BSN2A GROUP 3
Placenta is implanted abnormally in the
uterus. Most common cause of painless bleeding in the third trimester of pregnancy.
Low lying - implantation in the lower
rather than in the upper portion of the uterus. Marginal - the placenta edge approaches that of the cervical os. Partial - implantation that occludes a portion of the cervical os. Total placenta previa - totally obstructs the cervical os.
Bleeding is abrupt, painless , bright red and
sudden. Immediate care measures: Place the woman immediately on bed rest in a side lying position
Increased parity Advanced maternal age Past CS
Past uterine curettage
Multiple gestation Male fetus
Duration of pregnancy Time the bleeding began Estimate amt of blood loss Accompanying pain Color of the blood What has she done Prior episodes of bleeding Prior cervical surgery
Never attempt a pelvic or rectal
examination with painless bleeding late in pregnancy Obtain baseline VS IVF therapy I and O monitoring External monitoring equipment Complete blood count Blood typing and crossmatching
Avoid intercourse
Limit traveling
Avoid pelvic exams
Nora N. Nacua, 38yold; multi-gravida; Filipio
Add. Rosario,Cavite; from Misamis Oriental;
Catholic; high school graduate; Non-smoker; nonalcoholic; no allergies reported.
Patient was diagnosed with placenta previa.
Admitted Januray 6, 2012 at Dr. Jose Fabella Memorial Hospital DR due to labor pain with ruptured of amniotic sac and profuse vaginal bleeding.
Cesarean section
Baby boy 31 weeks of gestation 1305 g
APGAR score of 3 (one minute after birth) Score of 5 (five minutes after birth)
Score of 7 (ten minutes after birth)
Footling breech Placenta previa
V/S at admission: Temp- 38.2c PR-78 bpm RR-20 cpm BP- 80/60 mmHg
Vaginal bleeding
Active and cooperative. Natural hair color, dry hair, fair complexion
skin, smooth that have lesions could be moles, freckles, birthmarks, pink tone nails and brown body color. Always walk as her exercise Taken all immunization needed.
Stated help myself to a fast recovery, not
being dependent and ambulate frequently Breast self-examination every bath time. No history of chronic disease. No any cardio respiratory distress
Insomnia
No operation before this time
hospitalization Immunization: BCG given at birth,Tetanus, Pneumonia, Polio, Hepa B vaccine.
Weight gain in the last 6 mos. for about 2 lbs.
Good appetite.
No experience of any problems in nausea,
vomiting, swallowing and digestion.
Urinates 5x a day with the Smokey color of
urine. Never experience any problem related to urination Do not use any assistive device when urinating. Common bowel elimination is 2x a day with the color of brown stool.
Loves to read pocketbook.
House works ,preparing meal, taking care of
children. Performs the daily activities alone. Selling fish daliy
Sleeps at least 6 hours a day
Insomnia during young age
Sleep well recent years
Read and write.
Languages are tagalog, bisaya and limited
English Moderately easy decide in comes to family
Major concern at the current time is to go
home and take rest in own house Lose weight as result to her body changes when she is in the hospital. Positive mother.
Mother of a 3 children.
Living with children and husband but not yet
married. She stated yes, in my daily living when I ask her if theres any significant changes in patients usual family role when she admit to the hospital. Active social activities and comfortable social situations Fish vendor.
Feel stressful when she experience 60/60 life.
Poor handling of stress she can still joining
bible study to give her lakas ng loob. Need care from others after discharge.
Menarche occurred in 14years Common menstruation last 3-4days Lightly abdominal pain during
menstruation. Last menstrual period is June 4, 2011. G3P3 mother Takes pills for contraception No history of sexually transmitted disease or STD.
Roman Catholic.
Family is the most important for her
As stated din na ako naghahanap ng iba,
tanggap ko kung mahirap lang ako Goes to church every Sunday.
Orientation Appropriate behavior/communication
Level of consciousness Emotional state
Oriented to time, person and place Cooperative
Conscious Calm
General color Texture Turgor Temperature Moisture
Brownish Smooth Supple Moist Dry
Head
Hair Scalp Black hair Clean
Lids Conjunctiva Reaction to light Reaction to Accommodation
Visual Acuity Peripheral vision
Symmetrical Pink Constriction Constriction& Convergence when focus on near object Normal Intact/full
Septum Mucosa Patency Sinuses
Midline Pinkish Both patent Non-tender
Ears
External pinnae Tympanic membrane Gross hearing Symmetrical Intact Increased
Lips Mucosa Tongue Teeth Gums
Dry Pinkish Pink &moist& midline Complete & yellowish Pink& moist
Neck
Trachea Thyroids Midline Midline
Uvula Tonsils Mucosa
Midline Symmetric Pinkish
Abdomen
Configuration Bowel sounds Percussion Symmetrical normal Resonance
Range of motion Muscle tone& strength Spine Gait
Decreased ROM Fair Midline Coordinated
Cardiovascular Status
Heart sounds Peripheral pulses Capillary refill Regular Regular Normal,2 seconds
Heart sounds Peripheral pulses Capillary refill
Regular Regular Normal,2 seconds
Respiratory status
Breathing pattern Lung expansion Vocal/ tactile fremitus Percussion Breath sounds Cough Regular Symmetrical Symmetrical Resonant Broncho-vesicular none
CBC x 3
Urinalysis
Ultrasound
Elevation of WBC (4.5-11)X10-9/L 22.3X10-9/L (Jan,6) 32.8X10-9/L (Jan,7) 19.7X10-9/L (Jan,9)
Infection (rupture of membrane ,CS)
Low RBC(4.1-5.1)X10-12/L 3.12X10-12/L (Jan,6) 3.79X10-12/L (Jan,7) 3.59X10-12/L (Jan,9) Low hemoglobin(120-170)g/L 97g/L (Jan,6) 114g/L (Jan,7) 107g/L (Jan,9) Loss of blood(bleeding) Nutritional deficiency (iron, vitamin B12, folate)
Date : Jan,6 Jan,7 Jan,11
Blood type: A Rh+ Type of blood received: red blood
cells
Date : 01/08/2012
Color yellow
Abnormal finding: Blood in urine Red blood cell: 1.3 Pus cell:2-4 Infection or mix with vaginal discharge Protein in urine - indicate preeclampsia PIH
Date:01/06/2012
placenta: totally placenta previa
Fetus position: footling Baby:FHR:161bpm, sex: boy
Vaginal bleeding
Preterm rupture of membrane
Infection Fever temp.:38.2 Hypertension 150/80mmHg Anemia
Placental implantation is initiated by the
embryo (embryonic plate) adhering in the lower (caudad) uterus. With placental attachment and growth, the developing placenta may cover the cervical os. However, it is thought that a defective decidual vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes. As such, sections of the placenta having undergone atrophic changes could persist as a vasa previa.
A leading cause of third trimester hemorrhage,
placenta previa presents classically as painless bleeding. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor. When this occurs, bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Thrombin release from the bleeding sites promotes uterine contractions and a vicious cycle of bleeding-contractions-placental separationbleeding.
Risk for deficient Fluid Volume
Fear related to perceived threat of
death to the fetus
Acute pain
Deficient blood Volume related to Blood
loss during surgery
Acute pain related to post-op incision Risk for infection related to post-incisio
Assessment Masakit ang tahi ko sa may puson Pain scale of 9/ 10
Diagnosis Acute pain related to post-op incision
Planning After the 6 hour shift the client should be able to verbalize decrease in pain to a tolerable state. Pain scale of 3-4/ 10
Interventions Monitor VS
Rationale To obtain baseline data
Evaluation
Applied ice pack
Appears weak
Irritable
The patient verbalized that she can To reduce the tolerate more pain and to activities like prevent turning and hemorrhage sitting but by keeping with the fundus assisstance. contracted. Pain scale of 4 /10
Facial grimace when moving
Pallor
Provided health teaching as follows: Practice deep breathing exercise Turn side to side Ambulate early as recommended
To divert attention To be able to tolerate pain
Assessment
Diagnosis
Planning
Interventions By the doctor
Rationale
Evaluation
Administer Analgesia as ordered by the doctor
To decrease/ eradicate pain
Assessment O: NPO in the last 8 hours chapped lips dry mouth with surgical incision at the lower abdomen consumed 2 underpad for the last 24 hours Malaise Pallor
Diagnosis Deficient fluid volume related to
Planning After 4 days of continuous nursing interventions: Clients fluid volume is maintained at functional level The patient will be able to verbalize purpose of therapeutic interven-
Interventions Monitor Vital Signs Assess color, odor, consistency and amount of vaginal bleeding; weigh pads
Rationale To obtain baseline data Provides information about active bleeding versus old blood, tissue loss and degree of blood loss Provide information to know if the client is still at risk for shock To know if the client has
Evaluation The clients skin
Assess abdomen for tenderness
Assess clients skin color,
Assessment
Diagnosis Risk for Infection related to post-op incision
Planning At the end of the 6 hour shift the clients temperatu re should be within the normal range The patient will agree and show interest to the health teachings
Interventions Monitor VS
Rationale To obtain baseline data
Evaluation
The patient has incision in the lower part of the abdomen
The client showed interest to Health the health Teaching teaching and provided as verbalized follows: willingness Moist area to do the Proper cleaning will facilitate recommende of the incision the growth of d activities. site microorganis ms Keep the incision site clean and dry Compliance to the prescribed time of medication
To prevent infection and further complication
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
DRUG NAME
ACTION
INDICATION CONTRAINDIC ATION
ADVERSE REACTION
NURSING RESPONSIBILIT IES
Hydralazin e BRAND NAME Apresoline DOSAGE 5mg PRN for BP > 150/100
Acts directly on vascular smooth muscle to cause vasodilatio n maintains or increases renal and cerebral blood flow.
ROUTE ORAL
should not use this medication if you are allergic to hydralazin e, or if you have coronary artery disease, or rheumatic heart disease affecting CLASSIFI the mitral CATION valve. Antihyper tensive
Hypersensiti vity to hydralazine; coronary artery disease; mitral valvular rheumatic heart disease
Headache anorexia nausea vomiting diarrhea palpitation s tachycardia
Patients should be informed of possible side effects and advised to take the medication regularly and continuously as directed.
DRUG NAME
ACTION
NURSING INDICATI CONTRAINDIC ADVERSE RESPONSIBILI ON ATION REACTION TIES
inhibits Gentamici protein n sulfate synthesis in susceptible strains of gramBRAND negative bacteria; NAME appears to disrupt Garamycin functional integrity of bacterial cell membrane, DOSAGE causing cell death. 240mg in 100ccPNSS , OD CLASSIFIC ATION ROUTE Aminoglyc oside IM
Parenter al use restricted to treatment of serious infections of GI, respirator y, and urinary tracts
Contraindicat ed with allergy to any aminoglycosid es renal or hepatic disease; preexisting hearing loss active infection with herpes, vaccinia, varicella, fungal infections, myobacterial infections (ophthalmic preparations) myasthenia gravis; parkinsonism; infant botulism; lactation.
Palpitatio nshypoten sionhypert ension Hepatic toxicity nausea vomiting anorexia, weight loss stomatitis increased salivation
Cleanse area before application of dermatologic preparations. Ensure adequate hydration of patient before and during therapy. Monitor renal function tests, complete blood counts, serum drug levels during longterm therapy. Consult with prescriber to adjust dosage.
DRUG NAME
ACTION
INDICATI CONTRAIN ON DICATION
ADVERSE REACTION
NURSING RESPONSIBILITIE S
Nifedipine Nifedipin inhibits calcium e ion movement across cell membrane, depressing BRAND contraction of cardiac or NAME vascular smooth muscle. It also increases heart rate and cardiac output. Nifedipine DOSAGE decreases systemic 5mg 1cap vascular resistance and blood pressure ROUTE CLASSIFICATI ON Oral Antihypertensiv e
treatme nt of hyperten sion
Use cautiousl y with lactation, pregnant.
Nausea Drowsi ness Confusi on Slurred speech
Do not crush or break filmcoated tablets and sustainedrelease capsules. Check blood pressure for hypotension immediately prior to giving medication Assist with ambulation if client is lightheaded or dizziness occurs. Rise slowly from lying to sitting position, dangle legs from bed before standing to reduce hypotensive effect
DRUG NAME
ACTION
INDICATIO CONTRAINDI N CATION
ADVERSE REACTION
NURSING RESPONSIBILITIE S
inhibits Metronida DNA zole synthesis in specific (obligate) anaerobes, BRAND causing cell death; NAME antiprotozo altrichomona Flagyl cidal, amebicidal: biochemical mechanism of action is not known. DOSAGE CLASSIFIC 500mg A TION ROUTE Antibiotic, PO Antibacteria
l
Acute intestinal amebiasis
Amebic liver abscess Preoperati ve, intraopera tive, postopera tive prophylax is for patients undergoin g colorectal surgery
Contraindi cated with hypersensit ivity to metronidaz ole; pregnancy
Headache, dizziness, ataxia, vertigo, incoordina tion, insomnia, seizures, peripheral neuropathy, fatigue Unpleasan t metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, Cramps
Avoid use unless necessary. Metronidazole is carcinogenic in some rodents. Administer oral doses with food.
DRUG NAME
ACTION
NURSING INDICAT CONTRAIN ADVERSE RESPONSIBILITI ION DICATION REACTION ES
Ampicillin
Used for Hypersens Nausea Tell patient that Bactericidal treating itivity to medication may action bacterial ampicillin, Vomiting cause nausea or against infectio any vomiting(small, BRAND sensitive n component Loss frequent meals, organisms of the frequent mouth NAME formulatio of appetite care, sucking n or other lozenges, or penicillins Diarrhea chewing gum Novomay help) ampicillin Abdomin diarrhea (buttermilk, boil al pain DOSAGE ed milk, or yogurt may Rash CLASSIFICA help). 1g TIV TI Itching Instruct client ON Headache to maintain adequate Confusio hydration (2-3 L/day of fluids) Antibiotic, unless n ROUTE instructed to Penicillin Dizzines restrict fluid IV intake.
DRUG NAME
ACTION
INDICATI CONTRAIN ON DICATION
ADVERSE REACTION
NURSING RESPONSIBILIT IES
Paracetam ol Reduces fever by acting on the hypothalamus to cause BRAND vasodilatation and sweating NAME
Used for Contrain the relief dicated of fever, headach withallerg es y to acetamino phen or any componen DOSAGE CLASSIFICATI t. 500mg ON 1tab RTC Analgesic, antipyretic ROUTE ORAL
Chest pain Dyspnea Rash Fever Jaundice Acute kidney failure Hepatictoxici ty and failure
instruct client to report any adverse reaction like allergies to the physician or nurse. Warn patient that high doses or unsupervised long term use can cause liver damage.
DRUG NAME
ACTION
INDICATI CONTRAIN ON DICATION
ADVERSE REACTION
NURSING RESPONSIBILI TIES
Metoprolo l BRAND NAME lopressor DOSAGE 50mg BID
decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin, and lowering BP; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone.
Hypert ension, alone or with other drugs, especial ly diuretic s
Contrain dicated with sinus bradycard ia
Dizziness vertigo tinnitus fatigue
emotional depression paresthesia s sleep disturbances hallucinatio ns disorientati on memory loss slurred speech
Do not discontinue drug abruptly after longterm therapy
Provide continual cardiac monitoring for patients receiving IV metoprolol.
CLASSIFICATI ROUTE ON Antihypertensi PO ve
DRUG NAME
ACTION
CONTRAI INDICATIO NDICATIO N N
ADVERSE REACTION
NURSING RESPONSIBILIT IES
Ferrous Ferrous Sulfate is an sulfate essential component in the formation of hemoglobin, BRAND myoglobin and enzymes. It is NAME necessary for effective erythropoiesis Feosol and transport or utilization of oxygen.
DOSAG E 1tab ROUTE PO CLASSIFICATI ON Iron Preparation
The prevention or treatment of iron deficiency anemia due to inadequate diet, malabsorp tion pregnancy, and blood loss
Hyperse nsitivity Severe hypotens ion
Vomiting Severe abdomina l pain Diarrhea Dehydrati on Hyperven tilation Pallor or cyanosis Cardiovas cular collapse
Store all forms at room temperatu re tell the patient about the adverse reactions
Eggs and milk inhibit absorption
Discharged at jan,18 2012
Hydralazine- 5mg TIV 6hs prn for BP
150/100mmhg Ampicillin- 1g TIV 6hrs Metronidazole- 5OOmg TIV 8hrs Gentamycin- 240mg in 100cc Metropolol- 500mg BID Nifedipine- 5mg 1cap prn for BP 150/100 Paracetamol- 500mg 1tab Ferrous sulfate-1cap BID PNSS X3Omins OD
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. Encourage the patient to do some exercise would allowed good blood circulation as well as the prevention of the occurrence of bed sores.
Encourage the patient to do some stretching
exercise to prevent of the stiffness to the bone Due to less activity performed. Encourage patient to first sir up and dangle feet before standing from a lying position to prevent orthostatic hypotension.
Discussing the purpose of treatments to be done
and continue at home and report to the health professional when there is bleeding to alleviate symptoms of the patient condition and monitor for her recovery. Encourage the 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 relax which is also needed to arrived with a good prognosis.
A follow up check up is necessary for wound
elevation and to assess the progression of wound healing.
Encourage the patient to increase fluid
intake and to include fruits and vegetables rich in vitamin C for the production of milk need for the lactation Taking food rich in protein is also helpful to tissue repair.
Assess anxiety of client over preterm labor
possible feelings. Determine whether client wants a support person to be with her, to the presence of support person can offer additional comfort to a client
Group 3
