clinincal cycle report

C-Section Clinical Analysis

Student’s Name

Institution’s Name

Date

Patient Situation

Candace has undergone caesarian section and is 42 years old. She was to have a caesarian section, which was conducted on her first pregnancy. She has gestational diabetes that is associated with women who have given birth and their sugar levels in the blood are quite high (WLoch et al., 2012). Candace further has had a caesarian section which and is thus recovering from the procedure. Candace had an uneventful caesarian section. The surgery was stable and an IV was administered which was 8 ml /hr. there are various effects of the spinal aesthesis that was used on the patient. Her alertness is evident 150 mls is the total blood loss from the caesarean section. The temperature is 36.6; HR is 88, Sats 97% and BP 104/76. Candace further has a dry dressing, which is, and it is in good condition. In such a condition, she is still recuperating and therefore any changes in her case should be monitored.

Collect Information/ Cues

The observations are as below.

Temperature 36.6

Blood pressure 104/76

Oxygen saturation level 97%

Heart rate 88

New Information IV Fluids

The cues that are relevant in testing the condition of Candace are as follows

Appetite – zero

Oral mucosa condition – tongue in good condition

Poor skin turgor

The patient has abnormal thirst level

The color of the patient is normal

Pain on the VAS scale is 2-3

Processing Information

The various cues give much information that is helpful in giving the conditions that Candace is facing. The temperate at 36.6 is lower than the normal 37. It is near normal and the patient may be experiencing low temperature about the operation carried out and the loss of blood. She is thus recovering and her temperature is not as bad (Kainu et al., 2010). Her oxygen saturation levels are ok since they are within the normal range. Oxygen saturation readings of above 95% present a normal condition and as such, her breathing is normal. Her blood pressure is quite normal since it is below 120. As such, she has a normal diastolic and systolic blood pressure and is in no danger of having hypertension. The heart rate is normal with Candace having 88 beats per minute.

Blood pressure, temperature, oxygen saturation and appetite are further going to be used to determine the condition of Candace. Candace had a preoperative wound from her first presence, which was a C-section. As such, the bleeding was more than normal especially since the wound had healed to some extent after five years. Candace further has gestational diabetes.

The above cues are important in stating the condition of the patient. The patient has to have a clear diagnosis given to ensure that the situation in monitored and conducted to ensure treatment (Ardern, 2011). As such, Candace in having normal conditions about the cues shows that her recovery is happening quickly. IV fluids have been administered to Candace further showing that she is at present hypertensive. Hypotoxicity is present since Candace still has traces of spinal anesthesia in her system. The blood loss from the surgery further puts her in a hypertensive condition. The patient is suffering from pain because of the surgery done on her belly. Inferences that can be stated about Candace’s condition are:

Bradycardic and normotensive

Afebrile and hypotensive

Diabetic

Predictions

If fluid correction is not done promptly, various conditions may arise in the process of recovering. These conditions include:

She may undergo shock

Her state may continue improving over the coming days

Hypotoxicity may result from the remaining anesthesia in the body

Edema may result leading to accumulation of fluids in the tissues

She may succumb to her injuries especially the wound due to infections especially if they would is not cleaned and disinfected

Identifying the Problem

The patient may be suffering from dehydration and

The patient can suffered form anemia due to the loss of a lot of blood

The bowel or bladder can be injured in the process of delivery

Adhesions usually occur in the mothers pelvic regions tissues from the scar form and may increase pain and blockages

The woman may have hypervolemia which mostly can be caused by blood transfusions or intravenous fluids taken by Candace during the process of surgery

The mother in this case had an uneventful caesarian section and is in stable condition now. The likely problem may be hypervolemia and anemia since in mot C-sections mothers lose a lot of blood and the transfusion need to be done correcting regarding the blood sugar since Candace has gestational diabetes.

Establishing Goals

Various goals are established to ensure that Candace condition is improved. These goals are going to enable the nurse to come up with various possible actions, which will be monitored in the shortest time possible to determine if the medication given is working and leading to the goals set. As a result, it will be important for the nurse to take measures and act on them in the shortest time possible to ensure that the condition return to normal as soon as possible. Some of the goals are as below.

Blood transfusion to be carried to normalize blood level in 24hrs

Urine output of Candace to be normotensive ranging from 35 to 40 mls in two hours’ time

For Candace to have at least 30 to 40mls in the next 20 hours

Taking Action

Since the conditions and the cues noted can help in improving the condition of Candace various actions are going to be done to ensure her condition remains stable. Various worsening conditions in patient who have undergone surgery or other procedures are avoidable. Abnormalities that are documented are usually not considered carefully and most of the times lead to worsening condition in the patients. Critical changes arising from various body changes like heart rate may make the difference if noted and taken care of immediately. Since the patient at this moment is in stable condition, some of the actions to be taken will be to inform her that she is going to get well and in the process giving her reassurance. Since she has gestational diabetes she will be notified and informed that her condition is stable and it will not affect her recovery. Another action will be to check that the IV is continuously flowing to prevent and detect any blockage and rectify it promptly. The pain core will further be monitored since she has had a surgery, which has left a scar that takes some time to heal internally and is mostly accompanied by pain. Furthermore, they would be the need to monitor the wound and drain of Candace to ensure that she is in the best condition possible to increase her healing after the surgery. As such, the actions to be taken will be to change the position of the patient, reassure her, give the patient oral care and document all changes happening to the patient. The measurement of weight will be done together with checking the hemodynamic status.

Evaluation

The state of Candace is improving greatly and she is responding to medication and the IV fluid. The various signs associated with the heart and fluid level in her body are normal and she is recuperating quite easily. The cognitive status of Candace is normal and she is only a little restless due to the uneventful procedure. Her BP is still below 120 and normal as such. The heart rate has improved as a result form 88 to 80. As such, she is in a good position and is accepting treatment positively. Candace still requires carefully monitoring to ensure her condition does not get out of hand.

Reflection

Caring for a patient requires great concentration on the part of any signs that can change and quick decisions on how to act on the changing conditions. Some of the vital aspects I have learnt are that the patient is continuously recovering and his situation can change any time. As such, the nurse should be on the lookout to ensure that he or she does not miss any signs. It has made me appreciate alertness and quickness of mind in dealing with patients and not to take anything for granted be it a slight change or a complaint by the patient. Some of the actions that prevented any worsening of the Candace condition were the administration of IV and monitoring the vital signs regarding him heart condition together with the fluids. The actions that I would consider in my future assignments are the administration of intravenous body fluids, change position of the patient and measure their weight. Furthermore, I will consider giving the patient oral fluids and analyzing serum checks together with reassuring the patient on his recovery. I consider taking such actions important since patients are mostly dependent on the care of the nurses and any unnoticed conditions will worsen the situation and therefore all actions as stated above need to be taken to note changes and to ensure the nurse acts promptly to ensure the patient recovers normally.

References

Kainu, J. P., Sarvela, J., Tiippana, E., Halmesmäki, E., & Korttila, K. T. (2010). Persistent pain after caesarean section and vaginal birth: a cohort study. International Journal of Obstetric Anesthesia, 19(1), 4-9.

Ardern, C. L., Webster, K. E., Taylor, N. F., & Feller, J. A. (2011). Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery two-thirds of patients have not returned by 12 months after surgery. The American journal of sports medicine, 39(3), 538-543.

Wloch, C., Wilson, J., Lamagni, T., Harrington, P., Charlett, A., & Sheridan, E. (2012). Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 119(11), 1324-1333.