I. Introduction:

I. Introduction: Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset of labor at or beyond 37 weeks' gestation. The membranes that hold amniotic fluid (the water surrounding the baby) usually break at the end of the first stage of labor. However, in about 10% of pregnancies after 37 weeks, the membranes will break before labor. PROM occurs in about 10 percent of all pregnancies. PPROM (before 37 weeks) occurs in about 2 percent of all pregnancies The cause of PROM is often unknown. Some causes are thought to be: uterine or genital tract infections, including sexually transmitted diseases , poor nutrition, overstretching of the uterus and amniotic sac, which sometimes occurs with multiple fetuses or too much amniotic fluid (hydramnios), cigarette smoking, increased susceptibility if it occurred in previous pregnancies, previous cervical surgery, including cone biopsies or cerclage suture to hold the cervix closed, most women whose membranes rupture before labor don’t have a risk factor. The most important symptom of PROM is fluid leaking from the vagina. It may leak slowly or may gush out. Sometimes when it leaks out slowly, women mistake it for urine. Although some of the fluid is lost when the membranes rupture, the baby continues to produce more, so it may continue to leak. PROM is a complicating factor in as many as one third of premature births. A significant risk of PPROM is that the baby is very likely to be born within one week of the membrane rupture. Another major risk of PROM is development of a serious infection of the placental tissues called chorioamnionitis, which can be very dangerous for mother and baby. Other complications that may occur with PROM include placental abruption (early detachment of the placenta from the uterus), compression of the umbilical cord, cesarean birth, and postpartum (after delivery) infection. Treatment for premature rupture of membranes may include: hospitalization, expectant management (in some cases of PPROM, the membranes may seal over and the fluid may stop leaking without treatment.), monitoring for signs of infection such as fever, pain, increased fetal heart rate and/or laboratory tests, giving the mother medications called

corticosteroids that may help mature the lungs of the fetus (lung immaturity is a major problem of premature babies). However, corticosteroids may mask an infection in the uterus, antibiotics (to prevent or treat infections), tocolytics - medications used to stop preterm labor, and delivery (if PROM endangers the well-being of the mother or fetus, then an early delivery may be necessary to prevent further complications). Unfortunately, there is no way to actively prevent PROM. However, this condition does have a strong link with cigarette smoking and mothers should stop smoking as soon as possible. This case study is conducted with the following aims and objectives of the study: •

To have a thorough assessment on the patient

•

To obtain patient’s data to have a better bonding with my patient

•

To gain knowledge on premature rupture of membranes, its causes, symptoms and prevention of the case.

•

To plan necessary care to be rendered to the patient while in the hospital and also to give health teachings.

My Patient, Jesary Espiritu, has been hospitalized last June 22, 2008 at 2 am in Gabriela Silang General Hospital with the chief complains of lumbosacral pain and according to her it is also because of continuous leaking of vaginal fluid (amniotic fluid) that she thought as water. She was rushed in the hospital for all they knew is that she will already deliver the baby. Her Admitting diagnosis was Premature rupture of membranes and the admitting physician was Dra. Eugenio. It was June 23 when she delivered a baby girl through a caesarean section. She was then discharged after staying one week in the hospital.

VI. Anatomy and Physiology:

(Female Reproductive Parts)

Affected Parts: (Amnion and the Chorion)

The Amnion

- in the human embryo the earliest stages of the formation of the amnion have not been observed; in the youngest embryo which has been studied the amnion was already present as a closed sac and appears in the inner cell-mass as a cavity. This cavity is roofed in by a single stratum of flattened, ectodermal cells, the amniotic ectoderm, and its floor consists of the prismatic ectoderm of the embryonic disk - the continuity between the roof and floor being established at the margin of the embryonic disk. Outside the amniotic ectoderm is a thin layer of mesoderm, which is continuous with that of the somatopleure and is connected by the body-stalk with the mesodermal lining of the chorion. When first formed the amnion is in contact with the body of the embryo, but about the fourth or fifth week fluid (liquor amnii) begins to accumulate within it. This fluid increases in quantity and causes the amnion to expand and ultimately to adhere to the inner surface of the chorion, so that the extra-embryonic part of the celom is obliterated. The liquor amnii increases in quantity up to the sixth or seventh month of pregnancy, after which it diminishes somewhat; at the end of pregnancy it amounts to about 1 liter. It allows of the free movements of the fetus during the later stages of pregnancy, and also protects it by diminishing the risk of injury from without. It contains less than 2 per cent. of solids, consisting of urea and other extractives, inorganic salts, a small amount of protein, and frequently a trace of sugar. That some of the liquor amnii is swallowed by the fetus is proved by the fact that epidermal debris and hairs have been found among the contents of the fetal alimentary canal. The Chorion - the chorion consists of two layers: an outer formed by the primitive ectoderm or trophoblast, and an inner by the somatic mesoderm; with this latter the amnion is in contact. The trophoblast is made up of an internal layer of cubical or prismatic cells, the cytotrophoblast or layer of Langhans, and an external layer of richly nucleated protoplasm devoid of cell boundaries, the syncytiotrophoblast. It undergoes rapid proliferation and forms numerous processes, the chorionic villi, which invade and destroy the uterine decidua and at the same time absorb from it nutritive materials for the growth of the embryo. The chorionic villi are at first small and non-vascular, and consist of

trophoblast only, but they increase in size and ramify, while the mesoderm, carrying branches of the umbilical vessels, grows into them, and in this way they are vascularized. Blood is carried to the villi by the branches of the umbilical arteries, and after circulating through the capillaries of the villi, is returned to the embryo by the umbilical veins. Until about the end of the second month of pregnancy the villi cover the entire chorion, and are almost uniform in size, but after this they develop unequally. The greater part of the chorion is in contact with the decidua capsularis, and over this portion the villi, with their contained vessels, undergo atrophy, so that by the fourth month scarcely a trace of them is left, and hence this part of the chorion becomes smooth, and is named the chorion læve; as it takes no share in the formation of the placenta, it is also named the non-placental part of the chorion. On the other hand, the villi on that part of the chorion which is in contact with the decidua placentalis increase greatly in size and complexity, and hence this part is named the chorion frondosum.

Primary Transverse section of a chorionic villus.

chorionic

villi.

(Modified from Bryce.)

Diagrammatic.

External Parts of Female Reproductive Organ:

Internal Parts of Female Reproductive Organ :

LOCATION & STRUCTURE

FUNCTION DESCRIPTION

Breasts

Upper chest one on each side Lactation milk/nutrition for newborn. containing alveolar cells (milk production), myoepithelial cells

(contract to expel milk), and duct walls (help with extraction of milk). During childbirth, contractions of the uterus will dilate the cervix up to 10 cm The lower narrower portion of Cervix

in diameter to allow the child to pass the uterus. through. During orgasm, the cervix convulses and the external os dilates Small erectile organ directly in

Clitoris

Sexual excitation, engorged with blood. front of the vestibule. Extending upper part of the Egg transportation from ovary to uterus

Fallopian tubes uterus on either side.

(fertilization usually takes place here).

Thin membrane that partially Hymen

covers the vagina in young females. Outer skin folds that surround

Labia majora

Lubrication during mating. the entrance to the vagina. Inner skin folds that surround

Labia minora

Lubrication during mating. the entrance to the vagina. Mound of skin and underlying

Mons

fatty tissue, central in lower pelvic region Provides an environment for maturation

Ovaries (female Pelvic region on either side of of oocyte. Synthesizes and secretes sex gonads)

the uterus. hormones (estrogen and progesterone).

Short stretch of skin starting at Perineum

the bottom of the vulva and extending to the anus. Pelvic cavity above bladder,

Urethra

Passage of urine. tilted. To house and nourish developing

Uterus

Center of pelvic cavity. human. Receives penis during mating. Pathway through a womans body for the baby to take during childbirth. Provides the Canal about 10-8 cm long going route for the menstrual blood (menses)

Vagina

from the cervix to the outside of from the uterus, to leave the body. May the body. hold forms of birth control, such as an IUD, diaphragm, neva ring, or female condom Surround

Vulva

entrance

to

the

reproductive tract.(encompasses all external genitalia) The innermost layer of uterine Contains glands that secrete fluids that

Endometrium wall. Myometrium

bathe the utrine lining.

Smooth muscle in uterine wall. Contracts to help expel the baby.

VIII. Management A. Medical Surgical - the patient undergone caesarean section last June 23, 2008 and began at 1:40 p.m. and ended at 2:25 p.m. a baby girl was delivered at 1:45 p.m. with Dra. Eugenio as the surgeon. Induction of anesthesia started at 1:30 p.m. by Dr. Baniqued. Caesarean Section -(surgery done)

A caesarean section, or c-section, is a form of childbirth in which a surgical incision is made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would lead to medical complications, although it is increasingly common for otherwise normal births as well. There are several types of caesarean sections (CS):

•

The classical caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it more prone to complications.

•

The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.

•

An emergency caesarean section is a caesarean performed once labour has commenced.

•

A crash caesarean section is a caesarean performed in an obstetrical emergency.

•

A caesarean hysterectomy consists of a caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.

•

Traditionally other forms of CS have been used, such as extraperitoneal CS or Porro CS.

•

repeat caesarean section is done when a patient had a previous section. Typically it is performed through the old scar.

Indications Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Reasons for caesarean delivery include: •

prolonged labour or a failure to progress (dystocia)

•

apparent fetal distress

•

apparent maternal distress

•

complications (pre-eclampsia, active herpes)

•

catastrophes such as cord prolapse or uterine rupture

•

multiple births

•

abnormal presentation (breech or transverse positions)

•

failed induction of labour

•

failed instrumental delivery (by forceps or ventouse)

•

the baby is too large (macrosomia)

•

placental problems (placenta previa, placenta abruption,or placenta accreta)

•

contracted pelvis

•

prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)

However, different providers may disagree about when a caesarean is required. For example, one obstetrician may feel that a woman is too small to deliver her baby, another might well disagree. Similarly, some care providers may be much quicker to cite "failure

to progress" than others. Disagreements like this help to explain why caesarean rates for some physicians and hospitals are much higher than are those for others. The medicolegal restrictions on VBAC, vaginal birth after caesarean, have also increased the caesarean rate. As scheduled caesarean sections have become a rather safe operation, there has been a movement to perform caesarean delivery on maternal request (CDMR). There is also a consumer-driven movement to support VBAC as an alternative for repeat caesareans in the face of increased medico-legal restrictions on vaginal birth. Risks Statistics from the 1990s suggest that less than one woman in 2,500 who has a caesarean section will die, compared to a rate of one in 10,000 for a vaginal delivery. However the mortality rate for both continues to drop steadily. The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth. However, it is not possible to directly compare the mortality rates of vaginal and caesarean deliveries as women having the surgery are often those who were at a higher risk anyway. A study published in the June 2006 issue of the journal Obstetrics and Gynecology found that women who had multiple caesarian sections were more likely to have problems with later pregnancies, and recommended that women who want larger families should not seek caesarian section as an elective. The risk of placenta accreta, a potentially lifethreatening condition, is 0.13% after two c-sections, and increases to 2.13% after four and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk of emergency hysterectomies at delivery. The findings were based on outcomes from 30,132 cesarean deliveries. Babies born by caesarean sometimes have some initial trouble breathing. In addition, because the baby may be drowsy from the pain medication administered to the mother, and because the mother's mobility is reduced, breastfeeding may be difficult. A caesarean section is a major operation, with all that it entails, including the risk of postoperative adhesions. Pain at the incision can be intense, and full recovery of mobility can

take several weeks or more. A prior caesarean section increases the risk of uterine rupture during subsequent labour. If a CS is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anesthesia risk. Anaesthesia The mother has the option of receiving regional anaesthesia (spinal or epidural) or general anaesthesia for caesarean section. Regional anaesthesia has the advantage of allowing her to remain awake for the delivery and avoids sedation of the newborn. Pain relief after the caesarean is also improved. General anaesthesia for caesarean section is becoming less common as scientific research has now clearly established the benefits of regional anaesthesia for both the mother and baby. General anaesthesia tends to be reserved for emergencies where the mother or baby's life is immediately threatened or other high-risk cases. The risks of general anaesthesia for mother and baby are still extremely small overall. If the mother already has an epidural in this epidural can often be used for the caesarean section. Multiple recent studies have now shown that epidurals in labour do not increase the caesarean section rate (Meta analysis 2005 Anim-Somuah, Cochrane Review) but they may increase the risk of a forceps or instrumental delivery. At least one study however, has found that the risk of c-section doubles if the epidural is placed before the mother has reached 5cms cervical dilation. For this reason many UK hospitals are reluctant to give epidural anaesthesia before this stage. Epidurals placed after 5cms dilation is achieved do not affect chance of c-section. Epidurals traditionally have been known to slow down the progress of labour, but recent work has shown that they may actually speed up the labour process (COMET Study, Lancet 2001). This is because in women who are tense, exhausted and in pain labour can slow, and the "break" provided by the epidural which allows many women to sleep for a few hours, allowing her to relax enough to dilate fully and gather strength for the second (pushing) stage of labour. Deep transverse arrest, where the baby's head becomes lodged in the birth canal, can be a

complication of epidural anaesthesia because the tone of the pelvic floor, which helps to turn the baby's head as it passes through the pelvic bones, can be reduced or lost. To avoid this complication (which always results in forceps/ventouse/c-section delivery) experienced care-givers will often instruct the labouring woman not to push until the head is visible during contractions, ensuring it has already turned to pass under the pubic arch.

XII. Bibliography: Book Sources: Doenges, Marilyn E. et al. Nurse’s Pocket Guide. F.A. Davis Company, 2004. Doenges, Marilyn E. et al. Nursing Care Plans. F.A. Davis Company, 2002. Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincot Williams and Wilkins, 207. Sia, Maria Loreto J. Outline in Obstetrics A Textbook and a Reviewer. Quezon City: RMSIA Publishing, 2005. Internet Sources: http://en.wikipedia.org/wiki/Caesarian_section http://search.yahoo.com/search?p=diagnostic+procedure+for+Premature+rupture+of+membrane &vc=&fr=yfp-t-501&toggle=1&cop=mss&ei=UTF-8&fp_ip=PH http://www.caesarian.eu/ http://www.emedicine.com/med/topic3246.htm

http://www.merck.com/mmpe/index.html

http://www.moondragon.org/obgyn/pregnancy/placenta.html

http://www.moondragon.org/obgyn/pregnancy/prom.html

V. Diagnostic Procedures A. Ideal •

Ultrasound

- a diagnostic imaging technique which uses high-frequency. sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels. •

Amniocentesis

-a medical procedure during which a long, thin needle is inserted through the abdominal and uterine walls, and into the amniotic sac. A sample of amniotic fluid is withdrawn through the needle for examination.

•

Cervical cerclage

-a procedure in which the cervix is sewn closed; used in cases when the cervix starts to dilate too early in a pregnancy to allow the birth of a healthy baby.

•

Complete Blood Count

-a complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test requested by a doctor or other medical professional that gives information about the cells in a patient's blood. A lab technician (diploma holder) or technologist (bachelor holder) performs the requested testing and provides the requesting Medical Professional with the results of the CBC. A CBC is also known as a "hemogram".

The cells that circulate in the bloodstream are generally divided into three types: white blood cells (leukocytes), red blood cells (erythrocytes), and platelets or thrombocytes. Abnormally high or low counts may indicate the presence of many forms of disease, and hence blood counts are amongst the most commonly performed blood tests in medicine, as they can provide an overview of a patient's general health status. A CBC is routinely performed during annual physical examinations. Methods

• Samples A phlebotomist collects the specimen, in this case blood is drawn in a test tube containing an anticoagulant (EDTA, sometimes citrate) to stop it from clotting, and transported to a laboratory. In the past, counting the cells in a patient's blood was performed manually, by viewing a slide prepared with a sample of the patient's blood under a microscope (a blood film, or peripheral smear). Nowadays, this process is generally automated by use of an automated analyzer, with only specific samples being examined manually.

• Automated blood count The blood is well mixed (though not shaken) and placed on a rack in the analyzer. This instrument has many different components to analyze different elements in the blood. The cell counting component counts the numbers and types of different cells within the blood. The results are printed out or sent to a computer for review. Blood counting machines aspirate a very small amount of the specimen through narrow tubing. Within this tubing, there are sensors that count the number of cells going through it, and can identify the type of cell; this is flow cytometry. The two main sensors used are light detectors, and electrical impedance. One way the instrument can tell what type of blood cell is present is by size. Other instruments measure different characteristics of the cells to categorize them.

Because an automated cell counter samples and counts so many cells, the results are very precise. However, certain abnormal cells in the blood may be identified incorrectly, and require manual review of the instrument's results and identify any abnormal cells the instrument could not categorize. In addition to counting, measuring and analyzing red blood cells, white blood cells and platelets, automated hematology analyzers also measure the amount of hemoglobin in the blood and within each red blood cell. This information can be very helpful to a physician who, for example, is trying to identify the cause of a patient's anemia. If the red cells are smaller or larger than normal, or if there's a lot of variation in the size of the red cells, this data can help guide the direction of further testing and expedite the diagnostic process so patients can get the treatment they need quickly. Automated blood counting machines include the Beckman Coulter LH series, Sysmex XE-2100, Siemens ADVIA 120 & 2120, and the Abbott Cell-Dyn series.

• Manual blood count Counting chambers that hold a specified volume of diluted blood (as there are far too many cells if it is not diluted) are used to calculate the number of red and white cells per litre of blood. To identify the numbers of different white cells, a blood film is made, and a large number of white cells (at least 100) are counted. This gives the percentage of cells that are of each type. By multiplying the percentage with the total number of white blood cells, the absolute number of each type of white cell can be obtained. The advantage of manual counting (using helper tools like Grid cell counter) is that blood cells that may be misidentified by an automated counter can be identified visually. It is, however, subject to human error and sampling error because so few cells are counted compared with automated analysis. A complete blood count will normally include: Red cells

•

Total red blood cells - The number of red cells is given as an absolute number per litre.

•

Hemoglobin - The amount of hemoglobin in the blood, expressed in grams per decilitre. (Low hemoglobin is called anemia.)

•

Hematocrit or packed cell volume (PCV) - This is the fraction of whole blood volume that consists of red blood cells.

•

Red blood cell indices o

Mean corpuscular volume (MCV) - the average volume of the red cells, measured in femtolitres. Anemia is classified as microcytic or macrocytic based on whether this value is above or below the expected normal range. Other conditions that can affect MCV include thalassemia and reticulocytosis.

o

Mean corpuscular hemoglobin (MCH) - the average amount of hemoglobin per red blood cell, in picograms.

o

Mean corpuscular hemoglobin concentration (MCHC) - the average concentration of hemoglobin in the cells.

•

Red blood cell distribution width (RDW) - a measure of the variation of the RBC population

White cells •

Total white blood cells - All the white cell types are given as a percentage and as an absolute number per litre.

A complete blood count with differential will also include: •

Neutrophil granulocytes - May indicate bacterial infection. May also be raised in acute viral infections.Because of the segmented appearance of the nucleus, neutrophils are sometimes referred to as "segs." The nucleus of less mature neutrophils is not segmented, but has a band or rod-like shape. Less mature neutrophils - those that have recently been released from the bone marrow into the bloodstream - are known as "bands" or "stabs". Stab is a German term for rod.

•

Lymphocytes - Higher with some viral infections such as glandular fever and. Also raised in lymphocytic leukaemia CLL. Can be decreased by HIV infection. In adults, lymphocytes are the second most common WBC type after neutrophils. In young children under age 8, lymphocytes are more common than neutrophils..

•

Monocytes - May be raised in bacterial infection, tuberculosis, malaria, Rocky Mountain spotted fever, monocytic leukemia, chronic ulcerative colitis and regional enteritis

•

Eosinophil granulocytes - Increased in parasitic infections, asthma, or allergic reaction.

•

Basophil granulocytes- May be increased in bone marrow related conditions such as leukemia of lymphoma.

A manual count will also give information about other cells that are not normally present in peripheral blood, but may be released in certain disease processes. Platelets •

Platelet numbers are given, as well as information about their size and the range of sizes in the blood.

Interpretation Certain disease states are defined by an absolute increase or decrease in the number of a particular type of cell in the bloodstream. For example:

Type of Cell

Increase erythrocytosis

Red Blood Cells (RBC)

Decrease or anemia or erythroblastopenia

polycythemia White

Blood

Cells leukocytosis

leukopenia

-- lymphocytosis

-- lymphocytopenia

(WBC): -- lymphocytes

--- granulocytes:

granulocytopenia

or

-- granulocytosis agranulocytosis

-- --neutrophils

-- --neutrophilia

-- --neutropenia

-- --eosinophils

-- --eosinophilia

-- --eosinopenia

Platelets

thrombocytosis

thrombocytopenia

All cell lines

---

pancytopenia

Many disease states are heralded by changes in the blood count: •

leukocytosis can be a sign of infection.

•

thrombocytopenia can result from drug toxicity.

•

pancytopenia is generally as the result of decreased production from the bone marrow, and is a common complication of cancer chemotherapy.

B. Actual Complete Blood Count Results: Diagnostic Test WBC

Result 12.4 x 10^ 9/L

Reference Values 4 – 10

Interpretation

Significant Value

High

If high, leukocytosis If low, leukopenia If high,

Lymph#

1.1 x 10 ^ 9/L

.8 – 4.0

Normal lymphocytosis If low, lymphocytopenia

Mid#

1.6 x 10^9/L

.1- .9

High

Gran#

9.7 x 10^9/L

2.0-7.0

High

If high, granulocytosis If Low, granulocytopenia

Lymph%

8.6 %

20-40

Low

If high, leukocytosis If low, leukopenia

Mid%

13 %

3.0-9%

High

Gran%

78.4%

50-70%

High

If high, granulocytosis If Low,

granulocytopenia Hemoglobin

131 g/L

110-150

Normal

RBC

4.36x10^ 12/L

3.5-5.0

Normal

If high, erythrocytosis or polycythemia If low, anemia or erythroblastopenia

Hematocrit

40.6%

37-48

Normal

If high, Erythrocytosis If low, anemia

MCV

93.2fL

82 – 95

Normal

MCH

30.0 pg

27-31

Normal

MCHC

322 g/L

320-360

Normal

RDW-SD

46.8 fL

35-56.0

Normal

Platelet

319x10^9L

100-300

High If high, thrombocytosis If low, thrombocytopenia

MPV

7.0fL

7 – 11

Normal

PDW

15.3

15- 17

Normal

PCT

.223%

.108-.282

Normal

BLOOD TYPE: O

IV. PERSON ASSESSMENT: JUNE 23, 2008

P

Jesary Espiritu, 23 and at the early adulthood

stage

of

development,

is

admitted due to lumbosacral pain and continuous leakage of vaginal fluid. She lives at Cabaroan Daya, Vigan with her parents, four siblings and her partner. Before

hospitalization,

she

works

at

Benjo’s drugs as a saleslady and does some household chores like cleaning, washing the clothes and cooking their foods. When I handled her as my patient, she appears weak and complains pain on her abdomen that

radiates

to

her

back.

During

orientation, she speaks in Ilokano and restless. She has a little knowledge about her

condition

as

evidenced

by

the

verbalization of the patient as: “Apai gamin ta kastoy, nakasaksakit met haan mo man

E/A

pay lang ikabkabil dayta ah (stethoscope).” -During my shift, (she was transferred to DR At 9:05a.m.) she did not defecate nor urinated.

R

-With time of sleep less than 1 hour due to labor pain. -instructed patient to have bed rest to prevent cord prolapse.

S

-with no known allergies to food and drugs. -with medication (Hydralazine, Tramadol) taken regularly as prescribed. -BP-130/90mmHg -Temp-36.6oC per axilla. -with fair but dry skin -with IVF of D5LR -no wounds -WBC count-12.4 x 10^ 9/L

O

-Lymphocyte count-1.1 x 10 ^ 9/L - rapid breathing, clear breath sounds with no cough. -respiration-37 cycles per minute -pulse rate-61 beats per minute -Hgb count-131 g/L -Hct count-40.6%

N

-with an IVF of D5LR 1L regulatef at 25 gtts/min at right basilic vein -on NPO.

June 24,2008

P

-During orientation, she lies on her bed and gradually changes her position. -still weak in appearance

E

-complains post-operative pain. -with an IFC at 100 cc level at 9:00 a.m. with yellowish color of urine and at 250 cc level when pulled out at 11:30 a.m. -(-) bowel movement

A/R

-with lochial discharge. - (+) Difficulty in moving and complains pain when moving but increased activity tolerance. -had 5 hours of sleep. -she does walking as tolerated in the

S

afternoon. -no allergies to food and drugs. -with

medications

taken

regularly

as

prescribed. -with

post

operative

wound

at

the

abdominal area. -BP-130/90mmHg -Temperature-37.90C per axilla with fever and taken PRN meds (Paracetamol 1 amp, IV) -WBC count-12.4 x 10^ 9/L -Lymphocyte count-1.1 x 10 ^ 9/L

O

-clear breath sounds -rapid breathing -Respiration- 37cpm -Pulse rate- 91 bpm -Hgb count-131 g/L -Hct count-40.6%

N

-with an IVF of D5Lr 1L regulated at 28 gtts/min inserted at right cephalic vein. -still on NPO in the morning and shifted to liquid diet in the afternoon.

II. Patient’s Profile:

Name: Jesary Espiritu Age:23 years old

Address: Cabaroan Daya, Vigan City Civil Status: Single Educational Attainment: High School Graduate at Vigan National High School West Elementary: Cabaroan Daya Elementary School Date of Birth: June 22, 1985 Occupation: Saleslady Religion: Roman Catholic

Hospital Profile: Date Admitted: June 23, 3008 Agency: Gabriela Silang General Hospital Ward: OB Ward Chief Complaint: Lumbosacral Pain Admitting Diagnosis: Premature Rupture of Membarane Admitting Physician: Dr. Judylyn Eugenio OB History: G1P0 LMP: September ?, 2008 EDC: June ?, 2008 Vital Signs: June 23, 2008: BP: 130/90 mmHg

130/90 mmHg

PR: 61 bpm

91 bpm

RR: 37 cpm

37 cpm

Temp: 36.6 oC per axilla

37.9oC per axilla

FHT: 138

III. History of Past and Present Illness: Past Illnesses:

June 24, 2008

My patient, Jesary Espiritu has an OB history of G1P0, started to have menstruation when she was 14 years old and according to her she received complete immunization, “adda gamin center diay barangay mi ading su ti nagpatudukan ni nanang kinyak.” During assessment, she told me that there were no severe diseases that she experienced before but just simple headache and fever and during her childhood years, she had had chicken pox and measles, she also added that she never experienced to be confined in the hospital. When I asked the patient if there are diseases relating to pregnancy or reproductive system in their family, she answered none and added, “ni tatang ko lang ti malagip ko nga nagasaksakit idi ngem asthma met ken adda TB na, naconfine idi ngem diay ngato (medical ward) ken ni manong ngem gapu met diay saka ta nu pinagsiksikog awan met problema ken diay pamilya mi.” Past Illnesses 1) Fever 2) Headache

Medications taken Consulted Paracetamol Paracetamol, Alaxan

Not Consulted  

Present Illnesses: It was afternoon of June 21, 2008 (Saturday) when my patient experienced pain on the part of her abdomen radiating on her back. She then rested for a while thinking that it would relieve the pain and told me, “idi Sabado ket nasakit ngem haan unay ngem di dumteng ti Domingon ket alla kumaro metten diay sakit nan.” According also to her it was still Thursday 4 days before she was admitted she experienced leakage of fluid from her vagina and experienced continuous urination. Due to persisting pain and leakage of fluid she thought that she will already deliver her baby so her mother rushed her at Gabriela Silang General Hospital last June 23 at dawn and admitted at the same day. When I handled her as my patient, June 23, morning, she was already in labor and experiencing increased episodes of lumbosacral pain. During assessment, she told me that she experienced drinking alcohol but only in a little amount and told me, “bassit met laeng ken diay sigarilyo diak met pinadpadas.” She had experienced prenatal check-up twice during her pregnancy and regarding her diet, she eats everything. She also does some heavy works before like washing their clothes and lifting heavy objects. She was transferred to Delivery room at 9:05 am on the same day she was admitted but transferred

to Operating Room qt 1:40 p.m. and delivered a baby girl at 1:45 p.m. trough a caesarean section.

VII. Pathophysiology: A. Algorithm

RISK FACTORS: Infection of the membranes (Chorioamnionitis) Cigarette Smoking during pregnancy Overdistention in multiple pregnancy Hydramnios Abruptio Placenta

Idiopathic cause

Over distention of the membranes

Rupture of Amnion and Chorionic membranes

Leakage of Amniotic Fluid

amount of Amniotic Fluid

pH of Vagina increased risk for infection Signs and Symptoms: *Fever

pressure between the membranes and fetal parts

Compression of

Cord

umbilical cord by

Prolapse

fetal parts

* Increased WBC Pulmonary

Potter like

Hypoplasia

Syndrome

Fetal Circulation Impairment

Fetal Hypoxia

XI. Summary and Copy of Updates: Premature rupture of membranes is a rupture of fetal membranes with loss of amniotic fluid during pregnancy between 36-40 weeks. The cause of PROM is unknown but the most common cause is infection, Hydramnios, overdistention uterus in multiple pregnancy and smoking. Signs and symptoms of PROM include: •

Leakage of fluid in the vagina (main manifestation of PROM)

•

Constant wetness in the underwear

•

The passage of fluid is followed by signs of labor: cervical dilatation, uterine clamping, and pelvic pressure.

Complications of PROM: •

Premature labor and delivery of fetus

•

Infections

•

Cord Prolapse that may cause fetal hypoxia.

Management of PROM: •

Hospitalization

•

Mother is put into bed rest

•

If PROM occurred at term and labor does not begin in 24 hours, labor induction is performed to prevent infection from prolonged rupture of membranes.

Frequency: •

Prom occurs in about ten percent of all pregnancies.

- My patient Jesary Espiritu was admitted because of Premature rupture of membranes, and the signs of PROM like leakage of vaginal fluid was first experienced 4 days before

she was run in the hospital. She gave birth to a baby girl last June 23, 2008 thru a caesarean section and discharged after one week of staying at the hospital. B. Explanation: Premature Rupture of Membranes is rupture of fetal membranes with loss of amniotic fluid during pregnancy between 36-40 weeks of pregnancy. The cause of Premature rupture of membranes is unknown but it is usually associated with infection of membranes (Chorioamnionitis). It occurs 5-10% of pregnancies. Premature rupture of membranes results from over distention of the membranes and this causes leakage of Amniotic Fluid and that causes many complications. This leakage causes an alteration on the pH of vagina because the amniotic fluid is alkaline and in turn increases risk for maternal infection. Amniotic fluid serves as the cushion between the fetal parts and the fetal membranes so the decreased amount of it causes an increase pressure between the membranes and fetal parts that leads to potter like syndrome on the fetus when delivered. Yet another complication for the fetus to stay in the non-fluid environment is the compression of umbilical cord by fetal parts and also cord prolapse (extension of the cord out of uterine cavity into the vagina) a condition that can interfere with fetal circulation thereby causing fetal hypoxia. If PROM is diagnosed without infection, they prolong pregnancy to provide more time for fetal lungs to develop and mature. But if PROM is diagnosed with infection mother goes antibiotic therapy and labor induction to prevent fetal infection and sepsis.

C. Promotive and Preventive: To prevent PROM and other complications of Labor, a pregnant woman should: •

Have Pre-natal check up with the following schedules:

*From first visit to 32 weeks: every 4 weeks *From 32 to 36 weeks: every 2 weeks *from 36 weeks until delivery: every week •

Must complete her immunization of Tetanus Toxoid:

*TT1: Anytime during pregnancy (usually on the second trimester) *TT2: One month after TT1. gives 3years protection to the mother and protects infant from neonatal tetanus *TT3: Six months after TT2. gives 5 years protection to the mother anom neonatal tetanus. *TT4: One year after TT3/next pregnancy. Gives ten years protection to the mother and prevents neonatal tetanus. *TT5: One year after TT4 and gives lifetime protection to the mother and infants are protected. •

Refrain from drinking and smoking.

•

Consult her health care provider if she feels any unusual signs of pregnancy (severe bleeding, leakage of fluid in the vagina)

•

If there is any leakage of fluid, hospitalization is necessary.

•

If PROM is diagnosed, put mother on bed rest to prevent cord prolapse.

•

Stop exercising if diagnosed with PROM already.

•

Undergo labor induction if PROM occurred at term and labor does not begin in 24 hours to prevent infection from prolonged rupture.

DIET: Daily Food Guide for Filipino Pregnant Women Rice and alternatives 5 ½-6 cups of cooked rice where: 1 cup of cooked rice is equivalent to any of the following:

Fish, meat, poultry, dried

•

4pcs pandesal of about 17 grams each

•

4 slices of loaf bread of about 17 grams each

•

1 pack of 30g instant noodles

•

1 cup cooked macaroni or spaghetti

•

1 small-sized root crop, about 180g or 1 cup

cooked, diced root crop At least 3 ½ servings where:

beans or nuts 1 serving of cooked meat is equivalent to: •

30g or 30 cm cube

•

2 pieces medium-sized (55-60g each or about 16 inches long) fish

• Egg Milk

1 ½ cup cooked dried beans or nuts at least 3x a

week 1piece 3-4 times a week 1 glass whole milk (equivalent to 4 tablespoons of powdered whole milk or ½ cup of evaporated milk diluted with ½ cup of water.

Vegetables Green leafy Others Fruits Vitamin C-rich Others Fats and oils Sugar Water and beverages

3/4 cup cooked 1 cup cooked 1 medium size fruit or 1 slice of a big fruit 1 medium size fruit or 1 slice of a big fruit 7 teaspoons 6 teaspoons 6-8 glasses, 240 ml per glass

*Source: Nutritional Guidelines for Filipinos, 2000. Food and Nutrition Research Institute-Department of Science and Technology

X. Discharge Plan:

M-

edications:

-continue medications as prescribed by the physician -take antibiotics for presence of infection if prescribed.

E-

xercise

- active range of motion on extremities (flexion and extension) since patient undergone major operation and these prevent contractures on the muscles. - gradual ambulation without strenuous activities. - deep breathing and coughing exercises to prevent hypostatic pneumonia. - turning exercises in bed to prevent pressure ulcers.

T-

reatment:

- must continue medications and should follow all the orders of the physician.

H-

ealth Teachings:

- support the incision site. - take a rest. - commit self in diversional activities to alleviate pain.

- upon resuming normal diet, eat foods rich in protein and Vitamin C for faster wound healing and prevent infection.

O-

PD

- have follow up check up every 2 weeks for the first month with her baby after hospitalization and once a month for the succeeding months. - She must complete her baby’s immunization.

D-

iet

Foods to Eat more Foods to take in moderation Green Leafy vegetables Fatty foods High in protein foods Raw foods High in Vitamin C foods Have a balanced diet and a variety of nutritious foods.

IX. Drug Study

Name

Ordered Dose

Mechanism of Action

Tramadol

-100mg slow IV every -centrally

Hydrochloride

8 hours

Indication

Contraindication

acting -relief of moderate to -contraindicated

synthetic analgesic not moderately

severe patients

Adverse Reaction in -potential for abuse

with -anaphylactoid

chemically related to pains.

hypersensitivity

opioids.

tramadol opioids

or or

intoxication

to reactions

Nursing Responsibility -reassess patient’s level of pain at least 3o minutes

after

other -Nausea and Vomiting

administration.

acute -Seizures

-Monitor

with -dizziness

CV

and

respiratory status. With

alcohol or psychoactive

hold

drugs.

respirations decrease or

-use

cautiously

pregnancy, sezures,

in

lactation, contaminant

use of CNS depressants

rate

dose

is

below

if

12

breaths/minute. -for

better

analgesic

effect, give drug before

or

MAOI’s,

renal

onset of intense pain.

dysfunction, or hepatic

-monitor risk for drug

impairment.

dependence.

Name Hydralazine Hydrochloride

Ordered Dose 25mg IV

Mechanism of Action Acts

directly

vascular muscle

Indication

on Parenteral:

Contraindication severe -contraindicated

smooth essential hypertension hypersensitivity to

cause when

drug

can

Adverse Effects

with -headache to -orthostatic

be hydralazine

hypotension

Nursing Responsibility -assess hypersensitivity to hydralazine. -give oral drug with

vasodilatation, primary given orally or when -use cautiously with -nausea and vomiting

food

arteriolar, maintains or need to lower Bp is CVAs or severe renal -rashes

bioavailability

increases

should be given in a

renal

cerebral blood flow.

and urgent.

impairment those

and

taking

antihypertensives.

in -lupuslike syndrome other

to

increase (drug

constant relationship to ingestion of food for consistent response to therapy) -use

parenteral

immediately opening

drug after

ampule.

Hydralazine

changes

color after contact with metal and discolored solutions

should

be

discarded. -withdraw gradually

drug especially

from patients who have experienced marked BP reduction.

Rapid

withdrawal may cause a

possible

increase in BP.

sudden

Name Paracetamol

Ordered Dose 1 ampule IV PRN

Mechanism of Action -thought

to

Indication

Contraindication

produce -relief of mild pain or -contraindicated

analgesia effect.

fever.

Adverse Effects in -rashes

Responsibility -many OTC and

patient’s hypersensitive -hypoglycemia

prescription

to drugs.

contain acetaminophen.

-use

cautiously

in

patients

alcohol

difficulty

use

because

epatotoxicity in these patients.

products

-use liquid form for

patients with long term

therapeutic doses cause

B. Nursing Care Plan

Nursing

who

swallowing.

have of

Assessment

Nursing Diagnosis

Scientific Background

Nursing Interventions

Rationale

Evaluation

Objectives -after 30 minutes Independent:

Cues: S: “Nagsakit ditoy

met

ayan

ti

tiyan ko apti toy likod ko, haan ko kayan nak

Nursing

aganak san!”

as

verbalized by the patient.

Related

in

to

uterine contractions and

tissue

stretching.

S:

Lumbosacral

Facial Grimace

>facial grimace

appearance

E:

and due to pressure of fetal interventions

pain

O:

>weak

P: Chronic Pain

Pain due to uterine contractions, of

rendering >assessed pain reports, >indicates

stretching of cervix and perineum nursing

need

for a.m.

noting location, intensity, interventions and may After 30 minutes to frequency and time of signal development of of

presenting part on surrounding the patient, she onset. organs.

June 23,2008 8:50

Note

nonverbal complications.

nursing

would experience cues. lesser

pain

manifested decreased and

reports

as >Instructed

rendering

interventions, patient

to >efficacy

by report pain as it develops measures

of

comfort patient

and complains of pain

pain rather that waiting until medications is improved but of level is severe.

with timely intervention. palliative >promotes

still

was

slightly

decreased due to

decreased

>Performed

intensity of pain

measures like massage on decreases muscle tension. interventions done the affected area.

relaxation/ nursing

as evidenced by

>instructed patient with >promotes relaxation and lesser reports of

>complains

deep-breathing

Lumbosacral

techniques.

pain

Collaborative:

Increased

>Administer

>provides

Respiratory Rate

analgesics/antipyretics.

pain.

(Tachypnea): 37 cpm

to assist muscle.

pain.

Goal

partially met.

relief

from

was

Assessment Cues:

Nursing Diagnosis

S: “Nagbara

toy

mairkriknak,”

as

verbalized by the

to

secondary

to preterm rupture of

O: >Fever- 37.9oC at 8 a.m. 38.10C at 10:00

Related

a.m.

membranes

without

accompanying labor.

S: >fever

(temperature taken last June 24,2008) >Increased

client’s temperature

a day >

Promoted

Rationale

>Increased

the tepid

sponge

body immersion, will of

local

Evaluation June 25, 2008 7:45

surface > Cold application entails a.m. dissipation

bath, evaporation

via

After a day of

and rendering

application conduction. Thus, heat is interventions, ice

packs lost

thereby

subsiding client’s

nursing the body

subside as would be especially on the groin or fever.

temperature subsided

manifested by a body axilla.

as manifested by a

temperature ranging >

Provided

from 36.5 to 37.5 ventilation degrees

WBC count

Nursing Interventions Independent

of rendering nursing cooling by means of heat interventions,

infection

patient.

Nursing Objectives After

P: Hyperthermia E:

Scientific Background

Celsius, windows)

proper

body temperature of

(opening >

to

create

a

cool 37.4 degrees Celsius,

environment and as a absence of flushed

absence of flushed > Placed the client on means of convection.

and

and

warm-to-touch bed rest.

skin,

skin,

and

warm-to-touch and

WBC

count: 12.4 x 10^

> Placing the client on verbalization of the

verbalization of the

bed

rest

promotes client, “Haan unay

client, “Haan unay

relaxation

nabara ti riknakon.”

cause decreased oxygen Goal was met.

9/L

demand Collaborative: >

that

by

furthermore

the

would nabara ti riknakon.”

body

decreasing

Administered basal metabolic rate and

medications

as achieving decreased body

prescribed

by

physician

such

the temperature. as

antipyretic (Paracetamol 1 ampule).

> Reduces fever by acting directly

on

hypothalamic regulating

the heat-

center to

cause vasodilation and sweating,

which

helps

dissipate heat.

Assessment

Nursing Diagnosis

Scientific Background

Nursing Objectives

Cues: S:

P:

Reports of fatigue: “Nagsakit met gamin, agkakapsotak diak

pay

nga

payen

Activity

Intolerance

E:

the

patient.

to due to weakness and can

weakness labor pains.

Verbalization of

weakness

O: Increased

S:

Respiratory

Rate (Tachypnea): 37 cpm Weak in appearance

1-2

days

Tachycardia Weak in appearance Presence of pain

already

activities

report

tolerance

Evaluation

an and prevent injury. Bed a.m.

patient instituted bed rest.

rest is encouraged to After prevent cord prolapse.

measurable increase in >Promoted activity

Rationale

of >Assisted patient in all > to preserve strength June 24, 2008 11:40

Nursing her

endure daily activities interventions,

Related

makapigsa generalized

by

After

physiological energy to rendering

aggarawen,”as and Bed rest.

verbalized

Insufficient

Nursing Interventions Independent:

evidenced

by relief from pain.

increase

verbalization

of >Provided

of

nursing

comfort > enhances ability to interventions, reported

agpagna pagnan.”

day

rendering

as measures and provide participate in activities.

strength, “kayak met ti atmosphere

1

patient

measurable in

activity

positive > helps to minimize tolerance e.g. sitting, while frustration

acknowledging

rechannel energy.

and walking

in

near

distance and verbalized

difficulty of situation

“ kayak et ti agpagnan

for the client.

ti asideg.” Goal was

>Monitored Vital signs > to monitor maternal met.

Restlessness Complaints lumbosacral pain

every 30 minutes. of

>

Extremities

passively

and fetal distress. ate > exercise is helpful in

exercised preventing

through a full range of stasis motion.

which

venous may

predispose the patient to

thrombosis

and

pulmonary embolus. >

Position

gradually

changed > to prevent pressure.

Assessment Cues:

Nursing Diagnosis

P:

S: Inadequate knowledge

Scientific Background

Nursing Objectives

Knowledge Knowledge deficit due After

Deficit

1-2

to unfamiliarity of her rendering

on her condition as

condition

interventions,

days

Nursing Interventions Independent:

Rationale

of >Verified client’s level > provides opportunity June 24, 2008 8:00

nursing of knowledge about her to assure accuracy and a.m. her condition

completeness

of After

E: Related to first

knowledge about her

knowledge

verbalization of patient time of pregnancy and

condition will increase

future learning.

as: “Apai gamin ta unfamiliarity on

to be evidenced by >Determined

>provides

evidenced

kastoy,

by

the

her

nakasaksakit condition.

met haan mo man pay lang ikabkabil dayta ah (stethoscope).”

S:

Verbalization of

knowledge.

base

1

for rendering

day

of

nursing

interventions,

her

insight knowledge about her

cooperation to nursing motivation/expectations useful in developing condition is increased interventions

inadequacy

Evaluation

of

and for learning.

participate in learning process.

goals and identifying as information needs.

>Ascertained preferred >identifies methods of learning.

by

cooperation in nursing best interventions

and

approaches to facilitate learning process. Goal learning process.

>Identified/provided

evidenced

>use

of

multiple

was met.

information in varied formats

increases

formats appropriate to learning and retention client’s learning style. >Reviewed process

of material.

disease >provides

and

future base

expectations.

knowledge

from

patient

which

can

make

informed choices. Collaborative: >Identify

available >provides

additional

community

opportunities for role-

resources/support

modeling,

groups.

training,

skill anticipatory

problem solving.