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The patient came for a scheduled cesarean section due to a history of pregnancy-induced diabetes during her first pregnancy at age 33 and undergoing two previous cesarean deliveries. During hospitalization, she underwent a cesarean section and bilateral tubal ligation. She accepted her condition positively and adapted well to the changes in diet and limited activity required during her recovery.

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The disorder usually occurs in the third trimester of pregnancy and gets worse over time. In severe disease, the risk of poor outcomes for both the mother and the baby includes: red blood cells breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances. Risk factors for PE include: obesity, prior hypertension, older age, and diabetes mellitus. It is also more frequent in women's first pregnancy and if she is carrying twins. Risk factors for PE include: obesity, prior hypertension, older age, and diabetes mellitus. It is also more frequent in women's first pregnancy and if she undergone 2 Cesarean section already.
Name: RSD Age: 38 years old Address: Quezon City Sex: Female Marital Status: Single Religion: Roman Catholic Occupation: Budget and MGT Analyst
Before Hospitalization The client is aware of her health condition and obeyed her Physicians order which is to undergo another Caesarian Section Delivery because of her maternal age which is 38 years old and her history of pregnancy induced Diabetes on her 1st baby at 33 years old. During Hospitalization Patient came for scheduled Ceasarian Section with Bilateral Tubal Ligation with history of watery/bloody vaginal discharge, with good fetal movement.
Caesarian delivery on 1st and 2nd child Patient came for scheduled Ceasarian Section with Bilateral Tubal Ligation with history of watery/bloody vaginal discharge, with good fetal movement.
Addiction (Drugs/Alcohol) Occasional Arthritis (-) DM Pregnancy induced Mental Disorder (-) CVA (-) Kidney Disease (-) Cancer (-) Heart Disease (-) Hypertension: both parents Sickle Cell Anemia (-) Chronic Lung Disease (-) Others : none
Immunization/Exposure to Communicable Disease: With no previous diagnosed communicable disease and no known immunization.
Alcohol Use: Occasional Tobacco Use: No Drug Use: No Caffeine Intake: Yes
Menarche: Doesnt Recall For Pregnant Client: OB Score (GPTPALM): G3P2 (20020) LMP: February 15, 2019 EDC: November 22, 2019 AOG: 38 weeks
Pattern Before Hospitalization During Hospitalization Analysis Health Perception The patient is aware of her condition which is very fragile and sensitive so she keeps herself and the baby healthy by eating healthy foods and doing some exercises and house chores. She stated that they have a slight problem in financing health care services The patient was able to adapt with her situation and procedures done to her. She also understands why she felt pain in her belly and that it will take time to heal. She has no known allergies and their family has a history of hypertension. The patient knows and understands what the right things to do and she strictly compromise for the sake of her and her baby. Nutritional- Metabolic The patient eats less rice and drinks at least 8 glasses a day and eats at least 4 times a day. She sometimes eats snacks but most of the time she eats fruits and vegetables. She mentioned that she sometimes drinks softdrinks. The patient eats soft diet foods delivered by the dietary The patient is able to adapt with the changes in her diet. She strictly monitors her intake of foods and drinks.
Pattern Before Hospitalization During Hospitalization Analysis Elimination Usual pattern is every 2 days and with frequent urination pattern. Usual void is 8 a day Positive stool during the first day (1x) Have voided after the removal of the catheter Eliminated during the first day of hospitalization and was able to switch to Soft Diet. Activity/Exercise Participated to Zumba sessions, with continuous walking and commute from home to work Bedrest With Bathroom privilege The patient has a limited ROM due to her previous surgery.
Pattern Before Hospitalization During Hospitalization Analysis Sleep-Rest Sleeping pattern is between 11 pm to 4 am with no naps during the day due to her work but was able to sleep with ease. Usual time of sleep is at 11 pm and woke up at 6 due to hunger and nurses at rounds. The patient is lacking of good sleep because of her work and her duty as a mom. Cognitive/Perceptual Functioning well and is working during the days, with clear perception and was able to communicate well. Is easy to talk to with clear and good response with fast and detailed answers to questions. The patient has a good level of understanding and can communicate well. Role/Relationship Has a positive relationship with her family even if she is not yet married With good relationship towards her family , accompanied by her live in partner during hospitalization No alterations.
Pattern Before Hospitalization During Hospitalization Analysis Sexuality/Reproductiv e No family planning method used withdrawal method Underwent Bilateral Tubal Ligation The patient and her partner agreed to do the procedure since they are sexually active. Coping/Stress Tolerance The patient verbalized sleeping, eating, surfing the net (Facebook) and ignore things if stressed. Watching TV and surfing the net. Patient accepts present condition with a positive attitude. Value/Belief Roman Catholic , Bigkis, unton Due to her
BODY PART FINDINGS ANALYSIS Eyes Visual acuity- 550 eye grade Field of vision unable to see widely Cannot able to see far away objects without her glasses Lips Pale pink and slightly dry Due to post operation Abdomen Classical caesarean (horizontal cut incision) Patients choice (previous cut) Tender and restricted movement
case-study.pptx
case-study.pptx
Pre-operation Diagnosis: history of watery/bloody vaginal discharge, with good fetal movement. Post-operation Diagnosis Operative delivery term alive girl cephalic, 38 weeks AOG, G3P3 (20020)
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case-study.pptx

  • 2. The disorder usually occurs in the third trimester of pregnancy and gets worse over time. In severe disease, the risk of poor outcomes for both the mother and the baby includes: red blood cells breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances. Risk factors for PE include: obesity, prior hypertension, older age, and diabetes mellitus. It is also more frequent in women's first pregnancy and if she is carrying twins. Risk factors for PE include: obesity, prior hypertension, older age, and diabetes mellitus. It is also more frequent in women's first pregnancy and if she undergone 2 Cesarean section already.
  • 3. Name: RSD Age: 38 years old Address: Quezon City Sex: Female Marital Status: Single Religion: Roman Catholic Occupation: Budget and MGT Analyst
  • 4. Before Hospitalization The client is aware of her health condition and obeyed her Physicians order which is to undergo another Caesarian Section Delivery because of her maternal age which is 38 years old and her history of pregnancy induced Diabetes on her 1st baby at 33 years old. During Hospitalization Patient came for scheduled Ceasarian Section with Bilateral Tubal Ligation with history of watery/bloody vaginal discharge, with good fetal movement.
  • 5. Caesarian delivery on 1st and 2nd child Patient came for scheduled Ceasarian Section with Bilateral Tubal Ligation with history of watery/bloody vaginal discharge, with good fetal movement.
  • 6. Addiction (Drugs/Alcohol) Occasional Arthritis (-) DM Pregnancy induced Mental Disorder (-) CVA (-) Kidney Disease (-) Cancer (-) Heart Disease (-) Hypertension: both parents Sickle Cell Anemia (-) Chronic Lung Disease (-) Others : none
  • 7. Immunization/Exposure to Communicable Disease: With no previous diagnosed communicable disease and no known immunization.
  • 8. Alcohol Use: Occasional Tobacco Use: No Drug Use: No Caffeine Intake: Yes
  • 9. Menarche: Doesnt Recall For Pregnant Client: OB Score (GPTPALM): G3P2 (20020) LMP: February 15, 2019 EDC: November 22, 2019 AOG: 38 weeks
  • 10. Pattern Before Hospitalization During Hospitalization Analysis Health Perception The patient is aware of her condition which is very fragile and sensitive so she keeps herself and the baby healthy by eating healthy foods and doing some exercises and house chores. She stated that they have a slight problem in financing health care services The patient was able to adapt with her situation and procedures done to her. She also understands why she felt pain in her belly and that it will take time to heal. She has no known allergies and their family has a history of hypertension. The patient knows and understands what the right things to do and she strictly compromise for the sake of her and her baby. Nutritional- Metabolic The patient eats less rice and drinks at least 8 glasses a day and eats at least 4 times a day. She sometimes eats snacks but most of the time she eats fruits and vegetables. She mentioned that she sometimes drinks softdrinks. The patient eats soft diet foods delivered by the dietary The patient is able to adapt with the changes in her diet. She strictly monitors her intake of foods and drinks.
  • 11. Pattern Before Hospitalization During Hospitalization Analysis Elimination Usual pattern is every 2 days and with frequent urination pattern. Usual void is 8 a day Positive stool during the first day (1x) Have voided after the removal of the catheter Eliminated during the first day of hospitalization and was able to switch to Soft Diet. Activity/Exercise Participated to Zumba sessions, with continuous walking and commute from home to work Bedrest With Bathroom privilege The patient has a limited ROM due to her previous surgery.
  • 12. Pattern Before Hospitalization During Hospitalization Analysis Sleep-Rest Sleeping pattern is between 11 pm to 4 am with no naps during the day due to her work but was able to sleep with ease. Usual time of sleep is at 11 pm and woke up at 6 due to hunger and nurses at rounds. The patient is lacking of good sleep because of her work and her duty as a mom. Cognitive/Perceptual Functioning well and is working during the days, with clear perception and was able to communicate well. Is easy to talk to with clear and good response with fast and detailed answers to questions. The patient has a good level of understanding and can communicate well. Role/Relationship Has a positive relationship with her family even if she is not yet married With good relationship towards her family , accompanied by her live in partner during hospitalization No alterations.
  • 13. Pattern Before Hospitalization During Hospitalization Analysis Sexuality/Reproductiv e No family planning method used withdrawal method Underwent Bilateral Tubal Ligation The patient and her partner agreed to do the procedure since they are sexually active. Coping/Stress Tolerance The patient verbalized sleeping, eating, surfing the net (Facebook) and ignore things if stressed. Watching TV and surfing the net. Patient accepts present condition with a positive attitude. Value/Belief Roman Catholic , Bigkis, unton Due to her
  • 14. BODY PART FINDINGS ANALYSIS Eyes Visual acuity- 550 eye grade Field of vision unable to see widely Cannot able to see far away objects without her glasses Lips Pale pink and slightly dry Due to post operation Abdomen Classical caesarean (horizontal cut incision) Patients choice (previous cut) Tender and restricted movement
  • 17. Pre-operation Diagnosis: history of watery/bloody vaginal discharge, with good fetal movement. Post-operation Diagnosis Operative delivery term alive girl cephalic, 38 weeks AOG, G3P3 (20020)