Escolar Documentos
Profissional Documentos
Cultura Documentos
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
mothers health especially during the 9 months where the childs development has
already started. The mothers 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 mothers 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 weve 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 patients
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
2. Gather all necessary information regarding her and her family members as may be
related to our case study
3. Ascertain clients 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 clients 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
PATIENTS 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
After the completion of the case study, the student nurse shall be able to:
Present a comprehensive and detailed report regarding the patients illness
Have a complete picture of the patients physical, psychosocial and mental
status through daily assessment
Have a well-structured nursing diagnosis of the clients 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
patients anticipated needs
Provide relevant information on available alternative therapies and
management
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 5 th
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.
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
5
bleeding but she have a previous problem with serious of Urinary Tract Infection
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 5 th 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 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.
Father
Mother
(Arthritis)
Died (Cancer)
Older Brother
2nd Brother
Mrs. Nicole
Kidman
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
its 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 O 2
Nasal Canulla and IVF D5LRS FD 200CC.
5. Physical Examination
PHYSICAL EXAMINATION
36.6 OC
PR:
80 BPM
RR:
20 CPM
BP:
100/70 mmhg
37.3 OC
PR:
85 BPM
RR:
18 CPM
BP:
90/70 mmhg
10
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 patients
Straw
Clear straw to
colored liquid
and assessment
of body function.
- To help
Appearance
Clear
Clear to slightly
normal
hazy
discover
2. Notify the
diseases
6.5
1.010
4.6-8
1.005-1.025
renal
sample. Urine
To demonstrate disorders.
must be acquired
the
44
11
12
concentrating
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
CHEMICAL
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
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)
Responsibilities
1. Inform the
theres agglutination
compatibility
of the donor
test determines
and the
patient before
and B antigen is
transfusion.
2. Notify the
type is O
test blood
sample thus
venipuncture is
done.
3. Check the
patients history
for recent
administration of
blood, dextran or
I.V.
48
16
4. After the
procedure apply
direct pressure
to the
venipuncture to
the site until
bleeding stops.
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
infection or
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
g/L
Low HCT,
the amount of
the RBC
3. Inform the patient
that the procedure is
Hematocrit
L 0.35
0.36-0.48
percentage of
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pain.
nutritional
deficiencies,
the blood
volume
blood loss.
procedure, apply
direct pressure to the
venipuncture until
RBC
L 4.02
4.20-6.10
x10^6/uL x10^6/ uL
bleeding stops.
amount of RBC
5. Refer if
results to
venipuncture
anemia.
develops hematoma
Leukemia,
hemorrhage.
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
Normal
-Indicates the
nature and
volume of
hemoglobin, to
high may
indicate
spherocytosis or
in vitro
54
22
hemolysis
D. ULTRASOUND
-Presentation : Cephalic
Single, live
-Number: single
intrauterine
Nursing
Responsibilities
- To know fetal 1. Assure a
and
consent form
pregnancy,
pregnancy
signed by the
cephalic
abnormalities
patient. Explain
Date Test
10-17--09
2:35 pm
Result Impression
Rationale
55
23
-Sex: male
is painless and
-AOG: 32W 3D
-EDD: 10-11-08
BPD= 32 weeks
-FHB: 147bpm
differentiate
day
measurement
involved.
2. Emphasize the
importance of
totally covering
- To ensure
remaining still
Biophysical profile:
the OS (Placenta
the
-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
possible use
pillows to support
the area to be
examined. Coat
56
24
57
26
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.
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60
61
(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).
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(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
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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.
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
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.
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(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:
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(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.
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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
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,
shell
need
to
have
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
73
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
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 shes
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
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 shes less than
34 weeks,
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
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.
75
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
76
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
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
73
78
79
Nursing
Diagnosis
Scientific
explanation
Objectives
Interventions
Short term:
After 4 hrs. of
NI, patient will
verbalized the
pain is
controlled or
disappear
>Establish rapport
>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
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
80
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
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
81
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
Rationale
>establish
rapport
>to gain
patient
skin by
meanstrust
of
undressing
> to have
baseline
>monitor vital
data
sign
> to
promote
safety and
>promote
relax
comfort and
safety
> to assess
>assess patient
complain
> explain to
patient the
condition
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
82
c. Drugs
Name of Drugs
Date ordered
Route of admin
General action
Indication
Clients
response to the
Medication with
actual Side
Effect
83
Generic name:
Cefuroxime
Brand name:
Ceftin
Generic name:
Acetaminophen
Brand name:
Paracetamol
Generic name:
Follic acid
Brand name:
Folvite
>Inhibits synthesis
of bacteria cell
wall, causing cell
death.
>Lower respiratory
infections caused by
S. Pneumoniae, H.
Para influenza, H.
Influenza
Patient response
effectively with no
side effect noted.
>Reduces fever by
acting directly on
the hypothalamic
heat regulating
center to occur
vasodilator and
sweating which
helps dissipate
heat.
>Analgesic anti
pyretics in patients
with aspirin allergy,
hemostatic
disturbances
bleeding diatheses,
quoty artitis
Patient response
effectively with no
side effect noted.
>Stimulate normal
erythropoiesis and
nucleoprotein
synthesis
>To prevent
megaloblastic anemia
during pregnancy to
prevent fetal damage
Patient response
effectively with no
side effect noted.
84
Type of Diet
DAT
Date Ordered:
Date Started:
DO: 10-17-09
DS: 10-17-09
General
Description
Indication /
Purpose
To facilitate reduction of
sodium in the body,
thus reducing edema
and ascites.
Clients
Response /
reaction to the
diet
The patient refuses to
eat.
Nursing Responsibilities:
85
86
HEALTH TEACHINGS
* Encourage patient to express feelings and concerns
So that relief measure may be instituted
89
normal period
wound separation
redness or oozing at the incision site
severe abdominal pain
use relaxation
*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
the
Encourage ambulation
internal
equilibrium
. Provide a safe and comfortable environment because it could make the
preventing infections
Give client some lectures about proper wound care through changing the
vegetables rich in vitamin C for the production of milk needed for lactation.
Taking food rich in protein is also helpful for tissue repair.
89
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)
90