PURBANCHAL
UNIVERSITY
ASIAN COLLEGE FOR ADVANCE STUDIES
SATDOBATO,LALITPUR
A
CASE STUDY ON
ANTEPARTUM HAEMORRHAGE
(PLACENTA PREVIA)
SUBMITTED TO SUBMITTED BY:
MRS. PARBATI PANDEY SMRITI MANANDHAR
MR. RATNA GURAGAIN
MRS. MAIYA SHOVA MANANDHAR
MRS.BHAGWATI
ACKNOWLEDGEMENT
I am thankful to Asian
college of Advanced Studies for providing me an opportunity to carryout this
case study as practical fulfillment of First year curriculum of post basic bachelor
of midwifery nursing.
I would like to thank all the respected
Madams, hospital staffs and my friends and also to my subject teachers who have
contributed their valuable time, knowledge and guidance to prepare this small
case study about Antepartum haemorrhage.
I want to express my deep gratitude to
MEENA TAMANG (my case), her family and her visitors. This case study would have
never been success without her and her family’s co-operation.
At last I would like to express my
profound appreciation to all my colleagues for their help and support.
Yours Sincerely
SMRITI MANANDHAR
B. N. First Year
Roll No: 37
BACKGROUND
High risk pregnancy is defined as one
in which mother, fetus and newborn is or will be at increased risk for
mortality and morbidity due to problems and complication during pregnancy.
All pregnancies and deliveries are
potentially at risk. However, there are certain categories of pregnancies where
the mother, the fetus or the neonate is in a state of increased risk.
Incidence: - 45% in developing
countries and 25% in developed countries.
The high risk case study gives us the
knowledge about high risk condition in pregnancy; labour and puerperium like
prolong labour, PIH, Post term pregnancy, APH,
PPH, RH Negative, Maternal and Fetal distress, obstructed labour etc.
In this case study I got chance to get
some knowledge about how to manage maternal and fetal health, how to minimize
maternal and fetal risk factor to minimize maternal and fetal mortality and
morbidity.
Globally, 585,000 women died from the
complication of pregnancy and labour (WHO 1996). More than 99% of deaths
occurred in developing countries and the MMR
is at 100 times higher in Nepal
than in other developed countries. The MMR
of Nepal is 539/100000 (1996, DHS) live births in one of the highest in the
South East Asia Region and the world.
It is due to lack of knowledge, poor
health service, poor transportation, lack of awareness, low socio-economic
condition, cultural factors which determines the status of women and their
health seeking practices. If we detect these risks in time we can minimize the
complication and risk in Anti-natal, Intra-natal and Post-natal. Nowadays these
services are included in Safe Motherhood Program.
Objectives of high risk case study:
This
case study was done during my 3rd week of Midwifery practicum on Emergency in
Paropakar Maternity & Women’s Hospital, Thapathali. The objectives of this
case study are to provide holistic approach of care to patient, applying
nursing theory and gain detail knowledge about a particular disease or case.
The case that I have chosen for my case study was Antepartum
haemorrhage(placenta previa).
The specific
objectives of this case study are as follows:-
1.
To upgrade knowledge about Antepartum
haemorrhage(placenta previa), it’s diagnosis, treatment and management
including nursing management.
2.
To develop harmonious relationship among the
patient & visitors.
3. To
provide holistic nursing care to my patient by using nursing process and
nursing theories.
4. To gain the detail knowledge about one
specific case and it’s nursing management.
5. To
identify the causes, pathophysiology, clinical features and diagnostic
investigation of Antepartum haemorrhage(placenta previa).To obtain
detail history & perform physical examination of my patient.
6. To
compare the causes, clinical features, diagnostic investigation & treatment
of Antepartum haemorrhage(placenta
previa)., between the patient & book.
7. To
identify and compare normal developmental task of my patient.
8. To
apply knowledge from the basic science, nursing theory, nursing care plan,
pharmacy and pharmacology and other related courses to plan and implement
nursing care.
9. To
prevent the patient from further complication of disease.
10. To
provide the health education and preventive measures to client and his family
about betterment of health to maintain and promote health and prevent other
common illness and infection.
11. To
minimize the stress of the patient and his family by using appropriate diversional
therapy.
12. To
involve the patient, his family members and health team workers in discharge
planning and follow up.
13. To
precede information and knowledge about Antepartum haemorrhage(placenta
previa) through case presentation.
PART
I
Biographic
data of the patient
Name: MEENA
TAMANG
Age: 40yrs
Address: Makwanpur
Occupation: Housewife
Education: Illiterate
Blood group: O
+ve
Married for: 16
year
Religion: Hindu
Socioeconomic status: Low
socioeconomic status
Attended doctor: Group
‘F’
Unit Incharge: DR.Madhu Shrestha
Husband name: Rajendra Tamang
Occupation: Agriculture
I. P. No: 18255
Diagnosis: G6 P5 L4 at 29+2 WOG
with APH(Placenta Previa)
Date of
Admission: 2068-11-15 at 7.30
A.M
Ward: EMERGENCY
Hospital: Thapathali Maternity Hospital
History
taking
History taking is a type of interview that
is used to collect relevant data from patient. About 80% of the information is
obtained by history taking. History should be taken in systematic way without
any omissions & should be complete & accurate to develop a diagnosis
& effective care plan. The information obtained from history taking is
included in subjective data in the sense that it is given from the patient’s or
relatives own point of view.
I also collected subjective data of my
patient from thorough history. The result of data collected was as follows:
History of present
Illness:
40 yrs pregnant female
of 29 weeks and 2 days gestation
presents to the emergency room because of vaginal bleeding since 1 month;spotty
during early days but significant over the last 5 days. The patient also
reports some contractions, but denies any continuing abdominal pain. She
denies any recent trauma.
Early treatment was done on
reional hetauda Hospital.then the patient war referred to the center
hospital,Paropakar Maternity and Women’s Hospital,Thapathali.
Past Obsetrical History:
-G6 P5l4 (6 gestations, 5parity, 1 pre-term, 4 currently living)
-5 previous SVD’s (spontaneous vaginal delivery)
-4
female child birth in full term gestation and weight consequently
15yrs,12yrs,7yrs,and6 yrs ago
-Second male child birth 13years ago,weighed 2000grams,premature at 32 weeks of
gestation;but died
at 6months with unknown reason
- previous
obstetrical complications during pregnancies : All SVD’s with precipitated
labour of about 4-5 hours and a child
birth premature delivery with mortality of unknown cause at 6 months.
Menstrual History:
Menarche at the age of 15 years
with regular menstrual cycle of 28 -30days.
Minimal blood loss about 50
-100 ml in 4-6 days with occasional dysmenorrhage.
Past
Medical History:
None(no
any history of tuberculosis, diabetes,hypertension,anemia,heart disease,
childhood
disease,jaundice ,allergy to food and drugs and STD )
Past Surgical History:None
Family History:
Unremarkable, no history of twins or multiple gestations
Including no any remarkable medical history of illness in
family.
Social History:
Patient lives with her husband and daughters in rural region of Makwanpur
district. Denies any smoking, alcohol or other drug use during her
pregnancy. Denies any spousal abuse. Illiterate, currently works as
a housewife. Low economic status.
Current Gestational History:
- G6 P5l4
-Date
of Last Menstration: 20/04/068
-Estimated Date of Delivery: 27/1/068
-Estimated Gestational Age (based on dates): 29weeks 2 days
- Antenatal visit at the nearer health post
at hetauda twice ant 1st dose of Inj.T.T. 0.5ml I/M taken
Contraceptive history:
Depo-provera was used.
Health seeking practice:
She belongs to an
uneducated family. Although,she and her family have belief in traditional
method like “Dhami” and “Jhakri”, they were aware about the essentiality of the
health services.If somebody is sick,they
perfer visiting the health post nearby for treatment.
Environmental factor:
Habituated in 2 stroyed
resident with 7 rooms separate kitchen and sanitary laterine within local rural
environment of adequate electricity,water, transportation, local health and
education facilities.
Nutritional History:
Casual dietary pattern of
nepalese khana, roti and non vegeterian meals;usual 5/6 times during
pregnancy.No denial to food and appetite.
Developmental History:
Normal developmental history from infancy to young
adult.
Habits/Psychosocial History:
-sleeping pattern of around
8 hours at night and 2 hours a day if possible.
-interested in household
works and performing daily activities
-normal micturation and
regular bowel habits
-cope and understand the
situation well
-good relation with
family,parents ,peer groups and relatives
-Attitude of male dominant
society persist so,the family crisis of present health prblem and sex
determinance of the child was issued.
Physical
examination of my case
Objective Data :-
I also performed the physical examination
of Mrs.Meena Tamang to determine her
health status. The techniques used for physical examination are:
·
Inspection
·
Palpation
·
Auscultation
·
Percussion
Physical Exam during admission:
Vital Signs:
Stable (BP – 100/60, P – 86 b/min)
General Appearance:
No apparent distress, appeared clinically stable,pallor present
Skin :Elastic,
capillary reflex < 2 seconds
Weight :42kg
Height: 5feet
Uterine Height: 30 cm
Per vaginal bleeding:clots present with
placental tissue seen and
Fetal Lie: Longitudinal
Presentation:Cephalic
Enagement of Presenting part:Free
Contractions:
Present
Fetal Heart Tones:
138 x minute
Cervical Exam: Deferred but cervical OS opened
Brief Differential
Diagnosis:
- Placenta Previa
- Placental Abruption
- Displacement of Cervical Mucous Plug
- Premature Rupture of Membranes
- Cervicitis, Vaginitis/Vulvovaginitis
Diagnostic Tests: Transabdominal Ultrasound (see below)
Number of Gestations:
1
Lie: Longitudinal
Position/Presentation: Right
/Cephalic
Fetal Heart Tones:
144 x minute
Fetal Movements:
Present
Placenta: Partial occlusion of internal cervical os
a)
General
Appearance
Well oriented
to time, place and person. Well conscious, co-operative, slightly anxiety and
fear, no pallor and anemic.
b)
Vital
Sign
Pulse: 86/m
Respiration: 22/m
Temperature: 97 degree F
BP: 100/60
Weight:- 42kg
Height:- 5feet
c)
Nutritional
status
The mother has
gain average weight with respect to height.
d)
Mental
state
Alert response
appreciably
e)
Personal
Hygiene
Seems clear and
wear clean cloths
f)
Head
Clean, dry and
smooth hair, no lice, no extra growth
g)
Ears
Normal shape,
no swollen glands, no valve discharge
h)
Eyes
No discharge,
no swollen, normal vision, normal eye movement
i)
Lips
Normal lips,
moist, no cracks
j)
Tongue
Pink, no
dehydration, moist
k)
Gums
No swelling and
no bleeding
l)
Skin
Slightly pale, no redness, not any liaison
m) Lymph node
Not visible and
palpable
n)
Chest
Symmetric shape
and size of the chest, no shortness of breadth, no any abnormal sound, heart
beat regular and normal
o)
Breast
Both breasts
are symmetrical in shape and size. No lump found
p)
Arms
& legs
Shape and size
normal, full range of motion, Edema + in ankle
q)
Abdomen
1)
Inspection
Ovoid shape,
normal size, no any scar, linea nigra present, no any visible dilated veins
2)
Palpation
·
Fundal
palpation: There is normal growth of fetus
and fundal height term size
·
Pelvic
palpation:On pelvic palpation head is engaged
·
Pelvic
grip palpation: The head is fixed and engaged
3)
Auscultation
On auscultation
FHS is heard regular and 138/min
r)
Genitalia
No swelling, no
redness, no any infection.
s)
Reflexes:
§ Motor and sensory reflex-good
§ Corneal reflex-positive
§ Biceps reflex-positive
§ Triceps reflex-present
§ Brachio-radial reflex-both forearm
flex
§ Knee-jerk reflex-present
§ Planter reflex-present
§ Ankle reflex-present.
Summary of
History Taking and Physical Examination
History taking and physical examination
helps to reveal information about the patient. They are the tool in obtaining
subjective and objective data and thus helps to assemble information about
patient.
About 80% of the information in the
assessment is obtained by history taking. It is therefore essential to take
history in systematic manner. About 15% of the information is revealed by
physical examination. It helps to identify the health status of the patient.
Physical examination is performed to gather objective data and to correlate
them with subjective data. It also reveals additional problems that the patient
have not recognized. When doing physical examination, cephalo-caudal approach
is followed, that is head to toe approach.
After performing history taking and
physical examination following things were found:
·
Patient
was anxious, but cooperative.
·
Patient
belonged to middle class family.
·
No
history of alcoholism and smoking.
·
She
is anxious and restless too.
·
Vitals
are stable
·
Nutritional
status-satisfactory
·
No
any abnormalities found in other regions
·
Appetite-slightly
decreased
PART
II
Antepartum Haemorrhage
Any bleeding that occurs from the
genital tract after the 24 weeks of viability/gestation till before the birth
of the baby
Classification of antepartum
haemorrhage
1.Placental site Bleeding:
A.accidental haemorrhage or Abruptio
placenta:
A condition
characterized by separation of a normally implanted placenta
B.Placenta previa:
Placental
implantation in the lower uterine segment near or at internal cervical OS.
C.Vasa previa:
It is the
rupture of marginal sinuses,most probably the rare cause of APH.
2.Extra placental bleeding:
·
Local cause:
vulvular vein varicosities,cervical
erosions,cervical polyps,cervical carcinomas,and trauma
·
Other causes:
Excessive show
Coagulopathies
Uterine rupture
Idiopathies bleeding
·
Unclassified (bleeding of unknown origin)
PLANCENTA PREVIA:
The implantation of placenta in the
lower uterine segment near or at internal cervical OS.
Based on this patient’s clinical
presentation, placenta previa was suspected and further confirmed by
transvaginal ultrasound. Placenta previa is defined as the presence of
placental tissue over or adjacent to the cervical os.
Risk Factors:
Below is a list of several risk
factors that are associated with placenta previa. Our patient had
several, including increased parity, increased maternal age, and residence in
higher altitude.
List of associated
risk factors for placenta previa. From "Bates Obstetrics."
Epidemiology :
·
1:300livebirths
·
0.3-5% of total APH cases
·
1.5-5% of cases with pervious ceaserean
section
·
Complete placenta previa prevalence rate
:20-45%
·
Partial placenta previa prevalence rate:30%
·
Marginal placenta previa prevalence
rate:25-50%
Classification
of placenta previa:
I.
Type I Placenta previa(Low lying
placenta previa):
Only the lower margin
of placenta reaches into upper portion of uterine segment .vvaginal delivery is
possible. There is th e low risk of antepartum haemorrhage and maternal and
fetal condition is good.
II.
Type II Placenta previa(Low lying
Marginal placenta previa):
Marginal placenta
extends upto lower uterine segment neat the internal Os of the cervix. Vaginal
delivery is possible particularly if placenta is anterior .Blood loss is
usually moderate although maternal and fetal condition vary;fetal hypoxia is
more likely to be present than maternal shock.
III.
Type III placenta previa(incomplete
central placenta previa/partial placenta previa):
Placenta is located
over the internal Os but not centrally.Bleeding is likely to be
severe,particularly when lower uterine segment stretch and cervix begin to
efface and dilate in late pregnancy. Vaginal delivery is inappropriate because
placenta preceeds the fetus.
IV.
Type IV placenta previa(complete central
placenta previa/ total placenta previa )
Placenta is centrally
located over the internal Os and torrential haemorrhage is more likely.
Caesearean section is essential in order to sae the lives of both mother and
fetus.
Diagram showing
different categorizations of placenta previa.
Classically, the clinical
presentation of placenta previa is painless vaginal bleeding
in the second or third trimester. In contrast, placental abruption,
classically presents with painful vaginal bleeding.
Pathophysiolgy:
Placental implantation is intiated by the
embryo (embryonic plate) adhering in the lower (caudal)uterus.With the
placental attachment and growth ,the developing placenta may cover the cervical
os.However it is thought that a defective decidual devascularization occurs
over the cerix,possibly secondary to inflammatory or atrophic changes. As such
of the placenta haing undergone atrophic changes could persist as a vasa
previa.
A leading cause of third trimester bleeding/haemorrhage,placenta
previa present classically,a painless bleeding.Bleeding is though to occur in
association with the development of the lower uterine segment in third
trimester.placental attachment is disrupted at this area gradually in the preparation
of the onset of labour.When this occur
at implantation site as the uterus is unable to contract adequately and stop
thw flow of blood from the open vessels.
Thrombin release from the bleeding
site promotes uterine contraction and a vicious circle of bleeding,uterine
contraction placental separation and bleeding persists.
Aetiology:
The exact cause is generally unknown.
The predisposing factors includes
Predisposing factors includes
S.n
|
According to book
|
According to patient
|
1
|
Grand
multiparity
|
She
is also Grand multiparous mother.
|
2.
|
Multiple
pregnancies
|
Not
present.
|
3
|
Infertility
treatment
|
Not
present
|
4.
|
Previous
uterine surgery/ caeseran section
|
Not
present
|
5.
|
Fetal
Malpresentation
|
Not
present
|
6.
|
Uterine
anomalies
|
Not
present
|
7.
|
Short
interpregnancy interval
|
Interpregnancy
interal is about 1 ½ years
|
8.
|
Smoking
|
Patient
is non smoker
|
9.
|
Cocaine
|
Not
any
|
Sign and symptoms:
Signs:
S.n
|
According to book
|
According to patient
|
1
|
Patient
general condition is pale and anaemic are proportionate to visible blood loss
|
Patient
general condition is pale and anaemic
|
2.
|
On abdominal
examination;
·
The size of
uterus reveals proportion to period of gestation
·
The uterus
feels relaxed, soft and elastic without any localized area of tenderness
·
Persistence of
malpresentation(breech transverse or unstable lies is more frequent)
·
Head floating
while palpation
|
On abdominal examination;
·
The size of
uterus reveals proportion to period of gestation
·
The uterus
feels relaxed, soft and elastic without any localized area of tenderness
·
Persistence of
malpresentation(breech transverse or unstable lies is more frequent)
·
Head floating
while palpation
|
3
|
If severe,signs
of hypovolemic shock may present and fetal distress may predispose.
|
At operation,mild meuconium stained was
observed
|
4.
|
Blood
loss is often bright red
|
Bright red colored blood loss observed
|
Symptoms:
S.n
|
According to book
|
According to patient
|
1
|
Sudden onset
|
-bleeding
present spontaneously 5 days back
|
2.
|
Painless bleeding
|
-Presence of painless bleeding
|
3
|
Apparently
causeless and recurrent
|
No any history of trauma or injury or previous placenta
previa
|
Diagnostics investigations:
Transabdominal (96-98% sensitivity)
or transvaginal (almost 100% sensitivity) ultrasounds are the diagnostic methods of choice
for confirming placenta previa. Ultrasound can not only diagnose placenta
previa, but further define it as complete, partial, or marginal, which can have
implication in how to manage the patient. Placenta previa that is diagnosed
before 24 weeks of gestation should be managed conservatively, and a repeat
sonogrophy should be done between 28 and 32 weeks’ gestation. Many cases
of placenta previa that are diagnosed in the second trimester will resolve by
the third trimester.
Textbook image of
placenta previa from "William's Obstetrics." Transabdominal sonogram
of the placenta (white arrowheads) behind the bladder covering the cervix
(black arrowheads).
Textbook image of
placenta previa from "William's Obstetrics." Transvaginal sonographic
image of the placenta (arrows) completely covering the cervix adjacent to the
fetal head.
Cervical
Examination:
A cervical examination was deferred
in our patient, as appropriate management. Because of the risk of provoking
life-threatening hemorrhage, a digital examination is absolutely
contraindicated until placenta previa is excluded. Such digital cervical
examination is never permissible unless the woman is in an operating room with
all the preparations for immediate cesarean delivery—even the gentlest digital
examination can cause torrential hemorrhage.
Haematological reports:
·
Complete blood count
·
Haematocrit
·
Blood group and
crossmatch
·
Bleeding time/clotting
time
Investigation done to
my case
Investigation
|
Normal value
|
Findings
|
11/15
|
11/16
|
11/18
|
11/20
|
Blood Group
|
|
O positive
|
-
|
-
|
|
Hemoglobin
|
12 – 14 in female
|
7.3
|
9.1
|
4.6
|
9.7
|
WBC
|
|
|
|
|
|
Platelets
|
|
15000
|
-
|
-
|
-
|
Neutrophils
|
|
90
|
-
|
-
|
-
|
Lymphocytes
|
|
10%
|
-
|
-
|
-
|
Sugar (R)
|
80 – 100 mg
|
-
|
-
|
-
|
-
|
Urea
|
15 – 40 mg
|
18
|
-
|
-
|
-
|
Creatinine
|
0.4
|
0.7
|
-
|
-
|
-
|
Sodium
|
135 – 145 m.mol/l
|
138
|
-
|
-
|
-
|
Potassium
|
3.5 – 4.5 m.mol /l
|
4.2
|
-
|
-
|
-
|
Bilirubin T/D
|
|
T-0.9/D-0.3
|
-
|
-
|
-
|
PT
|
|
14sec
|
-
|
-
|
-
|
BT
|
|
12sec
|
-
|
-
|
-
|
SGPT
|
|
16
|
-
|
-
|
-
|
SGOT
|
|
24
|
-
|
-
|
-
|
VDRL
|
|
Non- reactive
|
-
|
-
|
-
|
HBSAG
|
|
-
|
-
|
-
|
HIV
|
|
-
|
-
|
-
|
Alkaline Phosphate
|
|
286
|
-
|
-
|
-
|
PCV
|
|
-
|
-
|
12
|
-
|
Reticulocyte
|
|
-
|
-
|
2.7
|
-
|
X-Ray Abdomen Erect and
Supine: Normal
Ultra Sonogram: Single live fetus with
cephalic presentation
Anterior lying placenta
Normal
AFI 12cm
Fetal
weight approx 1.4kg
Treatment
and management:
Women with a previa may be considered
in one of the following categories:
§ The fetus is preterm and there are no
other indications for delivery
§ The fetus is reasonably mature
§ Labor has ensured
§ Hemorrhage is so severe as to mandate
delivery despite gestational age.
Although our patient was clinically
stable, her bleeding could not be appropriately controlled. It was also
felt that her fetus was reasonably mature, and the decision was made to do an
emergency cesarean section.
Furthermore, as part of management,
large-bore intravenous access and baseline laboratory studies (hemoglobin,
hematocrit, platelet count, blood type and screen, and coagulation studies)
should be obtained. If the patient is less than 34 weeks’ gestation,
administration of antenatal corticosteroids should be undertaken (as was done
in our patient) as well as an assessment of the facility’s emergency
resources for both the mother and the neonate.
According
to Johnson and Macafee protocol:
The first step of management of these
patients is hospitalization
Immediate
treatment:
According to the
book
|
In my patient
|
1. Assessment
|
|
·
History
taking for the conformation of diagnosis
|
Presence of signs and symtoms of placenta previa while
history taking
|
·
Bleeding(fresh
or clots)
|
Fresh bleeding
|
·
Uterus(contracted/relaxed)
|
Relaxed uterus
|
·
Maternal
condition(stable /unstable)
If patient is in shock;
The initial treatment should be restorative consisting
of resucitation,
rest,warmth ,sedation,
and transfusion of blood to overcome shock and re
estabilishment of blood circulation with minimal delay
|
Pale, anemic maternal state,prone to shock
Patient was kept in complete bed rest.
Blood arranged and transfused to maintain blood
circuation
Patient instructed well about the disease condition and
encouraged to express feelings regarding the situation
|
2. Differential diagnosis via
Investigations:
|
|
·
Ultrasonography(allocate
the placenta)
|
USG done(low lying placenta previa identified)
|
·
Haematological
reports
(complete blood counts haematocrits,blood group and
cross match,bleeding time ,clotting time)
|
All these haematological investigations done
|
3.Futher examination
|
|
·
Avoid
vaginal examination
|
Vaginal examination avoided
|
·
Speculum
examination to rule out local cause
|
Speculum examination not done
|
Subsequent
management:
Subsequent management depends upon the
duration of gestaion and severity of the condition.
1.
Expectant
mangement:
The pre requisites for inclusion into expectant mangement
are
§ Gestation
age less than 37 weeks duration
§ Initial
amount of bleeding less than 600 ml
§ Patient
is not in labour
§ Maternal
and fetal condition not in jeopardy
§ Should
extend for more than 1 week in duration to call it successful
The expectant management consists of
the following measures
Ø Complete
bed rest with beside toilet facilities.sedatives such as diazepam 5mg may be
prescribed to improved compliance with bed rest
Ø Blood
should be grouped ,crossmatched and reserved for the patient at all times
Ø Iron
,vitamin and calcium supplements are continued.Laxatives may be given to avoid
straining at stools.Haemoglobin is estimated at regular intervals
Ø Vital
signs and fetal heart sound stable
Ø Approximately
3 days after all bleeding has ceased gentle speculum examination should be
performed to rule out local cause of bleeding
Ø Ultrasound
examination is preferred for placental localization ,it confirms the diagnosis
and judges the severity
Ø Minimal
ambulation
The expectant management is continued until
Ø 37
weeks of pregnancy are completed
Ø Severe
bout of bleeding occurs
Ø The
patient goes into labour
Ø Maternal
and fetal jeopardy
Definitive
mangement:
It
comprises prompt delivery.This is consider whenever
Ø
The patient has her first bout of bleeding after
37 completed weeks
Ø
Sucessful conservative treatment brings the
patient upto 37 weeks
Ø
If the initial or subsequent bout of bleeding
is very severe
Ø
Patient is in labour
Ø
Evidence of maternal or fetal jeopardy
Ø
Intrauterine fetal death
USG is done for determining placental
site –If likelihood for safe vaginal delivery .Vaginal examination is done .ARM
and oxytocin induction is done
If placenta previa of grade II, III
and central variety,serious loss of blood or vaginal delivery adds possibility
for considerable blood loss; Lower Segment ceaserean Section is the treatment
of choice in both before and after 37 weeks of gestation.
In case of profuse bleeding,after restorative
management , Lower Segment ceaserean Section is done.
In
my patient ,emergency
Lower Segment ceaserean Section is done after restorative management.
Mangement
before 37 weeks of pregnancy for LSCS for Fetus:
In the book
|
In my patient:
|
Assessment of lung maturity by
aminocentesis
|
Aminocentesis not done
|
Steroid therapy(betamethasone/Dexamethasone)
|
Dexamethasone 12 mg I/V two dose
given to the mother before LSCS
|
Complications:
According
to book:
1.
Maternal complications:
i.
During pregnancy :
·
Antepartum haemorrhage with varying degree of
shock is an inevitable complication
·
Malpresentation
·
Premature labour
ii.
During labour:
· Premature
rupture of membrane
· Cord
prolapsed
· Slow
dilation of cevix
· Intrapartum
haemorrhage
· High
incidence of operative interference
· Pastpartum
haemorrhage due to imperfect retraction of lower uterine segment on the site where placenta is implanted,atonic
uterus)
· Occasionally
associated (15%)of morbidity adherent placenta on lower segment
· Trauma
to cervix and lower uterine segment because of extreme softness and vascularity
· Patient
may be in shock in relatively small amount of blood loss
· Retained
placenta due to increase placental implant area in uterine segment and mordbid
adherent placenta
iii.
Pueperium:
·
Increase rate for sepsis(due to high
incidence of operative interference,placenta near vagina and anemia
devitalisation of the patient)
·
Subinvolution of the uterus
·
Embolism
2. Fetal
complications:
i. Low
birth weight
ii.Asphyxia
iii. Intra
uterine death
iv. Birth
injuries
v.Congenital malformation
According to the
patient:
1.Maternal
complication:
·
Antepartum
haemorrhage
·
Preterm
delivery
·
Post
partum haemorhage
2.Fetal
complication:
·
Low
birth weight
Nursing
process
Nursing process is defined as a
systematic way of assessing the patient’s needs, planning care, implementing
and evaluating the outcome of care given. It is a scientific and problem
solving approach in nursing. In this caring science, our concern is the patient
and his/her family, prevention of disease and promotion of health.
In my case study, I have provided care
on the base of nursing process. I have address the patient by collecting
subjective and objective data analysis and valid them. Then I detect some
nursing diagnosis such as she was anxiety due to knowledge deficiency about
labour, poor personal hygiene due to health condition (labour pain etc.)
So keeping those conditions of the
patient I applied Orem’s
self care theory while caring my patient.
Dorothea E. Orem: Self care theory
According to Dorothea E. Orem self care
is the ability of individuals to initiate and perform activities on their own
behalf in order to maintain life, health and well being.
Orem’s general theory of nursing is
composed of three inter-related theories, self care theory, self deficit theory
and nursing system theory.
·
Self
care theory: Identifies universal developmental and health deviation self care
requisites.
·
Self
care deficit theory: Which specifies when nursing care is needed, provides the
central focus of Orem’s
general theory of nursing. When the therapeutic self care demand is greater
than a patient’s self care agency, a self care deficit exists and nursing care
is required.
·
Nursing
systems theory comprise three systems – Wholly compensatory, partly
compensatory and supportive educative.
The nurse uses one or more nursing
systems to promote a patient self care.
Nursing Diagnosis done in my patient
·
Deficient Fluid Volume related to fluid shift
from intravascular to extravascular space secondary to vasospasm.
·
Ineffective airway clearance related to the
anesthetic effects.
·
Anxiety related to diagnosis and concern for
self and fetus.
·
Deficient Diversional Activity related to
prolonged bed rest.
·
Risk for urinary tract infection due to
indwelling catheter.
·
Acute pain related to operative procedure.
Nursing Interventions during
hospitalization
Maintaining Fluid Balance
·
Control I.V. fluid intake using a continuous
infusion pump.
·
Monitor intake and output strictly; notify
health care provider if urine output is less than 30 mL/hour.
·
Monitor hematocrit levels to evaluate
intravascular fluid status.
·
Monitor vital signs every hour.
·
Auscultate breath sounds every 2 hours, and
report signs of pulmonary edema (wheezing, crackles, shortness of breath,
increased pulse rate, increased respiratory rate).
Promoting Adequate Tissue Perfusion
·
Increase protein intake to replace protein lost
through kidneys
.
Decreasing Anxiety and Increasing Knowledge
- Explain the disease process and treatment plan
including signs and symptoms of the disease process.
- Allow time to ask questions and discuss feelings
regarding the diagnosis and treatment plan.
Promoting Diversional Activities
- Explain the need for bed rest to the woman and her
support persons.
- Explore woman's hobbies/diversional activities.
- Instruct family to arrange for easy access to TV,
phone, computer, and stereo to limit woman getting out of bed.
- Instruct family to arrange for community support (eg,
church, women's groups).
Maintaining Cardiac Output
I.
Control I.V. fluid intake using a continuous infusion pump.
ii. Monitor intake and output strictly;
notify primary care provider if urine output is less than 30 mL per hour.
iii.
Monitor maternal vital signs, especially mean BP and respirations.
iv.Monitor oxygenation saturation levels
with pulse oximetry. Report oxygenation saturation rate of less than 90% to
primary care provider.
Nursing Management During
the Postpartal Period.
Because
the woman with antepartum haemorrhage is hypovolemic, even normal blood loss
can be serious. Assess the amount of vaginal bleeding and observe the woman for
signs of shock. Monitor blood pressure and pulse every 2 hours for 48 hours.
Check hematocrit daily. Measure intake
and output.Postpartum depression can develop after such a difficult pregnancy.
To help prevent it, provide opportunities for frequent maternal-infant contact
and encourage family members to visit. The couple may have many questions, so be
available for discussion. Give the required information; information of caring
of the children and immunization.
Date
|
S.N
|
Nursing
Diagnosis
|
Goal of
Action
|
Plan of
Action
|
Rationale
|
Implementation
|
Evaluation
|
11/15
|
1
|
Impaired
fetal gas exchange related to altered blood flow and decreased surface area
of gas exchange at the site of pla
|
After 8 hours of nursing intervention ,the patient
will verbalise understanding of causative factors and appropriate treatment
|
-to asses vital sign
-to maintain rest
-to monitor amount and type of bleeding
-to maintain the position of mother on left
Side
-restrict vaginal examination
-monitor uterine contraction and FHS
-maintain positive attitude about fetal outcome
|
-provide
baseline data for maternal blood loss
-systemic
rest is mandatory and important throughout all phases of disease to reduce
fatiue and improve strength
-provide
objective evidence of bleeding
-to
promote placental perfusion
-prevent
tearing of placenta if placenta previa is cause of bleeding
-asses
whether labor is present and fetal status and external system avoids cervical
trauma
-support
mother and child bonding
|
-asses vital sign
-maintain rest
-monitor amount and type of bleeding by saving the
pads
-position mather on left lateral position
-restrict vaginal examination
-monitor uterine contraction and FHS
-maintain positive attitude about fetal outcome
|
After 8 hours of nursing intervention the patient
was able to verbalise understanding of causative factors and appropriate
intervention.My goal was met.
|
11/15
|
2
|
Fluid volume deficit related to excessive blood loss
|
Client’s vital signs and lab values remain normal
|
-to monitor vital signs
-to observe skin color,Oxygen saturation,skin
temperature and loss of conciousness
-evaluate the amount of vaginal bleeding
-to replace the fluid by blood transfusion
|
- provide baseline data for maternal blood loss
-assess
the general condition of patient
-provide
objective evidence of bleeding
-helps in
fluid replacement
|
-monitor vital signs
-observe skin color,Oxygen saturation,skin
temperature and loss of conciousness
- evaluate the amount of vaginal bleeding by
counting pads, presence of clots and pooling of blood
-fluid replacement by II pint blood transfusion
|
Client’s vital signs and lab values was normal in
following day investigations
|
11/16
|
3
|
Fluid volume deficit related to excessive blood loss
|
Client’s vital signs and lab values remain normal
|
-to monitor vital signs
-to observe skin color,Oxygen saturation,skin
temperature and loss of conciousness
-evaluate the amount of vaginal bleeding
-to replace the fluid by blood transfusion
|
- provide baseline data for maternal blood loss
-assess
the general condition of patient
-provide
objective evidence of bleeding
-helps in
fluid replacement
|
-monitor vital signs
-observe skin color,Oxygen saturation,skin
temperature and loss of conciousness
- evaluate the amount of vaginal bleeding by
counting pads, presence of clots and pooling of blood
-fluid replacement by I pint blood transfusion
|
Client’s vital signs and lab values was normal in
following day investigations
|
2068/11/17
|
4
|
Post-operative
pain and discomfort related to excessive cough.
|
Pain will be reduced within 2 hours.
|
- To keep the patient in comfortable position.
-To give analgesics as
prescribed.
- To provide psychological support.
-To give cough expectorant as prescribed.
-To support the incision site while coughing.
-To explain the patient about pain and ask to notify
the duty staff if pain is severe.
-To encourage for deep breathing and coughing
exercise.
|
-It helps
to promote rest and sleep.
-It
relieves from postoperative pain.
-This
reduces anxiety.
-This
helps in easy cough expectoration.
- Prevents
stress on the wound.
- To treat
accordingly.
-This
promotes ventilation in lungs
|
-Kept the
patient in comfortable position.
-Gave
analgesics as prescribed.
-Gave
psychological support.
-Gave
cough expectorant as prescribed.
-Support
the incision site with both hands while coughing.
-Explained
the patient to notify the duty staff about the pain if severe.
-Encouraged
her to take deep breathing and coughing exercises.
|
Goal was achieved as patient felt comfortable from
pain and cough was also reduced.
|
11/18
|
5
|
Fluid volume deficit related to excessive blood loss
|
Client’s vital signs and lab values remain normal
|
-to monitor vital signs
-to observe skin color,Oxygen saturation,skin
temperature and loss of conciousness
-evaluate the amount of vaginal bleeding
-to replace the fluid by blood transfusion
|
- provide baseline data for maternal blood loss
-assess
the general condition of patient
-provide
objective evidence of bleeding
-helps in
fluid replacement
|
-monitor vital signs
-observe skin color,Oxygen saturation,skin
temperature and loss of conciousness
- evaluate the amount of vaginal bleeding by
counting pads, presence of clots and pooling of blood
-fluid replacement by II pint blood transfusion
|
Client’s vital signs and lab values was normal in
following day investigations
|
11/19
|
6
|
Potential risk of infection related to poor hygiene.
|
Infection will be reduced during hospitalization.
|
-To maintain good personal and perineal hygiene.
-To keep the operative site clean and dry.
-To monitor vital signs regularly.
-To watch wound for pain, swelling, soakage and
discharge.
-To control the number of visitors.
|
-Prevents the organisms to enter the incision area.
-Prevents the growth of organisms.
-Elevated temperature indicates the signs of
infection.
-This helps to detect the wound infection.
-Helps in preventing the entry of infection that are
carried from outside by the visitors.
|
-Maintained good personal and perineal hygiene.
-Kept the operation site clean and dry.
-Monitored vital signs regularly.
-Watched the wound for pain, redness, swelling,
soakage and discharge.
-Controlled the number of visitors.
|
Goal was achieved as patient did not develop
infection during hospitalization.
|
11/19
|
7
|
Knowledge deficit related to breast feeding (baby in
PBU)
|
Patient’s knowledge will be increased at the time of
discharge.
|
-To instruct the patient to visit the baby at PBU
and breast feed according to instructed time.
-Teach the patient to feed colostrums.
-To encourage her to squeeze the breast and apply
breast binder.
-To encourage her to feed the baby 2 hourly and as
demanded.
|
-It helps her to learn in real situation.
-Because it is very nutritious for the baby it also
prevents from the diseases.
-To reduce the breast engorgement
-This prevents the baby from hypoglycemia.
|
-Take her to the PBU and handle the baby for breast
feeding.
- Taught her to feed the colostrums
-Encouraged her to squeeze the breast and apply
breast binder.
-Encouraged her to feed the baby 2 hourly and as
demanded.
|
Goal was achieved as patient can feed baby properly
without any difficulty after 5 days.
|
11/20
|
8
|
Alteration in body temperature (100 F) related to
cough on the 4th day of LSCS.
|
Temperature will be reduced to 98 degree F within 1
hour.
|
-To monitor the temperature.
-To open the windows to make the room well
ventilated.
-To remove the blankets.
-To give paracetamol 2 tabs as prescribed.
-To encourage to drink plenty of fluid.
|
-To reassess the fever.
-In order to promote cross ventilation.
-This decreases the temperature by evaporation.
-It directly acts on hypothalamus and decrease the
temperature
-It maintains fluid and electrolyte balance.
|
-Moniterd the temperature.
-Opened the windows to make the room well
ventilated.
-Removed the blankets.
-Gave paracetamol 2 tabs as prescribed.
-Encouraged to drink plenty of fluid.
|
Goal was achieved as patient’s temperature was
reduced to 98 F within 1 hour.
|
11/21
|
9
|
Risk of altered parenting related to infection and
interference with bonding
|
Client will resumes bonding with neonate
|
- to encourage baby care by the mother
-to continue breastfeeding
-to involve father also in baby care
|
-it upgrades the maternal child bonding
|
-encourage baby care by the mother
-continue breastfeeding
-involve partner also in baby care
|
Goal was achieved.The baby was being care by the
mother andfather affectionately.
|
11/22
|
10
|
Need for health education
|
To assist her in self care by upgrade knowlede
|
-to provide teaching about the importance of rest
and exercise, nutrition diet, breast feeding and medications and regular
follow up.
-to provide knowledge about Immunization of baby,
avoid lifting heavy and weighty.
Sign and symptoms of high risk of mother and baby
etc.
|
-upgrade knowledge
awareness of health and provide self
care and self dependence.It helps to self satisfaction.
|
-teach about the importance of rest and exercise,
nutrition diet, breast feeding. continuous with medicines and regular follow
up.
-Immunization of baby, avoid lifting heavy and
weighty.
Sign and symptoms of high risk of mother and baby
etc.
|
She can state about the importance of different
topics of the health care.She has positive response of health teaching so my
goal was fulfilled
|
NURSING CARE PLANS FOR BABY
Date
|
S.N
|
Nursing
Diagnosis
|
Goal of
Action
|
Plan of
Action
|
Rationale
|
Implementation
|
Evaluation
|
2068/11/22
|
1
|
Development of pustules related to poor personal
hygiene.
|
Pustules will be treated within the hospitalization
period.
|
-To assess the pustules.
-To give savlon solution bath and apply betadine on
pustules as ordered.
-Teach the family not to do oil massagetill pusules
present.
-To give psychological support.
-To keep the baby clean and dry.
|
-For prompt treatment
-This prevents the pustules from being spread.
-Oily skin becomes dirty easily and there is a
chance of increasing pustules.
-This reduces anxiety of the patient.
-This prevents from further infection.
|
-Assessed the pustules and informed paediatrician
-Gave savlon bath and applied betadine on pustules
as ordered.
-Taught the family not to do oil massage till
pustules present.
-Gave psychological support to the patient and the
family.
-Kept baby clean and dry.
|
Goal was achieved as pustules were treated.
|
11/22
|
3
|
Potential to develop hypothermia regarding
continuous exposure to external environment.
|
Baby will not develop hypothermia.
|
-To wrap the baby with warm clothes and change the
wet napkins frequently.
-To maintain the room temperature.
-To encourage the mother to feed the baby according
to baby’s demand.
-To monitor body temperature.
|
-This prevents the heat loss due to exposure to cool
environment.
-To provide optimal environmental temperature.
-This prevents from hypoglycemia and to stabilize
the baby’s temperature.
-It provides information as to source of changes in
temperature and to
Detect hypothermia.
|
-Wrapped the baby with warm clothes and changed wet
napkins frequently.
-Maintained the room temperature.
-Encouraged mother to feed the baby according to
baby’s demand.
-Monitored body temperature.
|
Goal was achieved as the baby did not develop any
signs of hypothermia.
|
Drugs
used in my case
1)
Inj.Ampicillin:
Group: Broad spectrum antibiotics
Mechanism:
-it inhibits
the bacterial cell wall synthesis in binary fission which ultimately leads to
cell lysis.
Uses:
-prophylaxis(to
reduce infection)
Dose:
-1
gm I/V 6 hourly
Side effect:
-diarrhoea, nausea,vomitting,skin
rashes,hypersensitivity reaction perioral oedema
Contra-indication:
- allergic
reaction of this drug.
Nursing
management
·
Ask
whether the patient has allergry to penicillin
·
Give
I/V intermittently toprevent the vein irritation
·
Dilute
medicine is stable only for 1 hour,so give after dilution.
2)
Inj.Dexona:
Group: Corticosteriods
Mechanism:
-
crossess
the placental brarrier and stimulates the production of surfactant in the lungs
of the fetus
Uses:
-
to
accelerate fetal lung maturity prior to preterm delivery
Dose:
-12
gm I/V twice a day
Side effect:
-Hypertension,
Decrease in urine output, Increase heart rate uterus, pre-matured birth, fetal
distress, fetal death etc.
Contra-indication:
-hypersentitivity.
Nursing management
·
Observe
carefully for the side effects of overdose.
3)
Oxytocin
(Syntocine)
Group: Hormonal drugs
Mechanism:
-Increase
calcium level in the cell, selective stimulation of uterine muscle and increase
construction of the uterus.
-It expels milk from smaller to larger
amount.
Uses:
-Induce
labour
-uterine
inertia
-to
induce uterine contraction
-pain
with breast engorgement
Dose:
-to
induce labour 2 to 5 units in 500ml of R/L IV drip
-post
delivery 10 unit IM
Side effect:
-Hypertension,
Decrease in urine output, Increase heart rate uterus, pre-matured birth, fetal
distress, fetal death etc.
Contra-indication:
-Feto pelvic
disproportion, fetal distress, abnormal presentation. It is not used if cervix
is not dilated, allergic reaction of this drug.
Nursing
management
·
Blood
pressure and fetal heart rate taken every ½ hourly. If increase stops call the
doctor.
·
If
oxytocine infusion slowly the rate can be increased, if this is no response.
·
Observe
carefully if uterus is contracted or not.
4)
Inj.Cifran:
Group: antibacterial
Mechanism:
-inhibits
bacterial DNA gyrase
Uses:
-enteric
fever
-septicemia
-prophylaxis(post
operatively)
Dose:
-200mg
I/V BD
-50mg
orally BD
Side effect:
- nausea
,vomitting, diarrhoea, joint pain, headache, dizziness, vertigo,jaundice,renal
failure.
Contra-indication:
-hypersentivity.
Nursing
management
·
Donot
chew before swallowing.This medicine may be taken on an empty stomach or with
food.Drink plenty of water or other fluids
·
Continue
taking medicine for the full course of treatment
5)
Metronidazole:
Group: anti protozoal drugs
Mechanism:
-not known,but
nitrogroup is reduced to intermidiate compounds which cause cyto
toxicity,probably by damagin DNA
Uses:
-post
operatively to reduce infection
Dose:
-400
mg TDS
Side effect:
-nausea
,vomitting, diarrhoea, metallic taste, abdominal pain, headache, dizziness,
vertigo.ataxia,urticaria, priritus, flushing
Nursing
management
·
Give
after meals,on full stomach.
·
Encourage
the patient to finish full course of medicine even though side effect may be
unpleasent
·
I/V
form should be administered by slowly infusion don’t by I/V bolus
·
Inform
patient may cause metallic taste
6)
Aciloc:
Group: H2 receptor antagonist
Mechanism:
-it inhibits
the action of histamine on the H2 receptors of parietal cells reducing artric
acid output and concentration under basal condition and also when stimulated by
food , insulin,histamine and caffeine
Uses:
-postoperatively
to avoid GI irritation
Dose:
-injection.Aciloc
50 mg TDS I/V
-Tab.Aciloc
150 mg TDS orally
Side effect:
-dizziness,headache,fatigue,confusion,skin
rashes,rarely liver dysfunction and blood disorders,bradycardia after rapid I/V
injection,hypersensitivity.
Contra-indication
and precaution:
-pregnancy,lactation,renal
and hepatic dysfunction,gastric cancer
Nursing
management
·
Administer
I/V push slowly
·
Instruct
patient to take drug as directed
·
Tell
patient to swallow oral form whole with water;don’t chew..
7)
Diclofenac:
Group: anti inflammatory,analgesic and anti
pyretic
Mechanism:
-analgesics:it
blocks the pain center in thalamus,it inhibits the synthesis of prostaglandin
and prevent sensitization of pain receptor to histamine,bradykinin and 5 HT
agent,mediators of pain and inflammatory
-anti inflammatory
-antipyretic:reduces the temperature
by resetting the temperature regulating center to normal.
Uses:
Postoperatively to
reduce pain
Dose:
-75mg
I/M TDS
-50
mg orally SOS
Side effect:
-nausea,dyspepsia,GI
bleeding,hypersensitivity reaction,tinnitus,mental
confusion,vertigo,thrombocytopenia.
Contra-indication:
-peptic
ulcer,bleeding disorders,severe hepatic and renal insufficiency
Nursing
management
·
Always
administer after meal or with food to decrease GI upset
·
Injection
should be iven deep I/M in luteal muscle;injection site should be rotate
because it is painful
·
Instruct
patient to immediately report GI problems
8)
Tranxemic
acid:
Group: Anti fibrinolytic
Mechanism:
-
It
inhibits activation of plasminogen to plasmin
Uses:
-to
prevent or reduce bleeding
Dose:
-1
gm I/V TDS
Side effect:
-dizziness,diarrhoea,unexpected
pain,eyesight problems,itchy,red or swollen skin,thrombosis
Contra-indication:
-allergy to tranexemic
acid,severe kidney problems,thrombosis,severe brusing,patient who have presence
of blood clots in their blood vessels
Nursing
management
·
Take
the oral medicine with a glass of water .Swallow the whole tablet ,donot crush
or chew
9)
Calcium:
Calcium is
essential nutrient for our body.
Function:
o
Help
to formation bone and teeth.
o
Help
to coagulation of blood.
o
Help
in contraction of muscle.
o
Relay
to electric and chemical massage.
o
Milk
production.
Dose:
o
500
mg/day for adult. Expectant and lactating mother’s required 1000mg/day.
o
Adverse
reaction.
o
Bradycardia,
arrhythmia etc.
Contra –
indication:
Hypercalcaemia, Hypercalciuria, severe renal failure,
renal calculi.
10) Iron (Fe++)
Iron is very
essential mineral for our body. It is involved in oxygen transport.
Dose:
o
Male
and female adult 20-30 mg/day.
o
Children
15-20 mg/day.
o
Pregnant
woman 20-40 mg/day.
o
Lactating
mother 20w-30 mg/day.
Function:
o
Involved
formation of hemoglobin.
o
Help
in brain development and regulation body function.
o
Help
in immuno system.
Uses:
Iron deficiency
anemia ferrous fumarate 400 – 600 mg daily.
Pregnant and
lactating mother: to prevent iron deficiency prophylaxis close 200mg daily.
Side effect:
- Myalgia,
arthralgia, fever, Urtiearia, skin pigmentation anaphylaxis.
11) Ringer’s lactate solution (Rehydration
therapy/ parenteral composition of Ringer’s lactate)
Three
types of chlorides (sodium chloride, potassium chloride, calcium chloride) and
sodium lactate. This solution is very important for our body because it
provides fluid, calories (lactate) and maintains metabolic acidosis in our
body.
Side effect:
-Pulmonary
edema, cardiac failure, hypothermia electrolyte imbalance, metabolic acidosis,
local irritation, conclusion in infant.
Contra
–indication:
- Renal failure, pulmonary edema,
proteiniemic.
Nursing
intervention:
- Watch for sign of fluid overload
PATIENT AND
FAMILY TEACHING DURING HOSPITALIZATION
Health education is a vital part of nursing care of
patient during hospitalization. It is a basis for providing preventive,
promotive, curative as well as rehabilitative services to the patient including
the visitors. As an approach of providing health education to my patient &
visitors, I have included the following points.
About the hospital rules & regulations.
I had explained the
patient about the hospital policy, visiting hours, medication system etc.
About the disease
I gave detail information
to the patient about the disease including causes, signs & symptoms,
treatment, prevention & health maintenance.
About investigations done in patient
During hospitalization the
patient had undergone various diagnostic investigation including blood test
& ultra sono graphy
About Treatment
I gave health teaching to
the patient about the progress of disease & the purposeof treatment,blodd
transfusion done and its requirement .
About possible complications
As
the patient had cesearean section, complication is possible for her. As the
mother is so worried about her condition, the possible complications were
explained to her.
Daily
progress and management of my case
Date: 2068-11-15 at 7.30 A.M.
Meena Tamang arrived
in emergency complaining of per vaginal bleeding,.Her general condition was
afebrile,pallor present.
Vitals:
Temperature: 97degree Fahrenheit
BP: 100/60
Respiration: 22/minute
Pulse: 86/min
FHS: 138/minute
Presentation: Cephalic
Position: LOA
Lie: Longitudinal
Head: 4/5th
Cervical Exam: Deferred
Investigation send for USG,haemoglobin,complete blood count,liver
function test,PT Alkaline phospate.
Management:
-save pads
-arrange IV pints of blood and II pint transfused
-Maintain left lateral position
-catheterization done
-patient admitted and transferred to ANC “B”
Medications:
Inj ampicillin 1gm QID
Inj dexona 12mg BD
Date: 2068-11-16
Vitals:
Temperature: 97degree Fahrenheit
BP: 100/60
Respiration: 22/minute
Pulse: 86/min
FHS: 138/minute
Presentation: Cephalic
Position: LOA
Lie: Longitudinal
Head: 4/5th
Cervical Exam: Deferred
Investigation send for haemoglobin
Management:
-continue observation
-save pads
-I pint blood transfused
-Maintain left lateral position
-catheterization continue
-bed rest
Date: 2068-11-17.
She was transferred to OT
as P/V bleeding preceeds and Emergency LSCS with BTL(Bilateral Tube
Ligation)done.Alive female baby of 1700 gm was delivered at 068/11/17 at 12:45
pm with APGAR 5/10 in 1 minute,9/10 in 5 minutes.
Delivery Report:
Alive female baby delivered
at 068/11/17 at 12:45 pm with APGAR 5/10 in 1 minute,9/10 in 5 minutes
Complete out of placenta
and membrane after 10 minute of baby delivered
Inj .syntocin has been
given I/M after baby born
Type of delivery was
Emergency LSCS with BTL(Bilateral Tube Ligation)
While delivery 700ml, blood loss monitored and slightly
meuconium stained liquor was observed .
Placenta weight 300 gm
Baby was send to PBU due to
premature delivery with low birth weight.
Post operative
interventions:
-patient tranferred to post
operative ward.
-Monitored vital signs ½
hourly
Vitals:
Temperature: 97degree Fahrenheit
BP: 90/60
Respiration: 24/minute
Pulse: 90min
-NPO for the day
-I/O charting done
-Obsevation for p/v
bleeding,abdominal distension and wound soakage
Medications:
-Inj.cifran IV BD
-Inj Metron IV 400mg TDS
-Inj Aciloc IV 50mg TDS
-Inj Tranxemic Acid 1gm TDS
-inj Pethidine 50mg+Inj
phenargan 25mg IM SOS
-Inj Voveran 75mg stat
Date:2068-11-18
She was transferred to
Annex 12,Bed no.202.
Investiagtion send:
Hb:4.6gm%
PCV:12
Reticulocytes:2.7
Physical Exam(postnatal examination):
Vital
Signs:
Stable (BP – 90/60, P – 102)
General Appearance:
No apparent distress, appeared clinically stable,pallor present,no oedema and
icterus
Skin:
Elastic, capillary reflex < 2 seconds
Uterine Height: 24 cm
per abdaomen examination:no abdomen
distension and soakage
Lochia:rubra(discharge
3-4pads a day)
Management :
-II pint whole blood
transfused
-Monitored vital signs ½
hourly
-sips to liquid diet
-I/O charting
done(intake:2900ml;output:1050ml)
-Obsevation for p/v
bleeding,abdominal distension and wound soakage
-Catheter continue
Medications:
-Tab.cifran 500m BD
-Tab Metron IV 400mg TDS
-Tab Aciloc IV 50mg TDS
-Tab Voveran 50mg SOS
Date:2068-11-19
Management :
-I pint whole blood
transfused
-Monitored vital signs
- liquid diet
-I/O charting
done(intake:2800ml;output:1550ml)
-Obsevation for p/v
bleeding,abdominal distension and wound soakage
-Catheter continue
Medications:
-Tab.cifran 500m BD
-Tab Metron IV 400mg TDS
-Tab Aciloc IV 50mg TDS
-Tab Voveran 50mg SOS
Date:2068-11-20
Physical Exam(postnatal examination):
Vital Signs:
Stable (BP – 90/60, P – 102)
General Appearance:
No apparent distress, appeared clinically stable,pallor present,no oedema and
icterus
Skin:
Elastic, capillary reflex < 2 seconds
Uterine Height: 22 cm
per abdaomen examination:no abdomen
distension and soakage
Lochia:rubra(discharge
3pads a day)
Breast:engorged
Management :
-sips to liquid diet
-I/O charting done
-Obsevation for p/v
bleeding,abdominal distension and wound soakage
-Catheter out
-Expressed breast milk
Medications:
-Tab.cifran 500m BD
-Tab Metron IV 400mg TDS
-Tab Aciloc IV 50mg TDS
-Tab Voveran 50mg SOS
Her general condition was improving than the day before. She looked clean and
tidy but she complained abdominal distention and pain. So I advised her to
ambulate.
Date:
2068-11-20 to 2068-11-23(discharge date)
Her general condition was fair. Lochia
rubra pesent at the normal blood loss and I advised her to ambulate and to do
pericare. And I also taught her about pelvic floor exercise, family planning,
hygiene diet, personal hygiene ,breast care etc. During these days her vital
signs are stable suture area also healing.
Baby’s
physical examination
Vital signs
Respiration: 32/m
Pulse: 130/m
Temperature: 97oc
Weight: 3 kg
Length: 45 cm
Sex: Male
General condition: Baby seems small. His movement of
limbs, trunk, head and neck are normal.
Skin: No
cynosis, no jaundice, no rash, color is normal and lymph nodes normal.
Skull: Shape
and size normal, no caput and haematoma, no any injury in head and both
fontanels are normal.
Eyes: Shape,
size and position are normal, no discharge from eyes. No redness and swelling
of any part of eyes.
Ears: Shape,
size and position are normal, no discharge from both ears.
Nose: Shape,
size and position are normal. No discharge. No swelling.
Mouth:
Lips are moist. No cracks, no swelling, no cleft plate and hair lips.
Color of lips is pink. Shape and size of tongue is normal.
Neck: No
congenital goiter and any abnormal presentation.
Chest: Shape and size normal, bell – shaped with
equal anterior, poster and lateral diameter.
Abdomen:
Abdomen is cylindrical shape and slightly distention. Prominent vein is
not dilated, No cord bleeding, Bowel sound are present. No rashes present in
skin.
Genitalia:
Shape, size and position is normal. No discharge. Position of testes is
also normal. No phymosis No scrotal swelling.
Limbs:
Position of upper and lower limbs is normal. No any congenital deformity
found. No rashes. No clubbing and extra fingers. Joint movement is also normal.
Spinal cord:
Normal, no spinal bifida present, no abnormalities found.
Anus:
Anus is also normal. He passed stool.
Rooting reflex:
Present
Sucking reflex: Good
Swallowing reflex: Good
Gagging reflex:
It is not seen or observed
Move reflex:
Present
Grasping, Dancing (stepping), Tonic
neck reflexes:Present
DIVERSIONAL THERAPY USED IN MY PATIENT
TO MINIMIZE THE STRESS
Everyone experiences stress and accompanying
anxiety; this anxiety is increased during illness and the recovery process.
Illness and stress are interwoven to such a degree it is difficult to
determine which precedes the other. When a
person’s adaptive attempts are unsuccessful, illness occurs. Also, a person who
is ill has fewer adaptive resources available to cope with stressors. Even
though some stressors may not directly cause illness, stress is a significant
component in the onset and progression of many diseases.
Being in an unfamiliar environment, losing control
over one’s schedule, and being dependent on others for care are all issues with
which hospitalized clients must cope. Each of these issues is a stressor that
requires adaptation in order to maintain a steady state. Most clients do not
have the energy to cope with the numerous changes simultaneously.
My
patient is a multiparous mother with diagnosis of antepartun haemorrhage. She
is in a state of stressful situation that she is so much worried about herself,
her baby & her husband. She continuously asked us whether she & her
baby is alright or not? So being hospitalized her level of stress has
increased. So as a nurse it is my duty to help my patient minimize her stress.
Here are some of the ways that I tried to minimize stress of my patient.
Meeting Basic Needs
There is a close relationship between basic
physiological needs and stress. Anything that interferes with the satisfaction
of basic needs evokes the stress response and attendant anxiety. Clients who
are cold, hungry, or in pain have higher anxiety levels than those who are
comfortable.
During the period of hospitalization my patient
had NPO for caesarean section for two days. So her basic needs are interrupted
.So in order to fulfill her basic needs I provided Intravenous fluid to her.
Likewise I also helped her to fulfill her elimination needs by helping her to
go to the toilet,
also assisted her to maintain personal hygiene .In
this way I tried my best to meet her basic needs as a way of minimizing her
stress.
Environmental Strategies
Because an individual’s immediate environment can
influence stress levels, it is important for the nurse to decrease
environmental stimuli that may contribute to anxiety.
I tried my best to make the hospital environment
clean, quite & familiar in order t
o reduce stress
of the patient.
Verbalization
Encouraging clients to express their feelings is
especially valuable in stress reduction. Freud (1959) used the term catharsis
to describe the process of talking out one’s feelings. People instinctively
know the value of “getting things off their chest” through verbalization. Verbalization promotes relaxation primarily
in two ways. First, when a feeling is
described it becomes real. Once
the problem is identified, the person can begin to deal effectively with it.
Also, the actual activity of talking uses energy and, therefore, reduces
anxiety.
I encouraged the patient to verbalize her feelings
about disease process, family background, economical status & the care
provided to her. She explained her feelings to me & experienced that her
stress was minimized. She was happy to talk with me.
Involvement of Family and
Significant Others
The client’s developmental stage influences the
type of intervention for stress management. Children and adolescents have
varying coping skills; children of all ages rely on their parents to a varying
degree for security and support. It is important to include the entire family
in the care of the client whenever possible.
As families provide essential support for clients
I allowed the client’s visitors to involve in caring the patient, as an
approach of decreasing client,s anxiety. Her husband was involved in her care
during hospitalization.
There are a variety of stress management
techniques that can easily be taught to clients, families, and significant
others. Many of these techniques are considered to be complementary modalities
as they are used in conjunction with traditional
medical treatment methods (i.e., medication, radiation therapy). Some of the
most common approaches for managing stress are discussed below.
Physical exercise is a powerful way to reduce
anxiety and can be used by clients of all ages and with varying physical
abilities; it must be done on regular basis.
I encouraged the patient to perform regular
physical exercise as tolerated by her in order to reduce stress & be
healthy.
Relaxation
Techniques
There are several approaches that help individuals
relax. (Such as aromatherapy, herbals,
music, and humor) that promote relaxation.
The patient used to listen soft music which is
also one of the approach of relaxation technique.
Progressive muscle relaxation
(PMR) is a method of inducing relaxation by tensing and releasing various
muscle groups. For example, the individual tightens her hands into a fist,
holds the tension for a few seconds, and then slowly relaxes
her fingers and hands, paying particular attention to the different sensations
of tension and relaxation.
I encouraged the patient to perform yoga which is
helpful in inducing muscle relaxation.
Another technique for helping clients manage
stress successfully is guided imagery, a process in which the person uses all
the senses to experience the sensation of relaxation. During guided imagery,
the client is directed to concentrate on a pleasant scene or image in order to
become more relaxed. In many situations, music is a helpful adjunct to guided
imagery.
I instructed the client to concentrate on a
pleasant sound or image to experience the sensation of relaxation.
It is the method of replacing painful and
unpleasant event or situation with pleasant over through self readiness and
action. It helps to relieve pain and induce sleep which can minimize the stress
easily. So I taught my patient about this method and provided her sufficient
rest & adequate sleep.
Health
teaching
Health teaching plays an important
role to prevent disease, promote health as well as to cure disease more rapidly
with out any complications. One of the most important roles of the nurse is to
provide health education. So I, being a nurse, I had also given health
education to patient and family.
·
To
promote the health
·
To
motivate for early diagnosis and treatment
·
To
help limit the disability
·
To
keep in relationship
Keeping above objectives in mind I had
given health education to the patient (since admission to the discharge date at
068/11/23)about following topics.
Topics
Nutrition-Pregnant and postnatal mother needs
balance diet which should have adequate protein, carbohydrate, vitamins,
calcium, iron etc. Balance diet helps to pregnant and postnatal mother to
regain her health and her baby’s health add to promote health and lactation.
She must eat four times per day which is required for lactation.
Most of the mothers are anemic so, the
iron containing diet is also encouraged.
Baby needs good nutrition so mother
has to breast feed the child regularly till 4-5 month without water also. This
is the only one source of good nutrition for the baby. She has to take care
about this
Rest
and activities- Rest
and sleep is very important during pregnant and postnatal mother. So she has to
rest in a day also. Sleep pattern should be good. Light exercise can be done.
Lifting heavy things should be avoided.
Personal
hygiene-This should
be done to prevent infection. Inner clothes should be cleaned, dry and changed
frequently.
Sexual
intercourse and family planning-We
discussed about sexual intercourse and family planning method. As,she has done
permanent family planning,counselling is done and the client opinions
positively towards the operation done.
Care
of the baby-Gently
handling of baby, daily care of eyes, ears and groins with warm cloth, periodic
bath and oil massage, frequently change of napkin, check frequently urine and
stool pass.
Breast
feeding of the baby-I
advice to teach her about demand feeding, exclusive breast feeding. Breast milk
secretion high in amount in night than day so breast feed in night as well as
day. Exclusive breast feeding help to temporary family planning method (LAM).
Medicine-Doctor has prescribed the following
medicines
Tab ferrous
sulphate 1 tab OD for 45 days
Tab calcium 1 tab OD for 45 days
I explained about its usefulness.
Immunization-I explained her about the
importance of immunization for the baby.
Follow
Up-I told her about
the importance of routine check up and health for follow up purpose.
Others-Immediate check up if any signs of
infection, fever, severe headache, pain, swelling, foul discharge, convulsion
etc.
If baby has any problem such as
dyspnoea fever, not sucking breast milk, increase respiration etc. to visit the
doctor as soon as possible.
What
I learn from case study
Case
study is a very good approach for the students to learn about the disease &
nursing practice in depth. It gives us comprehensive knowledge about a specific
disease& relate with real situation. It is the suitable way of applying
theory in practice in real situation. Here are some points which I learned from
this case study.
1)
About the disease
I studied about this disease in
depth by the resources available in, literatures, research, internet and some
journals. I also obtained information from doctor, sisters. I know about the
disease, it’s causes , predisposing factors, pathophysiology, signs &
symptoms, diagnosis, therapeutic management, conservative management, nursing
management, complications & get a chance to compare all these with real case.
2) About the patient
Through this case study I got
the opportunity to know the history of patient, his personal, family,social
,occupational ,educational as well as present & past health history, his
habit, way of living, ways of thinking and its influence on health and illness.
I also got chance to compare normal
developmental task with the patient.
3) About the
family and environment
I also got the information about my patient’s
family background, socio-cultural and education background, concept about
health and illness, nutrition, economic status, religion, traditional beliefs
and general attitude of family toward the disease and treatment
4) About the
nursing care
I applied holistic approach while
proceeding nursing care to the patient, I also applied Orem’s theory of nursing while caring my
patient I also used The NANDA’s diagnosis technique while using the nursing
process. I gain a lot of knowledge about the care plan.
5) About
documentation
Documentation is also the most important and useful skill. So through this
case study my skill of documenting was tremendously improved. I could formulate
the case study systematically and deeply.
6) About
the hospital policy
During my case study , I involved
in every sector of activities like from admission to discharge procedures. I
learnt about the routine care performed in Maternal Intensive Care Unit ,
investigation procedures, medication policy like supplies ,different units,
available resources as well as the process of
reporting , recording & reporting.
, So I could know lots of rules and policy about the Paropakar Maternity & women’s Hospital,
which is really very useful for me.
Summarization
During our clinical practice of major midwifery,
our posting was in thapathali maternity hospital there I have selected a case
for detail study which is in high risk group. In the Emergency The briefing
about the case study given below:
Meena Tamang ,40 years multi parous
woman diagnosed with 29+2 WOG with APH(Placenta Previa) She was came
from Makwanpur to this hospital with the complain of P/V bleeding since last 5
days. First we had done her physical examination then other all investigations
were conducted. The findings were low
lying placenta with patient in anemic state. After she was admitted transferred in ANC”B “at 2068 /11/15.
On the 2068-11-17
she had delivered female baby of 1700 gm. at 12:45 pm Emergency LSCS with
bilateral tube ligation.
During the
hospitalization of the mother and baby, I had provided holistic care to them
considering physical, mental, social, spiritual and economic aspect. I had
provided care on the base of Orem’s
Self care theory.
Patient totally
hospitalization was 8 days. At the time of discharge their (the mother and the
baby) condition was improved, looking happy and cheerful. I gave health
teaching to the patient and her family about nutrition, family planning,
immunization, personal hygiene, rest and exercise, care of baby, medicines;
follow up visit, breast feeding and high risk condition of baby and mother.
Conclusion
When I found this case ‘for the high
risk case study’ to be very important for me, gaining new knowledge, experience
about Antepartum haemorrhage(Placenta previa), physiology changes, complication
and management and up grading confidence in such types of patient care.
My case study was APH(Placenta Previa).
This case study helped me a lot of obtaining comprehensive practical experience
in nursing, management of APHcase.
I had provided total care of this
patient by applying Orem’s
self care theory in planning and implementation of patient’s care health
education gives to patient and her family members about the care of baby and
mother.
Thus the case study was completed on
the base of my plan. I learnt various new experiences. E.g.: theory application,
high risk management, knowledge into predical setting etc.
At last I am satisfied with this case
study because the goals (Objectives) are met.
~
THE END ~
Bibliography:-
1).John T. Queenan, John C.
Hobbins, Catherine Y.2005. Protocols for
high-risk pregnancies Spong.4th edition.
2) Dutta D.C,Text book of Obstretics,2004,page 256-278
3) Daftery Shirish N.,Chakrevarty Sudip,assisted by Daftery.S.:2007,Manual
of Obstretics,2nd edition,page no 230-235
