General Objectives:

The purpose of this study is to enhance and gain knowledge about, to develop communication and nursing skills to provide privacy and maintain
confidentiality of the patient and to apply the right attitude of the student nurses in rendering and giving care to the patient with Post Cesarean and Bilateral
Tubal Ligation, its importance and implication.
Specific Objectives:
To understand the condition of Post Cesarean and Bilateral Tubal Ligation and associate it with the patient through the introduction of the case.
To illustrate the anatomy and physiology of the affected organ or the part of the body.
To discuss the pathophysiology that causes anemia.
To be clinically aware of the clinical manifestation and its complication.
To develop an effective skill on how to plan and manage proper care in patient with Post CSBTL.
To provide the client nursing care plan and discharge plan to assure clients total wellness during her hospitalization up to time of his hospital discharge.
To apply right attitude by respect through providing privacy and maintaining clients confidentiality.
Scope and Delimitations
The study would only focus on Post CSBTL which is indicative to the patients health condition and its underlying nursing care relevant for the patient
confined in Quezon Medical Center.
The study was conducted at Quezon Medical Center (OB-Ward) during the nursing students exposure in the hospital (September 23,24 and 25 2012).
Nursing health history, physical assessment, nursing interventions and health teachings for the patient were included. Its primary focus is the client whose
diagnosis was Post CSBTL. The baseline data were gathered from the client, from the clients chart, and through the nurse-patient interaction during the
exposure.


Nursing History:
History of Present Illness:
Masakit ang tahi ko,as verbalized by the patient. She experienced lumbosacral pain before admission. She was brought to Quezon Memorial Center last
September 21, 2012. At 2:00 in the afternoon. She was brought to operating room around 10:30pm.
History of Past Illness:
According to the patient, she didnt experience any severe illness during her childhood. Her common illnesses are cough, colds, and fever. She doesnt had any
drug and food allergies. Her first baby was delivered through cesarean operation due to drained amniotic fluid. Her second baby, died four days after the delivery
due to heart failure and was delivered by cesarean operation. Her third baby was delivered through cesarean operation due to breech presentation of the baby. Her
fourth baby was also delivered through cesarean operation.
Family History:
The patient is the 2
nd
child of 4 siblings. Her father is diabetic. Her mother died while giving birth to her youngest child and was delivered through cesarean
operation.
Her sisters, according to her was in good health condition.
Genogram:
Legend:

-Female -deceased

-Male - deceased
giving birth diabetic

Personal/Social History:
Alcohol Use: Denies.
Tobacco Use: Denies.
Drug Use: Denies.
Travel History: Denies.
Economic Status: Farming as their means of livelihood.
Religion: Roman Catholic
s
Theoretical Framework

Watsons Caring
Theory:







Physical Assessment
Date of Assessment: September 25, 2012
General Appearance:
The patient is oriented and conscious. She wears neat clothes exactly for her mesomorph body. Upon assessment, the client is sitting on the chair, with a pulse rate
of 93 beats per minute, respiration rate of 18 breaths per minute, and temperature of 36.0 C.
BODY PART NORMALS FINDINGS ACTUAL FINDINGS INTERPRETATION/ ANALYSIS
A. HEAD
1. SKULL
Proportional to the size of the body,
round, with prominences in the
frontal area anteriorly and the
occipital area posteriorly
symmetrical in all planes.

Proportional to the size of the body,
symmetrical in all planes.

Normal.

2. SCALP

White, clean, free from masses,
lumps, scars, nits, dandruff, and
lesion
White, clean, free from masses,
lumps, scars, nits, and lesions
Normal
3. HAIR Black or whitish, evenly distributed
and covers the whole scalp, thick,
shiny, free from split ends.
Black; evenly distributed, thick. Normal
4. FACE Oblong/oval/square or heart-shaped,
symmetrical, facial expressions that
is dependent on the mood or true
feelings,
Round shape. Symmetrical, free
from wrinkles and scars. No
involuntary muscle movements.
normal
B. EYES Black, symmetrical, thick, can raise
and lower eyebrows symmetrically
Black, symmetrical. Can raise and
lower eyebrows.
normal
and without difficulty, evenly
distributed and parallel with each
other.
C. EARS Pinkish, clean, with scant amount of
cerumen and a few cilia.
Cerumen and a few cilia. Normal
D. NOSE Midline, symmetrical, and patent. Midline, symmetrical, and patent. Normal
E. MOUTH Pinkish, symmetrical lip margin,
well-defined, smooth and moist.
Pale Pallor due to decreased hemoglobin
and hematocrit.
F. NECK Proportional to the size of the body
and head, symmetrical and straight.
Proportional to the size of the body
and head, symmetrical and straight.
Normal
G. RANGE OF MOTION Freely movable with relative ease. Poor Range of Motion. >due to pain at incision site.
H. MUSCULAR STRENGTH Symmetrical movements and able to
resist force applied by the nurse.
Symmetrical movements and able to
resist force applied
Normal
I. HEART Regular beats
(60-100 beats per minute).
Regular beats (108 beats per minute) Deviation from normal
Patients who are anemic or have low
levels of hemoglobin thus carrying
less oxygen in the blood causing a
higher number of BPM in the heart
rate

J. ABDOMEN
Inspection
Unblemished skin; uniform color.
Flat, rounded; symmetric contour.
With presence of incision at the
abdomen; intact and no drainage
Due to caesarean section delivery
1. Abdomen skin
2. Contour and Symmetry
Symmetric movements caused by
respiration.
Auscultation Audible bowel sounds (5-30/min);
absence of arterial bruits and
friction rubs.
Audible bowel sounds (10/min). Normal
Palpation No tenderness;
With contracted hard abdomen.
Had incision site. Cannot be palpated due to pain at
incision site.
K. CHEST (THORAX)
Inspection
Chest symmetrical, skin intact, no
tenderness, no masses.
Chest symmetrical. No lumps,
tenderness and masses.
Respiration of 20breaths per minute.
Normal
Palpation Full and symmetric chest expansion.
Symmetric vocal fremitus.
Symmetric and expands. Normal
L. UPPER EXTREMITIES
1. ARMS
Inspection
Skin varies (pinkish, tan, dark
brown), skin is smooth, fine hair
evenly distributed, muscles
symmetrical, length symmetrical.
Edematous, Pale skin, fine muscle,
length symmetrical, fine hair evenly
distributed.
Deviation from normal
Pallor due to less oxygen being
available to the surface tissues
caused by decrease haemoglobin
level
Palpation Warm, dry and elastic, no areas of
tenderness. Muscle appears equal
Warm, dry and no areas of Normal
with good muscle tone. tenderness.
M. NAILS Nails are transparent, smooth, &
convex with pink nail beds & white
translucent tips.
Five fingers in each hand. As
pressure is applied to the nail bed, it
appears white or blanched & pink
color returns immediately as
pressure is released.
Complete fingers, 5 each hand.
Nails are thick, transparent, &
convex with pale nail beds & white
translucent tips.
As pressure is applied to the nailbed,
it appears white and color returns
after 4 seconds.
With deviation from normal
Patients with anemia may exhibit
delayed capillary refill - diminished
blood flow to the periphery and
compensatory vasoconstriction.
N. SHOULDERS, ARMS,
ELBOWS, HANDS & WRISTS
ABDUCTION AND ADDUCTION.
Performs with relative ease. Performs with relative ease. Normal
O. LOWER EXTREMITIES
1. LEGS
Inspection
Skin varies (pinkish, tan, dark
brown), skin is smooth, fine hair
evenly distributed, absence of
varicose veins, muscles symmetrical,
length symmetrical.
Edematous in the lower extremities
Skin is pale. Hair evenly distributed.
Deviation from normal
Due to excess fluid volume the
patient may experience edema
(Medical-Surgical Nursing by
Digiulio p.177)
Pallor due to less oxygen being
available to the surface tissues
caused by decrease haemoglobin
level
Palpation Muscles appear equal, warm & with
good muscle tone.
Muscles appear equal, warm & with
good muscle tone.
Normal
2. TOES
Inspection
Five toes in each foot: sole and
dorsal surface is smooth:
Five toes in each foot. Sole and
dorsal surface is smooth. With pale
nail beds.
Deviation from normal
Pale, whitish nail beds may indicate
a low red blood
P. LEGS, KNEES, ANKLES, TOES
ADDUCTION AND ABDUCTION.
Performs with relative ease. Performs with relative ease. Normal
Q. PERINEUM No excoriation, swelling and no foul
smell
No excoriation and no swelling. With
bleeding.
Normal

Laboratory Tests and Results:
CBC(Complete Blood Count)
Name of Test Date Done Actual Result Reference Value Indication Interpretation
Hemoglobin 09/24/12 7
M 14.0-18.0gm/dL F
12.0-15gm/dL
decrease anemia
Hematocrit

21
M 40-50 vol%
F 30-40 vol%
decrease anemia

Name of Test Date Done Actual Result Reference Value Indication Interpretation
Hemoglobin 09/21/12 11.3 M 14.0-18.0gm/dL F 12.0-
15gm/dL
decrease anemia
Hematocrit 33.4 M 40-50 vol%
F 30-40 vol%
Normal normal
WBC Count 6,300 5,000-10,000/comm Normal Normal

Name of Test Date Done Actual Result Reference Value
Neutrophils 09/21/12 74
Lymphocytes 26
100%

Platelet Count
BLOOD TYPE
217,000
A +



III-Clinical Discussion of the Case:
>Anatomy and Physiology:







>EXTERNAL GENITALIA:
Labia minora
Labia majora
Clitoris
>INTERNAL REPRODUCTIVE STRUCTURE:
The Vagina
The Cervix
Uterus
Oviducts (Fallopian Tube)
Ovaries








PATHOPHYSIOLOGY

















RISK FACTORS:
BLOOD LOSS
INADEQUATE RBC PRODUCATION OR
INCREASE RBC DESTRUCTION
NUTRITIONAL DEFICIENCY
AGE AND HEALTH STATUS


IN ATTEMPT TO CARDIAC OUTPUT
AND TISSUE PERFUSION
TISSUE HYPOXIA
OXYGEN CARRYING
CAPACITY OF THE
BLOOD
RBC / HEMOGLOBIN
COMPENSATORY MECHANISM OF THE BODY
MAY CAUSE ANGINA,
FATIGUE, DYSPNEA ON
EXERTION AND NIGHT
CRAMPS
CARDIAC AND RESPIRATION RATE
HEART
BRAIN CEREBRAL HYPOXIA
HEADACHE,
DIZZINESS
AND DIM
VISION
HEART FAILURE IN
SEVERE ANEMIA
BONES
STIMULATES
ERYTHROPOIETIN RELEASE
IN THE BONE MARROW
INCREASED
ERYTHROPOIETIN
ACTIVITY
MAY LEAD TO
BONE PAIN
PALLOR OF THE SKIN,
MUCOUS MEMBRANE,
CONJUNCTIVA AND NAIL BED
BLOOD LOSS
BLODD VOLUME DECREASE
HYPOTENSION AND
PERIPHERAL
CONSTRICTION OF
THE VESSEL
COOL AND
CLAMMY SKIN
DECREASED LOC
AND OLIGURIA
I. Nursing process
a. Long term objective
The study aims to influence the clients behavior and health and to express a clear precise meaning of diagnosis and aims to restore the patients normal activities of
daily living and to prevent of further complication that might be life threatening, through collaborative management of the physician.
b. Prioritized list nursing problem
Ranking Problem Justification
1
Acute pain related to tissue injury secondary to surgical
intervention
We prioritized this diagnosis because pain should
be attend to first, since the pain is intolerable for
the patient and interventions are to render
2
Fatigue related to inadequate tissue oxygenation
secondary to low hemoglobin count
We put this as the second because the underlying
factor that contribute to the fatigue is due to low
hemoglobin which should be correct through
undergoing blood transfusion
3
Disturbed body image related to effect of pregnancy and
presence of incision.

We considered this as the least because we
should give ample time for the patient to accept
the changes she had
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
S- masakit ang tahi ko as
verbalized by the patient
O abdominal pain scale of 9,
10 as the highest and 1 as the
lowest
-Guarding behavior noted
-Facial grimace noted
- Irritable noted
- Pallor
- Change of sleep pattern
- Restlessness
- Elevated pulse 102bpm
- Respiration -24
-
Acute pain related to tissue
injury secondary to surgical
intervention
After 2-4 hours of nursing
intervention the person will
verbalize relief from pain after
satisfactory measures
Monitor vital signs to
compare to its normal
value.
Teach specific
relaxation strategy
;(rhythmic breathing or
deep breath)
Instruct on techniques to
reduce skeletal muscle
tension, which will
reduce the intensity of
the pain.
Assess the patient
contractions and
discomfort.
Encourage the patient to
stand and walk as much
as possible during first
stage
Instruct the patient to
change the position at
least every hour.
Encourage diversional
activities such as talking
with the significant
others reading and so
on.
EXPECTED
OUTCOME
Goal partially met
At the end of nursing
intervention the patient
demonstrated a partial
relief in pain, from 9
down to 5
hindi na masyadong
masakit ang tahi ko as
verbalized by the patient
S- nanghihina ako as
verbalized by the patient .
O pale palpebral conjunctiva
Fatigue related to inadequate
tissue oxygenation secondary
to low hemoglobin count
After 1-3 days of nursing
intervention the patient will
participate in activities that
Emphasize the need for
rest and sleep period
Advice to avoid over
EXPECTED
OUTCOME

Poor capillary refill
-hgb 7gm/dl
- hct 21%


stimulates and balance. exertion.
Encourage to eat food
that are rich in iron.
Encourage increase
fluid intake

COLLABORATIVE
INTERVENTION
Blood transfusion as
ordered
Goal partially met.
At the end of nursing
interventions the patient
demonstrated partial
participation in activities
that will stimulates
balance and, physical
domains.
LONG TERM
S naiilang ako, kasi ang
taba ko at may tahi pa ako sa
tiyan as verbalized by the
patient.
affect noted
Not looking at body
part
Not touching at body
part

Disturbed body image related
to effect of pregnancy and
presence of incision.

After 1-2 weeks of nursing
intervention the patient will
able to verbalized and
demonstrate acceptance of
appearance.
Encourage to do light
exercise.

EXPECTED
OUTCOME

Goal partially met.
At the end of nursing
intervention the patient
demonstrated a
willingness and ability
to resume self-care and
acceptance of
appearance.






Drug Study
Drug name Classification Indication Ci and caution interaction Adverse effect Nursing intervention
Cefuroxime
sodium

Adults1.5g iv 30-
60mins before
surgery ;in lengthy
operations,750mg
iv or im every
8hrs.
Second
generation
cephalosporin
Peri-operative
pervention
-contraindicated in patients
hypersensitive to drug or
other cephalosporin
-use cautiously in patients
hypersensitive to penicilin
because of possibility to
cross-sensitivity with other
beta-lactam antibiotics
Gi: diarrhea,nausea,
vomiting
Skin:
Maculopapular and
erythematous rashes,
urticaria, pain, tissue
sloughing at i.m injection
site
-alert: tablets and suspension arent
bioequivalent and cant be substituted
miligram-for-miligram
-monitor patient for signs and
symptoms of super infection
Ketorolac
tromethamine

Im: adults less than
65 years of age
60mg
Iv: adults less than
65 years of age
30mg

Nsaid Short-term
management of
moderately severe,
acute pain for single-
dose treatment
Contraindicated in patients
hypersensitive to drug and
in those with active peptic
ulcer disease, recent gi
bleeding or perforation
Cns: headache, dizziness,
drowsiness, sedation
Correct hypovolemia beforegiving,
Oral therapy is only indicatedas a
continuation of i.m therapy in 5 days,
dont give drug epidurally or
intrathecally because of alcohol content
Bisacodyl

Adults and
children age 12
and older: 10 -15
mg p.o in evening
or before breakfast
Diphenylmethane
derivative
Preparation for
childbirth, surgery,
Contraindicated to patients
hypersensitive to drug or
its components and in
those with rectal bleeding,
gastroenteritis, intestinal
obstruction, abdominal
pain,nausea, vomiting and
other symptoms of
appendicitis
Cns: dizziness, faintness,
muscle weakness with
excessive use
Gi: abdominal cramps,
burning sensation in
rectum with
suppositories, nausea,
vomiting and diarrhea
Give drug at times that dont interfere
with scheduled activities or sleep. Soft
formed stools are usually produced 15
to 60 minutes after rectal use
Ranitidine
hydrochloride
H2-receptor
antagonist
Interactable duodenal
ulcer; pathologic
Contraindicated in patients
hypersensitive to drug or
Cns: vertigo, malaise
Hepatic: jaundice
Competitively inhibits action of h2 at
receptor sites of parietal cells,

Adults: 150mg p.o
bid or 300mg daily
h.s
hypersecretory
conditions, such as
zollinger ellison
syndrome; short-term
therapy for patients
unable to tolerate oral
forms
any of its content,
Use cautiously in patients
with hepatic dysfunction.
Adjust dosage in patients
with impaired kidney
function
Other: burning and
itching at injection site,
anaphylaxis
decreasing gastric acid and secretion
Oxytocin,
synthetic injection

Adults: initially
1ml ampule in
1000ml of d5w
injection
Pitocin To induce or
stimulate labor, to
reduce postpartum
bleeding after
expulsion of placenta
Contraindicated in patients
hypersensitive to drug.
Also contraindicated when
vaginal delivery isnt
advised
Cns: subarachnoid
hemorrhage, seizures and
coma
Cv: hypertension,
increased heart rate,
systemic venous return
Use with extreme caution during first
and second stages of labor because
cervical laceration, uterine rupture and
maternal and fetal death
Tramadol
hydrochloride

Adults: 50-100mg
p.o q4 to 6 hours,
prn maximum
400mg daily

Ultram Moderate to
moderately severe
pain
Contraindicated to patient
hypersensitive to drug and
in those with acute
intoxification from alcohol,
hypnotics, centrally actingg
analgesics.
Cns: dizziness, vertigo,
headache, somnolence
Cv: vasodilation
Gi:nausea, constipation,
vomiting, dyspepsia
Use cautiously in patients at risk for
seizures or respiratory depression; in
increased intracranial pressure





DISCHARGE
MEDICATIONS
Explain to the patient and family members the importance of taking medicines.
Discuss to the patient and family the dosage, frequency and adverse effects of the drugs.
Encourage to follow the dosages and proper timing of his meds.
ENVIRONMENT
Explain to significant others that the rehabilitation may be prolonged to be able for the family to prepare financial needs
Maintain a quiet, clean and calm environment for easy and good recovery of the Patient.
Provide safety measures to promote safe environment and individual safety
Treatment
Provide warm environment
Advice patient to avoid lifting heavy objects and use of too much force to prevent more serious injury.
Instruct to perform light physical activities
HEALTH TEACHINGS
Instruct the patient to take medications religiously
Improve nutritional status
Importance of proper hygiene for comfort
OUT-PATIENT CHECK-UP
The patient could avail his medication from government hospitals that he could get some benefits.
He will also be able to avail the services offered by the barangay health center and and at the Botika ng barangay.
Instruct patient to seek regular medical check-up
DIET
Eat five or more servings of vegetables and fruit daily.
Eat foods rich in Iron like liver and green leafy vegetables
Have supplement of iron and drink it with vitamin C to hasten the absorption
Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin turgor.
Avoid use of alcohol