BULACAN STATE UNIVERSITY COLLEGE OF NURSING S.Y.

2013-2014

A CASE STUDY OF 28 YEARS OLD FEMALE WHO UNDERGONE CAESARIAN SECTION AND BILATERAL TUBAL LIGATION

SUBMITTED BY: GROUP 2B BSN 3-D LEADER: Dela Cruz, Mary Grace C. MEMBER:
Maluyo, Sarah S. Masangcay, Milcah Lornel E. Masangkay, Kriselle Karissha T. Montales, Michelle D. Pascual, Rotche M.

SUBMITTED TO: Rosalinda Bartolome, RN CLINICAL INSTRUCTOR

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I.

INTRODUCTION

A Caesarian section is a form of childbirth in which a surgical incision is made through a mothers abdomen and uterus to deliver one or more babies. It is usually performed when a vaginal delivery would put the babys or mothers life or health at risk; although in recent times it has been also performed upon requests for births that would otherwise have been normal. Caesarian section (CS) is recommended when vaginal delivery might pose a risk to the mother or baby. Reasons for CS include: - Precious (high risk) fetus - Failed induction of labor - Prolonged labor or failureto progress (dystocia - Failed instrumental delivery - Apparent fetal distress - The baby is too large (macrosomia) - Apparent maternal distress - Placental problems (placenta previa, placental abruption) - Complications (pre-eclampsia, active herpes) - Umbilical cord abnormalities - Catastrophes such as cord prolapse or uterine rupture - Contracted pelvis - Multiple births - Sexually transmitted infections such as genital herpes - Abnormal presentation (breech or transverse positions) - Previous caesarian section - Old Age - Breech Presentation Bilateral Tubal Ligation is performed at caesarean section for medical reasons and when further pregnancies are deemed inadvisable and hazardous. It is a surgical procedure which a woman's fallopian tubes are clamped and blocked, or severed and sealed, either method of which prevents eggs from reaching the uterus for fertilization. Tubal ligation is considered a permanent method of sterilization and birth control. The prevalence of bilateral tubal ligation at caesarean section accounted for 2.7% of all clients offered family planning methods in the study. Of the 1,346 clients offered family planning methods during the review period, 78 clients had bilateral tubal ligation. Of the 78 women who had tubal ligation, 47.4% had the procedure at caesarean section, 46.2% had the procedure through minilaparotomy, while 6.4% had tubal ligation at laparotomy for ruptured uterus. In this case of Mrs. L.A., she underwent a low segment transverse Caesarian Section and Bilateral Tubal Ligation to prevent further complications because her doctor found out that she had Rheumatic Heart Disease. She was admitted last May 13, 2013 (5:30am) at Mary Immaculate Maternal and General Hospital.

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II.

OBJECTIVES CLIENT CENTERED: KNOWLDEGE: To develop patients awareness about her condition. To be able to understand the importance of complying her medications. To provide client education appropriate to her condition. SKILLS: To help the patient in motivating her to continue the health care provided by the health care worker. To conduct physical assessment and interpret it in order to give the care the patient needed. To be able to take care of herself even outside the hospital. ATTITUDE: To be able to comply with treatments to promote recovery. To be able to build trust with the hospital personnel. To support and encourage the client and her family to ask questions so that information could be clarified. STUDENT CENTERED: KNOWLEDGE: To gain knowledge about pharmacologic therapy given to the client who undergone Caesarian Section and Bilateral Tubal Ligation. To evaluate outcomes after implementation of nursing care to determine what nursing actions needs to be modified or improve. To identify and become familiar with the different diagnostic procedure applicable to our clients condition.

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SKILL: To do the necessary nursing intervention in hospital for the client. To give the known medication as prescribed by the doctor for the client. To collect and organize relevant information concerning the clients current health status. ATTITUDE: To give the proper care and build a genuine nurse-patient relationship conducive to good health. To establish appropriate behavior such as honest, reliable, courteous, and open minded. To develop our nursing responsibilities in dealing with the client. III. NURSING HEALTH HISTORY A. PATIENTS PROFILE NAME: ADDRESS: BIRTHDAY: AGE: SEX: CIVIL STATUS: RELIGION: NATIONALITY: EDUCTIONAL ATTAINMENT: SOURCE OF MEDICAL CARE: ADMISSION DATE: TIME: ADMITTING INSTITUTION: Mrs. L.A. Sto. Cristo, Malolos, Bulacan August 29, 1984 28 years old Female Married Roman Catholic Filipino College Graduate PhilHealth May 13, 2013 5:30am Mary Immaculate Maternal and General Hospital Page 4

B. REASON FOR VISIT (CHIEF COMPLAINT) Madalas ng humilab ang tiyan ko atska sbi ng doktor pwede na daw ako manganak kahit na anong araw ngayong buwan kasi caesarian naman ako, as verbalized by the client. C. HISTORY OF PRESENT ILLNESS Prior to admission, our client was assessed by her resident doctor, and found out that she has mild mitral and tricuspid regurgitation that leads to Rheumatic Heart Disease. The doctor advise her to have Caesarian Section and to prevent further complications, she must undergo Bilateral Tubal Ligation. D. HISTORY OF PAST ILLNESS According to our client, she easily gets tired in every simple thing she does, thats why she resigned on her work. That t ime, she didnt consult a doctor. Siguro dahil limang buwan na itong tiyan ko kaya madali akong hingalin ,as verbalized by the client. Last May 6, 2013, she consults her doctor to check the status of her baby inside her and undergone Ultrasound. The procedure reveals a healthy baby boy but according to her doctor assessment, Mrs. L.A. had a mild mitral and tricuspid regurgitation. Her past medical history also reveal that she experienced Rheumatic Fever last 2006. Her resident doctor advised her to undergone Caesarian Section since she was on her term this first or second week of May. The doctor also told her that she must undergo Bilateral Tubal Ligation to prevent future pregnancy that may cause further complication. E. FAMILY HISTORY OF ILLNESS According to Mrs. L.A., her family didnt have any illnesses except Hypertension of her grandmother.

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GENOGRAM

Mr. A.C.

Mrs. B.C.

Mr. J.M.

Mrs. M.M.

LEGEND: - male - female

Mr. J.C. Sr. 52 y/o A/W

Mrs. M.C. 47 y/o A/W

- deceased - deceased A/W R.H.D. - Alive & Well - Rheumatic Heart Disease - Unrecall the cause of death
Mrs. L.A. 28 y/o R.H.D.

Mr. J.C. 23 y/o A/W

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F. GORDONS FUNCTIONAL HEALTH PATTERN FUNCTIONAL HEALTH PATTERN Health Perception and Health Management PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

Mrs. L.A. took multivitamins. She used to consult her Our client is strong; she stated that her illness can be doctor every time she got sick. She also told us that cured through complying her medications and enough vegetables are very important to a human being because rest. it made our life longer.
Our client usually prefers to eat vegetables such as cabbage, potato, carrots and kangkong. She doesnt like to eat fatty foods. When she has wound it heals well. She doesnt have any dentures. 3 Day Dietary Recall Date Breakfast Lunch Dinner May 9, 2013 1 serving of sopas 250ml of milk cup of rice 1 pc. tortang talong 250ml of water cup of rice Small bowl of pakbet 250ml of water 250ml of milk cup of rice Smalo bowl of corned beef with potato 250ml of water 2 pcs of bread Our client was ordered NPO last May 13, 2013 at 5:45am in preparation for operation. After the operation, 2:00pm in the afternoon she was ordered clear liquid diet when she was fully awake. Then, at 6:30pm, the doctor ordered general liquid diet.

Nutritional and Metabolic Pattern

May 10,2013

2 pcs. of bread 250ml of milk 150ml of water 250ml of milk

cup of rice 1 pc. Fried fish 300ml of water

May 11,2013

1 cup of rice Small bowl

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of ginisang upo 250ml of water Elimination Pattern

250ml of milk.

According to Mrs. L.A., she doesnt have any difficulties in During hospitalization, she doesnt have difficulty urinating and urinating and defecating. She usually urinates 4 to 5 times a defecating. day and defecates every afternoon after lunch. Prior to hospitalization, the client easily gets tired when she During Hospitalization, she cannot do some of the activities does household chores. without supervision from the others. 0 feeding 0 bathing 0 toileting 0 bed mobility 0 dressing 0 grooming 0 ambulation 0 cooking 2 shopping 2 home maintenance 0 feeding n/a bathing 2 toileting 0 bed mobility 2 dressing 0 grooming 1 ambulation n/a cooking n/a shopping n/a home maintenance

Activity and Exercise Pattern

Level 0 full self care Level 0 full self care Level 1 requires use of equipment Level 1 requires use of equipment Level 2 requires assistance or supervision from another Level 2 requires assistance or supervision from another person person Level 3 requires assistance or supervision from another Level 3 requires assistance or supervision from another person or device person or device Level 4 dependent or does not participate Level 4 dependent or does not participate Sleep and Rest Pattern The patient sleeps at 11pm and wakes around 7am. She usually takes a nap in the afternoon. She doesnt have difficulty falling asleep. Watching her favorite Telenovela is her form of relaxation. She does not have problems in vision and hearing. She cannot sleep well because the nurses monitoring her vital signs every 4 hours but she was able to take a nap in the afternoon. She usually sleeps at 8pm then wakes up when nurses took her vital signs. No changes

Cognitive and Perceptual Pattern

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Self Perception and Self Concept

According to our client, she sees herself as friendly person. She accepts her condition being hospitalized with underlying Family is her strength. When there are circumstances that disease. She added that she wants to go home as soon as involving any family members, she was very concern and possible. make some moves to deal with it. The patient has a nuclear family. When problem arises, she The patient has been doing well on interacting and and the rest of her family talk about it to solve it. She has a lot communicating with different people around her. of friends in their neighborhood. Mrs. L.A. menarche starts when she was 14 years old. Her last The client delivered her first and previous baby through menstrual period was on August 20, 2012. She engages sexual Caesarian Section. And now she underwent Bilateral Tubal activity with her husband only. Ligation. Watching her favorite Telenovela is her form of relieving The client doesnt feel alone because her relatives and family stress. When she feels tense, her husband comforts her. are always visiting her in the hospital. Our client is a Roman Catholic. She make sure that every According to her, when she got home going to church the first Sunday, they must go to church and ask god for guidance. thing she would do.

Role and Relationship Pattern

Sexuality and Reproductive Pattern

Coping Stress Pattern

Value Belief Pattern

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IV.

GROWTH AND DEVELOPMENT PSYCHOSOCIAL (Erik Erickson) Intimacy vs. Isolation (20-30 years old) Young adults are still eager to blend their identities with friends. They want to fit in. Erikson believes we are sometimes isolated due to intimacy. We are afraid of rejections such as being turned down or our partners breaking up with us. We are familiar with pain, and to some of us, rejection is painful; our egos cannot bear the pain. PSYCHOSEXUAL (Sigmund Freud) Genital (13 years old and above) This state begins with puberty, the production of sexual hormones and maturation of the reproductive system. Genital organs become the major source of sexual pleasure and tension. The adolescent also focuses on relationship formation and prepares for more permanent relationship (e.g. marriage). A genital sexual pleasure continues throughout adulthood into advanced years. According to our patient, she engages sexual activity with her husband only. She was fully independent. She can make decision on her own. COGNITIVE (Jean Piaget) Formal Operation (11 years old and above) It marks a movement from an ability to think and reason from concrete visible events to an ability to think hypothetically; to entertain what-if possibilities about the world MORAL (Kohlberg) Post Conventional or Principled (Stage 5) Individuals make their own choices, understanding the views of other people but make their own decisions. Stage 5: Humans Rights and Social Welfare Morality Promote fundamental human rights and values Freely entered social contract to protect members rights and ensure the welfare of all Agreements determine the obligations of relationships of the individual. The patient understand the different roles of the society and can distinguish what is right or wrong based on internalized rules of conscience rather than the social law. According to her, she will follow all the orders of the doctor. Page 10

STAGE DEFINITION

ANALYSIS

Our client passed this stage. She was been able to develop close relationship with others. In fact, she has a lot of friends in their neighborhood.

The client thinks rationally and logically. She is able to solve problem with her family by communicating to them and vice versa

V.

ANATOMY AND PHYSIOLOGY REPRODUCTIVE SYSTEM

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

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INTERNAL REPRODUCTIVE STRUCTURE

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.

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The Cervix The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual reproductive functions. After intercourse, sperm ejaculated in the vagina pass through the cervix, then proceed through the uterus to the fallopian tubes where, if a sperm encounters an ovum (egg), conception occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly fluctuations in the levels of the two principle sex hormones, estrogen and progesterone. When estrogen levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to reach the fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then becomes thin and slippery, offering a much more friendly environment to sperm as they struggle towards their goal. (This phenomenon is employed by birth control pills, shots and implants. One of the ways they prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.) Uterus The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until 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 Page 13

VI.

PHYSICAL ASSESSMENT VITAL SIGNS BP: 110/80 mmHg TEMP: PULSE RATE: 78bpm RESPIRATORY RATE: 26cpm TECHNIQUE NORMAL FINDINGS General appearance ACTUAL FINDINGS REMARKS

PARTS TO BE ASSESSED

1. Body built in relation to clients age, lifestyle & health

Inspection

Proportionate and varies with lifestyle Relax, erect posture, coordinated body movements Neat No body odor or minor body odor relative No distress noted Healthy appearance

she has a proportionate (endomorph) body built which is appropriate with her lifestyle Cannot stand perfectly

Normal

2. lients posture & gait, standing, sitting & walking . lients overall hygiene & grooming 4. Body & breath odor 5. Signs of distress in posture or facial expression 6. Obvious signs of health or

Inspection

Deviation from normal due to the operation performed Normal Normal Deviation from normal due to the incision site Normal

Inspection Inspection Inspection Inspection

She is neat and clean. no body odor Distress noted Healthy appearance

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PARTS TO BE ASSESSED illness . lients attitude 8. lients affect/mood; appropriateness of the clients response 9. Quantity of speech, quality & organization 10. Relevance & organization of thoughts

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Inspection Inspection

Cooperative Appropriate to the situation Understandable, moderate pace; exhibits thought association Logical sequence; makes sense; has sense of reality. SKIN

Cooperative Appropriate to the situation

Normal Normal

Inspection

Understandable

Normal

Inspection

has sense of reality

Normal

1. Skin moisture

Inspection

moisture in skin fold and axillae smooth Springs back Nails

moisture in skin fold

Normal Deviation from normal due to the stretch skin during her pregnancy. Normal

2. Skin Texture 3. Skin turgor

Inspection Inspection and palpation

Rough at the abdomen Springs back

1. Fingernails plate shape to

Inspection

Convex curvature, angle of

Angle of nail plate about 160

Normal Page 15

PARTS TO BE ASSESSED determine its curvature & angle

TECHNIQUE

NORMAL FINDINGS nail plate about 160 degrees. Highly vascular and pink in light skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks. Intact epidermis. Smooth texture. Prompt return of pink or usual color (generally less than 4 seconds.) Hair

ACTUAL FINDINGS degrees.

REMARKS

2. Fingernail & toenail bed color

Inspection

Pinkish in color

Normal

3. Tissues surroundings nails 4. Fingernail texture & toenail

Inspection Palpation

She has an intact epidermis with no hangnails Smooth nail texture The color return to the original color in 2 seconds

Normal Normal

5. Blanch test of capillary refill

Palpation

Normal

1. Evenness of growth over the scalp 2. Hair thickness & thinness 3. Presence of infections or infestations

Inspection Palpation Inspection

Evenly distributed hair. Thick/thin hair. Not present.

Her hair is well distributed has a thick hair Not present.

Normal Normal Normal

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PARTS TO BE ASSESSED 4. Texture & oiliness over the scalp

TECHNIQUE Palpation

NORMAL FINDINGS Silky, resilient hair. SKULL Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour. Smooth, uniform consistency; absence of nodules or masses. FACE Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Symmetrical facial movements. Eyebrows and Eyelashes

ACTUAL FINDINGS Silky, resilient hair.

REMARKS Normal

1. Size, shape, symmetry

Palpation

Head is symmetrically rounded

Normal

2. Nodules or masses and depressions

Palpation

No mass or nodules

Normal

1. Facial features

Inspection

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

Normal

2. Symmetry of the facial movements

Inspection

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Hair evenly distributed; skin intact. Eyebrows asymmetrically aligned equal movement. Eyelashes curl slightly outward. Eyelids Skin intact, no discharge, no discoloration. Lids close symmetrically approximately 15-20 involuntary blinks per minute; bilateral blinking. When lids open, no open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. CONJUNCTIVA

ACTUAL FINDINGS Eyebrows and eyelashes are both evenly distributed, symmetrical aligned. Eyelashes curl slightly outward.

REMARKS

1. Evenness of distribution & direction of curl

Inspection

Normal

1. Surface characteristics & ability to blink

Inspection and Palpation

Eyelids skin are intact, no noted discharge, and no noted discoloration. Lids close symmetrically. Client exhibited 18 involuntary blinks per minute.

Normal

1. Bulbar conjunctivas color, texture and presence of lesions 2. Palpebral conjunctivas color, texture & presence of lesions

Inspection

Transparent; capillaries sometimes evident.

Transparent, capillaries evident, no discharge was noted. Shiny, smooth and red in color.

Normal

Inspection

Shiny, smooth, pink or red in color.

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Sclera

ACTUAL FINDINGS

REMARKS

1. Color & clarity

Inspection

Sclera appears white (yellowish in dark- skinned clients). Cornea Transparent, shiny and smooth; details of the iris are visible. In older people, a thin grayish white ring around the margin, called arcussenilis, may be evident. Iris

Sclera appears white

Normal

1.Clarity & color

Inspection

Details of iris are visible. Transparent, shiny and smooth. But she has visual of 450/400

Deviation from Normal

1. Shape & color

Inspection

Flat and round Pupils

Flat and round and uniform in color.

Normal

1. Color, shape & symmetry of size

Inspection

Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border. EARS AURICLE

Firm and equal pupils

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10cm from vertical. Mobile, firm and not tender, pinna recoils after it is folded. Nose

ACTUAL FINDINGS Color is same with facial skin, symmetrical with each other, auricle aligned with outer canthus of eye, about 10 cm vertical Both pinna recoils after being folded. Mobile, firm and not tender.

REMARKS

1. Color & symmetry of size & position

Inspection

Normal

2. Texture & elasticity & areas of tenderness

Palpation

Normal

1. Shape, size or color & flaring or discharge from the nares 2. Presence of redness, swelling, growths & discharge or nares using the flashlight 3. Position of nasal septum 4. Test patency of both nasal septum

Symmetric and straight Inspection No discharge or flaring Uniform color Mucosa pink Inspection Clear, watery discharge No lesions. Inspection Nasal septum intact and in midline, intact Air moves freely as the client breathes through the nares

No discharge. Symmetrical on both sides. Also uniform in color. Nasal flaring noted Mucosas are intact and pinkish; minimal moist noted inside; no swelling or nodules found. Nasal septum is intact and in midline Air moves freely as the client breathes through each nares

Deviation from normal due to mitral regurgitation.

Normal

Normal

Inspection

Normal

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PARTS TO BE ASSESSED 5. Tenderness, masses & displacement of bone & cartilage

TECHNIQUE

NORMAL FINDINGS

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

REMARKS

Palpation

Not tender; no lesions Lips Uniform pink color

Normal

Uniform pink color Soft, moist, smooth texture Symmetry of contour Has the ability to purse lips Normal

1. Symmetry of contour color & texture

Inspection and Palpation

Soft, moist, smooth texture Symmetry of contour Ability to purse lips Teeth

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

32 adult teeth Inspection Smooth, white, shiny tooth enamel Gums Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums She has smooth shiny 32 teeth Normal

1. Color & condition

Inspection

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS TONGUE/FLOOR OF THE MOUTH

ACTUAL FINDINGS

REMARKS

1. Color & texture of the mouth floor & frenulum

Inspection and Palpation

Smooth tongue base with prominent veins Central in position Pink in color (some brown pigmentation on tongue borders in darj-skinned clients); moist; slightly rough; thin white coating Smooth, lateral margins, no lesions Raised papillae (taste buds) Moves freely, no tenderness Abdomen Unblemished skin, uniform in color, silver white striae (stretch marks) or surgical scars. Flat, rounded (convex) or

Smooth tongue base with prominent veins Central in position Pink in color (some brown pigmentation on tongue borders in darj-skinned clients); moist; slightly rough; thin white coating Smooth, lateral margins, no lesions Raised papillae (taste buds) Moves freely, no tenderness

Normal

2. Position, color & texture, movement & base of the tongue

Inspection and Palpation

Normal

1. Skin integrity

Inspection

She has stretch marks

Normal

2. Abdominal contour

Inspection

Convex in shape.

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS scaphoid(concave)

ACTUAL FINDINGS

REMARKS

Audible bowel sounds 3. Bowel Sounds Auscultation Hyperactive bowel sounds Normal

VII.

PATIENT AND HIS CARE A. Medical Management

Medical Management treatment IVF D5LR 1L Date Ordered/Date Performed/Date Discontinue Date Ordered/ Performed: May 13, 2013 Date Discontinue: -----General Description Dextrose 5 Lactated Ringers Solution D5LR 1L to run at 30-31 gtts./min. Indication/Purpose It is use to supply water and electrolytes e.g. Calcium, Potassium, and Chloride. Clients Response to the Treatment Signs and symptoms of dehydration were not noted such as dry skin. Nursing Responsibilities

Type of Solution -Hypertonic -Nonpyrogenic, parenteral fluid, electrolyte and nutrient replenisher

Prior: Check the physicians order for IVF insertion, its drop factor and ordered amount. During: Secure the tube; make sure that the tube is not dislodging when the patient moves. Check for possible complication such as complication Observed for the IV site for its appearance. Check for its patency. After: Evaluate the patients response to treatment.

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B. Drugs
Generic / Brand Name / Classification Date
Ordered Given Changed Discontinue

Route of administration, dosage, frequency

Mechanism of Action

Clients Response

Nursing Resposibilities

Generic Name: NALBUPHINE HYDROCHLORIDE Brand Name: NUBAINE Classification: Narcotic agonistantagonist analgesic

5/13/13

5/13/13

----

----

Route of Administration: IV (prn meds.) Dosage/Frequency: 10mg IV q8x2doses

Nalbuphine acts as an - headache agonist at specific - restlessness opioid receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at receptorsIndications: - Relief of moderate to severe pain. -Preoperative analgesia, as a supplement to surgical anesthesia, and for obstetric analgesia during labor and delivery.

PRIOR: heck the medications chart to reduce error in medication administration. Monitor respiratory rate before and after giving nubain because it causes respiratorydepression. DURING: Monitor blood pressure before and after administering the medication to prevent any complication. Monitor I and O to determine if there is excessive fluid loss. AFTER: Evaluates appearance. patients

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Generic / Brand Name / Classification

Date
Ordered 5/13/13 Given 5/13/13 Changed ---Discontinue ----

Route of administration, dosage, frequency

Mechanism of Action

Clients Response ----

Nursing Resposibilities PRIOR: heck the medications chart to reduce error in medication administration. DURING: Check IV site carefully for signs of thrombosis or drug reaction. AFTER: Evaluates appearance. patients

Generic Name: Ampicillin Brand Name: Ampisan Classification: Penicillins

Route of Administration: Parenteral Dosage/Frequency: 1g TIV as loading dose then 500mg TIV q6 x 2 doses

A broad-spectrum semisynthetic aminopenicillin, is highly bactericidal even at low concentrations, but is inactivated by penicillinase. Uses Infections of GU, respiratory, and GI tracts and skin and soft tissues; also gonococcal infections, bacterial meningitis, otitis media, sinusitis, and septicemia and for prophylaxis of bacterial endocarditis. Used parenterally only for moderately severe to severe infections.

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C. Diet
Type of Diet Date General Description It is an instruction meaning to withhold oral foods and fluids, but for patient who will undergo surgery, the physician will allow small amount of fluid intake for oral medication. Indication/ Purposes This diet is usually ordered for preparation prior to surgery specially who will undergo general anesthesia to prevent aspiration and pneumonia. Specific foods/fluids taken None Clients Response The client feels hunger and thirst, she appears weak. Nursing Responsibilities

NPO (Nothing Per Orem)

5/13/13 5:45 am

5/13/13 2pm

- assess the level of understanding of the patient. - explain the importance of following strictly NPO in terms that the client can understand and then evaluate. -strictly monitor clients behavior in following NPO. - instruct the client to continue NPO as prescribed by the Physician.

Clear Liquid Diet

5/13/13 2pm

5/13/13 6:30pm

Clear liquid diet Is made up of only clear fluids and foods that turn to clear fluids when they are at room temperature.

A clear liquid diet is often used before tests, procedures or surgeries that require no food in your stomach or intestines, such as before colonoscopy. It may also be recommended as a short-term diet if you have certain digestive problems, such as nausea,

Jelly Ace

The patient - Make sure the patient is having the right adheres to the intake. order without complains.

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vomiting or diarrhea, or after certain types of surgery. D. Exercise

Type of Exercises Deep Breathing Exercise Date Started May 13, 2013 General Description Breathing that is done by contracting the diaphragm, a muscle located horizontally between the chest cavity and stomach cavity. Air enters the lungs and the belly expands during this type of breathing Indication/purpose To expel secretion and promotes lung expansion to ease difficulty of breathing Clients Response to the Activity The client verbalized that she practice DBE whenever she experience DOB Nursing Responsibilities Prior: Explain to her why she needs to perform exercises. During: Observe the patient if she did the exercise properly

Type of Exercises Ambulation

Date Started May 13, 2013

General Description The act of travelling by foot; is a healthy form of exercise.

Indication/purpose To regain strength and promote good circulation of Blood

Clients Response to the Activity The client verbalized that she does walking

Nursing Responsibilities Prior: Explain to her why she needs to perform exercises. During:

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Assists patient or the instruct the patients relative to assist the patient while performing the exercises.

VIII.

NURSING CARE PLAN

Assessment Diagnosis Ineffective Breathing Pattern related to underlying disease (Rheumatic Heart Disease) Planning Short Term Goal: After 30 minutes of Nursing Intervention the client will be able to: Establish a normal and effective respiratory pattern as evidence by the absence of nasal flaring, and restlessness with Respiratory Rate of 12-20cpm. Verbalize awareness of causative factor. Verbalize understanding of cause and therapeutic management regimen. Implementation Encourage slower / deeper respirations or use of purse-lip technique. Monitor respirations and breath sounds, noting the rate and sounds. Elevate head of bed or change position every 2 hours. Rationale Evaluation To assist client in Short Term Goal: taking control of the After 30 minutes of situation. Nursing Intervention the client was been able to: To ascertain status and Established normal note progress. and effective respiratory pattern as evidence by the To take advantage of absence of nasal gravity decreasing flaring, and pressure on the restlessness with diaphragm and Respiratory Rate of enhancing ventilation 19cpm. to different lung Verbalized segments. awareness of causative factor. Verbalized understanding of cause and therapeutic management regimen.

S: Minsan nahihirapan akong huminga , as verbalized by the client. O: Increased Respiratory Rate. (26cpm) Restlessness Nasal flaring

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Assessment S: mdyo masakit ung tahi ko , as verbalized by the client. O: Pain scale of 5 out of 10. Facial grimace Guarding behavior at the incision site

Diagnosis

Planning Short Term Goal: After 30 minutes of Nursing Intervention the client will be able to: Verbalize that the pain is lessen. Follow prescribed pharmacological regimen. Verbalize nonpharmacological methods that provide relief

Implementation Obtain clients assessment of pain including location, characteristic, onset, Duration, frequency, quality, Intensity, aggravating factors. Provide measures. comfort

Rationale to rule out worsening of underlying condition/development of complications

Evaluation Short Term Goal: After 30 minutes of Nursing Intervention the client was been able to: Verbalized that the pain is lessen. Followed prescribed pharmacological regimen. Verbalized nonpharmacological methods that provide relief

Acute Pain related to surgical procedure

to promote pharmacological management

non-

Instruct/encourage use of relaxation techniques such as focus breathing, music therapy encourage periods adequate

to distruct attention and reduce tension

to prevent fatigue

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IX.

HEALTH TEACHING
HEALTH TEACHING RATIONALE - To promote good circulation. - Deep breathing/ diversional activities help to reduce pain. - Splinting reduces the pressure in the abdomen thus reducing pain. - To prevent infection. - To prevent the spread of microorganism or cross contamination. - to reduce the risk of infection and to promote patients comfort.

1. Explain the importance of ambulation. 2. Explain the importance of deep breathing exercise/ diversional activities. 3. Explain the importance of splinting. 4. Explain not to touch the incision site with bare hands. 5. Explain the importance of proper hygiene. 6. Explain the importance of maintaining a clean and well ventilated environment.

X.

DISCHARGE PLANNING Medication o Advice the client to take her medication on time and with regular interval as indicated o Report any side effects or adverse effect of the medication Exercise/Environment o Provide the client with a clean and well ventilated room to prevent infection o Deep Breathing Exercises Treatments o Inform client to have a follow up checkup o Increase fluid intake of 2-3 Liters o Compliance to the medication Page 30

Health Teaching o Ways to prevent infection Out Patient o Report Any Pain or Effect of the medication Diet o Increase fluid intake o Avoid foods that may cause aspiration Spiritual o Always believe, pray, trust and have faith to God.

XI.

CONCLUSION

This case study gave the group more knowledge in making actual management for this kind of condition. Thus, the member of the group have realized the need of promoting and maintaining optimal health to both the patient and her significant others. With the proper knowledge about the nature of the disease as well as its preventive measures along with responsibility and sense of will, one can surely direct herself away from the complications.

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