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 neverending thanks to Almighty Father the most High for the love and care he showered upon us. Our genuine gratitude to our beloved parents for always supporting us physically, mentally, emotionally and financially in regards to this venture. Warmth thanks for entrusting to us their confidence and understanding not only in times of need but in everyday of our lives. They used to complain that we are getting too sovereign and matured; however we live in the ideology that letting go of their children is the hardest part of being a parent. Though it is not easy for us to acknowledge the fact that we are getting old bit by bit, we have to separate from them in order to understand the true essence of being a human, and still our love for them remains the same. To our dear parents, rest guaranteed that what we are doing right now will serve as a stepping stone towards a philosophical future and sagacious life, and that is being a nurse.
INTRODUCTION Pregnancy is an exciting time in any parent's life. It's a time of change, growth, discovery and a lot of questions. One of the most important factors of having a healthy baby is the mother’s health especially during the 9 months where the child’s development has already started. The mother’s nutrition, activity etc. greatly affect the developing fetus inside her womb such that any move could put the child at risk resulting to abnormalities, poor health or even death to the precious being anytime or even during 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 1
placenta is implanted close to or covers the cervical os. Normally, the placenta implants in the upper uterine segment, but in the case of placenta previa, the placenta implants in the lower part of the uterus. Placenta previa is experienced in 1 out of 200 pregnancies around the world. Maternal morbidity rate is approximately 5% and mortality rate is less than 1%. In the Philippines , it reached to 6,341 out of the 86,241,697 population estimate used in the year 2004. The mortality rate of placenta previa in the country is 0.17% according to DOH. During our duty in the Ob ward at Ospital Ning Angeles (ONA) , we decided to take the case of Mrs. Nicole Kidman in which she was diagnosed with placenta previa totalis because we would like to have a deeper understanding about this condition so that we could render the care the patient needed to arrive with a good prognosis. Management should therefore always be based on appropriate clinical judgment. We would like to apply all the things that we’ve learned through our lectures for the benefit of our patient and to enhance our skills as well. We hope that this case study will enable us, student nurses to better understanding about the disease process and that we will be more sensitive in attending to our patient’s need. For the community, we hope that this will increase the level of awareness among the members of the community so that it could help in the prevention of further pregnancy complications. 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
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2. Gather all necessary information regarding her and her family members as may be related to our case study 3. Ascertain client’s past and present health history 4. Trace her genogram or family tree 5. Trace the development data of the client 6. perform physical assessment on client’s condition so as to attain baseline data 7. Present the definitions of the complete diagnosis that would explain the illness of our client 8. Study the anatomy and physiology of female reproductive system 9. Trace the pathophysiology of placenta previa 10.Determine the diagnostic tests our client has undergone including their implications and nursing responsibilities 11.identify the drugs prescribed to our client, their action, side effects, indications, contraindications and nursing responsibilities 12.Identify and prioritize the need of our patient 13.Formulate an appropriate nursing care plan based on the assessment identified needs and problems of the patient 14.Render health teachings as part of our holistic care to alleviate problems identified 15.Evaluate complications to nursing practice, education and research PATIENT’S DATA Name: Mrs. Nicole Kidman Address: 160 Abacan, Malabanias Angeles City Age: 38 y/o. Birthday: 7-12-1971 Birthplace: Angeles City Civil Status: Married Religion: Roman Catholic Nationality: Filipino Educational Attainment: High School Graduate Occupation: Housewife Date Admitted: October 17, 2009 Time Admitted: 1:55pm 3
Ward: OB Bed no.: 22 Admitting Diagnosis: Pregnancy uterine 6 – 7 weeks AOG G5P4 UTI, Placenta Previa
Student Nurse Centered:
After the completion of the case study, the student nurse shall be able to: • Present a comprehensive and detailed report regarding the patient’s illness • Have a complete picture of the patient’s physical, psychosocial and mental status through daily assessment • Have a well-structured nursing diagnosis of the client’s status based from an integration of data gathered • Understand the factors that might have contributed to the development of the disease • Provide organized and structured nursing interventions as a response to the patient’s anticipated needs • Provide relevant information on available alternative therapies and management
III. Nursing Process 4
A. Assessment
1. Personal History
a. Demographic Data
Mrs. Nicole Kidman is a 38 years old Mother. She was born on July 12, 1971 in 160 Abacan St, Malabanias Angeles City, she is a Filipino Citizen and a Roman Catholic. She is the youngest child among the three children. This is her 5th pregnancy on her G5P4 6-7 weeks Age of Gestation. She has a Four Children the 3 boys aged 11, 7, and 4 years old and girl is 9 years old. They live in a compound together with their relatives according to the husband of Mrs. Nicole Kidman they are very crowded in their compound because there are 8 families in their compound and each family they have a range of 3-4 children in each families.
b. Socio Economic and Cultural Factors
As a Roman Catholic Mrs. Nicole Kidman also going to church every Sunday and she also pray before she going to sleep. Although they are Roman Catholic they believe in Herbularyos and Hilots, according to them that one time in her pregnancy she consulted a Hilot in Mabalacat. She never consulted for a prenatal check up in any medical institution or health center in there barangay during her past pregnancy. She is giving birth only in there home and was delivered by a midwife. But all her previous pregnancy she never had a problem like vaginal bleeding but she have a previous problem with serious of Urinary Tract Infection
5
which she only treated by a antibiotic and was only OTC medicine which she never consulted a physician.
The couples are practicing family planning method Mrs. Nicole Kidman used to drink a type of Pills before she got pregnant on her 5th child. She told us that she suddenly stop drinking pills because she just forgot to buy the next set of tablets. Then she told us that the couple just plan to have an another child so she got pregnant.
Mrs. Nicole Kidman is a plain housewife and her husband is working as a permanent welder in a Construction Company here in Angeles City he earn P 400 a day. Both of them finish High School and there 3 children are studying in a public school at Don Teodoro Elementary School in Abacan, Angeles City.
2. Family Health – Illness History
Mrs. Nicole Kidman diseases has no direct connection with the past illnesses. Her Placenta Previa meaning is a complication of pregnancy in which the
placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix. Mrs. Nicole Kidman mother died in a Cancer at 56 years old. Her father has arthritis. Aside from these illnesses no significant disease was mentioned by the client.
6
Father
Mother
(Arthritis)
Died (Cancer)
Older Brother
2nd Brother
Mrs. Nicole Kidman
3. History of Past Illness
Mrs. Nicole Kidman have no medical record of any hospitalization in her life. She told us that her common illness is Fever and colds only. She told us that this is the first time she will be hospitalize that why she feel anxious about the situation.
4. History of Present Illness
According to the Client in the morning of October 17, 2009 she is complaining of back pain to her husband who is about to going to work. But her husband think it’s only normal in her 5th pregnancy so he neglect it and tell her to just take a rest. She just take a rest in that morning but in the afternoon she experienced vaginal bleeding and dizziness. Then she was later admitted in Ospital Ning Angeles (ONA) on October 17, 2009 at 1:55pm with Chief Complain of Vaginal Bleeding / Dizziness and was Medically diagnosed UTI and T/C Threatened Abortion. Upon 7
her admission she experienced heavy vaginal bleeding and later that day she has fever of 39 OC and she has difficulty of breathing that why they hooked an O2 Nasal Canulla and IVF D5LRS FD 200CC.
5. Physical Examination
PHYSICAL EXAMINATION
October 17, 2009 (Saturday) Upon Admission Appearance and Behavior: Appears well when not moving but shows slight facial grimaces upon movement and approachable Mental Status: Conscious and Coherent Language: Kapampangan Posture: On a Semi Fowlers position Vital Signs: T:
36.6 OC
PR:
80 BPM
RR:
20 CPM
BP:
100/70 mmhg
Skin: with no pallor; no jaundice Head: No lesions noted, no palpable nodules, symmetrical 8
Hair: Shoulder length, black and curly hair. No presence of dandruff Eyes: Anictenic Sclerae, Pink Conjunctiva Abdomen: Flabby, soft & non tender Genitalia: dosed cervix x 1(4) Spotting
October 18, 2009 Actual Physical Examination Appearance and Behavior: Appears well when not moving but shows slight facial grimaces upon movement and approachable Mental Status: Conscious and Coherent Language: Kapampangan Posture: On a Semi Fowlers position Vital Signs: T:
37.3 OC
PR:
85 BPM
RR:
18 CPM
BP:
90/70 mmhg
Skin: with no pallor; no jaundice Head: No lesions noted, no palpable nodules, symmetrical Hair: Shoulder length, black and curly hair. No presence of dandruff Eyes: Anictenic Sclerae, Pink Conjunctiva
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Chest & Lungs: SCE, with retractions Abdomen: Flabby, soft & non tender Genitalia: painless, Heavy Vaginal Bleeding Extremities: full and equal pulses
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DIAGNOSTIC AND LABORATORY EXAMS
A. URINALYSIS Actual Values
Date Test
Normal Values
Implications
10-17-09 PHYSICAL EXAMINATION Color
Nursing Rationale Responsibilities - To examine 1. Tell the patient the patient’s
Straw
that the test is for
Clear straw to
Liver problems urine for sign the detection or
colored liquid
or jaundice migh of renal or have occur
renal and urinary
urinary tract tract disorders disease.
and assessment of body function.
- To help Appearance
Clear
Clear to slightly
normal
hazy
discover
2. Notify the
diseases
patient that the
that is not in procedure relation with requires a urine Reaction Specific Gravity
6.5 1.010
4.6-8 1.005-1.025
renal
sample. Urine
To demonstrate disorders.
must be acquired
the
most likely on the
44
11
12
concentrating
first void in the
and diluting
- To identify morning.
In normal
ability of the
drugs or
condition there
kidneys.
substances
3. Notify the
is no protein
that has
laboratory and
that can be
been taken.
physician of any
detect
drugs that the patient has taken
CHEMICAL
that may affect
EXAMINATION
the results.
Albumin
Sugar
Negative Normal
Negative
Presence of sugar in urine may indicate diabetes, chronic kidney disease
45
13
MICROSCOPIC EXAMINATION Epithelial Cells Squamous
Pus cells and 0.2 hpf bacteria should
May be a sign of swelling in the
Renal
be absent in
kidney and
Pus Cells
urine
pelvic region, urethral ulceration and chronic specific inflammatory of the bladder
RBC
Blood in the urine may sometimes a serious urinary tract problem
Mucous Threads Bacteria
# 46
14
Yeast Cells Oil Globules Spermatozoa
B. BLOOD TYPING
47
15
Nursing Date Test Result 10-17-09 Blood Type (ABO+Rh)
Normal Results Implications Rationale A (+) In forward typing, if None known - To check
Responsibilities 1. Inform the
there’s agglutination
compatibility
patient that the
patient’s RBC’s are
of the donor
test determines
mixed with anti-A and
and the
her blood group.
anti-B serum, the A
patient before
and B antigen is
transfusion.
2. Notify the
present, thus blood
patient that the
type is O
test blood sample thus venipuncture is done. 3. Check the patient’s history for recent administration of blood, dextran or I.V.
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16
4. After the procedure apply direct pressure to the venipuncture to the site until bleeding stops.
C. COMPLETE BLOOD COUNT Normal
Nursing 49
17
Date Test 10-17-09 WBC
Result H 15.19
Values 5-10
x10^3/uL x10^3/uL
Implications Rationale Leukemia, - To verify
Responsibilities 1. Explain to the
bacterial
patient the necessity
infection or
infection, severe inflammation in of undergoing the sepsis
the body and
test that it helps
observe its
detect occurrence of
responses to
anemia and
specific
polycythemia.
therapies. 2. Notify the patient that the test requires Hemoglobin
122g/L
115-155
Normal
- To recognize
blood sample as well
g/L
Low HCT,
the amount of
as the person who
suggest anemia, O2 carrying hemodilution or protein
will perform the venipuncture and the
enormous blood contained within time. loss.
the RBC 3. Inform the patient that the procedure is
Hematocrit
L 0.35
0.36-0.48
Rule out anemia - To identify the of slight discomfort due to
percentage of
and may feel a little 50
18
pain.
nutritional deficiencies,
the blood volume
blood loss.
occupied by red 4. After the blood cells.
procedure, apply direct pressure to the venipuncture until
RBC
L 4.02
4.20-6.10
x10^6/uL x10^6/ uL
Low RBC is due - To know the to enormous
bleeding stops.
amount of RBC
blood loss which in the blood.
5. Refer if
results to
venipuncture
anemia.
develops hematoma
Leukemia,
and monitor the
hemorrhage.
pulses distal to the site.
Differential Count Neutrophil
73%
55-75%
Normal
- To point out the presence of 51
19
bacterial infection and amount of Leukocyte
Lymphocytes
L 18%
20-35%
Leukemia,
-To recognize if
systemic lupus
there is an
erythematosus
unusual amount of lymphocyte that may indicate viral infection such as HIV.
Monocytes
7%
2-10%
Normal
-Increase of these may respond to corticosteroid, with pus conditions, 52
20
hemorrhage Eosinophil
2%
1-6%
Normal
-High percentage of eosinophil, may indicate bacterial infestation or allergies
Basophil
0%
0-1%
Normal
-Increase of basophil may indicate parasite, hypersensitiven ess and heartworm causing endocrine disease, chronic liver disease 53
21
MCV
88.1fl
79.40-
Normal
94.80 fl
-To determine the ratio of hematocrit to RBC count -To identify the
MCH
30.3
25.60-
pg
32.20 pg
Normal
average mass of hemoglobin per RBC
MCHC
34.5 g/dL 32.2035.30 g/dL
Normal
-Indicates the nature and volume of hemoglobin, to high may indicate spherocytosis or in vitro 54
22
hemolysis
D. ULTRASOUND
U
-Presentation : Cephalic
Single, live
L
-Number: single
intrauterine
Nursing Responsibilities - To know fetal 1. Assure a and consent form
T
- Amniotic fluid: AFI 11.1 cm
pregnancy,
pregnancy
signed by the
R
-Placental location: anterior
cephalic
abnormalities
patient. Explain
Date Test 10-17--09 2:35 pm
Result Impression
Rationale
55
23
A
-Placental grade: III
presentation, with and
that the procedure
S
-Sex: male
good cardiac and
is painless and
O
-AOG: 32W 3D
somatic activities; of organ size
U
-EDD: 10-11-08
BPD= 32 weeks
and structure. radiation
N
-FHB: 147bpm
and 5 days; FL=
To identify and exposure is
D
Estimated Fetal Weight: 2233 g 31 weeks and 1
differentiate
-normohydramnios (11.1 cm)
cyst and solid
day
measurement
safe and that no
involved.
-amniotic fluid volume: normal Placenta anterior, tumor.
2. Emphasize the
-previa: placenta previa totalis early grade III,
importance of
totally covering
- To ensure
remaining still
Biophysical profile:
the OS (Placenta
the
during the scan to
-amniotic fluid: 2
previa totalis)
presentation
prevent distorted
-fetal tone: 2
and identify
image.
-fetal breathing: 2
complications
-gross movement: 2
of the fetus.
3. Assist the
Total =8
To detect if
patient into a
there is risk of supine position; if pregnancy.
possible use pillows to support the area to be examined. Coat 56
24
the target area with a watersoluble jelly. If necessary to assist the patient into lateral positions for consequent view.
57
26
THE FEMALE REPRODUCTIVE SYSTEM
GENERAL The organs of the reproductive systems are concerned with the general process of reproduction, and each is adapted for specialized tasks. These organs are unique in that their functions are not necessary for the survival of each individual. Instead, their functions are vital to the continuation of the human species. In providing maternity gynecologic health care to women, you will find that it is vital to your career as a practical nurse and to the patient that you will require a greater depth and breadth of knowledge of the female anatomy and physiology than usual. The female reproductive system consists of internal organs and external organs. The internal organs are located in the pelvic cavity and are supported by the pelvic floor. The external organs are located from the lower margin of the pubis to the perineum. The appearance of the external genitals varies greatly from woman to woman, since age, heredity, race, and the number of children a woman has borne determines the size, shape, and color. See figure 1-1 for the female reproductive organs.
58
TERMS AND DEFINITIONS These are only a few terms and definitions that will be used in this lesson. Other terms and definitions will be dispersed throughout the lesson. A. Broad Ligaments. Two wing-like structures that extend from the lateral margins of the uterus to the pelvic walls and divide the pelvic cavity into an anterior and a posterior compartment. B. Corpus Luteum. The yellow mass found in the graafian follicle after the ovum has been expelled. C. Estrogen. The generic term for the female sex hormones. It is a steroid hormone produced primarily by the ovaries but also by the adrenal cortex. D. Fimbriae. Fringes; especially the finger-like ends of the fallopian tube. E. Follicle. A pouch like depression or cavity. F. Follicle Stimulating Hormone. The follicle stimulating hormone (FSH) is a hormone produced by the anterior pituitary during the first half of the menstrual cycle. It stimulates development of the graafian follicle. G. Graafian Follicle. A mature, fully developed ovarian cyst containing the ripe ovum. H. Hormone. A chemical substance produced in an organ, which, being carried to an associated organ by the bloodstream excites in the latter organ, a functional activity. I. Lactation. The production of milk by the mammary glands. J. Luteinizing Hormone. A hormone produced by the anterior pituitary that stimulates ovulation and the development of the corpus luteum. 59
K. Oocyte. A developing egg in one of two stages. L. Ovum. The female reproductive cell. M. Progesterone. The pure hormone contained in the corpora lutea whose function is to prepare the endometrium for the reception and development of the fertilized ovum. N. Reproduction. The process by which an off- spring is formed.
Anterior view of the uterus and related structures
60
Wall of the uterus
INTERNAL FEMALE ORGANS The internal organs of the female consist of the uterus, vagina, fallopian tubes, and the ovaries. A. Uterus. The uterus is a hollow organ about the size and shape of a pear. It serves two important functions: it is the organ of menstruation and during pregnancy it receives the fertilized ovum, retains and nourishes it until it expels the fetus during labor.
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(1) Location. The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments. (2) Divisions of the uterus. The uterus consists of the body or corpus, fundus, cervix, and the isthmus. The major portion of the uterus is called the body or corpus. The fundus is the superior, rounded region above the entrance of the fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the vagina. The isthmus is the slightly constricted portion that joins the corpus to the cervix. (3) Walls of the uterus (see figure 1-3). The walls are thick and are composed of three layers: the endometrium, the myometrium, and the perimetrium. The endometrium is the inner layer or mucosa. A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial lining sloughs off about every 28 days in response to changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle component of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues. During the monthly female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. B. Vagina. (1) Location. 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. (2) Function. The vagina provides the passageway for childbirth and menstrual flow; it receives the penis and semen during sexual intercourse. C. Fallopian Tubes (Two). 62
(1) Location. Each tube is about 4 inches long and extends medially from each ovary to empty into the superior region of the uterus. (2) Function. The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries. (3) Description. The distal end of each fallopian tube is expanded and has fingerlike projections called fimbriae, which partially surround each ovary. When an oocyte is expelled from the ovary, fimbriae create fluid currents that act to carry the oocyte into the fallopian tube. Oocyte is carried toward the uterus by combination of tube peristalsis and cilia, which propel the oocyte forward. The most desirable place for fertilization is the fallopian tube. D. Ovaries (2) (see figure 1-4). (1) Functions. The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone). (2) 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 63
surrounded by one or more layers of follicle cells. As the developing egg begins to ripen or mature, follicle enlarges and develops a fluid filled central region. When the egg is matured, it is called a graafian follicle, and is ready to be ejected from the ovary.
(3) Process of egg production--oogenesis (see figure 1-5). (a) The total supply of eggs that a female can release has been determined by the time she is born. The eggs are referred to as "oogonia" in the developing fetus. At the time the female is born, oogonia have divided into primary oocytes, which contain 46 chromosomes and are surrounded by a layer of follicle cells. (b) Primary oocytes remain in the state of suspended animation through childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the anterior pituitary gland secretes follicle-stimulating hormone (FSH), which stimulates a small number of primary follicles to mature each month.
64
(c) As a primary oocyte begins dividing, two different cells are produced, each containing 23 unpaired chromosomes. One of the cells is called a secondary oocyte and the other is called the first polar body. The secondary oocyte is the larger cell and is capable of being fertilized. The first polar body is very small, is nonfunctional, and incapable of being fertilized. (d) By the time follicles have matured to the graafian follicle stage, they contain secondary oocytes and can be seen bulging from the surface of the ovary. Follicle development to this stage takes about 14 days. Ovulation (ejection of the mature egg from the ovary) occurs at this 14-day point in response to the luteinizing hormone (LH), which is released by the anterior pituitary gland. (e) The follicle at the proper stage of maturity when the LH is secreted will rupture and release its oocyte into the peritoneal cavity. The motion of the fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also causes the ruptured follicle to change into a granular structure called corpus luteum, which secretes estrogen and progesterone. (f) If the secondary oocyte is penetrated by a sperm, a secondary division occurs that produces another polar body and an ovum, which combines its 23 chromosomes with those of the sperm to form the fertilized egg, which contains 46 chromosomes. (4) Process of hormone production by the ovaries. (a) Estrogen is produced by the follicle cells, which are responsible secondary sex characteristics and for the maintenance of these traits. These secondary sex 65
characteristics include the enlargement of fallopian tubes, uterus, vagina, and external genitals; breast development; increased deposits of fat in hips and breasts; widening of the pelvis; and onset of menses or menstrual cycle. (b) Progesterone is produced by the corpus luteum in presence of in the blood. It works with estrogen to produce a normal menstrual cycle. Progesterone is important during pregnancy and in preparing the breasts for milk production.
EXTERNAL FEMALE GENITALIA
66
The external organs of the female reproductive system include the mons pubis,
labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a group, these structures that surround the openings of the urethra and vagina compose the vulva, from the Latin word meaning covering. See Figure 1-6. a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with thick coarse hair. b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are the 2 elongated hair covered skin folds. They enclose and protect other external reproductive organs. c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They protect the opening of the vagina and urethra. d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the vaginal introitus. (1) The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is sexual excitation.
67
(2) The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular structure that drains urine from the bladder. (3) T e. Perineum. This is the skin covered muscular area between the vaginal opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and anal opening. It also helps support the pelvic contents. f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The Bartholin's glands lie on either side of the vaginal opening. They produce a mucoid substance, which provides lubrication for intercourse. BLOOD SUPPLY The blood supply is derived from the uterine and ovarian arteries that extend from the internal iliac arteries and the aorta. The increased demands of pregnancy necessitate a rich supply of blood to the uterus. New, larger blood vessels develop to accommodate the need of the growing uterus. The venous circulation is accomplished via the internal iliac and common iliac vein. FACTS ABOUT THE MENSTRUAL CYCLE Menstruation is the periodic discharge of blood, mucus, and epithelial cells from the uterus. It usually occurs at monthly intervals throughout the reproductive period, except during pregnancy and lactation, when it is usually suppressed. The menstrual cycle is controlled by the cyclic activity of follicle stimulating hormone (FSH) and LH from the anterior pituitary and progesterone and estrogen from the ovaries. In other words, FSH acts upon the ovary to stimulate the maturation of a follicle, and during this development, the follicular cells secrete increasing amounts of estrogen (see figure 1-7). Hormonal interaction of the female cycle is as follows:
68
(1) Days 1-5. This is known as the menses phase. A lack of signal from a fertilized egg influences the drop in estrogen and progesterone production. A drop in progesterone results in the sloughing off of the thick endometrial lining which is the menstrual flow. This occurs for 3 to 5 days. (2) Days 6-14. This is known as the proliferative phase. A drop in progesterone and estrogen stimulates the release of FSH from the anterior pituitary. FSH stimulates the maturation of an ovum with graafian follicle. Near the end of this phase, the release of LH increases causing a sudden burst like release of the ovum, which is known as ovulation. (3) Days 15-28. This is known as the secretory phase. High levels of LH cause the empty graafian follicle to develop into the corpus luteum. The corpus luteum releases progesterone, which increases the endometrial blood supply. Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo produces human chorionic gonadotropin (HCG). Thehuman chorionic gonadotropin signals the corpus luteum to continue to supply progesterone to maintain the uterine lining. Continuous levels of progesterone prevent the release of FSH and ovulation ceases. Additional Information.
(1) The length of the menstrual cycle is highly variable. It may be as short as 21 days or as long as 39 days. (2) Only one interval is fairly constant in all females, the time from ovulation to the beginning of menses, which is almost always 14-15 days. (3) The menstrual cycle usually ends when or before a woman reaches her fifties. This is known as menopause.
69
Ovulation Ovulation is the release of an egg cell from a mature ovarian follicle (see figure 15 for ovulation). Ovulation is stimulated by hormones from the anterior pituitary gland, which apparently causes the mature follicle to swell rapidly and eventually rupture. When this happens, the follicular fluid, accompanied by the egg cell, oozes outward from the surface of the ovary and enters the peritoneal cavity. After it is expelled from the ovary, the egg cell and one or two layers of follicular cells surrounding it are usually propelled to the opening of a nearby uterine tube. If the cell is not fertilized by union of a sperm cell within a relatively short time, it will degenerate.
MENOPAUSE As mentioned in paragraph 1-6c (3), menopause is the cessation of menstruation. This usually occurs in women between the ages of 45 and 50. Some women may reach menopause before the age of 45 and some after the age of 50. In common 70
use, menopause generally means cessation of regular menstruation. Ovulation may occur sporadically or may cease abruptly. Periods may end suddenly, may become scanty or irregular, or may be intermittently heavy before ceasing altogether. Markedly diminished ovarian activity, that is, significantly decreased estrogen production and cessation of ovulation, causes menopause.
DESCRIPTION OF THE DISEASE Placenta previa is an obstetric complication in which the placenta is lying unusually low in the uterus, next to or covering the cervix. The placenta is
the pancake-
71
shaped organ — normally located near the top of the uterus — that supplies the baby with nutrients through the umbilical cord. Placenta previa is a placental attachment that is too low in the uterus and covers the cervix. Normally the placenta is attached to the uterus above the cervix. The placenta completely covers the internal os in slightly more than 10 percent of placenta previa cases. Under these circumstances the placenta precedes the fetus in vaginal delivery. This can be life-threatening to the unborn child and mother if untreated. It occurs to some degree in 1 of 200 pregnancies.
Placenta previa is not usually a problem early in pregnancy. But if it persists into later pregnancy, it can cause bleeding, which may require the pregnant woman to deliver early and can lead to other complications. If a woman has placenta previa when it's time
to
deliver
her
baby,
she’ll
need
to
have
a
c-section.
If the placenta covers the cervix completely, it's called a complete or total previa. If it's right on the border of the cervix, it's called a marginal previa. (You may also hear the term "partial previa," which refers to a placenta that covers part of the cervical opening once the cervix starts to dilate.) If the edge of the placenta is within 2 centimeters of the
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cervix but not bordering it, it's called a low-lying placenta. The location of the placenta will be checked during the midpregnancy ultrasound exam.
It depends on how far along the client is in pregnancy. Don't panic if her second trimester ultrasound shows that she has placenta previa. As her pregnancy progresses, the placenta is likely to "migrate" farther from the cervix and no longer be a problem. (Since the placenta is implanted in the uterus, it doesn't actually move, but it can end up farther from the cervix as theuterus expands. Also, as the placenta itself grows, it's likely to grow toward the richer blood supply in the upper part of the uterus.) Only about 10 percent of women who have placenta previa noted on ultrasound at midpregnancy still have it when they deliver their baby. A placenta that completely covers the cervix is more likely to stay that way than one that's bordering it (marginal) or nearby(low-lying). Even if previa is discovered later in pregnancy, the placenta may still move away from the cervix (although the later it's found, the less likely this is to happen). You'll have a follow-up ultrasound early in your third trimester to check on the location of your
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placenta. If the client has any vaginal bleeding in the meantime, an ultrasound will be done then to find out what's going on. If the follow- up ultrasound reveals that the placenta is still covering or too close to the cervix, the client will be monitored carefully, has regular ultrasounds, and need to watch for vaginal bleeding. She'll be put on "pelvic rest," which means no intercourse or vaginal exams for the rest of her pregnancy. And she'll be advised to take it easy and avoid activities that might provoke bleeding, such as strenuous housework or heavy lifting. Bleeding from a placenta previa happens when the cervix begins to thin out or dilate (even a little) and disrupts the blood vessels in that area. It's usually painless, can start without warning, and can range from spotting to extremely heavy bleeding. If her bleeding is severe, she may have to deliver her baby premature.
The
pregnant
woman
may
also
right away, even if he's still need
a
blood
transfusion.
It's unusual for bleeding to start before late in the second trimester, and about half the time it doesn't begin until you're nearly full-term (37 weeks). The bleeding will often stop on its own, but it's likely to start again at some point. (If she has bleeding and she’s Rh negative, she'll need a shot of Rh immune globulin, unless the baby's father is Rh negative,too.) If the client start bleeding or has
contractions, she'll need to be hospitalized. What
happens then will depend on how far along you are in her pregnancy, how heavy the bleeding is, and how you and your baby are doing. If she is near full-term, the baby will be delivered by c-section right away. If the baby is still premature, he'll be delivered by c-section immediately if his condition warrants it or if the client have heavy bleeding that doesn't stop.
Otherwise, she'll be watched in the hospital until the bleeding stops. If she’s less than 34 weeks,
the client may be given corticosteriods to
speed up her baby's lung
development and to prevent other complications in case he ends up being delivered prematurely. 74
If the bleeding stops, and both the mother and her baby are in good condition, she'll probably be sent home. But she'll need to return to the hospital immediately if the bleeding starts again. If she and her baby continue to do well and she doesn't need to deliver
early,
she'll
have
a
scheduled
c-section
at
37
weeks.
No matter when she delivers, if she still has placenta previa, she'll need a c-section. With a complete previa, the placenta blocks the baby's way out. And even if it's only bordering the cervix, she'll still need a c-section in most cases because the placenta could bleed profusely if the cervix dilated.
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PATHOPHYSIOLOGY No specific cause of placenta previa has yet been found but it is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, it may shear off and a small section may bleed. Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta. Praevia can be confirmed with an ultrasound. In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre. The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby's chance of survival is as good as at full term. Placenta previa is classified according to the placement of the placenta: •
Type I or low lying: The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os.
•
Type II or marginal: The placenta touches, but does not cover, the top of the cervix.
•
Type III or partial: The placenta partially covers the top of the cervix
•
Type IV or complete: The placenta completely covers the top of the cervix
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Placenta previa is itself a risk factor of placenta accreta. Placenta Previa Painless Vaginal Bleeding
Ultrasound Risk Factors Late Maternal Age
Infection (UTI)
Complete Previa Partial Previa
Multiparity
Marginal Previa Bleeding stops
Low-lying place
Fetus stable
Bed Rest
Observe Urine Output Hypotension Maternal Hemorrhage
Pale, cool skin Bleeding continues Bleeding Restarts
Capillary refill tachycardia Pulse
Complications: Congenital Anomalies Maternal Mortality Intrauterine Growth
Cesarian Birth
Vaginal or 77
Cesarian Birth
S O A P I E October 17, 2009
7–3
S> ”Masakit ang puwerta ko” as verbalized by the patient O> Guarding behavior > Facial grimace > Generalized body weakness > Pain Scale 4/5 > (+) DOB A> Acute Pain r/t Inflammatory Response P> After 4O of nursing intervention, the patient will report pain is relieved/controlled I> Established rapport > Monitored v/s taken and recorded > Morning Care Rendered > Instructed patient to exercise deep breathing every time the pain occur > Encouraged the patient verbalization of feelings about pain > Instructed the patient to have proper hygiene > Position the patient in Semi fowler’s position > Provided safety and comfort E> Goal met as evidenced by the pt. report pain is relieved/controlled
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b. PLANNING (Nursing Care Plan) Cues S>”Masakit ang puwerta ko” as verbalized by the patient O> The pt. may manifested the ffg: >Pain, 4/5 >Guarding behavior >Facial grimace >Generalized Body Weakness > (+) DOB > Perspiration >
Nursing Diagnosis
Scientific explanation
>Acute pain r/t Inflammatory Response
Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury as lasting from second to 6 months. In cases of fracture, pain is continuous & increasing in severity until bone fragments are immobilized. In this type of fracture, the main medical management is open reduction with internal fixation (ORIF), wherein the fracture fragments are reduced & internal fixation devices are used to hold the bone fragment in position until solid bone healing occurs.
Objectives
Interventions
Short term: After 4 hrs. of NI, patient will verbalized the pain is controlled or disappear
>Establish rapport
>To gain pt. trust
>Monitor v/s
>To have baseline data
>Encourage pt. deep breathing exercise when pain occur
>To decrease the pain
>Promote safety and comfort
>To
>Avoid environmental stimulant
>To avoid the pain to occur
Long term: After 2 days of NI, pt. will maintain the absence of pain
Rationales
Expected outcomes Short term: Goal met as evidenced by the pt. verbalized the pain is controlled or disappear Long term: Goal met as evidenced by the pt. maintain the absence of pain
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Cues S>“Pakiramdam ko mainit buong katawan ko” as verbalize by the patient O> The pt. manifested the ffg: >skin warm to touch >dry lips >fatigue >redness
Nursing diagnosis >Hyperthermia related to inflammatory process.
Scientific explanation Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability and death.
Planning Short term: After 4 hours of NI, patient will decrease temperature from 38.9 c to 37.5 c
Intervention > Establish rapport
>Monitor vital sign
>provide TSB
Rationale > To gain the trust of the patient
> to have baseline data
>to decrease heat
Long term: After 2 days of NI, patient will maintain absence of hyperthermia
>promote comfort and safety
>Promote ventilation of the skin by means of undressing
> make safety and relax the patient
Evaluation Short term: Goal met AEB the patient temperature decrease from 38.9 c to 37.5 c
Long term: Goal met AEB the patient maintain the absence of hyperthermia
> treatment for mild to moderate hyperthermia
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Cues S> “Nahihirapan akong gumalaw kasi masakit yung bahay bata ko” as verbalize by the patient O> (+) pain, 4/5 >facial grimace >guardianing behavior >limited movement
Nursing diagnosis >impaired physical mobility related to pain
Scientific Explanation
Planning
The movement of body structures is accomplished by the contraction of muscles. Muscles may move parts of the skeleton relatively to each other, or may move parts of internal organs relatively to each other. All such movements are classified by the directions in which the affected structures are moved. In human anatomy, all descriptions of position and movement are based on the assumption that the body is its complete medial and abduction stage in anatomical position.
Short term: After 3 hours of NI, patient will verbalize understandi ng for individual situation Long term: After 2 days NI, patient will maintain the absence of pain
Intervention >establish rapport
>monitor vital sign
>promote comfort and safety
>assess patient complain
> explain to patient the condition
Rationale >to gain patient trust > to have baseline data > to promote safety and relax > to assess and treat patient problem
Evaluation Short term: Goal met AEB the patient verbalize understanding for individual situation Long term: Goal met AEB the patient maintain the absence of pain
> to understand the patient her/his condition
> to decrease the pain >encourage patient to exercise deep breathing every time pain occur
> Avoid Environmental stimulant
> to decrease pain
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83
c. Drugs
84
Type of Diet Name of Drugs
DAT Generic name: Cefuroxime Brand name: Ceftin
Generic name: Acetaminophen Brand name: Paracetamol
Generic name: Follic acid Brand name: Folvite
Date Ordered: Date Started: Date ordered
General Description
Route of admin
Indication / Purpose
General action
Indication
Client’s Response / reaction to the Client’s diet response to the
Medication with actual Side Effectto To facilitate reduction of The patient refuses
DO: 10-17-09 There is a dietary sodium Date taken/given: Dosage: >Inhibits synthesis respiratory restriction on patient sodium in>Lower the body, eat. 10/17/09 Adults: of bacteria cell infections DS: 10-17-09 thus reducing edemacaused by >250 mg bid for wall, causing cell S. Pneumoniae, H. and ascites. Date changed: severe infections, death. Para influenza, H. maybe increased to Influenza 500 mg bid Frequency of It also aide in the admin: reduction of conjunction of vascular fluids since Date taken/given: Dosage: >Reduces fever by attracts >Analgesic anti sodium water. 10/17/09 Adults acting directly on pyretics in patients >by supporting 365- the hypothalamic with aspirin allergy, Date changed: 600 mg q 4-6 hr. or heat regulating hemostatic P.O, 1000 mg tid to center to occur disturbances qid. Do not exceed vasodilator and bleeding diatheses, 4 q/day sweating which quoty artitis helps dissipate heat. Date taken/given: Dosage: 10/17/09 Adults: >up to 1 mg P.O, Date changed: I.M or S.C daily throughout pregnancy
>Stimulate normal erythropoiesis and nucleoprotein synthesis
Patient response effectively with no side effect noted.
Patient response effectively with no side effect noted.
>To prevent Patient response megaloblastic anemia effectively with no during pregnancy to side effect noted. prevent fetal damage
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Nursing Responsibilities: • • • • •
Explain the purpose. Assess for patient condition, how he respond diet. Provide variety of choices of foods low sodium. Be sure patient is taking / eating foods he can tolerate. Explain importance of compliance.
86
HEALTH TEACHINGS * Encourage patient to express feelings and concerns ® So that relief measure may be instituted 89
* Teach family / significant others to foster independence, and to intervene if the patient becomes fatigued, is unable to perform task or becomes excessively frustrated ® Demonstrates caring / concern * Teach patient perineal hygiene ® to decrease risk of ascending infections * Splint incision when moving or coughing ® to decrease pain and to prevent wound separation * Encourage the patient to comply with medications given ® The use of medicines is a pharmacologic method that aids in the recovery of the client *Encourage the client to eat foods to stimulate the production of milk · temperature
exceeding 38C
· painful urination · lochia heavier than
normal period
· wound separation · redness or oozing at the incision site · severe abdominal pain · use relaxation
techniques such as music, breathing, and dim lights
· apply heating
pad to the abdomen
*GAS pain 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 87
· Inculcate
to the client the importance of proper hand washing
® Hand washing if the single most effective way in controlling infection DISCHARGE PLAN Medications: · Teach patient and her family
or significant others the proper dosage and
the right time to take the medication. · Emphasize to the
patient the importance of obediently taking the
prescribed medications and the disadvantages or complications that may arise if these are not taken properly. · Inform and
discuss the possible side effects and reactions that these
drugs might produce and seek medical attention immediately is these arise · Discourage
to use of OTC medications or at least inform the physician if
she’s taking other OTC medications. This is essential to prevent any occurrence of drug interactions. Exercise: · Tell client to refrain
from straining activities
· Encourage ambulation
as a form of light exercise that would help in the
progression of her recovery and wound healing. · Range
of motion. Encouraging the patient to do some exercises would
allow good blood circulation as well as the prevention of the occurrence of bed sores. · Encourage patient to do some stretching exercise to prevent stiffness of
the bone due to less activity performed. · Encourage patient to first sit up and dangle
feet before standing from a
lying position to prevent orthostatic hypotention 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 88
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.
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JOSE C. FELICIANO COLLEGE INSTITUTE OF NURSING, MIDWIFE AND NURSING AIDE DAU EXIT, DAU EXPRESSWAY DAU MABALACAT PAMPANGA
PLACENTA PREVIA (A CASE STUDY IN OBSTETRIC WARD) BSN II – A (GROUP 2) SUBMITTED BY: AGUIRRE, ROXANNE BACANTE, CIELITO JOHN BISCO, MICHELAN CANIEL, JOSEPH CORTEZ, KAREN ESPIRITU, PRECIOUS ANN GUTIERREZ, NICKKY MARK LIWANAG, JEEANNE NAVARRO, JOEL SANTOS, MATTHEW FAITH SANTIAGO, KAREN KRISTA TEODORO, JOHNNA CLAIRE SUBMITTED TO: MS. GENICIA R. MORALESRN MSN CLINICAL INSTRUCTOR (OB WARD)
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