CASE STUDY

Submitted by: BSN 3y3-13A Agoyaoy, Leah G. Aler, Riza F. Andres, Kimberly Joy C. Balatbat, Kasselyn Bautista, Jesaren Bautista, Dan Leonard

Submitted to: Mr. Marshal Espiritu

OBJECTIVES OF THE STUDY

The significance of the study is for us third year students to apply the principles and concepts that we have learned in the NCM 103 (Medical and Surgical Nursing) in our rotation at Bulacan Provincial Hospital , with the following learning objectives:

1. Cognitive To be able to review concepts and theories in medical and surgical nursing. To be able to describe the development, pathophysiology, medicalsurgical management, and nursing care of a client who have undergone a surgery. To be able to design a Nursing Care Plan for the patient who have undergone surgery. To be able to provide information and heath teachings to the patient in the postoperative period.

2. Psychomotor To be able carry-out hospital routines and the treatment prescribed to the patient. To be able to perform nursing procedures and nursing considerations for a client in the preoperative, intraoperative and postoperative stages

INTRODUCTION

Nursing Process is a patient centered, goal oriented method of caring that provides a framework to the nursing care. The nursing process exists for every problem that the patient has and for every element of patient care, rather than once for the patients needs are likely to change during their stay in hospital as their health either improves or deteriorates. Nursing process was used in this case study for a more systematic to care for a client who have undergone a cesarean section birth.

Caesarean Section A Caesarean section (US: Cesarean section), also C-section, Caesarian section, Cesarian section, Caesar, etc., is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a hysterotomy abortion and is very rarely performed. A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has been also performed upon request for childbirths that could otherwise have been natural. There are several types of Caesarean section (CS). An important distinction lies in the type of incision (longitudinal or latitudinal) made on the uterus, apart from the incision on the skin.

The classical Caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications.

The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.

An emergency Caesarean section is a Caesarean performed once labour has commenced.

A crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, child(ren) or both.

A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.

Traditionally other forms of Caesarean section have been used, such as extraperitoneal Caesarean section or Porro Caesarean section.

a repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the old scar.

In many hospitals, the mother's birth partner is encouraged to attend the surgery to support the mother and share the experience. The anaesthetist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn. Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Not all of the listed conditions represent a mandatory indication, and in many cases the obstetrician must use discretion to decide whether a caesarean is necessary. Some indications for caesarean delivery are: Complications of labor and factors impeding vaginal delivery such as:

prolonged labor or a failure to progress (dystocia) fetal distress cord prolapse

uterine rupture increased blood pressure (hypertension) in the mother or baby after amniotic rupture

increased heart rate (tachycardia) in the mother or baby after amniotic rupture

placental problems (placenta praevia, placental abruption or placenta accreta)

abnormal presentation (breech or transverse positions) failed labor induction failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of forceps/ventouse' is tried out - This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched to a caesarean section.

overly large baby (macrosomia) umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and succenturiate-lobed placentas, velamentous insertion)

contracted pelvis

Other complications of pregnancy, preexisting conditions and concomitant disease such as

pre-eclampsia hypertension multiple births precious (High Risk) Fetus HIV infection of the mother Sexually transmitted infections such as genital herpes (which can be passed on to the baby if the baby is born vaginally, but can usually be treated in with medication and do not require a Caesarean section)

previous Caesarean section (though this is controversial see discussion below)

prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)

Other

Lack of Obstetric Skill (Obstetricians not being skilled in performing breech births, multiple births, etc. [In most situations women can birth under these circumstances naturally. However, obstetricians are not always trained in proper procedures])

Improper Use of Technology (Electric Fetal Monitoring [EFM])

Risks for the mother: As with all types of abdominal surgery, a Caesarean section is associated with risks of post-operative adhesions, incisional hernias (which may require surgical correction) and wound infections.[18] If a Caesarean is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anaesthesia risk. Other risks include severe blood loss (which may require a blood transfusion) and post spinal headaches. A study published in the June 2006 issue of the journal Obstetrics and Gynecology found that women who had multiple Caesarean sections were more likely to have problems with later pregnancies, and recommended that women who want larger families should not seek Caesarean section as an elective. The risk of placenta accreta, a potentially life-threatening condition, is only 0.13% after two Caesarean sections but increases to 2.13% after four and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk of emergency hysterectomies at delivery. The findings were based on outcomes from 30,132 caesarean deliveries.

It is difficult to study the effects of caesarean sections because it can be difficult to separate out issues caused by the procedure itself versus issues caused by the conditions that require it. For example, a study published in the February 2007 issue of the journal Obstetrics and Gynecology found that women who had just one previous caesarean section were more likely to have problems with their second birth. Women who delivered their first child by Caesarean delivery had increased risks for malpresentation, placenta previa, antepartum hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second delivery. However, the authors conclude that some risks may be due to confounding factors related to the indication for the first caesarean, rather than due to the procedure itself. Risks for the child: This list covers the most commonly discussed risks to the child. Some risks are rare, and as with most medical procedures the likelihood of any risk is highly dependant on individual factors such as whether other pregnancy complications exist, whether the operation is planned or done as an emergency measure, and how and where it is performed.

Neonatal depression: babies may have an adverse reaction to the anesthesia given to the mother, causing a period of inactivity or sluggishness after delivery.Fetal injury: injury may occur to the baby during uterine incision and extraction.

Breathing problems: babies born by Caesarean section, even at full term, are more likely to have breathing problems than are babies who are delivered vaginally.

Breastfeeding problems: babies born by Caesarean section are less likely to successfully breastfeed than those delivered vaginally.

Potential for early delivery and complications: One study found an increased risk of complications if a repeat elective Caesarean section is performed even a few days before the recommended 39 weeks.

Type 1 Diabetes: a 2008 study found that children born by Caesarean section have a 20% higher likelihood of developing type 1 Diabetes in their lifetimes than babies born vaginally.

Risks for both mother and child: Due to extended hospital stays, both the mother and child are at risk for developing a hospital-borne infection. Studies have shown that mothers who have their babies by caesarean take longer to first interact with their child when compared with mothers who had their babies vaginally. Anesthesia: Both general and regional anaesthesia (spinal, epidural or combined spinal and epidural anaesthesia) are acceptable for use during caesarean section. Regional anaesthesia is preferred as it allows the mother to be awake and interact immediately with her baby. Other advantages of regional anesthesia include the absence of typical risks of general anesthesia: pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and Oesophageal intubation. Regional anaesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anaesthesia being the most commonly used regional techniques in scheduled caesarean section. Regional anaesthesia during caesarean section is different to the analgesia (pain relief) used in labor and vaginal delivery. The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense nerve block. The dermatomal level of anesthesia required for caesarean delivery is also higher than that required for labor analgesia.

General anesthesia may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia. General anesthesia is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia. Vaginal birth after caesarean: While Vaginal birth after caesarean (VBAC) are not uncommon today, their numbers are shrinking[50]. The medical practice until the late 1970s was "once a caesarean, always a caesarean" but a consumer-driven movement supporting VBAC changed the medical practice. Rates of VBAC in the 80s and early 90s soared, but more recently the rates of VBAC have dramatically dropped owing to medico-legal restrictions. In the past, caesarean sections used a vertical incision which cut the uterine muscle fibres in an up and down direction (a classical caesarean). Modern caesareans typically involve a horizontal incision along the muscle fibres in the lower portion of the uterus (hence the term lower uterine segment caesarean section, LUSCS/LSCS). The uterus then better maintains its integrity and can tolerate the strong contractions of future childbirth. Cosmetically the scar for modern caesareans is below the "bikini line". Obstetricians and other caregivers differ on the relative merits of vaginal and caesarean section following a caesarean delivery; some still recommend a caesarean routinely, others do not. What should be emphasized in modern obstetric care is that the decision should be a mutual decision between the obstetrician and the mother/birth partner after assessing the risks and benefits of each type of delivery. As is the case for all surgical procedures a patient signed form relating to informed consent must be obtained prior to surgery attesting the completeness of patient information because of reasonable and viable alternatives to maternal choice CS.

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care. This recommendation has, in some cases, had a major impact on the availability of VBACs to birthing mothers in the United States. For example, a study of the change in frequency of VBAC deliveries in California after the change in guidelines, published in 2006, found that the VBAC rate fell to 13.5% after the change, compared with 24% VBAC rate before the change. The new recommendation has been interpreted by many hospitals as indicating that a full surgical team must be standing by to perform a caesarean section for the full duration of a VBAC woman's labor. Hospitals that prohibit VBACs entirely are said to have a 'VBAC ban'. In these situations, birthing mothers are forced to choose between having a repeat caesarean section, finding an alternate hospital in which to deliver their baby or attempting delivery outside the hospital setting. Recovery Period: Typically the recovery time depends on the patient and their pain/ inflammation levels. Doctors do recommend no strenuous work i.e. lifting objects over 10 lbs., running, walking up stairs, or athletics for up to two weeks.

ANATOMY OF FEMALE REPRODUCTIVE SYSTEM The female reproductive system (or female genital system) contains two main parts: the uterus, which hosts the developing fetus, produces vaginal and uterine secretions, and passes the male's sperm through to the fallopian tubes; and the ovaries, which produce the female's egg cells. These parts are internal; the vagina meets the external organs at the vulva, which includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the Fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina. The ova are larger than sperm and have formed by the time a female is born. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation.

A female's internal reproductive organs are the vagina, uterus, fallopian tubes, cervix and ovary. Vagina The vagina is a fibro muscular tubular tract leading from the uterus to the exterior of the body in female mammals, or to the cloaca in female birds and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the oviduct. The vagina is the place where semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation. Around the vagina, pubic hair protects the vagina from infection and is a sign of puberty. The vagina is mainly used for sexual intercourse. Cervix The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible, the remainder lies above the vagina beyond view. The vagina has a thick layer outside and it is the opening where baby comes out during delivery. The cervix is also called the neck of the uterus. Uterus The uterus or womb is the major female reproductive organ of humans. The uterus provides mechanical protection, nutritional support, and waste removal for the developing embryo (weeks1-8) and fetus (from week 9-delivery). In addition, contractions in the muscular wall of the uterus are important in ejecting the fetus at the time of birth. The uterus contains three suspensory ligaments that help stabilize the position of the uterus and limits it's range of movement. The uterosacral ligaments, keep the

body from moving inferiorly and anteriorly. The round ligaments, restrict posterior movement of the uterus. The cardinal ligaments, also prevent the inferior movement of the uterus. The uterus is a pear-shaped muscular organ. 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. If the egg does not embed in the wall of the uterus, a woman begins menstruation and the egg is flushed away. Oviducts The Fallopian tubes or oviducts are two 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 small, paired organs that are located near the lateral walls of the pelvic cavity. These organs are responsible for the production of the ova and the secretion of hormones. 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, after traveling down the oviduct to the uterus, occasionally being fertilized 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.

PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM Female Reproductive System

Produces eggs (ova) Secretes sex hormones Receives the male spermatazoa during Protects and nourishes the fertilized egg until it is fully developed Delivers fetus through birth canal Provides nourishment to the baby through milk secreted by mammary glands in the breast

External Genitals

Vulva The external female genitals are collectively referred to as The Vulva. This consists of the labia majora and labia minora (while these names translate as "large" and "small" lips, often the "minora" can be larger, and protrude outside the

"majora"), mons pubis, clitoris, opening of the urethra (meatus), vaginal vestibule, vestibular bulbs, vestibular glands. The term "vagina" is often improperly used as a generic term to refer to the vulva or female genitals, even though - strictly speaking - the vagina is a specific internal structure and the vulva is the exterior genitalia only. Calling the vulva the vagina is akin to calling the mouth the throat. Mons Veneris The mons veneris, Latin for "mound of Venus" (Roman Goddess of love) is the soft mound at the front of the vulva (fatty tissue covering the pubic bone). It is also referred to as the mons pubis. The mons veneris is sexually sensitive in some women and protects the pubic bone and vulva from the impact of sexual intercourse. After puberty it is covered with pubic hair, usually in a triangular shape. Heredity can play a role in the amount of pubic hair an individual grows. Labia Majora The labia majora are the outer "lips" of the vulva. They are pads of loose connective and adipose tissue, as well as some smooth muscle. The labia majora wrap around the vulva from the mons pubis to the perineum. The labia majora generally hides, partially or entirely, the other parts of the vulva. There is also a longitudinal separation called the pudendal cleft. These labia are usually covered with pubic hair. The color of the outside skin of the labia majora is usually close to the overall color of the individual, although there may be some variation. The inside skin is usually pink to light brown. They contain numerous sweat and oil glands. It has been suggested that the scent from these oils are sexually arousing. Labia Minora

Medial to the labia majora are the labia minora. The labia minora are the inner lips of the vulva. They are thin stretches of tissue within the labia majora that fold and protect the vagina, urethra, and clitoris. The appearance of labia minora can vary widely, from tiny lips that hide between the labia majora to large lips that protrude. There is no pubic hair on the labia minora, but there are sebaceous glands. The two smaller lips of the labia minora come together longitudinally to form the prepuce, a fold that covers part of the clitoris. The labia minora protect the vaginal and urethral openings. Both the inner and outer labia are quite sensitive to touch and pressure. Clitoris

The clitoris, visible as the small white oval between the top of the labia minora and the clitoral hood, is a small body of spongy tissue that functions solely for sexual pleasure. Only the tip or glans of the clitoris shows externally, but the organ itself is elongated and branched into two forks, the crura, which extend downward along the rim of the vaginal opening toward the perineum. Thus the clitoris is much larger than most people think it is, about 4" long on average. The clitoral glans or external tip of the clitoris is protected by the prepuce, or clitoral hood, a covering of tissue similar to the foreskin of the male penis. However, unlike the penis, the clitoris does not contain any part of the urethra. During sexual excitement, the clitoris erects and extends, the hood retracts, making the clitoral glans more accessible. The size of the clitoris is variable

between women. On some, the clitoral glans is very small; on others, it is large and the hood does not completely cover it. Urethra The opening to the urethra is just below the clitoris. Although it is not related to sex or reproduction, it is included in the vulva. The urethra is actually used for the passage of urine. The urethra is connected to the bladder. In females the urethra is 1.5 inches long, compared to males whose urethra is 8 inches long. Because the urethra is so close to the anus, women should always wipe themselves from front to back to avoid infecting the vagina and urethra with bacteria. This location issue is the reason for bladder infections being more common among females. Hymen

The hymen is a thin fold of mucous membrane that separates the lumen of the vagina from the urethral sinus. Sometimes it may partially cover the vaginal orifice. The hymen is usually perforated during later fetal development. Because of the belief that first vaginal penetration would usually tear this membrane and cause bleeding, its "intactness" has been considered a guarantor of virginity. However, the hymen is a poor indicator of whether a woman has actually engaged in sexual intercourse because a normal hymen does not completely block the vaginal opening. The normal hymen is never actually "intact" since there is always an opening in it. Furthermore, there is not always bleeding at first vaginal penetration. The blood that is sometimes, but not always, observed after first penetration can be due to tearing of the hymen, but it can also be from injury to nearby tissues. A tear to the hymen, medically referred to as a "transection," can be seen in a small percentage of women or girls after first penetration. A transection is caused

by penetrating trauma. Masturbation and tampon insertion can, but generally are not forceful enough to cause penetrating trauma to the hymen. Therefore, the appearance of the hymen is not a reliable indicator of virginity or chastity.

Perineum The perineum is the short stretch of skin starting at the bottom of the vulva and extending to the anus. It is a diamond shaped area between the symphysis pubis and the coccyx. This area forms the floor of the pelvis and contains the external sex organs and the anal opening. It can be further divided into the urogenital triangle in front and the anal triangle in back. The perineum in some women may tear during the birth of an infant and this is apparently natural. Some physicians however, may cut the perineum preemptively on the grounds that the "tearing" may be more harmful than a precise cut by a scalpel. If a physician decides the cut is necessary, they will perform it. The cut is called an episiotomy. Internal Genitals Vagina The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches long in a grown woman. The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes, which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur.

The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the penis. microscopically the vaginal rugae has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer muscular layer is especially important with delivery of a fetus and placenta. Purposes of the Vagina

Receives a males erect penis and semen during sexual intercourse. Pathway through a woman's body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body.

May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom.

Cervix The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened.

The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping. The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates. Uterus The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses. The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to

help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible. The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus. Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery. Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of ovaries and hormone production.

Fallopian Tubes At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg. When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the fimbriae. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes four to five days to travel down the length of the fallopian tube. If enough sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant itself in the uterine wall where it will grow and develop. If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage and possible death of the mother.

Mammary glands

Cross section of the breast of a human female. Mammary glands are the organs that produce milk for the sustenance of a baby. These exocrine glands are enlarged and modified sweat glands. The basic components of the mammary gland are the alveoli (hollow cavities, a few millimetres large) lined with milk-secreting epithelial cells and surrounded by myoepithelial cells. These alveoli join up to form groups known as lobules, and each lobule has a lactiferous duct that drains into openings in the nipple. The myoepithelial cells can contract, similar to muscle cells, and thereby push the milk from the alveoli through the lactiferous ducts towards the nipple, where it collects in widenings (sinuses) of the ducts. A suckling baby essentially squeezes the milk out of these sinuses. The development of mammary glands is controlled by hormones. The mammary glands exist in both sexes, but they are rudimentary until puberty when - in response to ovarian hormones - they begin to develop in the female. Estrogen promotes formation, while testosterone inhibits it. At the time of birth, the baby has lactiferous ducts but no alveoli. Little branching occurs before puberty when ovarian estrogens stimulate branching differentiation

of the ducts into spherical masses of cells that will become alveoli. True secretory alveoli only develop in pregnancy, where rising levels of estrogen and progesterone cause further branching and differentiation of the duct cells, together with an increase in adipose tissue and a richer blood flow. Colostrum is secreted in late pregnancy and for the first few days after giving birth. True milk secretion (lactation) begins a few days later due to a reduction in circulating progesterone and the presence of the hormone prolactin. The suckling of the baby causes the release of the hormone oxytocin which stimulates contraction of the myoepithelial cells. The cells of mammary glands can easily be induced to grow and multiply by hormones. If this growth runs out of control, cancer results. Almost all instances of breast cancer originate in the lobules or ducts of the mammary glands.

PATHOPHYSIOLOGY Release of FSH by the interior pituitary gland Development of the graafian follide Production of estrogen (Thickening of the endometrium) Release of the lutenizing hormone Ovulation (Release of the mature ovum from the graafian follicle) Ovum travels to fallopian tube Zygote travels from the fallopian tube to the uterus Implantation Development of the fetus /embryo and placental structure until full term

PRELIMINARY SIGN OF LABOR Lightening (Descent of the fetal Braxton Hicks Contraction (false labor) Goodles sign

\______________________________________________________________/ TRUE LABOR Uterine contractions -increase in duration and SHOW pink tinge of blood, a mixture And intensity -pain is not relieved no matter What activity -achieve cervical dilatation of blood and fluid Rapture of members

\_______________________________________________________________/ Falled to progress labor (due to previous cesarian birth ,cervical arrest, cervical atrophy) Increase risk for fetal distress (meconium staining, hypoxia)

Emergent cesarian delivery (the incision made on the lower part of the abdomen ) Expulsion of the fetus

NURSING HEALTH HISTORY Patients Profile Name: Pagunuran, Digna Santiago Age: 23 years old Birthday: January 16, 1987 Address: San Pascual, Obando Bulacan Name of Spouse: Ruel Pagunuran Name of Father: Arthur Santiago Name of Mother: Mel Santiago Nationality: Filipino Occupation: Housewife Educational Attainment: High School Admission Date: 08-25-2010 5:57:40pm Discharge Date: 08-28-2010 Surgery Performed: LTS

History of Past and Present Illness

The patient stands 63cm and weighs about 50kg. Her AOG is 40 weeks, LMP was last November 15, 2010 and her EDC was on August 22, 2010. She was only 17 years old when she gave birth to her first child through Cesarean Section (Low Transverse Segment), because she had a difficulty in delivering the child due to her age and lack of knowledge.

It was on August 25, 2010 at around 6pm when patient Digna S. Pagunuran admitted at the OB ward of Bulacan Medical Center and was sent to the OR-DR for an internal examination and was told that pregnancy was already over due. The patient opted for another Cesarean Section for this pregnancy.

GORDONS FUNCTIONAL HEALTH PATTERN

Pattern 1. Health Perception Health Management

Before Patient goes to the health center once when she got pregnant. All in all, she thinks she is in a healthy state.

Present Patient is concern about her second cesarean section thinking that it may be detrimental to her health.

Interpretation Patient cannot function normally anymore like before because of her hospitality confinement and conscious to her body image changed after surgical procedure done. Patients

2. Nutritional Metabolic Management

Prior to confinement, patient loves eating instant foods and fatty foods like fries and burgers. She also loves condiments like patis, vinegar, and soy sauce. She basically eats whatever she likes.

During

hospitalization, the nutritional and patient is on diet as tolerated. She eats fruits like apples and oranges. She eats bread instead of rice. She said she lost her appetite since her onset of labor. metabolic status has been changed due to her confinement.

3. Elimination Pattern

Bowel: Patient defecates

Bowel: Patient defecates

Bowel: There was a

1-2 times a day, usually in the morning, and in the afternoon. Stool is brown in color and well formed.

once a day but not change in the on a regular basis. frequency and Stool is soft, minimal in amount and brown in color. amount.

Bladder: Patient voids usually 6-8 times a day. Urine yellow in color. No pain when voiding. 4. Activity, Leisure, and Recreation Pattern Patient is a housewife so she is always in charge of the household chores. Her leisure time would include watching television. 5. Sleep and Rest Pattern Patient puts herself to sleep by watching television programs. She usually sleeps at around 11pm to 6am. She feels

Bladder: Patient voids 3-4 times a day without pain and discomfort. Patients activities in the hospital are the ambulation, deep breathing and coughing exercise, taking a bath or personal hygiene.

Bladder: There was a change in the frequency and amount. During patients confinement in the hospital, there is a limitation in her activities of daily living and a disruption in her leisure and recreation patter.

Due to her uncomfortable condition and pain, patient complains of difficulty of sleeping and short period of sleeps.

Patient sleep and rest pattern changed when she was admitted. She cannot put herself to sleep anymore due to present condition

rested when sleeping and thinks that her energy is sufficient for her activities. 6. Cognitive Patient is a high Patients present condition is not a hindrance to her cognitive perceptual pattern.

and pain plays a big factor for her sleep disturbances.

No changes/ alterations.

Perceptual Pattern school graduate. She can read and write. She can speak and be understood by others. 7. Self Perception/ Self concept Pattern Patient is a friendly person; she loves to socialize with her friends in neighborhoods. She considers herself as holistic human being as long as she is healthy, complete and her family is always there. 8. Role Relationship Patient can understand English, Tagalog and Kapampangan. She has 5

During times of her confinement, she doesnt thinks that she is a holistic person anymore. However she is positive that she will be ok after confinement.

There is a slight change in her self perception due to present condition.

The patients family is supportive. She is happy with their presence.

Normal/ No alterations.

siblings. 9. Sexuality/ Reproductive Pattern 10. Coping and Stress Tolerance Patient has been with her partner for 3years. When patient is stressed, she sings in the karaoke and eats comfort foods like burgers and fries. When it comes to problems, she lets herself think immediately for a solution. 11. Values- Belief Pattern Patient is a Roman Catholic. She has a strong faith to God and goes to mass every Sunday with her family. She follows a therapeutic regimen and her Due to her confinement, patient is trusting Patient reserved her right to privacy. The recent hospitalization of the patient was stressful and source of anxiety. However, she is positive that she will be able to cope up with current condition. Patient reserved her right to privacy. Patient accepts present condition with a positive attidude.

strong faith to God God that she will accounts to her fast recovery. be discharge soon and will recover without any complications.

PHYSICAL ASSESSMENT

Skull

Generally round, with prominences in the frontal and occipital area. (Normocephalic).

Scalp

Lighter in color than the complexion. Moist. No scars noted. No lesions should noted.

Hair

Can be black, brown or burgundy depending on the race. Evenly distributed covers the whole scalp (No evidences of Alopecia)

CN VII (Facial)

Rounded in shape. Face is symmetrical. No involuntary muscle movements. Move facial muscles at will. Symmetrical and in line with each

Eyebrows

other. Black in color. Eyes Evenly distributed. Evenly placed and inline with each

other. Non protruding.

Eyelashes

Color dependent on race. Evenly distributed. Turned outward.

Eyelids

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.

 No PTOSIS noted. (drooping of upper eyelids). Meets completely when eyes Conjunctivae Both conjunctivae are pinkish or red

in color. With presence of many minutes

capillaries. Moist No ulcers No foreign objects

Sclerae

Sclerae is white in color (anicteric

sclera) No yellowish discoloration (icteric

sclera). Cornea Some capillaries are visible. There are no irregularities on the

surface. Looks smooth. The features of the iris should be

fully visible through the cornea. There is a positive corneal reflex.

Pupils

Equally round. Constrict sluggishly when light is

directed to the eye, both directly and consensual. Pupils dilate when looking at distant

objects, and constrict when looking at nearer objects.

Ears

The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the eye. Skin is same in color as in the complexion. No lesions noted on inspection. No discharges or lesions noted at the ear canal.

Nose and Paranasal Sinuses

Nose in the midline No Discharges. Both nares are patent. No bone and cartilage deviation noted on palpation. The nasal mucosa is pinkish to red in color.

Extremities

Both extremities are equal in size.

Have the same contour with prominences of joints.

No involuntary movements. Color is even. Temperature is warm and even. Has equal contraction and even. No crepitus noted on joints.

LABORATORY EXAMINATIONS

LAB EXAMINATIONS Hgb

LAB RESULTS 110

NORMAL VALUE FEMALE: 120150 gm/ L

SIGNIFICANCE

The patient may be anemic because of the large amount of blood that she loss during the CS delivery.

Hct

.33

FEMALE: 0.370.47

The patient may be anemic because of the large amount of blood that she loss during the CS delivery.

WBC count

10.5

5-10 x 10/L

Increase in the number of WBC may indicate presence of infection in the body.

Rbc count

3.7

FEMALE: 4.05.5 x 10/L

This result may indicate that the patient has anemia because of the blood loss, and this is the reason why Hgb and Hct is decrease in amount.

Neutrophils

0.82

0.55-0.65

As one kind of a WBC, increase in amount of Neutrophils may indicate presence of infection in the patients body.

Lymphocytes

0.18

0.25-0.40

A low normal to low absolute lymphocyte concentration is associated with increased

rates of infection after surgery or trauma.

URINALYSIS RESULTS

LAB EXAMINATIONS (Characteristics) Macroscopic: Color

LAB RESULTS

NORMAL

SIGNIFICANCE

Yellow

Yellow

>Yellow is the natural color for urine

Transparency

Turbid

Clear

>Turbid urine may indicates that the patient is suffering from a UTI or other infection

Specific Gravity

1.015

1.0031.035 (gcm3)

> The patients urine S. Gravity is normal because its in the range of 1.003-1.035 > Patients urine is in a normal pH, but it is slightly acidic

Reaction (pH)

6.0

Close to neutral (7) but can normally vary between 4.4 and 8

Chemical test: Sugar Negative None > it means that absence of sugar in the urine is normal

Albumin

Trace

None

> There is a positive

proteinuria, this may indicate increase in GFR Microscopic: RBC 0-12 none None > RBC in the urine or Hematuria is abnormal. > Red blood cells in urine can be due an inflammation, disease, or injury to the urinary tract system.

WBC

14-18

None or up to 5 WBC/HPF generally are considered acceptable as "normal".

> Greater numbers (pyuria) generally indicate the presence of an inflammatory process somewhere along the course of the urinary tract (or urogenital tract in voided specimens).

Epithelial cells

Moderate

Normal if it is not so many > Amount of epithelial cells can be increased in infections and inflammations. > Amount of epithelial cells is also increased in malignancies, but this absolutely is not the only

Mucus Threads

None

None

sign of cancer.

> presence of mucus threads can either mean that the collection was not clean catch and the urine has been

contaminated by contact with mucus membranes, or a Yeast cells None None possible infection.

Bacteria

Few

None

> If these are present, it can mean you have an infection.

> Indicates infection, this also related why there is presence of WBC in the urine and increase amount of urine in the blood. Crystals: A. Urates few None > Urate is a kind of kidney stones, and this is abnormal. Other Test: Leukocyte +1 None > This indicates UTI of infection in the urinary system

CONCLUSION

This case study adds to growing scientific body that exercise during and after caesarian delivery helps maintain physiologic function that may be otherwise devastated during treatment. The case study provided the basis for our assessment procedures and outlined the specific nursing interventions intensities used in our nursing plan of care to the patient. Additionally, this case study also helps to improved not only our capabilities but as well as the patient too. Our client was a highly motivated mother who possessed a strong desire to contribute to her health and rehabilitation during her treatment. She is capable and many times would like to participate in nursing interventions during and after their health teachings to take an active role for the development of her health yet get imprecise direction on how much and how hard safe is. Participation in plan of care and should be considered as part of a therapeutic modality for a mother like her.

DISCHARGE PLANNING M Medication Methylgonometrine 1 tab TID Mefenamic Acid 250mg 1 tab q4 hrs Ferrous sulfate 1 tab once a day E Environment Instructed the patient to stay calm, quiet environment Home environment must be free from slipping or accident hazards.

T Treatment Informed patient to have a follow-up check-up after 1-2 weeks.

H Health Teachings Informed patient to avoid lifting heavy objects for 1-2 week Stressed the importance of perineal cleanliness Encouraged client to have hot sitz bath Instructed patient to increase intake of protein-rich foods to promote faster wound healing Instructed to promote adequate fluid intake Discouraged patient to participate in strenuous activities that might precipitate stress and trauma to the wound. Instructed patient to promote breastfeeding

O Observable Signs and Symptoms Observe for dehiscence and evisceration Instructed patient to report to physician any signs of infection Instructed patient to report any case of hemorrhage or abnormal bleeding. D Diet Encouraged client to increase intake of fiber to avoid constipation Instructed to increase fluid intake Instructed to increase intake of nutritious foods such as fruits and vegetables.