Far Eastern University Nicanor Reyes st.

Sampaloc, Manila Institute of Nursing

INTRODUCTION
PLACENTA PREVIA (Low-Lying Placenta)

DESCRIPTION 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% 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.

Persistent excessive prenatal bleeding may seriously threaten the mother. The maternal (not fetal) circulation is the source of bleeding. Vaginal or rectal examination or attempts to deliver from below may lacerate or separate the placenta, and as a consequence, the draining of blood (exsanguinating) maternal or fetal hemorrhage may occur. Placenta previa is a major cause of maternal and perinatal morbidity and mortality. FREQUENT SIGNS & SYMPTOMS Sudden, painless bleeding during the second or third trimester of pregnancy is the primary symptom. Bleeding may begin slight or moderately and become severe and is bright red in color. Bleeding can occur as early as the 20th week of pregnancy but is most common during the third trimester.

 Cramping in some women. Signs of preterm labor. One in 5 women with signs of placenta previa also has uterine contractions. Bleed from placenta previa may taper off and even stop for a while. However, it nearly always starts again days or weeks later. Abnormal fetal position in the uterus. Some women with placenta previa do not have any symptoms. In this case, placenta previa may only be diagnosed by an ultrasound done for other reasons.

CAUSES Normally, the placenta attaches high on the uterus wall, away from the cervix. In placenta previa, the placenta covers the cervix partially or completely. Any change in the cervix, such

as the softening and dilating that occurs prior to delivery, can cause the placenta to bleed as it separates from the uterus. RISK INCREASES WITH Previous uterine procedures or surgery that affect the uterine lining, such as cesarean section or dilation and curettage (D & C) done with sharp curettage (rare) after a miscarriage (spontaneous abortion) or a medical abortion. Of women who have had a previous cesarean delivery, as many as 4 in 100 develop placenta previa. Of Women who have had four or more C-sections, 10 in 100 develop placenta previa. Fibroid tumors of the uterus. Smoking. Cigarette smoking is strongly linked to 1 of every 4 previas. Smoking decreases the amount of oxygen transferred to the fetus, thereby stimulating the growth of a larger placenta, which is more likely to grow low into the uterus. Multiple previous pregnancies and deliveries. Placenta previa occurs in 1 in 1,500 first time pregnancies. In women who have had five or more pregnancies, this increases to about 5 in 100. Advancing maternal age. Among women 19 or younger, only 1 in 1,500 develops placenta previa. Of women age 35 and over, 1 in 100 develops placenta previa. Cocaine or crack cocaine use during pregnancy. History of previous placenta previa. If your midwife or health care provider has identified a placenta previa or low-lying placenta before your 20th week of pregnancy, chances are good that it will resolve on its own. About 90% of placenta previa cases diagnosed before the 20th week resolve on their own by the end of the pregnancy. As the lower uterus grows, the position of the placenta can change in relation to the cervix so that by the end of the pregnancy, the placenta no longer blocks the cervix. PREVENTIVE MEASURES Get good prenatal care during a pregnancy. It will not prevent previa, but can help identify complications early. Don't smoke (or use cocaine) during pregnancy. Smoking also causes a secondary problem that can lead to poor growth of the fetus. EXPECTED OUTCOME With prompt care, mothers and most infants survive without complications. Delivery is by cesarean section in most cases.

POSSIBLE COMPLICATIONS Premature delivery or fetal death, if extensive placenta previa develops before the expected delivery date.

 Placental abruptio, also called placenta abruptio, is the separation of the placenta from the uterine wall, either partially or totally resulting in potentially hazardous blood loss before or during delivery. Hemorrhaging requiring blood transfusions for the mother prior to delivery or following delivery may be needed. This can be life threatening for both mother and her baby. when the placenta has abnormally attached or grown into the uterine wall (placenta accreta, placenta increta, or placenta percreta), bleeding can be severe enough to require a hysterectomy. Poor fetal growth due to an abnormal placenta providing a decreased blood flow and oxygen delivery. The site of implantation and size of the placenta are related. The circulation of the lower uterine segment is less favorable than that of the fundus (top of the uterus), placenta previa may have to cover a larger area for adequate efficiency. In placenta previa the surface area may be at least 30% greater than the average placenta implanted in the fundus. Twice as many placenta previas involve the anterior uterine wall as in normal implantation, and the probability is even greater after a cesarean birth because of scarring. Placenta previa or low-lying placenta may encourage breech or transverse presentation and my prevent engagement of either fetal part. Premature, or preterm, delivery (before the 37th week of pregnancy), which typically poses the greatest risk to the fetus. Birth defects occur 2.5 times more frequently in pregnancies affected by placenta previa than in unaffected pregnancies. the cause is currently unknown. It may be that placenta previa is slightly more common among older women, as are babies with birth defects. Puerperal infection (child bed fever or infection of the uterus). Anemia from blood loss. TREATMENT A.GENERAL MEASURES 1.DIAGNOSIS Have regular checkups during pregnancy with your midwife or health care provider. If signs of placenta previa appear (such as picking up placental sounds in the lower part of the uterus while checking for fetal heart tones) be prepared to go to the hospital for diagnosis confirmation, early observation and possible delivery. Arrange for fast transportation to the hospital in case of emergency, especially massive bleeding. Diagnostic tests may include laboratory blood studies to determine the amount of blood loss. ultrasonography of the uterus is used most frequently to diagnose placenta previa and to determine exact location of the placenta. Most placenta previas are identified during the second trimester during a routine ultrasound or amniocentesis for a genetic testing, or when assessing the cause of vaginal bleeding or when bleeding begins at the onset of labor. However, ultrasound does not always provide a clear picture of the placenta's location. When an early delivery is needed, an amniocentesis may be done. It is used to find out whether the fetus's lungs are ready to breathe well after birth. For an amniocentesis, a needle is inserted into the mother's belly to take a small sample of amniotic fluid from inside the

uterus. This fluid is made by the fetus's lungs. A lab test of the fluid can test for signs that the lungs are well-developed.

With bleeding placenta previa, it is important that you avoid sexual intercourse, office vaginal exams, or putting anything else in your vagina since there is a high risk of further injuring the placenta, causing heavier bleeding. You may, however, have a carefully done vaginal exam at the hospital with an emergency surgery team standing by for an immediate cesarean delivery, just in case of hemorrhage. Clinical classification is often described as complete, total, or central if the internal os is entirely covered by the placenta when the cervix is fully dilated (See fig. A.). Partial placenta previa implies incomplete coverage (See fig. B.). Nonetheless, complete placenta previa may be partial after dilation of the internal os, and marginal previa may become partial. Hence, with this terminology, accurate comparisons are impossible.

Marginal placenta previa indicates that only an edge of the placenta approaches the internal os (See fig. C.). The term low-lying implantation is used when the placenta is situated in the lower uterine segment but away from the os. A better classification of placenta previa is the estimation of percentage coverage of the internal os at full dilation, the diameter required for delivery of a mature fetus through the cervix (See lower A., B., C.).

To better assess the percentage coverage, the healthcare provider should note whether on gentle vaginal examination the placental edge can be felt at or near the center of the internal os. (Vaginal examination of a woman with a known placenta previa is not recommended outside of a medical facility having full emergency surgical services immediately available!) Upon examination, the health care provider must consider how much of the os would be covered if the cervix were fully dilated. If about half of the area would be covered by the placenta with the cervix at full dilation, this would be a 50% placenta previa.

Although this is admitted to be an estimate, and one should not pursue the examination too vigorously or hemorrhage may occur, a woman with placenta previa less than 30% probably can be delivered safely vaginally. A woman with a placenta previa greater than 30% is better to have a cesarean birth. HOME TREATMENT If you are pregnant, be alert for any vaginal bleeding. Sudden, painless vaginal bleeding may be the only symptom of placenta previa, a placenta that partially or fully covers the cervix. Call your midwife or health care provider or go to the closest emergency room immediately if you have: Moderate to severe vaginal bleeding during the first trimester. Severe vaginal bleeding means soaking more than one pad in 1 hour (you should not be using tampons). Moderate vaginal bleeding means soaking more than eight pads in 24 hours. Any vaginal bleeding in the second or third trimesters. Call your health professional today if you have mild vaginal bleeding (soaking fewer than eight pads in 24 hours) during the first trimester of pregnancy.

If you have had placenta previa - You may have questions about a future pregnancy once you have experienced placenta previa. Based on the nature of your condition, your midwife or health care provider will be able to answer your questions and address your concerns.

In very rare cases, placenta previa causes a stillbirth or newborn death. Should you experience such a loss, allow yourself time to grieve. Expect that your partner, children, and other family members may also be deeply affected. Consider meeting with a support group, reading about the experiences of other women, and talking to friends, a counselor, or a member of the clergy to help you and your family cope with your loss. Although placenta previa is contraindicated for a homebirth setting or birthing center delivery, often times your midwife will be able to continue prenatal care and support before a cesarean delivery is performed, and provide delivery support to the mother and her partner during the cesarean surgery, and afterwards continue with postpartum and breast-feeding support and care for mother and newborn infant. As stated before, a midwife or other health care provider should NEVER do a vaginal or rectal examination on a woman with vaginal bleeding and suspected placenta previa outside of a fully staffed emergency surgery unit available. MEDICAL TREATMENT If you have placenta previa, your treatment will depend upon: How much you are bleeding (which influences whether you are monitored as an outpatient or in the hospital), whether you need a blood transfusion, and when delivery is necessary. Your overall physical condition, such as whether you've lost blood and are anemic. Your fetus's overall maturity and physical condition. Whenever possible, delivery is delayed until fetal lungs are mature. How much of your cervix is covered by the placenta. Because a vaginal delivery is likely to cause heavy placental bleeding, a cesarean is used for placenta previa deliveries.

If you have placenta previa and are not bleeding, it is important to follow certain precautions: Avoid all strenuous activities, such as running or lifting more than approximately 20lb (9.1kg). See your midwife or health care provider immediately if you have any bleeding. Be sure that he or she knows you have placenta previa. Have a phone nearby at all times.

Advise all health professionals who examine you that you must not have pelvic examinations. Refrain from sexual intercourse after 28 weeks of pregnancy; before 28 weeks, ask your midwife or health care provider about any possible risks.

 Avoid inserting anything, such as tampons or vaginal douches, into the vagina. Be close to a hospital that can provide emergency care for both you and a sick or premature infant.

If you have placenta previa and begin to bleed, you may be hospitalized. If your fetus is mature, you will have a cesarean delivery. If your bleeding lessens or stops, delivery can most likely be delayed. This watching and waiting approach is called expectant management. The course of expectant management is based on your and your fetus's condition. Electronic fetal monitoring is used in the hospital to check the fetus's condition.

If your fetus is 24 to 34 weeks' gestation, you may be given corticosteroids to improve fetal lung development and prepare for an early birth. You may have an amniocentesis to see how developed your fetus's lungs are. You may also be given iron supplements to treat or prevent anemia and a high-fiber diet with stool softeners to ease any straining during a bowel movement. If you have Rh-negative blood, you will be given Rh immune globulin in case your fetus has Rh-positive blood. Should you be exposed to your fetus's Rh-positive blood without Rh immune globulin, your immune system will develop antibodies that are dangerous to an Rh-positive fetus (Rh sensitization). If your bleeding does not stop, expect to remain hospitalized and closely monitored until your fetus is mature enough to deliver. Moderate blood loss can be replaced with a blood transfusion to prolong your pregnancy until your fetus is mature enough to deliver. If you have labor contractions, you may be given tocolytic medication to slow or stop the contractions. However, the benefit of tocolytic medications in stopping labor is uncertain. Should bleeding become severe and uncontrollable, an immediate cesarean delivery, possibly with a blood transfusion, is the only treatment available for stopping it. About 1 in 10 of women with placenta previa requires a hysterectomy to stop uncontrollable bleeding. A marginal placenta previa requires bed rest, usually in the hospital, sometimes at home, until bleeding stops. If bleeding stops, you may get up, but you should stay in the hospital if your midwife and other health care providers recommend it until delivery. If you leave the hospital, your life and that of your child will be at risk. Massive bleeding can occur before you can get back to the hospital.

DELIVERY In determining the best time for delivery, tests of fetal lung maturity, amniotic fluid studies and ultrasonic growth measurements (not reliable) are usually recommended.

 If you are near the expected delivery date and studies reveal more than a marginal or lowlying placenta, cesarean section is often recommended to reduce the complications for both mother and child that could result from an emergency delivery.

Delivery involving placenta previa is done by cesarean section. Cesarean delivery is the method of choice with placenta previa. When your fetus is mature enough, or if too much bleeding is endangering you or your fetus, your baby will be delivered. Because disturbing the placenta with a vaginal delivery can cause severe bleeding, a cesarean section is always used when placenta previa is present. Emergency surgery may need to be performed if severe bleeding (hemorrhage) occurs.

Nearly half of placenta previa deliveries are preterm (before the 37th week of pregnancy). 10 Infant problems following placenta previa are usually related to prematurity. If your infant is premature, he or she may need care in a neonatal intensive care unit, or NICU. Care in the NICU can last days or weeks, depending on the extent of a baby's problems and the amount of care needed.

Treatment for placenta previa can be done by an obstetrician or perinatologist. Treatment for a premature infant can be provided by a neonatologist. MEDICATION Only minimal analgesic medications, if any, will be used in delivery so as to increase the child's survival chances. Blood transfusions may be necessary. Don't use aspirin during pregnancy unless advised to do so by your midwife or health care provider (it may increase risk of bleeding). If the mother is Rh negative and the baby is Rh positive, the mother may be given a Rhogam injection to help prevent Rh antibodies from developing in the mother (Rh sensitivity) either during her pregnancy or within 72 hours of delivery. The mother should be informed about pros and cons of Rhogam and the potential hazards and side effects associated with it. Rhogam is a blood-product and it isn't 100% effective. ACTIVITY If you are able to remain at home, rest in bed until bleeding and other symptoms cease. Do not resume normal activities until specific instructions to do so are given to you. Avoid sexual relations until otherwise instructed. DIET While you are bleeding and as long as surgery is being considered, drink liquids only. Eating solid food before surgery can cause anesthesia problems. If you are resting at home, continue with your regular prenatal dietary program.

ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

A. PARTS AND FUNCTIONS OF THE FEMALE REPRODUCTIVE SYTEM The female reproductive organs consist of the ovaries, uterine tubes (or fallopian tubes), uterus, vagina, external genitalia, and mammary glands. The internal reproductive organs of the female are located within the pelvis, between the urinary bladder and the rectum. The uterus and the vagina are in the midline, with an ovary too each side of the uterus. The internal reproductive organs are held in place within the pelvis by a group of ligaments. The most conspicuous is the broad ligament, which spreads out on both sides of the uterus and to which the ovaries and uterine tubes attach.

Ovaries

The two ovaries are small organs suspended in the pelvic cavity by ligaments. The suspensory ligament extends from each ovary to the lateral body wall, and the ovarian ligament attaches the ovary to the superior margin of the uterus. In addition, the ovaries are attached to the posterior surface of the broad ligament by folds of peritoneum called the mesovarium. The ovarian arteries, veins, and nerves traverse the suspensory ligament and enter the ovary through the mesovarium.

A layer of visceral peritoneum covers the surface of the ovary. The outer part of the ovary is made up of dense connective tissue and contains ovarian follicles. Each of the ovarian follicles contains an oocyte, the female germ cell. Loose connective tissue makes up the inner pan of the ovary, where blood vessels, lymphatic vessels, and nerves are located.

Uterine Tubes

uterine

tube,

also

called a fallopian tube, or oviduct is associated with each ovary. The uterine tubes extend from the area of the ovaries to the uterus. They open directly into the peritoneal cavity near each ovary and receive the oocyte. The opening of each uterine tube is surrounded by long, thin processes called fimbriae.

The

fimbriae

nearly

surround the surface of the ovary. As a result, as soon as the oocyte is ovulated, it comes into contact with the surface of the fimbriae. Cilia on the fimbriae surface sweep the oocyte into the uterine tube. Fertilization usually occurs in the part of the uterine tube near the ovary.

Uterus The uterus is as big as a medium-sized pear. It is oriented in the pelvic cavity with the larger, rounded part directed superiorly. The part of the uterus superior to the entrance of the uterine tubes is called the fundus. The main part of the uterus is called the body, and the narrower part, the cervix, is directed inferiorly. Internally, the uterine cavity in the fundus and uterine body continues

through the cervix as the cervical canal, which opens into the vagina. The cervical canal is lined by mucous glands. The uterine wall is composed of three layers: a serous layer, a muscular layer, and a layer of endometrium. The outer layer, called the serous layer, or perimetrium, of the uterus, is formed from peritoneum. The middle layer, called the muscular layer, or myometrium, consists of smooth muscle, is quite thick, and accounts for the bulk of the uterine wall. The innermost layer of the uterus is the endometrium. The endometrium consists of simple columnar epithelial cells with an underlying connective tissue layer. Simple tubular glands, called endometrial glands, are formed by folds of the endometrium. The superficial part of the endometrium is sloughed off during menstruation. The uterus is supported by the broad ligament and the round ligament. In addition to these ligaments that support the uterus, much support is provided inferiorly to the uterus by skeletal muscles of the pelvic floor. If these muscles are weakened such as in childbirth, the uterus can extend inferiorly into the vagina, a condition called a prolapsed uterus. Vagina

The

vagina

is

the

female organ of copulation and functions to receive the penis during intercourse. It also allows menstrual flow and childbirth. The vagina extends from the uterus to the outside of the body. The superior portion of the vagina is attached to the side of the cervix so that a part of the cervix extends into the vagina The wall of the vagina consists of an outer muscular layer and an inner mucous membrane. The muscular layer is smooth muscle and contains many elastic fibers. Thus the vagina can increase in size to accommodate the penis during intercourse, and it can stretch

greatly during childbirth. The mucous membrane is moist stratified squamous epithelium that forms a protective surface layer. Lubricating fluid passes through the vaginal epithelium into the vagina. In young females, the vaginal opening is covered by 3 thin mucous membrane called the hymen. The hymen can completely close the vaginal orifice, in which case it must be removed to allow menstrual flow. More commonly, the hymen is perforated by one or several holes. The openings in the hymen are usually greatly enlarged during the first sexual intercourse. The hymen can also be perforated or torn at some earlier time in a young female's life during a variety of activities including strenuous exercise. The condition of the hymen is therefore not a reliable indicator of virginity. External Genitalia

The

external

female

genitalia, also called the vulva, or pudendum, consist of the vestibule and its surrounding structures. The vestibule is the space into which the vagina and urethra open. The urethra opens just anterior to the vagina. The vestibule is bordered by a pair of thin, longitudinal skin folds called the labia minora. A small erectile structure called the clitoris is located in the anterior margin of the vestibule. The two labia minora unite over the clitoris to form a fold of skin called the prepuce.

The clitoris consists of a shaft and a distal glans. Like the glans penis, the clitoris is well supplied with sensory receptors, and it is made up of erectile tissue. Additional erectile tissue is located on either side of the vaginal opening. On each side of the vestibule, between the vaginal opening and the labia minora, are openings of the greater vestibular glands. They produce a lubricating fluid that helps maintain the moistness of the vestibule.

Lateral to the labia minora are two prominent, rounded folds of skin called the labia majora. The two labia majora unite anteriorly in an elevation of tissue over the pubic The lateral surfaces of the labia majora are the symphysis called the mons (mound) pubis.

surface of the mons pubis are covered with coarse hair . The medial surfaces of the labia majora are covered with numerous sebaceous and sweat glands. The space between the labia majora is called the pudendal cleft. Most of the time, the labia majora are in contact with each other across the midline, closing the pudendal cleft and coverer, the deeper structures within the vestibule. The region between the vagina and the anus is the clinical perineum. The skin and muscle of this region can tear during childbirth. To prevent such tearing, an incision called an episiotomy is sometimes made in the clinical perineum. This clean, straight incision is easier to repair than a tear. Alternatively, allowing the perineum to stretch slowly during the delivery can prevent tearing, making an episiotomy unnecessary. Mammary Glands

The mammary glands are the organs of milk pro duction and are located in the breasts, or mammae. The mammary glands are modified sweat glands. Externally, each of the breasts of both males and fe males have a raised nipple surrounded by a circular, pigmented areola. In prepubescent children, the general structure of the male and female breasts is similar, and both males and females possess a rudimentary duct system. The female breasts begin to enlarge during puberty, under the influence of estrogen and progesterone. Some males also experience a minor and tem porary enlargement of the breasts at puberty. The breasts of a male can become permanently enlarged, however, a condi tion called gynecomastia. Causes of gy-necomastia include hormonal imbalances and the abuse of anabolic steroids.

Each adult female breast contains mammary glands con sisting of usually 15 to 20 glandular lobes covered by a considerable amount of fat tissue. It is primarily this superficial fat that gives the breast its form. Each lobe possesses a single duct which opens independently to the surface of the nipple. The duct of each lobe is formed as several smaller ducts that originated from lobules converge. Within a lobule, the ducts branch and become even smaller. In the milk-producing, or lactating, mammary gland, the ends of these ducts expand to form secretory sacs called alveoli.

The breasts are supported by the mammary ligaments, which extend from the fascia over the pectoralis major muscles to the skin over the breasts and prevent them from excessive sagging. In older adults, the mammary ligaments can weaken and elongate, increasing the tendency for the breasts to sag. The nipples are very sensitive to tactile stimulation and contain smooth muscle. When the smooth muscle contracts, the nipple becomes erect, the smooth muscle cells contract in response to stimuli such as touch, cold, and sexual arousal.

B. FUNCTIONS OF THE FEMALE REPRODUCTIVE SYSTEM The female reproductive system performs the following functions: 1. Production of female sex cells. The reproductive system produces female sex cells in the ovaries. 2. Reception of sperm cells from the male.

The female reproductive system includes structures that receives sperm cells from the male and transports the sperm cells to the site of fertilization.

3. Nurturing the development of and providing nourishment for the new individuals The female reproductive system nurtures the development of a new individual in the uterus until birth and provides nourishment in the form of milk after birth. 4. Production of female sex hormones Hormones produced by the female reproductive system control the development of the reproductive system itself and of the female body form. These hormones are also essential for the normal function of the reproductive system and reproductive behavior.

STUDENTS INSIGHTS AND EXPERIENCES Nursing life is a journey of a lifetime to be cherished, to treasure and to take pride of. As we take another step of our dream, indeed we are so much blessed to be a part of recognized and well-established institution, Felix Y Manalo Puericulture Center. Undeniably, experiences are our best teacher but without the people to deal with and take part of these experiences, we cannot say that we have achieved the best knowledge we are opt to have. Our stay in F. Manalo Lying-In has been so memorable and definitely remarkable. With the new learning, new acquaintances and new experiences we have gained during our stay, we cannot ask for more. You have given us unforgettable and superb experience in handling patients most particularly with regard to suturing and performing Leopolds maneuver. We were able to meet new faces whom we consider friends, eat a lot of scrumptious foods, and most especially establish a lifetime relationship with you, Maam. You have been so kind and understanding. Youre astonishing beauty inside and out make us admire you. You serve as our inspiration to fulfill our dreams as we take the challenges of nursing life. With you, maam, we experience no dull moments, you filled our faces with smiles and laughter. Thank you maam for being a great clinical instructress and a mother to the 112 babies. We will never forget you maam! We love you! General Objective: To be able acquire the knowledge, skills and attitude relevant to the care of clients with nursing problems related to reproductive system, utilizing nursing process. Specific Objectives: To be able to discuss the nature and pathophysiology of Placenta Previa. 2. To be able to enhance the skills in assessing, diagnosing, planning, implementing and evaluating for the improvement of our skills and also the improvement of the clients condition. 3. To be able to utilize the nursing care process in prioritizing the needs of a client with disturbances in reproductive system.

NURSING PROCESS I. Biographic Data

Name: Mrs. R Address: #42 A&L Subd., N. Domingo St., San Juan City Age: 32 y.o. Gender: F Religious Affiliation: Iglesia ni Cristo Marital Status: Married Occupation: housewife Chief Complaint: bleeding

Provisional Diagnosis: Placenta Previa II. Nursing History

A. Past Health History The client had acquired chicken pox, measles, and mumps during her childhood years. According to her, she had received 5 doses of tetanus toxoid during her previous pregnancies. She has no known allergies on food and medications. She has been hospitalized twice when she gave birth via normal spontaneous delivery in 2004 of a baby girl and via caesarian section in 2006 of twin boys. She is currently taking her Iberet (Folic, 100mg) and Ferrous sulfate (100mg) a day as prescribed by her obstetrician. B. History of Present Illness One day prior to admission, the client suffered from unexplained vaginal bleeding and fever. On the day of consultation, the client underwent examinations that prompt to admission for management of the condition. C. Family History The patient has acquired familial diseases from both sides of her family. PATERNAL SIDE (+) Hypertension (+) Diabetes (+) Heart disease (-) Cancer D. Obstetric History The client is 27 2/7 weeks pregnant on her third pregnancy. Her last menstrual period was on October 15, 2007. Her estimated date of confinement is on July 22, 2008. The clients obstetric score is G3P2 (3003). III. Patterns of Functioning MATERNAL SIDE (+) Hypertension (+) Diabetes (-) Heart disease (-) Cancer

A. Psychological Health

1. Coping Pattern The client feels stressed whenever she have to simultaneously attend to the needs of her 4 year old daughter and 1 and half year old twin sons. To ease and cope with the stress, the client makes her self relaxed by reading books and some magazines. Often times, she watches television and takes a nap whenever she feels tired. A month ago, the clients mother decided to stay in their house in order to help her take care of her children. The client stated that she felt relieved upon knowing her mothers decision since her husband left for Qatar for work three months ago. Although, she feels stressed when taking care of her children and bearing with her pregnancy, she is still positive and very happy because in 3 months time, she will be

delivering another member of the family. The client stated that her husband calls her every two days and though far away, she still feels his love and support. Interpretation: It is normal that the client feels exhausted upon attending to the needs of her children, especially now that she is in her 27 2/7 weeks of pregnancy. Her activities like reading books and magazines and watching tv is her way of responding to stress. Analysis: Stress results from a change in environment that is perceived as a challenge, a threat, or a danger, and can have both positive and negative effects. The major sources of stress in our society arise from interpersonal relationships and performance demands rather than from actual physical threat (Pender, 2002). Exhaustion results when the adaptive mechanisms are exhausted. Without defense against the stressor, the body may either rest or mobilize its defenses to return to normal or reach total exhaustion and die. (Fundamentals of Nursing, 5th edition, Taylor, et.al., p.850-852) Situational stress can occur at any time, an example of situational stress which may be either positive or negative includes the following: illness, accident, marriage or divorce, loss (belongings, relationships, and family member), new job and pregnancy. Each individual has different ways on how to cope with these situational stressors. (Taylor, et. al. Fundamentals of Nursing: The art and Science of Nursing, 5th edition. P. 858). The family can provide the social support necessary to help the patient manage and adapt to stress. Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. (Taylor, et. al. Fundamentals of Nursing: The art and Science of Nursing, 5th edition. P. 858). 2. Interaction Pattern The patient said that she has an open communication with her family and with her inlaws. She talks to them whenever she has problems. She said that they are open to one another and they help one another when they have problems. The patient said that she is friendly to her neighbors. She talks to them in a nice way. She verbalized that now that she is pregnant and her husband works abroad, she needs the company and support of family and friends to keep her happy and to keep her going. She said that she also enjoys being with her children and taking care of them. She doesnt have any regrets of not working because she said that it is better that she spends quality time with her children even at their young age. Interpretation: It is normal that the patient recognizes the importance of her family and friends especially in times when she needs them most. Analysis: Family and friends can provide the social support necessary to help the patient manage and adapt to stress. Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. (Taylor, et. al. Fundamentals of Nursing: The art and Science of Nursing, 5th edition. P. 858)

3. Cognitive Pattern
The client does not experience any memory loss. Furthermore, the client has no complaint with regards to her senses. According to the client, her vision is 20/20.The client exhibits association of verbalization. When listening to the clients speech, it is understandable and in moderate pace. The client displays appropriateness to the situation. The clients words make sense and have sense of reality.

Interpretation: The clients sensory perception is in normal condition and it functions very well so her ability to deal with her environment is also normal. Analysis: An individuals senses are essential for growth, development, and survival. Sensory stimuli give meaning to events in the environment. Any alteration in peoples sensory functions can affect their ability to function within the environment. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.939) 4. Self-Concept The client stated that she is a simple person whos not fond of dressing up except only on special occasions. Even though she doesnt have a job, she finds contentment in doing the household chores and attending the needs of her children. She also stated that whats more important for her is to meet her role expectations. The client also stated that she feels good about herself and how she looks. The client is not affected emotionally with the changes that occur in her weight and physique. She also added that she gets depressed when she fails to do a household chore due to lack of energy to do so. She doesnt like it whenever she gets sick. Whenever shes angry or anxious, all she has to do is to take a rest to help her self alleviate negative feelings. She is satisfied with what she is and what she has right now. Interpretation: Being an optimistic person really helps people to become contented to what they have. Also, it is good that in the clients case she finds happiness and satisfaction in doing the household chores as a part of her role as a mother and wife. It is also normal that the client experiences weight gain in relation to her pregnancy. Analysis: People with a positive self-concept usually have a greater and more diversified self-knowledge, more realistic perceptions and expectations, and higher selfesteem. (Fundamentals of Nursing, 5th edition, Taylor, et.al., p.822) Often people who have serious doubts about their capabilities decrease their efforts and give up, whereas those with a strong sense of efficacy exert greater effort to master problems or challenges. (Kozier, et. al., Fundamentals in Nursing 7th ed., p. 124.) Maternal optimal weight depends on the womans weight for height and her prepregnant nutritional state. Normal weight gains for pregnant women is 25-35 lbs (11.5-16 kg). (Foundations and Clinical Applications of Nutrition by Groadner et. al. 3rd ed. P. 273). 5. Emotional Pattern The client communicates her emotions verbally. When she is mad or annoyed, she usually verbalizes her feelings and sentiments to the person she is mad to. After doing so, she said that she feels lighter. She is delighted every time she is with her family because it is to her family whom she usually expresses and conveys her feelings since she is very open to them. Interpretation: The client is expressive when it comes to her feelings and emotions. It is good that she is attached to her family who serves as her primary support system and helps her during her pregnancy. Analysis: Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. The inclusion of family members in problem solving helps both the patient and the family to maintain their self-esteem and feeling worth. (Taylor, et. al. Fundamentals of Nursing: The art and Science of Nursing, 5th edition. P. 858).

6. Sexuality The client is not comfortable when talking about her sexual preferences and satisfaction with sexual activity. However, she said that she and her husband express their sexuality not only through sexual intercourse. They always hug and kiss each other even their children. She said that sexual intercourse is not the only basis of love. The client also stated that she was fourteen years old when her menstruation started. She stated that she has a regular menstrual cycle and her menses lasts from 3-4 days. She doesnt suffer from dysmennorhea during her menses. She also said that after her menses, she performs self-breast examination. She and her husband plans the family with two-year interval. The client said that they have decided that this will be her last pregnancy and she will undergo bilateral tubal ligation upon giving birth. Interpretation: The client is not comfortable in sharing the things about their sexual relationship. However, it is normal to show affection through hugging and kissing. Analysis: Clients are often hesitant to introduce the topic of sex with their primary health care providers. They may be too embarrassed or they may think that they should not have sexual problems in our liberated times. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.973) Adults may define sexuality far more broadly and include in their definition such things as touching, hugging, romantic gestures, comfort, warmth, dressing up, joy, spirituality and beauty. (Fundamentals of Nursing by Kozier. p. 978) 7. Family Coping Pattern The client stated that financial resources needed by their family are supported by her husband. It is her task to ensure that each member gets adequate nutrition and other needs are attended, she said that they will do their best so that their children will grow as responsible and God-fearing adults. When problem arises, she and her husband talk it over and decide together on how to solve it. Interpretation: It is normal that the elderly members of the family provide the needs of the younger ones. The family also has a normal family coping pattern. They were able to communicate well when problems occur. Analysis: The economic resources needed by the family are secured by adult members. The family protects the physical health of its members by providing adequate nutrition and health care services. (Fundamentals of Nursing 7th ed., Kozier et. al., pg 191) Family coping mechanisms are the behaviors families used to deal with stress or changes imposed from either within or without. Coping mechanisms can be viewed as an active method of problem solving develops to meet lifes challenges. The coping mechanisms families and individuals develop reflect their individuals resourcefulness. (Fundamentals of Nursing 7th ed., Kozier et. al., pg 193)

B. Socio-Cultural Patterns 1. Cultural Patterns

The client is raised in San Juan City. She has lived a life of a city lady. According to her, she is raised to be independent that is why she usually does things on her own. She celebrates fiesta with her relatives in the provinces and shows that there is still a room for the typical Filipino culture in her heart. With regards to the authority inside their house, she follows the culture that her husband stands for the most authoritative and the one who decides although she can also intervene if its time for decision- making. Whenever health problems arise, she makes solutions based on what her parents have thought her first before seeking advice or help from health professionals. She speaks both English and Tagalog as her medium of communication. Interpretation: The client has lived up the cultural values that she has been exposed to when she was still a child and it has helped her to manage her and her familys life. Analysis: Cultural values often determine the roles of family members, their interactions, who have the authority to make decision and family involvement about care. All aspect of care is influenced by the culture. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.1413) 2. Significant Relationships The client is a mother of a lovely daughter and twin sons. She plays as an ever loving wife to her husband and mother to her children. Her family has a very harmonious relationship and open communication to one another even her relations to other people like their neighbors are quite as well good. She considers her family as the most important persons in her life. Secondly, her friends count a lot too and where she seeks some advices when problem arises. She also has significant relationship with God. She is involved in their communitys charitable projects and other social works. Interpretation: A person normally assumes different roles throughout life. People need to know the expectations of persons around them in order to appropriately act the role. The client is able to meet the expectations of the roles she presume. Analysis: Young adults are typically busy people who face many challenges. They are expected to assume new roles at work, in the home, and in the community, and to develop interests, values and attitudes related to these roles. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.394) 3. Recreation Patterns The client is a housewife. She keeps herself busy doing the household chores and attending the needs of her children with the help of her mother. She is fond of watching the television and reading books and magazines. She also finds time to mingle with her friends whenever they visit her. She added that because of her changing body conditions, she cannot do heavy errands and odd jobs. She is able to do exercise through walking in their garden and watering the plants. Interpretation: The client has sedentary lifestyle. She is not able to do most of the activities she wants because of her present condition. Analysis: People often define their health and physical fitness by their activities because of mental well being and the effectiveness of body functioning depends largely on their mobility status. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.1059) 4. Environment

The client and her children live in an owned house in a private subdivision in San Juan City. According to her, they have 3 rooms and all are air-conditioned and well-ventilated. They use fluorescent lights in their house for proper lighting. Furthermore, she said that their house is very conducive to her health and for her children because it is always kept clean and hazard free. They have fire extinguisher for them to be prepared during emergencies. She always sees to it that all things are in order and are kept clean for she is the one who manages their household. The client stated that the living space in their house are adequate and is conducive to health. Additionally, they have enough source of water and have sewage system. Garbage is collected by the city dump trucks everyday so they have no problem with regards to proper waste disposal. With regards to the community that she is into, she said that their subdivision is always kept clean and orderly because the committee of their subdivision has assigned street sweepers to do the cleaning in their community. There is also adequate street lighting in their subdivision. Interpretation: The client has safe environment, both in their house and community. She has achieved adequate sources of lighting, ventilation and living space. Analysis: Adequate street lighting, safe water and sewage treatment, and regulation of sanitation in food buying and handling all contribute to a healthy, hazard-free community. A safe and secure community strives to be free of excess noise, crime, traffic congestion, dilapidated housing, or unprotected creeks and landfills. A safe home requires well-maintained flooring and carpets, functioning smoke alarms that are strategically placed, and knowledge of fire escape routes. Adequate lighting, both inside and outside, will minimize the potential for accidents. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.671) 5. Economic The client is a plain housewife. Her husband works as an engineer in an oil company in Qatar and earns approximately 50,000 a month as of the moment. With that income, she said that they can suffice all their needs and wants. They dont have any problems with regards to paying all their bills, buying food, maintaining their house, educational plans for their children and health insurance. Interpretation: The client has no problem financially. Their familys needs are met and suffice adequately. Analysis: The economic resources needed by the family are secured by other members. In addition to providing an environment conducive to physical growth and health, the family creates an atmosphere that influences the cognitive and psychosocial growth of its members. As individual needs are met, family members are able to reach out to others in the family and the community, and to society. (Fundamentals of Nursing 7th ed., Kozier et. al., pg 191) C. Spiritual Patterns 1. Religious Beliefs and Practices The clients religion is Iglesia ni Cristo. She believes in God and doesnt forget to pray to seek for guidance in her everyday living and in overcoming all the problems that she encounters. In fact, she always has a rosary in her pocket for she believes that it will protect

her from accidents and evil spirits. When she was young, she used to go to church every Sunday but now, she seldom makes it because of her changing body conditions like she gets easily tired and she often experiences pain in the lower back portion of her body. During Holy week, she practices the belief of fasting and abstinence. It is also the time wherein she restricts herself from eating meat. Interpretation: It is good that despite of her changing health conditions, her faith is still strong and she doesnt forget to pray to cope with her problems. Analysis: Spiritual beliefs and practices are associated with all aspects of a persons life, including health and illness. Life affirming influences enhance life, give meaning and purpose to existence, strengthens ones feelings of self-worth, encourages self-actualization and is health giving and health sustaining. (Taylor, et. al. Fundamentals of Nursing: The art and Science of Nursing, 5th edition. P. 976). 2. Values and Valuing The client is usually optimistic in her actions and decisions. She views most of the things happening to her in a positive way and that helps her to surpass all the problems that come into her way. She values herself and more importantly her family who becomes the center of her attention and life. That is the reason why she plays as a housewife for she values her children and husband too much and she really gives her whole time for them. Moreover, she believes in God, in the dignity and worth of each person. Interpretation: Every person develops different values and beliefs based on their own family orientation, culture, social system and environment. It is natural that people have certain differences to one another because each individual acts through their own choice of actions based on their values. Analysis: Values are freely chosen, enduring beliefs or attitudes about the worth of a person, object, idea or action. Values are important because they influence decisions and actions. . (Kozier, et. al. Fundamentals of Nursing: Concepts, Process and Practice, 7th edition. P. 69). An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family and culture. (Fundamentals of Nursing, 5th edition, Taylor, et.al., p.91) IV. ADL Nutrition Activities of daily Living Before Hospitalization The client has no allergies on food. The client admitted that she is fond of eating vegetables and fruits. The client usually eats five times a day which includes breakfast, 2 snacks, lunch and dinner. She further stated that it is her mother who plans, buys and cooks their meal. The client takes in daily During Hospitalization The client verbalized that she feels weak and seems like she doesnt get hungry. However, she still eats regularly for the fear that her eating pattern might affect her baby. She still continues taking Iberet (Folic) 100mg, Ferrous Analysis and Interpretation Interpretation: It is normal that the client gives significant to her nutritional status as it can greatly influence her health and that of her fetus. Analysis: Pregnancy is not a time for dieting, and severe weight restrictions during pregnancy can result in maternal ketosis, a threat to fetal well-being. (Ladewig, et. al. Maternal Newborn Nursing Care, 5th ed.

100mg of Iberet (Folic), ferrous Sulfate 100mg and drinks two glasses of Anmun Materna as prescribed by her obstetrician. Breakfast- 5 pcs. Pan de sal with peanut butter spread, 1 glass of milk Snack- 1 medium sized ensaymada, 1 glass of water Lunch- 2 cups of rice, 1 cup tinolang manok (breast), 1 medium-sized lakatan, 2 glasses of water Snack- serving of pancit bihon, 1 glass of water Dinner- 1 cup of rice, 1 cup chopsuey, 1 mediumsized daing na bangus, 2 glasses of water

Sulfate 100mg and two glasses of Anmun Materna daily. Breakfast- cup of rice, 1 serving of steamed tilapia, 2 glasses of water. Snack- 1 sky flakes, 1 glass of water Lunch- 1 cup of rice, 1 serving of ampalaya, and 2 glasses of water Snack- 1 chicken sandwich and 2 glasses of water Dinner- 1 cup of rice, 1 serving of steamed vegetables, and 2 glasses of water Bowel elimination The clients defecating pattern changed from once every 2 days to an irregular interval of twice or thrice every six days. The amount of her stool varies from about 100-300 grams per day. It is brown in color, semisolid in form, cylindrical in shape, and has an aromatic odor. Urinary elimination The client urinates for about five times a day. The amount of

P.274) Folic acid, or Folate, is required for normal growth, reproduction, and lactation and prevents the macrocytic, megalobalstic anemia of pregnancy. (Ladewig, et. al. Maternal Newborn Nursing Care, 5th ed. P.281)

Eliminati on

Bowel elimination The client defecates once every other day. It is usually in the morning after she takes her breakfast. Her stool varies in amount from about 100-400 grams per day. It is brown in color, semi-solid in form, cylindrical in shape, and has an aromatic odor. The client said that she does not feel any discomfort in defecating. The patient does not make use of any aids in regulating her pattern of defecation. Urinary elimination The client urinates for about five times a day. The amount of her urine ranges

Interpretation: The patients bowel elimination is normal. The patients voiding pattern is normal; her urine is within normal level and usual in characteristics as well. Analysis: Patterns of defecation vary in frequency, quantity and consistency. Normal stool should be brown in color, formed and semi-solid, aromatic in color and cylindrical in shape. Its regular amount is 100-400 grams per day. (Fundamental of Nursing by: Barbara Kozier pp. 1227) The characteristics of normal feces are - consistency: formed, semi-fluid, Shape is Cylindrical Amount: varies with diet, Odor is aromatic (Kozier, et. al, Fundamentals of Nursing, 5th ed. p. 1183)

from 600-800 ml per day. It is dark amber in color.

her urine ranges from 700-900 ml per day. It is dark amber in color.

A healthy adult produces about 0.5 to 2 liters of urine per day (Smith, Complete Family Health Encyclopedia, p.1034) Characteristics of Urine: Color is amber to straw, Clarity is transparent and clear, and the Odor is faint aromatic. (Kozier, et. al, Fundamentals of Nursing, 7th ed. P. 1262). Voiding in sufficient quantities should be at least every 4-6 hours. (Ladewig, et. al. Maternal Newborn Nursing Care, 5th ed. P.795)

Exercise

The client has a sedentary lifestyle. The client is plain housewife and stays at home most of the time. Her only form of exercise is walking within their backyard and doing some gardening. She said that she does not have any form of formal routine exercises.

The client seldom walks and get up from her bed. She either lay or sit on her bed while watching the television and chatting with her family members.

Interpretation: The change in the clients activity is due to her condition. Analysis: Limitations to movement may be medically prescribed for some health problems. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.1224, 1067)

Hygiene

The client takes a bath twice a day. One in the morning and one in the afternoon. She brushes her teeth every after taking her meals. She regularly cut her nails and changes her clothes as often as the situation asks her to. She always wears slippers inside and outside their house. She also puts makeup whenever she goes out of the house. She uses deodorant, powder, and lotion every after taking a bath.

The client seldom takes a full bath. She only takes towel bath daily that is being provided to her by her mother. She brushes her teeth twice a day. This is in the morning and in the evening before she sleeps. The client also wears, uses deodorant, and powder after taking a towel bath. The client changes her clothes twice a day or as the situation requires.

Interpretation: The clients hygiene prior to hospitalization is normal. She can perform all her hygienic practices with out limitations and restrictions. However, during her stay in the hospital, some of her routinehygiene practices become limited due mainly because of her condition. Daily bath and oral care are affected because of the contraptions attached to her and limited mobility making her unable to go to the bathroom without help and assistance. Analysis: Ill people may not have the motivation or energy to attend to hygiene. (Fundamental of Nursing by: Barbara Kozier pp. 699)

Disease and injury may reduce a persons ability to perform hygiene measures or motivation to follow usual hygiene habits. Weakness, dizziness, and fear of falling may prevent an individual from entering a tub or shower or from bending to wash lower extremities. (Fundamentals of Nursing, 5th edition, Taylor, et.al., p.1009) Sleep Rest Pattern The client sleeps at about 11:00 in the evening and wakes up at about 7:00 in the morning. She sleeps for about 8 hours daily. She takes afternoon naps for about 2 hour every day. She often drinks milk to make her sleep more comfortable. The client does not experience any nightmare. Upon waking up in the morning, the client said that she generally feels rested and that she feels that her energy is just right for her daily activities. The client usually sleeps at about 12:00 in the morning and wakes up at about 6:00 in the morning. She sleeps for about six hours in a day. According to the client, oftentimes she wakes up in the middle of the night due to the hospital staff checking her condition. She is confined to bed and is oftentimes asleep during the day. Interpretation: The client has a normal sleeping pattern before hospitalization. During hospitalization, her sleep pattern changed. Frequent awakenings during the night, because of the constant assessment of the nurse on duty to her, made her sleep disrupted, not enough and unrefreshing. Analysis: Illness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep that normal and the normal rhythm of sleep and wakefulness is often disturbed. (Fundamental of Nursing by: Barbara Kozier pp. 1117-1119) Bed rest may be the therapeutic choice for certain clients; for example, to relieve edema, to reduce metabolic and oxygen needs, to promote tissue repair, or to decrease pain. (Fundamentals of Nursing, 7th edition, Kozier, et.al., p.1224, 1067) Interpretation: It is normal for the client to express his sexuality through caring and giving support to his husband and children. Analysis: Sexual Activity does not have to include intercourse. Many of the nurturing sexual needs of the pregnant woman can be satisfied, cuddling, kissing and being held. (Taylor, et. al. Fundamentals of Nursing: The Art

Sexual activity

The client is married and has 3 children. The client has been married for almost 10 years now and their relationship is still strong. They show their affection by caring for one another and communication more often especially now that her husband is working abroad. The husband always supports the client even if

The client expresses her affection to her husband whenever the latter calls to check on her health and their children. Also, she shows her concern even more to her family now that she is hospitalized. She is very thankful for

he is away.

having a wonderful family who takes care of her.

and Science of edition. P. 247)

Nursing,

5th

V. Physical Assessment A. General Survey Weight: FINDINGS 62.5 kg ANALYSIS AND INTERPRETATION Normal Maternal optimal weight depends on the womans weight for height and her prepregnant nutritional state. Normal weight gains for women is 25-35 lbs (11.5-16 kg) (Foundations and Clinical Applications of Nutrition by Groadner et. al. 3rd ed. P. 273) Normal The average height for Filipino women is 52. (Nutritional Guidelines for Filipinos) Abnormal The expected temperature ranges from 35.8 - 37.3 C Abnormal For adult, normal PR ranges from 60- 100 bpm Abnormal For adult, normal RR ranges from 12 20 cpm Normal For adult, normal BP ranges from 90-130/60-90 mmHg

Height:

52

Temperature: Pulse Rate: Respiratory Rate: Blood Pressure:

37.7C 110 bpm 23 cpm 90/70 mmHg

B. Head-to-Toe Assessment PARTS PHYSICAL ASSESSMENT TECHNIQUE NORMAL FINDINGS Kozier, et. al, Fundamentals of nursing,2004 Chapter 28 Health Assessment ACTUAL FINDINGS ANALYSIS

General Appearance a. mood affect b. signs of distress c. posture d. height and weight e. body movement f. hygiene and grooming

Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Palpation Palpation Palpation

- Appropriate to situation. - No distress noted. - Relaxed, erect posture: coordinated movement. - Clean and neat. - Healthy appearance. Understandable, moderate pace; exhibits thought. - Logical sequence; make sense; has sense of reality

Height: 62 in (52) Weight: 144.1 lbs (65.5 kgs) - clean and tidy - appears weak and dizzy - appears restless - has sense of reality - has difficulty in answering some questions

Normal

Problems in mental status can have many reasons. Further assessment would be needed.

g. obvious signs of illness h. type of clothing i. j. Skin quantity of speech relevance & organization of thoughts a. b. c. d. Color skin moisture skin temperature skin turgor

- Varies from light to deep brown; from ruddy pink to light pink; from yellow tones to olive; uniform in color - moisture in skin folds and axillae - uniform; within normal range - when pinched, skin springs back - 160 convex curvature - highly vascular and pink in light skinned clients; dark-skinned clients may have brown or black pigmentations in

- skin color is light brown - little skin moisture - warm to touch - Skin moves back slowly

Many nutritional deficiencies and fluid imbalance can be recognized by changes to the skin.

Nails

e. f. g. h. i.

plate shape toenail/fingernail color texture tissues surrounding nails blanch test

Inspection Inspection Palpation Inspection

-nails with light nail polish has intact epidermis

Normal

Palpation

longitudinal streaks - smooth texture - intact epidermis - delayed capillary refill

Hair a. evenness of growth over 'the scalp. b. hair thickness or thinness. c. hair texture and oiliness. d. presence of infection Skull & Face j. size, shape, symmetry k. nodules, masses or depressions l. symmetry of facial movements

Inspection Inspection Inspection Inspection Inspection, Palpation Palpation Inspection

- Evenly distributed hair. - Thick Hair. - Silky, resilient hair. No infection or infestation. - Rounded, smooth round contour smooth, uniform consistency; absence of nodules or masses -symmetric or slightly asymmetrical facial features; palpebral fissures equal in size; symmetric nasolabial folds - hair evenly distributed; skin intact - symmetrically aligned; equal movement skin intact; no discharge/discoloration; approximately 15-20 involuntary blinks/minute; bilateral blinking; when lids open, no visible sclera above corneas and upper and lower borders of cornea are slightly covered

- shoulder length straight black hair evenly distributed hair skull is normocephalic and symmetric facial movements are symmetrical

Normal

Normal

Eyes

m. n. o. p. q. r. s.

eyebrows eyelashes eyelids bulbar conjunctiva palpebral conjunctiva sclera lacrimal sac & nasolacrimal duct t. cornea u. pupils

Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection

- eyebrow and lashes aligned and evenly distributed - white sclera - cornea is shiny - able to blink - has 20/20 vision - able to read newspaper but emphasizes that occasionally she experienced

Normal

- transparent; capillaries sometimes evident; sclera appears white - shiny, smooth and pink or red - sclera is white - no edema or tearing - transparent, shiny and smooth; iris visible - black in color; equal in size; 3-7 mm in diameter; round, smooth border, iris is flat and round Ears a. Auricles b. gross hearing acuity tests * normal voce tones Inspection Inspection Inspection Inspection -color same as skin, symmetrical, aligned with outer canthus of eye, mobile and firm and not tender; pinna recoils after it is folded - normal voice tones audible - symmetric and straight; no discharge or flaring; uniform color; not tender; no lesions - air moves freely as the client breathes through the nares -mucosa pink, clear watery discharge, no lesions - intact and in midline - uniform pink in color, soft moist, smooth texture, symmetry of contour, ability to purse lips, no lesions

blurred vision

- auricle is aligned with outer canthus of her eye - does not have difficulty hearing voices

Normal

Nose a. external nose b. patency c. presence of redness, swelling, growths, discharges

Inspection Inspection Inspection

- no deviation in nose appearance - doesnt complain on nose patency

Normal

Mouth a. outer lips b. teeth and gums c. dentures

Inspection Inspection Inspection

pale dry lips intact dentures

Dry, flaking or cracked lips may be caused by dehydration

- 32 adult teeth; smooth, white, shiny tooth enamel; pink gums; moist; no retraction of gums - intact dentures Neck muscles Inspection, palpation - Muscles equal in size; head centered - Coordinated smooth movements with no discomfort - Head flexes 450 - Head hyperextends 600 - Head laterally flexes 400 - Head rotates 700 - Muscles equal in size; head centered Coordinated smooth movements with no discomfort - Head flexes 450 Head hyperextend 600 - Head laterally flexes 400 - Head rotates 700 - It is not visible in inspection Normal

Thyroid gland

Inspection

- not visible on inspection; glands ascend during swallowing but is not visible; lobes may not be palpated; if palpated, lobes are small, smooth centrally located, painless and rise freely with swallowing quiet, rhythmic, effortless - skin intact; uniform temperature; chest wall intact; no tenderness; no masses

Normal

Anterior Thorax a. breathing pattern

Inspection

- quiet, rhythmic, effortless skin intact; uniform temperature; chest wall intact; no tenderness; no masses

Normal

Cardiovascular

a. inspection and palpation of precordium * aortic and pulmonic area * tricuspid area * apical area *epigastric area b. auscultation of heart in all 4 anatomic sites: * aortic * pulmonic * tricuspid * apical (mitral)

Carotid Artery a. palpation b. auscultation

Jugular Veins Breast and axillae a. size, symmetry, contour/shape

Inspection Inspection

- no pulsations - no pulsations; no lifts or heaves - pulsations visible in 50% adults and palpable in most PMI in 5th LICS at or medial to MCL; diameter of 1-2 cm; no lifts or heaves - aortic pulsations - S1: usually heard at all sites; louder at apical S2: heard at all sites; louder at base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60-90 bpm) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many other adults Symmetric pulse volumes; full pulsations, thrusting quality; quality remains the same when client breathes, turns head and changes from sitting to supine position; elastic arterial wall - no sound heard - veins not visible - females: rounded shape, slightly unequal in size,

There are no pulsations in the aortic and pulmonic area. There are no pulsations in the area of tricuspid. There are no pulsations in the apical area. There is presence of aortic pulsation. The S1 and S2 are the only sounds that have been auscultated. S1 was heard louder.

Normal

There are full pulsations on the clients carotid area. No presence of sound heard in the carotid area when auscultated. The jugular veins of the client are not visible. Her breast is symmetrical. The

Normal

Normal Normal

b. skin c. areola d. nipples

generally symmetric Males: breast even with chest wall; if obese, may be similar in shape to female breasts - uniform in color, smooth and intact, diffuse symmetric horizontal or vertical vascular pattern in light skinned people, striae (stretch marks); moles and nevi - round or oval and bilaterally the same; color varies; irregular placement of sebaceous glands on surface of areola; no masses or nodules - round, everted, equal in size, similar in color, soft and smooth; both nipples point in same direction; no discharge except in pregnant and breastfeeding females; inversion of one or both nipples that is present from puberty; no tenderness, masses or nodules Inspection Inspection Inspection unblemished skin; uniform color; silver-white striae or surgical scars - flat or rotund abdomen; progressive enlargement of uterus due to pregnancy - no visible vascular pattern

skin color is light brown and is uniform w/ the other parts of the body. No visible retraction. Her areola is light brown and sebaceous gland is distributed unevenly. It is round and symmetrical. It is pointing to one direction. No tenderness, masses or nodules presence. No discharges and presence of nodules in his nipples. It is round and equal in size.

Abdomen a. skin integrity b. contour and symmetry c. vascular pattern

presence of silver-white striae and a surgical scar - rotund abdomen; progressive enlargement of uterus due to pregnancy

Normal

no visible vascular pattern Muscles a. size b. contractures c. Fasciculations and tremors d. muscle tonicity e. muscle strength Inspection Inspection Inspection - equal size on both sides of the body - no contractures - no fasciculations and tremors - normally firm - Equal strength on each body side - no swelling, tenderness, crepitation or nodules; joints move smoothly - varies to some degree in accordance with persons genetic make-up and degree of physical activity - equal size on both sides of the body - no contractures - no fasciculations and tremors - normally firm - Equal strength on each body side - There is no presence of swelling, crepitation, and nodules. - Wide joint of motion range. - She can stretch her joint in a normal range. She can move it with no signs of difficulties. Normal

Joints a. swelling, tenderness, smoothness of movement, crepitation, presence of nodules b. range of motion

Palpation

Normal

Inspection

References: Fundamentals of Nursing 7th ed. Kozier, Barbara Medical-Surgical Nursing 1991 Ignatavicius and Bayne Health Assessment for Nursing Practice 3rd ed. Wilson

VI. Laboratory and Diagnostic Examination Results Date April 24, 2008 Procedure Hematology RBC Norms 3.55 x 106/mcl Results 3.1 x 106/mcL Interpretation and Analysis Interpretation: The RBC count is below normal. Analysis: Iron deficiency will lower RBC count. In more reduced count, it may indicate hemorrhage, parasites, bone marrow disease, B-12 deficiency, folic acid deficiency or copper deficiency. RBC lives for 120 days so an anemia of any kind other than hemorrhage indicates a long standing problem. Interpretation: The hct count is below normal. Analysis: Provides information on the amount of red blood cells (RBC) present in the blood. Decreased levels means anemia from hemorrhage, parasites, nutritional deficiencies or chronic disease process, such as liver disease, cancer, etc. Increased levels are often seen in dehydration. Interpretation: The amount of hemoglobin is below the normal range. Analysis: The essential oxygen carrier of the blood. Decreased levels indicate the presence of hemorrhage, anemia, iron deficiency. Increased levels indicate higher than normal concentrate of RBC, B12 deficiency (because there are fewer cells). Interpretation: The amount of platelets is below its normal range. Analysis: Decrease in number occurs in bone marrow depression, autoimmune hemolytic anemia, systemic lupus, severe hemorrhage or intravascular coagulation. Increased number may occurs with fracture or blood vessel injury, or cancer. Interpretation: WBC count is within the normal range. Analysis: The body's primary means of fighting infection. Decreased levels may indicate an overwhelming infections (viruses), or drug / chemical poisoning. Increased levels indicate bacterial infection, emotinal upsets and blood disorders.

Hct

36%-44.6%

34 %

Hgb

12.115.3 g/dl

11.2 g/dL

Platelets

130-400 x 10 mcL

125 x 10 mcL

WBC

4.5-11.0x10 3 /mm 3

9.0x10 3 /mm 3

April 24, 2008

Urinalysis Color Appearance Straw Clear Straw Clear Interpretation: The color of the urine and appearance is normal. Analysis: Normal color is yellow to amber. Red is caused by Blood, Dark yellow to brown with yellow form are caused by bilirubin, reddish brown is caused by hemoglobin / myoglobin. Interpretation: The specific gravity is within the normal range. Analysis: 1.007 ~ 1.029 occurs with diabetes mellitus, insipidus, overactive adrenals, excessive thirst and pyometra. Over 1.040 occurs with high fever, dehydration, diabetes mellitus, vomiting, diarhea and severe hemorrhage. Interpretation: The pH level is within the normal range. Analysis: Below the normal pH level or < 4.5 is considered acidic and above the pH level or >8 is alkalosis. Interpretation: There is no presence of protein in the urine. Analysis: Normally, protein is not found in the urine of healthy individuals. If it is found, it is usually albumin. Persistent protenuria is an indication of renal disease. (Wilson, Jane, Clinical Laboratory Guide for Practice, pg 475.) Interpretation: Normal because glucose should not be present in the urine. Analysis: Normally, no glucose is present in the urine. Glucosuria occurs in diabetes militus, adrenal and thyroid disorders and hepatic and central nervous system disease. (Lippincott Williams and Wilkins, Professional Guide to Diagnostic Test, pg 930.) Interpretation: The patient has placenta previa and it is considered to be abnormal. Analysis: Normally, the placenta is attached to the uterus above the cervix. In rare cases, the placentaform low in the uterus and is partially to completely covering the cervix. When the placenta is blocking the cervix, it is called placenta previa.

Specific Gravity

1.015-1.025

1.024

pH

4.5-8

Protein

negative

negative

Glucose

negative

negative

April 24, 2008

Ultrasound: Transvaginal ultrasonograph y

The placenta has attached to the uterine wall close to the cervix

VII. Medication Generic/ Trade Name Terbutaline Sulfate Dosage/ Frequency Adults and patients > 15 yrs: ORAL 5 mg at 6 hour intervals tid during waking hours. If side effects are pronounced, reduce to 2.5 mg tid. Do not exceed 15 mg/day. PARENTERAL 0.25 mg subcutaneously in the lateral deltoid area. If no significant improvement in 15 minutes, give another 0.25 mg dose. Dont exceed 0.5 mg per 4 hours. Indication Tocolytic to prevent preterm labor Contraindication Contraindicated with hypersensitivity to terbutaline; tachyarrhythmia, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane, which sensitize the myocardium to catecholamine; unstable vasomotor system disorders; labor and delivery (may inhibit labor; parenteral use of beta adrenergic can accelerate fetal heart beat, cause hypoglycemia, hypokalemia and pulmonary edema in the mother and hypoglycemia in the neonate), lactation Use cautiously with diabetes, coronary Side effects CNS: restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesias, insomnia, tremor, drowsiness, irritability, weakness, vertigo, headache, seizure, CV, cardiac arrhythmias, palpitation, anginal pain (less likely with bronchodilator doses of this drug than with bronchodilator doses of a non selective beta agonist, changes in BP, ECG changes) GI: nausea, vomiting, heartburn, unusual or bad taste in mouth RESPIRATORY: respiratory difficulties, pulmonary edema, coughing, brochospasm Nursing Responsibilities NURSING INTERVENTIONS: Use minimal doses for minimal periods of time; drug tolerance can occur with prolonged use. WARNING: If a betaadrenergic locker (a cardioselective beta blocker such as atenolol, should be used in patients with respiratory distress) readily available in case cardiac arrhythmias occur. Do not exceed the recommended dosage. TEACHING POINTS: Tell the client not to exceed recommended dosage; adverse effects or loss of effectiveness may result. Read product instructions. Consult health care provider if she has any questions. Inform the client that she may experience these side effects: weakness, dizziness, inability to sleep,

insufficiency, CAD, history of stroke, COPD, hyperthyroidism, history of seizure, psychoneurotic individuals and hypertension. Ferrous Sulfate (FeSO4) Daily requirement for pregnant women: 30-60 mg/day PO Dietary supplemen tation for iron Contraindicated with allergy to any ingredient; sulfite allergy; hemochromatosis, hemosiderosis, hemolytic anemias. Use cautiously with normal iron balance; peptic ulcer, regional enteritis, ulcerative colitis.

OTHER: sweating, pallor, flushing, muscle cramps

nausea, vomiting, fast heart rate, anxiety. Remind the client to report chest pain, dizziness, and insomnia, weakness, tremor or irregular heartbeat, failure to respond to usual dosage. NURSING INTERVENTIONS: Give drug with meals (avoiding milk, eggs, coffee, and tea) if GI discomfort is severe, and slowly increase to build up tolerance. Warn patients that stool may be dark or green. Arrange fro periodic monitoring of Hct and Hgb levels. TEACHING POINTS:

CNS: CNS toxicity, acidosis, coma and death with overdose GI: GI upset, anorexia, nausea, vomiting, constipation, diarrhea, dark stools, temporary staining of the teeth (liquid preparations)

Take drug on an empty

stomach with water. Take after meals f GI upset is severe (avoid milk, eggs, coffee, and tea).

Have periodic blood tests during therapy to determine the appropriate dosage. Do not take this preparation with antacids or

tetracyclines. If these drugs are needed, they will be prescribed. Report severe GI upset, lethargy, rapid respirations, and constipation. NURSING INTERVENTIONS: Administer orally if at all possible.. with sever GI malabsorption or very severe disease, give IV, IM or subcutaneously.

Iberet (Folic acid)

0.8 mg/day

Vitamin supplemen tation of folic acid

Contraindicated with allergy to folic acid preparations; pernicious, aplastic, normocytic anemias.

HYPERSENSITIVITY: Allergic reactions

Test using Schilling test and

serum vitamin B12 levels to rule out pernicious anemia. Therapy may mask signs of pernicious anemia while the neurologic deterioration continues.

TEACHING POINTS: When the cause of megaloblastic anemia is treated or passes, there may be no need for folic acid because it normally exists in sufficient quantities in the diet. Report rash, difficulty breathing, pain or discomfort at injection site.

VIII. Pathophysiology of Placenta Previa

Risk factors: Previous placenta previa Previous caesarean delivery Abortion Multiparity

Short inter-pregnancy interval Women with large placenta from twins or erythroblastosis Smoking Cocaine use Woman who are younger than 20 are at high risk and women older than 30 are increasing risk as they get older

TRAUMA

SURGERY

INFECTION

Scarring/atrophy/inflammation

Abnormal vascularization of endometrium

Placental implantation initiated by the embryo adhering in the lower uterus Covering of cervical OS as placental attachment and growth occurs

Abnormal fetal presentation

(1) Prolonged labor

Placental attachment disrupted as the area gradually thins

(2) Possible caesarean birth (3)Higher perinatal morbidity and mortality rate

Placenta is sheared from the uterine wall, exposing torn vessels and uterine sinus

Uterus unable to contract adequately

Unable to stop the flow of blood from the open blood vessels

HEMORRHAGE Thrombin release Promote VV uterine contractions and vicious from the bleeding cycle of bleeding-contractions-placental site separation-bleeding Hypovolemic shock

Maternal death

Fetal death

Abruptio placenta

S/S:

Hypotension Hyperthermia/hypothermia Tachycardia Restlessness Confusion Chest pain Tachypnea Pallor Cyanosis Decrease urinary output

IX. Ecologic Model Not Applicable X. PRIORITIZED LIST OF NURSING PROBLEMS

NURSING PROBLEMS IDENTIFIED Fluid Volume Deficit R/t Hypovolemia 2/T excessive blood loss

CUES Subjective The client verbalized, Nagulat na nga lang ako, may dugo sa panty ko. Medyo nanghihina ako Objective: T: 37.7C PR: 110 bpm RR: 23 cpm BP: 90/70 mmHg pale appears weak and dizzy dry lips has little skin moisture uterus remains soft and non-tender

JUSTIFICATION Hypovolemia is a serious fluid imbalance that can be associated to blood loss. It can be life-threatening and is considered to be a high priority problem especially for the pregnant client to prevent further fluid and/or electrolyte imbalance.

Risk for Impaired Gas Exchange of the fetus R/T decreased blood volume and maternal hypotension

A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Anxiety R/T concern for own personal status and babys safety

Subjective: The patient verbalized, Natatakot talaga ako sa pwedeng mangyari eh. Ayoko mamatayan ng baby kaya pumunta ako kagad dito nung dinugo ako. Balak naming mag-asawa na maging last na naming baby ito kaya mas lalo akong natatakot.

The placenta is the means of metabolic and nutrient exchange between fetal and maternal circulations. Abnormality in the implantation of the placenta can compromise fetal oxygenation and fetal hypoxia (FHR below 110nbpm) may develop. This problem is a response to perceived threat that is consciously recognized as a danger. It is highly individual and a client experiencing anxiety may require ongoing nursing support to meet client needs and enhance client coping.

Objective: fearful restlessness facial tension Altered thermoregulation, Hyperthermia R/T Hypovolemia Subjective: The client verbalized, Ang init ng pakiramdam ko. Para akong nilalagnat. Kahapon pa ito eh nung dinugo ako. Objective: T: 37.7C PR: 110 bpm RR: 23 cpm BP: 90/70 mmHg pale appears weak and dizzy dry lips has little skin moisture Risk for deficient diversional activitiy R/T bedrest A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. This is an actual problem present at the time of nursing assessment and must be given prompt intervention. According to Maslows hierarchy of needs a normal body temperature signifies a regular body functioning and an increase on the temperature may affect the daily body activities.

Since the client is confined to bed, there is a risk of limited activity and the problem is likely to develop unless health care providers or significant others intervene.

XI. Nursing Care Plan Cues Subjective The client verbalized, Nagulat na nga lang ako, may dugo sa panty ko. Medyo nanghihina ako Objective: T: 37.7C PR: 110 bpm RR: 23 cpm BP: 90/70 mmHg pale appears weak and dizzy dry lips has little skin moisture Nursing Diagnosis Fluid volume deficit related to hypovolemia secondary to excessive blood loss Hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma. Less obvious causes of hypovolemia are internal bleeding and dehydration. Traumatic accidents, chronic illnesses, ruptured ectopic pregnancies, and surgery can all cause internal bleeding. Low fluid intake, extensive vomiting, and severe diarrhea are common causes of dehydration. Goal & objectives Goal: After 24 hours of performing all the nursing interventions, the patient will be able to maintain fluid volume at a functional level as evidenced by stable vital signs, moist mucous membranes, good skin turgor, adequate urinary output, and laboratory values within normal range. Objectives: After performing all the nursing interventions, the client will be able to: 1. Attain normal ranges of vital signs Nursing Interventions Rationale Evaluation Was the Goal Met? Partially met? Unmet? Effectiveness: 1. Was the client able to attain normal ranges in vital signs? () Yes () No 2. Was the client able to have more or less equal fluid intake and output? () Yes () No 3. Was the client able to diminished signs of fluid volume deficit? () Yes () No INDEPENDENT 1a. Monitor Vital Signs, noting signs of tachycardia, tachypnea and fever. Measure central venous pressure if available. Aids in evaluating degree of fluid volume deficit, effectiveness of fluid volume therapy and response to medications. 4. Was the client able to reduce the factors contributing to the problem? () Yes () No 5. Was the client able to know information pertaining to the underlying

2. Have an accurate fluid intake and output 3. Have diminished signs of fluid volume deficit

2. Measure fluid intake and output. 3a. Measure urine specific gravity. 3b. Monitor the client for signs of fluid volume deficits: poor skin turgor, dry mucous membrane, soft and sunken eyeballs, increased pulse rate to rapid, weak, thready pulse that is easily obliterated 4a. Eliminate noxious sights/smell from environment. Limit intake of ice chips. 4b. Change position frequently, provide skin care and maintain dry/wrinkle free bedding. 5a. Monitor amount and characteristics of urine. 5b. Weigh patient daily

Reflects overall hydration status. Reflects hydration status and renal function, which may warn on developing acute renal failure in response to hypovolemia and effect of toxins. Ongoing assessment promotes the nurse to detect early signs and symptoms of complications. Reduces gastric stimulation and vomiting response

condition? () Yes () No 6. Was the client able to correct/replace fluid losses to reverse pathophysiological mechanism? () Yes () No Adequacy: Was the number of interventions sufficient? () Yes () No Why? Acceptability: Were the interventions suitable for the client? () Yes () No Why? Appropriateness: Were the interventions setting result to the clients situation? () Yes () No Why?

4. Decrease feeling of nausea and vomiting

Edematous tissue with compromised circulation is prone to breakdown

5. Obtain information pertaining to her medical condition

Assists in early detection of possible complications. Daily weight is the most sensitive

indicator of fluid loss or gain. COLLABORATIVE: 5c. Monitor laboratory studies. 6. Receive IV fluids and electrolytes, blood or diuretics as ordered by the physician. Cues Subjective: The patient verbalized, Natatakot talaga ako sa pwedeng mangyari eh. Ayoko mamatayan ng baby kaya pumunta ako kagad dito nung dinugo ako. Balak naming magasawa na maging last na naming baby ito kaya mas lalo akong natatakot. Nursing Diagnosis Anxiety related to concern for own personal status and the babys safety Anxiety is a physiological state characterized by cognitive, somatic, emotional, and behavioral components These components combine to create the feelings that we typically recognize as fear, apprehension, or worry. Anxiety is often 6. Administer plasma or blood, fluids, electrolytes, or diuretics as indicated Provides information about hydration and organ function. Replenishes/maintain s circulating volume and electrolyte balance

Goals and Objectives After an hour of performing all the nursing interventions, the patient will appear relaxed and report anxiety is reduced to a manageable level. Objectives: After performing all the nursing interventions, the patient will be able to: 1. Identify feelings of anxiety

Nursing Interventions

Rationale

Evaluation Was the Goal Met? Partially met? Unmet? Effectiveness: 1. Was the client able to identify feelings of anxiety? () Yes () No 2. Was the client able to promote welllness? () Yes () No

1. a. Assess level of anxiety.

b. Monitor

Stress and anxiety can increase a persons risk of stress-related illness.

3. Was the client able to identify healthy ways to deal with and express anxiety? () Yes () No

Objective: fearful restlessness facial tension has difficulty in answering some questions

accompanied by physical sensations such as heart palpitations, nausea, chest pain, shortness of breath, stomach aches, or headache. The cognitive component entails expectation of a diffuse and certain danger. Somatically the body prepares the organism to deal with threat (known as an emergency reaction): blood pressure and heart rate are increased, sweating is increased, bloodflow to the major muscle groups is increased, and immune and digestive system functions are inhibited. Externally, somatic signs of anxiety may include pale skin, sweating,

physical responses. 2. Promote wellness c.Observe behavior indicative of level of anxiety. 2. a. Establish a therapeutic relationship, conveying empathy and unconditional positive regards. b. Be available to client for listening and talking.

Anxiety interferes with a persons ability to relax, rest and sleep. Anxiety interferes with a persons ability to relax, rest and sleep. Trust is an essential first step in the therapeutic relationship.

4. Was the client able to demonstrate problem-solving skills? () Yes () No

Adequacy: Was the number of interventions sufficient? () Yes () No Why? Acceptability: Were the interventions suitable for the client? () Yes () No Why? Appropriateness: Were the interventions setting appropriate to the clients situation? () Yes () No Why?

3. Identify healthy ways to deal with and express anxiety

c. Encourage client to acknowledge and to express feelings.

Anxiety is aroused by a vague, nonspecific threat, identifying the clients perspective will facilitate planning for the best approach to anxiety reduction. Open expression of feelings facilitates identification of specific emotions such as anger, or helplessness, distorted perceptions and unrealistic fears. Describing what

trembling, and pupillary dilation. Emotionally, anxiety causes a sense of dread or panic and physically causes nausea, and chills. Behaviorally, both voluntary and involuntary behaviors may arise directed at escaping or avoiding the source of anxiety and often maladaptive, being most extreme in anxiety disorders. However, anxiety is not always pathological or maladaptive: it is a common emotion along with fear, anger, sadness, and happiness, and it has a very important function in relation to survival. Cues Subjective: The client Nursing Diagnosis Altered thermoregulation,

4. Demonstrate problem-solving skills

3. Assist client to develop self awareness of verbal and nonverbal behavior.

4. a. Assist her to use coping responses that have been successful in the past.

the person experienced immediately prior to feeling anxious, and identifying associated events, will enable the patient to prevent or recognize his anxiety in order to initiate problem solving. Feelings of safety and security increase when an individual identifies previously successful ways of dealing with anxiety-provoking or fearful situations. Fear is reduced when the reality of a situation is confronted in a safe environment.

b. Provide comfort measures.

Goals and Objectives After performing all of the nursing

Nursing Interventions

Rationale

Evaluation Was the Goal Met?

verbalized, Ang init ng pakiramdam ko. Para akong nilalagnat. Kahapon pa ito eh nung dinugo ako. Objective: T: 37.7C PR: 110 bpm RR: 23 cpm BP: 90/70 mmHg pale appears weak and dizzy dry lips has little skin moisture

Hyperthermia R/T Hypovolemia Hyperthermia is a body temperature above the usual range. The clinical signs of fever vary with the onset, course and abatement stages of the fever. These sign occur as a result of changes in the set point of the temperature control mechanism regulated by the hypothalamus. Under normal conditions, whenever the core temperature rises above 37C (98.6 F), the rate of heat loss is increased, resulting in a fall of temperature toward the setpoint level. Conversely, when the core temperature falls below 37C (98.6F), the rate heat production is increased, resulting in a rise in temperature toward the set

interventions, the client will be able to maintain core temperature within normal range. Objectives: After performing all the nursing interventions, the client will be able to: 1. Reduce body temperature by applying necessary undertaking s regarding her fever. a. Monitor vital signs. Vital signs are usually altered when a person has hyperthermia Alcohol sponges are no longer used because they can increase peripheral vascular constriction and CNS depression: cold water sponges/immersion can increase shivering, producing heat. (Doenges, Nurses Pocket Guide, pg 200) To minimize shivering

Partially met? Unmet? Effectiveness: 1. Was the client able to reduce body temperature by applying necessary undertakings regarding her fever? () Yes () No 2. Was the client able to promote welllness? () Yes () No Adequacy: Was the number of interventions sufficient? () Yes () No Why? Acceptability: Were the interventions suitable for the client? () Yes () No Why? Appropriateness: Were the interventions setting appropriate to the clients situation?

b. Promote surface cooling by means of cool tepid sponge baths, local ice pack especially in groin and axillae.

c. Monitor use of hypothermia blanket an wrap extremities. d. Promote cliet safety upon usage

To prevent skin

point.

of hypothermia blanket. e. Maintain bed rest.

trauma

() Yes () No Why?

f. Administer antipyretic, orally as ordered. g. Administer replacement fluids and electrolytes. h. Administer medications to treat underlying cause as ordered. i. Provide highcalorie diet. 2. Promote wellness upon cessation of fever. a. Discuss importance of adequate fluid intake. b. Review signs and symptoms of hyperthermia.

To reduce metabolic demands/oxygen consumption. To allow for timely alterations in therapeutic regimen. Fluids and electrolytes support circulating volume and tissue perfusion. Treatment of underlying causes will prevent the recurrence of hyperthermia. To meet increased metabolic demands To prevent dehydration

Indicates need for prompt intervention

XII. Discharge Plan Medication: Continue oral medications: Terbutaline sulfate, Iberet and Ferrous Sulfate as prescribed. Exercise: Avoid exhaustion and try to reduce stress. If possible, maintain bed rest. Treatment: Not Applicable Heath Teaching: Take medications as prescribed. Have an adequate sleep, good diet and no fatigue. No sudden increase in activity level. Stress the need for personal safety precautions. Recognize signs and symptoms so that if problem occurs, it will be reported immediately to the doctor. Out-Patient: Observe strictly scheduled prenatal check ups and other examinations. Diet: Continue oral supplementation of Folic acid and Iron. Continue drinking two glasses of Anmum Materna daily. Increase intake of carbohydrates like dairy products, fruits, vegetables, and whole grain cereals and breads. Eat high quality protein found in animal products. Fat requirement are unchanged and should account for about 30% of daily caloric intake, of which less than 10% should be saturated fat. Consume at least 8 to 10 (8 oz) glasses of fluid each day, of which 4 to 6 glasses should be water. Spiritual: Advise client to always pray.

Far Eastern University

Nicanor Reyes st. Sampaloc, Manila Institute of Nursing

NURSING PROCESS (PLACENTA PREVIA)

Respectfully Submitted to:

Ms. Emerlyn Gacuya