Republic of the Philippines

Tarlac State University

College of Nursing
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph
________________________________________________________________________

A Case Study on Placenta Previa

In Partial Fulfillment
Of the Requirements of the Subject
NCM 101

Presented by:

BSN III Group A1

Abraham, Aliana Kristel P.

Acena, Honey Lei
Aganon, Christian Lloric C.
Aguinaldo, Ademar A.
Alfonso, Tracy Oliver T.
Bautista, Ellein T.
Campana, Rhomyrose S.
Canlas, Mary Ann M.
Capian, Jeiel Ann D.
Capuno, Michael M.
Cariaga, Miriam Thea Consuelo J.

Presented to
Ms. Gienelle Mallari, RN

1
 Table of Contents
I. Introduction………………………………………………………………………...1
Objectives………………………………………………………………………….5
II. Nursing Process
A.Assessment
1. Personal Data………………………………………………………….…….6
a)Demographic Data…………………………………………….……..6
b)Environmental Status……………………………………….………..6
c)Lifestyle………………………………………………………………7
2.Family History of health and Illness
3. History of Past Illness…………………………………………….….………9
4.History of Present Illness…………………………………………….……….9
5.Physical Assessment...........................................................................................9
6.Diagnostics and laboratory Procedures………………………..…………….18
7.Anatomy And Physiology……………………………………...…………….19
8.Pathophysiology
i.Book-based……………………………………………..…………….24
ii.Client-based…………………………………………..……………...26
B. Planning
1. Nursing Care Plans………………………………………….……………..28

C.Implementation
1.Medical Management
i.IVFs,BT,NGT feeding,Nebulization,TPN,Oxygen Therapy etc……36
ii.Drugs………………………………………………………………..42
iii.Diet…………………………………………………………………46
iv.Activity/Exercise…………………………………………………...49
2.Surgical Management……………………………………………………….51
3.Nursing Management(SOAPIE)…………………………………………….53
D.Evaluation
1.Patient’s Daily Program in the hospital……………………………………...60
2.Discharge Planning…………………………………………………………..61

III. Conclusion…………………………………………………………………………62
IV. Recommendation…………………………………………………………………..62
V. Bibliography……………………………………………………………………….63

INTRODUCTION
2
 Placenta previa is a condition in which the placenta is located low in the uterine cavity,
partially or completely covering the opening of the cervix. This can cause bleeding and interfere
with a normal vaginal delivery. Placenta previa occurs in four degrees: implantation in the lower
uterine rather than in the upper portion of the uterus (low-lying placenta); marginal implantation
(the placenta approaches that of cervical os); implantation that protrudes a portion of the cervical
os (partial placenta previa and implantation that totally obstructs the cervical os (total placenta
previa). The degree to which the placenta covers the internal cervical os is generally estimated in
percentages 100%, 75%, 30% and so forth. Increased parity, advanced maternal age, past
cesarean births, post uterine curettage, multiple gestations, and perhaps a male fetus are all
associated with placenta previa.

The incidence of placenta previa is approximately 5 per 1,000 pregnancies. It is thought

to occur whenever the placenta is forced to spread to find an adequate exchange surface. An
increase in congenital fetal anomalies may occur if the low implantation does not allow optimal
fetal nutrition or oxygenation. The incidence of placenta previa in the United States is
approximately 0.5%, or 1 in 200 women. The maternal mortality rate is 0.03%. The retrospective
"Maternal Mortality Study" (1979-1986) showed that in 44 maternal deaths, placenta previa was
listed as an underlying obstetric condition contributing to death. This resulted in a case fatality
rate of .03%. The incidence of maternal death was 1 in 3,300 cases of placenta previa. There are
still no current trends about the medications and other diagnostic procedures in preventing and
curing placenta previa. Ultrasonography is still the basis of diagnosis but for patient with cases of
abdominal wall scarring, obesity, or an incomplete filled bladder, MR imaging reveals placenta
previa since in ultrasonography placenta previa may not be clearly seen due to blockage of cord-
placenta insertions or vessels over the cervix during visualization.

The group chooses this case because more clinical skills will be developed by
experiencing the clinical management of this disease-condition and it will enhance one’s
knowledge in implementing proper nursing intervention to the patient towards recovery.

IMPORTANCE OF THE CASE STUDY

3
 One of the most perceived importance’s to conduct this study is to enable the student
nurses to practice the concepts and knowledge learned from the four-sided room to the actual
clinical setting. By this, the student’s knowledge, skills and experience will be enhanced. This
case study also provides ways to practice the nursing process which is the core of nursing
profession.
In relation with this case study is systematic in nature. It gives acquaintance to the
condition known as “Placenta Previa”. It allows the student to acquire specific information on
the said condition and able to obtain knowledge on what are the proper medical interventions
that should be done and the rationale for such procedure.
In a deeper sense, the case study wanted to be part of the development of self-care to
prevent the said condition and to achieve the optimal health of our patients in the future.

Objectives
4
Nurse Centered:
General:
To enhance the students skills, comprehension and approach in the practice of nursing
and be able to establish knowledge on the risk factors, prognosis nursing management, current
trends and incidence of the disease condition that was chosen.
Specific:
 To come up with a comprehensive presentation of the disease condition by means of
correct presentation of the data gathered through the use of nursing process.
 To present the current trends about the disease condition; the reason for choosing
such case for presentation; and the importance of the case study.

Patient Centered:
General:
To be able for the client to fully understand and recognize the disease condition,
emphasize the importance of making appropriate action and to guide the patient towards
recovery.
Specific:
 To impart knowledge about the importance of healthy lifestyle.
 To render proper nursing management and medical regimen needed by the patient.
 To identify predisposing factors that aggregate the present condition of the patient.

II. NURSING PROCESS

5
 A. ASSESSMENT

1. Personal Data
A. Demographic data

Date: August 27, 2009

Name: Mrs X Age: 35y/o
Sex: female Civil status: married
Occupation: none Religion: Roman Catholic
Role in the family: mother Address: Brgy. CV Tarlac City
Date & place of birth: July 11, 1974 Nationality: Filipino
Tarlac City
Source of referral: husband & other relatives
Usual source of care: albularyo
Admitting diagnosis or impression: G3P2 PUFT, Placenta Previa Totalis

B. Environmental Status

Upon interview, we have known that the patient and her family are presently residing in
Brgy. CV Tarlac City. They have been living in the said Barangay for twelve years. Their house
is a nipa hut located near the rice fields. They have a television set and a radio. Their source of
water comes from a water pump, which they used for drinking, washing clothes and the dishes.
The toilet they are using is not their own, it is owned by her parents who lives beside them. They
have pets in their house such as dog and cat. When it comes to garbage disposal, they use
burning system. Their mode of transportation is via public utility jeepney (PUJ) and their means
of communication is through cell phones.

Norms:

6
 Most houses in a rural setting are made of light materials such as wood and other wood
materials while other houses are made of a combination of light and concrete materials. Toilet
facilities in this setting are most often water-sealed type. In rural areas, the water source usually
comes from wells and they make use of manual water pumps to extract water from the well.
People in the rural areas usually dispose of their garbage in a pit dug in their back yard. Garbage
collected inside the pit is either burned or covered in soil. A typical family in this kind of a
setting is composed of a father, mother and children. The father plays the role of the breadwinner
and decision maker while the mother takes care of the family’s well being. (COPAR book)

Analysis:
The patient’s house is a standard house made of light materials. Her family is made of the
father, mother and the children. The family is headed by the father who works and decides for
the family.

C. Lifestyle

Mrs. X usually wakes up between 6-7 AM., to prepare a breakfast for her daughter who goes
to school and to her husband who goes to work. . Their breakfast is usually composed of two
pieces pandesal, one cup of great taste coffee, one cup of rice and one piece of boiled egg. Mrs.
X eats a variety of foods such as banana fruits, malunggay, jute vegetables, and meats. She is
also fond of eating salty foods like fried peanuts and chicharong bulaklak. Mrs. X usually spends
her time cleaning their house, washing their clothes, cooking foods, and taking care of her two
children. Her life focuses on her family. After doing all the household chores, she will take a nap
or will stay outside their house taking care of her second child while having conversation with
her neighbors, but most of her time; she is just staying inside of their house and listening to the
radio or watching television. She denied having any vices like smoking and drinking alcoholic
beverages. The patient usually sleeps at around nine - ten o’clock in the evening, because she
always waits for the arrival of her favourite teleserye “tayong dalawa”
Norms:
An adult usually sleeps between a minimum of six to eight hours daily. In order to have a
healthy life style, eating the right kind of food is also necessary i.e. Grow, Glow and Go food
groups. “Smoking is dangerous to your health”, that is what the general surgeon’s warning

7
placed on the cover of cigarette packs. Regular exercise will keep you in good shape; it is
strongly advised that you exercise daily. (Nutrition and Diet therapy, 9th edition, Ruth Roth)
Analysis:
Mrs. X meets the six to eight hours sleep requirement for an adult however, her diet is not
ideal since she loves eating salty foods that are high in sodium. She should also improve her diet
with rich in proteins, calories and vitamins and minerals i.e. vegetables, fruits, milk, fish, lean
meat etc.

2. Family History of Health and Illness

See genogram – next page

8
GENOGRAM

8 9
8 8
3 0
4
OLD0AGE
AST HTN HTN

3 6 4
6 4 4 5 5 5
0 3 9
0 9 9 8 5 3
HTN SUICIDE AST AW HTN AW AW AW AW

2 2 2 1
2 2 1 1 1 6
6 9 4 1
3 2 8 5 1
GSW AW AST AW AW AW AW AW AST
AW

LEGEND:
- POINTS TO THE PATIENT
3 AW AW – ALIVE & WELL
3 - THE FAMILY HAS A HISTORY HTN – HYPERTENSION
7 ASTHMA AND HYPERTENSION.
5 AST – ASTHMA
- THEY DON’T HAVE ANY GSW –GUN SHOT WOUND
COMMUNICABLE DISEASES. -DECEASED FEMALE
- DECEASED MALE
AW 4 N AW NB- NEWBORN
1 B
2 AW
9
 3. History of Past Illness
During her childhood, Mrs. X had chickenpox. She often had cough, colds and fever.
They have a history of hypertension and asthma. She has a complete vaccination status as a child
but she only received 2 doses of tetanus toxoid vaccine during her pregnancy.
According to the patient, her first child was delivered in the house by a “hilot” while her
second child was delivered in Tarlac Provincial Hospital via NSD. She told us that if she can
tolerate the pain, she would like to have her second baby delivered in their house but the pain is
unbearable that is why they rushed her to the hospital last four years ago.

4. History of Present Illness

The patient claimed that her Expected Date of Delivery is August 22, 2009. She was
alarmed because her baby is still inside her womb and it already exceeded her due date. August
27, 2009, she woke up at around 5 am and she noticed a slight vaginal bleeding as she went to
the comfort room. That added to her worries but she didn’t feel any contractions.
Her husband and other elatives decided to bring her to the hospital and they found out
that the placenta is coming out first. The doctors told them that Mrs. X needs to undergo
caesarean delivery, and so that is what happened.

5. Physical Assessment
1. Social Status

The patient is 35 year old and currently living with her husband and two children on her
parents’ compound at Brgy. CV, Tarlac. According to her, in their family they have good
communication and relationship. Each family member perform their respected roles such us her
husband works as a farmer to finance their family needs. She also stated that whenever one of the
family members has a health or any problem the whole family as well as the relatives were
always there to give support. She also denies any conflict among the family members as well as
the family resources.

Norms:
Family members should perform their roles. Good communication within the family must
be maintained to obtain a healthy relationship with one another. Social support is a perception
10
 that one has an emotional and tangible resource to call on when needed; perceived social support
is being followed by the family to express the love and care to the family. Financial aspect is one
of the normal constraints in the family.(Kozier, Copyright 2004)

Analysis:
The patient receives social support from the family and relatives. They have good
communication and harmonious relationship. The family does not experience any problem
with regards to the living.

2. Mental Status

Level of consciousness
Upon receiving the patient, we noticed that she is weak but conscious about what is
happening around her. We conducted our interview after five hours, to allow her to have her rest.
The client responds to the questions that were asked. She gives appropriate answers to the
questions and she even smiles when her needs are being given. She can recall the names of all
her relatives present in the hospital. She knows about her condition and she is well-oriented
about the place she is in.

Norms:
Level of Consciousness determines whether a person is oriented to the things that are
happening. Response to verbal stimuli indicates that the patient is oriented to the place he or she
is in. (Kozier, Copyright 2004)

Analysis:
The patient is well oriented and responds appropriately with questions that were asked to
her.

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Mood
During the interview, the patient responds well to the questions. She also appears to be
irritable and sleepy.

Norms:
Moods are dependent on a person’s view of what is happening around him for example
person who is lacking of sleep may not be approachable. (Kozier, Copyright 2004)

Analysis:
The client still manages to answer all of the questions that were asked to her in spite of
her condition. Her irritability is well understood because she is in pain.

Thought processes and perception

The patient can still identify what is reality. She can express her thoughts freely and she
even shared some of her point of view about her condition. She told us that what is happening
right now is God’s will and it is only a trial in life that will make her stronger.

Norms:
Thought processes is the person’s ability to identify the reality from not. Feelings need to
be explored to determine whether they are based on reality or interpretations memories or fears.
(Kozier, Copyright 2004)

Analysis:
The patient is still in the right state of mind since she still knows what is reality from not,
as she talked to us about things that really happens in reality.

Cognitive Abilities
The client is well oriented on the place, time, and date. She is also aware of her condition.
She responded well on the neurological tests that were performed during the interview but she
was not able to do the Romberg’s Test because she she is still too weak to stand.

12
Norms:
Clients undertaking a Romberg’s test should be able to stand upright while the eyes
closed then with eyes open. It is a negative Romberg if the client sways slightly but is able to
maintain upright posture. It is positive if the client cannot maintain an upright position. (Kozier,
Copyright 2004)

Analysis:
The client’s full awareness indicates that she is not having problems when it comes to his
cognitive abilities. Her failure to do the Romberg’s test is due to her condition so it is not an
accurate test for her cognitive abilities.

3. Emotional Status

The client states that she knows her condition. She knows the things that may happen if
she was not given proper treatment. Though she shows fear about the incision in her abdomen,
she is still calm. She even stated that whatever may happen is according to God’s plan. She
shows a positive outlook in life by stating that each problem that she may encounter has a
corresponding solution.

Norms:
A person’s emotional status depends much on his ability to cope up with the happenings
in his/her life. He or she may not be in the right mood if some unnecessary things had happened.
(Nursing CEU.com: The process of human development)

Analysis:
The patient has a stable emotional status and can handle her emotional status in spite of
her condition.

13
4. SENSORY PERCEPTION

Sense of taste
The patient can determine taste. As she verbalized “mapait yung ininom kong tsaa
kanina”. No lesions or abnormalities were found in the tongue and oral cavities and it is
symmetrical.

Norms:
Normal sensation would be accurate perceptions of sweet, sour, salty, and bitter taste.
(Estes, Third edition, Copyright 2006)

Analysis:
Since the diet of the patient is restricted and she is only allowed to eat crackers, drink tea
and take sips of water, the tea was our basis about her normal sense of taste.

Auditory Activity
Hearing test was performed in the patient to check if she has a good auditory acuity. We
whispered words 3 inches away from her, she was able to repeat the words correctly and clearly
as we asked her to repeat it; we call her name and claimed that she clearly heard us about 10 and
20 feet away. She was able to answer our question correctly. No bleeding, wounds found on her
external ear.

Norms:
Patient should hear whispered words or watch tick test and ear must free from lesions and
masses. (Estes, Third edition, Copyright 2006)

Analysis:
The patient’s auditory sense is intact and has no problem.

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Sense of Smell
She can distinguish different odors. She was able to differentiate the smell of a cologne,
and alcohol that we provided. Her nose lies on the midline of her face and it is symmetrical and
nostrils are intact, no bleeding and wounds found.

Norms:
Patient must able to identify different smell; nose should be at the midline position of the
face, free from lesions and intact nostrils. (Estes, Third edition, Copyright 2006)

Analysis:
The patient’s sense of smell has no problem.

Sense of Sight
We asked her to read the sentence with different sizes of letters, and we found out that
she has no difficulty in reading. We also observed her if she had difficulties in identifying far
objects, we found out that she does not have any difficulty in identifying far objects. Her external
eyes are symmetrical, no lesions and bleeding found.

Norms:
The patient who has a visual acuity of 20/20 in a Snellen chart test is considered to have a
normal visual acuity. (Estes, Third edition, Copyright 2006)

Analysis:
Her visual acuity has no problem.

Pain Sensation
The patient is experiencing pain in the incision site at her abdomen. We ask her to rate
the pain from 1 to 10 and she rated it 10. We pinched her skin to assess her sensitivity to pain;
she was able to feel it as claimed.

15
 Norms:
Reacting with a stimulus is a sign of good sensation. (Estes, Third edition, Copyright
2006)

Analysis:
The patient’s pain sensation is active and it is a good indication which means the nerve
endings of the patient reacts to the stimulus which has caused the sensation.

MOTOR STABILITY

The client was in a bed rest so her walking gait was not assessed.
Norms:
Normal motor stability includes the ability to perform the different steps in doing range
of motion. It should be firm with smooth and coordinated movements (Estes, Third edition,
Copyright 2006)

Analysis:
The patient’s motor stability should be present after a day or two. It should start at
turning side to side and gradually increasing mobility. At her second day, she should be able to
sit and on the third day, ambulate with assistance at first.

6. BODY TEMPERATURE
Upon assessment she was not warm to touch neither cool to touch.
The following body temperatures were obtained:
DATE TIME TEMPERATURE (◦C)
August 27, 2009 8:00am 36.2
10:00am 36.7
August 28, 2009 8:00am 37.1
10:00am 37.6

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Norms:
36.5 C to 37.5 ◦C is the normal body temperature (Kozier, Seventh edition, Copyright
2004)
Analysis:

The patient has a normal body temperature. This may indicate the absence of infection
with a normal WBC count.

7. RESPIRATORY STATUS
 The patient has undergone O2 Therapy during her first day. It is regulated at 2 lpm.
 Respiration is slightly elevated.

Table below shows the respiratory rate of the patient.

Date Time Respiratory Rate
August 27, 2009 8 am 24 cpm
10 am 24cpm
August 28, 2009 8 am 25 cpm
10 am 20 cpm

Norms:
Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of pattern,
normal respiration must be regular and even in rhythm. The normal depth of respirations is none
exaggerated and effortless (Health Assessment and Physical Examination 3 rd Edition Mary Ellen
Zator Estes).

Analysis:
The patient’s body is trying to compensate with the pain she is experiencing which made
her respiratory rate elevated. She also has a decreased blood volume due to her surgery which
made her body demand for more oxygen.

8. CIRCULATORY STATUS

17
 The patient nail color turns back within 2 seconds and she has no edema.
However, her pulse is weak and thready on the first day.
The following pulse rate and blood pressure were obtained:
DATE TIME PULSE BLOOD
(bpm) PRESSURE
(mmHg)
August 27, 2009 8:00am 56 130/100
10:00am 56 130/90
August 28, 2009 8:00am 63 120/80
10:00am 58 130/80

Norms:
The average heart rate and blood pressure of an adult are 60-120bpm and 120/80mmHg.
No edema should be observed on the extremities because it indicates venous insufficiency
(Kozier, Seventh edition, Copyright 2004). The normal range of capillary refill test is within 2-3
sec.(Estes, Third edition, Copyright 2006)
Analysis:
With regard to her circulatory status, it shows that her pulse rate was quite decreased l
and her blood pressure was slightly elevated. She also has sufficient venous return and normal
capillary refill.

9.) NUTRITIONAL STATUS

The client claimed to us that her weight is 55 kg before she got pregnant. Since we did
not have the chance to weigh her, we just assumed that her current weight is not that far from her
pre-pregnant weight. She told us that she eat 3 times a day. She loves to eat “adobong manok”
Her family has the ability to provide her nutritional needs. She has no known food and drug
allergies and her body mass index (BMI) was 22.8. But upon her admission in the OB ward, the
Doctor ordered an NPO diet for 8 hours post-op due to her surgery. After that, she was on a
liquid diet which composed of: sips of water, tea, and crackers. This will be changed on her third
day with a soft diet and then DAT.
Norms:

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 BMI is a measurement that indicated body composition. The degree of overweight or
obesity as well as the degree of underweight can be determined. (Estes, Third edition, Copyright
2006)
Standard Body Mass Index for Adults
 Underweight = <18.5
 Normal weight = 18.5-24.9
 Overweight = 25-29.9
 Obesity = BMI of 30 or greater

Analysis:
The patients’ family has the capability of providing her nutritional needs, as evidenced by
the patients’ normal body mass index measurement. Due to her present condition, the patient is
in a restricted diet which is not normal. But it should go back to normal after her confinement.

10. ELIMINATION STATUS

The patient usually defecates one to two times a day, brown in color, and soft but formed.
She also urinates once every two hours. But upon admission at the OB ward, she was not able to
defecate for two days because she was on NPO status and she also has an indwelling foley
catheter. Two underpads were used on her first day and one during her second day.
Norms:
Normal bowel movement is usually 2-3 times a day which help in elimination of
unnecessary waste material in the body in the GI tract. It should be soft but formed and brown in
color. Urine output of an adult is usually 1200-1500mL per day. (Kozier Seventh edition,
Copyright 2004)

Analysis:
The patient has regular bowel and has normal urinary elimination status before she was
admitted in the hospital. But upon admission, her regular bowel movement was altered due to her
NPO status. This should return in normal after her NPO and liquid die
11. REPRODUCTIVE STATUS

19
 According to the patient, her menarche was 12. Her menstrual period is regular and she
usually consumes 2-3 pads a day for the first 3 days of her menstruation and 1-2 pads for the last
2 days. She was taking pills before she got pregnant to her third child. She was 23 when she gave
birth to her first child and as claimed, it was in their home where she gave birth with the help of a
“hilot”. While on her second child, she was 31 and gave birth at Tarlac Provincial Hospital via
NSD. For her last baby, she delivered it via caesarean section. All of her child are breast fed and
she plans to breastfeed her youngest too. She denied any complications on her pregnancy over
her first and second child. It was only this third time of her delivery wherein she experienced
such complication. There were no regular check-up done during her entire pregnancy and as
claimed, she only visited in the health center once.

Norms:
Sexual activity/status can be determined through the presence or absence of sexual urge.
Age is also one of the factors that affect one’s reproductive status because of the hormonal
changes. (Maternal and Child Health Nursing, Fourth Edition by Piliterri)
Analysis:
The patient has a normal reproductive status in terms of her menstruation. But there was a
deviation in terms of her last pregnancy.

12.) STATE OF PHYSICAL REST AND COMFORT

Before admission, the patient usually slept at 9-10:00pm and woke up at around 6:00am
to do the house chores and cook breakfast for her family. But upon admission in the hospital she
could not sleep properly because of the environmental stimulus.

Norms:
A normal sleep hours of an adult per day is 6 - 8 hours without being disturbed (Kozier,
Seventh edition, Copyright 2004)

Analysis:

20
 The patient has adequate rest and sleep. But this was altered when she was admitted in
the hospital. This indicates that she has an abnormal sleep and rest upon her admission.

13. STATE OF SKIN APPENDAGES

The patient skin was light brown and uniform in color. There is incision present in her

lower abdomen; the dressing is dry and intact. An indwelling foley catheter is inserted and she

also has an intravenous fluid on her right arm regulated at 15gtts/minute, infusing well. During

her 3 hours post-op state, she also had an O 2 therapy regulated at 2 lpm. The scalp has no flakes

and free from lesions. The hair was properly distributed, black and free from infestations. Nails

are in normal angle of 160o characterized as intact but pale in color and no lesions found. No

bleeding or wounds found in the extremities.

Norms:
Skin varies from light to brown from ruddy pink to light pink. Generally, uniform except
in areas exposed to the sun, areas of lighter pigmentation in palms, nail beds, and lips. The hair
should be evenly distributed, thick, shiny and free from infestation. The nails should be 160◦ and
smooth in texture. (Kozier, Seventh edition, Copyright 2004)

Analysis:
The patient indicates that she has normal skin and appendages except for the incision she
had due to the surgery and to the intravenous line present on her right arm.

5. Diagnostic and Laboratory Procedures

21
Diagnostic/ Date Indication/s Result/s Normal Analysis and
Laboratory Ordered and or Purposes Values Interpretation
Procedures date Result/s (Units used of results
In in the
Hospital)
CBC August 27 CBC is used N/A N/A N/A
2009 – as a broad
August 28, screening test
2009 to determine
disorder as
anemia.

>WBC August 27, This is used 7.5 4.1 – 10.9 Normal

2009 to determine g/dL >No indicative
if there is abnormalities
infection noted.
present.

>Hgb August 27, 80 F (123-153 Abnormal due

2009 g/L) to bleeding.
>If
hemoglobin is
low, there is
not enough
oxygen in the
blood.

>Hct August 27, A measure of 0.266 F(0.359- Abnormal due

2009 the packed 0.466 vol%) to bleeding

22
 cell volume and blood loss
of red cells, during surgery.
express as a >If hematocrit
percentage of is low, there is
the total decreased
blood blood volume.
volume. In caesarean
delivery there
is 500-1000mL
blood loss.

NURSING RESPONSIBILITIES:
Before:
 Determine the clients understanding of the procedure
 Determine the clients response to previous testing

During:
 Ensure client’s comfort until the procedure will be done

After:
 Document the method of testing and results on the clients record
 Immediately reached the blood sample on the laboratory
 Follow-up result from laboratory

6. Anatomy and Physiology

23
 Anatomy and Physiology of Female Reproductive System

INTERNAL FEMALE ORGANS

The internal organs of the female consists of the
uterus, vagina, fallopian tubes, and the ovaries
(see figures 1-1 and 1-2).

a. Uterus. The uterus is a hollow organ about the

size and shape of a pear. It serves two important functions: it is the organ of menstruation
and during pregnancy it receives the fertilized ovum, retains and nourishes it until it
expels the fetus during labor.
i. Location. The uterus is located between the urinary bladder and the rectum. It is
suspended in the pelvis by broad ligaments.
ii. 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.
iii. 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,

24
 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.
i. 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.
ii. Function. The vagina provides the passageway for childbirth and menstrual flow; it
receives the penis and semen during sexual intercourse.
c. Fallopian Tubes (Two).
i. Location. Each tube is about 4 inches long and extends medially from each ovary to
empty into the superior region of the uterus.
ii. Function. The fallopian tubes transport ovum from the ovaries to the uterus. There
is no contact of fallopian tubes with the ovaries.
iii. Description. The distal end of each fallopian tube is expanded and has finger-like
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).
i. Functions. The ovaries are for oogenesis-the production of eggs (female sex cells)
and for hormone production (estrogen and progesterone).
ii. 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

25
 ovaries, which are called ovarian follicles. The follicles are tiny sac-like structures
that consist of an immature egg 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.

EXTERNAL FEMALE GENITALIA

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.
 The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is
sexual excitation.

26
  The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular
structure that drains urine from the bladder.
 The vaginal introitus is the vaginal entrance.

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.

PLACENTA PREVIA
Placenta previa is hemorrhage resulting from the low implantation of the placenta on the interior
uterine wall. It is common in multiparous mothers. The cause is unknown.

There are three types of placenta previa. Each type is identified according to the degree to which
condition is present (see figure 1-5).
Total placenta previa. This occurs when the placenta completely covers the internal os.
Partial placenta previa. This occurs when the placenta partially covers the internal os.
Low implantation of placenta previa. This occurs when the placenta is attached at the opening
or border to the cervical os, but not covering it.

27
 Pathophysiology of Placenta Previa (Book-based)

Modifiable factors: Nonmodifiable

Women who smokes factors:
Multiparity
Multiple gestation 28
Previous cesarian
Uterine Low Placental Abnormal
Birth Vascularization of
TotalAtrophy Placenta
implantation
Implantation Previa
in (2 nd
Lowand Endometrium
3 Pregnancy
rd
uterine Low-lying
 Bright red vaginal Partial
bleeding

Cervical Cover Disrupted Placental Uterine

dilation internal OS attachment Contraction
Blood loss

Malpresentation Decrease
Uterine blood
Decrease of fetus
blood
flow
Volume

Hypovolemia
Bright red vaginal
bleeding Decrease Uterine
blood flow
Pallo
r

Hypotensio Compensator
n Decrease fetal
y mechanism
Cold
Clammy oxygen supply
29
Skin

Tachypnea
Tachycardi
 Fetal distress

IUGR

Preterm Labor

Decrease kidney Decrease

capillary Congenital
perfusion
refill anomalies

Decrease
Urine
output

Pathophysiology of Placenta Previa (Client-based)

30
 Nonmodifiable
factors:
Multiparity
Multiple gestation
Advance maternal Age

Pregnancy

Uterine Atrophy Abnormal Vascularization of

Endometrium

Low Placental implantation

(2nd and 3rd trimester)

Implantation in Low uterine

Placenta Previa

Tota

Cervical Cover Disrupted Placental

dilation internal OS attachment
Blood loss
Malpresentation
of fetus
Decrease blood
Volume

Bright red vaginal

Hypovolemia
bleeding

Pallo
r

Hypotensio Compensator
n y mechanism
Cold
Clammy 31
Skin

Tachypnea
Tachycardi
Bright red vaginal
bleeding

32
B. Planning Date/time: August 27,2009/8:00 am
CUES SCIENTIFIC NURSING PLANNING INTERVENTION & RATIONALE EVALUATION
EXPLANATION DX
S: Post-operative Acute Pain After 30 >Build rapport with the patient After 30
>“Masakit ang tahi pertains to the r/t surgical minutes of R: This is to gain trust by the patient, minutes of
ko sa may puson.” period of time incision. proper nursing thus making working relationship proper nursing
Pain Scale: 10/10 after surgery. It intervention, comfortable for both the nurse and the intervention, the
O: begins with the the patient will patient. patient will
>weak in patient’s verbalize >Place ice pack at the incision site. verbalize
appearance emergence from decreased in R: To reduce the pain and to prevent decreased in
>restless and anesthesia and pain to a hemorrhage by keeping the fundus pain to a
irritable continues through tolerable state. contracted. tolerable state.
>pale looking the time required From a pain >Encourage the patient to do breathing From a pain
>tachypnea:RR:24 for the acute scale of 10 to exercises. scale of 10 to 2.
cpm effects of the 2. R: This will promote good oxygenation, AEB:
>grimace anesthetic and therefore promote good tissue perfusion. a.) Absence of
surgical >Provide emotional support by grimace
procedures to encouraging the patient to verbalize what b.) Normal
abate. she feels. respiration.
R: This is to increase patient’s self- RR:17cpm
worth.
>Assist the patient when turning side to
side.
R: The client is still weak and needs
assistance by the nurse. Turning side to
side every 2 hours promote lung
expansion and it prevents complications
like pressure ulcers and aspiration
pneumonia.
>Administer analgesics as ordered by the
physician.
R: To eradicate, if not, reduce/decrease
the pain.
33
Date: August 28, 2009

CUES SCIENTIFIC NURSING PLANNING INTERVENTION & RATIONALE EVALUATION

EXPLANATION DX
S: Ø Post-operative Impaired After 30 >Build rapport with the patient After 30
O: discomfort felt by physical minutes of R: This is to gain trust by the patient, minutes of
>with surgical the client after the mobility proper nursing thus making working relationship proper nursing
incision at the lower anesthesia has r/t surgical intervention, comfortable for both the nurse and the intervention, the
abdomen subsided causes incision. the patient will patient. patient will be
>inability to sit pain and will lead be able to >Assist patient in turning side to side able to
>difficulty turning decreased client’s gradually every 2 hours. gradually
to side tolerance to increase R: Turning side to side is important to increase
>weak in activity mobility. promote lung expansion and to prevent mobility by
appearance complications like pressure ulcers and turning side to
>restless and aspiration pneumonia. side.
irritable >Provide emotional support by AEB:
>pale looking encouraging the patient to verbalize what a.) Absence of
>tachypnea:RR:24 she feels. grimace
> grimace R: This will increase the patient’s self- b.) Ability to
worth. turn side to side
>Instruct the patient to do breathing with minimal
exercises. assistance.
R: This will help alleviate the pain and
will promote good oxygenation, therefore
promote good tissue perfusion.
>Administer analgesics as ordered by the
physician.
R: To eradicate, if not, reduce/decrease
the pain.

34
 DAT CUES SCIENTIFIC NURSIN PLANNIN INTERVENTION & EVALUATIO
E EXPLANATIO G DX G RATIONALE N
N
August S: Ø Heavy bleeding Deficient After 1 hour Independent: After 1 hour of
27, 2009 O: may double for fluid of proper 1. Monitor Vital signs of proper nursing
>have no oral intake for the the postpartum volume r/t nursing client’s with deficient fluid intervention, the
woman, because blood loss intervention, volume every 4hrs. Observe patient will
last 8 hours
she may during the patient for tachycardia, tachypnea, maintain fluid
>chapped lips haemorrhage surgery will maintain decreased pulse pressure first,
balance in a
vaginally from fluid balance then hypotension, decreased functional level
>dry mouth
an uncontracted in a pulse volume, and as evidenced by:
>with surgical incision at uterus as well as functional increase/decrease body a. Patient’s
internally from level as temperature. blood pressure
the lower abdomen
blood vessels evidenced is 100/60 mmHg
>consumed 2 underpad for that were not by: ®Decrease pulse pressure is or higher
securely ligated a. Patient’s an earlier indicator of shock b. Pulse remains
the last 24 hours
blood than is the systemic blood between 60
>weak in pressure is pressure. Decrease and 100 bpm
100/60 intravascular volume results c. Scant to no
appearance
mmHg or in hypotension and decreased bleeding on
>restless and irritable higher tissue oxygenation. The surgical
b. Pulse temperature will be decreased dressing is
>pale looking
remains as a result of decreased apparent
>grimace between metabolism, or it may be
60 and increased if there is a
>tachypnea: RR=24
100 bpm infection or hypernatremia.
>bradycardia: PR=56 c. Scant to
no 2. Advise client to have
>HCT=0.266%
bleeding frequent oral hygiene, at least
>HGB=80g/L on twice a day.
surgical
>urine output=30 cc/hr

35
>Capillary refill=3sec dressing is ®Oral hygiene decreases
apparent unpleasant taste in the mouth
and allows the client to
respond to the sensation of
thirst.

Collaborative
3. Encourage patient to drink
prescribed fluid amounts

®This provides water for

replacement of intravascular
or intracellular volume as
necessary.

4. Hydrate the client with

ordered intravenous solution

®Intravenous route is one of

the fastest ways to deliver
fluids and medications
throughout the body.

5. Maintain Patent IV access,

set an appropriate infusion
flow rate and administer at
constant rate as ordered.

® Isotonic IVF such as 0.9%

Normal Saline or Lactated
Ringer’s allow replacement
of Intravascular volume.

36
 DAT CUES SCIENTIFIC NURSING PLANNING INTERVENTION & EVALUATION
E EXPLANATION DX RATIONALE
August S: “Hindi ko magalaw Because a Risk for After 1 hr Independent After 1 hr of
29, 2009 ang paa ko.” woman’s ineffective of proper 1. Assist patient in turning proper nursing
abdominal tissue nursing from side to side every 1-2 intervention,
O: muscles are lax perfusion r/t intervention hours the client will
-Weak in appearance from the immobility , the client maintain a
stretching that after will ®Turning helps in venous capillary refill
-Pale
occurred during surgery maintain a stasis, thrombophlebitis, of less than 5
-With limited pregnancy, capillary pressure ulcer formation and seconds and
abdominal refill of less respiratory complication. will not report
movements
contents tend to than 5 of calf pain,
-Difficulty shift forward and seconds and 2. Assist client in extremity redness, edema,
put pressure on will not exercise. or areas of
raising/flexing the legs
the suture line report of warmth on
-Weak peripheral when she is calf pain, ® Helps to prevent lower
sitting or redness, circulatory problem by extremities
pulses
standing, causing edema, or facilitating venous return to
-Capillary refill = pain and areas of the heart.
uncomfortable warmth on
3seconds
feeling. lower 3. Early ambulation should
extremities be encouraged whenever
appropriate.

® Early ambulation are a

woman’s best safeguards
against lower extremity
circulatory problems

4. Encourage deep breathing

and coughing exercise

37
® This promotes optimal
lung ventilation and
perfusion.

5. Ensure that bedcovers

must be loose enough

® Permits free movements of

the toes and feet

38
 Assessment Diagnosis Scientific Planning Interventions Rationale Evaluation
Explanation

S: Ø Risk for Due to large Within 2 hours  Monitor vital To identify if Within 2 hours
Injury r/t amounts of of proper signs every 15 there are of proper nursing
O: blood loss blood loss, there nursing minutes changes in the interventions, the
 blood loss- during are possible interventions, normal ranges patient was able
consumed 1 surgery conditions that the patient will and to monitor if to have a
soaked may occur, and have decreased interventions decreased risk
underpad patient with risk for injury. have helped for injury.
 UO- 30cc/hr hemorrhage have normalized the
 HGT- altered level of client’s status.
0.266% consciousness.  Assist the
 HGB-80 g/L client in a To promote lung
 Pale comfortable expansion and
 Dyspnea position facilitate gas
particularly in exchange.
 Weak in
Semi-
appearance
Fowler’s or
 Weak and
High Fowler’s
thready
position.
 56 bpm-PR
 Restless and  Encourage the
irritable client to To determine the
 RR: 24- verbalize her other signs and
feelings and symptoms felt
worries. by the client and
to know the
appropriate
nursing
interventions to
be done.

39
 Increase
frequent To prevent the
observation , client from
and if accidentally
possible, stay falling or other
with the client cause of injury.
and enforce
security
measures (e.g
Raise side
rails)

 Encourage the
client to have To conserve
bed rest. energy and feel
relaxed.
 Advise the
client to To replace lost
increase fluid fluid and
intake. electrolytes.

 Administer
medications To facilitate
as prescribed. faster healing
and
management.

40
 Subjective Objective Analysis Planning Implementation Evaluation
Ø  blood loss- Risk for Within 2 hours of After 2 hours of proper nursing
consumed 1 Injury r/t proper nursing  Monitored vital signs every interventions, the patient was
soaked blood loss interventions, the 15 minutes able to have a decreased risk for
underpad during surgery patient will have  Assisted the client in a injury.
 UO- 30cc/hr decreased risk for comfortable position
 HGT- injury. particularly in Semi-Fowler’s
0.266% or High Fowler’s position.
 HGB-80 g/L  Encouraged the client to
 Pale verbalize her feelings and
 Dyspnea worries.
 Weak in  Increased frequent
appearance observation , and if possible,
stay with the client and
 Weak and
enforce security measures
thready
(e.g Raise side rails)
 56 bpm-PR
 Encouraged the client to have
 Restless and bed rest.
irritable  Advised the client to increase
 RR: 24- fluid intake.
 Administered medications as
prescribed by the physician.

C. Implementation

41
 1. Medical Management

i. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy etc.

Medical Date Ordered/ Date General Description Indication/s, Purpose/s Client's reaction to
Management/Treatm Taken/ the treatment
ent Given
Date Changed/ Date
Discontinued
IV Therapy IV Therapy is the giving of IV Therapy is usually The patient did not
liquid directly into a vein. performed for fluid volume reported pain in the
1L LRS (isotonic) with Started on August 27, maintenance, fluid volume IV site
oxytocin regulated at 2009, discontinued on the replacement, medication
15 gtts/min same date administration, blood
administration, total
1L D5 NM August 27, 2009-August parenteral nutrition and
(hypertonic) regulated 28, 2009 serves as an emergency
at 30 gtts/min line

1L D5 LRS Started on August 28,

(hypertonic) regulated 2009 discontinued on the
at 30 gtts/min same date

1L D5 NM
(hypertonic) with 1
amp Moriamin August 28, 2009- august
regulated at 30 29, 2009
gtts/min

Prior:

42
> understand why the therapy is needed.
> determine potential outcomes for the client
> understand the fluid and electrolyte and acid base status of the client
> provide an explanation to the client and gain cooperation
> select the appropriate IV set

During:
> assess the following:
a. right intravenous fluids infusing
b. right intravenous fluids for the client
c. date on the tubing
d. right rate according to the rate prescribed and the clients condition
e. absence of kinks in the tubing that could result in occlusion of the fluid flow
f. date on the intravenous access device
g. insertion site and vein access for evidence of pain, redness, warmth, or coolness, and swelling

After:
> discard the administration set accordingly
>document relevant data.

Medical Date Ordered/ Date General Description Indication/s, Purpose/s Client's reaction to
Management/Treatm Taken/ the treatment

43
ent Given
Date Changed/ Date
Discontinued
Oxygen Therapy Oxygen therapy is any Clients who have difficulty The patient tolerated
procedure in which oxygen ventilating all areas of their the administered
2 Lpm for 3 hours August 27, 2009 is administered to a patient lungs, those whose gas oxygen and
via nasal prong to relieve hypoxia. exchange is impaired, or verbalized relief from
people who have heart DOB
failure may require oxygen
therapy to prevent hypoxia.

Prior:
>determine the need for oxygen therapy, and verify the order for the therapy.
>perform a respiratory assessment to develop baseline data if not already available.
>inform the client and support people about the safety precautions connected with oxygen use such as:
a) avoiding materials that generate static electricity, such as woolen blankets and synthetic fabrics.
b) avoiding the use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone.
> provide an explanation to the client and gain cooperation.
>assist the client to a semi-Fowler’s position.
>set up the oxygen equipment and the humidifier

During:

44
>check that the oxygen is flowing freely from the tubing. There should be no kinks in the tubing, and the connections should be
airtight. There should be bubbles in the humidifier as the oxygen flows through. Feel the oxygen at the outlets of the cannula.
>monitor the level of water in the humidifier.
>set the oxygen at the flow rate ordered.
>if the cannula will not stay in place, tape it at the sides of the face.

After:
>report significant deviation such as tracheal irritation and coughing, dyspnea, and decreased pulmonary ventilation.

Medical Date Ordered/ Date General Description Indication/s, Purpose/s Client's reaction to

45
Management/Treatm Taken/ the treatment
ent Given
Date Changed/ Date
Discontinued
Urinary August 27, 2009-August Urinary Catheterization Indications of urinary The client didn’t
Catheterization 28, 2009 is the introduction of a catheterization includes relief verbalize any
catheter through the from discomfort due to bladder discomfort and have
urethra into the urinary distention or to provide gradual adequate (>30cc/hr),
bladder decompression of a distended amber colored urine
bladder, to empty the bladder output.
completely prior to surgery, to
facilitate accurate measurement
of urinary output for critically
ill clients whose outputs need
to be monitored hourly, to
prevent urine from contacting
an incision after perineal
surgery.

Prior:
> Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as total
amount of urine to be removed and size of catheter to be used.
>use an indwelling catheter if the bladder must remain empty or continuous urine measurements/collection is needed.
> Assess the client’s overall condition. Determine if the client is able to cooperate and hold still during the procedure and if the client
can be positioned supine with head relatively flat.
> Determine when the client last voided or was last catheterized.
>Percuss the bladder to check for fullness or distention.

46
During:
>Ensure that there are no obstructions in the drainage. Check that there are no kinks in the tubing, the client is not lying on the tubing,
and the tubing is not clogged with mucus or blood.
>Check that there is no tension on the catheter or tubing, that the catheter is securely taped to the thigh, and that the tubing is fastened
appropriately to the bedclothes.
>Ensure that gravity drainage is maintained. Make sure that there are no loops in the tubing below its entry to the drainage receptacle
and that the drainage receptacle is below the level of the client’s bladder.
>Ensure that the drainage system is well-sealed or closed. Check that there are no leaks at the connection sites in open systems. Apply
water proof tape around the connection site of the catheter and tubing.
>Observer the flow of the urine every 2-3 hours, and note color, odor and any abnormal constituents. If sediments are present, check
the catheter more frequently to ascertain whether it is plugged.

After:
>Conduct appropriate follow-up such as notifying the primary care provider the catheterization results.
> Performed a detailed follow-up based on findings that deviated from normal for the client.
> Relate findings to previous assessment data if available.

47
ii. Drugs

Name/s of drugs Date ordered/ Route of Mechanism of Indication/s Client’s response

(generic and brand Date taken/ administration & action Purpose/s to medication with
name) Date changed dosage & actual side effect
frequency of
administration
Generic Name: August 27-28, 2009 750 mg, IVF q 8 It is a anti- infective Low respiratory The client did not
Cefuroxime Sodium hours drug and its main infections, exhibit any adverse
action is combat the Pharyngitis or reactions from the
preset bacteria and tonsillitis drug
inhibit increased
growth.

Before:
 check the expiration date of the drug
 check the doctor's order
 assess the client's understanding about the drug
 assess for skin allergies

During:
 Reconstitute the drug with 8 ml of sterile water.
 Slowly inject the drug over 3 to 5 mins.

After:
 Evaluate the client for adverse effect.
 Report lack of response, persistent diarrhea or signs ad symptoms of Anemia.

Name/s of drugs Date ordered/ Route of Mechanism of Indication/s Client’s response

(generic and brand Date taken/ administration & action Purpose/s to medication with

48
 name) Date changed dosage & actual side effect
frequency of
administration
Generic Name: August 27-28, 2009 30 mg, IVF q 6 Possesses anti- Use for The client did not
Ketorolac hours X 6 doses inflammatory, management of exhibit any adverse
Tromethamie analgesics ad moderate ad severe reactions from the
antipyretic. acute pain. drug
Completely
absorbed following
IM use.

Before:
 check the expiration date of the drug
 check the doctor's order
 assess the client's understanding about the drug

During:
 Do not mix IV ketorolac in a small volume with morphine sulfate.
 The IV bolus must be given over o less than 15 sec.

After:
 Monitor for adverse effect.
 Report ay unusual bruising or bleeding, weight gain, swelling of feet/ ankles, increased joint pain, change in urine patterns.

49
 Name/s of drugs Date ordered/ Route of Mechanism of Indication/s Client’s response
(generic and brand Date taken/ administration & action Purpose/s to medication with
name) Date changed dosage & actual side effect
frequency of
administration
Generic Name: August 27-28, 2009 100 mg, TID A Centrally acting Use for The client did not
Tramadol analgesic no related management of exhibit any adverse
Hydrocloride chemically to moderate ad severe reactions from the
opiates. Precise acute pain. drug
mechanism is
unknown.

Before:
 check the expiration date of the drug
 check the doctor's order
 assess the client's understanding about the drug
During:
 Give the IV dose slowly over a period of 2 mins or as a continuous infusion.
 Oral and IV dose are therapeutically equivalent, may switch to and from the IV form wit o cage in dose as prescribed.

After:
 Monitor for adverse effect.
 Report immediate ay chest pain, increased SOB, or sudden weight gain.

Name/s of drugs Date ordered/ Route of Mechanism of Indication/s Client’s response

(generic and brand Date taken/ administration & action Purpose/s to medication with
name) Date changed dosage & actual side effect
frequency of
administration
Generic Name: August 27-28, 2009 Q 12 hours X 2 Hough to be a Use for The client did not
Omeprazole doses gastric pump management of exhibit any adverse

50
 inhibitor and that it active duodenal reactions from the
blocks the final step ulcer, gastric ulcer, drug
of acid production. erosive esophagitis
By inhibiting the and heartburn
Hydrogen/
Potassium ATP-ase
system at te
secretory surface of
the gastric parietal
cell.

Before:
 check the expiration date of the drug
 check the doctor's order
 assess the client's understanding about the drug
During:
 The capsule should be taken 30 mins before eating and is to be swallowed whole.
 Antacid can be administer with omeprazole

After:
 Monitor for adverse effect.
 Report to the physician if chest pain, abdominal pain and fecal discoloration occurred.

iii. Diet

51
 Date ordered/ General Indication/s Specific foods Client’s response
Type of Diet Date taken/ Description Purpose/s Taken to medication with
Date changed actual side effect
NPO (nothing by August 27, 2009 A patient care It is usually ordered Foods, beverages ad The client strictly
mouth) instruction advising whenever the medicine are complied.
that the patient is patient wills prohibited.
prohibited from undergoes surgery
ingesting food, or other diagnostic
beverages, or procedure requiring
medicine. that the digestive
tract be empty.
Before:
 Explain to the client and significant others the purpose, indication and the duration of the diet.
 Assist the client’s compliance ability to the diet.

During:
 Advise the client to avoid foods.
 Provide frequent oral hygiene
 Monitor the compliance of the patient to the diet.
After:
 Evaluate the effect of the diet to the client.
 Report excessive weight loss.
 Assess any nutritional disturbances and notify the physician.

Type of Diet Date ordered, General Indication/s Specific Foods Client’ s response
Date started, Date description Purpose/s Taken and/or response to
changed the diet
Clear liquid diet August 27, 2009 This client provides This diet is Crackers The client strictly
the client with fluid indicated for post Sips of water and complied
and carbohydrate operative patient’s tea

52
 but does not supply first feeding when it
adequate protein, is necessary to fully
vitamins, minerals, ascertain return of
or calories gastrointestinal
function

Prior:
>assess ability to feed self and prepare meals
>determine need for special drinking cups, plates, or feeding utensils
>explain the purpose of the diet
>discussed allowed and prohibited foods

During:
>assist the client to a comfortable position in bed or in a chair, whichever is appropriate
>provide assistance of the client is unable to handle eating utensils or to open containers and packages
>always allow ample time for the client to chew and swallow the food before offering more

After:
>after the client has completed the meal, observe how much the client has eaten and the amount of fluid taken, record the fluid intake
and calorie count as required
>provide hygiene measures after feeding
>record any pain, fatigue or nausea experienced by client

53
 Date ordered/ General Indication/s Specific foods Client’s response
Type of Diet Date taken/ Description Purpose/s Taken to medication with
Date changed actual side effect
Soft Diet August 28, 2009 A diet that is soft in It provides nutrition Sips of water, tea, The client strictly
texture, low in to the client who crackers complied.
residue, easily has just undergone
digested and well surgery and client
tolerated. who cannot tolerate
hard foods.

Before:
 Explain to the client and significant others the purpose, indication and the duration of the diet.
 Assist the client’s compliance ability to the diet.

During:
 Position the client in a sitting or high or fowler position.
 Advise the client to consume foods that are easily digested.
 Monitor the compliance of the patient to the diet.
After:
 Evaluate the effect of the diet to the client.
 Assess any nutritional disturbances and notify the physician.

Type of Diet Date ordered, Date General description Indication/s Specific Foods Client’ s response
started, Date Purpose/s Taken and/or response to
changed the diet
Diet as tolerated August 30, 2009 The patient can eat To increase rate of Rice The client did not
(DAT) any food as long as healing Vegetables exhibit any allergic
tolerated Chicken meat reactions to the
Red meat food taken
Fruits
Gelatin

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 Crackers

Prior
>caution patient to avoid food such as eggs, nuts, milk, sulfites, fish and chocolate that can trigger asthma attack.

During:
>Advise client to properly chew the food.

After:
>advise patient to report any allergic reaction to the food taken.

iv. Activity / Exercise

Type of Date Ordered General Description Indications or Specific Client’s response and/or
exercise Date Started Purposes exercise/activit reaction to
Date Changed y the diet
Flat on bed Aug. 27,2009 It is type of exercise To prevent Complete bed The client complied to the
done after the surgical spinal rest within 8 ordered exercise
procedure; the client headache. hours.
must be in a supine
position without using a
pillow. After 8 hours
the client must be able
to use pillow already.
Turn from side Aug. 28, 2009 Patient will turn on the To increase Turn from side Patient was able to tolerate the
to side right side then rotate to blood to side every 2 exercise but with a little
the opposite side after 2 circulation and hours discomfort due to surgical
hours prevent incision
pressure ulcer
Sitting on bed Aug. 29, 2009 It is a type of exercise To increase Sitting on the Patient was able to tolerate the

55
 done after the client blood bed without exercise but with a little
able to turn side to side, circulation assistance discomfort due to surgical
and the back of the incision
client is unsupported
and legs hanging freely
Standing beside Aug. 29, 2009 It is a type of exercise To increase Standing in the Patient was able to tolerate the
the bed when the client is able blood side of the bed exercise but with a little
to stand by her own and circulation without discomfort due to surgical
no significant others assistance incision
assisted to her.
Ambulation Aug. 29, 2009 Patient will walk To increase Walking on the Patient was able to tolerate the
unaided on the side of blood side of the bed exercise but with a little
the bed and on the circulation without discomfort due to surgical
hallway assistance incision
ROM (Range of Aug. 29, 2009 A body action involving These The client Patient was able to tolerate
Motion) the muscles, joints, and exercises participated in the exercise but with a little
natural movements reduce the activity. discomfort due to surgical
such as abduction, stiffness and incision
adduction, flexion, help keep your
extension, pronation, joints flexible.
supination, and
rotation.

Nursing Responsibilities

Prior:
a. Learn passive ROM exercises from the person's caregiver. Practice the exercises with the caregiver first. The caregiver can
make sure you are doing the exercises right.
b. Raise the person's bed to a height that is comfortable for you. This will help keep you from hurting your back or other muscles.
c. Make sure the wheels of the bed or wheelchair are locked before you start the exercises.

56
During
a. Do all ROM exercises smoothly and gently. Never force, jerk, or over-stretch a muscle. This can hurt the muscle or joint
instead of helping.
b. Move the joint slowly. This is especially important if the person has muscle spasms (tightening). Move the joint only to the
point of resistance. This is the point where you cannot bend the joint any further. Put slow, steady pressure on the joint until
the muscle relaxes.
c. Stop ROM exercises if the person feels pain. Ask the person to tell you right away if he feels any pain. Watch for signs of pain
if the person is unable to talk. The exercises should never cause pain or go beyond the normal movement of that joint

After:
a. Make ROM exercises a part of the person's daily routine.
b. Follow the caregiver's orders. The person's caregiver will tell you how many times per day you should do ROM exercises. The
caregiver will tell you how many repetitions (number of times) you should do exercises on each joint.

2. Surgical Management

Name of Date Performed Brief Description Indication/Purpose Client’s response to the

Procedure
Cesarean Birth August 27, 2009 A cesarean birth is a
delivery of a fetus through
abdominal and uterine
incisions; laparotomy or
hysterectomy,
respectively.
A cesarean delivery may
be indicated for a woman
with known placenta
previa.
operation
The patient complained of
difficulty of breathing and
reported little sensation on the
lower extremities upon
discharge from the PACU. It
was observed that the patient
was also drowsy.

Prior:
>Always check to see if the informed consent has been given and that a signed form documents it.
> Ask the woman when she last had anything to eat or drink.

57
> Frequently, an antacid is given before surgery to reduce the risk of aspiration while the woman is under the effects of anesthesia.
>Ensure that an intravenous fluid is in place with a large bore catheter
>Ensure that an abdominal shave preparation is done immediately before surgery
>Ensure that a foley catheter is in place
>Ensure that laboratory studies ordered are completed

During
>The nurse supports the woman so that her back remains in a c-shaped curve during placement or a regional anesthesia by the
anesthesiologist
>The nurse assists the woman to the supine position on the O.R table
>The nurse places a wedge under one hip, and then places a warm blanket and safety strap on the woman’s legs
>Ensure that a sterile abdominal preparation with alcohol or Betadine is performed and a sterile drape is provided
>The nurse performs the second O.R count

After:
>The nurse transfers the woman from the operative suite to the PACU
>Ensures connection of monitoring devices that will record the electrocardiogram, blood pressure, pulse, and oxygen saturation of the
blood
>Monitor vital signs and pulse oximetry reading every 5 minutes until the readings are stable, and then 15 to 30 minutes until the
patient has met predetermined criteria
>Monitor the patient’s urinary output to make certain it is atleast 30 cc/hour
>Evaluates and record the condition of the fundus along with vital signs

58
>Assess the amount and type of lochia flow

DATE CUES NURSING PLANNING INTERVENTION & RATIONALE EVALUATION

DX
Aug. 27, 2009 S: Acute Pain After 30 >Built rapport with the patient After 30
>“Masakit ang tahi r/t surgical minutes of >Placed ice pack at the incision site. minutes of
ko sa may puson.” incision. proper nursing >Encouraged the patient to do breathing proper nursing
Pain Scale: 10/10 intervention, exercises. intervention, the
O: the patient will >Provided emotional support by patient
>weak in verbalize encouraging the patient to verbalize what verbalized
appearance decreased in she feels. decreased in
>restless and pain to a >Assisted the patient when turning side pain to a
irritable tolerable state. to side. tolerable state.
>pale looking From a pain >Administered analgesics as ordered by From a pain

59
 >tachypnea:RR:24 scale of 10 to the physician. scale of 10 to 2.
cpm 2. AEB:
>grimace a.) Absence of
grimace
b.) Normal
respiration.
RR:17cpm

3. Nursing Management
Aug. 27, 2009 S: Ø Deficient fluid After 1 hour of Independent: After 1 hour of
O: volume r/t proper nursing >Monitored Vital signs of client’s with proper nursing
>have no oral intake contraindicated intervention, deficient fluid volume every 4hrs. intervention, the
for the last 8 hours intake via oral the patient will Observe for tachycardia, tachypnea, patient
>chapped lips route & blood maintain fluid decreased pulse pressure first, then maintained fluid
>dry mouth loss during balance in a hypotension, decreased pulse volume, and balance in a
>with surgical surgery functional increase/decrease body temperature. functional level
incision at the lower level after after nothing per
abdomen nothing per >Advised client to have frequent oral orem order as
>consumed 2 orem order as hygiene, at least twice a day. evidenced by:
underpad for the last evidenced by: g. Urine
24 hours d. Urine >Advised client to increase water intake output of
>weak in output of to more that 1.5L per day after NPO ≥30ml/hr
appearance ≥30ml/hr orders. h. Normal BP,
>restless and irritable e. Normal pulse and
>pale looking BP, pulse Collaborative Respirations

60
 >grimace and >Hydrated the client with ordered i. Elastic skin
>tachypnea: Respiration intravenous solution turgor, moist
RR:24 s tongue and
>bradycardia: f. Elastic skin >Maintained Patent IV access, set an mucous
PR:56 turgor, appropriate infusion flow rate and membrane
>HCT=0.266% moist administer at constant rate as ordered.
>HGB=80g/L tongue and
>urine output=30 mucous
cc/hr membrane
>Capillary refill=3sec

Date Assessment Diagnosis Planning Interventions Evaluation

August
27,2009 S: Ø Risk for Within 2  Monitored vital signs every 15 minutes Within 2 hours of
Injury r/t hours of proper nursing
O: blood loss proper interventions, the
 blood loss- during nursing  Assisted the client in a comfortable patient was able
consumed 1 surgery interventions, position particularly in Semi-Fowler’s to have a
soaked the patient or High Fowler’s position. decreased risk for
underpad will have injury.
 UO- 30cc/hr decreased  Encouraged the client to verbalize her
 HGT- risk for feelings and worries.
0.266% injury.
 HGB-80 g/L
 Pale
 Dyspnea  Increased frequent observation , and if
possible, stay with the client and
 Weak in
enforce security measures (e.g Raise
appearance
side rails)

61
  Weak and
thready  Encouraged the client to have bed rest.
 56 bpm-PR
 Restless and  Advised the client to increase fluid
irritable intake.
 RR: 24-
 Administered medications as
prescribed.

DATE CUES NURSING PLANNING INTERVENTION & RATIONALE EVALUATION

DX
Aug. 28, 2009 S: Ø Impaired After 30 >Built rapport with the patient After 30
O: physical minutes of minutes of
>with surgical mobility proper nursing >Assisted patient in turning side to side proper nursing
incision at the lower r/t surgical intervention, every 2 hours. intervention, the
abdomen incision. the patient will patient was able
>inability to sit be able to >Provided emotional support by to gradually
>difficulty turning gradually encouraging the patient to verbalize what increase
to side increase she feels. mobility.

62
 >weak in mobility. AEB:
appearance >Instructed the patient to do breathing a.) Absence of
>restless and exercises. grimace
irritable b.) Ability to
>pale looking >Administered analgesics as ordered by turn side to side
>tachypnea:RR:24 the physician. with minimal
> grimace assistance.

DATE CUES NURSING PLANNING INTERVENTION & RATIONALE EVALUATION

DX
Aug. 28, 2009 S: “Hindi ko Risk for After 1 hr of 1. Assist patient in turning from side to After 1 hr of
magalaw ang paa ineffective proper nursing side every 1-2 hours proper nursing
ko.” tissue intervention, intervention, the
perfusion the client will 2. Assist client in extremity exercise client will
O: r/t maintain a maintain a
>Weak in immobility capillary refill 3. Early ambulation should be capillary refill
appearance after of less than 5 encouraged whenever appropriate. of less than 5
>Pale surgery seconds and seconds and will
>With limited will not report 4. Encourage deep breathing and not report of
movements of calf pain, coughing exercise calf pain,
>Difficulty redness, redness, edema,
raising/flexing the edema, or 5. Ensure that bedcovers must be loose or areas of

63
 legs areas of enough warmth on
>Weak peripheral warmth on lower
pulses lower extremities
>Capillary extremities
refill=3seconds

Daily Program August 27, 2009(Day 1) August 28, 2009(Day 2) August 29, 2009(Day 3)
Vital Signs 8:00 AM – T: 36. 2 8:00 AM – T: 37.1 8:00 AM – T: 36.9
P: 56 P: 63 P: 70
R: 24 R: 25 R: 19
BP: 130/100 BP: 120/80 BP: 110/80
10:00 AM – T: 36.7 10:00 AM – T: 37.6 10:00 AM – T: 36.8
P: 56 P: 58 P: 77
R: 26 R: 20 R: 19
BP: 130/90 BP: 130/80 BP: 120/90
Laboratory and Complete Blood Count
Diagnostic
Procedures
Medical and 5% Dextrose in Lactated Ringer’s 5% Dextrose in Lactated Ringer’s D5NM with 1 ampule of
Surgical Solution: Solution: Moriamin:
Management 15 gtts/min 15 gtts/min 15 gtts/min

D5NM with Tramadol:

15 gtts/min

64
 Oxygen Therapy:
Regulated at 2L/minute
Drugs Cefuroxime Sodium 750mg q 8 Cefuroxime Sodium 750mg q 8 Cefalexin 250 mg TID
Ketorolac 30mg q6 x 6doses Ketorolac 30mg q6 x 6doses Mefenamic Acid 500 mg capsule
Tramadol 100mg TID Tramadol 100mg TID TID
Omeprazole 40mg q12 x 2doses Omeprazole 40mg q12 x 2doses Ferrous Sulfate 15mg OD
Diet NPO Soft Diet DAT
Exercise Passive ROM ROM, turning side to side Active ROM, minimum level of
activities

D. Evaluation:
Patient’s daily program in the hospital

1. Discharge Planning

i. General condition of the client during discharge

Upon client’s discharge (August 29, 2009), the client appeared neatly dressed with no apparent body odor. He was afebrile.
She was able tolerate minimal levels of activity such as walking, moving from place to place and transferring from sitting to standing

65
position without dizziness. She was able to take any food tolerated. She also does not perspire excessively or show signs of emotional
distress such as nail biting or avoidance of eye contact.
ii. METHOD approach
Medications Exercise Treatment Health Teaching OPD Follow-Up Diet
 Mefenamic Acid Limb Exercise Limb Exercises The client was Client was Advised the
500 mg capsule R: To improve R: To improve advised the advised to return client to increase
peripheral blood peripheral blood following: to OPD for intake of foods
 Cefalexin circulation. circulation.  The importance follow-up rich in protein,
Deep breathing Minimal of a clean treatment and calories and
 Ferrous Sulfate Exercises: activities environment. check-up at calcium.
R: To promote R: To improve September 5, Rationale: To
effective lung client’s activity  The significance 2009 facilitate faster
expansion. tolerance. of bedrest, eating and effective
Minimal wound and body
healthy foods,
Activities e.g function
walking, and increased recovery.
transferring fluid intake.
from sitting to
standing  The importance
position with complying
R: To improve with prescribed
client’s activity medications.
tolerance

66
III Conclusion:

This case served as a realization for both the group and their client. It required thorough
investigation about client’s condition against both theory and the large comparative environment.
In this study, objectives are important. The group formulated their objectives before conducting
the study of Placenta Previa. It consists of Nurse and Client – centered objectives.
After doing this case study, the group attained the formulated nurse-centered objectives. They
were able to come up with a comprehensive presentation of the disease condition by means of
correct presentation of the data gathered through the use of nursing process. The group also able
to present the current trends about the disease condition, the reason for choosing such case for
presentation; and the importance of the case study.
By means of proper education rendered by the group, their client was able to fully understand
and recognized the disease condition. The client learned the importance of healthy lifestyle and
identified the predisposing factors that aggregated her condition.

IV Recommendation:

Close monitoring is important with patient or pregnant woman having placenta previa. The
group is recommending the following for the management of Placenta Previa:

To the Community:
 Conduct seminars about Maternal and Child Health
 Importance of follow-up check up should be emphasized to the community through
seminars, health promotion, etc

To the Client:
 Stress the importance of prenatal check-up and post natal check-up especially to the
client having this condition.
 Accentuate the importance of bed rest

To the next researcher:

This case study will serve as an additional source of information about the condition: Placenta
Previa.

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V. BIBLIOGRAPHY
1. Health Assessment and Physical Examination, Mary Ellen Zator Estez,
3rd edition
Edition
2. Fundamentals of Nursing, Barbara Kozier; 7th edition
3. Maternal & Child Health Nursing, Pilliterri, Adele PilliteriVolume 2,
2007
4. Wong’s Essentials of Pediatric Nursing 7th edition
5. Craven Hirnle, Fundamentals of Nursing: Human Health & Functions;
Fourth Edition
6. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing Eleventh
Edition Volume 1 by Suzzane B. Smeltzer et. al., copyright 2008
7. Essentials of Anatomy and Physiology Fourth Edition by Seely et.al.,
Copyright 2002

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