UNIVERSITY OF PERPETUAL HELP - ISABELA CAMPUS

COLLEGE OF NURSING

Cauayan City, Isabela

A CASE STUDY ON CESAREAN DELIVERY

In Partial Fulfillment of the

Requirements in Maternal Lab
University of Perpetual Help - Isabela Campus

Submitted to:
Cherybelle B. Noche
(Clinical Instructor)

Submitted by:

Atienza, Kate M.
Domincel, Precious Anne M.
Lucquiao, Desiree A.
Mangalindan, Kathleen Joyce G.
Mendoza, Lyra Mae E.

I. INTRODUCTION
a. Brief description of the disease condition.

A cesarean section, also known as a C-section, is a surgical procedure to deliver a baby through
an incision in the mother's abdomen and uterus. It is typically performed when a vaginal delivery may
pose risks to the mother or baby.

b. Current trends and Statistics about the disease condition.

Currently, the rate of cesarean sections varies among countries, with some experiencing high
rates while others have lower rates. According to the World Health Organization (WHO), the optimal rate
of cesarean sections ranges from 10% to 15%. However, in many countries, the rates are higher,
sometimes reaching 40% or more.

c. Reasons for choosing the case for presentation.

Cesarean section is an important topic because it is a commonly performed surgical procedure in

childbirth.

It can be interesting for a variety of reasons:

Medical advancement: Cesarean section has evolved over time and continues to be refined with the use
of new techniques and technologies.
Studying cesarean section allows us to understand these advancements and their impact on maternal
and neonatal outcomes.

Maternal and fetal health: Cesarean section can be necessary in certain situations to protect the health
and well-being of both the mother and the baby. Understanding the indications and risks associated with
cesarean section helps healthcare professionals make informed decisions for the best possible outcomes.

Patient preferences and decision-making: In some cases, cesarean section may be performed based on
the preferences and choices of the expectant mother. Studying cesarean section provides insights into
patient-centered care and shared decision-making processes.

Global trends and variations: Cesarean section rates vary significantly between countries and regions.
Examining the reasons behind these variations can shed light on cultural, social, and healthcare system
factors that impact childbirth practices.

d. Objectives

General:
● To expand our knowledge and skills in our specialist area, particularly in the OB ward, and to
learn about different types of cases in the OB ward.
Specific:

● To ensure the safety of both the mother and the baby during delivery.
● To prevent fetal distress and birth complications.
● Facilitating delivery in cases of emergencies or urgent situations.
● To reduce the risk of birth injuries or complications for the baby.
 ● To address specific maternal health concerns or conditions that make vaginal delivery risky.

II. NURSING PROCESS

A. ASSESSMENT

PERSONAL DATA

a. Demographic data:

Name: Patient X
Age: 35y/o
Sex: Female
Civil Status: Married
Occupation: Housewife
Role in the Family: Mother
Address: P4 Cabaruan, Cauayan City, Isabela
Date of Birth: May 08, 1988
Place of Birth: Nationality: Filipino
Chief of Complaint: Occasional Uterine Contractions
Admitting Diagnosis: G2P1 (1001) PU 38 weeks and 4 days AOG prev CSx1
LMP: January 13, 2023
EDC: October 20, 2023
Attending Physician: Dr. Nelma Tan

b. Environmental Status

According to the patient, their house is away from the roadway. They can take in more fresh air,
which is good for their health and the baby's because there will be no traffic noise. She also noted that
they have a garden at the back of their property, with a garbage can next to it.

c. Lifestyle (habits, recreation, hobbies)

The patient enjoys cooking, and making ice for their business. She also loves taking care of her child.

Family history of health and illness

The patient has four siblings, and both of her parents have hypertension; she is currently on
maintenance medication and vitamins.
History of past illness

The patient has a history of hospitalization because her first child was born through cesarean
section, and she has a food allergy, specifically to shrimp. She has a history of hypertension as well.

History of present illness

She was admitted with a chief complaint of occasional uterine contraction. Her working diagnosis is
G2P1(1001) IU 38 weeks and 4 days AOG prev CS x1. Her blood pressure is fluctuating from high to low.
Throughout the delivery, she was conscious and there was no difficulty.

Physical Assessment (IPPA)

Date performed Area Findings Interpretation

10/9/23 Head -Rounded and No abnormalities

symmetrical(Fontal,
parietal and
occipital)
-Smooth skull
contour
-Symmetric
facial features

10/9/23 Face -Symmetrical No presence of

-No involuntary muscle asymmetry.
movements
-Can move facial
muscles at will

10/9/23 Eyes Normal vision No abnormalities

(20/20)

10/9/23 Ears Symmetrical, No abnormalities

with upper attachment
at eye
corner level,
and is fleshed
colored

10/9/23 Nose -Located No abnormalities

symmetrically,
midline of the face
-No swelling
-No bleeding
-No lesions

10/9/23 Mouth -Moist oral cavity No presence of lesion

-Pink mucosa and no abnormal
-No discoloration findings.
lesions, nodules, or
swelling
-Tonsils are visible but
not enlarged
 10/9/23 Nails -Convex curvature - The assessment of the
Smooth texture nail beds appears to be
-Intact epidermis within normal
-Prompt return of pink parameters.
or usual color

10/9/23 Skin -No edema No abnormalities

-No abrasions, and
other lesions
-Moisture of
skin smooth and
even.
-Temperature in
normal range

10/9/23 Abdomen -Presence of incision at Normal

lower abdomen
(transverse)
-Redness at incision
site
-Bulgy belly

10/9/23 Female genitalia -Intact No abnormalities

-Non-inflamed vaginal
and vulvar tissues

10/9/23 Lower Extremities

Foot -Intact skin No abnormalities

-Absence of swelling or
inflammation
-Strong regular pulses
in both feet

10/9/23 Vaginal Discharge -Presence of blood Presence of blood

-Brick-red discharge called lochia rubra and
with small clots is normal for the first
few (3-4) days

Laboratory and diagnostic procedures

DATE: June 23, 2023

CASE NO: 23-2042

NAME: Santos, Shirmay

AGE: 35 Y/O
ATTENDING PHYSICIAN: DR. Nelma Tan
G2P1 (1001)
LMP: January 13, 2023
AOG by LMP: 23 weeks
EDC: October 20, 2023
Fetus: PLACENTA:
Number: singleton Location: anterior
Presentation: cephalic Grade: I-II
Fetal Heart Rate: 149 bpm Distance from the os: high lying

BPD: 55mm 23 w0d AMNIOTIC FLUID VOLUME:

OFD: 71mm 22w3d SVP: 3.97cm (NV:2-8cm)
HC: 199mm 22w1d
AC: 167mm 21w6d
FL: 32mm 20w1d

Ratios: NON-BIOMETRIC PARAMETERS:

FL: BPD: 58% (71-87%) Cerebellum:
FL/AC: 20% (20-24%) Colonic grade:
FL/HC: 20% (20-24%) DFE:
HC: AC: 119 (92-127) PTE:
PHE:

GENDER: FEMALE
ESTIMATED FETAL WEIGHT: 140 grams (4oz)
AVERAGE ULTRASONIC AGE: 21 Weeks and 6 days
ULTRASONIC EDD: October 28, 2023

IMPRESSION:
Pregnancy uterine 21 weeks and 6 days by fetal biometry, live, singleton in cephalic presentation
Anterior placenta, grade I-II, high lying
Adequate amniotic fluid volume
Short right femur with slight abnormal angulation, rule out skeletal dysplasia
Suggest repeat scan after 2 months for bone growth monitoring

CONGENITAL ANOMALY SCAN

DATE: June 23, 2023

CASE NO: 22-4042
1. HEAD:
Skull - smooth, football shape Cisterna magna: 5.0mm (NV: <10mm)
Cerebellum: TCD 23mm 21w3d Nuchal fold thickness: 3.6mm (NV: < 6mm)
Atrial width: 7.3mm Others:
Face: Intraorbital Right: 10mm Intraorbital Left: 10mm Intraorbital: 10mm Biorbital: 31mm
Right Lens: Seen Left Lens: Seen
Nasal Bone: Seen
Lips: Intact Ears: Seen

2.SPINAL COLUMN: Intact

3.CHEST:
Diaphragm: Intact Lungs: Seen
Cardiac thoracic ratio: 17:38mm (NV: <0.5)
4-Chamber heart Seen Outflow tracts: Seen Right: Seen Left: Seen
Situs ( / ) Normal ( )Normal
Axis ( / ) Normal ( )Normal
4.ABDOMEN
Stomach bubble: Seen Intestine: Seen
Cord Insertion: Intact 3 vessel cord Seen
Right Kidney: 22 x 11 x 12mm Left Kidney: 23 x 12 x 12mm
Bladder: Seen Genitalia: Female
5.LIMBS:
Upper extremities:
Right Humerus: 33mm Left Humerus: 33mm
Right Radius: 24mm Left Radius: 24mm
Right Ulna: 28mm Left Ulna: 28mm
Right Fingers: Seen Left Fingers: Seen
Lower extremities:
Right femur: 28mm Left femur: 32mm
Right tibia: 28mm Left tibia: 28mm
Right fibula: 24mm Left fibula: 24mm
Right toes: Seen Left toes: Seen

IMPRESSION:

Short right femur with slight abnormal angulation, rule out skeletal dysplasia
No other obvious congenital anomaly seen on evaluated organ systems at the time of the scan.
Suggest repeat scan after 2 months for bone growth monitoring.

OBSTETRIC ULTRASOUND
2ND AND 3RD TRIMESTER

DATE: August 23, 2023

CASE NO: 23-2721

Fetus: PLACENTA:
Number: singleton Location: anterofundal
Presentation: cephalic Grade: II
Fetal Heart Rate: 126 bpm Distance from the os: high lying
BPD: 82mm 33w2d AMNIOTIC FLUID VOLUME:
OFD: 97mm 29w6d 4.57 3.38
HC: 289mm 31w6d
AC: 246mm 28w6d 2.56 3.03 = 13.54cm
FL: 47mm 26w0d

Ratios: NON-BIOMETRIC PARAMETERS:

FL: BPD: 57% (71-87%) Cerebellum:
FL/AC: 19% (20-24%) Colonic grade:
FL/HC: 16% (20-24%) DFE:
HC: AC: 117 (92-127) PTE:
PHE:
IMPRESSION:
Pregnancy uterine 30 weeks and 1 day by fetal biometry, live, singleton in cephalic presentation
Anterofundal placenta, grade II, high lying
Adequate amniotic fluid volume
Short upper and lower limb dysplasia, consider skeletal dysplasia with hypoplastic thorax, leading to
restriction of lung growth and pulmonary hypoplasia.

CONGENITAL ANOMALY SCAN

DATE: August 23, 2023

CASE NO: 22-2721
1.HEAD:
Skull - smooth, football shape Cisterna magna: 2.3mm (NV: <10mm)
Cerebellum: TCD 38mm 31w3d Nuchal fold thickness: 3.3mm (NV: < 6mm)
Atrial width: 11mm Others:
Face: Intraorbital Right: 14mm Intraorbital Left: 14mm Intraorbital: 14mm Biorbital: 43mm
Right Lens: Seen Left Lens: Seen
Nasal Bone: 7mm
Lips: Intact Ears: Seen

2.SPINAL COLUMN: Intact

3.CHEST:
Diaphragm: Intact Lungs: Seen
Cardiac thoracic ratio: 28:43mm (NV: <0.5)
4-Chamber heart Seen Outflow tracts: Seen Right: Seen Left: Seen
Situs ( / ) Normal ( )Normal
Axis ( / ) Normal ( )Normal
4.ABDOMEN
Stomach bubble: Seen Intestine: Seen
Cord Insertion: Intact 3 vessel cord Seen
Right Kidney: 36 x 17 x 18mm Left Kidney: 35 x 18 x 16mm
Bladder: Seen Genitalia: Female
5.LIMBS:
Upper extremities:
Right Humerus: 41mm Left Humerus: 41mm
Right Radius: 39mm Left Radius: 39mm
Right Ulna: 41mm Left Ulna: 41mm
Right Fingers: Seen Left Fingers: Seen
Lower extremities:
Right femur: 47mm Left femur: 47mm
Right tibia: 44mm Left tibia: 44mm
Right fibula: 42mm Left fibula: 42mm
Right toes: Seen Left toes: Seen

IMPRESSION:
Short upper and lower limb dysplasia, consider skeletal dysplasia with hypoplastic thorax, leading to
restriction of lung growth and pulmonary hypoplasia.

Anatomy and Physiology

Anatomy: The uterus, also known as the womb, is a muscular

organ located in the female pelvis. It is shaped like an
inverted pear and is responsible for holding and nourishing
the developing fetus during pregnancy. During a cesarean
section, a surgical incision is made in the lower abdomen to
access the uterus.
Physiology: During pregnancy, the uterus undergoes various
changes to accommodate the growing fetus. It expands in
size and its muscular walls thicken to provide support and
protection to the developing baby. The uterus is highly
vascularized, meaning it has a rich blood supply, which is
important for delivering oxygen and nutrients to the fetus.
During labor, the uterus contracts rhythmically to help not be
possible or safe for both the mother and the baby. Layers of
tissue are incised to access the uterus. The uterus is then
carefully opened, allowing the healthcare provider to deliver the baby through the incision. After the baby
is delivered, the uterus is sutured closed, and the incisions in the abdominal wall are closed as well. This
surgical procedure ensures a safe delivery when a vaginal birth is not possible or poses risks to the
mother or baby. It is typically done under anesthesia, and the recovery period may vary depending on
individual factors.

PATHOPHYSIOLOGY
Book based
Patient manifestation
B. PLANNING NURSING CARE PLAN

NCP: Acute Pain

ASSESSME DIAGNOSIS PLANNING IMPLEMENTA RATIONALE EXPECTED
NT TION OUTCOME

S: Acute pain Short term: Independent:

“Masakit ang related to - After 1hr of -Establish –To have a - Goal met,
tahi ko” as presence of nursing rapport good nurse- after 1hr of
verbalized postoperative interventions, the client nursing
by the surgical patient will relationship interventions,
patient incision as verbalize the patient will
evidenced by decrease of pain - Monitor V/S -To establish verbalize
Pain scale: disruption of baseline data decrease of
5/10 skin tissue, Long term: pain as
verbal report - After 8hrs of - Determine - Pain rating evidenced by
O: of pain, nursing the type of scale can help normal range
-V/S: guarding interventions, the discomfort the the patient of vital signs
BP:140/90 behavior, and patient will patients identify the
RR:18 facial verbalize a sense experiencing, focus of - Goal met,
PR:85 grimace. of comfort and such as discomfort after 8hrs of
02 SAT:99 free from pain. physical pain (e.g., physical, nursing
-Afebrile using pain emotional, or interventions,
36.4 rating scale social) the patient will
-Facial verbalize
grimace - Promote - Brings this to sense of
-Irritability overall health client’s comfort as
-Guarding measures awareness and evidenced by
behavior (e.g., nutrition, promotes use calm behavior,
adequate fluid in current demonstrated
intake, situation relaxation, and
elimination, a pain scale of
and 3/10
appropriate
vitamin and
iron
supplementatio
n

-Provide -Calm
comfortable environment
environment helps promote
by cleaning likelihood of
bed and proper decreasing
ventilation pain, anxiety
and discomfort
- Advise the
S/O to put - To increase
warm blanket comfort ability
in patient

- Keep the
environment - To reduce
stress-free. stimuli by
 decreasing
outside noise,
dimming the
lights, and
ensuring
privacy by
keeping the
door closed.
- Offer hygiene
care or items - Feeling
to clean unclean has a
themselves. huge impact
on comfort.
- To ease
Dependent: discomfort.
- Administer
medication - To manage
such as moderate to
tramadol and moderately
diclofenac as severe pain
Doctor’s order

Collaborative:
- Collaborate in
treating or
managing
medical
conditions

NCP: Risk for bleeding

Assessment Diagnosis Planning Implementatio Rationale Evaluation
n

S: "medyo Risk for Short term: Independent: After 8 hours

makirot pa bleeding of nursing
yung sugat ko" related to After 1 hour of -Establish -To have a interventions,
as verbalized surgery/trauma nursing rapport good nurse- the patient will
by the patient as evidenced interventions, client be free from
by disruption of the patient relationship signs of active
O: tissue will: bleeding such
-V/S: as excessive
BP:140/80 -The patient -Monitor V/S -To establish blood loss as
RR:19 will verbalize baseline data evidenced by
PR:70 understanding stable vital
O2SAT:99 of and -Note risk -To help the signs and
-Afebrile 35.9 willingness to factors for patient usual
-Facial follow up occurrence of identify the mentation and
grimace prescribed bleeding present risk urinary output.
-Irritability regimen factors that
-Identify the may add up
risk factors to bleeding
that are
present -Educate the -Information
-Have partial patient about about
understanding precautionary precautionary
about bleeding measures to measures
control prevent tissue lessens the
trauma or risk of
Long term: disruption of bleeding.
the normal
After 8hrs of clotting
nursing mechanism.
interventions,
the patient -Educate the -Early
will: patient and evaluation and
family treatment of
-Have full members bleeding by a
knowledge in about signs of healthcare
identifying bleeding that provider
the risk need to be reduce the risk
factors of the reported to a of
bleeding health care complications
-Be free from provider from blood los
signs and
symptoms of -Monitor
bleeding blood loss
such as the
site, type,
amount, and
presence of
clots

Dependent:

-Administer -Blood product

blood products transfusion
if indicated as replace blood
ordered by clotting factors
the physician

Collaborative:
-Provide client -Health
and family education
education builds
knowledge
appropriate to
the plan of
patient care
C. IMPLEMENTATION

DRUGS

NAME OF DATE ROUTE OF MECHANIS INDICATIO CLIENT’S NURSING

DRUGS ADMINISTE ADMINISTR M OF N RESPONSE RESPONSI
RED ATION, ACTION TO BILITIES
DOSAGE MEDICATIO PRIOR TO,
AND N WITH DURING,
FREQUENC ACTUAL AND
Y SIDE AFTER
EFFECTS ADMINISTR
ATION

GENERIC 10/09/2023 1.5g IV anst -Cefuroxime - Common - Common Prior to

NAME: is a second- indications side effects Administrat
Cefuroxime generation include may include ion:
cephalospori respiratory gastrointesti
BRAND n antibiotic. tract nal upset Assess the
NAME: infections, (such as client’s
Ceftin - It works by urinary tract nausea, medical
zinacef inhibiting the infections, diarrhea), history,
synthesis of skin and soft headache, including
the bacterial tissue or allergic allergies,
cell wall, infections, reactions. previous
leading to and certain antibiotic
cell wall types of use, and the
instability bacterial nature of the
and meningitis infection.
eventual cell
lysis. During
Administrat
ion:

Monitor the
client for any
immediate
adverse
reactions,
such as
allergic
responses.

After
Administrat
ion:

Monitor for
any delayed
side effects
or
complication
s, such as
 diarrhea or
secondary
infections.

DRUGS DATE ROUTE OF MECHANIS INDICATIO CLIENT’S NURSING

ADMINISTE ADMINISTR M OF N RESPONSE RESPONSI
RED ATION, ACTION TO BILITIES
DOSAGE MEDICATIO PRIOR TO,
AND N WITH DURING,
FREQUENC ACTUAL AND
Y SIDE AFTER
EFFECTS ADMINISTR
ATION

GENERIC 10/09/2023 5 mg IV q6 -Hydralazine -It is used to -The Prior to

NAME: for BP less interferes control high patient's Administrat
Hydralazine than 140/90 with calcium blood response to ion:
transport to pressure in this
BRAND relax a mother medication -Confirm
NAME: arteriolar during which are the correct
Apresoline smooth pregnancy common dosage
muscle and (pre- adverse and route
lower blood eclampsia or reactions to of
pressure. eclampsia) hydralazine administrat
or in are ion based
emergency headache, on the
situations palpitation, patient’s
when blood tachycardia, specific
pressure is and drug- condition.
extremely induced
high lupus During
(hypertensiv syndrome. Administrat
e crisis). ion:

-Monitor the
patient
during
hydralazine
medication
until BP
stabilizes.

After
Administrat
ion:

-Monitor the
patient for
adverse and
allergic
reactions to
 the
medication.

NAME OF DATE ROUTE OF MECHANIS INDICATIO CLIENT’S NURSING

DRUG ADMINISTE ADMINISTR M OF N RESPONSE RESPONSI
RED ATION, ACTION TO BILITIES
DOSAGE. MEDICATIO PRIOR TO,
AND N WITH DURING,
FREQUENC ACTUAL AND
Y SIDE AFTER
EFFECTS ADMINISTR
ATION

Generic 10/09/2023 50mg IV q6 -Tramadol is -Tramadol is -The patient Prior to

Name: x4 doses an opioid used for the may Administrat
Tramadol analgesic short-term experience ion:
that works relief of the side
Brand by binding to severe pain. effects of -Assess the
Name: opioid medication patient's
Not receptors in including pain level
specified the brain headaches, and baseline
and spinal feeling vital signs.
cord, sleepy,
altering the feeling tired, During
perception dizzy, Administrat
of pain and feeling of ion:
reducing the being sick
emotional (nausea or -Monitor the
response to vomiting), patient
pain. constipation, closely for
dry mouth, any adverse
and reactions or
sweating. signs of
overdose,
such as
respiratory
depression,
dizziness, or
sedation.

After
Administrat
ion:

-
Continuousl
y assess the
patient's
pain relief
and monitor
vital signs,
particularly
respiratory
 rate.

NAME OF DATE ROUTE OF MECHANIS INDICATIO CLIENT’S NURSING

DRUG ADMINISTE ADMINISTR M OF N RESPONSE RESPONSI
RED ATION, ACTION TO BILITIES
DOSAGE. MEDICATIO PRIOR TO,
AND N WITH DURING,
FREQUENC ACTUAL AND
Y SIDE AFTER
EFFECTS ADMINISTR
ATION

Generic 10/09/2023 1amp IV -It is a -This -The side Prior to

Name: incorporated nonsteroidal treatment is effects with Administrat
Diclofenac in IV fluid anti- the indicated this ion:
D5LR inflammator regimen for medicine
Brand y drug migraines, may include -Administer
Name: (NSAID) osteoarthriti decreased the
Not used to treat s, urination, medication
specified pain and generalized severe using the
inflammator pain, stomach prescribed
y diseases primary pain, skin route and
such as dysmenorrh rash, document
gout. ea, and swelling of the
rheumatoid the face, administratio
arthritis. fingers, feet, n in the
or lower patient's
legs, record.
unusual
bleeding or During
bruising, Administrat
and ion:
vomiting.
-Provide
reassurance
and support
to the
patient
during the
administratio
n if needed.

After
Administrat
ion:

-Educate the
patient on
the
importance
of reporting
any side
effects or
 changes in
pain
intensity
promptly.

NAME OF DATE ROUTE OF MECHANIS INDICATIO CLIENT’S NURSING

DRUG ADMINISTE ADMINISTR M OF N RESPONSE RESPONSI
RED ATION, ACTION TO BILITIES
DOSAGE. MEDICATIO PRIOR TO,
AND N WITH DURING,
FREQUENC ACTUAL AND
Y SIDE AFTER
EFFECTS ADMINISTR
ATION

Generic 10/09/2023 20"u" IV -Oxytocin -Oxytocin is -The Prior to

Name: incorporated stimulates a patient's Administrat
Oxytocin in IV fluid the smooth recombinant response in ion:
D5LR muscle of hormone this
Brand the uterus, used to medication -Assess the
Name: more induce or is more client’s
Not powerfully strengthen intense or medical
specified towards the uterine more history,
end of contractions frequent including
pregnancy, in pregnant contractions any
during labor, women to (this is an allergies or
and aid in labor expected contraindicat
immediately and delivery effect of ions.
postpartum. or to control oxytocin),
postpartum runny nose, During
-Oxytocin bleeding. sinus pain or Administrat
stimulates irritation, ion:
uterine and memory
contractions problems. -While the
to speed up patient
the process -The side receiving
of childbirth. effects of oxytocin,
In its natural oxytocin teach the
form, it also includes patient that
plays a role headache, with this
in maternal fast or drug, there
bonding and irregular may be
milk heartbeat, some painful
production. abdominal contractions.
pain or After
cramping, Administrat
nausea, ion:
weakness,
dizziness, -Intake and
and chest output need
pain or to be
discomfort. monitored
because a
side effect of
 oxytocin is
water
retention

MEDICAL MANAGEMENT

MEDICAL DATE BRIEF INDICATION CLIENT’S

MANAGEMENT/ PERFORMED DESCRIPTION REACTION TO
TREATMENT TREATMENT

Cefuroxime 10/09/2023 Cefuroxime is Cefuroxime is The patient may

(Profurex) 1.5g to used to treat indicated experience
be administered bacterial infections for the nausea, vomiting,
through IV after a in many different treatment diarrhea, strange
negative skin test. parts of the body. of various taste in the mouth,
It belongs to the bacterial or stomach pain
class of medicines infections may occur.
known as caused by Dizziness and
cephalosporin susceptible drowsiness may
antibiotics. organisms. occur less often,
especially with
higher doses.

MEDICAL DATE BRIEF INDICATION CLIENT’S

MANAGEMENT/ PERFORMED DESCRIPTION REACTION TO
TREATMENT TREATMENT

Hydralazine 5mg 10/09/2023 Hydralazine is in a Hydralazine is Common adverse

to be administered class of used to treat high reactions to
through IV as medications called blood pressure hydralazine are
taken every six vasodilators. It (hypertension). It headache,
hours (q6) for works by relaxing is also used to palpitations,
blood pressure the blood vessels control high blood tachycardia, and
less than 140/90. so that blood can pressure in a drug-induced
. flow more easily mother during lupus syndrome.
through the body. pregnancy (pre- Other adverse
High blood eclampsia or reactions include
pressure is a eclampsia) or in dizziness,
common condition emergency diarrhea, nausea,
and when not situations when vomiting, edema,
treated, can cause blood pressure is and peripheral
damage to the extremely high neuropathy.
brain, heart, blood (hypertensive
vessels, kidneys crisis).
and other parts of
the body.

MEDICAL DATE BRIEF INDICATION CLIENT’S

MANAGEMENT/ PERFORMED DESCRIPTION REACTION TO
TREATMENT TREATMENT
Tramadol 50mg to 10/09/2023 Tramadol is an It has specific The patient may
be administered opioid medicine indications for experience side
through IV as used for the short- moderate to effects such as
taken every six term relief of severe pain. It is drowsiness,
hours (q6) with a moderate to considered a class confusion,
total of four doses severe pain. It is IV drug by the constipation,
(x4 doses).. not usually FDA and has been nausea and
. recommended for since July of 2014. vomiting,
the treatment of Due to possible respiratory
chronic (long- misuse disorder depression or
term) pain. potential, urine retention.
Tramadol is only limitations to its
available with a use should be for
prescription from pain that is
the doctor. refractory to other
pain medication,
such as non-
opioid pain
medication.

MEDICAL DATE BRIEF INDICATION CLIENT’S

MANAGEMENT/ PERFORMED DESCRIPTION REACTION TO
TREATMENT TREATMENT

Diclofenac 1 10/09/2023 Diclofenac is a This treatment is Side effects

ampule to be medication used in the indicated includes stomach
administered the management regimen for pain, confusion,
through IV . and treatment of migraines, difficulty with
inflammatory osteoarthritis, breathing,
conditions and generalized pain, irregular
pain. It is in the primary heartbeat, nausea
class of non- dysmenorrhea, or vomiting,
steroidal anti- and rheumatoid nervousness,
inflammatory arthritis. numbness or
drugs (NSAID). Diclofenac tingling in the
epolamine is hands, feet, or
available as a lips, or weakness
1.3% transdermal or heaviness of
patch to be the legs.
applied twice daily
over the affected Check with your
area to relieve doctor right away
pain and if you have
inflammation. experienced those
reactions to
medication.

MEDICAL DATE BRIEF INDICATION CLIENT’S

MANAGEMENT/ PERFORMED DESCRIPTION REACTION TO
TREATMENT TREATMENT

Oxytocin 20 "u" to 10/09/2023 Oxytocin is a Oxytocin is Side effects that

be administered hormone that acts indicated and the patient may
through IV . on organs in the approved by the experience
body (including FDA for two includes allergic
the breast and specific time reactions or skin
uterus) and as a frames in the rash, itching,
chemical obstetric world hives, swelling of
messenger in the which are the the face, lips,
brain, controlling antepartum and tongue, or throat.
key aspects of the postpartum. In the Heart rhythm
reproductive antepartum changes fast or
system, including period, exogenous irregular
childbirth and oxytocin is FDA- heartbeat,
lactation, and approved for dizziness, feeling
aspects of human strengthening faint or
behavior. uterine lightheaded, chest
contractions with pain, trouble
the aim of breathing. Heavy
successful vaginal vaginal bleeding.
delivery of the
fetus.

MEDICAL DATE BRIEF INDICATION CLIENT’S

MANAGEMENT/ PERFORMED DESCRIPTION REACTION TO
TREATMENT TREATMENT

D5LR (5% 10/09/2023 Lactated Ringer's These solutions This medicine can
Dextrose in and 5% Dextrose are indicated for affect the
Lactated Ringer's Injection, USP is a parenteral potassium level in
Injection) IVF 20 sterile, replacement of the patient's body.
"u" . nonpyrogenic extracellular Contact the doctor
solution for fluid losses of fluid and immediately if you
and electrolyte electrolytes, with experience a slow
replenishment and minimal or irregular
caloric supply in a carbohydrate heartbeat, muscle
single dose calories, as weakness or limp
container for required by the feeling, leg
intravenous clinical condition cramps, tingling
administration. of the patient. feelings,
confusion, unusual
thirst, or urinating
more than usual.

MEDICAL DATE BRIEF INDICATION CLIENT’S

MANAGEMENT/ PERFORMED DESCRIPTION REACTION TO
TREATMENT TREATMENT

PLRS IV solution 10/09/2023 Lactated Ringer’s Medical uses of Some side effects
solution, or LR, is lactated Ringer's that the patient
an intravenous to treat may experience
(IV) fluid you may dehydration. To includes allergic
receive if you’re facilitate the flow reactions, such as
dehydrated, of IV medication localized hives,
 having surgery, or during surgery. To itching, or
receiving IV restore fluid swelling, back
medications. It’s balance after pain, fever,
also sometimes significant blood headache,
called Ringer’s loss or burns. To nausea, stomach
lactate or sodium keep a vein with pain, and
lactate solution. an IV catheter vomiting.
open.

SURGICAL MANAGEMENT

NAME OF DATE BRIEF INDICATION CLIENT’S NURSING

PROCEDUR PERFORMED DESCRIPTION RESPONSE RESPONSIBIL
E TO ITIES PRIOR
OPERATION TO, DURING,
AND ACTUAL
SURGICAL
PROCEDURE

Transverse 10/9/2023 A low transverse This procedure Following the Monitor:

Cesarean cesarean section is typically procedure, the - Blood
Section (C-section) is a performed client may pressure, heart
surgical when a experience rate, and the
procedure pregnant pain, amount of your
involving the individual discomfort, vaginal
delivery of a baby requires a C- and fatigue, bleeding.
through an section for the which are - Incision
incision made safe delivery of typical status, pain,
horizontally the baby due to aftereffects of respirations,
across the lower various medical surgery. There and lung and
abdomen, just reasons, such may also be bowel sounds.
above the pubic as post-operative
hairline (low complications care
transverse during considerations,
incision). This pregnancy, such as wound
particular style of breech care, pain
cesarean section presentation of management,
is preferred the baby, or and recovery
because it previous C- guidelines.
crosses the sections.
lower, thinner
portion of the
uterus, which
results in less
bleeding

DIET

TYPE OF DIET DATE INDICATION NURSING

 RESPONSIBILITY

General liquid diet 10/9/2023 Recommended for 8 to 24 hours Nurses promote healthy
after the surgery. nutrition to prevent
disease, assist patients
to recover from illness
Soft diet Soft diets consist of foods that and surgery, and teach
are easy to chew and digest. patients how to
They are frequently administered optimally manage
to persons with medical illness with healthy food
conditions, swallowing difficulty, choices. Furthermore,
abdominal surgery, and other nurses ensure that
conditions. patients are well
supported and that their
nutritional intake is well
Nutrient dense foods Nutrient dense foods are rich in monitored and
nutrients relative to calorie documented.
content. These include various
healthy foods such as whole
vegetables, fruits, cocoa,
seafood, eggs, and liver.

Vitamin-rich foods Vitamins and minerals are

essential for bodily functions
such as helping to fight infection,
wound healing, making bones
strong and regulating hormones.

Protein-rich foods Protein helps in the healing

process and is essential for
recovery.
Protein fuels practically every
system in the body, from bone,
muscle, and cartilage strength
High-protein diets are vital
because they include essential
amino acids that our bodies
require and can only obtain from
food.

ACTIVITY/ EXERCISE

GENERAL
TYPE OF EXERCISE DESCRIPTION INDICATION/PURPOSE CLIENT'S
RESPONSE
 For Cesarean:

Early ambulation Performs physical For normal functioning and The patient maintained
activity circulation of the muscle strength and
independently cardiovascular and improves circulation
musculoskeletal systems.
The patient will relieve
Improves muscle circulation pain and improve
Kegel’s exercise It is a pelvic floor and speeds up the healing muscle strength perineal
exercise that helps process in patients floor.
improve pelvic
muscle strength
and support pelvic
organs. Promotes comfort and
relaxation to the patient
Respiratory and Essential far vasodilation and to prevent fatigue.
Deep/Focus breathing tissue circulation improves circulation. Breath
exercise focus allows you to focus on
calm, deep breathing while
disengaging from distracting
ideas and sensations.

NURSING MANAGEMENT

DATE AND TIME NURSE’S NOTES

PATIENT X
10/09/23
CASE: CESAREAN
10:24 am
WARD: OB WARD

S: “Medyo masakit pa yung tahi ko” as verbalized by the patient.

O: AOG 38 weeks and 4 days, facial grimace, uncomfortable, irritability,

restlessness, guarding behavior

Vital Signs: BP= 140/90

Pain Scale: 5/10

A: Evaluate the mother's coping mechanisms and response to pain. Determine

if pharmacological pain management options are appropriate based on the
maternal preference. Consider any contraindications to certain pain
medications.

P: The mother will be encouraged to engage in relaxation techniques, such as

breathing exercises, to manage anxiety and promote a calm birthing
environment. Pain management options will be reviewed and discussed with the
mother to empower her with the necessary knowledge to make informed
decisions during labor. Close communication with the healthcare team will occur
 to ensure a smooth transition from pregnancy to the delivery process.

I: Provide education and support to the mother and her support person.
Encourage the use of relaxation techniques and assist with positioning changes.
Administer prescribed pain medications as ordered and monitor their
effectiveness.

E: Continuously assess the mother's pain level and response to interventions.

Make any necessary adjustments to the pain management plan based on the
mother's feedback and the progress of labor. Document the effectiveness of
interventions and any changes in the mother's pain level.

III. CONCLUSION

During our duty duration, we were assigned to the OB ward section for the experience and the
exposure as we encountered different cases of the patient. From the individually assigned patient, upon
the monitoring of their vital signs, assisting to what they need and other healthcare, we have the case
study proposed about the cesarean delivery. This case study will explore the conditions of a C-section
delivery, focusing on the causes, procedures, and implications for the mother and the baby. It was of the
utmost significance for the care of expectant moms, babies, and their families as we worked in the OB
ward area. To make sure they receive the care they deserve, we do our duty as we collaborate. By
obtaining sufficient knowledge and abilities, we can give patients superior care and support in this area,
promoting their well-being and recovery. A deep experience, working in the OB ward department of a
hospital has its own perks and challenges. Although the high levels of tension and emotional ups and
downs can be demanding, the opportunity for one's own development and the honor of witnessing when
these situations unfold make it sincerely remarkable. We are committed to taking care of the mother and
their babies, and this is what drives us in our profession. We are eternally appreciative to our clinical
instructor for helping to mold us. Your kindness and willingness to impart your extensive expertise have
been essential to our development throughout this clinical thrilling experience. Your support at tough
times, your helpful criticism, and your ongoing support for patient-centered care have helped us become
more empathic. We want to express our gratitude once more for your outstanding mentoring and
guidance.