Faculty of Health Sciences

Department of nursing
Tripoli Campus

Obstetric and genecology practice

NURS 407

Case study assignment about patient

Having cesarean surgery

Presented By: Razan Nasereddine

Instructor’s Name: Miss Maha Dankar

Date: 19/11/2019

Outline:
 1. Patient’s information and observation
2. Patient’s vital signs and medications at my shift and medications in operation
room
3. NCP

1. Patient’s bio sociodemographic information:

Patient Fatima haydar entered maternity department yesterday in 18/11/2019 at 7 AM in

order to undergo a cesarean surgery after a full term pregnancy of 38 weeks and admitted
to room 302 having signs of pain in her lower abdomen. The patient is 25 years old and
has no allergy and she doesn’t smoke nor drink alcohol where her surgical history was 2
cesarean operations and one abortion having two kids. The patient doesn’t work.

 Medical history: patient has no medical history

 Family history : hypertension
 Surgical history : two caesarean operations
 Patient blood type: O+
 Patient had a normal pregnancy and a follow up
 Patient had normal diet

Patient observation:

 Patient removed the urine bag the next day of surgery in the morning
 Patient had IV perfusion dextrose 5% 1L
 Patient was cooperative
 patient drinks water and milk and still didn’t eat solid foods
 patient went to the toilet and urinated and didn’t eliminate stool and gas
 patient started to walk normally
 patient’s all systems where normal
The patient’s blood results came out in 14/11/2019 where they were almost normal
values

2. Medications and vital signs in 19/11/2019:

 Blood pressure: 120/70mmhg

 Pulse: 78beats/min
 Temperature:36.5 degrees C

 Augmentin 1.2g
 Perfalgon 1g
 Dextrose 5% 1L

Medications taken in OR :

 piton 4 amp
Nursing diagnosis goal outcome
1. pain related to Pain will be decreased from  ask the patient about the
abdominal discomfort as 7 till 2 in 1-2 hours pain
evidenced by patient’s scale,duration,frequency
verbal expression , quality and site
 Precipitating or
relieving factors
 Get rid of additional
stressors or sources of
discomfort whenever
possible.
 Provide rest periods to
promote relief, sleep,
and relaxation.
 Use distraction
techniques such as
watch TV
 Educate the patient to
drink herbs and eat
fibers and massage the
abdominal area if
applicable
 Try to do some exercise
to help get rid of
abdominal discomfort
 In collaboration
administer analgesics as
prescribed

2. Constipation related to Enhance the paient to get  Educate the patient to

 lack of physical exercise rid of constipation drink enough amount of
as evidenced by water (2L/day)
patient’s verbal  Eat food rich in fiber
expression and stay away from
food that causes
constipation (food rich
in carbohydrates)
 Do some physical
exercise and exercises
that enhance elimination
 Take a hot bath
 Abdominal massage:
Using the heel of the
hand or a tennis ball,
apply and release
pressure firmly but
gently around the
abdomen in a clockwise
direction.
 In collaboration:
administer laxatives as
prescribed

3. Risk for bleeding Patient will be free of  Educate the patient and
related to surgical open bleeding family members about
wound signs of bleeding that
need to be reported to a
health care provider.
 Monitor pulse and blood
pressure for any
changes(hypotension
and tachycardia)and any
dizziness felt by the
patient
 Monitor surgical site for
any signs of bleeding
 Educate the patient
about over-the-counter
drugs and avoid
products that contain
aspirin or NSAIDs such
as ibuprofen and
naproxen.
 Educate the patient and
family members about
limiting the use of
herbal remedies that are
linked with an increased
risk for bleeding like,
feverfew, ginger, ginkgo
biloba, and chamomile.
 Keep in touch with
blood transfusion center
.
4. Risk for surgical site Patient will be free of  Monitor any signs of
infection related to infection infection(swelling,
caesarean surgery readness, hotness, pain)
 Limit visitors
 If infection occurs,
teach the patient to take
antibiotics as
prescribed. Instruct
patient to take the full
course of antibiotics
even if symptoms
improve or disappear.
 Educate the patient to
pay attention about the
surgical insight and that
no water will enter it
 Maintain or teach
asepsis for dressing
changes and wound care
 Wash hands frequently
between the patients and
before and after
touching the patient and
patient surrounding and
before any procedure
 Use aseptic technique
with invasive
procedures.