Case Study (Placenta Previa) This is It!!! (1)

Republic of the PhilippinesTarlac State University

College of NursingLucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300

Tel. No.: 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph________________________________________________________________________

A Case Study on Placenta Previa

In Partial FulfillmentOf the Requirements of the Subject

NCM 101

Presented by:

BSN III Group A1

Abraham, Aliana Kristel P.Acena, Honey Lei

Aganon, Christian Lloric C.Aguinaldo, Ademar A.

Alfonso, Tracy Oliver T.Bautista, Ellein T.

Campana, Rhomyrose S.Canlas, Mary Ann M.Capian, Jeiel Ann D. Capuno, Michael M.

Cariaga, Miriam Thea Consuelo J.

Presented toMs. Gienelle Mallari, RN

1

http://www.tsu.edu.ph/

Table of ContentsI. Introduction………………………………………………………………………...1

Objectives………………………………………………………………………….5II. Nursing Process

A.Assessment1. Personal Data………………………………………………………….…….6

a)Demographic Data…………………………………………….……..6b)Environmental Status……………………………………….………..6c)Lifestyle………………………………………………………………7

2.Family History of health and Illness3. History of Past Illness…………………………………………….….………94.History of Present Illness…………………………………………….……….95.Physical Assessment...........................................................................................96.Diagnostics and laboratory Procedures………………………..…………….187.Anatomy And Physiology……………………………………...…………….198.Pathophysiology

i.Book-based……………………………………………..…………….24ii.Client-based…………………………………………..……………...26

B. Planning1. Nursing Care Plans………………………………………….……………..28

C.Implementation1.Medical Management

i.IVFs,BT,NGT feeding,Nebulization,TPN,Oxygen Therapy etc……36ii.Drugs………………………………………………………………..42iii.Diet…………………………………………………………………46iv.Activity/Exercise…………………………………………………...49

2.Surgical Management……………………………………………………….513.Nursing Management(SOAPIE)…………………………………………….53

D.Evaluation1.Patient’s Daily Program in the hospital……………………………………...602.Discharge Planning…………………………………………………………..61

III. Conclusion…………………………………………………………………………62IV. Recommendation…………………………………………………………………..62V. Bibliography……………………………………………………………………….63

INTRODUCTION

2

Placenta previa is a condition in which the placenta is located low in the uterine cavity,

partially or completely covering the opening of the cervix. This can cause bleeding and interfere

with a normal vaginal delivery. Placenta previa occurs in four degrees: implantation in the lower

uterine rather than in the upper portion of the uterus (low-lying placenta); marginal implantation

(the placenta approaches that of cervical os); implantation that protrudes a portion of the cervical

os (partial placenta previa and implantation that totally obstructs the cervical os (total placenta

previa). The degree to which the placenta covers the internal cervical os is generally estimated in

percentages 100%, 75%, 30% and so forth. Increased parity, advanced maternal age, past

cesarean births, post uterine curettage, multiple gestations, and perhaps a male fetus are all

associated with placenta previa.

The incidence of placenta previa is approximately 5 per 1,000 pregnancies. It is thought

to occur whenever the placenta is forced to spread to find an adequate exchange surface. An

increase in congenital fetal anomalies may occur if the low implantation does not allow optimal

fetal nutrition or oxygenation. The incidence of placenta previa in the United States is

approximately 0.5%, or 1 in 200 women. The maternal mortality rate is 0.03%. The retrospective

"Maternal Mortality Study" (1979-1986) showed that in 44 maternal deaths, placenta previa was

listed as an underlying obstetric condition contributing to death. This resulted in a case fatality

rate of .03%. The incidence of maternal death was 1 in 3,300 cases of placenta previa. There are

still no current trends about the medications and other diagnostic procedures in preventing and

curing placenta previa. Ultrasonography is still the basis of diagnosis but for patient with cases of

abdominal wall scarring, obesity, or an incomplete filled bladder, MR imaging reveals placenta

previa since in ultrasonography placenta previa may not be clearly seen due to blockage of cord-

placenta insertions or vessels over the cervix during visualization.

The group chooses this case because more clinical skills will be developed by

experiencing the clinical management of this disease-condition and it will enhance one’s

knowledge in implementing proper nursing intervention to the patient towards recovery.

IMPORTANCE OF THE CASE STUDY

3

One of the most perceived importance’s to conduct this study is to enable the student

nurses to practice the concepts and knowledge learned from the four-sided room to the actual

clinical setting. By this, the student’s knowledge, skills and experience will be enhanced. This

case study also provides ways to practice the nursing process which is the core of nursing

profession.

In relation with this case study is systematic in nature. It gives acquaintance to the

condition known as “Placenta Previa”. It allows the student to acquire specific information on

the said condition and able to obtain knowledge on what are the proper medical interventions

that should be done and the rationale for such procedure.

In a deeper sense, the case study wanted to be part of the development of self-care to

prevent the said condition and to achieve the optimal health of our patients in the future.

Objectives

4

Nurse Centered:

General:

To enhance the students skills, comprehension and approach in the practice of nursing

and be able to establish knowledge on the risk factors, prognosis nursing management, current

trends and incidence of the disease condition that was chosen.

Specific:

To come up with a comprehensive presentation of the disease condition by means of

correct presentation of the data gathered through the use of nursing process.

To present the current trends about the disease condition; the reason for choosing

such case for presentation; and the importance of the case study.

Patient Centered:

General:

To be able for the client to fully understand and recognize the disease condition,

emphasize the importance of making appropriate action and to guide the patient towards

recovery.

Specific:

To impart knowledge about the importance of healthy lifestyle.

To render proper nursing management and medical regimen needed by the patient.

To identify predisposing factors that aggregate the present condition of the patient.

II. NURSING PROCESS

5

A. ASSESSMENT

1. Personal Data

A. Demographic data

Date: August 27, 2009

Name: Mrs X Age: 35y/o

Sex: female Civil status: married

Occupation: none Religion: Roman Catholic

Role in the family: mother Address: Brgy. CV Tarlac City

Date & place of birth: July 11, 1974 Nationality: Filipino

Tarlac City

Source of referral: husband & other relatives

Usual source of care: albularyo

Admitting diagnosis or impression: G3P2 PUFT, Placenta Previa Totalis

B. Environmental Status

Upon interview, we have known that the patient and her family are presently residing in

Brgy. CV Tarlac City. They have been living in the said Barangay for twelve years. Their house

is a nipa hut located near the rice fields. They have a television set and a radio. Their source of

water comes from a water pump, which they used for drinking, washing clothes and the dishes.

The toilet they are using is not their own, it is owned by her parents who lives beside them. They

have pets in their house such as dog and cat. When it comes to garbage disposal, they use

burning system. Their mode of transportation is via public utility jeepney (PUJ) and their means

of communication is through cell phones.

Norms:

6

Most houses in a rural setting are made of light materials such as wood and other wood

materials while other houses are made of a combination of light and concrete materials. Toilet

facilities in this setting are most often water-sealed type. In rural areas, the water source usually

comes from wells and they make use of manual water pumps to extract water from the well.

People in the rural areas usually dispose of their garbage in a pit dug in their back yard. Garbage

collected inside the pit is either burned or covered in soil. A typical family in this kind of a

setting is composed of a father, mother and children. The father plays the role of the breadwinner

and decision maker while the mother takes care of the family’s well being. (COPAR book)

Analysis:

The patient’s house is a standard house made of light materials. Her family is made of the

father, mother and the children. The family is headed by the father who works and decides for

the family.

C. Lifestyle

Mrs. X usually wakes up between 6-7 AM., to prepare a breakfast for her daughter who goes

to school and to her husband who goes to work. . Their breakfast is usually composed of two

pieces pandesal, one cup of great taste coffee, one cup of rice and one piece of boiled egg. Mrs.

X eats a variety of foods such as banana fruits, malunggay, jute vegetables, and meats. She is

also fond of eating salty foods like fried peanuts and chicharong bulaklak. Mrs. X usually spends

her time cleaning their house, washing their clothes, cooking foods, and taking care of her two

children. Her life focuses on her family. After doing all the household chores, she will take a nap

or will stay outside their house taking care of her second child while having conversation with

her neighbors, but most of her time; she is just staying inside of their house and listening to the

radio or watching television. She denied having any vices like smoking and drinking alcoholic

beverages. The patient usually sleeps at around nine - ten o’clock in the evening, because she

always waits for the arrival of her favourite teleserye “tayong dalawa”

Norms:

An adult usually sleeps between a minimum of six to eight hours daily. In order to have a

healthy life style, eating the right kind of food is also necessary i.e. Grow, Glow and Go food

groups. “Smoking is dangerous to your health”, that is what the general surgeon’s warning

7

placed on the cover of cigarette packs. Regular exercise will keep you in good shape; it is

strongly advised that you exercise daily. (Nutrition and Diet therapy, 9th edition, Ruth Roth)

Analysis:

Mrs. X meets the six to eight hours sleep requirement for an adult however, her diet is not

ideal since she loves eating salty foods that are high in sodium. She should also improve her diet

with rich in proteins, calories and vitamins and minerals i.e. vegetables, fruits, milk, fish, lean

meat etc.

2. Family History of Health and Illness

See genogram – next page

8

GENOGRAM

9

83 8

0

60

49

30

49

63 5

855

53

49

90 8

4

35

37

12

26

29

24

11

623

22

18

15

11

AW

AW AW AW AW AW

AW AW AW AW AW AW

AW

AW

AW

AST

AST

AST

AST

OLD AGE HTN HTN

HTN SUICIDE HTN

GSW

LEGEND: - POINTS TO THE PATIENT AW – ALIVE & WELL HTN – HYPERTENSION AST – ASTHMA GSW –GUN SHOT WOUND -DECEASED FEMALE

- DECEASED MALENB- NEWBORN

- THE FAMILY HAS A HISTORY ASTHMA AND HYPERTENSION.- THEY DON’T HAVE ANY COMMUNICABLE DISEASES.

4 NB

AW

3. History of Past Illness

During her childhood, Mrs. X had chickenpox. She often had cough, colds and fever.

They have a history of hypertension and asthma. She has a complete vaccination status as a child

but she only received 2 doses of tetanus toxoid vaccine during her pregnancy.

According to the patient, her first child was delivered in the house by a “hilot” while her

second child was delivered in Tarlac Provincial Hospital via NSD. She told us that if she can

tolerate the pain, she would like to have her second baby delivered in their house but the pain is

unbearable that is why they rushed her to the hospital last four years ago.

4. History of Present Illness

The patient claimed that her Expected Date of Delivery is August 22, 2009. She was

alarmed because her baby is still inside her womb and it already exceeded her due date. August

27, 2009, she woke up at around 5 am and she noticed a slight vaginal bleeding as she went to

the comfort room. That added to her worries but she didn’t feel any contractions.

Her husband and other elatives decided to bring her to the hospital and they found out

that the placenta is coming out first. The doctors told them that Mrs. X needs to undergo

caesarean delivery, and so that is what happened.

5. Physical Assessment

1. Social Status

The patient is 35 year old and currently living with her husband and two children on her

parents’ compound at Brgy. CV, Tarlac. According to her, in their family they have good

communication and relationship. Each family member perform their respected roles such us her

husband works as a farmer to finance their family needs. She also stated that whenever one of the

family members has a health or any problem the whole family as well as the relatives were

always there to give support. She also denies any conflict among the family members as well as

the family resources.

Norms:

Family members should perform their roles. Good communication within the family must

be maintained to obtain a healthy relationship with one another. Social support is a perception

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that one has an emotional and tangible resource to call on when needed; perceived social support

is being followed by the family to express the love and care to the family. Financial aspect is one

of the normal constraints in the family.(Kozier, Copyright 2004)

Analysis:

The patient receives social support from the family and relatives. They have good

communication and harmonious relationship. The family does not experience any problem

with regards to the living.

2. Mental Status

Level of consciousness

Upon receiving the patient, we noticed that she is weak but conscious about what is

happening around her. We conducted our interview after five hours, to allow her to have her rest.

The client responds to the questions that were asked. She gives appropriate answers to the

questions and she even smiles when her needs are being given. She can recall the names of all

her relatives present in the hospital. She knows about her condition and she is well-oriented

about the place she is in.

Norms:

Level of Consciousness determines whether a person is oriented to the things that are

happening. Response to verbal stimuli indicates that the patient is oriented to the place he or she

is in. (Kozier, Copyright 2004)

Analysis:

The patient is well oriented and responds appropriately with questions that were asked to

her.

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Mood

During the interview, the patient responds well to the questions. She also appears to be

irritable and sleepy.

Norms:

Moods are dependent on a person’s view of what is happening around him for example

person who is lacking of sleep may not be approachable. (Kozier, Copyright 2004)

Analysis:

The client still manages to answer all of the questions that were asked to her in spite of

her condition. Her irritability is well understood because she is in pain.

Thought processes and perception

The patient can still identify what is reality. She can express her thoughts freely and she

even shared some of her point of view about her condition. She told us that what is happening

right now is God’s will and it is only a trial in life that will make her stronger.

Norms:

Thought processes is the person’s ability to identify the reality from not. Feelings need to

be explored to determine whether they are based on reality or interpretations memories or fears.

(Kozier, Copyright 2004)

Analysis:

The patient is still in the right state of mind since she still knows what is reality from not,

as she talked to us about things that really happens in reality.

Cognitive Abilities

The client is well oriented on the place, time, and date. She is also aware of her condition.

She responded well on the neurological tests that were performed during the interview but she

was not able to do the Romberg’s Test because she she is still too weak to stand.

12

Norms:

Clients undertaking a Romberg’s test should be able to stand upright while the eyes

closed then with eyes open. It is a negative Romberg if the client sways slightly but is able to

maintain upright posture. It is positive if the client cannot maintain an upright position. (Kozier,

Copyright 2004)

Analysis:

The client’s full awareness indicates that she is not having problems when it comes to his

cognitive abilities. Her failure to do the Romberg’s test is due to her condition so it is not an

accurate test for her cognitive abilities.

3. Emotional Status

The client states that she knows her condition. She knows the things that may happen if

she was not given proper treatment. Though she shows fear about the incision in her abdomen,

she is still calm. She even stated that whatever may happen is according to God’s plan. She

shows a positive outlook in life by stating that each problem that she may encounter has a

corresponding solution.

Norms:

A person’s emotional status depends much on his ability to cope up with the happenings

in his/her life. He or she may not be in the right mood if some unnecessary things had happened.

(Nursing CEU.com: The process of human development)

Analysis:

The patient has a stable emotional status and can handle her emotional status in spite of

her condition.

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4. SENSORY PERCEPTION

Sense of taste

The patient can determine taste. As she verbalized “mapait yung ininom kong tsaa

kanina”. No lesions or abnormalities were found in the tongue and oral cavities and it is

symmetrical.

Norms:

Normal sensation would be accurate perceptions of sweet, sour, salty, and bitter taste.

(Estes, Third edition, Copyright 2006)

Analysis:

Since the diet of the patient is restricted and she is only allowed to eat crackers, drink tea

and take sips of water, the tea was our basis about her normal sense of taste.

Auditory Activity

Hearing test was performed in the patient to check if she has a good auditory acuity. We

whispered words 3 inches away from her, she was able to repeat the words correctly and clearly

as we asked her to repeat it; we call her name and claimed that she clearly heard us about 10 and

20 feet away. She was able to answer our question correctly. No bleeding, wounds found on her

external ear.

Norms:

Patient should hear whispered words or watch tick test and ear must free from lesions and

masses. (Estes, Third edition, Copyright 2006)

Analysis:

The patient’s auditory sense is intact and has no problem.

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Sense of Smell

She can distinguish different odors. She was able to differentiate the smell of a cologne,

and alcohol that we provided. Her nose lies on the midline of her face and it is symmetrical and

nostrils are intact, no bleeding and wounds found.

Norms:

Patient must able to identify different smell; nose should be at the midline position of the

face, free from lesions and intact nostrils. (Estes, Third edition, Copyright 2006)

Analysis:

The patient’s sense of smell has no problem.

Sense of Sight

We asked her to read the sentence with different sizes of letters, and we found out that

she has no difficulty in reading. We also observed her if she had difficulties in identifying far

objects, we found out that she does not have any difficulty in identifying far objects. Her external

eyes are symmetrical, no lesions and bleeding found.

Norms:

The patient who has a visual acuity of 20/20 in a Snellen chart test is considered to have a

normal visual acuity. (Estes, Third edition, Copyright 2006)

Analysis:

Her visual acuity has no problem.

Pain Sensation

The patient is experiencing pain in the incision site at her abdomen. We ask her to rate

the pain from 1 to 10 and she rated it 10. We pinched her skin to assess her sensitivity to pain;

she was able to feel it as claimed.

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Norms:

Reacting with a stimulus is a sign of good sensation. (Estes, Third edition, Copyright

2006)

Analysis:

The patient’s pain sensation is active and it is a good indication which means the nerve

endings of the patient reacts to the stimulus which has caused the sensation.

MOTOR STABILITY

The client was in a bed rest so her walking gait was not assessed.

Norms:

Normal motor stability includes the ability to perform the different steps in doing range

of motion. It should be firm with smooth and coordinated movements (Estes, Third edition,

Copyright 2006)

Analysis:

The patient’s motor stability should be present after a day or two. It should start at

turning side to side and gradually increasing mobility. At her second day, she should be able to

sit and on the third day, ambulate with assistance at first.

6. BODY TEMPERATURE

Upon assessment she was not warm to touch neither cool to touch.

The following body temperatures were obtained:

DATE TIME TEMPERATURE (◦C)

August 27, 2009 8:00am 36.2

10:00am 36.7

August 28, 2009 8:00am 37.1

10:00am 37.6

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Norms:

36.5 C to 37.5 ◦C is the normal body temperature (Kozier, Seventh edition, Copyright

2004)

Analysis:

The patient has a normal body temperature. This may indicate the absence of infection

with a normal WBC count.

7. RESPIRATORY STATUS

The patient has undergone O2 Therapy during her first day. It is regulated at 2 lpm.

Respiration is slightly elevated.

Table below shows the respiratory rate of the patient.

Date Time Respiratory Rate

August 27, 2009 8 am 24 cpm

10 am 24cpm

August 28, 2009 8 am 25 cpm

10 am 20 cpm

Norms:

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of pattern,

normal respiration must be regular and even in rhythm. The normal depth of respirations is none

exaggerated and effortless (Health Assessment and Physical Examination 3rd Edition Mary Ellen

Zator Estes).

Analysis:

The patient’s body is trying to compensate with the pain she is experiencing which made

her respiratory rate elevated. She also has a decreased blood volume due to her surgery which

made her body demand for more oxygen.

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8. CIRCULATORY STATUS

The patient nail color turns back within 2 seconds and she has no edema.

However, her pulse is weak and thready on the first day.

The following pulse rate and blood pressure were obtained:

DATE TIME PULSE

(bpm)

BLOOD

PRESSURE

(mmHg)

August 27, 2009 8:00am 56 130/100

10:00am 56 130/90

August 28, 2009 8:00am 63 120/80

10:00am 58 130/80

Norms:

The average heart rate and blood pressure of an adult are 60-120bpm and 120/80mmHg.

No edema should be observed on the extremities because it indicates venous insufficiency

(Kozier, Seventh edition, Copyright 2004). The normal range of capillary refill test is within 2-3

sec.(Estes, Third edition, Copyright 2006)

Analysis:

With regard to her circulatory status, it shows that her pulse rate was quite decreased l

and her blood pressure was slightly elevated. She also has sufficient venous return and normal

capillary refill.

9.) NUTRITIONAL STATUS

The client claimed to us that her weight is 55 kg before she got pregnant. Since we did

not have the chance to weigh her, we just assumed that her current weight is not that far from her

pre-pregnant weight. She told us that she eat 3 times a day. She loves to eat “adobong manok”

Her family has the ability to provide her nutritional needs. She has no known food and drug

allergies and her body mass index (BMI) was 22.8. But upon her admission in the OB ward, the

Doctor ordered an NPO diet for 8 hours post-op due to her surgery. After that, she was on a

liquid diet which composed of: sips of water, tea, and crackers. This will be changed on her third

day with a soft diet and then DAT.

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Norms:

BMI is a measurement that indicated body composition. The degree of overweight or

obesity as well as the degree of underweight can be determined. (Estes, Third edition, Copyright

2006)

Standard Body Mass Index for Adults

Underweight = <18.5

Normal weight = 18.5-24.9

Overweight = 25-29.9

Obesity = BMI of 30 or greater

Analysis:

The patients’ family has the capability of providing her nutritional needs, as evidenced by

the patients’ normal body mass index measurement. Due to her present condition, the patient is

in a restricted diet which is not normal. But it should go back to normal after her confinement.

10. ELIMINATION STATUS

The patient usually defecates one to two times a day, brown in color, and soft but formed.

She also urinates once every two hours. But upon admission at the OB ward, she was not able to

defecate for two days because she was on NPO status and she also has an indwelling foley

catheter. Two underpads were used on her first day and one during her second day.

Norms:

Normal bowel movement is usually 2-3 times a day which help in elimination of

unnecessary waste material in the body in the GI tract. It should be soft but formed and brown in

color. Urine output of an adult is usually 1200-1500mL per day. (Kozier Seventh edition,

Copyright 2004)

Analysis:

The patient has regular bowel and has normal urinary elimination status before she was

admitted in the hospital. But upon admission, her regular bowel movement was altered due to her

NPO status. This should return in normal after her NPO and liquid die

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11. REPRODUCTIVE STATUS

According to the patient, her menarche was 12. Her menstrual period is regular and she

usually consumes 2-3 pads a day for the first 3 days of her menstruation and 1-2 pads for the last

2 days. She was taking pills before she got pregnant to her third child. She was 23 when she gave

birth to her first child and as claimed, it was in their home where she gave birth with the help of a

“hilot”. While on her second child, she was 31 and gave birth at Tarlac Provincial Hospital via

NSD. For her last baby, she delivered it via caesarean section. All of her child are breast fed and

she plans to breastfeed her youngest too. She denied any complications on her pregnancy over

her first and second child. It was only this third time of her delivery wherein she experienced

such complication. There were no regular check-up done during her entire pregnancy and as

claimed, she only visited in the health center once.

Norms:

Sexual activity/status can be determined through the presence or absence of sexual urge.

Age is also one of the factors that affect one’s reproductive status because of the hormonal

changes. (Maternal and Child Health Nursing, Fourth Edition by Piliterri)

Analysis:

The patient has a normal reproductive status in terms of her menstruation. But there was a

deviation in terms of her last pregnancy.

12.) STATE OF PHYSICAL REST AND COMFORT

Before admission, the patient usually slept at 9-10:00pm and woke up at around 6:00am

to do the house chores and cook breakfast for her family. But upon admission in the hospital she

could not sleep properly because of the environmental stimulus.

Norms:

A normal sleep hours of an adult per day is 6 - 8 hours without being disturbed (Kozier,

Seventh edition, Copyright 2004)

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Analysis:

The patient has adequate rest and sleep. But this was altered when she was admitted in

the hospital. This indicates that she has an abnormal sleep and rest upon her admission.

13. STATE OF SKIN APPENDAGES

The patient skin was light brown and uniform in color. There is incision present in her

lower abdomen; the dressing is dry and intact. An indwelling foley catheter is inserted and she

also has an intravenous fluid on her right arm regulated at 15gtts/minute, infusing well. During

her 3 hours post-op state, she also had an O2 therapy regulated at 2 lpm. The scalp has no flakes

and free from lesions. The hair was properly distributed, black and free from infestations. Nails

are in normal angle of 160o characterized as intact but pale in color and no lesions found. No

bleeding or wounds found in the extremities.

Norms:

Skin varies from light to brown from ruddy pink to light pink. Generally, uniform except

in areas exposed to the sun, areas of lighter pigmentation in palms, nail beds, and lips. The hair

should be evenly distributed, thick, shiny and free from infestation. The nails should be 160◦ and

smooth in texture. (Kozier, Seventh edition, Copyright 2004)

Analysis:

The patient indicates that she has normal skin and appendages except for the incision she

had due to the surgery and to the intravenous line present on her right arm.

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5. Diagnostic and Laboratory Procedures

Diagnostic/

Laboratory

Procedures

Date

Ordered and

date Result/s

In

Indication/s

or Purposes

Result/s Normal

Values

(Units used

in the

Hospital)

Analysis and

Interpretation

of results

CBC

>WBC

>Hgb

August 27

2009 –

August 28,

2009

August 27,

2009

August 27,

2009

CBC is used

as a broad

screening test

to determine

disorder as

anemia.

This is used

to determine

if there is

infection

present.

N/A

7.5

80

N/A

4.1 – 10.9

g/dL

F (123-153

g/L)

N/A

Normal

>No indicative

abnormalities

noted.

Abnormal due

to bleeding.

>If

hemoglobin is

low, there is

not enough

oxygen in the

blood.

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>Hct August 27,

2009

A measure of

the packed

cell volume

of red cells,

express as a

percentage of

the total

blood

volume.

0.266 F(0.359-

0.466 vol%)

Abnormal due

to bleeding

and blood loss

during surgery.

>If hematocrit

is low, there is

decreased

blood volume.

In caesarean

delivery there

is 500-

1000mL blood

loss.

NURSING RESPONSIBILITIES:

Before:

Determine the clients understanding of the procedure

Determine the clients response to previous testing

During:

Ensure client’s comfort until the procedure will be done

After:

Document the method of testing and results on the clients record

Immediately reached the blood sample on the laboratory

Follow-up result from laboratory

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6. Anatomy and Physiology

Anatomy and Physiology of Female Reproductive System

INTERNAL FEMALE ORGANS

The internal organs of the female consists of the

uterus, vagina, fallopian tubes, and the ovaries

(see figures 1-1 and 1-2).

a. Uterus. The uterus is a hollow organ about the

size and shape of a pear. It serves two important functions: it is the organ of menstruation

and during pregnancy it receives the fertilized ovum, retains and nourishes it until it

expels the fetus during labor.

i. Location. The uterus is located between the urinary bladder and the rectum. It is

suspended in the pelvis by broad ligaments.

ii. Divisions of the uterus. The uterus consists of the body or corpus, fundus, cervix,

and the isthmus. The major portion of the uterus is called the body or corpus. The

fundus is the superior, rounded region above the entrance of the fallopian tubes. The

cervix is the narrow, inferior outlet that protrudes into the vagina. The isthmus is

the slightly constricted portion that

joins the corpus to the cervix.

iii. Walls of the uterus (see figure 1-3).

The walls are thick and are composed

of three layers: the endometrium, the

myometrium, and the perimetrium. The

endometrium is the inner layer or

mucosa. A fertilized egg burrows into the endometrium (implantation) and resides

there for the rest of its development. When the female is not pregnant, the

endometrial lining sloughs off about every 28 days in response to changes in levels

of hormones in the blood. This process is called menses. The myometrium is the

smooth muscle component of the wall. These smooth muscle fibers are arranged. In

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longitudinal, circular, and spiral patterns, and are interlaced with connective tissues.

During the monthly female cycles and during pregnancy, these layers undergo

extensive changes. The perimetrium is a strong, serous membrane that coats the

entire uterine corpus except the lower one fourth and anterior surface where the

bladder is attached.

b. Vagina.

i. Location. The vagina is the thin in walled muscular tube about 6 inches long

leading from the uterus to the external genitalia. It is located between the bladder

and the rectum.

ii. Function. The vagina provides the passageway for childbirth and menstrual flow; it

receives the penis and semen during sexual intercourse.

c. Fallopian Tubes (Two).

i. Location. Each tube is about 4 inches long and extends medially from each ovary to

empty into the superior region of the uterus.

ii. Function. The fallopian tubes transport ovum from the ovaries to the uterus. There

is no contact of fallopian tubes with the ovaries.

iii. Description. The distal end of each fallopian tube is expanded and has finger-like

projections called fimbriae, which partially surround each ovary. When an oocyte is

expelled from the ovary, fimbriae create fluid currents that act to carry the oocyte

into the fallopian tube. Oocyte is carried toward the uterus by combination of tube

peristalsis and cilia, which propel the oocyte forward. The most desirable place for

fertilization is the fallopian tube.

d. Ovaries (2) (see figure 1-4).

i. Functions. The ovaries are for oogenesis-the production of eggs (female sex cells)

and for hormone production (estrogen and progesterone).

25

ii. Location and gross anatomy. The ovaries are about the size and shape of almonds.

They lie against the lateral walls of the pelvis, one on each side. They are enclosed

and held in place by the broad ligament. There are compact like tissues on the

ovaries, which are called ovarian follicles. The follicles are tiny sac-like structures

that consist of an immature egg surrounded by one or more layers of follicle cells.

As the developing egg begins to ripen or mature, follicle enlarges and develops a

fluid filled central region. When the egg is matured, it is called a graafian follicle,

and is ready to be ejected from the ovary.

EXTERNAL FEMALE GENITALIA

The external organs of the female reproductive system include the mons pubis, labia majora,

labia minora, vestibule, perineum, and the Bartholin's glands. As a group, these structures that

surround the openings of the urethra and vagina compose the vulva, from the Latin word

meaning covering. See Figure 1-6.

a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with

thick coarse hair.

b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are the 2

elongated hair covered skin folds. They enclose and protect other external reproductive organs.

c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They

protect the opening of the vagina and urethra.

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d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the vaginal introitus.

The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is

sexual excitation.

The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular

structure that drains urine from the bladder.

The vaginal introitus is the vaginal entrance.

e. Perineum. This is the skin covered

muscular area between the vaginal

opening (introitus) and the anus. It aids

in constricting the urinary, vaginal, and

anal opening. It also helps support the

pelvic contents.

f. Bartholin's Glands (Vulvovaginal

or Vestibular Glands). The Bartholin's

glands lie on either side of the vaginal

opening. They produce a mucoid

substance, which provides lubrication

for intercourse.

PLACENTA PREVIA

Placenta previa is hemorrhage resulting from the low implantation of the placenta on the interior

uterine wall. It is common in multiparous mothers. The cause is unknown.

There are three types of placenta previa. Each type is identified according to the degree to which

condition is present (see figure 1-5).

Total placenta previa. This occurs when the placenta completely covers the internal os.

Partial placenta previa. This occurs when the placenta partially covers the internal os.

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Low implantation of placenta previa. This occurs when the placenta is attached at the opening

or border to the cervical os, but not covering it.

Pathophysiology of Placenta Previa (Book-based)

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Modifiable factors:Women who smokes

Nonmodifiable factors:MultiparityMultiple gestationPrevious cesarian Birth

Pregnancy

Uterine Atrophy

Abnormal Vascularization of Endometrium

Low Placental implantation (2nd and 3rd

Implantation in Low uterine

Placenta Previa

Total Low-lying

Uterine Contraction

Decrease Uterine blood

flow

Partial

Cervical dilation

Cover internal OS

Disrupted Placental attachment

Malpresentation of fetus

Bright red vaginal bleeding


Tachypnea

Blood loss

Decrease blood Volume

Hypovolemia

Hypotension

Pallor

Cold Clammy

Skin

Compensatory mechanism

Tachycardia

Decrease Uterine blood flow

Pathophysiology of Placenta Previa (Client-based)

30

Decrease fetal oxygen supply

Fetal distress

Decrease kidney perfusion

Decrease Urine output

Decrease capillary refill

IUGR

Preterm Labor

Congenital anomalies

31

Nonmodifiable factors:MultiparityMultiple gestationAdvance maternal Age

Pregnancy

Uterine Atrophy Abnormal Vascularization of Endometrium

Low Placental implantation (2nd and 3rd trimester)

Implantation in Low uterine

Placenta Previa

Tota

Cervical dilation

Cover internal OS

Malpresentation of fetus

Disrupted Placental attachment


32

Tachypnea

Blood loss

Decrease blood Volume

Hypovolemia

Hypotension

Pallor

Cold Clammy

Skin

Compensatory mechanism

Tachycardia


B. Planning Date/time: August 27,2009/8:00 am

33

CUES SCIENTIFIC EXPLANATION

NURSING DX

PLANNING INTERVENTION & RATIONALE EVALUATION

S: >“Masakit ang tahi ko sa may puson.”Pain Scale: 10/10O: >weak in appearance>restless and irritable>pale looking>tachypnea:RR:24 cpm >grimace

Post-operative pertains to the period of time after surgery. It begins with the patient’s emergence from anesthesia and continues through the time required for the acute effects of the anesthetic and surgical procedures to abate.

Acute Pain r/t surgical incision.

After 30 minutes of proper nursing intervention, the patient will verbalize decreased in pain to a tolerable state. From a pain scale of 10 to 2.

>Build rapport with the patientR: This is to gain trust by the patient, thus making working relationship comfortable for both the nurse and the patient. >Place ice pack at the incision site.R: To reduce the pain and to prevent hemorrhage by keeping the fundus contracted.>Encourage the patient to do breathing exercises.R: This will promote good oxygenation, therefore promote good tissue perfusion.>Provide emotional support by encouraging the patient to verbalize what she feels.R: This is to increase patient’s self-worth.>Assist the patient when turning side to side.R: The client is still weak and needs assistance by the nurse. Turning side to side every 2 hours promote lung expansion and it prevents complications like pressure ulcers and aspiration pneumonia.>Administer analgesics as ordered by the physician.R: To eradicate, if not, reduce/decrease the pain.

After 30 minutes of proper nursing intervention, the patient will verbalize decreased in pain to a tolerable state. From a pain scale of 10 to 2. AEB:a.) Absence of grimaceb.) Normal respiration. RR:17cpm

Date: August 28, 2009


NURSING DX


S: ØO:>with surgical incision at the lower abdomen>inability to sit>difficulty turning to side >weak in appearance>restless and irritable>pale looking>tachypnea:RR:24> grimace

Post-operative discomfort felt by the client after the anesthesia has subsided causes pain and will lead decreased client’s tolerance to activity

Impaired physical mobility r/t surgical incision.

After 30 minutes of proper nursing intervention, the patient will be able to gradually increase mobility.

>Build rapport with the patientR: This is to gain trust by the patient, thus making working relationship comfortable for both the nurse and the patient. >Assist patient in turning side to side every 2 hours.R: Turning side to side is important to promote lung expansion and to prevent complications like pressure ulcers and aspiration pneumonia.>Provide emotional support by encouraging the patient to verbalize what she feels.R: This will increase the patient’s self-worth.>Instruct the patient to do breathing exercises.R: This will help alleviate the pain and will promote good oxygenation, therefore promote good tissue perfusion.>Administer analgesics as ordered by the physician.R: To eradicate, if not, reduce/decrease the pain.

After 30 minutes of proper nursing intervention, the patient will be able to gradually increase mobility by turning side to side.AEB:a.) Absence of grimaceb.) Ability to turn side to side with minimal assistance.

34

DATE

CUES SCIENTIFIC EXPLANATIO

N

NURSING DX

PLANNING

INTERVENTION & RATIONALE

EVALUATION

August 27, 2009

S: Ø O:>have no oral intake for the

last 8 hours

>chapped lips

>dry mouth

>with surgical incision at

the lower abdomen

>consumed 2 underpad for

the last 24 hours

>weak in

appearance

>restless and irritable

>pale looking

>grimace

>tachypnea: RR=24

>bradycardia: PR=56

>HCT=0.266%

>HGB=80g/L

Heavy bleeding may double for the postpartum woman, because she may haemorrhage vaginally from an uncontracted uterus as well as internally from blood vessels that were not securely ligated

Deficient fluid volume r/t blood loss during surgery

After 1 hour of proper nursing intervention, the patient will maintain fluid balance in a functional level as evidenced by:a. Patient’s

blood pressure is 100/60 mmHg or higher

b. Pulse re-mains be-tween 60 and 100 bpm

c. Scant to no bleed-ing on sur-gical dressing is

Independent:1. Monitor Vital signs of client’s with deficient fluid volume every 4hrs. Observe for tachycardia, tachypnea, decreased pulse pressure first, then hypotension, decreased pulse volume, and increase/decrease body temperature.

®Decrease pulse pressure is an earlier indicator of shock than is the systemic blood pressure. Decrease intravascular volume results in hypotension and decreased tissue oxygenation. The temperature will be decreased as a result of decreased metabolism, or it may be increased if there is a infection or hypernatremia.

2. Advise client to have frequent oral hygiene, at least twice a day.

After 1 hour of proper nursing intervention, the patient will maintain fluid balance in a functional level as evidenced by:a. Patient’s blood pressure is 100/60 mmHg or higherb. Pulse remains

between 60 and 100 bpm

c. Scant to no bleeding on surgical dressing is apparent

35

>urine output=30 cc/hr

>Capillary refill=3sec

apparent ®Oral hygiene decreases unpleasant taste in the mouth and allows the client to respond to the sensation of thirst.

Collaborative3. Encourage patient to drink prescribed fluid amounts

®This provides water for replacement of intravascular or intracellular volume as necessary.

4. Hydrate the client with ordered intravenous solution

®Intravenous route is one of the fastest ways to deliver fluids and medications throughout the body.

5. Maintain Patent IV access, set an appropriate infusion flow rate and administer at constant rate as ordered.

® Isotonic IVF such as 0.9% Normal Saline or Lactated Ringer’s allow replacement of Intravascular volume.

36

DATE


NURSING DX

PLANNING INTERVENTION & RATIONALE

EVALUATION

August 29, 2009

S: “Hindi ko magalaw ang paa ko.”

O:-Weak in appearance

-Pale

-With limited

movements

-Difficulty

raising/flexing the legs

-Weak peripheral

pulses

-Capillary refill =

3seconds

Because a woman’s abdominal muscles are lax from the stretching that occurred during pregnancy, abdominal contents tend to shift forward and put pressure on the suture line when she is sitting or standing, causing pain and uncomfortable feeling.

Risk for ineffective tissue perfusion r/t immobility after surgery

After 1 hr of proper nursing intervention, the client will maintain a capillary refill of less than 5 seconds and will not report of calf pain, redness, edema, or areas of warmth on lower extremities

Independent1. Assist patient in turning from side to side every 1-2 hours

®Turning helps in venous stasis, thrombophlebitis, pressure ulcer formation and respiratory complication.

2. Assist client in extremity exercise.

® Helps to prevent circulatory problem by facilitating venous return to the heart.

3. Early ambulation should be encouraged whenever appropriate.

® Early ambulation are a woman’s best safeguards against lower extremity circulatory problems

4. Encourage deep breathing and coughing exercise

After 1 hr of proper nursing intervention, the client will maintain a capillary refill of less than 5 seconds and will not report of calf pain, redness, edema, or areas of warmth on lower extremities

37

® This promotes optimal lung ventilation and perfusion.

5. Ensure that bedcovers must be loose enough

® Permits free movements of the toes and feet

38

Assessment Diagnosis Scientific Explanation

Planning Interventions Rationale Evaluation

S: Ø

O: blood loss-

consumed 1 soaked underpad

UO- 30cc/hr HGT-

0.266% HGB-80 g/L Pale Dyspnea Weak in

appearance Weak and

thready 56 bpm-PR Restless and

irritable RR: 24-

Risk for Injury r/t blood loss during surgery

Due to large amounts of blood loss, there are possible conditions that may occur, and patient with hemorrhage have altered level of consciousness.

Within 2 hours of proper nursing interventions, the patient will have decreased risk for injury.

Monitor vital signs every 15 minutes

Assist the client in a comfortable position par-ticularly in Semi-Fowler’s or High Fowler’s position.

Encourage the client to ver-balize her feelings and worries.

To identify if there are changes in the normal ranges and to monitor if interventions have helped normalized the client’s status.

To promote lung expansion and facilitate gas exchange.

To determine the other signs and symptoms felt by the client and to know the appropriate nursing interventions to be done.

Within 2 hours of proper nursing interventions, the patient was able to have a decreased risk for injury.

39

Increase fre-quent obser-vation , and if possible, stay with the client and enforce security mea-sures (e.g Raise side rails)

Encourage the client to have bed rest.

Advise the client to in-crease fluid intake.

Administer medications as prescribed.

To prevent the client from accidentally falling or other cause of injury.

To conserve energy and feel relaxed.

To replace lost fluid and electrolytes.

To facilitate faster healing and management.

40

Subjective Objective Analysis Planning Implementation EvaluationØ blood loss-


UO- 30cc/hr HGT-


appearance Weak and


irritable RR: 24-



Monitored vital signs every 15 minutes

Assisted the client in a com-fortable position particularly in Semi-Fowler’s or High Fowler’s position.

Encouraged the client to ver-balize her feelings and wor-ries.

Increased frequent observa-tion , and if possible, stay with the client and enforce security measures (e.g Raise side rails)

Encouraged the client to have bed rest.

Advised the client to increase fluid intake.

Administered medications as prescribed by the physician.

After 2 hours of proper nursing interventions, the patient was able to have a decreased risk for injury.

C. Implementation

41

1. Medical Management

i. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy etc.

Medical Management/Treatment

Date Ordered/ Date Taken/Given

Date Changed/ Date Discontinued

General Description Indication/s, Purpose/s Client's reaction to the treatment

IV Therapy

1L LRS (isotonic) with oxytocin regulated at 15 gtts/min

1L D5 NM (hypertonic) regulated at 30 gtts/min

1L D5 LRS (hypertonic) regulated at 30 gtts/min

1L D5 NM (hypertonic) with 1 amp Moriamin regulated at 30 gtts/min

Started on August 27, 2009, discontinued on the same date

August 27, 2009-August 28, 2009

Started on August 28, 2009 discontinued on the same date

August 28, 2009- august 29, 2009

IV Therapy is the giving of liquid directly into a vein.

IV Therapy is usually performed for fluid volume maintenance, fluid volume replacement, medication administration, blood administration, total parenteral nutrition and serves as an emergency line

The patient did not reported pain in the IV site

Prior:

42

> understand why the therapy is needed.

> determine potential outcomes for the client

> understand the fluid and electrolyte and acid base status of the client

> provide an explanation to the client and gain cooperation

> select the appropriate IV set

During:

> assess the following:

a. right intravenous fluids infusing

b. right intravenous fluids for the client

c. date on the tubing

d. right rate according to the rate prescribed and the clients condition

e. absence of kinks in the tubing that could result in occlusion of the fluid flow

f. date on the intravenous access device

g. insertion site and vein access for evidence of pain, redness, warmth, or coolness, and swelling

After:

> discard the administration set accordingly

>document relevant data.

Medical Management/Treatm

Date Ordered/ Date Taken/

General Description Indication/s, Purpose/s Client's reaction to the treatment

43

ent GivenDate Changed/ Date

Discontinued

Oxygen Therapy

2 Lpm for 3 hoursvia nasal prong

August 27, 2009

Oxygen therapy is any procedure in which oxygen is administered to a patient to relieve hypoxia.

Clients who have difficulty ventilating all areas of their lungs, those whose gas exchange is impaired, or people who have heart failure may require oxygen therapy to prevent hypoxia.

The patient tolerated the administered oxygen and verbalized relief from DOB

Prior:

>determine the need for oxygen therapy, and verify the order for the therapy.

>perform a respiratory assessment to develop baseline data if not already available.

>inform the client and support people about the safety precautions connected with oxygen use such as:

a) avoiding materials that generate static electricity, such as woolen blankets and synthetic fabrics.

b) avoiding the use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone.

> provide an explanation to the client and gain cooperation.

>assist the client to a semi-Fowler’s position.

>set up the oxygen equipment and the humidifier

During:

44

>check that the oxygen is flowing freely from the tubing. There should be no kinks in the tubing, and the connections should be

airtight. There should be bubbles in the humidifier as the oxygen flows through. Feel the oxygen at the outlets of the cannula.

>monitor the level of water in the humidifier.

>set the oxygen at the flow rate ordered.

>if the cannula will not stay in place, tape it at the sides of the face.

After:

>report significant deviation such as tracheal irritation and coughing, dyspnea, and decreased pulmonary ventilation.

Medical Date Ordered/ Date General Description Indication/s, Purpose/s Client's reaction to

45

Management/Treatment

Taken/Given

Date Changed/ Date Discontinued

the treatment

Urinary Catheterization

August 27, 2009-August 28, 2009

Urinary Catheterization is the introduction of a catheter through the urethra into the urinary bladder

Indications of urinary catheterization includes relief from discomfort due to bladder distention or to provide gradual decompression of a distended bladder, to empty the bladder completely prior to surgery, to facilitate accurate measurement of urinary output for critically ill clients whose outputs need to be monitored hourly, to prevent urine from contacting an incision after perineal surgery.

The client didn’t verbalize any discomfort and have adequate (>30cc/hr), amber colored urine output.

Prior:

> Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as total

amount of urine to be removed and size of catheter to be used.

>use an indwelling catheter if the bladder must remain empty or continuous urine measurements/collection is needed.

> Assess the client’s overall condition. Determine if the client is able to cooperate and hold still during the procedure and if the client

can be positioned supine with head relatively flat.

> Determine when the client last voided or was last catheterized.

>Percuss the bladder to check for fullness or distention.

46

During:

>Ensure that there are no obstructions in the drainage. Check that there are no kinks in the tubing, the client is not lying on the tubing,

and the tubing is not clogged with mucus or blood.

>Check that there is no tension on the catheter or tubing, that the catheter is securely taped to the thigh, and that the tubing is fastened

appropriately to the bedclothes.

>Ensure that gravity drainage is maintained. Make sure that there are no loops in the tubing below its entry to the drainage receptacle

and that the drainage receptacle is below the level of the client’s bladder.

>Ensure that the drainage system is well-sealed or closed. Check that there are no leaks at the connection sites in open systems. Apply

water proof tape around the connection site of the catheter and tubing.

>Observer the flow of the urine every 2-3 hours, and note color, odor and any abnormal constituents. If sediments are present, check

the catheter more frequently to ascertain whether it is plugged.

After:

>Conduct appropriate follow-up such as notifying the primary care provider the catheterization results.

> Performed a detailed follow-up based on findings that deviated from normal for the client.

> Relate findings to previous assessment data if available.

47

ii. Drugs

Name/s of drugs (generic and brand

name)

Date ordered/Date taken/

Date changed

Route of administration &

dosage & frequency of

administration

Mechanism of action

Indication/sPurpose/s

Client’s response to medication with actual side effect

Generic Name:Cefuroxime Sodium

August 27-28, 2009 750 mg, IVF q 8 hours

It is a anti- infective drug and its main action is combat the preset bacteria and inhibit increased growth.

Low respiratory infections, Pharyngitis or tonsillitis

The client did not exhibit any adverse reactions from the drug

Before: check the expiration date of the drug check the doctor's order assess the client's understanding about the drug assess for skin allergies

During: Reconstitute the drug with 8 ml of sterile water. Slowly inject the drug over 3 to 5 mins.

After: Evaluate the client for adverse effect. Report lack of response, persistent diarrhea or signs ad symptoms of Anemia.




Mechanism of action


Client’s response to medication with

48

name) Date changed dosage & frequency of

administration

actual side effect

Generic Name:Ketorolac Tromethamie

August 27-28, 2009 30 mg, IVF q 6 hours X 6 doses

Possesses anti-inflammatory, analgesics ad antipyretic. Completely absorbed following IM use.

Use for management of moderate ad severe acute pain.


Before: check the expiration date of the drug check the doctor's order assess the client's understanding about the drug

During: Do not mix IV ketorolac in a small volume with morphine sulfate. The IV bolus must be given over o less than 15 sec.

After: Monitor for adverse effect. Report ay unusual bruising or bleeding, weight gain, swelling of feet/ ankles, increased joint pain, change in urine patterns.

49


name)


Date changed



administration

Mechanism of action



Generic Name:Tramadol Hydrocloride

August 27-28, 2009 100 mg, TID A Centrally acting analgesic no related chemically to opiates. Precise mechanism is unknown.

Use for management of moderate ad severe acute pain.



During: Give the IV dose slowly over a period of 2 mins or as a continuous infusion. Oral and IV dose are therapeutically equivalent, may switch to and from the IV form wit o cage in dose as prescribed.

After: Monitor for adverse effect. Report immediate ay chest pain, increased SOB, or sudden weight gain.


name)


Date changed



administration

Mechanism of action



Generic Name:Omeprazole

August 27-28, 2009 Q 12 hours X 2 doses

Hough to be a gastric pump

Use for management of

The client did not exhibit any adverse

50

inhibitor and that it blocks the final step of acid production. By inhibiting the Hydrogen/ Potassium ATP-ase system at te secretory surface of the gastric parietal cell.

active duodenal ulcer, gastric ulcer, erosive esophagitis and heartburn

reactions from the drug


During: The capsule should be taken 30 mins before eating and is to be swallowed whole. Antacid can be administer with omeprazole

After: Monitor for adverse effect. Report to the physician if chest pain, abdominal pain and fecal discoloration occurred.

iii. Diet

51

Type of DietDate ordered/Date taken/

Date changed

General Description


Specific foods Taken


NPO (nothing by mouth)

August 27, 2009 A patient care instruction advising that the patient is prohibited from ingesting food, beverages, or medicine.

It is usually ordered whenever the patient wills undergoes surgery or other diagnostic procedure requiring that the digestive tract be empty.

Foods, beverages ad medicine are prohibited.

The client strictly complied.

Before: Explain to the client and significant others the purpose, indication and the duration of the diet. Assist the client’s compliance ability to the diet.

During: Advise the client to avoid foods. Provide frequent oral hygiene Monitor the compliance of the patient to the diet.

After: Evaluate the effect of the diet to the client. Report excessive weight loss. Assess any nutritional disturbances and notify the physician.

Type of Diet Date ordered, Date started, Date

changed

General description


Specific Foods Taken

Client’ s response and/or response to

the dietClear liquid diet August 27, 2009 This client provides

the client with fluid and carbohydrate

This diet is indicated for post operative patient’s

CrackersSips of water and tea

The client strictly complied

52

but does not supply adequate protein, vitamins, minerals, or calories

first feeding when it is necessary to fully ascertain return of gastrointestinal function

Prior:

>assess ability to feed self and prepare meals

>determine need for special drinking cups, plates, or feeding utensils

>explain the purpose of the diet

>discussed allowed and prohibited foods

During:

>assist the client to a comfortable position in bed or in a chair, whichever is appropriate

>provide assistance of the client is unable to handle eating utensils or to open containers and packages

>always allow ample time for the client to chew and swallow the food before offering more

After:

>after the client has completed the meal, observe how much the client has eaten and the amount of fluid taken, record the fluid intake

and calorie count as required

>provide hygiene measures after feeding

>record any pain, fatigue or nausea experienced by client

53

Type of DietDate ordered/Date taken/

Date changed

General Description


Specific foods Taken


Soft Diet August 28, 2009 A diet that is soft in texture, low in residue, easily digested and well tolerated.

It provides nutrition to the client who has just undergone surgery and client who cannot tolerate hard foods.

Sips of water, tea, crackers

The client strictly complied.

Before: Explain to the client and significant others the purpose, indication and the duration of the diet. Assist the client’s compliance ability to the diet.

During: Position the client in a sitting or high or fowler position. Advise the client to consume foods that are easily digested. Monitor the compliance of the patient to the diet.

After: Evaluate the effect of the diet to the client. Assess any nutritional disturbances and notify the physician.

Type of Diet Date ordered, Date started, Date

changed

General description Indication/sPurpose/s

Specific Foods Taken

Client’ s response and/or response to

the dietDiet as tolerated(DAT)

August 30, 2009 The patient can eat any food as long as tolerated

To increase rate of healing

RiceVegetablesChicken meatRed meat FruitsGelatin

The client did not exhibit any allergic reactions to the food taken

54

Crackers

Prior>caution patient to avoid food such as eggs, nuts, milk, sulfites, fish and chocolate that can trigger asthma attack.

During:>Advise client to properly chew the food.

After:>advise patient to report any allergic reaction to the food taken.

iv. Activity / Exercise

Type of exercise

Date OrderedDate StartedDate Changed

General Description Indications or Purposes

Specific exercise/activit

y

Client’s response and/or reaction to

the dietFlat on bed Aug. 27,2009 It is type of exercise

done after the surgical procedure; the client must be in a supine position without using a pillow. After 8 hours the client must be able to use pillow already.

To prevent spinal headache.

Complete bed rest within 8 hours.

The client complied to the ordered exercise

Turn from side to side

Aug. 28, 2009 Patient will turn on the right side then rotate to the opposite side after 2 hours

To increase blood circulation and prevent pressure ulcer

Turn from side to side every 2 hours

Patient was able to tolerate the exercise but with a little discomfort due to surgical incision

Sitting on bed Aug. 29, 2009 It is a type of exercise To increase Sitting on the Patient was able to tolerate the

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done after the client able to turn side to side, and the back of the client is unsupported and legs hanging freely

blood circulation

bed without assistance

exercise but with a little discomfort due to surgical incision

Standing beside the bed

Aug. 29, 2009 It is a type of exercise when the client is able to stand by her own and no significant others assisted to her.

To increase blood circulation

Standing in the side of the bed without assistance


Ambulation Aug. 29, 2009 Patient will walk unaided on the side of the bed and on the hallway

To increase blood circulation

Walking on the side of the bed without assistance


ROM (Range of Motion)

Aug. 29, 2009 A body action involving the muscles, joints, and natural movements such as abduction, adduction, flexion, extension, pronation, supination, and rotation.

These exercises reduce stiffness and help keep your joints flexible.

The client participated in the activity.


Nursing Responsibilities

Prior:a. Learn passive ROM exercises from the person's caregiver. Practice the exercises with the caregiver first. The caregiver can

make sure you are doing the exercises right. b. Raise the person's bed to a height that is comfortable for you. This will help keep you from hurting your back or other muscles.c. Make sure the wheels of the bed or wheelchair are locked before you start the exercises.

56

Duringa. Do all ROM exercises smoothly and gently. Never force, jerk, or over-stretch a muscle. This can hurt the muscle or joint in-

stead of helping.b. Move the joint slowly. This is especially important if the person has muscle spasms (tightening). Move the joint only to the

point of resistance. This is the point where you cannot bend the joint any further. Put slow, steady pressure on the joint until the muscle relaxes.

c. Stop ROM exercises if the person feels pain. Ask the person to tell you right away if he feels any pain. Watch for signs of pain if the person is unable to talk. The exercises should never cause pain or go beyond the normal movement of that joint

After:a. Make ROM exercises a part of the person's daily routine. b. Follow the caregiver's orders. The person's caregiver will tell you how many times per day you should do ROM exercises. The

caregiver will tell you how many repetitions (number of times) you should do exercises on each joint.

2. Surgical Management

Name of Procedure

Date Performed Brief Description Indication/Purpose Client’s response to the operation

Cesarean Birth August 27, 2009 A cesarean birth is a delivery of a fetus through abdominal and uterine incisions; laparotomy or hysterectomy, respectively.

A cesarean delivery may be indicated for a woman with known placenta previa.

The patient complained of difficulty of breathing and reported little sensation on the lower extremities upon discharge from the PACU. It was observed that the patient was also drowsy.

Prior:

>Always check to see if the informed consent has been given and that a signed form documents it.

> Ask the woman when she last had anything to eat or drink.

57

> Frequently, an antacid is given before surgery to reduce the risk of aspiration while the woman is under the effects of anesthesia.

>Ensure that an intravenous fluid is in place with a large bore catheter

>Ensure that an abdominal shave preparation is done immediately before surgery

>Ensure that a foley catheter is in place

>Ensure that laboratory studies ordered are completed

During

>The nurse supports the woman so that her back remains in a c-shaped curve during placement or a regional anesthesia by the

anesthesiologist

>The nurse assists the woman to the supine position on the O.R table

>The nurse places a wedge under one hip, and then places a warm blanket and safety strap on the woman’s legs

>Ensure that a sterile abdominal preparation with alcohol or Betadine is performed and a sterile drape is provided

>The nurse performs the second O.R count

After:

>The nurse transfers the woman from the operative suite to the PACU

>Ensures connection of monitoring devices that will record the electrocardiogram, blood pressure, pulse, and oxygen saturation of the

blood

>Monitor vital signs and pulse oximetry reading every 5 minutes until the readings are stable, and then 15 to 30 minutes until the

patient has met predetermined criteria

>Monitor the patient’s urinary output to make certain it is atleast 30 cc/hour

>Evaluates and record the condition of the fundus along with vital signs

58

>Assess the amount and type of lochia flow

DATE CUES NURSING DX


Aug. 27, 2009 S:

>“Masakit ang tahi

ko sa may puson.”

Pain Scale: 10/10

O:

>weak in

appearance

>restless and

irritable

>pale looking

Acute Pain

r/t surgical

incision.

After 30

minutes of

proper nursing

intervention,

the patient will

verbalize

decreased in

pain to a

tolerable state.

From a pain

>Built rapport with the patient

>Placed ice pack at the incision site.

>Encouraged the patient to do breathing

exercises.

>Provided emotional support by

encouraging the patient to verbalize what

she feels.

>Assisted the patient when turning side

to side.

>Administered analgesics as ordered by

After 30

minutes of

proper nursing

intervention, the

patient

verbalized

decreased in

pain to a

tolerable state.

From a pain

59

>tachypnea:RR:24

cpm

>grimace

scale of 10 to

2.

the physician. scale of 10 to 2.

AEB:

a.) Absence of

grimace

b.) Normal

respiration.

RR:17cpm

3. Nursing Management

Aug. 27, 2009 S: Ø O:>have no oral intake for the last 8 hours>chapped lips>dry mouth>with surgical incision at the lower abdomen>consumed 2 underpad for the last 24 hours >weak in appearance>restless and irritable>pale looking

Deficient fluid volume r/t contraindicated intake via oral route & blood loss during surgery

After 1 hour of proper nursing intervention, the patient will maintain fluid balance in a functional level after nothing per orem order as evidenced by:d. Urine out-

put of ≥30ml/hr

e. Normal BP, pulse

Independent:>Monitored Vital signs of client’s with deficient fluid volume every 4hrs. Observe for tachycardia, tachypnea, decreased pulse pressure first, then hypotension, decreased pulse volume, and increase/decrease body temperature.

>Advised client to have frequent oral hygiene, at least twice a day.

>Advised client to increase water intake to more that 1.5L per day after NPO orders.

Collaborative

After 1 hour of proper nursing intervention, the patient maintained fluid balance in a functional level after nothing per orem order as evidenced by:g. Urine out-

put of ≥30ml/hr

h. Normal BP, pulse and Respirations

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>grimace>tachypnea:RR:24>bradycardia: PR:56>HCT=0.266%>HGB=80g/L>urine output=30 cc/hr>Capillary refill=3sec

and Respi-rations

f. Elastic skin turgor, moist tongue and mucous membrane

>Hydrated the client with ordered intravenous solution

>Maintained Patent IV access, set an appropriate infusion flow rate and administer at constant rate as ordered.

i. Elastic skin turgor, moist tongue and mucous membrane

Date Assessment Diagnosis Planning Interventions Evaluation

August 27,2009 S: Ø

O: blood loss-


UO- 30cc/hr HGT-


appearance Weak and



Monitored vital signs every 15 minutes

Assisted the client in a comfortable po-sition particularly in Semi-Fowler’s or High Fowler’s position.

Encouraged the client to verbalize her feelings and worries.

Increased frequent observation , and if possible, stay with the client and en-force security measures (e.g Raise side rails)

Within 2 hours of proper nursing interventions, the patient was able to have a decreased risk for injury.

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irritable RR: 24-

Encouraged the client to have bed rest.

Advised the client to increase fluid in-take.

Administered medications as pre-scribed.

DATE CUES NURSING

DX


Aug. 28, 2009 S: Ø

O:

>with surgical

incision at the lower

abdomen

>inability to sit

>difficulty turning

to side

Impaired

physical

mobility

r/t surgical

incision.

After 30

minutes of

proper nursing

intervention,

the patient will

be able to

gradually

increase

>Built rapport with the patient

>Assisted patient in turning side to side

every 2 hours.

>Provided emotional support by

encouraging the patient to verbalize what

she feels.

After 30

minutes of

proper nursing

intervention, the

patient was able

to gradually

increase

mobility.

62

>weak in

appearance

>restless and

irritable

>pale looking

>tachypnea:RR:24

> grimace

mobility.

>Instructed the patient to do breathing

exercises.

>Administered analgesics as ordered by

the physician.

AEB:

a.) Absence of

grimace

b.) Ability to

turn side to side

with minimal

assistance.

DATE CUES NURSING

DX


Aug. 28, 2009 S: “Hindi ko

magalaw ang paa

ko.”

O:

>Weak in

appearance

>Pale

>With limited

movements

>Difficulty

Risk for

ineffective

tissue

perfusion

r/t

immobility

after

surgery

After 1 hr of

proper nursing

intervention,

the client will

maintain a

capillary refill

of less than 5

seconds and

will not report

of calf pain,

redness,

1. Assist patient in turning from side to

side every 1-2 hours

2. Assist client in extremity exercise

3. Early ambulation should be

encouraged whenever appropriate.

4. Encourage deep breathing and

coughing exercise

After 1 hr of

proper nursing

intervention, the

client will

maintain a

capillary refill

of less than 5

seconds and will

not report of

calf pain,

redness, edema,

63

raising/flexing the

legs

>Weak peripheral

pulses

>Capillary

refill=3seconds

edema, or

areas of

warmth on

lower

extremities

5. Ensure that bedcovers must be loose

enough

or areas of

warmth on

lower

extremities

Daily Program August 27, 2009(Day 1) August 28, 2009(Day 2) August 29, 2009(Day 3)Vital Signs 8:00 AM – T: 36. 2

P: 56 R: 24 BP: 130/10010:00 AM – T: 36.7 P: 56 R: 26 BP: 130/90

8:00 AM – T: 37.1 P: 63 R: 25 BP: 120/8010:00 AM – T: 37.6 P: 58 R: 20 BP: 130/80

8:00 AM – T: 36.9 P: 70 R: 19 BP: 110/8010:00 AM – T: 36.8 P: 77 R: 19 BP: 120/90

Laboratory and Diagnostic Procedures

Complete Blood Count

Medical and Surgical Management

5% Dextrose in Lactated Ringer’s Solution:15 gtts/min

D5NM with Tramadol:

5% Dextrose in Lactated Ringer’s Solution:15 gtts/min

D5NM with 1 ampule of Moriamin:15 gtts/min

64

15 gtts/min

Oxygen Therapy:Regulated at 2L/minute

Drugs Cefuroxime Sodium 750mg q 8Ketorolac 30mg q6 x 6dosesTramadol 100mg TIDOmeprazole 40mg q12 x 2doses

Cefuroxime Sodium 750mg q 8Ketorolac 30mg q6 x 6dosesTramadol 100mg TIDOmeprazole 40mg q12 x 2doses

Cefalexin 250 mg TIDMefenamic Acid 500 mg capsule TIDFerrous Sulfate 15mg OD

Diet NPO Soft Diet DATExercise Passive ROM ROM, turning side to side Active ROM, minimum level of

activities

D. Evaluation:Patient’s daily program in the hospital

1. Discharge Planning

i. General condition of the client during discharge

65

Upon client’s discharge (August 29, 2009), the client appeared neatly dressed with no apparent body odor. He was afebrile. She was able tolerate minimal levels of activity such as walking, moving from place to place and transferring from sitting to standing position without dizziness. She was able to take any food tolerated. She also does not perspire excessively or show signs of emotional distress such as nail biting or avoidance of eye contact.ii. METHOD approachMedications Exercise Treatment Health Teaching OPD Follow-Up Diet

Mefenamic Acid 500 mg capsule

Cefalexin

Ferrous Sulfate

Limb ExerciseR: To improve peripheral blood circulation.Deep breathing Exercises:R: To promote effective lung expansion.Minimal Activities e.g walking, transferring from sitting to standing positionR: To improve client’s activity tolerance

Limb ExercisesR: To improve peripheral blood circulation.Minimal activitiesR: To improve client’s activity tolerance.

The client was advised the following: The importance

of a clean environment.

The significance of bedrest, eating healthy foods, and increased fluid intake.

The importance with complying with prescribed medications.

Client was advised to return to OPD for follow-up treatment and check-up at September 5, 2009

Advised the client to increase intake of foods rich in protein, calories and calcium. Rationale: To facilitate faster and effective wound and body function recovery.

66

III Conclusion:

This case served as a realization for both the group and their client. It required thorough

investigation about client’s condition against both theory and the large comparative environment.

In this study, objectives are important. The group formulated their objectives before conducting

the study of Placenta Previa. It consists of Nurse and Client – centered objectives.

After doing this case study, the group attained the formulated nurse-centered objectives. They

were able to come up with a comprehensive presentation of the disease condition by means of

correct presentation of the data gathered through the use of nursing process. The group also able

to present the current trends about the disease condition, the reason for choosing such case for

presentation; and the importance of the case study.

By means of proper education rendered by the group, their client was able to fully understand

and recognized the disease condition. The client learned the importance of healthy lifestyle and

identified the predisposing factors that aggregated her condition.

IV Recommendation: Close monitoring is important with patient or pregnant woman having placenta previa. The

group is recommending the following for the management of Placenta Previa:

To the Community:

Conduct seminars about Maternal and Child Health

Importance of follow-up check up should be emphasized to the community through

seminars, health promotion, etc

To the Client:

Stress the importance of prenatal check-up and post natal check-up especially to the

client having this condition.

Accentuate the importance of bed rest

To the next researcher:

This case study will serve as an additional source of information about the condition: Placenta

Previa.

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V. BIBLIOGRAPHY

1. Health Assessment and Physical Examination, Mary Ellen Zator Estez,

3rd edition

Edition

2. Fundamentals of Nursing, Barbara Kozier; 7th edition

3. Maternal & Child Health Nursing, Pilliterri, Adele PilliteriVolume 2,

2007

4. Wong’s Essentials of Pediatric Nursing 7th edition

5. Craven Hirnle, Fundamentals of Nursing: Human Health & Functions;

Fourth Edition

6. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing Eleventh

Edition Volume 1 by Suzzane B. Smeltzer et. al., copyright 2008

7. Essentials of Anatomy and Physiology Fourth Edition by Seely et.al.,

Copyright 2002

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Documents

Case Study (Placenta Previa) This is It!!! (1)