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

Republic of the Philippines Tarlac State University College of Nursing Lucinda 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 Fulfillment Of 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 to Ms. Gienelle Mallari, RN Table of Contents 1

I. Introducti Introduction……… on………………… …………………… …………………… …………………… …………………… …………………… …………...1 ...1 Objectives……………………………………………… Objectives………………… ……………………………………………………… ………………………….5 .5 II. II. Nurs Nursin ing g Pro Proces cesss A.Assessment 1. Personal Data…………………… Data………………………………………………… …………………………………….…….6 ……….…….6 a)Demographic Data………………………… Data…………………………………………….……..6 ………………….……..6  b)Environmental Status……………………………………….…… Status……………………………………….………..6 …..6 c)Lifestyle…………………………………… c)Lifestyle………………………………………………………………7 …………………………7 2.Family History of health and Illness 3. History of Past Illness…………………………………………….….………9 Illness…………………………………………….….………9 4.History of Present Illness…………………………………………….……….9 Illness…………………………………………….……….9 5.Physical Assessment...........................................................................................9 6.Diagnostics and laboratory Procedures………………………..…………….18 Procedures………………………..…………….18 7.Anatomy And Physiology…………………………………… Physiology……………………………………...…………….19 ...…………….19 8.Pathophysiology i.Book-based……………………………………………..…………….24 ii.Client-based…………………………………………..……………...26 B. Planning 1. Nursing Nursing Care Plans………… Plans…………………… …………………… …………………… ………….……… .……………..2 ……..28 8 C.Implementation 1.Medical Management i.IVFs,BT,NGT feeding,Nebulization,TPN,Oxygen Therapy etc……36 ii.Drugs………………………………………………………………..42 iii.Diet……………………………………… iii.Diet………………………………………………………………… …………………………46 46 iv.Activity/Exercise…………………………………………………...49 2.Surgical Management……………………… Management…………………………………………………… ……………………………….51 ….51 3.Nursing Management(SOAPIE)…………… Management(SOAPIE)……………………………………… ……………………………….53 …….53 D.Evaluation 1.Patient’s Daily Program in the hospital……………………………………...60 hospital……………………………………...60 2.Discharge Planning…………………… Planning……………………………………………… ……………………………………..61 …………..61 III. Conclusion……………………… Conclusion…………………………………………………… …………………………………………………62 ……………………62 IV. Recommendation………………………… Recommendation……………………………………………………… ………………………………………..62 …………..62 V. Bibliography Bibliography………… …………………… …………………… …………………… …………………… …………………… ………………….6 ……….63 3

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 implantati implantation on that totally totally obstructs obstructs the cervical cervical os (total (total placenta placenta  previa). The degree to which the placenta covers the internal cervical os is generally estimated in   perce percenta ntages ges 100%, 100%, 75%, 75%, 30% and so forth. forth. Increa Increased sed parity parity,, advance advanced d matern maternal al age, age, past past cesarean births, post uterine curettage, multiple gestations, and perhaps a male fetus are all associated with placenta previa.

The incidence of placenta placenta previa is approximat approximately ely 5 per 1,000 pregnancies. 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 feta fetall nutr nutrit itio ion n or oxyg oxygen enat atio ion. n. The The inci inciden dence ce of plac placen enta ta previ previaa in the the Unit United ed Stat States es 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 listed as an underlying underlying obstetric obstetric condition condition contributi contributing ng to death. This resulted in a case fatality fatality rate of .03%. The incidence of maternal death was 1 in 3,300 cases of placenta previa. There are still still no current trends about the medications medications and other diagnostic diagnostic procedures 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 The grou group p choo choose sess this this case case beca becaus usee more more clin clinic ical al skil skills ls will will be deve develo lope ped d by experi experienci encing ng the clinic clinical al managem management ent of this this diseas disease-c e-condi onditio tion n and it will will enhance enhance one’s 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

8 3

8 0

AST

6 0 HTN

2 6 GSW

OLD AGE

4 9

3 0

SUICIDE

AST

HTN

AW

2 9

2 4

2 3

AST

AW

AW

3 7

3 5

AW

6 3

4 9

1 2

4

N B

2 2 AW

9 0

8 4

HTN

HTN

5 8

5 5 AW

AW

1 8 AW

AW

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

4 9

5 3 AW

1 5 AWA

AW

1 1

1 1

6

AW

AW

AST

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

FEMALE - DECEASED MALE NB- NEWBORN

AW 9

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 10

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.

13

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.

14

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.

15

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 August 27, 2009

August 28, 2009

TIME

8:00am 10:00am

TEMPERATURE (◦C) 36.2 36.7

8:00am 10:00am

37.1 37.6

16

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

August 27, 2009

August 28, 2009

Time

Respiratory Rate

8 am

24 cpm

10 am

24cpm

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.

8. CIRCULATORY STATUS

17

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

August 27, 2009 August 28, 2009

TIME

8:00am 10:00am 8:00am 10:00am

56 56 63 58

PULSE

BLOOD

(bpm)

PRESSURE (mmHg) 130/100 130/90 120/80 130/80

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. Norms:

18

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 = WBC

August

27, This is used 7.5

2009

to

determine

if

there

4.1

–

10.9  Normal

g/dL

>No indicative

is

abnormalities

infection

noted.

 present.

>Hgb

August

27,

80

2009

F

(123-153 Abnormal due

g/L)

to bleeding. >If  hemoglobin is low, not

there

is

enough

oxygen in the  blood.

>Hct

August 2009

27, A measure of  0.266 the

packed

F(0.359-

Abnormal due

0.466 vol%)

to bleeding and

22

cell

volume

blood

loss

of red cells,

during surgery.

express as a

>If hematocrit

  percentage of 

is low, there is

the

decreased

total

 blood

  blood volume.

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 24

  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.

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).

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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. 26

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.

28

Pathophysiology of Placenta Previa (Book-based) Modifiable factors: Women who smokes

 Nonmodifiable factors: Multiparity Multiple gestation Previous cesarian Birth

Pre nanc Abnormal Vascularization of  Endometrium

Uterine Atro h

Low Placental im lantation 2nd and 3rd

Im lantation in Low uterine

Placenta Previa Total

Cervical dilation

Partial

Cover  internal OS

Malpresentation of fetus

Low-l in

Disrupted Placental attachment

Uterine Contraction

Decrease Uterine blood

Bright red vaginal  bleeding

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Decrease Uterine  blood flow

Bright red vaginal  bleeding

Blood loss

Decrease fetal oxygen supply

Decrease blood Volume

Fetal distress IUG R

Hypovolemia

Pallo r 

Decrease capillary refill

Decrease kidney

 perfusion Hypotensio

Congenital anomalies Compensat ory mechanism

n Cold Clammy Skin

Preterm Labor

Decrease Urine output

Tachycardi

Tachypnea

a

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Pathophysiology of Placenta Previa (Client-based)  Nonmodifiable factors: Multiparity Multiple gestation Advance maternal Age

Pre nanc Abnormal Vascularization of  Endometrium

Uterine Atrophy

Low Placental implantation (2nd and 3rd trimester)

Im lantation in Low uterine

Placenta Previa Tota

Cervical dilation

Cover  internal OS

Disrupted Placental attachment

Malpresentation of fetus

Bright red vaginal  bleeding

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Bright red vaginal  bleeding

Blood loss

Decrease blood Volume Hypovolemia

Pallo r  Hypotensio n

Cold Clammy Skin

Compensator  y mechanism

Tachycardi a

Tachypnea

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

Date/time: August 27,2009/8:00 am INTERVENTION & RATIONALE EVALUATION

SCIENTIFIC  NURSING PLANNING EXPLANATION DX Post-operative Acute Pain After 30 >Build rapport with the patient  pertains to the r/t surgical minutes of  R: This is to gain trust by the patient,  period of time incision.  proper nursing thus making working relationship after surgery. It intervention, comfortable for both the nurse and the  begins with the the patient will  patient.  patient’s verbalize >Place ice pack at the incision site. emergence from decreased in R: To reduce the pain and to prevent anesthesia and  pain to a hemorrhage by keeping the fundus continues through tolerable state. contracted. the time required From a pain >Encourage the patient to do breathing for the acute scale of 10 to exercises. effects of the 2. R: This will promote good oxygenation, anesthetic and therefore promote good tissue perfusion. surgical >Provide emotional support by  procedures to encouraging the patient to verbalize what abate. she feels. R: This is to increase patient’s selfworth. >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  grimace  b.) Normal respiration. RR:17cpm

33

Date: August 28, 2009 CUES

SCIENTIFIC  NURSING PLANNING INTERVENTION & RATIONALE EVALUATION EXPLANATION DX S: Ø Post-operative Impaired After 30 >Build rapport with the patient After 30 O: discomfort felt by  physical minutes of  R: This is to gain trust by the patient, minutes of  >with surgical the client after the mobility  proper nursing thus making working relationship  proper nursing incision at the lower  anesthesia has r/t surgical intervention, comfortable for both the nurse and the intervention, the abdomen subsided causes incision. the patient will  patient.  patient will be >inability to sit  pain and will lead  be able to >Assist patient in turning side to side able to >difficulty turning decreased client’s gradually every 2 hours. gradually to side tolerance to increase R: Turning side to side is important to increase >weak in activity mobility.  promote lung expansion and to prevent mobility by appearance complications like pressure ulcers and turning side to >restless and aspiration pneumonia. side. irritable >Provide emotional support by AEB: >pale looking encouraging the patient to verbalize what a.) Absence of  >tachypnea:RR:24 she feels. grimace > grimace R: This will increase the patient’s self b.) Ability to worth. turn side to side >Instruct the patient to do breathing with minimal exercises. assistance. 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.

34

DATE

CUES

SCIENTIFIC EXPLANATION August S: Ø Heavy bleeding 27, 2009 O: may double for  >have no oral intake for the the postpartum woman, because last 8 hours she may >chapped lips haemorrhage vaginally from >dry mouth an uncontracted >with surgical incision at the uterus as well as internally from lower abdomen  blood vessels >consumed 2 underpad for  that were not securely ligated 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 >urine output=30 cc/hr 

 NURSING DX Deficient fluid volume r/t  blood loss during surgery

PLANNING 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 remains  between 60 and 100  bpm c. Scant to no  bleeding on surgical dressing is apparent

INTERVENTION & RATIONALE 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.

EVALUATION 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 remains  between 60 and 100 bpm c. Scant to no  bleeding on surgical dressing is apparent

2. Advise client to have frequent oral hygiene, at least twice a day. ®Oral hygiene decreases 35

>Capillary refill=3sec

unpleasant taste in the mouth and allows the client to respond to the sensation of  thirst. Collaborative 3. 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.

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DATE

CUES

SCIENTIFIC  NURSING PLANNING EXPLANATION DX August S: “Hindi ko magalaw Because a Risk for  After 1 hr of  29, 2009 ang paa ko.” woman’s ineffective  proper  abdominal tissue nursing O: muscles are lax  perfusion r/t intervention, -Weak in appearance from the immobility the client stretching that after surgery will -Pale occurred during maintain a -With limited  pregnancy, capillary abdominal refill of less movements contents tend to than 5 -Difficulty shift forward and seconds and  put pressure on will not raising/flexing the legs the suture line report of  -Weak peripheral pulses when she is calf pain, sitting or  redness, -Capillary refill = standing, causing edema, or  3seconds  pain and areas of  uncomfortable warmth on feeling. lower  extremities

INTERVENTION & RATIONALE Independent 1. 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.

EVALUATION 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

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 ® This promotes optimal 37

lung ventilation and  perfusion. 5. Ensure that bedcovers must  be loose enough ® Permits free movements of  the toes and feet

38

Assessment

S: Ø O: •

• •

• • • •

•

• •

•

 blood lossconsumed 1 soaked underpad UO- 30cc/hr  HGT0.266% HGB-80 g/L Pale Dyspnea Weak in appearance Weak and thready 56 bpm-PR  Restless and irritable RR: 24-

Diagnosis

Risk for  Injury r/t  blood loss during surgery

Scientific Explanation

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

Planning

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

Interventions



Monitor vital signs every 15 minutes



Assist the client in a comfortable  position  particularly in SemiFowler’s or  High Fowler’s  position.

Rationale

Evaluation

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

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

To promote lung expansion and facilitate gas exchange.



Encourage the To determine the client to verbalize her  other signs and symptoms felt feelings and  by the client and worries. to know the appropriate nursing interventions to  be done.



Increase 39

frequent observation , and if   possible, stay with the client and enforce security measures (e.g Raise side rails) 

Encourage the client to have  bed rest.



Advise the client to increase 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 Ø

Objective Analysis Planning Risk for  Within 2 hours of   blood lossInjury r/t  proper nursing consumed 1  blood loss interventions, the soaked during surgery  patient will have underpad decreased risk for  • UO- 30cc/hr  injury. • HGT0.266% • HGB-80 g/L • Pale • Dyspnea • Weak in appearance • Weak and thready • 56 bpm-PR  • Restless and irritable • RR: 24-

Implementation

•

 





  

Monitored vital signs every 15 minutes Assisted the client in a comfortable position  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 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.

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

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C. Implementation 1. Medical Management i. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy etc. Medical Management/Treatm ent

Date Ordered/ Date Taken/ Given Date Changed/ Date Discontinued

IV Therapy

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

1L LRS (isotonic) with Started on August 27, oxytocin regulated at 2009, discontinued on the 15 gtts/min same date 1L D5 NM (hypertonic) regulated at 30 gtts/min

August 27, 2009-August 28, 2009

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

Started on August 28, 2009 discontinued on the same date

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

General Description

Indication/s, Purpose/s

Client's reaction to the treatment

IV Therapy is usually The patient did not  performed for fluid volume reported pain in the maintenance, fluid volume IV site replacement, medication administration, blood administration, total   parenteral nutrition and serves as an emergency line

August 28, 2009- august 29, 2009

42

Prior: > 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.

43

Medical Management/Treatm ent

Date Ordered/ Date Taken/ Given Date Changed/ Date Discontinued

Oxygen Therapy 2 Lpm for 3 hours via nasal prong

August 27, 2009

General Description

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

Indication/s, Purpose/s

Client's reaction to the treatment

Clients who have difficulty The patient tolerated ventilating all areas of their  the administered lungs, those whose gas oxygen and exchange is impaired, or  verbalized relief from   people who have heart DOB failure may require oxygen therapy to prevent hypoxia.

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 

44

During: >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.

45

Medical Management/Treatm ent

Urinary Catheterization

Date Ordered/ Date Taken/ Given Date Changed/ Date Discontinued

General Description

August 27, 2009-August 28, 2009

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

Indication/s, Purpose/s

Client's reaction to the treatment

Indications of urinary The client didn’t catheterization includes relief  verbalize any from discomfort due to bladder  discomfort and have distention or to provide gradual adequate (>30cc/hr), decompression of a distended amber colored urine   bladder, to empty the bladder  output. 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.

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.

46

>Percuss the bladder to check for fullness or distention.

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

Generic Name: Cefuroxime Sodium

August 27-28, 2009

Route of  administration & dosage & frequency of  administration 750 mg, IVF q 8 hours

Mechanism of  action

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

Indication/s Purpose/s

Low respiratory infections, Pharyngitis or  tonsillitis

Client’s response to medication with actual side effect

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.

48

Name/s of drugs (generic and brand name)

Generic Name: Ketorolac Tromethamie

Date ordered/ Date taken/ Date changed

August 27-28, 2009

Route of  administration & dosage & frequency of  administration 30 mg, IVF q 6 hours X 6 doses

Mechanism of  action

Possesses antiinflammatory, analgesics ad antipyretic. Completely absorbed following IM use.

Indication/s Purpose/s

Client’s response to medication with actual side effect

Use for  management of  moderate ad severe acute pain.

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 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/s of drugs (generic and brand name)

Generic Name: Tramadol Hydrocloride

Date ordered/ Date taken/ Date changed

August 27-28, 2009

Route of  administration & dosage & frequency of  administration 100 mg, TID

Mechanism of  action

A Centrally acting analgesic no related chemically to opiates. Precise mechanism is unknown.

Indication/s Purpose/s

Client’s response to medication with actual side effect

Use for  management of  moderate ad severe acute pain.

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 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.

50

Name/s of drugs (generic and brand name)

Generic Name: Omeprazole

Date ordered/ Date taken/ Date changed

August 27-28, 2009

Route of  administration & dosage & frequency of  administration Q 12 hours X 2 doses

Mechanism of  action

Hough to be a gastric pump 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.

Indication/s Purpose/s

Use for  management of  active duodenal ulcer, gastric ulcer, erosive esophagitis and heartburn

Client’s response to medication with actual side effect

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

51

After:  

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

iii. Diet

Type of Diet

 NPO (nothing by mouth)

Date ordered/ Date taken/ Date changed August 27, 2009

General Description

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

Indication/s Purpose/s

Specific foods Taken

It is usually ordered Foods, beverages ad whenever the medicine are  patient wills  prohibited. undergoes surgery or other diagnostic   procedure requiring that the digestive tract be empty.

Client’s response to medication with actual side effect 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.

52

Type of Diet

Clear liquid diet

Date ordered, Date started, Date changed August 27, 2009

General description

This client provides the client with fluid and carbohydrate  but does not supply adequate protein, vitamins, minerals, or calories

Indication/s Purpose/s

This diet is indicated for post operative patient’s first feeding when it is necessary to fully ascertain return of  gastrointestinal function

Specific Foods Taken

Crackers Sips of water and tea

Client’ s response and/or response to the diet The client strictly complied

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:

53

>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

Type of Diet

Soft Diet

Date ordered/ Date taken/ Date changed August 28, 2009

General Description

Indication/s Purpose/s

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.

Specific foods Taken

Sips of water, tea, crackers

Client’s response to medication with actual side effect 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. 54

Type of Diet

Diet as tolerated (DAT)

Date ordered, Date started, Date changed August 30 30, 20 2009

Gener General al descr descript iption ion

Indica Indicatio tion/s n/s Purpose/s

The pa patient ca can ea eat any food as long as tolerated

To increase rate of  healing

Specific Foods Taken Rice Vegetables Chicken meat Red meat Fruits Gelatin Crackers

Client’ s response and/or response to the diet The client did not exhibit any allergic reactions to the food taken

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

55

Type of  exercise

Flat on bed

Date Ordered Date Started Date Changed Aug. 27,2009

Turn from side to side

Aug. Aug. 28, 28, 2009 2009

Sitting on bed

Aug. 29, 2009

Standing beside the bed

Aug. Aug. 29, 29, 200 2009 9

Ambulation

Aug. 29, 2009

ROM (Range of Motion)

Aug. 29, 2009

Gene Genera rall Desc Descri ript ptio ion n

Indi Indica cati tion onss or Purposes

It is type of exercise To prevent done after the surgical spinal  procedure;  procedure; the client headache. must be in a supine  position without using a  pillow. After 8 hours the client must be able to use pillow already. Pati Patien entt will will turn turn on the the To increase right side then rotate to  blood the opposite side after 2 circulation and hours  prevent  pressure ulcer  It is a type of exercise To increase done after the client able  blood to turn side to side, and circulation the back of the client is unsupported and legs hanging freely It is a typ typee of of exe exerc rcis isee To increase when the client is able to  blood stand by her own and no circulation significant others assisted to her. Patient will walk   To increase unaided on the side of   blood the bed and on the circulation hallway

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

 These exercises reduce stiffness and help keep your  joints flexible.

Specific exercise/activity

Complete bed rest within 8 hours.

Client’s response and/or reaction to the diet The client complied to the ordered exercise

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 the  bed without assistance

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

Standing in the side of the bed without assistance

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

Walking on the side of the bed without assistance

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

 The client participated in the activity.

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

56

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.

During a.

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

57

2. Surgical Management

Name of  Procedure Cesarean Birth

Date Performed

Brief Description

August 27, 2009

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

Indication/Purpose

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

Client’s response to the operation 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. > 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 58

>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 >Assess the amount and type of lochia flow

59

3. Nursing Management Aug. 27, 2009 DATE Aug. 27, 2009

S: Ø Deficient fluid CUES NURSING O: volume DXr/t >have no contraindicated S: oral intake Acute Pain for the last 8 hours intake via oral >“Masakit ang tahi r/t surgical >chapped lips route & blood ko sa may puson.”loss during incision. >dry mouth >with surgical Pain Scale: 10/10 surgery incision at the lower  O: abdomen >weak in >consumed 2 appearance underpad for the last 24 hours >restless and >weak in irritable appearance >pale >restless andlooking irritable >pale looking >tachypnea:RR:24 >grimace cpm >tachypnea: RR:24 >grimace >bradycardia: PR:56 >HCT=0.266% >HGB=80g/L >urine output=30 cc/hr  >Capillary refill=3sec

After 1 hour of  PLANNING  proper nursing intervention, After 30 the patient will minutes of  maintain fluid  proper nursing  balance in a functional intervention, level after  the patient will nothing per  verbalize orem order as decreasedby: in evidenced d.  painUrine to a output of  tolerable state. ≥30ml/hr  From a pain e. Normal BP,ofpulse scale 10 to and 2. Respiration s f. Elastic skin turgor, moist tongue and mucous membrane

Independent: INTERVENTION & RATIONALE >Monitored Vital signs of client’s with deficient fluid volume 4hrs. >Built rapport with theevery patient Observe for tachycardia, tachypnea, >Placed ice pack at the incision site. decreased pulse pressure first, then >Encourageddecreased the patientpulse to dovolume, breathing hypotension, and increase/decrease body temperature. exercises. >Provided emotional support by >Advised client to have frequent oral encouraging the patient to verbalize what hygiene, at least twice a day. she feels. >Advised to increase intake >Assistedclient the patient when water turning side to more that 1.5L per day after NPO to side. orders. >Administered analgesics as ordered by Collaborative the physician. >Hydrated the client with ordered intravenous solution >Maintained Patent IV access, set an appropriate infusion flow rate and administer at constant rate as ordered.

After 1 hour of  EVALUATION  proper nursing intervention, the After 30  patient minutes of  maintained fluid  proper  balancenursing in a functional level intervention, the after nothing per   patient orem order as verbalized evidenced by: decreased g. Urine in  painoutput to a of  ≥30ml/hr  tolerable state. h. Normal BP, From a pain  pulse and Respirations scale of 10 to 2. i. Elastic skin AEB: turgor, moist a.) Absence of  tongue and mucous grimace membrane  b.) Normal respiration. RR:17cpm

60

Date

August 27,2009

Assessment

S: Ø O: •

• •

• • • •

•

• •

•

 blood lossconsumed 1 soaked underpad UO- 30cc/hr  HGT0.266% HGB-80 g/L Pale Dyspnea Weak in appearance Weak and thready 56 bpm-PR  Restless and irritable RR: 24-

Diagnosis

Risk for  Injury r/t  blood loss during surgery

Planning

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

Interventions



Monitored vital signs every 15 minutes



Assisted the client in a comfortable  position 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 enforce security measures (e.g Raise side rails)



Encouraged the client to have bed rest.



Advised the client to increase fluid intake.



Evaluation

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

Administered medications as  prescribed.

61

DATE Aug. 28, 2009

CUES

NURSING PLANNING

INTERVENTION & RATIONALE

EVALUATION

S: Ø

DX Impaired

After 30

>Built rapport with the patient

After 30

O:

 physical

minutes of 

>with surgical

mobility

 proper nursing

>Assisted patient in turning side to side

 proper nursing

incision at the lower  r/t surgical

intervention,

every 2 hours.

intervention, the

abdomen

the patient will

incision.

minutes of 

 patient was able

>inability to sit

 be able to

>Provided emotional support by

to gradually

>difficulty turning

gradually

encouraging the patient to verbalize what

increase

to side

increase

she feels.

mobility.

>weak in

mobility.

AEB:

appearance

>Instructed the patient to do breathing

a.) Absence of 

>restless and

exercises.

grimace

irritable

 b.) Ability to

>pale looking

>Administered analgesics as ordered by

turn side to side

>tachypnea:RR:24

the physician.

with minimal

> grimace

assistance.

62

DATE Aug. 28, 2009

CUES

NURSING PLANNING

INTERVENTION & RATIONALE

EVALUATION

S: “Hindi ko

DX Risk for 

1. Assist patient in turning from side to

After 1 hr of 

magalaw ang paa

ineffective  proper nursing

side every 1-2 hours

 proper nursing

ko.”

tissue

intervention,

 perfusion

the client will

O:

r/t

maintain a

>Weak in

immobility capillary refill

3. Early ambulation should be

capillary refill

appearance

after 

of less than 5

encouraged whenever appropriate.

of less than 5

>Pale

surgery

seconds and

After 1 hr of 

intervention, the 2. Assist client in extremity exercise

client will maintain a

seconds and will

>With limited

will not report

4. Encourage deep breathing and

not report of 

movements

of calf pain,

coughing exercise

calf pain,

>Difficulty

redness,

raising/flexing the

edema, or 

5. Ensure that bedcovers must be loose

or areas of 

legs

areas of 

enough

warmth on

>Weak peripheral

warmth on

lower 

 pulses

lower 

extremities

>Capillary

extremities

redness, edema,

refill=3seconds

63

Daily Program Vital Signs

Laboratory and Diagnostic Procedures Medical and Surgical Management

August 27, 2009(Day 1) 8:00 AM – T: 36. 2 P: 56 R: 24 BP: 130/100 10:00 AM – T: 36.7 P: 56 R: 26 BP: 130/90 Complete Blood Count

August 28, 2009(Day 2) 8:00 AM – T: 37.1 P: 63 R: 25 BP: 120/80 10:00 AM – T: 37.6 P: 58 R: 20 BP: 130/80

August 29, 2009(Day 3) 8:00 AM – T: 36.9 P: 70 R: 19 BP: 110/80 10:00 AM – T: 36.8 P: 77 R: 19 BP: 120/90

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

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

D5NM with 1 ampule of  Moriamin: 15 gtts/min

Cefuroxime Sodium 750mg q 8 Ketorolac 30mg q6 x 6doses Tramadol 100mg TID Omeprazole 40mg q12 x 2doses Soft Diet ROM, turning side to side

Cefalexin 250 mg TID Mefenamic Acid 500 mg capsule TID Ferrous Sulfate 15mg OD DAT Active ROM, minimum level of   activities

D5NM with Tramadol: 15 gtts/min

Drugs

Diet Exercise

Oxygen Therapy: Regulated at 2L/minute Cefuroxime Sodium 750mg q 8 Ketorolac 30mg q6 x 6doses Tramadol 100mg TID Omeprazole 40mg q12 x 2doses NPO Passive ROM

64

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

1. Discharge Planning i.

General condition of the client during discharge

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 approach Medications Exercise Treatment Health Teaching OPD Follow-Up Diet Limb Exercise Limb Exercises The client was Client was Advised the client  Mefenamic Acid R: To improve R: To improve advised the advised to return to increase intake 500 mg capsule  peripheral blood   peripheral blood  following: to OPD for  of foods rich in circulation. circulation. follow-up  protein, calories The   Cefalexin Deep breathing Minimal treatment and and calcium. importance of a  Rationale: To Exercises: activities check-up at  Ferrous Sulfate clean R: To promote R: To improve September 5,  facilitate faster  environment. effective lung  client’s activity 2009 and effective 65

expansion. Minimal Activities e.g walking, transferring from sitting to standing position R: To improve client’s activity tolerance

tolerance.



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

wound and body  function recovery.



The importance with complying with  prescribed medications.

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 cond ition. 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. 67