Placenta Previa Case Study

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.

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.

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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 1%. In the Philippines , it reached to 6,341 out of the 86,241,697

population estimate used in the year 2004. The mortality rate of placenta

previa in the

country is 0.17% according to DOH.

During our duty in the Ob ward at Ospital Ning Angeles (ONA) , we decided

to take the case of Mrs. Nicole Kidman in which she was diagnosed with

placenta previa totalis because we would like to have a deeper

understanding about this condition so that we could render the care the

patient needed to arrive with a good prognosis. Management should

therefore always be based on appropriate clinical judgment. We would like

to apply all the things that 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.

OBJECTIVES

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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

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: Mrs. Nicole Kidman

Address: 160 Abacan, Malabanias Angeles City

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Age: 38 y/o.

Birthday: 7-12-1971

Birthplace: Angeles City

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Educational Attainment: High School Graduate

Occupation: Housewife

Date Admitted: October 17, 2009

Time Admitted: 1:55pm

Ward: OB

Bed no.: 22

Admitting Diagnosis: Pregnancy uterine 6 – 7 weeks AOG G5P4 UTI,

Placenta Previa

Student Nurse Centered:

After the completion of the case study, the student nurse shall

be able to:

Present a comprehensive and detailed report regarding the

patient’s illness

Have a complete picture of the patient’s physical, psychosocial and

mental status through daily assessment

Have a well-structured nursing diagnosis of the client’s status

based from an integration of data gathered

Understand the factors that might have contributed to the

development of the disease

Provide organized and structured nursing interventions as a

response to the patient’s anticipated needs4

Provide relevant information on available alternative therapies and

management

III. Nursing Process

A. Assessment

1. Personal History

a. Demographic Data

Mrs. Nicole Kidman is a 38 years old Mother. She was born on July

12, 1971 in 160 Abacan St, Malabanias Angeles City, she is a Filipino

Citizen and a Roman Catholic. She is the youngest child among the

three children. This is her 5th pregnancy on her G5P4 6-7 weeks Age

of Gestation. She has a Four Children the 3 boys aged 11, 7, and 4

years old and girl is 9 years old. They live in a compound together

with their relatives according to the husband of Mrs. Nicole Kidman

they are very crowded in their compound because there are 8 families

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in their compound and each family they have a range of 3-4 children

in each families.

b. Socio Economic and Cultural Factors

As a Roman Catholic Mrs. Nicole Kidman also going to church

every Sunday

and she also pray before she going to sleep. Although they are Roman

Catholic they believe in Herbularyos and Hilots, according to them

that one time in her pregnancy she consulted a Hilot in Mabalacat.

She never consulted for a prenatal check up in any medical institution

or health center in there barangay during her past pregnancy. She is

giving birth only in there home and was delivered by a midwife. But

all her previous pregnancy she never had a problem like vaginal

bleeding but she have a previous problem with serious of Urinary

Tract Infection which she only treated by a antibiotic and was only

OTC medicine which she never consulted a physician.

The couples are practicing family planning method Mrs. Nicole

Kidman used to drink a type of Pills before she got pregnant on her 5 th

child. She told us that she suddenly stop drinking pills because she

just forgot to buy the next set of tablets. Then she told us that the

couple just plan to have an another child so she got pregnant.

Mrs. Nicole Kidman is a plain housewife and her husband is

working as a permanent welder in a Construction Company here in

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Angeles City he earn P 400 a day. Both of them finish High School and

there 3 children are studying in a public school at Don Teodoro

Elementary School in Abacan, Angeles City.

2. Family Health – Illness History

Mrs. Nicole Kidman diseases has no direct connection with the past

illnesses. Her Placenta Previa meaning is a complication of

pregnancy in which the placenta grows in the lowest part of the

womb (uterus) and covers all or part of the opening to the cervix.

Mrs. Nicole Kidman mother died in a Cancer at 56 years old. Her

father has arthritis. Aside from these illnesses no significant

disease was mentioned by the client.

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Father

(Arthritis)

Mother

Died (Cancer)

Mrs. Nicole KidmanOlder Brother 2nd Brother

3. History of Past Illness

Mrs. Nicole Kidman have no medical record of any

hospitalization in her life. She told us that her common illness is Fever

and colds only. She told us that this is the first time she will be

hospitalize that why she feel anxious about the situation.

4. History of Present Illness

According to the Client in the morning of October 17, 2009 she is

complaining of back pain to her husband who is about to going to

work. But her husband think it’s only normal in her 5th pregnancy so

he neglect it and tell her to just take a rest. She just take a rest in that

morning but in the afternoon she experienced vaginal bleeding and

dizziness. Then she was later admitted in Ospital Ning Angeles (ONA)

on October 17, 2009 at 1:55pm with Chief Complain of Vaginal

Bleeding / Dizziness and was Medically diagnosed UTI and T/C

Threatened Abortion. Upon her admission she experienced heavy

vaginal bleeding and later that day she has fever of 39 OC and she has

difficulty of breathing that why they hooked an O2 Nasal Canulla and

IVF D5LRS FD 200CC.

5. Physical Examination

PHYSICAL EXAMINATION

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October 17, 2009 (Saturday)

Upon Admission

Appearance and Behavior: Appears well when not moving but

shows slight facial grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 36.6 OC

PR: 80 BPM

RR: 20 CPM

BP: 100/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

Abdomen: Flabby, soft & non tender

Genitalia: dosed cervix x 1(4) Spotting

October 18, 2009

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Actual Physical Examination

Appearance and Behavior: Appears well when not moving but

shows slight facial grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 37.3 OC

PR: 85 BPM

RR: 18 CPM

BP: 90/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

Chest & Lungs: SCE, with retractions

Abdomen: Flabby, soft & non tender

Genitalia: painless, Heavy Vaginal Bleeding

Extremities: full and equal pulses

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DIAGNOSTIC AND LABORATORY EXAMS

A. URINALYSIS

Actual Normal Nursing Date Test Values Values Implications Rationale

Responsibilities10-17-09 PHYSICAL - To examine 1. Tell the patient

EXAMINATION the patient’s that the test is for

Color Straw Clear straw to Liver problems urine for sign the detection or

colored liquid or jaundice migh of renal or renal and urinary

have occur urinary tract tract disorders

disease. and assessment

of body function.

- To help

Appearance Clear Clear to slightly normal discover 2. Notify the

hazy diseases patient that the

that is not in procedure

relation with requires a urine

Reaction 6.5 4.6-8 renal sample. Urine

To demonstrate disorders. must be acquired

Specific Gravity 1.010 1.005-1.025 the most likely on the

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concentrating first void in the

and diluting - To identify morning.

In normal ability of the drugs or

condition there kidneys. substances 3. Notify the

is no protein that has laboratory and

that can be been taken. physician of any

detect drugs that the

patient has taken

CHEMICAL that may affect

EXAMINATION the results.

Albumin NegativeNormal

Sugar Negative Presence of

sugar in urine

may indicate

diabetes,

chronic kidney

disease

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MICROSCOPIC

EXAMINATION

Epithelial Cells Pus cells and May be a sign of

Squamous 0.2 hpf bacteria should swelling in the

Renal be absent in kidney and

Pus Cells urine pelvic region,

urethral

ulceration and

chronic specific

inflammatory of

the bladder

RBC Blood in the

urine may

sometimes a

serious urinary

tract problem

Mucous Threads

Bacteria #

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Yeast Cells

Oil Globules

Spermatozoa

B. BLOOD TYPING

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Nursing

Date Test Result Normal Results Implications Rationale Responsibilities10-17-09 Blood Type A (+) In forward typing, if None known - To check 1. Inform the

(ABO+Rh) there’s agglutination compatibility patient that the

patient’s RBC’s are of the donor test determines

mixed with anti-A and and the her blood group.

anti-B serum, the A patient before

and B antigen is transfusion. 2. Notify the

present, thus blood patient that the

type is O test blood

sample thus

venipuncture is

done.

3. Check the

patient’s history

for recent

administration of

blood, dextran or

I.V.

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4. After the

procedure apply

direct pressure

to the

venipuncture to

the site until

bleeding stops.

C. COMPLETE BLOOD COUNT

Normal Nursing

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Date Test Result Values Implications Rationale Responsibilities10-17-09 WBC H 15.19 5-10 Leukemia, - To verify 1. Explain to the

x10^3/uLx10^3/uL bacterial infection or patient the necessity

infection, severe inflammation in of undergoing the

sepsis the body and test that it helps

observe its detect occurrence of

responses to anemia and

specific polycythemia.

therapies.

2. Notify the patient

that the test requires

Hemoglobin 122g/L 115-155 Normal - To recognize blood sample as well

g/L Low HCT, the amount of as the person who

suggest anemia, will perform the O2 carrying

hemodilution or protein venipuncture and the

enormous blood contained within time.

loss. the RBC

3. Inform the patient

that the procedure is

Hematocrit L 0.35 0.36-0.48 Rule out anemia - To identify the of slight discomfort

due to percentage of and may feel a little

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nutritional the blood pain.

deficiencies, volume

blood loss. occupied by red 4. After the

blood cells. procedure, apply

direct pressure to the

venipuncture until

RBC L 4.02 4.20-6.10 Low RBC is due - To know the bleeding stops.

x10^6/uLx10^6/ uL to enormous amount of RBC

blood loss which in the blood. 5. Refer if

results to venipuncture

anemia. develops hematoma

Leukemia, and monitor the

hemorrhage. pulses distal to the

site.

Differential

Count

Neutrophil 73% 55-75% Normal - To point out

the presence of

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bacterial infection and

amount of

Leukocyte

Lymphocytes L 18% 20-35% Leukemia, -To recognize if

systemic lupus there is an

erythematosus unusual amount

of lymphocyte

that may

indicate viral

infection such

as HIV.

Monocytes 7% 2-10% Normal -Increase of

these may

respond to

corticosteroid,

with pus

conditions,

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hemorrhage

Eosinophil 2% 1-6% Normal -High

percentage of

eosinophil, may

indicate

bacterial

infestation or

allergies

Basophil 0% 0-1% Normal -Increase of

basophil may

indicate

parasite,

hypersensitiven

ess and

heartworm

causing

endocrine

disease, chronic

liver disease

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MCV 88.1fl 79.40- Normal -To determine

94.80 fl the ratio of

hematocrit to

RBC count

-To identify the

MCH 30.3 25.60- Normal average mass

pg 32.20 pg of hemoglobin

per RBC

MCHC 34.5 g/dL 32.20- Normal -Indicates the

35.30 g/dL nature and

volume of

hemoglobin, to

high may

indicate

spherocytosis or

in vitro

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hemolysis

D. ULTRASOUND

Nursing Date Test Result Impression Rationale Responsibilities

10-17--09 U -Presentation : Cephalic Single, live - To know fetal 1. Assure a

2:35 pmL -Number: single intrauterine and consent form

T - Amniotic fluid: AFI 11.1 cmpregnancy, pregnancy signed by the

R -Placental location: anteriorcephalic abnormalities patient. Explain

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A -Placental grade: III presentation, with and that the procedure

S -Sex: male good cardiac and measurement is painless and

O -AOG: 32W 3D somatic activities; of organ size safe and that no

U -EDD: 10-11-08 BPD= 32 weeks and structure. radiation

N -FHB: 147bpm and 5 days; FL= To identify and exposure is

D Estimated Fetal Weight: 2233 g31 weeks and 1 differentiate involved.

-normohydramnios (11.1 cm)day cyst and solid

-amniotic fluid volume: normalPlacenta anterior, tumor. 2. Emphasize the

-previa: placenta previa totalisearly grade III, importance of

totally covering - To ensure remaining still

Biophysical profile: the OS (Placenta the during the scan to

-amniotic fluid: 2 previa totalis) presentation prevent distorted

-fetal tone: 2 and identify image.

-fetal breathing: 2 complications

-gross movement: 2 of the fetus. 3. Assist the

Total =8 To detect if patient into a

there is risk of supine position; if

pregnancy. possible use

pillows to support

the area to be

examined. Coat

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the target area

with a water-

soluble jelly. If

necessary to

assist the patient

into lateral

positions for

consequent view.

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THE FEMALE REPRODUCTIVE SYSTEM

GENERAL

The organs of the reproductive systems are concerned with the general

process of reproduction, and each is adapted for specialized tasks. These

organs are unique in that their functions are not necessary for the survival

of each individual. Instead, their functions are vital to the continuation of

the human species. In providing maternity gynecologic health care to

women, you will find that it is vital to your career as a practical nurse and to

the patient that you will require a greater depth and breadth of knowledge

of the female anatomy and physiology than usual. The female reproductive

system consists of internal organs and external organs. The internal organs

are located in the pelvic cavity and are

supported by the pelvic floor. The

external organs are located from the

lower margin of the pubis to the

perineum. The appearance of the

external genitals varies greatly from

woman to woman, since age, heredity,

race, and the number of children a

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woman has borne determines the size, shape, and color. See figure 1-1 for

the female reproductive organs.

TERMS AND DEFINITIONS

These are only a few terms and definitions that will be used in this

lesson. Other terms and definitions will be dispersed throughout the

lesson.

A. Broad Ligaments. Two wing-like structures that extend from the

lateral margins of the uterus to the pelvic walls and divide the pelvic

cavity into an anterior and a posterior compartment.

B. Corpus Luteum. The yellow mass found in the graafian follicle after

the ovum has been expelled.

C. Estrogen. The generic term for the female sex hormones. It is a

steroid hormone produced primarily by the ovaries but also by the

adrenal cortex.

D. Fimbriae. Fringes; especially the finger-like ends of the fallopian

tube.

E. Follicle. A pouch like depression or cavity.

F. Follicle Stimulating Hormone. The follicle stimulating hormone

(FSH) is a hormone produced by the anterior pituitary during the first

half of the menstrual cycle. It stimulates development of the graafian

follicle.

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G. Graafian Follicle. A mature, fully developed ovarian cyst containing

the ripe ovum.

H. Hormone. A chemical substance produced in an organ, which,

being carried to an associated organ by the bloodstream excites in the

latter organ, a functional activity.

I. Lactation. The production of milk by the mammary glands.

J. Luteinizing Hormone. A hormone produced by the anterior pituitary

that stimulates ovulation and the development of the corpus luteum.

K. Oocyte. A developing egg in one of two stages.

L. Ovum. The female reproductive cell.

M. Progesterone. The pure hormone contained in the corpora lutea

whose function is to prepare the endometrium for the reception and

development of the fertilized ovum.

N. Reproduction. The process by which an off- spring is formed.

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Anterior view of the uterus and related structures

Wall of the uterus

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INTERNAL FEMALE ORGANS

The internal organs of the female consist of the uterus, vagina,

fallopian tubes, and the ovaries.

A. Uterus. The uterus is a hollow organ about the size and shape of a

pear. It serves two important functions: it is the organ of

menstruation and during pregnancy it receives the fertilized ovum,

retains and nourishes it until it expels the fetus during labor.

(1) Location. The uterus is located between the urinary bladder and

the rectum. It is suspended in the pelvis by broad ligaments.

(2) Divisions of the uterus. The uterus consists of the body or corpus,

fundus, cervix, and the isthmus. The major portion of the uterus is

called the body or corpus. The fundus is the superior, rounded region

above the entrance of the fallopian tubes. The cervix is the narrow,

inferior outlet that protrudes into the vagina. The isthmus is the

slightly constricted portion that joins the corpus to the cervix.

(3) Walls of the uterus (see figure 1-3). The walls are thick and are

composed of three layers: the endometrium, the myometrium, and the

perimetrium. The endometrium is the inner layer or mucosa. A

fertilized egg burrows into the endometrium (implantation) and

resides there for the rest of its development. When the female is not

pregnant, the endometrial lining sloughs off about every 28 days in

response to changes in levels of hormones in the blood. This process

is called menses. The myometrium is the smooth muscle component of

the wall. These smooth muscle fibers are arranged. In longitudinal,

circular, and spiral patterns, and are interlaced with connective 62

tissues. During the monthly female cycles and during pregnancy,

these layers undergo extensive changes. The perimetrium is a strong,

serous membrane that coats the entire uterine corpus except the

lower one fourth and anterior surface where the bladder is attached.

B. Vagina.

(1) Location. The vagina is the thin in walled muscular tube about 6

inches long leading from the uterus to the external genitalia. It is

located between the bladder and the rectum.

(2) Function. The vagina provides the passageway for childbirth and

menstrual flow; it receives the penis and semen during sexual

intercourse.

C. Fallopian Tubes (Two).

(1) Location. Each tube is about 4 inches long and extends medially

from each ovary to empty into the superior region of the uterus.

(2) Function. The fallopian tubes transport ovum from the ovaries to

the uterus. There is no contact of fallopian tubes with the ovaries.

(3) Description. The distal end of each fallopian tube is expanded and

has finger-like projections called fimbriae, which partially surround

each ovary. When an oocyte is expelled from the ovary, fimbriae

create fluid currents that act to carry the oocyte into the fallopian

tube. Oocyte is carried toward the uterus by combination of tube

peristalsis and cilia, which propel the oocyte forward. The most

desirable place for fertilization is the fallopian tube.

D. Ovaries (2) (see figure 1-4).

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(1) Functions. The ovaries are for oogenesis-the production of eggs

(female sex cells) and for hormone production (estrogen and

progesterone).

(2) Location and gross anatomy. The ovaries are

about the size and shape of almonds. They lie against the lateral walls

of the pelvis, one on each side. They are enclosed and held in place by

the broad ligament. There are compact like tissues on the ovaries,

which are called ovarian follicles. The follicles are tiny sac-like

structures that consist of an immature egg surrounded by one or more

layers of follicle cells. As the developing egg begins to ripen or

mature, follicle enlarges and develops a fluid filled central region.

When the egg is matured, it is called a graafian follicle, and is ready

to be ejected from the ovary.

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(3) Process of egg production--oogenesis (see figure 1-5).

(a) The total supply of eggs that a female can release has been

determined by the time she is born. The eggs are referred to as

"oogonia" in the developing fetus. At the time the female is born,

oogonia have divided into primary oocytes, which contain 46

chromosomes and are surrounded by a layer of follicle cells.

(b) Primary oocytes remain in the state of suspended animation

through childhood until the female reaches puberty (ages 10 to 14

years). At puberty, the anterior pituitary gland secretes follicle-

stimulating hormone (FSH), which stimulates a small number of

primary follicles to mature each month.

(c) As a primary oocyte begins dividing, two different cells are

produced, each containing 23 unpaired chromosomes. One of the cells

is called a secondary oocyte and the other is called the first polar 65

body. The secondary oocyte is the larger cell and is capable of being

fertilized. The first polar body is very small, is nonfunctional, and

incapable of being fertilized.

(d) By the time follicles have matured to the graafian follicle stage,

they contain secondary oocytes and can be seen bulging from the

surface of the ovary. Follicle development to this stage takes about 14

days. Ovulation (ejection of the mature egg from the ovary) occurs at

this 14-day point in response to the luteinizing hormone (LH), which is

released by the anterior pituitary gland.

(e) The follicle at the proper stage of maturity when the LH is

secreted will rupture and release its oocyte into the peritoneal cavity.

The motion of the fimbriae draws the oocyte into the fallopian tube.

The luteinizing hormone also causes the ruptured follicle to change

into a granular structure called corpus luteum, which secretes

estrogen and progesterone.

(f) If the secondary oocyte is penetrated by a sperm, a secondary

division occurs that produces another polar body and an ovum, which

combines its 23 chromosomes with those of the sperm to form the

fertilized egg, which contains 46 chromosomes.

(4) Process of hormone production by the ovaries.

(a) Estrogen is produced by the follicle cells, which are responsible

secondary sex characteristics and for the maintenance of these traits.

These secondary sex characteristics include the enlargement of

fallopian tubes, uterus, vagina, and external genitals; breast

development; increased deposits of fat in hips and breasts; widening

of the pelvis; and onset of menses or menstrual cycle.

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(b) Progesterone is produced by the corpus luteum in presence of in

the blood. It works with estrogen to produce a normal menstrual

cycle. Progesterone is important during pregnancy and in preparing

the breasts for milk production.

EXTERNAL FEMALE GENITALIA

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The external organs of the female reproductive system include the

mons pubis, labia majora, labia minora, vestibule, perineum, and the

Bartholin's glands. As a group, these structures that surround the

openings of the urethra and vagina compose the vulva, from the Latin

word meaning covering. See Figure 1-6.

a. Mons Pubis. This is the fatty rounded area overlying the symphysis

pubis and covered with thick coarse hair.

b. Labia Majora. The labia majora run posteriorly from the mons

pubis. They are the 2 elongated hair covered skin folds. They enclose

and protect other external reproductive organs.

c. Labia Minora. The labia minora are 2 smaller folds enclosed by the

labia majora. They protect the opening of the vagina and urethra.

d. Vestibule. The vestibule consists of the clitoris, urethral meatus,

and the vaginal introitus.

(1) The clitoris is a short erectile organ at the top of the vaginal

vestibule whose function is sexual excitation.68

(2) The urethral meatus is the mouth or opening of the urethra. The

urethra is a small tubular structure that drains urine from the

bladder.

(3) T e. Perineum. This is the skin covered muscular area between the

vaginal opening (introitus) and the anus. It aids in constricting the

urinary, vaginal, and anal opening. It also helps support the pelvic

contents.

f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The

Bartholin's glands lie on either side of the vaginal opening. They

produce a mucoid substance, which provides lubrication for

intercourse.

BLOOD SUPPLY

The blood supply is derived from the uterine and ovarian arteries that

extend from the internal iliac arteries and the aorta. The increased

demands of pregnancy necessitate a rich supply of blood to the

uterus. New, larger blood vessels develop to accommodate the need

of the growing uterus. The venous circulation is accomplished via the

internal iliac and common iliac vein.

FACTS ABOUT THE MENSTRUAL CYCLE

Menstruation is the periodic discharge of blood, mucus, and epithelial

cells from the uterus. It usually occurs at monthly intervals

throughout the reproductive period, except during pregnancy and

lactation, when it is usually suppressed.

The menstrual cycle is controlled by the cyclic activity of

follicle stimulating hormone (FSH) and LH from the

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anterior pituitary and progesterone and estrogen from the

ovaries. In other words, FSH acts upon the ovary to

stimulate the maturation of a follicle, and during this

development, the follicular cells secrete increasing

amounts of estrogen (see figure 1-7).

Hormonal interaction of the female cycle is as follows:

(1) Days 1-5. This is known as the menses phase. A lack of signal from

a fertilized egg influences the drop in estrogen and progesterone

production. A drop in progesterone results in the sloughing off of the

thick endometrial lining which is the menstrual flow. This occurs for 3

to 5 days.

(2) Days 6-14. This is known as the proliferative phase. A drop in

progesterone and estrogen stimulates the release of FSH from the

anterior pituitary. FSH stimulates the maturation of an ovum with

graafian follicle. Near the end of this phase, the release of LH

increases causing a sudden burst like release of the ovum, which is

known as ovulation.

(3) Days 15-28. This is known as the secretory phase. High levels of

LH cause the empty graafian follicle to develop into the corpus

luteum. The corpus luteum releases progesterone, which increases

the endometrial blood supply. Endometrial arrival of the fertilized

egg. If the egg is fertilized, the embryo produces human chorionic

gonadotropin (HCG). Thehuman chorionic gonadotropin signals the

corpus luteum to continue to supply progesterone to maintain the

uterine lining. Continuous levels of progesterone prevent the release

of FSH and ovulation ceases.

Additional Information.

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(1) The length of the menstrual cycle is highly variable. It may be as

short as 21 days or as long as 39 days.

(2) Only one interval is fairly constant in all females, the time from

ovulation to the beginning of menses, which is almost always 14-15

days.

(3) The menstrual cycle usually ends when or before a woman reaches

her fifties. This is known as menopause.

Ovulation

Ovulation is the release of an egg cell from a mature ovarian follicle

(see figure 1-5 for ovulation). Ovulation is stimulated by hormones

from the anterior pituitary gland, which apparently causes the mature

follicle to swell rapidly and eventually rupture. When this happens,

the follicular fluid, accompanied by the egg cell, oozes outward from

the surface of the ovary and enters the peritoneal cavity. After it is

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expelled from the ovary, the egg cell and one or two layers of

follicular cells surrounding it are usually propelled to the opening of a

nearby uterine tube. If the cell is not fertilized by union of a sperm

cell within a relatively short time, it will degenerate.

MENOPAUSE

As mentioned in paragraph 1-6c (3), menopause is the cessation of

menstruation. This usually occurs in women between the ages of 45

and 50. Some women may reach menopause before the age of 45 and

some after the age of 50. In common use, menopause generally means

cessation of regular menstruation. Ovulation may occur sporadically

or may cease abruptly. Periods may end suddenly, may become scanty

or irregular, or may be intermittently heavy before ceasing altogether.

Markedly diminished ovarian activity, that is, significantly decreased

estrogen production and cessation of ovulation, causes menopause.

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DESCRIPTION OF THE DISEASE

Placenta previa is an obstetric complication in which the placenta is lying

unusually low in the uterus, next to or covering the cervix. The

placenta is the pancake- shaped organ — normally located near the

top of the uterus — that supplies the baby with nutrients through the

umbilical cord.

Placenta previa is a placental attachment that is too low in the uterus and

covers the cervix. Normally the placenta is attached to the uterus above the

cervix. The placenta completely covers the internal os in slightly more than

10 percent of placenta previa cases. Under these circumstances the

placenta precedes the fetus in vaginal delivery. This can be life-threatening

to the unborn child and mother if untreated. It occurs to some degree in 1

of 200 pregnancies.

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Placenta previa is not usually a problem early in pregnancy. But if it

persists into later pregnancy, it can cause bleeding, which may require

the pregnant woman to deliver early and can lead to other

complications. If a woman has placenta previa when it's time to deliver

her baby, she’ll need to have a c-section.

If the placenta covers the cervix completely, it's called a complete or total

previa. If it's right on the border of the cervix, it's called a marginal

previa. (You may also hear the term "partial previa," which refers to a

placenta that covers part of the cervical opening once the cervix starts to

dilate.) If the edge of the placenta is within 2 centimeters of the cervix but

not bordering it, it's called a low-lying placenta. The location of the

placenta will be checked during the midpregnancy ultrasound exam.

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It depends on how far along the client is in pregnancy. Don't panic if her

second trimester ultrasound shows that she has placenta previa. As her

pregnancy progresses, the placenta is likely to "migrate" farther from the

cervix and no longer be a problem. (Since the placenta is implanted in the

uterus, it doesn't actually move, but it can end up farther from the cervix as

theuterus expands. Also, as the placenta itself grows, it's likely to grow

toward the richer blood supply in the upper part of the uterus.)

Only about 10 percent of women who have placenta previa noted on

ultrasound at midpregnancy still have it when they deliver their baby. A

placenta that completely covers the cervix is more likely to stay that way

than one that's bordering it (marginal) or nearby(low-lying).

Even if previa is discovered later in pregnancy, the placenta may still move

away from the cervix (although the later it's found, the less likely this is to

happen). You'll have a follow-up ultrasound early in your third trimester to

check on the location of your placenta. If the client has any vaginal bleeding

in the meantime, an ultrasound will be done then to find out what's going

on.

If the follow- up ultrasound reveals that the placenta is still covering or

too close to the cervix, the client will be monitored carefully, has regular

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ultrasounds, and need to watch for vaginal bleeding. She'll be put on

"pelvic rest," which means no intercourse or vaginal exams for the rest

of her pregnancy. And she'll be advised to take it easy and avoid activities

that might provoke bleeding, such as strenuous housework or heavy

lifting.

Bleeding from a placenta previa happens when the cervix begins to thin

out or dilate (even a little) and disrupts the blood vessels in that area. It's

usually painless, can start without warning, and can range from spotting

to extremely heavy bleeding. If her bleeding is severe, she may have

to deliver her baby right away, even if he's still premature. The

pregnant woman may also need a blood transfusion.

It's unusual for bleeding to start before late in the second trimester, and

about half the time it doesn't begin until you're nearly full-term (37 weeks).

The bleeding will often stop on its own, but it's likely to start again at some

point. (If she has bleeding and she’s Rh negative, she'll need a shot of Rh

immune globulin, unless the baby's father is Rh negative,too.)

If the client start bleeding or has contractions, she'll need to be

hospitalized. What happens then will depend on how far along you are in

her pregnancy, how heavy the bleeding is, and how you and your baby

are doing. If she is near full-term, the baby will be delivered by c-section

right away. If the baby is still premature, he'll be delivered by c-section

immediately if his condition warrants it or if the client have heavy bleeding

that doesn't stop.

Otherwise, she'll be watched in the hospital until the bleeding stops. If

she’s less than 34 weeks, the client may be given corticosteriods to

speed up her baby's lung development and to prevent other

complications in case he ends up being delivered prematurely.

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If the bleeding stops, and both the mother and her baby are in good

condition, she'll probably be sent home. But she'll need to return to the

hospital immediately if the bleeding starts again. If she and her baby

continue to do well and she doesn't need to deliver early, she'll have a

scheduled c-section at 37 weeks.

No matter when she delivers, if she still has placenta previa, she'll need

a c-section. With a complete previa, the placenta blocks the baby's way

out. And even if it's only bordering the cervix, she'll still need a c-section

in most cases because the placenta could bleed profusely if the cervix

dilated.

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PATHOPHYSIOLOGY

No specific cause of placenta previa has yet been found but it is

hypothesized to be related to abnormal vascularisation of the endometrium

caused by scarring or atrophy from previous trauma, surgery, or infection.

In the last trimester of pregnancy the isthmus of the uterus unfolds and

forms the lower segment. In a normal pregnancy the placenta does not

overlie it, so there is no bleeding. If the placenta does overlie the lower

segment, it may shear off and a small section may bleed.

Women with placenta previa often present with painless, bright red vaginal

bleeding. This bleeding often starts mildly and may increase as the area of

placental separation increases. Praevia should be suspected if there is

bleeding after 24 weeks of gestation. Abdominal examination usually finds

the uterus non-tender and relaxed. Leopold's Maneuvers may find the fetus

in an oblique or breech position or lying transverse as a result of the

abnormal position of the placenta. Praevia can be confirmed with an

ultrasound. In parts of the world where ultrasound is unavailable, it is not

uncommon to confirm the diagnosis with an examination in the surgical

theatre.

The proper timing of an examination in theatre is important. If the woman is

not bleeding severely she can be managed non-operatively until the 36th

week. By this time the baby's chance of survival is as good as at full term.

Placenta previa is classified according to the placement of the placenta:

Type I or low lying: The placenta encroaches the lower segment of

the uterus but does not infringe on the cervical os.

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Type II or marginal: The placenta touches, but does not cover, the

top of the cervix.

Type III or partial: The placenta partially covers the top of the cervix

Type IV or complete: The placenta completely covers the top of the

cervix

Placenta previa is itself a risk factor of placenta accreta.

Placenta Previa

Painless Vaginal Bleeding

Ultrasound

Risk Factors

Late Maternal Age Infection (UTI)

Multiparity

Complete Previa

Marginal Previa

Partial Previa Bleeding stops Low-

lying place

Fetus stable

Bed Rest

Observe

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Urine Output Pale, cool

skin

Hypotension Bleeding continues Capillary

refill

Maternal Hemorrhage Bleeding Restarts

tachycardia

Pu

lse

Complications:

Congenital Anomalies

Maternal Mortality

Intrauterine Growth

Cesarian Birth

Vaginal or

Ce

sarian Birth

S O A P I E

October 17, 2009 7 – 3

S> ”Masakit ang puwerta ko” as verbalized by the patient

O> Guarding behavior

> Facial grimace

> Generalized body weakness

> Pain Scale 4/5

> (+) DOB

A> Acute Pain r/t Inflammatory Response

P> After 4O of nursing intervention, the patient will report pain is relieved/controlled

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I> Established rapport

> Monitored v/s taken and recorded

> Morning Care Rendered

> Instructed patient to exercise deep breathing every time the pain occur

> Encouraged the patient verbalization of feelings about pain

> Instructed the patient to have proper hygiene

> Position the patient in Semi fowler’s position

> Provided safety and comfort

E> Goal met as evidenced by the pt. report pain is relieved/controlled

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b. PLANNING (Nursing Care Plan)

CuesNursing

DiagnosisScientific

explanationObjectives Interventions Rationales

Expected outcomes

S>”Masakit ang puwerta ko” as verbalized by the patient

O> The pt. may manifested the ffg:

>Pain, 4/5 >Guarding behavior >Facial grimace >Generalized Body Weakness > (+) DOB > Perspiration >

>Acute pain r/t Inflammatory Response

Acute pain is described as an unpleasant sensory or emotional experienceassociated with actual orpotential tissue damageor injury as lasting fromsecond to 6 months. Incases of fracture, painis continuous & increasing in severity until bone fragmentsare immobilized. Inthis type of fracture, themain medical management is open reduction with internalfixation (ORIF), whereinthe fracture fragments are reduced & internalfixation devices areused to hold the bone

Short term:After 4 hrs. of NI, patient will verbalized the pain is controlled or disappear

Long term:After 2 days of NI, pt. will maintain the absence of pain

>Establish rapport

>Monitor v/s

>Encourage pt. deep breathing exercise when pain occur

>Promote safety and comfort

>Avoid environmental stimulant

>To gain pt. trust

>To have baseline data

>To decrease the pain

>To

>To avoid the pain to occur

Short term:Goal met as evidenced by the pt. verbalized the pain is controlled or disappear

Long term:Goal met as evidenced by the pt. maintain the absence of pain

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fragment in position untilsolid bone healing occurs.

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CuesNursing

diagnosisScientific

explanationPlanning Intervention Rationale Evaluation

S>“Pakiramdam ko mainit buong katawan ko” as verbalize by the patient

O> The pt. manifested the ffg:

>skin warm to touch

>dry lips

>fatigue

>redness

>Hyperthermia related to inflammatory process.

Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability and death.

Short term:

After 4 hours of NI, patient will decrease temperature from 38.9 c to 37.5 c

Long term:

After 2 days of NI, patient will maintain absence of hyperthermia

> Establish rapport

>Monitor vital sign

>provide TSB

>promote comfort and safety

>Promote ventilation of the skin by means of undressing

> To gain the trust of the patient

> to have baseline data

>to decrease heat

> make safety and relax the patient

> treatment for mild to moderate hyperthermia

Short term:

Goal met AEB the patient temperature decrease from 38.9 c to 37.5 c

Long term:

Goal met AEB the patient maintain the absence of hyperthermia

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Cues Nursing diagnosis

Scientific Explanation

Planning Intervention Rationale Evaluation

S> “Nahihirapan akong gumalaw kasi masakit yung bahay bata ko” as verbalize by the patient

O> (+) pain, 4/5

>facial grimace >guardianing behavior

>limited movement

>impaired physical mobility related to pain

The movement of body structures is accomplished by the contraction of muscles. Muscles may move parts of the skeleton relatively to each other, or may move parts of internal organs relatively to each other. All such movements are classified by the directions in which the affected structures are moved. In human anatomy, all descriptions of position and movement are based on the assumption that the body is its complete

Short term:

After 3 hours of NI, patient will verbalize understanding for individual situation

Long term:

After 2 days NI, patient will maintain the absence of pain

>establish rapport

>monitor vital sign

>promote comfort and safety

>assess patient complain

> explain to patient the condition

>encourage patient to exercise deep breathing every time pain occur

> Avoid Environmental stimulant

>to gain patient trust

> to have baseline data

> to promote safety and relax

> to assess and treat patient problem

> to understand the patient her/his condition

> to decrease the pain

> to decrease pain

Short term:

Goal met AEB the patient verbalize understanding for individual situation

Long term:

Goal met AEB the patient maintain the absence of pain

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c. Drugs

Name of Drugs Date ordered Route of admin General action Indication

Client’s response to

the Medication with actual Side Effect

Generic name:Cefuroxime

Brand name:Ceftin

Date taken/given:10/17/09

Date changed:

Dosage: Adults: >250 mg bid for severe infections, maybe increased to 500 mg bidFrequency of admin:

>Inhibits synthesis of bacteria cell wall, causing cell death.

>Lower respiratory infections caused by S. Pneumoniae, H. Para influenza, H. Influenza

Patient response effectively with no side effect noted.

Generic name:Acetaminophen

Brand name:Paracetamol

Date taken/given:10/17/09

Date changed:

Dosage:Adults>by supporting 365-600 mg q 4-6 hr. or P.O, 1000 mg tid to qid. Do not exceed 4 q/day

>Reduces fever by acting directly on the hypothalamic heat regulating center to occur vasodilator and sweating which helps dissipate heat.

>Analgesic anti pyretics in patients with aspirin allergy, hemostatic disturbances bleeding diatheses, quoty artitis

Patient response effectively with no side effect noted.

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Generic name:Follic acid

Brand name:Folvite

Date taken/given:10/17/09

Date changed:

Dosage:Adults:>up to 1 mg P.O, I.M or S.C daily throughout pregnancy

>Stimulate normal erythropoiesis and nucleoprotein synthesis

>To prevent megaloblastic anemia during pregnancy to prevent fetal damage

Patient response effectively with no side effect noted.

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Type of DietDate Ordered:Date Started:

General Description

Indication / Purpose

Client’s Response /

reaction to the diet

DAT DO: 10-17-09

DS: 10-17-09

There is a dietary sodium restriction on patient

To facilitate reduction of sodium in the body, thus reducing edema and ascites.

It also aide in the reduction of conjunction of vascular fluids since sodium attracts water.

The patient refuses to eat.

Nursing Responsibilities:

Explain the purpose. Assess for patient condition, how he respond diet. Provide variety of choices of foods low sodium. Be sure patient is taking / eating foods he can tolerate. Explain importance of compliance.

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HEALTH TEACHINGS

* Encourage patient to express feelings and concerns

® So that relief measure may be instituted

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* 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

· temperature exceeding 38C

· painful urination

· lochia heavier than normal period

· wound separation

· redness or oozing at the incision site

· severe abdominal pain

· 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

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· 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

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

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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.

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JOSE C. FELICIANO COLLEGE

INSTITUTE OF NURSING, MIDWIFE AND NURSING AIDE

DAU EXIT, DAU EXPRESSWAY DAU MABALACAT

PAMPANGA

PLACENTA PREVIA(A CASE STUDY IN OBSTETRIC WARD)

BSN II – A (GROUP 2)

SUBMITTED BY:

AGUIRRE, ROXANNE

BACANTE, CIELITO JOHN

BISCO, MICHELAN

CANIEL, JOSEPH

CORTEZ, KAREN

ESPIRITU, PRECIOUS ANN

GUTIERREZ, NICKKY MARK

LIWANAG, JEEANNE

NAVARRO, JOEL

SANTOS, MATTHEW FAITH

93

SANTIAGO, KAREN KRISTA

TEODORO, JOHNNA CLAIRE

SUBMITTED TO:

MS. GENICIA R. MORALESRN MSN

CLINICAL INSTRUCTOR (OB WARD)

94