I.

INTRODUCTION

This is a case of a 38-year old multipara named M.I.S. who underwent Caesarian Section Delivery last 8 th of February 2010 with a diagnosis of G3P2 (2012), cephalic presentation to a live baby girl delivered by Low Transverse Caesarian Section due to Gestational Diabetes Mellitus with Gestational Hypertension. Gestational diabetes mellitus (GDM) is defined as the glucose intolerance of variable degree with an onset or first recognition during pregnancy. It accounts for 90% diabetes mellitus cases in pregnancy. Type II diabetes mellitus accounts for 8% of cases of diabetes mellitus in pregnancy.GDM is the most common medical complication of pregnancy. It occurs in women who have insulin resistance and a relative impairment of insulin secretion. These women have a significant risk of developing diabetes later in life. Identifying this group of women is important in not only preventing perinatal morbidity but also improving long-term outcomes for the mothers and their children. There are several fetal and maternal complications associated with Gestational Diabetes Mellitus. Fetal complications include macrosomia, neonatal hypoglycemia, perinatal mortality, congenital malformation, hyperbilirubinemia, polycythemia, hypocalcemia, and respiratory distress syndrome. Macrosomia, defined as birth weight > 4,000 g, occurs in 20-30% of infants whose mothers have GDM. Maternal factors associated with an increased incidence of macrosomia include hyperglycemia, high BMI, older age, and multiparity. This excess in fetal growth can lead to increased fetal morbidity at delivery, such as shoulder dystocia, and an increased rate of cesarean deliveries. Neonatal hypoglycemia can occur within a few hours of delivery. This results from maternal hyperglycemia causing fetal hyperinsulinemia. The association between GDM and perinatal mortality has been more controversial. Several studies have concluded that the rate of perinatal mortality (including stillbirths and neonatal deaths) was increased in women with GDM in the past. However, recent studies have shown that, with the combination of increased antepartum monitoring, medical nutrition therapy (MNT), and insulin therapy if needed, this difference in perinatal mortality rates is potentially avoidable. Another controversial association is that between GDM and congenital malformations. The incidence of a major malformation in an infant whose mother does not have any history of diabetes is 1-3%. In women with a history of diabetes before pregnancy, this risk is increased three to eight times.19 In women with GDM, an increased incidence of malformations occurs when the mother also has fasting hyperglycemia. Long-term complications to the offspring include an increased risk of glucose intolerance, diabetes, and obesity. Maternal complications associated with GDM include hypertension, preeclampsia, and an increased risk of cesarean delivery. The hypertension may be related to insulin resistance. Therefore, interventions that improve insulin sensitivity may help prevent this complication. In addition, women with a history of GDM have an increased risk of developing diabetes after pregnancy compared to the general population, with a conversion rate of up to 3% per year. 1|Page

Hypertension complicates 5% to 10% of pregnancies and includes several disorders: preeclampsia (proteinuric hypertension), gestational (nonproteinuric) hypertension, and chronic hypertension with or without superimposed preeclampsia. Despite the significant morbidity associated with newonset hypertension in pregnancy, the pathogenesis remains unclear, which limits the ability to prevent and treat this disorder. Although it is likely that the cause of pregnancy-induced hypertension (PIH) is multifactorial and involves both genetic2 and other factors, insulin resistance may be an important contributor to the development of both preeclampsia and gestational hypertension. The association of essential hypertension with insulin resistance and hyperinsulinemia has been well described. Cross-sectional studies of patients with established gestational hypertension or preeclampsia are ambiguous as to the possible pathogenic effect of insulin resistance. Cohort studies initiated in early and mid-pregnancy show evidence that both gestational hypertension and preeclampsia may be more prevalent in gravidas with greater insulin resistance. The association of gestational glucose intolerance with gestational hypertension appears to be independent of obesity and ambient glycemia but explained in part by insulin resistance. More than 40 years ago, a relationship between insulin resistance and PIH was postulated. However, it was not until recent years that more widespread interest developed in the possible role of insulin resistance in the pathogenesis of PIH. The term PIH is used in this report to represent new-onset hypertension in pregnancy and includes both preeclampsia and gestational hypertension. Gestational hypertension (GH) is defined as systolic blood pressure 140 mmHg and/or a diastolic blood pressure 90 mmHg, in the absence of proteinuria, in a previously normotensive pregnant woman at or after 20 weeks of gestation. The blood pressure readings should be documented on at least two occasions at least six hours apart. Gestational hypertension is considered severe when sustained elevations in systolic blood pressure 160 mmHg and/or diastolic blood pressure 110 mmHg occur for at least six hours. These criteria distinguish gestational hypertension from chronic hypertension (hypertension antedates pregnancy or develops before the 20th week of pregnancy). A. Current Trends about the Condition A.1 International Statistics Recent data shows that gestational diabetes mellitus (GDM) prevalence has increased by 10100% in several race/ethnicity groups during the past 20 years. A true increase in the prevalence of GDM, aside from its adverse consequences for infants in the newborn period, might also reflect or contribute to the current patterns of increasing diabetes and obesity, especially in the offspring. The prevalence of gestational diabetes is strongly related to the patient's race and culture. Prevalence rates are higher in African, Hispanic, Native American and Asian women than in white women. Typically, only 1.5-2% of Caucasian women develop gestational diabetes mellitus, while Native Americans from the southwestern United States may have rates as high as 15%.In Hispanic, African American, and Asian populations, the incidence is 5-8%. In these high-risk populations, the recurrence risk with future pregnancies has been reported to be as high as 68%. In addition, approximately one-third will develop overt diabetes mellitus within 5 years of delivery, with higher risk ethnicities having risks nearing 50%. Race 2|Page

also influences many complications of diabetes mellitus in pregnancy. For instance, African Americans have been shown to have lower rates of macrosomia, despite similar levels of glycemic control. Conversely, Hispanic women have higher rates of macrosomia and birth injury than women of other ethnicities, even with aggressive management. A.2 Statistics in Asia In this global epidemic of gestational diabetes mellitus, Asian countries undergoing economic and nutritional transitions have experienced a particularly notable increase. In China, the prevalence of diabetes increased from 1% in 1980 to 5.5% in 2001, with much higher rates in urban areas such as Shanghai. Nearly 10% of Chinese adults residing in affluent regions such as Hong Kong and Taiwan have diabetes. Among individuals with diabetes, two-thirds in Mainland China and one-half in Hong Kong and Taiwan remain undiagnosed. In urban Indian adults, GDM prevalence increased from 3% in the early 1970s to 12% in 2000, with a narrowing rural-urban gradient. In 2006, the rate of type 2 diabetes in rural South India was 9.2%, compared with an increase in urban South India from 13.9% in 2000 to 18.6% in 2006. In rural Bangladesh, prevalence of diabetes increased from 2.3% to 6.8% between 1999 and 2004. In a national survey in 2001, 8% of Korean adults had this endocrine disorder, with little difference between urban and rural areas. In a nationwide survey in Singapore in 1998, Indians had the highest prevalence (12.8%), followed by Malays (11.3%) and Chinese (8.4%). Similarly, 11% of Malays living in Malaysia have it. Other Asian countries including Japan, Philippines, Sri Lanka, Indonesia, Thailand, and Vietnam also have experienced a marked increase in prevalence of GDM. While some Asian countries like China and India have a very large number of patients with diabetes, the prevalence can be as high as 40% in some Pacific Island populations. A.3 Maternal Morbidity Maternal morbidity due to GDM may be immediate or long-term. Many studies have documented an increase in pre-eclampsia, polyhydramnios, and operative delivery in pregnancies complicated by GDM. The prospective cohort study which evaluates maternal and fetal outcomes of increasing carbohydrate intolerance observed a significant association between glucose intolerance and an increased incidence of cesarean delivery, preeclampsia, and length of maternal hospitalization. Women with GDM also have a significant risk of developing diabetes later in life. Researches about former gestational diabetic women and found diabetes or impaired glucose tolerance (IGT) in 6% of those tested at 02 years, 13% at 34 years, 15% at 56 years, and 30% at 710 years postpartum. Other studies have documented type 2 diabetes 35 years postpartum in 3050% of women who had a pregnancy complicated by GDM. Episodes of insulin resistance due to additional pregnancies increased the rate of developing type 2 diabetes independent of pregnancy3|Page

associated weight gain. They also found the relative risk for type 2 diabetes was 1.95 for each 10 pounds gained during follow-up after adjusting for the number of pregnancies and other risk factors. The implications of GDM are significant, since women with prior GDM are at greater risk for developing hypertension, hyperlipidemia, electrocardiogram abnormalities, and mortality. Clients with GDM have higher triglycerides, free fatty acids, and beta-hydroxybutyrate and lower high-density level (HDL) cholesterol than pregnant-controlled subjects. These metabolic differences persisted when body mass index was considered. They have a significantly higher total cholesterol, triglycerides, low-density level (LDL) cholesterol levels, and systolic blood pressure than in previous GDM patients. These data suggest that women with prior GDM have lipid abnormalities that have been correlated with cardiovascular risk. A.4 Perinatal Morbidity and Mortality Infants of mothers with GDM are not at increased risk for congenital anomalies unless these women have pre-existing diabetes mellitus. However, these neonates do have an increased risk of perinatal mortality and morbidity, including hyperbilirubinemia, macrosomia and birth trauma, and hypoglycemia.Increase in perinatal mortality rates in pregnancies is complicated by improperly managed GDM. Several other studies have found an increased rate of stillbirths in untreated GDM. Today, in pregnancies identified and treated appropriately, intrauterine fetal demise is not increased in GDM. Infants have an increased risk of macrosomia, defined as fetal weight >90th percentile for gestational age or >4,000 grams. Macrosomia complicates 20% of GDM pregnancies. Maternal hyperglycemia leads to fetal hyperglycemia and fetal hyperinsulinemia with subsequent increases in fetal growth. Fetal growth occurs preferentially in adipose and liver tissue, both of which are insulin-sensitive. This growth pattern of increased adiposity and organomegaly (enlargement of the organs) leads to a disproportionate increase in trunk and shoulder girth compared to head circumference. Consequently, shoulder dystocia is increased two- to six fold. The risk of shoulder dystocia is even further increased in IGDM with fetal weight >4,000 g. Brachial plexus injury is one of the most serious complications associated with shoulder dystocia. The incidence increases with fetal weight and occurs in 35% of infants weighing <4,500 g and 1530% of infants weighing >4,500 g. Most brachial plexus injuries (8090%) will completely resolve in the first year, and an additional percentage will have partial recovery. Between 0.2% and 2% will continue to manifest a permanent injury. Neonatal hypoglycemia is a common and a transient complication. It occurs in 50% of macrosomic infants and in 515% of infants of mothers with optimally controlled GDM. The neonate experiences a drop in blood glucose levels at delivery when the cord is clamped and continues to have exaggerated insulin release secondary to pancreatic -cell hyperplasia. Control of maternal diabetes during the latter half of 4|Page

pregnancy and during labor and delivery influences the occurrence of neonatal hypoglycemia. The frequency of hypoglycemia increases significantly when maternal blood glucose during labor and delivery exceeds 90 mg/dl. A.5 Treatment Researchers in Australia and New Zealand found that implanted insulin pump therapy helped women with severe gestational diabetes. The study was fairly small wherein 30 women used the implanted pumps out of 251 women with gestational diabetes. But researchers note that such pumps are often used successfully by pregnant women who've had type 1 diabetes since childhood. Now, it appears, there's a second, larger group of women who can benefit from the technology. In fact, pump therapy controlled hyperglycemia, or high blood sugar, better than insulin shots, and none of the mothers suffered an episode of low blood sugar. Their babies' health was comparable to infants born to mothers with less severe gestational diabetes. B. Reason for choosing such Case Study This study of a post-operative client with Gestational Diabetes Mellitus intends to provide and share information to: allow nursing students to help them picture and foresee patients experiencing GDM and to guide them how to apply patient-centered nursing interventions for the patients condition. impart knowledge and information to childbearing and childrearing individuals and to other people who are interested in the abovementioned study and on what types of management are applicable and appropriate when experiencing this conditions stated. C. Objectives C.1 General Objectives: Our case study aims to enhance the knowledge of nursing students who had or will encounter this kind of disease, to educate the reproductive women regarding the said endocrine disorder, its complications, associated risk factors and appropriate clinical interventions needed during the manifestation of the condition and to develop the awareness of other health care providers about this particular kind of situation, which in effect enhance their skills in providing quality nursing care.

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C.2 Specific Objectives: C.2.1 Client-centered objectives: 1. To inform the patient about the complications of Gestational Diabetes Mellitus 2. To allow patient to gain learning about her health condition and how she can cope up with it 3. To convey the significant changes and its interpretation of her status during postpartum period 4. To impart knowledge about post-operative complications in relation with the nursing process to achieve quality maternal and child nursing care C.2.2 Student-centered objectives: 1. To assess the patient and her family for the deviations or complications of normal pregnancy 2. To impart the necessary knowledge and information regarding Gestational Diabetes Mellitus and its complications 3. To formulate appropriate nursing care plan related to a complicated postpartum period 4. To evaluate expected outcomes for the effectiveness of care for GDM patients II. NURSING ASSESSMENT A. Biographic Profile of the Patient Name: MIS Age: 38 years old Sex: Female Civil Status: Single Position in the Family: Mother of 2 children Address: Iba o Este, Calumpit, Bulacan Date of Birth: January 6, 1972 Place of Birth: Gapan, Nueva Ecija Nationality: Filipino 6|Page

Race: Asian Religion: Roman Catholic Educational Attainment: Primary Secondary Castillano Elementary School Liway Memorial High school

Health care Financing: Husbands remuneration Usual Source of Medical Care: Baranggay Health Center Date of Admission: February 7, 2010, 6:30 PM Date of Discharge: February 11, 2010, 4:30 PM Provisional Diagnosis: PU 39 weeks 3/7 days Age of Gestation Final Diagnosis: PU delivered by LTCS to an alive baby girl cephalic presentation, G3P2 (2012) due to Gestational Diabetes Mellitus with Gestational Hypertension B. Chief Complaint and Reason for Visit "Noong bandang hapon ng February 7, sumakit na yung tiyan ko, nagle-labor na pala ako kaya isinugod agad ako sa ospital nung alas sais ng hapon, as verbalized by the patient. The patient was urgently brought to the hospital because of frequent contractions with strong intensity. C. History of Past Illness MIS had Chickenpox and Mumps in her childhood years, as well as intermittent episodes of common colds and dry cough. "Nagkabeke at nabulutong na ko nung bata ko, minsan nagkakasipon at ubo din ako" as the patient verbalized. She also had complete immunizations given in childhood years and three Tetanus Toxoid shots (TT1 to TT3) in her 2nd pregnancy.

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D.

History of Present Illness The patient mentioned upon interview that her present condition started, as well as Gestational Hypertension and Urinary Tract Infection, when she had her first child. "Mayroon akong Diabetes sa pagbubuntis ko sa first baby ko at nagka-UTI at na-highblood din ako noon sa unang pagbubuntis ko," as verbalized by the patient. In her current pregnancy, the patient was not aware that her previous endocrine disease occurs again, until she had her first prenatal check-up in her 6th month of conception. MIS was not able to recognize any specific signs or symptoms associated to GDM, as she thought that the increased periods of thirst, hunger and urination was only because of her pregnancy. Akala ko wala akong sakit, kasi kapag buntis naman di ba laging nagugutom at naiihi, as she verbalized.

E.

Family Health History of Illness The patients nuclear family and relatives are in optimal health condition for the past 3 weeks. In her maternal side, her mother as well as her uncle and aunts were diagnosed with Hypertension. On the other hand, our patients grandparents and one of her uncles in her paternal side passed away because of their old age.

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E.1 Genogram of the Patient PATERNAL MATERNAL

TS 85

RS 84

GI 86

MN 88

LS 68

MS 66

SS 64

RS 36

CM 66

JS 64

MP 60

AI 58

TI 57

MS 55

VA 51

LEGEND:
Client Female

Male
Hypertension Gestational Hypertension Gestational Diabetes Mellitus Urinary Tract Infection Deceased

RS 39 MIS 38

MAS 33

GM 31 HR 41

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F.

Functional Health Patterns

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FUNCTIONAL HEALTH PATTERN

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION

Health Perception and Health Management Pattern

MIS general health was in an optimal condition (was rated 9, after assessing her health before hospitalization). She maintains a healthy body by following the advices from her immediate family members, having regular time for exercise suitable for her, and maintaining enough sleep and rest. She does not smoke, drink any alcoholic beverages, and use drugs as well. She doesnt believe in faith healers and often practices self-medication for common illnesses. Her check-ups from the healthcare providers in their nearest District Hospital serves as a tool in monitoring and managing her health. The patient defined health as the energy and capability to do things whereas illness is the opposite of being healthy wherein a person becomes unhappy and pale.

The clients health condition, as she had reported, was due to her hypertensive clan in her mothers side and eating habits. A rating of 7 was given; a result of her own observations and assessments. Necessary action (check-up in their nearby healthcare facility) was done. She is expecting to recover with the help of the health care providers attending to her needs and the assurance of the efficiency and potency of the medications given to her.

Nutritional and Metabolic Pattern

The patients food intake for the entirety of her 3rd pregnancy has a remarkable increase and difference, as to what she eats before getting pregnant. She usually consumes at least 2 cups of steamed rice during meals with high-fat viands. Her water intake also increased to at least 8 glasses of water/day from her regular fluid consumption of 4-7 glasses. Snacks inbetween meals become more frequent, eating carbohydrate-rich foods with fruit juices or bottled sodas as her beverage. As a result, MIS gained too much weight for about 20 kilograms. In addition, our

MIS was not able to get the enough nourishment from a regular diet due to an NPO order from his physician before the operation had started. Intravenous Fluids such as D5LR and Plain NSS were infused to our client to maintain her adequate fluid and electrolyte supply temporarily. After she became positive for the presence of flatus, a full liquid (tea and cracker) diet was followed, still restricting the introduction of several foods. When she defected, an order to change her diet into soft diet was immediately carried out to start gaining nourishment from foods that can be easily digested and are soft in consistency. Meal February 8, 2010 February 9, 2010 February 10, 201011 | P a g e 1 pack of cracker and 1cup of tea

Breakfast

NPO

NPO

Lunch

NPO

NPO 1 pack of crackers and 1 cup of tea

Dinner

NPO

G.

Growth and Development Freuds Five Stages of Development

STAGE

CHARACTERISTICS Energy is toward full sex maturity and function and development of skills needed to cope with the environment.

SIGNIFICANT BEHAVIOR The client is separated from her parents but she doesnt show any untoward reaction with this situation because she know that she has a supportive family that would help her not to be dependent to her parents. She can also decide for herself as well as for her family.

Genital

Eriksons Eight Stages of Development

STAGE

CENTRAL TASK

Adulthood

Generativity Versus Stagnation

SIGNIFICANT BEHAVIOR The client settles down with in a relationship. She helps her husband to raise their children properly. She wants her children to reach their dreams. The client shows sign of concern and affection to her family. She prioritizes the needs and sometimes the wants of her family. 12 | P a g e

 Piagets Phases of Cognitive Development

PHASES AND STAGES Formal Operations Phase

CHARACTERISTICS Uses rational thinking. Reasoning is deductive and futuristic.

SIGNIFICANT BEHAVIOR The client thinks rationally and finds a reason first before making a rational decision. She thinks the consequences of doing or not doing something if it will benefit or harm her family or not.

Kohlbergs Stages of Moral Development

LEVEL Post conventional The person lives autonomously and defines moral values and principles that are distinct from personal identification with group values. She lives according to principles that are universally agreed on and that the person considers appropriate for life.

STAGE Social Contract Legalistic Orientation The social rules are not the sole basis for decisions and behavior because the person believes a higher moral principle applies such as equality, justice, or due process.

SIGNIFICANT BEHAVIOR The client makes an effort to define valid values without regard to authority or to the expectations of others by following her personal identification. She would all want certain basic rights, such as liberty and life, to be protected and justice should be involved. 13 | P a g e

 Westerhoffs Stages of Faith Development

STAGE Owned Faith III. ANATOMY AND PHYSIOLOGY A. Reproductive System Changes in Pregnancy A.1 Uterine Changes

CHARACTERISTICS Puts faith into personal and social action and is willing to stand up for what the individual believes even against the nurturing community.

SIGNIFICANT BEHAVIOR According to the client, her way of being or behaving is based on what she believes. She takes responsibility for her personal faith. It becomes apart of her and impacts her decisions, choices, and actions

The most obvious alteration in the womans body during pregnancy is the increase in the size of the uterus to accommodate the growing fetus. Over the 10 lunar months of pregnancy, the uterus increase in length, depth, width, weight, wall thickness and volume. Length grows from approximately 6.5 to 32 cm Depth increases from 2.5 to 22cm Width expands from 4 to 24 cm. Early in pregnancy, the uterine wall thickens from about 1 cm to about 2 cm; toward the end of pregnancy, the wall thins to become supple not only about 0.5 cm thick. The volume of the uterus increases from about 2 ml to more than 1,000 ml of amniotic fluid for a total of about 400g. This great uterine growth is due partly to formation of a few new muscle fibers in the uterine myometrium but principally to the stretching of existing muscle fibers: by the end of pregnancy, muscle fibers in the uterus have become two to seven times longer than they were before pregnancy. The uterus is able to withstand this stretching of its muscle fibers because of the formation of extra fibroelastic tissue 14 | P a g e

between fibers, which binds them closely together. Because uterine fibers simply stretch during pregnancy and are not newly built, the uterus is able to return to is pregnant state at the end of the pregnancy with little difficulty and almost no destruction of tissue.

The uterine height is measured from the top of symphysis pubis over the top of the uterine 3.1 Anatomy of the Uterus of a Non-pregnant fundus. Because a uterine tumor could mimic this steady growth, uterine Figure Figure 3.2 Anatomy of the Uterus of a Pregnant Client growth is only a presumptive sign of pregnancy. The exact shape of the expanding uterus is influenced by the position of the fetus inside. The fundus of the uterus usually remains in the midline during pregnancy, although it may be pushed slightly to the right side because of the larger bulk of the sigmoid colon on the left. As the uterus increase in size, it pushes the intestines to the sides of the abdomen, elevates the diaphragm and liver, compresses the stomach and puts pressure on the bladder. Uterine blood flow increases during pregnancy as the placenta grows and requires more and more blood for perfusion. A.2 Amenorrhea It occurs with pregnancy because of the suppression of follicle-stimulating hormone (FSH) by rising estrogen levels. In a healthy woman who has menstruated previously, the absence of menstruation strongly suggests that impregnation has occurred. A.3 Cervical Changes

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In response to the increased level of circulating estrogen from the placenta during pregnancy, the cervix of the uterus becomes more vascular and edematous. Increased fluid between cells causes the cervix to soften in consistency, and increased vascularity causes it to darken from a pale pink to a violet hue. Softening of the cervix in pregnancy (Goodells sign) is marked. The consistency of a nonpregnant cervix may be compared with that of the nose, whereas the consistency of a pregnant cervix more closely resembles that of an earlobe. Just before labor, the cervix becomes so soft that it takes on the consistency of butter or is said to be ripe for birth.

A.4 Vaginal Changes

Figure 3.3 Cervix of a Non-pregnant

Figure 3.4 Cervix of a Pregnant Woman

Under the influence of estrogen, the vaginal epithelium and underlying tissue become hypertrophic and enriched with glycogen; structures loosen from their connective tissue attachments in preparation for great distention at birth. This increase in the activity of the epithelial cells results in a white vaginal discharge throughout pregnancy. An increase in vascularity of the vagina, beginning early in pregnancy, parallels the vascular changes in the uterus. The resulting increase in circulation changes the color of the vaginal walls from the normal light pink to a deep violet (Chadwicks sign), a probable sign of pregnancy. A.5 Ovarian Changes Ovulation stops with pregnancy because of the active feedback mechanism of estrogen and progesterone produced by the corpus luteumearly in pregnancy and by the placenta later in pregnancy. This feedback causes the pituitary gland to halt the production of FSH and luteinizing hormone (LH). Without stimulation of these hormones, ovulation does not occur 16 | P a g e

A.6 Changes in the Breast Subtle changes in the breasts that occur as a result of estrogen and progesterone production may be one of the first physiologic changes of pregnancy a woman notices. She may experience a feeling of fullness, tingling, or tenderness in her breasts because of the increased stimulation of breast tissue by the high estrogen level in the body. As pregnancy progresses, breast size increases because of hyperplasia of the mammary alveoli and fat deposits. The areola of the nipple darkens, and its diameter increases from about 3.5 cm to 5 0r 7.5 cm. There is additional darkening of the skin surrounding the areola in some women, forming a secondary areola. As vascularity increases, blue veins may become prominent over the surface of the breasts. The sebaceous glands of the areola enlarge and become protuberant.

B.

Systemic Changes in Pregnancy Figure 3.5 Breasts of a Non-pregnant B.1 Integumentary System Figure 3.6 Breast of a Pregnant Woman

As the uterus increases in size, the abdominal wall must stretch to accommodate it. This stretching can cause rupture and atrophy of small segments of the connective layer of the skin. This leads to pink or reddish streaks (striae gravidarum) appearing on the sides of the abdominal wall and sometimes on the thighs. During the week after birth, striae gravidarum lighten to silvery-white color (striae albicantes or atrophicae), and, although permanent, they become barely noticeable. Extra pigmentation generally appears on the abdominal wall. A narrow, brown line (linea nigra) may form running from the umbilicus to the symphysis pubis and separating the abdomen into right and left hemispheres. Darkened areas may appear on the face as well, particularly on the cheeks and across the nose. This is known as melasma (chloasma) or the mask of pregnancy. These increases in pigmentation are caused by melanocyte-stimulating hormone produced by the pituitary.

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Figure 3.7 Skin of a Non-pregnant

Figure 3.8 Skin of a Pregnant Client with Striae Gravidarum

Figure 3.9 Facial Skin of a Pregnant Client with Chloasma B.2 Respiratory System

Figure 3.9 Skin of a Pregnant Client with Linea Nigra

A local change that often occurs in the respiratory system is marked congestion, or stuffiness, of the nasopharynx, a response to increased estrogen levels. As the uterus enlarges during pregnancy, a great deal; of pressure is put on the diaphragm and ultimately, on the lungs. The diaphragm may be displaced by as much as 4 cm upward. This crowding of the chest cavity causes an acute sensation of shortness of breath late in pregnancy, until lightening relieves the pressure. Variable Vital Capacity Tidal volume Respiratory rate Residual volume Plasma PCO2 Plasma pH Plasma PO2 Change No change Increased by 30%-40% Increased, 1 or 2 minute Decreased by 20% Decreased to about 27-32 mm Hg Increased to 7.40 -7.45 Increased to 104-108 mmHg 18 | P a g e

Respiratory minute volume Expiratory reserve

Increased by 40 % Decreased by 20 %

Table 3.1 Respiratory Changes during Pregnancy B.3 Cardiovascular System B.3.1 Blood Volume To provide for an adequate exchange of nutrients in the placenta and to provide adequate blood to compensate for blood loss at birth, the total circulatory blood volume of the womans body increases by at least 30% (and possibly as much as 50%) during pregnancy. Blood loss at a normal vaginal birth is about 300 to 400 ml; blood loss from a caesarian birth can be as high as 800 to 1,000 mL. The increase in blood volume occurs gradually, beginning at the end of the first trimester. Because the plasma volume increases faster than red blood cell production does, the concentration of hemoglobin and erythrocytes may decline, giving the woman a pseudoanemia early in pregnancy. The womans body compensates for this change by producing more red blood cells again by the second trimester. B.3.2 Iron Needs Almost all women need some iron supplementation during pregnancy because of a variety of factors. The fetus requires a total of about 350 to 400 mg of iron to grow. The increases in the mothers circulatory red blood cell mass require an additional 400 mg of iron. This is a total increased need of about 800 mg. Because the average womans store of iron is less than this amount (about 500 mg), and because iron absorption may be impaired during pregnancy as a result of decreased gastric acidity (iron is absorbed best from an acid medium), additional iron is often prescribed during pregnancy to prevent a true anemia. Either a hemoglobin concentration is less than 11.5 g/100 mL or a hematocrit value below 30% is considered true anemia, for which iron therapy above normal supplementation is advocated. The need for folic acid increases even more during pregnancy; if the intake of folic acid is not great enough, megalohemoglobinemia (large, nonfunctioning red blood cells) will result. Prenatal vitamins that contain folic acid are routinely prescribed. B.3.3 Heart 19 | P a g e

To handle the increase in blood volume in the circulatory system, a womans cardiac output increases significantly, by 25% to 50%; the heart rate increases by 10 beats per minute. Like the circulating volume increase, the bulk of the cardiac work increase in the third trimester. However, this rise in circulating load has implications for the woman with cardiac disease. Because the diaphragm is pushed upward by growing uterus late in pregnancy, the heart is shifted to a more transverse position in the chest cavity, a position that may make it appear enlarged on x-ray examination. Some women have audible functional (innocent) heart murmurs during pregnancy, probably because of the altered heart position. Palpitations of the heart are not uncommon during pregnancy, particularly on quick motion. Palpitations in the early months of pregnancy are probably caused by sympathetic nervous system stimulation; in later months, they may result from increased thoracic pressure caused by the pressure of the uterus against the diaphragm.

B.3.4 Blood Pressure Despite the hypervolemia of pregnancy, the blood pressure does not normally rise because the increased heart action takes care of the greater amount of circulating blood. In most women, blood pressure actually decreases slightly during the second trimester because the peripheral resistance to circulation is lowered as the placenta expands rapidly. During the third trimester, the blood pressure rises again to first-trimester levels. B.4 Gastrointestinal System As the uterus increases in size, it tends to push the stomach and intestines toward the back and sides of the abdomen. At about the midpoint of pregnancy, this pressure may be sufficient to slow intestinal peristalsis and the emptying time of the stomach, leading to heartburn, constipation and flatulence. Pressure from the uterus on veins returning from the lower extremities can lead to hemorrhoids. At least 50% of women experience some nausea and vomiting early in pregnancy. This is one of the first sensations a woman may experience with pregnancy. It is most apparent early in the morning, on rising, or if the women who smoke cigarettes. Known as morning 20 | P a g e

sickness, nausea and vomiting begin to be noticed at the same time levels of hCG and progesterone begin to rise. Sickness may occur as a systemic reaction to increased estrogen levels or decreased glucose levels, because glucose is being used in such great quantities by the growing fetus.

Figure 3.10 Hemorrhoids B.5 Urinary System Changes in the urinary system result from the following: Effects of high estrogen and progesterone levels Compression of the bladder and ureters by the growing uterus Increased blood volume Postural influences B.5.1 Fluid Retention To provide sufficient fluid volume for effective placental exchange, total body water increases to 7.5 L; this requires the body to increase its sodium reabsorption in the tubules to maintain osmolarity. Under the influence of progesterone, there is an increased response of angiotensin-renin system in the kidney, which leads to an increase in aldosterone production. Aldosterone aids sodium reabsorption. Progesterone appears to be potassium-sparing, so that even with an increased urine output, potassium levels remain adequate. B.6 Skeletal System 21 | P a g e

Calcium and phosphorus needs are increased during pregnancy, because the fetal skeleton must be built. As pregnancy advances, there is a gradual softening of the womans pelvic ligaments and joints to create pliability and to facilitate passage of the baby through the pelvis at birth. This softening is probably caused by the influence of both ovarian hormone relaxin and placental progesterone. Excessive mobility of the joints can cause discomfort. A wide separation of the symphysis pubis, as much as 3 to4 mm by 32 weeks of pregnancy, may occur. This makes women walk with difficulty because of pain. To change her center of gravity and make ambulation easier, a pregnant woman tends to stand straighter and taller than usual. This stance is referred to as the pride of pregnancy. Standing this way, with the shoulders back and abdomen forward, creates a lordosis (forward curve of the lumbar spine), which may lead to backache.

B.7 Endocrine System B.7.1 Placenta Figure 3.11 Lordotic Client The most striking change in the endocrine system during pregnancy is the addition of the placenta as an endocrine organ that produces large amounts of estrogen, progesterone, hCG, human placental lactogen, relaxin and prostaglandins. Estrogen causes breast and uterine enlargement. Progesterone has a major role in maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of the breast for lactation. Relaxin, secreted primarily by the corpus luteum, is responsible for helping to inhibit uterine activity and to soften the cervix and the collagen in the joints. hCG is secreted by the trophoblast cells of the placenta in early pregnancy. It stimulates progesterone and estrogen synthesis in the ovaries until the placenta can assume this role. hPL, is also known as human chorionic somatomammotropin, is also produced by the placenta. It serves as an antagonist to insulin, making insulin less effective, which allows more glucose to become available for fetal growth. In addition to these changes, prostaglandins are found and the deciduas during pregnancy. Prostaglandins affect smooth muscle contractility to such an extent they may be trigger that initiates labor at term. B.7.2 Pituitary Gland 22 | P a g e

The pituitary gland is affected by pregnancy, because there is a halt in the production of FSH and LH brought on by the high estrogen and progesterone levels of the placenta. There is increased production of growth hormone and melanocyte-stimulating hormone (which causes skin pigment changes). Late in pregnancy, the posterior pituitary begins to produce oxytocin, which will be needed to aid labor. Prolactin production is also begun late in pregnancy, as the breasts prepare for lactation. B.7.3 Thyroid and Parathyroid Glands The thyroid gland enlarges in early pregnancy to such an extent that the basal metabolic rate increases by about 20%. Levels of protein-bound iodine, butanol-extractable iodine and thyroxine are all elevated in blood serum. If a sufficient supply of iodine is not present during pregnancy, goiter (thyroid hypertrophy) can occur as the gland intensifies its productive effort The parathyroid glands, which are necessary for the metabolism of calcium, also increase in size during pregnancy. Because calcium is important for fetal growth, the hypertrophy is probably necessary to satisfy the increased requirement of calcium. B.7.4 Adrenal Glands Adrenal gland activity increases in pregnancy as increased levels of corticosteroids and aldosterone are produced. It is assumed that these increased levels in aid in suppressing an inflammatory reaction for help to reduce the possibility of the womans body rejecting the foreign protein of the fetus, the same as it would a foreign tissue transplant. They also help to regulate glucose metabolism in the woman. The increased level of aldosterone aids in promoting sodium reabsorption and maintaining osmolarity in the amount if fluid retained. This indirectly helps to safeguard the blood volume and to provide adequate perfusion pressure across the placenta. B.8 Immune System Immunologic competency during pregnancy apparently decreases, probably to prevent the womans body from rejecting the fetus as if it were a transplanted organ. Immunoglobulin G (IgG) production is particularly decreased, which can make a woman more prone to infection during pregnancy. A simultaneous increase in the white blood cell count may help to counteract the decrease in IgG response. C. Physical Assessment 23 | P a g e

Name: MIS Age: 38 years old Date Taken: February 10, 2010 Time Taken: 11:35 AM 12:50 PM V/S: Temperature 37.9 C Pulse Rate 97 bpm Respiratory Rate 18 cpm Blood Pressure 140 / 90 mmHg Anthropometric Measurements: Height: 5 ft 2in Weight: 75 kg Body Mass Index: 29.86, Obese

24 | P a g e

ASSESSMENT

TECHNIQUE USED

NORMAL FINDINGS A. GENERAL APPEARANCE

ACTUAL FINDINGS

REMARKS

Observe body built, height, and weight Inspection in relation to the patients age, lifestyle and health PATIENT AND HER ILLNESS IV. THE Observe clients posture, and gait, Inspection standing, sitting, and walking Observe the clients over-all hygiene and grooming Describe body and breath odor Identify signs of distress in posture or facial expression Identify obvious signs of health or illness Describe clients attitude Describe clients affect/mood; assess the appropriateness of the clients responses Describe quantity of speech, quality and organization Listen for relevance and organization of thoughts Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection

Proportionate, varies with lifestyle Relaxed, lordotic posture; coordinated movement Clean, neat No body odor or minor body odor relative to work or exercise; no breath odor No distress noted Healthy appearance Cooperative Appropriate to situation Understandable, moderate pace; exhibits thought association Logical sequence; makes sense; has sense of reality

Obese, mesomorph in appearance Her posture was relaxed and upright. She has coordinated movement Client was untidy and messy in appearance Unusual body and breath odor Deep breathing and bending over because of abdominal pain Slightly weak and weary in appearance Cooperative, followed instruction when asked to do Answers question when asked, and able to follow instructions with a good mood Speech is in an understandable and in moderate pace Responses are appropriate to situation

DUE TO PREGNANCY AND EXCESSIVE FOOD INTAKE NORMAL DUE TO LACK OF CARE IN APPEARANCE AND GROOMING DUE TO THE ABSENCE OF WASH AREA / LACK OF HYGIENIC MEASURES DUE TO SURGICAL INCISION DUE TO SURGICAL INCISION AND LACK OF CONDUCIVE ENVIRONMENT NORMAL NORMAL NORMAL NORMAL

B. INTEGUMENTARY SYSTEM B.1 SKIN Inspect skin color Inspection Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive Generally uniform except in areas exposed to the sun; areas of lighter pigmentation in darkBrown color NORMAL 25 | P a g e Uniform, except in the areas where hyperpigmentation is present DUE TO PREGNANCY

Inspect uniformity of skin color

Inspection

i.

Pathophysiology

A. Schematic Diagram
Patient, 38 y/o, Multipara

NON MODIFIABLE FACTORS

MODIFIABLE FACTORS

Age Pregnancy
Cell Membrane Alteration Impairment in the function of pancreatic cells Impaired insulin secretion Resistance of cells to insulins ability to stimulate glucose utilization and to suppress both glucose production and fatty acid levels Serum levels of Estrogen, Progesterone and other hormones Level of leptin Content of fat in liver Level of

Obesity

INTRACELLULAR HYPOGLYCEMIA Insufficient glucose supply in cells

EXTRACELLULAR HYPERGLYCEMIA Increased glucose levels in blood

26 | P a g e

Energy (ATP) production WEAKNESS

Cellular starvatio n Stimulation of the Satiety Center of the Excessive Hunger (POLYPHAG IA)

Glucagon release Gluconeogenesis

Blood sugar level exceeds renal threshol Incomplete reabsorpti on of glucose Excess glucose is excreted in the urine (GLYCOSURIA) Glucose attracts water during urination (osmotic diuretic

Osmotic pressure in the blood stream Fluid shifts from intracellular to extracellular

Chronic elevation of blood glucose throughout

Protein synthesis Gamma globulins Susceptibility to infection

Protein glycation in the endothelial cells

Blood volume

URINARY TRACT INFECTION

Elasticity of the endothelium (endothelial dysfunction)

Volume of urine to be excreted (POLYURIA) Stimulation thirst Excessive of the Thirst Center of sensation Cellthe Brain (POLYDIPSIA) dehydration Excessive fluid

Microangiopat 27 hy a g e |P

Periph eral resistance Blood Pressure (Gestational Hypertensio n) Utero placental blood flow Fetal Distress Caesarian Delivery

B. Definition of the Disease

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Gestational diabetes mellitus is defined as any degree of glucose intolerance that has its onset or is first diagnosed during pregnancy. It complicates about 7% of all pregnancies. Women who are markedly obese, have a prior history of GDM, have glycosuria, or have strong family history of diabetes are at high risk. The incidence of GDM also increases with maternal age. Except for showing an impaired tolerance to glucose, the woman may remain asymptomatic or may have a mild form of the disease. Diagnosis of GDM is important, however, because even mild diabetes causes increased risk for perinatal morbidity and mortality. Furthermore, with time, many women with GDM progress to overt type 2 diabetes mellitus. Gestational (transient) hypertension is characterized by a rise in blood pressure, usually in late pregnancy, which returns to normal within 12 weeks of delivery (either before, during, or after labor). Gestational hypertension is most likely: (i) during a woman's first pregnancy, (ii) in women who are pregnant with twins or triplets, and (iii) in those who had pregnancy-related hypertension in an earlier pregnancy. Gestational hypertension is a relatively mild hypertensive disorder that does not affect a woman's pregnancy. Its diagnosis can only be confirmed after delivery. If hypertension does not resolve or if proteinuria (protein in your urine) or edema develop, you do not have gestational hypertension. During your pregnancy, your doctor monitors you carefully for these and other signs and symptoms. C. Predisposing and Precipitating Factors C.1 Predisposing Factor Age the risk of GDM increases as people get older. The structure of the cells slowly degenerates, causing different complications

C.2 Precipitating Factors Pregnancy normal pregnancy is often referred to as a diabetogenic state. The hormonal changes of normal pregnancy cause resistance to insulin use, which increases blood sugar. Women with marginally productive pancreatic cells may not be able to meet the additional needs for insulin and develop GDM Obesity elevated levels of free fatty acids, a common feature of obesity, may contribute to the pathogenesis of GDM. It can impair glucose utilization in skeletal muscles, promote glucose production by the liver and impair beta cell function. Obesity desensitizes (increase the resistance to the effects of leptin) a protein hormone called leptin, an adipose derived hormone that plays a role in regulating energy intake and energy expenditure. It also decreases the level of adinopectin, a hormone that controls sensitivity to insulin, in the bloodstream.

D. Signs and Symptoms of the Condition 29 | P a g e

SIGNS AND SYMTPOMS Polyuria

RATIONALE Due to the osmotic diuretic effect of the glucose, which attracts water during urination or voiding Due to the activation of the Thirst Center in the Hypothalamus resulting from the intracellular dehydration or fluid volume depletion Due to the decreased glucose uptake by the cells which leads to the stimulation of the Satiety Center of the Hypothalamus resulting to a hunger sensation Due to the excess glucose compared to the kidney threshold which results to the excretion of the sugar in the urine Due to the decreased glucose consumption by the cells leading to decreased energy or Adenosinetriphosphate production Due to the increased peripheral resistance of the blood vessels and blood volume Due to the decreased protein synthesis which leads to an inadequate number of immunoglobulin

DATE OF OCCURENCE 2nd -3rd trimester of Pregnancy

Polydipsia

2nd -3rd trimester of Pregnancy

Polyphagia

2nd -3rd trimester of Pregnancy

Glycosuria

2nd -3rd trimester of Pregnancy

Weakness Increased Blood Pressure (GH) Increased Susceptibility to Infection (UTI)

Whole Period of Pregnancy

Whole Period of Pregnancy 3rd Trimester of Pregnancy

E. Review of Systems 30 | P a g e

E.1 Endocrine System The hormonal changes of normal pregnancy cause resistance to insulin use, which increases blood sugar. High blood levels of glucose caused increased insulin production, which increases the rate of fat breakdown and protein synthesis, In this manner, additional amounts of glucose and amino acids are made available for fetal consumption, and an alternative source of fuelfree fatty acidsis provided for maternal energy requirements. Women with marginally productive pancreatic cells may not be able to meet the additional needs for insulin and develop gestational diabetes that resolves after delivery. Pancreas The actual amount of insulin produced is regulated by serum glucose levels. When serum glucose that passes through the pancreas exceeds 100mg/dL, beta cells increase insulin production. When blood serum levels are lowered, production decreases. Both the ability to secrete additional insulin and the action to decrease production are immediate responses. If glucose is unable to enter body cells because of a lack of insulin, it builds up in the bloodstream (hyperglycemia), and this underlying defect leads to other metabolic consequences. Placenta The placenta supplies a growing fetus with nutrients and water, as well as produces a variety of hormones to maintain the pregnancy. Some of these hormones (estrogen, cortisol, and human placental lactogen) can have a blocking effect on insulin, which usually begins about 20 to 24 weeks into the pregnancy. As the placenta grows, more of these hormones are produced, and insulin resistance becomes greater. Normally, the pancreas is able to make additional insulin to overcome insulin resistance, but when the production of insulin is not enough to overcome the effect of the placental hormones, gestational diabetes results. E.2 Urinary System The kidneys attempt to lower to normal levels by excreting glucose into the urine when the kidneys detect hyperglycemia (greater than the renal threshold of about 160 mg/dL). Glucose in the urine exerts osmotic pressure in the filtrate, resulting in a large volume of urine 31 | P a g e

excreted. Polyuria is indicated by urinary frequency, which is often noticed by the patient at night (nocturia) with the excretion of large volumes of fluid and electrolytes from the body tissues. During pregnancy, the urinary system undergoes physiologic changes. When a client has hypertension the kidneys is unable to excrete sodium, resulting in natriuretic factors such as atrial Natriuretic Factor being secreted to promote salt excretion with the side effect of raising total peripheral resistance, thus raising blood pressure. E.3 Immune System The immune system is affected when levels of glucose rise above normal. As a result, people with gestational diabetes or other forms of diabetes are at increased risk for developing an infection. Once a person with diabetes has developed an infection, the body is less capable of fighting it off because high glucose levels interfere with the normal action of white blood cells. E.4 Cardiovascular System Blood Pressure In pregnancy state, the arterial blood pressure remains the same as pre pregnancy level. It may drop slightly on the second trimester due to peripheral vasodilation but returns to normal level on third trimester. But when a woman develops an elevated blood pressure of 140/90 mmHg but has no proteinuria or edema, she then has a gestational hypertension. Many people with diabetes have hypertension (high blood pressure). Although high blood pressure causes few symptoms, it has two negative effects: it stresses the cardiovascular system and speeds the development of diabetic complications of the kidney and eye. Gestational diabetes can elevate the blood pressure of a patient due to increase activity of the heart in compensating with insulin deficit of the patient. In addition the heart pumps more blood to compensate the fluid loss because of urinary frequency during pregnancy and the effect of the diabetes.

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ii.

Diagnostic and Laboratory Procedures

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DIAGNOSTIC / LABORATORY PROCEDURE

DATE INDICATION ORDERED and S or DATE PURPOSE RESULT IN

RESULT

NORMAL VALUES

Urinalysis

1 month of pregnancy

st

To test for proteinuria, glycosuria and pyuria.

Positive for Urinary Tract Infection

Color: dark Transpare ncy: slightly turbid

ANALYSIS AND INTERPRETA NURSING RESPONSIBILITIES TION OF THE RESULTS The patient must then take PRIOR: antibacterial Explain the procedure to the patient drugs as and why it is needed prescribed by the Give the patient a clean vial and doctor because instruct to void directly into the of the infection. specimen bottle The infection is Provide privacy associated with DURING: pregnancy, poor Collect 10ml of urine collection perineal hygiene AFTER: and diabetes Prompt the delivery of the urine sample to the laboratory PRIOR: Explain the procedure to the patient and why it is indicated Inform the patient that fluid and food restriction is not required Tell the patient that she may experience transient discomfort from the needle puncture Fill up the laboratory request form properly and send it to the laboratory technician during the collection of the blood sample DURING: Inform the patient to calm down to avoid any discomfort and uneasiness AFTER: Apply pressure on the puncture site to prevent bleeding Apply warm compress if34 | P a g e Hematoma will develop at the site PRIOR: Explain the procedure to the client DURING:

Complete Blood Count WBC Count Lymphocytes Eosinophils Hemoglobin Hematocrit February 5, 2010; 9:05am

To see if there is an Anemia Infection

Hemoglobin: 147 g/L Hematocrit: 0.45

Hemoglobi n: 110-165 g/L Hematocri t: 0.35 - 0.5

The hemoglobin is normal, negative for anemia

V. THE PATIENT AND HER CARE A .Medical Management MEDICAL MANAGEMENT TREATMENT Intravenous Fluid Infusion DATE ORDERED/ DATE PERFORMED/ DATE CHANGED Date Ordered: 07 February 2010 Date Performed: 07 February 2010 GENERAL DESCRIPTION INDICATION/ PURPOSE Draws fluid out of the interstitial compartments into the vascular compartment, expanding vascular volume, in preparation for a surgical procedure Draws fluid out of the interstitial compartments into the vascular compartment, expanding vascular volume. CLIENTS RESPONSE TO TREATMENT Client was comfortable after the IVF insertion; no negative reactions observed. NURSING RESPONSIBILITIES PRIOR: Verify the physicians order Maintain Strict Aseptic Technique Examine the Solution Check expiration dates DURING: Administer IVF AFTER: Maintain occlusive dressing Monitor IV infusion system Inspect the appearance of the insertion site Maintain right client 35 | P a g e

1L D5LR regulated at KVO

Date Ordered: 08 February 2010 Date Performed: 08 - 09 February 2010

1L D5LR + 10 u oxytocin regulated at 30 gtts/min

Date Ordered: 08 February 2010 Date Performed: 08 February 2010

200cc of PNSS regulated at fast drip

Blood loss replacement because it stays in the vascular compartment, therefore expanding vascular volume.

positioning to relieve clients discomfort

B. Drugs ROUTE OF ADMINISTR ATION, DOSAGE, FREQUENCY Date Ordered: 19 mg TIV q 8 February 8, 2010 hours ANST Date Taken/Given: February 8, 2010 DATE ORDERED, TAKEN/GIVEN GENERAL ACTION, CLASSIFICATION, MECHANISM OF ACTION Interferes with bacterial-cell wall synthesis, causing cell to rupture. CLIENTS RESPONSE TO INDICATIONS/PURPO MEDICATION & SES ACTUAL SIDE EFFECTS Treatment of infections Client understood of respiratory tract, the purpose of urinary tract, skin and medication; no skin structures, biliary actual side effects tract, and bone and joint; noted

GENERIC NAME (BRAND NAME) Cefazolin Sodium

NURSING RESPONSIBILITIES PRIOR: Before giving drug, ask patients if he is allergic to penicillin or cephalosporins. Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin while awaiting results. If creatinine clearancefall below 55ml/minute, adjust dosage. DURING: After reconstitution, inject drugs I.M. without further dilution. This drug isnt as 36 | P a g e

Hydralazine Hydrochlorid e

Date Ordered: 5 mg/IV q 6 February 8, 2010 hours Date Taken/Given: February 8, 2010

Relaxes vascular smooth muscles of arteries and arterioles, causing peripheral vasodilation and decreasing peripheral vascular resistance. These actions decrease blood pressure and increase heart rate, stroke volume, and cardiac output.

Hypertension

Client understood the purpose of medication; no actual side effects noted

painful as other cephalosporin. Give injection deep into a large muscle, such as gluteus maximus or the side of the thigh. AFTER: If large doses are given, therapy is prolonged, or patient is at high risk, monitor patients for signs and symptoms of super- infection. PRIOR: Check blood pressure. Arrange for CBC, LE cell preparations, and ANA titers before therapy. Assess for contraindicated conditions. Observe the 15 rights of drug administration. Assess bowel sounds. Assess voiding pattern. DURING: Give oral drug with food. Use parenteral drug immediately after opening ampule. Discard discolored solutions. Arrange for CBC, LE cell preparations, and ANA titers during prolonged therapy. Instruct to take drug exactly as prescribed. 37 | P a g e

AFTER: Withdraw drug gradually. Discontinue if blood dyscrasias occur. Arrange for pyridoxine therapy if patient develops symptoms of peripheral neuritis. Monitor for orthostatic hypotension. Report persistent or severe constipation, unexplained fever or malaise, muscle or joint aching, chest pain, rash, numbness, tingling. Do proper documentation. Diclofenac Sodium Date Ordered: February 8, 2010 Date Taken/Given: February 8, 2010 50 mg/slow IV q 8 hours ANST x 3 doses Unclear. Thought to block activity of cyclooxygenase, thereby inhibiting inflammatory response of vasodilation and swelling and blocking transmission of painful stimuli Acute or long-term treatment of mild to moderate pain, including dysmenorrhea. Client understood the purpose of medication; no actual side effects noted PRIOR: Assess for history of renal impairment, impaired hearing; allergies, hepatic, CV, and GI conditions; lactation DURING: Administer drug with food or after meals if GI upset occurs. Take only the prescribed dosage. These side effects may occur: Dizziness, drowsiness (avoid driving or using dangerous machinery while using this drug). 38 | P a g e

AFTER: Arrange for periodic ophthalmologic exam during long-term therapy. Institute emergency procedures if overdose occurs (gastric lavage, induction of emesis, supportive therapy). Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision; black, tarry stools. Nalbuphine Hydrochlorid e Date Ordered: 10 mg IV q 6 February 8, 2010 prn Date Taken/Given: February 8, 2010 Nalbuphine acts as Relief of moderate to an agonist at specific severe pain. opioid receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at receptors. No actual side effects noted PRIOR: Constipation is often severe with maintenance therapy. Make sure stool softener or other laxative is ordered. Psychological and physical dependence may occur with prolonged use. Remind patient not to confuse Nubain with Navane. DURING: Nalbuphine acts as an opioid antagonist and may cause withdrawal syndrome. For patients who have received log-term opioids, give 25% of the usual dose initially. Watch for sings of withdrawal. Monitor circulatory and 39 | P a g e

Ranitidine

Date Ordered: 50 mg IV q 8 February 8, 2010 hours while on NPO Date Taken/Given: February 8, 2010

Competitively inhibits the action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin.

Short-term treatment of active duodenal ulcer Maintenance therapy for duodenal ulcer at reduced dosage Short-term treatment of active, benign gastric ulcer

No actual side effects noted

respiratory status, bladder and bowel function. If respirations are shallow or rate is below 12 breaths/minute, withhold dose and notify prescriber AFTER: Reassess patients level of pain at least 15 and 30 minutes after parenteral administration Alert: Drug causes respiratory depression, which at 10mg is equal to respiratory depression produced by 10 mg of morphine. PRIOR: Assess for history of allergy to ranitidine, impaired renal or hepatic function, lactation, pregnancy. DURING: 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 into large muscle group. AFTER: Arrange for regular followup, including blood tests to 40 | P a g e

Cephalexine

Date Ordered: 500 mg cap q 6 It is active against February 9, 2010 hrs many gram-positive aerobic cocci and Date much less active Taken/Given: against GramFebruary 9, 2010 negative bacteria. Effectively treats osteomyelitis, otitis media, streptococcal pharyngitis, prostate and respiratory infections, skin and urinary tract infections, eliminating or reducing infection.

GU infections caused by E. coli, P. mirabilis, Klebsiella

Client understood the purpose of medication; no actual side effects noted

Mefenamic Acid

Date Ordered: 500 mg cap q 6 Possesses antiFebruary 9, 2010 hours inflammatory, antipyretic and

Relief of pain including muscular, rheumatic, traumatic, dental, post-

Client was relieved; no actual side effects noted

evaluate effects. Report sore throat, fever, unusual bleeding or bruising, severe headache and etc. PRIOR: Arrange for culture and sensitivity tests of infection before and during therapy if infection does not resolve. This drug is prescribed for this particular infection; do not self-treat any other infection. DURING: Give drug with meals; arrange for small, frequent meals if GI complications occur. Take this drug with food. Refrigerate suspension; discard any drug after 14 days. Complete the full course of this drug even if you feel better. AFTER: Report severe diarrhea with blood, pus, or mucus; rash or hives; difficulty breathing; unusual tiredness, fatigue; unusual bleeding or bruising. PRIOR: Assess patients pain before therapy 41 | P a g e

Date Taken/Given: February 9, 2010

analgesic properties. Known to inhibit both prostaglandin and leukotriene synthesis, to have antibradyki-nin activity and to stabilize lysosomal membranes.

op and postpartum pain, headache, migraine, fever, dysmenorrheal.

DURING: Identify patient Assess client in semifowlers position Assess in administering the medication to the patient AFTER: Monitor for possible drug induced adverse reactions. Advice pt. not to take drug for more than 7 days. Advice patient to report immediately persistence or failure to relieve pain. Client understood the purpose of medication; no actual side effects noted PRIOR: Obatin baseline assessment of patients iron deficiency before starting therapy. DURING: Evaluate hemoglobin, hematocrit, and reticulocyte count during therapy. Be alert for adverse reactions and drug interactions. AFTER: Assess patients and familys knowledge of drug therapy.

Ferrous Sulfate

Date Ordered: 1 cap OD February 9, 2010 Date Taken/Given: February 9, 2010

Chemical effect: provides elemental iron, an essential component in formation of hemoglobin. Therapeutic effect: Relives iron deficiency.

Iron deficiency

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C. Diet

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TYPES OF DIET NPO

DATE STARTED Date Ordered: 07 February 2010 Date Started: 08 February 2010

GENERAL DESCRIPTION Nothing per Orem. The client cannot take anything, food and water alike, by mouth. Source of nutrition is through IVF.

INDICATIONS/ PURPOSES To avoid aspiration for gag reflex is not present To avoid constipation because of the absence of peristalsis due to the effect of anesthesia.

SPECIFIC FOODS TAKEN None

CLIENTS RESPONSE TO DIET The client was cooperative.

NURSING RESPONSIBILITIES

PRIOR Instruct the client that she She sometimes says that she cannot eat anything until is already hungry. she had a flatulence Check the clients Keeps on asking whether comfort. what time she can eat. DURING Emphasize NPO to client Assess if there is a presence of flatus and BM AFTER Observe the clients condition

Tea and Cracker diet

Date Ordered: 09 February 2010 Date Started: 09 February 2010

A diet which permits the patient to have water, tea and crackers

Nutrition and Diet Therapy, Dellova, Roxas, Velasco, Pataunia The digestive system is ready to function, though not fully. Nutrition and Diet Therapy, Dellova, Roxas, Velasco, Pataunia

Water, Tea and Crackers

The client took the food she may already take.

PRIOR Instruct the client on what she can already eat DURING Check the food that the client is taking Emphasize the kind of diet the client can eat AFTER Maintain the proper diet 44 | the client should take.P a g e

D. Activity / Exercise TYPE OF EXERCISE DATE GENERAL ORDERED DESCRIPTION DATE STARTED, CHANGED/D/C Feb. 8, 2010 A pattern of inspiration Feb. 9, 2010 and expiration in which most of the ventilatory work is done with the abdominal muscles. INDICATIONS/PURPOSES CLIENTS RESPONSE TO THE ACTIVITY/EXERCISE It activates all the organs of the digestive system. It cures acidity, indigestion, constipation and gas related problems. It makes one cool, calm and free of tension. NURSING RESPONSIBILITIES

Abdominal breathing

The client was PRIOR: cooperative. She was able Verify the to follow the instructions physicians order and performed it well. Identify patient Explain to the patient how you are going to assist, why abdominal breathing is necessary, and how he or she can cooperate. DURING: Place client in a sitting position Demonstrate deep breathing exercise AFTER: Instruct the client to repeat the exercise several times a day Document the result 45 | P a g e

Coughing exercise

Feb. 8, 2010 Feb. 9, 2010

Coughing is a reflex action started by stimulation of sensory nerves in the lining of the respiratory passages - the tubes we use to breathe.

It facilitates a wide exchange The client can cough but of gases. sputum is not produced. It maximizes the amount of oxygen available to the cells. It prevents orthostatic pneumonia. It makes you relaxed. It helps you cope with pain. It helps reduce the chances of chest complications after surgery.

PRIOR: Review physicians order Verify the clients identity using agency protocol Explain the procedure DURING: Keep the client in a sitting position Demonstrate coughing AFTER: Encourage the client to use a pillow or other splinting method to ease the discomfort of coughing Assess the sputum produced by coughing, noting the amount, color, and odor Offer oral care such as mouth rinse after sputum has been expectorated. PRIOR: Review physicians 46 | P a g e

Ambulation

Feb. 8, 2010 Feb. 9, 2010

Procedure to accelerate the ability of a patient

Prevent constipation The client can walk Prevent circulatory problems without falling.

to walk or move about by reducing the time to AMBULATION. It is characterized by a shorter period of hospitalization or recumbency than is normally practiced.

thrombophlebitis Prevent urinary problems Promote rapid recovery and return of womens strength Hastens drainage of lochia Improves gastrointestinal and urinary function Provide a sense of wellbeing

order Check the patients identity Assess the length of time in bed and time up previously, baseline vital signs, range of motion of joints needed for ambulating, and muscle strength of lower extremities. Explain to the client how you are going to assist, why ambulation is necessary, and how he or she can cooperate. DURING Ensure client safety while assisting the client to ambulate Encourage the client to assume a normal walking stance and gait as much as possible AFTER: Document distance and duration of ambulation in the 47 | P a g e

client record using forms or checklists supplemented by narrative notes when appropriate. Include description of the clients gait (including body alignment) when walking. Leg raising and stretches exercise Feb. 8, 2010 Feb. 9, 2010 Leg RaisingTighten abdominal muscles Abdominal exercise, where you elevate your legs with the strength of your abdominals. To loosen tight muscles Leg Stretches- Any of various exercises involving controlled contraction and release of the muscles at the base of the pelvis, used especially as a treatment for urinary incontinence. The client was able to performed exercise. PRIOR: Review physicians order Identify patient Explain leg exercises and why is it necessary Instruct client to relax and breathe deeply throughout and between the exercise Encourage the client to support head and shoulders with a pillow for comfort DURING: Keep the client in a lying position Instruct client to return demonstrate 48 | P a g e

in bed AFTER: Document all relevant information Turn in bed and get out of bed Feb. 8, 2010 Feb. 9, 2010 To promote comfort and relaxation. To reduces the chance or reduce the intensity of bed sores. To prevent deformities. To relieve pressure and prevent strain The client can follow the instructions how to turn in bed and get out of bed. She was able to turn the side of the bed and raise up to a sitting position. PRIOR: Verify physicians order Verify the clients identity using agency protocol Explain the purpose of the procedure and how it will help DURING: Shows the client the procedure Have the client return demonstrate how to turn in bed and get out of bed with assistance AFTER: Document all relevant information Record: Time and change of position Any signs of pressure areas Ability of client to turn and get out of bed 49 | P a g e

E. Surgical Management of Caesarian Delivery E.1 Brief Description The patient had undergone LT Caesarean section, a surgical procedure in which incisions are made through the abdomen and the uterus to deliver the baby. This is done so when vaginal delivery is contraindicated due to complications of pregnancy, in the case of the client she is hypertensive, has GDM and has had previous caesarean section. Date Ordered : Date Performed : 07 February 2010 08 February 2010

E.2 Visuals

it is the surgical incision made the fundus of the uterus to access the baby inside.

Fundal Hysterotomy

It is the actual delivery of the baby accomplished by caesarean section.

Actual delivery of baby (via caesarean section) 50 | P a g e


The removal of placenta after the cord was clamped and cut.

Is the suturing of the fundus of the uterus after all products of conception was removed or delivered.

Removal of Placenta

Two layer Fundic Hysterotomy Closur

E.3 Patients Response to Operation Prior to Operation: During the Operation: The client exhibits a slight uneasiness and is anxious about the procedure especially that her condition may result to further complications The client is sleeping during the operation as a result of the anesthetics given to her.

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After the Operation:

The client looks pale and weak, is slightly awake and she kept on holding her abdomen, and was wincing and groaning in pain. When she was fully awake she cooperates with the treatment given to her, she turns to her side when instructed and tried to stand and walk.

E.4 Nursing Responsibilities E.4.1 Prior to the operation Monitor V/S Monitor fetal heart rate, fetal position and the 5 Ps of labor o Person o Passenger o Passageway o Psyche o Power Secure consent for caesarean section Remove all accessories, dentures and nail polish of the client. Instruct NPO to client Infuse, maintain and monitor IVF as ordered Change clothing to operating gown Ask the client to void Administer pre-op meds as ordered Relieve patients anxiety by explaining the procedure Prepare all surgical materials needed E.4.3 During the operation Check V/S Assess level of consciousness 52 | P a g e

 Check patients chart for o Consent form o IVF order o Medications given o V/S Count all surgical materials Abdomino - perineal preparation Catheter the patient with IFC connected to UB Notify the surgeon/OB that patient is ready Assist surgeon/OB Count all the surgical materials used Document the procedure done Document babys information E.4.3 After the operation Maintain patient flat on bed for 8 hours Monitor V/S every 15 minutes for 2 hours/ until stable then every 1 hour 53 | P a g e

 Check doctors post- op orders and adjust IVF accordingly Post op meds given Emphasize NPO Monitor I and O

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E.5

Specific Details E.5.1 Instruments Used Instruments Allis Forceps Kidney Basin Kelly Curve Tissue Forceps Needle Holder Cord Forceps Scalpel Towel Clip Metzenbaum Scissors Army Navy Retractor Bladder Retractor Richardson Retractor Bandage Scissor Total Instruments Needles APs : 23 : 5 :3 Initial 4 2 5 1 2 2 1 1 1 1 1 1 1 23 Final 4 2 5 1 2 2 1 1 1 1 1 1 1 23

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F. Nursing Care Plans F.1 Nursing Prioritization NURSING DIAGNOSIS 1. Hyperthermia related to post operative procedure as evidenced by increase in body temperature (T: 37.9C) and skin warm to touch. PRIORITY High Priority RATIONALE It is considered as a high priority problem because according to ABCs of life, temperature has the possibility to affect the respiration or breathing of an individual, which is one of the highest priorities the nurse must address. In addition, based on Maslows Hierarchy of Needs, temperature maintenance belongs to physiologic needs, which is the first and most important level. Therefore, it is crucial for survival. Acute pain neither belongs to airway, breathing, nor circulation (ABCs) of the body. However, based on Maslows Hierarchy of Needs, physical aspects of an individual belong to safety and security needs, which is the second level. If pain is present in the body, an individual may not feel safe and might be anxious about her health condition. This is the reason why it is considered as a high priority problem. Skin integrity neither belongs to airway, breathing, nor circulation (ABCs) of the body although it can lead to infection when a deviation from normal occurs. For the moment, the nurse does not need to address this problem. In addition, based on Maslows Hierarchy of Needs, physical aspects of an individual belong to safety and security needs, which is the second level. Skin is a large part of it. This is the reason why it is considered as a high priority problem. Activity intolerance neither belongs to airway, breathing, nor circulation (ABCs) of the body. In addition, based on Maslows Hierarchy of Needs, 56 | P a g e

2. Acute pain related to surgical incision secondary to Caesarean operation as evidenced by guarding behavior, moaning, and irritability.

High Priority

3. Impaired skin integrity related to surgical incision secondary to Caesarean operation as evidenced by disruption of epidermis and destruction of dermis.

Medium Priority

4. Activity intolerance (Level III) related to immobility secondary to Caesarian operation as manifested by abnormal blood pressure (BP:

Low Priority

140/90 mmHg) and pallor.

5. Self-care deficit related to impaired mobility status secondary to Caesarean operation.

Low Priority

activity intolerance is linked with physical aspect (safety and security needs) of an individual. But for the moment, the nurse may not address this problem. This is the reason why it is considered as a low priority problem. Self-grooming neither belongs to airway, breathing, nor circulation (ABCs) of the body. In addition, based on Maslows Hierarchy of Needs, self-grooming is linked with physical aspect (safety and security needs) of an individual. But for the moment, the nurse may not address this problem. This is the reason why it is considered as a low priority problem.

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CUES Subjective Data: Ang sakitsakit ng tahi ko, as verbalized by the patient. Objective Data: guarding behavior positioning to avoid pain moaning crying irritability seeking out other people

NURSING DIAGNOSIS Acute pain related to surgical incision secondary to Caesarean operation as evidenced by guarding behavior, moaning, and irritability.

SCIENTIFIC KNOWLEDGE Due to tissue destruction, the specialized pain receptors known as nociceptors will be activated by painful stimulation that causes movement of ions across cell membranes. The transmission of pain, which includes three segments, will occur. During the first segment, the pain impulse travels from the peripheral nerve fibers to the spinal cord. The second segment is transmission from the spinal cord and ascension, via spinothalamic tracts, to the brain stem and thalamus. The third segment involves transmission of signals between the thalamus to the somatic sensory cortex where pain receptor occurs.

GOALS/OBJECTIVES Short-term Goal: After 30 minutes-1 hour of nursing intervention, the patient will be able to report pain is decreased by being relaxed. Long-term Goal: After 1-2 days of nursing intervention, the patient will be able to verbalize nonpharmacologic methods that provide relief.

NURSING INTERVENTIONS Independent: 1. Identify ways of avoiding/minimizing pain (e.g., splinting incision during cough).

RATIONALE

EVALUATION Goal Met:

positioning keeps pressure off the wound (Ref.: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice; Eighth Edition, Volume Two p.919) to alleviate/control pain (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.501) to distract attention and reduce tension (Ref.: Nurses

After 1 hour of nursing intervention, the patient was able to report relief from pain.

2. Provide comfort measures (e.g., repositioning), quiet environment, and calm activities.

3. Encourage use of relaxation techniques, such as focused breathing, imaging.

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Moreover, neurons in the thalamus and brain stem send signals back down to the dorsal horn of the spinal cord. Perception will take place when the patient becomes conscious of the pain. Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice (Eighth Edition, Volume Two pgs. 1190-1191)

Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.501) 4. Encourage adequate to prevent fatigue rest periods. (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.502) Dependent: 5. Administer analgesics, as indicated, to maximum dosage, as needed. goals of analgesics include comfort and safety of the patient (Ref.: Fundamentals of Maternal and Child Nursing Care; Second Edition, Volume One p.556)

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CUES Subjective Data: Ang init-init ng pakiramdam ko, as verbalized by the patient. Objective Data: increase inbody temperature (T: 37.9C) flushed skin skin warm to touch

NURSING DIAGNOSIS Hyperthermia related to post operative procedure as evidenced by increase in body temperature (T: 37.9C) and skin warm to touch.

SCIENTIFIC KNOWLEDGE Due to the effects of tissue destruction, the hypothalamus will be stimulated to generate a systemic response to the body. It will regulate the set point of the temperature control mechanism. The hypothalamic thermostat changes suddenly from the normal level to a higher than normal level. As a result, the core temperature falls, and the rate of heat production increases. Thus, the body temperature will rise toward the set point. Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice (Eighth Edition, Volume One pg. 530)

GOALS/OBJEC75TIVES Short-term Goal: After 30 minutes - 1 hour of nursing intervention, patient will be able to decrease elevated body temperature from 37.9C to 36.7C. Long-term Goal: After 1-2 days of nursing intervention, patient will be able to demonstrate behaviors to maintain normothermia.

NURSING INTERVENTIONS Independent: 1. Promote surface cooling by means of cool/tepid sponge baths.

RATIONALE

EVALUATION Goal Met: After 40 minutes of nursing intervention, the patient was able to decrease elevated temperature from 37.9C to 36.8C.

to increase heat loss through conduction (Ref.: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice; Eighth Edition, Volume Two p. 531) to minimize shivering (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.386) to assist with measures to reduce body temperature (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.385) to limit heat production

2. Wear loose clothing.

3. Increase fluid intake.

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4. Provide well ventilated environment.

CUES Subjective Data: Masakit at nangangati yung tahi ko, as verbalized by the patient. Objective Data: disruption of epidermis (presence of abrasion) destruction of dermis by skin incision

NURSING DIAGNOSIS Impaired skin integrity related to surgical incision secondary to Caesarean operation as evidenced by disruption of epidermis and destruction of dermis.

SCIENTIFIC KNOWLEDGE Skin is considered the bodys first line of defense. It serves five major functions: protects underlying tissues from injury by preventing the passage of microorganisms; regulates the body temperature; secretes sebum that softens and lubricates the hair and skin, lessens the amount of heat lost from the skin, and has a bactericidal action; transmits sensations through nerve receptors; and produces and absorbs Vitamin D in conjunction with ultraviolet rays. Any break in the skin or skin impairments can readily serve as a portal of entry of microorganisms which can lead to infection and skin problems.

GOALS/OBJECTIVES Short-term Goal: After 4-5 hours of nursing intervention, patient will be able to gain knowledge about preventing infection associated with impaired skin integrity. Long-term Goal: After 1-2 days of nursing intervention, patient will be able to verbalize ability to manage situation for impaired skin integrity.

NURSING INTERVENTIONS Independent: 1. Keep area clean/dry and carefully dress wounds.

RATIONALE

EVALUATION Goal Partially Met: After 2 days of nursing intervention, the patient was able to verbalize ability to manage skin impairment.

to assist bodys natural process of repair (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.621) to protect the wound from microbial infections (Ref.: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice; Eighth Edition, Volume Two p.922) moisture potentiates skin

2. Use appropriate barriers dressing and wound coverings.

3. Remove

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Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice (Eighth Edition, Volume One pgs.672,742-743)

wet/wrinkled linens promptly.

breakdown (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.622) Vitamin C facilitates wound healing (Ref.: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice; Eighth Edition, Volume Two p.919) goals of analgesics include comfort and safety of the patient (Ref.: Fundamentals of Maternal and Child Nursing Care; Second 62 | P a g e

4. Encourage to take foods rich in Vitamin C.

Dependent: 5. Administer analgesics, as indicated.

Edition, Volume One p.556) G. Health Teachings DATE AND TIME Health teaching is done at OB ward in BMCH at 10:00- 10:15 in the morning on February 10, 2010. OBJECTIVES After the patients health teaching, the patient will be able to: Underst and the importance of proper and good nutrition Underst and the functions and purposes of the essential nutrients LEARNING CONTENTS NUTRITION- basic human needs that change throughout the life cycle and along wellnessillness continuum. Encourage the client to have a: - moderation on sugar intake - moderation on salt intake - high protein(for the development of muscles and for fast wound healing) Ex. Meat, tofu, fish -Rich in Vitamin C Ex. Orange juice, guava -Rich in iron Ex. Green leafy vegetable STRATEGIES DISCUSSION is the way we have chosen to disseminate the learning contents of the client because it provides a faster learning of the patient when it is discussed and at the same time, it is the time where the patient can asked questions for clarifications about the procedure. TARGET POPULATION Our main target is our client and her relatives in this course of health teaching. RESOURCES BOOKS: - Maternal and child nursing (pg.593, volume 1, 3rd edition) Man power BSN-2B GROUP#2 - Frank - Jielyn - Erin - Nica - Trizzle - Cristine - Christine Marie - Maribel - Roma - Mei EVALUATION The client can verbalize the importance of good nutrition on our body by stating that she will change her lifestyle and eating habits. OUTCOME The client had understood the importance of proper and good nutrition and started eating foods that rich in Vitamin C and high protein foods.

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DATE AND TIME Health teaching is done at OB ward in BMCH at 12:00-12:15 in the afternoon on February 10, 2010.

OBJECTIVES After the patients health teaching, the client will be able to: - Understand the importance of perineal care - Know of what are the problems and management for this which are related to perineal care. - Value prevention measures that promote health and reduce the likelihood of infection.

LEARNING CONTENTS Perineal care- it is the cleaning of the perineum. - Urinating can be painful after delivery; squirting warm water over the perineum during urination may ease the pain. When finished urinating, gently pat the perineum dry. - Always wipe from front to back after voiding and defecation. Problems that could arise from deficiency in perineal hygiene: -infection -invasion of pathogen into the vagina.

STRATEGIES DISCUSSION is the way we have chosen to disseminate the learning contents of the client because it provides a faster learning of the patient when it is discussed and at the same time, it is the time where the patient can asked questions for clarifications about the procedure.

TARGET POPULATI ON Our main target is our client in this course of health teaching.

RESOURCES BOOKS: - Maternal and child nursing (pg.596. volume 1, 3rd edition) Man power BSN-2B GROUP#2 - Frank - Jielyn - Erin - Nica - Trizzle - Cristine - Christine Marie - Maribel - Roma - Mei

EVALUATIO N The client can verbalize the importance of perineal care and how to manage problems with regards to this.

OUTCOME The client had understood the importance of perineal care and also identifies diseases that underlying this. Also the client had the knowledge on how to make the perineum to clean.

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DATE AND TIME Health teaching is done at OB ward in BMCH at 12:20- 12-35 in the afternoon on February 10, 2010.

OBJECTIVES After 15-20 minutes of health teaching, the client will be able to: -Understand the importance of proper wound care. - perform wound care in the correct manner -have knowledge on proper diet that will help promote wound healing.

LEARNING CONTENTS Interventions for proper wound care: - Assess the wound site first. Determine presence of cardinal signs of infection - Use the correct antiseptic solution for the type of wound: open and close: hydrogen peroxide - Start cleaning from the inner to outer part use one cotton balls for each strokes, apply dressing. - Instruct to increase protein, vitamin C, and iron intake. - Keep the wound area moisture free. Avoid strenuous activity.

STRATEGIES DISCUSSION and DEMOSTRATI ON are the way we have chosen to disseminate the learning contents of the client because it provides a faster learning of the patient when it is discussed and demonstrated and at the same time, it is the time where the patient can asked questions for clarifications about the procedure.

TARGET POPULATI ON Our main target is our client and her relatives in this course of health teaching.

RESOURCES BOOKS: - Maternal and child nursing (pg. 541. Volume 1, 3rd edition) Man power BSN-2B GROUP#2 - Frank - Jielyn - Erin - Nica - Trizzle - Cristine - Christine Marie - Maribel - Roma - Mei

EVALUATIO N The client and significant others can verbalize the importance of proper wound care and shows a readiness on performing the proper wound care.

OUTCOME The client and significant others had understood the importance of proper wound care and they are ready to perform the proper wound care.

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VI. DISCHARGE PLANNING

A. General Condition of the Patient upon Discharge

The patient being discharged after cesarean birth takes home not only her new baby, but a fair amount of pain and discomfort as well. Upon discharge, the patient is conscious and coherent with the vital signs are in the range of normal which are BP- 120/90 T- 36.8 C PR-90 RR21.
B. Discharge Planning using METHODS

MEDICINE The patient was advised to take the prescribed oral medications continuously for 7 days. These medications are: Cefalexin Dosage: 500 mg cap Frequency: every 6 hours for 1 week Nursing Responsibilities: - Give drug with meals; arrange for small, frequent meals if GI complications occur. - Complete the full course of this drug even if you feel better. - Finish the drug for exactly 7 days to prevent drug resistance. Mefenamic Acid Dosage: 500 mg cap Frequency: every 6 hours for 1 week Nursing Responsibilities: o Instruct patient to avoid alcohol (includes wine, beer, and liquor) when taking this medicine since it can cause increases in stomach irritation. 66 | P a g e

o Use caution if the patient has a weakened heart. It may cause increased shortness of breath or weight gain. Then recommend to talk with healthcare provider or its own physician. o Avoid aspirin, aspirin-containing products, other pain medicines, other blood thinners (warfarin, ticlopidine, clopidogrel), garlic, ginseng, ginkgo, and vitamin E while taking. Talk with healthcare provider. Ferrous sulfate Dosage: 325 mg cap Frequency: once a day for 2-4 weeks Nursing Responsibilities: Take ferrous sulfate on an empty stomach, at least 1 hour before or 2 hours after a meal. EXERCISE Postpartum and post-operative exercises should begin as soon as possible. The post-operative patient should start with simple ones and gradually advances to more strenuous exercises. These exercises are done to restore muscle tone as well as improve circulation, promote involution, and regain general strength. PELVIC FLOOR EXERCISE To cope with pressure, for example when you sneeze, cough or laugh. This works the muscles that quickly shut off the flow of urine. The movement is an upward and inward contraction, not a bearing-down effort. When you first start the exercises, check that you are doing them correctly. Put your hands on your abdomen and buttocks to make sure you cant feel your belly, thighs, or buttocks moving. Don't hold your breath. You should be able to hold a conversation at the same time, or try counting aloud while you're doing the exercises. Don't tighten the tummy, thigh or buttock muscles - you'll be exercising the wrong muscle groups. 67 | P a g e Avoid taking antacids or antibiotics within 2 hours before or after taking ferrous sulfate . Advised to eat or take foods that rich in vitamin C for faster absorption of ferrous sulfate.

Don't squeeze your legs together. Lift your pelvic floor muscles quickly. Hold the contraction for one second. Relax the muscles and rest for one second. Repeat the contractions 10 times.

ANKLE CIRCLES To enhanced circulation. Make 10 circles with your ankles clockwise, and then repeat counterclockwise. Do the ankle circles in different position such as sitting, lying, etc. Repeat circular pattern 3 to 5 times

GENTLE SIT-UPS Always bend your knees tighten your pelvic floor and tummy as you gently lift your head and shoulders slightly off the floor. If your stomach muscles dome as you sit-up, or if you find this difficult or painful, its too early for to start doing sit-ups.

To help shed your remaining pregnancy pounds is through aerobic exercise such as walking, jogging, swimming, or cycling. Start slowly and build up gradually, oyu may only be able to do 10-15 minutes to begin with, but you will gradually get stronger. Add the leg sliding exercise and the arm and upper stretch exercises to previous exercises during the rest of week one.

TREATMENT 68 | P a g e

The client was advised to perform a self monitoring of blood glucose (SMBG) which can be the guide to know if the blood glucose is elevating weekly and monitor the blood pressure with the use of sphygmomanometer and stethoscope daily. Also, the client was advised to stay away from too much pollution and avoid alcohol consumption and harmful drugs. HEALTH TEACHING The client should know about the following: Continue taking of oral medication. Encouraged to have bonding with her newborn by simply holding her newborn tighter, play with her and many more. Avoid heavy work like lifting the first 3 weeks of delivery. Have at least one rest period each day; try to get a good night sleep to avoid fatigue. For her hygiene: she is allowed to take shower and cleanse the perineum from front to back to avoid infection. Breastfed her baby, cleanse first the nipple before breastfeeding the baby. OUT-PATIENT The client is required to attend the follow-up check-up on February 18, 2009 at BMCH. It usually includes a breast examination, a pelvic examination, any necessary laboratory test, and a health education component covering such areas as breastfeeding, birth control, weight reduction, and removal of suture. This check-up is also an opportunity to review the pregnancy and birth experience to discuss problems and assess for depression, to provide emotional support, to answer questions, to consider if any further referrals are necessary for the new mother. DIET The client was advised to have moderation on sugar and salt intake to prevent disorder from recurring. Also she was advised to have a: High caloric diet 69 | P a g e

Ex. Chocolates, nut High protein diet- for the development of muscles and fast wound healing. Ex. meat, tofu, dairy products, fish Increased fluid intake breastfeeding mother are usually thirsty and also to flush the infection from the bladder. Ex. 2 to 3 quartz of fluid a day Rich in vitamin c, protein, iron- for the faster wound healing. Ex. Orange, guava, green leafy vegetables.

SEXUALITY and SAFETY The client was advised that she can resume coitus at least 3 months. Also she was advised to limit the number of stairs she climbing during first week, and if her lochia discharge was normal, she may starts to gradually increase her activities. If the patient is breastfeeding, she will experience amenorrhea as long as she continuously breastfeed her newborn. Although menstrual cycle is absent, the client was taught that pregnancy is possible for the reason that ovulation still occurs.

VII. CONCLUSION

Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy. Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. Diagnostic tests detect inappropriately high levels of glucose in blood samples. Gestational diabetes affects 3-10% of pregnancies, depending on the population studied.[1] No specific cause has been identified, but it is believed that the hormones produced during pregnancy increase a woman's resistance to insulin, resulting in impaired glucose tolerance. Gestational diabetes is a treatable condition and women who have adequate control of glucose levels can effectively decrease these risks such as larger for gestational age, low blood sugar, and jaundice. Women with gestational diabetes are at increased risk of developing type 2 diabetes mellitus. Most patients are treated only with diet modification and moderate exercise but some take anti-diabetic drugs, including insulin. 70 | P a g e

In this case study we have gained knowledge about gestational diabetes mellitus, pregnancy induced hypertension, and also on urinary tract infection. We have learned what the causes, signs and symptoms, are and nursing interventions to do with the said diseases, we also have a health teaching to the patient about the importance of proper and good nutrition, perineal care and proper wound care. We have concluded that with t6he help of this case study. We have improved and enhanced our knowledge regarding the changes that occur during pregnancy and delivery and how the pregnant and postpartum mother and her family respond and core with these changes. We have also developed a knowledge regardi8ng a plan of care for postpartum client even after discharge. Even though we are pioneer when it comes to cause presentation, we did our best.

VIII. BIBLIOGRAPHY

A. Book References
Balita, Carlito. Ultimate Learning Guide to Nursing Review. 1st ed. Philippines: Ultimate Learning Series, 2005. Print. Delaune, Sue, et al. Fundamentals of Nursing: Standards and Practice. 3rd ed. Singapore: Thomson Learning Asia, 2006. Print. Doenges, Marilyn, et al. Nurses Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. 11th ed. New York: F.A. Davis Company, 2006. Print. Estes, Marie, et al. Health Assessment and Physical Examination. 3rd ed. Singapore: Thomson Learning Asia, 2006. Print. Kelly, William, et al. Nursing 2003 Drug Handbook. 23rd ed. New York: Lippincott Williams and Wilkins, 2003. Print. Kozier, Barbara, et al. Fundamentals of Nursing Concepts, Process and Practice. 7th ed. Singapore: Pearson Education South Asia Pte. Ltd., 2004. Print. Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Vol. 1. 3rd ed. New York: Lippincott 71 | P a g e

Williams and Wilkins, 2007. Print. Sia, Maria Loreto. Outline in Obstetrics: A Textbook and Reviewer for Nurses and Midwives. 3rd ed. Philippines: RM Sia Publishing, 2006. Print. Taylor, Carol, et al. Fundamentals of Nursing: The Art and Science of Nursing Care. 5th ed. New York: Lippincott Williams and Wilkins, 2005. Print.

B. Online References
Caesarian Section. WebMD.com. Web. 3 March 2010. <http://www.webmd.com/baby/guide/the-truth-about-c-section >. Caesarian Section. Wikipedia.com. Web. 3 March 2010. <http://wikipedia.com/c-section >. Diabetes Mellitus. Diabetesjournals.org Web. 8 March 2010. < http://care.diabetesjournals.org/content/30/Supplement_2/S141.full>. Gestational Diabetes. Healthline.com. Web. 26 February 2010. < http://www.healthline.com/blogs/pregnancy_childbirth/labels/gestational%20diabetes.html>. Leptin Wikipedia.com. Web. 26 February 2010. < http://en.wikipedia.org/wiki/Leptin >. Oral Glucose Tolerance Test. WebMD.com. Web. 3 March 2010. <http://www.webmd.com/baby/oral-glucosetolerance-test >. Ultrasound. WebMD.com. Web. 3 March 2010. <http://www.webmd.com/baby/ultrasound

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