Professional Documents
Culture Documents
A. What is the case problem of the patient? Prepare the pathophysiology of the case of the
patient using the available information from the video case.
- The case problem of the patient is uterine rupture with postpartum hemorrhage which is a
complication after 9hrs of induction of labor without augmentation. Patient appears vitally
stable with no vaginal or cervical tears. After 13 hours of delivery, an ultrasound was made
and result presented a hematoma in vesicouterine pouch following symptoms of abdomen
distention, tenderness, guarding and vital signs stable after 24 hours of delivery. Thus
exploratory laparotomy is done. Rarely uterine rupture may occur with patient being vitally
stable.
PATHOPHYSIOLOGY:
B. What is the history and chief complain presented in the video? What are the signs and
symptoms that the patient presented in the video? Prepare your 13 areas of assessment using
the available data from the video case. In cases where there are no data provided under a
specific area if assessment, then there is no need to include the mental status assessment in
your 13 areas of assessment report.
- A 35 years old patient who has previous four pregnancies with a history of one abortion and
two preterm births. She’s overdue by 7 days and was induced during labor. 12 hours after
delivery, patient presented symptoms of abdominal pain. She’s showing signs of a rapid heart
rate of 100bpm and low blood pressure of 112/70. Patient’s experiencing abdomen distention
and tenderness which persisted for 24 hours. Guarding was also observed to the patient.
13 AREAS OF ASSESSMENT
1) Sensory Status - The patient skin has receptors for pain and pressure. Such as pain and
tenderness in her abdomen. The pressure from her abdomen that is presented by her
guarding behavior.
2) Motor Status - The patient had just undergone a vaginal delivery so her range of motion
is altered. She needs assistance when performing vigorous activities of daily living. There
is presence of discomfort during range of motion exercises as manifested by symptoms of
abdomen al distention, pain and tenderness in the abdomen.
3) Circulatory Status - The blood pressure of the patient is 112/70 which is below normal
the average baseline of 120/80mmHg.
4) Sleep, Rest and Comfort Status – The patient’s status of sleep, rest and comfort is altered
with the presented symptoms of pain and abdominal distention which persisted 24 hours
after the delivery.
5) Reproductive Status - Some of her Reproductive organ is altered especially the external
area due to episiotomy but it is considered normal due to the process of delivery. Physical
assessment after the delivery shows that uterus is well contracted but symptoms of
abdominal distention and tenderness was observed which persisted for 24 hours. Pelvic
examination reveals that cervix is 2cm dilated and contour of the uterus maintained with
no mass felt in B/L broad ligament. An ultrasound was done 13 hours after delivery and
results showed hematoma on vesicouterine pouch.
C. What were the diagnostic procedures done on the patient to determine the real cause of the
patient’s health problems?
Source:
https://www.healthline.com/health/ultrasound
2. Laparotomy
A laparotomy is a surgical incision into the
abdominal cavity. A laparotomy is performed to
examine the abdominal organs and
aid diagnosis of any problems. Exploratory
laparotomy is used to visualize and examine the
structures inside of the abdominal cavity. This
method of diagnostic tool allows physicians to
examine the abdominal organs. The procedure
may be recommended for a patient who has
abdominal pain of unknown origin or who has
sustained an injury to the abdomen.
Source: https://www.surgeryencyclopedia.com/La-
Pa/Laparotomy-Exploratory.html#ixzz6LH6ngz00
3. CBC
A complete blood count (CBC) is a blood test used
to evaluate your overall health and detect a wide
range of disorders, including anemia, infection and
leukemia. A CBC may be ordered when a person
has any number of signs and symptoms that may
be related to disorders that affect blood cells.
When an individual has an infection,
inflammation, bruising, or bleeding, a doctor may
order a CBC to help diagnose the cause and/or
determine its severity.
Source: https://www.mayoclinic.org/tests-
procedures/complete-blood-count/about/pac-
20384919
D. What are the Drugs prescribed to the patient to address the patient’s health problem? Prepare your Drug Study following the
prescribed format of CON.
AFTER:
Dx:
a. Assess
knowledge/teach
patient appropriate use
,interventions to
reduce side effects,
and adverse symptoms
to report.
b. Monitor for
effectiveness as
exhibited by a
decrease in symptoms
c. Monitor for side
effects.
Tx:
a. Provide safety
measures (e.g.
adequate lighting,
raised side rails, etc.)
to prevent injuries.
b. Provide comfort
measures (e.g. voiding
before dosing, etc.) to
help patient tolerate
drug effects.
c. Introduce name and
build a good rapport to
the patient.
Edx:
a. Monitor patient
compliance to drug
therapy.
b. Monitor patient for 2-
4 weeks to ascertain
onset of full
therapeutic effect.
c. Advise pt. to avoid
alcohol intake.
d. Instruct patient to
verbalize feelings and
concerns.
DRUG NAME MECHANISM OF INDICATION / ADVERSE EFFECT NURSING
ACTION CONTRAINDICATION RESPONSIBILITIES
DURING:
Dx:
a. Obtain vital signs.
b. Assess for nausea
and vomiting,
thirst, and severe
constipation.
c. Check if it is the
right medication.
Tx:
a. Assist client on
bathroom
privileges.
b. Assist client in
taking the
medication.
Edx:
a. Advice the client
to take the
medication after
meals.
b. Encourage the
client to verbalize
feelings and
concerns.
c. Instruct client the
drug is taken
through the mouth.
d. Educate regarding
the purpose or use
of the medication.
AFTER:
Dx:
a. Instruct patient to
report reduced
urinary output,
persistent diarrhea,
bruising, and
bleeding.
b. Assess calcium
level of the patient.
c. Assess for any
adverse effects of
the drug.
d. Assess
knowledge/teach
patient appropriate
use and
interventions to
reduce side effects.
e. Monitor for
effectiveness as
exhibited by a
decrease in
symptoms.
f. Asses the response
of the client to the
medication.
Tx:
a. Provide safety
measures to the
client.
b. Assist client on
bathroom
privileges.
c. Monitor patient’s
compliance to
drug.
Edx:
a. Instruct client to
verbalize feelings
and concerns.
b. Instruct not to
exceed
recommended
dosage.
c. Advice client to
increase fluid
intake.
d. Advice to notify
prescriber of
therapeutic
response to drug
decreases.
e. Instruct patient to
report if adverse
effect of drug is
experience.
DRUG NAME MECHANISM OF INDICATION / ADVERSE EFFECT NURSING
ACTION CONTRAINDICATION RESPONSIBILITIES