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INSTITUTE OF NURSING
BATCH 2010
CASE PRESENTATION
BSN048
GROUP 190-B
Rieza, Wendy Ann M.
Salamat, Neoma Syrilla T.
Santos, Janessa Joy S.
The client chosen for this case is R.T.C NORD, female, 26 years of age,. Her religion is Roman Catholic She was
born on July 24, 1981 in Tuguegarao City. And married to PO1 T.C PNPSAF B96L28 from Paliparan Dasma, Cavite.
Admitted to OBward by admitting officer/ admitting physician PSUPT Guiatani on 21 2330H July 2008, room
number 3 with hospital no. 04-01-35. Is Dependent, ambulatory, First type of admission with Direct source of
Admission. Has admitting Diagnosis of G2P1 PU 23 4/7 weeks AOG, Pre Term Labor. R.T.C is accompanied by husband
with cc of vaginal spotting or verbalized. LmP is February 22, 2008, EDC is November 29, 2008, RR of 21 cycles/min,
BP 130/80mmhg with temp of 36.7 and cardiac rate of 78bpm.Conscious and coherent, with negative uterine
contraction and positive on vaginal spotting.
We chose this case because this case is more challenging among other cases that we’ve handled and there’s
a lot to learn from this case. In addition to that, the diagnosis of the patient might be a threat to the fetus that needs
to be focused on, assessed for nursing intervention to help prevent further complications.
II Nursing History
A. Past health History
R.T.C 26 y/o G2P1 doesn’t have history on Hypertension, Diabetes mellitus, and asthma. She is diagnosed of
hyperthyroidism during her first pregnancy on the year 2006 on PTV but stop after several weeks.
Discharge Plan
Exercise:
-CBR
Treatment:
-rest and sleep
-medication
-increase fluid intake
Health Teaching:
Low levels of amniotic fluid can increase your risk of complications during labor. The main concern is that the fluid level will get so
low that your baby's movements or your contractions will compress the umbilical cord. So Oligohydramnios can sometimes be
treated with bed rest, oral and intravenous hydration, antibiotics, steroids, and amnioinfusion. It is advised to
continue the increse of oral fluids, have bed rest and consult doctor as advised.
Out Patient:
-The patient should consult doctor/physician if there are complications after discharge for immediate action.
-The patient should follow the physicians order.
Diet:
Practice good eating habits. Just as important as what you eat is the manner in which you eat. Eat moderate
proportions, eat at regular times and relax while you eat advised a low residue diet. Increase fluid intake to
2liters/day.
Walking during pregnancy is a great way to feel good and become more fit.
Stand tall. Stand up straight and use your abdominal muscles to support your back. Practice relaxing your
stomach, then pulling it back in so you get a feel for what it means to hold in your abs. If you're very
pregnant, you may want to wear a maternity belt under your clothes for additional abdominal support. A
maternity belt has is a wide band that goes under your tummy for support. You can buy one in a maternity
store or catalog.
Look ahead. Look at the ground a few steps ahead of you — not straight down (which strains your neck and
hunches your shoulders) or far off into the distance (in case you have to dodge people or tackle tough
terrain).
Get into position. Keep your elbows close to your body, your shoulders back slightly, and your elbows bent.
Hold your hands in light fists, as if you're grasping an egg.
Start off small. Begin walking in short strides. Long ones can hurt your hips and pelvic area, which are
loosened by hormones released during pregnancy.
Safety:
Pregnancy Fitness Safety Tips
Staying fit during pregnancy is an important part of feeling your best. If yours is a low-risk pregnancy, and your
doctor approves, you can continue to exercise and derive health benefits even from mild-to-moderate fitness
routines. The American College of Obstetricians and Gynecologists recommends following these guidelines to ensure
a healthy pregnancy — for you and your baby.
• Stay consistent. Exercise regularly (at least three times a week) — not intermittently. Exercising three days
a week is a good routine. Keep your fitness regimen in the mild-to-moderate range.
• Easy does it. Avoid activities that require jumping motions or sudden changes in direction because these
may strain your joints and injure you.
• Watch your back. Don't exercise on your back after the first trimester. Also, avoid prolonged periods of
motionless standing. Both actions can reduce blood flow to the uterus.
• Don't overexert yourself. Be aware that you have less oxygen available for exercise. Stop exercising when
you become fatigued, and don't exercise to the point of exhaustion.
• Keep your balance. Avoid exercises that could cause a quick loss of balance or mild trauma to the abdomen.
• Eat a good diet. Be sure you eat an adequate diet that allows you to gain 25 to 35 pounds over the nine
months. Most pregnant women require an additional 300 calories a day. If you exercise regularly, you will
probably require more. Include plenty of carbohydrates in your diet, as pregnant women use up this fuel
source more quickly during exercise than non-pregnant women.
• Drink up! Drink plenty of water to keep you hydrated and prevent overheating.
• Get comfortable. Wear comfortable, cool, and supportive clothing in layers that can be easily removed.
Wear a bra that fits properly and supports your breasts.
• Keep cool. Be mindful not to become overheated, especially in the first trimester. According to the American
College of Obstetricians and Gynecologists, overheating, especially in the first trimester, may be a
contributing factor to the development of birth defects. Drink plenty of fluids before and during exercise, wear
layers of "breathable" clothing, don't exercise on hot, humid days, and don't immerse yourself in a hot tub or
sauna.
• Avoid certain sports. According to the Mayo Clinic, you'll want to avoid certain sports altogether while
you're pregnant. These include activities at high altitudes and those that are associated with a risk of falling or
colliding with another participant, such as horseback riding, climbing and snow and water skiing. Also, avoid
scuba diving because there's a risk that your oxygen intake could be compromised, and diving can put
pressure on your organs and baby.
Anatomy and Physiology
The amnion grows and begins to fill, mainly with water, around two
weeks after fertilization. After a further 10 weeks the liquid contains
proteins, carbohydrates, lipids and phospholipids, urea and electrolytes,
all which aid in the growth of the fetus. In the late stages of gestation
much of the amniotic fluid consists of fetal urine.
The amniotic fluid increases in volume as the fetus grows. The amount
of amniotic fluid is greatest at about 34 weeks after conception or 34
weeks ga (gestational age). At 34 weeks ga, the amount of amniotic
fluid is about 800 ml. This amount reduces to about 600 ml at 40 weeks
ga when the baby is born.
Amniotic fluid is continually being swallowed and "inhaled" and replaced through being "exhaled", as well as being
urinated by the baby. It is essential that the amniotic fluid be breathed into the lungs by the fetus in order for the
lungs to develop normally. Swallowed aminotic fluid contributes to the formation of meconium.
Analysis of amniotic fluid, drawn out of the mother's abdomen in an amniocentesis procedure, can reveal many
aspects of the baby's genetic health. This is because the fluid also contains fetal cells which can be examined for
genetic defects. Recent research by researchers led by Anthony Atala of Wake Forest University and a team from
Harvard University has found that amniotic fluid is also a plentiful source of non-embryonic stem cells. These cells
have demonstrated the ability to differentiate into a number of different cell-types, including brain, liver and bone.
Amniotic fluid also protects the developing baby by cushioning against blows to the mother's abdomen, allows for
easier fetal movement, promotes muscular/skeletal development, and helps protect the fetus from heat loss.
The forewaters are released when the amnion ruptures, commonly known as when a woman's "water breaks". When
this occurs during labor at term, it is known as "spontaneous rupture of membranes" (SROM). If the rupture
precedes labor at term, however, it is referred to as "premature rupture of membranes" (PROM). The majority of the
hindwaters remain inside the womb until the baby is born.
Too little amniotic fluid (oligohydramnios) or too much (polyhydramnios or hydramnios) can be a cause or an
indicator of problems for the mother and baby. In both cases the majority of pregnancies proceed normally and the
baby is born healthy but this isn't always the case. Babies with too little amniotic fluid can develop contractures of
the limbs, clubbing of the feet and hands, and also develop a life threatening condition called hypoplastic lungs. If a
baby is born with hypoplastic lungs, which are small underdeveloped lungs, this condition is potentially fatal and the
baby can die shortly after birth.
On every prenatal visit, the obstetrician/gynaecologist should measure the patient's fundal height with a tape
measure. It is important that the fundal height be measured and properly recorded to insure proper fetal growth and
the increasing development of amniotic fluid. The obstetrician/gynaecologist should also routinely ultrasound the
patient—this procedure will also give an indication of proper fetal growth and amniotic fluid development.
Oligohydramnios can be caused by infection, kidney dysfunction or malformation (since much of the late amniotic
fluid volume is urine), procedures such as chorionic villus sampling (CVS), and preterm premature rupture of
membranes (PPROM).
Oligohydramnios can sometimes be treated with bed rest, oral and intravenous hydration, antibiotics, steroids, and
amnioinfusion.
Polyhydramnios is a predisposing risk factor for cord prolapse and is sometimes a side effect of a macrosomic
pregnancy. Hydramnios is associated with esophageal atresia. Amniotic fluid is primarily produced by the mother
until 16 weeks of gestation.
COLOR OF AMNIOTIC FLUID WITH CONTRAINDICATIONS GREEN - neco state YELLOW - hemolitic deisease BROWN -
infection
R.T.C was admitted to Ob ward on July 21, 2008 with the BP of 130/80, temperature of 36.7’C and 23 4/7
weeks AOG. Diet is DAT. Undergone CBC and UA results were normal. Given IVF of D5 W 1L +8amps duvadilan to run
for 15ugtts/min after checking BP and CR. Given the medicine Ampicillin 1g IV q’6 ANST, Natalbes 1tab OD, Femiron
1tab OD, Folart (folic acid) 1 tab, calcium 1tab q’12. R.T.C undergone transvaginal ultrasound. Monitor V/S every
shift. 22 2100H July 2008. Continue duvadilan drip and increase OF 2L/day. Dx asymptomatic FT3 FT4 FST
(047/2008) normal. Undergone transabdominal ultrasound at 24 1500H July 2008 for amniotic fluis quantification
resulted oligohydramnios, intramural myoma nodule upper anterior (3.5x2.0cm) with note of multicystic left kidney,
suggested congenital anomaly scan at 24 weeks AOG by physician. Advised increase of Oral Fluids to 2L/day. 25
0700H July 2008, IVF to follow are D5LR 1L fast drip 300cc then regulate to 6 hrs, D5NM 1L X 6hours, D5LR IL X
6hours. To discontinue ampicillin IV and duvadillan drip to consume and then shift to duvadilan tablet BID. Advised to
maintain in lateral derubitus position. Monitored V/s FHT and recorded.1100H permitted to take a bath. Last Bp
taken was Immunology Result Unit Reference- Analysis?
ranges
110/70 FT3 (ECLIA) 3.710 Pmol/L 2.80-7.10
temperature is FT4(ECLIA) 13.59 Pmol/L 12-22
TSH(ECLIA) 2.370 uIU/ml 0.27-4.20
37’C RR-20, PR-
82. 26 0725H July 2008, R.T.C is advised on a low residue diet, still increase of fuid intake and to continue IV series
D5LR5 1L x 6 hours, D5NM 1L x 6 hours, D5NR IL x 6 hours, D5NM IL x 6 hours, pt may turn on Lest and right. 20 July
2008 undergone transvaginal ultrasound at AGRA. 30 1930 July 2008 for congenital scanning @ 28 weeks (august
12, 2008) or on next ultrasound. Vital sign ans FHT monitored and recorded.
Hematology 04/30/08
Ultrasound 1
Obstetrics Ultrasound Report
24 July 2008
Final impression:
Cephalic presentation, live singleton
No previa
Posterior placenta location]
Amniotic fluid volume: oligohydramnios (AFI=1.7cm)
Placental grade: grade 1
Pregnancy Uterine, 21 wks 3 days AOG by fetal biometry
Intramural myoma nodule, upper anterior (3.5 x 2.0)
With note of multicystic left kidney
Suggest congental anomaly scan at 24 weeks AOG.
Ultrasound 2
Obstetrics Ultrasound Report
7/28/2008
2nd and 3rd trimester
Number of fetus: 1
Presentation: breech
Amniotic fluid volume: 39 (2vp)
Q1- 1.8
Q2- 2.1
Fetal Biometry
BPD - 52mm 21weeks 4days
HC - 192mm 21weeks 3days
AC - 163mm 21weeks 1day
FL - 35mm 22weeks 1day
AV Sonar age 21 weeks 4 days
Estimated date of delivery: 12/04
Wstimated fetal weight. 429 grams
Remarks: The amniotic Fluid index has improved slightly., but generally
scanning showed still with oligohydramnios
Generic Dosage/ Classificatio Indications Contraindicat Side effects Nursing
Name Frequency n ions Consideratio
ns
Cues Nursing Analysis Planning Intervention Rationale Evaluation
Diagnosis
4. Assisting
4. Help client to empower the
identify Braxton- client to recognize
Cues Nursing Analysis Planning Intervention Rationale Evaluation
Diagnosis
Goal: All the
O- doctors Deficient Decreased After 4 hrs of nursing Nursing
order to have Diversional stimulation intervention, the intervention
complete bed Activity from client will verbalize rendered to
rest with out related to recreational examples of the client
bathroom prescribed or leisure satisfying activities were
privileges complete activities. within personal limits appropriate,
bed rest efficient ,
without Objective: effective and
bathroom After 4 hrs of nursing adequate for
privileges intervention, the the clients
secondary client will: condition.
to preterm 1 .Determine 1. Presence of Through this
labor 1. 1. Be motivated and ability to depression, interventions
stimulate client participate in problem of the client
involvement in activities that are mobility, was able to
solution available protective verbalize
isolation, or understandin
2. Promote wellness 2.Acknowledge sensory g about s/s of
reality of situation deprivation may preterm labor
and feelings of the onterfere with and what’s its
client desired activity possible
prevention
3. Interventions
3. Provide for decrease
physical as well as distractions and
mental diversional promote
activities learning; family
may reinforce
teaching and
help client
comply.
5. Accept hostile
expressions while 5. Assisting
limiting aggressive empower the
acting-out client to
behavior recognize mild
uterine
contraction.
Many women are
unaware that
Braxton-Hicks
are contraction
even if they are
not painful
6. Make
appropriate
referrals to
available support 6. Teaching
groups, hobby promotes self
clubs, service care and
organizations assessment
skills. The
fundus is the
thickest part of
the uterus where
contractions are
most easily felt.
6. Teaching
promotes
awareness of
sensations of
contractions and
fetal movement.
Journal provides
a written record
of activity.
7. Teaching
empowers client
to recognize
subtle signs of
preterm labor.
Client may not
experience
contractions as
such.
8. Dehydration
or a distended
bladder may
increase uterine
irritability/activit
y.
9. Instruction
avoids activity
that may cause
the release of
oxytocin from
posterior
pituitary gland.
Semen contains
prostaglandins
that may affect
uterine activity.
10. Instruction
allows client to
have some
evaluation of
preterm labor
Prioritization:
A. Hypothesis
Based on the gathered data and information, we presume that the fetus is the host, the mother is the agent and the
amniotic fluid is the environment. The mother acquired oligohydramnios because of certain factors such as decrease
fluid intake (1 liter/day)
B. Predisposing Factors
After analyzing the client’s predisposing factors that affect her condition, we conclude that the agent is the primary
factor that causes her to acquire her present condition. As stated by the client, she has inadequate gluid intake
before admission to the hospital.
As for the recommendation, we advise the client to continue her ongoing treatment for the promotion of her
wellness and her baby’s wellness and reduce further complication.
PATHOPHYSIOLOGY
(Can be associated)
Fetal abnormalities (growth restricted fetuses)
Poor fetal lung development (pulmonary hypoplasia), malformations may result to compression of fetal parts, fetal
death