• PATIENT’S DEMOGRAPHIC DATA NAME: MARIFE PRIMERO AGE: 28 YEARS OLD ADDRESS: GUIMBA STATUS: SINGLE OCCUPATION: HOUSE WIFE RELIGION: ROMAN CATHOLIC DIAGNOSIS: G1 P1 LCCS (PLACENTA PREVIA)
• Patient Marife Primero is a 28- year old Filipina female who is living with her family at Guimba, Nueva Ecija. Her religion is Roman Catholic. A non-smoker, non –alcoholic, and no allergies reported. Patient has placenta previa with bleeding during her delivery. Patient was admitted last March 11,2019 at ELJ, because of abnormal separation of the placenta. With that, patient undergone cesarean section.
Normal Placenta During Childbirth Process of placental growth and uterine wall changes during pregnancy • 1. The placenta grows with the placental site during pregnancy. • 2. During pregnancy and early labor the area of the placental site probably changes little, even during uterine contractions. • 3.The semi rigid, non-contractile placenta cannot alter its surface area.
• 1. The cotyledons of the maternal surface of the placenta extend into the decidua basalis, which forms a natural cleavage plane between the placenta and the uterine wall. • 2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches of the uterine arteries that run through the wall of the uterus to the placental area. • 3. The placental site is usually located on either the anterior or the posterior uterine wall. • 4. The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is located
I. Introduction to Disease The upper part of the uterus is the most favorable area for placental implantation because it is rich in blood and, therefore, nutrients and oxygen. The lower uterine segment is not and, therefore, it is possible that if the baby implants too low (lowlying placenta), risks of intrauterine growth restriction and preterm labor are much higher .During the last trimester, and especially in the last month, the lower uterine segment thins appreciably and pulls up a bit, which is what causes cervical effacement(thinning) and early dilatation. If the placenta is impinging on the lower segment and is not up in the fundus where it is supposed to be, then part of the placenta may dislodge and hemorrhage may occur. This condition is called PLACENTA PREVIA PLACENTA PREVIA Is an abnormal low implantation of the placenta in proximity to the internal cervical os. Placenta previa is a condition in which the placenta attaches to the uterine wall in the lower portion of the uterus and covers all or part of the cervix
Mothers who are above 35 years old and below 18 years old as well as to those multiparous mothers are at risk in developing placenta previa. In addition to that, mothers who have previous uterine surgery, large placenta that would include multiple gestation and erythroblastosis, and maternal smoking will also likely to develop placenta previa. When true placenta previa at term is very serious. Complications for the baby include (1) Problems for the baby, secondary to acute blood loss, (2) Intrauterine growth retardation due to poor placental perfusion, (3) Increased incide nce of congenital anomalies. The signs and symptoms of placenta previa vary, but the most common symptom is painless bleeding during the third trimester. Other reasons to suspect placenta previa would be include (a) Premature contractions, (b) Baby is breech, or in transverse position, (c) Uterus measures larger than it should according to gestational age.
• Some of the nursing actions that would manage the occurrence of placenta previa is to give drugs that can prevent premature labor or birth exa mple is progesterone. Ultrasound exams to determine migration of an early diagnosed previa or classification of the previa as total, partial, marginal, or low-lying would also help in managing placenta previa. When the client experience a small first bleed, client may sent home on bed rest if she can return to hospital quickly and if bleeding is more profuse client is required to be hospitalized on bed rest with BRP, IV access; labs: Hgb and Hct, urinalysis, blood group and type and cross match for 2 units of blood hold, possible transfusions; goal is to maintain the pregnancy fetal maturity. No vaginal exams are performed except under special conditions requiring a double set-up for immediate cesarean birth should hemorrhage result. Instruct patient to position herself in a low lying or marginal previas to allow vaginal delivery if the fetal head acts as tamponade to prevent hemorrhage. In some cases, procedure of Cesarean birth, often with vertical uterine incision, is used for total placenta previa. Steroid shots may be given to help mature the baby's lungs.
Predisposing Factors 1. Multiparity (80% of affected clients are multiparous) 2. Advanced maternal age (older than 35 years old in 33% of cases 3. Multiple gestation 4. Previous Cesarean birth 5. Uterine Incisions 6. Prior placenta previa ( incidence is 12 times greater in women with previous placenta previa)
• PLACENTA PREVIA THE EXACT CAUSE IS UNKNOWN. HOWEVER, THERE ARE SOME RISK FACTORS. MY PATIEnT HAS NO RISK FACTORS FROM THOSE WHAT I’VE MENTIONED. MOST PROBABLY, HER CAUSE IS UNKNOWN
Predisposing Factors Pregnancy Placental implantation Placental attachment and growth
Insufficient blood supply possibly secondary to inflammatory or atrophic changes Placenta migrates to where there is sufficient blood supply Placenta resides in the lower uterine segment
• Family History: No family history of Placenta Previa. • Past Medical/Surgical History - none • Menstrual History Age of menarche: 12 years old Cycle: Regular Duration of menarche: 28 days Interval of cycle: 6 days • Obstetric History: Gravida- 1 Para- 1 Abortions- 0 Fetal Death- 0 Died- 0 Alive-1
PHYSICAL EXAMINATION
ACTUAL VALUES
NORMAL VALUES
COLOR
STRAW
CLEAR STRAW TO COLORED LIQUID
APPEARANCE
CLEAR
CLEAR TO SLIGHTLY HAZY
REACTION
6.5
4.6-8
SPECIFIC GRAVITY
1.010
1.005-1.025
RESULT
NORMAL VALUES
WBC
H 15.19X10^3/uL
5-10x10^3/uL
Hemoglobin
122g/L
115-155g/L
Hematocrit
L 0.35
0.36-0.48
RBC
L 4.02
4.20-6.10x10^6/uL
IMPLICATIONS
RESULT
NORMAL VALUES
IMPLICATIONS
NEUTROPHIL
73%
55-75%
NORMAL
LYMPHOCYTES
L. 18%
20-35%
MONOCYTES
7%
2-10%
NORMAL
EOSINOPHIL
2%
1-6%
NORMAL
BASOPHIL
0%
0-1%
NORMAL
MCV
88.1fl
79.40-94.80 fl
NORMAL
MCH
30.3 pg
25.60-32.20pg
NORMAL
MCHC
34.5 g/dL
32.20-35.30 g/dL
NORMAL
Differential Count
ULTRASOUND RESULT IMPRESSION Presentation: Number: Amniotic Fluid: Placental location: Sex: LMP: EDD: FHB: Previa:
Biophysical profile: Amniotic Fluid: Fetal Tone: Fetal Breathing: Gross Movement: Total:
Cephalic Single AFI 11.1cm Anterior Boy June 10,2018 March 17,2019 147bpm Placenta Previa Totalis
2 2 2 2 8
ASSESSMENT
NURSING DIAGNOSIS
SCIENTIFIC INFERENCES
PLANNING
INTERVENTION
“Dinudugo ako. Sobrang dami. Pero wala namang masakit sakin.” As verballized by the patient.
Deficient Fluid Volume related to Active Blood Loss Secondary to Disrupted Placental Implantation.
Placenta pre via is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. Placen ta previa is a lifethreatening maternal ble eding typicall y necessitates t ermination of the pregnanc y. Maternal prognosis is good if hemorrhage can be controlled;
After 8 hrs of nursing interventio, the patient will be able to: - Demonstrate improve fluid balance as evidence by stable vital signs, good skin turgor and adequate urinary output.
INDEPENDENT - Establish Rapport. - Monitor VS - Assess color, odor, consistency and amount of vaginal bleeding; weighing pads. - Assess hourly intake and output.
RATIONALE -
-
-
-
To gain patient’s trust. - To obtain baseline data Provides info about active bleeding versus old blood, tissue loss and degree of blood loss. Provides info about maternal and fetal physiologic compensati on to blood loss
EVALUATION GOAL PARTIALLY MET After 8 hrs of nursing interventio, the patient was able to: - Demonstrate improve fluid balance as evidence by stable vital signs, good skin turgor and adequate urinary output.
ASSESSMENT
NURSING DIAGNOSIS .
VITAL SIGN TEMPERATURE : 36.6 °c PULSE: 78 bpm RESPIRATION: 19 cpm BLOOD PRESSURE: 90/60 Painless Bright Red Vaginal Bleeding Pallor Restlessness
SCIENTIFIC INFERENCES fetal prognosis depends on the gestational age and amount of blood lost. Anemia may be managed by blood transfusion to permit the pregnancy to continue in utero. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum hemorrhage (vaginal bleed ing). It affects approximately 0.5% of all labors.
PLANNING
INTERVENTION
RATIONALE
Dependent: - Initiate IV fluids as ordered - Provide supplemental O2 as ordered - Preparation for medication to be administered. - Preparation for possible OR
-
COLLABORATIVE
Lab works provides information about degree of blood loss; prepares for possible transfusion. Ultrasound provides info about the cause of bleeding.
Monitor lab. work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinlaysis, etc. Scheduled for ultrasound as ordered
-
For replacem ent of blood loss Interventi on increases available O2 to saturate decrease d hemoglob in
EVALUATION
NAME OF DRUGS CEFALEXIN
CLASSIFICATIONS
INDICATIONS AND CONTRAINDICATI ONS
SIDE EFFECTS AND ADVERSE EFFECTS
Binds to 1 or Cephalosporin more of the penicillinbinding proteins(PBPs) which inhibits the final transpeptidat ion step of peptidoglyca n synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell wall.
I: Skin of soft tissue infections. Uncomplicat ed UTI. Bone and joint infections; Respiratory tract infections. Streptococca l pharyngitis.
GI disturbances (eg. Nausea, vomiting, diarrhea, abdominal discomfort) dyspepsia; allergic reactions (eg. Rash, urticaria, angioedema ) genital candidiasis, vaginitis and vaginal discharge, dizziness, fatigue, headache, agitation.
ACTIONS
CI: Hypersensiti vity to cefalexin, other cephalospori n
NURSING RESPONSIBILITIES
EVALUATION
-
- Evaluat e for therape utic respons e. - Evaluat e for any side effects - Evaluat e for signs and sympto ms of infection .
-
-
Assess patient for infection. Monitor VS Assess patient’s intake and output Assess patient’s history to determine previous use of and reactions to penicillin and cephalosp orin.
NAME OF DRUGS
ACTIONS
CLASSIFICATIONS
INDICATIONS AND CONTRAINDICATI ONS
SIDE EFFECTS AND ADVERSE EFFECTS
NURSING RESPONSIBILITIES
-
-
-
Patients with negative history of sensitivity to this kind of medication may still have an allergic response. Monitor signs and symptoms of anaphylax is Proper preparati on and dosage medication s.
EVALUATION
NAME OF DRUGS
ACTIONS
CLASSIFICATIONS
INDICATIONS AND CONTRAINDICATI ONS
MEFENAMIC ACID
An anthracitic acid derivative is a prototypical NSAID. It reversibly inhibits the cyclooxygen ase-1 and 2 (COX-1 and -2) enzymes, thus resulting in reduced synthesis of prostaglandi n precursors.
NON STEROIDAL ANTI INFLAMMA TORY DRUGS (NSAIDs)
I: Pain and Inflammator y
SIDE EFFECTS AND ADVERSE EFFECTS
CHF (Congestive Heart Failure) CI: Hypersensiti HTN (Hypertensi vity to on), mefenamic acid, aspirin tachycardi or other a, syncope, NSAIDs. arrhythmia, Patient w/ vasculitis, inflammator hypotensio y bowel n, disease, palpitation active ulceration, or s, abdominal chronic inflammation pain, of the upper or lower GI tract,
NURSING RESPONSIBILITIES
EVALUATION
-
-
-
-
-
-
Proper preparati on and dosage of medication s. Check for any allergy. dose. Check doctor’s order. Assess for history of allergies to NSAIDs. Educate patient that prolonged use of any drug may damage liver.
-
Evaluate therapeu tic response. Evaluate for any side effects.
NAME OF DRUGS
ACTIONS It has analgesic and antipyretic properties with minor antiinflammato ry activity
CLASSIFICATIONS
INDICATIONS AND CONTRAINDICATI ONS
SIDE EFFECTS AND ADVERSE EFFECTS
NURSING RESPONSIBILITIES
renal failure, History of asthma, urticarial, allergic type reactions. Treatment of preoperative pain in the setting of CABG (Coronary artery bypass graft) surgery.
vomiting, dyspepsia, constipation, diarrhea, nausea, heart burn, GI perforation, peptic ulcer, flatulence, anemia
During: - Give drug wit food, milk or antacids. - Do not increase or double dose, follow exactly as prescribed and indicated. - Administer drug with full glass of water.
EVALUATION
NAME OF DRUGS
ACTIONS
CLASSIFICATIONS
INDICATIONS AND CONTRAINDICATI ONS
Serrapeptase
Is a preteolytic enzyme of Serratia spp source. When taken orally, it relieves inflammatio n and edema associated with trauma, infection or chronic venous insufficiency
AntiInflammatory Enzymes
I: Inflammati on and edema.
SIDE EFFECTS AND ADVERSE EFFECTS
NURSING RESPONSIBILITIES
EVALUATION
- 10 rights - Evaluate Skin rash, of therapeu diarrhea, medicati tic anorexia, on response. GI - Take - Evaluate disturbance history of for any s, epistaxis allergies. side (rare) - Take effects.
-
-
vital signs Watch out for allergies Instruct the patient about the medicati on.