Case Study
I. ACKNOWLEDGEMENT
We would like to thank our beloved family for their support and understanding when we are doing this case. To our group mates who shared their ideas and knowledge, for the patience, for the understanding, encouragement and hard work that they had given through the entire process and helped bring out the best in us during our hard time on the hospital duty.
We would like to express our gratitude on the management and staff ofUnciano Medical Center and to our Clinical Instructor Mrs. Ma. Luz Dieron and to our Head Nurse Ms. RoanneCeninfor their guidance and understanding.
We would also like to acknowledge Mrs. N.C and his relatives for being approachable and cooperative in sharing and giving us the information regarding his present condition.
And above all, we all like to give thanks to God our Lord that gives us the inspiration and positive throughout this case.
I. INTRODUCTION
In partial fulfillment of the NCM 107 requirements, we the group 2 of section A, were given the opportunity to study and assist in challenging cases in Unciano Medical Center. Our exposure to various cases gave us the chance to enhance the attitude, knowledge and skills that we have learned from Unciano Colleges Antipolo.
For our case study, our group decided to focus on the case of Mrs. N.C female, 21 years old who had been diagnosed with Abruptio Placenta and undergone Cesarian Section because of his cooperativeness, status of the recent condition, and patients will. This case will serve as an opportunity for the client to acquire knowledge regarding his condition.
We devoted ourselves to carrying out the nursing responsibilities assigned to us, both in assisting to restore Mrs. N.C ’s health, as well as in establishing nurse-patient interaction so that he will cooperate with us as we gather information to aid his in regaining health and attaining optimum level of functioning.
II. BACKGROUND OF STUDY
Abruptio Placenta * Painful bleeding * Placenta is implanted correctly but it begins to separate and bleeding result * Separation generally occurs late in pregnancy * It may occur as late as during 1st stage of or second stage of labor * Cause is unknown * Predisposing Factors * Highly parity * Advanced maternal age * Short umbilical cord * Chronic hypertensive disease * Pregnancy induced hypertension * Direct trauma (as form an automobile accident or intimate partner abuse) * Vasoconstriction from cocaine or cigarette use * Thrombophilitic conditions that lead to thrombosis such as auto immune antibodies, protein C, and factor V Leiden it may be caused by chorioamnionitis infection of the fetal membranes and fluid * Signs and Symptoms * Premature separation of placenta follow b y a rapid decrease in intrauterine volume, such as occurs within sudden release of amniotic fluid * Sharp, stabbing pain high in the uterine fundus as the initial separation occurs * If labor begins with separation, each contractions will be accompanied by pain over and above the pain of the contractions * Heavy bleeding * Extreme bleeding if placenta separate first * Uterus becomes tense and feels rigid to touch * Couvilaire uterus or utero-placental apoplexy forming a hard board like uterus * Complications * Disseminated intravascular Coagulation * Diagnostics * Bleeding Time * Hemoglobin level * Typing and cross matching * Fibrinogen level * Blood Clotting – draw 5 ml and place it in a clean, dry test tube, stand it aside uncovered for 5 minutes if the clot not formed suspect interference with blood coagulation * Therapeutic Management * Need Intravenous fluid for fluid replacement * Oxygen mask to limit fetal anoxia * Monitor fetal heart sounds externally to establish baselines and observe progress * Record maternal vital signs every 5 to 15 minutes to establish baselines and observe progress * Keep woman in lateral position not supine to prevent pressure on the vena cava and additional interference with fetal circulation * Do not perform any abdominal, vaginal, or pelvic examination even it is suspected placental separation so the placenta will not be disturbed * If vaginal birth does not seen imminent, caesarean birth is the birth method of choice * If DIC has developed, caesarean surgery may pose a grave risk because of possible haemorrhage. * Administration of fibrinogen or cryopreciptate to elevate woman’s fibrinogen levelprior and concurrently with surgery. * Hysterectomy might be necessary to prevent exsanguination. * Placenta: Degree of Separation * O – no symptoms of separation were apparent from maternal or fetal signs, placenta shows a recent adherent clot on the maternal surface. * 1 – minimal separation, but enough to cause vaginal bleeding and changes in maternal sides * 2 – moderate separation, evidence of fetal distress, uterus is tense and painful on palpation * 3 – extreme separation, without immediate interventions, maternal shock and fetal death will result. * Death can occur from massive haemorrhage leading to shock and circulatory collapse * Incidence * Abruptio placenta also occurs in abuot 1% of all pregnancies throughout the world. * A fetal mortality rate of 20–40% depending on the degree of separation. * Placental abruption is also a significant contributor to maternal mortality. * The risk of ocurrence of abruptio placenta is reported 4-12%,if the patient has abruptio placenta in 2 consecutive pregnancies, the risk of occurrence rises to 25%.
III. OBJECTIVES
GENERAL OBJECTIVE: Within 48 hours of exposure at Unciano Medical Center , we, the 4th Year Nursing students of Unciano Colleges – Antipolo City, Section A-Group 2 is aim to enhance our knowledge, skills and attitude in rendering care to our client.
SPECIFIC OBJECTIVES: 1. To be able to establish rapport to the client and to his family. 2. To be able to assess our client’s condition and to identify the client’s health needs. 3. To be able to master the anatomy and physiology of the Reproductive System. 4. To be able to formulate a nursing diagnosis. 5. To be able to formulate a plan of care to our client with Post-op Cesarian Section (Abruption Placenta). 6. To raise the level of awareness of patient on health problems that he may encounter. 7. To facilitate patient in taking necessary actions to solve and prevent the identified problems on his own. 8. To help patient in motivating him to continue the health care provided by the health workers. 9. To render nursing care and information to patient through the application of the nursing skills. 10. To be able to give health teachings to the client and his family. 11. To be able to evaluate the effectiveness of our nursing care plans and imparted health teachings to our client.
IV. PATIENT’S PROFILE
Case Number: 553394
Ward: OB Ward
Bed Number: 8
Name/ Initials: Mrs. N.C
Gender: Female
Civil Status: Single
Age: 21 years old Date of Birth: November 25, 1991 Place of Birth: Taytay Rizal Address: Taytay Rizal
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: Dec 11, 2012
Time of Admission: 11:00 p.m
Resident on Duty: Dr. Lat
Admitting Diagnosis: G2P2 (1001) LTCS I 36-37 AOG CIBL / Abruptio Placentae Final Diagnosis: G2P2 (2002) PUFT Cephalic live baby boy via CS
Date of Assessment: December 12, 2011
Time of Assessment: 10:00 a.m LMP: March 11, 2012 EDC: December 18, 2012 Date and Time of Delivery: Decembery12, 2012; 11:30 pm
V. NURSING HISTORY
CHIEF COMPLAINT:
“Masakitangtahiko…” as verbalized by the client.
HISTORY OF PRESENT ILLNESS: At around 10:30 in the evening,December 11, 2012 when Mrs. N.C is walking inside their house when suddenly she felt labor pains that radiates from her left epigastric and umbilicus area. Her mother immediately called an ambulance in their barangay health center. At around 11:00 p.m Mrs. N.C immediately brought to the Emergency Room of Rizal Provincial Hospital in Morong. Vital signs takentemperature 37 °C, pulse rate 78 bpm, respiratory rate 24 cpm and blood pressure 160/90 mmHg, She was seen and examined by Dr. Lat find out that there is heavy bleeding and separation of placenta. An IVF of D5LR1L X 12 gtts/mins.Inserted on her left metacarpal vein gauge 20 and medication Hydralazine 5mg TIV for hypertension, and Oxytocin 10 units in IL D5LR and laboratory examination Hematology and Blood Chemistry was ordered. At around 11:30pm, Mrs. N.C was transferred to the Operating Room and undergoneCesarean Operation then she was transferred to O.B Ward at around 12:30am.
HISTORY OF PAST ILLNESS: According to Mrs. N.C she had no history of any illness for the last five years.
HEREDO-FAMILIAL HISTORY: According to Mrs. N.C her both mother and father hadno history of any illness.
SOCIO- ECONOMIC HISTORY: Mrs. N.C is a plain housewife. In the house her daily routine is only listening music and watching tv. Her husband works at SM Taytay as a salesman. Her Husband will shoulder the payments for the hospital bills and medications.
OBSTETRICAL HISTORY: Mrs. N.C was diagnosed with G2P2 (1001) Abruptio Placentae 36-37 weeks. Her LMP was March 11, 2012; her Estimated Date of Confinement was December 18 , 2012. Mrs. N.C gave Decembery 12, 2012 at11:30 to a PUFT Cephalic live baby boy via CS. She had her prenatal check - ups 5 times in their local health center and she received Tetanous Toxoid Immunizations 2 times. GYNECOLOGIC HISTORY:
Mrs. N.C’s has 2 child right now. She had her menarche when she was 13 years old. According to Mrs. N.C, her menstruation lasts for 3-5 days. Heavy flow of blood was experienced during first and second day of her first menstruation and she used 2-3 napkins a day. She doesn’t even experience dysmenorrheal during her period days.
VI. REVIEW OF BODY SYSTEM
1. SENSORY-PERCEPTUAL
a. Mental Status
Upon assessment Mrs. N.C was conscious and coherent. She was able to answer our questions clearly. She speaks in Tagalog dialect. As we began our interview, we test her orientation to time, place and person. We ask her what year is it, where she was and whose with her. She answered that it was year 2012; she’s on the hospital with her mother and her husband. For her short term memory, we asked her what time it is, she was able to tell us what time is it. For her long-term memory we asked her if she could remember the president last 2009 she was able to tell us that it was President Gloria Macapagal – Arroyo. For the assessment of the memory we test first her immediate recall by asking the client to recite the numbers up to 9 (1, 3, 5, 7, 9) the client was able to utter the said digits. Then afterwards we asked her to repeat it backward and the client was able to repeat the digits in reverse order.
She is a high school graduate. She used non-technical words during the assessment and communicates well in Tagalog.
b. Vision
Mrs. N.C’s eyebrows were symmetrical aligned and evenly distributed. We observed a thin and smooth skin on her eyelid. The eyelids close easily and eyelashes turn outward. The eyelashes were equally distributed, and slightly curled outward. We ask the client to rise and lower her eye brows and unequal movement was observed. Her sclera was white in color. There were no lesions, discharges, swelling & redness on her both eyes. The eyeballs are symmetrically aligned. Mrs. N.C responds to PERRLA (pupils equal, round, reactive to light, and accommodation) her pupils constricted for approximately 3mm which was normal to an adult client when the light was illuminated on them from outer to inner canthus. We tested accommodation of her pupils by holding the penlight about 12-15 inches from the client. She focused on the penlight and remains focused in as we moved it closer in toward her eyes. This was done on both eyes. In assessing the six ocular movements, we asked Mrs. N.C to look straight and follow the movement of the pen with her eye. Moving the pen in a slow orderly manner bilaterally, the client’s eyes were able to move through the following direction moderately. We also asked Mrs. N.C to read from a book with room lighting for reading. She was able to read the different sentences correctly. As we moved the book nearer she was able to read it correctly.
c. Auditory
Mrs. N.C’s ears were aligned and symmetrical with the outer canthus of the eye. The skin is smooth with no lesions, lumps, or nodules. Color is consistent with facial color. In assessing the elasticity of the ears, we gently pulled each pinna upward and downward. Each was firm and recoiled after it was folded. Earlobes were pendulous. We have palpated the auricle and mastoid process. No discharges, lesions, redness or inflammation was observed.
In assessing the hearing ability of the client, we performed watch tic test bilaterally on both ear. We placed a wrist watch 2cm from her left ear & covered her right ear. We did the same procedure on her right ear & she was able to hear the tic-tac sound of the wrist watch. We also performed voice-whisper test to examine or to detect obvious hearing loss. We instruct the client to put a hand over one ear and to repeat the sentence we whisper by standing approximately 1 foot away from the client. She said that she was able to hear the whispered sentence. d. Olfactory
Mrs. N.C’s nose is located at the midline of her face. The color is the same as the rest of the facial skin; nose and nasal passages are not inflamed, and skin and mucous membrane are intact. The nasal structure is smooth and symmetric. Smelling test was performed to determine her ability to identify the different kinds of odors by closing her eyes. We let her smell different scents like white flower, cologne that we applied on cotton balls. We let her smell it one at a time. First we asked her to smell the white flower and she said that it smells like mint. Secondly, we asked her to smell the cologne and she verbalize it as fragrant. The smell tests were done to her right and left nares.
e. Gustatory
Mrs. N.C’s outer lips were symmetrical, smooth and moist without lesions or swelling. Her buccal mucosa is pink in color and moist. We observed the tongue it is the central position. The tongue is pink, moist a moderate size with papillae present. No lesions are present. The client refused because she is still in a clear liquid diet. f. Tactile
We checked Mrs. N.C’s sense of touch by letting her identify the different textures with her eyes. First we let her touch the cotton balls and she described it as soft. Secondly, we let her touch the tip of the percussion hammer and she described it as pointed.
Thirdly, we let her touched the handle of the percussion hammer and she described it as rough. Lastly, we let her touch the rubber head of the percussion hammer and she described it as hard. The touch tests were done bilaterally on both hands and on lower extremities also. She identified all the sensation correctly.
2. SKIN
Mrs. N.C was afebrile during our assessment. Her body temperature was 36.3 °C taken via her left axilla using a digital thermometer and warm to touch. Edema was present in her right and left lower extremities. Scale for pitting edema was 1+, somewhat deeper pit and no readily detectable distortion, disappears in 10-15 seconds.She has a vertical surgical incision on her lower abdomen about 3 inches long.
3. RESPIRATORY
Mrs. N.C’s respiratory rate at the time of our assessment was 17 cycles per minute, which is normal according to the normal range of 16-20 cycles per minute. There were no adventitious sounds heard.
4. CARDIOVASCULAR
Mrs. N.C’s pulse rate was 94 beats per minute taken via right radial artery. Her blood pressure was 150/110 mm Hg taken on her left brachial artery while lying on bed. The pulse pressure is 40 mm Hg. We also performed Capillary Refill Time (CRT) by pressing on the nail beds for 3 seconds. Nail beds return to normal pinkish color within 4 seconds. A normal CRT values is 1-3 seconds.
5. GASTROINTESTINAL
Mrs. N.C’s gums and tongue were pinkish in color, her teeth was slightly yellowish in color. There were no observable lesions. Our client also told us that she has 4 dentures. During our assessment she was infused with D5LR 1L with 10 units of oxytocin regulated at 10-15 gtts/min located at her left metacarpal vein. It was at 900 cc level and infusing well during our assessment. According to Mrs. N.C, she wasn’t defecated during our assessment. We assessed her bowels sounds for each quadrant then we get 16 bowels sounds. 4 sound each quadrant in 5 minutes. No distension noted
6. GENITOURINARY
According to Mrs. N.C, She doesn’t experience difficulty in urinating and according to her, the color of her urine is light yellow in color and the color of her discharge is dark red.
7. MUSCULOSKELETAL
Mrs. N.C was able to ambulate she can do active and passive range of movements was tested by flexion, extension, abduction, adduction and rotation on client’s upper and lower extremities. All of these movements were slow in motion. Muscle grading was Grade 4-Active (movement against gravity and some resistance) described as fair strength.
VII. ANATOMY AND PHYSIOLOGY
INTERNAL FEMALE ORGANS
The internal organs of the female consist of the uterus, vagina, fallopian tubes, and the ovaries.
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.
Location: The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments.
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.
Walls of the uterus:The walls are thick and are composed of three layers: the endometrium, the myometrium, and the perimetrium. The endometrium is the inner layer or mucosa. A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial lining sloughs off about every 28 days in response to changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle component of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues.
During the monthly female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. * Vagina.
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.
Function: The vagina provides the passageway for childbirth and menstrual flow; it receives the penis and semen during sexual intercourse. * Fallopian Tubes
Location: Each tube is about 4 inches long and extends medially from each ovary to empty into the superior region of the uterus.
Function:The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries.
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. * Ovaries
Functions: The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone).
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.
Process of egg production--oogenesis : The total supply of eggs that a female can release has been determined by the time she is born. The eggs are referred to as "oogonia" in the developing fetus. At the time the female is born, oogonia have divided into primary oocytes, which contain 46 chromosomes and are surrounded by a layer of follicle cells. Primary oocytes remain in the state of suspended animation through childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the anterior pituitary gland secretes follicle-stimulating hormone (FSH), which stimulates a small number of primary follicles to mature each month. As a primary oocyte begins dividing, two different cells are produced, each containing 23 unpaired chromosomes. One of the cells is called a secondary oocyte and the other is called the first polar body. The secondary oocyte is the larger cell and is capable of being fertilized. The first polar body is very small, is nonfunctional, and incapable of being fertilized. By the time follicles have matured to the graafian follicle stage, they contain secondary oocytes and can be seen bulging from the surface of the ovary. Follicle development to this stage takes about 14 days. Ovulation (ejection of the mature egg from the ovary) occurs at this 14-day point in response to the luteinizing hormone (LH), which is released by the anterior pituitary gland.
The follicle at the proper stage of maturity when the LH is secreted will rupture and release its oocyte into the peritoneal cavity. The motion of the fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also causes the ruptured follicle to change into a granular structure called corpus luteum, which secretes estrogen and progesterone.
If the secondary oocyte is penetrated by a sperm, a secondary division occurs that produces another polar body and an ovum, which combines its 23 chromosomes with those of the sperm to form the fertilized egg, which contains 46 chromosomes.
Process of hormone production by the ovaries.
Estrogen is produced by the follicle cells, which are responsible secondary sex characteristics and for the maintenance of these traits. These secondary sex characteristics include the enlargement of fallopian tubes, uterus, vagina, and external genitals; breast development; increased deposits of fat in hips and breasts; widening of the pelvis; and onset of menses or menstrual cycle. Progesterone is produced by the corpus luteum in presence of in the blood. It works with estrogen to produce a normal menstrual cycle. Progesterone is important during pregnancy and in preparing the breasts for milk production
EXTERNAL FEMALE GENITALIA
* Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with thick coarse hair. * 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. * Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They protect the opening of the vagina and urethra. * 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. * 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. * 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.
VIII. PATHOPYSIOLOGY
X. LABORATORIES AND DIAGNOSTIC STUDIES Date: December 11, 2012
HEMATOLOGY TYPES OF EXAMINATION | NORMAL VALUES | RESULT | SIGNIFICANCE | Hemoglobin | 140-160g/L | 80g/L | Decrease, due to bleeding | Hematocrit | 0.42-0.50% | 0.24% | Decrease, due to bleeding | Ma. Melinda M. Olesco, MD, FPSP
Pathologist
BLOOD CHEMISTRY TYPES OF EXAMINATION | NORMAL VALUES | RESULT | SIGNIFICANCE | Blood Uric Acid | 0.142-0.336mmol/l | 0.336mmol/l | Normal | Creatinine | 53-115umol/l | 81.1umol/l | Normal | Blood Urea Nitrogen | 2.5-6.5mmol/l | 5.28mmol/l | Normal | SGOT/AST | 0-42u/L | 13.8u/L | Normal | SGPT/ALT | 0-41u/L | 13-9u/L | Normal |
Babelyn C. Alagen, RMT
Medtech
XI. DRUG STUDY
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Oxytocin(Fetusin)10 units in 1L D5LRInfused at 1 – 2 milliunits/ min. | * Oxytocic * Initiation or improvement of uterine contractions * To control postpartum bleeding | Acts directly on myofibrils, producing uterine contractions: stimulates milk ejection by the breast. | Hypotension | No manifestationPossible Adverse Reactions:Maternal:CV: hypertension GI: nausea, vomiting GU: abruption placentae, titanic uterine contractionHematologic: afibrinogenenemia possibly r/o post partum bleedingOther: hypersensitivity reactionFetalCNS: infant brain damageCV:bradycardiaEENT: retinal hemorrhageHepatic: jaundiceRespiratory: anoxia, asphyxiaOther: Low Apgar score | * Monitor Blood Pressure, fluid intake and output, and labor closely if using oxytocin for induction; fetal monitoring is strongly recommended. * Assess labor contractions: fetal heart tones,frequency, dyration, intensity of contractions. * Assess water intoxication. * Watch for fetal distress, acceleration, deceleration, fetal presentation, pelvic dimension. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Ferrous Sulfate250 mg 1 capOD PO | * Anti-anemic * pregnancy * Prevention and treatment of iron deficiency | Provides/replace elemental iron, an essential component in formation of hemoglobin in red blood cell development ferrous fumarate contains 33% elemental iron, ferrous gluconate – 12%, ferrous sulfate-20% ferrous sulfate desiccated – 30% | Peptic ulceration | No manifestationPossible Adverse Reactions:GI: irritation CNS: Nausea, Vomiting, Constipation, Dark stoolOTHERS: Teeth staining with liquid formation | * Assess diet and nutritional amount of iron in diet (meat, dark green leafy vegetables, dried beans, dried fruit and eggs * Monitor adverse reaction * Give between meals for best absorption; may give with juice but not with antacids like milk * Oral iron may turn stools black although this unabsorbed iron is harmless it could mask melena. * Advise patient to report constipation and changes in stool color or consistency. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Tramadol 50 mgVery slow IV push | * Antagonist * opiates * Moderate to moderately severe pain | Unknown. A centrally acting synthetic analgesic compound not chemically related no opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin. | Hypersensitivity, acute intoxication with alcohol | * edemaPossible Adverse Reactions:CNS: drowsiness, dizziness, confusion, sleep disorder, malaiseCV: vasodilationEENT: visual disturbancesGI: Nausea, vomiting, abdominal painGU: urine retention, urinary frequency, proteinuriaMUSCULOSKELETAL: hypertoniaRESPIRATORY: respiratory depressionSKIN: pruritus, diaphoresis, rash | * Assess patient’s pain (location, type, character) before therapy and regularly thereafter to monitor drug effectiveness (give before pain become extreme). * Monitor for possible drug induced adverse reaction. * Monitor input-output which may indicate retention. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Cefuroxime(Furoxy) 1.5 g IV as loading doseThen 750 mg IV q8ANST(-) | * Antibiotic * Postpartum prophylaxis * Prevent postpartum infection | Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. | Allergy of cephalosporin | No manifestationPossible Adverse ReactionsCV: phlebitis, thrombophlebitisGI: nausea, vomiting, anorexia, diarrheaHematologic: hemolytic anemia, transient neutropenia, eosinophilia.Skin: erythematous rashes, urticaria, sterile abscessesOther: anaphylaxis, hypersensitivity reactions, serum sickness | * Before giving drug, ask patient if she is allergic to penicillin or cephalosporin. * Monitor patient for signs and symptoms of super infection. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Mefenamic Acid500 mg 1 capQ6 PO | * analgesic, anti-inflammatory and anti-pyretic * relief of pain | Inhibits cyclooxygenase and also antagonize certain effects of prostaglandin | Pregnancy and lactation | No manifestationPossible Adverse Reaction:GI: diarrhea, constipation, gas pain, nausea, vomitingCNS: drowsiness, dizziness, nervousnessSKIN: rash, urticariaRESPIRATORY: bronchoconstriction, asthmaHEMATOLOGIC: autoimmune hemolytic anemia | * Monitor adverse reaction * Should not be more than 7 days * Assess patients and family’s knowledge on drug therapy |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Amoxicillin(Amoxil)500 mg i capQ8 for 7 daysPO | * Antibiotic * Treatment of infections | Prevents bacterial cell wall-synthesis during replication | Hypersensitivity to penicillins | No manifestationPossible Adverse Reaction:CNS: lethargy, hallucination, seizuresGI: glossitis, stomatitis, gastritisGU: nephritisHEMATOLOGIC: anemia, leucopenia, neutropeniaHYPERSENSITIVITY: rash, fever, wheezingOTHER: superinfection | * Monitor for bleeding, signs of nephrotoxicity, allergic reactions. * Give even doses around the clock for 10-14 days, may give with food to prevent GI upset. * Advice patient to take entire quantity of exactly prescribed even after feeling better and not to double dose. * Tell SO/’s to report immediately if there is adverse reaction seen on patient. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Methyldopa(Aldomet)250 mg q6PO | * Anti hypertensive * Hypertension | Alpha-methyl norepinephrine stimulates central alpha 2 adrenergic receptors in the CNS, resulting in decrease symphatetic outflow from the brain, heart and kidney. | Active hepatic disease | No manifestationPossible Adverse Reaction:CNS: sedation, headache, weakness, dizzinessCV: bradycardia, heart failure, orthostatic hypotensionEENT: nasal congestionGI: nausea, vomiting, diarrheaGU: impotenceHEMATOLOGIC: hemolytic anemiaHEPATIC: necrosisMETABOLIC: gain weightSKIN: rashOTHER:gynecomastia, drug induced fever | * Monitor BP and pulse regularly, allergic reaction, CNS symptoms * Give before meals * Assess patient’s family’s knowledge on drug therapy |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Hydralazine(Apresoline)5 mg TIDIV push | * Anti hypertensive * Hypertension | Unknown. Directly relaxes anterior smooth muscles to cause vasodilation and decreased Blood Pressure. | Severe tachycardia and heart failure with a high cardiac output. | No manifestationPossible Adverse Reaction:CNS: Headache, dizzinessCV: orthostatic hypotension, tachycardiaGI: nausea, vomiting, diarrhea | * Monitor BP before starting therapy and reassess regular after, Hydration status daily. * Administer in recumbent position keep position for 1 hour after administration. * Tell SO/’s to report immediately if there is adverse reaction seen on patient. * Assess patients and families knowledge about drug therapy. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Magnesium sulfate(Hizon Magnesium sulfate injection)5mg on each buttocks | * Electrolytes * Inhibits uterine contractions in preterm labor. Prevent seizure in eclampsia or pre eclampsia | May decreased acethylcoline released by nerve impulses, but anti convulsan mechanism is unknown. | Myocardia damage or heart block | No manifestationPossible Adverse Reaction:CNS:drowsiness, depressed reflexes, paralysis, hypothermiaCV: hypotension, flushing, depressed cardiac funcrionMETABOLIC:hypocalcemiaRESPIRATORY: Respiratory paralysisSKIN: diaphoresis | * Monitor respiratory rate, watch out for respiratory depression and signs of heart block, Renal status, Signs of magnesium toxicity (disappearance of knee-jerk patellar reflexes). * Administer slowly because circulatory collapse may occur. * Stress importance of immediate reporting of any adverse reaction. |
XII. NURSING CARE PLAN
Actual Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective: * “May manasakosapaa”, as verbalized by the client.Objectives: * Elevated blood pressure 150/110 * Prolonged CRT=4 seconds * Edema +1 | Nursing Diagnosis:Inffective tissue perfusion due to interruption of blood flow as manifested by: * Elevated blood pressure 150/110 * Prolonged CRT=4 seconds * Edema +1 | Within 8 hours of nursing intervention the client will be able to lower blood pressure within normal range and absence of edema | InterventionsINDEPENDENT: * Monitor vital signs * Elevate the head of bed (semi-fowlers) * Advise the client to elevate her legs. * Encourage the client to have an early ambulation.DEPENDENT: * Give medication as ordered:Methyldopa 250mg q6,PO | * for baseline data. * To promote circulation/venous drainage. * to enhances venous return. * to enhances venous return. * to lowers blood pressure | After 8 hours of nursing intervention the client blood pressure is within normal range and absence of edema as evidenced by: BP:130/100 |
Actual Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:” Masaki tang tahiko” as verbalized by the client.Objective: * Pain scale 4/10 * Facial grimace * Guarding behavior (protective gesture) | Pain due to post-op surgery as manifested by: * Pain scale 4/10 * Facial grimace * Guarding behavior (protective gesture) | Within 8 hours of nursing intervention the client will be able to verbalize pain to O | InterventionsINDEPENDENT: * Provide comfort measures (touch, repositioning) * Encourage use of relaxation techniques such as focused breathing. * Advise the client to have adequate rest. * Administer medication as ordered:DEPENDENT:Menamic Acid 500mg 1 cap, q6, PO | * To promote nonpharmacological pain management. * To distract attention and reduces tension. * To promote wellness. * to maintain acceptable level of pain. | After 8 hours of nursing intervention the client will be able to verbalize pain to O |
Actual Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:“Hirapakongtumayo, nanghihina pa din akoanobaangdapatkonggawin” as verbalized by the client.Objective: * presence of incision | Health Seeking Behaviors due to post-op surgery as manifested by: * presence of incision | Within30 minutes of nursing intervention the client will be able to know the importance of early prevention to avoid any complication. | * Advise the client the importance of early ambulation. * Advise the client to eat nutritious food. * Advise the client to continue taking medication as prescribed | * Increase the client knowledge about early ambulation. * Increase the client about eating nutritious food. * To promote wellness. | After 30 minutes of nursing intervention the client will be able to know the importance of early prevention to avoid any complication as evidenced by verbalization of understanding about early prevention and follow the instruction provided. |
Potential Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Objective: * presence of vertical incision * HCT-80g/l * HGT-0.24% | Risk for Infection due to post-op surgery as manifested by: * presence of vertical incision * HCT-80g/l * HGT-0.24% | Within 8 hours of nursing intervention the client will be able to identify interventions to prevent/reduce the risk of infection | InterventionsINDEPENDENT: * Advise the client to stress proper hand hygiene before and after touching the wound. * Advise the client to use personal protective equipment when touching the wounds * Advise the client that use aseptic technique before and after cleaning the surgical wounds and always keep it clean and dry. * Advise the client to take the medication as ordered:DEPENDENT:Cefuroxime 750mg TIV q8Amoxicillin 500mg 1 cap q8 x 7 days | * To prevent the spread of microorganism. * To reduce the risk of cross contamination. * To reduce the risk of cross contamination. | After 8 hours of nursing intervention the client identify interventions to prevent/reduce the risk of infection |
XIII. EVALUATION
GENERAL OBJECTIVE: After 48 hours of exposure at Unciano Medical Center , we, the 4th Year Nursing students of Unciano Colleges – Antipolo City, Section A-Group 2 is aim to enhance our knowledge, skills and attitude in rendering care to our client.
SPECIFIC OBJECTIVES: 1. We were able to establish rapport to the client and to his family. 2. We were able to assess our client’s condition and to identify the client’s health needs. 3. We were able to master the anatomy and physiology of the Reproductive System. 4. We were able to formulate a nursing diagnosis. 5. We were able to formulate a plan of care to our client with Post-op Cesarian Section (Abruption Placenta). 6. We were able to raise the level of awareness of patient on health problems that he may encounter. 7. We were able to facilitate patient in taking necessary actions to solve and prevent the identified problems on his own. 8. We were able to help patient in motivating him to continue the health care provided by the health workers. 9. We were able to render nursing care and information to patient through the application of the nursing skills. 10. We were able to give health teachings to the client and his family. 11. We were be able to evaluate the effectiveness of our nursing care plans and imparted health teachings to our client
XIV. BIBLIOGRAPHY
* http://www.google.com.ph/search?sourceid=navclient&ie=UTF_8&rlz=1T4GGLJ_enAE310AE311&q=female+internal+reproductive+system+anatomy * Biology by Carmelita Murphy Capco * Compton’s Encyclopedia * Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions 5th Edition
Elsevier, Singapore, PTE LTD 2002 * Lippincot Williams & Wilkins; Nursing 2007 Drug Handbook 27th Edition * Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales 11thEdition * Maternal and Child Health Nursing:Care of the Childbearing & Childrearing Family Fifth Editionby Adele Pillitteri * Mosby’s Pocket Dictionary of Medicine,Nursing and Health profession * Nurse’s Pocket Guide 11th Edition, Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr * PPD’s Nursing Drug Guide 2nd edition, Medicomm Pacific * Health Assessment in Nursing, Janet Weber, Jane Kelly * Compton’s Encyclopedia * Medical-Surgical Nursing, Lippincott Williams and Wilkins * Nursing Drug Guide, 2009 Edition, Amy M.Karch
XV. PROGNOSS AND DISCHARGE PLANNING
Prognosis
Mrs. N.C will need to undergo follow up check-ups and activities that can help for her speedy recovery. If she complies with the medication, follows the health teachings including right nutrition, she will be in right track and will be back to usual activities of daily living.
Discharge Planning
Medication
Eat your meal before take all the medicine.
Take your medicine on right drugs, time, dosage. 1. Mefenamic Acid 500mg 1 cap ,q6 (12am-6am-12pm-6pm) 2. Amoxicillin 500mg, 1cap,q8 ( 8am-4pm-12pm) 3. Ferrous sulfate 250mg, 1cap once a day. 4. Cefuroxime 500mg, 1cap TID (8am-1pm-6pm.
Exercise 1. Walking 2. Yoga/pilates 3. Kegels exercise
Treatment * Abruptioplacenta were treated with heparin, and coagulation was monitored by thromboelastography as well as the usual hematology tests.
Health teaching * Maintain bedrest * Daily wound care and use abdominal binder * Do not lift anything heavy * Avoid stress * Do not have sex until your doctor says it is OK.
Out patient
After 2 weeks patient must go to the hospital for follow up check-up.
Diet 1. Rich in iron 2. Vegetables 3. Maintain 8 glasses of water
Spiritual * Attend mass every Sunday
Give Praise and Thank to God
Bibliography: * Nursing Drug Guide, 2009 Edition, Amy M.Karch XV
We would like to thank our beloved family for their support and understanding when we are doing this case. To our group mates who shared their ideas and knowledge, for the patience, for the understanding, encouragement and hard work that they had given through the entire process and helped bring out the best in us during our hard time on the hospital duty.
We would like to express our gratitude on the management and staff ofUnciano Medical Center and to our Clinical Instructor Mrs. Ma. Luz Dieron and to our Head Nurse Ms. RoanneCeninfor their guidance and understanding.
We would also like to acknowledge Mrs. N.C and his relatives for being approachable and cooperative in sharing and giving us the information regarding his present condition.
And above all, we all like to give thanks to God our Lord that gives us the inspiration and positive throughout this case.
I. INTRODUCTION
In partial fulfillment of the NCM 107 requirements, we the group 2 of section A, were given the opportunity to study and assist in challenging cases in Unciano Medical Center. Our exposure to various cases gave us the chance to enhance the attitude, knowledge and skills that we have learned from Unciano Colleges Antipolo.
For our case study, our group decided to focus on the case of Mrs. N.C female, 21 years old who had been diagnosed with Abruptio Placenta and undergone Cesarian Section because of his cooperativeness, status of the recent condition, and patients will. This case will serve as an opportunity for the client to acquire knowledge regarding his condition.
We devoted ourselves to carrying out the nursing responsibilities assigned to us, both in assisting to restore Mrs. N.C ’s health, as well as in establishing nurse-patient interaction so that he will cooperate with us as we gather information to aid his in regaining health and attaining optimum level of functioning.
II. BACKGROUND OF STUDY
Abruptio Placenta * Painful bleeding * Placenta is implanted correctly but it begins to separate and bleeding result * Separation generally occurs late in pregnancy * It may occur as late as during 1st stage of or second stage of labor * Cause is unknown * Predisposing Factors * Highly parity * Advanced maternal age * Short umbilical cord * Chronic hypertensive disease * Pregnancy induced hypertension * Direct trauma (as form an automobile accident or intimate partner abuse) * Vasoconstriction from cocaine or cigarette use * Thrombophilitic conditions that lead to thrombosis such as auto immune antibodies, protein C, and factor V Leiden it may be caused by chorioamnionitis infection of the fetal membranes and fluid * Signs and Symptoms * Premature separation of placenta follow b y a rapid decrease in intrauterine volume, such as occurs within sudden release of amniotic fluid * Sharp, stabbing pain high in the uterine fundus as the initial separation occurs * If labor begins with separation, each contractions will be accompanied by pain over and above the pain of the contractions * Heavy bleeding * Extreme bleeding if placenta separate first * Uterus becomes tense and feels rigid to touch * Couvilaire uterus or utero-placental apoplexy forming a hard board like uterus * Complications * Disseminated intravascular Coagulation * Diagnostics * Bleeding Time * Hemoglobin level * Typing and cross matching * Fibrinogen level * Blood Clotting – draw 5 ml and place it in a clean, dry test tube, stand it aside uncovered for 5 minutes if the clot not formed suspect interference with blood coagulation * Therapeutic Management * Need Intravenous fluid for fluid replacement * Oxygen mask to limit fetal anoxia * Monitor fetal heart sounds externally to establish baselines and observe progress * Record maternal vital signs every 5 to 15 minutes to establish baselines and observe progress * Keep woman in lateral position not supine to prevent pressure on the vena cava and additional interference with fetal circulation * Do not perform any abdominal, vaginal, or pelvic examination even it is suspected placental separation so the placenta will not be disturbed * If vaginal birth does not seen imminent, caesarean birth is the birth method of choice * If DIC has developed, caesarean surgery may pose a grave risk because of possible haemorrhage. * Administration of fibrinogen or cryopreciptate to elevate woman’s fibrinogen levelprior and concurrently with surgery. * Hysterectomy might be necessary to prevent exsanguination. * Placenta: Degree of Separation * O – no symptoms of separation were apparent from maternal or fetal signs, placenta shows a recent adherent clot on the maternal surface. * 1 – minimal separation, but enough to cause vaginal bleeding and changes in maternal sides * 2 – moderate separation, evidence of fetal distress, uterus is tense and painful on palpation * 3 – extreme separation, without immediate interventions, maternal shock and fetal death will result. * Death can occur from massive haemorrhage leading to shock and circulatory collapse * Incidence * Abruptio placenta also occurs in abuot 1% of all pregnancies throughout the world. * A fetal mortality rate of 20–40% depending on the degree of separation. * Placental abruption is also a significant contributor to maternal mortality. * The risk of ocurrence of abruptio placenta is reported 4-12%,if the patient has abruptio placenta in 2 consecutive pregnancies, the risk of occurrence rises to 25%.
III. OBJECTIVES
GENERAL OBJECTIVE: Within 48 hours of exposure at Unciano Medical Center , we, the 4th Year Nursing students of Unciano Colleges – Antipolo City, Section A-Group 2 is aim to enhance our knowledge, skills and attitude in rendering care to our client.
SPECIFIC OBJECTIVES: 1. To be able to establish rapport to the client and to his family. 2. To be able to assess our client’s condition and to identify the client’s health needs. 3. To be able to master the anatomy and physiology of the Reproductive System. 4. To be able to formulate a nursing diagnosis. 5. To be able to formulate a plan of care to our client with Post-op Cesarian Section (Abruption Placenta). 6. To raise the level of awareness of patient on health problems that he may encounter. 7. To facilitate patient in taking necessary actions to solve and prevent the identified problems on his own. 8. To help patient in motivating him to continue the health care provided by the health workers. 9. To render nursing care and information to patient through the application of the nursing skills. 10. To be able to give health teachings to the client and his family. 11. To be able to evaluate the effectiveness of our nursing care plans and imparted health teachings to our client.
IV. PATIENT’S PROFILE
Case Number: 553394
Ward: OB Ward
Bed Number: 8
Name/ Initials: Mrs. N.C
Gender: Female
Civil Status: Single
Age: 21 years old Date of Birth: November 25, 1991 Place of Birth: Taytay Rizal Address: Taytay Rizal
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: Dec 11, 2012
Time of Admission: 11:00 p.m
Resident on Duty: Dr. Lat
Admitting Diagnosis: G2P2 (1001) LTCS I 36-37 AOG CIBL / Abruptio Placentae Final Diagnosis: G2P2 (2002) PUFT Cephalic live baby boy via CS
Date of Assessment: December 12, 2011
Time of Assessment: 10:00 a.m LMP: March 11, 2012 EDC: December 18, 2012 Date and Time of Delivery: Decembery12, 2012; 11:30 pm
V. NURSING HISTORY
CHIEF COMPLAINT:
“Masakitangtahiko…” as verbalized by the client.
HISTORY OF PRESENT ILLNESS: At around 10:30 in the evening,December 11, 2012 when Mrs. N.C is walking inside their house when suddenly she felt labor pains that radiates from her left epigastric and umbilicus area. Her mother immediately called an ambulance in their barangay health center. At around 11:00 p.m Mrs. N.C immediately brought to the Emergency Room of Rizal Provincial Hospital in Morong. Vital signs takentemperature 37 °C, pulse rate 78 bpm, respiratory rate 24 cpm and blood pressure 160/90 mmHg, She was seen and examined by Dr. Lat find out that there is heavy bleeding and separation of placenta. An IVF of D5LR1L X 12 gtts/mins.Inserted on her left metacarpal vein gauge 20 and medication Hydralazine 5mg TIV for hypertension, and Oxytocin 10 units in IL D5LR and laboratory examination Hematology and Blood Chemistry was ordered. At around 11:30pm, Mrs. N.C was transferred to the Operating Room and undergoneCesarean Operation then she was transferred to O.B Ward at around 12:30am.
HISTORY OF PAST ILLNESS: According to Mrs. N.C she had no history of any illness for the last five years.
HEREDO-FAMILIAL HISTORY: According to Mrs. N.C her both mother and father hadno history of any illness.
SOCIO- ECONOMIC HISTORY: Mrs. N.C is a plain housewife. In the house her daily routine is only listening music and watching tv. Her husband works at SM Taytay as a salesman. Her Husband will shoulder the payments for the hospital bills and medications.
OBSTETRICAL HISTORY: Mrs. N.C was diagnosed with G2P2 (1001) Abruptio Placentae 36-37 weeks. Her LMP was March 11, 2012; her Estimated Date of Confinement was December 18 , 2012. Mrs. N.C gave Decembery 12, 2012 at11:30 to a PUFT Cephalic live baby boy via CS. She had her prenatal check - ups 5 times in their local health center and she received Tetanous Toxoid Immunizations 2 times. GYNECOLOGIC HISTORY:
Mrs. N.C’s has 2 child right now. She had her menarche when she was 13 years old. According to Mrs. N.C, her menstruation lasts for 3-5 days. Heavy flow of blood was experienced during first and second day of her first menstruation and she used 2-3 napkins a day. She doesn’t even experience dysmenorrheal during her period days.
VI. REVIEW OF BODY SYSTEM
1. SENSORY-PERCEPTUAL
a. Mental Status
Upon assessment Mrs. N.C was conscious and coherent. She was able to answer our questions clearly. She speaks in Tagalog dialect. As we began our interview, we test her orientation to time, place and person. We ask her what year is it, where she was and whose with her. She answered that it was year 2012; she’s on the hospital with her mother and her husband. For her short term memory, we asked her what time it is, she was able to tell us what time is it. For her long-term memory we asked her if she could remember the president last 2009 she was able to tell us that it was President Gloria Macapagal – Arroyo. For the assessment of the memory we test first her immediate recall by asking the client to recite the numbers up to 9 (1, 3, 5, 7, 9) the client was able to utter the said digits. Then afterwards we asked her to repeat it backward and the client was able to repeat the digits in reverse order.
She is a high school graduate. She used non-technical words during the assessment and communicates well in Tagalog.
b. Vision
Mrs. N.C’s eyebrows were symmetrical aligned and evenly distributed. We observed a thin and smooth skin on her eyelid. The eyelids close easily and eyelashes turn outward. The eyelashes were equally distributed, and slightly curled outward. We ask the client to rise and lower her eye brows and unequal movement was observed. Her sclera was white in color. There were no lesions, discharges, swelling & redness on her both eyes. The eyeballs are symmetrically aligned. Mrs. N.C responds to PERRLA (pupils equal, round, reactive to light, and accommodation) her pupils constricted for approximately 3mm which was normal to an adult client when the light was illuminated on them from outer to inner canthus. We tested accommodation of her pupils by holding the penlight about 12-15 inches from the client. She focused on the penlight and remains focused in as we moved it closer in toward her eyes. This was done on both eyes. In assessing the six ocular movements, we asked Mrs. N.C to look straight and follow the movement of the pen with her eye. Moving the pen in a slow orderly manner bilaterally, the client’s eyes were able to move through the following direction moderately. We also asked Mrs. N.C to read from a book with room lighting for reading. She was able to read the different sentences correctly. As we moved the book nearer she was able to read it correctly.
c. Auditory
Mrs. N.C’s ears were aligned and symmetrical with the outer canthus of the eye. The skin is smooth with no lesions, lumps, or nodules. Color is consistent with facial color. In assessing the elasticity of the ears, we gently pulled each pinna upward and downward. Each was firm and recoiled after it was folded. Earlobes were pendulous. We have palpated the auricle and mastoid process. No discharges, lesions, redness or inflammation was observed.
In assessing the hearing ability of the client, we performed watch tic test bilaterally on both ear. We placed a wrist watch 2cm from her left ear & covered her right ear. We did the same procedure on her right ear & she was able to hear the tic-tac sound of the wrist watch. We also performed voice-whisper test to examine or to detect obvious hearing loss. We instruct the client to put a hand over one ear and to repeat the sentence we whisper by standing approximately 1 foot away from the client. She said that she was able to hear the whispered sentence. d. Olfactory
Mrs. N.C’s nose is located at the midline of her face. The color is the same as the rest of the facial skin; nose and nasal passages are not inflamed, and skin and mucous membrane are intact. The nasal structure is smooth and symmetric. Smelling test was performed to determine her ability to identify the different kinds of odors by closing her eyes. We let her smell different scents like white flower, cologne that we applied on cotton balls. We let her smell it one at a time. First we asked her to smell the white flower and she said that it smells like mint. Secondly, we asked her to smell the cologne and she verbalize it as fragrant. The smell tests were done to her right and left nares.
e. Gustatory
Mrs. N.C’s outer lips were symmetrical, smooth and moist without lesions or swelling. Her buccal mucosa is pink in color and moist. We observed the tongue it is the central position. The tongue is pink, moist a moderate size with papillae present. No lesions are present. The client refused because she is still in a clear liquid diet. f. Tactile
We checked Mrs. N.C’s sense of touch by letting her identify the different textures with her eyes. First we let her touch the cotton balls and she described it as soft. Secondly, we let her touch the tip of the percussion hammer and she described it as pointed.
Thirdly, we let her touched the handle of the percussion hammer and she described it as rough. Lastly, we let her touch the rubber head of the percussion hammer and she described it as hard. The touch tests were done bilaterally on both hands and on lower extremities also. She identified all the sensation correctly.
2. SKIN
Mrs. N.C was afebrile during our assessment. Her body temperature was 36.3 °C taken via her left axilla using a digital thermometer and warm to touch. Edema was present in her right and left lower extremities. Scale for pitting edema was 1+, somewhat deeper pit and no readily detectable distortion, disappears in 10-15 seconds.She has a vertical surgical incision on her lower abdomen about 3 inches long.
3. RESPIRATORY
Mrs. N.C’s respiratory rate at the time of our assessment was 17 cycles per minute, which is normal according to the normal range of 16-20 cycles per minute. There were no adventitious sounds heard.
4. CARDIOVASCULAR
Mrs. N.C’s pulse rate was 94 beats per minute taken via right radial artery. Her blood pressure was 150/110 mm Hg taken on her left brachial artery while lying on bed. The pulse pressure is 40 mm Hg. We also performed Capillary Refill Time (CRT) by pressing on the nail beds for 3 seconds. Nail beds return to normal pinkish color within 4 seconds. A normal CRT values is 1-3 seconds.
5. GASTROINTESTINAL
Mrs. N.C’s gums and tongue were pinkish in color, her teeth was slightly yellowish in color. There were no observable lesions. Our client also told us that she has 4 dentures. During our assessment she was infused with D5LR 1L with 10 units of oxytocin regulated at 10-15 gtts/min located at her left metacarpal vein. It was at 900 cc level and infusing well during our assessment. According to Mrs. N.C, she wasn’t defecated during our assessment. We assessed her bowels sounds for each quadrant then we get 16 bowels sounds. 4 sound each quadrant in 5 minutes. No distension noted
6. GENITOURINARY
According to Mrs. N.C, She doesn’t experience difficulty in urinating and according to her, the color of her urine is light yellow in color and the color of her discharge is dark red.
7. MUSCULOSKELETAL
Mrs. N.C was able to ambulate she can do active and passive range of movements was tested by flexion, extension, abduction, adduction and rotation on client’s upper and lower extremities. All of these movements were slow in motion. Muscle grading was Grade 4-Active (movement against gravity and some resistance) described as fair strength.
VII. ANATOMY AND PHYSIOLOGY
INTERNAL FEMALE ORGANS
The internal organs of the female consist of the uterus, vagina, fallopian tubes, and the ovaries.
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.
Location: The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments.
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.
Walls of the uterus:The walls are thick and are composed of three layers: the endometrium, the myometrium, and the perimetrium. The endometrium is the inner layer or mucosa. A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial lining sloughs off about every 28 days in response to changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle component of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues.
During the monthly female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. * Vagina.
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.
Function: The vagina provides the passageway for childbirth and menstrual flow; it receives the penis and semen during sexual intercourse. * Fallopian Tubes
Location: Each tube is about 4 inches long and extends medially from each ovary to empty into the superior region of the uterus.
Function:The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries.
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. * Ovaries
Functions: The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone).
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.
Process of egg production--oogenesis : The total supply of eggs that a female can release has been determined by the time she is born. The eggs are referred to as "oogonia" in the developing fetus. At the time the female is born, oogonia have divided into primary oocytes, which contain 46 chromosomes and are surrounded by a layer of follicle cells. Primary oocytes remain in the state of suspended animation through childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the anterior pituitary gland secretes follicle-stimulating hormone (FSH), which stimulates a small number of primary follicles to mature each month. As a primary oocyte begins dividing, two different cells are produced, each containing 23 unpaired chromosomes. One of the cells is called a secondary oocyte and the other is called the first polar body. The secondary oocyte is the larger cell and is capable of being fertilized. The first polar body is very small, is nonfunctional, and incapable of being fertilized. By the time follicles have matured to the graafian follicle stage, they contain secondary oocytes and can be seen bulging from the surface of the ovary. Follicle development to this stage takes about 14 days. Ovulation (ejection of the mature egg from the ovary) occurs at this 14-day point in response to the luteinizing hormone (LH), which is released by the anterior pituitary gland.
The follicle at the proper stage of maturity when the LH is secreted will rupture and release its oocyte into the peritoneal cavity. The motion of the fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also causes the ruptured follicle to change into a granular structure called corpus luteum, which secretes estrogen and progesterone.
If the secondary oocyte is penetrated by a sperm, a secondary division occurs that produces another polar body and an ovum, which combines its 23 chromosomes with those of the sperm to form the fertilized egg, which contains 46 chromosomes.
Process of hormone production by the ovaries.
Estrogen is produced by the follicle cells, which are responsible secondary sex characteristics and for the maintenance of these traits. These secondary sex characteristics include the enlargement of fallopian tubes, uterus, vagina, and external genitals; breast development; increased deposits of fat in hips and breasts; widening of the pelvis; and onset of menses or menstrual cycle. Progesterone is produced by the corpus luteum in presence of in the blood. It works with estrogen to produce a normal menstrual cycle. Progesterone is important during pregnancy and in preparing the breasts for milk production
EXTERNAL FEMALE GENITALIA
* Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with thick coarse hair. * 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. * Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They protect the opening of the vagina and urethra. * 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. * 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. * 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.
VIII. PATHOPYSIOLOGY
X. LABORATORIES AND DIAGNOSTIC STUDIES Date: December 11, 2012
HEMATOLOGY TYPES OF EXAMINATION | NORMAL VALUES | RESULT | SIGNIFICANCE | Hemoglobin | 140-160g/L | 80g/L | Decrease, due to bleeding | Hematocrit | 0.42-0.50% | 0.24% | Decrease, due to bleeding | Ma. Melinda M. Olesco, MD, FPSP
Pathologist
BLOOD CHEMISTRY TYPES OF EXAMINATION | NORMAL VALUES | RESULT | SIGNIFICANCE | Blood Uric Acid | 0.142-0.336mmol/l | 0.336mmol/l | Normal | Creatinine | 53-115umol/l | 81.1umol/l | Normal | Blood Urea Nitrogen | 2.5-6.5mmol/l | 5.28mmol/l | Normal | SGOT/AST | 0-42u/L | 13.8u/L | Normal | SGPT/ALT | 0-41u/L | 13-9u/L | Normal |
Babelyn C. Alagen, RMT
Medtech
XI. DRUG STUDY
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Oxytocin(Fetusin)10 units in 1L D5LRInfused at 1 – 2 milliunits/ min. | * Oxytocic * Initiation or improvement of uterine contractions * To control postpartum bleeding | Acts directly on myofibrils, producing uterine contractions: stimulates milk ejection by the breast. | Hypotension | No manifestationPossible Adverse Reactions:Maternal:CV: hypertension GI: nausea, vomiting GU: abruption placentae, titanic uterine contractionHematologic: afibrinogenenemia possibly r/o post partum bleedingOther: hypersensitivity reactionFetalCNS: infant brain damageCV:bradycardiaEENT: retinal hemorrhageHepatic: jaundiceRespiratory: anoxia, asphyxiaOther: Low Apgar score | * Monitor Blood Pressure, fluid intake and output, and labor closely if using oxytocin for induction; fetal monitoring is strongly recommended. * Assess labor contractions: fetal heart tones,frequency, dyration, intensity of contractions. * Assess water intoxication. * Watch for fetal distress, acceleration, deceleration, fetal presentation, pelvic dimension. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Ferrous Sulfate250 mg 1 capOD PO | * Anti-anemic * pregnancy * Prevention and treatment of iron deficiency | Provides/replace elemental iron, an essential component in formation of hemoglobin in red blood cell development ferrous fumarate contains 33% elemental iron, ferrous gluconate – 12%, ferrous sulfate-20% ferrous sulfate desiccated – 30% | Peptic ulceration | No manifestationPossible Adverse Reactions:GI: irritation CNS: Nausea, Vomiting, Constipation, Dark stoolOTHERS: Teeth staining with liquid formation | * Assess diet and nutritional amount of iron in diet (meat, dark green leafy vegetables, dried beans, dried fruit and eggs * Monitor adverse reaction * Give between meals for best absorption; may give with juice but not with antacids like milk * Oral iron may turn stools black although this unabsorbed iron is harmless it could mask melena. * Advise patient to report constipation and changes in stool color or consistency. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Tramadol 50 mgVery slow IV push | * Antagonist * opiates * Moderate to moderately severe pain | Unknown. A centrally acting synthetic analgesic compound not chemically related no opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin. | Hypersensitivity, acute intoxication with alcohol | * edemaPossible Adverse Reactions:CNS: drowsiness, dizziness, confusion, sleep disorder, malaiseCV: vasodilationEENT: visual disturbancesGI: Nausea, vomiting, abdominal painGU: urine retention, urinary frequency, proteinuriaMUSCULOSKELETAL: hypertoniaRESPIRATORY: respiratory depressionSKIN: pruritus, diaphoresis, rash | * Assess patient’s pain (location, type, character) before therapy and regularly thereafter to monitor drug effectiveness (give before pain become extreme). * Monitor for possible drug induced adverse reaction. * Monitor input-output which may indicate retention. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Cefuroxime(Furoxy) 1.5 g IV as loading doseThen 750 mg IV q8ANST(-) | * Antibiotic * Postpartum prophylaxis * Prevent postpartum infection | Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. | Allergy of cephalosporin | No manifestationPossible Adverse ReactionsCV: phlebitis, thrombophlebitisGI: nausea, vomiting, anorexia, diarrheaHematologic: hemolytic anemia, transient neutropenia, eosinophilia.Skin: erythematous rashes, urticaria, sterile abscessesOther: anaphylaxis, hypersensitivity reactions, serum sickness | * Before giving drug, ask patient if she is allergic to penicillin or cephalosporin. * Monitor patient for signs and symptoms of super infection. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Mefenamic Acid500 mg 1 capQ6 PO | * analgesic, anti-inflammatory and anti-pyretic * relief of pain | Inhibits cyclooxygenase and also antagonize certain effects of prostaglandin | Pregnancy and lactation | No manifestationPossible Adverse Reaction:GI: diarrhea, constipation, gas pain, nausea, vomitingCNS: drowsiness, dizziness, nervousnessSKIN: rash, urticariaRESPIRATORY: bronchoconstriction, asthmaHEMATOLOGIC: autoimmune hemolytic anemia | * Monitor adverse reaction * Should not be more than 7 days * Assess patients and family’s knowledge on drug therapy |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Amoxicillin(Amoxil)500 mg i capQ8 for 7 daysPO | * Antibiotic * Treatment of infections | Prevents bacterial cell wall-synthesis during replication | Hypersensitivity to penicillins | No manifestationPossible Adverse Reaction:CNS: lethargy, hallucination, seizuresGI: glossitis, stomatitis, gastritisGU: nephritisHEMATOLOGIC: anemia, leucopenia, neutropeniaHYPERSENSITIVITY: rash, fever, wheezingOTHER: superinfection | * Monitor for bleeding, signs of nephrotoxicity, allergic reactions. * Give even doses around the clock for 10-14 days, may give with food to prevent GI upset. * Advice patient to take entire quantity of exactly prescribed even after feeling better and not to double dose. * Tell SO/’s to report immediately if there is adverse reaction seen on patient. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Methyldopa(Aldomet)250 mg q6PO | * Anti hypertensive * Hypertension | Alpha-methyl norepinephrine stimulates central alpha 2 adrenergic receptors in the CNS, resulting in decrease symphatetic outflow from the brain, heart and kidney. | Active hepatic disease | No manifestationPossible Adverse Reaction:CNS: sedation, headache, weakness, dizzinessCV: bradycardia, heart failure, orthostatic hypotensionEENT: nasal congestionGI: nausea, vomiting, diarrheaGU: impotenceHEMATOLOGIC: hemolytic anemiaHEPATIC: necrosisMETABOLIC: gain weightSKIN: rashOTHER:gynecomastia, drug induced fever | * Monitor BP and pulse regularly, allergic reaction, CNS symptoms * Give before meals * Assess patient’s family’s knowledge on drug therapy |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Hydralazine(Apresoline)5 mg TIDIV push | * Anti hypertensive * Hypertension | Unknown. Directly relaxes anterior smooth muscles to cause vasodilation and decreased Blood Pressure. | Severe tachycardia and heart failure with a high cardiac output. | No manifestationPossible Adverse Reaction:CNS: Headache, dizzinessCV: orthostatic hypotension, tachycardiaGI: nausea, vomiting, diarrhea | * Monitor BP before starting therapy and reassess regular after, Hydration status daily. * Administer in recumbent position keep position for 1 hour after administration. * Tell SO/’s to report immediately if there is adverse reaction seen on patient. * Assess patients and families knowledge about drug therapy. |
DRUG NAME | CLASSIFICATION/ INDICATIONS | ACTION | CONTRAINDICATIONS | ADVERSE REACTIONS | NURSING CONSIDERATIONS | Magnesium sulfate(Hizon Magnesium sulfate injection)5mg on each buttocks | * Electrolytes * Inhibits uterine contractions in preterm labor. Prevent seizure in eclampsia or pre eclampsia | May decreased acethylcoline released by nerve impulses, but anti convulsan mechanism is unknown. | Myocardia damage or heart block | No manifestationPossible Adverse Reaction:CNS:drowsiness, depressed reflexes, paralysis, hypothermiaCV: hypotension, flushing, depressed cardiac funcrionMETABOLIC:hypocalcemiaRESPIRATORY: Respiratory paralysisSKIN: diaphoresis | * Monitor respiratory rate, watch out for respiratory depression and signs of heart block, Renal status, Signs of magnesium toxicity (disappearance of knee-jerk patellar reflexes). * Administer slowly because circulatory collapse may occur. * Stress importance of immediate reporting of any adverse reaction. |
XII. NURSING CARE PLAN
Actual Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective: * “May manasakosapaa”, as verbalized by the client.Objectives: * Elevated blood pressure 150/110 * Prolonged CRT=4 seconds * Edema +1 | Nursing Diagnosis:Inffective tissue perfusion due to interruption of blood flow as manifested by: * Elevated blood pressure 150/110 * Prolonged CRT=4 seconds * Edema +1 | Within 8 hours of nursing intervention the client will be able to lower blood pressure within normal range and absence of edema | InterventionsINDEPENDENT: * Monitor vital signs * Elevate the head of bed (semi-fowlers) * Advise the client to elevate her legs. * Encourage the client to have an early ambulation.DEPENDENT: * Give medication as ordered:Methyldopa 250mg q6,PO | * for baseline data. * To promote circulation/venous drainage. * to enhances venous return. * to enhances venous return. * to lowers blood pressure | After 8 hours of nursing intervention the client blood pressure is within normal range and absence of edema as evidenced by: BP:130/100 |
Actual Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:” Masaki tang tahiko” as verbalized by the client.Objective: * Pain scale 4/10 * Facial grimace * Guarding behavior (protective gesture) | Pain due to post-op surgery as manifested by: * Pain scale 4/10 * Facial grimace * Guarding behavior (protective gesture) | Within 8 hours of nursing intervention the client will be able to verbalize pain to O | InterventionsINDEPENDENT: * Provide comfort measures (touch, repositioning) * Encourage use of relaxation techniques such as focused breathing. * Advise the client to have adequate rest. * Administer medication as ordered:DEPENDENT:Menamic Acid 500mg 1 cap, q6, PO | * To promote nonpharmacological pain management. * To distract attention and reduces tension. * To promote wellness. * to maintain acceptable level of pain. | After 8 hours of nursing intervention the client will be able to verbalize pain to O |
Actual Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:“Hirapakongtumayo, nanghihina pa din akoanobaangdapatkonggawin” as verbalized by the client.Objective: * presence of incision | Health Seeking Behaviors due to post-op surgery as manifested by: * presence of incision | Within30 minutes of nursing intervention the client will be able to know the importance of early prevention to avoid any complication. | * Advise the client the importance of early ambulation. * Advise the client to eat nutritious food. * Advise the client to continue taking medication as prescribed | * Increase the client knowledge about early ambulation. * Increase the client about eating nutritious food. * To promote wellness. | After 30 minutes of nursing intervention the client will be able to know the importance of early prevention to avoid any complication as evidenced by verbalization of understanding about early prevention and follow the instruction provided. |
Potential Problem
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Objective: * presence of vertical incision * HCT-80g/l * HGT-0.24% | Risk for Infection due to post-op surgery as manifested by: * presence of vertical incision * HCT-80g/l * HGT-0.24% | Within 8 hours of nursing intervention the client will be able to identify interventions to prevent/reduce the risk of infection | InterventionsINDEPENDENT: * Advise the client to stress proper hand hygiene before and after touching the wound. * Advise the client to use personal protective equipment when touching the wounds * Advise the client that use aseptic technique before and after cleaning the surgical wounds and always keep it clean and dry. * Advise the client to take the medication as ordered:DEPENDENT:Cefuroxime 750mg TIV q8Amoxicillin 500mg 1 cap q8 x 7 days | * To prevent the spread of microorganism. * To reduce the risk of cross contamination. * To reduce the risk of cross contamination. | After 8 hours of nursing intervention the client identify interventions to prevent/reduce the risk of infection |
XIII. EVALUATION
GENERAL OBJECTIVE: After 48 hours of exposure at Unciano Medical Center , we, the 4th Year Nursing students of Unciano Colleges – Antipolo City, Section A-Group 2 is aim to enhance our knowledge, skills and attitude in rendering care to our client.
SPECIFIC OBJECTIVES: 1. We were able to establish rapport to the client and to his family. 2. We were able to assess our client’s condition and to identify the client’s health needs. 3. We were able to master the anatomy and physiology of the Reproductive System. 4. We were able to formulate a nursing diagnosis. 5. We were able to formulate a plan of care to our client with Post-op Cesarian Section (Abruption Placenta). 6. We were able to raise the level of awareness of patient on health problems that he may encounter. 7. We were able to facilitate patient in taking necessary actions to solve and prevent the identified problems on his own. 8. We were able to help patient in motivating him to continue the health care provided by the health workers. 9. We were able to render nursing care and information to patient through the application of the nursing skills. 10. We were able to give health teachings to the client and his family. 11. We were be able to evaluate the effectiveness of our nursing care plans and imparted health teachings to our client
XIV. BIBLIOGRAPHY
* http://www.google.com.ph/search?sourceid=navclient&ie=UTF_8&rlz=1T4GGLJ_enAE310AE311&q=female+internal+reproductive+system+anatomy * Biology by Carmelita Murphy Capco * Compton’s Encyclopedia * Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions 5th Edition
Elsevier, Singapore, PTE LTD 2002 * Lippincot Williams & Wilkins; Nursing 2007 Drug Handbook 27th Edition * Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales 11thEdition * Maternal and Child Health Nursing:Care of the Childbearing & Childrearing Family Fifth Editionby Adele Pillitteri * Mosby’s Pocket Dictionary of Medicine,Nursing and Health profession * Nurse’s Pocket Guide 11th Edition, Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr * PPD’s Nursing Drug Guide 2nd edition, Medicomm Pacific * Health Assessment in Nursing, Janet Weber, Jane Kelly * Compton’s Encyclopedia * Medical-Surgical Nursing, Lippincott Williams and Wilkins * Nursing Drug Guide, 2009 Edition, Amy M.Karch
XV. PROGNOSS AND DISCHARGE PLANNING
Prognosis
Mrs. N.C will need to undergo follow up check-ups and activities that can help for her speedy recovery. If she complies with the medication, follows the health teachings including right nutrition, she will be in right track and will be back to usual activities of daily living.
Discharge Planning
Medication
Eat your meal before take all the medicine.
Take your medicine on right drugs, time, dosage. 1. Mefenamic Acid 500mg 1 cap ,q6 (12am-6am-12pm-6pm) 2. Amoxicillin 500mg, 1cap,q8 ( 8am-4pm-12pm) 3. Ferrous sulfate 250mg, 1cap once a day. 4. Cefuroxime 500mg, 1cap TID (8am-1pm-6pm.
Exercise 1. Walking 2. Yoga/pilates 3. Kegels exercise
Treatment * Abruptioplacenta were treated with heparin, and coagulation was monitored by thromboelastography as well as the usual hematology tests.
Health teaching * Maintain bedrest * Daily wound care and use abdominal binder * Do not lift anything heavy * Avoid stress * Do not have sex until your doctor says it is OK.
Out patient
After 2 weeks patient must go to the hospital for follow up check-up.
Diet 1. Rich in iron 2. Vegetables 3. Maintain 8 glasses of water
Spiritual * Attend mass every Sunday
Give Praise and Thank to God
Bibliography: * Nursing Drug Guide, 2009 Edition, Amy M.Karch XV
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