I.

INTRODUCTION

Caesarean delivery is a surgical procedure which includes making incision on

mother’s abdomen and uterus to deliver the fetus. The term “cesarean” was came after
the birth of Julius Caesar as he was the first baby born through caesarean section.
According to the CDC, in 2010, almost 33% of births were by cesarean delivery.
According to the Agency for Healthcare Research and Quality. There are some several
reasons of cesarean delivery such as woman is carrying more than one fetus,
Complications in labor occur, fetus is too large, mother has an infection, problems with
the placenta. In this case the reason of cesarean is breech presentation it means that
the infant is upside down and the feet instead of the head would be delivered first.

Cesarean delivery is safe, but it is still surgery, with risks and complications to
consider. Recovery from a cesarean also often takes longer than from a vaginal
delivery. Some women may request a cesarean birth even if vaginal delivery is an
option. However, cesarean births can raise the risk of medical problems and having
difficulties with future pregnancies. Also, infants delivered by cesarean delivery may
experience more breathing problems than infants born by vaginal delivery.

As a 2nd year nursing students it is essential that we are familiar at Caesarean

Section Delivery as one of our nursing course-NCM 101 is focus in maternal and child
health nursing.

II. OBJECTIVES

 To gain more knowledge about cesarean section delivery procedure

 To be efficient in making nursing care plan for a postpartum mother
 To identify what theoretical foundation lies in performing postpartum care

III. THEORETICAL FOUNDATION

The days and weeks after the delivery of the baby is called postpartum period. In
this period the body of the mother will start to undergo changes and return to its no
pregnant condition. During this phase mothers are unable to care for themselves or their
infants due to anesthesia, birth trauma, lack of energy, large blood loss, severe pain,
nausea, vomiting, as they were the side effects of the operation of giving birth or the
medicine that they had been taken. At this time nurses will play their role. Like what
Dorothea Orem describes at her self-care deficit nursing theory (SCDNT) that the
nurses will provide self-care and dependent-care (for newborns) when these patients
(postpartum mother) have these self-care limitations. Of course nurses will never miss
their routine functions. They will collect vital signs and lab work, monitor intake and
output, perform full physical assessments, massage fundus and monitor lochia to
reduce the incidence of postpartum hemorrhage, administer medications and
therapeutic interventions to provide comfort from surgical, uterine, or perineal pain,
evaluate emotional health and mother-infant bonding, and educate patients on
postpartum, surgical, breastfeeding, and infant care.

Generally within four hours after birth, the mother’s symptoms that cause these
limitations are already resolved. At this time, nurse will start teaching and encouraging
the patients to provide their own self-care and dependent-care for their infants. They
will teach their patients how to alleviate pain and to avoid infection during perineal or
surgical care, how to do breastfeeding and avoid breast engorgement, when to call a
doctor when there are some postpartum complications and how to perform care for
their infants properly which includes bathing, feeding and diapering. When the patient
will become educated, this education will empower the patients to act as a self-care
and dependent-care agent .Promoting self-care can promote patient autonomy, give
them a sense of empowerment and responsibility, and over all improve their quality of
life .“The success of self-care is dependent on the active participation of individuals in
their own [and their dependents] health care.” Slusher et al. (2010, pp. 85).

IV. NURSING HISTORY

A. BIOGRAPHICAL DATA:

Patient Name: A. S. B.
Address: Brgy. Bago Gen. Tinio Nueva Ecija
Date of Birth: Feb. 9, 1976
Birth Place: Nueva Ecija
Occupation: DepEd Teacher-EDW
Source of Health Assistance: Hospital, Clinic
Source of referral: AFP Medical Hospital
Emergency Contact Person and Number: Sgt. Reynante L. Alaska

B. Reason for seeking health care:

To know what is their illness, to lessen their problems and to seek
medical assistance immediately.
CHIEF COMPLAINT: irregular uterine contractions

LMP: 27 October 2015

EDC: 03 August 2016

AOG: 38 weeks AOG by LMP

C. History of Present Illness (HPI)

History of present condition started few hours prior to consult when

patient experienced irregular uterine contractions, moderate to strong in
intensity, occurring every 5 to 10 minutes, lasting for few seconds. There
were no other associated symptoms such as vaginal bleeding, watery vaginal
discharge, fever nor dysuria. Persistence of the above symptoms prompted
consult at our institution, hence, this admission.

D. Past Health History (PHH)

(-) Bronchial Asthma (-) thyroid problem

(-) diabetes mellitus (-) Hypertension
(+) excision of on breast mass LLQ (2007 and 2013)

E. Family Health History (FFH)

(-) Bronchial asthma (+) Hypertension: mother

(-)Diabetes Mellitus (-) Thyroid Problem

F. Personal and Social History

Patient is a college graduate of B.S Education and is currently employed
as an elementary school teacher .Patient is a non-smoker, non-alcoholic
beverage drinker, and denies illicit drug use. There were no known allergies to
food nor medications.

G. Menstrual History:
 Patient had her menarche at 12 years old, occurred at regular monthly
interval, .lasting for 8 days consuming 5 to 6 pad per day, moderately soaked
with no associated dysmenorrhea. Subsequent menses came in regularly with
the same amount, flow and duration.

H. Obstetrical History:

I. Prenatal History

Patients was cognizant of pregnancy at 4 weeks age of gestation due to

missed menses supported by a positive pregnancy test. During the first trimester,
patient has her prenatal check-ups at a private OB-GYN in Nueva Ecija wherein CBC
with QPC and urinalysis were claimed to be normal. No early ultrasound was done

G1 2008 Live full boy LTCS 1 Paulino J. BW (-)

term secondary Garcia 3200g fetomaternal
to Arrest Hospital complication
in (Cabanatuan)
Descent

G2 2010 Live full boy LTCS Immaculate BW (-)

term Conception 3200g fetomaternal
(Nueva Ecija) complication

G3 2016 Present
pregnancy

Patients was given Folic Acid once daily, calcium tablets twice daily and multivitamins
once daily taken with good compliance.

During the second trimester, subsequent prenatal-check up were done at the

same OB GYN and were claimed to be unremarkable. Patient claimed to have urinary
tract infection at 24 weeks AOG and was given unrecalled antibiotics for 7 days. No
repeat urinalysis was done. Patient was given ferrous sulfate once daily, and
multivitamins once daily taken with good compliance.

During the third trimester, subsequence prenatal check-ups were done at the
same OB-GYN. Patient continued her medication with good compliance. No later
ultrasound was done. Patient denies any of teratogenic use, exposure to radiation nor
any maternal illness.

IV. ANATOMY AND PHSYIOLOGY

 Vagina is a muscular, hollow organ that allows vagina to expand and contract. It
is 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.
 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 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, 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 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.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.
V. PATHOPHYSIOLOGY

VI. GORDON’S FUNCTIONAL HEALTH PATTERN

 Pattern Before During Analysis
Hospitalization Hospitalizatio
n

Health Perception Patient A.S.B.goes Patient A.S.B. Patient cannot

to hospital to check concern about normally deliver after
openly after she her third her first cs section.So
got pregnant, and cesarian now patient have
she believe she’s section thinking another pregnancy
healthy. that it may be that she need the cs
detrimental to section for this baby.
her health.

Nutritional Metabolic Prior to During her Patient continue her

confinement,patien hospitalization normal diet and we
t likes to eat the Patient looking suggest to eat more
fried foods such normal but she vegetables.
us, fried egg, need to eat
bananacue, and more
she also eat the vegetables than
fish vegetable and fried food.
the fruits ,
barbecue.

Elimination Bowel: Bowel: Bowel:

Patients A.S.B. Patient There was a change

defecates every defecates once in frequency in
morning and stool a day but not amount.
is brown in color on a regular
and well- formed. basis.Stool is
soft, minimal in Bladder:
Bladder:
amount and
We should suggest
Patient avoid s brown in color.
that the patient she
usually 4-6 times a
Bladder: need to take more
day . Urine is
liquid intake so that
yellow in color. No Ptient voids 2-3
she can produce
pain when times aday
more frequency of
avoiding. without pain
urine.
and discomfort.
Activity/Exercise Patient is a DEPED Patient During patient’s
teacher and she activities in the confinement in the
always go to work hospital are hospital, there is a
but they don’t have ambulation limitation in her
any exercise and deep breathing activities in daily
activity after work. and coughing living.
exercise, taking
a bath or
personal
hygiene.

Sleep/Rest Patients puts Due to her a Patient’s sleep and

herself to sleep by uncomfortable rest pattern changed
watching television condition and when she was
program, reading pain, patient admitted she cannot
news paper, and complains of put himself to sleep
magazine. She difficulty of anymore due t
usually sleeps at sleeping and present condition and
around 8pm to short period of pain plays a big
2am in the sleep. factor for her sleep
morning. disturbance.

Cognitive/Perceptual Patients is a Patient’s No changes

teacher . She can present alterations.
read and write. condition is not
She can also a hindrance to
speak clearly and her cognitive-
understood by perceptual
others. pattern

Role/Relationship Patient live with The patient’s Normal no

her family her family is alterations.
children, husband. supportive to
the patient. She
is happy with
their presence
and support.

Sexuality/Reproductiv Patients have only Patient Patient reserved her

1 partner married reserved her
e more than 10 right to right to privacy.
years , privacy.
menstruation is 8-
10 days irregular.

Coping/Stress When patient is The recent Patients accepts

Tolerance stressed, She hospitalization present condition
going to her room of the patient with a positive
to take more rest was stressful attitude.
and sleeping. and source of
When it comes to anxiety.
the problems she However shes
will talk to her positive that
family especially she will be
to her husband so able cope up
that it can be fine with current
sulotion . condition.

Value/Belief Patient is a She follows a Due to her

Roman Catholic. therapeutic confinement, patient
She has a strong regimen and is trusting God that
faith to God and her strong she will be
goes to mass faith to God discharge soon and
every sunday with accounts for will recover without
her family. her fast any complication.
recovery.
VII. PHYSICAL EXAMINATION:

General survey: Conscious coherent, not in cardio-pulmonary disease

Vital signs: BP: 120/80mmHg HR: 81 bpm RR: 19 bpm

Temp: 36.9 C

HEENT: Anicteric sclerine, Pink palpebral

Heart: a dynamic pericardium, normal rate, regular rhythm no murmur

Chest and Lungs: equal chest expansion, no refractions, clear breath

sounds

Abdomen: Globular

FH – 32CM LM1: Breech

FHT – 140 bpm 1.10 LM2: Fetal back Left

EFW – 3,100g

Speculum Examination: cervix is vaginal bleeding per Osiolaceous,

smooth, no polyp, no erosion with minimal

Internal examination: cervix is 1-2 cm dilated beginning effacement,

cephalic,

Extremities: grossly normal full and equal pulses

ASSESSMENT:

G3P2 (2002) Pregnancy Uterine 38 weeks Age of Gestation by

LMP; Cephalic in Labor Previous LTCS II (CS1 secondary to Arrest in
Descent)

Plan: for emergency Low Transverse Caesarian Section III under spinal
anesthesia

VIII. DIAGNOSIS/ LABORATORY

Examination: Normal Findings Analysis Nursing Alert

Values
Hemoglobin 120-160 111.00 Normal
HgB g/dl

Hematocrit 0.37-0.43 0.34 Decrease Indicates hypo coagulation

Hct

RBC 4.0-5.4 4.23 Normal

WBC 4.0-10.0 11.80 Increase Indicates presence of infection

Neutrophils 0.05- 0.70 0.67 Normal

Lymphocytes 0.25 - 0.35 0.21 Decrease Indicates high risk for acquiring
infection

Eosinophil 0.02 – 0.04 0.02 Normal

Monocyte 0.03 - 0.06 0.09 Increase

Basophil 0.00 – 0.01 0.01 Normal

MCV 80 - 100 60.0 Normal

MCH 26 - 32 26.3 Normal

MCHC 32. 0 – 36.0 33 Normal

RDW 11 - 15 14.90 Normal

Platelet 130 - 400 357 Normal

Count

IX. MEDICAL DIAGNOSIS

Initial Diagnosis:

G3P2 (2002)Pregnancy Uterine 38 weeks of Age of Gestation by LMP ; Cepahlic

in Labor ;Previous LTCS (CS 1 Secondary to arrest in descent.

Final Diagnosis:

G3P3 (3003) Pregnancy uterine Delivered term, Cephalic left occiput

posterior to a live baby boy Apgar Score 8, 9 Appropriate for Gestational Age
(Birth weight 3000 grams: birth length 48cm, 38 weeks by Ballards Score) by
 Mechani
Name of Dos Indicatio Contraindic Adverse Nursing
sm of
Drug age n ation Reaction Alert
Action

Low Transverse and Caesarian Section III: CS 1secondary to Arrest in Descent

under Spinal Anesthesia

X. DRUG STUDY
Generic Second- 500 Pharyngit Contraindicat Body as a Determine
Name: generati MG is, ed in the whole: history of
CEFURO on tonsillitis, patients thrombophlebiti hypersensi
XIME cephalos infections hypersensitiv s (IVsite); pain, tivity
porin of the e to drug. burning, reactions
Brand that urinary cellulitis, (IM to
Name: inhibits and lower site); cephalosp
Use
Zoltax cell- wall respirator superinfections horins,
cautiously in
synthesi y tract, , positive penicillins
patients
Classifica s, and skin Coombs’ test and history
hypersensitiv
tion: promotin and skin- of allergies
e to penicillin
Antibiotic g structure GI: particularly
because of
osmotic infections Diarrhea, to drugs
possibility of
Frequenc instabilit caused Nausea, before
cross
y: y; by antibiotic- therapy is
sensitivity
BID usually streptocc associated initiated.
with other
bacterici us colitis.
betalactam
Dosage: dal pneumon Report
antibiotics.
1 tab 500 ia and S, Skin: onselt of
mg pyogenes Rash, pruritus, loose
, Use with urticaria. stools
Route: Haemoph caution in
PO illus breastfeedin Urogenital; Absorption
aureus, g women Increased s of
Escheric and in serum cefuroxime
hia coli. patients with cretonne and is
history of BUN, enhanced
colitis or decreased by food.
renal creatinine
sufficiency clearance Notify
prescriber
about
rashes or
superinfect
ions
DICLOFE May 25M Ankylosin Contraindicat CNS: aseptic Because
NAC inhibit G g ed for the meningitis, NSAID’s
SODIUM prostagl spondyliti treatment of anxiety, impair the
andin s perioperative depression, synthesis
synthesi pain after dizziness of renal
s to Osteoart CABG drowsiness, prostaglan
produce hritis surgery headache, dins, they
anti insomnia, can
inflamma Rheumat Hypersensiti irritability decrease
tory, oid ve to drugs the renal
analgesi arthritis and those CV: heart blood flow
c, and with hepatic failure, edema, and lead to
antipyreti Analgesi porphyria or fluid retention, reversible
c effects a, history of hypertension renal
primary asthma, impairment
dysmeno urticaria, or EENT: , especially
rrheal other laryngeal in patients
NSAID’s edema, blurred with renal
Acute vision, or heart
pain due Avoid using epistaxis, eye failure or
to minor during late pain, night liver
strains, pregnancy or blindness, dysfunctio
sprains breastfeedin reversible n, in
and g hearing loss, elderly
contusion swelling of the patients,
s History of lips and and in
PUD hepatic tongue, tinnitus those
dysfunction, taking
cardiac GI: diuretics
disease, Abdominal closely.
hypertension pain or
, fluid cramps, Liver
retention, or bleeding, functions
impaired constipation, test values
renal diarrhea, may
function flatulence, increase
indigestion, during
 melena, therapy.
nausea, peptic Monitor
ulceration, transamina
taste disorder, s
bloody
diarrhea,
appetite
change, colitis

GU: nephritic

Ferrous Tetracycl 300 Preventio Patients GI irritation & Should be

sulfate ine, mg n& receiving abnormal pain taken on
antacids Folic treatment blood w/ nausea, an empty
acid of Fe- transfusion, vomiting, stomach
250 deficienc w/ anemias diarrhea or
mg y anemia; not produced constipation. Patient w/
prenatal by Fe Fe-
1 tab hematinic deficiency shortage
daily or Fe-
absorption
Folate-
dependent
tumors.

XI. MEDICAL/SURGICAL MANAGEMENT

The normal cesarean procedure averages 45 minutes to an hour. The baby is

usually delivered in the first 5-15 minutes with the remaining time used for
closing the incision.
Pre-surgery:

 Before surgery, you will be given an anesthetic (spinal).

Spinal anesthesia will numb the area from the abdomen to
below the waist (sometimes the legs can be numb also), so
that nothing can be felt during the procedure.

Surgery:

 The health care provider will make an vertical incision (low

transverse incision) on the abdominal wall as the mother is an
emergency cesarean so the incision will start from the navel
to pubic area to deliver the baby faster. The incision will then
be made into the uterus.
Note: Low transverse incision has fewer risks and
complications than the others and allows most women to
attempt a VBAC in their next pregnancy with little risk of
uterine rupture.
 The health care provider will then suction out the amniotic
fluid.
 In delivery, the baby’s head will be delivered first so that the
mouth and nose can be cleaned out to allow it to breathe.
Once the whole body is delivered, the health care provider
will lift up and show the baby.
 Health care providers will then pass the baby on to the nurse
for evaluation.
 Finally, placenta will be delivered (some tugging may occur)
after which the surgical team will begin the close up process.

After the Surgery:

 After the surgery, you might begin to experience some nausea

and trembling. This can be caused by the anesthesia, by the
effects of your uterus contracting or from an adrenaline let down.
These symptoms usually pass quickly and can be followed by
drowsiness.
 If your baby is healthy, skin to skin contact is performed by
placing the baby on the mother’s chest. So that breatfeeding
and bonding will be initiated.
 You and your baby will continually be monitored for any potential
complications.
 When you are discharged from the hospital you will be advised on the
proper post-operative care for your incision and yourself.

XII. NURSING CARE PLAN

Assessment Diagnosis Planning Implementation Evaluation

Subjective: none Risk for infection STG: After the 4 Independent: Patient is
related to hours of nursling expected to be
Objective: Monitor the Vital
surgical incision intervention the free from
Signs
dressing dry and patient will be infection as
intact able to Inspect the evidence by
understand the dressing and normal vital signs
V/S:
causative factors, perform wound and absence .of
BP: identify the signs care discharges in the
120/80mmHg of infection and incision.
report them to Monitor white
HR: 81 bpm blood cell
the health care
RR: 19 cpm
provider
Temp: 36.9 C Monitor elevated
immediately.
temperature,

LTG:After 2-3 redness,

days of nursing swelling,

of intervention increased pain at

the patient will incisions.

achieve timely
Encourage fluid
wound healing,
intake 2000ml-
be free from
3000ml.
infection.
Administer
antibiotics
XIII. BUBBLESHE

B- Breast

 Palpate breasts to determine if they are soft or filling

 Teach to promote milk production & let down, and methods to prevent and treat
engorgement
 Ensure proper bra fit
 Nipples should be soft, pliable, intact & everted
 If mother is NOT breast feeding - DO NOT palpate breasts or assess nipples

Abnormal Findings (Breasts) Redness, heat, pain, cracked, and fissured nipples,
inverted nipples, palpable mass, painful, bleeding, bruised, blistered, cracked nipples
U- Uterus

 Ensure bladder is empty & lay patient supine

 Fundus should be firm; if not firm massage until firm
 Fundal height measured in cm above or below the umbilicus
 fundus is 2 cm below the level of the umbilicus immediately after birth;
 fundus descends approximately 1 cm per day; by the 10th day the fundus should
no longer be palpated

Abnormal Findings (Uterus) Fundus is deviated from the midline, boggy consistency,
remains above the umbilicus for after 24 hours

Note: *If fundus is deviated or elevated above level of umbilicus always rule out
DISTENDED BLADDER

B- Bladder

 Assess abdomen for distention, LBM, bowel sounds, hemorrhoids

 Abnormal Findings (Bowel): Constipation, diarrhea, epigastric pain, hemorrhoids

B- Bowel

 Asses last void, rule out urinary retention

Abnormal Findings (Bladder): Inability to void, frequency, urgency, dysuria

L- Lochia

 Note amount, color, consistency, odor, presence of clots

Note: * amount is assessed in relation to TIME (scant, light, moderate, and heavy)

Abnormal Findings (Lochia): Heavy, foul, odor, bright red bleeding.

E- Episiotomy

 Assessment of Episiotomy (Perineum) Assess using REEDAO

 Asses hemorrhoids for it’s size number and other factor.
 Assess abdominal incision (C-section).
 Assess knowledge, practice, & effectiveness of self peri-care

Abnormal Findings (Perineum): Pronounced edema, not intact, signs of infection,

marked discomfort.

S- Sex
  Health teaching the patient should refrain from sex

H – Homan’s Sign

 Assess for edema (peripheral, sacral, dependent), varicose veins, risk factors of
thrombophlebitis and for Homan's sign

Abnormal Findings (Legs): Positive Homan's sign-painful, reddened area, warmth on

posterior aspect of calf.

E- Emotional Response

 Assess for sleep deprivation, ability to rest, energy level, comfort level, anxiety
level, appetite, bonding behaviors, support system