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.
1
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
2
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
3
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
5
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
6
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.
7
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
8
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
9
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
10
11
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
44
12
13
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
45
14
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 #
46
15
Yeast Cells
Oil Globules
Spermatozoa
B. BLOOD TYPING
47
16
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.
48
17
4. After the
procedure apply
direct pressure
to the
venipuncture to
the site until
bleeding stops.
C. COMPLETE BLOOD COUNT
Normal Nursing
49
18
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
50
19
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
51
20
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,
52
21
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
53
22
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
54
23
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
55
24
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
56
25
the target area
with a water-
soluble jelly. If
necessary to
assist the patient
into lateral
positions for
consequent view.
57
27
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
58
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.
59
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.
60
Anterior view of the uterus and related structures
Wall of the uterus
61
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).
63
(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.
64
(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.
66
(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
67
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
69
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
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SANTIAGO, KAREN KRISTA
TEODORO, JOHNNA CLAIRE
SUBMITTED TO:
MS. GENICIA R. MORALESRN MSN
CLINICAL INSTRUCTOR (OB WARD)
94