Arellano University

College Of Nursing
Legarda, Manila

CASE STUDY
POST CESAREAN SECTION

SUBMITTED BY:
BSN III-12

GROUP 48

LIMUCO, JANNA ZENNA

MANTALA, MICHELLE

MARTINEZ, MARK KEVIN

MARZO, AYESHA CLAIRE

MURILLO, ROSE ANN

NAPULE, CHARLOTTE

NUGUID, GLACIE LYNNE

REAGO, JESTORI

REMOLLO, KEVIN

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VILLARANTE, JHUNNAR

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I. INTRODUCTION

Cesarean birth, birth accomplished through an abdominal incision into the uterus, is one
of the oldest typed of surgical procedure known. Unfortunately, it is a procedure always more
hazardous than vaginal birth. Fortunately, when compared with other surgical procedures, it
is one of the safest types of surgeries and one with few complications.

The word “cesarean” is derived from the Latin “caedore” which means “to cut”. At one
time, there was a popular belief that Julius Caesar was delivered by a cesarean birth and that
procedure was named for him. However, because Caesar was born before antibiotics and
sterile surgical techniques, it seems likely that his mother would have survived the said
procedure. Currently, cesarean birth is used most often prophylactic measures, to alleviate
problems of birth for conditions such as cephalopelvic disproportion, cervical cerclage,
placenta previa, umbilical cord prolapsed, fetal distress, transverse fetal lie, etc. It is
generally contraindicated when there is a documented dead fetus.

You might need to have a planned cesarean delivery if a patient condition is in

Cephalopelvic disproportion (CPD), Previous cesarean birth, Multiple pregnancy, Placenta
previa, Transverse lie, or Breech presentation. In a Cephalopelvic disproportion (CPD), the
baby’s head or body is too large to pass safely through the mother’s pelvis, or the mother’s
pelvis is too small to deliver a normal-sized baby. In Previous cesarean birth, although it is
possible to have a vaginal birth after a previous cesarean, it is not an option for all women.
Factors that can affect whether a cesarean is needed include the type of uterine incision used
in the previous cesarean and the risk of rupturing the uterus with a vaginal birth. In Multiple
pregnancy, although twins can often be delivered vaginally, two or more babies might
require a cesarean delivery. In Placenta previa, a cesarean delivery is done if the placenta is
attached too low in the uterine wall and blocks the baby’s exit through the cervix. A mother
also underwent a cesarean delivery if the baby is in a Transverse Lie presentation because
the baby is in a horizontal or sideways position in the uterus. In this condition, a cesarean
delivery is always used. And for Breech presentation or Breech birth, the baby is

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positioned to deliver feet or bottom first. If your doctor determines that the baby can’t be
turned through abdominal manipulation, you will need to have a cesarean delivery.

The term cesarean birth rather than cesarean delivery is generally used to accentuate that
this is a birth more than surgical procedure. A major concern in maternal and child health
nursing is the increasing number of cesarean births being performed annually.

In South East Asian countries, Overall 27% of women had a caesarean section, with rates
varying from 19% to 35% between countries and 12% to 39% between hospitals within
countries. The most common indications for caesarean were previous caesarean (7.0%),
cephalopelvic disproportion (6.3%), malpresentation (4.7%) and fetal distress (3.3%).
Neonatal resuscitation rates ranged from 7% to 60% between countries. Prophylactic
antibiotics were almost universally given but variations in timing occurred between countries
and between hospitals within countries.

There are two types of Cesarean Birth: scheduled and emergency. In the first instance,
there is time for thorough preparation, some women may have even taken a child preparation
class specifically for cesarean birth. Scheduling cesarean birth this freely also resulted in
preterm births. A physical indication for cesarean birth such as transverse presentation,
genital herpes, cephalopelvic disproportion, or avoidance of post-procedure stress
incontinence, must be documented before a cesarean procedure can be performed. Cesarean
birth reduces the transfer of HIV from mother to newborn (Read et al. 2001). With new
surgical techniques, particularly a low cervical incision, “once a cesarean, always a cesarean”
no longer applies. Most of women who have had cesarean birth, after 10 years are eligible to
give birth vaginally in subsequent pregnancies if the circumstances are otherwise are
appropriate for vaginal birth. About 60% of woman todat have vaginal birth after a cesarean
birth (VBAC). VBAC’s are the most successful if there is an interval greater than 19 months
between the cesarean and the VBAC (Huonget Al., 2002). Emergency cesarean births are
done for reasons such as placenta previa, abruption placentae, fetal distress or failure to
progress in labor. An emergency cesarean birth carries with it the risk of all emergency
surgery: a woman may not be a prime candidate for anesthesia and who is psychologically

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unprepared for the experience. In addition, the woman may have a fluid electrolyte
imbalance and be both physically and emotionally exhausted form a long labor.

II. OBJECTIVES

General objective:

We, BSN 3 – Group 48 of Arellano University College of Nursing aims to develop our
skills in performing assessment procedures and the necessary intervention for quality client care
of patient with post cesarean client, to enhance our knowledge in understanding the procedure
and identify specific treatment and last and foremost is for us to be able to give knowledge about
cesarean.

Specific objectives:

At the end of the presentation our group will be able:

 To describe indications of cesarean birth.

 Formulate diagnosis related to Cesarean birth.
 Establish outcomes that meet the needs of woman requiring cesarean birth.
 Plan appropriate nursing care to ensure family centered care.
 Evaluate outcomes for achievement and effectiveness of nursing care.

III.THEORETICAL FOUNDATION

Dorothea Orem's Self-Care Theory

This theory composed of three related theories including self care, self care agency, and
therapeutic self care demand. In Self care theory, an individual initiate and perform his/her own
activities to maintain life, health and well being. In Self care agency, a multidimensional
concept in nursing theory includes motivation, decision-making, energy, and knowledge
necessary to perform self-care actions. In Therapeutic self care demand, "totality of self care

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actions to be performed for some duration in order to meet self care requisites by using valid
methods and related sets of operations and actions".

A Self care requisite is an action directed towards provision of self care. There are 3 categories
of self care requisites are: 1) The Universal, which includes developmental and health deviation;
2) the Universal self-care requisites associates with life processes and the maintenance of the
integrity of human structure and functioning and activity of daily living (ADL). These requisites
identify maintenance of sufficient intake of air, water, and food. Also provision of care
associated with elimination process, balances between activity and rest between solitude and
social interaction, prevention of hazards to human life well-being and promotion of human
functioning and lastly; 3) the Developmental self care requisites associates with developmental
processes/derives from a condition or associates with an event and this also includes health
deviation self-care that requires condition of illness, or disease. It also seeks and secures
appropriate medical assistance, being aware of and attending to the effects and results of
pathologic conditions, effectively carrying out medically prescribed measures, modifies self
concept in accepting oneself as being in a particular state of health and in specific forms of
health care and learning to live with effects of pathologic conditions.

“Dorothea Orem’s theory encompasses that patient is requiring nursing care. It is needed if there
is a problem that prevents a person from reaching their optimal health. Restoring, promoting and
maintaining health are the goals of Dorothea Orem’s Self-care Model, these include the interventions
and teachings design to return a person to or sustain a level of optimal health and well being, It is when
an adult is incapable or limited in the provision of continuous effective self-care. In this case, the
patient has ineffective health continuance because of the procedure she had undergone and due to
the incision she had have the nurses role in helping the client to achieve or maintain a level of
optimal health and wellness to act as an advocate, redirector, support person and teach and to
provide an environment conducive to therapeutic ddevelpoment.

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IV. NURSING HISTORY

A. Biographical Data

Patient Name: A. M.

Address: Delpan ST., Barangay Kasilawan, Makati City

Date of Birth: April 13, 1981

Place of Birth: Pangasinan City

Age: 25 years old

Nationality: Filipino

Educational Attainment: BS Electrical and Communications Engineering

Religion: Roman Catholic

Data of Admission: August 24, 2006

Mode of arrival: Ambulatory

B. Chief Complaint

“Noong pag-ihi ko may sumabay na dugo” as verbalized by the patient.

C. History of present Illness

Two days prior to admission, patient experienced bloody vaginal discharge upon
urinating. The bloody vaginal discharge she noted prompted her to go to the hospital and
subsequently admitted. (delte breast changes. Eklabu)

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Pain experienced:

Location is in right and lower left quadrant of abdomen specifically on the incision site.
Radiation localized pain. Quality is recurrent and throbbing pain. Aggravating Factor is during
activity. Alleviating factor was medications. Time usually lasts for 1-2 hours

D. History of Past Illness

On the 1st trimester of her pregnancy, she experienced discomforts like breast changes,
urinary frequency, fatigue, nausea and vomiting. Urinary frequency accompanied by leg cramps
was also experienced in the 2nd and 3rd trimester. The patient had her Urinary tract Infection when
she was in her 7th month of pregnancy and her Physician prescribed her a Cefalexin as treatment
for the said illness. And She have had undergone a procedure of dilatation and curettage due to
her miscarriage. And had no allergies to any food and medications.

E. Family Health History

Patient’s father was noted to be hypertensive.

F. Social History

Work Environment: She works at MDS, a web design company located at The Fort Strip.

Home Environment: Resides in 2 bedrooms, 1 bathroom concrete house.

Education: A degree holder of Bachelor of Science in Electrical and Communications

Engineering.

Role Relationship: Wife and daughter.

Childhood Immunization: Patient had completed childhood immunization.

G. Obstetrical History

Menarche: 14 years old.

Monthly cycle duration: 3-5 days, 2-3 pads moderately soaked.

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Last Menstrual Period: November 19, 2005

Age of Gestation: 40 weeks and 2 days (via LMP)

: 38 weeks and 4 days (via pelvic ultrasound)

Expected Date of Confinement: September 2, 2006

OB Score: G2 P1 (T1 P0 A1 L1 M0)

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V. ANATOMY AND PHYSIOLOGY

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ANATOMY

The pelvic girdle is the place where the lower limbs attach to the body. The right and left
coxae, or hip bones, join each other anteriorly and the sacrum posteriorly, to form a ring of bone
called the pelvic girdle and the coccyx. The sacrum and the coccyx form part of the pelvis but
are also part of the axial skeleton. Each coxa formed by the three bones fused to one another to
form a single bone. The ilium is the most superior, the ischium is the inferior and the pubis is the
anterior and inferior. An iliac crest can be seen alongthe superior margin of each ilium and an
anterior iliac spine, an important hip landmark, is located at the anterior end of the iliac crest.
The coxae join each other anteriorly at the pubic symphysis and join the sacrum posteriorly at the
sacro ilac joints. The acetabulum is the socket of the hip joint. The obturator foramen is the large
hole in each coxa that is closed off by muscles and other structures.

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PHYSIOLOGY

The organs of the reproductive systems are concerned with the general process of
reproduction, and each is adapted for specialized tasks. These organs are unique in that their
functions are not necessary for the survival of each individual. Instead, their functions are vital to
the continuation of the human species. In providing maternity gynecologic health care to women,
you will find that it is vital to your career as a practical nurse and to the patient that you will
require a greater depth and breadth of knowledge of the female anatomy and physiology than
usual. The female reproductive system consists of internal organs and external organs. The
internal organs are located in the pelvic cavity and are supported by the pelvic floor. The external
organs are located from the lower margin of the pubis to the perineum. The appearance of the
external genitals varies greatly from woman to woman, since age, heredity, race, and the number
of children a woman has borne determines the size, shape, and color.

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VI. PATHOPHYSIOLOGY

Physiologic Factors: Predisposing Factors:

 Presumptive signs: breasts changes,  Occupation

urinary frequency, fatigue, nausea and  History of Abortion
Launch Internet
vomiting on the 1st trimester
Explorer Browser.lnk
and leg  UTI during her 7th month of pregnancy
cramps on her 2 and 3rd trimester.
nd

 LMP: November 19 , 2005 and her EDC:

September 2, 2006
 Pelvic Ultrasound

TRUE LABOR

(+) bloody vaginal discharge

During Transition Phase the The Presenting part was still

presenting part was at above the ischial spine and
station -1 has not crowned yet

Arrest in Cervical
Dilatation

Swelling or discharges on the Immediate Low Transverse

surgical incision site Cesarean Section

Low Segment Incision on the Acute Pain r/t surgical incision

Abdomen (PS: 5/10)

Expulsion of Fetus Activity Intolerance as

manifested by Weakness and
discomfort
Expulsion of Placenta accompanied
by blood loss of 800 cc

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VII. GORDON’S FUNCTIONAL PATTERN

BEFORE DURING ANALYSIS

HOSPITALIZATION HOSPITALIZATION

-The patient had complete -“parang hindi ko kaya na

immunizations and had hindi ako kakain ng ganon -The patient was anxious
HEALTH undergone laboratory and katagal, paano ako about her condition and how
PERCEPTION/HE diagnostic procedures of lalakas? As verbalized by will she able to recover easily
ALTH ultrasound and urinalysis. She the patient. if she’s under NPO.
MANAGEMENT regularly intakes .
PATTERN multivitamins and Iron - Early and consistent
( caltrate and honorate). And Konek? prenatal care is essential to
throughout the preganancy, the health and health of her
she had completed the pre- baby.
natal check up. (maternal &child health
nursing vol.1,p595)

-The patient eats usual foods -The patient was under -There is a change in the diet
such as sinigang and adobo NPO and being given by modification of the patient
NUTRITIONAL- and she has ability in an IVF of D5LR 1L to run because the patient is a post
METABOLIC swallowing and chewing for 8 hours at 32 gtts/ min CS she must be in NPO since
PATTERN foods and feeds herself. She’s as ordered. And she loss her peristalsis movement is
taking regular meals. blood about 800 cc on the not yet returning to normal.
operation. There’s a risk in deficient
fluid volume.
-a pregnant woman should
eat a sufficient diet to allow
for the growth of fetus and
also provide for the need of
her on growing baby.
(maternal and child nursing
vol.1,p657)
-most women have a IVF line
before the surgery with a
fluid .it helps to ensure that a
woman is fully hydrated.
(maternal &child health
nursing vol.1,p657)

-The patient had a regular -The patient was -There is a change in the
bowel movement. Her last catheterized her urine is urine pattern because the
menstrual period was last bloody in color and has an patient had been catheterized

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November 19, 2005. Duration output of 400cc per/hr. and the patient’s elimination
ELIMINATION of her menstrual period was The patient undergone was also changed because
PATTERN 3- 5 days, 2-3 pads, water glycerine enema water glycerine enema was
moderately soaked. prior to the procedure. administered to the client due
Transfer the mens eke k sa to her condition.
sexual ekek.
-“di ko naman masyadong -before the hospitalization
nararamdaman na patient had a normal
lumalabas yoong ihi ko elimination pattern, can void
-“Nung pag-ihi ko may pero nakikita ko may freely but when she got
sumabay na dugo” as laman naman yoong bag” hospitalized her sensation of
verbalized by the patient. as verbalized by the voiding become altered.
patient.

Not approrioate. Sensation

eklabu.

ACTIVITY- -The patient is able to feed, -The patient was not able - the patient uses her full
EXERCISE bathe and groom herself. She to do things independently range of motion and have
PATTERN has sufficient energy for and became dependent. active exercise before she
desired and/or required She had a difficult time hospitalized and become
activity. She is in full range of moving around the bed to altered when she got into the
motion. And practices active change position due to the hospital because of pain and
exercises. pain weakness due to the
procedure.
Delete feeding churva. -People often define their
health and physical fitness by
their activity because mental
well-being and the
effectiveness of body
function depend largely on
their mobility status.
(fundamentals of nursing
vol.2, p1106)

-She had a normal sleep and -She experienced -Due to the procedure that
rest pattern. difficulty in sleeping as the client had undergone, she
SLEEP AND she experienced pain. was having difficulty, since
REST PATTERN Not applicable yung normal she cannot move freely and
the presence of incision in
her abdomen and the pain in
it, made her difficult to sleep.

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COGNITIVE -Before the hospitalization, - Patient was then asked -The patient’s cognitive
PERCEPTUAL the patient experienced how she felt after the perceptual pattern changed
PATTERN discomforts like breast operation and she due to the patient’s condition
changes, urinary frequency verbalized and maybe due to knowledge
nausea and vomiting. And “nararamdaman ko yoong deficit.
urinary frequency sakit ng tahi” and “kung i-
accompanied by leg cramps rarate ko yoong sakit mga -According to Piaget stage of
on the 2nd and 3rd trimester of 5/10. She also added Cognitive development-
pregnancy. “medyo nauuhaw ako na formal operational- the
parang natutuyo person can solve hypothetical
lalamunan ko siguro dahil problems with scientific
Not applicable.what was the sa pagod tsaka sa tagal ng reasoning understand s
perceptiot the s/sn abou operasyon” and “parang causality and can deal with
hindi ko kaya na hindi ako the past present and future.
kakain ng ganoon katagal, (maternal &child health
paano ako lalakas?” nursing vol.2,p801)

-
-The patient believes that her -The patient is concern -Herself perception is mainly
SELF needs for intimacy and with her current health focused on her health
PERCEPTION affection are being met. She condition and how she condition.
PATTERN-SELF feels good most of the time. will be getting well and
CONCEPT her present health goal is
PATTERN to eat to be able to get
well.

-She is living with her -She was a mom now, and --throughout life people
husband and a family oriented trying to adjust on things under go numerous role
person. She isn’t a member of like taking care of her changes.
ROLE any organization. newborn, etc. (fundamentals of nursing
RELATIONSHIP vol.2,p1006)
-Patient AM had moderate
self esteem with close
relationship with the member
of her family.

-Her first menstrual period -She had delivered a live - according to Freud stages of
SEXUALITY- was when she was 14 years full term baby girl. psychosexual a person
REPRODUCTIVE old and her Last Menstrual develops sexual maturity and
Period was last November 19, learns to establish
2005. And have had satisfactory relationship with
undergone D&C due to the opposite sex.
miscarriage on her first (maternal &child health
pregnancy. nursing vol.2,p803)

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- She was married to his
husband on March 2005.

-She got pregnant to her first

baby but unluckily
experienced miscarriage due
to week fetal heart tone.

-Later on she had an OB

history of gravida 2, parity 1,
and abortion 1.

-And lastly became pregnant

to a 40 weeks and 2/7 days
baby girl.

STRESS -She is coping well in every -She is stressed and has -She became stressful
TOLERANCE problems encountered with worries and fears. because of her condition.
PATTERN the help of her husband and
faith to God.

VALUE BELIEF -She is a Roman Catholic and ??????? - religion may be considered
PATTERN goes to church regularly, it is a system of belief, practices
where she gets her courage in and ethical values about
every circumstances that divine or superhuman power
comes along her way. or power of worshipped as
the creators and rulers of the
universe.
(fundamentals of nursing
vol.1,p315)

Relate before and during.

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VIII. PHYSICAL ASSESSMENT

General Survey: The patient is conscious and coherent upon examination, weighs for 64kg and
stands 5’3”. The client don’t have body odor nor breath odor. The client is relaxed every time we
speak to her.

Vital Signs:

BP: 130/80 mmHg

PR: 92 bpm

RR: 20 cpm

TEMP: 37.6

 P (Precipitating Factor) – Aggravated by activity

 Q (Quality) – Localized, recurrent and throbbing quality

 R (Radiating) – Right and Lower left quadrant of the abdomen specifically

on the site of incision

 S (Severity) – 5/10

 T (Time or Onset) – Onset of pain is gradual, usually lasts for 1-2 hours

BODY FINDINGS ANALYSIS NURSING ALERT

PART
Head Normocephalic with Normal no signs of ????
smooth, black and asymmetry and
evenly distributed hair deformities.
and small traces of
dandruff on the scalp
Face Symmetrical eyebrows, No deviations like
eyelids, eyelashes, increased facial hair, moon
pupils and eyeballs are face.
normally aligned
Eyes Smooth clear cornea No signs of trauma or
and lens, (+) reflexes, abration that results to
whitish sclera, pinkish opaque appearance of the

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conjunctivae, intact eye. Positive reflexes
and normal lacrimal means no neurological
apparatus. impairment of the cranial
nerves.
Ears Symmetrical,(-) Normal, no signs of
discharges and waxy congenital abnormality like
texture and normal low set ears (Trisomy 21)
hearing acuity
Nose Normally deviated Pt. is not experiencing
with patent nostril, non DOB, nasal flaring and no
tender sinuses, pinkish abnormal discharge.
turbinate’s, moist and (-) lesions like polyps
pinkish nasal mucosa Nasal septum intact at the
with (-) discharge middle.
Mouth Lips were slightly dry No signs of cyanosis, no
and pink in color, mucosal cysts or tumor.
symmetrical and with Slightly yellowish teeth
no lesions. indicates the pt. have not
Slightly yellowish performing good oral
complete set of teeth hygiene the past days after
pinkish gums and the surgery
buccal mucosa, tonsils
with midline tongue
and uvula
Lung Symmetrical lung Indicates healthy lung and
expansion and resonant normal lung sounds
respiratory sounds
Heart Apical Heart sound Apical sound is normally
heard at the 5th heard on that part because
intercostals space, left the apex of the heart is
mid clavicular line normally located there nad
with (-) murmur absence of murmurs
indicates the pt. has no
heart problem
Abdome Presence of linea nigra Umbilicus is stretched
n and striae gravidarum. during pregnancy to such
Low segment Incision extent that by the 28th
due to CS delivery week. Extrapigmentation
with extreme swelling generally appears on the
and or discharge. abdominal wall. A narrow
brown like linea nigra may
form running from the
umbilicus to the symphisis
pubis.
Reference: Maternal and
Child’s Health 6th edition

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vol. 1 Adele Pilliteri page
234
Lower segment incision is
one made horizontally
across the abdomen just
over the symphysis pubis
and also horizontally
across the uterus just over
the cervix
Reference: Maternal and
Child’s Health 6th edition
vol. 1 Adele Pilliteri page
661
Skin Smooth, warm and No signs of pallor,
with good turgor cyanosis, jaundice and
erythema. Warm skin may
indicate risk for infection
due to surgical incision.
Nails Nail beds pink, intact No signs of infection or
with soft texture 1-2 injuries on the nailsand
sec. of capillary refill. poor circulating problem.

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IX. Laboratory Examination

Examination Results

Impression: Single live intrauterine pregnancy

in cephalic presentation of about 38 weeks and
Pelvic Examination 4/7 days age of gestation based on biparietal
diameter, fetal lie and abdominal
circumference with normal placental
localization and amniotic fluid volume.
Sonographic fetal weight is appropriate for
gestational age.

X. Medical/Surgical Management

I. Management:

A. Transfer to postpartum ward when stable

B. Vital Signs q15 minutes for 1 hour, then q4 hours

C. Monitor intakes and outputs every 4 hours for 24 hours

D. Activity:

1. Bed rest

2. Supine for 8 hours after spinal anesthetic

3. Incentive Spirometry every 1 hour while awake

E. Standard Diet

1. Nothing by mouth for 8 hours after cesarean section

2. Sips of water after 8 hour window

3. Advance to clear liquids as tolerated

4. Advance to Regular diet when flatus or Bowel Movement

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F. Early Solid Diet Protocol

1. Solid food within 8 hours of C-Section

2. Well tolerated

3. Resulted in faster bowel function return

4. Shortened hospital stay by 24 hours

5. Patolia (2001) Obstet Gynecol 98:113-6

G. Intravenous fluids

1. D5LR OR D51/2NS at 125 cc/hour

2. Foley to gravity

3. Urine output

a. Foley Catheter in place: <60 cc in 2 hours

b. Intermittent Urine collection: <300 cc per shift

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Name of Drug Mechanism of Indication Contraindicatio Adverse Reaction Nursing Responsibility
Action n

Skin structuring Use cautiously in - Before administration ask

Generic Name: Second infections cause by patients CV:phlebitis, patients if she is allergic to
Cefuroxime generation streptococcus hypersensitive to thrombophlebitis penicillin or
Sodium cephalosporins pneumonia and penicillin cephalosporins.
that inhibits cell S.pyogenes, because of GI: pseudo membranos - If large doses are given,
wall synthesis, haemophilus possibility of colitis, nausea, anorexia, therapy is prolonged, or
promoting influenza cross sensitivity vomiting, diarrhea patient is at high risk,
osmotic staphylococcus with other beta monitor patient for signs
instability, aureus, E.coli. lactam HEMA: Transient neutopenia and symptoms of
usually antibiotics. eosinophilia, hemolitic superinfection.
Brand Name: bacteracidal anemia and -Obtain specimen for
Zegen thrombocytopenia culture and sensitivity test
SKIN: Maculopapular and before given first dose
erythematous rashes, - instruct patient to notify
urticaria, pain,in duration, prescriber about rash or
Drug sterile abcesses, temp. evidence of superinfection.
Classification: elevation, sloughing IM
Anti- Effectives injection site

OTHER:
Hypersensitivity reaction,
serum sickness, anaphylaxis

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Name of Dosage Indication Contraindication Adverse Reaction Nursing
Drug Responsibility

Demerol Injection-  moderate to  contraindicated to CNS: physical Active metabolite of

10mg/ml, severe pain patients dependence, sedation meperidine may
12mg/ml,  preoperative hypersensitive to accumulate in patients
100mg/ml analgesia the drug and in CV: hypotension, with renal dysfunction,
 adjunct to those who have bradycardia causing increased CNS
Syrup- anesthesia received MAO reaction.
50mg/ml  obstetric inhibitors within GI: constipation, dry Drug may be used in
Tablets- analgesia the past 14 days. mouth, nausea some patients who are
500mg, 100mg  Avoid use in allergic to morphine.
patients with end GU: urine retention Syrup has local
stage renal anesthetic effect, give
disease. with a full glass of
water.
Watch for withdrawal
symptom after long
term use.

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Acute pain related Short Term: INDEPENDENT:
to surgical incision -After 30 minutes to  After 1 hr,
“Nararamdaman secondary to 1 hour of nursing  Provide  To avoid the patient
ko yoong sakit ng tahi cesarean section as intervention the comfort direct pain scale
ko” as verbalized by manifested by pain patient’s pain scale measures such pressure to 5/10
the patient. scale of 5/10 and of 5/10 will decrease as the incision decreased to
difficulty moving to 2/10. repositioning to site and 2/10.
without assistance supine promote non-  The patient
Objective: position, use of pharmacologi know how to
Long Term: heat packs, c pain divert herself
 Pain scale of Inference: Since the -After 2 days of quiet management. to other
5/10 patient had nursing intervention, environment, activities to
undergone delivery the patient will be and calm lessen the
 Difficulty in via low transverse able to move freely activities. pain.
moving caesarean section, with less discomfort  After 2 days,
without she has incision on and without  Instruct or the patient
assistance the lower quadrant assistance. encourage use can move
of her abdomen of relaxation  To distract freely
 Surgical which causes pain. techniques attention and without
incision such as focused reduce discomfort
breathing, tension. and
 Facial listening to assistance
Grimace music and from others.
socialization.
 specify freely
 Instruct the chuva.
client on how  It will lessen
to do deep the pain.
breathing
exercise

 Teach the

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patient on how  To avoid
to do coughing accidental
exercise and removal of
instruct the the sutures
client not to lift and bleeding
heavy objects on the site.
or do straneous
activities. n/a  To prevent
fatigue.
 Encouraged
adequate rest
periods.  To help in
early
 Check for foul detection of
smelling infection and
discharge and other
swelling on the complications
site

 Evaluates client
response to  To maintain
analgesics and acceptable
assists altering level of pain.
drug regimen
based on
patient’s
needs.  Increasing
and
decreasing
DEPENDENT: dosage helps
in self
 Administer management
analgesics of pain.
(Mefenamic

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acid), as
needed.

Collaborative:
 Provide  Promote
physical active role
therapy/ and enhances
exercise sense of
program based control
on client’s
ability.
N/A

-use of abdominal
binder

References sa ifernce at rationale.

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DISCHARGE PLAN

MEDICATION:

• Take home medication as prescribed by the physicians.

E- Exercise

• Encouraged early ambulation (walking )

T – Treatment

• Explain to the patient how she will take care of her situation toward the treatment
she had undergone.

H- Health Teaching

• Informed patient to avoid lifting heavy objects for one to two weeks.

• Stressed the importance of perineal cleanliness.

• 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 wound healing/ breast feeding

• Contact physician for

• Temperature > 100.4

• Systolic Blood Pressure <90 mmHg or >140 mmHg

• Diastolic Blood Pressure >90 mmHg or <50 mmHg

• Heart Rate >130 or <60

• Respiratory Rate >32 or <8

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O- OPD follow-up

• Informed patient to have a follow-up check up.

• Instructed the patient to report to physician any signs of infection.

D- Diet

• Encouraged client to increase intake of fiber to avoid constipation.

• Instructed to increase fluid intake.

• Instructed to increase intake of nutritious food such as fruits and vegetables.

S- Sex

• 3-4 weeks or if the client don’t feel pain nor discomforts.

BUBBLES

• B- Breast

• Encourage the client to breastfeed 15 mins. Each breast.

• Instruct the client to check her nipples or signs of sores or cracks which may lead to
discomfort.

• U- Uterus

• Instructed the patient that distended uterus is normal.

• B- Bladder

• Encouraged patient to increased fluid intake.

• Instruct the client that day by day her uterus will go back into its normal position.

B- Bowel

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• Encouraged patient to increased fiber intake to avoid constipation.

L- Lochia

• Check for cervical secretions characteristics, amount, color, and odor.

S- Sex

• 3-4 weeks or if the client don’t feel pain nor discomforts.

H- Hygiene

• Regularly wound cleaning/ dressing.

E- Exercise

• Encouraged early ambulation (walking )

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