baby kamz edited

8/7/2019 Baby Kamz Edited

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Di ko pinakealaman ung:

Temp

WBC

Urinalysis

Isang NCP dapat infection r/t hyperthermia

Sopie ng 5 na ncp.

Skin and appendages (presence of episiotomy)

Forward back nyu nlng saken ulet.


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Republic of the PhilippinesTARLAC STATE UNIVERSITY

COLLEGE OF NURSINGLucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300

Tel. No.: (045) 982-6062 Fax: (045) 982-0110 website: www/tsu.edu.ph

A clinical case study

Presented to

Tarlac State University College of Nursing

Lucinda Campus

Brgy. Ungot, Tarlac City

Normal Spontaneous Delivery

(with Premature Rupture Of Membrane)

In Partial Fulfillment

of the Requirements of the Subject

NURSING CARE MANAGEMENT 102

Prepared by:

Agustin, Ronaldo D.

Arciaga, Karen P.

Artizona, Cherry Kate V.Astrero, Kamille Joyce F.

Bagsic, Brandon L.

Baldonaza, Mhay V.

Balibat, Rudolf John L.Barte, Fatima Q.

Briones, Gaila T.

BSN III-B (B1)

Submitted to:

Mrs.Rofel Reubal RN.

MISSION

It is the mission of the College ofNursing to create and foster anenvironment which providesopportunities to student-athletesto enrich their collegiateexperience through participationon competitive & cooperativeteams. The department isdedicated to providingopportunities, which will promotehealthy living, enhance theintellectual, physical, social, andcultural development of thewhole person, while conductingall activities with honesty andintegrity. The department valuesgender diversity and iscommitted to providingequitable opportunities for allstudents and staff.

GOALS

In pursuit of its mission, the College of Nursing strives to:

1. Conduct all activi ties withthe health, education, andwelfare of all student-athletes.

2. Conduct a program that isintegra l par t of theeducational system, withthe student-athlete as aparticipant in the studentbody.

3. Recruit athletically talentedstudents who are capable,prepared, and motivated to

succeed academically andathletically.

4. Provide sta ff , resourcesand facilities to supportprograms that arecompetitive in the SCUAAand National competitions.Foster a sense of community amongstudents, staff and thelarger community.

5. Establish and adhere tostandards of conduct forstaff and students that areconsistent with thedevelopment of strongmoral character, mutualrespect and responsiblebehavior

OBJECTIVES

1. To provide opportunities for individualdevelopment through a variety of programs balanced between light and vigorousexercise, team, and individual competitionto meet all skill levels.

2. To safeguards participants health by achoice of physical activities, developingrules with safety in mind, providingfunctional equipment and adequatesupervision.

3. To broaden participation throughincreased activity options, both structuredand unstructured.


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Clinical Instructor

I. Introduction

Spontaneous vaginal delivery implies that the birth occurred without the need for forceps,

vacuum, or any other instrumentation. This term does not imply that every part of the birth was

without medical care or intervention. Lacerations (tearing of the tissues) can occur during

spontaneous vaginal delivery and may require repair. A mother may choose different levels of

pain relief and still experience a spontaneous vaginal delivery. This is still the most common

type of delivery and that to which all other modes of delivery are compared. (www.wrong

diagnosis.com)

Premature rupture of membranes (PROM) is an event that occurs during pregnancy when

the sacs containing the developing baby (fetus) and the amniotic fluid bursts or develops a hole

prior to the start of labor.

During pregnancy, the unborn baby (fetus) is surrounded and cushioned by a liquid called

amniotic fluid. This fluid, along with the fetus and the placenta, is enclosed within a sac called

the amniotic membrane. The amniotic fluid is important for several reasons. It cushions and

protects the fetus, allowing the fetus to move freely. The amniotic fluid also allows the umbilical

cord to float, preventing it from being compressed and cutting off the fetuss supply of oxygen

and nutrients. The amniotic membrane contains the amniotic fluid and protects the fetal

environment from the outside world. This barrier protects the fetus from organisms (like bacteria

or viruses) that could travel up the vagina and potentially cause infection.

Although the fetus is almost always mature at between 36-40 weeks and can be born

without complication, a normal pregnancy lasts an average of 40 weeks. At the end of 40 weeks,

the pregnancy is referred to as being term. At term, labor usually begins. During labor, the

muscles of the uterus contract repeatedly. This allows the cervix to begin to grow thinner (called

effacement) and more open (dilatation). Eventually, the cervix will become completely effaced

and dilated. In the most common sequence of events (about 90% of all deliveries), the amniotic

membrane breaks (ruptures) around this time. The baby then leaves the uterus and enters the


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birth canal. Ultimately, the baby will be delivered out of the mothers vagina. In the 30 minutes

after the birth of the baby, the placenta should separate from the wall of the uterus and be

delivered out of the vagina.

Sometimes the membranes burst before the start of labor, and this is called premature

rupture of membranes (PROM). There are two types of PROM. One occurs at a point in

pregnancy before normal labor and delivery should take place. This is called preterm PROM.

The other type of PROM occurs at 36-40 weeks of pregnancy.

PROM occurs in about 10% of all pregnancies. Only about 20% of these cases are

preterm PROM. Preterm PROM is responsible for about 34% of all premature births.

(www.wrong diagnosis.com)

Statistics:

In United States there are 68.92 % of Normal Delivery (Updated last December 22, 2009,

www.cdc.gov).

In the Philippines 74 % is in line with normal delivery (October 09, 2008,

http://www.unicef.org/about/execboard/files/A-63-327-ADD1.pdf)

In Tarlac Provincial Hospital the case of normal delivery is 632 cases from January to

September. (Medical record of TPH)

IMPORTANCE OF CASE STUDY

This case study is primarily important because it enhances the students skills, knowledge

and attitudes in the practice of nursing practice. It provides broader comprehension about the

condition chosen through research and actual observation as it serves as a training ground and

practice in developing learned skills in the assessment and management of normal spontaneous

delivery with premature rupture of membrane for 3 hours.
http://www.unicef.org/about/execboard/files/A-63-327-ADD1.pdfhttp://www.unicef.org/about/execboard/files/A-63-327-ADD1.pdf


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Through this case study, a strict and more holistic approach in assessing the patients

health will be delivered, where it can be immediately attended to and given proper interventions.

It serves as a way to familiarize the students with the different medical approaches toward the

ongoing curative phase.

This study serves as a tool for future reference of upcoming nursing students of the

school to share to other student nursing colleagues to understand the dynamics of normal

spontaneous delivery with premature rupture of membranes as to the book-base management and

actual clinical interventions. Furthermore, this study maybe use as a spring board for a more

advance and in depth study that is in occurrence to changing development society.

Reason for choosing such case for presentation

Out of curiosity and interest, the case of normal spontaneous delivery with premature

rupture of membrane was chosen by the group as a case study. The group was enthralled to know

more about the condition, its causes, treatment the proper nursing management for this patient

with this kind of condition. This case study will help the group in acquiring sufficient

information and apply it in that actual hospital setting to the patient with the same diagnosis.

Promotion of health, prevention of diseases and illnesses, rehabilitation and restoration of

good health are important in doing the case. In the accomplishment of the case study, the group

will be able to know and develop more fully our skills in assessment, planning through nursing

care plans, implementations/ interventions and evaluation.


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Objectives

General:

Nurse Centered

This study aims to broaden the knowledge of the researchers and readers and also to

come up with a detailed study about normal spontaneous delivery with premature rupture of

membranes before the labor and to identify and as well as to provide an appropriate, accurate and

effective nursing measures and intervention and responsibilities to consider while taking care of

the patient.

Specific:

Nursed Centered

This study aims to:

1. Assess properly to determine the contributing factors regarding to the clients condition and

identify any present abnormalities

a. Personal Data

b. Family history of health and illness

c. History of past illness

d. History of present illness

e. Thirteen areas of assessment

2. Develop an individualized plan considering client characteristics or the situation and setting a

specific, measurable, attainable, realistic and time bounded plan that reflect the onset, date of

problem identified

a. Planning (nursing care plan)


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3. Provide appropriate interventions for every problem encountered and monitor the client's

response to treatment and therapies through means of physical assessment and communication

with the client

a. Medical management

b. Surgical management

4. Broaden the knowledge of each member through further research about the latest news

articles and journals regarding to the client disease

General:

Client Centered

To upgrade the total well being and to alleviate the discomforts of the patient.

Specific:

Client Centered

To have an understanding about the condition and to have a positive outlook

towards the ongoing curative phase.

To gain knowledge from the health teachings of the student nurse and to

comply on the recommended regimen.

To be able to interact and express feelings about the condition to the nurse and

participate appropriately.


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II. Nursing Process

A. ASSESSMENT

1. Personal Data

a. Demographic Data

Name: Ms. PROM

Age: 22

Sex: Female

Civil Status: single

Occupation: fish vendor

Role/Position: Mother

Nationality: Filipino

Date of Admission: Oct. 1 2010 12:34 pm

Chief Complaint: leaking of clear liquid in her vagina and labor pain

Admitting Diagnosis: pregnancy uterine 38 wks 6/7 age of gestation, cephalic in

labor G2P1 (1001) PROM x 3 hours

Final Diagnosis: Pregnancy uterine delivered via normal spontaneous delivery to

a term cephalic, live baby boy

Date of delivery: October 1, 2010

Time of delivery: 8:45 AM

b. Environmental Status

Ms. PROM is living with her live in partner in San Pablo Tarlac City where in

their house is located to a free way area. Their house is made up of concrete materials and

it suggests congestion because they live in one compound with 6 houses. Around their

house is fully cemented and open canal is located outside of their gate. Their primary


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source of water is coming from a faucet, it is their source of drinking water, water used

for bathing, cleaning, cooking and washing dishes. Transportation is always available at

their residence. The garbage is regularly collected by the garbage collectors in their place.

Ms. PROM and her live in partner together with their first child and her live in partners

family are living in the same house. They are 8 members in the family. Therefore the type

of family they have is an extended family.

c. Lifestyle

Before the admission, Ms. PROM usually wakes up at 7:00 in the morning and

starts her day by cooking for their breakfast and sleeps around 9-10 in the evening. During her

pregnancy, she washes the clothes of her family and helps her partners mother in selling fish in

the Tarlac wet market. According to her, she usually does household chores and she spends her

leisure time in watching television and chatting with her neighbors and sometimes she is taking a

nap in the afternoon. When she was in 28-32 weeks of gestation, she had difficulty in doing

activities of daily living due to enlargement of her abdomen.


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2. Family History of Health and Illness

Paternal Maternal

HPN 75 Asthma 78 OA 77 HPN 69

AW 45 HPN 47

A&W Ap NSD A&W A&W A&W A&W

27 25 22 19 17 15 10

Schematic Diagram Legends:

- living male A&W- Alive and well NSD- Normal Spontaneous Delivery

- living female Ap- Appendicitis A-Asthma

- deceased OA- Old Age


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3. History of Past Illness

According to Ms. PROM she already had chicken pox and measles specifically when

she was on grade 4 at the age of 10 she stated that her immunization was completed. She

experienced common illnesses like coughs, colds and fever and as remedy she took over the

counter drugs like biogesic, medicol and neozep. She stated that she doesnt have any allergies to

animals, drugs or insects.

March 2010 Ms. PROM went to Tarlac Provincial Hospital for prenatal checkup. The

doctor noticed that her abdomen was not proportion to her 8 weeks age of gestation. The doctor

advised her to undergo ultrasound because they cannot hear the fetal heart tone and they found

out that she has an ovarian cyst that needs to be removed.

On May 2010, because of the presence of an ovarian cyst on her left ovary Ms. PROM

undergo Exploratory Laparotomy, Left Oophorectomy.

4. History of Present Condition

Ms. PROM was admitted at Tarlac Provincial Hospital on October 1, 2010. Her last

menstrual period is on January 1 and October 9, 2010 was her expected date of confinement.

Three hours prior to admission, she experienced leaking of clear liquid in her vagina in moderate

amount so she was brought to Tarlac Provincial Hospital.

Internal examination was done by an OB doctor and the cervix revealed 7 cm dilated with

an effacement of 80%, cephalic in presentation negative 2 stations and a positive bloody show,

fetal heart tone of 135 beats per minute, PROM for 3 hours. Her contraction occurs every 4-5

minutes lasting 40-60 seconds and of moderate to severe intensity hence, advised for admission.

At exactly at 2:55 pm she was delivered spontaneously to an alive baby boy with right medio-

lateral episiotomy.


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5. Thirteen Areas of Assessment

5.1 Social Status

Ms, PROM is recently residing at Manila until she decided to live in Tarlac with her

living-partner. Now, they are residing at San Pablo, Tarlac City with her 2 year old son. She is

the third among the 7 siblings; she speaks Tagalog and can understand Kapampangan. Her

mother-in-law has a small store in the market, she helps on selling fish. She often socialized with

her neighbors. She doesnt have time to meet with her friends due to lack of time. She is a

Roman Catholic and attended the mass every Sunday. She maintains the harmony,

communication and love in their family. She preferred to discuss any conflicts or issues of their

family like financial matter.

Norms:

Family members should help one another by doing their responsibilities in the family.

Good communication within the family must be maintained to obtain a healthy relationship with

one another. Social support is a perception that one has an emotional and tangible resource to

call on when needed. Perceived social support is being followed by the family to express the love

and care to each one of them (Kozier, 2004).

Analysis

Ms. PROM has more focus with her family and to her work. She doesnt have much time

in socializing with her friends though sometimes she mingles with her neighbors. They maintain

healthy relationship with one another, though problem occurs to their family and sometimes

conflict happens between the couple.

5.2 Mental Status

Ms. PROM was able to state her name, address, birthday and other question that was

asked to her. She was able to read the object that is given to her such as the label of the box of


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gloves and she was able to state the time that was asked in the clock. She is able to identify the

things we have showed to her like thermometer and gloves. She manages to answer the question

appropriately and correctly throughout the interview even though she is experiencing labor pain.

She was instructed about breathing exercise and the right position during labor period. She has

an evidenced of facial grimace and she is irritable upon contractions but she still responds to the

questions being asked appropriately and correctly. She maintains eye contact during our

interview

Norms

The patient should appear relaxed with the appropriate amount of concern for the

assessment. The patient should exhibit erect posture, smooth gait and symmetrical body

movements. The patient should be clean and well-groomed and should wear appropriate clothing

for age, weather and socioeconomic status. Facial expressions should be appropriate to the

content of the conversation and should be symmetrical. The patient should be able to produce

spontaneous, coherent speech. Content of the message should make sense. The patients ability

to read and write should match the patients educational level.

The patient should be correctly responding to questions and to identify all the objects as

requested. The patient should demonstrate a realistic awareness and understanding of self. The

patient should be able to evaluate and act appropriately in situations requiring judgment. Thought

processes should be logical, coherent and goal-oriented. Thought content should be based on

reality. (Health Assessment and Physical Examination, 3rd edition,)

Analysis:

Ms. PROMs answered all the questions that were asked appropriately and correctly. She

was able to identify objects accordingly. She was aware about the time and date and she knows

where she is. She followed instruction that was advised. It shows that she is in right state of

mind and she is interested, because she can respond well to the questions and instruction.


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5.3 Emotional Status

The expression of pain was observed in Ms. PROM face during the uterine contraction,

but when the contraction stops, she still manages to express her emotions regarding her

upcoming second child, she told us that she and her live-in partner was excited in the birth of

their second son. She already knows on how to manage the pain when contracting. She has a

positive outlook in life by stating that no matter what happens she will raise her two sons.

Norms

Normally, the patient should have the ability to manage stress and to express emotions

appropriately. It also involves the ability to recognize, accept and express feelings and to accept

once limitations. (Fundamentals of Nursing: Concepts, Practice, and Process, 7th Edition, 2004)

Analysis:

Ms. PROM can still manage the stress due to her labor pain; she knows what to do when

the uterus is contracting she helps herself in bearing down. She already has the idea on how to

manage the pain because it is her second pregnancy.

5.4 Sensory Perception

Sense of Sight

. For the test of papillary constriction we used a penlight, light was introduced in front

and in the lateral side of one eye and then repeated in the other eye. Both pupils constricted as

the light was directed to her. Her eyes are symmetrical and no lesions were found. Pupils are

equally rounded, react to light and have good accommodation. Aside from the six cardinal gazes

test, she was also able to read the word safe hands in a distance of 2 meters, clearly and

correctly.


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Norms:

A person is considered to have a normal vision if he or she is able to name the different

colors shown. Anatomically, eyelids should appear symmetrical with no tumors on the lids and

the patient is able to raise both eyelids symmetrical. Normal lid margins are smooth with lashes

which are evenly distributed. Eyebrows are present bilaterally and are symmetrical and without

lesions. Palpebral conjunctiva should appear pink and moist without swelling, lesions, exudates

or foreign bodies. Sclera should be white in light skinned individuals and may have tiny brown

patches of melanin or muddy color in dark skinned with some small vessels. Pupils should

constrict briskly to direct and consensual light and accommodation and should be deep black,

round and equal in diameter. (Health Assessment and Physical Examination, 3rd Edition)

Analysis:

Ms. PROM has clear vision because she was able to read the word clearly and correctly.

It means that her eyes are both functioning well.

Sense of Smell

In assessing the patients taste of smell, we instructed her to close her eyes and

distinguish the things we ask her to smell like alcohol, and hydrogen peroxide. She appropriately

distinguished it and recognized the variations between alcohol and hydrogen peroxide.

Her nose lies in the midline of her face and it is symmetrical, nostrils are intact and no

bleedings were found.

Norms:

A functional olfactory sense will reveal findings that a client was able to smell and

distinguish different odors (Fundamentals of Nursing: Concepts, Practice and Process,

2004).


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Analysis:

No abnormalities observed. Ms. PROMs sense of smell is normal for she was able to

identify and distinguished the smell of the alcohol and hydrogen peroxide.

Sense of Taste

Unable to assess the sense of taste due to prescribed diet, nothing per orem. There is no

lesion or abnormalities found in the tongue and oral cavity.

Norms:

Four qualities of taste are found in the taste buds distributed over the surface of the

tongue, bitter is located at the base, sour along the sides and salty and sweet near the tip.

A person has no problem about his sense of taste if he can identify the flavors of the

foods he eats, (Estes, 2006).

Analysis:

The patients tongue is free from lesions or other abnormal findings.

Auditory Activity

For the auditory assessment, to assure the sound of the tic tac of the watch was place

behind the ear in a distance of 2 feet and asked if she can hear and determine the sounds and she

stated that she can hear it clearly and it sounds like the tic tac of the watch. No bleeding,

discharges, wounds, and abnormalities were found in her outer ear.

Norms:

The patient should not complain of pain, tenderness during palpation and should be

able to repeat or respond to questions clearly and correctly to be evaluated to have normal

auditory function (Health Assessment and Physical Examination, 3rd Edition).


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Analysis:

There were no abnormalities found on assessing her ears.

Tactile

The patient felt the pain on her pelvic area radiating at her back with a pain scale of 8

out of 10.

Norms:

Normally, middle-aged patients have unaltered perception of light, touch, and superficial

pain, decreased perception of deep pain and decreased perception stimuli. (Fundamentals of

Nursing: Concepts, Practice and Process, 2004)

Analysis

There is presence of pain upon contractions.

5.5 Motor Stability

Ms. PROM is on bed during the assessment, she was on dorsal recumbent position

holding the upper rails of the bed and pushing herself through her hands during the contraction.

She has limited movements upon changing her position. She can stand and transfer herself from

bed to he wheelchair with the assistance of the student nurse. She was transferred from labor

room to delivery room via wheelchair and assisted to position herself in delivery table.

Norms:

Normally, muscles on one side of the body are the same to the muscle on the

other side. The muscles and tendons are free from contractures (shortening). The muscles are

free from fasciculation and tremors with smooth, coordinated movements. There is equal

strength on each bony side with no deformities. There must be no tenderness or swelling and


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joints move smoothly. Movements vary to some degrees in accordance with the persons degree

of physical activity. (Fundamentals of Nursing: Concepts, Process and Practice, 7th Ed. 2004)

Analysis

Ms. PROM has limited movements. She is experiencing pain upon changing

position.

5.6 Body Temperature

October 1, 2010

Antepartal Postpartal Interpretation

12:34 pm 4:00 pm

Within Normal

Range37.3 C 36.9C

Norms:

The normal body temperature for adults is 36.7 C to 37.5 C (98.06F to 99.32 F)

by axilla. (Health Assessment and Physical Examination, 3rd Edition.)

Analysis:

Ms. PROMs body temperature was in normal range.

5.7 Respiratory Rate

October 1, 2010 Antepartal Postpartal Interpretation

12:34 pm

28bpm

4:00 pm

18bpm

During antepartal period the patient was

tacheipnic because of pain.

Oct. 2, 2010 10 am

18bpm

2pm

20bpmThe patients respiration is within normal


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The patient was tachypneic during the second stage of labor. There is difficulty in

breathing. She had a regular breathing pattern. Depth of respiration is not exaggerated but there

is presence of use of accessory muscle: abdominal. She inhale and exhale through her nose.

Thorax rises and fall in unison in the respiratory cycle as observed.

Norms:

In resting adults, the normal respiratory rate is 12-20 cycles per minute. No

accessory muscles are used in breathing. Normal respirations are regular and even in rhythm The

normal depth of inspiration is non exaggerated and effortless. The healthy adults thorax rises

and fall I unison in the respirator cycle. There is no paradoxical movement. The healthy adult

breathes comfortably in a supine, prone, or upright position. Normal findings varies among

individual but, generally, most patient inhale and exhale through the nose. (Health Assessment

and Physical Examination Third Edition, Mary Ellen Zator Estes, 2006).

Analysis:

Respiratory rate is slightly elevated. There is difficulty in breathing as evidenced

by the use of accessory muscle due to labor pain.

5.8 Circulatory Status

October 1, 2010 Antepartal Postpartal

12:34 pm 4:00 pm

Pulse rate 80bpm 73bpm

Blood pressure 120/80 110/80

Ms. PROM has a good capillary refill after applying a gentle pressure at the nail beds.

The blanch test results in slow returning of pinkish color of the nail beds for three seconds. The

clients skin turgor after pinching turns to its normal position. The elasticity of Ms. PROMs

pulse was 2+ which is normal.


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Norms:

The force of the arterial pulse can be classified as in the three point

3+..fall, bounding

2+..normal

1+..weak thready

0.absent

The normal pulse rate ranges from 60-100 beats per minute and the rhythm is normal due

to it is regular with equal bilateral strength upon bounding. The normal blood pressure is within

the 120 to 140 systolic pressure and 80-90 diastolic pressure. (Health Assessment and Physical

Examination Third Edition, Mary Ellen Zator Estes, 2006).

Analysis:

The elasticity of pulse is normal. The pulse rate is within normal range. Ms.

PROMs blood pressure is within normal range.

5.9 Nutritional Status

As verbalized by Ms. PROM she eats three times a day (breakfast, lunch and dinner) and

two light meals (am and pm snacks) she doesnt eat salty and fatty foods. She likes eating fruits

like mango and grapes likewise vegetables. She consumes only 6-8 glasses of water a day. The

patient now weighs 75 kilogram and 1.60 cm in height.

BMI = 62.5kg/1.62

62.5/2.56= 24.03

BMI = 75 kg/(1.6m)2 =

75 kg/2.56m = 29.29

Norms:


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Consider cultural and religious variations. Normal eating pattern is at on the

minimum three times per day depending upon then metabolic demands band needs of the patient.

Fluid intake is on the average of 8-10 glasses per day. (Monahan, 2002)

A weight gain of 11.2 kilogram to 15.9 kilogram or 25-35 pounds is currently

recommended as an average weight gain in pregnancy. (Pillitteri, 2007).

According to Estes 2006, BMI is a measurement that indicates body composition.

The degree of overweight or obesity as well as the degree of underweight can be determined by

the use of BMI. Standard BMI for adults is as follows.

Normal BMI range:

30..obesity

Normal BMI range of pregnant women:

36.. obesity

Analysis:

As the result of body mass index the BMI of Ms. PROM when she was not pregnant is

24.03 and that is under healthy range. During pregnancy period, her BMI is 29.9 and she belongs

to healthy range.

5.10 Elimination Status


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Bowel habits: Ms PROM defecates once a day week as characterized by soft, formed,

yellowish to brownish stool. She usually defecates early in the morning.

Bladder habits: She voids 8 to 9 times a day with clear yellow urine. She denies

problems upon urination. The amount of her urine varies from her fluid intake.

Norms:

The amount of urine output is 1200 to 1500 cc and normal color is straw, amber, and

transparent. (Fundamentals of Nursing: Concepts, Process and Practice, 7th Ed. 2004)

The normal characteristics of stool is brown, the consistency should be formed

solid/semisolid or moist. Normal pattern should be regular with no pain.

Analysis:

The client experiences no abnormalities in elimination and characteristics of urine are

normal.

5.11 Reproductive Status

Ms. PROM menarche started at the age of 13. Her menstrual cycle is regular. According

to her she usually consumes four sanitary pads per day. Her menstruation last for 4-7 days. She

usually complains dysmenorrhea during the 1st day. She claimed to have only one sexual partner.

This is her 2nd pregnancy. She always had prenatal check-up. She takes vitamins and iron

supplement. LMP (last menstrual period) was last January 1, 2010.

Upon admission, Ms. PROM has a leaking bag of water. The baby is 38 6/7 weeks age of

gestation; her EDC is on October 9, 2010. The fetus is cephalic in presentation. As of 12:34 pm,

IE reveals 7 cm dilated. Her fundic height is 30 cm. Ms. PROM is G 2T2P1A0L1M0. Ms. PROM

has an engorge breast, nipple and areola is dark brown in color.

Norms:


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Pregnancy ending 2 weeks before or 2 weeks after the calculated EDC is considered well

within normal limits. Menarche starts from 11-13 years of age. Duration of menstrual flow of 2-7

days is considered normal. Lochia amount vary from woman to woman. It should contain no

large clots. Clots may indicate that a portion of placenta has been retained and is preventing

closure of the maternal uterine blood sinuses. Lochia is red for 1 to 3 days and it has the same

odor as menstrual period. (Pilliteri, 2007)

Analysis:

The client delivered a full term baby. Her menstrual cycle is normal and her breast also

poses normal findings.

5.12 State of Physical Rest and Comfort

Before the patient was hospitalized, she said that her regular hour of sleep was 8 hours.

She would wake up at 5 am to prepare their breakfast and to fix herself. At 6:00 am she goes to

the market to sell fishes, she almost spent the whole day in the market. When she was in their

house, she usually clean and do household chores but in present, during the hospitalization, she is

usually irritable and lack of rest due to the pain when her uterus is contracting.

Norms:

The older adult sleeps 6 hours at night. About 20% to 25% is REM sleep. Stage IV sleeps

is markedly decreased and some instances absent. The first REM period is longer. (Kozier et. al.,

Fundamentals of Nursing 7th edition)

Analysis:

The patient has disturbed in rest and comfort ability during the hospitalization.


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5.13 State of Skin Appendages

The patients skin is brown and her hair is evenly distributed in her body. There were no

edemas noted in her lower extremities. The scalp has no flakes and is free of lesions. The

patients hair is black and is free of infestations. Nails has an approximately angle of 160

characterized as intact but pale in color and have no lesions found. Her skin is warm to touch.

She has a linea negra and striae gravidarum in her abdomen. She also has a surgical incision in

the abdomen due to removal of her ovarian cystl. She has a darker pigmentation in the under arm

and genital area. PRESENCE OF EPISIOTOMY (D BA INTRA-OP LNG?)

Norms:

The normal generalized color for dark-skinned individuals is light to dark brown to olive

with milder colored palms, soles, nail beds and lips. Texture is described as smooth, soft, warm,

and dry to touch. Pinched skin to test for skin turgor should return immediately after. There

should also be no swelling, pitting or edema present when pressed firmly for 5 to 10 seconds

over tibia or ankle.

Nails are present per distal phalanx, are in pink color, round and with a 160 degree nail

base. It is also hard, immobile and firm in texture. ( Health Assessment and Physical

Examination Third Edition, Mary Ellen Zator Estes, 2006).

Striae and linea nigra are normal to pregnant women due to increase estrogen which

cause hyperpigmentation. (wikipedia)

Analysis:Dark discolorations around the neck are due to hormonal changes. Presence of striae and

linea nigra are due to increase estrogen that cause increase in pigment melanin

(hyperpigmentation)


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6. Anatomy and Physiology

EXTERNAL GENITALIA

The Labia Majora

The labia (L. large lips) are two symmetrical folds of skin, which provide protection for

the urethral and vaginal orifices.

These open into the vestibule of the vagina.

Each labium majus, largely filled with subcutaneous fat, passes posteriorly from the mons

pubis to about 2.5 cm from the anus.

They are situated on each side of the pudendal cleft, which is the slit between the labia

majora into which the vestibule of the vagina opens.

The labia majora meet anteriorly at the anterior labial commissure.
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They do not join posteriorly but a transverse bridge of skin called the posterior labial

commissure passes between them.

The Labia Minora

The labia minora (L. small lips) are thin, delicate folds of fat-free hairless skin.

They are located between the labia majora.

The labia minora contain a core of spongy tissue with many small blood vessels but no

fat.

The internal surface of each labium minus consists of thin skin and has the typical pink

colour of a mucous membrane.

It contains many sensory nerve endings.

Sebaceous and sweat glands open on both of their surfaces.

The labia minora enclose the vestibule of the vagina and lie on each side of the orifices of

the urethra and vagina.

They meet just superior to the clitoris to form a fold of skin called the prepuce (clitoral

hood).

In young females the labia minora are usually united posteriorly by a small fold of

the skin, the frenulum of the labia minora.

The Clitoris

The clitoris is 2 to 3 cm in length.

It is homologous with the penis and is an erectile organ.

Unlike the penis, the clitoris is not traversed by the urethra; therefore it has no corpus

spongiosum.

The clitoris is located posterior to the anterior labial commissure, where the labia

majora meet.

It usually hidden by the labia when it is flaccid.

The clitoris consists of a root and a body that are composed of two crura, two corpora

cavernosa, and a glans.

It is suspended by a suspensory ligament.
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The parts of the labia minora passing anterior to the clitoris form the prepuce of the

clitoris (homologous with the male prepuce).

The parts of the labia passing posterior to the clitoris form the frenulum of the clitoris,

which is homologous with the frenulum of the penile prepuce.

It is highly sensitive and very important in the sexual arousal of a female.

The Vaginal Orifice

This large opening is located inferior and posterior to the much smallerexternal urethral

orifice.

The size and appearance of the vaginal orifice varies with the condition of the hymen (G.

membrane), a thin fold of mucous membrane that surrounds the vaginal orifice.

The External Urethral Orifice

This median aperture is located 2 to 3 cm posterior to the clitoris and immediately

anterior to the vaginal orifice.

On each side of this orifice are the openings of the ducts of the paraurethral

glands (Skene's glands).

These glands are homologous to the prostate in the male.
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INTERNAL GENITALIA

Vagina

The vagina extends from the vaginal opening to the cervix, the opening to the uterus. The

vagina serves as the receptacle for the penis during sexual intercourse, and as the birth canal

through which the baby passes during labor. The average vaginal canal is three inches long,

possibly four in women who have given birth. This may seem short in relation to the penis, but

during sexual arousal the cervix will lift upwards and the fornix (see illustration) may extend

upwards into the body as long as necessary to receive the penis. After intercourse, the

contraction of the vagina will allow the cervix to rest inside the fornix, which in its relaxed state

is a bowl-shaped fitting perfect for the pooling of semen.

At either side of the vaginal opening are the Bartholin's glands, which produce small

amounts of lubricating fluid, apparently to keep the inner labia moist during periods of sexual


29/65

excitement. Further within are the hymenglands, which secrete lubricant for the length of the

vaginal canal.

"G-Spot"

The word is in quotes because there is still some debate as to the existance or purpose of

the G- spot. In the illustration above, what is indicated as the g-spot in fact points to a region

known as the Skenes glands, the purpose of which are unknown. Despite the controversy, one

fact remains-- there are many women who claim that pressure on this region of the vagina is

extremely pleasurable. Usually, two fingers are used, and because the spot is deep within the

tissue, some pressure may be needed. Also, because the Skenes glands are alongside the bladder,

some women may found that the increased pressure makes them feel as if they need to urinate.

Cervix

The cervix is the opening to the uterus. It varies in diameter from 1 to 3 millimeters,

depending upon the time in the menstrual cycle the measurement is taken. The cervix is

sometimes plugged with cervical mucous to protect the cervix from infection; during ovulation,

this mucous becomes a thin fluid to permit the passage of sperm.

Uterus

The uterus, or womb, is the main female internal reproductive organ. The inner lining of

the uterus is called the endometrium, which grows and changes during the menstrual cycle to

prepare to receive a fertilized egg, and sheds a layer at the end of every menstrual cycle if

fertilization does not happen. The utereus is lined with powerful muscles to push the child out

during labor.

Ovaries

The ovaries perform two functions: the production of estrogen and progesterone, the

female sex hormones, and the production of mature ova, or eggs. At birth, the ovaries contain

nearly 400,000 ova, and those are all she will ever have. However, that is far more than she will


30/65

need, since during an average lifespan she will go through about 500 menstrual cycles. After

maturing, the single egg travels down the fallopian tube, a journey of three or four days-- this is

the period during which a woman is fertile and pregnancy may occur. Eggs that are not fertilized

are expelled during menstruation.

Premature rupture of membranes (PROM) is an event that occurs during pregnancy when

the sac contains the developing baby (fetus) and the amniotic fluid bursts or develops a hole prior

to the start of labor.

During pregnancy, the unborn baby (fetus) is surrounded and cushioned by a liquid called

amniotic fluid. This fluid, along with the fetus and the placenta, is enclosed within a sac called

the amniotic membrane. The amniotic fluid is important for several reasons. It cushions and

protects the fetus, allowing the fetus to move freely. The amniotic fluid also allows the umbilical

cord to float, preventing it from being compressed and cutting off the fetuss supply of oxygen

and nutrients. The amniotic membrane contains the amniotic fluid and protects the fetal

environment from the outside world. This barrier protects the fetus from organisms (like bacteriaor viruses) that could travel up the vagina and potentially cause infection.

Although the fetus is almost always mature at between 36-40 weeks and can be born

without complication, a normal pregnancy lasts an average of 40 weeks. At the end of 40 weeks,

the pregnancy is referred to as being term. At term, labor usually begins. During labor, the


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muscles of the uterus contract repeatedly. This allows the cervix to begin to grow thinner (called

effacement) and more open (dilatation). Eventually, the cervix will become completely effaced

and dilated. In the most common sequence of events (about 90% of all deliveries), the amniotic

membrane breaks (ruptures) around this time. The baby then leaves the uterus and enters the

birth canal. Ultimately, the baby will be delivered out of the mothers vagina. In the 30 minutes

after the birth of the baby, the placenta should separate from the wall of the uterus and be

delivered out of the vagina.

Sometimes the membranes burst before the start of labor, and this is called premature

rupture of membranes (PROM). There are two types of PROM. One occurs at a point in

pregnancy before normal labor and delivery should take place. This is called preterm PROM.

The other type of PROM occurs at 36-40 weeks of pregnancy.

7.1 Pathology and Physiology (book base)

Modifiable Factors

Smoking

Poor nutrition and hygiene and lack

of proper prenatal care

Incompetent cervix (perhaps as a

result of abortions)

increased intrauterine tension due to

Hydramnios or multiple pregnancies

defects in the Amniochorial

membranes tensile strength

Non-Modifiable Factors

Age

Gender
http://wrongdiagnosis.pubs.righthealth.com/topic/Nutrition%20disorder?as=clink&ac=1437&afc=2168586466&p=&dqp.cache.mode=PMBypasshttp://wrongdiagnosis.pubs.righthealth.com/topic/Cervical%20incompetence?as=clink&ac=1437&afc=2168586466&p=&dqp.cache.mode=PMBypasshttp://wrongdiagnosis.pubs.righthealth.com/topic/Polyhydramnios?as=clink&ac=1437&afc=2168586466&p=&dqp.cache.mode=PMBypasshttp://wrongdiagnosis.pubs.righthealth.com/topic/Nutrition%20disorder?as=clink&ac=1437&afc=2168586466&p=&dqp.cache.mode=PMBypasshttp://wrongdiagnosis.pubs.righthealth.com/topic/Cervical%20incompetence?as=clink&ac=1437&afc=2168586466&p=&dqp.cache.mode=PMBypasshttp://wrongdiagnosis.pubs.righthealth.com/topic/Polyhydramnios?as=clink&ac=1437&afc=2168586466&p=&dqp.cache.mode=PMBypass


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Inability of the fetus to regulate the amniotic fluid

Over stretch amniotic membrane

Accumulation of excess plasma fluid

Inability of the fetus to secret

the fluid to the kidney of the

mother

Inability of the fetus to

swallow the amniotic fluid


33/65

Rupture of the amniotic membrane

Weakening of the amniotic

Cord loop/cord prolapse

Gradual/sudden gush of

fluid membrane in the

Immature lung surfactant

Ineffective airway

clearance in the fetus

Invasion of group b streptococci to the

membrane

Compression of the

umbilical cord

endometritis

Absence of fluid in the uterus that

serves as a lubricant for the cord

to float and for the freely fetal

movement

Higher risk for infection

amnionitis


34/65

7.2 Pathology and Physiology (client base)

Ineffective tissue perfusion

Cyanosis

Absence/decrease nutrients

and oygen supply to the

fetus.

Stillbirth

Non-Modifiable Factors

Age: 22 years old

Gender: female

Modifiable Factors

Second hand Smoker

Poor hygiene and lack of proper

prenatal care


35/65

Gradual/sudden gush of

fluid membrane in the

Ineffective airway

clearance in the fetus

Higher risk for

infection

Rupture of the amniotic membrane

Absence of fluid in the uterus that

serves as a lubricant for the cord

to float and for the freely fetal

movement

Weakening of the amniotic

Invasion of group B streptococci to the

membrane


36/65

Risk for Immature fetal

lung surfactant


37/65

B. Planning

Nursing Care Plan


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39/65

ASESSMENT PLANNING INTERVENTIONS EXPECTED OUTCOMES

S> Nanghihina ako,

nahihirapan akong kumilosO> irritable

>uncomfortable

>limited movement

>weak in appearance>report lack of energy>decreased performance

>dyspneic

RR-28 cpm>excessive sweating

Analysis:

Activity intolerance related tolimited strength, pain, and

discomfort

Scientific Explanation:

Due to decrease in oxygen

supply and increased oxygendemand of the cells, there isinsufficient physiological

energy to endure on completerequired or desired daily

activities.

Within 1 hour of rendering

appropriate nursingintervention, the client will use

identified techniques to

increase activity tolerance

Provide safety and

comfortRationale:

T o prevent injury

Instruct the client to use

controlled breathingtechniques throughactivities

Rationale:

For relaxation

Provide rest periods if

there is no uterinecontraction

Rationale:

To facilitate comfort, relaxation

and to prevent fatigue

Provide adequate rest

Rationale:

To increase oxygen supply

Instruct the client torefrain from performing

unnecessary movementsRationale:

To reduce oxygen demand

Instruct anddemonstrate to the

client the proper pacingsuch as moving slowly

on bed

Rationale:

After 1 hour of rendering

appropriate nursinginterventions, the client will use

identified techniques to

increase activity tolerance as

evidenced by: Explained methods to

increase activity

tolerance such as havingproper rest periods

every after uterine

contraction.

Verbal report of comfort

RR of 20 cpm


40/65

To improve activity tolerancegradually.

Demonstrate to theclient the proper bearing

down technique

Rationale:

To decrease discomfort and

promote fetal delivery

Keep side rails up andbed in low position

Rationale:

Promote a safe environment


S> Medyo nahihirapan akong

huminga

O> dyspneic: RR-28 cpm>tachypneic: PR___bpm

> nasal flaring>irritable

> use of accessory muscles

Within 30 minutes to 1 hour of

rendering appropriate nursing

intervention, the clientsrespiratory rate and rhythm will

reach the normal limits.

Monitored vital signs

Rationale:

For base line data

Instruct and

demonstrate to thepatient about relaxation

technique

After 30 minutes to 1 hour of

rendering appropriate nursing

interventions, the client willachieve RR within normal

range as evidenced by:

RR of 20 cpm

Reduced facial grimace


41/65

> facial grimace noted>pursed-lip breathing or

prolonged expiratory phase

Analysis:

Ineffective breathing patternrelated to hyperventilation


Hyperventilation occurs when awoman exhales more deeply

than she inhales. As a result,extra carbon dioxide is blown

off and respiratory alkalosisresults. This can occur when a

woman is practicing breathing

exercises in preparation forlabor, but it is most apt to occur

during actual labor.

Rationale:

To improve breathing pattern

Instruct the client to dodeep breathing exercise

Rationale:

To prevent fatigue

Place patient with

appropriate body

alignment formaximum breathing

patternRationale:

A sitting position permits formaximum lung excursion and

chest expansion

Provide rest periods

every after contraction

Rationale:

To increase oxygen supply

Instruct the client to

refrain from performingunnecessary activities

Rationale:

To reduce oxygen demand

Utilize painmanagement as needed

Rationale:

Facilitates for pain relief and

the capability to deep breathe

Absence of nasal flaring

Demonstrated deep

breathing exercise

Regular rhythm of

respiratory rate



42/65

S>O> risk for identified

>Premature rupture ofmembrane for 3 hours

>WBC: __ G/L

>RR-26 cpm>leaking of amniotic fluid from

the vagina clear and moderatein amount

> wet under pad

Analysis:

Risk for infection related to

premature rupture of membrane


Rupture of amniotic fluid

increase risk for being invadedby pathogenic organisms

(GAGWIN INFECTION R/OHYPERTHERMIA)

Within 1 hour of renderingappropriate nursing

interventions, the client willremain free from infection

Independent:

Monitor vital signs

specifically the bodytemperature

Rationale:

Elevated temperature indicates

infection

Emphasize the

importance of properhygiene

Rationale:

To decrease pathogens from

accumulating to the area

Maintain cleanliness of

the surrounding

Rationale:

To prevent accumulation of

pathogens.

Provide safety such as

assisting from activities

Rationale:

To prevent injury

Provide adequate restperiods

Rationale:

To prevent fatigue

Dependent:

Administer Cefazolin as

prescribed

Instruct the client to

keep area of identifiedrisk factor to be clean

After 1 hour of renderingappropriate nursing

interventions, the client willremain free from infection as

evidenced by:

Normal body

temperature

Clean and dry site of

identified risk factor Maintain good hygiene

No signs and symptomsof infection not noted


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and dryRationale:

To prevent accumulation ofmicroorganism

Remove wet under pador wrinkled linens

promptly

Rationale:

Prevent invasion of bacteria


S>O> overexcited on the pending

operation>excessive sweating

>sleep disturbance

>restlessness>poor eye contact

>irritable>increased tension

>facial tension

Analysis:

Anxiety related to currenthealth status


It is an easy feeling or discomfort which may be

accompanied by autonomic

After 2 hours of proper nursinginterventions, patients anxiety

will decrease and ismanageable.

Place in a comfortableposition that patient can

tolerate

Rationale:

Proper positioning based on

tolerance level on the patientassist her to be relaxed and thus

lessening the feeling of anxiety.

Divert patients

attention throughmaintaining acontinuous and

enjoyable conversationand through giving any

reading materials.

Rationale:

Diversional activities can alter

temporarily the perception orfeeling of anxiety.

Explore patients

After 2 hours of proper nursinginterventions, patients anxiety

will be decreased and will bemanageable as manifested by:

Verbalized relief on her

anxiety or fear.

Identify and

demonstrate techniquesto control anxiety

Able to concentratesome activities toreassure self


44/65

response of the body, either thesympathetic stimulation. It is

also a feeling of apprehensionor as a result of anticipated

danger on client basis, feeling

of being anxious is caused bythreat to client health status.

positive coping skillsand ways, previously

used by the patient torelieve anxiety and

reinforce those skills

Rationale:

Methods of coping with anxiety

that was helpful in the past arelikely to be effective in the

present.

Maintain a calm and

tolerant manner while

interacting with thepatient

Health teachings:

Encourage patient that

as much as possiblealways divert her

attention as she feelsanxious

Advice family membersor significant others to

be cooperative and

always support patientthrough giving advises

and being alwaysphysically present.


45/65


46/65

Laboratory Result

Ultrasound

September 15, 2010

Procedure: PelvicFindings:

Pelvic ultrasound shows a single live fetus, in cephalic presentation with the followingparameters:

BPD 89 mm corresponding to 36.3 weeks AOGFL 71 mm corresponding to 36.1 weeks AOG

AC 326 mm corresponding to 36.5 weeks AOG

Analysis:

Good fetal somatic motions and cardiac activity are noted. No gross fetal abnormality is

seen. Amniotic fluid volume is adequate. Placenta anterior fundal, draping to the right and left,grade II. The fetus is probably male.

Impression:

Single live fetus, in cephalic presentation with composite age of gestation of 36 weeks

and 2 days. EFW=2989 grams. EDC= 10-10-10. Anterior placenta. Normohydramnios.


47/65


48/65

Laboratory

procedure

Date

ordered/

date of

result

Indication/

Purpose

Result Normal

Value

Analysis

Urinalysis October

1, 2010/

October

2, 2010

It is a

physical,

chemical,microscopic

examination

of urine. Itreveals

disease that

has gone

unnoticedbecause they

do not

produce

strikingsymptoms.

Leukocytes:

moderate

Nitrite: negative

Urobilinogen:normal

Protein: negative

pH: 5.0

Blood cells:

negative

Specific gravity:1.015

Ketone: small

Bilirubin:

negative

Glucose: negative

Color: yellowTransparency:

turbid

Pus cell: 12.5

Red blood cell:

none

Epithelial cells:

occasionally

Mucous: few

Bacteria:

occasional

bacteria

Crystal: calcium

oxalate

occasionally

Negative

negative

0.1-1.0

negative

5-7

negative

1.001-1.025

Negative

Negative

Negative

amber

Transparent

0-5/hpf

Negative orrare

Negative

negative

Increase,

presence of

infectionNormal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal


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Nursing Responsibility

Inform the client that would prepare for urinalysis.

Discuss the importance of the procedure. Instruct the patient to void and collect the specimen in the midstream urine using

specimen cap.

Instruct patient not to fill with any other specimen to the specimen cap to preventcontamination.

Label the specimen cap with her complete name and the procedure.

After collecting the specimen, immediately send it to the laboratory to preventcontamination.

Laboratory

procedure

Date

ordered/ date

of result

Indication/ Purpose Result Normal Value Analysis

Hematology Result

White Blood Cells

October

1,2010

Identifies the total

number of blood cell

as well as the

hemoglobin andhematocrit indices.

10 G/L 4.1-10.9G/L Normal


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Red Blood Cells

a. Hematocrit

b. Hemoglobin

Platelets

3.89T/L

.345 L/L

112G/L

192 G/L

4.20-6.30TL

.370.510L/L

120-180G/L

140-440G/L

Decrease

Decrease, indicates

anemia.

Normal

Normal

Nursing Responsibility

Inform the client about the procedure to be done.

Prepare client (it is best to avoid fatty meals prior to having patient blood drawn)

Specimen collection

Vital signs

Monitoring and follow up care.

C. Implementations

1. DRUGS

Name of

Drug

Date

Administered

Route and

Dosage

Mechanism of

Action

Indication Clients

response to

medication

Oxytocin Oct.1, 2010 10 units

incorporated

Acts directly

on myofibrils,

Initiation or

improvement of

Promoted

strong uterine


51/65

to above IVF producing

uterine

contractions;

stimulates milk

ejection by the

breast

uterine

contractions to

achieve early

vaginal delivery

for maternal or

fetal reasons;

management of

inevitable or

incomplete

abortion;

stimulation of

uterine

contractions

during 3rd stage

of labor;

stimulation

reinforcement of

labor; control

postpartumbleeding;

initiation of milk

let-down

contractions

after

administrations

Nursing Responsibilities

Monitor and record uterine contractions, heart rate, BP, intrauterine pressure, fetal heart

rate, and blood loss q15 hr.

Be alert for adverse reaction

Never give oxytoxin simultaneously by more than one route.

If contractions are less than 2minutes apart, if above 50mmHg, or if last 90seconds or

longer, stop infusion, and turn patient on her side, and notify prescriber


52/65

Name of Drug Date

Administered

Route

and

Dosage

Mechanism of

Action

Indication Clients

response to

medication

Methylergometrine

Maleate

Oct. 1, 2010 200 mcg,

IV

Act directly at

the uterine

smooth

muscles to

stimulate rate,

tone and

amplitude of

contractions. It

induces rapid,sustained

titanic

uterotonic

effects that

shortens the

3rd stage of

labor and

reduce blood

flow.

Active

management

of the 3rd

stage of labor,

interior

haemorrhage

following

separation of

placenta anduterine atony,

subinvolution

of puerperal

uterus,

iochiometra,

caesarean

sections, post

partum

bleeding

Clients

bleeding was

minimized

and

promoted

uterine

contraction.


be alert for adverse reactions and drug interactions

this drug should be used extremely carefully because of its potent vasoconstrictor action.IV use may induce sudden hypertension and cerebrovascular accidents.

Give IV slowly over several minutes and monitor blood pressure closely


53/65

Name of

Drug

Date

Administered

Route and Mechanism of

Action

Indication Clients

response to

medication

Ampicillin Oct.1, 2010 2 grams

IV

A

semisynthetic,

acid resistant,

penicillinase

sensitive

penicillin used

as an

antibacterial

against manygram-negative

and gram

positive

bacteria; also

used as the

sodium salt.

It is prescribe

in the

treatment of

infections

caused by a

broad

spectrum of

sensitive gram

negative andgram

positive

organisms.

No signs and

symptoms of

infection

noted.

Nursing Consideration

Administer this drug around the clock.

Administer the full course of therapy; do not stop taking the drug if you feel better.

Administer the oral drug in an empty stomach, 1hr before or 2hr after meals; the oral

solution is stable for 7 days at room temperature or 14 days refrigerated.

This antibiotic is specific to your problem and should not be used to self treat other

infections.

Client may experience these side effects: nausea and vomiting, GI upset, diarrhea.

Report pain or discomfort at sites, unusual bleeding or brusing, mouth sores, rash, hives,

fever, itching, severe diarrhea, DOB.


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Name of Drug Date

Administered

Route

and

Dosage

Mechanism of

Action

Indication Clients

response to

medication

Hyoscine

Butylbromide

Oct. _, 2010 20 mg

IV

Inhibits

muscarinic

actions of

acetylcholine in

the ANS

Affecting neural

pathway

Relieves

spasticity,

nausea and

vomiting;

reduces

secretions; and

blocks cardiac

vagal reflexes.

Promotes

cervical

effacement

To reduce

secretions

perioperatively

The cervix of

the patient

becomes soft

and

gastrointestinal

spasms

subsides


Be alert adverse reactions and drug interactions.


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Encourage client to void

Monitor BP for possible hypotension

Monitor cervical effacement and dilation

Name of Drug Date ordered Route Action Indication Clients

Response

Cephalexin 500 mg /

TID / per

orem

Inhibits DNA

synthesis by

inhibiting

DNA gyrase insusceptible

gram negative

and positive

organisms

Infection on

the skin

structures

No signs of

infection


Check doctors order

Observe 10 Rs before administration

Assess for allergy to drug

Advise patient not to take drugs with dairy or caffeinated products

Inform physician if allergies or rashes abruptly

Name of Drug Date ordered Route Action Indication Clients

Response

Mefenamic

Acid

500mg /

PRN for pain

per orem

Inhibits

reuptake of

serotoninnorepine

Moderate to

moderately

severe pain

Pain

subsides


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Check doctors order

Tell the patient that the drug works best when taken before pain becomes severe

Recommend abstinence from alcohol when taking medications

Caution patient that the drug can cause dependence

Name of

Drug

Date

ordered

Route Action Indication Clients

Response

Ferrous

Sulfate

1 cap OD

per orem

Elevate serum iron

concentrationwhich then helps to

form high trapped

in thereticuloendothelial

cells for storage

and eventual

conversion to ausable form of iron

Dietary

supplement foriron

Blood loss

is replaced


Advise the patient to take medicine as prescribed

Caution patient to make position changes slowly to minimize orthostatic hypotension

Instruct the patient to avoid concurrent use of alcohol or OTC medicine without

consulting the physician

Advise patient to consult physician if irregular hearbeat, dyspnea, swelling of the hands

and feet and hypotension occurs

Inform patient that angina attacks may occur after 30 minutes of administration due to

reflex tachycardia

Encourage patient to comply with addition intervention for hypertension like proper diet,

regular exercise, lifestyle changes and stress management


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3. Diet

TYPE OF diet

GENERAL

DESCRIPTIONINDICATION

Specific

foods

CLIENTS

RESPONSE

NPO Not taking any

fluids or foods by

mouth

Doctors order

prior to operation.

To prevent

excessive nausea

and vomiting.

To prevent

aspiration during

delivery.

none

Clients complaint of

thirst but willing to

cooperate with the

doctors order

Nursing Responsibilities:

Monitor or strict compliance of client during NPO, note that NPO is indicated to avoid

aspirations during labor.

Explain to the client the purpose of maintaining NPO state.

Wipe the lips of the client with wet cotton as needed.

Make sure that the client will not take any kind of food and fluid until in the NPO state

4. Activity and Exercise

TYPE OF

EXERCISE

GENERAL

DESCRIPTIONINDICATION CLIENTS RESPONSE

Flat on bed in

dorsal recumbent

The client is lying

in bed in a flat in

This can alleviate pain

and promote the

The client was able to

maintain flat on bed in


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position dorsal recumbent

position

circulation in the body.

This can also help to

promote fast lighting of

the baby.

dorsal recumbent position,

but there were times that

the client wants to sit

because of the pain she felt

but unable to move freely

due to the instruction and it

is not recommended to sit

or stand during labor.

Deep Breathing

Exercise

strainingexercise

Deep inhalation and

exhalation pattern

during theconstriction of the

fundus

To promote

oxygenation

To fascilitate fast

lightening of the baby.

Nursing Responsibilities: Flat on Bed in Dorsal Recumbent Position

Instruct the client to remain flat on bed in dorsal recumbent position unleast the baby is

crowning.

Provide client safety procedure like fall prevention

Provide comfort measures to ease the pain during contraction

Nursing Responsibilities: Deep Breathing Exercise and straining exercise

Instruct to the client the proper breathing exercise and straining during the contraction.

Explain to the client the importance of the deep breathing exercise and straining.

D. EVALUATION

METHOD

The method is a discharge plan that is needed to be implemented by the client with the

help of her significant others.

M-EDICATIONS


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Continue taking maintenance medications w/c includes the ff:

o Cephalexin 500mg/TID/Per Orem

o Ferrous Sulfate 1Cap OD/Per Orem

o Mefenamic Acid 500mg/PRN for pain/Per Orem

E-XERCISE

Performs Activities of daily living (ADLs) as tolerated

T-REATMENT

N/A

o The patient has no further prescribed treatments

H-EALTH TEACHINGS

The client must be instructed to eat well-balanced diet, drink six to eight glasses of water

daily and get plenty of rest.

To reduce stress on her pelvic muscles and suture sites, heavily lifting should be avoided

for 6 weeks until the wound is healed

Proper perineal care is also necessary to prevent infection

It is recommended that breast feeding is best for nursing the baby for at least 6 months

Instruct the client on proper cord dressing to her baby

Advise the client to go on follow-up check-up after two weeks

O-PD FOLLOW-UP

Instructed the client to go on follow-up check-ups

D-IET

Diet as Tolerated (DAT)

Foods rich in protein


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Evaluation and Implication of this case study to:

Nursing Practice

The result of this case study would provide the student nurse with sufficient knowledge,

attitude and skills towards the management of patients with a term Premature Rupture of

Amniotic Membrane. This study would help the student nurse in providing a higher quality of

care of patients with the same condition. It is important that the proper and ideal managements

and interventions are done in order to give a more holistic approach and optimum care to clients

with PROM. This would ensure the timely healing and the prevention of any further

complications.

Nursing Education

Education can promote enhancement of professionalism through an ongoing learning

process, whether self- motivated, people- oriented and having a commitment to the organization,

nurses are likely to become well respected through the formal educational programs. Through

this case study, it is important to know all areas of patient are both knowledge and skills to

manage effectively in all aspects of their professional nursing practice.

Nursing Research

Nursing research is essential for the development of scientific knowledge that enables

nurses to provide evidenced-based health care. Broadly nursing is accountable to society for

providing quality, cost effective care and for seeking ways to improve that care. More

specifically, nurses are accountable to their patients to promote a maximum level of health.

This case study would contribute more information and facts about NSD with PROM.

This could contribute to the development of the case study of PROM its prevention, causes,

signs and symptoms, and nursing management. Hopefully, this case study will lead to

development of new skills and new approaches to the care of patients with PROM. This case


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study could also as basis for related study and will provide facts for further research in aiming

for the improvement of these patients.

III. Conclusion

Getting the trust of the patient is one of the most important things to do in order to get the

necessary information that can be used in doing a case study. To gain trust, we must establish

rapport to the patient. And because we have established a good relationship with our patient, data

collection became modest for us.

Through the information, assessments, and the complaints the patient told us, we have

determined specific problems the patient is experiencing. With this, we have come up to a

nursing care plan, which the main purpose is to help the client improve her condition.

The problems that we had encountered were properly addressed and solved through the

formulation of nursing care plans and the implementations of formulated interventions.

We were able to develop our understandings about nature and concepts of Normal

Spontaneous Delivery with Premature Rupture of Membranes and medical information about

Normal Spontaneous Delivery.

And lastly we were able to enhance our knowledge and skills in assessment of patient

who undergone Normal Spontaneous Delivery with Premature Rupture of Membranes that will

surely help us in dealing a patient with the same condition in the future.

IV. Recommendation

The nurses and the patients relatives have perceived problems experienced by our

patient; to prevent further complications we formulated some recommendations for the patient to

use to improve his health condition. These recommendations are the following:


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Go for post partum check-ups

Continue taking the medications as prescribed.

Go to the clinic or nearest health center for new born check-ups

Practice proper breast feeding.

The client must be instructed to eat a well-balanced diet, drink six to eight glasses of

water daily and get plenty of rest

To reduce stress on her pelvic muscles and suture sites heavy lifting should be avoided

for 6 weeks until wound is healed

Proper perineal care is also necessary to prevent infection

It is recommended that breastfeeding is best for nursing the baby for at least 6 months

Instruct the client on proper cord dressing to her baby

Advise the client to go on follow-up check-up after two weeks

V. Bibliography

Fundamentals of Nursing, Kozier, 2004

Health Assessment and Physical Examination, Estes, 2006

Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing. 10

th

Edition Philadelphia: I.B Lippincott Company. 2004.

Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott Company.

2001.


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Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork: Addison-

Weatleylongman, Incorporated. 1998.

Marleb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition. Singapore.

Pearson Education South Asia Pte. Ltd. 2004.

Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore: C.V.

Mosby and Company. 2005.

Doenges, M., Moorhouse, M.F. , Geissler Murr, A. Nurses Pocket Guide, Diagnosis,

interventions and rationales, 9th Edition (2004).

Doenges, M., Moorhouse, M.F. , Geissler Murr, A., Nursing Care Plans. Guidelines

for Individualizing Patient Care. 6th Edition. F.A. Davis Company, 2002.


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