Case Presentation Cs 2

8/11/2019 Case Presentation Cs 2

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General Objectives:

The purpose of this study is to enhance and gain knowledge about, to develop communication and nursing skills to provide privacy and maintain

confidentiality of the patient and to apply the right attitude of the student nurses in rendering and giving care to the patient with Post Cesarean and Bilateral

Tubal Ligation, its importance and implication.

Specific Objectives:

To understand the condition of Post Cesarean and Bilateral Tubal Ligation and associate it with the patient through the introduction of the case.

To illustrate the anatomy and physiology of the affected organ or the part of the body.

To discuss the pathophysiology that causes anemia.

To be clinically aware of the clinical manifestation and its complication.

To develop an effective skill on how to plan and manage proper care in patient with Post CSBTL.

To provide the client nursing care plan and discharge plan to assure clients total wellness during her hospitalization up to time of his hospital discharge.

To apply right attitude by respect through providing privacy and maintaining clients confidentiality.

Scope and Delimitations

The study would only focus on Post CSBTL which is indicative to the patients health condition and its underlying nursing care relevant for the patient

confined in Quezon Medical Center.

The study was conducted at Quezon Medical Center (OB-Ward) during the nursing students exposure in the hospital (September 23,24 and 25 2012).

Nursing health history, physical assessment, nursing interventions and health teachings for the patient were included. Its primary focus is the clientwhose

diagnosis was Post CSBTL. The baseline data were gathered from the client, f rom the clients chart, and through the nurse-patient interaction during the

exposure.


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Nursing History:

History of Present Illness:

Masakit ang tahi ko,as verbalized by the patient. She experienced lumbosacral pain before admission. She was brought to Quezon Memorial Center last

September 21, 2012. At 2:00 in the afternoon. She was brought to operating room around 10:30pm.

History of Past Illness:

According to the patient, she didnt experience any severe illness during her childhood. Her common illnesses are cough, colds, and fever. She doesnt had any

drug and food allergies. Her first baby was delivered through cesarean operation due to drained amniotic fluid. Her second baby, died four days after the delivery

due to heart failure and was delivered by cesarean operation. Her third baby was delivered through cesarean operation due to breech presentation of the baby. Her

fourth baby was also delivered through cesarean operation.

Family History:

The patient is the 2

nd

child of 4 siblings. Her father is diabetic. Her mother died while giving birth to her youngest child and was delivered through cesareanoperation.

Her sisters, according to her was in good health condition.

Genogram:

Legend:

-Female -deceased

-Male - deceased

giving birth diabetic


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Personal/Social History:

Alcohol Use: Denies.

Tobacco Use: Denies.

Drug Use: Denies.

Travel History: Denies.

Economic Status: Farming as their means of livelihood.

Religion: Roman Catholic

s

Theoretical Framework

Watsons Caring

Theory:


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Physical Assessment

Date of Assessment: September 25, 2012

General Appearance:

The patient is oriented and conscious. She wears neat clothes exactly for her mesomorph body. Upon assessment, the client is sitting on the chair, with a pulse rate

of 93 beats per minute, respiration rate of 18 breaths per minute, and temperature of 36.0 C.

BODY PART NORMALS FINDINGS ACTUAL FINDINGS INTERPRETATION/ ANALYSIS

A.

HEAD

1. SKULL

Proportional to the size of the body,

round, with prominences in the

frontal area anteriorly and the

occipital area posteriorly

symmetrical in all planes.

Proportional to the size of the body,

symmetrical in all planes.

Normal.

2. SCALP White, clean, free from masses,

lumps, scars, nits, dandruff, and

lesion

White, clean, free from masses,

lumps, scars, nits, and lesions

Normal

3. HAIR Black or whitish, evenly distributed

and covers the whole scalp, thick,

shiny, free from split ends.

Black; evenly distributed, thick. Normal

4. FACE Oblong/oval/square or heart-shaped,

symmetrical, facial expressions that

is dependent on the mood or true

feelings,

Round shape. Symmetrical, free

from wrinkles and scars. No

involuntary muscle movements.

normal

B. EYES Black, symmetrical, thick, can raiseand lower eyebrows symmetrically

Black, symmetrical. Can raise andlower eyebrows.

normal


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and without difficulty, evenly

distributed and parallel with each

other.

C. EARS Pinkish, clean, with scant amount of

cerumen and a few cilia.

Cerumen and a few cilia. Normal

D. NOSE Midline, symmetrical, and patent. Midline, symmetrical, and patent. Normal

E. MOUTH Pinkish, symmetrical lip margin,

well-defined, smooth and moist.

Pale Pallor due to decreased hemoglobin

and hematocrit.

F. NECK Proportional to the size of the body

and head, symmetrical and straight.

Proportional to the size of the body

and head, symmetrical and straight.

Normal

G. RANGE OF MOTION Freely movable with relative ease. PoorRange of Motion. >dueto pain at incision site.

H. MUSCULAR STRENGTH Symmetrical movements and able toresist force applied by the nurse.

Symmetrical movements and able toresist force applied

Normal

I. HEART Regular beats

(60-100 beats per minute).

Regular beats (108 beats per minute) Deviation from normalPatients who are anemic or have low

levels of hemoglobin thus carrying

less oxygen in the blood causing a

higher number of BPM in the heart

rate

J. ABDOMEN

Inspection

Unblemished skin; uniform color.

Flat, rounded; symmetric contour.

With presence of incision at the

abdomen; intact and no drainage

Due to caesarean section delivery


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1. Abdomen skin

2. Contour and Symmetry

Symmetric movements caused by

respiration.

Auscultation Audible bowel sounds (5-30/min);

absence of arterial bruits andfriction rubs.

Audible bowel sounds (10/min). Normal

Palpation No tenderness;

With contracted hard abdomen.

Had incision site. Cannot be palpated due to pain at

incision site.

K. CHEST (THORAX)

Inspection

Chest symmetrical, skin intact, no

tenderness, no masses.

Chest symmetrical. No lumps,

tenderness and masses.

Respiration of 20breaths per minute.

Normal

Palpation Full and symmetric chest expansion.

Symmetric vocal fremitus.

Symmetric and expands. Normal

L. UPPER EXTREMITIES

1. ARMS

Inspection

Skin varies (pinkish, tan, dark

brown), skin is smooth, fine hair

evenly distributed, muscles

symmetrical, length symmetrical.

Edematous, Pale skin, fine muscle,

length symmetrical, fine hair evenly

distributed.

Deviation from normal

Pallor due to less oxygen being

available to the surface tissues

caused by decrease haemoglobin

level

Palpation Warm, dry and elastic, no areas of

tenderness. Muscle appears equal

Warm, dry and no areas of Normal


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with good muscle tone. tenderness.

M. NAILS Nails are transparent, smooth, &

convex with pink nail beds & white

translucent tips.

Five fingers in each hand. As

pressure is applied to the nail bed, it

appears white or blanched & pink

color returns immediately as

pressure is released.

Complete fingers, 5 each hand.

Nails are thick, transparent, &

convex with pale nail beds & whitetranslucent tips.

As pressure is applied to the nailbed,

it appears white and color returns

after 4 seconds.

With deviation from normal

Patients with anemia may exhibit

delayed capillary refill - diminished

blood flow to the periphery and

compensatory vasoconstriction.

N. SHOULDERS, ARMS,

ELBOWS, HANDS & WRISTS

ABDUCTION AND ADDUCTION.

Performs with relative ease. Performs with relative ease. Normal

O. LOWER EXTREMITIES

1. LEGS

Inspection

Skin varies (pinkish, tan, dark

brown), skin is smooth, fine hair

evenly distributed, absence of

varicose veins, muscles symmetrical,

length symmetrical.

Edematous in the lower extremities

Skin is pale. Hair evenly distributed.

Deviation from normal

Due to excess fluid volume the

patient may experience edema

(Medical-Surgical Nursing by

Digiulio p.177)

Pallor due to less oxygen being

available to the surface tissues

caused by decrease haemoglobin

level


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Hematocrit 33.4 M 40-50 vol%

F 30-40 vol%

Normal normal

WBC Count 6,300 5,000-10,000/comm Normal Normal

Name of Test Date Done Actual Result Reference Value

Neutrophils 09/21/12 74

Lymphocytes 26100%

Platelet CountBLOOD TYPE

217,000A +

III-Clinical Discussion of the Case:

>Anatomy and Physiology:


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>EXTERNAL GENITALIA:

Labia minora

Labia majora

Clitoris

>INTERNAL REPRODUCTIVE STRUCTURE:

The Vagina

The Cervix

Uterus

Oviducts (Fallopian Tube)

Ovaries


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Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S- masakit ang tahi ko as

verbalized by the patientOabdominal pain scale of 9,

10 as the highest and 1 as the

lowest-Guarding behavior noted

-Facial grimace noted- Irritable noted-

Pallor

- Change of sleep pattern-

Restlessness

- Elevated pulse102bpm

- Respiration -24-

Acute pain related to tissue

injury secondary to surgicalintervention

After 2-4 hours of nursing

intervention the person willverbalize relief from pain after

satisfactory measures

Monitor vital signs to

compare to its normalvalue.

Teach specific

relaxation strategy;(rhythmic breathing or

deep breath) Instruct on techniques to

reduce skeletal muscle

tension, which willreduce the intensity of

the pain.

Assess the patientcontractions and

discomfort. Encourage the patient to

stand and walk as muchas possible during first

stage Instruct the patient to

change the position atleast every hour.

Encourage diversionalactivities such as talking

with the significantothers reading and so

on.

EXPECTED

OUTCOME

Goal partially met

At the end of nursing

intervention the patientdemonstrated a partial

relief in pain, from 9down to 5

hindi na masyadongmasakit ang tahi ko asverbalized by the patient

S- nanghihina ako asverbalized by the patient .

Opale palpebral conjunctiva

Fatigue related to inadequatetissue oxygenation secondary

to low hemoglobin count

After 1-3 days of nursingintervention the patient will

participate in activities that

Emphasize the need forrest and sleep period

Advice to avoid over

EXPECTEDOUTCOME


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Adults: 150mg p.o

bid or 300mg dailyh.s

hypersecretoryconditions, such as

zollinger ellisonsyndrome; short-term

therapy for patientsunable to tolerate oral

forms

any of its content,Use cautiously in patients

with hepatic dysfunction.Adjust dosage in patients

with impaired kidneyfunction

Other: burning anditching at injection site,

anaphylaxis

decreasing gastric acid and secretion

Oxytocin,synthetic injection

Adults: initially

1ml ampule in1000ml of d5w

injection

Pitocin To induce orstimulate labor, to

reduce postpartumbleeding after

expulsion of placenta

Contraindicated in patientshypersensitive to drug.

Also contraindicated whenvaginal delivery isnt

advised

Cns: subarachnoidhemorrhage, seizures and

comaCv: hypertension,

increased heart rate,systemic venous return

Use with extreme caution during firstand second stages of labor because

cervical laceration, uterine rupture andmaternal and fetal death

Tramadolhydrochloride

Adults: 50-100mg

p.o q4 to 6 hours,prn maximum

400mg daily

Ultram Moderate tomoderately severe

pain

Contraindicated to patienthypersensitive to drug and

in those with acuteintoxification from alcohol,

hypnotics, centrally actingganalgesics.

Cns: dizziness, vertigo,headache, somnolence

Cv: vasodilationGi:nausea, constipation,

vomiting, dyspepsia

Use cautiously in patients at risk forseizures or respiratory depression; in

increased intracranial pressure


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DISCHARGE

MEDICATIONS

Explain to the patient and family members the importance of taking medicines.

Discuss to the patient and family the dosage, frequency and adverse effects of the drugs.

Encourage to follow the dosages and proper timing of his meds.

ENVIRONMENT

Explain to significant others that the rehabilitation may be prolonged to be able for the family to prepare financial needs

Maintain a quiet, clean and calm environment for easy and good recovery of the Patient.

Provide safety measures to promote safe environment and individual safety

Treatment

Provide warm environment

Advice patient to avoid lifting heavy objects and use of too much force to prevent more serious injury.

Instruct to perform light physical activities

HEALTH TEACHINGS

Instruct the patient to take medications religiously

Improve nutritional status


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Case Presentation Cs 2

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