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Sampaloc, Manila Institute of Nursing
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.).
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.To better assess the percentage coverage. Based on the nature of your condition. 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. . • Any vaginal bleeding in the second or third trimesters. Although this is admitted to be an estimate. HOME TREATMENT If you are pregnant. (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. painless vaginal bleeding may be the only symptom of placenta previa. 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. a woman with placenta previa less than 30% probably can be delivered safely vaginally. • Moderate vaginal bleeding means soaking more than eight pads in 24 hours. and one should not pursue the examination too vigorously or hemorrhage may occur. be alert for any vaginal bleeding. the health care provider must consider how much of the os would be covered if the cervix were fully dilated. • Severe vaginal bleeding means soaking more than one pad in 1 hour (you should not be using tampons). Sudden.You may have questions about a future pregnancy once you have experienced placenta previa. • 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 . A woman with a placenta previa greater than 30% is better to have a cesarean birth. your midwife or health care provider will be able to answer your questions and address your concerns. a placenta that partially or fully covers the cervix.
• How much of your cervix is covered by the placenta. and afterwards continue with postpartum and breast-feeding support and care for mother and newborn infant. • See your midwife or health care provider immediately if you have any bleeding. • Refrain from sexual intercourse after 28 weeks of pregnancy. reading about the experiences of other women. placenta previa causes a stillbirth or newborn death. Whenever possible.In very rare cases. it is important to follow certain precautions: • Avoid all strenuous activities. a cesarean is used for placenta previa deliveries. often times your midwife will be able to continue prenatal care and support before a cesarean delivery is performed. allow yourself time to grieve. your treatment will depend upon: • How much you are bleeding (which influences whether you are monitored as an outpatient or in the hospital). ask your midwife or health care provider about any possible risks. before 28 weeks. whether you need a blood transfusion. If you have placenta previa and are not bleeding. • Have a phone nearby at all times. such as whether you've lost blood and are anemic. • Your fetus's overall maturity and physical condition. • Advise all health professionals who examine you that you must not have pelvic examinations. and other family members may also be deeply affected. . Be sure that he or she knows you have placenta previa. 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. a counselor. Although placenta previa is contraindicated for a homebirth setting or birthing center delivery. and provide delivery support to the mother and her partner during the cesarean surgery. and talking to friends. • Your overall physical condition. Because a vaginal delivery is likely to cause heavy placental bleeding. MEDICAL TREATMENT If you have placenta previa. As stated before. and when delivery is necessary.1°kg). Expect that your partner. such as running or lifting more than approximately 20°lb (9. Should you experience such a loss. or a member of the clergy to help you and your family cope with your loss. Consider meeting with a support group. delivery is delayed until fetal lungs are mature. children.
If you have Rh-negative blood. expect to remain hospitalized and closely monitored until your fetus is mature enough to deliver. you may be hospitalized. tests of fetal lung maturity. Massive bleeding can occur before you can get back to the hospital. • Be close to a hospital that can provide emergency care for both you and a sick or premature infant. usually in the hospital. If you have placenta previa and begin to bleed. • If your fetus is 24 to 34 weeks' gestation. This watching and waiting approach is called expectant management. is the only treatment available for stopping it.• Avoid inserting anything. If you leave the hospital. until bleeding stops. A marginal placenta previa requires bed rest. The course of expectant management is based on your and your fetus's condition. If bleeding stops. the benefit of tocolytic medications in stopping labor is uncertain. amniotic fluid studies and ultrasonic growth measurements (not reliable) are usually recommended. into the vagina. but you should stay in the hospital if your midwife and other health care providers recommend it until delivery. However. 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. you may be given tocolytic medication to slow or stop the contractions. Moderate blood loss can be replaced with a blood transfusion to prolong your pregnancy until your fetus is mature enough to deliver. • Should bleeding become severe and uncontrollable. • If you have labor contractions. You may have an amniocentesis to see how developed your fetus's lungs are. delivery can most likely be delayed. an immediate cesarean delivery. your immune system will develop antibodies that are dangerous to an Rh-positive fetus (Rh sensitization). you may get up. About 1 in 10 of women with placenta previa requires a hysterectomy to stop uncontrollable bleeding. possibly with a blood transfusion. sometimes at home. Electronic fetal monitoring is used in the hospital to check the fetus's condition. . you will have a cesarean delivery. If your fetus is mature. you may be given corticosteroids to improve fetal lung development and prepare for an early birth. DELIVERY In determining the best time for delivery. such as tampons or vaginal douches. Should you be exposed to your fetus's Rh-positive blood without Rh immune globulin. • If your bleeding does not stop. If your bleeding lessens or stops. you will be given Rh immune globulin in case your fetus has Rh-positive blood. your life and that of your child will be at risk.
or if too much bleeding is endangering you or your fetus. or NICU. he or she may need care in a neonatal intensive care unit. cesarean section is often recommended to reduce the complications for both mother and child that could result from an emergency delivery. 10 Infant problems following placenta previa are usually related to prematurity. Emergency surgery may need to be performed if severe bleeding (hemorrhage) occurs. Care in the NICU can last days or weeks. depending on the extent of a baby's problems and the amount of care needed. If you are near the expected delivery date and studies reveal more than a marginal or lowlying placenta. a cesarean section is always used when placenta previa is present. Cesarean delivery is the method of choice with placenta previa. Because disturbing the placenta with a vaginal delivery can cause severe bleeding. . your baby will be delivered. When your fetus is mature enough. Delivery involving placenta previa is done by cesarean section. If your infant is premature. Nearly half of placenta previa deliveries are preterm (before the 37th week of pregnancy).
MEDICATION Only minimal analgesic medications. will be used in delivery so as to increase the child's survival chances. Don't use aspirin during pregnancy unless advised to do so by your midwife or health care provider (it may increase risk of bleeding). ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM . DIET While you are bleeding and as long as surgery is being considered. Rhogam is a blood-product and it isn't 100% effective. Eating solid food before surgery can cause anesthesia problems. Blood transfusions may be necessary. drink liquids only. Do not resume normal activities until specific instructions to do so are given to you.Treatment for placenta previa can be done by an obstetrician or perinatologist. Treatment for a premature infant can be provided by a neonatologist. The mother should be informed about pros and cons of Rhogam and the potential hazards and side effects associated with it. Avoid sexual relations until otherwise instructed. If the mother is Rh negative and the baby is Rh positive. continue with your regular prenatal dietary program. If you are resting at home. ACTIVITY If you are able to remain at home. if any. 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. rest in bed until bleeding and other symptoms cease.
uterine tubes (or fallopian tubes). 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. The internal reproductive organs of the female are located within the pelvis. The uterus and the vagina are in the midline. Ovaries . and mammary glands. with an ovary too each side of the uterus. between the urinary bladder and the rectum. PARTS AND FUNCTIONS OF THE FEMALE REPRODUCTIVE SYTEM The female reproductive organs consist of the ovaries. external genitalia. uterus. vagina. The internal reproductive organs are held in place within the pelvis by a group of ligaments.A.
the ovaries are attached to the posterior surface of the broad ligament by folds of peritoneum called the mesovarium. The ovarian arteries. and nerves are located. Each of the ovarian follicles contains an oocyte. the female germ cell.The two ovaries are small organs suspended in the pelvic cavity by ligaments. and the ovarian ligament attaches the ovary to the superior margin of the uterus. The outer part of the ovary is made up of dense connective tissue and contains ovarian follicles. Loose connective tissue makes up the inner pan of the ovary. Uterine Tubes . veins. lymphatic vessels. A layer of visceral peritoneum covers the surface of the ovary. where blood vessels. and nerves traverse the suspensory ligament and enter the ovary through the mesovarium. The suspensory ligament extends from each ovary to the lateral body wall. In addition.
rounded part directed superiorly.A uterine tube. and the narrower part. As a result. Internally. The fimbriae nearly surround the surface of the ovary. Cilia on the fimbriae surface sweep the oocyte into the uterine tube. also called a fallopian tube. thin processes called fimbriae. is directed inferiorly. It is oriented in the pelvic cavity with the larger. The uterine tubes extend from the area of the ovaries to the uterus. Fertilization usually occurs in the part of the uterine tube near the ovary. the uterine cavity in the fundus and uterine body continues . They open directly into the peritoneal cavity near each ovary and receive the oocyte. or oviduct is associated with each ovary. Uterus The uterus is as big as a medium-sized pear. The part of the uterus superior to the entrance of the uterine tubes is called the fundus. it comes into contact with the surface of the fimbriae. the cervix. as soon as the oocyte is ovulated. The main part of the uterus is called the body. The opening of each uterine tube is surrounded by long.
called the serous layer. and it can stretch . The vagina extends from the uterus to the outside of the body. a muscular layer. It also allows menstrual flow and childbirth.through the cervix as the cervical canal. is quite thick. which opens into the vagina. the uterus can extend inferiorly into the vagina. consists of smooth muscle. The cervical canal is lined by mucous glands. The muscular layer is smooth muscle and contains many elastic fibers. or perimetrium. 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. Vagina The vagina is the female organ of copulation and functions to receive the penis during intercourse. The middle layer. called endometrial glands. a condition called a prolapsed uterus. The superficial part of the endometrium is sloughed off during menstruation. The uterine wall is composed of three layers: a serous layer. Simple tubular glands. The outer layer. is formed from peritoneum. In addition to these ligaments that support the uterus. much support is provided inferiorly to the uterus by skeletal muscles of the pelvic floor. called the muscular layer. The uterus is supported by the broad ligament and the round ligament. and a layer of endometrium. The endometrium consists of simple columnar epithelial cells with an underlying connective tissue layer. The innermost layer of the uterus is the endometrium. or myometrium. are formed by folds of the endometrium. and accounts for the bulk of the uterine wall. If these muscles are weakened such as in childbirth. Thus the vagina can increase in size to accommodate the penis during intercourse. of the uterus.
The urethra opens just anterior to the vagina. and it is made up of erectile tissue. . More commonly. are openings of the greater vestibular glands. On each side of the vestibule. The vestibule is the space into which the vagina and urethra open. consist of the vestibule and its surrounding structures. in which case it must be removed to allow menstrual flow. The hymen can completely close the vaginal orifice. the clitoris is well supplied with sensory receptors. longitudinal skin folds called the labia minora. The mucous membrane is moist stratified squamous epithelium that forms a protective surface layer. or pudendum. 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. In young females. Additional erectile tissue is located on either side of the vaginal opening. The clitoris consists of a shaft and a distal glans.greatly during childbirth. also called the vulva. the hymen is perforated by one or several holes. Lubricating fluid passes through the vaginal epithelium into the vagina. The two labia minora unite over the clitoris to form a fold of skin called the prepuce. Like the glans penis. The condition of the hymen is therefore not a reliable indicator of virginity. They produce a lubricating fluid that helps maintain the moistness of the vestibule. the vaginal opening is covered by 3 thin mucous membrane called the hymen. The vestibule is bordered by a pair of thin. A small erectile structure called the clitoris is located in the anterior margin of the vestibule. External Genitalia The external female genitalia. The openings in the hymen are usually greatly enlarged during the first sexual intercourse. between the vaginal opening and the labia minora.
closing the pudendal cleft and coverer. The space between the labia majora is called the pudendal cleft. Externally. and both males and females possess a rudimentary duct system. surface of the mons pubis are covered with coarse hair . 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. the general structure of the male and female breasts is similar. the deeper structures within the vestibule. . The skin and muscle of this region can tear during childbirth. however. the labia majora are in contact with each other across the midline. In prepubescent children. Some males also experience a minor and tem porary enlargement of the breasts at puberty. a condi tion called gynecomastia. Mammary Glands The mammary glands are the organs of milk pro duction and are located in the breasts. Alternatively. Most of the time. each of the breasts of both males and fe males have a raised nipple surrounded by a circular. To prevent such tearing. The mammary glands are modified sweat glands. allowing the perineum to stretch slowly during the delivery can prevent tearing. making an episiotomy unnecessary. The breasts of a male can become permanently enlarged. This clean. pigmented areola.Lateral to the labia minora are two prominent. Causes of gy-necomastia include hormonal imbalances and the abuse of anabolic steroids. or mammae. straight incision is easier to repair than a tear. The medial surfaces of the labia majora are covered with numerous sebaceous and sweat glands. The region between the vagina and the anus is the clinical perineum. an incision called an episiotomy is sometimes made in the clinical perineum. The female breasts begin to enlarge during puberty. under the influence of estrogen and progesterone.
or lactating. These hormones are also essential for the normal function of the reproductive system and reproductive behavior. B. and sexual arousal. FUNCTIONS OF THE FEMALE REPRODUCTIVE SYSTEM The female reproductive system performs the following functions: 1. the ends of these ducts expand to form secretory sacs called alveoli. . which extend from the fascia over the pectoralis major muscles to the skin over the breasts and prevent them from excessive sagging. • The reproductive system produces female sex cells in the ovaries. The nipples are very sensitive to tactile stimulation and contain smooth muscle. 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. mammary gland. Within a lobule. It is primarily this superficial fat that gives the breast its form. • The female reproductive system includes structures that receives sperm cells from the male and transports the sperm cells to the site of fertilization. Each lobe possesses a single duct which opens independently to the surface of the nipple. 4. In the milk-producing. the smooth muscle cells contract in response to stimuli such as touch. In older adults. The breasts are supported by the mammary ligaments. The duct of each lobe is formed as several smaller ducts that originated from lobules converge. Reception of sperm cells from the male. 3. the nipple becomes erect. cold.Each adult female breast contains mammary glands con sisting of usually 15 to 20 glandular lobes covered by a considerable amount of fat tissue. the ducts branch and become even smaller. When the smooth muscle contracts. 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. Production of female sex cells. increasing the tendency for the breasts to sag. 2. the mammary ligaments can weaken and elongate.
diagnosing. 2. indeed we are so much blessed to be a part of recognized and well-established institution. As we take another step of our dream. you filled our faces with smiles and laughter. Manalo Lying-In has been so memorable and definitely remarkable. To be able to enhance the skills in assessing. To be able to utilize the nursing care process in prioritizing the needs of a client with disturbances in reproductive system. ma’am. With you. Our stay in F. We will never forget you ma’am! We love you! General Objective: To be able acquire the knowledge. Undeniably. You have given us unforgettable and superb experience in handling patients most particularly with regard to suturing and performing Leopold’s maneuver. Specific Objectives: To be able to discuss the nature and pathophysiology of Placenta Previa. Felix Y Manalo Puericulture Center. planning. NURSING PROCESS I. You have been so kind and understanding. to treasure and to take pride of. N. implementing and evaluating for the improvement of our skills and also the improvement of the client’s condition. With the new learning. . R Address: #42 A&L Subd. and most especially establish a lifetime relationship with you. skills and attitude relevant to the care of clients with nursing problems related to reproductive system. eat a lot of scrumptious foods. Biographic Data Name: Mrs. Thank you ma’am for being a great clinical instructress and a mother to the 112 babies. experiences are our best teacher but without the people to deal with and take part of these experiences.. we cannot ask for more. Ma’am. You serve as our inspiration to fulfill our dreams as we take the challenges of nursing life.STUDENTS’ INSIGHTS AND EXPERIENCES Nursing life is a journey of a lifetime to be cherished. Gender: F Religious Affiliation: Iglesia ni Cristo Marital Status: Married Occupation: housewife Chief Complaint: bleeding .o. Domingo St. utilizing nursing process.. You’re astonishing beauty inside and out make us admire you. we cannot say that we have achieved the best knowledge we are opt to have. new acquaintances and new experiences we have gained during our stay. We were able to meet new faces whom we consider friends. 3. we experience no dull moments. San Juan City Age: 32 y.
Her estimated date of confinement is on July 22. measles. and mumps during her childhood years. she feels stressed when taking care of her children and bearing with her pregnancy. To ease and cope with the stress.Provisional Diagnosis: Placenta Previa II. 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. the client suffered from unexplained vaginal bleeding and fever. History of Present Illness One day prior to admission. Obstetric History The client is 27 2/7 weeks pregnant on her third pregnancy. III. Family History The patient has acquired familial diseases from both sides of her family. She has no known allergies on food and medications. she will be . She is currently taking her Iberet (Folic. C. The client stated that she felt relieved upon knowing her mother’s decision since her husband left for Qatar for work three months ago. Past Health History The client had acquired chicken pox. B. the client’s mother decided to stay in their house in order to help her take care of her children. Nursing History A. PATERNAL SIDE (+) Hypertension (+) Diabetes (+) Heart disease (-) Cancer D. she watches television and takes a nap whenever she feels tired. 2007. On the day of consultation. Often times. 2008. the client makes her self relaxed by reading books and some magazines. Her last menstrual period was on October 15. 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. Patterns of Functioning MATERNAL SIDE (+) Hypertension (+) Diabetes (-) Heart disease (-) Cancer A. the client underwent examinations that prompt to admission for management of the condition. she is still positive and very happy because in 3 months time. Although. According to her. 100mg) and Ferrous sulfate (100mg) a day as prescribed by her obstetrician. Psychological Health 1. she had received 5 doses of tetanus toxoid during her previous pregnancies. A month ago. The client’s obstetric score is G3P2 (3003).
it is understandable and in moderate pace. et. and can have both positive and negative effects. Furthermore. . 5th edition. P. et. 2. she still feels his love and support. (Fundamentals of Nursing. The client displays appropriateness to the situation. Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. especially now that she is in her 27 2/7 weeks of pregnancy. The major sources of stress in our society arise from interpersonal relationships and performance demands rather than from actual physical threat (Pender.850-852) Situational stress can occur at any time. Fundamentals of Nursing: The art and Science of Nursing.The client exhibits association of verbalization. Each individual has different ways on how to cope with these situational stressors. or a danger. 858). The client’s words make sense and have sense of reality. 858) 3. She said that she also enjoys being with her children and taking care of them. Analysis: Family and friends can provide the social support necessary to help the patient manage and adapt to stress. 5th edition. Her activities like reading books and magazines and watching tv is her way of responding to stress. 858). et. She talks to them in a nice way.. Fundamentals of Nursing: The art and Science of Nursing. her vision is 20/20. Exhaustion results when the adaptive mechanisms are exhausted. She doesn’t 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. She verbalized that now that she is pregnant and her husband works abroad. 5th edition. When listening to the client’s speech. Without defense against the stressor. (Taylor. and family member). a threat. loss (belongings. al. an example of situational stress which may be either positive or negative includes the following: illness.al. 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. al. Interpretation: It is normal that the patient recognizes the importance of her family and friends especially in times when she needs them most. P. Interpretation: It is normal that the client feels exhausted upon attending to the needs of her children. (Taylor. According to the client. new job and pregnancy. P. The patient said that she is friendly to her neighbors. Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. Interaction Pattern The patient said that she has an open communication with her family and with her inlaws. Fundamentals of Nursing: The art and Science of Nursing. (Taylor. she needs the company and support of family and friends to keep her happy and to keep her going. Analysis: Stress results from a change in environment that is perceived as a challenge. relationships. Taylor. The client stated that her husband calls her every two days and though far away. accident. marriage or divorce. 2002). Cognitive Pattern The client does not experience any memory loss. p. al. the client has no complaint with regards to her senses. The family can provide the social support necessary to help the patient manage and adapt to stress. the body may either rest or mobilize its defenses to return to normal or reach total exhaustion and die. et. 5th edition.delivering another member of the family.
. and higher selfesteem. Self-Concept The client stated that she is a simple person who’s not fond of dressing up except only on special occasions. Even though she doesn’t have a job. 5th edition. it is good that in the client’s case she finds happiness and satisfaction in doing the household chores as a part of her role as a mother and wife. She is satisfied with what she is and what she has right now. (Fundamentals of Nursing. Taylor. It is good that she is attached to her family who serves as her primary support system and helps her during her pregnancy. 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. p. p. et. Interpretation: Being an optimistic person really helps people to become contented to what they have. Whenever she’s angry or anxious. Kozier. The inclusion of family members in problem solving helps both the patient and the family to maintain their self-esteem and feeling worth. p. Fundamentals in Nursing 7th ed. Fundamentals of Nursing: The art and Science of Nursing.. 5th edition. Also. (Fundamentals of Nursing.al. 124.5-16 kg). She doesn’t like it whenever she gets sick. (Kozier. When she is mad or annoyed. . Analysis: An individual’s senses are essential for growth. The client also stated that she feels good about herself and how she looks. more realistic perceptions and expectations. Any alteration in people’s sensory functions can affect their ability to function within the environment. et. The client is not affected emotionally with the changes that occur in her weight and physique. 5. Sensory stimuli give meaning to events in the environment. It is also normal that the client experiences weight gain in relation to her pregnancy. whereas those with a strong sense of efficacy exert greater effort to master problems or challenges. 273). Normal weight gains for pregnant women is 25-35 lbs (11.al.) Maternal optimal weight depends on the woman’s weight for height and her prepregnant nutritional state. she said that she feels lighter. (Taylor. she finds contentment in doing the household chores and attending the needs of her children. 7th edition. et. al. She also stated that what’s more important for her is to meet her role expectations. et. 858). 3rd ed. Analysis: People with a positive self-concept usually have a greater and more diversified self-knowledge.. After doing so. Interpretation: The client is expressive when it comes to her feelings and emotions. P. al. (Foundations and Clinical Applications of Nutrition by Groadner et. Emotional Pattern The client communicates her emotions verbally. She also added that she gets depressed when she fails to do a household chore due to lack of energy to do so.939) 4. al.Interpretation: The client‘s sensory perception is in normal condition and it functions very well so her ability to deal with her environment is also normal.822) Often people who have serious doubts about their capabilities decrease their efforts and give up. development. she usually verbalizes her feelings and sentiments to the person she is mad to. all she has to do is to take a rest to help her self alleviate negative feelings. P. Analysis: Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. and survival..
spirituality and beauty. She stated that she has a regular menstrual cycle and her menses lasts from 3-4 days. (Fundamentals of Nursing. she said that they will do their best so that their children will grow as responsible and God-fearing adults. Analysis: The economic resources needed by the family are secured by adult members. The family also has a normal family coping pattern. She doesn’t suffer from dysmennorhea during her menses. However. Kozier. 978) 7. She also said that after her menses. When problem arises. pg 193) B. (Fundamentals of Nursing 7th ed. she said that she and her husband express their sexuality not only through sexual intercourse. she performs self-breast examination. p. p. she and her husband talk it over and decide together on how to solve it. The client also stated that she was fourteen years old when her menstruation started. They always hug and kiss each other even their children. al. romantic gestures.. hugging. She said that sexual intercourse is not the only basis of love. The family protects the physical health of its members by providing adequate nutrition and health care services. Coping mechanisms can be viewed as an active method of problem solving develops to meet life’s challenges. 7th edition. However.6.al. Kozier et. She and her husband plans the family with two-year interval. (Fundamentals of Nursing by Kozier. Kozier et. They were able to communicate well when problems occur. Socio-Cultural Patterns 1. Cultural Patterns . Analysis: Clients are often hesitant to introduce the topic of sex with their primary health care providers. The client said that they have decided that this will be her last pregnancy and she will undergo bilateral tubal ligation upon giving birth. it is normal to show affection through hugging and kissing. pg 191) Family coping mechanisms are the behaviors families used to deal with stress or changes imposed from either within or without.. dressing up.. joy. (Fundamentals of Nursing 7th ed. comfort. al.. They may be too embarrassed or they may think that they should not have sexual problems in our liberated times. et. Interpretation: It is normal that the elderly members of the family provide the needs of the younger ones. Interpretation: The client is not comfortable in sharing the things about their sexual relationship. Family Coping Pattern The client stated that financial resources needed by their family are supported by her husband. warmth.. The coping mechanisms families and individuals develop reflect their individuals resourcefulness.973) Adults may define sexuality far more broadly and include in their definition such things as touching. It is her task to ensure that each member gets adequate nutrition and other needs are attended. Sexuality The client is not comfortable when talking about her sexual preferences and satisfaction with sexual activity.
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. et. Analysis: Cultural values often determine the roles of family members. They are expected to assume new roles at work. (Fundamentals of Nursing. She keeps herself busy doing the household chores and attending the needs of her children with the help of her mother.The client is raised in San Juan City. Kozier. Kozier. The client is able to meet the expectations of the roles she presume. and to develop interests. (Fundamentals of Nursing. Environment .. She considers her family as the most important persons in her life. She plays as an ever loving wife to her husband and mother to her children.al. she makes solutions based on what her parents have thought her first before seeking advice or help from health professionals. values and attitudes related to these roles. People need to know the expectations of persons around them in order to appropriately act the role. 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 family’s life. She has lived a life of a city lady. she cannot do heavy errands and odd jobs. Interpretation: A person normally assumes different roles throughout life. 7th edition. Kozier. She added that because of her changing body conditions. She is not able to do most of the activities she wants because of her present condition. p. p. 7th edition. in the home. et. With regards to the authority inside their house. She is able to do exercise through walking in their garden and watering the plants. Secondly.394) 3. who have the authority to make decision and family involvement about care. She is involved in their community’s charitable projects and other social works. 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. and in the community. She is fond of watching the television and reading books and magazines. et. She also has significant relationship with God. Interpretation: The client has sedentary lifestyle. 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 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. She speaks both English and Tagalog as her medium of communication.al.making. All aspect of care is influenced by the culture.al. According to her. p. She also finds time to mingle with her friends whenever they visit her. Analysis: Young adults are typically busy people who face many challenges.1059) 4. Recreation Patterns The client is a housewife. Whenever health problems arise. 7th edition.. their interactions.1413) 2. Significant Relationships The client is a mother of a lovely daughter and twin sons. (Fundamentals of Nursing. her friends count a lot too and where she seeks some advices when problem arises..
The client and her children live in an owned house in a private subdivision in San Juan City. Their family’s needs are met and suffice adequately. they have 3 rooms and all are air-conditioned and well-ventilated. (Fundamentals of Nursing 7th ed. Interpretation: The client has no problem financially. ventilation and living space. traffic congestion. Analysis: Adequate street lighting. She has achieved adequate sources of lighting.000 a month as of the moment. will minimize the potential for accidents. Adequate lighting. Interpretation: The client has safe environment. A safe and secure community strives to be free of excess noise. al. hazard-free community. In addition to providing an environment conducive to physical growth and health. family members are able to reach out to others in the family and the community. and knowledge of fire escape routes. she said that their house is very conducive to her health and for her children because it is always kept clean and hazard free. Spiritual Patterns 1.671) 5. 7th edition. both inside and outside. She believes in God and doesn’t forget to pray to seek for guidance in her everyday living and in overcoming all the problems that she encounters. They have fire extinguisher for them to be prepared during emergencies. and to society.. pg 191) C. Her husband works as an engineer in an oil company in Qatar and earns approximately 50. Economic The client is a plain housewife. functioning smoke alarms that are strategically placed. safe water and sewage treatment. As individual needs are met. maintaining their house. The client stated that the living space in their house are adequate and is conducive to health. she said that they can suffice all their needs and wants. 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. the family creates an atmosphere that influences the cognitive and psychosocial growth of its members. In fact. According to her.. Furthermore. Analysis: The economic resources needed by the family are secured by other members. buying food. (Fundamentals of Nursing. she always has a rosary in her pocket for she believes that it will protect . They don’t have any problems with regards to paying all their bills. They use fluorescent lights in their house for proper lighting. they have enough source of water and have sewage system.. Kozier. Garbage is collected by the city dump trucks everyday so they have no problem with regards to proper waste disposal. There is also adequate street lighting in their subdivision. A safe home requires well-maintained flooring and carpets. Additionally. With regards to the community that she is into. or unprotected creeks and landfills. dilapidated housing. educational plans for their children and health insurance. both in their house and community. Kozier et. She always sees to it that all things are in order and are kept clean for she is the one who manages their household. p. Religious Beliefs and Practices The client’s religion is Iglesia ni Cristo. and regulation of sanitation in food buying and handling all contribute to a healthy. et.al. With that income. crime.
91) IV. However. 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. When she was young. she practices the belief of fasting and abstinence. al. (Fundamentals of Nursing. Fundamentals of Nursing: Concepts.al. encourages self-actualization and is health giving and health sustaining. enduring beliefs or attitudes about the worth of a person. Analysis: Values are freely chosen. Analysis: Pregnancy is not a time for dieting. her faith is still strong and she doesn’t forget to pray to cope with her problems. lunch and dinner. Taylor. She values herself and more importantly her family who becomes the center of her attention and life. object. The client admitted that she is fond of eating vegetables and fruits. et. social system and environment. give meaning and purpose to existence. Moreover. ADL Nutrition Activities of daily Living Before Hospitalization The client has no allergies on food. P. al. It is also the time wherein she restricts herself from eating meat. 5th edition.. .her from accidents and evil spirits. culture. she used to go to church every Sunday but now. (Kozier. Interpretation: It is good that despite of her changing health conditions. Maternal Newborn Nursing Care. strengthens one’s feelings of self-worth. she still eats regularly for the fear that her eating pattern might affect her baby. 2 snacks. During Holy week. 5th edition. The client takes in daily During Hospitalization The client verbalized that she feels weak and seems like she doesn’t get hungry. a threat to fetal well-being. al. rather. buys and cooks their meal. Interpretation: Every person develops different values and beliefs based on their own family orientation. 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. values are formed during a lifetime from information from the environment. . 976). 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. and severe weight restrictions during pregnancy can result in maternal ketosis. family and culture. et. She still continues taking Iberet (Folic) 100mg. (Taylor. Process and Practice. et. Life affirming influences enhance life. An individual is not born with values. idea or action. 7th edition. 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. including health and illness. she believes in God. in the dignity and worth of each person. (Ladewig. Values and Valuing The client is usually optimistic in her actions and decisions. Fundamentals of Nursing: The art and Science of Nursing. The client usually eats five times a day which includes breakfast. 5th ed. She further stated that it is her mother who plans. 2. et. 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. p. P. Values are important because they influence decisions and actions. Analysis: Spiritual beliefs and practices are associated with all aspects of a person’s life. 69).
The amount of her urine ranges Interpretation: The patient’s bowel elimination is normal. and lactation and prevents the macrocytic.1 ½ cup of rice. The patient does not make use of any aids in regulating her pattern of defecation. cylindrical in shape. al. or Folate. semi-fluid. 1183) . al. It is usually in the morning after she takes her breakfast. Normal stool should be brown in color.274) Folic acid. is required for normal growth.5 pcs. 2 glasses of water Snack. quantity and consistency. Odor is aromatic (Kozier. Snack. ferrous Sulfate 100mg and drinks two glasses of Anmun Materna as prescribed by her obstetrician. It is brown in color. and has an aromatic odor. and 2 glasses of water Bowel elimination The client’s defecating pattern changed from once every 2 days to an irregular interval of twice or thrice every six days. her urine is within normal level and usual in characteristics as well. 1 cup chopsuey. et. et. 1 medium-sized lakatan. 1 glass of water Lunch. formed and semi-solid. 1 mediumsized daing na bangus.1 medium sized ensaymada. Urinary elimination The client urinates for about five times a day. Analysis: Patterns of defecation vary in frequency. 5th ed. Its regular amount is 100-400 grams per day.281) Eliminati on Bowel elimination The client defecates once every other day. 1 serving of ampalaya. Her stool varies in amount from about 100-400 grams per day.1 sky flakes. Breakfast. Maternal Newborn Nursing Care. aromatic in color and cylindrical in shape. Shape is Cylindrical Amount: varies with diet. It is brown in color. The client said that she does not feel any discomfort in defecating. megalobalstic anemia of pregnancy. 5th ed. Breakfast. 1 glass of water Lunch.1 cup of rice. 1227) The characteristics of normal feces are . reproduction. 1 glass of milk Snack.1 chicken sandwich and 2 glasses of water Dinner. 2 glasses of water. 1 serving of steamed tilapia. (Fundamental of Nursing by: Barbara Kozier pp. and 2 glasses of water Snack. and has an aromatic odor.½ serving of pancit bihon. P. 1 ½ cup tinolang manok (breast). semisolid in form. Urinary elimination The client urinates for about five times a day. p. Pan de sal with peanut butter spread. (Ladewig.consistency: formed. The amount of P.100mg of Iberet (Folic).½ cup of rice. 2 glasses of water Sulfate 100mg and two glasses of Anmun Materna daily. Fundamentals of Nursing. The amount of her stool varies from about 100-300 grams per day. semi-solid in form. cylindrical in shape.2 cups of rice.1 cup of rice. The patient’s voiding pattern is normal. 1 serving of steamed vegetables. 1 glass of water Dinner.
It is dark amber in color. She either lay or sit on her bed while watching the television and chatting with her family members. et. She uses deodorant. her urine ranges from 700-900 ml per day. Kozier. (Fundamentals of Nursing. She brushes her teeth twice a day. However. The client seldom walks and get up from her bed. Interpretation: The change in the client’s activity is due to her condition. uses deodorant. and powder after taking a towel bath. Complete Family Health Encyclopedia. powder. 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. (Fundamental of Nursing by: Barbara Kozier pp. P. Maternal Newborn Nursing Care. This is in the morning and in the evening before she sleeps. al. The client is plain housewife and stays at home most of the time.5 to 2 liters of urine per day (Smith. 5th ed.. Voiding in sufficient quantities should be at least every 4-6 hours. et. Analysis: Limitations to movement may be medically prescribed for some health problems. She regularly cut her nails and changes her clothes as often as the situation asks her to. Analysis: Ill people may not have the motivation or energy to attend to hygiene. 1262). 699) . Her only form of exercise is walking within their backyard and doing some gardening. 7th edition. (Ladewig. P.1224. al. She only takes towel bath daily that is being provided to her by her mother. The client changes her clothes twice a day or as the situation requires. The client seldom takes a full bath. It is dark amber in color. and lotion every after taking a bath. One in the morning and one in the afternoon.from 600-800 ml per day. p. during her stay in the hospital. She can perform all her hygienic practices with out limitations and restrictions. She always wears slippers inside and outside their house. p.1034) Characteristics of Urine: Color is amber to straw. She said that she does not have any form of formal routine exercises.al. and the Odor is faint aromatic. Fundamentals of Nursing. 7th ed. She brushes her teeth every after taking her meals. et. Interpretation: The client’s hygiene prior to hospitalization is normal.795) Exercise The client has a sedentary lifestyle. The client also wears. She also puts makeup whenever she goes out of the house. A healthy adult produces about 0. Clarity is transparent and clear. 1067) Hygiene The client takes a bath twice a day. (Kozier. some of her routinehygiene practices become limited due mainly because of her condition.
1224. 7th edition. the client said that she generally feels rested and that she feels that her energy is just right for her daily activities. During hospitalization. her sleep pattern changed. Upon waking up in the morning. al.al. (Fundamentals of Nursing. she shows her concern even more to her family now that she is hospitalized. Many of the nurturing sexual needs of the pregnant woman can be satisfied.. 5th edition. Frequent awakenings during the night. Fundamentals of Nursing: The Art Sexual activity The client is married and has 3 children. made her sleep disrupted. et. because of the constant assessment of the nurse on duty to her. et. p. They show their affection by caring for one another and communication more often especially now that her husband is working abroad. She takes afternoon naps for about 2 hour every day. According to the client. She sleeps for about six hours in a day. or to decrease pain. Analysis: Illness that causes pain or physical distress can result in sleep problems.Disease and injury may reduce a person’s ability to perform hygiene measures or motivation to follow usual hygiene habits. She is confined to bed and is oftentimes asleep during the day. Weakness. 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. to reduce metabolic and oxygen needs. cuddling. She is very thankful for . kissing and being held. Interpretation: The client has a normal sleeping pattern before hospitalization. (Fundamental of Nursing by: Barbara Kozier pp. not enough and unrefreshing. (Taylor. for example. oftentimes she wakes up in the middle of the night due to the hospital staff checking her condition. The client usually sleeps at about 12:00 in the morning and wakes up at about 6:00 in the morning. The client does not experience any nightmare. et. She sleeps for about 8 hours daily.. 1117-1119) Bed rest may be the therapeutic choice for certain clients. dizziness. 1067) Interpretation: It is normal for the client to express his sexuality through caring and giving support to his husband and children. She often drinks milk to make her sleep more comfortable. to relieve edema. Kozier. Analysis: Sexual Activity does not have to include intercourse.1009) Sleep Rest Pattern The client sleeps at about 11:00 in the evening and wakes up at about 7:00 in the morning. and fear of falling may prevent an individual from entering a tub or shower or from bending to wash lower extremities. p.al. Taylor. Also. The client has been married for almost 10 years now and their relationship is still strong. (Fundamentals of Nursing. to promote tissue repair. People who are ill require more sleep that normal and the normal rhythm of sleep and wakefulness is often disturbed.
having a wonderful family who takes care of her.he is away. 5th . and Science of edition. P. 247) Nursing.
Physical Assessment A. al. Normal weight gains for women is 25-35 lbs (11.2004 Chapter 28 Health Assessment ACTUAL FINDINGS ANALYSIS .3 ˚C Abnormal For adult. (Nutritional Guidelines for Filipinos) Abnormal The expected temperature ranges from 35.5 kg ANALYSIS AND INTERPRETATION Normal Maternal optimal weight depends on the woman’s weight for height and her prepregnant nutritional state.37. General Survey Weight: FINDINGS 62.100 bpm Abnormal For adult. 3rd ed. 273) Normal The average height for Filipino women is 5’2. normal RR ranges from 12 – 20 cpm Normal For adult. Head-to-Toe Assessment PARTS PHYSICAL ASSESSMENT TECHNIQUE NORMAL FINDINGS Kozier. al. et.V. P. normal PR ranges from 60. normal BP ranges from 90-130/60-90 mmHg Height: 5’2 Temperature: Pulse Rate: Respiratory Rate: Blood Pressure: 37.5-16 kg) (Foundations and Clinical Applications of Nutrition by Groadner et. Fundamentals of nursing.7°C 110 bpm 23 cpm 90/70 mmHg B.8˚ .
height and weight e. erect posture: coordinated movement. type of clothing i.Logical sequence. has sense of reality Height: 62 in (5’2”) Weight: 144.has difficulty in answering some questions Normal Problems in mental status can have many reasons.warm to touch .No distress noted.Healthy appearance. Skin quantity of speech relevance & organization of thoughts a.appears weak and dizzy . skin springs back . c. h.has sense of reality . from yellow tones to olive.General Appearance a. plate shape toenail/fingernail color texture tissues surrounding nails blanch test Inspection Inspection Palpation Inspection -nails with light nail polish has intact epidermis Normal . body movement f. make sense. dark-skinned clients may have brown or black pigmentations in .uniform. mood affect b. Nails e. g.Relaxed.5 kgs) .Clean and neat.Skin moves back slowly Many nutritional deficiencies and fluid imbalance can be recognized by changes to the skin. within normal range .highly vascular and pink in light skinned clients. moderate pace. exhibits thought.when pinched. .clean and tidy . Further assessment would be needed.little skin moisture .skin color is light brown . signs of distress c.Varies from light to deep brown. g. obvious signs of illness h. Understandable. j. .160° convex curvature . . .1 lbs (65.Appropriate to situation. from ruddy pink to light pink. d. i. uniform in color . .appears restless . b. posture d. f.moisture in skin folds and axillae . Color skin moisture skin temperature skin turgor . hygiene and grooming Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Palpation Palpation Palpation .
absence of nodules or masses -symmetric or slightly asymmetrical facial features. resilient hair. equal movement skin intact. eyebrows eyelashes eyelids bulbar conjunctiva palpebral conjunctiva sclera lacrimal sac & nasolacrimal duct t. bilateral blinking.shoulder length straight black hair evenly distributed hair skull is normocephalic and symmetric facial movements are symmetrical Normal Normal Eyes m. uniform consistency.delayed capillary refill Hair a. p.hair evenly distributed.intact epidermis . No infection or infestation.Silky. s. Palpation Palpation Inspection .symmetrically aligned. no discharge/discoloration.smooth texture . palpebral fissures equal in size.Rounded. approximately 15-20 involuntary blinks/minute. . cornea u. c. pupils Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection .Evenly distributed hair. o. symmetry of facial movements Inspection Inspection Inspection Inspection Inspection.cornea is shiny . r. when lids open. hair thickness or thinness. symmetry k. n.able to read newspaper but emphasizes that occasionally she experienced Normal . . smooth round contour smooth.white sclera . masses or depressions l. symmetric nasolabial folds .eyebrow and lashes aligned and evenly distributed .Thick Hair. nodules. size. shape.Palpation longitudinal streaks . b. skin intact . no visible sclera above corneas and upper and lower borders of cornea are slightly covered . hair texture and oiliness. evenness of growth over 'the scalp.has 20/20 vision . presence of infection Skull & Face j. . d. q.able to blink .
intact and in midline . 3-7 mm in diameter.shiny. soft moist. sclera appears white . uniform color. discharges Inspection Inspection Inspection . iris visible . growths.normal voice tones audible . no lesions . smooth border.sclera is white . equal in size.no deviation in nose appearance . Auricles b.symmetric and straight. shiny and smooth.auricle is aligned with outer canthus of her eye . presence of redness. pinna recoils after it is folded .no edema or tearing . flaking or cracked lips may be caused by dehydration .. gross hearing acuity tests * normal voce tones Inspection Inspection Inspection Inspection -color same as skin. not tender. ability to purse lips. mobile and firm and not tender. symmetry of contour. swelling. teeth and gums c. smooth and pink or red .air moves freely as the client breathes through the nares -mucosa pink. outer lips b. dentures Inspection Inspection Inspection - pale dry lips intact dentures Dry.doesn’t complain on nose patency Normal Mouth a. no discharge or flaring. no lesions . capillaries sometimes evident.black in color. smooth texture.uniform pink in color. round. no lesions blurred vision . patency c.does not have difficulty hearing voices Normal Nose a. aligned with outer canthus of eye. iris is flat and round Ears a.transparent. symmetrical.transparent. external nose b. clear watery discharge.
Head rotates 700 .not visible on inspection.Head hyperextends 600 . uniform temperature. palpation . effortless .It is not visible in inspection Normal Thyroid gland Inspection . lobes may not be palpated.Muscles equal in size.Head flexes 450 Head hyperextend 600 . moist.skin intact. chest wall intact.Coordinated smooth movements with no discomfort .Head flexes 450 .Head laterally flexes 400 . white. no masses Normal Anterior Thorax a. uniform temperature. pink gums. no tenderness. head centered Coordinated smooth movements with no discomfort . effortless skin intact. glands ascend during swallowing but is not visible. breathing pattern Inspection . lobes are small. smooth centrally located.32 adult teeth. chest wall intact. rhythmic. no retraction of gums . no masses Normal Cardiovascular . if palpated.Head laterally flexes 400 .quiet.Muscles equal in size. head centered .intact dentures Neck muscles Inspection. rhythmic.. no tenderness. painless and rise freely with swallowing quiet.Head rotates 700 . smooth. shiny tooth enamel.
louder at apical S2: heard at all sites.aortic pulsations . no lifts or heaves . quality remains the same when client breathes.veins not visible . louder at base of heart Systole: silent interval.no sound heard . Her breast is symmetrical. slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many other adults Symmetric pulse volumes. size. symmetry.a. slightly unequal in size.pulsations visible in 50% adults and palpable in most PMI in 5th LICS at or medial to MCL. The Normal Normal Normal . S1 was heard louder. contour/shape Inspection Inspection . auscultation Jugular Veins Breast and axillae a. There are no pulsations in the apical area. The jugular veins of the client are not visible. There are no pulsations in the area of tricuspid. full pulsations. turns head and changes from sitting to supine position.S1: usually heard at all sites. elastic arterial wall .no pulsations . auscultation of heart in all 4 anatomic sites: * aortic * pulmonic * tricuspid * apical (mitral) Carotid Artery a.no pulsations. inspection and palpation of precordium * aortic and pulmonic area * tricuspid area * apical area *epigastric area b. diameter of 1-2 cm. There is presence of aortic pulsation. slightly shorter duration than diastole at normal heart rate (60-90 bpm) Diastole: silent interval.females: rounded shape. palpation b. no lifts or heaves . Normal There are full pulsations on the client’s carotid area. No presence of sound heard in the carotid area when auscultated. The S1 and S2 are the only sounds that have been auscultated. There are no pulsations in the aortic and pulmonic area. thrusting quality.
rotund abdomen.no visible vascular pattern skin color is light brown and is uniform w/ the other parts of the body. progressive enlargement of uterus due to pregnancy . no discharge except in pregnant and breastfeeding females. no tenderness. both nipples point in same direction. smooth and intact.round. It is pointing to one direction. silver-white striae or surgical scars . contour and symmetry c. masses or nodules Inspection Inspection Inspection unblemished skin. skin c. diffuse symmetric horizontal or vertical vascular pattern in light skinned people.flat or rotund abdomen. Her areola is light brown and sebaceous gland is distributed unevenly. may be similar in shape to female breasts . masses or nodules presence. soft and smooth. uniform color. irregular placement of sebaceous glands on surface of areola. areola d. striae (stretch marks). equal in size. It is round and equal in size. progressive enlargement of uterus due to pregnancy Normal . similar in color. if obese. vascular pattern presence of silver-white striae and a surgical scar . inversion of one or both nipples that is present from puberty. No visible retraction. It is round and symmetrical. color varies. No tenderness.uniform in color. No discharges and presence of nodules in his nipples. nipples generally symmetric Males: breast even with chest wall. skin integrity b. Abdomen a.round or oval and bilaterally the same. moles and nevi .b. everted. no masses or nodules .
equal size on both sides of the body . tenderness.There is no presence of swelling. size b.no swelling. Fasciculations and tremors d.no fasciculations and tremors . She can move it with no signs of difficulties.Equal strength on each body side .Equal strength on each body side . joints move smoothly .no fasciculations and tremors . . Normal Joints a.no visible vascular pattern Muscles a.She can stretch her joint in a normal range. muscle tonicity e.equal size on both sides of the body . crepitation. and nodules. smoothness of movement. swelling. muscle strength Inspection Inspection Inspection .Wide joint of motion range. crepitation.no contractures .normally firm . Kozier. . tenderness.normally firm . range of motion Palpation Normal Inspection References: Fundamentals of Nursing 7th ed. crepitation or nodules. Wilson . presence of nodules b. Barbara Medical-Surgical Nursing 1991 Ignatavicius and Bayne Health Assessment for Nursing Practice 3rd ed.no contractures . contractures c.varies to some degree in accordance with person’s genetic make-up and degree of physical activity .
Increased levels indicate higher than normal concentrate of RBC. Interpretation: The amount of platelets is below its normal range. cancer. 2008 Procedure Hematology RBC Norms 3. iron deficiency.VI. it may indicate hemorrhage. In more reduced count. Increased levels indicate bacterial infection. severe hemorrhage or intravascular coagulation.5–5 x 106/mcl Results 3. autoimmune hemolytic anemia. such as liver disease.6% 34 % Hgb 12. Increased number may occurs with fracture or blood vessel injury. Analysis: Provides information on the amount of red blood cells (RBC) present in the blood. etc. Interpretation: The hct count is below normal. Analysis: The body's primary means of fighting infection. systemic lupus. RBC lives for 120 days so an anemia of any kind other than hemorrhage indicates a long standing problem. parasites. Decreased levels may indicate an overwhelming infections (viruses). anemia. or drug / chemical poisoning. parasites.1 x 106/mcL Interpretation and Analysis Interpretation: The RBC count is below normal.3 g/dl 11. Decreased levels indicate the presence of hemorrhage. Decreased levels means anemia from hemorrhage. Increased levels are often seen in dehydration. bone marrow disease. nutritional deficiencies or chronic disease process. or cancer. Interpretation: WBC count is within the normal range.0x10 3 /mm 3 9. Interpretation: The amount of hemoglobin is below the normal range.0x10 3 /mm 3 .2 g/dL Platelets 130-400 x 10³ mcL 125 x 10³ mcL WBC 4. Laboratory and Diagnostic Examination Results Date April 24. Hct 36%-44. B-12 deficiency.1–15. Analysis: Iron deficiency will lower RBC count. emotinal upsets and blood disorders. Analysis: The essential oxygen carrier of the blood.5-11. folic acid deficiency or copper deficiency. B12 deficiency (because there are fewer cells). Analysis: Decrease in number occurs in bone marrow depression.
dehydration.040 occurs with high fever. Analysis: Normally. Clinical Laboratory Guide for Practice.5 is considered acidic and above the pH level or >8 is alkalosis. it is usually albumin. Analysis: Below the normal pH level or < 4.) Interpretation: The patient has placenta previa and it is considered to be abnormal. overactive adrenals.029 occurs with diabetes mellitus. adrenal and thyroid disorders and hepatic and central nervous system disease. Interpretation: There is no presence of protein in the urine. insipidus. Analysis: Normally. When the placenta is blocking the cervix. Analysis: Normally. Analysis: Normal color is yellow to amber. pg 930. 2008 Urinalysis Color Appearance Straw Clear Straw Clear Interpretation: The color of the urine and appearance is normal. pg 475. protein is not found in the urine of healthy individuals. diabetes mellitus.5-8 5 Protein negative negative Glucose negative negative April 24. Specific Gravity 1. vomiting. In rare cases. the placentaform low in the uterus and is partially to completely covering the cervix. (Wilson. reddish brown is caused by hemoglobin / myoglobin.April 24. If it is found. Red is caused by Blood. Interpretation: The specific gravity is within the normal range. Jane.) Interpretation: Normal because glucose should not be present in the urine.025 1. diarhea and severe hemorrhage. 2008 Ultrasound: Transvaginal ultrasonograph y The placenta has attached to the uterine wall close to the cervix .015-1. (Lippincott Williams and Wilkins. no glucose is present in the urine. excessive thirst and pyometra. Glucosuria occurs in diabetes militus.007 ~ 1. Over 1.024 pH 4. Dark yellow to brown with yellow form are caused by bilirubin. Interpretation: The pH level is within the normal range. Persistent protenuria is an indication of renal disease. Professional Guide to Diagnostic Test. it is called placenta previa. the placenta is attached to the uterus above the cervix. Analysis: 1.
CV. PARENTERAL 0. should be used in patients with respiratory distress) readily available in case cardiac arrhythmias occur. CNS stimulation. • WARNING: If a betaadrenergic locker (a cardioselective beta blocker such as atenolol. ECG changes) GI: nausea. fear.VII. lactation Use cautiously with diabetes. Indication Tocolytic to prevent preterm labor Contraindication Contraindicated with hypersensitivity to terbutaline. vertigo. vomiting. apprehension. dizziness.5 mg per 4 hours. weakness. • Inform the client that she may experience these side effects: weakness. cardiac arrhythmias. Read product instructions. anxiety. headache. give another 0. labor and delivery (may inhibit labor. tremor. which sensitize the myocardium to catecholamine. TEACHING POINTS: • Tell the client not to exceed recommended dosage. hypokalemia and pulmonary edema in the mother and hypoglycemia in the neonate). pulmonary edema. inability to sleep. changes in BP.25 mg dose. hyperkinesias.25 mg subcutaneously in the lateral deltoid area. anginal pain (less likely with bronchodilator doses of this drug than with bronchodilator doses of a non selective beta agonist. reduce to 2. coughing. parenteral use of beta adrenergic can accelerate fetal heart beat. palpitation. irritability. general anesthesia with halogenated hydrocarbons or cyclopropane. 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 no significant improvement in 15 minutes. tachycardia caused by digitalis intoxication. Do not exceed 15 mg/day. Consult health care provider if she has any questions.5 mg tid. brochospasm Nursing Responsibilities NURSING INTERVENTIONS: • Use minimal doses for minimal periods of time. . insomnia. drowsiness. coronary Side effects CNS: restlessness. drug tolerance can occur with prolonged use. • Do not exceed the recommended dosage. heartburn. unstable vasomotor system disorders. If side effects are pronounced. adverse effects or loss of effectiveness may result. tachyarrhythmia. Don’t exceed 0. unusual or bad taste in mouth RESPIRATORY: respiratory difficulties. cause hypoglycemia. seizure.
and tea). TEACHING POINTS: CNS: CNS toxicity. sulfite allergy. hemochromatosis. Ferrous Sulfate (FeSO4) Daily requirement for pregnant women: 30-60 mg/day PO Dietary supplemen tation for iron Contraindicated with allergy to any ingredient. regional enteritis. muscle cramps nausea. acidosis. vomiting. flushing. weakness. and insomnia. dizziness. psychoneurotic individuals and hypertension. Use cautiously with normal iron balance. • Warn patients that stool may be dark or green. hyperthyroidism. constipation. • Have periodic blood tests during therapy to determine the appropriate dosage. history of stroke. anorexia. diarrhea. Take after meals f GI upset is severe (avoid milk. dark stools. pallor. and slowly increase to build up tolerance. eggs. ulcerative colitis. coma and death with overdose GI: GI upset. fast heart rate.insufficiency. peptic ulcer. vomiting. tremor or irregular heartbeat. • Do not take this preparation with antacids or . temporary staining of the teeth (liquid preparations) • Take drug on an empty stomach with water. history of seizure. COPD. NURSING INTERVENTIONS: • Give drug with meals (avoiding milk. hemosiderosis. OTHER: sweating. • Arrange fro periodic monitoring of Hct and Hgb levels. • Remind the client to report chest pain. anxiety. coffee. coffee. CAD. failure to respond to usual dosage. and tea) if GI discomfort is severe. nausea. hemolytic anemias. eggs.
• Report rash. HYPERSENSITIVITY: Allergic reactions • Test using Schilling test and serum vitamin B12 levels to rule out pernicious anemia. difficulty breathing. IM or subcutaneously. normocytic anemias. pain or discomfort at injection site. lethargy.tetracyclines. they will be prescribed. pernicious. . If these drugs are needed. Iberet (Folic acid) 0. Therapy may mask signs of pernicious anemia while the neurologic deterioration continues.8 mg/day Vitamin supplemen tation of folic acid Contraindicated with allergy to folic acid preparations. and constipation. with sever GI malabsorption or very severe disease. TEACHING POINTS: • When the cause of megaloblastic anemia is treated or passes. aplastic.. rapid respirations. there may be no need for folic acid because it normally exists in sufficient quantities in the diet. • Report severe GI upset. give IV. NURSING INTERVENTIONS: • Administer orally if at all possible.
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 .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.
PRIORITIZED LIST OF NURSING PROBLEMS .V Abruptio placenta S/S: • • • • • • • • • • Hypotension Hyperthermia/hypothermia Tachycardia Restlessness Confusion Chest pain Tachypnea Pallor Cyanosis Decrease urinary output IX. Ecologic Model – Not Applicable X.
It is highly individual and a client experiencing anxiety may require ongoing nursing support to meet client needs and enhance client coping. Anxiety R/T concern for own personal status and baby’s safety Subjective: • The patient verbalized.7°C 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. “Nagulat na nga lang ako. Ayoko mamatayan ng baby kaya pumunta ako kagad dito nung dinugo ako. “Natatakot talaga ako sa pwedeng mangyari eh.” • “Balak naming mag-asawa na maging last na naming baby ito kaya mas lalo akong natatakot. Abnormality in the implantation of the placenta can compromise fetal oxygenation and fetal hypoxia (FHR below 110nbpm) may develop.” The placenta is the means of metabolic and nutrient exchange between fetal and maternal circulations. as the problem has not occurred and nursing interventions are directed at prevention. may dugo sa panty ko.” “Medyo nanghihina ako” Objective: T: 37. This problem is a response to perceived threat that is consciously recognized as a danger. 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.NURSING PROBLEMS IDENTIFIED Fluid Volume Deficit R/t Hypovolemia 2/T excessive blood loss CUES Subjective The client verbalized. 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. there is a risk of limited activity and the problem is likely to develop unless health care providers or significant others intervene. .” Objective: T: 37. This is an actual problem present at the time of nursing assessment and must be given prompt intervention. Para akong nilalagnat.Objective: • fearful • restlessness • facial tension Altered thermoregulation.” • “Kahapon pa ito eh nung dinugo ako. Hyperthermia R/T Hypovolemia Subjective: The client verbalized. Since the client is confined to bed. • “Ang init ng pakiramdam ko. According to Maslow’s hierarchy of needs a normal body temperature signifies a regular body functioning and an increase on the temperature may affect the daily body activities.7°C 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.
moist mucous membranes. Was the client able to diminished signs of fluid volume deficit? () Yes () No INDEPENDENT 1a. Goal & objectives Goal: After 24 hours of performing all the nursing interventions.7°C 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.XI. Aids in evaluating degree of fluid volume deficit. Nursing Care Plan Cues Subjective The client verbalized. the client will be able to: 1. Monitor Vital Signs. decrease in volume of blood plasma. Objectives: After performing all the nursing interventions. good skin turgor. tachypnea and fever. ruptured ectopic pregnancies. Low fluid intake. more specifically. noting signs of tachycardia. Was the client able to have more or less equal fluid intake and output? () Yes () No 3. may dugo sa panty ko. and laboratory values within normal range. Measure central venous pressure if available. chronic illnesses. Was the client able to know information pertaining to the underlying . Less obvious causes of hypovolemia are internal bleeding and dehydration. Attain normal ranges of vital signs Nursing Interventions Rationale Evaluation Was the Goal Met? Partially met? Unmet? Effectiveness: 1. Traumatic accidents. 4. and severe diarrhea are common causes of dehydration. Was the client able to reduce the factors contributing to the problem? () Yes () No 5. Was the client able to attain normal ranges in vital signs? () Yes () No 2. effectiveness of fluid volume therapy and response to medications. extensive vomiting. adequate urinary output. and surgery can all cause internal bleeding.” “Medyo nanghihina ako” Objective: T: 37. the patient will be able to maintain fluid volume at a functional level as evidenced by stable vital signs. “Nagulat na nga lang ako.
Have diminished signs of fluid volume deficit 2. 5a. increased pulse rate to rapid.2. Weigh patient daily Reflects overall hydration status. Monitor the client for signs of fluid volume deficits: poor skin turgor. 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 client’s situation? () Yes () No Why? 4. thready pulse that is easily obliterated 4a. Decrease feeling of nausea and vomiting Edematous tissue with compromised circulation is prone to breakdown 5. Change position frequently. Measure urine specific gravity. Limit intake of ice chips. 5b. 3a. Measure fluid intake and output. Eliminate noxious sights/smell from environment. Daily weight is the most sensitive . soft and sunken eyeballs. provide skin care and maintain dry/wrinkle free bedding. which may warn on developing acute renal failure in response to hypovolemia and effect of toxins. Obtain information pertaining to her medical condition Assists in early detection of possible complications. 4b. Ongoing assessment promotes the nurse to detect early signs and symptoms of complications. weak. dry mucous membrane. Have an accurate fluid intake and output 3. 3b. Reduces gastric stimulation and vomiting response condition? () Yes () No 6. Reflects hydration status and renal function. Monitor amount and characteristics of urine.
COLLABORATIVE: 5c. b. Anxiety is often 6. Was the client able to identify feelings of anxiety? () Yes () No 2. 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. and behavioral components These components combine to create the feelings that we typically recognize as fear. Cues Subjective: • The patient verbalized. blood or diuretics as ordered by the physician. the patient will appear relaxed and report anxiety is reduced to a manageable level. Monitor Stress and anxiety can increase a person’s risk of stress-related illness.” Nursing Diagnosis Anxiety related to concern for own personal status and the baby’s safety Anxiety is a physiological state characterized by cognitive. fluids. electrolytes. Ayoko mamatayan ng baby kaya pumunta ako kagad dito nung dinugo ako. or worry. 6. Was the client able to identify healthy ways to deal with and express anxiety? () Yes () No . Identify feelings of anxiety Nursing Interventions Rationale Evaluation Was the Goal Met? Partially met? Unmet? Effectiveness: 1.” • “Balak naming magasawa na maging last na naming baby ito kaya mas lalo akong natatakot. Assess level of anxiety. “Natatakot talaga ako sa pwedeng mangyari eh. Administer plasma or blood. apprehension. emotional. Was the client able to promote welllness? () Yes () No 1. Receive IV fluids and electrolytes. the patient will be able to: 1. a.indicator of fluid loss or gain. Monitor laboratory studies. Objectives: After performing all the nursing interventions. somatic. 3.
Anxiety interferes with a person’s ability to relax. stomach aches. nonspecific threat. 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 client’s situation? () Yes () No Why? 3. sweating is increased. and immune and digestive system functions are inhibited. Encourage client to acknowledge and to express feelings. Open expression of feelings facilitates identification of specific emotions such as anger. rest and sleep. 2. Be available to client for listening and talking. Promote wellness c. identifying the client’s perspective will facilitate planning for the best approach to anxiety reduction. b. rest and sleep. Externally. somatic signs of anxiety may include pale skin. physical responses. Anxiety is aroused by a vague. chest pain. Trust is an essential first step in the therapeutic relationship. nausea. Identify healthy ways to deal with and express anxiety c. 4. shortness of breath. Somatically the body prepares the organism to deal with threat (known as an emergency reaction): blood pressure and heart rate are increased. Anxiety interferes with a person’s ability to relax. Describing what . a. Establish a therapeutic relationship.Objective: • fearful • restlessness • facial tension • has difficulty in answering some questions accompanied by physical sensations such as heart palpitations. sweating. or helplessness.Observe behavior indicative of level of anxiety. or headache. distorted perceptions and unrealistic fears. The cognitive component entails expectation of a diffuse and certain danger. conveying empathy and unconditional positive regards. bloodflow to the major muscle groups is increased. 2.
anxiety is not always pathological or maladaptive: it is a common emotion along with fear. and pupillary dilation. 4. Feelings of safety and security increase when an individual identifies previously successful ways of dealing with anxiety-provoking or fearful situations. b. Fear is reduced when the reality of a situation is confronted in a safe environment. Behaviorally. will enable the patient to prevent or recognize his anxiety in order to initiate problem solving. 4. anxiety causes a sense of dread or panic and physically causes nausea. being most extreme in anxiety disorders. However. the person experienced immediately prior to feeling anxious. Assist client to develop self awareness of verbal and nonverbal behavior. Demonstrate problem-solving skills 3. and it has a very important function in relation to survival. Goals and Objectives After performing all of the nursing Nursing Interventions Rationale Evaluation Was the Goal Met? .trembling. Assist her to use coping responses that have been successful in the past. Cues Subjective: The client Nursing Diagnosis Altered thermoregulation. Provide comfort measures. anger. Emotionally. and chills. sadness. both voluntary and involuntary behaviors may arise directed at escaping or avoiding the source of anxiety and often maladaptive. and identifying associated events. a. and happiness.
7°C 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. Was the client able to reduce body temperature by applying necessary undertakings regarding her fever? () Yes () No 2. resulting in a fall of temperature toward the setpoint level. Monitor use of hypothermia blanket an wrap extremities.” Objective: T: 37. pg 200) To minimize shivering Partially met? Unmet? Effectiveness: 1. whenever the core temperature rises above 37C (98. Objectives: After performing all the nursing interventions. Monitor vital signs. The clinical signs of fever vary with the onset. 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.” “Kahapon pa ito eh nung dinugo ako. c. the rate heat production is increased. Promote surface cooling by means of cool tepid sponge baths.verbalized. the client will be able to: 1. local ice pack especially in groin and axillae. Reduce body temperature by applying necessary undertaking s regarding her fever. d. resulting in a rise in temperature toward the set interventions. Under normal conditions. course and abatement stages of the fever. Conversely. producing heat. Para akong nilalagnat. 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 client’s situation? b. Promote cliet safety upon usage To prevent skin . a. the rate of heat loss is increased. These sign occur as a result of changes in the set point of the temperature control mechanism regulated by the hypothalamus.6F).6 F). when the core temperature falls below 37C (98. (Doenges. the client will be able to maintain core temperature within normal range. Nurse’s Pocket Guide. • “Ang init ng pakiramdam ko.
To allow for timely alterations in therapeutic regimen.point. To reduce metabolic demands/oxygen consumption. a. e. Administer replacement fluids and electrolytes. g. i. Administer antipyretic. Treatment of underlying causes will prevent the recurrence of hyperthermia. trauma () Yes () No Why? f. orally as ordered. 2. Administer medications to treat underlying cause as ordered. b. Promote wellness upon cessation of fever. Provide highcalorie diet. Maintain bed rest. To meet increased metabolic demands To prevent dehydration Indicates need for prompt intervention . Fluids and electrolytes support circulating volume and tissue perfusion. h. Discuss importance of adequate fluid intake. Review signs and symptoms of hyperthermia. of hypothermia blanket.
Treatment: Not Applicable Heath Teaching: • Take medications as prescribed. maintain bed rest. Exercise: Avoid exhaustion and try to reduce stress. Diet: • Continue oral supplementation of Folic acid and Iron. • Increase intake of carbohydrates like dairy products. vegetables. • Have an adequate sleep. If possible. Iberet and Ferrous Sulfate as prescribed. Out-Patient: Observe strictly scheduled prenatal check ups and other examinations.XII. • Consume at least 8 to 10 (8 oz) glasses of fluid each day. • No sudden increase in activity level. good diet and no fatigue. and whole grain cereals and breads. of which 4 to 6 glasses should be water. Spiritual: Advise client to always pray. • Eat high quality protein found in animal products. • Recognize signs and symptoms so that if problem occurs. fruits. it will be reported immediately to the doctor. of which less than 10% should be saturated fat. • Continue drinking two glasses of Anmum Materna daily. Far Eastern University . • Stress the need for personal safety precautions. • Fat requirement are unchanged and should account for about 30% of daily caloric intake. Discharge Plan Medication: Continue oral medications: Terbutaline sulfate.
Nicanor Reyes st. Sampaloc. Manila Institute of Nursing NURSING PROCESS (PLACENTA PREVIA) Respectfully Submitted to: Ms. Emerlyn Gacuya .
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