Davao Doctors College, Inc.

College of Allied Health Sciences

Nursing Program

NRG204: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS

(ACUTE & CHRONIC)
Learning Maternal & Child Health Nursing One Case Analysis at a Time!

Getting to Know the Course Instructor

Hello! I am Ana Patricia D. Birrey, and I will be your instructor
for NRG204: Care of Mother, Child at Risk or with Problems
(Acute & Chronic) for the 8th week. Before we begin, allow me
to introduce myself. I am Ma’am Ana, a part-time faculty
member of the Nursing Program of Davao Doctors College,
Inc. for this semester. I garnered my BS Nursing degree from
Ateneo de Davao University, Davao City last 2011 and I earned
my Master of Arts in Nursing degree from Davao Doctors
College, Inc last 2019. I recently passed the National Council
Licensure Examination (NCLEX-RN) and currently processing
and waiting to begin my practice as an entry level USRN. I have
over 8 years of Cardiac Rehabilitation, ECG technician,
Ambulance nurse and Emergency Room nurse experience.
Congratulations on finishing our third module for this semester! I hope that you learned a lot about
Human Immunodeficiency Virus in Pregnant Clients from our previous week’s discussion. If you have
queries regarding the topic(s) that we have covered last week, just let me know.

For this week, we will be learning about a client with a case of Abortion+ Premature
Rupture Of Membranes. I am looking forward to guiding you in learning this course well. If
you want to reach me for any academic-related concerns, you can reach me through the
following:

Contact No: Available upon request

Facebook account: Ana Patty
E-mail address: anapatriciabirrey@davaodoctors.edu.ph
Consultation hours: MONDAY (Feb.15, 2021 8am-4pm)

Requirements in Completing the RLE Activities

Since most of our sessions for this semester will be delivered through distance learning activities,
the submissions will also be primarily done online. To do this, you need to have access to the
following applications:

1. Microsoft Office/Google Docs

2. Microsoft PowerPoint/Google Slides
3. Google Classroom or Quipper (Will depend on the instructor in-charge)
4. Google Meet (or any other teleconferencing app, duly agreed by the whole group)
5. Internet connectivity
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Please expect that you might need to print some parts of the worksheets in this module (i.e.,
documentation and transcribing parts). If any difficulties in participating in synchronous classes
are encountered, inform your instructor right away! For absences, secure an excuse slip from
your RLE supervisor.

Submissions must be submitted through the Learning Management System (LMS) so that it
will be traced and secured easily.

Daily Activities
Every week, you are expected to follow through the following deliverables:

Day 1 (Monday/Thursday) Day 2 (Tuesday/Friday) Day 3 (Wednesday/Saturday)

Virtual Circle (Asynchronous Virtual Circle Virtual Circle
Meeting )
Receiving of Handover Case Presentation (cont.)
Completion of Module, to be
submitted within the day Case Presentation Weekly Quiz and Discussion of
Module and Quiz Answers
Preparation of PPT
Presentation Orientation of Next Week’s Activity

Now that you are done acquainting yourself with the instructor and the course itself, please
proceed to Module 4: Care of Clients with Abortion and Premature Rupture of
Membranes.

Term: Second Semester S.Y. 2020-2021

Dates: Week 8 – March 1 to 3, 2021
Class Schedule: MTW: 8:00AM – 4:00PM
No. of Hours: 8 HRS/DAY
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Instructions
The case analysis manuscript may be handwritten or computer written. Observe pagination.
Once done, send the compilation of your group’s answers to your clinical instructor.

After the submission, prepare a PPT presentation for your case presentation slated for Days 2
and 3 of your RLE classes. Each member of the group is expected to present during the case
presentations.

Learning Outcomes
At the end of this module, you are expected to:
1. Utilize the nursing process in the care of clients with problems in Abortion and
Premature Rupture of Membranes.
2. Perform a comprehensive health history and assessment based on the case scenario
presented.
3. Utilize assessment information to formulate a patient-centered plan of care.
4. Discuss the therapeutics done for the simulated patient.
5. Explain appropriate nursing interventions per problems identified.
6. Document the care rendered to assigned patient in the simulated health care record
accurately.

As you start with this module, you are free to consult and coordinate with your assigned clinical
instructor. Be sure to get his/her email address and contact number for collaboration and
assistance. Just keep going,you can do it!
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Case Scenario: Patient with Abortion and Premature Rupture of Membranes

Course in the Ward:

21-year-old Petina came into the Emergency room at Davao Doctors Hospital on February 15,
2021 at 8:30 am with the complaint of sudden gush of clear fluid from her vagina, not associated
with pain or bleeding but with continued minimal leakage since 10 pm on February 14, 2021. It
is her first pregnancy at 19 weeks age of gestation. Upon admission, vital signs revealed increased
body temperature of 38.7 degree Celsius, pulse rate of 122 bpm, respiratory rate of 20 cpm and
blood pressure of 100/60 mmHg. As they were preparing documents for Petina to be admitted in
the OB ward for further diagnosis and monitoring, the nurse gathered data for the initial interview.
Petina verbalized: “I thought I had only peed but I started suspecting something else because I
noticed that the stream of liquid exiting my vagina was constant and lasted longer than peeing.
When I woke up, I noticed that our bed was very wet. It also seemed like there’s a decrease in
the size of my abdomen and it got me really worried.” She also added that prior to her symptoms,
she had a quarrel with her live-in partner, Jake, who accidentally pushed her so she fell to the
floor. “He didn’t mean to push me because he was drunk last night. Sometimes, he blames me
for things I didn’t do. I feel so scared and somehow depressed. That is why I can’t help but pick
up bad habits such as smoking twice a week or drinking alcoholic beverages once a week.”

Family/Social Profile

Petina is living together with his boyfriend, Jake, for 2 years now in a boarding house. Her parents
already passed away from a car accident. She wasn’t able to finish high school and started
working as a baby-sitter to one of her relatives. As of the moment, she is being supported by
Jake who is an employee in a one-star hotel. No significant illnesses or known hereditary
conditions in the family .

Obstetric History (Menstrual and Pregnancy Hx)

Patient had her menarche at 13 years of age. She had a regular menstruation that lasts for 5
days. She usually changes her pads 4 to 5 times a day and is soaked in the first 3 days and
moderate to light flow in the succeeding days. She reported midline cramp-like lower abdominal
or back pain at the time of menses. She uses heat by putting a hot water bottle on her lower
abdomen to ease menstrual cramps. The type of contraception she used before becoming
pregnant was Desogestrel or progestin- only pill. She mentioned that she often forgets to take
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her pill at some time that is why she is pregnant right now. The first day of her last menstrual
period was on October 5, 2020.

• 1st trimester:
She had a regular prenatal check-up every month. Transvaginal ultrasound was done on her 12th
week and found out that she has a short cervix with cervical length of < 25mm.

• 2nd trimester:
On her recent prenatal, her OB-GYNE requested for a cervical swab/ pap test for culture or antigen
testing for Chlamydia. She tested positive for Chlamydial infection. This was requested by her
physician because she experienced yellow to green vaginal discharge, pain during sexual
intercourse, burning or pain when urinating, and pelvic pain. She was prescribed with an oral
antibiotic- Azithromycin tablet. Her live-in partner, Jake, was also advised for treatment to prevent
her from being reinfected. However, she wasn’t able to complete her antibiotic therapy due to
financial constraints. Jake was also uncompliant with the treatment regimen.

Past Medical History

• No major hospitalizations or surgical procedures have been reported.

• No known allergies.
• On 2019, she was diagnosed with Peptic Ulcer Disease, which resolved after two
months of taking Cimetidine 400mg tablet twice daily.
• She already received tetanus toxoid shots as prescribed. Other medications she took
are the following: Hemarate FA tablet and Calcium tablet.

Physical Examination (Pertinent Findings per system)

General Survey: Awake, febrile, not in respiratory distress

Vital Signs:
Temperature: 38.7˚ Celsius
Pulse rate: 122 bpm
Respiratory rate: 20 cpm
Blood pressure: 100/60 mmHg
Weight: 59 kg
Height: 5 feet 3 inches
Blood type: A +
Fundic Height: 16 cms
FHT: ranges from 160- 166 bpm via Doppler in right lower quadrant
HEENT: anicteric sclera (AS), pink palpebral conjunctiva (PPC)
CHEST/LUNGS: equal chest expansion (ECE), clear breath sounds (CBS)
CVS: distinct heart sounds (DHS), increased cardiac rate and rhythm (NCRR)
ABDOMEN: soft, normoactive bowel sounds
GU (IE): (-) kidney punch sign
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SKIN/ EXTREMITIES: full and equal pulses, capillary refill time < 2 seconds, no edema
NEURO EXAMINATION: GCS 15

Inspection:
• The patient has evenly medium-colored complexion, without unusual or prominent
discoloration
• Head is normocephalic
• Melasma noted on forehead, cheeks, and bridge of the nose
• Anicteric sclera, pink palpebral conjunctiva, PERRLA
• There were no eye, ear and nasal discharges or flaring noted
• Nasal septum in midline, dry lips, moist oral mucosa, tonsils non hyperemic, non-
hypertrophic
• Patient has relaxed posture, normal musculature, anteroposterior diameter less than
transverse diameter
• Breasts are symmetric, no dimpling and discoloration noted
• Nipples are erect and increase in size and areolae are larger and more pigmented
• Presence of linea nigra in the abdomen
• Extremities have a good range of motion
• Pink tones seen in the nailbeds; there is a 160- degree angle between the nail base and
the skin
• Capillary refill actively returns to its normal color in less than 2 seconds
• No varicosities or edema on lower extremities
• Vaginal walls are bluish purple in color, thick vaginal mucosa and vaginal rugae (folds) are
prominent
• (+) gush of clear fluid from the vagina noted
• No hemorrhoids seen

Auscultation:
• Lung sounds are vesicular over peripheral fields
• No adventitious breath sounds
• Heart has a dynamic precordium, normal rate and regular rhythm
• No heart murmurs noted
• Normal/audible bowel sounds
• FHT can be heard on the right lower quadrant

Palpation:
• No areas of tenderness or deformity on head
• Neck had no cervical lymphadenopathy
• No areas of tenderness or deformity on the ribs and sternum
• Presence of tactile fremitus
• Fundus is nearly at the level of the umbilicus
• Has a soft, tender abdomen
•
Percussion:
• No pathological/ hyperactive reflexes noted
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• No abdominal tenderness noted

Continuation of course in the ward (Day 1):

Before transferring the patient to the ward, the resident physician performed a sterile speculum
examination to look for a pool of fluid near the cervix and estimated cervical dilation and
effacement. The clear fluid was confirmed by a positive nitrazine paper test which turned out to
be dark blue in color. Ferning test was also ordered by the physician, therefore a sample was also
sent to the laboratory for microscopic examination of the fluid. Assessment on the cervix was
soft, with some dilation and effacement. Patient was given Duvadilan 10 mg tablet as per doctor’s
order.
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DDC-0009 Ragudo, Petina 02/11/2000 202b Dr. Velez None

Please admit under the service of Dr. Angeline Velez

February 15, 2021 -Secure consent to care
@ 8:30AM -Monitor VS q4 I and O q shift
-NPO
-start Venoclysis with D5LR 1L at 120cc/hr
T- 38.7 ˚
B/P-100/60 mmHg Labs:
RR- 20 cpm -CBC, PC
-Blood Typing
PR-122bpm -Hbsag
-Chest XRAY
(+) minimal vaginal fluid -Urinalysis
leakage -COVID Rapid Antigen Test
-Nitrazine test
-Ferning test

Meds:
Ampicillin 1gm IVTT q6 2
Paracetamol 300 mg IVTT q4

-FHT monitoring

-Refer for profused vaginal bleeding or passage of meaty

tissue
Possible curettage of uterine cavity once fetus has
passed out.

-Refer
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DDC-0009 Ragudo, Petina 02/11/2000 202b. Dr. Velez None

February 15, 2021 Plans:

@ 9:30AM
(+) active uterine bleeding
(+) severe abdominal cramping and
the urge to bear down
For Completion Curettage
Secure Consent
Inform OR, Anesthesia
Refer IM for Clearance

Ana Birrey, RN, MAN

02/15/2021 @9:35am

February 15, 2021 -IM CP-

@ 9:50 AM
Will classify patient as low CP risk
No contraindication for the contemplated procedure
(completion curettage)

Olivia V. Nielsen, RN, MAN

02/15/2021 @ 9:55am
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Diagnostic and Laboratory Results:

CBC PLATELET Upon admission

Ul

Patient Name: Ragudo, Petina C. Age/Sex: 21/F Date Requested: 02/15/2021

Physician: Dr. Velez Ward/Rm #: 202b Draw Date/Time: 02/15/2021 @ 8:45 am
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URINALYSIS

Patient Name: Ragudo, Petina C. Age/Sex: 21/F Date Requested: 02/15/2021

Physician: Dr. Velez Ward/Rm #: 202b Date/Time: 02/15/2021 @ 9 am

Hbsag and Blood typing

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NITRAZINE PAPER TEST

Patient Name: Ragudo, Petina C. Age/Sex: 21/F Date Requested: 02/15/2021

Physician: Dr. Velez Ward/Rm #: 202b Date/Time: 02/15/2021 @ 8:38am

Result: Positive
of amniotic fluid

Color of strip:
Blue

pH: 7
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FERN TEST
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COVID RAPID ANTIGEN TEST

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CHEST XRAY
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CBC PLATELET POST DILATATION AND CURETTAGE

Patient Name: Ragudo, Petina C. Age/Sex: 21/F Date Requested: 02/15/2021

Physician: Dr. Velez Ward/Rm #: 202b Date/Time: 02/15/2021 @ 6 pm
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TRANSVAGINAL ULTRASOUND REPORT

Patient Name: Ragudo, Petina C. Age/Sex: 21/F Date Requested: 02/15/2021

Physician: Dr. Velez Ward/Rm #: 202b Date/Time: 02/15/2021 @ 10 am

IMPRESSION:

Thickened, heterogeneous, and hyperechoic material within the endometrial cavity. There
is also echogenic material located in the lower uterine segment. (+) Heterogeneous
echogenic endometrial tissue and echogenic material in the lower uterine segment near
the cervical os. Findings consistent with retained products of conception.
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Course in the Ward: continuation of Day 1

On February 15, 2021 at around 9: 30 AM, Petina complained of an active uterine

bleeding and severe abdominal cramping with pain specifically on her umbilical area. She
was asked by the nurse on duty to rate her pain scale and mentioned “8/10.” She has the
urge to bear down and asked the nurse if she can be assisted to the comfort room for a
while. Petina suddenly noticed a sudden gush of blood, and the fetus coming out of her
vagina while urinating. To her dismay, she shouted for help while inside the comfort room
and passed out.

Seen and observed fresh clots, bright red in color, and other clots have the appearance
of liver and may have strands of fibers running through them. Placental tissue is grayish
pink in color, has a less compact appearance than clot and when submerged in bin water
reveals delicate fern -like villi.

Patient Petina was seen and examined by her OB Dr. Angeline Velez. Her attending
physician looked for evidence of any retained products of conception by performing a
transvaginal ultrasonography. Ultrasound findings revealed that there were retained bits
of tissue and came into a conclusion that patient Petina had an incomplete abortion. Dr.
Angeline Velez ordered and scheduled Dilatation and Curettage ( D & C) at 1pm of the
same day. The NOD accompanied Dr/. Velez and explained to the patient about the need
and importance of the procedure and soon was able to obtain consent for operation.

Patient was wheeled in to the operating room at 1:00 pm for her scheduled operation of
D & C. She was placed on the DR table at lithotomy position. D5 LR1 liter was hooked as
initial venoclysis. The following medications were administered by the Operating Room
nurse: Midazolam 3 ml + 0.5 ml; Nubain IVTT. Bupicacaine 0.5 .% 10 mng10mg was
inducted as spinal anesthesia by Dr. Jeffrey Madrigal. At 1:10 pm, D & C was already
started by Dr. Angeline Velez and the OR team. There were placental fragments and
these were removed via curette. Thereafter, the specimen was extracted and isolated.
Vaginal pack was also inserted and noted for removal. Perineal washing and post- partum
care was done and placed the patient on diaper. Methergine 1 ampule IVTT was the
additional medication that was given to patient Petina to prevent bleeding. Vital signs
were continuously monitored for any changes to detect possible hypovolemic shock. After
a few hours, patient Petina’s vital signs were stable and was transferred back to the ward
with ongoing IVF.
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What to Do?
To immerse yourself in the care management of your patient, let us do some detailed description
of your patient care tasks. Using the Case Scenario assigned to you, you are expected to perform
the following:

1. Fill-up the needed data based on the given scenario/case.

2. Conduct a history taking and physical assessment of your patient. Discuss the health
history of the patient narratively, in chronological order as much as possible. Use the DDC
Health Assessment form for documenting PA findings.
3. Discuss the pathophysiology of the patient’s condition. Discuss the FF: definition of
diagnosis, etiology, symptomatology, schematic diagram of the pathophysiology of the
condition of the patient, narrative description of the condition of the patient.
4. Interpret the therapeutics done for the patient: doctor’s orders, laboratory and
diagnostic tests done, and surgical procedures to be performed. Use format presented.
5. Present your drug study and IVF data. One drug study per student. Transcribe the
IVF and medications in the appropriate sheets.
6. Formulate a patient-centered care plan for your patient. Integrate in your care
intervention significant bioethical and legal standards of patient care. One NCP per
student.
7. Document the care given by making a nurse documentation following the FDAR format.
8. Clinical Reasoning Questions - Collaboration:
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9. Clinical Reasoning Questions - Ethico-Moral-Legal: As a nurse, you are about

to assist a medical abortion due to ectopic pregnancy.

Have you answered all of the questions above? Great! Congratulations!

You have completed this module. You may now proceed to the next activity for the
week. Please wait for further instructions from you instructor

ADDITIONAL ACTIVITIES: FILLING OUT HOSPITAL FORMS

You are to give the following medications/IV fluids: Vital Signs Sheet (3-11 shift):
4PM VS: Temp: 37.3 deg. Cel. BP: 120/80 mmHg PR: 76 bpm HR: 76 bpm RR: 16 cpm
O2 sat: 98% Pain Scale: 2/10 (headache)
8PM VS: Temp: 38 deg. Cel. BP: 130/90 mmHg PR: 81 bpm HR: 80 bpm RR: 19 cpm
O2 sat: 98% Pain Scale: 4/10 (headache)
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Medication Administration Record (3-11 shift):

Butamirate citrate 50mg/tab 1 tab OD PO - 8PM Atorvastatin 40mg/cap 1 cap OD PO -
9PM Ampicillin sulbactam 1.5g IVTT q8 - 10PM Paracetamol 500mg/tab 1 tab Q4 PRN
for fever - 8:30PM TEMP: 38.0 deg. Cel.
Instructions: Supposing you have given all of the due medications for your shift, fill out
the MAR. Plot your VS results in the VS and TPR Sheets as well.
IV Flow Sheet + I/O Sheet:
Scenario: At 3:00PM during the handover, you received Patient A of having #4 PNSS
1L @ 100 ml/hr, infusing well at left MCV, G.20. It was ordered.
In addition, from 3PM to 11PM, the patient had 3/4's of a liter of water, ate corned beef
+ rice and drank a 300ml-glass of orange juice for breakfast, and ate 1 chicken cordon
bleu, 1 cup of rice, and 2 glasses of softdrinks for lunch. At 10am, he had a cup (150ml)
of black coffee. He voided twice, one in 4:30PM (approx. 200ml), and one at dinner-
time, 7:00PM (approx. 300ml). Around dinner-time, he defecated once as well.
Complete fill-out the IV Flow Sheet + I/O Sheet.

References:

Murray, S. and McKinney, E., 2014. Foundations Of Maternal-Newborn And Women’s

Health Nursing. 6th ed. MISSOURI: Saunders, an imprint of Elsevier Inc., pp.504-506.

The McGraw-Hill Companies, Inc. (2010). Maternal-Newborn Nursing Demystified (pp.

161-163). New York City.

Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal and Child Health Nursing Care of the
Childbearing and Childrearing Family (8th ed., p.529-533). Philadelphia: Wolters
Kluwer.