This case study will help us, student nurses in understanding the disease process of the patient. This would also help us identify the primary needs of the patient have undergone Cesarean Section. Effective management of the problems identified will help the patient to recover faster and maintain a holistic sense of wellness even in the hospital.

Giving a sufficient nursing care for the patients enhances its capabilities in recovery. Doing a nursing research or study about the patient’s condition gives adequate information on how to assess thoroughly the patient, what specific intervention we could give as a nurse and what will be the possible complication could happen if the disease aggravated. This case study make us student nurse be more confident in dealing with the patients and give as an additional understanding about the disease and the disease process. This is one way also of showing the student’s intellectual capacity.

A Cesarean Section is the delivery of a baby through a cut (incision) in the mother's belly and uterus. It is often called a C-section. In most cases, a woman can be awake during the birth and be with her newborn soon afterward. If you are pregnant, chances are good that you will be able to deliver your baby through the birth canal (vaginal birth). But there are cases when a C-section is needed for the safety of the mother or baby.

A C-section may be planned or unplanned. In most cases, doctors do cesarean sections because of problems that arise during labor. Reasons you might need an unplanned C-section include: Labor is slow and hard or stops completely; the baby shows signs of distress, such as a very fast or slow heart rate; a problem with the placenta or umbilical cord puts the baby at risk; the baby is too big to be delivered vaginally.

When doctors know about a problem ahead of time, they may schedule a C-section. Reasons you might have a planned C-section include: The baby is not in a head-down position close to your due date; you have a problem such as heart disease that could be made worse by the stress of labor; you have an infection that you could pass to the baby during a vaginal birth; you are carrying more than one baby (multiple pregnancy); you had a C-section before, and you have the same problems this time or your doctor thinks labor might cause your scar to tear (uterine rupture).

In some cases, a woman who had a C-section in the past may be able to deliver her next baby through the birth canal. This is called vaginal birth after cesarean (VBAC). If you have had a previous C-section, ask your doctor if VBAC might be an option this time.

In the past 40 years, the rate of cesarean deliveries has jumped from about 1 out of 20 births to about 1 out of 4 births. This trend has caused experts to worry that C-section is being done more often than it is needed. Because of the risks, experts feel that C-section should only be done for medical reasons.

This case study will help the group in understanding the disease process of the patient. This would also help the group in identifying the primary needs of the patient who has a final diagnosis of Pregnancy uterine, term, breech, livebirth, delivered via LTCSI for Placenta Previa Totalis in hemorrhage to a Baby girl. By identifying such needs and health problems arise the group can now formulate an individualized care plan for the patient that would address these needs and problems effectively. Effective management of the problems identified will help the patient to recover faster and maintain a holistic sense of wellness even while in the hospital.

This case study would also equip the group with knowledge, skills and attitude on how to manage future patients with the same or similar disease.

This case presentation aims to identify and determine the general health problems and needs of the patient who had Low Transerve Cesarian Section I. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. To be knowledgeable about the nature of C-Section management and treatment to be able to render effective nursing care to the client.

To assess client’s acceptance or non-acceptance of situation.

To raise the level of awareness of patient on health problems that she may encounter.

To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own.

To help patient in motivating her to continue the health care provided by the health workers.

To render nursing care and information to patient through the application of the nursing skills.

Dorothy Johnson’s Behavioral System Model

Dorothy first proposed her model of nursing care in 1968 as fostering of ―the efficient and effective behavioral functioning in the patient to prevent illness".

She also stated that nursing was ―concerned with man as an integrated whole and this is the specific knowledge of order we require‖.

In 1980 Johnson published her conceptualization of ―behavioral system of model for nursing‖where she explains her definitions of the behavioral system model.

Johnson’s Behavioral Subsystem

Attachment or affiliative subsystem: ―social inclusion intimacy and the formation and attachment of a strong social bond.‖

Dependency subsystem: ―approval, attention or recognition and physical assistance‖

Ingestive subsystem: ―the emphasis is on the meaning and structures of the social events surrounding the occasion when the food is eaten‖

Eliminative subsystem: “human cultures have defined different socially acceptable behaviors for excretion of waste, but the existence of such a pattern remains different from culture to Culture.‖

Sexual subsystem:" both biological and social factor affect the behavior in the sexual subsystem‖

Aggressive subsystem: " it relates to the behaviors concerned with protection and self-preservation Johnson views aggressive subsystem as one that generates defensive response from the individual when life or territory is being threatened‖

Achievement subsystem: “provokes behavior that attempt to control the environment intellectual, physical, creative, mechanical and social skills achievement are some of the areas that Johnson recognizes".

The four major concepts ―Human being‖ as having two major systems, the biological system and

the behavioral system. It is role of the medicine to focus on biological system where as Nursling's focus is the behavioral system.

―Society‖ relates to the environment on which the individual exists. According to Johnson an individual’s behavior is influenced by the events in the environment

―Health‖ is a purposeful adaptive response, physically mentally, emotionally, and socially to internal and external stimuli in order to maintain stability and comfort.

―Nursing‖ has a primary goal that is to foster equilibrium within the individual. Nursing is concerned with the organized and integrated whole, but that the major focus is on maintaining a balance in the Behavior system when illness occurs in an individual.

Name: Patient RV

Age: 35 years old

Birth date: June 27, 1977

Sex: Female

Civil Status: Married

Religion: Roman Catholic

Date of Admission: February 19, 2013

Chief Complaint: Vaginal Bleeding

Impression/Diagnosis: 37-38 weeks AOG, Breech, Placenta PreviaTotalis in Hemorrhage

PATIENT HISTORY

Patient had her regular prenatal check-up and intake of multivitamins. Few hours prior to admission, patient had vaginal bleeding consuming 2 pads fully soaked associated with uterine contractions 10 to 15 minutes lasting for a few minutes with a pain scale of 5/10 persistence of symptoms prompted consult was subsequently admitted.

Past Medical History

Patient had known history of Sciatica (2008). She had a symptom of back pain and was treated via Vitamin B Complex. No known allergies were noted.

Social History

Patient was an occasional drinker of alcohol approximately 2-3 bottles of beer but when she got pregnant, patient doesn’t drink alcohol anymore. She doesn’t smoke at all. Before she got pregnant, she was a traveler.

Environmental History

Patient lives near the river, where there are a lot of trees that made their place a well-ventilated area. Although they live near the river, their residence is not a total danger zone.

Menstruation History

Menarche: 12 years old

Interval: Regular

Duration: 3 days

Amount: 3 pads

Symptoms: (+) Occasional Dysmenorrhea

Gynecological History

Pap’s Smear (2010) normal

One Combination Oral Pill (2004)

OB History

LMP: June 4 – 7, 2012

PMP: May 2012

EXAM NAME RESULTS NORMAL RANGE ANALYSIS

Hemoglobin 142 120-150 Normal

Hematocrit 0.41 0.37-0.48 Normal

Erythrocytes 4.88 4.0-5.0 Normal

MCV 83.40 80-96 Normal

MCH 29.10 27-33 Normal

MCHC 34.90 33-36 Normal

Total WBC 10.7 5.0-10.0 Infected

Platelet Estimate Normal Normal

Neutrophils 0.71 0.55-0.65 Infected

Lymphocytes 0.19 0.25-0.40 Normal

Eosinophils 0.02 0.01-0.05 Normal

Monocytes 0.08 0.02-0.06 Normal

GENERAL SURVEY (February 21, 2013)

Patient was seen on bed awake, conscious and coherent, with her baby. Listening to our questions, oriented about the interview and the patient is cooperative. There is no sign of dizziness, headache or pain.

PR : 80

T. :36.2 ºC

RR : 20

BP : 110/80 mm/Hg

Female Reproductive System

Ovaries — A woman normally has a pair of ovaries that resemble almonds in size and shape. They are home to the female sex cells, called eggs, and they also produce estrogen, the female sex hormone. Women’s ovaries already contain several hundred thousand undeveloped eggs at birth, but the eggs are not called into action until puberty. Roughly once a month, starting at puberty and lasting until menopause, the ovaries release an egg into the fallopian tubes; this is called ovulation. When fertilization does not occur, the egg leaves the body as part of the menstrual cycle.

Fallopian tubes — The ovaries connect to the uterus via the fallopian tubes. Fertilization usually happens within the fallopian tubes. Then, the fertilized egg makes its way down to the uterus.

Uterus — The uterus is located in the pelvis of a woman’s body and is made up of smooth muscle tissue. Commonly referred to as the womb, the uterus is hollow and holds the fetus during pregnancy. Each month, the uterus develops a lining that is rich in nutrients. The reproductive purpose of this lining is to provide nourishment for a developing fetus. Since eggs aren’t usually fertilized, the lining usually leaves the body as menstrual blood during a woman’s monthly period.

Cervix — The lower part of the uterus, which connects to the vagina, is known as the cervix. Often called the neck or entrance to the womb, the cervix lets menstrual blood out and semen into the uterus. The cervix remains closed during pregnancy but can expand dramatically during childbirth.

Vagina — The vagina has both internal and external parts and connects the uterus to the outside of the body. Made up of muscle and skin, the vagina is a long hollow tube that is sometimes called the ―birth canal‖ because, if you are pregnant, the vagina is the pathway the baby will take when it’s ready to be born. The vagina also allows menstrual blood to leave a woman's body during reproduction and is where the penis deposits semen during sexual intercourse.

Female Sexual Anatomy: External Parts

The entrance to the vagina is surrounded by external parts that generally serve to protect the internal organs; this area is called the vulva. The vulva consists of the following:

Labia majora — Translated as ―large lips,‖ this flap of skin protects the vagina from foreign particles.

Labia minora — The ―small lips‖ also surround and protect the vaginal opening and are located inside the labia majora.

Clitoris — The clitoris is a sensitive organ located above the vaginal opening. The clitoris does not directly affect reproduction, but it is an important part of the female sexual anatomy; many women need clitoral stimulation to orgasm.

Mons pubis — The fatty mound of tissue that covers the pubic bone. Often called the "mons."

Perineum — A stretch of hairless, sensitive skin that extends from the bottom of the vaginal opening back to the anus

Description

A C-section delivery is done when it is not possible or safe for the mother to deliver the baby through the vagina.

The procedure is usually done while the woman is awake. The body is numbed from the chest to the feet using epidural or spinal anesthesia.

The surgeon make a cut across the belly just above the pubic area. The womb (uterus) and amniotic sac are opened, and the baby is delivered.

The health care team clears the baby's mouth and nose of fluids, and the umbilical cord is cut. The pediatrician or nurse makes sure that the infant's breathing is normal and that the baby is stable.

The mother is awake, and she can hear and see her baby. The father or another support person is often able to be with the mother during the delivery.

Why the Procedure Is Performed

The decision to have a C-section delivery depends on:

Your doctor

Where you are having the baby

Previous childbirth

Your medical history

Some reasons for having C-section instead of vaginal delivery include:

Problems with the baby:

Abnormal heart rate in the baby

Abnormal position of the baby in the womb, such as crosswise (transverse) or feet-first (breech)

Developmental problems such as hydrocephalus or spina bifida

Multiple pregnancy (triplets, and sometimes, twins)

Health problems and medical history in the mother:

Active genital herpes infection

Large uterine fibroids near the cervix

HIV infection in the mother

Previous C-section

Previous uterine surgery

Severe illness in the mother, including heart disease, preeclampsia or eclampsia

Problems with labor or delivery:

Baby's head is too large to pass through the birth canal

Labor that takes too long or stops

Very large baby

Problems with the placenta or umbilical cord: Placenta covers all or part of the opening to the birth canal

(placenta previa)

Placenta prematurely separated from uterine wall (placenta abruptio)

Umbilical cord comes through the opening of the birth canal before the baby (umbilical cord prolapse)

Risks A C-section is a safe procedure. The rate of serious complications is

extremely low. However, certain risks are higher after C-section than after vaginal delivery. These include:

Infection of the bladder or uterus

Injury to the urinary tract

Injury to the baby

A C-section may also cause problems in future pregnancies. This includes a higher risk for:

Placenta previa

Placenta growing into the muscle of the uterus and has trouble separating after the baby is born (placenta accreta)

Uterine rupture

These conditions can lead to severe bleeding (hemorrhage), which may require blood transfusions or removal of the uterus (hysterectomy).

All surgeries carry risks. Risks due to anesthesia may include:

Reactions to medications

Problems breathing

Risks related to surgery in general may include:

Bleeding

Blood clots in the leg or pelvic veins

Infection

Outlook (Prognosis)

Most mothers and infants do well after a c-section. Women who have a C-section may have a vaginal

delivery if another pregnancy occurs, depending on:

The type of C-section done

Why the C-section was done

Vaginal birth after cesarean (VBAC) delivery is usually successful. However, there is a small risk of uterine rupture, which can harm the mother and the baby. It is important to discuss the benefits and risks of VBAC with your health care provider.

Recovery The average hospital stay after C-section is 2 - 4 days.

Recovery takes longer than it would from a vaginal birth. You should walk around after the C-section to speed recovery. Pain medication taken by mouth can help ease any pain.

Medication

Continue medicines as ordered by the physician

Zegen 500g BID

Cataflam 50mg TID

Exercise

Ambulation in the house Deep breathing exercises

Coughing exercises

Treatment

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

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

Out Patient Have a follow up check up after a week with her Ob-gyne and pediatrician

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

Sexual/Spiritual Advised the patient that she and her husband can resume sexual activity

Advised the patient that she can resume her rituals during Sunday since she is a Roman Catholic.