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.
Likewise, the group would like to express our appreciation to the members
and staff of the Obstetrical Ward and the midwives of the Birthing Home of
Davao Medical Center, for allowing us to choose our case study from their
respected institution.
To our adored mentors and clinical instructors especially Mrs. Aurea
Llamido and Mrs. Mary Jean Tulas, thank you so much for everything. Thank you
for the patience, in spite of our unfathomable enthusiasm in talking, for the
camaraderie founded based on accepting individuals discrepancy and all the
things that you’ve taught us. We’ve learn many possessions from you our dear
teachers. And for this words will not be enough to express our gratefulness.
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Friends and classmates, we are delighted of how thoughtful you all are in
sharing one school year. Thank you for giving out your insights, knowledge and
ideas that helped a lot in putting this assignment, this case presentation a
comprehensive one.
Lastly, to the special people behind this project, this is not the end of the
world yet… We still have more case presentation waiting ahead of us and this
may serve a new beginning and a stepping stone for more decisive case
presentations in our higher year.
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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 pregnancy if mother’s health
is being taken for granted.
Complications may occur at any time during pregnancy and can result
from pre-existing maternal medical problems or from the pregnancy itself. Early
and consistent prenatal care results in improved fetal and maternal
outcomes, regardless of complications that may occur.
One of these complications, placenta previa, is a condition in which the
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
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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, Davao as of 2007. While mortality rate in the
locality of Davao is 0% as of 2007.
During our duty in the Ob ward at Davao Medical Center , we decided to
take the case of Ms. Skema 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.
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OBJECTIVES
General
This case study aims that the students and the readers will gain
knowledge and further understanding about Placenta Previa.
Specific
To be able to:
1. Establish rapport with our client including her family members
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
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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: Skema
Address: Purok 3, Durian Street, Tugbok, Davao City
Age: 23 y.o.
Birthday: October 05, 1984
Birthplace: Davao City
Civil Status: Single
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: First Year College, Mass Communication
Occupation: Housekeeper
Spouse: None
Date Admitted: August 30, 2008
Time Admitted: 6:10 am
Ward: OB
Bed no.: 22
Admitting Diagnosis: Pregnancy uterine 37 3/7 weeks AOG, G2P1,
Placenta Previa Totalis
Final Diagnosis: Pregnancy uterine cephalic delivered term baby boy
livebirth via low segment transverse cesarean section;
Placenta Previa Totalis G2P2 (2002)
Admitting Doctor: Dr. Brana, Analita V.
Consultant Doctor: Dr. Ayunan
Admitting Clerk: Mallwat, Carmelita C.
Attending Physician: Manual Aries, MD
Herrera Eustaquio, MD
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HEALTH HISTORY
Family Health History
The patient's grandfather on her mother's side, Bernardeno, died due to
old age and her grandmother, Teofila, died of because of asthma. Her father,
Paulino, died in the year 1996 due to hypertension while her mother, Evangeline,
is still alive and doesn't experience any serious illness at present. Skema has
three siblings and all of them are still alive except for the youngest of them,
Barry, who died in the car accident. Her elder sister Hazel has hypertension while
her younger brothers, Glenn Paul, have vices, which include smoking and
drinking alcohol.
On the other hand, the patient's grandfather on her father's side died of
hypertension.
The patient is the 2nd child in the family. She’s still single but living with
Jaguar (her partner) for 3 years now, and they are currently living at P3, Durian
St., Tugbok (POB), Davao City. They are what we call as “cohabiting” family.
They eat three times a day and their food intake is usually fried foods such as
fish, eggs and rice in the morning while soup at noon and in the evening. They
usually sleep at 9 pm and their waking time is at 6 am. Jaguar goes to work at 7
am and come home late in the afternoon while Skema stays at home and do the
household chores and take care of Trisha Mae (their first child). The patient
doesn't drink alcohol and doesn't even smoke.
History of Past Illness
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The patient verbalizes that her past illnesses were fever, headache and
colds. She only takes a rest and drink medicines such that are over the counter
drugs, and also she had her increase of fluid intake. She also said that when she
was on her school age, she experienced having a chicken pox. She said that she
has never been hospitalized before, except on her first pregnancy.
Obstetrical History
Upon interview, the patient told us that her menarche started at the age of
13, irregular, with 1 – 2 months interval. Her menstrual period usually lasts from 5
days and she could use up 2 napkins per day. She can’t remember the date
when her last menstrual period of her first baby. She only tells us that her first
baby is a girl and she delivers her baby through normal spontaneous vaginal
delivery last 2005 and she also said that there are no complications occur. On
her second pregnancy the patient also told us that her last menstrual period was
on December 10, 2007.
The patient told us that she never used any contraceptive ever since and
all the babies are all planned.
History of Present Illness
The patient verbalized that it was her second pregnancy. Her last
menstrual period for her second pregnancy was on December 10, 2007. She has
her prenatal check-up at Rusiana lying-in. On her second trimester, she
experienced her first vaginal bleeding and because she’s afraid to lose her baby,
she immediately goes for a check-up and has an ultrasound, that’s when she
discovers that she has placenta previa. She was advised to have a full rest and
move carefully. The estimated time of confinement is September 17, 2008, with
the age of gestation of 37 3/7 weeks. When August 30, 2008 arrived, she had the
8
chief complaint of having a vaginal bleeding, so she was confine immediately and
it was then the placenta overlap the entirety of the cervical os.
9
GENOGRAM
Mother’s Side Father’s Side
10
Bernardeno
Teofila
Libeth
BernardGloria
EvangelineDelia
Francisco↑
Paulino↑
Regina↑
Teofredo
Ely
Hazel↑
SkemaΩ
Glenn Paul Barry
Legend: Ω - Placenta Previa - asthma ↑ - hypertension
- Deceased
Developmental Data
Theorist Theory Developmental Task Result and Justification
Robert
Havighurst
Developmental Task Theory,
based on learning and learned
behaviors, called developmental
tasks that emanate from
biologic, psychological and
social origins during lifespan.
Specific developmental tasks
are assigned to the various
stages of life. Failure to
complete the tasks assigned to
each stage may lead to failure in
tasks in subsequent stages.
According to this theory,
success in achieving the
Developmental tasks leads to
success with tasks in later
stages of life.
She is 23 years old. She
belongs in the early adulthood
from 20 to 40 years of age. The
developmental tasks of our
client are to select a mate, learn
to live with a partner, start a
family, rear children, manage a
home, get started in an
occupation, take on civic
responsibility and find a
congenial social group.
1. Selecting a life partner
√
She has achieved this because she
has a guy who lives with her and
considers him as a husband.
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2. Learning to live with a partner √ She has achieved this because she
lives with her “husband” for almost 4
years. They where not married at all
but all the time she considers him as
her husband.
3. Starting a family √
She and her partner have already a
daughter which is already 3 years old
and now a new son. Both of there
children were planned according to
them.
4. Rearing children √
She has achieved this task. She takes
care of her children. Her eldest is
Trisha Mae, as she grows; she was
also taught with good moral values at
home even at a young age. Also she
takes care of her in any way she could.
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5. Managing a home
√
She and her partner have a house of
their own. They do not live in the same
roof with their parents. She is able to
organize their home effectively. The
money that her husband gets is
equally distributed to them.
6. Getting started in an
occupation √
She has achieved this task. She was a
cashier on a grocery store near there
place; but now, she retired and took
the responsibility of being a housewife.
7. Taking on civic responsibility
√
She votes during election period. She
is also concerned of the crisis that is
happening today especially the
increasing prices of goods.
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8. Finding a congenial social
group
√ She achieved this because she joins
the activities in there community like
Barangay health programs.
Erik
Erickson
Erikson envisions life as a
sequence of levels of
achievement. Each stage
signals a task that must be
achieved. The resolution of a
task can be complete, partial, or
unsuccessful. Erikson believes
that the greater the task
achievement, the healthier the
personality of the person; failure
to achieve a task influences the
person’s ability to achieve the
next task. Erikson’s eight stages
reflect both positive and
negative aspects of the critical
life periods. The resolution of
the conflicts at each stage
enables the person to function
She belongs to Eric Erikson’s
stage of Intimacy vs. Isolation. It
is from 20 to 25 years of age.
In Young adulthood, we begin
to share ourselves more
intimately with others. We
explore relationships leading
toward longer term
commitments with someone
other than a family member.
Successful completion can lead
to comfortable relationships and
a sense of commitment, safety,
and care within a relationship.
Avoiding intimacy, fearing
commitment and relationships
can lead to isolation, loneliness,
√
She has achieved this stage which is
intimacy, because she learned how to
love. And so their love brought them
Trisha Mae and now a new son. Even
though they are not married, they still
consider themselves married because
the way they love each other is like the
love you can find in married couples.
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effectively in the society. and sometimes depression.
Lawrence
Kohlberg
Kohlberg’s model states that a
person’s ability to made moral
judgments and behave in a
morally correct manner develops
over a period of time and
progresses in relationship to
cognitive development.
Her age correlates to the post-
conventional level.
The individual makes a clear
effort to define moral values
and principles that have validity
and application apart from the
authority of the groups of
persons holding them and apart
from the individual's own
identification with the group.
√
She understands what laws are for and
their purpose. And so she knows what is
right and what is wrong. When talking
about abortion, she told us that it is really
not right to abort a baby because it’s
against the law and it’s really considered a
sin because you kill someone’s life.
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DEFINITION OF COMPLETE DIAGNOSIS
PLACENTA PREVIA TOTALIS
Low Segment Transverse Cesarean Section - the incision is always made
horizontally across the lower end of the uterus , resulting in reduced blood
loss and a decreased chance of rupture.
Source:
http://www.answers.com/topic/caesarean-section
Low Segment Transverse Cesarean Section - Incision made horizontally
across the lower end of the uterus; this kind of incision is preferred for less
bleeding and stronger healing.
Source:
http://www.answers.com/topic/low-transverse-incision
Low Segment Transverse Cesarean Section - the incision is made
horizontally across the lower uterine segment.
Source:
http://www.encyclopedia.com/doc/1G2-3447200117.html
Placenta previa - is an obstetric complication in which the placenta has
attached to the uterine wall close to or covering the cervix. It can some
times occur in the latter part of the first trimester, but usually during the
second or third. It is a leading cause of antepartum hemorrhage (vaginal
bleeding).
Source:
http://en.wikipedia.org/wiki/Placenta_previa
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Placenta previa - is defined as implantation of the placenta in the lower
uterine segment in advance of the fetal presenting part.
Source: http://www.womenshealthsection.com/content/print.php3?
title=obs018&cat=2&lng=english
Placenta previa is an obstetric complication that occurs in the second and
third trimesters of pregnancy.
Source:
http://www.emedicine.com/emerg/topic427.htm
Complete placenta previa - is where the placenta completely covers the
internal os.
Source: http://www.womenshealthsection.com/content/print.php3?
title=obs018&cat=2&lng=english
Placenta Previa Totalis – is implanted in the lower segment near or over
the internal cervical os. A total previa, the internal is entirely covered by
the placenta.
Source:
Maternity Nursing, Lowdermilk, 7th ed.
Total placenta previa - covers and blocks the cervical opening
Source:
http://www.webmd.com/content/article/13/3608_263
PHYSICAL ASSESSMENT
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General Survey
We received Mrs.Skema, 23 years of age, 5’2’’ tall, weighing 55kg, 2
days post-partum, was assessed on September 1, 2008 at Davao Medical
Center, OB ward at bed no22. The client was conscious, alert, coherent,
cooperative and oriented to time, place, person and her surroundings. No IVF
line. She is mesomorphic built. Facial grimace and abdominal guarding were
noted.
Vital Signs
Shift: 11-7
T : 36.5C
PR : 86bpm
RR : 22bpm
BP : 80/60
Skin
Client has brown complexion. Skin is smooth, moist, warm to touch and
has a good turgor. Capillary refill time of 2 seconds. Skin integrity was no longer
intact due to a lesion on the right lower leg and a horizontal or transverse
cesarean incision made through the maternal abdomen. Bleeding and bruises
were not seen upon observation.
Head
The head configuration is normocephalic. Facial movements are
symmetrical. The hair color is black, long, oily and evenly distributed over the
scalp. There were no signs of dandruff. No swelling, lacerations, bruises and
tenderness was seen upon inspection.
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Eye
The eyelids are symmetrical with each other. Conjunctiva is pink and the
cornea is moist and white in color and lacrimal apparatus is present on both
eyes. The iris appears to be black on both eyes. With 2 mm size pupils, equally
round and briskly reactive to light and accommodation. Eyebrows are thin and
eyelashes are evenly distributed along the margin of the eyelids and visual acuity
is grossly normal. There were no lesions and unusual secretions observed.
Ears
The external pinnae are symmetrical. The gross hearing is also
symmetrical. Upper margin of the pinnae is in line with the outer canthus of the
eyes. No signs of lesions and bruises were seen upon observation. There were
no foul smelling and purulent discharges noted in the external canal.
Nose
External surface of the nose was oily and pimples were noted. Nasolabial
folds were not flaring and nasal septum is in the midline of the head. Nasal
mucosa is moist, pinkish and nasal hair is present.. Air patency is good. Gross
smell is symmetrical. No foul discharges, lesions or masses were noted.
Mouth
Lips are pale, slightly dry and without lesions. Mucosa is pinkish red,
smooth and moist. The tongue is midline position and tonsils are not inflamed.
Teeth are not complete, upper and lower right canine were missing with chalky
white discoloration of the enamel. Upper front teeth were replaced by false
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dentures. Gums are pinkish and there were no signs of swelling, bleeding, and
lesions. On soft diet with good appetite.
Neck
Neck can move easily without any discomfort which includes right and left
lateral, right and left rotation, flexion and hyperextension. Trachea is located
midline with no deviation upon palpation. Carotid pulse is palpable.. Lymph
nodes in the neck are not enlarged. No rigid and masses or any deformities are
noted.
Chest and Lungs
Shape of chest is normal and with symmetrical lung expansion. Thorax is
symmetrical. Respiratory rate is 22 cycles per minute, with regular pattern and
absence use of the accessory muscles. Patient is not in any respiratory distress.
There were no signs of productive cough and difficulty in breathing. Breath
sounds is clear and heard almost of all of anterior lungs upon auscultation.
Heart
The apical pulse is auscultated at the left midclavicular line, fifth
intercostals space. The cardiac sounds were regular and are not difficult to
auscultate, in which the cardiac rate was 84 beats per minute.
Breast and Axillae
Client has a rounded shape breast, slightly unequal in size, however
generally symmetric. Breasts are engorged, full and slightly tender with secretion
of breast milk. Areola is dark brown in color. Axilla is dark and moist. No masses
palpated.
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Abdomen
Has soft, globular, non-distended abdomen. Horizontal (transverse) type
of incision was made 1 to 2 inches above the pubic hair line and was secured
with a binder. Dressing of the operative site on patient’s abdominal area is dry
and intact, however it was not cleaned yet since the operation as verbalized by
the client. Stretch marks and linea nigra were evident upon inspection.
Normoactive sounds heard upon ausculattion. Facial grimacing and abdominal
guarding noted upon palpation of abdomen, also when client moves.
GenitoUrinary
Client can urinate properly without difficulties and without any assistance.
Client was using a diaper.
Upper Extremities
Upper are bilaterally symmetrical. Both arms can strech, flex, rotate and
extend without difficulty. Handgrip was strong. No signs of lesions and bruises
noted. Fingernails were not trimmed and were dirty. Peripheral pulses of the
client are symmetrical with regular and strong pulsation.
Lower Extremities
Lower extremities are symmetrical. Both legs can flex, rotate, extend and
bend without difficulty. Legs can support the body and can slightly move without
difficulty. Lessions on the right lower leg was noted. Toenails were untrimmed.
Deformities, bleeding and bruises were not noted.
ANATOMY AND PHYSIOLOGY
OF THE
21
FEMALE REPRODUCTIVE SYSTEM
Internal Structure
22
Vagina
The vagina is a hollow musculomembranous canal located posterior to the
bladder and anterior to the rectum. It extends from the cervix of the uterus to the
external vulva. Its function is to act as an organ of intercourse and to convey
sperm to the cervix so that sperm can meet to the ovum in the fallopian tube.
With childbirth it expands to serve the birth canal. When a woman is lying on her
back the course of the vagina is inward and downward. Because of this
downward slant and the angle of the uterine cervix, the length of the anterior wall
of the vagina is approximately 6-7 cm; the posterior wall is 8-9 cm. At the cervical
end of the structure, there are recesses on all the sides of the cervix, termed
fornices. Behind the cervix is the posterior fornix; at the front, the anterior fornix;
and at the sides, the lateral fornices. The posterior fornix serves as a place for
the pulling of semen after coitus; this allows a large number of sperm to remain
close to the cervix and encourages sperm migration into the cervix.
Ovaries
The ovaries are grayish-white and appear pitted or with minute
indentations on the surface. An unruptured, glistening, clear, fluid-filled graafian
follicle (an ovum about to be discharged) or miniatured yellow corpus luteum
often can be observed on the surface of the ovary. Ovaries are located close to
and on both sides of the uterus and the lower abdomen. The function of the two
ovaries is to produce, mature and discharged ova. Ovarian function is necessary
for maturation and maintenance of secondary sex characteristics in females. The
ovaries are held suspended and in close contact with the ends of the fallopian
tubes by three strong supporting ligaments attached to the uterus or the pelvic
wall.
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Fallopian Tube
These are narrow tubes that are attached to the upper part of the uterus
and serve as tunnels for the ova (egg cells) to travel from the ovaries to the
uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the
fallopian tubes. The fertilized egg then moves to the uterus, where it implants to
the uterine wall.
Uterus
The uterus is a hollow, muscular, pear-shaped organ located in the lower
pelvis, posterior to the bladder and anterior to the rectum. The function of the
uterus is to receive the ovum from the fallopian tube; provide a place for
implantation and nourishment during fetal growth; furnish protection to a growing
fetus; and, at mmaturity of the fetus, expel it from the woman’s body.
Anatomically, the uterus consists of three divisions; the body or corpus,
the isthmus and the cervix. The body of the uterus is the uppermost part and
forms the bulk of the organ. The lining of the cavity is continuous with that of the
fallopian tubes, which enter at its upper aspects. The portion of the uterus
between the points of attachment of the fallopian tubes is termed the fundus.
During pregnancy, the body of the uterus is the portion of the structure that
expands to contain the growing fetus. The fundus is the portion that can be
palpated abdominally to determine the amount of uterine growth occurring during
pregnancy, to measure the force of uterine contractions during labor, and to
assess that the uterus is returning to its non-pregnant state after childbirth. The
isthmus is a short segment between the body and cervix. During pregnancy this
portion also enlarges greatly to aid in accomodating the growing fetus. The
cervix, is the lowest portion of the uterus. It represents approximately one-third of
the total uterus size and is approximately 2-5 cm long. Approximately, half of it
lies above the vagina and half extends to the vagina. A central cavity is turned
24
the cervical canal. The opening of the canal at the junction of the cervix and the
isthmus is the internal cervical os; the distal opening to the vagina is the external
os. The level of ther external os is at the level of the ischial spines.
Pelvis
The pelvis serves both to support and protect the reproductive and other
pelvic organs. It is a bony ring formed by four united bones; the two innominate
bones which formed the anterior and lateral portion of the ring, and the coccix
and sacrum, which form the posterior aspects. Each innominate bone is divided
into three parts: ilium, ischium and the pubis. The ilium forms the upper and
lateral portion. The flaring superior border of these bones is what forms the
prominence of the hip. The ischium is the inferior portion. At the lowest portion of
the ischium are two projections; the ischial tuberosites. This is the portion of bone
on which a person sits. These projections are important markers used to
determine lower pelvic grid. Other important terms in relation the pelvis are the
inlet, the pelvic cavity and the outlet. The inlet is the entrance to the true pelvis or
the upper ring of bone through which the fetus must pass to be born vaginally. It
is at the level of the linea terminalis or is marked by the sacral prominence in the
back. The ilium of the sides and the superior aspects of the symphisis pubis is in
the front. If one looks down at the pelvic inlet, the passageway at this point
appears heart-shaped because of the jutting sacral prominence. It is wider
transversely than in the anteroposterior dimension. The outlet is the inferior
portion of the pelvis, or the portion bounded in the back of the coccyx, at the
sided by the ischial tuberositis and in front by the inferior aspect of the symphysis
pubis. In contrast to the inlet of the pelvis, the greatest diameter of the outlet is its
anteroposterior diameter. For the baby to be delivered vaginally, he or she must
be able to pass through the inlet, the cavity and the outlet of the pelvic bone. This
is not a problem for an average fetus; it may be a problem if a mother is a young
25
adolescent who has not yet achieved full pelvic growth or a woman who has not
had an injury.
Placenta
Organ that develops in the uterus during pregnancy. It is a unique
characteristic of the higher (or placental) mammals. In humans it is a thick mass,
about 7 in. (18 cm) in diameter, liberally supplied with blood vessels. The
placenta is attached to the uterus, and the fetus is connected to the placenta by
the umbilical cord. The placenta draws nourishment and oxygen, which it
supplies to the fetus, from the maternal circulation. In turn, the placenta receives
the wastes of fetal metabolism and discharges them into the maternal circulation
for disposal. There are 15-20 cotyledons found in the placenta.
External Structure
Mons Veneris
The mons veneris is a pad of adipose tissue located over the symphisis
pubis, the pubic bone joint. It is covered by a triangle of coarse, curly hairs. Its
purpose is to protect the pubic bone from trauma.
26
Labia Majora
The labia majora are two fold of adipose tissue covered by loose
connective tissue and epithelium; they are positioned later to the labia minora.
Covered by pubic hair, the labia majora serves as a protection for the external
genitalia and the distal urethra and vagina.
Labia Minora
It is located posterior to the mons veneris spread two hairless fold of
connective tissue. Before the menarche, these folds are fairly small; by
childbearing age, they are firm and full; after menopause they atrophy and again
they become smaller.
Clitoris
The clitoris is a small rounded organ of erectile tissue at the forward
junction of the labia minora. It is covered by fold of skin known as the prepuce. It
is sensitive to touch and temperature and is the center of sexual arousal and
orgasm in the female. When the ischiocavernosus muscle surrounding it
contracts with sexual arousal, the venous outflow for the clitoris is blocked
leading to clitoral erection.
27
ETIOLOGY
Predisposing
Factors Remarks Rationale Justification
Age x Women older than
30 years are 3 times
more likely to have
placenta previa than
women younger than
20 years
This is not applicable to
our patient since her age
is 23 years old.
Family history of
Hypertension
/ Having a family
member or relative
who had
experienced is a risk
factor for having
placenta previa
According to the patient’s
family background, her
family or relatives does
have a hypertension.
Race / Importance of race is
fairly debatable.
several studies
propose an
increased risk of
placenta previa
among African
Americans and
Asians, whereas
other studies
mention no
Our patient is a Filipino
woman so this factor is
considered to be
contributory to her
condition.
28
discrepancy.
Gender / Only pregnant
women can
experience this
condition.
Our patient is a women
and she can have the risk
of having placenta previa
Precipitating
Factors Remarks Rationale Justification
Multiple Gestation / Placenta previa
occurs in 1 in 1,500
first-time
pregnancies. In
women who have
had five or more
pregnancies, this
condition increases
to about 5 in 100.
This is our patient’s
second pregnancy.
Previous cesarean
delivery (C-section)
x Of women who have
had two cesarean
deliveries in the past,
about 2 out of 100
have placenta
previa. For women
with three or more
cesarean deliveries,
the chance of
placenta previa
Our patient did not have
previous cesarean
delivery after the present.
She delivered her first
child through NSVD.
29
increases to more
than 4 out of 100
Cigarette Smoking x Smoking decreases
the amount of
oxygen transferred
to the fetus, thereby
stimulating the
growth of a larger
placenta, which is
more likely to grow
low into the uterus.
Patient is not a smoker.
History of previous
placenta previa
x Women who have
experienced
placenta previa in
previous
pregnancies may
have a risk for
developing placenta
previa in succeeding
pregnancies.
Our patient is not reported
to have a previous case of
placenta previa in past
History of medical
procedures that
affect uterine lining
x Medical procedures
that affect the uterine
lining such as
abortion, or
myomectomy to
remove uterine
fibroids or dilation
and curettage (D and
This is not manifested
since our patient has
stated that she has not
have had procedures that
should have affected the
uterine lining before.
30
C) to scrape the
uterine lining may
increase chances of
having placenta
previa.
Male fetus / Placenta previa may
also be associated
with a male
fetus.This is because
they have hormones
that coud be more
likely to cause
placenta previa than
those with female
fetus.
The patient’s child is a
male.
SYMPTOMATOLOGY
31
SYMPTOMS RATIONALE
Occurs after 20weeks of
gestation
/ The placenta in this stage is well
developed or matured and needed
more blood supply, so it migrates
to a more vascularized part of the
uterus.
Bleeding, bright red in color / This bleeding, bright red in color, is
associated with the stretching and
thinning of the lower uterine
segment that occurs during the
third trimester.
Painless vaginal bleeding
/ The uterus is not able to
adequately contract and stop blood
flow from open vessels.
32
33
Fertilization of sperm and
ovum
Reproduction of a fertilized
ovum (zygote)
Implantation of blastocyst to the uterine
endometrium
Pre-embryonic
Stage
Predisposing Factors:RaceGender
Increase in progesterone and estrogen levels
Precipitating Factors: Second
Pregnancy Male fetus
34
Insufficient blood supply in the placenta
Migrates to where there is sufficient blood
supply
Placenta resides in the lower uterine segment
Embryonic Stage
The placenta arises out of the
trophoblast tissue
low-lying placenta should move away from the cervix and out of the
lower uterine segment
35
Total Placenta Previa
Implantation totally obstruct the cervical os
Painless vaginal bleeding
Profuse bright-red bleeding
Hypotension
Hypovolemic Shock
36
Treated
Good Prognosis
Untreated
Birth defects Premature deliveryAnemiaInfectionFDIUAbnormal placental attachments
If treated, there will be good maternal vital signs and the fetus will be delivered successfully without complications
Medical assistanceCesarean section during labor and deliveryMedications to prevent uterine contractions
PATHOPHYSIOLOGY
(Narrative)
During pregnancy, your placenta repositions itself as your uterus stretches
and grows. In early pregnancy, a low-lying placenta is very common. But as your
pregnancy progresses, the enlarging uterus should "pull" the placenta toward the
top of your uterus. By your third trimester, the placenta should be near the top of
your uterus, leaving the opening of the cervix clear for the delivery.
Placenta previa typically occurs as a result of abnormally low implantation.
Although no specific cause has been identified to date, this condition has been
hypothesized to occur as a result of abnormal endometrial vascularization related
to atrophy or scarring from prior trauma or inflammation.
As the lower uterine segment thins in late pregnancy, the margins of the
abnormally implanted placenta are altered. Various degrees of placental
detachment may develop, with ensuing maternal hemorrhage from the
intervillous space. During labor, significant fetal hemorrhage also can occur as a
result of disrupted villous placental vessels.
Risk factors for placenta previa include prior placenta previa, prior
cesarean delivery, increased maternal age, large placentae (eg, multiple
gestations or erythroblastosis), and a maternal history of smoking.
If untreated, it may lead to severe maternal hemorrhage, premature
delivery, and birth defects and the like.
If this is treated, there will be a good prognosis
37
DOCTOR’S ORDER
DATE ORDER RATIONALE REMARKS
08-30-08
6:10am
* Please admit
* NPO
* Vsq4
* Labs :
- CBC
- UA
- HBsAg
- BT
* For legal purposes
* To prevent aspiration
during the procedure.
* To have baseline data.
*Laboratory test help
determine clients general
health status.
* CBC identifies the total
number of white blood
cell and red blood cell,
the platelet count, and
hemoglobin and
hematocrit.
* UA a test to detect
semi-quantitatively
measures various
compounds that are
eliminated in the urine.
* HBsAg is a test to
examine if patient is
immune from acquiring
hepatitis B.
* BT is a test to
determine if what ABO
blood group and Rh
factor status the patient
DONE
DONE
DONE
DONE
DONE
DONE
DONE
DONE
38
* Start Venoclysis with D5lR 1L @
120cc/hr
* Secure Consent
* Abdominal Perineal Preparation
* Inform OR (PROD/AROD)
belong.
* IV administration is
performed to replace
fluids, administer
medications and to
provide water and
electrolyte.
* Signed consent
ensures that the patient
is properly informed
regarding the process,
risks, and possible
complications of the
procedures and is not
forced to coerce to
undergo the said
procedures.
* To make sure that
perineal area is clean
and as a pre op
preparation for CS.
* Inform OR and the
anesthesiologist for the
patient’s schedule of
operation.
* Cefazolin an anti-
DONE
DONE
DONE
DONE
39
8-30-08
9:35 am
- Cefazolin 1g IVTT q 8º
* Refer
* To secure 1 unit of PRBC of patient’s
blood type for on use.
POST OP ORDERS
* To PACU then to OB ward
* NPO
* VSq15 until stable then q hourly
* IVF with D5LR 1L+10units oxytocin @
120cc/hr
infective. Treats skin and
skin structue infection.
* For co-management
* To restore/increase
circulating blood volume
after childbirth.
* For close monitoring of
the recovery.
* The client is not
allowed to take any food
until she can flatus. This
is a sign that the
gastrointestinal system is
starting to function.
* Monitor closely of the
patient’s condition
* This intravenous fluid
helps in supplying
potassium and calcium to
provide adequate fluids
and electrolytes for
maintenance of body
function. It also has
oxytocin to control
bleeding.
DONE
DONE
DONE
DONE
DONE
DONE
DONE
40
* Meds:
- Tramadol 50 mg q 6 hours slow IVTT
- Ketorolac 30 mg q 8 hours IVTT
- Ranitidine 50 mg q 8 hours IVTT
* continue meds
* O2 inhalation @ 4-6 L/min
* Keep patient warm
* I & O monitoring q hourly then q shift
* Watch out for unusualites
* Tramadol for
management of pain.
* Ketorolac is an
analgesic, and it is a
short-term management
of pain.
* Ranitidine decreases
gastric acid secretion.
*For treatment
* Oxygen therapy may be
needed to treat
abnormally low blood
oxygen.
* To provide a good
environment for
recovery.
*Measurement of a
patient's fluid intake and
output will identify those
patients at risk of
becoming dehydrated or
over hydrated.
* For closely monitoring
the patient’s condition.
*for co-management
DONE
DONE
DONE
DONE
DONE
DONE
DONE
DONE
41
08-31-08
5:00 am
* Refer
* For BT to start @ PACU
* General liquids and crackers, soft diet
once with flatus
* VSq4
* C/D IVF and IVTT meds
* Meds:
- Cefadroxil 50 g 1 cup BID
- FesO4 1 cup OD
- M. Maleate 1 tab TID
- Diclofenac K+ 50 g 1 tab TID
*To replace blood loss.
* It is ordered for easy
tolerance and digestion
as client’s peristaltic
movement is still slow.
* Monitor closely of the
patient’s condition
* Consume and
discontinue IVF and IVTT
medication to shift and
continue medication
orally.
* Cefadroxil is the
treatment for skin and
skin structure infection.
* Ferrous sulfate is used
to treat iron deficiency
anemia (a lack of red
blood cells caused by
having too little iron in
the body).
* M. Maleate directly
stimulates unterine and
vascular smooth muscle.
* Diclofenac is a
nonopoid analgesics,
that suppress pain and
inflammation.
DONE
DONE
DONE
DONE
DONE
DONE
DONE
DONE
DONE
42
09-01-08
9:00 am
09-02-08
* Remove foley catheter, should void 4-6º
* May sit up on bed
* Refer
* Soft diet, DAT once with BM
* VSq4º
* For wound dressing
* Continue PO meds
* MGH
* Take home meds:
* To assess patient for
urinary function.
* Enhances circulation
and return of normal
organ function
*For co-management
* Soft diet as ordered for
easy tolerance and
digestion as client’s
peristaltic movement is
still slow.
* Monitor closely of the
patient’s condition
* This is to prevent
infection.
*This is for treatment and
continuity of care
* The client May Go
Home, she is ready to
stay at home but should
recommend continuing
the compliance of her
medications.
* Cefadroxil is the
treatment for skin and
skin structure infection.
* Ferrous sulfate is used
DONE
DONE
DONE
DONE
DONE
DONE
DONE
DONE
DONE
43
- Cefadroxil 500mg 1cp BID
- FeO4 1g OD
- Diclofenac 5g 1 tab TID
* Follow-up @ OPD on September 10,
2008
to treat iron deficiency
anemia (a lack of red
blood cells caused by
having too little iron in
the body).
* Diclofenac is a
nonopoid analgesics,
that suppress pain and
inflammation.
* To monitor client’s
progress and response
to the treatment and to
check if there are any
deviations in her health.
DONE
DONE
DONE
44
DIAGNOSTIC AND LABORATORY EXAMS
A. URINALYSIS
Date TestActualValues
NormalValues Implications Rationale
Nursing Responsibilities
07-01-08 PHYSICAL
EXAMINATION
Color
Appearance
Reaction
Specific Gravity
Straw
Clear
6.5
1.010
Clear straw to
colored liquid
Clear to slightly
hazy
4.6-8
1.005-1.025
Liver problems
or jaundice migh
have occur
normal
To demonstrate
the
- To examine
the patient’s
urine for sign
of renal or
urinary tract
disease.
- To help
discover
diseases
that is not in
relation with
renal
disorders.
1. Tell the patient
that the test is for
the detection or
renal and urinary
tract disorders
and assessment
of body function.
2. Notify the
patient that the
procedure
requires a urine
sample. Urine
must be acquired
most likely on the
45
CHEMICAL
EXAMINATION
Albumin
Sugar
Negative
Negative
In normal
condition there
is no protein
that can be
detect
Normal
concentrating
and diluting
ability of the
kidneys.
Presence of
sugar in urine
may indicate
diabetes,
chronic kidney
disease
- To identify
drugs or
substances
that has
been taken.
first void in the
morning.
3. Notify the
laboratory and
physician of any
drugs that the
patient has taken
that may affect
the results.
46
MICROSCOPIC
EXAMINATION
Epithelial Cells
Squamous
Renal
Pus Cells
RBC
0.2 hpf
Pus cells and
bacteria should
be absent in
urine
May be a sign of
swelling in the
kidney and
pelvic region,
urethral
ulceration and
chronic specific
inflammatory of
the bladder
Blood in the
urine may
sometimes a
serious urinary
tract problem
47
Mucous Threads
Bacteria
Yeast Cells
Oil Globules
Spermatozoa
#
48
B. BLOOD TYPING
Date Test Result Normal Results Implications Rationale
Nursing
Responsibilities
8-18-08 Blood Type
(ABO+Rh)
A (+) In forward typing, if
there’s agglutination
patient’s RBC’s are
mixed with anti-A and
anti-B serum, the A
and B antigen is
present, thus blood
type is O
None known - To check
compatibility
of the donor
and the
patient before
transfusion.
1. Inform the
patient that the
test determines
her blood group.
2. Notify the
patient that the
test blood
sample thus
venipuncture is
done.
3. Check the
patient’s history
for recent
administration of
blood, dextran or
49
I.V.
4. After the
procedure apply
direct pressure
to the
venipuncture to
the site until
bleeding stops.
C. COMPLETE BLOOD COUNT
50
Date Test Result
Normal
Values Implications Rationale
Nursing
Responsibilities
8-18-08 WBC
Hemoglobin
H 15.19
x10^3/uL
122g/L
5-10
x10^3/uL
115-155
g/L
Leukemia,
bacterial
infection, severe
sepsis
Normal
Low HCT,
suggest anemia,
hemodilution or
enormous blood
loss.
- To verify
infection or
inflammation in
the body and
observe its
responses to
specific
therapies.
- To recognize
the amount of
O2 carrying
protein
contained within
the RBC
1. Explain to the
patient the necessity
of undergoing the
test that it helps
detect occurrence of
anemia and
polycythemia.
2. Notify the patient
that the test requires
blood sample as well
as the person who
will perform the
venipuncture and the
time.
3. Inform the patient
that the procedure is
51
Hematocrit
RBC
Differential
Count
L 0.35
L 4.02
x10^6/uL
0.36-0.48
4.20-6.10
x10^6/ uL
Rule out anemia
due to
nutritional
deficiencies,
blood loss.
Low RBC is due
to enormous
blood loss which
results to
anemia.
Leukemia,
hemorrhage.
- To identify the
percentage of
the blood
volume
occupied by red
blood cells.
- To know the
amount of RBC
in the blood.
of slight discomfort
and may feel a little
pain.
4. After the
procedure, apply
direct pressure to the
venipuncture until
bleeding stops.
5. Refer if
venipuncture
develops hematoma
and monitor the
pulses distal to the
site.
52
Neutrophil
Lymphocytes
Monocytes
73%
L 18%
7%
55-75%
20-35%
2-10%
Normal
Leukemia,
systemic lupus
erythematosus
Normal
- To point out
the presence of
bacterial
infection and
amount of
Leukocyte
-To recognize if
there is an
unusual amount
of lymphocyte
that may
indicate viral
infection such
as HIV.
-Increase of
these may
53
Eosinophil
Basophil
2%
0%
1-6%
0-1%
Normal
Normal
respond to
corticosteroid,
with pus
conditions,
hemorrhage
-High
percentage of
eosinophil, may
indicate
bacterial
infestation or
allergies
-Increase of
basophil may
indicate
parasite,
hypersensitiven
ess and
heartworm
54
MCV
MCH
MCHC
88.1fl
30.3
pg
34.5 g/dL
79.40-
94.80 fl
25.60-
32.20 pg
32.20-
Normal
Normal
Normal
causing
endocrine
disease, chronic
liver disease
-To determine
the ratio of
hematocrit to
RBC count
-To identify the
average mass
of hemoglobin
per RBC
-Indicates the
nature and
volume of
hemoglobin, to
55
35.30 g/dL high may
indicate
spherocytosis or
in vitro
hemolysis
D. ULTRASOUND
Nursing
56
Date Test Result Impression Rationale Responsibilities
06-21-08
2:35 pm
U
L
T
R
A
S
O
U
N
D
-Presentation : Cephalic
-Number: single
- Amniotic fluid: AFI 11.1 cm
-Placental location: anterior
-Placental grade: III
-Sex: male
-AOG: 32W 3D
-EDD: 10-11-08
-FHB: 147bpm
Estimated Fetal Weight: 2233 g
-normohydramnios (11.1 cm)
-amniotic fluid volume: normal
-previa: placenta previa totalis
Biophysical profile:
-amniotic fluid: 2
-fetal tone: 2
-fetal breathing: 2
-gross movement: 2
Single, live
intrauterine
pregnancy,
cephalic
presentation, with
good cardiac and
somatic activities;
BPD= 32 weeks
and 5 days; FL=
31 weeks and 1
day
Placenta anterior,
early grade III,
totally covering
the OS (Placenta
previa totalis)
- To know fetal
and
pregnancy
abnormalities
and
measurement
of organ size
and structure.
To identify and
differentiate
cyst and solid
tumor.
- To ensure
the
presentation
and identify
complications
of the fetus.
To detect if
1. Assure a
consent form
signed by the
patient. Explain
that the
procedure is
painless and safe
and that no
radiation
exposure is
involved.
2. Emphasize the
importance of
remaining still
during the scan to
prevent distorted
image.
57
Total =8 there is risk of
pregnancy.
3. Assist the
patient into a
supine position; if
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.
58
NURSING THEORIES
Nightingale’s Environmental Model
Nightingale Environmental areas that a nurse can control are: ventilation
and warming, light, noise, variety, bed and bedding, personal cleanliness,
nutrition and taking food, and chattering hopes and advices. When one or more
aspects of the environment are out of balance, the client will be using increased
energy to counter the environmental stress. The stresses drain the client of
energy that should’ve been used for healing. It is the role of the nurse to
manipulate the environment to compensate for the client’s response to it.
Our patient was admitted to the OB ward of DMC hospital after her CS
delivery. The environment was not well ventilated and body odor from the great
number of people confined to the same area contributed to the unpleasant smell
in the whole of the ward. The place was also very warm. Nurses should then
advise patients to dress lightly and avoid wrapping newborns heavily to prevent
hyperthermia. Most of the beds were soiled, untucked, or didn’t have any bed
sheet at all. Not all wall fans are also functioning well and so it leads to a warmer
environment. As a nurse we should give health teachings as our main role
concerning personal hygiene so as to promote better health. For our client, we
told her to take a bath, change clothing everyday, and to do simple exercises so
that she won’t experience any bed sores or fatigue.
59
Lydia Hall’s Care, Core, Cure theory
Lydia Hall’s theory is visually presented by interlocking circles and each
represents a particular aspect of nursing. The three circles represent the care,
core and cure. The major aspect of care is to achieve an interpersonal
relationship with the health care provider that will much more facilitate
development. This aspect provides motherly care and comfort, provide teaching-
learning activities and support the daily biological function of the patient. The
closeness of the nurse and patient promotes the sharing and exploration of
feelings with the nurse. The core aspect emphasized the therapeutic use of self
and usage of reflective technique. The patient become more aware of the feeling
being experienced as evidenced of making conscious decision, understand and
accept feeling. The cure circle is based on pathological and therapeutic
sciences. The patient has a negative perspective about the nurse as potential
cause of pain rather than a comforting being. These three aspects function
independently but they are interrelated and the circle’s size represents the
progress in each aspect.
In our case, the care aspect shows the relationship between the patient
and the health care provider by this the patient is able to get health teaching and
support. Our patient followed our health teaching so as to avoid anymore
complications, we also told her to verbalize any feelings she would like to
express so that we could know if she needs more care to be provided so as to
promote further wellness. The core aspect helped the patient reflect on her
situation and she was able to make decision by her own. Our patient was able to
ambulate for a faster healing of wounds and she doesn’t refuse in taking her
medication daily. So from that situation we can say that she understands her
situation and so she copes up with it to promote better healing. As for the cure
aspect, when the doctor ordered that she is NPO, she followed it and the nurse
60
that was assigned to her also implemented it so that she won’t forget it. In that
way safety was maintained.
Dorothea Orem’s self-care deficit theory
Orem developed the Self-Care Deficit Theory of Nursing which is
composed of three interrelated theories: self-care theory, self-care deficit theory
and theory of nursing systems. Self-care is the performance or practice of
activities that individuals initiate and perform on their own behalf to maintain life,
health, and well-being. Self-care agency is the human’s ability or power to
engage in self-care. Therapeutic self-care demand is the totality of “self-care
actions to be performed for some duration in order to meet known self-care
requisites by using valid methods and related sets of operations and actions.
Then there are three categories of self-care requisites: universal, developmental,
and health deviation. Self-care requisites are actions directed toward the
provision of self-care. In the second vital part of Orem’s theory is the self-care
deficit theory wherein nursing is needed when the self-care demands are greater
than the self-care abilities. The nursing system is based on the self-care needs
and abilities of the patient to perform self-care activities. Orem has identified
three classifications of nursing systems to meet the self-care requisites of the
patient and these are: wholly compensatory system, the partly compensatory
system, and the supportive educative system.
We applied this theory because for a few days after the labor the patient
was not able to do self-care and shows inadequacies of self-care requisites. Also
acute pain is one of the major complaints in the post cesarean section women.
They may not want to cleanse or bath because of fear of pain, but as a nurse we
encouraged our client to perform daily hygiene and assisted her in task that she
cannot do by herself alone.
61
DRUG STUDY
Generic Name: CEFADROXIL
Brand Name: Drolex
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
-
Cephalosporins
Ordered at 8/31/08
- 50 g 1 cup BID
PO
Ordered at 9/2/08
- 500 mg 1 cup
BID
Cefadroxil binds to
one or more of the
penicillin-binding
proteins (PBPs)
which inhibits the
final
transpeptidation
step of
peptidoglycan
synthesis in
bacterial cell wall,
thus inhibiting
biosynthesis and
arresting cell wall
assembly resulting
in bacterial cell
death. Cefadroxil is
not active against
Proteus,
Infections
caused by
susceptible
strains of
organisms in
UTI, skin &
skin structure
infections,
pharyngitis
&/or tonsillitis.
-Hypersensitivity to
cephalosporins.
-Impaired renal
function
Prothrombin time
prolonged; bleeding
may occur when
taken with
anticoagulants.
Decreased
elimination with
probenecid.
-Nausea,
vomiting,
diarrhoea,
abdominal
discomfort; skin
rash,
angioedema;
elevated liver
enzyme values;
superinfection
with resistant
organisms
especially
candida.
-Anaphylactic
reaction;
pseudomembran
ous colitis.
1. Advise patient that
Cefadroxil may be taken with
or without food (May be taken
w/ meals to reduce GI
discomfort.).
2. Tell patient to take
Cefadroxil exactly as directed
by the doctor. Do not take
more or less than instructed by
the doctor.
3. Advise patient to alert the
doctor if she or he have a
history of allergic reactions
(rash, breathlessness, swollen
mouth or eyes).
4. Tell patient to not take
Cefadroxil together with
antacids because antacids
could reduce the effectiveness
62
Pseudomonas,
Enterobacter,
Morganella,
Serratia and
Listeria
monocytogenes.
of the antibiotic.
5. Advise patient that if
Cefradroxil have been given
tablets or capsules, swallow it
whole.
Generic Name: CEFAZOLIN
Brand Name: Anzif
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
63
-Anti-infective,
first-generation
cephalosporin
Ordered at 8/30/08
-1g IVTT q 8º
-binds to bacterial
cell wall
membrane, causing
cell death
-active against may
gram-positive cocci
- treatment of
skin and
structure
infections
-otitis media
-urinary tract
infections
-septicemia
-hypersensitive to
cephalosporins and
penicillins
-increased risk of
nephrotoxicity when
aminoglycosides or
collistimethate
-probencid decreases
excretion and
increases blood levels
CNS: headache,
dizziness,
lethargy,
paresthesias
GI:
pseudomembran
ous colitis, liver
toxicity
GU:
Nephrotoxicity
Hematologic:
Bone marrow
depression
Hypersensitivity:
ranging from
rash to fever to
anaphylaxis
Other:
superinfections,
pain, abscess.
1.Assess patient for infection;
appearance of wound at
beginning and throughout
course of therapy
2.Before initiating therapy
obtain a history to determine
previous use of and reactions
to penicillins or
cephalosporins
3. Obtain specimens for
culture and sensitivity before
initiating therapy.
4.Do not use solutions that are
cloudy or contain a precipitate
5. If aminoglycosides are
administered concurrently, if
possible, at least 1 hour apart.
6. Advise patient to report
signs of superinfection.
Generic Name: Diclofenac Brand Name: Cataflam Voltaren Rapide)
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
64
-Therapeutic:
nonopiod analgesics,
nonsteroidal anti-
inflammatory
agents.
Ordered at 8/31/08
- 50 g 1 tab TID PO
Ordered at 9/2/08
- 5g 1 tab TID PO
- Inhibits
prostaglandin
synthesis.
Therapeutic
effects:
suppression of
pain and
inflammation.
- PO:
Managemen
t of
inflammator
y disorders
including:
Rheumatoid
arthritis,
Osteoarthriti
s,
Ankylosing
pspondylitis,
Relief of
milt to
moderate
pain of
dysmenorrh
eal.
- Topical:
Treatment of
actinic
keratoses.
-Hypersensitivity
to diclofenac or
other
components of
formulation
- Cross-
sensitivity may
occur with other
NSAIDs
including aspirin
- Active GI
bleeding/ulcer
disease.
DRUG-DRUG
- concurrent use with
aspirin may decrease
effectiveness
- additive adverse GI
effects with aspirin,
other NSAIDs,
potassium
supplements,
corticosteroids or
alcohol
- chronic use with
acetaminophen may
increase the risk of
adverse renal
reactions
- may decrease the
effectiveness of
diuretics or
hypertensive
- may increase serum
lithium levels and
increase the risk of
toxicity.
- increased risk if
- CV:
hypertension
-CNS: dizziness,
drowsiness,
tremors
GI: GI Bleeding,
abdominal pain,
dyspepsia,
heartburn,
diarrhea,
hepatotoxicity
- GU: acute renal
failure, dyuria,
frequency,
hematuria,
nephritis,
proteinuria
- Derm: eczema,
photosensitivity,
rashes
- F and E: edema
- Hemat:
prolonged
bleeding time
- Local: Tropical
1. Advise to administer after
meals, with food, or with an
antacid containing aluminum
or magnesium to minimize
gastric irritation.
2. Administer as soon as
possible after the onset of
menses. Prophylactic
treatment has not been shown
to be effective.
3. Instruct patient to take
diclofenac with a full glass of
water and to maintain in a
upright position for 15-30 min
after administration.
4. Instruct patient to notify
health care professional of
medication regimen before
treatment or surgery.
5. Caution patient to wear
sunscreen and protective
clothing to prevent
photosensitivity reactions.
6. Advise patient to consult
health care professional if
65
bleeding with
cefamandole, cefoten
cefoperazone,
valproic acid,
plicamycin,
thrombolytic agents
or anticoagulants
- may increase the
risk of nephrotoxicity
from cyclosporine.
DRUG-NATURAL
PRODUCTS
- increased bleeding
risk with anise,
arnica, chamomile,
garlic, ginger, ginko,
Panax ginseng
only – contact
dermitis, dry
skin, exfoliation,
rash
- Misc: allergic
reactions
including
Anaphylaxis
rash, itching, visual
disturbances, tinnitus, weigh
gain, edema, black stools,
persistent headache, or
influenza-like syndrome
occurs.
Generic Name: Ferros Sulfate, FeO4 Brand Name: Feosol, Feratab, Fer-gen-sol, Fer-In-Sol
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
66
- Therapeutic:
antianemics
- Pharmacologic:
iron supplements
Ordered at 8/31/08
- 1 cup OD PO
Ordered at 9/2/08
- 1g OD PO
- An essential
mineral found
in hemoglobin,
myoglobin,
and many
enzymes.
- Parenteral
iron enters the
bloodstream
and organs of
the
reticuloendoth
elial system,
where iron is
separated out
and becomes
part of iron
stores.
- Therapeutic
effects:
Prevention.trea
tment of iron
deficiency.
- PO:
Prevention/
treatment of
iron-
deficiency
anemia
- IM, IV:
Iron dextran
–
treatment/pr
evention of
iron-
deficiency
anemia in
patients who
cannot
tolerate oral
iron
-Primary
hemochromatosis
- Hemolytic
anemia’s and other
anemia’s not due
to iron deficiency
- Some products
contain alcohol,
tartrazine, or
sulfites and should
be avoided in
patients with
known intolerance
or hypersensitivity
- Concurrent oral
iron therapy
DRUG-DRUG
- Tetracycline and
antacids ↑ oral
absorption of iron
by forming
insoluble
compounds
- Oral iron
supplements ↓
absorption of
Tetracyclines,
fluroquinolones, and
penicillamine
- ↓ absorption of
and may ↓ effects of
levodopa and
methyldopa
- May ↓ efficacy of
levothyroxine
DRUG-FOOD:
- Iron absorption is
↓ 33-50% by
concurrent
administration of
- CNS: IM, IV –
seizure,
dizziness,
headache,
syncope
- CV: IM, IV –
hypotension,
tachycardia
GI: nausea; PO
– constipation,
dark stools,
diarrhea,
epigastric pain,
GI bleeding
Derm: IM, IV –
flushing,
urticaria
Local: pain at IM
site (iron
dextran),
phlebitis at IV
site, skin staining
at IM site (iron
dextran)
MS: IM, IV –
1. Encourage patient to
comply with medication
regimen.
2. If you missed a dose, take it
as soon as remembered within
12 hr; otherwise, return to
regular dosing schedule.
3. Do not overdose or
underdose when taking in the
medication.
4. Advise patient that stools
may become dark green or
black and that this change is
harmless.
5. Instruct patient to follow a
diet high in iron.
6. Place medication out of
reach of children
7. Place medication at room
temperature.
67
food. arhralgia,
myalgia
- Misc: PO –
staining of teeth
(liquid
preparations);
IM, IV- allergic
reactions
including
anapyhylaxis,
fever,
lymphadenopath
y.
Generic Name: KETOROLAC Brand Name: Acular, Toradol
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
68
- Non-steroidal anti-
inflammatory agents
- Non-opioid
Analgesics
- Analgesic, anti-
inflammatory,
antipyretic effects
Ordered at 8/30/08
- 30 mg q 8 hours IVTT
- Inhibits
prostaglandin
synthesis by
decreasing an
enzyme
needed for
biosynthesis
Short-term
management
of pain (not
to exceed 5
days total
for all routes
combined)
Hypersensitivity;
cross-sensitivity
with other
NSAIDs may
exist; labor,
delivery or
lactation; pre- or
perioperative
use; known
alcohol
intolerance
DRUG-DRUG
- concurrent use with
aspirin may decrease
effectiveness
- additive adverse GI
effects with aspirin,
other NSAIDs,
potassium
supplements,
corticosteroids or
alcohol
- chronic use with
acetaminophen may
increase the risk of
adverse renal
reactions
- may decrease the
effectiveness of
diuretics or
hypertensive
- may increase serum
lithium levels and
increase the risk of
toxicity.
- increased risk if
- CV:
hypertension,
flushing,
syncope, pallor,
edema,
vasodilation
- CNS:
dizziness,
drowsiness,
tremors
- EENT:
tinnitus, blurred
vision. Hearing
loss
- GI: nausea,
anorexia,
vomiting,
diarrhea,
constipation,
flatulence,
cramps
- GU:
Nephrotoxicity:
dysuria,
hematuria,
1. Obtain patient’s vital signs
to note for signs of
hypertension.
2. Assess for patient’s
hypersensitivity reactions
especially those who have
asthma, aspirin-induced
allergy, and nasal polyps.
3. For patient’s experiencing
pain, note the type, location
and intensity of pain prior to
1-2 hr following
administration.
4. Instruct patient to make
medication exactly as directed.
If dose is missed, it should be
taken as soon as remembered
if not almost time for next
dose.
5. Advice patient to call for
assistance when ambulating
and to avoid driving or ithe
activitiues requiring alertness
until response to the
69
bleeding with
cefamandole, cefoten
cefoperazone,
valproic acid,
plicamycin,
thrombolytic agents
or anticoagulants
- may increase the
risk of nephrotoxicity
from cyclosporine.
DRUG-NATURAL
PRODUCTS
- increased bleeding
risk with anise,
arnica, chamomile,
garlic, ginger, ginko,
Panax ginseng
oliguria,
azotemia
- HEMA: blood
dyscrasias,
prolonged
bleeding
- INTEG:
pupura, rash,
pruritus,
sweating
medication is known.
Generic Name: Methylergonovine Brand Name: Methergine
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
70
- Therapeutic:
oxytoxic
- Pharmacologic:
ergot alkaloids
Ordered at 8/31/08
- 1 tab TID PO
- Directly
stimulates
uterine and
vascular
smooth muscle.
- Therapeutic
effect: uterine
contraction.
- Prevention
and
treatment of
post partum
or post
abortion
hemorrhage
caused by
uterine
atony or
subinbolutio
in.
Hypersensitivity.
Should not be
used to induce
labor.
DRUG-DRUG
- Excessive
vasoconstriction may
result when used with
heavy cigarette
smoking (nicotine) or
other vasopressors
such as dopamine.
CNS: dizziness,
headache
EENT: tinnitus
Resp: dyspnea
CV: hypotension
GI: nausea,
vomiting
GU: cramps
Derm:
diaphoresis
Misc: allergic
reactions
1. Monitor BP, HR, and
uterine response frequently
during medication
administration
2. Assess for signs of
ergotism
3. Instruct patient to take
medication as directed, do not
skip or double up on missed
doses
4. Advise patient that
medication may cause
menstrual-like cramps
5. Instruct patient to notify
health care professional if
infection develops.
Generic Name: Oxytocin
Brand Name: Pitocin
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
71
- Oxitoxicity Ordered at 8/30/08
- 10 units oxytocin
IVTT
- Hormone that
causes potent
and selective
stimulation of
uterine and
mammary
gland smooth
muscle.
- To induce or
stimulate labor
- To reduce
postpartum
bleeding after
expulsion of
placenta
- Incomplete or
inevitable
abortion
- Contraindicated in
patients
hypersensititve to
drug
- Contraindicated
when vaginal
delivery isn’t
advised, when
cephalopelvic
disproportion is
present, or when
delivery requires
conversion, as in
transverse lie.
- Contraindicated in
fetal distress when
delivery isn’t
imminet, I
prematurity, in other
obstetric
emergencies, and in
patients with severe
toxemia or
hypertonic uterine
Drug-drug:
Cyclopropane
anesthetics: May
cause less
pronounced
bradycardia and
hypotension. Use
together cautiously.
Thiopental
anesthetics: May
delay induction. Use
together cautiously.
Vasoconstrictors:
May cause severe
hypertension if
oxytocin is given
within 3 to 4 hours of
vasoconstrictor in
patient receiving
caudal block
anesthetic. Avoid
using together.
CNS:
subarachnoid
hemorrage,
seizures, coma
CV:
hypertension;
increased heart
rate. Systemic
venous return,
and cardiac
output;
arrythmias.
GI: nausea,
vomitting
GU: titanic
uterine
contraction,
abruption
placentae,
impaired uterine
blood flow,
pelvic
hematoma,
1. Drug isn’t recommended for
routine I.M. use, but 10 units
may be given I.M. after
delivery of placenta to control
postpartum uterine bleeding.
2. Never give oxytocin
simultaneopusly by more than
one route.
3. Drug is used to induce or
reinforce labor only when
pelvis is known to be adequate,
when vaginal delivery is
indicated, when fetal maturity is
assured, and when fetal position
is favorable. Use drug only in
hospital where critical care
facilities and prescriber are
immediately available.
4. Monitor fluid intake and
output. Antidiuretic effect may
lead to fluid overload, seizures,
and coma from water
intoxication.
72
patterns. increased uterine
motility, uterine
rupture,
postpartum
hemorrhage.
Hematologic:
afibrinogenemia
possibly related
to postpartum
bleeding.
Other:
hypersensitivity
reaction,
anaphylaxis,
death from
oxytocin-induced
water
intoxication.
5. Monitor and record uterine
contractions, heart rate, blood
pressure, intrauterine pressure,
fetal heart rate, and character of
blood loss every 15 minutes.
6. Have 20% magnesium
sulfate solution available to
relax the myometrium.
7. If contractions occur less
than 2 minutes apart, exceed 50
mm, or last 90 seconds or
longer, stop infusion, turn
patient on her side, and notify
physician.
8. Drug doesn’t cause fetal
abnormalities when used as
indicated.
Generic Name: Ranitidine hydrochloride
Brand Name: Zantac
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
73
- Antiulcer Ordered at 8/30/08
-50 mg q 8 hours
IVTT
-Competitively
inhibits action
of histamine
on the h2 at
receptor sites
of parietal
cells,
decreasing
gastric acid
secretion.
- Duodenal and
gastric ulcer
(short-term
treatment);
pathologic
hypersecretory
conditions, such
as Zollinger-
Ellison
syndrome
- Maintenance
therpy for
duodenal or
gastric ulcer.
-
Gastroesophage
al reflux disease
- Erosive
esopaghitis
- Heartburn
- Contraindicated in
patients
hypersensitive to
drug and those with
acute porphyria.
Drug-drug.
Antacids: May
interfere with
ranitiding absorption.
Stagger doses, if
possible.
Diazepam: May
decrease absorption
of diazepam. Monitor
patient closely.
Glipizide: May
increase
hypoglycaemic
effect. Adjust
glipizide dosage, as
directed.
Procainamide: May
decrease renal
clearance of
procainamide.
Monitor patient
closely for toxicity.
Warfarin: May
CNS: vertigo,
malaise,
headache
EENT: blurred
vision
Hepatic:
jaundice
Other: burning
and itching at
injection site,
anaphylaxis,
angioedema
1. Assess patient for abdominal
pain. Note presence of blood in
emesis, stool, or gastric
aspirate.
2. Ranitidine may be added to
total parenteral nutritional
solution.
3. Ranitidine may be added to
total parenteral nutrition
solutions.
Alert: Don’t confuse ranitidine
with rimantadine: don’t
confuse Zantac with Xanac or
Zyrtec.
74
interfere with
warfarin clearance.
Monitor patient
closely.
Generic Name: TRAMADOL HYDROCHLORIDE
Brand Name: Tramal, Siverol
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities
- Central Nervous
System Agent
- Opiate Agonist
- Narcotic Analgeic
Ordered at 8/30/08
-50 mg q 6 hours
IVTT
- Effective
agent for
control of
moderate to
moderately
severe pain
- Management
of moderate to
moderately
severe pain.
- Hypersensitivity
to tramadol or
other opioid
analgesics; patient
on MAO
inhibitors; patient
acutely intoxicated
with alcohol,
hypnotics, centrally
acting analgesics,
opioids, or
- Carbamazipine:
significantly
decreases tramadol
levels (may need up
to twice usual doses).
Tramadol may
increase adverse
effects of MAO
inhibitors. Tricyclic
antidepressants.
Cyclobenzaprine,
- CNS:
drowsiness,
dizziness,
vertigo, fatigue,
headache,
somnolence,
restlessness,
euphoria,
confusion,
anxiety,
coordination
1. Assess for level of pain
relief and administer PRN
dose as needed but not to
exceed the total daily dose.
2. Monitor vital signs and
assess for orthostatic
hypotension or signs of CNS
depression.
3. Discontinue drug and notify
physician if S&S of
hypersensitivity occur.
75
psychotropic drugs;
patients on
obstetric
preoperative
medication;
lactation.
Debilitated
patients; chronic
respiratory
disorders; liver
disease; renal
impairment;
myxedema;
hypothyroidism; or
hypoadrenalism;
acute abdominal
conditions;
increase ICP or
head injury; history
of seizures;
pregnancy
(category C);
patients >75 yrs.
safety and efficacy
in children are not
phenothiazine,
selective serotonin-
reuptake inhibitors,
MAO inhibitors may
enhance seizures risk
with tramadol, may
increase CNS adverse
effects when used
with other CNS
depressants. Herbal:
St. John’s wort may
increase sedation.
disturbance,
sleep
disturbances,
seizure.
- CV:
palpitations,
vasodilation
- GI: nausea,
constipation,
vomiting,
xerostomia,
dyspepsia,
diarrhea,
abdominal pain,
anorexia,
flatulence
- Body as a
whole: sweating,
anaphylactic
reaction (even
with first dose)
- SPECIAL
SENSE: visual
disturbances
4. Assess bowel and bladder
function; report urinary
frequency or retention.
5. Use seizure precautions for
patients who have a history of
seizures or who are
concurrently using drugs that
lower the seizure threshold.
6. Monitor ambulation and
take up appropriate safety
precautions.
7. Exercise caution with
potentially hazardous
activities until response to
drug is known.
8. Understand potential
adverse effects and report
problems with bowel and
bladder function. CNS
impairment, and any other
bothersome adverse effects to
physician.
9. Do not breastfeed while
taking this drug.
76
established. -
UROGENITAL:
urinary retention/
frequency,
menopausal
symptoms
NURSING CARE PLAN
Date/
Time Cues Need
Nursing
Diagnosis
Objectives of
Care Nursing Intervention Evaluation
77
S
E
P
T
E
M
B
E
R
2,
2
0
0
8
@
Subjective :
“naa gihapon
gamay na
sakit tungod
sa akong
tahi”
Objective:
- Guarding
behavior
- pain scale of
2 out of 5
- grimaced
face
C
O
G
N
I
T
I
V
E
-
P
E
R
C
E
P
T
U
A
L
Acute pain related
to presence of
surgical incision
secondary to
cesarean section
Rationale:
acute pain is an
unpleasant sensory
and emotional
experience arising
from actual or
potential tissue
damage or
described in terms f
such damage
(international
Association for the
Study of Pain);
sudden or slow
onset of any
Within the 4
hours span of
care, patient will
be able to report
reduced pain as
evidenced by
client’s
verbalization.
1. Monitor and record vital signs
Rationale: Monitoring the patient helps in the
continuity of care. Vital signs are also important to
determine the difference between the normal and the
not.
2. Assess for appropriate referred pain.
Rationale: Assessment helps determine possibility of
underlying organ dysfunction requiring treatment.
3. Acknowledge the pain experienced and express
acceptance of client’s response to pain.
Rationale: Pain is a subjective experience and
cannot be felt by others.
4. Provide comfort measures such as back rub and
changing of position
Rationale: to provide nonpharmacological care
management.
5. Teach patient relaxation techniques like deep-
breathing exercise
September
03,
2008
@
4:00 am
Goal met
After the 4
hours span of
care, patient
was able to
report
reduced pain
and
verbalized,
“hay salamat
nakaginhawa
pud ko maski
78
12am P
A
T
T
E
R
N
intensity from mild
to severe with an
anticipated or
predictable end and
a duration of less
than 6 months
Rationale: to alleviate pain
96. Promote sufficient resting periods particularly
when apply too much effort to an activity
Rationale: Adequate rest period prevent fatigue.
6. Evaluate measures done and inform client when
management may cause pain.
Rationale: the client’s knowledge regarding episode
of pain lessens the concern of the unfamiliar.
gamay.”
Date/
Time Cues Need
Nursing
Diagnosis
Objectives of
Care Nursing Intervention Evaluation
79
S
E
P
T
E
M
B
E
R
2,
2
0
0
8
@
Subjective :
“Dili pa kayo
ko
makatarong
ug lakaw”
Objective:
- weakness
noted
- moves
slowly
- needs
assistance to
balance
before
standing up.
A
C
T
I
V
I
T
Y
-
E
X
E
R
C
I
S
E
P
A
T
Activity Intolerance
related to
generalized
weakness
secondary to post
cesarean section
Rationale:
Activity intolerance
is insufficient
physiological or
psychological
energy to endure or
complete required
or desired daily act.
At the end of our
shift, patient will
use identified
techniques to
enhance activity
such as walking.
1. Establish rapport
R: Patient will gain trust and cooperation.
2. Assist patient with activities and monitor patient’s
use of assistive devices such as chair.
R: It will protect the patient from injury.
3. Promote comfort measures and provide for relief
of pain.
R: It enhances the ability of the patient to participate
in activities.
4. Plan care with rest periods between activities.
R: Reduces fatigue
5. Provide positive atmosphere, while acknowledging
difficulty of the situation for the client.
R: Help minimize frustrations.
September
03,
2008
@
4:00 am
Goal met
At the end of
our shift, the
patient was
able to
enhance
activity such
as walking.
80
12am T
E
R
N
Date/Time
Cues Need Nursing Diagnosis
with Rationale
Objectives/ Plan
Nursing Intervention with Rationale
Evaluation
81
S
E
P
T
E
M
B
E
R
2,
2
0
0
8
@
12am
11-7
Subjective :
“gi CS man ko
sa akong
pagpaanak”
Objective:
- Client is 3
days
postpartum
- Client
underwent a
cesarean
section.
- Surgical
incision on the
abdomen
- Client lacks
personal
hygiene
H
E
A
L
T
H
-
P
E
R
C
E
P
T
I
O
N
H
E
A
L
Risk for infection
related to
presence of
surgical incision
secondary to
cesarean section.
Rationale:
Client’s
undergoing a
surgical
procedure impairs
the body’s normal
defense
mechanisms;
thereby,
increasing the
risk of being
invaded by
pathogenic
organisms.
(Sue C. Delaune,
Patricia K.
Within the 4
hours span of
care, patient
will be able to
identify
interventions
to prevent/
reduce risk of
infection.
1. Establish rapport with the patient and
significant others.
Rationale: Establishing rapport is essential in
gaining the trust and cooperation of the patient
which can greatly help in meeting the goals set
for the patient
2. Monitor and record vital signs
Rationale: Monitoring the patient helps in the
continuity of care. Vital signs are also essential
to determine deviations from normal
3. Observe for localized signs of infection at
insertion sites of invasive lines, sutures,
surgical incisions/ wounds.
Rationale: Assessing the client helps determine
prioritization of care.
4. Emphasize the importance of perineal care
and proper hygiene (e.g., wiping from front to
back and changing soaked perineal pads
regularly)
Rationale: These reduce the risk of ascending
September 2,
2008
@
4:00am
GOAL MET
Within my 4
hours span of
care, patient
was able to
identify
interventions
like taking a
bath to
prevent/reduc
e risk of
infection and
as evidence
by “maligo
dyud diay
82
- Bed linens
are dirty and
not wrinkle-
free
- Binder on
Abdomen
T
H
M
A
N
A
G
E
M
E
N
T
P
A
T
T
E
R
N
Ladner,
Fundamentals of
Nursing, 2006)
urinary tract infection.
6. Change surgical/other wound dressings as
indicated, using proper technique for
changing/disposing of contaminated materials
Rationale: Sterile technique prevents
contamination and reduces risk for infection.
7. Keep bedclothes dry and wrinkle-free, use
nonirritating linens.
Rationale: Dry, wrinkle-free and nonirritating
linens promote comfort and prevents
contamination thereby reducing the risk for
infection acquired from soiled bed linens.
9. Encourage increased fluid intake and diet
high in protein and vitamin C
Rationale: These vitamin and nutrient are
necessary for wound healing and prevention of
infection.
10. Emphasize the importance of practicing
hand washing specially after being in contact
dapat ko para
malimpyo ko,”
as verbalized
by client.
83
with soiled items.
Rationale: Clear and concise instructions about
wound care is important to discard soiled
dressings appropriately to safeguard the
women and the caregivers.
11. Monitor medication regimen (e.g., topical
antibiotics).
Rationale: Monitoring for medications helps
determine for effectiveness of therapy and
presence of side effects.
Date Cues Need Nursing Diagnosis
Objectives of Care
Nursing Interventions Evaluation
S
E
Subjective:
> “Wala pa ko
A
C
Self-Care
Deficit
Within the
span of 4
Independent:
1.) Assess exact cause of deficitSeptember
02,
84
P
T
E
M
B
E
R
01,
2008
12:00
am
nakaligo sukad
nanganak ko.”
Objective:
inability to
wash body or
body parts
untidy
appearance
untrimme
d nails
physical
immobility
noted
2 days
post CS
Foul odor
noted
T
I
V
I
T
Y
-
E
X
E
R
C
I
S
E
related to
post
cesarean
section.
R: Impaired
ability to
carry out,
bathing/
hygiene,
dressing
and
grooming,
or toileting
activities
for oneself
(on a
temporary,
permanent,
or
progressing
hours of care,
patient will be
able to safely
perform self-
care activities.
R: Different causes may require
more specific interventions to enable
self-care.
2.) Situate short-term goals with
client.
R: To aid learning and decrease
aggravation.
3.) Promote independence, but
intercede when patient cannot
perform
R: To drop off disappointment.
4.) Make use of consistent practices
of daily hygiene.
R: This facilitates the client to put in
order and carry out self-care skills
5.) Provide recurrent support and
assistance as needed with dressing.
R: To reduce energy outflow and
aggravation
6.) Encourage patient to do own self
2008 @4:00 am
Goal met
After 4 hours,
client was able
to perform
safely self-
care activities
within level of
own ability.
85
basis) care practices.
R: To develop independence
7.) Instruct client to select bath time
when rested and unhurried.
R: This helps client to organize and
carry out self-care skills
8.) Offer frequent encouragement of
doing daily perineal care/hygiene.
R: Clients often have difficulty
seeing progress
10.) Assist client in
removing/replacing necessary
clothing.
R: This helps client to organize and
carry out self-care skills
86
PROGNOSIS
Criteria Good Fair Poor Justification Rationale
Onset of
illness
X
Upon the start
of bleeding,
immediately
went to see
the doctor and
has
undergone
ultrasound.
She was
detected with
placenta
previa and
informed to
take a lot of
rest that would
lessen the
bleeding.
When the
manifestations
are being
experienced
and
unusualities are
being detected,
it should be
given time as
early as
possible so as
not to make
things
complicated.
Through the
help of medical
assistance and
diagnostic
examinations, it
would help a lot
in identifying
the condition..
Duration of
illness
X
From the start
of the first
bleeding, she
consulted the
The patient’s
initiative to
obey the doctor
is one way or
87
doctor
immediately.
She was
advised to
take a lot of
rest and told
by the doctor
to consult the
doctor again if
bleeding
would still
occur. By the
second time
she had her
bleeding, she
went back
immediately to
the doctor.
another a help
in preventing
further
complications.
It would also be
a factor in the
progress of the
patient’s
condition.
Environment
X
Their place is
conducive for
the client’s
condition.
They live far
from the
polluted and
noisy city.
Their house is
clean and they
see to it that it
is not messed
The
continuance of
clean
environment
plays a role in
the recovery of
the patient. The
environment is
a factor that
affects the
health and
illness of the
88
up. It is a
good place
wherein the
patient can
take a good
rest.
individual.
Family
Support X
Well
supported by
the family,
from the start
of her
condition, the
husband told
her to stop
from her work
so that she
could take a
lot of rest. Her
sister in laws
took over of
the household
chores.
The family
members offer
encouragement
to the family
member who is
sick. Their
motivation is a
great help in
the progress of
the client’s
condition.
Willingness
to take
medications
X
The client
takes her
medications
as ordered by
the doctor but
in some
instances,
they cannot
The compliance
to the treatment
regimen is one
of the best
ways to have a
good
advancement in
the condition of
89
afford some of
the
medications
so the client
sometimes
cannot
complete the
period
wherein she
should take
the prescribed
medications.
the client.
Precipitating
Factors X
The client is
pregnant that
cause her to
develop a
placenta
previa, a low
implantation of
the placenta
covering the
cervical os.
She is
pregnant with
her second
child and it is
a male fetus.
these factors
are modified
the occurrence
of the illness
will be
prevented or
less
complication.
Predisposing
Factors X
Among the
predisposing
factors
The
predisposing
factors play a
90
present in the
client are
gender and
race.
critical role in
setting risks for
the client to
acquire such
disease. This
factors can’t be
change.
CALCULATIONS:
Good: 3 x 4 = 12
Fair: 2 x 2 = 4
Poor: 1 x 2 = 2
TOTAL: 15 = 18 / 7 = 2.57
Range of Value: 1.0 - 1.6 for Poor; 1.7 - 2.3 for Fair; 2.4 – 3.0 for Good
Client has a GOOD prognosis as shown in the computation. She has a
chance of recovering from her condition, placenta previa totalis.
91
HEALTH TEACHINGS
* Encourage patient to express feelings and concerns
® So that relief measure may be instituted
* 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
® For the nutrition of her baby
*Teach signs of post-op complications and report the ff. signs to health care
provider:
temperature exceeding 38C
painful urination
lochia heavier than normal period
wound separation
92
redness or oozing at the incision site
severe abdominal pain
*Teach postpartum pain relief after cesarean birth
-INCISIONAL pain
splint incision with a pillow when moving or coughing
use relaxation techniques such as music, breathing, and dim lights
apply heating pad to the abdomen
*GAS pain
walk as often as you can
Don't drink or eat gas-forming foods, carbonated beverages, or whole milk
Take antiflatulence medication if prescribed
Lie on your left side to expel gas
Emphasize to client to regularly perform wound dressing
® Prevent infection
Inculcate to the client the importance of proper hand washing
® Hand washing if the single most effective way in controlling infection
93
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.
Encourage patient to first sit up and dangle feet before standing from a
lying position to prevent orthostatic hypotention
94
Treatment
Discussing the purpose of treatments to be done and continued at home
and report to the health professional when there is bleeding to alleviate
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.
95
REFERENCE
DeLaune, S.C. 2006. “Fundamentals of Nursing: Standards and Practice.”
3rd ed. New York: Delmar.
Maternal and child health nursing. Pillitteri. Fifth edition.2007. Lippincott
Williams & Wilkins.
Maternity Nursing. Seventh edition. Lowdermilk & Perry.
Fundamentals of Maternal and Child Nursing Care, London, Marcia;
Ladewig, Patricia W.; Wall, Jane W.; Bindler, Ruth C.; Pearson Education,
Inc., 2007
Nursing 2008 Drug Handbook, Lippinocott, Wilkins &Williams, 2008
Kozier, B., Erb, G., and Oliviere, R. 2004. “Fundamentals of Nursing:
Concepts, Process, and Practice.” 7th ed. Redwood City, Ca: Addison-
Wesley
Marriner-Tomey, S. 2002. “Nursing Theorists and Their Works.” 5 th ed. St.
Louis: Mosby.
KUNA: A Maternal and Child with Pediatric Nursing Handbook, 1st ed.,
Aaron “CY” Tuesca Untalan, RN
http://www.usaid.gov
http://www.wikipedia.org
96
http://www.emedicinehealth.com
http://www.usaid.gov
http://academic.kellog.edu/herbrandsonc/bio201_McKinley/f28-
2_sagittal_section_c.jpg
http://www.webdelbebe.com/wp-content/uploads/2006/11/placenta.jpg
http://www.answers.com/topic/placenta
97
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