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A CASE STUDY OF CLIENT G2P2(1102) THAT

UNDERGONE CESARIAN SECTION POST


OPERATIVE
Submitted by:
BSN 31A-Group 1B
Bernardo, Jamaica Ezza
Bonifacio, Ann Rio S.
Bulanadi, Krisna Jane D.
Carlos, Jenikka Mhae
Carlos, Vitanie Ann Carlos
Cascante Paulyn Nica
Submitted to:
Clinical Instructor
Maria Socorro T. Tolentino RN, MSN
Jose Florante C. Nabong RN, MAN
Edna M. Anies RN, MAN
Arthur Luther P. Izon RN, MAN
Daisy S. Reyes RN, MAN
Leila N. Calma RN, MAN
Maria C. Ongleo RN, MAN
May 26, 2014

INTRODUCTION
A case of a 28 year old female, a resident of Marikina City, who was admitted in Melverey Maternity Hospital on May
19, 2014at 8:00 in the morning, with the initial diagnosis of G 2P1(1001) pregnancy uterine 36-37 weeks Age of
Gestation. She was transferred to the Operating Room and had a caesarean section by the doctor. She was also given
spinal anesthesia at 6:01 pm and the operation started at 6:04pm. The procedure lasts for 49 minutes and delivered an
alive baby girl at 6:53 pm together with the placenta and the operation ended at exactly 7:03 pm.
A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the
United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems
happen during delivery. These include: Health problems in the mother ,The position of the baby, Not enough room for the
baby to go through the vagina, Signs of distress in the baby, C-sections are also more common among women, carrying
more than one baby. The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also
takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the
wall of the uterus. This could cause problems with an attempted vaginal birth later.
Cesarean Section is a surgical procedure in which incisions are made through a womans abdomen and uterus to deliver
her baby. The most common reason that a caesarean section is performed (35% of all cases according to the United States
Public Health Service) is that the woman has had a previous Cesarean Section. Once a Cesarean, always a cesarean.
30% of all cases of Cesarean section birth are due to difficult child birth due to non progressive labor. Another 12% of
Cesarean Sections are performed to deliver a baby in a breech presentation. 9% of all cases, Cesarean Sections are
performed in response to fetal distress. 14% of Cesarean Sections are indicated by other serious maternal factors such as
goiter. By UNICEF (http://www.unicef.org/infobycountry/philippines_statistics.html) The Delivery care (%) 20082012*, Skilled attendant at birth is 62.2 % , Delivery care (%) 2008-2012*, Institutional delivery 44.2% and Delivery
care (%) 2008-2012*, C-section 9.5%

Objectives
General Objective:
After 2 hours of case presentation the students will be able to present a comprehensive study of the cesarean section delivery.
Specific Objective:
Knowledge
To be informed about cesarean delivery.
To plan for needed interventions for the recovery of the patient that underwent cesarean section delivery.
To develop Nursing Care Plan that will meet the needs of patient
To have a subsequent evaluation of the clients conditions and well being
Skills
To obtain sufficient data of the clients history of past and present illness.
To provide a drug study of the medication being administered after delivery.
To do a comprehensive physical examination to a woman who underwent cs delivery.
To analyze the different laboratory examination to the woman who underwent cs delivery.
Attitude
To be able to effectively establish rapport, essential for the cooperation of the client to the health care.
To practice the use of therapeutic use of self for the complete recovery of the patient.
To recognize and understand the clients situation.
To work as a team necessary for this case study.
To practice leadership, a unique trait a student nurse should have.

NURSING ASSESSMENT

PERSONAL HISTORY
Name: Mrs. SM
Address: Marikina City
Age: 28 years old
Sex: Female
Marital Status: Married
Occupation: none
Religion: Methodist
Birthdate: March 8, 1986
Birthplace: Antipolo City
Educational Attainment: College Graduate
Position in the Family: Mother
Health care financing and usual sources of medical care: Philhealth member
Date of Admission: May 19, 2014
Time of Admission: 8:00 am
Admitting Diagnosis: G2P1 (1001) PU 36-37 weeks Age of Gestation
Final Diagnosis: G2P2 (1102)
CHIEF COMPLAINT
Uterine Contraction and Scheduled for Cesarian Section

HISTORY OF PRESENT ILLNESS


According to Mrs. SM, she noticed a small lump in her throat so she
immediately went to a doctor for consultation. She was diagnosed with
goiter since January 2011. She was prescribed by her doctor to take thyrax
once a day. When she got pregnant on her first baby, she stopped taking it
because shes afraid it might affect her pregnancy. After giving birth, she
continued taking thyrax. On her second pregnancy, again, Mrs. SM
discontinued taking thyrax.

PAST HISTORY

According to Mrs. SM, during her childhood, she had asthma. She has a
complete immunization which includes diphtheria pertussis, oral polio
vaccine, anti-measles vaccine and BCG.

GROWTH AND DEVELOPMENT


Stage

Young adulthood

Psychosocial

Adulthood
(25 to 65 y/o)

Generativity
VS
Stagnation

Positive Resolution:
Creativity, productivity,
concern for others

Negative Resolution:
Self-indulgence, selfconcern, lack of interests
and commitments

Psychosexual

Cognitive

Moral

Genital

Puberty and after

Energy is directed toward


full sexual maturity and
function and
development of skills
needed to cope with the
environment.

Encourage separation
from parents,
achievement of
independence, and
decision making.

Formal operation
phase:

Growth may be
promoted by major
life events (such as
entry into a new
career or the birth of
a child) or by brain
growth (such as the
development of the
frontal lobe) or,
perhaps, by
interaction of nature
and nurture

Adolescence and Adulthood

Conventional Person is
concerned with maintaining
expectations and rules of
the family, group, nation, or
society. The person values
conformity, loyalty, and
active maintenance of
social order and control.

Law and order orientation The person wants


established rules from
authorities and the reasons
for decisions is that social
and sexual rules and
traditions demand response.

Spiritual

Individuling reflexive

Constructing ones
own explicit system;
high degree of selfconsciousness.


Description

Findings and Analysis

Remarks

Erik Eriksons stage of


psychosocial refers to the
development of
personality. Personality is
a complex concept that is
difficult to define. It can
be considered as the
outward (interpersonal)
expression of the inner
(intrapersonal) self. It
encompasses a persons
temperament, feelings,
characters traits,
independence self
esteem, self concept,
behavior, ability to
interact with others, and
ability to adapt to life
changes.

Sigmund Freud (18561939) the personality


develops in five
overlapping stages from
birth to adulthood. The
libido changes its
location of emphasis
within the body from
one stage to another.
Therefore a particular
body area has special
significance to a client
at particular stage.

Piagets theory of
cognitive
development is a
manner which
people learn to think
reason and use
language. It involves
a persons
intelligence,
perceptual ability
and ability to
process information.

Lawrence Kohlbergs
theory holds that moral
reasoning is a process that
is principally concerned
with justice and that it
continued throughout the
individuals lifetime.
Learning what ought to be
and ought not to be done.

James W. Fowler,
describes the
development of faith
as a force that gives
meaning to a
persons life. He
believes that the
development of faith
is an interaction
process between the
person and the
environment.

As we observe Mrs. SM is
close with his husband,
children and family. Even
though shes admitted in
the hospital she still thinks
about her family and shes
a jolly person.

Our client have a two


children. Her sexual life
is active and contented.

She understands all


our questions and she
answer straight to the
point.

Our client follows all the


rules and knows her
responsibilities and duty in
their family.

Our client is
Methodist. She always
go their church and
she have a high
degree of selfconsciousness.

Positive

Positive

Positive

Positive

Positive

APPLICATION OF THEORIES IN THE CARE OF CLIENT

THEORY

THEORIST

DESCRIPTION

APPLICATION TO THE CLIENT

Comfort
Theory

Katharine Kolcaba

Kolcaba described comfort as existing in 3 forms:relief, ease, and


transcendence.
If specific comfort needs of a patient are met, for example,
thereliefof postoperative pain by administering prescribed analgesia,
the individual experiences comfort in the relief sense.
If the patient is in a comfortable state of contentment, the person
experiences comfort in theeasesense, for example, how one might
feel after having issues that are causing anxiety addressed.
Lastly,transcendenceis described as the state of comfort in which
patients are able to rise above their challenges.

In relation to the Comfort theory of


Kolcaba, our client needs different comfort
measures to ease the pain shes feeling
because of her post cesarian operation.

Environmental
Theory

Florence
Nightingale

Concepts
Person- Patient who is acted on by nurse
Affected by environment
Has reparative powers
Environment- Foundation of theory. Included everything, physical,
psychological, and social
Health- Maintaining well-being by using a persons powers
Maintained by control of environment
Nursing- Provided fresh air, warmth, cleanliness, good diet, quiet to
facilitate persons reparative process

In relation to the Environmental Theory of


Nightingale, our client needs a kind of
environment conducive to the healing of
his incision and also for her comfort like a
clean room that has proper ventilation.

Core, Care,
Cure Model

Lydia Hall

The theory contains of three independent but interconnected circles:


the core, the care and the cure
The coreis the person or patient to whom nursing care is directed and
needed. The core has goals set by himself and not by any other person.
The core behaved according to his feelings, and value system.
The carecircle explains the role of nurse
The cureis the attention given to patients by the medical professionals.

In relation to the Core, Care, Cure Model


of Lydia Hall, our client, the nurses and
also his doctors are working hand-in-hand
for the fast recovery of our client.

ANATOMY AND PHYSIOLOGY

The Vagina
The vagina is a muscular, ridged sheath connecting the external genitals to the uterus, where the embryo
grows into a fetus during pregnancy. In the reproductive process, the vagina functions as a two-way street
accepting the penis and sperm during intercourse and roughly nine months later, serving as the avenue of
birth through which the new baby enters the world.
The Cervix
The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual
reproductive functions. After intercourse, sperm ejaculated in the vagina pass through the cervix, and then
proceed through the uterus to the fallopian tubes where, if sperm encounters an ovum (egg), conception
occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly
fluctuations in the levels of the two principle sex hormones, estrogen and progesterone. When estrogen
levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to reach the
fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then
becomes thin and slippery, offering a much friendlier environment to sperm as they struggle towards their
goal. (This phenomenon is employed by birth control pills, shots and implants. One of the ways they
prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.)


Uterus
The uterus or womb is the major female reproductive organ of humans. One end, the cervix,
opens into the vagina; the other is connected on both sides to the fallopian.
The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a
fertilized ovum which becomes implanted into the endometrium, and derives nourishment from
blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an
embryo, develops into a fetus and gestates until childbirth.
Oviducts
The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female
mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture,
allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus,
pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or
days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the
endometrium when it reaches the uterus, which signals the beginning of pregnancy.
Ovaries
The ovaries are the place inside the female body where ova or eggs are produced. The process
by which the ovum is released is called ovulation. The speed of ovulation is periodic and
impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the
oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilised on its
way by an incoming sperm, leading to pregnancy and the eventual birth of a new human
being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help
the egg cell travel.

PATIENT AND HIS CONDITION / ILLNESS


PHYSICAL ASSESSMENT
NAME: SM
AGE: 28 years old
DATE: May 20, 2014
12 PM
VITAL SIGNS: PR= 71 bmp
TEMPERATURE= 37.1 C
RR= 18 cpm
BP= 110/70 mmHg

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

GENERAL APPEARANCE

1. Body built, height &


weight in relation to
Inspection
clients age, lifestyle &
health

Weight: 70.4 kilogram


Proportionate and varies Height : 5 feet and 1
with lifestyle.
inch
BMI: 29.3

Deviation from normal


due to overweight

3.
Clients
overall
Inspection
hygiene & grooming

Clean, neat

NORMAL

4. Body & breath odor

No body odor or minor


Neither body odor nor
body odor relative to
breath
odor
was NORMAL
work or exercise, no
observed.
breath odor.

Inspection

Client is clean and neat.

5. Signs of distress in
posture
or
facial Inspection
expression
6. Obvious signs
health or illness

of

Inspection

No distress noted.

Eye contact
distress noted

and

no

Healthy appearance.

Deviation from normal


Obvious sign of illness
due to bloodloss and
such as pallor and in pain
pain in incision site

NORMAL

SKIN

1.
Skin
uniformity

color

&

Inspection and Palpation

Color- varies from light


to deep brown; from
ruddy pink to light pink;
from yellow overtones to The client has a light
olive.
brown
complexion,
Normal
due
to
those
with
Uniformitygenerally except
physiologic
changes
uniform except in areas clothes,and have line during her pregnancy
exposed
to
sunlight; nigra, striae gravidarum
areas
of
lighter on abdomen
pigmentation
(palms,
lips, nail beds) in dark
skinned people.

2. Presence of edema

Inspection

No edema.

No edema noted.

NORMAL

3. Skin lesions

Inspection

Freckles,
some
Skin lesion located at
birthmarks, some flat
Deviation from normal
the left hand due to IV
and raised nevi; no
due to formation of
insertion, warts in neck,
abrasions
or
other
scars and warts
and scars in the right leg
lesions.

4. Skin moisture

Palpation

Moisture in skin
and axillae (varies
environmental
temperature
humidity,
temperature
activity.)

5. Skin temperature

Palpation

Uniform; within normal


Uniform in temperature.
range

6. Skin turgor

Palpation

folds
with
Moistened
skin
and especially in the skin NORMAL
body folds.
and

NORMAL

When
pinched,
skin
springs back to previous
Skin returns back to
state.
previous state in less NORMAL

than 1 seconds.
\

NAILS
1.
Fingernails
plate
shape to determine its Inspection
curvature & angle

Convex curvature, angle


Nails are
of nail plate about 160
curvature;
degrees.

2. Fingernail & toenail


Inspection
bed color

Highly vascular and pink


in light skinned clients;
dark- skinned clients may Fingernails and toe nails
NORMAL
have brown or black color are pinkish.
pigmentation
in
longitudinal streaks.

3. Tissues surroundings
Inspection
nails

Intact epidermis.

Intact epidermis, pale in


NORMAL
color

4. Fingernail & toenail


Palpation
texture

Smooth texture.

Clients nails are smooth


NORMAL
in texture

in

convex

NORMAL

5. Blanch test
capillary refill

of

Palpation

Prompt return of pink


Prompt return of pink NORMAL
or
usual
color
or
usual
color
3
(generally less than 4

seconds
seconds.)

HAIR & SCALP


1. Evenness of growth
Inspection
over the scalp

Evenly distributed hair.

Hairs
are
distributed.

2. Hair
thinness

Thick/thin hair.

The client has thick hair


NORMAL
on head.

Not present.

No infestations noted

4. Texture & oiliness


Palpation
over the scalp

Silky, resilient hair.

Oily, thick, resilient hair NORMAL

Palpation

Rounded
(normocephalic
and
symmetrical,
with Head is symmetrically
NORMAL
frontal, parietal, and round.
occipital prominences);
smooth skull contour.

thickness

3.
Presence
infections
infestations

&

Palpation

of
or Inspection

evenly

NORMAL

NORMAL

SKULL

1. Size,
symmetry

shape

&

2. Nodules or masses &


Palpation
depressions

Smooth,
uniform
No mass
consistency; absence of
noted
nodules or masses.

or

nodules

NORMAL

FACE

1. Facial features

Inspection

Symmetric or slightly
asymmetric
facial
features;
palpebral
fissures equal in size;
symmetric nasolabial
folds.

Symmetrical
facial
features;
palpebral
fissures equal in size; NORMAL
nasolabial folds are
symmetrical

2. Symmetry of the
Inspection
facial movements

Symmetrical
movements.

facial Facial movements are


NORMAL
all symmetrical

EYEBROWS & EYELASHES

1.
Evenness
of
distribution & direction Inspection
of curl

Hair evenly distributed;


skin intact. Eyebrows
asymmetrically aligned
equal
movement.
Eyelashes curl slightly
outward.

Eyebrows and eyelashes


are
both
evenly
distributed,
NORMAL
symmetrical
aligned.
Eyelashes curl slightly
outward.

EYELIDS

Skin
intact,
no
discharge,
no
discoloration. Lids close
symmetrically
approximately
15-20
1.
Surface
involuntary
blinks
per
characteristics
& Inspection and Palpation
minute;
bilateral
ability to blink
blinking.
When
lids
open, no open, no
visible sclera above
corneas, and upper and
lower borders of cornea
are slightly covered.

Eyelids skin are intact,


no noted discharge, and
no noted discoloration.
Lids
close NORMAL
symmetrically.
Client
exhibited 15 involuntary
blinks per minute.

CONJUNCTIVA
1. Bulbar conjunctivas
color,
texture
& Inspection
presence of lesions

Transparent, capillaries
Transparent; capillaries
evident, no discharge NORMAL
sometimes evident.
was noted.

2.
Palpebral
conjunctivas
color,
Inspection
texture & presence of
lesions
SCLERA
1. Color & clarity

Shiny, smooth, pink or Shiny, smooth and pale


NORMAL
red in color.
in color

Inspection

Sclera appears
(yellowish
in
skinned clients).

white
dark- Sclera appears white

Inspection

Transparent, shiny and


smooth; details of the
iris are visible. In older Details of iris are
people, a thin grayish visible.
Transparent,
white ring around the shiny and smooth.
margin, called arcus
senilis, may be evident.

NORMAL

CORNEA

1.Clarity & color

NORMAL

IRIS
1. Shape & color

Inspection

Flat and round

Flat and round


uniform in color.

and

Black in color; equal in


size; normally 3-7 mm
in diameter; round,
smooth border.

Black, equal in size,


about
3
mm
in NORMAL
diameter;
round,
smooth & symmetrical.

NORMAL

PUPILS

1. Color, shape
symmetry of size

&

Inspection

2. Pupil light reaction


Inspection
& accommodation

Illuminate
constricts
response)

pupil
Illuminated
(direct
constricts

pupil

NORMAL

3. Pupils direct &


consensual reaction to Inspection
light

Nonillluminated pupil
constricts (consensual Non-illuminated pupil
constricts too. Pupils
response)
dilated when ask to
Pupils constrict when look
on
distant
looking at near object; objects,
constricts NORMAL
pupil
dilates
when when pen was placed
looking at far object; near eyes; when pen
pupils converge when is moved towards the
object
is
moved nose
towards the nose.

LACRIMAL GLAND, LACRIMAL SAC & NASOLACRIMAL DUCT


No edema or tenderness
1. Presence of edema
Inspection
over lacrimal gland.
VISUAL FIELDS
When looking straight
1. Test for peripheral
ahead, the client can
Inspection
visual fields
see objects in the
periphery.
EARS AURICLE
Color same as facial
skin,
symmetrical,
1. Color & symmetry of
auricle aligned with
Inspection
size & position
outer canthus of eye,
about
10cm
from
vertical.
Mobile, firm and not
2. Texture & elasticity
Palpation
tender, pinna recoils
& areas of tenderness
after it is folded.

No edema noted

NORMAL

Client can see objects


NORMAL
in the periphery.

Color is same with facial


skin, symmetrical with
each
other,
auricle NORMAL
aligned
with
outer
canthus of eye,
Both pinna recoils after
being folded. Mobile, NORMAL
firm and not tender.

EXTERNAL EAR CANAL


1.
Cerumen,
skin
Inspection
lesions, pus & blood

Distal third contains


hair
follicles
and
glands. Dry cerumen in
various
shades
of
brown

No noted pus, blood NORMAL


and
odor.
Minimal
cerumen noted.

NOSE

1. Shape, size or color


& flaring or discharge Inspection
from the nares

Symmetric and straight


No discharge or flaring
Uniform color

No discharge and/or
flaring
noted.
Symmetrical on both NORMAL
sides. Also uniform in
color.

2.
Presence
of
redness,
swelling,
growths & discharge or Inspection
nares
using
the
flashlight

Mucosa pink

3. Position
septum

Inspection

Nasal septum intact and Nasal septum is intact


NORMAL
in midline, intact
and in midline

4. Test patency of both


Inspection
nasal septum

Air moves freely as the Air moves freely as the


client breathes through client breathes through NORMAL
the nares
each nares

of

nasal

5. Tenderness, masses
&
displacement
of Palpation
bone & cartilage

Clear, watery discharge


No lesions.

Not tender; no lesions

Mucosa is intact and


pinkish; minimal moist
noted
inside;
no NORMAL
swelling
or
nodules
found.

No
tenderness,
no
lesions
noted.
No
NORMAL
displacement of bone &
cartilage.

SINUSES

1.
Presence
tenderness

of

Palpation

Not tender

Not tenderness noted.

NORMAL

LIPS

1.
Symmetry
contour
color
texture

Uniform
pink
color
(darker, e.g., bluish
hue, in Mediterranean
groups and dark-skinned
Uniform
pink
color,
clients)
of
smooth,
soft
and
& Inspection and Palpation
NORMAL
Soft, moist, smooth symmetrical. Client is
able to purse lips.
texture
Symmetry of contour
Ability to purse lips

BUCCAL MUCOSA
Uniform
pink
color
(freckled
brown
pigmentation in dark1. Color, moisture,
skinned
clients)Moist,
texture & presence of Inspection and Palpation smooth, soft, glistening,
lesions
and
elastic
texture
(drier oral mucosa in
elderly
due
to
decreased salivation)

Uniform
pink
color.
Moist,
smooth,
NORMAL
glistening and elastic
texture.

TEETH
1. Inspect for color,
number & condition & Inspection
presence of dentures

32 adult teeth
Smooth, white,
tooth enamel

Deviation from normal


1 Tooth Decay at the
due
to
improper
shiny upper molar
mouth care and

GUMS

1. Color & condition

Inspection

Pink gums (bluish or


dark patches in dark- Pink gums, moist, firm,
skinned clients)
no noted lesions and NORMAL
Moist, firm texture to nodules
gums

TONGUE/FLOOR OF THE MOUTH


1. Color & texture of
Smooth tongue base Smooth tongue base
the mouth floor & Inspection and Palpation
NORMAL
with prominent veins
with prominent veins
frenulum
Central in position

Pink in color (some


brown pigmentation on
tongue borders in darkskinned clients); moist;
slightly
rough;
thin Centered; slightly pink
2. Position, color &
in color, moist, slightly
white coating
texture, movement & Inspection and Palpation
rough, has thin white NORMAL
base of the tongue
Smooth,
lateral coating, smooth, no
margins, no lesions
lesions; moves freely.
Raised papillae (taste
buds)

Moves
freely,
tenderness

no

PALATES & UVULA

1. Color & shape,


Inspection
texture & presence of
Palpation
bony prominences

Soft palate- light pink, Light pink, smooth and


smooth, no lesions, moist soft palate.
moist.
Light pink, irregular
and
Hard palate- lighter textured and moist NORMAL
pink, more irregular hard palate.
texture/ridges
lesions

no No noted nodules or
masses

2. Position of the uvula


Inspection
& mobility

Positioned in midline of
Midline of soft palate
soft palate.

NORMAL

Pink
and
posterior wall.

NORMAL

OROPHARYNX & TONSILS


1. Color & texture

Inspection and Palpation

smooth Smooth
and
posterior wall

pinkish

2. Size of the tonsils,


Inspection
color & discharge

Tonsils are of normal size


or not visible, pink in
color and smooth. No
discharge.

Tonsils are normal size or


not visible, smooth and
NORMAL
pink
in
color.
No
discharge noted.

3. Gag reflex

Present

Present

1. Symmetry & visible


mass in the thyroid Inspection
gland

Not visible on inspection

Slighlty enlarged on right Deviation from normal


neck
due to Goiter

2.
Presence
of
tenderness or nodules in Inspection and Palpation
the lymph nodes

Not palpable.

nodules were palpated

3. Placement
trachea

Central placement in Trachea is placed at the


midline of neck, spaces center. Spaces are equal NORMAL
are equal on both sides.
on both sides.

Inspection

NORMAL

NECK & LYMPH NODES

of

the

Inspection

4. Smoothness & areas


of enlargement, masses
Inspection
or
nodules
in
the
thyroid gland

Lobes may not be


palpitated. If palpitated,
lobes are small, smooth, Rise
freely
centrally
located, swallowing.
painless, and rise freely
with swallowing.

when

Devioation from normal


due to goiter

NORMAL

BREAST
Engorged Breast with
wider and darker
Symmetrical, no visible
areola, prominent
masses upon inspection.
veins.Tubercle of
Montgomerys enlarged

1.

Symmetry
and
visible mass in Inspection
the breast.

1.

Color, moisture,
Uniformity in color,
texture
and
Uniform in color,
Inspection and Palpation moisture and texture.
presence
of
lesion was noted
No presence of lesion.
lesion

Normal due to release


of milk

no NORMAL

POSTERIOR THORAX
1. Shape, symmetry &
compare the diameter
of antero posterior Inspection
thorax to transverse
diameter

Anteroposterior
to
transverse
diameter
ratio of 1:2, chest is
symmetric.

2. Spinal alignment

Inspection

Spine vertically aligned.

3. Breathing excursion

Inspection

5.
Temperature,
Palpation
tenderness, masses

8.
Auscultate
posterior thorax

the

1:2
ratio
of
the
anteroposterior
to
NORMAL
transverse diameter is
symmetric.

Spine
is
vertically
NORMAL
aligned.
No
Adventitious
No adventitious breath
breathing
was NORMAL
sounds.
inspected.
Uniform
skin No mass were palpated
temperature, no masses and
uniform
skin NORMAL
or tenderness.
temperature.

Auscultation

Vesicular
bronchovesicular
breathe sounds.

Bronchovesicular sound
was heard at the upper
and
portion and vesicular
sound was heard at the
lower portion of the
thorax.

NORMAL

Inspection

Quiet, rhythmic, and


Effortless respiration
effortless respirations.

NORMAL

ANTERIOR THORAX
1. Breathing pattern

Uniform
skin
Uniform
skin
2.
Temperature,
temperature,
neither
Inspection and Palpation temperature, no masses
NORMAL
tenderness, masses
masses nor tenderness
or tenderness.
was palpated.
6.
Auscultate
trachea

the

7.
Auscultate
anterior thorax

the

Auscultation

Bronchial and
breath sounds.

tubular Bronchial and tubular


NORMAL
breath sounds were heard

Auscultation

Bronchovesicular
and
Bronchovesicular
and
vesicular breath sounds NORMAL
vesicular breath sounds.
were heard.

CAROTID ARTERIES
1. Pulsation of carotid
Palpation
arteries

No pulsations, lifts or No pulsations and lifts


NORMAL
heaves.
observed.

2. Auscultation of the
Auscultation
carotid arteries

No sound heard
auscultation.

on No sound was heard upon


NORMAL
auscultation.

JUGULAR VEIN
1. Visibility of jugular
Inspection
vein

Veins not visible.

Veins were not visible


NORMAL
upon inspection.

ABDOMEN

1. Skin integrity

2. Abdominal contour

Inspection

Skin integrity in the


abdomen is intact with
Unblemished
skin, hypertrophic scar
uniform in color, silver approximately 4.5 inches Deviation from normal
white striae (stretch long secondary to
due to surgical incision.
marks) or surgical scars. cesarian section note on
the lower abdomen. With
white striae gravidarum

Inspection

Sligthly globular upon


Flat, rounded (convex)
Deviation from normal
inspection with
or scaphoid(concave)
due to incision site.
distention and pain

3. Enlarge
spleen

liver

or

4. Symmetry of contour

5.
movements

Abdominal

6. Vascular patterns

Palpation

No
evidence
of
No enlargement
enlargement of liver or
observed.
spleen.

Inspection

Symmetric contour.

Inspection

Symmetric
movements
caused by respiration.
Symmetric
movement
Visible peristalsis in very
due
to
respiration. NORMAL
lean
people.
Aortic
Peristalsis not visible.
pulsations in thin persons
at epigastric area.

Inspection

No
visible
pattern.

vascular

Symmetric contour.

was

NORMAL
NORMAL

No
visible
pattern.

vascular NORMAL

7.
Bowel
sounds,
vascular
sound
& Auscultation
peritoneal sounds

Audible bowel sounds, No arterial bruit was


absence of arterial bruit heard. Audible bowel NORMAL
and friction rubs.
sound.

8. Percuss
quadrants

Tympanic sound over the


stomach and gas-filled
bowels;
dullness,
especially over the liver
and spleen or in full
bladder.

abdominal

Percussion

9. Light palpation of
Palpation
abdominal quadrants

Tenderness
may
be
present near xiphoid
process, over cecum,
and over sigmoid colon.

NOT DONE

Uncomfortable for the


client
to
percuss
because of the surgical
incision
in
the
abdomen.

NOT DONE

Uncomfortable for the


client to percuss
because of the surgical
incision in the
abdomen.

MUSCOLOSKELETAL SYSTEM
1. Muscle size compare
the muscles on one side
of the body (arm, thigh, Inspection
calf) to the same muscle
on the other side

Equal size on both sides Slightly Equal on both


NORMAL
of body.
sides of the body.

2.
Constructures
(shortening)
of
the Inspection
muscles & tendons

No contractures.

No contractures.

NORMAL

3. Muscle fasciculations
& tremors. Presence of
tremors of the hands & Inspection
arms when stretched in
front of the body

No tremors.

No tremors.

NORMAL

4. Muscle tonicity

Inspection

Normally firm.

Firm.

NORMAL

5. Muscle strength

Inspection

Equal strength on each Equal strength on each


NORMAL
body side.
body side.

1. Normal structure

Inspection

No deformities.

2. Edema & tenderness

Inspection

No
tenderness
swelling.

Inspection

No swelling.

BONES
or

No deformities

NORMAL

No tenderness.

NORMAL

No swelling.

NORMAL

JOINTS
1. Swelling

2.
Presence
of
tenderness, smoothness
of movement, swelling, Inspection
crepitation & presence
of nodules

No tenderness, swelling, Joints move smoothly.


crepitation or nodules. No
tenderness
was NORMAL
Joints move smoothly.
observed.

RANGE OF MOTION

1. Upper extremities

Inspection

Uniform in color, veins


are visible in face, neck
and dorsum of the
hands, average muscles
size,
fingers
are
complete
No lesions, no edema.

2. Lower extremities

Inspection

Uniform in color, veins


are visible in face,
neck, average muscles
Deviation from normal
size,
fingers
are
due to skin lesions
complete. Skin Lesions
due to IV insertion,
warts on neck

Uniform in color, no
Uniform in color, no
deformities, complete Deviation from normal
deformities, complete
fingers in both feet. due to scars.
fingers in both feet.
scars in right leg

THE PATIENT AND HIS CARE


MEDICAL MANAGEMENT
INTRAVENOUS THERAPHY
Medical Management

Date Ordered/ Date


Given/Change/Discontinued

General Description

Nursing Responsibility

D5LR
41-42 gtts/min

05/20/14

Prior:
-Check the physicians order in
thrice check
-Explain to the client the
antibiotics and IV that the
patient will encounter
-Monitor the vital signs
-Determine the allergies to
the antibiotics
-Prepare the client for the
surgery

During:
-Check for the physicians
order of doses
-Check for the gtts/min
-Check for the time
management of the medicines
-Monitor the clients response
-Assess the vital signs.

After:
-Monitor the vital signs and
the clients reaction/response
-Check for the physicians
order
-Monitor the ugtts/min
-Time of the medication
-Report and document the
procedure

The
Dextrose 5% in Lactated R
ingers Solution (D5LRS)
is useful for daily
maintenance of body fluids
and nutrition, and for
rehydration.

DRUGS

Generic/Brand
Name

Diclofenac
Voltaren

Date ordered,
Route of
General Action,
Taken/Given, Administratiomn
Classification,
Date
, Doseage,
Mechanism of
change/Discon
Frequency
Action
tinued

50mg PO
-Although its exact
05/19/20
QID
mechanism of
action has not
been fully
elucidated, it
appears to be a
potent inhibitor of
cyclooxygenase,
thereby decreasing
the synthesis of
prostaglandins

Indication

-Carefully consider the potential benefits


and risks of Diclofenac sodium extendedrelease tablets, USP and other treatment
options before deciding to use Diclofenac
sodium extended-release. Use the lowest
effective dose for the shortest duration
consistent with individual patient treatment
goals.
Diclofenac sodium extended-release tablets
are indicated:

For relief of the signs and symptoms


of osteoarthritis

For relief of the signs and symptoms


of rheumatoid arthritis

Contraindications

Nursing Responsibilities

wks may be need for beneficial effects with


rheumatoid arthritis or osteoarthritis.

bloodglucose.

Observe and report signs of bleeding (e.g.,


petechiae, ecchymoses, bleeding gums, bloody
or black stools, cloudy or bloody urine).

Monitor BP for hypertension and blood sugar


for hyperglycemia.
Monitor diabetics closely for loss of diabetic
control.
Monitor for increased serum sodium and
potassium in patients receiving potassiumsparing diuretics.

Diclofenac sodium extended-release is

contraindicated for the treatment of


perioperative pain in the setting of coronary
artery bypass graft (CABG) surgery.

Lab tests: Periodic liver function, serum uric


acid concentrations Hct, PT/INR, and

Diclofenac sodium extended-release tablets,


USP are contraindicated in patients with

known hypersensitivity to Diclofenac.


Diclofenac sodium extended-release should
not be given to patients who have
experienced asthma, urticaria, or allergictype reactions after taking aspirin or other
NSAIDs. Severe, rarely fatal, anaphylacticlike reactions to NSAIDs have been reported
in such patients.

Monitor for therapeutic effectiveness. Up to 3

Monitor weight and report gains greater than 1


kg (2 lb)/24 h.
Monitor for signs and symptoms of GI irritation
and ulceration.

Methergine
Methylergonovine
Maleate

05/19/14

Tablet PO TID

-Directly stimulates
vascular smoothmuscle
contractions in
uterus and cervix
and decreases
bleeding after
delivery.

-Methylergonovine
maleate(methergin
e) is an ergot
alkaloid that
stimulate smooth
muscle
tissue.Because the
smooth muscle of
the uterus is
especially sensitive
to this drug ,it is
used postpartally
to stimulate the
uterus to contract
in order to
decrease blood loss
by clamping off
uterine blood
vessels and to
promote the
involution
process .In addition
the drug has
vasoconstrictive
effect on all blood
vessels,especially
the larger arteries.

-Prevention and
treatment of postpartum
hemorrhage.

Contraindications
Hypersensitivity to
drug
Hypertension
Toxemia
Pregnancy (except
during third stage of
labor)

Be alert for adverse


reaction and drug
interaction
This drug should be used
extremely carefully
because of its potent
vasoconstriction, action,
I.V, use may induce
sudden hypertension
and cerebrovascular
accidents. As a last
resort give I.V slowly
over several minutes
and nonitor blood
pressure closely.


Bisacodyl
Dulcolax

05/19/14

Tablet PO TID

-Expands
-Treatment for
intestinal fluid constipation.
volume by
increasing
epithelial
permeability.

-Stimulates
peristalsis by
directing
irritating the
smooth
muscle of the
intestine,
possibly the
colonic
intramural
plexus, alters
water and
electrolyte
secretion
producing
intestinal fluid
accumulation
and laxation.

Assess patient for


abdominal
distention,
presence of
bowel sounds,
and usual pattern
of bowel
function.
Assess color.
Consistency and
amount of stool
produce.

DIET

TYPE OF
DIET

NPO
(Nothing
Per Orem)

Soft
diet

DATE
ORDERED,DATE
STARTED, DATE
CHANGED, DATE
CONTINUED

May 19,2014

May 20,2014

GENERAL
DESCRIPTION

Nothing by mouth
meaning no food,
medication and
water should be
ingested orally.

A diet that is soft


in texture, easily
digested, and well
tolerated. It
provides the
essential nutrients
in the form of
liquids and
semisolid foods.

PURPOSE

To prevent aspiration
or regurgitation of
gastric contents.

SPECIFIC
FOOD TAKEN

No food,
medication
and water at
all.

For post-operative
cases when patient
can tolerate solid food
but not a full diet
enhances patients
energy for future
activities. Prevent
dehydration and keep
colon contents to a
minimum. Used as a
transition diet
between full liquid
and regular diet.

CLIENTS
RESPONSE

NURSING
RESPONSIBILITIES

Sabi ng doctor
ko wag na muna
daw akong
kumain hanggang
di aq
umuutot,as
verbalized by the
client.

Check for
doctors
order
Monitor vital
signs.
Monitor urine
output

Check for
doctors
order
Monitor vital
signs
Monitor urine
output

ACTIVITY EXERCISE
Type of
Exercise

Date started
Date changed

General Description

ROM(Range
of motion)

Date started
05/19/14
After delivery

ROM is the degree


of movement
possible to each
joint. It is
determined by
genetic make-up,
developmental
patterns, and the
presence or absence
of desease.

ACTIVE ROM
A person
moves each
joints in the
body though
its complete
range of
movement,
maximally
stretching all
muscles groups
within which
plane over the
joint.

Purposes

Clients response

To promote blood
The patient is
circulation.
cooperative and was
To maintain joint
able to perform the
movement.
exercise.
To maintain or
increase flexibility.
Helps to maintain
cardiorespiratory
function.

Nursing responsibilities

Prior

Review clients chart for


physical assessment,
findings, physicians
order, medical diagnosis
and medical history.

Verify the clients name.

Assess the clients


condition.
Explain the purpose of

the exercise to the


patient.
During:

Assist the patient in


doing the exercise.

Complete exercises from


head-to-toe. Inform
client how this exercise
done.

Assist the patient in a


comfortable position
after doing the exercise.
After

Evaluate clients
response.
Record type of exercise,

degree of joint
abnormalities, and
clients activity
tolerance.

Ambulatio
n

Date
started
05/20/14

Ambulation
is to walk
from place
to place or
the act of
walking.

Early
ambulation
promotes
healing and
prevents
respiratory,
circulatory,
urinary and
gastro intestinal
complication,
also prevent
muscles
weakness.

Prior
sinabi kase
Review clients chart for

sakin ni doc na
physical assessment, findings,
kailangan ko
physicians order, medical
daw maglakad
diagnosis and medical history
pag nakakaya
Determine clients readiness.

ko na as
Explain purpose of ambulation.
verbalized by

Assess client level of comfort


the client.
before performing ambulation.

Ensure client appropriate


dressed to walk and has shoes
or slippers.

During:

Assess clients to out in bed,


instruct to stand carefully to
begin the exercise.
Ensure client safety.
Remain physically close to
client in case of assistance is
needed in any point.

After:

Evaluate clients response.


Document distance and
duration of ambulation.
Includes description of the
clients activity tolerance when
walking (PR, facial color, feeling
of dizziness or weakness).

SURGICAL MANAGEMENT
Brief Description of the Procedure
A Caesarean Section is surgical procedure in which one or more incisions are made though a mothers
abdomen and uterus to deliver one or more babies, or rarely to remove a dead fetus. A Caesarean Section is
often performed when a vaginal delivery would put the babys mothers life or health at risk. Many are also
performed by request. Both general and regional anaesthesia are acceptable for use during C-section. General
anaesthesia affecting the entire body and accompanied by loss of consciousness. Regional anaesthesia may be
performed as a single shot or with a continuous catheter through which medication is given over a prolonged
period.
Nursing Responsibilities
Prior:
Check the doctors order.
Monitor the vital signs
Encourage conversation to find out the patient's concerns, feelings, and the level of understanding.
Acceptance and understanding instructions surgery
Medicines for fever.
If fever, must be lowered before anaesthesias.
During:
Check for the doctors order
Check for the time management of the medicines
Monitor the clients response
Assess the vital signs
After:
Monitor the vital signs and the clients reaction/response
Check for the doctors order
8 hours after surgery patients are encouraged to have an early ROM and ambulation.
On the second day the patient can stand and sit outside the room.
Report and document the procedure

NURSING CARE PLAN No. 1


Assessment

Subjective:
Masakit yung
tahi ko ,as
verbalized
by
the
client.
Pain scale: 7/10

Objective:
Facial
Grimace
Guarding
behaviour

PR=71
bmp
TEMPERATURE=
37.1 C

RR= 18cpm
BP= 110/70 mmHg

Nursing
Diagnosis

Planning

Acute pain related Short term goal:


to tissue injury
After 30 minutes
secondary
to
of
nursing
surgical
intervention,
incision;Caesarian
the client will
Section.
be
able
to
verbalize
alleviation
of
pain, from a
pain scale of
7/10 to 6/10.

Long term goal:


Within 8 hours, the
client will be
able to report
that pain is
relieved/contro
lled

Within 8 hours, the


client will be
able to follow
prescribed
pharmacologica
l regimen.

Within 8 hours, the


client will be
able
to
demonstrate
ways on how to
manage pain.

Intervention

Independent
Encourage use of
relaxation
techniques such
as listening to
music.

Encourage
verbalization of
feelings about
the pain.

Encourage
adequate rest
period.

Instruct
deep
breathing
exercise.

Dependent
Take medicines as
prescribed

Rationale

Increases release
ofendorphins and
enhance
the
therapeutic
effects
ofpain
management

To serve as baseline
data.

To prevent fatigue.

to relieve pain.

To alleviate the pain


that the client is
experiencing.

Evaluation

Short term goal:


After 30 minutes of
nursing intervention, the
client will be able to
verbalize alleviation of
pain, from a pain scale of
7/10 to 6/10.

GOAL MET

Long term goal:

Within 8 hours, the


client will be able:

to report the pain is


relieved

will be able to follow


prescribed
pharmacological regimen.

demonstrate ways on
how to manage pain.

GOAL MET

NURSING CARE PLAN No. 2


Assessment

Subjective:
none
Objective:
dressing dry
and intact

Nursing
agnosis

Planning

Intervention

Risk
for Short term goal:
Independent
infection
After 30 minutes
Instruct proper
related
to
of
nursing
handwashing
inadequate
intervention,
the
.
primary
client
and
defense
significant others
secondary to
will be able to
Inspet incision
identify causative
site/dressing.
factors and signs
and symptoms of
infection and report
Note
for
them to the health
fever,chills,
care
provider
diaphoresis,
accordingly.
and
increasing
Long term goal:
abdominal
Within 8 hours,
pain.
the client will be
able to achieve
timely
wound
healing and be free
of
signs
of
infection
and Dependent
inflammation,
Take medicines
purulent drainage
as prescribed
and fever.

Rationale

Evaluation

Short term goal:


Reduces risk of spread After 30 minutes of
of bacteria.
nursing intervention,
the
client
and
significant others will
Provides
early be able to identify
detection
of causative factors and
developing
signs and symptoms
infectious process.
of infection and report
them to the health
care
provider
Suggestive of presence accordingly.
of
GOAL MET
infection/developing
sepsis,
abscess, Long term goal:
peritonitis.
Within 8 hours, the
client will be able to
achieve timely wound
healing and be free of
signs of infection and
inflammation,
purulent drainage and
fever.
GOAL MET
To alleviate the pain
that the client is
experiencing.

NURSING CARE PLAN No. 3


Assessment

Subjective:
Hindi
pa
ako
dumudumi
,as
verbalized by the
client.

Objective:
patient has not yet
defecated
normal elimination
pattern has not yet
returned

Nursing
Diagnosis

Planning

Risk
to Short term goal:
constipation
After 30 minutes
related to post
of
nursing
pregnancy
intervention, the
cesarea
client will be
section.
able
to
demonstrate
behaviours
or
plan of lifestyle
change
to
prevent
developing
problems.

Long term goal:


Within 8 hours, the
client will be
able to have
normal
elimination
patter.
.

Intervention

Independent
Assess client's
normal bowel
pattern abot how
many times a day
she defecates.

Encourage to
increase fluid
intake

Encourage
ambulation within
individual limits.

Rationale

To provide
baseline
information.

To soften stool
and facilitate
passage
through the
colon

To stimulate
contraction
of intestines
and avoid
post
operative
complication.

Evaluation

Long term goal:


After 30 minutes of
nursing
intervention,
the
client will be able
to
demonstrate
behaviours or plan
of lifestyle change
to
prevent
developing
problems.
GOAL MET

Short term goal:


Within 8 hours,
the client will be
able to have normal
elimination patter.
GOAL MET