Holy Infant CollegeTacloban City

Final OutputGrand Case Presentation

BSN 3 Group 4

Prepared by:

Ala, Rudtard ChadAlvarina, MyraAniano,JeromeAriza, Ma.Liza

Paner,Mark GeraldPorta, CarmillineTiempo,VanessaToreno,JasmineTorlao,DyeselVerzo, Jamela

Hydatidiform Mole(H-Mole)

Gestational trophoblastic disease is abnormal proliferation and degeneration of the trophoblasitic villi. As the cells degenerate, they become filled with fluid and appear as clear fluid, grape-sized vesicles. With this condition, the embryo fails to develop beyond a primitive start.

PATIENT’S ASSESSMENT

Source of Info: Patient% of Reliability: 95%

I. Patient’s Profile Name: Alma Duque Age: 36y/o Status: Married Address: Brgy. Gacao, Palo Leyte Educ’l Attainment: College Graduate (Midwifery Graduate) Occupation: Housewife Religion: Roman Catholic Date & Time Admitted: 3/16/10 @ 2:10 PM C/C: vaginal bleeding, pain on the hypogastric area radiating to the back. Attending Physician: Dra. Ma. Teresa Lita Diagnosis/Impression: Incomplete Abortion, Spontaneous 15 3/7 weeks AOG late,

Non-septic G6P3 (5-0-1-3)Procedure: Completion Curettage

(diagnosed with hydatidiform mole after procedure)

II. Health HistoryPresent Illness2 months PTA patient assumed that she is 2-month pregnant due to amenorrhea and nausea & vomiting usually during the morning. No pregnancy test and no consult done. 11 days PTA patient experienced vaginal spotting associated with sharp, stabbing hypogastric pain radiating to the back, describing it as like having dysmenorrhea. Consumes 1 pad of

napkin per day. Pain is aggravated by work and is temporarily relieved by rest. No meds taken and no consult done. Other associated signs and symptoms include fever, headache, dizziness, nausea and vomiting. No meds taken and consult done.

5 days PTA, vaginal bleeding was noted, now associated with increased hypogastric pain still radiating to the back. Pain became persistent and is now unrelieved by rest.Fever recurred,.headache, dizziness, nausea and vomiting are still noted. Patient took paracetamol (Biogesic)500mg OD for fever.Fever was relieved the day after. Patient sought consultation at Leyte Provincial Hospital and was given unrecalled medicines to prevent bleeding which provided temporary relief.

A day PTA, pt sought consultation at EVRMC and had undergone laboratory exams and transvaginal UTZ and was initially diagnosed with incomplete abortion the following day; hence, subsequent admission.

Past Health HistoryUsual illness experiences include fever, cough and colds. Usually take OTC meds such as paracetamol (Biogesic and Neozep) as relief measure .Had complete Tetanus Toxoid vaccine. No

history of previous operations or injuries. No known allergy to food and medication.

Family HistoryPatient’s 2nd child died due to ‘lockjaw’ 7 days after birth as stated by the pt. Her 4th child died due to leukemia @ 3years old. Her other 3 children are all apparently wellPatient’s father died due to heart attack at the age of 55. Has positive family history of hypertension and asthma on paternal side; and anemia on maternal side.No other known heredofamilial diseases like DM, and mental illness.

Gynecologic HistoryPatient had her menarche at the age of 16. With regular monthly menstruation of 4-6 days, and consumes 3-4 napkins per day. Usually experiences dysmenorrhea during menstruation and

occasionally takes mefenamic acid as remedy.Patient uses Calendar method as means of family planning and denies use of any artificial contraceptive. No history of any reproductive disorder.

Obstetric HistoryPatient is a G6P5(5-0-1-3) with an LMP of November 28, 2009. No previous abortions. No problems encountered during previous labor and deliveries. Occasionally take

paracetamol(Biogesic) for relief of fever even during pregnancy. Her 5 children were delivered NSVD on good condition. Two of her child however died at an early age.

Child Year of Birth Place of Birth Manner of Delivery

Current condition

1 1999 hospital NSVD Apparently well2 2001 home(hilot) NSVD Deceased due to tetanus(lockjaw) as

stated by the pt.

3 2003 hospital NSVD Apparently well4 2007 home(hilot) NSVD Deceased due to leukemia5 2009 hospital NSVD Apparently well

Psychosocial HistoryPatient is a plain housewife and does household chores like washing dishes and clothes, cleaning the house and cooking. Lives in a semi-concrete house with a potable water

source. She is a non-smoker and an occasional alcoholic drinker. Husband, however, is a smoker.The family is able to meet their basic needs and is supported well by their relatives financially. Patient relates well to family members.

III. Reactions and ExpectationThe patient hopes to be discharged soon because she worries much about her children, especially her 11 month old child left at home with her mother. She is still affected with the loss of

her supposed child and usually seen silent and teary – eyed.; however, she tries to accept it with the help of the family members.She relates well with the hospital staff and complies with all medical requirements. She is contented with the medical services rendered by the institution.

II. PATTERNS OF FUNCTIONING AND PHYSICAL EXAMINATION

Patterns of Functioning Pre-Hospital Assessment Clinical Inspection Other Sources1. Respiratory - last had cough and colds 2 months ago associated

with fever. Took paracetamol (Biogesic) and Neozep as remedy. Symptoms were resolved 4 days after.-non-smoker ( husband however, is a smoker)-

RR-24; with regular breathing pattern - Does not use accessory muscle in breathing - with clear breath sound upon auscultation - no cough, colds and oral discharges noted.

2. Circulatory - non-hypertensive- occasionally experiences dizziness especially when doing strenuous activities and during previous pregnancies- unable to recall occurrence of palpitations and chest pains.

BP- 180/100mmHg(upon D&C) 90/60mmHg(after D&C)PR- 110bpm-pale conjunctiva, pale lips-poor capillary refill > 3 sec-facial pallor-cold,clammy skin-“Malingaw tak ulo”,as verbalized by the patient.-no edematous parts noted

CBC Ct (abnormal findings)

Hgb – 89g/L ↓ Hct – 34% ↓Lynphocytes - 0.15% ↓

3.Food and Fluid Intake -usually eats 3x a day.-prefers eating rice, fish and vegetables during meals-no known allergies to food and medications

- drinks 6-8 glasses of water per day- occasional alcoholic beverage drinker; usually consumes 8-10 glassess per session.

- has thin body appearance.-poor appetite -drinks 5-6 glasses of water per day-cold,clammy skin,-poor skin turgor -dry lips

With an IVF of D5LR 1L @750 cc level regulated @ 20 gtts/min infusing well@ right cephalic vein.

PO meds taken: mefenamic acid 500

mg 1 cap TID ferrous sulfate 1 cap

OD clindamycin 300 mg 1

cap TID methylergonovine

maleate (Methergine) 1 tab TID x 9 doses, hold for BP ≥ 140/90 mmHg

4. Elimination -usually voids at least 6x per day with yellow-colored urine.-no voiding difficulties experienced-defecates 1-2 times per day usually in the morning with brown stool.

-Urinates 2-3 times a day in minimal amount with yellow-colored urine.- no dysuria or hematuria noted-has not defecated since admission- with minimal perspiration -no vomiting noted-no aids used in elimination

Urinalysis result (significant findings)

Glucose - ++Blood - ++HCG - +WBC – traceRBC- 4-8

5.Regulatory Mechanism -had fever 11 days PTA . no meds taken and no consult done.-5 days PTA,fever recurred.patient took paracetamol (Biogesic) 500nmg OD.fever was relieved the day after.-menarche @ 16 with regular monthly menstruation of 4-6 days and consumes 3-4 napkins per day.-LMP : 11-28-2009-no artificial contraceptives taken.

Temp. – 36.7(axillary)- cold,clammy skin-with minimal perspiration at the back- still with minimal vaginal spotting-with globular shaped abdomen-breast engorged-no twitching paralysis noted-reddened and swollen vulva

6.Hygiene -usually takes a bath once a day-uses shampoo when available-changes clothes everyday- no known allergy to soap or shampoo- believes that bathing should be avoided during menstruation.

- appears unkept- hair is unkept,- long and dirty fingernails, -with foul-smelling body odor-with bad breath-with vaginal discharge noted.

7. Exercise and Locomotion -does household chores everyday such as: washing clothes and dishes, cooking and cleaning the house.- occasionally experiences dizziness when doing strenuous activities

-appears generally weak.-“Nanluluya man ako pirmi”, as verbalized by the patient.- stays at bed most of the time

-has limited movements-needs assistance in walking-no fractures, contractures, and joint stiffness noted.

8.Rest and Sleep - usually sleeps at 7:30 pm and arise at 5pm-take daytime nap usually at 1-3pm-prefers side-lying position when sleeping and uses 1 pillow.

-believes that it is not good to sleep in supine position since it may cause nightmares

-sleeps for just 2-3 hours at night.-“Diri ako nangangaturog hin tuhay kay maaringasa ngan mapaso”, as verbalized by the patient.-take daytime naps for 30 min – 1 hour

-eyebags noted

9. Communication and Special Senses

-right – handed-no eyeglasses or hearing aids used-no visual or auditory disturbanes-speaks in Waray

-EYES : eyelashes evenly distributed PERRLA Whitish sclera Positive corneal reflex Pale conjunctiva-EARS: symmetrical, in line with outer canthus of eyes no swelling and discharges presence of earwax no swelling and tendernessNOSE: straight, at midline, firm septum is thick, at midline no nasal flaring

no lesion and dischargesVOICE: speaks on soft, moderate voice

10.Sensory -no history of convulsions, epilepsy and loss of

consciousness-awake, coherent and oriented with time and place.-able to respond to questions well-no seizures noted

11. Pain and Discomfort -“ Nagsisinakit na ak tyan pagdugui ha akon” ; as verbalized by the patient-complained hypogastric pain radiating to the back 11 days PTA usually in the morning No meds taken and consult done Pain aggravated by work and is temporarily relieved by rest

-facial grimace noted-“Masakit tak pus-on tikadi ha ak likod”, as verbalized by the patient-abdominal guarding noted-pain scale of 7 ( 10 being the highest)-minimal perspiration noted -“Malingaw tak ulo”,as verbalized by the patient-“Nanluluya man ako pirmi”, as verbalized by the patient.-restlessness

Medications taken for pain :Mefenamic acid – 500 mg TID

12.Recreation and Diversion -watches t.v. at home for recreation Likes watching WOWOWEE at noon-chats with neighbors during spare time

-usually observed silent and seldom talks with SO- uses cp when bored

13. Religious -attends Sunday masses regularly -no religious medals worn-“Nangangadi nala ako pime para matanggal akon kulba”; as verbalized by the patient

14.Coping Mechanism -talks with family members and prays when faced with stressful situation.

-usually silent.- does not talk much with SO ,roommates and hospital staff-usually observed teary-eyed when talking about the loss of child-“Masakit gad liwat kay nalaom ako nga tawo na adto, diri ngean”; as verbalized by the patient.

15. Social - a plain housewife-does household chores at home like washing dishes and clothes, cooking and cleaning the house.-relates well with family members and friends

-silent most of the time-does not talk much w/ SO, roommates and hospital staff.-complies well with medical requirements.

III. Anatomy and Physiology

FEMALE INTERNAL STRUCTURE

1. VAGINA – is a thin tube 8-10 cm long. It lies between the bladder and rectum and extend from the cervix to the body to the body exterior. Often called the birth canal. Functions:

- passageway for the delivery of the infant and for the menstrual flow to leave the body.- female organ of copulation, since it receives the penis ( and semen )- excretion organ of the fetus

Characteristics:- rugae- thick walled of tissue- secretion

Hymen - distal end of the vagina is partially closed by thin fold of the mucosa. INTERNAL VAGINAL CANAL

1. Anterior wall2. Lateral wall3. Posterior wall

Vagina is acidic in his environment

3 SOURCES OF BLOOD SUPPLY OF VAGINA 1. Upper third- supply cervico-vagina artery

2. Middle third – supply by vesico-vagina artery 3. Lower third- pudendal artery ( supply to the external genitalia )

2. UTERUS – located in the pelvis between the urinary bladder and rectum. Is a hallow organ, that function to receive, retain and nourish the fertilized egg.

Functions:- organ of conception - organ of menstruation

2 PARTS OF THE UTERUS

1. Corpus (body)a. Fundusb. Cornuac. Isthmus

2. Cervix a. Internal osb. External os

LAYER OF THE UTERUS

1. Endometrium – also called decidua during pregnancy 2. Myometrium – middle layer of the uterus, the figure of the 8 muscles3. Perimetrium- thin cover of the uterus and the one that is adhere in the contact to the abdomen

UTRINE LIGAMENTS1. Transverse cervical ligament or Cardinal ligament position , located at the cervix2. Round ligament – is a handle of ligament, it originates on the cornua3. Broad ligament – the one is attached to the uterus and the one is attached to the pelvis , maintain the position of the

uterus, it is where the ovaries and attached4. Pubo-cervical ligament – coming from the pubic to the cervix

Avocado or pearshaped is the shape of the uterusPosition is at the center and it is anteflexion and anteversion

Size: 60 grams 1000 grams – weight of the uterus only if woman is pregnantLenght: 7 cm

UTERINE BLOOD SUPPLY1. Uterine artery –

- ascending branch- supplies blood to the upper part of the uterus- descending branch- supplies blood to the lower part of the uterus and also the cervix

2. Ovarian artery – supplies blood to the ovary and other to the uterus

3. UTERINE (FALLOPIAN) TUBES – from the initial part of the duct system Functions:

- site of fertilization- receives the ovulated oocyte- transport the sperm cells

Hormones – is responsible in the entering the sperm to the fallopian tube

PARTS OF THE FALLOPIAN TUBE1. Interstitial 2. Isthmus3. Ampulla – where the fertilization occurs4. Infundilum

5. OVARIES

Functions :1. endocrine function - produces hormones estrogen and progsterone2. oogenesis

Intrauterine Fetal Growth and Development

Fertilization – union of egg and sperm cell

Fertilization

Zygote formation Migrates to the body of uterus within 4 days

Reaches the uterus(4th day)

Morula formation(stays afloat for 3-4 days)

Attaches to the endometrium

Blastocyst formation

Inner cell mass trophoblast

Develops into an embryo develops into placenta (from implantation to 5 – 8 wks)

Fetal development (from 5-8 wks to until term)

IV. PATHOPHYSIOLOGY : Hydatidiform Mole

< Age 20 and >35

Asian heritage

Uterine and ovum abnormalities

Low folic acid intake

Low CHON intake

Abnormal fertilization of egg and sperm

(failure of egg cell to change in composition)

Low caroteine intake

Formation of swollen and cystic trophoblast

Abnormal Blastocyst formation and implantation

Incomplete formation of inner cell mass

Embryonic death(usually 9wks AOG)

Impaired embryonic development

+ pregnancy test

Absence of fetal heart

sounds

Duplication of haploid

chromosome

2 sperm fertilize 1

ovum

Continued blood supply to the throphoblast or chorionic villi

Tremendous increase in CGH

(usually 100x higher than in normal

pregnancy)

Enlarged uterus not comparable

to AOG

Separation of molar cyst from decidua(usually after 16 wks)

Proliferation of trophoblast(hyperplasia)

Uterine distention theory

Formation of molar cyst

Hyperemesis

gravidarum

Formation of grape-sized

vesicle

Vaginal bleeding

Increased PR

Increased RR

Decreasd urine output

dizziness

death

Lower abdomina

l pain

Decreased blood volume(hemmho

rage)

Impaired immune function

Hypovolemic shock

sepsis

V. LABORATORY EXAMS STUDY

HEMATOLOGY

Test Result Unit Normal Range in Female Clinical SignificanceHemoglobinHematocritErythrocytesLeukocytes Granulocytes Lymphocytes MonocytesPlatelet CountMCVMCHMCHC

Blood Type

Clotting timeBleeding time

8934

4.229.600.800.150.0530580.027.10341

“O” RH (+)

3 min 33 sec1 min 57 sec

g/L%

10 /L10 /L

%%%

10 /Lflpg

120-16036-474.2-5.44.5-10.0

0.500-0.7500.200-0.3500.020-0.060

150-45080-9627-31

320-360

8-15 mins1-7 mins

↓ Hemorrhage or bleeding ↓ Hemorrhage or bleeding Normal Normal Normal ↓ immunodeficiency Normal Normal Normal Normal Normal

URINALYSIS

Test Result Unit Normal Range Clinical SignificanceColor Yellow

transparency Clear clear normalSpecific gravity 1.020 1.010 – 1.025 normal

pH 6.0 6-7 normalglucose ++ -albumin Traceblood ++HCG + Pregnancy WBC TraceRBC 4-8

Epithelial cells moderate

TRANSVAGINAL ULTRASOUND

Test Result Normal Significanceuterus With in the uterus is thick walled anechoic

area representing a gestational sac with no embryo and having no demonstrable cardiac flickers. Uterus measures 8.7x5.3x6.4 cm.

Anembryonic gestation

VI. DRUG STUDY

DRUG GEN. ACTION SPECIFIC ACTION INDICATION CONTRAINDICATION ADVERSE REACTION NSG. RESPONSIBILITIES

mefenamic acid 500 mg 1 cap TID

ferrous sulfate 1 cap OD

clindamycin 300 mg 1 cap TID

methylergonovine maleate (Methergine) 1 tab TID x 9 doses, hold for BP ≥ 140/90 mmHg

- anti-inflammatory drug

- hematinics

- anti- infectives

- oxytocics

- inhibition of prostaglandin synthesis

- produces increase number of erythrocytes and/or hemoglobin concentration in erythrocytes

- Inhibition of bacterial growth, bactericidal.

-increases motor activity of the uterus by direct stimulation of the smooth muscle, and to reduce blood loss.

- mild to moderate pain

-indicated for iron deficiency- as a supplement during pregnancy

- indicated for pelvic inflammatory disease

- to prevent and treat postpartum hemorrhage caused by uterine atony or subinvolution

- contraindicated to pt with hypersensitivity to drug.

- use cautiously on long term basis.

- contraindicated in patients hypersensitive to drug or lincomycin

- Contraindicated in pregnant patients with hypertension or toxemia

CNS: dizziness, headacheCV: edema, fluid retentionEENT: tinnitusGI: abdominal pain, constipation, decreased appetite, nausea

GI: nausea, epigastric pain, vomiting, constipation, diarrhea, anorexia

CV: thrombophlebitisGI: nausea, abdominal pain, diarrhea, vomitingHepatic: jaundice

CV: hypertension, palpitation, hypotensionEENT: tinnitus, nasal congestionGI: nausea, vomiting, diarrheaGU: hematuria

- Tell pt to take meds with meals to reduce adverse GI reactions- Teach pt to watch for & report to prescriber stat S/S of GI bleeding.

- Advise pt. to report constipation and change in stool color is a normal response to medications

- Check patient’s hydration status- Tell patient to report discomfort at IV insertion site

- Monitor and record V/S and uterine response- Explain use of drug to patient and SO- Instruct patient to

report adverse reactions promptly.

VII. NURSING CARE PLAN