Saint John Colleges

Calamba, City
COLLEGE OF NURSING

CAESARIAN

Submitted by:
Group II

Bautista, Arvin
Pajutan, Roide S.
Bautista, Carlyn Joy
Garcia, Mary Anne
Teope, Elsadora

July 2010
 ST. JOHN COLLEGES
College Of Nursing
Chipeco Avenue, Calamba City

A. General Objectives

To gain knowledge about caesarian section. It is important that we have an adequate knowledge about the procedure, the
possible risks and complications in order for the nursing students to impart right information to the patient and for future
profession.

B. Specific Objectives

 To know more about the nursing responsibilities in handling patient who has undergone caesarian section.

 To be familiar with the procedure and medications used that may help us in doing health teaching with our client.

 To inculcate awareness with the different manifestations and complications brought by the procedure.

CASE OVERVIEW

CAESARIAN

Caesarian delivery, specifically hysterectomy, is a major abdominal surgery involving an incision into the uterus to deliver a baby
MATERNAL COMPLICATIONS:

 Urinary retention due to bladder atony

 Bladder injury

 Bowel injury

COMPLICATIONS FOR THE INFANT

 Injury during the delivery

 Lung immaturity if delivered before 39 weeks of gestation

LONG TERM COMPLICATION

 Breaking open of the incision scar during a later pregnancy or labor (uterine rupture)

 Placenta previa

 Placenta accreta, placenta increta, placenta percreta which can lead to severe bleeding

RISK FOR THE MOTHER

 Three times higher mortality rate than that of vaginal delivery

 Possible problems in later pregnancies such as malpresentation, placenta previa, antepartum hemorrhage, placenta accreta,
prolonged labor, uterine rupture, preterm birth, low birth weight, and still birth
  Increased risks for placenta accreta

 Risks for wound infection

RISKS FOR THE CHILD

 Neonatal depression

 Fetal injury

 Type 1 diabetes

 Breathing problems

 Breast feeding problems

 Potential for early delivery and complications

 Risks for both mother and child

 Risks for developing hospital borne infection because of prolonged hospital stays

 Longer time before good mother-child interactions can be achieved

ANATOMY AND PHYSIOLOGY
MAMMARY GLAND

Lobule
 It is where milk is made
 Contain lactiferous ducts that converge toward the nipple

Mammary Duct
 Carry milk from the lobes of each breast to the nipple

Lactiferous Sinus
 Serves as a reservoir for accumulated milk in the mammary gland

Nipple
 The most anterior part of the breast
 The portion of the breast that is taken by the suckling infant
 The most erogenous region of the breast in women

Areola
 a circular area of surrounding a central point, as that surrounding the nipple of the breast
 Have sebaceous gland that help lubricate the nipple during breastfeeding

Adipose Tissue
 Provides the bulk for the breasts
 Hold the milk duct system within them
ABDOMINAL LAYERS

1. Skin

2. Subcutaneous tissue

3. Fascia

4. Muscle

5. Peritoneum
PATIENT ASSESSSMENT DATA BASE

A. BIOGRAPHIC DATA

Name: Añonuevo, Janet Laguartilla Religion: Born Again

Address: Jacinto St. Salac Lumban Laguna Nationality: Filipino

Age: 39 years old Date of Admission: 7-19-2010

Sex: Female Time of Admission: 8:30 pm

Civil Status: Married Attending Physician: Reva Torres M.D.

B. OPERATION RECORDS

Pre Op DIagnosis: G6 P5 28-29 weeks Labor Eclampsia T/C Abruption Placenta

Post Op Diagnosis: Deliver to alive baby girl preterm @ 9:16 pm

Surgeon: Dra. Añonuevo

Anesthesiologist: Dr. Gutierez

 Anesthesia SAB: Began 9:00 pm

Operation Date: 7-19-2010

Operation Began: 7:07 pm Title of operation: Hysterectomy with BAL

Operation Ended: 10:00 pm Findings: Benign Abruptio placenta

PAST HISTORY

Three years prior to admission the patient had a hypertension with an average of 160/110 mmHg which prompted her to consult a doctor
who is Dr. Chin who prescribed her with an anti-hypertensive drug.

With unrecalled date of hospitalization the patient had a CS with her second child at LPH due to hypertension.

With different unrecalled date the patient had a NSVD with her first, third, and fourth child at their home.

With unrecalled date of hospitalization the patient delivered her fifth child at Pacquil District Hospital.

Several months prior to admission the patient felt nauseated, and she also had headache and hypertension

PRESENT HISTORY

The patient has undergone CS with her sixth child

The patient verbalized dizziness, weakness, and verbalized pain in the incision site with pain scale of 4/10

FAMILY HISTORY

No known family history of diseases

ACTIVI
MOBILIT
TY LEV LEV
Y
DAILY EL EL
STATUS
LIVING
Feeding 20 Bed 20
Mobility
Dressing 20
Chair/toilet 20
Groomin 20
g Transfer 30
30
Toileting Ambulatio 20
n

GORDONS FUNCTIONAL HEALTH PATTERN

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

She perceived herself as not healthy because She perceived herself as not healthy because
Pattern of Health Perception and Health she feels like she was sick before she was she feels weak.
Management admitted. She felt nauseated and she also had
headache and hypertension

She eats bread for breakfast with combination She is currently on a soft diet
Nutritional-Metabolic Pattern with either milo, coffee, or milk.

She eats rice and viand for dinner and lunch.a

Activities of Daily Living and Mobilization

Status Functional Level Classification
0- Completely Independent
1-Requires use of equipment or device
2- Requires help from another person for
assistance, supervision or teaching
3- Requires help from another person and
equipment device
4- Dependent does not participate in activity
Pattern of Sleep and Rest Sleeps at 10pm and wakes up at 6am Sleeps most of the time the whole day.

Pattern of Elimination Bowel Elimination

Defecates once a day, with yellowish >Does not defecate during hospitalization
brown solid stool

Urinary Elimination

Urinates 5 times a day to a yellowish clear >The patient is on folly catheter and voids
uring with approximately1000cc each day 2-3 times a day

Sexual Pattern Had a satisfactory sexual intercourse with her Is unable to do sexual intercourse
husband once a week

Cognitive Perceptual Pattern The patient is a teacher in kinder school. She Patient's current condition doesn't affect her
knows how to read and write, can speak clearly cognitive perceptual pattern
and can be understood well.
Self Perception The patient is a friendly person. She is kind to She is still kind to other people and she
her students and also to other people. believes that she will be okay after
confinement.

Role Relationship Patient can understand Tagalog and English Her husband is supportive to her who is by her
language. She has 6 siblings and she lives side to comfort her and cheer her up. She is
happily with them together with her husband. happy being with her husband.

Coping Stress Tolerance When the patient is stress and facing problems The patient prays to cope up for her current
she prays to God for help then she finds ways situation with the help of her husband who
to solve them. supports and cheers her up.

Values and Belief The patient is a born again who has a strong She believes that she will be alright after the
faith to God. hospitalization especially with the help of her
faith with God.
 METHODS OF
SYSTEM FINDINGS ANALYSIS
ASSESSMENT

I.GENERAL SURVEY Inspection - the patient looks weak and pale

- the patient is holding her
Abdomen assuming a guarding
behavior
-facial grimace

BP- 190/120mmHg Elevated BP due to pain level

II. VITAL SIGNS Palpation and Auscultation Pulse- 78 bpm after surgery.
Respiration- 26 cpm
Tempearture- 37.2ᵒC

III.1 INTEGUMENTARY
-pale skin
A. Skin Inspection -smooth -Paleness of the skin is a
-norashes manifestation after surgery.
-has wound on the incision site -wound is cause by the surgery

Palpation -warm to touch normal

-good skin turgor
-smooth

B. Hair Inspection -evenly distributed normal

 C. Nails Inspection -convex curvature, angle of nail normal
plate about 1600

Palpation and Inspection -good capillary refill (2sec) normal

III.2 HEAD

A. Head and Face Inspection -normocephalic -Facial grimace due to pain

-facial grimace
-with black hair
-facial structures are symmetrical

Palpation -temporal artery is palpable Normal

between the eye and top of the
ear

- no tenderness in the Normal

temporomandibular joint

-no tenderness over maxillary normal

and frontal sinuses

B. Eyes

B.1. Protrusion Inspection -no protrusion of eyeballs normal

B.2. Palpebral Fissure Inspection -appear equal in size when the normal
eyes are open
 B.3. Eyelashes Inspection -evenly distributed normal

B.4. Conjunctiva Palpation and Inspection -pale conjunctiva

B.5. Sclera Inspection -white Normal

B.6. Pupils Inspection -equally, round, and reacts to light Normal

B.7. Extraocular Inspection -follows direction Normal

Movement

-blurred vision on left and right -Nearsightedness

B.8. Vision Inspection eye when being asked to read the
newspaper
C. Ears and Hearing

C.1. Pinna Inspection -appropriate size with the face Normal

-same color as the face
-no lesions and masses

C.2. External Canal Inspection -clear with minimal cerumen Normal

C.3. Whisper voice test Inspection -able to hear the whispered Normal
words equally in both ears
-nasal septum is straight
D. Nose Inspection -no discharge present Normal
-patent airway
-mucous membrane are pink
 E. Mouth and Throat

E.1. Lips Inspection -dry lips -dehydrated

E.2. Gums Inspection -dry -dehydrated

-no bleeding
-no discharge

E.3. Tongue Inspection -at the midline -dehydrated

-dry

E.4. Tonsils Inspection -no swelling Normal

E.5. Teeth Inspection -false teeth on the upper part

-with good range of

III.3. NECK Inspection motion Normal
-no masses
-no swelling

IV. RESPIRATORY
a. Breath sounds Auscultation -clear breath sound Normal
-no bulges on the chest Normal
Inspection -no other pulsation except
apical impulse
V. CARDIOVASCULAR
Palpation -no thrills and other pulsations Normal
-two sounds are heard Normal
Auscultation
-Heart rate is 78bpm
VI. BREAST Inspection -no discharge
-same color with the skin -normal

-no masses and tenderness -normal

Palpation

VII. ABDOMEN Inspection -with wound and redness on the -Due to surgery
incision site
(hypogastric area)
-slightly bulge
-with tenderness on the -due to surgery
Palpation
hypogastric area
-no swelling
VIII. MUSCULOSKELETAL Inspection -no redness normal
-no masses
-no deformities
Palpation -no tenderness Normal
-no swelling
-no masses
Muscle Testing -with full ROM against gravity
-with full resistance normal
-muscle strength is equal
bilaterally
IX. NEUROLOGIC SYSTEM
>Oriented to time, place, and >normal
A. Level of Consciousness Person
>GCS 15
 RESULT NORMAL VALUE SIGNIFICANCE
Creatinine 1.0 mg/dl 0.7-1.2 mg/dl Normal
SgpT/ALT 26 U/L 7-56 U/L Normal
Sodium 141mmol/L 135-148 mmol/L Normal
3.2 mmol/L 3.5-5.3 mmol/L Cirrhosis with ascites,
Potassium hyperaldosteronism(steroid
therapy), malignant
hypertension, poor dietary
habits, chronic diarrhea,
diaphoresis, renal tubular
necrosis, malabsorption
syndrome, vomiting
7/19/10

RESULT NORMAL VALUES SIGNIFICANCE

WBC 19.4 4.1-10.9 Bacterial infection, severe
sepsis
Lymphocytes 1.8 0.6-4.1 Normal
Mid 0.8 0.0-1.8 Normal
Gran 16.8 2.0-7.8
 RESULT NORMAL VALUES SIGNIFICANCE
RBC 4.98 4.20-6.30 ml/uL Normal
Hemoglobin 14.3 12.0-18.0 g/dl Normal
Hematocrit 41.5 37.0-51.0 % Normal
Mcv 88.3 80.0-97.0 fL Normal
McHc 34.5 31.0-36.0 % Normal
RDW 15.8 140-440 %

7/19/10

RESULT NORMAL VALUES SIGNIFICANCE

Hemoglobin 12.6 g/dl 12.0-18.0 g/dl Normal
Hematocrit 38.9% 37.0-51.0%
WBC 16,500/mm3 Bacterial infection, severe
sepsis
Neutrophils 85% 40-74% Acute bacterial infection,
inflammation, stress, drug
reaction
Lymphocytes 11% 20-40% Anemia, systemic lupus
erythematosus
Eosinophils 0-5%
Monocytes 4% 3-11% Normal
Platelet 273,000 130,000-500,000 Normal
Blood type AB +
Bleeding time 3mins & 57 secs. 1-3mins. Anemia,DIC,leukemia
Clotting time 4mins. & 39 secs 3-6mins. Normal
 7/20/10
RESULT NORMAL VALUES SIGNIFICANCE
WBC 17.6 4.1-10.9 Bacterial infection, severe
sepsis
Lymphocytes 2.5 0.6-4.1 Normal
Mid 0.8 0.0-1.8 Normal
Granules 14.2 2.0-7.8

RESULT NORMAL VALUES SIGNIFICANCE

RBC 3.73 M/uL 4.20-6.30 Anemia,
luekemia,hemorrhage, and
after hemorrhage when
blood volume has been
restored
Hgb 10.4 g/dl 12.0-18.0 Anemia, hemorrhage
Hct 31.1 % 37.0-51.0 Normal
McV 83.4 fL 80-97.0 Normal
McH 27.9 pg Normal
McHc 33.4 g/dl 31.0-36.0 Normal
RDW 16.3% 140-440
Platelet 85 k/uL
CUES NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective: Risk for infection After nursing  Monitor V/S  To establish  After nursing
related to broken skin interventions the baseline data. interventions the
 Conscious and secondary to patient will be free  Assess for  For early patient is free of
coherent. cesarean section of infection and signs/symptoms detection of infection and has
 Afebrile achieve timely of infection. infection. achieved timely
 Weak in wound healing.  Wash hands and  To reduce risk wound healing.
appearance teach other cross-
 With health care contamination
abdominal provider to wash of
incision. hands before and microorganism
after contact to .
patient.
 Change surgical  To prevent
wound dressing contamination
as indicated. of infection.
 Administer  For
antibiotic as effectiveness
ordered. of treatment.

CUES NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Decrease cardiac After of nursing  Monitor V/S  To establish  After of nursing
output related to interventions the Suggest frequent baseline data. interventions the
"Nahihilo ako at decreased venous patient will position changes.  It may decrease patient
masakit ang batok return as evidenced maintain cardiac peripheral maintained an
ko" as verbalized by by elevated BP. output and cardiac venous pooling adequate cardiac
the patient. index. that may output and
potential to cardiac index.
 Observe skin vasodilators.
Objective: color,  Peripheral
temperature, and vasoconstriction
 Conscious and capillary refill may result to
coherent time. pale, cool,
 Afebrile clammy skin
 (+) dizziness with prolonged
 With body capillary refill
malaise tome.
 Pale in  Instruct the client  Restriction can
appearance on fluid assist with
 With edema restriction and decrease fluid
 With elevated restriction of retention and
BP. sodium intake. hypertensive
BP: 180/110 thereby
improving
cardiac output.
 Administer  To promote
medications as wellness.
prescribed by
physician.

CUES NURSING PLANNING INTERVENTIOS RATIONALE EVALUATION

DIAGNOSIS
 Sumasakit and Impaired skin  After of nursing  Establish rapport  To gain trust  After nursing
sugat ko as integrity related care the patient with the patient. care the patient
verbalized by the to skin damage will be able to  Perform bedside  To enhance has able to
patient. secondary to display timely care patient’s self display timely
cesarean section. healing of wound esteem and to healing of wound
without provide comfort without
Objective: complication to the patient. complication.
 Conscious and  Inspect skin on  To determine
coherent. daily basis and unusual changes
 With redness on observe for and report to
incision site changes and physician.
 Destruction of unusualities
skin tissue  Keep the area  To prevent from
clean. Carefully infection.
dress wound,
support incision,  Maintain clean,
 Encourage client dry skin provides
to demonstrate barriers to
good skin infection.
hygiene.
 Administer  To prevent post
medication such operative wound
as antibiotics. complication.
 Provide optimum
nutrition such as  To provide a
increased protein positive tissue
intake. repair.

BRAND NAME ADVERSE NURSING

CLASSIFICATION CONTRAINDICATION INDICATION
AND GENERIC EFFECT RESPONSIBILITY
NAME

Methyldopa Anti hypertensive Contraindicated to patient Indicated for the Dizziness, Monitor the vital
with history of liver treatment of drowsiness, signs
 Aldomet problem hypertension, headache, dry
And any allergies to meds preeclampsia, mouth, Monitor the BP
and food eclampsia, and fatigue, chest
other pain, difficulty Report to the
hypertensive breathing, physician if signs of
disorder during depression, hypotension occurs
pregnancy severe
stomach
cramps,

BRAND NAME CLASSIFICATION CONTRAINDICATION INDICATION ADVERSE NURSING

AND GENERIC EFFECT RESPONSIBILITY
NAME

Monitor the BP
HYDRALAZINE Anti hypertensive Hypersensitivity to Lowering high flushing
hydralazine; coronary blood pressure (feeling of Monitor for any
 Apresoline artery disease; mitral helps prevent warmth) signs of hypotension
valvular rheumatic heart strokes, heart
disease. attacks headache Patients should be
informed of possible
also be used upset stomach side effects and
with other advised to take the
medications to vomiting medication regularly
treat heart and continuously as
failure. loss of directed.
appetite
Inform the physician
diarrhea for the severe
adverse effect
constipation

eye tearing

stuffy nose

rash
BRAND
NAME AND ADVERSE NURSING
CLASSIFICATION CONTRAINDICATION INDICATION
GENERIC EFFECT RESPONSIBILITY
NAME

Cefazolin Antibiotic Contraindicated to patient used to treat vomiting, Monitor vital signs
that is hypersensitive to bacterial nausea,
cefazolin infections of the stomach Monitor the BP
skin. It can also cramps,
be used to treat Swelling, Check for allergic
moderately redness, pain, reaction
severe bacterial or soreness at
infections the injection
involving the site may occur
lung, bone, joint,
stomach, blood,
heart valve, and
urinary tract
BRAND NAME
ADVERSE NURSING
AND GENERIC CLASSIFICATION CONTRAINDICATION INDICATION
EFFECT RESPONSIBILITY
NAME

Tramadol analgesic Hypersensitivity to indicated for the nausea, Monitor vital signs
tramadol management of constipation,
 Ultram moderate to dizziness, Monitor Intake and
moderately headache, output for urinary
severe pain in drowsiness, retention
adults. and vomiting
nausea, Observe patient for
constipation, dyspnea
dizziness,
headache,
drowsiness,
and vomiting
BRAND NAME
ADVERSE NURSING
AND GENERIC CLASSIFICATION CONTRAINDICATION INDICATION
EFFECT RESPONSIBILITY
NAME

Ketorolac analagesics hypersensitivity to aspirin Short term CNS: Assess pain

or other NSAIDs management of drowsiness
pain dizziness advise patient to
 Toradol euphoria consult if rash,
headache- itching, visual
disturbances,
asthma tinnitus, weight gain,
dyspnea edema, black stools,
persistent headche,
edema or influenza-like
pallor syndromes
vasodilation (chills,fever,muscles
aches, pain) occur.
abnormal taste
diarrhea assess for rhinitis,
dry mouth asthma, and
dyspepsia urticaria.
GI pain nausea
BRAND NAME
ADVERSE NURSING
AND GENERIC CLASSIFICATION CONTRAINDICATION INDICATION
EFFECT RESPONSIBILITY
NAME

Co amoxiclav antibiotic Hypersensitivity to drug Used for lethargy, Instruct patient to

or any penicillin treatment of hallucinations, immediately report
 Augmentin infections anxiety, signs or symptoms
confusion, of hypersensitivity
agitation, reaction, such as
depression, rash, fever, or chills.
dizziness,
fatigue, Advise patient to
hyperactivity, minimize GI upset
insomnia, by eating small,
behavioral frequent servings of
changes, food and drinking
seizures (with plenty of fluids.
high doses)
nausea, Tell patient taking
vomiting, hormonal
diarrhea, contraceptives that
abdominal drug may reduce
pain, contraceptive
stomatitis, efficacy. Suggest she
glossitis, use alternative birth
gastritis, black control method.
"hairy" tongue,
furry tongue, Tell patient he may
take drug with or
without food.
BRAND NAME
ADVERSE NURSING
AND GENERIC CLASSIFICATION CONTRAINDICATION INDICATION
EFFECT RESPONSIBILITY
NAME

Mefenamic acid Analgesic Contra indicated to used for short nausea, loss of Advise patient to
patient with inflammatory term treatment of appetite, discontinue
bowel disease; peptic mild to moderate dizziness, medication if rash
ulcer; neonates; pain. drowsiness, develops and to
pregnancy (3rd trimester), diarrhea, and contact health care
lactation. Coronary artery headache. provider.
bypass graft surgery, Abdominal pain,
severe renal impairment, dyspepsia, Advise patient to
severe heart failure. avoid intake of
alcoholic beverages.

Instruct patient to
report the following
symptoms to health
care provider: rash,
visual problems,
dark stools,
decreased urinary
output, persistent
headache or stomach
pain and unusual
bruising or bleeding.
BRAND NAME
AND ADVERSE NURSING
CLASSIFICATION CONTRAINDICATION INDICATION
GENERIC EFFECT RESPONSIBILITY
NAME

Fe So4 Iron supplement Patients receiving For the treatment GI irritation, Check for allergic
repeated blood of mild anemia abdominal pain reaction
transfusions; anaemia not and cramps,
due to iron deficiency nausea, vomiting, Asked the patient if
constipation, there are any
diarrhoea, dark medications taken
stool and that may decrease
discoloration of the effectiveness of
urine; heartburn. ferrous sulfate

Check the level of

iron in the blood