ACKNOWLEDGEMENT

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 never-ending 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.

Likewise, the group would like to express our appreciation to the members

and staff of the Obstetrical Ward and the midwives of the Birthing Home of

Davao Medical Center, for allowing us to choose our case study from their

respected institution.

To our adored mentors and clinical instructors especially Mrs. Aurea

Llamido and Mrs. Mary Jean Tulas, thank you so much for everything. Thank you

for the patience, in spite of our unfathomable enthusiasm in talking, for the

camaraderie founded based on accepting individuals discrepancy and all the

things that you’ve taught us. We’ve learn many possessions from you our dear

teachers. And for this words will not be enough to express our gratefulness.

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Friends and classmates, we are delighted of how thoughtful you all are in

sharing one school year. Thank you for giving out your insights, knowledge and

ideas that helped a lot in putting this assignment, this case presentation a

comprehensive one.

Lastly, to the special people behind this project, this is not the end of the

world yet… We still have more case presentation waiting ahead of us and this

may serve a new beginning and a stepping stone for more decisive case

presentations in our higher year.

2

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 mother’s health especially during the 9 months

where the child’s development has already started. The mother’s 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 mother’s 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

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

3

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, Davao as of 2007. While mortality rate in the

locality of Davao is 0% as of 2007.

During our duty in the Ob ward at Davao Medical Center , we decided to

take the case of Ms. Skema 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 we’ve 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 patient’s 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.

4

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 client’s 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 client’s 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

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14.Render health teachings as part of our holistic care to alleviate problems

identified

15.Evaluate complications to nursing practice, education and research

PATIENT’S DATA

Name: Skema

Address: Purok 3, Durian Street, Tugbok, Davao City

Age: 23 y.o.

Birthday: October 05, 1984

Birthplace: Davao City

Civil Status: Single

Religion: Roman Catholic

Nationality: Filipino

Educational Attainment: First Year College, Mass Communication

Occupation: Housekeeper

Spouse: None

Date Admitted: August 30, 2008

Time Admitted: 6:10 am

Ward: OB

Bed no.: 22

Admitting Diagnosis: Pregnancy uterine 37 3/7 weeks AOG, G2P1,

Placenta Previa Totalis

Final Diagnosis: Pregnancy uterine cephalic delivered term baby boy

livebirth via low segment transverse cesarean section;

Placenta Previa Totalis G2P2 (2002)

Admitting Doctor: Dr. Brana, Analita V.

Consultant Doctor: Dr. Ayunan

Admitting Clerk: Mallwat, Carmelita C.

Attending Physician: Manual Aries, MD

Herrera Eustaquio, MD

6

HEALTH HISTORY

Family Health History

The patient's grandfather on her mother's side, Bernardeno, died due to

old age and her grandmother, Teofila, died of because of asthma. Her father,

Paulino, died in the year 1996 due to hypertension while her mother, Evangeline,

is still alive and doesn't experience any serious illness at present. Skema has

three siblings and all of them are still alive except for the youngest of them,

Barry, who died in the car accident. Her elder sister Hazel has hypertension while

her younger brothers, Glenn Paul, have vices, which include smoking and

drinking alcohol.

On the other hand, the patient's grandfather on her father's side died of

hypertension.

The patient is the 2nd child in the family. She’s still single but living with

Jaguar (her partner) for 3 years now, and they are currently living at P3, Durian

St., Tugbok (POB), Davao City. They are what we call as “cohabiting” family.

They eat three times a day and their food intake is usually fried foods such as

fish, eggs and rice in the morning while soup at noon and in the evening. They

usually sleep at 9 pm and their waking time is at 6 am. Jaguar goes to work at 7

am and come home late in the afternoon while Skema stays at home and do the

household chores and take care of Trisha Mae (their first child). The patient

doesn't drink alcohol and doesn't even smoke.

History of Past Illness

7

The patient verbalizes that her past illnesses were fever, headache and

colds. She only takes a rest and drink medicines such that are over the counter

drugs, and also she had her increase of fluid intake. She also said that when she

was on her school age, she experienced having a chicken pox. She said that she

has never been hospitalized before, except on her first pregnancy.

Obstetrical History

Upon interview, the patient told us that her menarche started at the age of

13, irregular, with 1 – 2 months interval. Her menstrual period usually lasts from 5

days and she could use up 2 napkins per day. She can’t remember the date

when her last menstrual period of her first baby. She only tells us that her first

baby is a girl and she delivers her baby through normal spontaneous vaginal

delivery last 2005 and she also said that there are no complications occur. On

her second pregnancy the patient also told us that her last menstrual period was

on December 10, 2007.

The patient told us that she never used any contraceptive ever since and

all the babies are all planned.

History of Present Illness

The patient verbalized that it was her second pregnancy. Her last

menstrual period for her second pregnancy was on December 10, 2007. She has

her prenatal check-up at Rusiana lying-in. On her second trimester, she

experienced her first vaginal bleeding and because she’s afraid to lose her baby,

she immediately goes for a check-up and has an ultrasound, that’s when she

discovers that she has placenta previa. She was advised to have a full rest and

move carefully. The estimated time of confinement is September 17, 2008, with

the age of gestation of 37 3/7 weeks. When August 30, 2008 arrived, she had the

8

chief complaint of having a vaginal bleeding, so she was confine immediately and

it was then the placenta overlap the entirety of the cervical os.

9

GENOGRAM

Mother’s Side Father’s Side

10

Bernardeno

Teofila

Libeth

BernardGloria

EvangelineDelia

Francisco↑

Paulino↑

Regina↑

Teofredo

Ely

Hazel↑

SkemaΩ

Glenn Paul Barry

Legend: Ω - Placenta Previa - asthma ↑ - hypertension

- Deceased

Developmental Data

Theorist Theory Developmental Task Result and Justification

Robert

Havighurst

Developmental Task Theory,

based on learning and learned

behaviors, called developmental

tasks that emanate from

biologic, psychological and

social origins during lifespan.

Specific developmental tasks

are assigned to the various

stages of life. Failure to

complete the tasks assigned to

each stage may lead to failure in

tasks in subsequent stages.

According to this theory,

success in achieving the

Developmental tasks leads to

success with tasks in later

stages of life.

She is 23 years old. She

belongs in the early adulthood

from 20 to 40 years of age. The

developmental tasks of our

client are to select a mate, learn

to live with a partner, start a

family, rear children, manage a

home, get started in an

occupation, take on civic

responsibility and find a

congenial social group.

1. Selecting a life partner

√

She has achieved this because she

has a guy who lives with her and

considers him as a husband.

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2. Learning to live with a partner √ She has achieved this because she

lives with her “husband” for almost 4

years. They where not married at all

but all the time she considers him as

her husband.

3. Starting a family √

She and her partner have already a

daughter which is already 3 years old

and now a new son. Both of there

children were planned according to

them.

4. Rearing children √

She has achieved this task. She takes

care of her children. Her eldest is

Trisha Mae, as she grows; she was

also taught with good moral values at

home even at a young age. Also she

takes care of her in any way she could.

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5. Managing a home

√

She and her partner have a house of

their own. They do not live in the same

roof with their parents. She is able to

organize their home effectively. The

money that her husband gets is

equally distributed to them.

6. Getting started in an

occupation √

She has achieved this task. She was a

cashier on a grocery store near there

place; but now, she retired and took

the responsibility of being a housewife.

7. Taking on civic responsibility

√

She votes during election period. She

is also concerned of the crisis that is

happening today especially the

increasing prices of goods.

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8. Finding a congenial social

group

√ She achieved this because she joins

the activities in there community like

Barangay health programs.

Erik

Erickson

Erikson envisions life as a

sequence of levels of

achievement. Each stage

signals a task that must be

achieved. The resolution of a

task can be complete, partial, or

unsuccessful. Erikson believes

that the greater the task

achievement, the healthier the

personality of the person; failure

to achieve a task influences the

person’s ability to achieve the

next task. Erikson’s eight stages

reflect both positive and

negative aspects of the critical

life periods. The resolution of

the conflicts at each stage

enables the person to function

She belongs to Eric Erikson’s

stage of Intimacy vs. Isolation. It

is from 20 to 25 years of age.

In Young adulthood, we begin

to share ourselves more

intimately with others. We

explore relationships leading

toward longer term

commitments with someone

other than a family member.

Successful completion can lead

to comfortable relationships and

a sense of commitment, safety,

and care within a relationship.

Avoiding intimacy, fearing

commitment and relationships

can lead to isolation, loneliness,

√

She has achieved this stage which is

intimacy, because she learned how to

love. And so their love brought them

Trisha Mae and now a new son. Even

though they are not married, they still

consider themselves married because

the way they love each other is like the

love you can find in married couples.

14

effectively in the society. and sometimes depression.

Lawrence

Kohlberg

Kohlberg’s model states that a

person’s ability to made moral

judgments and behave in a

morally correct manner develops

over a period of time and

progresses in relationship to

cognitive development.

Her age correlates to the post-

conventional level.

The individual makes a clear

effort to define moral values

and principles that have validity

and application apart from the

authority of the groups of

persons holding them and apart

from the individual's own

identification with the group.

√

She understands what laws are for and

their purpose. And so she knows what is

right and what is wrong. When talking

about abortion, she told us that it is really

not right to abort a baby because it’s

against the law and it’s really considered a

sin because you kill someone’s life.

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DEFINITION OF COMPLETE DIAGNOSIS

PLACENTA PREVIA TOTALIS

Low Segment Transverse Cesarean Section - the incision is always made

horizontally across the lower end of the uterus , resulting in reduced blood

loss and a decreased chance of rupture.

Source:

http://www.answers.com/topic/caesarean-section

Low Segment Transverse Cesarean Section - Incision made horizontally

across the lower end of the uterus; this kind of incision is preferred for less

bleeding and stronger healing.

Source:

http://www.answers.com/topic/low-transverse-incision

Low Segment Transverse Cesarean Section - the incision is made

horizontally across the lower uterine segment.

Source:

http://www.encyclopedia.com/doc/1G2-3447200117.html

Placenta previa - is an obstetric complication in which the placenta has

attached to the uterine wall close to or covering the cervix. It can some

times occur in the latter part of the first trimester, but usually during the

second or third. It is a leading cause of antepartum hemorrhage (vaginal

bleeding).

Source:

http://en.wikipedia.org/wiki/Placenta_previa

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Placenta previa - is defined as implantation of the placenta in the lower

uterine segment in advance of the fetal presenting part.

Source: http://www.womenshealthsection.com/content/print.php3?

title=obs018&cat=2&lng=english

Placenta previa is an obstetric complication that occurs in the second and

third trimesters of pregnancy.

Source:

http://www.emedicine.com/emerg/topic427.htm

Complete placenta previa - is where the placenta completely covers the

internal os.

Source: http://www.womenshealthsection.com/content/print.php3?

title=obs018&cat=2&lng=english

Placenta Previa Totalis – is implanted in the lower segment near or over

the internal cervical os. A total previa, the internal is entirely covered by

the placenta.

Source:

Maternity Nursing, Lowdermilk, 7th ed.

Total placenta previa - covers and blocks the cervical opening

Source:

http://www.webmd.com/content/article/13/3608_263

PHYSICAL ASSESSMENT

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General Survey

We received Mrs.Skema, 23 years of age, 5’2’’ tall, weighing 55kg, 2

days post-partum, was assessed on September 1, 2008 at Davao Medical

Center, OB ward at bed no22. The client was conscious, alert, coherent,

cooperative and oriented to time, place, person and her surroundings. No IVF

line. She is mesomorphic built. Facial grimace and abdominal guarding were

noted.

Vital Signs

Shift: 11-7

T : 36.5C

PR : 86bpm

RR : 22bpm

BP : 80/60

Skin

Client has brown complexion. Skin is smooth, moist, warm to touch and

has a good turgor. Capillary refill time of 2 seconds. Skin integrity was no longer

intact due to a lesion on the right lower leg and a horizontal or transverse

cesarean incision made through the maternal abdomen. Bleeding and bruises

were not seen upon observation.

Head

The head configuration is normocephalic. Facial movements are

symmetrical. The hair color is black, long, oily and evenly distributed over the

scalp. There were no signs of dandruff. No swelling, lacerations, bruises and

tenderness was seen upon inspection.

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Eye

The eyelids are symmetrical with each other. Conjunctiva is pink and the

cornea is moist and white in color and lacrimal apparatus is present on both

eyes. The iris appears to be black on both eyes. With 2 mm size pupils, equally

round and briskly reactive to light and accommodation. Eyebrows are thin and

eyelashes are evenly distributed along the margin of the eyelids and visual acuity

is grossly normal. There were no lesions and unusual secretions observed.

Ears

The external pinnae are symmetrical. The gross hearing is also

symmetrical. Upper margin of the pinnae is in line with the outer canthus of the

eyes. No signs of lesions and bruises were seen upon observation. There were

no foul smelling and purulent discharges noted in the external canal.

Nose

External surface of the nose was oily and pimples were noted. Nasolabial

folds were not flaring and nasal septum is in the midline of the head. Nasal

mucosa is moist, pinkish and nasal hair is present.. Air patency is good. Gross

smell is symmetrical. No foul discharges, lesions or masses were noted.

Mouth

Lips are pale, slightly dry and without lesions. Mucosa is pinkish red,

smooth and moist. The tongue is midline position and tonsils are not inflamed.

Teeth are not complete, upper and lower right canine were missing with chalky

white discoloration of the enamel. Upper front teeth were replaced by false

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dentures. Gums are pinkish and there were no signs of swelling, bleeding, and

lesions. On soft diet with good appetite.

Neck

Neck can move easily without any discomfort which includes right and left

lateral, right and left rotation, flexion and hyperextension. Trachea is located

midline with no deviation upon palpation. Carotid pulse is palpable.. Lymph

nodes in the neck are not enlarged. No rigid and masses or any deformities are

noted.

Chest and Lungs

Shape of chest is normal and with symmetrical lung expansion. Thorax is

symmetrical. Respiratory rate is 22 cycles per minute, with regular pattern and

absence use of the accessory muscles. Patient is not in any respiratory distress.

There were no signs of productive cough and difficulty in breathing. Breath

sounds is clear and heard almost of all of anterior lungs upon auscultation.

Heart

The apical pulse is auscultated at the left midclavicular line, fifth

intercostals space. The cardiac sounds were regular and are not difficult to

auscultate, in which the cardiac rate was 84 beats per minute.

Breast and Axillae

Client has a rounded shape breast, slightly unequal in size, however

generally symmetric. Breasts are engorged, full and slightly tender with secretion

of breast milk. Areola is dark brown in color. Axilla is dark and moist. No masses

palpated.

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Abdomen

Has soft, globular, non-distended abdomen. Horizontal (transverse) type

of incision was made 1 to 2 inches above the pubic hair line and was secured

with a binder. Dressing of the operative site on patient’s abdominal area is dry

and intact, however it was not cleaned yet since the operation as verbalized by

the client. Stretch marks and linea nigra were evident upon inspection.

Normoactive sounds heard upon ausculattion. Facial grimacing and abdominal

guarding noted upon palpation of abdomen, also when client moves.

GenitoUrinary

Client can urinate properly without difficulties and without any assistance.

Client was using a diaper.

Upper Extremities

Upper are bilaterally symmetrical. Both arms can strech, flex, rotate and

extend without difficulty. Handgrip was strong. No signs of lesions and bruises

noted. Fingernails were not trimmed and were dirty. Peripheral pulses of the

client are symmetrical with regular and strong pulsation.

Lower Extremities

Lower extremities are symmetrical. Both legs can flex, rotate, extend and

bend without difficulty. Legs can support the body and can slightly move without

difficulty. Lessions on the right lower leg was noted. Toenails were untrimmed.

Deformities, bleeding and bruises were not noted.

ANATOMY AND PHYSIOLOGY

OF THE

21

FEMALE REPRODUCTIVE SYSTEM

Internal Structure

22

Vagina

The vagina is a hollow musculomembranous canal located posterior to the

bladder and anterior to the rectum. It extends from the cervix of the uterus to the

external vulva. Its function is to act as an organ of intercourse and to convey

sperm to the cervix so that sperm can meet to the ovum in the fallopian tube.

With childbirth it expands to serve the birth canal. When a woman is lying on her

back the course of the vagina is inward and downward. Because of this

downward slant and the angle of the uterine cervix, the length of the anterior wall

of the vagina is approximately 6-7 cm; the posterior wall is 8-9 cm. At the cervical

end of the structure, there are recesses on all the sides of the cervix, termed

fornices. Behind the cervix is the posterior fornix; at the front, the anterior fornix;

and at the sides, the lateral fornices. The posterior fornix serves as a place for

the pulling of semen after coitus; this allows a large number of sperm to remain

close to the cervix and encourages sperm migration into the cervix.

Ovaries

The ovaries are grayish-white and appear pitted or with minute

indentations on the surface. An unruptured, glistening, clear, fluid-filled graafian

follicle (an ovum about to be discharged) or miniatured yellow corpus luteum

often can be observed on the surface of the ovary. Ovaries are located close to

and on both sides of the uterus and the lower abdomen. The function of the two

ovaries is to produce, mature and discharged ova. Ovarian function is necessary

for maturation and maintenance of secondary sex characteristics in females. The

ovaries are held suspended and in close contact with the ends of the fallopian

tubes by three strong supporting ligaments attached to the uterus or the pelvic

wall.

23

Fallopian Tube

These are narrow tubes that are attached to the upper part of the uterus

and serve as tunnels for the ova (egg cells) to travel from the ovaries to the

uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the

fallopian tubes. The fertilized egg then moves to the uterus, where it implants to

the uterine wall.

Uterus

The uterus is a hollow, muscular, pear-shaped organ located in the lower

pelvis, posterior to the bladder and anterior to the rectum. The function of the

uterus is to receive the ovum from the fallopian tube; provide a place for

implantation and nourishment during fetal growth; furnish protection to a growing

fetus; and, at mmaturity of the fetus, expel it from the woman’s body.

Anatomically, the uterus consists of three divisions; the body or corpus,

the isthmus and the cervix. The body of the uterus is the uppermost part and

forms the bulk of the organ. The lining of the cavity is continuous with that of the

fallopian tubes, which enter at its upper aspects. The portion of the uterus

between the points of attachment of the fallopian tubes is termed the fundus.

During pregnancy, the body of the uterus is the portion of the structure that

expands to contain the growing fetus. The fundus is the portion that can be

palpated abdominally to determine the amount of uterine growth occurring during

pregnancy, to measure the force of uterine contractions during labor, and to

assess that the uterus is returning to its non-pregnant state after childbirth. The

isthmus is a short segment between the body and cervix. During pregnancy this

portion also enlarges greatly to aid in accomodating the growing fetus. The

cervix, is the lowest portion of the uterus. It represents approximately one-third of

the total uterus size and is approximately 2-5 cm long. Approximately, half of it

lies above the vagina and half extends to the vagina. A central cavity is turned

24

the cervical canal. The opening of the canal at the junction of the cervix and the

isthmus is the internal cervical os; the distal opening to the vagina is the external

os. The level of ther external os is at the level of the ischial spines.

Pelvis

The pelvis serves both to support and protect the reproductive and other

pelvic organs. It is a bony ring formed by four united bones; the two innominate

bones which formed the anterior and lateral portion of the ring, and the coccix

and sacrum, which form the posterior aspects. Each innominate bone is divided

into three parts: ilium, ischium and the pubis. The ilium forms the upper and

lateral portion. The flaring superior border of these bones is what forms the

prominence of the hip. The ischium is the inferior portion. At the lowest portion of

the ischium are two projections; the ischial tuberosites. This is the portion of bone

on which a person sits. These projections are important markers used to

determine lower pelvic grid. Other important terms in relation the pelvis are the

inlet, the pelvic cavity and the outlet. The inlet is the entrance to the true pelvis or

the upper ring of bone through which the fetus must pass to be born vaginally. It

is at the level of the linea terminalis or is marked by the sacral prominence in the

back. The ilium of the sides and the superior aspects of the symphisis pubis is in

the front. If one looks down at the pelvic inlet, the passageway at this point

appears heart-shaped because of the jutting sacral prominence. It is wider

transversely than in the anteroposterior dimension. The outlet is the inferior

portion of the pelvis, or the portion bounded in the back of the coccyx, at the

sided by the ischial tuberositis and in front by the inferior aspect of the symphysis

pubis. In contrast to the inlet of the pelvis, the greatest diameter of the outlet is its

anteroposterior diameter. For the baby to be delivered vaginally, he or she must

be able to pass through the inlet, the cavity and the outlet of the pelvic bone. This

is not a problem for an average fetus; it may be a problem if a mother is a young

25

adolescent who has not yet achieved full pelvic growth or a woman who has not

had an injury.

Placenta

Organ that develops in the uterus during pregnancy. It is a unique

characteristic of the higher (or placental) mammals. In humans it is a thick mass,

about 7 in. (18 cm) in diameter, liberally supplied with blood vessels. The

placenta is attached to the uterus, and the fetus is connected to the placenta by

the umbilical cord. The placenta draws nourishment and oxygen, which it

supplies to the fetus, from the maternal circulation. In turn, the placenta receives

the wastes of fetal metabolism and discharges them into the maternal circulation

for disposal. There are 15-20 cotyledons found in the placenta.

External Structure

Mons Veneris

The mons veneris is a pad of adipose tissue located over the symphisis

pubis, the pubic bone joint. It is covered by a triangle of coarse, curly hairs. Its

purpose is to protect the pubic bone from trauma.

26

Labia Majora

The labia majora are two fold of adipose tissue covered by loose

connective tissue and epithelium; they are positioned later to the labia minora.

Covered by pubic hair, the labia majora serves as a protection for the external

genitalia and the distal urethra and vagina.

Labia Minora

It is located posterior to the mons veneris spread two hairless fold of

connective tissue. Before the menarche, these folds are fairly small; by

childbearing age, they are firm and full; after menopause they atrophy and again

they become smaller.

Clitoris

The clitoris is a small rounded organ of erectile tissue at the forward

junction of the labia minora. It is covered by fold of skin known as the prepuce. It

is sensitive to touch and temperature and is the center of sexual arousal and

orgasm in the female. When the ischiocavernosus muscle surrounding it

contracts with sexual arousal, the venous outflow for the clitoris is blocked

leading to clitoral erection.

27

ETIOLOGY

Predisposing

Factors Remarks Rationale Justification

Age x Women older than

30 years are 3 times

more likely to have

placenta previa than

women younger than

20 years

This is not applicable to

our patient since her age

is 23 years old.

Family history of

Hypertension

/ Having a family

member or relative

who had

experienced is a risk

factor for having

placenta previa

According to the patient’s

family background, her

family or relatives does

have a hypertension.

Race / Importance of race is

fairly debatable.

several studies

propose an

increased risk of

placenta previa

among African

Americans and

Asians, whereas

other studies

mention no

Our patient is a Filipino

woman so this factor is

considered to be

contributory to her

condition.

28

discrepancy.

Gender / Only pregnant

women can

experience this

condition.

Our patient is a women

and she can have the risk

of having placenta previa

Precipitating

Factors Remarks Rationale Justification

Multiple Gestation / Placenta previa

occurs in 1 in 1,500

first-time

pregnancies. In

women who have

had five or more

pregnancies, this

condition increases

to about 5 in 100.

This is our patient’s

second pregnancy.

Previous cesarean

delivery (C-section)

x Of women who have

had two cesarean

deliveries in the past,

about 2 out of 100

have placenta

previa. For women

with three or more

cesarean deliveries,

the chance of

placenta previa

Our patient did not have

previous cesarean

delivery after the present.

She delivered her first

child through NSVD.

29

increases to more

than 4 out of 100

Cigarette Smoking x Smoking decreases

the amount of

oxygen transferred

to the fetus, thereby

stimulating the

growth of a larger

placenta, which is

more likely to grow

low into the uterus.

Patient is not a smoker.

History of previous

placenta previa

x Women who have

experienced

placenta previa in

previous

pregnancies may

have a risk for

developing placenta

previa in succeeding

pregnancies.

Our patient is not reported

to have a previous case of

placenta previa in past

History of medical

procedures that

affect uterine lining

x Medical procedures

that affect the uterine

lining such as

abortion, or

myomectomy to

remove uterine

fibroids or dilation

and curettage (D and

This is not manifested

since our patient has

stated that she has not

have had procedures that

should have affected the

uterine lining before.

30

C) to scrape the

uterine lining may

increase chances of

having placenta

previa.

Male fetus / Placenta previa may

also be associated

with a male

fetus.This is because

they have hormones

that coud be more

likely to cause

placenta previa than

those with female

fetus.

The patient’s child is a

male.

SYMPTOMATOLOGY

31

SYMPTOMS RATIONALE

Occurs after 20weeks of

gestation

/ The placenta in this stage is well

developed or matured and needed

more blood supply, so it migrates

to a more vascularized part of the

uterus.

Bleeding, bright red in color / This bleeding, bright red in color, is

associated with the stretching and

thinning of the lower uterine

segment that occurs during the

third trimester.

Painless vaginal bleeding

/ The uterus is not able to

adequately contract and stop blood

flow from open vessels.

32

33

Fertilization of sperm and

ovum

Reproduction of a fertilized

ovum (zygote)

Implantation of blastocyst to the uterine

endometrium

Pre-embryonic

Stage

Predisposing Factors:RaceGender

Increase in progesterone and estrogen levels

Precipitating Factors: Second

Pregnancy Male fetus

34

Insufficient blood supply in the placenta

Migrates to where there is sufficient blood

supply

Placenta resides in the lower uterine segment

Embryonic Stage

The placenta arises out of the

trophoblast tissue

low-lying placenta should move away from the cervix and out of the

lower uterine segment

35

Total Placenta Previa

Implantation totally obstruct the cervical os

Painless vaginal bleeding

Profuse bright-red bleeding

Hypotension

Hypovolemic Shock

36

Treated

Good Prognosis

Untreated

Birth defects Premature deliveryAnemiaInfectionFDIUAbnormal placental attachments

If treated, there will be good maternal vital signs and the fetus will be delivered successfully without complications

Medical assistanceCesarean section during labor and deliveryMedications to prevent uterine contractions

PATHOPHYSIOLOGY

(Narrative)

During pregnancy, your placenta repositions itself as your uterus stretches

and grows. In early pregnancy, a low-lying placenta is very common. But as your

pregnancy progresses, the enlarging uterus should "pull" the placenta toward the

top of your uterus. By your third trimester, the placenta should be near the top of

your uterus, leaving the opening of the cervix clear for the delivery.

Placenta previa typically occurs as a result of abnormally low implantation.

Although no specific cause has been identified to date, this condition has been

hypothesized to occur as a result of abnormal endometrial vascularization related

to atrophy or scarring from prior trauma or inflammation.

As the lower uterine segment thins in late pregnancy, the margins of the

abnormally implanted placenta are altered. Various degrees of placental

detachment may develop, with ensuing maternal hemorrhage from the

intervillous space. During labor, significant fetal hemorrhage also can occur as a

result of disrupted villous placental vessels.

Risk factors for placenta previa include prior placenta previa, prior

cesarean delivery, increased maternal age, large placentae (eg, multiple

gestations or erythroblastosis), and a maternal history of smoking.

If untreated, it may lead to severe maternal hemorrhage, premature

delivery, and birth defects and the like.

If this is treated, there will be a good prognosis

37

DOCTOR’S ORDER

DATE ORDER RATIONALE REMARKS

08-30-08

6:10am

* Please admit

* NPO

* Vsq4

* Labs :

- CBC

- UA

- HBsAg

- BT

* For legal purposes

* To prevent aspiration

during the procedure.

* To have baseline data.

*Laboratory test help

determine clients general

health status.

* CBC identifies the total

number of white blood

cell and red blood cell,

the platelet count, and

hemoglobin and

hematocrit.

* UA a test to detect

semi-quantitatively

measures various

compounds that are

eliminated in the urine.

* HBsAg is a test to

examine if patient is

immune from acquiring

hepatitis B.

* BT is a test to

determine if what ABO

blood group and Rh

factor status the patient

DONE

DONE

DONE

DONE

DONE

DONE

DONE

DONE

38

* Start Venoclysis with D5lR 1L @

120cc/hr

* Secure Consent

* Abdominal Perineal Preparation

* Inform OR (PROD/AROD)

belong.

* IV administration is

performed to replace

fluids, administer

medications and to

provide water and

electrolyte.

* Signed consent

ensures that the patient

is properly informed

regarding the process,

risks, and possible

complications of the

procedures and is not

forced to coerce to

undergo the said

procedures.

* To make sure that

perineal area is clean

and as a pre op

preparation for CS.

* Inform OR and the

anesthesiologist for the

patient’s schedule of

operation.

* Cefazolin an anti-

DONE

DONE

DONE

DONE

39

8-30-08

9:35 am

- Cefazolin 1g IVTT q 8º

* Refer

* To secure 1 unit of PRBC of patient’s

blood type for on use.

POST OP ORDERS

* To PACU then to OB ward

* NPO

* VSq15 until stable then q hourly

* IVF with D5LR 1L+10units oxytocin @

120cc/hr

infective. Treats skin and

skin structue infection.

* For co-management

* To restore/increase

circulating blood volume

after childbirth.

* For close monitoring of

the recovery.

* The client is not

allowed to take any food

until she can flatus. This

is a sign that the

gastrointestinal system is

starting to function.

* Monitor closely of the

patient’s condition

* This intravenous fluid

helps in supplying

potassium and calcium to

provide adequate fluids

and electrolytes for

maintenance of body

function. It also has

oxytocin to control

bleeding.

DONE

DONE

DONE

DONE

DONE

DONE

DONE

40

* Meds:

- Tramadol 50 mg q 6 hours slow IVTT

- Ketorolac 30 mg q 8 hours IVTT

- Ranitidine 50 mg q 8 hours IVTT

* continue meds

* O2 inhalation @ 4-6 L/min

* Keep patient warm

* I & O monitoring q hourly then q shift

* Watch out for unusualites

* Tramadol for

management of pain.

* Ketorolac is an

analgesic, and it is a

short-term management

of pain.

* Ranitidine decreases

gastric acid secretion.

*For treatment

* Oxygen therapy may be

needed to treat

abnormally low blood

oxygen.

* To provide a good

environment for

recovery.

*Measurement of a

patient's fluid intake and

output will identify those

patients at risk of

becoming dehydrated or

over hydrated.

* For closely monitoring

the patient’s condition.

*for co-management

DONE

DONE

DONE

DONE

DONE

DONE

DONE

DONE

41

08-31-08

5:00 am

* Refer

* For BT to start @ PACU

* General liquids and crackers, soft diet

once with flatus

* VSq4

* C/D IVF and IVTT meds

* Meds:

- Cefadroxil 50 g 1 cup BID

- FesO4 1 cup OD

- M. Maleate 1 tab TID

- Diclofenac K+ 50 g 1 tab TID

*To replace blood loss.

* It is ordered for easy

tolerance and digestion

as client’s peristaltic

movement is still slow.

* Monitor closely of the

patient’s condition

* Consume and

discontinue IVF and IVTT

medication to shift and

continue medication

orally.

* Cefadroxil is the

treatment for skin and

skin structure infection.

* Ferrous sulfate is used

to treat iron deficiency

anemia (a lack of red

blood cells caused by

having too little iron in

the body).

* M. Maleate directly

stimulates unterine and

vascular smooth muscle.

* Diclofenac is a

nonopoid analgesics,

that suppress pain and

inflammation.

DONE

DONE

DONE

DONE

DONE

DONE

DONE

DONE

DONE

42

09-01-08

9:00 am

09-02-08

* Remove foley catheter, should void 4-6º

* May sit up on bed

* Refer

* Soft diet, DAT once with BM

* VSq4º

* For wound dressing

* Continue PO meds

* MGH

* Take home meds:

* To assess patient for

urinary function.

* Enhances circulation

and return of normal

organ function

*For co-management

* Soft diet as ordered for

easy tolerance and

digestion as client’s

peristaltic movement is

still slow.

* Monitor closely of the

patient’s condition

* This is to prevent

infection.

*This is for treatment and

continuity of care

* The client May Go

Home, she is ready to

stay at home but should

recommend continuing

the compliance of her

medications.

* Cefadroxil is the

treatment for skin and

skin structure infection.

* Ferrous sulfate is used

DONE

DONE

DONE

DONE

DONE

DONE

DONE

DONE

DONE

43

- Cefadroxil 500mg 1cp BID

- FeO4 1g OD

- Diclofenac 5g 1 tab TID

* Follow-up @ OPD on September 10,

2008

to treat iron deficiency

anemia (a lack of red

blood cells caused by

having too little iron in

the body).

* Diclofenac is a

nonopoid analgesics,

that suppress pain and

inflammation.

* To monitor client’s

progress and response

to the treatment and to

check if there are any

deviations in her health.

DONE

DONE

DONE

44

DIAGNOSTIC AND LABORATORY EXAMS

A. URINALYSIS

Date TestActualValues

NormalValues Implications Rationale

Nursing Responsibilities

07-01-08 PHYSICAL

EXAMINATION

Color

Appearance

Reaction

Specific Gravity

Straw

Clear

6.5

1.010

Clear straw to

colored liquid

Clear to slightly

hazy

4.6-8

1.005-1.025

Liver problems

or jaundice migh

have occur

normal

To demonstrate

the

- To examine

the patient’s

urine for sign

of renal or

urinary tract

disease.

- To help

discover

diseases

that is not in

relation with

renal

disorders.

1. Tell the patient

that the test is for

the detection or

renal and urinary

tract disorders

and assessment

of body function.

2. Notify the

patient that the

procedure

requires a urine

sample. Urine

must be acquired

most likely on the

45

CHEMICAL

EXAMINATION

Albumin

Sugar

Negative

Negative

In normal

condition there

is no protein

that can be

detect

Normal

concentrating

and diluting

ability of the

kidneys.

Presence of

sugar in urine

may indicate

diabetes,

chronic kidney

disease

- To identify

drugs or

substances

that has

been taken.

first void in the

morning.

3. Notify the

laboratory and

physician of any

drugs that the

patient has taken

that may affect

the results.

46

MICROSCOPIC

EXAMINATION

Epithelial Cells

Squamous

Renal

Pus Cells

RBC

0.2 hpf

Pus cells and

bacteria should

be absent in

urine

May be a sign of

swelling in the

kidney and

pelvic region,

urethral

ulceration and

chronic specific

inflammatory of

the bladder

Blood in the

urine may

sometimes a

serious urinary

tract problem

47

Mucous Threads

Bacteria

Yeast Cells

Oil Globules

Spermatozoa

#

48

B. BLOOD TYPING

Date Test Result Normal Results Implications Rationale

Nursing

Responsibilities

8-18-08 Blood Type

(ABO+Rh)

A (+) In forward typing, if

there’s agglutination

patient’s RBC’s are

mixed with anti-A and

anti-B serum, the A

and B antigen is

present, thus blood

type is O

None known - To check

compatibility

of the donor

and the

patient before

transfusion.

1. Inform the

patient that the

test determines

her blood group.

2. Notify the

patient that the

test blood

sample thus

venipuncture is

done.

3. Check the

patient’s history

for recent

administration of

blood, dextran or

49

I.V.

4. After the

procedure apply

direct pressure

to the

venipuncture to

the site until

bleeding stops.

C. COMPLETE BLOOD COUNT

50

Date Test Result

Normal

Values Implications Rationale

Nursing

Responsibilities

8-18-08 WBC

Hemoglobin

H 15.19

x10^3/uL

122g/L

5-10

x10^3/uL

115-155

g/L

Leukemia,

bacterial

infection, severe

sepsis

Normal

Low HCT,

suggest anemia,

hemodilution or

enormous blood

loss.

- To verify

infection or

inflammation in

the body and

observe its

responses to

specific

therapies.

- To recognize

the amount of

O2 carrying

protein

contained within

the RBC

1. Explain to the

patient the necessity

of undergoing the

test that it helps

detect occurrence of

anemia and

polycythemia.

2. Notify the patient

that the test requires

blood sample as well

as the person who

will perform the

venipuncture and the

time.

3. Inform the patient

that the procedure is

51

Hematocrit

RBC

Differential

Count

L 0.35

L 4.02

x10^6/uL

0.36-0.48

4.20-6.10

x10^6/ uL

Rule out anemia

due to

nutritional

deficiencies,

blood loss.

Low RBC is due

to enormous

blood loss which

results to

anemia.

Leukemia,

hemorrhage.

- To identify the

percentage of

the blood

volume

occupied by red

blood cells.

- To know the

amount of RBC

in the blood.

of slight discomfort

and may feel a little

pain.

4. After the

procedure, apply

direct pressure to the

venipuncture until

bleeding stops.

5. Refer if

venipuncture

develops hematoma

and monitor the

pulses distal to the

site.

52

Neutrophil

Lymphocytes

Monocytes

73%

L 18%

7%

55-75%

20-35%

2-10%

Normal

Leukemia,

systemic lupus

erythematosus

Normal

- To point out

the presence of

bacterial

infection and

amount of

Leukocyte

-To recognize if

there is an

unusual amount

of lymphocyte

that may

indicate viral

infection such

as HIV.

-Increase of

these may

53

Eosinophil

Basophil

2%

0%

1-6%

0-1%

Normal

Normal

respond to

corticosteroid,

with pus

conditions,

hemorrhage

-High

percentage of

eosinophil, may

indicate

bacterial

infestation or

allergies

-Increase of

basophil may

indicate

parasite,

hypersensitiven

ess and

heartworm

54

MCV

MCH

MCHC

88.1fl

30.3

pg

34.5 g/dL

79.40-

94.80 fl

25.60-

32.20 pg

32.20-

Normal

Normal

Normal

causing

endocrine

disease, chronic

liver disease

-To determine

the ratio of

hematocrit to

RBC count

-To identify the

average mass

of hemoglobin

per RBC

-Indicates the

nature and

volume of

hemoglobin, to

55

35.30 g/dL high may

indicate

spherocytosis or

in vitro

hemolysis

D. ULTRASOUND

Nursing

56

Date Test Result Impression Rationale Responsibilities

06-21-08

2:35 pm

U

L

T

R

A

S

O

U

N

D

-Presentation : Cephalic

-Number: single

- Amniotic fluid: AFI 11.1 cm

-Placental location: anterior

-Placental grade: III

-Sex: male

-AOG: 32W 3D

-EDD: 10-11-08

-FHB: 147bpm

Estimated Fetal Weight: 2233 g

-normohydramnios (11.1 cm)

-amniotic fluid volume: normal

-previa: placenta previa totalis

Biophysical profile:

-amniotic fluid: 2

-fetal tone: 2

-fetal breathing: 2

-gross movement: 2

Single, live

intrauterine

pregnancy,

cephalic

presentation, with

good cardiac and

somatic activities;

BPD= 32 weeks

and 5 days; FL=

31 weeks and 1

day

Placenta anterior,

early grade III,

totally covering

the OS (Placenta

previa totalis)

- To know fetal

and

pregnancy

abnormalities

and

measurement

of organ size

and structure.

To identify and

differentiate

cyst and solid

tumor.

- To ensure

the

presentation

and identify

complications

of the fetus.

To detect if

1. Assure a

consent form

signed by the

patient. Explain

that the

procedure is

painless and safe

and that no

radiation

exposure is

involved.

2. Emphasize the

importance of

remaining still

during the scan to

prevent distorted

image.

57

Total =8 there is risk of

pregnancy.

3. Assist the

patient into a

supine position; if

possible use

pillows to support

the area to be

examined. Coat

the target area

with a water-

soluble jelly. If

necessary to

assist the patient

into lateral

positions for

consequent view.

58

NURSING THEORIES

Nightingale’s Environmental Model

Nightingale Environmental areas that a nurse can control are: ventilation

and warming, light, noise, variety, bed and bedding, personal cleanliness,

nutrition and taking food, and chattering hopes and advices. When one or more

aspects of the environment are out of balance, the client will be using increased

energy to counter the environmental stress. The stresses drain the client of

energy that should’ve been used for healing. It is the role of the nurse to

manipulate the environment to compensate for the client’s response to it.

Our patient was admitted to the OB ward of DMC hospital after her CS

delivery. The environment was not well ventilated and body odor from the great

number of people confined to the same area contributed to the unpleasant smell

in the whole of the ward. The place was also very warm. Nurses should then

advise patients to dress lightly and avoid wrapping newborns heavily to prevent

hyperthermia. Most of the beds were soiled, untucked, or didn’t have any bed

sheet at all. Not all wall fans are also functioning well and so it leads to a warmer

environment. As a nurse we should give health teachings as our main role

concerning personal hygiene so as to promote better health. For our client, we

told her to take a bath, change clothing everyday, and to do simple exercises so

that she won’t experience any bed sores or fatigue.

59

Lydia Hall’s Care, Core, Cure theory

Lydia Hall’s theory is visually presented by interlocking circles and each

represents a particular aspect of nursing. The three circles represent the care,

core and cure. The major aspect of care is to achieve an interpersonal

relationship with the health care provider that will much more facilitate

development. This aspect provides motherly care and comfort, provide teaching-

learning activities and support the daily biological function of the patient. The

closeness of the nurse and patient promotes the sharing and exploration of

feelings with the nurse. The core aspect emphasized the therapeutic use of self

and usage of reflective technique. The patient become more aware of the feeling

being experienced as evidenced of making conscious decision, understand and

accept feeling. The cure circle is based on pathological and therapeutic

sciences. The patient has a negative perspective about the nurse as potential

cause of pain rather than a comforting being. These three aspects function

independently but they are interrelated and the circle’s size represents the

progress in each aspect.

In our case, the care aspect shows the relationship between the patient

and the health care provider by this the patient is able to get health teaching and

support. Our patient followed our health teaching so as to avoid anymore

complications, we also told her to verbalize any feelings she would like to

express so that we could know if she needs more care to be provided so as to

promote further wellness. The core aspect helped the patient reflect on her

situation and she was able to make decision by her own. Our patient was able to

ambulate for a faster healing of wounds and she doesn’t refuse in taking her

medication daily. So from that situation we can say that she understands her

situation and so she copes up with it to promote better healing. As for the cure

aspect, when the doctor ordered that she is NPO, she followed it and the nurse

60

that was assigned to her also implemented it so that she won’t forget it. In that

way safety was maintained.

Dorothea Orem’s self-care deficit theory

Orem developed the Self-Care Deficit Theory of Nursing which is

composed of three interrelated theories: self-care theory, self-care deficit theory

and theory of nursing systems. Self-care is the performance or practice of

activities that individuals initiate and perform on their own behalf to maintain life,

health, and well-being. Self-care agency is the human’s ability or power to

engage in self-care. Therapeutic self-care demand is the totality of “self-care

actions to be performed for some duration in order to meet known self-care

requisites by using valid methods and related sets of operations and actions.

Then there are three categories of self-care requisites: universal, developmental,

and health deviation. Self-care requisites are actions directed toward the

provision of self-care. In the second vital part of Orem’s theory is the self-care

deficit theory wherein nursing is needed when the self-care demands are greater

than the self-care abilities. The nursing system is based on the self-care needs

and abilities of the patient to perform self-care activities. Orem has identified

three classifications of nursing systems to meet the self-care requisites of the

patient and these are: wholly compensatory system, the partly compensatory

system, and the supportive educative system.

We applied this theory because for a few days after the labor the patient

was not able to do self-care and shows inadequacies of self-care requisites. Also

acute pain is one of the major complaints in the post cesarean section women.

They may not want to cleanse or bath because of fear of pain, but as a nurse we

encouraged our client to perform daily hygiene and assisted her in task that she

cannot do by herself alone.

61

DRUG STUDY

Generic Name: CEFADROXIL

Brand Name: Drolex

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

-

Cephalosporins

Ordered at 8/31/08

- 50 g 1 cup BID

PO

Ordered at 9/2/08

- 500 mg 1 cup

BID

Cefadroxil binds to

one or more of the

penicillin-binding

proteins (PBPs)

which inhibits the

final

transpeptidation

step of

peptidoglycan

synthesis in

bacterial cell wall,

thus inhibiting

biosynthesis and

arresting cell wall

assembly resulting

in bacterial cell

death. Cefadroxil is

not active against

Proteus,

Infections

caused by

susceptible

strains of

organisms in

UTI, skin &

skin structure

infections,

pharyngitis

&/or tonsillitis.

-Hypersensitivity to

cephalosporins.

-Impaired renal

function

Prothrombin time

prolonged; bleeding

may occur when

taken with

anticoagulants.

Decreased

elimination with

probenecid.

-Nausea,

vomiting,

diarrhoea,

abdominal

discomfort; skin

rash,

angioedema;

elevated liver

enzyme values;

superinfection

with resistant

organisms

especially

candida.

-Anaphylactic

reaction;

pseudomembran

ous colitis.

1. Advise patient that

Cefadroxil may be taken with

or without food (May be taken

w/ meals to reduce GI

discomfort.).

2. Tell patient to take

Cefadroxil exactly as directed

by the doctor. Do not take

more or less than instructed by

the doctor.

3. Advise patient to alert the

doctor if she or he have a

history of allergic reactions

(rash, breathlessness, swollen

mouth or eyes).

4. Tell patient to not take

Cefadroxil together with

antacids because antacids

could reduce the effectiveness

62

Pseudomonas,

Enterobacter,

Morganella,

Serratia and

Listeria

monocytogenes.

of the antibiotic.

5. Advise patient that if

Cefradroxil have been given

tablets or capsules, swallow it

whole.

Generic Name: CEFAZOLIN

Brand Name: Anzif

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

63

-Anti-infective,

first-generation

cephalosporin

Ordered at 8/30/08

-1g IVTT q 8º

-binds to bacterial

cell wall

membrane, causing

cell death

-active against may

gram-positive cocci

- treatment of

skin and

structure

infections

-otitis media

-urinary tract

infections

-septicemia

-hypersensitive to

cephalosporins and

penicillins

-increased risk of

nephrotoxicity when

aminoglycosides or

collistimethate

-probencid decreases

excretion and

increases blood levels

CNS: headache,

dizziness,

lethargy,

paresthesias

GI:

pseudomembran

ous colitis, liver

toxicity

GU:

Nephrotoxicity

Hematologic:

Bone marrow

depression

Hypersensitivity:

ranging from

rash to fever to

anaphylaxis

Other:

superinfections,

pain, abscess.

1.Assess patient for infection;

appearance of wound at

beginning and throughout

course of therapy

2.Before initiating therapy

obtain a history to determine

previous use of and reactions

to penicillins or

cephalosporins

3. Obtain specimens for

culture and sensitivity before

initiating therapy.

4.Do not use solutions that are

cloudy or contain a precipitate

5. If aminoglycosides are

administered concurrently, if

possible, at least 1 hour apart.

6. Advise patient to report

signs of superinfection.

Generic Name: Diclofenac Brand Name: Cataflam Voltaren Rapide)

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

64

-Therapeutic:

nonopiod analgesics,

nonsteroidal anti-

inflammatory

agents.

Ordered at 8/31/08

- 50 g 1 tab TID PO

Ordered at 9/2/08

- 5g 1 tab TID PO

- Inhibits

prostaglandin

synthesis.

Therapeutic

effects:

suppression of

pain and

inflammation.

- PO:

Managemen

t of

inflammator

y disorders

including:

Rheumatoid

arthritis,

Osteoarthriti

s,

Ankylosing

pspondylitis,

Relief of

milt to

moderate

pain of

dysmenorrh

eal.

- Topical:

Treatment of

actinic

keratoses.

-Hypersensitivity

to diclofenac or

other

components of

formulation

- Cross-

sensitivity may

occur with other

NSAIDs

including aspirin

- Active GI

bleeding/ulcer

disease.

DRUG-DRUG

- concurrent use with

aspirin may decrease

effectiveness

- additive adverse GI

effects with aspirin,

other NSAIDs,

potassium

supplements,

corticosteroids or

alcohol

- chronic use with

acetaminophen may

increase the risk of

adverse renal

reactions

- may decrease the

effectiveness of

diuretics or

hypertensive

- may increase serum

lithium levels and

increase the risk of

toxicity.

- increased risk if

- CV:

hypertension

-CNS: dizziness,

drowsiness,

tremors

GI: GI Bleeding,

abdominal pain,

dyspepsia,

heartburn,

diarrhea,

hepatotoxicity

- GU: acute renal

failure, dyuria,

frequency,

hematuria,

nephritis,

proteinuria

- Derm: eczema,

photosensitivity,

rashes

- F and E: edema

- Hemat:

prolonged

bleeding time

- Local: Tropical

1. Advise to administer after

meals, with food, or with an

antacid containing aluminum

or magnesium to minimize

gastric irritation.

2. Administer as soon as

possible after the onset of

menses. Prophylactic

treatment has not been shown

to be effective.

3. Instruct patient to take

diclofenac with a full glass of

water and to maintain in a

upright position for 15-30 min

after administration.

4. Instruct patient to notify

health care professional of

medication regimen before

treatment or surgery.

5. Caution patient to wear

sunscreen and protective

clothing to prevent

photosensitivity reactions.

6. Advise patient to consult

health care professional if

65

bleeding with

cefamandole, cefoten

cefoperazone,

valproic acid,

plicamycin,

thrombolytic agents

or anticoagulants

- may increase the

risk of nephrotoxicity

from cyclosporine.

DRUG-NATURAL

PRODUCTS

- increased bleeding

risk with anise,

arnica, chamomile,

garlic, ginger, ginko,

Panax ginseng

only – contact

dermitis, dry

skin, exfoliation,

rash

- Misc: allergic

reactions

including

Anaphylaxis

rash, itching, visual

disturbances, tinnitus, weigh

gain, edema, black stools,

persistent headache, or

influenza-like syndrome

occurs.

Generic Name: Ferros Sulfate, FeO4 Brand Name: Feosol, Feratab, Fer-gen-sol, Fer-In-Sol

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

66

- Therapeutic:

antianemics

- Pharmacologic:

iron supplements

Ordered at 8/31/08

- 1 cup OD PO

Ordered at 9/2/08

- 1g OD PO

- An essential

mineral found

in hemoglobin,

myoglobin,

and many

enzymes.

- Parenteral

iron enters the

bloodstream

and organs of

the

reticuloendoth

elial system,

where iron is

separated out

and becomes

part of iron

stores.

- Therapeutic

effects:

Prevention.trea

tment of iron

deficiency.

- PO:

Prevention/

treatment of

iron-

deficiency

anemia

- IM, IV:

Iron dextran

–

treatment/pr

evention of

iron-

deficiency

anemia in

patients who

cannot

tolerate oral

iron

-Primary

hemochromatosis

- Hemolytic

anemia’s and other

anemia’s not due

to iron deficiency

- Some products

contain alcohol,

tartrazine, or

sulfites and should

be avoided in

patients with

known intolerance

or hypersensitivity

- Concurrent oral

iron therapy

DRUG-DRUG

- Tetracycline and

antacids ↑ oral

absorption of iron

by forming

insoluble

compounds

- Oral iron

supplements ↓

absorption of

Tetracyclines,

fluroquinolones, and

penicillamine

- ↓ absorption of

and may ↓ effects of

levodopa and

methyldopa

- May ↓ efficacy of

levothyroxine

DRUG-FOOD:

- Iron absorption is

↓ 33-50% by

concurrent

administration of

- CNS: IM, IV –

seizure,

dizziness,

headache,

syncope

- CV: IM, IV –

hypotension,

tachycardia

GI: nausea; PO

– constipation,

dark stools,

diarrhea,

epigastric pain,

GI bleeding

Derm: IM, IV –

flushing,

urticaria

Local: pain at IM

site (iron

dextran),

phlebitis at IV

site, skin staining

at IM site (iron

dextran)

MS: IM, IV –

1. Encourage patient to

comply with medication

regimen.

2. If you missed a dose, take it

as soon as remembered within

12 hr; otherwise, return to

regular dosing schedule.

3. Do not overdose or

underdose when taking in the

medication.

4. Advise patient that stools

may become dark green or

black and that this change is

harmless.

5. Instruct patient to follow a

diet high in iron.

6. Place medication out of

reach of children

7. Place medication at room

temperature.

67

food. arhralgia,

myalgia

- Misc: PO –

staining of teeth

(liquid

preparations);

IM, IV- allergic

reactions

including

anapyhylaxis,

fever,

lymphadenopath

y.

Generic Name: KETOROLAC Brand Name: Acular, Toradol

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

68

- Non-steroidal anti-

inflammatory agents

- Non-opioid

Analgesics

- Analgesic, anti-

inflammatory,

antipyretic effects

Ordered at 8/30/08

- 30 mg q 8 hours IVTT

- Inhibits

prostaglandin

synthesis by

decreasing an

enzyme

needed for

biosynthesis

Short-term

management

of pain (not

to exceed 5

days total

for all routes

combined)

Hypersensitivity;

cross-sensitivity

with other

NSAIDs may

exist; labor,

delivery or

lactation; pre- or

perioperative

use; known

alcohol

intolerance

DRUG-DRUG

- concurrent use with

aspirin may decrease

effectiveness

- additive adverse GI

effects with aspirin,

other NSAIDs,

potassium

supplements,

corticosteroids or

alcohol

- chronic use with

acetaminophen may

increase the risk of

adverse renal

reactions

- may decrease the

effectiveness of

diuretics or

hypertensive

- may increase serum

lithium levels and

increase the risk of

toxicity.

- increased risk if

- CV:

hypertension,

flushing,

syncope, pallor,

edema,

vasodilation

- CNS:

dizziness,

drowsiness,

tremors

- EENT:

tinnitus, blurred

vision. Hearing

loss

- GI: nausea,

anorexia,

vomiting,

diarrhea,

constipation,

flatulence,

cramps

- GU:

Nephrotoxicity:

dysuria,

hematuria,

1. Obtain patient’s vital signs

to note for signs of

hypertension.

2. Assess for patient’s

hypersensitivity reactions

especially those who have

asthma, aspirin-induced

allergy, and nasal polyps.

3. For patient’s experiencing

pain, note the type, location

and intensity of pain prior to

1-2 hr following

administration.

4. Instruct patient to make

medication exactly as directed.

If dose is missed, it should be

taken as soon as remembered

if not almost time for next

dose.

5. Advice patient to call for

assistance when ambulating

and to avoid driving or ithe

activitiues requiring alertness

until response to the

69

bleeding with

cefamandole, cefoten

cefoperazone,

valproic acid,

plicamycin,

thrombolytic agents

or anticoagulants

- may increase the

risk of nephrotoxicity

from cyclosporine.

DRUG-NATURAL

PRODUCTS

- increased bleeding

risk with anise,

arnica, chamomile,

garlic, ginger, ginko,

Panax ginseng

oliguria,

azotemia

- HEMA: blood

dyscrasias,

prolonged

bleeding

- INTEG:

pupura, rash,

pruritus,

sweating

medication is known.

Generic Name: Methylergonovine Brand Name: Methergine

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

70

- Therapeutic:

oxytoxic

- Pharmacologic:

ergot alkaloids

Ordered at 8/31/08

- 1 tab TID PO

- Directly

stimulates

uterine and

vascular

smooth muscle.

- Therapeutic

effect: uterine

contraction.

- Prevention

and

treatment of

post partum

or post

abortion

hemorrhage

caused by

uterine

atony or

subinbolutio

in.

Hypersensitivity.

Should not be

used to induce

labor.

DRUG-DRUG

- Excessive

vasoconstriction may

result when used with

heavy cigarette

smoking (nicotine) or

other vasopressors

such as dopamine.

CNS: dizziness,

headache

EENT: tinnitus

Resp: dyspnea

CV: hypotension

GI: nausea,

vomiting

GU: cramps

Derm:

diaphoresis

Misc: allergic

reactions

1. Monitor BP, HR, and

uterine response frequently

during medication

administration

2. Assess for signs of

ergotism

3. Instruct patient to take

medication as directed, do not

skip or double up on missed

doses

4. Advise patient that

medication may cause

menstrual-like cramps

5. Instruct patient to notify

health care professional if

infection develops.

Generic Name: Oxytocin

Brand Name: Pitocin

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

71

- Oxitoxicity Ordered at 8/30/08

- 10 units oxytocin

IVTT

- Hormone that

causes potent

and selective

stimulation of

uterine and

mammary

gland smooth

muscle.

- To induce or

stimulate labor

- To reduce

postpartum

bleeding after

expulsion of

placenta

- Incomplete or

inevitable

abortion

- Contraindicated in

patients

hypersensititve to

drug

- Contraindicated

when vaginal

delivery isn’t

advised, when

cephalopelvic

disproportion is

present, or when

delivery requires

conversion, as in

transverse lie.

- Contraindicated in

fetal distress when

delivery isn’t

imminet, I

prematurity, in other

obstetric

emergencies, and in

patients with severe

toxemia or

hypertonic uterine

Drug-drug:

Cyclopropane

anesthetics: May

cause less

pronounced

bradycardia and

hypotension. Use

together cautiously.

Thiopental

anesthetics: May

delay induction. Use

together cautiously.

Vasoconstrictors:

May cause severe

hypertension if

oxytocin is given

within 3 to 4 hours of

vasoconstrictor in

patient receiving

caudal block

anesthetic. Avoid

using together.

CNS:

subarachnoid

hemorrage,

seizures, coma

CV:

hypertension;

increased heart

rate. Systemic

venous return,

and cardiac

output;

arrythmias.

GI: nausea,

vomitting

GU: titanic

uterine

contraction,

abruption

placentae,

impaired uterine

blood flow,

pelvic

hematoma,

1. Drug isn’t recommended for

routine I.M. use, but 10 units

may be given I.M. after

delivery of placenta to control

postpartum uterine bleeding.

2. Never give oxytocin

simultaneopusly by more than

one route.

3. Drug is used to induce or

reinforce labor only when

pelvis is known to be adequate,

when vaginal delivery is

indicated, when fetal maturity is

assured, and when fetal position

is favorable. Use drug only in

hospital where critical care

facilities and prescriber are

immediately available.

4. Monitor fluid intake and

output. Antidiuretic effect may

lead to fluid overload, seizures,

and coma from water

intoxication.

72

patterns. increased uterine

motility, uterine

rupture,

postpartum

hemorrhage.

Hematologic:

afibrinogenemia

possibly related

to postpartum

bleeding.

Other:

hypersensitivity

reaction,

anaphylaxis,

death from

oxytocin-induced

water

intoxication.

5. Monitor and record uterine

contractions, heart rate, blood

pressure, intrauterine pressure,

fetal heart rate, and character of

blood loss every 15 minutes.

6. Have 20% magnesium

sulfate solution available to

relax the myometrium.

7. If contractions occur less

than 2 minutes apart, exceed 50

mm, or last 90 seconds or

longer, stop infusion, turn

patient on her side, and notify

physician.

8. Drug doesn’t cause fetal

abnormalities when used as

indicated.

Generic Name: Ranitidine hydrochloride

Brand Name: Zantac

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

73

- Antiulcer Ordered at 8/30/08

-50 mg q 8 hours

IVTT

-Competitively

inhibits action

of histamine

on the h2 at

receptor sites

of parietal

cells,

decreasing

gastric acid

secretion.

- Duodenal and

gastric ulcer

(short-term

treatment);

pathologic

hypersecretory

conditions, such

as Zollinger-

Ellison

syndrome

- Maintenance

therpy for

duodenal or

gastric ulcer.

-

Gastroesophage

al reflux disease

- Erosive

esopaghitis

- Heartburn

- Contraindicated in

patients

hypersensitive to

drug and those with

acute porphyria.

Drug-drug.

Antacids: May

interfere with

ranitiding absorption.

Stagger doses, if

possible.

Diazepam: May

decrease absorption

of diazepam. Monitor

patient closely.

Glipizide: May

increase

hypoglycaemic

effect. Adjust

glipizide dosage, as

directed.

Procainamide: May

decrease renal

clearance of

procainamide.

Monitor patient

closely for toxicity.

Warfarin: May

CNS: vertigo,

malaise,

headache

EENT: blurred

vision

Hepatic:

jaundice

Other: burning

and itching at

injection site,

anaphylaxis,

angioedema

1. Assess patient for abdominal

pain. Note presence of blood in

emesis, stool, or gastric

aspirate.

2. Ranitidine may be added to

total parenteral nutritional

solution.

3. Ranitidine may be added to

total parenteral nutrition

solutions.

Alert: Don’t confuse ranitidine

with rimantadine: don’t

confuse Zantac with Xanac or

Zyrtec.

74

interfere with

warfarin clearance.

Monitor patient

closely.

Generic Name: TRAMADOL HYDROCHLORIDE

Brand Name: Tramal, Siverol

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities

- Central Nervous

System Agent

- Opiate Agonist

- Narcotic Analgeic

Ordered at 8/30/08

-50 mg q 6 hours

IVTT

- Effective

agent for

control of

moderate to

moderately

severe pain

- Management

of moderate to

moderately

severe pain.

- Hypersensitivity

to tramadol or

other opioid

analgesics; patient

on MAO

inhibitors; patient

acutely intoxicated

with alcohol,

hypnotics, centrally

acting analgesics,

opioids, or

- Carbamazipine:

significantly

decreases tramadol

levels (may need up

to twice usual doses).

Tramadol may

increase adverse

effects of MAO

inhibitors. Tricyclic

antidepressants.

Cyclobenzaprine,

- CNS:

drowsiness,

dizziness,

vertigo, fatigue,

headache,

somnolence,

restlessness,

euphoria,

confusion,

anxiety,

coordination

1. Assess for level of pain

relief and administer PRN

dose as needed but not to

exceed the total daily dose.

2. Monitor vital signs and

assess for orthostatic

hypotension or signs of CNS

depression.

3. Discontinue drug and notify

physician if S&S of

hypersensitivity occur.

75

psychotropic drugs;

patients on

obstetric

preoperative

medication;

lactation.

Debilitated

patients; chronic

respiratory

disorders; liver

disease; renal

impairment;

myxedema;

hypothyroidism; or

hypoadrenalism;

acute abdominal

conditions;

increase ICP or

head injury; history

of seizures;

pregnancy

(category C);

patients >75 yrs.

safety and efficacy

in children are not

phenothiazine,

selective serotonin-

reuptake inhibitors,

MAO inhibitors may

enhance seizures risk

with tramadol, may

increase CNS adverse

effects when used

with other CNS

depressants. Herbal:

St. John’s wort may

increase sedation.

disturbance,

sleep

disturbances,

seizure.

- CV:

palpitations,

vasodilation

- GI: nausea,

constipation,

vomiting,

xerostomia,

dyspepsia,

diarrhea,

abdominal pain,

anorexia,

flatulence

- Body as a

whole: sweating,

anaphylactic

reaction (even

with first dose)

- SPECIAL

SENSE: visual

disturbances

4. Assess bowel and bladder

function; report urinary

frequency or retention.

5. Use seizure precautions for

patients who have a history of

seizures or who are

concurrently using drugs that

lower the seizure threshold.

6. Monitor ambulation and

take up appropriate safety

precautions.

7. Exercise caution with

potentially hazardous

activities until response to

drug is known.

8. Understand potential

adverse effects and report

problems with bowel and

bladder function. CNS

impairment, and any other

bothersome adverse effects to

physician.

9. Do not breastfeed while

taking this drug.

76

established. -

UROGENITAL:

urinary retention/

frequency,

menopausal

symptoms

NURSING CARE PLAN

Date/

Time Cues Need

Nursing

Diagnosis

Objectives of

Care Nursing Intervention Evaluation

77

S

E

P

T

E

M

B

E

R

2,

2

0

0

8

@

Subjective :

“naa gihapon

gamay na

sakit tungod

sa akong

tahi”

Objective:

- Guarding

behavior

- pain scale of

2 out of 5

- grimaced

face

C

O

G

N

I

T

I

V

E

-

P

E

R

C

E

P

T

U

A

L

Acute pain related

to presence of

surgical incision

secondary to

cesarean section

Rationale:

acute pain is an

unpleasant sensory

and emotional

experience arising

from actual or

potential tissue

damage or

described in terms f

such damage

(international

Association for the

Study of Pain);

sudden or slow

onset of any

Within the 4

hours span of

care, patient will

be able to report

reduced pain as

evidenced by

client’s

verbalization.

1. Monitor and record vital signs

Rationale: Monitoring the patient helps in the

continuity of care. Vital signs are also important to

determine the difference between the normal and the

not.

2. Assess for appropriate referred pain.

Rationale: Assessment helps determine possibility of

underlying organ dysfunction requiring treatment.

3. Acknowledge the pain experienced and express

acceptance of client’s response to pain.

Rationale: Pain is a subjective experience and

cannot be felt by others.

4. Provide comfort measures such as back rub and

changing of position

Rationale: to provide nonpharmacological care

management.

5. Teach patient relaxation techniques like deep-

breathing exercise

September

03,

2008

@

4:00 am

Goal met

After the 4

hours span of

care, patient

was able to

report

reduced pain

and

verbalized,

“hay salamat

nakaginhawa

pud ko maski

78

12am P

A

T

T

E

R

N

intensity from mild

to severe with an

anticipated or

predictable end and

a duration of less

than 6 months

Rationale: to alleviate pain

96. Promote sufficient resting periods particularly

when apply too much effort to an activity

Rationale: Adequate rest period prevent fatigue.

6. Evaluate measures done and inform client when

management may cause pain.

Rationale: the client’s knowledge regarding episode

of pain lessens the concern of the unfamiliar.

gamay.”

Date/

Time Cues Need

Nursing

Diagnosis

Objectives of

Care Nursing Intervention Evaluation

79

S

E

P

T

E

M

B

E

R

2,

2

0

0

8

@

Subjective :

“Dili pa kayo

ko

makatarong

ug lakaw”

Objective:

- weakness

noted

- moves

slowly

- needs

assistance to

balance

before

standing up.

A

C

T

I

V

I

T

Y

-

E

X

E

R

C

I

S

E

P

A

T

Activity Intolerance

related to

generalized

weakness

secondary to post

cesarean section

Rationale:

Activity intolerance

is insufficient

physiological or

psychological

energy to endure or

complete required

or desired daily act.

At the end of our

shift, patient will

use identified

techniques to

enhance activity

such as walking.

1. Establish rapport

R: Patient will gain trust and cooperation.

2. Assist patient with activities and monitor patient’s

use of assistive devices such as chair.

R: It will protect the patient from injury.

3. Promote comfort measures and provide for relief

of pain.

R: It enhances the ability of the patient to participate

in activities.

4. Plan care with rest periods between activities.

R: Reduces fatigue

5. Provide positive atmosphere, while acknowledging

difficulty of the situation for the client.

R: Help minimize frustrations.

September

03,

2008

@

4:00 am

Goal met

At the end of

our shift, the

patient was

able to

enhance

activity such

as walking.

80

12am T

E

R

N

Date/Time

Cues Need Nursing Diagnosis

with Rationale

Objectives/ Plan

Nursing Intervention with Rationale

Evaluation

81

S

E

P

T

E

M

B

E

R

2,

2

0

0

8

@

12am

11-7

Subjective :

“gi CS man ko

sa akong

pagpaanak”

Objective:

- Client is 3

days

postpartum

- Client

underwent a

cesarean

section.

- Surgical

incision on the

abdomen

- Client lacks

personal

hygiene

H

E

A

L

T

H

-

P

E

R

C

E

P

T

I

O

N

H

E

A

L

Risk for infection

related to

presence of

surgical incision

secondary to

cesarean section.

Rationale:

Client’s

undergoing a

surgical

procedure impairs

the body’s normal

defense

mechanisms;

thereby,

increasing the

risk of being

invaded by

pathogenic

organisms.

(Sue C. Delaune,

Patricia K.

Within the 4

hours span of

care, patient

will be able to

identify

interventions

to prevent/

reduce risk of

infection.

1. Establish rapport with the patient and

significant others.

Rationale: Establishing rapport is essential in

gaining the trust and cooperation of the patient

which can greatly help in meeting the goals set

for the patient

2. Monitor and record vital signs

Rationale: Monitoring the patient helps in the

continuity of care. Vital signs are also essential

to determine deviations from normal

3. Observe for localized signs of infection at

insertion sites of invasive lines, sutures,

surgical incisions/ wounds.

Rationale: Assessing the client helps determine

prioritization of care.

4. Emphasize the importance of perineal care

and proper hygiene (e.g., wiping from front to

back and changing soaked perineal pads

regularly)

Rationale: These reduce the risk of ascending

September 2,

2008

@

4:00am

GOAL MET

Within my 4

hours span of

care, patient

was able to

identify

interventions

like taking a

bath to

prevent/reduc

e risk of

infection and

as evidence

by “maligo

dyud diay

82

- Bed linens

are dirty and

not wrinkle-

free

- Binder on

Abdomen

T

H

M

A

N

A

G

E

M

E

N

T

P

A

T

T

E

R

N

Ladner,

Fundamentals of

Nursing, 2006)

urinary tract infection.

6. Change surgical/other wound dressings as

indicated, using proper technique for

changing/disposing of contaminated materials

Rationale: Sterile technique prevents

contamination and reduces risk for infection.

7. Keep bedclothes dry and wrinkle-free, use

nonirritating linens.

Rationale: Dry, wrinkle-free and nonirritating

linens promote comfort and prevents

contamination thereby reducing the risk for

infection acquired from soiled bed linens.

9. Encourage increased fluid intake and diet

high in protein and vitamin C

Rationale: These vitamin and nutrient are

necessary for wound healing and prevention of

infection.

10. Emphasize the importance of practicing

hand washing specially after being in contact

dapat ko para

malimpyo ko,”

as verbalized

by client.

83

with soiled items.

Rationale: Clear and concise instructions about

wound care is important to discard soiled

dressings appropriately to safeguard the

women and the caregivers.

11. Monitor medication regimen (e.g., topical

antibiotics).

Rationale: Monitoring for medications helps

determine for effectiveness of therapy and

presence of side effects.

Date Cues Need Nursing Diagnosis

Objectives of Care

Nursing Interventions Evaluation

S

E

Subjective:

> “Wala pa ko

A

C

Self-Care

Deficit

Within the

span of 4

Independent:

1.) Assess exact cause of deficitSeptember

02,

84

P

T

E

M

B

E

R

01,

2008

12:00

am

nakaligo sukad

nanganak ko.”

Objective:

inability to

wash body or

body parts

untidy

appearance

untrimme

d nails

physical

immobility

noted

2 days

post CS

Foul odor

noted

T

I

V

I

T

Y

-

E

X

E

R

C

I

S

E

related to

post

cesarean

section.

R: Impaired

ability to

carry out,

bathing/

hygiene,

dressing

and

grooming,

or toileting

activities

for oneself

(on a

temporary,

permanent,

or

progressing

hours of care,

patient will be

able to safely

perform self-

care activities.

R: Different causes may require

more specific interventions to enable

self-care.

2.) Situate short-term goals with

client.

R: To aid learning and decrease

aggravation.

3.) Promote independence, but

intercede when patient cannot

perform

R: To drop off disappointment.

4.) Make use of consistent practices

of daily hygiene.

R: This facilitates the client to put in

order and carry out self-care skills

5.) Provide recurrent support and

assistance as needed with dressing.

R: To reduce energy outflow and

aggravation

6.) Encourage patient to do own self

2008 @4:00 am

Goal met

After 4 hours,

client was able

to perform

safely self-

care activities

within level of

own ability.

85

basis) care practices.

R: To develop independence

7.) Instruct client to select bath time

when rested and unhurried.

R: This helps client to organize and

carry out self-care skills

8.) Offer frequent encouragement of

doing daily perineal care/hygiene.

R: Clients often have difficulty

seeing progress

10.) Assist client in

removing/replacing necessary

clothing.

R: This helps client to organize and

carry out self-care skills

86

PROGNOSIS

Criteria Good Fair Poor Justification Rationale

Onset of

illness

X

Upon the start

of bleeding,

immediately

went to see

the doctor and

has

undergone

ultrasound.

She was

detected with

placenta

previa and

informed to

take a lot of

rest that would

lessen the

bleeding.

When the

manifestations

are being

experienced

and

unusualities are

being detected,

it should be

given time as

early as

possible so as

not to make

things

complicated.

Through the

help of medical

assistance and

diagnostic

examinations, it

would help a lot

in identifying

the condition..

Duration of

illness

X

From the start

of the first

bleeding, she

consulted the

The patient’s

initiative to

obey the doctor

is one way or

87

doctor

immediately.

She was

advised to

take a lot of

rest and told

by the doctor

to consult the

doctor again if

bleeding

would still

occur. By the

second time

she had her

bleeding, she

went back

immediately to

the doctor.

another a help

in preventing

further

complications.

It would also be

a factor in the

progress of the

patient’s

condition.

Environment

X

Their place is

conducive for

the client’s

condition.

They live far

from the

polluted and

noisy city.

Their house is

clean and they

see to it that it

is not messed

The

continuance of

clean

environment

plays a role in

the recovery of

the patient. The

environment is

a factor that

affects the

health and

illness of the

88

up. It is a

good place

wherein the

patient can

take a good

rest.

individual.

Family

Support X

Well

supported by

the family,

from the start

of her

condition, the

husband told

her to stop

from her work

so that she

could take a

lot of rest. Her

sister in laws

took over of

the household

chores.

The family

members offer

encouragement

to the family

member who is

sick. Their

motivation is a

great help in

the progress of

the client’s

condition.

Willingness

to take

medications

X

The client

takes her

medications

as ordered by

the doctor but

in some

instances,

they cannot

The compliance

to the treatment

regimen is one

of the best

ways to have a

good

advancement in

the condition of

89

afford some of

the

medications

so the client

sometimes

cannot

complete the

period

wherein she

should take

the prescribed

medications.

the client.

Precipitating

Factors X

The client is

pregnant that

cause her to

develop a

placenta

previa, a low

implantation of

the placenta

covering the

cervical os.

She is

pregnant with

her second

child and it is

a male fetus.

these factors

are modified

the occurrence

of the illness

will be

prevented or

less

complication.

Predisposing

Factors X

Among the

predisposing

factors

The

predisposing

factors play a

90

present in the

client are

gender and

race.

critical role in

setting risks for

the client to

acquire such

disease. This

factors can’t be

change.

CALCULATIONS:

Good: 3 x 4 = 12

Fair: 2 x 2 = 4

Poor: 1 x 2 = 2

TOTAL: 15 = 18 / 7 = 2.57

Range of Value: 1.0 - 1.6 for Poor; 1.7 - 2.3 for Fair; 2.4 – 3.0 for Good

Client has a GOOD prognosis as shown in the computation. She has a

chance of recovering from her condition, placenta previa totalis.

91

HEALTH TEACHINGS

* Encourage patient to express feelings and concerns

® So that relief measure may be instituted

* Teach family / significant others to foster independence, and to intervene if the

patient becomes fatigued, is unable to perform task or becomes excessively

frustrated

® Demonstrates caring / concern

* Teach patient perineal hygiene

® to decrease risk of ascending infections

* Splint incision when moving or coughing

® to decrease pain and to prevent wound separation

* Encourage the patient to comply with medications given

® The use of medicines is a pharmacologic method that aids in the recovery of

the client

*Encourage the client to eat foods to stimulate the production of milk

® For the nutrition of her baby

*Teach signs of post-op complications and report the ff. signs to health care

provider:

temperature exceeding 38C

painful urination

lochia heavier than normal period

wound separation

92

redness or oozing at the incision site

severe abdominal pain

*Teach postpartum pain relief after cesarean birth

-INCISIONAL pain

splint incision with a pillow when moving or coughing

use relaxation techniques such as music, breathing, and dim lights

apply heating pad to the abdomen

*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

Inculcate to the client the importance of proper hand washing

® Hand washing if the single most effective way in controlling infection

93

DISCHARGE PLAN

Medications:

Teach patient and her family or significant others the proper dosage and

the right time to take the medication.

Emphasize to the patient the importance of obediently taking the

prescribed medications and the disadvantages or complications that may

arise if these are not taken properly.

Inform and discuss the possible side effects and reactions that these

drugs might produce and seek medical attention immediately is these

arise

Discourage to use of OTC medications or at least inform the physician if

she’s taking other OTC medications. This is essential to prevent any

occurrence of drug interactions.

Exercise:

Tell client to refrain from straining activities

Encourage ambulation as a form of light exercise that would help in the

progression of her recovery and wound healing.

Range of motion. Encouraging the patient to do some exercises would

allow good blood circulation as well as the prevention of the occurrence of

bed sores.

Encourage patient to do some stretching exercise to prevent stiffness of

the bone due to less activity performed.

Encourage patient to first sit up and dangle feet before standing from a

lying position to prevent orthostatic hypotention

94

Treatment

Discussing the purpose of treatments to be done and continued at home

and report to the health professional when there is bleeding to alleviate

symptoms of the patient’s condition and monitor for her recovery.

Encourage patient to have a sufficient rest and sleep to maintain internal

equilibrium

. Provide a safe and comfortable environment because it could make the

patient more relaxed which is also needed to arrived with a good

prognosis

Hygiene:

Discuss the significance of personal hygiene and proper hand washing in

preventing infections

Give client some lectures about proper wound care through changing the

dressing as often as possible so as to protect the wound from invasion of

microorganisms as well as to reduce the risk of microorganism

transmission to others.

Outpatient Care:

A follow up check-up is necessary for wound evaluation and to assess the

progression of wound healing.

Diet:

Encourage the patient to increased fluid intake and to include fruits and

vegetables rich in vitamin C for the production of milk needed for lactation.

Taking food rich in protein is also helpful for tissue repair.

95

REFERENCE

DeLaune, S.C. 2006. “Fundamentals of Nursing: Standards and Practice.”

3rd ed. New York: Delmar.

Maternal and child health nursing. Pillitteri. Fifth edition.2007. Lippincott

Williams & Wilkins.

Maternity Nursing. Seventh edition. Lowdermilk & Perry.

Fundamentals of Maternal and Child Nursing Care, London, Marcia;

Ladewig, Patricia W.; Wall, Jane W.; Bindler, Ruth C.; Pearson Education,

Inc., 2007

Nursing 2008 Drug Handbook, Lippinocott, Wilkins &Williams, 2008

Kozier, B., Erb, G., and Oliviere, R. 2004. “Fundamentals of Nursing:

Concepts, Process, and Practice.” 7th ed. Redwood City, Ca: Addison-

Wesley

Marriner-Tomey, S. 2002. “Nursing Theorists and Their Works.” 5 th ed. St.

Louis: Mosby.

KUNA: A Maternal and Child with Pediatric Nursing Handbook, 1st ed.,

Aaron “CY” Tuesca Untalan, RN

http://www.usaid.gov

http://www.wikipedia.org

96

http://www.emedicinehealth.com

http://www.usaid.gov

http://academic.kellog.edu/herbrandsonc/bio201_McKinley/f28-

2_sagittal_section_c.jpg

http://www.webdelbebe.com/wp-content/uploads/2006/11/placenta.jpg

http://www.answers.com/topic/placenta

97