DISCHARGE PLANNING

M – Medication

 Take home medication as prescribed by the Physician

 Methylgonometrine 1 tab TID

E – Environment

 Instructed patient to stay in calm, quiet environment

 Home environment must be free from slipping or accident

hazards

T – Treatment

 Informed patient to have a follow-up check up after 1- 2 weeks

H – Health Teachings

 Informed patient to avoid lifting heavy objects for 1-2 weeks

 Stressed the importance of perineal cleanliness

 Encouraged client to have hot sitz bath

 Instructed patient to increase intake of protein-rich foods to

promote faster wound healing

 Instructed to promote adequate fluid intake

 Discouraged patient to participate in strenuous activities that

might precipitate stress and trauma to the wound

 Instructed patient to promote breastfeeding

O – Observable Signs and Symptoms

 Observe for dehiscence and evisceration

 Instructed patient to report to physician any signs of infection

 Instructed patient to report any case of hemorrhage or abnormal

bleeding

D – Diet
  Encouraged client to increase intake of fiber to avoid
constipation

 Instructed to increase fluid intake

 Instructed to increase intake of nutritious foods such as fruits

and vegetables

LEARNING OUTCOMES

Cesarean section is one of the most common procedures done

on the OR/DR. everyone seems to be pretty familiar with it, us included.
However, encountering a cesarean section procedure and participating in it
as student nurses is an entirely different experience.

BEING a scrub nurse, the principles of sterility are considered the

mantras, serving as guides. Preparing the operating table, counting and
arranging the instruments are the main responsibilities. Intraoperatively,
constant vigilance and initiative must be observed. One must listen to the
surgeon; attend to the immediate needs for operation. It’s a great stressor to
stand beside the doctor, but as the procedure progresses, confidence boosts
in unbelievable level.

Circulating nurses are said to be out of spotlight. True as it is, it

doesn’t mean their job is insignificant. They’re as important as the scrub
nurses. Everything enclosing the sterile field is ensured by the sterile team’s
circulating nurse making sure that what they need is always available. One
elementary initiative she must remember is that taking of blood pressure
before and after operation. It’s very crucial to remember such things.

Cord care and care of the newborn for cesarean section is more
or less the same as that in normal spontaneous delivery. All the same,
additional attention must be paid. This is because the newborn might have
complications brought about by the procedure. Patent airway and
thermoregulation is two of the main concerns.
 The Operating Room/Delivery Room opened up a new world to us
as we explored medical and surgical nursing. It’s also like travelling back to
the obstetrics. The best bit of it was there was actualization of the return
demonstrations we have been looking forward of putting into practice. It felt
like we became nurses already.

PHYSIOLOGY OF PUFT CESAREAN DELIVERY

Release of FSH by

the anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickening

of the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from

the graafian follicle)

Ovum travels into the fallopian tube

 Fertilization (union of the ovum

and sperm in the ampulla)

Zygote travels from the fallopian tube

to the uterus

Implantation

Development of the fetus/embryo &

placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Contraction Ripening of the cervix

(descent of the fetal (false labor) (Goodell’s Sign

wherein

head into the pelvis) >begin and remain irregular the cervix feels
softer like

>1st felt abdominally consistency of the

earlobe

>pain disappears with ambu-

lation

>do not increase in duration

and intensity

>do not achieve cervical

dilatation
 TRUE LABOR

Uterine Contractions SHOW Rupture of

Membranes
>increase in duration (pink-tinge of blood, (rupture of the
amniotic sac)

and intensity a mixture of blood and fluid)

>1st felt at the back &

radiates to the abdomen

>pain is not relieved no

matter what the activity

>achieve cervical dila-

tation

Failed to progress labor

(due to previous cesarean birth, cervical arrest,

cervical atrophy)

increase risk for fetal distress

(meconium staining, hypoxia)

 Increase risk of fetal death

Emergent cesarean delivery

(the incision made on the lower part of the abdomen)

Expulsion of the fetus

Expulsion of the placenta

(accompanied by bloodless approximately

1000-1500 mL)

LABORATORY RESULTS

Urine Analysis

Date Ordered: November 28, 2008

Date Performed: November 28, 2008

Microscopic Exam Chemical Exam

Color: Yellow Albumin: Negative

Transparency: Hazel Sugar: Negative

Rection pH: 6.0 (Normal: 7.35-7.45)

Specific Gravity: 1.010 (Normal: 1.010-1.025)

Pus Cells: 0.2

Epithelial Cells: Moderate

Normal Interpretatio
Result Significance
Values n

RBC 5.4 4.5 – 6.0 x 10/L Normal

Indicates
WBC 10.1 5 – 10 x 10/L Increase presence of
infection

Indicates
HgB 116 120 – 140 g/dl Decrease occurrence of
anemia

Indicates hyper
Hct 0.35 0.30 Increase
coagulation

150 – 400 x
Platelet 320 Normal
09/L

DIFFERENTIAL COUNTING

Indicates
Neutrophils 0.86 0.05 – 0.70 Increase infection or
inflammation

Indicates high
Lymphocytes 0.14 0.20 – 0.40 Decrease risk for acquiring
infection

DRUG LIST

Requesting Dosage, Frequency

Date Ordered Drug Name
Physician and Route

November 29,
Dr. Calamba Ranitidine(PREOP) 50mg IV q8h
2008

November 29,2008 Dr. Calamba Ampicillin(PREOP) 500 mg IV q6h

November 29, Nalbuphine

Dr. Villanueva 5 mg IV q6h x2/day
2008 (Nubain) (INTRAOP)

Ketorolac 30 mg IV q8h x3
November 29,
Dr. Villanueva (Kortezor) doses, followed by
2008
(INTRAOP) 15 mg IV q8h
 November 29, Methylergonomitrin
Dr. Calamba 1 tab TID(ORAL)
2008 e (POSTOP)

9 RIGHTS IN GIVING MEDICATION

 RIGHT PATIENT
 RIGHT DRUG
 RIGHT DOSE
 RIGHT TIME
 RIGHT ROUTE
 RIGHT TO REFUSE
 RIGHT TO RATIONALE
 RIGHT TO DOCUMENTATION
 RIGHT INFORMATION

PROBLEM LIST

Date
Proble Type of Date
Nursing Diagnosis Identifie
m# Problem Evaluated
d
1 PREOP Imbalanced Nutrition: More November Not
than body requirements r/t 29, 2008 Evaluated
excessive intake in relation
to metabolic need
2
PREOP Deficient knowledge r/t lack Not
November
of interest in learning Evaluated
29, 2008

3 November Not
POSTOP Acute pain r/t traumatized
29, 2008 Evaluated
skin tissue

4 Risk for infection r/t November Not

POSTOP
29, 2008 Evaluated
traumatized skin tissue 2°
to cesarean section

5 Risk for constipation r/t November Not

POSTOP Evaluated
post pregnancy 2° to 29, 2008

cesarean section
 NURSING HEALTH HISTORY

Nursing health history is the first part of the client’s health status, it is
systematic collection of subjective data provided by the patient’s/significant
other’s verbalizations and supplemental by objective data gathered during
physical assessment. It is needed for solving and determining a patient’s
problem and for the nurse to know what interventions to be applied and
what may be the cause of the illness.

Since our patient cannot really express much of herself due to her
condition, we chose to gather information from her mother whom is very
close to her.

It was on December 28, 2008, Friday, when we chose a case for our
individual case study. During my first encounter with the patient, she was
lying on DR table with #1 IVF of D5LR @ 30 gtts/min. hooked at the left
cephalic vein.

For the patient’s trust, privacy, dignity and respect we gave herm we
decided to hide her name and called her Patient B.

Patient B is an 18-year-old female, who is pregnant for more than 42

weeks, married, and a mother of one. She is a Muslim, with fair complexion.
Stands 153 centimeters and weighs about 83 kilograms. Her AOG is 43
weeks, LMP was last February 3, 2008, and her EDC would be on November
10, 2008. She was born on May 15, 1990 through normal spontaneous
delivery at Agusan del Norte Provinvial Hospital (ADNPH). She was the 3rd
eldest among the 5 siblings.

Patient B grew up at Purok 10, Ong Yiu, Butuan City with her family,
and has been used to the Muslim traditions since both of her parents were
Muslims. Patient B finished her secondary level at Agusan National High
School, and was already married at the age of 16 years old to a Muslim who
was then a close relative to their family. She was only 17 years old when she
gave birth to her first child through Cesarean Section (Low Segment
Transverse), because she had a difficulty in delivering the child due to her
age and the lack of knowledge.
 It was on November 28, 2008 at around 9:00PM when Patient B was
admitted at the Ob-ward of Elisa R. Ochoa Memorial Hospital and was sent to
the OR/DR for an internal examination and was told that her pregnancy was
already over due. Upon admission, she had the following vs:

 T = 37.2°C
 P = 90 bpm
 R = 20 bpm
 BP=110/80 mmHg
Dr. Calamba, her surgeon gave her the following orders:

 November 28, 2008

o > NPO
o U/A
o Start D5LR 1L @ 30 gtts/min
 November 29, 2008
o Ampicillin 1gm ANST
o Stat low segment transverse cesarean section as
performed by Dr. Calamba, the surgeon, together
with Dr. Quinte, the assistant surgeon and Dr.
Villanueva, her anesthesiologist at 4:20PM which
ended at 5:28 Pm
o Flat on bed until 10PM then sit on bed until
tolerated
o NPO until flatulence
o Repeat hgb + hct tomorrow morning
o Nualbuphine(Nubain) 5 mg IV q6h x 2/day
o Ketorolac(Kortezor) 30mg IV q8h x 3 doses then
15 mg IV q6h
o Ranitidine 50 mg IV q8h
o Ampicillin 500mg IV q6h
o Ice pack to hypogastrium RTC to ensure uterine
contraction
o Refer accordingly
During the procedure, we have observed how the surgeons incised the
5-layered abdominal skin tissue. The first to be incised was the sin followed
by the subcutaneous layer. The subcutaneous fats of the patient were so
thick that we weren’t able to distinguish whether it is still a skin or not. So,
the assistant surgeon explained to us what they were cutting. Then follows
the fascia, which is dark red in appearance as well as the appearance. The
incision of the peritoneum was quite delayed because the surgeons had to
clamp the subcutaneous folds. In a matter of seconds, the head of the baby
came out, so the doctor instructed the circulating nurses present to prepare
the suction and the bassinette, and also instructed to turn the air conditioner
off to prevent physiologic weightloss of the infant. When the baby came out,
he was of pale color, so the assigned student nurse for cord care, together
with out clinical instructor suctioned the baby and established patent airway.
Patient B was still asleep at that time due to the anesthetic effects.
 We rendered care to Patient B and her baby on November 29, 2008 at
the OR for the Cesarean Section Procedure. Together with Dr. Calamba, the
surgeon, Dr. Quinte, the assistant surgeon and Dr. Villanueva, the
anesthesiologist, the procedure was successful.

PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the

Cephalocaudal assessment. This is done systematically using the techniques of
inspection, palpation, percussion and auscultation with the use of materials and
investments such as the penlight, thermometer, sphygmomanometer, tape
measure and stethoscope and also the senses. During the procedure, I made
every effort to recognize and respect the patient’s feelings as well as to provide
comfort measures and follow appropriate safety precautions.

A. General Physical Assessment

Patient is an 18 year old female, stands 5’4. She is conscious and

coherent upon interaction but answers only the questions she is comfortable
with. Vital signs were not taken except for her BP with a reading of
130/80mmHg.

B. Assessment of the Head

 Head is round in shape. Hair is long, thick and coarse, straight and evenly
distributed. Scalp is smooth and white in color, minimal lesions were noted.
Dandruff and lice were seen.

C. Assessment of the Eyes

Her eyes are symmetrical, black in color, almond shape. Pupils constricts
when diverted to light and dilates when she gazes afar, conjunctivas are pink.
Eyelashes are equally distributed and skin around the eyes is intact. The eyes
involuntarily blink.

D. Assessment of the Ears

Ears are clean, no ear wax was noted and of the same size and shape.
Patient can hear normally when spoken softly.

E. Assessment of the Nose

With narrow nose bridge, there were discharges noted upon inspection.
No swelling of the mucous membrane and presence of nasal hairs were seen.

F. Assessment of the Mouth

She has a complete set of teeth with minimal dental caries noted. Oral
mucosa and gingival are pink in color, moist and there were no lesions nor
inflammation noted. Tongue is pinkish and is free of swelling and lesions.
Presence of uvula was noted and there is absence of swelling.

J. Assessment of the Neck

Lymph nodes noted. Neck has strength that allows movement back and
forth, left and right. Patient is able to freely move her neck.
H. Assessment of the Lungs and Thoracic Region

No reports of pain during the inhalation and exhalation.

I. Assessment of the Heart

Heart was not assessed.

J. Assessment of the Abdomen

Abdominal movement as with respiration. There is incision on the lower

abdominal portion. The post operative incision appears reddish as normal
finding for the first 2 days after the operation. The sutures were intact with no
discharges noted.

K. Assessment of the Upper Extremities

Skin: White in color; presence of marks/scars of wounds in the arms, neck

and legs. Skin is smooth, moist and soft to touch.

Hands: Medium in size with 5 fingernails in each side. Nails are short,
small dusty particles are present. A capillary refill of 1-2 seconds
was noted.

Arms: Able to move through active ROM. Able to extend arms in

front or push them out to the side.

L. Assessment to the Lower Extremities

Size of the feet is undefined with lines on the sole, presence of scars and
lesions. Ten fingers are present. Nails are clean and short. No apparent pain
upon movement therefore indicates negative Homan’s sign. Patient is
ambulatory.

M. Assessment of the Genitourinary

Patient urinates 2-4 times a day and has not defecated yet since her
delivery.

N. Assessment of the Perineum

 Absence of lesions and swelling.

O. Neurological Assessment

Behavior – Patient is silent but is conscious and coherent upon

interaction. She sits and walks if she wants to.

Motor Functioning - Able to move extremities through active ROM.

Able to extend arms front and resist active as pushed
down/up on his hands.

Reflexes - reflexes were present such as the blinking reflex and deep
tendon reflex.

Sensory Functioning – Patient’s sensory system is intact, she was able

to distinguish touch, pain, hot and cold.