Holy Angel University Angeles City, Pampanga College of Nursing In Partial Fulfillment of the Requirements in Nursing Care Management - Related Learning Experience 103 Jose B. Lingad Memorial Regional Hospital OB Ward

Case study on:

Inverted UterusSubmitted by: N-301 Dizon, Crisfer Gonzales, April Jamaica Liew, Louie Andrew Pradilla, Angelica Quedit, Jennine Rosario, Annie Grace Sagcal, Ramil Samson, Evangeline Soriano, Mary Grace Tayag, Patrisha

Submitted to: Eliezer R. Dizon RN, Ph.D. Date of Submission: August 8, 2011

TABLE OF CONTENTS I. Introduction 1 2 2 2 2 3 3 3 4-6 7-8 9-11 9 9 9 10-11 12 12-15 13-14 15 15 20-21 22-23 24

II. Personal Data A. Demographic Data B. Activities of Daily Living C. Socioeconomic, Religion, Cultural Beliefs and Practices III. History of Past and Present Illness A. Obstetric History B. History of Present Illness IV. Diagnostic Procedures V. Anatomy and Physiology VI. Pathophysiology A.Definition B.Predisposing and Precipitating Factors C.Signs and Symptoms D.Schematic Diagram VII. Treatment and Management A. Surgical Intervention B. Drug Study C. Diet D. Activity VIII. Nursing Care Plan

IX. Problems and Difficulties Encountered X. Bibliography

I. IntroductionUterine inversion during the acute postpartum period is a relatively rare complication. Severe post-partum hemorrhage and shock result from the uterine fundus collapsing. If unrecognized, this obstetric emergency could cause serious morbidity or death. Most commonly, the frequency is reported to be approximately 1 in 2000 deliveries. Maternal mortality has been reported to be as high as 15%. Treatment options for this obstetric complication are also quite varied. Several pharmacologic methods, as well as manual and surgical options, have been described for correcting an inversion. The most important aspect of treatment remains immediate recognition and prompt attention to its management. Following is a case report of complete uterine inversion with a discussion of classification, etiology, diagnosis, and methods of treatment for this lifethreatening obstetric event. Objectives: After the 2 days of Nurse Patient Interaction the student nurse will be able to:

Gather demographic, socioeconomic and cultural data of the patient as well as her maternal history. Enumerate the diagnostic and laboratory procedures done with the patient. Identify the anatomy and physiology of female reproductive system. Identify and make out a pathophysiology of the condition of patient (inverted Uterus), its synthesis, definition, precipitating, and predisposing factor. Itemize the surgical/ medical management done in the patient including the IVF and formulate a drug study of all drugs given in the patient. Specify the diet and exercise of the patient from the admission to discharge. Make out a nursing care plan of the problems and needs of the patient Design a health teaching plans for the patient.

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II.Personal DataA.Demographic Data

Mrs. Marie is a 26 years old plain housewife who lives in Dau, Mabalacat Pampanga. She was born on March 9, 1985. Her education attainment is third year high school. According to her she didnt finish her study because of financial constraints. They have 3 siblings already. The first one is a 7 years old boy, second is a 4 years old boy and third is the newly born baby girl.

B.Activities of Daily Living

At 5:30 am, Mrs. Marie wakes up to cook breakfast for her husband who will go at work. Then at 7:00 am, she will ready her son who will be going to the school. At 8:00 am she will do her household chores while caring her other sibling. Then at 10:00, she will go to the market to buy foods to cook for their lunch. At 12:00 noon she will wait for her husband and her son to eat their lunch. At afternoon, she will spend he time watching telenovelas and take snap. At 6:00 pm she will cook food for their dinner and eat at 7:00 pm. Then from 8:00 pm- 10:00 pm she will watch again telenovelas then sleeps. C.Socioeconomic, Religion, Cultural Beliefs and Practices

Mrs. Marie is a plain housewife taking care of her children. Her husband, Mr. Mike, is the one who earns for their living he is a truck driver and earns 6,000 pesos a month. Her affiliation in religious views is Roman Catholic. According to her she visits the church when she is not busy, even there is no mass. According to her, she believes in pasma and usog. She seldom uses herbal medicines. They usually take medicines when they feel ill such as biogesic when with fever, robitusin when coughing.

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III.History of Past and Present IllnessA.Obstetric History

Mrs. Maries first menarche arouse in the age of 12, she is first year highschool student then. She has a 4 days regular menstrual cycle. Her GP (TPALM) is G3P3 (T3P0A0L3M0) means she has had three pregnancies and three deliveries at terms after 24 weeks of gestation. Her last menstrual period was November 11, 2010. According to her she had a monthly prenatal check up in their Barangay Health Center. She is advised to take vitamins and Ferrous sulfate. Her expected date of delivery is August 18, 2011. Age of Gestation is 37 weeks and 3 days

B.History of Present Illness

Mrs. Marie is admitted last July 31, 2011 with a chief complaint of unconscious, introital mass adherent to the placenta, vaginal bleeding, pallor with an initial assessment of flabby abdomen and tachycardia. According to her, she is still conscious when she delivered her baby but when the midwife is delivering her placenta she just felt dizzy. unti-unti dumilim yung paningin ko, hanggang sa hindi ko na alam ang mga nang yari she added.

Admitting Diagnosis: G3p3(3003) via normal spontaneous delivery, intrapartum hemorrhage, incomplete 3rd stage of labor, inverted uterus, anemia secondary.

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IV. Diagnostic ProcedureDiagnostic/ Laboratory Procedure Hemoglobin Indication/ Purposes Signifies if the patient has anemia. To help make decision whether patient needs blood transfusion or not. Signifies the hydration of the RBCs and WBCs Date July 31, 2011 Result 17g/L abnormal Normal Values 115g/L Analysis and Interpretation Patient hemoglobin level is decrease. It means patient may have anemia.

Hematocrit

July 31, 2011

.05g/L abnormal

White Blood Cells Lymphocytes

To check whether

July 31, 2011

8.1

patient has an infection . To check if patient has a viral infection which functions in the immune system. To check if patient clotting factors are normal. July 31, 2011 0.20

Platelet

70

Patient hematocrit level is decrease. Patient may suffer dehydration and lack of nutrients in the cells. 3 5-10 x 10 /L Patients WBC count is within the normal range means no infection. 0.20-0.35 Patients Lymphocytes level is within the normal range means no viral Infection. 3 150-400 x 10 /L Patients platelet count is low. Patient is at risk of prolonged clotting and bleedingtime

0.40-0.52g/L

4

RBS

To check blood glucose level

8.35

3.85-9.0 mmoL/L

Patient RBS within normal range

BUN

Urea is cleared by the kidney and diseases which compromises the function of the kidney will frequently lead to increased blood levels The kidneys maintain the blood creatinine in a normal range Creatinine has been found to be a fairly reliable indicator of kidney function A breakdown product of purines that are part of many foods.

1.9

1.7-8.3

Patient BUN Level is within normal range

Creatinine

58.6

58-100

Patient creatinine level is within normal range

Uric Acid

0.46

0.145-0.37

Uric Acid is elevated Patient is susceptible on having gout

LDH

To check if there are internal tissue damage

1.013

225-140 iu/L

Serum glutamic oxaloacetic transaminase (SGOT)

An enzyme that is normally present in liver and heart cells levels are thus elevated with liver damage

54.4

10-40

Patient SGOT level is increase It may be indicative of liver damage

Serum glutamic pyruvic transaminase

(SGPT) Sodium

SGPT is released into blood when the liver or heart are damaged. A major electrolyte in the cell A water loving electrolyte To check if patient is susceptible to hypertension To check if patient susceptible to hypertention

27.3

0-39

Patient SGPT level is within normal range Patient has elevated sodium level Patient may have hypertension Patient has low Potassium level Effect of low potassium is muscle cramp and muscle weakness Patient has increased chloride level May be indicative of kidney problem

155.5

136-145 mmoL/L

Potassium

2.65

3.5-5.0 mmoL/L

chloride

Major electrolyte in the body To check is there proper cellular nutrition in the body

116.7

101-111 mmoL/L

V. Anatomy and Physiology

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next step for the fertilized egg is to implant into the walls of the uterus, beginning the initial stages of pregnancy. If fertilization and/or implantation do not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be menopausal. The female reproductive anatomy includes parts inside and outside the body. The function of the external female reproductive structures (the genitals) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oilsecreting glands. After puberty, the labia majora are covered with hair. 7

Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholin's glands: These glands are located beside the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs in the female include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall.

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VI. PathophysiologyA.Definition It refers to the uterus turning inside out with either birth of the fetus or delivery of the placenta. The uterine fundus that has inverted and lies within the endometrial cavity without extending beyond the external os is called an incomplete inversion. Complete/ total inversion describes an inverted fundus that extends beyond the external os. In our case it is complete inversion. B. Predisposing and Precipitating Factors The predisposing factor for our patient is an adherent placenta and the precipitating factor is the Pulling of the Attached Placenta Down, the placenta is reluctant to separate and is retained inside the uterus, the midwife may try to remove it manually with hands forcing the placenta down that has not easily separated, it can bring the top of the uterus down with it.

C. Signs and Symptoms with rationale (patient centered)

Introital mass adherent to the placenta o Due to complete inversion of the fundus that extends beyond external os. Vaginal Bleeding o Because of incomplete placental separation and not contracted uterus. Pallor o Because of excessive blood loss, the body will supply first the important organs resulting to decreased blood supply to the peripheral organs including the skin. Unconscious o The blood supply in the brain cells decreased.

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D.Schematic Diagram Predisposing factor: Adherent Placenta Precipitating factor: Pulling of the Attached Placenta Down

Forcing the placenta down

Uterus will be pulled down ( where placenta is still attached)

Introital mass adherent to the placenta

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Open blood vessels large amount of Blood suddenly gushes Not contracted uterus Decreased in circulating blood in the body

Vaginal bleeding compensatory mechanism tachycardia

Increased blood supply in important/main organs(brain, kidneys,lungs,hear t) Blood loss continues decreased supply in the brain dizziness

unconscio us

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VII. Treatment and ManagementA. Surgical Intervention An abdominal hysterectomy involves the removal of the uterus through a long incision in the abdomen. The surgeon will either make a vertical or horizontal incision in the abdomen, and the direction of the incision is dependent upon the reason for the hysterectomy and the size of the uterus. In the case of our patient vertical incision is made.

During the surgery, the surgeon separates the uterus from the vagina, ovaries, and fallopian tubes. The cervix is usually removed along with the body of the uterus, which is called a total hysterectomy that is done in our patient. If the cervix is not removed as well, the procedure is called a partial hysterectomy, after the uterus is removed; the layers of the abdominal tissue are closed with stitches and staples. Intravenous Fluids Patient IV fluid at right arm is D5LRS 1L regulated at 30 gtts /min infusing well in the left arm started on august 2, 2011 at 7:00 in the morning with side drip of D5W 500 ml with tramadol regulated at 12 gtts/min started. with D5W 500ml connected to a CVP line at 12 gtts/ min. At her left hand is 0.9% NACL I liter regulated at 12 gtts/min started on august 1, 2011 at 8:00 in the evening with side drip of amino acid 5% sorbitol regulated at 12 gtts/min. Nursing responsibilities: (prior/during/after)

check the patient's name before administration verify physician's order indicating the type of solution, amt to be administered, the rate of flow of solution, client allergies. explain the procedure to the patient and/ or SO and wash hands. explain the skin status at IV site, status of dressing and consistency of IV flow rate with that ordered In administering and starting line of the patient always start with identifying the patient and explain the procedure to gain patient's trust. Count drops per minute in the drip chamber, and adjusts the drip rate if necessary. Ensure that the infusion rate and other controls on the pump or the controller are correctly set and the pump or controller is operating. Be sure to label the bottle with the following: date started patient's name and number of IV bottle. After removing IV, apply warm compress.

The patient had 16 bags of blood for transfusion.

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C.Drug Study Name of The Drug & Stock Dose Dosage, Route, Frequency of administratio n 200mg /cap BID( twice a day) Nursing responsibilities

General action

Indication

Side effects

Generic : Ferrous Sulfate Brand : feosol Stock Dose : 200mg/cap

Anti-anemia

The patient hemoglobin is 17 g/L

Dark Stool Constipation Stomach upset

Generic name: 250 mg Electrolytes Hypokalemia GI discomfort

Warn patient that stool maybe dark If drug will be continue at home, teach patient to: Do not take with antacids take with Vitamin C rich food and fluid like calamansi juice. Increase fluid intake Administer

Kalium Durulle Stock Dose: 250 mg/tab TID(thrice a day)

drug with food and full glass of water to decrease GI discomfort. Teach patient to not break or chew the drug. Take it as a whole.

Generic : Mefanamic Acid Brand : Ponstan Stock Dose : 500mg

500mg TID(three times a Day)

Analgesic

To relieve Pain -Pain due to surgical incision made

che ss

Heada Dizzine GI Pain

Teach patient take drug with food Provi de bed rest Take only the prescribe dose Take the meds on time Do not administer oral drugs

Generic name: Calcium Carbonate

1000mg TID(three times a day) Antacid, Electrolyte

Treatment of calcium deficiency

Nausea Vomiting constipation

Stock Dose: 1000mg

in tetany of the newborn Prevention of hypocalce mia during exchange transfusion Improves weak or ineffective myocardial contraction s when epinephrin e fails in cardiac resuscitatio n

abdominal pain dry mouth thirst

within 1-2 hours of antacid administrat ion Give calcium carbonate antacid 1 and 3hr after meals and at bedtime Monitor cardiac response closely during parenteral treatment with calcium

C. DietDuring the time of the researchers visit last august 1 2011 the patient diet is on Nothing per Orem and at August 2, 2011is soft diet.

D.ActivityOn August 01, 2011 patient is advice to be flat on bed for at least eight hours but patient may turn to sides every hour. On August 02, 2011 the patient is advice to begin early and frequently to start recovering with the surgery like doing her personal hygiene and begin to sit and ambulate with assistance.

VIII. Nursing Care Plan

IX.Problems and Difficulties EncounteredI encountered many difficulties in doing this case study, starting from caring the patient in the hospital; she is my patient for 2 days, taking her CVP line every hour at first day. Then at second day I checked her 5 IVF fluids, her vital signs, intake and output, again her CVP line. Though that is the case, I learned a lot in taking care of this patient, especially in measuring the CVP line. It is my first time to see and measure such. I learned the technique in proper measurement. I dont have problems encountered in making the Demographic data of the patient, only in making the Pathophysiology. I spent almost half of the day in doing it, getting data in the net and books that will help me a lot, making it step by step, knowing it will be the heart of our case study. And also I have difficulty in compiling the whole case study because I need to wait for my group mates first to send their part and edit them. -Samson, Evangeline

The problems that I encountered was first in doing a drug study because other drugs are difficult to find and a lot of effort and patience is required in it and at the same time I dont even know how to start and if I am doing the correct/right thing. The second is the copying of some data that is needed for our case study because some words in the chart are difficult to understand. The third one is that the internet connection was having a technical problem and it is difficult to send a data/ a finished part to our leader because of the internet connection. Soriano, Mary Grace

The problems I have encountered in making our group case study is in the process of disseminating the workloads. And the time frame before the submission of the paper. Other members are in a rush because their own case study is also coinciding with the group case study. also maybe lack of resources. Some may find it hard to do the work especially if there is lack of comput ,laptop, esp internet shops for those who are staying at dormitories. The possible solutions for the time frame may be time management, in the dissemination of workload may be in the process of fishbowl method wherein a member will pick up a paper ,inside it corresponds the particular part that member will be doing. Also, in the case of "resources", it is not enough that we have our online resources; we should also browse in our books for possible ideas. some may find it hard to do the work especially if there is

lack of computer, laptop, esp internet shops for those who are staying at dormitories.

I have encounters problems while doing and copying our patients chart for our case study like I cant understand some words in the doctors order where in fact it is hard to read the writings of the doctor. And one thing is the chart is not always in our hands thats why there are some information that has not been collect. Pradilla, Angelica E.

I have encountered problem especially while copying the chart of our patient in this case study. Many words in the doctors order are hard to read, many term that I cannot understand that I think that the first time I have encountered such. I think one of the problem also is having lack of the time, each of us have a very busy day and I dont know how to spare some time doing this because of a lot thing to do. -Sagcal, Ramil C. The problems I have encountered in making our group case study is in the process of dissiminating the workloads. and the time frame before the submission of the paper. Other members are in a rush because their own case study is also coinciding with the group case study. also maybe lack of resources. Some may find it hard to do the work especially if there is lack of computer,laptop,esp internet shops for those who are staying at dormitories. The possible solutions for the time frame may be time management, in the dissimination of workload may be in the process of fishbowl method wherein a member will pick up a paper ,inside it corresponds the particular part that member will be doing. Also, in the case of "resources", it is not enough that we have our online resources,we should also browse in our books for possible ideas.some may find it hard to do the work especially if there is lack of computer,laptop,esp internet shops for those who are staying at dormitories. -Tayag,Patrisha Marie N.

XI.

Bibliography

Books:

Maternal and Child Health Nursing 5th ed. By Adele Pilliteri 2007 Lippincott Williams & Wilkins

Nurses Pocket Guide edition ed. Doenges, Moorhouse, Murr 207 Nursing drug guide ed. Amy M. Karch 2007 Lippincott

Websites:

http://www.innerbody.com/image/repfov.html http://www.medscape.com/viewarticle/405770_3 http://www.mims.com.ph/Philippines/drug/info/Kalium/Kalium%20durule http://www.babycenter.com.ph/pregnancy/complications/uterusabnormal/ http://www.medterms.com/script/main/art.asp?articlekey=9968