De La Salle Lipa

President Jose P. Laurel Highway, Lipa, Batangas

Philippines 4200

A Case Analysis:

CESAREAN SECTION: PATIENT WITH EDEMA

EXPERIENCING ACUTE PAIN IN INCISION SITE
G2A-1
Alcalde, Alliana Marie
Bañaga, Junifer Arien I C.
Bolante, Maria Samantha Nicole D.
Callejo, Charlene C.
De Villa, Cannesa M.
Inocencio, Rain Iryl B.
Lipardo, Diana Denise
Macaraeg, Mikhaela Joyce B.
Soriano, Lance Marion
Viray, Marilou Daze L.

Clinical Instructor
Eden Apostol Santos
Alicia Barte

Area of Exposure
Lipa Medix Medical Center
Obstetric and Gynecology Ward

Date and Time of Exposure:

February 24 - 26, 2020
March 2 - 4, 2020
6:00 - 2:00 P.M.
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TABLE OF CONTENTS
I. Introduction …………………………………………………………………………… 3 - 5
(De Villa, Cannesa & Bolante, Samantha)

II. Demographic Data ………………………………………………………………….. 6

(De Villa, Cannesa)

III. Medical History ……………………………………………………………………… 7 - 8

(Viray, Marilou Daze L. & Callejo, Charlene)

IV. Physical Assessment ……………………………………………………………….. 9 - 14

(Macaraeg, Mikaela Joyce)

V. Normal Anatomy and Physiology ………………………………………………….. 15 - 18

(Macaraeg, Mikaela Joyce)

VI. Laboratory and Diagnostic Procedure …………………………………………. 18 - 19

(Bañaga, Junifer Arien I C.)

VII. Medical and Surgical Management …………………………..………………….. 20 - 21

(Soriano, Lance Marion & Lipardo, Diana Denise)

VIII. Drug Study ………………………….……………………………………………… 22 -

30
(Alcalde, Alliana Marie V.)

IX. Nursing Care Plan ………………………………………………………………….. 31 - 35

(Inocencio, Rain Iryl B.)

XI. References …………………………………………………………………………... 36

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INTRODUCTION

A study about a 48 years old postpartum cesarean woman who was admitted last March
2, 2020 with a diagnosis of excess fluid volume related to sodium retention as manifested by
presence of edema in both lower extremities and acute pain related to pain resulting from
surgical incision due to cesarean birth as evidenced by facial grimace with a pain scale of 5.
The goal of this study is to provide students some knowledge regarding sodium retention,
edema, and acute pain. Also, nursing interventions in response to real life situations were given
in this study.

Respectively, this study aims to:

· Supply accurate and authentic information regarding sodium retention,

edema and acute pain

· Provide the anatomy and physiology related to edema and cesarean section

· Give some information about procedures done during hospitalization

· Identify nursing intervention to patient who is suffering from edema and acute
pain

According to medicinenet, edematous patients were characterized as having observable

swelling fluid in the body which usually occurs in the lower extremities specifically in the feet.
This kind of edema is sometimes called pedal edema. The excess fluid under the skin in the
spaces between the tissues made the swelling possible. Moreover, there are other types of
edema namely:

Peripheral edema happened in extremities such as legs, feet, ankles and arms and could be a
sign of problems in circulatory system, lymph nodes or kidney.

Lymphedema is caused by the damage of lymph nodes due to cancer treatments like surgery
or radiation.

Pulmonary Edema ​is due to excess fluid in the lungs.

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​ appened in the brain, caused by a blood vessel being blocked or bursted, or
Cerebral Edema h
having a tumor or allergic reaction.

Macular Edema ​is caused by the leakage of fluid in the macular, part of an eye which is the
center of retina due to the damage blood vessels.

As stated in the articles of Cunha (2019), when a woman is pregnant, her body produces
50% more blood and other body fluids than usual to help support the developing fetus in her
body. This causes edema of the hands, face, legs, ankles and feet, which is a normal and
common part of pregnancy. Swelling can also be prominent in the legs and feet because of the
enlargement of the mother’s womb. It is taking up the space in the abdomen thus, inhibiting the
return of fluids from the legs. Edema during pregnancy can happen any time throughout the
gestation, but most women start to experience it around the fifth month, and edema may be
worse in the third trimester. Mild swelling is common, but sudden swelling of the hands or face
can be a sign of preeclampsia, a complication of pregnancy. dema may continue even after you
have given birth. Postpartum edema usually gradually resolves within a week or so after giving
birth and is generally not a serious condition. If the postpartum swelling does not resolve within
about a week or if the patient experiences headaches or pain in her legs, this may be a sign of
high blood pressure and preeclampsia.

Furthermore, the most common cause of edema involves the heart, liver and kidneys
which is primarily because of the body's retention of too much salt (sodium). This happens when
the kidneys react to the decreased blood flow wherein it concludes that the body is in need of
more fluid and results to edematous. On the other hand, according to a healthline article, the
balance of fluids both inside and outside of the cell is maintained by the sodium which binds
water in the body. Therefore, eating much of foods high in salt like processed foods may retain
water in the body. Also, this could reduce the ability of the kidneys to remove water and higher
blood pressure may occur due to extra fluid and extra strain on the delicate blood vessel leading
to the kidneys.

According to Berry (2017), excess fluid volume or hypervolemia is a condition wherein

the patient has too much fluid in the blood. This condition usually occurs when the body has
difficulty in regulating sodium and water. Too much sodium in the body will cause fluid retention
since the body will retain water to balance it. Cirino (2017) stated that one of the most common
causes of excess fluid volume is pregnancy. During the gestational period, the mother’s
 5
hormones become imbalanced which can lead to fluid retention. Berry (2017) also indicated the
common signs and symptoms of excess fluid volume which includes: unexplained and rapid
weight gain, abdominal swelling which is common to patients with liver problems, shortness of
breath caused by fluid in the lungs, and lastly edema in the arms and/or legs.

On the other hand, according to DeVries (2015), acute pain has a specific cause, usually
provoked by disease process, injuries, and inflammation. It usually lasts within a specific time,
fading along with the cause of the pain when it is healed or resolved. It is ultimately described
as mild to sharp pain that is suddenly felt and lasts from a few seconds up or even a couple of
months.

As stated by James (2006), women who are undergoing cesarean delivery are unique
because in along with their own recovery, they must also start caring for their newborns
immediately after undergoing a surgery. The need for fast and safe recovery is crucial with the
mothers due to an increased risk of thromboembolic complications. Approximately 1 in 5
mothers who undergo cesarean delivery are experiencing severe acute postoperative pain.
According to Ward (2014), postoperative pain frequently has sensitive characteristics, it derives
from tissue or organ lesions, whose sensitive stimuli are perceived as painful. In some cases of
direct nerve lesion or compression, neuropathic pain may also be present.
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DEMOGRAPHIC DATA

Name:​ Pt. L,A C.

Sex: ​Female

Age: ​48 years old

Address: ​Purok 2 141 Anilao, Lipa City, Batangas

Status: ​Married

Nationality: ​Filipino

Date and time of admission: ​March 2, 2020 at 2:10pm

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MEDICAL HISTORY

a. ​HISTORY OF PRESENT ILLNESS

The female patient of 48 years of age, was admitted to the obstetric ward at Lipa
Medix Medical Center. Patient’s LMP was last June 15, 2019. The patient has a Gravida
of three and Para of two (preoperative diagnosis) with an AOG (age of gestation) of 37
2/7 weeks and confirmed that she was pregnant via an ultrasound. The patient came in
for a prenatal check-up and was advised to repeat CS + BTL (cesarean section with
bilateral tubal ligation) due to elevated blood pressure. Hence, admitted.

b. ​ PAST MEDICAL HISTORY

According to the patient, she has no family history of diabetes, cancer, asthma,
hypertension and other hereditary diseases. The patient had been complaining about
her headache whenever she’s stressed or tired. However, she also never had any
history of gynecological diseases such as pelvic infection or pelvic mass. The patient
also was never admitted to the hospital due to any medical illness prior to pregnancy.
Moreover, the patient has no allergy to any variety of foods and medicines. The patient
also never took any harmful medications that are harmful to her pregnancy and doesn’t
have any vices.

c. ​ LIFESTYLE

Based on the interview with the patient regarding her lifestyle, her diet does not
particularly follow a consistent pattern during her pregnancy, but she always makes
it a point to eat healthy foods such as fruits and vegetables that are good for both
her and the baby. She also did not have much exercise or physical activities during
 8
pregnancy, since she is considered high-risk due to her age and condition. The
patient also says she has no vices such as drinking alcohol and smoking.

Dorothea Orem’s Self-Care Deficit Theory of nursing is composed of three

related theories: the theory of Self-Care, the theory of Self-Care Deficit and, the
theory of Nursing Systems. Orem’s theory views the individual as a self – care agent
with special needs. When ‘self-care’ is practiced it enhances health and well-being.
There is a visible link between responsibility and self-care; Self-care can be stated
as a self-initiated, deliberate and purposeful activity linked to health and well-being.
In the case of a pregnant woman, especially for those with complications, there is a
need for them to know how to properly care for themselves and also for the sake of
the baby. Proper nursing intervention and health teaching shall be provided for the
mother to follow, in order to avoid or lessen further unnecessary complications.

Being a multigravida mother, it would not be her first time to care for herself and
for her baby, so that gave her an advantage and the correct idea on how to properly
handle pregnancy. However, given her case, perhaps a more careful understanding
of its indications must be explained for her to know the risks and how to avoid them.
Generally, she establishes a healthy lifestyle by avoiding vices, eating the right kinds
of foods, and resting well for a better outcome of her delivery.
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PHYSICAL ASSESSMENT

Lipa Medix Medical Center Obygne Ward: Rm. 400 G

Date Performed: March 3, 2020

Height: 1.52m / 5ft / 60in

Weight: 61 kg / 134.5 lbs

Vital Signs

March 3, 2020

12:00 nn

Temperature: 36.0 o​​ C

Pulse Rate: 70 bpm

Respiratory Rate: 21 br/min

Blood Pressure: 140/70

Body Part Method Used Findings Significance

Integumentary

-​ Warm, moist,
​
Skin Inspection Normal
no skin
turgor/rashes
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-​ Thin but
​
Hair Inspection Normal
evenly distributed
-​ No signs of
​

infection and
infestation
-​ No lesions
​

-​ Proper
​
Nails Inspection Normal
pigmentation
-​ Capillary refill:
​

3 secs

Head

-​ No nodules,
​
Skull Palpation Normal
lumps or bumps

-​ Normal
​
Head Inspection Normal
Cephalic; head is
round

-​ Face
​
Face Inspection Normal
appeared to be
symmetrical
-​ No presence
​

of
nodules/masses

Eye and Vision

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-​ Pupils are
​
Eyes Inspection Normal
black and equal
in size, PERRLA
-​ Pupils
​

constrict
-​ Pale
​

conjunctiva:
white sclera
-​ Normal eye
​

movement
-​ No swelling/
​

lesions or
discharge

-​ Symmetrical
​
Ears Inspection Normal
to the face
-​ No discharges
​

-​ No
​
Palpation Normal
tenderness of
auricle and
mastoid process

Mouth, Nose

-​ Symmetrical
​
Nose Inspection Normal
and uniform in
color
-​ No swelling,
​

exudate,
bleeding, ulcers,
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perforated
septum or polyps

-​ Moist and
​
Mouth Inspection Normal
smooth in
texture; No
pungent odor
-​ No presence
​

of color variation
in the tongue
(smooth and
pinkish)
-​ No presence
​

of cavities

Neck

- Symmetrical;
​
Neck Inspection Normal
no presence of
lumps and
masses

- No lymph
​
Palpation Normal
nodes felt

Thorax, Lungs and Abdomen

- Symmetrical
​
Lungs/Chest Inspection Normal
chest wall
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- No
​
Palpation Normal
tenderness
- No presence
​

of lesions
/masses
- Symmetrical
​

chest expansion

- Rhythmic and
​
Auscultation Normal
effortless
respiration
- No
​

adventitious sign

- Vertically
​
Spine Palpation Normal
aligned
-​ Full ROM
​

-​ No back pain
​

- No presence
​
Heart Auscultation Normal
of murmurs
- No abnormal
​

pulsations

- Symmetric
​
Abdomen Inspection Normal
contour
-​ Globular
​

- No
​
Palpation Normal
tenderness
present in the
four quadrants
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- No presence
​
Auscultation Normal
of abnormal
abdomen bowel
sounds

Breast

- Normal size;
​
Breast Inspection Normal
equal both sides
- Dark brown
​

(areola and
nipple color)

- No nodules or
​
Palpation Normal
masses

-
Extremities

- Warm, moist,
​
Upper Inspection Normal
no skin
Extremities
turgor/rashes

-​ (+) edema
​
Lower Inspection Caused by
Extremities postpartum
pregnancy
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ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external genital area— or vulva
—which runs from the pubic area downward to the rectum. Two folds of fatty, fleshy
tissue surround the entrance to the vagina and the urinary opening: the labia majora, or
outer folds, and the labia minora, or inner folds, located under the labia majora. The
clitoris, is a relatively short organ (less than one inch long), shielded by a hood of flesh.
When stimulated sexually, the clitoris can become erect like a man's penis. The hymen,
a thin membrane protecting the entrance of the vagina, stretches when you insert a
tampon or have intercourse.
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INTERNAL REPRODUCTIVE SYSTEM

The Vagina

The vagina is a muscular, rigid sheath connecting the external genitals to the uterus,
where the embryo grows into a fetus during pregnancy. In the reproductive process, the
vagina functions as a two-way street, accepting the penis and sperm during intercourse
and roughly nine months later, serving as the avenue of birth through which the new
baby enters the world.

The Cervix

The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina,
the cervix has dual reproductive functions.

After intercourse, sperm ejaculated in the vagina pass through the cervix, then proceed
through the uterus to the fallopian tubes where, if a sperm encounters an ovum (egg),
conception occurs. The cervix is lined with mucus, the quality and quantity of which is
governed by monthly fluctuations in the levels of the two principle sex hormones,
estrogen and progesterone.
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When estrogen levels are low, the mucus tends to be thick and sparse, which makes it
difficult for sperm to reach the fallopian tubes. But when an egg is ready for fertilization
and estrogen levels are high the mucus then becomes thin and slippery, offering a
much more friendly environment to sperm as they struggle towards their goal. (This
phenomenon is employed by birth control pills, shots and implants. One of the ways
they prevent conception is to render the cervical mucus thick, sparse, and hostile to
sperm.)

Uterus

The uterus or womb is the major female reproductive organ of humans. One end, the
cervix, opens into the vagina; the other is connected on both sides to the fallopian
tubes. The uterus mostly consists of muscle, known as myometrium. Its major function
is to accept a fertilized ovum which becomes implanted into the endometrium, and
derives nourishment from blood vessels which develop exclusively for this purpose. The
fertilized ovum becomes an embryo, develops into a fetus and gestates until child birth.

The Oviducts

The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of
female mammals into the uterus.

On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to
escape and enter the Fallopian tube. There it travels toward the uterus, pushed along
by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If
the ovum is fertilized while in the Fallopian tube, then it normally implants in the
endometrium when it reaches the uterus, which signals the beginning of pregnancy.
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Ovaries

The ovaries are the place inside the female body where ova or eggs are produced. The
process by which the ovum is released is called ovulation. The speed of ovulation is
periodic and impacts directly to the length of a menstrual cycle.

After ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct
to the uterus, occasionally being fertilized on its way by an incoming sperm, leading to
pregnancy and the eventual birth of a new human being. The Fallopian tubes are often
called the oviducts and they have small hairs (cilia) to help the egg cell travel.

LABORATORY RESULTS

Test Date: 02/17/20

Examination: Blood Chemistry, Blood Typing, Hematology, Serology

A test done on a sample of blood to measure the amount of certain substances in
the body. These substances include electrolytes (such as sodium, potassium, and
chloride), fats, proteins, glucose (sugar), and enzymes. Blood chemistry tests give
important information about how well ​a person’s kidneys, liver, and other organs are
working. An abnormal amount of a substance in the blood can be a sign of disease or
side effect of treatment. Blood chemistry tests are used to help diagnose and monitor
many conditions before, during, and after treatment. Also called blood chemistry study.

Hematology is the branch of medicine concerning the study of blood, the

blood-forming organs, and blood diseases. Hematology tests include laboratory
assessments of blood formation and blood disorders.

Serologic tests are blood tests that look for antibodies in your blood. They can
involve a number of laboratory techniques. Different types of serologic tests are used to
diagnose various disease conditions.
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Serology / Immunology
HBsAG (Screening)
HIV (Screening) - Non Reactive
RPR/VDRL

Blood Type: O
RH Type: Positive (+)
HBsAG (-)
G3P2 (2002)
Hematology
Hematocrit 35-46 vol% 33.0 vol%
Hemoglobin 12-16 g% 11.2 g%
WBC count 5000 - 10 000 5 500 /cumm
/cumm
Differential Count
Segmenter 40% - 60% 73%
Lymphocyte 20% - 40% 19.1%
Midcell 252 000 / cumm
Platelet 150 000 - 400 000 / 252 000 / cumm
cumm
Monocyte
Eosinophil
Basophil

MCV 80 - 97 fl 83.4
MCH 26 - 32 pg 28.3
MCHC 31 - 36 g/dl 33.9
RDW 13.6%
RBC 4.20 - 6.30 m/ul 3.96
 20
MEDICAL AND SURGICAL MANAGEMENT

Doctor’s Order Rationale

Intravenous Fluid of 5% Dextrose · Treatment for persons

in Lactated Ringer’s Solution 1L x needing extra calories who
30 gtts/min at 6 AM cannot tolerate fluid
overload. It helps prevent
dehydration to the patient.

· is a medical instruction
Nothing Per Orem (NPO) after 10 meaning to withhold food
PM and fluids.

· In order to identify which

Monitor vital signs, Fetal Heart are the normal and
Tone (FHT) every 4 hours and abnormal findings.
record.

· The drug is indicated for

urinary tract infection,
pneumonia, otitis, sinusitis,
and other infectious
Cefuroxime diseases.
· Cefuroxime is found in
breast milk

· Most commonly used type
Lower (Uterine) Segment
Cesarean Section (LSCS)
21
of Caesarean section. It
includes a transverse cut
1-2 centimetres above the
attachment of the urinary
bladder to the uterus,
called the Pfannenstiel
incision in the lower
segment.