I.

INTRODUCTION

Nursing process is a patient centered, goal oriented method of caring that provides a frame
work 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 each patient. The nurse's evaluation of
care will lead to changes in the implementation of the care and the patient's 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.

A cesarean birth, also known as C-section, happens through an incision in the abdominal
wall and uterus rather than through the vagina. Some C-sections are planned due to pregnancy
complications or because you've had a previous C-section. But, in many cases, the need for a
first-time C-section doesn't become obvious until labor has already started. Knowing what to
expect during the procedure and recovery can help the mother prepare.
There has been a gradual increase in cesarean births over the past 30 years. In November
of 2005, the Centers for Disease Control and Prevention (CDC) reported the national cesarean
birth rate was the highest ever at 29.1%, which is over a quarter of all deliveries. This means
that over 1 in 4 women will experience a cesarean birth.
II. OBJECTIVES

The significance of the study is for us third year students to apply the principles and concepts
that we have learned in the NCM 101 (Maternal and Child Nursing) in our rotation at Porac
District Hospital, with the following learning objectives:

1. Cognitive
To be able to review concepts and theories in maternal and child nursing.
To be able to describe the development, pathophysiology, medical-surgical
management, and nursing care of a client who have undergone a cesarean
section birth.
To be able to design a Nursing Care Plan for the patient who have undergone
cesarean birth.
To be able to provide information and heath teachings to the patient in the
postpartum 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 and postoperative stages
 To be able to implement the nursing care plan.
3. Affective
To be able to establish a good working relationship with the patient and hospital
staff.

III. NURSING ASSESSMENT

Demographic Profile:
Name : Patient Sik Ret Bontes
Age : 18 years old
Birthday : February 29, 1991
Address : AMB Bldg, Brgy. Saguin, CSFP
Name of Spouse : Mambo Bontes
Name of Father : Muh Ret
Name of Mother : Malah Ret
Nationality : Filipino
Occupation : Housewife
Educational Attainment: High School Graduate
Admission Date : April 22, 2009
Discharge Date : April 24, 2009
Surgery Performed : LTCS II

IV. FAMILY HISTORY

Unremarkable.

V. HISTORY OF PAST AND PRESENT ILLNESS

The patient stands 153 centimeters and weighs about 83 kilograms. Her AOG is 43
weeks, LMP was last November 1, 2008, and her EDC was on April 8, 2009. Her OB score is
G2P1 (2,0,0,2). She was already married at the age of 16 years old. She was only 17 years old
when she gave birth to her first child through Cesarean Section (Low Segment Transverse),
because she had a difficulty in delivering the child due to her age and the lack of knowledge.
 It was on April 22, 2008 at around 8:00am when Patient Sik Ret Bontes was admitted at
the Ob-ward of Porac District Hospital and was sent to the OR/DR for an internal examination
and was told that her pregnancy was already over due. The patient opted for another cesarean
section for this pregnancy.
VI. PHYSICAL ASSESSMENT
Gordon’s Level of Functioning
Pattern Before Present Interpretation
1.Health Perception- Patient goes to the Patient is concern Patient cannot
Health Management health center once about her second function normally
upon when she got cesarean section anymore like before
pregnant. All in all, thinking that it may be because of her
she thinks she is in a detrimental to her hospital confinement
healthy state. health. and condition. Her
body image changed
after the surgical
procedure done.
2. Nutritional- Prior to confinement, During hospitalization, Patient’s nutritional
Metabolic patient loves eating the patient is on diet and metabolic status
Management instant foods and fatty as tolerated. She eats has been changed
foods like fries and fruits like apples and due to her
burgers. She also oranges. She eats confinement.
loves condiments like bread instead of rice.
“patis”, vinegar, and She said she loss her
soy sauce. She appetite since her
basically loves eating onset of labor.
whatever she likes.
3.Elimination Pattern Bowel: Bowel: Bowel:

Patient defecates 1-2 Patient defecates There was a change

times a day, usually once a day but not on in the frequency and
morning and in the a regular basis. Stool amount.
afternoon. Stool is is soft, minimal in
brown in color and amount and brown in
well-formed. color.

Bladder:

Patient voids usually Bladder:

6-8 times a day. Urine
Patient voids 3-4 Bladder:
is yellow in color. No
times a day without
pain when voiding. There was a change
pain and discomfort.
in the frequency and
amount.
4.Activity, Leisure, Patient is a housewife Patient’s activities in During patient’s
and Recreation so she is always in the hospital are confinement in the
Pattern charge of the ambulation, deep hospital, there is a
household chores. breathing and limitation in her
Her leisure time would coughing exercise, activities of daily living
include playing with taking a bath or and a disruption in her
her firstbornand personal hygiene. leisure and recreation
watching television. pattern.
5.Sleep and Rest Patient puts herself to Due to her Patient’s sleep and
Pattern sleep by watching uncomfortable rest pattern changed
television programs. condition and pain, when she was
She usually sleeps at patient complains of admitted. She cannot
around 11pm to 6am. difficulty of sleeping put himself to sleep
She feels rested when and short period of anymore due to
sleeping and thinks sleeps. present condition and
that her energy is pain plays a big factor
sufficient for her for her sleep
activities. disturbances.
6.Cognitive – Patient is a high Patient’s present No changes/
Perceptual Pattern school graduate. She condition is not a alterations.
can read and write. hindrance to her
She can speak and cognitive- perceptual
be understood by pattern.
others.
7. Self-Perception / Patient is a friendly During the times of There is a slight
Self-Concept Pattern person; she loves to her confinement, she change in her self-
socialize with his doesn’t think that she perception due to
friends in their is a holistic person present condition.
neighborhoods. She anymore. However,
considers himself as she is positive that
holistic human being she will be ok after
as long as she is confinement.
healthy, complete,
and his family is
always there.
8. Role Relationship Patient can The patient’s family is Normal/ No
understand English, supportive to the alterations.
Tagalog, and patient. She is happy
Kapampangan. She with their presence
has 5 siblings. She is and support.
married with 1 child.
9. Sexuality/ Patient has been Patient reserved her Patient reserved her
Reproductive Pattern married for 3 years. right to privacy. right to privacy.
10.Coping and Stress When patient is The recent Patient accepts
Tolerance stressed, she sings in hospitalization of the present condition with
the karaoke and eats patient was stressful a positive attitude.
 comfort foods like and source of anxiety.
burgers, fries, and her However, she is
favorite sizzling sisig. positive that she will
When it comes to be able to cope up
problems, she lets with current condition.
herself think
immediately for a
solution.
11.Values- Belief Patient is a Roman She follows a Due to her
Pattern Catholic. She has a therapeutic regimen confinement, patient
strong faith to God and her strong faith to is trusting God that
and goes to mass God accounts for her she will be discharge
every Sunday with her fast recovery. soon and will recover
family. without any
complications.

VII. ANATOMY AND PHYSIOLOGY

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. The middle layer 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.
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.
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.
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 frimbriae.
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 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.
VIII. PATHOPHYSIOLOGY

Release of FSH by
the anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickening

of the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from

the graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovum

and sperm in the ampulla)

Zygote travels from the fallopian tube

to the uterus

Implantation

Development of the fetus/embryo &

placental structure until full term
 PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Contraction Ripening of the cervix

(descent of the fetal (false labor) (Goodell’s Sign wherein
head into the pelvis) >begin and remain irregular the cervix feels softer like
>1st felt abdominally consistency of the earlobe
>pain disappears with
ambulation
>do not increase in duration
and intensity
>do not achieve cervical
dilatation

TRUE LABOR

Uterine Contractions SHOW Rupture of

Membranes
>increase in duration (pink-tinge of blood, (rupture of the
and intensity a mixture of blood and fluid) amniotic sac)
>1st felt at the back &
radiates to the abdomen
>pain is not relieved no
matter what the activity
>achieve cervical dila-
tation

Failed to progress labor

(due to previous cesarean birth, cervical arrest,
cervical atrophy)

increase risk for fetal distress

(meconium staining, hypoxia)

Increase risk of fetal death

 Emergent cesarean delivery
(the incision made on the lower part of the abdomen)

Expulsion of the fetus

Expulsion of the placenta

(accompanied by blood approximately
500-1000 mL)

IX. LABORATORY PROCEDURES

Urine Analysis

Date Ordered: April 22, 2009

Date Performed: April 22, 2009

Microscopic Exam Chemical Exam

Color: Yellow Albumin: Negative

Transparency: Hazel Sugar: Negative

Rection pH: 6.0 (Normal: 7.35-7.45)

Specific Gravity: 1.010 (Normal: 1.010-1.025)

Pus Cells: 0.2

Epithelial Cells: Moderate

Normal Interpretatio
Result Significance
Values n

4.5 – 6.0 x
RBC 5.4 Normal
10/L
Indicates
WBC 10.1 5 – 10 x 10/L Increase presence of
infection
Indicates
120 – 140
HgB 116 Decrease occurrence of
g/dl
anemia
Indicates
Hct 0.35 0.30 Increase hyper
coagulation
150 – 400 x
Platelet 320 Normal
09/L
 DIFFERENTIAL COUNTING

Indicates
Neutrophils 0.86 0.05 – 0.70 Increase infection or
inflammation
Indicates
high risk for
Lymphocytes 0.14 0.20 – 0.40 Decrease
acquiring
infection

X. COURSE IN THE WARD

April 22, 2008

S – “Sobrang sakit,” as verbalized by the patient.

O–
– received patient awake on bed, conscious and coherent, with ongoing D5LRS 1L x
30gtts/min, hooked on the left hand, infusing well.
– Pain scale= 8/10
– Teary eyed
– (+) guarding behavior
– (+) facial grimace
– Irritable
– Pale palpebral conjunctiva
– Skin warm to touch
– BP= 110/80
– PR= 80
– RR= 22
– T= 37.6
A – Acute pain r/t disruption of skin and tissue secondary to cesarean section.
P – After 1-2hr of nursing intervention, patient will verbalize decrease intensity of pain from 8/10
to 3/10.
I–
– Established rapport.
– Monitored vital signs.
– Assessed quality, characteristics, severity of pain.
– Dressed wound as indicated.
– Provided comfortable environment – changed bed linens and turned on the fan.
 – Instructed to put pillow on the abdomen when coughing or moving.
– Instructed patient to do deep breathing and coughing exercise.
– Instructed patient to ambulate.
– Provided diversionary activities.
– Administer analgesic as per doctor’s order.
– Due meds given.
– Needs attended.
E – Goal met. Patient verbalized pain decreased from a scale of 8/10 – 3/20 as evidenced by
(-) facial grimace
(-) guarding behavior.
Frequent small talks with significant others.

Endorsed.
 XI. NURSING CARE PLAN

Post-operative NCP

CUES DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Due to an STG: Independent Patient is

– none infection related elective After 4 hours of -Monitor vital -To establish a expected to be
inadequate cesarean nursing signs baseline data free of
Objective: primary section, intervention, infection, as
- dressing dry defenses patient’s skin patient will be -Inspect dressing -Moist from evidenced by
and intact secondary to and tissue were able to and perform drainage can be a normal vital
-V/S taken as surgical incision mechanically understand wound care source of infection signs and
follows: interrupted. causative absence of
T: 37.3 Thus, the factors, identify - Monitor white - Rising WBC purulent
P: 80 wound is at risk signs of blood count (WB indicates body’s drainage from
R: 19 of developing infection and efforts to combat wounds,
BP: 120/80 infection. report them to pathogens; incisions, and
health care normal values: tubes.
provider 4000 to 11,000
accordingly. mm3
- Monitor
LTG: Elevated -these are signs
After 2-3 days temperature, of infection
of nursing Redness,
intervention, swelling,
patient will increased pain,
achieve timely or purulent
wound healing, drainage at
be free of incisions
purulent
drainage or - Wash hands -Friction and
erythema, be and teach other running water
afebrile and be caregivers to effectively remove
free of infection. wash hands microorganisms
before contact from hands.
with patient and Washing between
between procedures
procedures with reduces the risk of
patient. transmitting
pathogens from
one area of the
body to another

- Encourage fluid - Fluids promote

intake of 2000 ml diluted urine and
to 3000 ml of frequent emptying
water per day of bladder;
(unless reducing stasis of
contraindicated). urine, in turn,
reduces risk of
bladder infection
or urinary tract
infection (UTI).

- Encourage - These measures

coughing and reduce stasis of
deep breathing; secretions in the
consider use of lungs and
incentive bronchial tree.
spirometer. When stasis
occurs, pathogens
can cause upper
respiratory
infections,
including
pneumonia.
Independent:
– Administe -Antibiotics have
r bactericidal effect
antibiotics that combats
pathogens
 NURSING
CUES PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective Cues:
• Patient has Risk for Short Term INDEPENDENT After 8º of
not yet constipation r/t Goal: INTERVENTIONS: nursing
eliminated post pregnancy • Ascertain normal • This is to interventions,
since 2° cesarean Within 8º of bowel functioning of determine the the patient was
delivery section nursing the patient, about normal bowel able to identify
• Absence of how many times a pattern
interventions, measures to
bruit sounds day does she
the patient will prevent infection
• Normal defecate • To increase the
be able to as manifested by
pattern of • Encourage intake of bulk of the
bowel has demonstrate client’s
foods rich in fiber stool and
not yet behaviors or such as fruits verbalization of:
facilitate the
returned lifestyle changes “Iinom ako ng
passage
to prevent through the maraming tubig
developing colon at kakain ng
problem • Promote adequate • To promote prutas para
fluid intake. moist soft stool makadumi ako.”
Suggest drinking of
warm fluids,
Long Term Goal: especially in the
morning to
Within 3 days of stimulate peristalsis
• To stimulate
• Encourage
nursing contractions of
ambulation such as the intestines
interventions,
walking within and prevent
the patient will individual limits
be able to post operative
complications
maintain usual • However, since she • To avoid stress
pattern of bowel has had cesarean, on the
functioning also encourage cesarean
adequate rest incision/ wound
periods

COLLABORATIVE:
• Administer bulk- • To promote
forming agents or defecation
stool softeners such
as laxatives as
indicated or
prescribed by the
physician
 XII. 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 patient to stay in 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 weeks

✔ 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