ACKNOWLEDGEMENT
This project would not be made possible without the help and guidance of our Almighty Father, who conveyed our group adequate knowledge, sufficient vigor and bravery to face innovative and peculiar defy during the entire course of this project. Our never-ending thanks to Almighty Father the most High for the love and care he showered upon us.
Our genuine gratitude to our beloved parents for always supporting us physically, mentally, emotionally and financially in regards to this venture. Warmth thanks for entrusting to us their confidence and understanding not only in times of need but in everyday of our lives. They used to complain that we are getting too sovereign and matured; however we live in the ideology that letting go of their children is the hardest part of being a parent. Though it is not easy for us to acknowledge the fact that we are getting old bit by bit, we have to separate from them in order to understand the true essence of being a human, and still our love for them remains the same. To our dear parents, rest guaranteed that what we are doing right now will serve as a stepping stone towards a philosophical future and sagacious life, and that is being a nurse.
INTRODUCTION
Pregnancy is an exciting time in any parent's life. It's a time of change, growth, discovery and a lot of questions. One of the most important factors of having a healthy baby is the mother’s health especially during the 9 months where the child’s development has already started. The mother’s nutrition, activity etc. greatly affect the developing fetus inside her womb such that any move could put the child at risk resulting to abnormalities, poor health or even death to the precious being anytime or even during
placenta is implanted close to or covers the cervical os. Normally, the placenta implants in the upper uterine segment, but in the case of placenta previa, the placenta implants in the lower part of the uterus.
Placenta previa is experienced in 1 out of 200 pregnancies around the world. Maternal morbidity rate is approximately 5% and mortality rate is less than 1%. In the Philippines , it reached to 6,341 out of the 86,241,697 population estimate used in the year 2004. The mortality rate of placenta previa in the
country is 0.17% according to DOH.
During our duty in the Ob ward at Ospital Ning Angeles (ONA) , we decided to take the case of Mrs. Nicole Kidman in which she was diagnosed with placenta previa totalis because we would like to have a deeper understanding about this condition so that we could render the care the patient needed to arrive with a good prognosis. Management should therefore always be based on appropriate clinical judgment. We would like to apply all the things that we’ve learned through our lectures for the benefit of our patient and to enhance our skills as well.
We hope that this case study will enable us, student nurses to better understanding about the disease process and that we will be more sensitive in attending to our patient’s need. For the community, we hope that this will increase the level of awareness among the members of the community so that it could help in the prevention of further pregnancy complications.
2. Gather all necessary information regarding her and her family members as may be related to our case study
3. Ascertain client’s past and present health history 4. Trace her genogram or family tree
5. Trace the development data of the client
6. perform physical assessment on client’s condition so as to attain baseline data
7. Present the definitions of the complete diagnosis that would explain the illness of our client
8. Study the anatomy and physiology of female reproductive system 9. Trace the pathophysiology of placenta previa
10.Determine the diagnostic tests our client has undergone including their implications and nursing responsibilities
11.identify the drugs prescribed to our client, their action, side effects, indications, contraindications and nursing responsibilities
12.Identify and prioritize the need of our patient
13.Formulate an appropriate nursing care plan based on the assessment identified needs and problems of the patient
14.Render health teachings as part of our holistic care to alleviate problems identified 15.Evaluate complications to nursing practice, education and research
PATIENT’S DATA Name: Mrs. Nicole Kidman
Address: 160 Abacan, Malabanias Angeles City Age: 38 y/o.
Birthday: 7-12-1971 Birthplace: Angeles City
Ward: OB Bed no.: 22
Admitting Diagnosis: Pregnancy uterine 6 – 7 weeks AOG G5P4 UTI, Placenta Previa
Student Nurse Centered:
After the completion of the case study, the student nurse shall be able to:
• Present a comprehensive and detailed report regarding the patient’s illness
• Have a complete picture of the patient’s physical, psychosocial and mental status through daily assessment
• Have a well-structured nursing diagnosis of the client’s status based from an integration of data gathered
• Understand the factors that might have contributed to the development of the disease
• Provide organized and structured nursing interventions as a response to the patient’s anticipated needs
• Provide relevant information on available alternative therapies and management
A. Assessment
1. Personal History
a. Demographic Data
Mrs. Nicole Kidman is a 38 years old Mother. She was born on July 12, 1971 in 160 Abacan St, Malabanias Angeles City, she is a Filipino Citizen and a Roman Catholic. She is the youngest child among the three children. This is her 5th pregnancy on her G5P4 6-7 weeks Age of Gestation. She has a Four Children the 3 boys aged 11, 7, and 4 years old and girl is 9 years old. They live in a compound together with their relatives according to the husband of Mrs. Nicole Kidman they are very crowded in their compound because there are 8 families in their compound and each family they have a range of 3-4 children in each families.
b. Socio Economic and Cultural Factors
As a Roman Catholic Mrs. Nicole Kidman also going to church every Sunday and she also pray before she going to sleep. Although they are Roman Catholic they believe in Herbularyos and Hilots, according to them that one time in her
which she only treated by a antibiotic and was only OTC medicine which she never consulted a physician.
The couples are practicing family planning method Mrs. Nicole Kidman used to drink a type of Pills before she got pregnant on her 5th child. She told us that she suddenly stop drinking pills because she just forgot to buy the next set of tablets. Then she told us that the couple just plan to have an another child so she got pregnant.
Mrs. Nicole Kidman is a plain housewife and her husband is working as a permanent welder in a Construction Company here in Angeles City he earn P 400 a day. Both of them finish High School and there 3 children are studying in a public school at Don Teodoro Elementary School in Abacan, Angeles City.
2. Family Health – Illness History
Mrs. Nicole Kidman diseases has no direct connection with the past illnesses. Her Placenta Previa meaning
is a complication of pregnancy in which the
placenta grows in the lowest part of the womb (uterus) and covers all or part
of the opening to the cervix.
3. History of Past Illness
Mrs. Nicole Kidman have no medical record of any hospitalization in her life. She told us that her common illness is Fever and colds only. She told us that this is the first time she will be hospitalize that why she feel anxious about the situation.
4. History of Present Illness
According to the Client in the morning of October 17, 2009 she is complaining Father (Arthritis) Mother Died (Cancer) Mrs. Nicole Kidman Older Brother 2nd Brother
her admission she experienced heavy vaginal bleeding and later that day she has fever of 39 OC and she has difficulty of breathing that why they hooked an O
2 Nasal Canulla and IVF D5LRS FD 200CC.
5. Physical Examination
PHYSICAL EXAMINATION
October 17, 2009 (Saturday) Upon Admission
Appearance and Behavior: Appears well when not moving but shows slight
facial grimaces upon movement and approachable
Mental Status: Conscious and Coherent Language: Kapampangan
Posture: On a Semi Fowlers position Vital Signs:
T: 36.6 OC
Hair: Shoulder length, black and curly hair. No presence of dandruff Eyes: Anictenic Sclerae, Pink Conjunctiva
Abdomen: Flabby, soft & non tender Genitalia: dosed cervix x 1(4) Spotting
October 18, 2009
Actual Physical Examination
Appearance and Behavior: Appears well when not moving but shows slight
facial grimaces upon movement and approachable
Mental Status: Conscious and Coherent Language: Kapampangan
Posture: On a Semi Fowlers position Vital Signs:
T: 37.3 OC
PR: 85 BPM
RR: 18 CPM
Chest & Lungs: SCE, with retractions Abdomen: Flabby, soft & non tender
Genitalia: painless, Heavy Vaginal Bleeding Extremities: full and equal pulses
DIAGNOSTIC AND LABORATORY EXAMS
A. URINALYSIS
Actual Normal Nursing
Date Test Values Values Implications Rationale Responsibilities
10-17-09 PHYSICAL - To examine 1. Tell the patient
EXAMINATION the patient’s that the test is for
Color Straw Clear straw to Liver problems urine for sign the detection or colored liquid or jaundice migh of renal or renal and urinary
have occur urinary tract tract disorders disease. and assessment
of body function. - To help
Appearance Clear Clear to slightly normal discover 2. Notify the
hazy diseases patient that the
that is not in procedure relation with requires a urine
Reaction 6.5 4.6-8 renal sample. Urine
To demonstrate disorders. must be acquired
concentrating first void in the and diluting - To identify morning.
In normal ability of the drugs or
condition there kidneys. substances 3. Notify the
is no protein that has laboratory and
that can be been taken. physician of any
detect drugs that the
patient has taken
CHEMICAL that may affect
EXAMINATION the results.
Albumin Negative Normal
Sugar Negative Presence of
sugar in urine may indicate diabetes, chronic kidney disease
MICROSCOPIC EXAMINATION
Epithelial Cells Pus cells and May be a sign of Squamous 0.2 hpf bacteria should swelling in the
Renal be absent in kidney and
Pus Cells urine pelvic region,
urethral ulceration and chronic specific inflammatory of the bladder RBC Blood in the urine may sometimes a serious urinary tract problem Mucous Threads Bacteria #
Yeast Cells Oil Globules Spermatozoa
Nursing Date Test Result Normal Results Implications Rationale Responsibilities 10-17-09 Blood Type A (+) In forward typing, if None known - To check 1. Inform the
(ABO+Rh) there’s agglutination compatibility patient that the patient’s RBC’s are of the donor test determines mixed with anti-A and and the her blood group. anti-B serum, the A patient before
and B antigen is transfusion. 2. Notify the
present, thus blood patient that the
type is O test blood
sample thus venipuncture is done. 3. Check the patient’s history for recent administration of blood, dextran or I.V.
4. After the procedure apply direct pressure to the
venipuncture to the site until bleeding stops.
C. COMPLETE BLOOD COUNT
Date Test Result Values Implications Rationale Responsibilities 10-17-09 WBC H 15.19 5-10 Leukemia, - To verify 1. Explain to the
x10^3/uL x10^3/uL bacterial infection or patient the necessity infection, severe inflammation in of undergoing the sepsis the body and test that it helps
observe its detect occurrence of responses to anemia and
specific polycythemia. therapies.
2. Notify the patient that the test requires Hemoglobin 122g/L 115-155 Normal - To recognize blood sample as well
g/L Low HCT, the amount of as the person who suggest anemia, O2 carrying will perform the hemodilution or protein venipuncture and the enormous blood contained within time.
loss. the RBC
3. Inform the patient that the procedure is Hematocrit L 0.35 0.36-0.48 Rule out anemia - To identify the of slight discomfort
nutritional the blood pain. deficiencies, volume
blood loss. occupied by red 4. After the blood cells. procedure, apply
direct pressure to the venipuncture until RBC L 4.02 4.20-6.10 Low RBC is due - To know the bleeding stops.
x10^6/uL x10^6/ uL to enormous amount of RBC
blood loss which in the blood. 5. Refer if
results to venipuncture
anemia. develops hematoma
Leukemia, and monitor the
hemorrhage. pulses distal to the
site.
Differential Count
Neutrophil 73% 55-75% Normal - To point out
bacterial infection and amount of Leukocyte
Lymphocytes L 18% 20-35% Leukemia, -To recognize if systemic lupus there is an erythematosus unusual amount
of lymphocyte that may indicate viral infection such as HIV.
Monocytes 7% 2-10% Normal -Increase of
these may respond to corticosteroid, with pus conditions,
hemorrhage
Eosinophil 2% 1-6% Normal -High
percentage of eosinophil, may indicate bacterial infestation or allergies
Basophil 0% 0-1% Normal -Increase of
basophil may indicate parasite, hypersensitiven ess and heartworm causing endocrine disease, chronic liver disease
MCV 88.1fl 79.40- Normal -To determine
94.80 fl the ratio of
hematocrit to RBC count
-To identify the
MCH 30.3 25.60- Normal average mass
pg 32.20 pg of hemoglobin
per RBC
MCHC 34.5 g/dL 32.20- Normal -Indicates the
35.30 g/dL nature and volume of hemoglobin, to high may indicate spherocytosis or in vitro
hemolysis
D. ULTRASOUND
Nursing Date Test Result Impression Rationale
Responsibilities 10-17--09 U -Presentation : Cephalic Single, live - To know fetal 1. Assure a
2:35 pm L -Number: single intrauterine and consent form
T - Amniotic fluid: AFI 11.1 cm pregnancy, pregnancy signed by the R -Placental location: anterior cephalic abnormalities patient. Explain
A -Placental grade: III presentation, with and that the procedure S -Sex: male good cardiac and measurement is painless and O -AOG: 32W 3D somatic activities; of organ size safe and that no
U -EDD: 10-11-08 BPD= 32 weeks and structure. radiation N -FHB: 147bpm and 5 days; FL= To identify and exposure is D Estimated Fetal Weight: 2233 g 31 weeks and 1 differentiate involved.
-normohydramnios (11.1 cm) day cyst and solid
-amniotic fluid volume: normal Placenta anterior, tumor. 2. Emphasize the -previa: placenta previa totalis early grade III, importance of
totally covering - To ensure remaining still Biophysical profile: the OS (Placenta the during the scan to -amniotic fluid: 2 previa totalis) presentation prevent distorted
-fetal tone: 2 and identify image.
-fetal breathing: 2 complications
-gross movement: 2 of the fetus. 3. Assist the
Total =8 To detect if patient into a
there is risk of supine position; if pregnancy. possible use
pillows to support the area to be examined. Coat
the target area with a water-soluble jelly. If
necessary to assist the patient into lateral positions for consequent view.
THE FEMALE REPRODUCTIVE SYSTEM
GENERAL
The organs of the reproductive systems are concerned with the general process of reproduction, and each is adapted for specialized tasks. These organs are unique in that their functions are not necessary for the survival of each individual. Instead, their functions are vital to the continuation of the human species. In providing maternity gynecologic health care to women, you will find that it is vital to your career as a practical nurse and to the patient that you will require a greater depth and breadth of knowledge of the female anatomy and physiology than usual. The female reproductive system consists of internal organs and external organs. The internal organs are located in the pelvic cavity and are supported by the pelvic floor. The external organs are located from the lower margin of the pubis to the
perineum. The appearance of the external genitals varies greatly from woman to woman, since age, heredity, race, and the number of children a woman has borne determines the
TERMS AND DEFINITIONS
These are only a few terms and definitions that will be used in this lesson. Other terms and definitions will be dispersed throughout the lesson.
A. Broad Ligaments. Two wing-like structures that extend from the lateral margins of the uterus to the pelvic walls and divide the pelvic cavity into an anterior and a posterior compartment.
B. Corpus Luteum. The yellow mass found in the graafian follicle after the ovum has been expelled.
C. Estrogen. The generic term for the female sex hormones. It is a steroid hormone produced primarily by the ovaries but also by the adrenal cortex. D. Fimbriae. Fringes; especially the finger-like ends of the fallopian tube. E. Follicle. A pouch like depression or cavity.
F. Follicle Stimulating Hormone. The follicle stimulating hormone (FSH) is a hormone produced by the anterior pituitary during the first half of the menstrual cycle. It stimulates development of the graafian follicle.
G. Graafian Follicle. A mature, fully developed ovarian cyst containing the ripe ovum.
K. Oocyte. A developing egg in one of two stages. L. Ovum. The female reproductive cell.
M. Progesterone. The pure hormone contained in the corpora lutea whose
function is to prepare the endometrium for the reception and development of the fertilized ovum.
N. Reproduction. The process by which an off- spring is formed.
Wall of the uterus
INTERNAL FEMALE ORGANS
(1) Location. The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments.
(2) 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.
(3) 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 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.
(1) Location. Each tube is about 4 inches long and extends medially from each ovary to empty into the superior region of the uterus.
(2) Function. The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries.
(3) 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).
(1) Functions. The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone).
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.
(3) Process of egg production--oogenesis (see figure 1-5).
(a) The total supply of eggs that a female can release has been determined by the time she is born. The eggs are referred to as "oogonia" in the developing fetus. At the time the female is born, oogonia have divided into primary oocytes, which contain 46 chromosomes and are surrounded by a layer of follicle cells.
(b) Primary oocytes remain in the state of suspended animation through
childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the anterior pituitary gland secretes follicle-stimulating hormone (FSH), which stimulates a small number of primary follicles to mature each month.
(c) As a primary oocyte begins dividing, two different cells are produced, each containing 23 unpaired chromosomes. One of the cells is called a secondary oocyte and the other is called the first polar body. The secondary oocyte is the larger cell and is capable of being fertilized. The first polar body is very small, is nonfunctional, and incapable of being fertilized.
(d) By the time follicles have matured to the graafian follicle stage, they contain secondary oocytes and can be seen bulging from the surface of the ovary. Follicle development to this stage takes about 14 days. Ovulation (ejection of the mature egg from the ovary) occurs at this 14-day point in response to the luteinizing hormone (LH), which is released by the anterior pituitary gland.
(e) The follicle at the proper stage of maturity when the LH is secreted will rupture and release its oocyte into the peritoneal cavity. The motion of the fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also causes the ruptured follicle to change into a granular structure called corpus luteum, which secretes estrogen and progesterone.
(f) If the secondary oocyte is penetrated by a sperm, a secondary division occurs that produces another polar body and an ovum, which combines its 23
characteristics include the enlargement of fallopian tubes, uterus, vagina, and external genitals; breast development; increased deposits of fat in hips and breasts; widening of the pelvis; and onset of menses or menstrual cycle.
(b) Progesterone is produced by the corpus luteum in presence of in the blood. It works with estrogen to produce a normal menstrual cycle. Progesterone is
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.
(2) The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular structure that drains urine from the bladder.
(3) T 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.
BLOOD SUPPLY
The blood supply is derived from the uterine and ovarian arteries that extend from the internal iliac arteries and the aorta. The increased demands of pregnancy necessitate a rich supply of blood to the uterus. New, larger blood vessels develop to accommodate the need of the growing uterus. The venous circulation is accomplished via the internal iliac and common iliac vein.
FACTS ABOUT THE MENSTRUAL CYCLE
Menstruation is the periodic discharge of blood, mucus, and epithelial cells from the uterus. It usually occurs at monthly intervals throughout the reproductive period, except during pregnancy and lactation, when it is usually suppressed.
The menstrual cycle is controlled by the cyclic activity of follicle stimulating hormone (FSH) and LH from the anterior pituitary and
(1) Days 1-5. This is known as the menses phase. A lack of signal from a fertilized egg influences the drop in estrogen and progesterone production. A drop in progesterone results in the sloughing off of the thick endometrial lining which is the menstrual flow. This occurs for 3 to 5 days.
(2) Days 6-14. This is known as the proliferative phase. A drop in progesterone and estrogen stimulates the release of FSH from the anterior pituitary. FSH stimulates the maturation of an ovum with graafian follicle. Near the end of this phase, the release of LH increases causing a sudden burst like release of the ovum, which is known as ovulation.
(3) Days 15-28. This is known as the secretory phase. High levels of LH cause the empty graafian follicle to develop into the corpus luteum. The corpus luteum releases progesterone, which increases the endometrial blood supply.
Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo produces human chorionic gonadotropin (HCG). Thehuman chorionic
gonadotropin signals the corpus luteum to continue to supply progesterone to maintain the uterine lining. Continuous levels of progesterone prevent the release of FSH and ovulation ceases.
Additional Information.
(1) The length of the menstrual cycle is highly variable. It may be as short as 21 days or as long as 39 days.
Ovulation
Ovulation is the release of an egg cell from a mature ovarian follicle (see figure 1-5 for ovulation). Ovulation is stimulated by hormones from the anterior pituitary gland, which apparently causes the mature follicle to swell rapidly and eventually rupture. When this happens, the follicular fluid, accompanied by the egg cell, oozes outward from the surface of the ovary and enters the peritoneal cavity. After it is expelled from the ovary, the egg cell and one or two layers of follicular cells surrounding it are usually propelled to the opening of a nearby uterine tube. If the cell is not fertilized by union of a sperm cell within a relatively short time, it will degenerate.
use, menopause generally means cessation of regular menstruation. Ovulation may occur sporadically or may cease abruptly. Periods may end suddenly, may become scanty or irregular, or may be intermittently heavy before ceasing
altogether. Markedly diminished ovarian activity, that is, significantly decreased estrogen production and cessation of ovulation, causes menopause.
shaped organ — normally located near the top of the uterus — that supplies the baby with nutrients through the umbilical cord.
Placenta previa is a placental attachment that is too low in the uterus and covers the cervix. Normally the placenta is attached to the uterus above the cervix. The placenta completely covers the internal os in slightly more than 10 percent of placenta previa cases. Under these circumstances the placenta precedes the fetus in vaginal delivery. This can be life-threatening to the unborn child and mother if untreated. It occurs to some degree in 1 of 200 pregnancies.
Placenta previa is not usually a problem early in pregnancy. But if it persists into later pregnancy, it can cause bleeding, which may require the pregnant woman to deliver early and can lead to other complications. If a woman has placenta previa when it's time to deliver her baby, she’ll need to have a c-section.
cervix but not bordering it, it's called a low-lying placenta. The location of the placenta will be checked during the midpregnancy ultrasound exam.
It depends on how far along the client is in pregnancy. Don't panic if her second
trimester ultrasound shows that she has placenta previa. As her pregnancy progresses, the placenta is likely to "migrate" farther from the cervix and no longer be a problem. (Since the placenta is implanted in the uterus, it doesn't actually move, but it can end up farther from the cervix as theuterus expands. Also, as the placenta itself grows, it's likely to grow toward the richer blood supply in the upper part of the uterus.)
Only about 10 percent of women who have placenta previa noted on ultrasound at midpregnancy still have it when they deliver their baby. A placenta that completely covers the cervix is more likely to stay that way than one that's bordering it (marginal)
placenta. If the client has any vaginal bleeding in the meantime, an ultrasound will be done then to find out what's going on.
If the follow- up ultrasound reveals that the placenta is still covering or too close to the cervix, the client will be monitored carefully, has regular ultrasounds, and need to watch for vaginal bleeding. She'll be put on "pelvic rest," which means no intercourse or vaginal exams for the rest of her pregnancy. And she'll be advised to take it easy and avoid activities that might provoke bleeding, such as strenuous housework or heavy lifting.
Bleeding from a placenta previa happens when the cervix begins to thin out or dilate (even a little) and disrupts the blood vessels in that area. It's usually painless, can start without warning, and can range from spotting to extremely heavy bleeding. If her bleeding is severe, she may have to deliver her baby right away, even if he's still premature. The pregnant woman may also need a blood transfusion.
It's unusual for bleeding to start before late in the second trimester, and about half the time it doesn't begin until you're nearly full-term (37 weeks). The bleeding will often stop on its own, but it's likely to start again at some point. (If she has bleeding and she’s Rh negative, she'll need a shot of Rh immune globulin, unless the baby's father is Rh negative,too.)
If the client start bleeding or has contractions, she'll need to be hospitalized. What happens then will depend on how far along you are in her pregnancy, how heavy the bleeding is, and how you and your baby are doing. If she is near full-term, the baby will be delivered by c-section right away. If the baby is still premature, he'll be delivered by c-section immediately if his condition warrants it or if the client have heavy bleeding
If the bleeding stops, and both the mother and her baby are in good condition, she'll probably be sent home. But she'll need to return to the hospital immediately if the bleeding starts again. If she and her baby continue to do well and she doesn't need to deliver early, she'll have a scheduled c-section at 37 weeks.
No matter when she delivers, if she still has placenta previa, she'll need a c-section. With a complete previa, the placenta blocks the baby's way out. And even if it's only bordering the cervix, she'll still need a c-section in most cases because the placenta could bleed profusely if the cervix dilated.
PATHOPHYSIOLOGY
No specific cause of placenta previa has yet been found but it is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection.
In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, it may shear off and a small section may bleed.
Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta. Praevia can be confirmed with an ultrasound. In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre.
The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby's chance of survival is as good as at full term.
Placenta previa is itself a risk factor of placenta accreta. Placenta Previa
Painless Vaginal Bleeding
Ultrasound
Risk Factors
Late Maternal Age Infection (UTI) Multiparity
Complete Previa Marginal Previa Partial Previa Bleeding stops Low-lying place Fetus stable
Bed Rest
Observe
Urine Output Pale, cool skin Hypotension Bleeding continues Capillary refill Maternal Hemorrhage Bleeding Restarts tachycardia
Cesarian Birth
S O A P I E
October 17, 2009 7 – 3
S> ”Masakit ang puwerta ko” as verbalized by the patient O> Guarding behavior
> Facial grimace
> Generalized body weakness > Pain Scale 4/5
> (+) DOB
A> Acute Pain r/t Inflammatory Response
P> After 4O of nursing intervention, the patient will report pain is relieved/controlled
I> Established rapport
> Monitored v/s taken and recorded > Morning Care Rendered
> Instructed patient to exercise deep breathing every time the pain occur > Encouraged the patient verbalization of feelings about pain
> Instructed the patient to have proper hygiene > Position the patient in Semi fowler’s position > Provided safety and comfort
b. PLANNING (Nursing Care Plan)
Cues DiagnosisNursing explanationScientific Objectives Interventions Rationales outcomesExpected
S>”Masakit ang puwerta ko” as verbalized by the patient
O> The pt. may manifested the ffg: >Pain, 4/5 >Guarding behavior >Facial grimace >Generalized Body Weakness > (+) DOB > Perspiration > >Acute pain r/t Inflammatory Response
Acute pain is described as an unpleasant sensory or emotional experience
associated with actual or potential tissue damage or injury as lasting from second to 6 months. In cases of fracture, pain is continuous & increasing in severity until bone fragments are immobilized. In this type of fracture, the
main medical management is open reduction with internal fixation (ORIF), wherein
the fracture fragments
Short term: After 4 hrs. of NI, patient will verbalized the pain is controlled or disappear Long term: After 2 days of NI, pt. will maintain the absence of pain >Establish rapport >Monitor v/s >Encourage pt. deep breathing exercise when pain occur >Promote safety and comfort >Avoid environmental stimulant >To gain pt. trust >To have baseline data >To decrease the pain >To
>To avoid the pain to occur Short term: Goal met as evidenced by the pt. verbalized the pain is controlled or disappear Long term: Goal met as evidenced by the pt. maintain the absence of pain
Cues Nursing diagnosis
Scientific
explanation Planning Intervention Rationale Evaluation
S>“Pakiramdam ko mainit buong katawan ko” as verbalize by the patient O> The pt. manifested the ffg: >skin warm to touch >dry lips >fatigue >redness >Hyperthermia related to inflammatory process. Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability and death. Short term: After 4 hours of NI, patient will decrease temperature from 38.9 c to 37.5 c Long term: After 2 days of NI, patient will maintain absence of hyperthermia > Establish rapport >Monitor vital sign >provide TSB >promote comfort and safety > To gain the trust of the patient > to have baseline data >to decrease heat > make safety and relax the patient
> treatment for mild to
Short term: Goal met AEB the patient temperature decrease from 38.9 c to 37.5 c
Long term: Goal met AEB the patient maintain the absence of hyperthermia
Cues Nursing diagnosis
Scientific Explanation
Planning Intervention Rationale Evaluation
S> “Nahihirapan akong gumalaw kasi masakit yung bahay bata ko” as verbalize by the patient O> (+) pain, 4/5 >facial grimace >guardianing behavior >limited movement >impaired physical mobility related to pain The movement of body structures is accomplished by the contraction of muscles. Muscles may move parts of the skeleton relatively to each other, or may move parts of internal organs relatively to each other. All such movements are classified by the directions in which the affected structures are moved. In human anatomy, all Short term: After 3 hours of NI, patient will verbalize understandi ng for individual situation Long term: After 2 days NI, patient will maintain the absence of pain >establish rapport >monitor vital sign >promote comfort and safety >assess patient complain > explain to patient the condition >to gain patient trust > to have baseline data > to promote safety and relax > to assess and treat patient problem > to understand the patient her/his condition > to decrease the pain Short term: Goal met AEB the patient verbalize understanding for individual situation Long term: Goal met AEB the patient maintain the absence of pain
Name of Drugs Date ordered Route of admin General action Indication Client’s response to the Medication with actual Side Effect Generic name: Cefuroxime Brand name: Ceftin Date taken/given: 10/17/09 Date changed: Dosage: Adults: >250 mg bid for severe infections, maybe increased to 500 mg bid Frequency of admin: >Inhibits synthesis of bacteria cell wall, causing cell death. >Lower respiratory infections caused by S. Pneumoniae, H. Para influenza, H. Influenza Patient response effectively with no side effect noted.
Generic name: Acetaminophen Brand name: Paracetamol Date taken/given: 10/17/09 Date changed: Dosage: Adults >by supporting 365-600 mg q 4-6 hr. or P.O, 1000 mg tid to qid. Do not exceed 4 q/day >Reduces fever by acting directly on the hypothalamic heat regulating center to occur vasodilator and sweating which helps dissipate heat. >Analgesic anti pyretics in patients with aspirin allergy, hemostatic disturbances bleeding diatheses, quoty artitis Patient response effectively with no side effect noted.
Type of Diet
Date Ordered:
Date Started
:General
Description
Indication /
Purpose
Client’s
Response /
reaction to the
diet
DAT DO: 10-17-09 DS: 10-17-09There is a dietary sodium restriction on patient
To facilitate reduction of sodium in the body, thus reducing edema and ascites.
It also aide in the
reduction of conjunction of vascular fluids since sodium attracts water.
The patient refuses to eat.
Nursing Responsibilities: • Explain the purpose.
• Assess for patient condition, how he respond diet.
• Provide variety of choices of foods low sodium.
• Be sure patient is taking / eating foods he can tolerate.
HEALTH TEACHINGS
* Encourage patient to express feelings and concerns ® So that relief measure may be instituted
89
* Teach family / significant others to foster independence, and to intervene if the patient becomes fatigued, is unable to perform task or becomes excessively frustrated
® Demonstrates caring / concern * Teach patient perineal hygiene
® to decrease risk of ascending infections * Splint incision when moving or coughing
® to decrease pain and to prevent wound separation * Encourage the patient to comply with medications given
® The use of medicines is a pharmacologic method that aids in the recovery of the client
*Encourage the client to eat foods to stimulate the production of milk · temperature exceeding 38C
· painful urination
· lochia heavier than normal period · wound separation
· redness or oozing at the incision site · severe abdominal pain
· use relaxation techniques such as music, breathing, and dim lights · apply heating pad to the abdomen
*GAS pain
· Inculcate to the client the importance of proper hand washing
® Hand washing if the single most effective way in controlling infection DISCHARGE PLAN
Medications:
· Teach patient and her family or significant others the proper dosage and the right time to take the medication.
· Emphasize to the patient the importance of obediently taking the
prescribed medications and the disadvantages or complications that may arise if these are not taken properly.
· Inform and discuss the possible side effects and reactions that these drugs might produce and seek medical attention immediately is these arise
· Discourage to use of OTC medications or at least inform the physician if she’s taking other OTC medications. This is essential to prevent any occurrence of drug interactions.
Exercise:
· Tell client to refrain from straining activities
· Encourage ambulation as a form of light exercise that would help in the progression of her recovery and wound healing.
· Range of motion. Encouraging the patient to do some exercises would allow good blood circulation as well as the prevention of the occurrence of bed sores.
· Encourage patient to do some stretching exercise to prevent stiffness of the bone due to less activity performed.
symptoms of the patient’s condition and monitor for her recovery.
· Encourage patient to have a sufficient rest and sleep to maintain internal equilibrium
· . Provide a safe and comfortable environment because it could make the patient more relaxed which is also needed to arrived with a good
prognosis Hygiene:
· Discuss the significance of personal hygiene and proper hand washing in preventing infections
· Give client some lectures about proper wound care through changing the dressing as often as possible so as to protect the wound from invasion of microorganisms as well as to reduce the risk of microorganism
transmission to others. Outpatient Care:
· A follow up check-up is necessary for wound evaluation and to assess the progression of wound healing.
Diet:
· Encourage the patient to increased fluid intake and to include fruits and vegetables rich in vitamin C for the production of milk needed for lactation. · Taking food rich in protein is also helpful for tissue repair.