Case Study 2 .docx

Case study 2 A CASE STUDY ON POSTPARTUM HEMORRHAGE (PPH)

PREPARED BY : SEIF SAID KHALFAN

• Postpartum hemorrhage (PPH) is the second leading cause of maternal mortality worldwide with a prevalence rate of approximately 6%;

Africa has the highest prevalence rate of about 10.5%. • In Africa and Asia, where most maternal deaths occur, PPH accounts for more than 30% of all maternal deaths • Each year, almost 7,900 mothers die due to

childbirth and pregnancy related complications

in Tanzania. According to Muhimbili National Hospital postpartum deaths in a year 2011 – 2014 is of an average of 14.9% of all direct causes of maternal deaths. • In Zanzibar data obtained from the Muembe Ladu Hospital shows the incidence of

postpartum hemorrhage for the years 2013 – 2015 are 14.76%, 18.01% and 16.17% respectively. • PPH is defined as blood loss of greater than 500 mL after vaginal delivery and greater than 1000 mL after cesarean delivery. DEMOGRAPHIC DATA

• Patient name: H. A. N • Address: Chukwani • Age: 33 years • occupation: Housewife • Sex: Female • Marital status: Married • Hospital: Mnazi Mmoja • Date of admission: march 04, 2016

Medical history • In 2013, she diagnosed with peptic ulcer disease, which resolved after three months on cimetidine. She describes no history of cancer, lung disease or previous heart disease. She also has allergy with Penicillin; experienced rash and hives in 2008.

Present history • The patient has been admitted at Mnazi Mmoja Hospital since March 04, 2016. She was in her usual state of good health until one day prior to admission. Weight of patient is 65kg. She complains of labour pain which started at 04:30am Current diagnosis

• Postpartum hemorrhage (PPH)

• Patient vital signs on admission are:BP = 130/90, Pulse Rate = 78 bpm, Temperature = 36.4 0C, Resp. rate = 20r/m. • Patient vital signs after delivery ( during PPH ) BP = 92/47, Pulse rate = 102bpm, Temperature = 36.1 0C, Resp. rate = 30r/m Treatment

Non-pharmacological treatment • Resuscitation with intravenous fluid e.g. ringer lactate • Uterine massage every 15 minutes for the first two hours Pharmacological treatment • Oxytocin 40 I.U via I.V in ringer lactate Test results

• HB – 8.4mls • Blood group - O+ • PMTCT - 2 • Bleeding time (BT) – Normal • Clotting time (CT) – Normal Nursing observation on mental state of the patient

• Language: patient able to express by speech of signs

• Orientation: well oriented to person, time and place • Attention: able to concentrate • Level of consciousness: she is conscious (awake)

NURSING CARE PLAN

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTION

EVALUATION

Fluid volume deficit After 2 – 5 days I/: Advise patients to sleep with After 2 days the related to uterine will be Prevented feet higher, while the body client’s

atony as evidenced by

excessive

vaginal blood loss.

from

remained supine.

dysfunctional

R/: With feet higher will increase improved

bleeding

and the venous return, and allowing

improve

fluid the blood to the brain and other

volume.

organs. I/: Monitor vital signs. R/: Changes in vital signs when bleeding occurs more intense.

I/: Monitor intake and output every 15 minutes. R/: Change the output is a sign of impaired renal function.

fluid

body volume

NURSING DIAGNOSIS Ineffective

EXPECTED OUTCOME

INTERVENTION

tissue After 2 – 3 days vital I/: Monitor vital signs every 5-

perfusion related to signs and blood gases 10 minutes.

EVALUATIO N After 2 days patient’s vital

vaginal bleeding as will be within normal R/: Changes in tissue perfusion signs were at evidenced

by limits.

causing changes in vital signs.

fluctuation of vital

I/: Monitor blood gas levels

signs

and pH

R/: Changes in blood gases and pH levels are a sign of tissue hypoxia I/: Give oxygen therapy R/: Oxygen transport is needed to maximize circulation to tissue.

normal range.

NURSING DIAGNOSIS

EXPECTED OUTCOME

Body weakness • Verbalize related to altered

increase in

body chemistry

energy level.

(insufficient electrolytes)

as • Display

evidenced

by

improved ability

inability

to

to

maintain

usual

routines.

participate

in desired activities.

INTERVENTION

EVALUATION

I/: Discuss with patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue. R/: Education may provide motivation to increase activity level even though patient may feel too weak initially.

The patient can

I/: Increase patient participation in ADLs as tolerated. R/: It can increases confidence level, self-esteem and tolerance. I/: Alternate activity with periods of rest and uninterrupted sleep. R/: It can prevent excessive fatigue.

perform some activities

z

NURSING DIAGNOSIS

EXPECTED OUTCOME

Anxiety related to The client can knowledge deficit verbalize regarding

anxiety and said

procedures,

anxiety is

management and reduced or lost. disease condition

as evidenced by patient asks many questions the disease.

about

INTERVENTION

EVALUATION

I/: Assess the client's psychological response to the post- childbirth bleeding. R/: Perceptions of client influence the intensity of anxiety.

Client said anxiety is reduced.

I/: Treat the patient calm, empathetic and supportive attitude. R/: Provide emotional support. I/: Provide information about care and treatment. R/: Accurate information can reduce the anxiety and fear of the unknown. I/: Help clients identify a sense of anxiety. R/: The expression can reduce feelings of anxiety.

NURSING DIAGNOSIS

EXPECTED INTERVENTION OUTCOME

EVALUATION

Sleeping pattern

Falls asleep

I/: Assess for new onset of depression:

After 2 days the

disturbance

without

depressed mood state, statement of

patient

falls

related to acute

difficulty

hopelessness and poor appetite

asleep

without

pain as

R/: It can help to understand which

difficulty

evidenced by

psychological therapy can help the patient

verbal report of

difficult falling asleep.

I/: Provide pain relief shortly before bedtime R/: Help to keep the body not to suffer from pain at that time. I/: Keep environment quit R/: This can reduce anxiety and lead to peace of mind

NURSING DIAGNOSIS

EXPECTED INTERVENTION OUTCOME

EVALUATION

Risk for infection related to excessive blood loss and exposed placental attachment site and lacerations.

To keep I/: Note the changes in vital signs. patient free R/: Changes in vital signs (temperature) is from indicative of infection. infection I/: Note the signs of fatigue, chills, anorexia, and uterine contractions were flabby and pelvic pain. R/: The signs are an indication of the occurrence of bacteremia, shock is not detected.

After 5 days the patient was free from infection

I/: Consider the possibility of infection in other places, such as respiratory infections, mastitis and urinary tract. R/: Infection elsewhere worsens the situation. I/: Give antibiotics R/: Antibiotics are necessary for the proper state of infection.