BSN2A GROUP 3

Placenta is implanted abnormally in the

uterus. Most common cause of painless bleeding in the third trimester of pregnancy.

 Low lying - implantation in the lower

rather than in the upper portion of the uterus. Marginal - the placenta edge approaches that of the cervical os. Partial - implantation that occludes a portion of the cervical os. Total placenta previa - totally obstructs the cervical os.

Bleeding is abrupt, painless , bright red and

sudden. Immediate care measures: Place the woman immediately on bed rest in a side lying position

 Increased parity Advanced maternal age Past CS

Past uterine curettage

Multiple gestation Male fetus

 Duration of pregnancy Time the bleeding began Estimate amt of blood loss Accompanying pain Color of the blood What has she done Prior episodes of bleeding Prior cervical surgery

 Never attempt a pelvic or rectal

examination with painless bleeding late in pregnancy Obtain baseline VS IVF therapy I and O monitoring External monitoring equipment Complete blood count Blood typing and crossmatching

 Avoid intercourse

Limit traveling
Avoid pelvic exams

 Nora N. Nacua, 38yold; multi-gravida; Filipio

Add. Rosario,Cavite; from Misamis Oriental;

Catholic; high school graduate; Non-smoker; nonalcoholic; no allergies reported.

Patient was diagnosed with placenta previa.

Admitted Januray 6, 2012 at Dr. Jose Fabella Memorial Hospital DR due to labor pain with ruptured of amniotic sac and profuse vaginal bleeding.

 Cesarean section

Baby boy 31 weeks of gestation 1305 g

APGAR score of 3 (one minute after birth) Score of 5 (five minutes after birth)

Score of 7 (ten minutes after birth)

Footling breech Placenta previa

V/S at admission: Temp- 38.2c PR-78 bpm RR-20 cpm BP- 80/60 mmHg

Vaginal bleeding

Active and cooperative. Natural hair color, dry hair, fair complexion

skin, smooth that have lesions could be moles, freckles, birthmarks, pink tone nails and brown body color. Always walk as her exercise Taken all immunization needed.

Stated help myself to a fast recovery, not

being dependent and ambulate frequently Breast self-examination every bath time. No history of chronic disease. No any cardio respiratory distress

Insomnia

No operation before this time

hospitalization Immunization: BCG given at birth,Tetanus, Pneumonia, Polio, Hepa B vaccine.

Weight gain in the last 6 mos. for about 2 lbs.

Good appetite.
No experience of any problems in nausea,

vomiting, swallowing and digestion.

Urinates 5x a day with the Smokey color of

urine. Never experience any problem related to urination Do not use any assistive device when urinating. Common bowel elimination is 2x a day with the color of brown stool.

Loves to read pocketbook.

House works ,preparing meal, taking care of

children. Performs the daily activities alone. Selling fish daliy

Sleeps at least 6 hours a day

Insomnia during young age

Sleep well recent years

Read and write.

Languages are tagalog, bisaya and limited

English Moderately easy decide in comes to family

Major concern at the current time is to go

home and take rest in own house Lose weight as result to her body changes when she is in the hospital. Positive mother.

 Mother of a 3 children.

Living with children and husband but not yet

married. She stated yes, in my daily living when I ask her if theres any significant changes in patients usual family role when she admit to the hospital. Active social activities and comfortable social situations Fish vendor.

Feel stressful when she experience 60/60 life.

Poor handling of stress she can still joining

bible study to give her lakas ng loob. Need care from others after discharge.

Menarche occurred in 14years Common menstruation last 3-4days Lightly abdominal pain during

menstruation. Last menstrual period is June 4, 2011. G3P3 mother Takes pills for contraception No history of sexually transmitted disease or STD.

Roman Catholic.

Family is the most important for her

As stated din na ako naghahanap ng iba,

tanggap ko kung mahirap lang ako Goes to church every Sunday.

Orientation Appropriate behavior/communication

Level of consciousness Emotional state

Oriented to time, person and place Cooperative

Conscious Calm

General color Texture Turgor Temperature Moisture

Brownish Smooth Supple Moist Dry

Head
Hair Scalp Black hair Clean

Lids Conjunctiva Reaction to light Reaction to Accommodation

Visual Acuity Peripheral vision

Symmetrical Pink Constriction Constriction& Convergence when focus on near object Normal Intact/full

Septum Mucosa Patency Sinuses

Midline Pinkish Both patent Non-tender

Ears
External pinnae Tympanic membrane Gross hearing Symmetrical Intact Increased

Lips Mucosa Tongue Teeth Gums

Dry Pinkish Pink &moist& midline Complete & yellowish Pink& moist

Neck
Trachea Thyroids Midline Midline

Uvula Tonsils Mucosa

Midline Symmetric Pinkish

Abdomen
Configuration Bowel sounds Percussion Symmetrical normal Resonance

Range of motion Muscle tone& strength Spine Gait

Decreased ROM Fair Midline Coordinated

Cardiovascular Status
Heart sounds Peripheral pulses Capillary refill Regular Regular Normal,2 seconds

Heart sounds Peripheral pulses Capillary refill

Regular Regular Normal,2 seconds

Respiratory status
Breathing pattern Lung expansion Vocal/ tactile fremitus Percussion Breath sounds Cough Regular Symmetrical Symmetrical Resonant Broncho-vesicular none

CBC x 3

Urinalysis
Ultrasound

Elevation of WBC (4.5-11)X10-9/L 22.3X10-9/L (Jan,6) 32.8X10-9/L (Jan,7) 19.7X10-9/L (Jan,9)

Infection (rupture of membrane ,CS)

Low RBC(4.1-5.1)X10-12/L 3.12X10-12/L (Jan,6) 3.79X10-12/L (Jan,7) 3.59X10-12/L (Jan,9) Low hemoglobin(120-170)g/L 97g/L (Jan,6) 114g/L (Jan,7) 107g/L (Jan,9) Loss of blood(bleeding) Nutritional deficiency (iron, vitamin B12, folate)

Date : Jan,6 Jan,7 Jan,11

Blood type: A Rh+ Type of blood received: red blood

cells

 Date : 01/08/2012

Color yellow

Abnormal finding: Blood in urine Red blood cell: 1.3 Pus cell:2-4 Infection or mix with vaginal discharge Protein in urine - indicate preeclampsia PIH

Date:01/06/2012

placenta: totally placenta previa

Fetus position: footling Baby:FHR:161bpm, sex: boy

Vaginal bleeding

Preterm rupture of membrane

Infection Fever temp.:38.2 Hypertension 150/80mmHg Anemia

 Placental implantation is initiated by the

embryo (embryonic plate) adhering in the lower (caudad) uterus. With placental attachment and growth, the developing placenta may cover the cervical os. However, it is thought that a defective decidual vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes. As such, sections of the placenta having undergone atrophic changes could persist as a vasa previa.

 A leading cause of third trimester hemorrhage,

placenta previa presents classically as painless bleeding. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor. When this occurs, bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Thrombin release from the bleeding sites promotes uterine contractions and a vicious cycle of bleeding-contractions-placental separationbleeding.

 Risk for deficient Fluid Volume

Fear related to perceived threat of

death to the fetus

Acute pain

 Deficient blood Volume related to Blood

loss during surgery

Acute pain related to post-op incision Risk for infection related to post-incisio

Assessment Masakit ang tahi ko sa may puson Pain scale of 9/ 10

Diagnosis Acute pain related to post-op incision

Planning After the 6 hour shift the client should be able to verbalize decrease in pain to a tolerable state. Pain scale of 3-4/ 10

Interventions Monitor VS

Rationale To obtain baseline data

Evaluation

Applied ice pack

Appears weak
Irritable

The patient verbalized that she can To reduce the tolerate more pain and to activities like prevent turning and hemorrhage sitting but by keeping with the fundus assisstance. contracted. Pain scale of 4 /10

Facial grimace when moving

Pallor

Provided health teaching as follows: Practice deep breathing exercise Turn side to side Ambulate early as recommended

To divert attention To be able to tolerate pain

Assessment

Diagnosis

Planning

Interventions By the doctor

Rationale

Evaluation

Administer Analgesia as ordered by the doctor

To decrease/ eradicate pain

Assessment O: NPO in the last 8 hours chapped lips dry mouth with surgical incision at the lower abdomen consumed 2 underpad for the last 24 hours Malaise Pallor

Diagnosis Deficient fluid volume related to

Planning After 4 days of continuous nursing interventions: Clients fluid volume is maintained at functional level The patient will be able to verbalize purpose of therapeutic interven-

Interventions Monitor Vital Signs Assess color, odor, consistency and amount of vaginal bleeding; weigh pads

Rationale To obtain baseline data Provides information about active bleeding versus old blood, tissue loss and degree of blood loss Provide information to know if the client is still at risk for shock To know if the client has

Evaluation The clients skin

Assess abdomen for tenderness

Assess clients skin color,

Assessment

Diagnosis Risk for Infection related to post-op incision

Planning At the end of the 6 hour shift the clients temperatu re should be within the normal range The patient will agree and show interest to the health teachings

Interventions Monitor VS

Rationale To obtain baseline data

Evaluation

The patient has incision in the lower part of the abdomen

The client showed interest to Health the health Teaching teaching and provided as verbalized follows: willingness Moist area to do the Proper cleaning will facilitate recommende of the incision the growth of d activities. site microorganis ms Keep the incision site clean and dry Compliance to the prescribed time of medication

To prevent infection and further complication

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation

DRUG NAME

ACTION

INDICATION CONTRAINDIC ATION

ADVERSE REACTION

NURSING RESPONSIBILIT IES

Hydralazin e BRAND NAME Apresoline DOSAGE 5mg PRN for BP > 150/100

Acts directly on vascular smooth muscle to cause vasodilatio n maintains or increases renal and cerebral blood flow.

ROUTE ORAL

should not use this medication if you are allergic to hydralazin e, or if you have coronary artery disease, or rheumatic heart disease affecting CLASSIFI the mitral CATION valve. Antihyper tensive

Hypersensiti vity to hydralazine; coronary artery disease; mitral valvular rheumatic heart disease

Headache anorexia nausea vomiting diarrhea palpitation s tachycardia

Patients should be informed of possible side effects and advised to take the medication regularly and continuously as directed.

DRUG NAME

ACTION

NURSING INDICATI CONTRAINDIC ADVERSE RESPONSIBILI ON ATION REACTION TIES

inhibits Gentamici protein n sulfate synthesis in susceptible strains of gramBRAND negative bacteria; NAME appears to disrupt Garamycin functional integrity of bacterial cell membrane, DOSAGE causing cell death. 240mg in 100ccPNSS , OD CLASSIFIC ATION ROUTE Aminoglyc oside IM

Parenter al use restricted to treatment of serious infections of GI, respirator y, and urinary tracts

Contraindicat ed with allergy to any aminoglycosid es renal or hepatic disease; preexisting hearing loss active infection with herpes, vaccinia, varicella, fungal infections, myobacterial infections (ophthalmic preparations) myasthenia gravis; parkinsonism; infant botulism; lactation.

Palpitatio nshypoten sionhypert ension Hepatic toxicity nausea vomiting anorexia, weight loss stomatitis increased salivation

Cleanse area before application of dermatologic preparations. Ensure adequate hydration of patient before and during therapy. Monitor renal function tests, complete blood counts, serum drug levels during longterm therapy. Consult with prescriber to adjust dosage.

DRUG NAME

ACTION

INDICATI CONTRAIN ON DICATION

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Nifedipine Nifedipin inhibits calcium e ion movement across cell membrane, depressing BRAND contraction of cardiac or NAME vascular smooth muscle. It also increases heart rate and cardiac output. Nifedipine DOSAGE decreases systemic 5mg 1cap vascular resistance and blood pressure ROUTE CLASSIFICATI ON Oral Antihypertensiv e

treatme nt of hyperten sion

Use cautiousl y with lactation, pregnant.

Nausea Drowsi ness Confusi on Slurred speech

Do not crush or break filmcoated tablets and sustainedrelease capsules. Check blood pressure for hypotension immediately prior to giving medication Assist with ambulation if client is lightheaded or dizziness occurs. Rise slowly from lying to sitting position, dangle legs from bed before standing to reduce hypotensive effect

DRUG NAME

ACTION

INDICATIO CONTRAINDI N CATION

ADVERSE REACTION

NURSING RESPONSIBILITIE S

inhibits Metronida DNA zole synthesis in specific (obligate) anaerobes, BRAND causing cell death; NAME antiprotozo altrichomona Flagyl cidal, amebicidal: biochemical mechanism of action is not known. DOSAGE CLASSIFIC 500mg A TION ROUTE Antibiotic, PO Antibacteria
l

Acute intestinal amebiasis

Amebic liver abscess Preoperati ve, intraopera tive, postopera tive prophylax is for patients undergoin g colorectal surgery

Contraindi cated with hypersensit ivity to metronidaz ole; pregnancy

Headache, dizziness, ataxia, vertigo, incoordina tion, insomnia, seizures, peripheral neuropathy, fatigue Unpleasan t metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, Cramps

Avoid use unless necessary. Metronidazole is carcinogenic in some rodents. Administer oral doses with food.

DRUG NAME

ACTION

NURSING INDICAT CONTRAIN ADVERSE RESPONSIBILITI ION DICATION REACTION ES

Ampicillin

Used for Hypersens Nausea Tell patient that Bactericidal treating itivity to medication may action bacterial ampicillin, Vomiting cause nausea or against infectio any vomiting(small, BRAND sensitive n component Loss frequent meals, organisms of the frequent mouth NAME formulatio of appetite care, sucking n or other lozenges, or penicillins Diarrhea chewing gum Novomay help) ampicillin Abdomin diarrhea (buttermilk, boil al pain DOSAGE ed milk, or yogurt may Rash CLASSIFICA help). 1g TIV TI Itching Instruct client ON Headache to maintain adequate Confusio hydration (2-3 L/day of fluids) Antibiotic, unless n ROUTE instructed to Penicillin Dizzines restrict fluid IV intake.

DRUG NAME

ACTION

INDICATI CONTRAIN ON DICATION

ADVERSE REACTION

NURSING RESPONSIBILIT IES

Paracetam ol Reduces fever by acting on the hypothalamus to cause BRAND vasodilatation and sweating NAME

Used for Contrain the relief dicated of fever, headach withallerg es y to acetamino phen or any componen DOSAGE CLASSIFICATI t. 500mg ON 1tab RTC Analgesic, antipyretic ROUTE ORAL

Chest pain Dyspnea Rash Fever Jaundice Acute kidney failure Hepatictoxici ty and failure

instruct client to report any adverse reaction like allergies to the physician or nurse. Warn patient that high doses or unsupervised long term use can cause liver damage.

DRUG NAME

ACTION

INDICATI CONTRAIN ON DICATION

ADVERSE REACTION

NURSING RESPONSIBILI TIES

Metoprolo l BRAND NAME lopressor DOSAGE 50mg BID

decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin, and lowering BP; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone.

Hypert ension, alone or with other drugs, especial ly diuretic s

Contrain dicated with sinus bradycard ia

Dizziness vertigo tinnitus fatigue

emotional depression paresthesia s sleep disturbances hallucinatio ns disorientati on memory loss slurred speech

Do not discontinue drug abruptly after longterm therapy

Provide continual cardiac monitoring for patients receiving IV metoprolol.

CLASSIFICATI ROUTE ON Antihypertensi PO ve

DRUG NAME

ACTION

CONTRAI INDICATIO NDICATIO N N

ADVERSE REACTION

NURSING RESPONSIBILIT IES

Ferrous Ferrous Sulfate is an sulfate essential component in the formation of hemoglobin, BRAND myoglobin and enzymes. It is NAME necessary for effective erythropoiesis Feosol and transport or utilization of oxygen.
DOSAG E 1tab ROUTE PO CLASSIFICATI ON Iron Preparation

The prevention or treatment of iron deficiency anemia due to inadequate diet, malabsorp tion pregnancy, and blood loss

Hyperse nsitivity Severe hypotens ion

Vomiting Severe abdomina l pain Diarrhea Dehydrati on Hyperven tilation Pallor or cyanosis Cardiovas cular collapse

Store all forms at room temperatu re tell the patient about the adverse reactions

Eggs and milk inhibit absorption

Discharged at jan,18 2012

 Hydralazine- 5mg TIV 6hs prn for BP

150/100mmhg Ampicillin- 1g TIV 6hrs Metronidazole- 5OOmg TIV 8hrs Gentamycin- 240mg in 100cc Metropolol- 500mg BID Nifedipine- 5mg 1cap prn for BP 150/100 Paracetamol- 500mg 1tab Ferrous sulfate-1cap BID PNSS X3Omins OD

Tell client to refrain from straining

activities. Encourage ambulation as a form of light exercise that would help in the ??? Progression of her recovery and wound healing. Encourage the patient to do some exercise would allowed good blood circulation as well as the prevention of the occurrence of bed sores.

Encourage the patient to do some stretching

exercise to prevent of the stiffness to the bone Due to less activity performed. Encourage patient to first sir up and dangle feet before standing from a lying position to prevent orthostatic hypotension.

 Discussing the purpose of treatments to be done

and continue at home and report to the health professional when there is bleeding to alleviate symptoms of the patient condition and monitor for her recovery. Encourage the patient to have a sufficient rest and sleep to maintain internal equilibrium. Provide a safe and comfortable environment because it could make the patient more relax which is also needed to arrived with a good prognosis.

A follow up check up is necessary for wound

elevation and to assess the progression of wound healing.

Encourage the patient to increase fluid

intake and to include fruits and vegetables rich in vitamin C for the production of milk need for the lactation Taking food rich in protein is also helpful to tissue repair.

Assess anxiety of client over preterm labor

possible feelings. Determine whether client wants a support person to be with her, to the presence of support person can offer additional comfort to a client

Group 3