit letdown reflex and make breast milk less available
at feeding. Also, advise the woman to avoid taking medications and drugs
without provider approval, because many substances pass into the breast milk
and may affect milk production or the infant.
Review methods of contraception. Sexual arousal may cause milk to leak
from breasts. Breastfeeding is not a reliable method of contraception.
Inform the woman that menstruation usually returns within 4 to 8 weeks if
bottle-feeding; if breast-feeding, menstruation usually returns within 4 months,
but may return between 12-18 months postpartum. Nursing mothers may ovulate
even if experiencing amenorrhea, so a form of contraception should be used if
pregnancy is to be avoided.
Counsel the woman to provide quiet times for herself at home, and to help
her establish realistic goals for resuming her own interest and activities.
Encourage the couple to provide times to reestablish their own relationship and
to renew their social interests and relationship.

Diet
It is recommended that the patient eats nutritious foods, with a balanced
diet. Instruct the breast-feeding woman to add between 500 and 750 additional
calories daily for milk production. Inform her that she needs also 2-3 quarts of
liquid per day; 20 grams more protein than before pregnancy; and additional
calcium, phosphorus, vitamins D, A, C, E, B, and B2; and additional niacin, zinc
and iodine.
Aside from vitamins and supplements, it is suggested that the mother eats
more green leafy vegetables (petchay, kangkong, etc) because these are good
sources of iron for the replenishment of blood loss during child delivery. This is to
prevent iron-deficiency anemia.
The mother is also encouraged to eat fruits because these are rich in
vitamin C, and so with foods high in protein. The injury at the perineal area
(laceration, episiotomy) sustained during the childbirth process needs to be
healed soon to prevent infection. Vitamin C and protein promotes cell reparation
or cell regeneration at the injured site. Protein is also the source of antibodies in
the body that can fight possible infection.

Referral
The patient upon discharge from the hospital will be referred to a local
health center nearest to the patient's residence for follow up check up. She will
be given a referral slip by her OB doctor at JRB Hospital so that she can avail of
the services in the local health center. The patient is advised to report to the X
one week after discharge for a postnatal check up. The patient is also advised to
go back to the health center two weeks after delivery for the first immunization of
her infant.

BIBLIOGRAPHY

 Pilitteri, Adelle. Maternal and Child Health Nursing: Care of

Childbirth and Childbearing Family. 4th ed. Lippincott William
and Wilkins Company. 2003.
 Marlow, Dorothy R. Redding, Barbara A. Pediatric Nursing.
6th ed. Philadelphia .. W.B Saunder’s Company. 1988.
 Nursing 2006: Drug Handbook. 26th ed. Philippines .
Lippincott William and Wilkins Company. 2006.
 Doenges, M.E.,Moorehouse.M.F and Geissler,A.C. Nursing
Care Plans: Guidelines for individualizing Patient Care.
Philadelphia . F.A. Davis Company. 2002.
 Karch, Amy M. Focus on Nursing Pharmacology.
Philadelphia : J.B Lippincott Co. 2000.
 Kozier, B. et al. Fundamentals of Nursing, 7th edition. New
Jersey: Pearson Education, Inc., 2004 pp. 1132-1687: 1261-
1262
 www. Wikipedia.com