Name of Student: REGIDOR, ANGELICA B Section: BSN 2-A6

Concept:
Name of Clinical Instructor: MR. BILLY ADRENEDA MARVELO

Patients Data: Occupation: Sales Agent

Name: Rhiza M. Noel
Gender: Female Nationality: Filipino
Birth Date: March 18, 1997
Religion: Roman Catholic
Birth Place: Minglanilla, Cebu
Source of Data: Emergency Room Record_
Age: 23
Address: Minglanilla, Cebu Date & Time of Admission: _7-22-20 12:53am_
Educational Level: Attending Physician: Dr. Seboa
Marital Status: Single Diagnosis:

Chief Complaint: Watery Vaginal Discharge

LMP:
AOG:
EDC:

Students RLE Guide

CNC Page 1
 Anatomy & Physiology
(This will show a drawing of the organ affected related to the diagnosis of the patient.)

Uterus - strong muscular sac that fetus can develop in.

-expulsion during childbirth.
Placenta - an organ that develops in your uterus.
-responsible for producing hormones.
Umbilical Cord - sometimes called the baby's "supply
line" because it carries the baby's blood back & forth, between the baby and the placenta.
Cervix - a passage of sperm into the uterus and the exit of menstrual blood.
Amniotic fluid - a sac that holds the baby.
Vagina - organ of intercourse, birth canal.

The rupture of fetal membranes (water breaks) before the beginning of labor is considered a complication of pregnancy
known as premature rupture of membranes. This can happen at any gestational age, even full term. Despite what movies may
depict, this sudden gush or steady trickle of fluid only occurs in about 10% of term pregnancies and 4% of preterm pregnancies.
When the
membranes rupture prior to 37 weeks gestation, it is considered preterm premature rupture of membranes (PPROM). Regardless of
gestational age, when the membranes rupture, the protective barrier between the vagina and the fetus is lost and increases the risk
of maternal and fetal infection. There is no specific cause, but there are many factors that may increase the risk of PROM. Maternal
or intra-amniotic infection and chronic disease, such as systemic lupus erythematosus, direct abdominal trauma, nutritional
deficiencies, smoking and placenta abruption all increase the risk of PROM. Multiple pregnancy (twins or more) and a history of
previous PROM also indicate an increased risk.
1. PROM is associated with malpresentation, possible weak areas in the amnion and chorion, subclinical infection, and,
possibly, incompetent cervix.
2. Basic and effective defense against the fetus contracting an infection is lost and the risk of ascending intrauterine infection,
known as chorioamnionitis, is increased.
3. The leading cause of death associated with PROM is infection.
4. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection
is low.
Laboratory Test

Date Type of exam Patient’s Result Normal Significance / Interpretation

Values
11/25/20 CBC WBC: 11.24 4.4 – 11.0 Higher than normal count of neutrophils
NEU: 81.30 37.0 – 80.0 can be a sign of infection.
LYM: 11.80 10.0 – 50.0
MON: 6.10 0.0 – 12.0
EOS: 0.50 0.0-7.0
BAS: 0.30 0.0 – 2.5

RBC: 3.62 4.5 – 5.1

HGB: 11.50 12.3 – 15.3
HCT: 34.00 35.9 – 44.6

MCV: 93.90 80 – 96
MCH: 31.70 27.5 – 33.2
MCHC: 33.80 32.0 – 36.0
RDW: 14.30 11.6 – 14.8

PLT: 132 150 – 450

MPV: 10.00 6.0 – 11.0
Urinalysis Macroscopic Examination Hazy urine during pregnancy is normal due
Color: YELLOW YELLOW to vaginal discharge. Protein/Albumin in
Volume: 30 mL urine may indicate a kidney disease. Blood
Transparency: HAZY CLEAR in urine may be a sign of labor.
Specific Gravity: 1.010 1.005 – 1.025

Chemical Examination
Albumin: TRACE NEGATIVE
pH: 6.5 4.5 – 8.0
Ketone: 2+ NEGATIVE
Blood: 1+ NEGATIVE
Glucose: NEGATIVE NEGATIVE
Nitrate: NEGATIVE NEGATIVE
Bilirubin: NEGATIVE NEGATIVE
 Urobilinogen: NORMAL

Microscopic Examination
WBC: 1-4 /HPF 0-5 HPF
RBC: 1-3 /HPF 0-4 HPF
Epithelial Cells: FEW
Mucus Threads: RARE
Bacteria: MODERATE

Crystals
Amorphous Phosphates: RARE

Blood Typing Blood Type: O Patient’s blood type is O negative.

Rh: NEGATIVE

Diagnostic Tests

Date Type of test Patient’s result Significance/ interpretation

Evaluation of Gestation Single, live, intrauterine
pregnancy, 34 weeks and 6 days
by fetal biometric cephalic
presentation.
Cephalic presentation or head-first presentation
is a situation at childbirth where the fetus is in a
longitudinal lie and the head enters the pelvis
first. It's safest for the mother and baby when it
comes to giving birth.

Placenta previa Placenta posterior high lying,
grade 1-2.
Amniotic Fluid Index Amniotic Fluid Volume –
Adequate.
Grade 1 – (minor) the placenta is mainly in the
upper part of the womb, but some extends to
the lower part.
Grade 2 – (marginal) the placenta reaches the
cervix, but doesn't cover it.
Normal
 Problem List

Number of Focus/Nursing Diagnosis

Priority
1 Risk for maternal infection related to rupture of amniotic membranes as evidenced by onset
watery vaginal discharges
2
Risk for fetal injury related to rupture of amniotic membranes

3 Anxiety related to situational crisis

Drug Study
Drug name Classification Mechanism of Indication Contraindica Adverse reaction Nursing responsibilities
action tion
o Generic Name Pharmacologic: An essential mineral A prescription iron This product is Allergic sensitization Before
FeSO4 + MV Water-soluble found in supplement contraindicated has been reported Observe proper dosage of
o Brand Name vitamins, iron haemoglobin, indicated for use in in patients with following both oral medication
Beniforte supplements myoglobin, and many improving the a known and parenteral
enzymes. Enters the nutritional status of hypersensitivity administration of Acquire Lab test results:
o Actual dosage, Therapeutic: bloodstream and is iron deficiency. to any of the Beniforte Periodic CBC with differential,
route, frequency Vitamins, transported to the ingredients. Hct & Hgb, LFTs.
Cap OD Minerals, organs of the Hemochromato
Antianemics reticuloendothelium sis and During
system, where it is hemosiderosis Administer with full glass of
separated out and are water.
becomes part of iron contraindication
stones. s to iron Inform patient about dark,
therapy green or black stools to avoid
panic.

After
Monitor for changes.

Orient patient about its side

effects.
 Nursing Care Plan 1

Defining Nursing Scientific Analysis Goal of Care Intervention Rationale

Characteristics Diagnosis
Subjective: Risk for Premature Rupture of Short Term: Independent 1. The incidence of chorioamnionitis (intra-
-Patient maternal the Membranes (PROM) After two days 1. Monitor vital signs, amniotic infection) increases within 4 hours after
complains about infection is a complication of nurse and and white blood cell rupture of membranes, as evidenced by
watery vaginal related to occurring during client (WBC) count, as elevations of WBC count and abnormal vital signs.
discharge. rupture of pregnancy in which the interaction, the indicated. 2. Reduces risk of acquiring/spreading infective
amniotic mother’s membranes client will be agents.
Objective: membranes. as rupture (this is commonly able to: 3. The amniotic fluid during an infection becomes
VS: evidenced by referred to as the “water 1. Gain 2. Demonstrate good thicker and yellow-tinged and has a foul-smelling
BP – 110/70 onset watery breaking”) more than an knowledge hand washing odor.
PR – 85 vaginal hour before labor begins. about the techniques. 4. Reduces risk of ascending tract infection.
RR – 19 discharges PROM puts unborn infections. 3. 3. Monitor and
Temp - 36.8 babies at risk of not 2. Report describe the
O2 Sat – 98% getting enough oxygen problems about character of
Weight – 117lbs because their umbilical the matter, if amniotic fluid.
cord becomes there is any. 4. Encourage perineal
compressed, as well as 3. Demonstrate care after 1. Maintains hydration and a general sense of
becoming infected and a meticulous elimination and prn well-being.
experiencing other hand washing as indicated; change
dangerous consequences. technique. underpad/ linen 2. Detects and identifies causative organism(s).
One complication when wet.
associated with PROM is Long Term: Collaborative
the maternal infection: To be free to the 1. Provide oral and parenteral
Without the protection of signs of fluids, as indicated. Reference:
the amniotic sac, infection 2. Obtain blood cultures if 36 Labor Stages, Induced and Augmented Labor
maternal infections can symptoms of sepsis are Nursing Care Plans Paul Martin- By-Paul Martin
be easily transmitted to present. https://nurseslabs.com/labor-stages-labor-
the baby, potential induced-nursing-care-plan/#a4
leading to sepsis,
meningitis, and
permanent brain Reference:
damage. 36 Labor Stages, Induced and
Augmented Labor Nursing
 Care Plans Paul Martin- By-
Paul Martin
https://nurseslabs.com/labor-
Reference: stages-labor-induced-nursing-
Premature Rupture Of care-plan/#a4
Membranes: Birth Injury
and Pregnancy Faqs Jesse
Reiter
 NCP 2

Defining Nursing Scientific Analysis Goal of Care Intervention Rationale

Characteristics Diagnosis
Subjective: Risk for fetal Premature rupture of membranes Short term: Independent:
-Patient complains injury related to (PROM) refers to a patient who is Within 20-40 minutes of Educate mother to Bed rest helps prevent
about watery rupture of beyond 37 weeks' gestation and has administering IV fluids and have a complete bed further complications and
vaginal discharge. amniotic presented with rupture of membranes oxygen supplement to the rest. helps limit oxygen
membranes (ROM) prior to the onset of labor. mother, the fetus will be consumption.
Objective: Preterm premature rupture of able to receive adequate
VS: membranes (PPROM) is ROM prior to amount of oxygen and Assess and monitor Alterations of the vital signs
BP – 110/70 37 weeks' gestation. Spontaneous nutrients for life support. continuously the vital of the mother and fetus from
PR – 85 preterm rupture of the membranes signs of the mother the normal values may
RR – 19 (SPROM) is ROM after or with the Long term: and the fetus. indicate that there is
Temp - 36.8 onset of labor occurring prior to 37 Within 1-4hrs of letting something wrong in the body
O2 Sat – 98% weeks. Prolonged ROM is any ROM the mother have of the mother.
Weight – 117lbs that persists for more than 24 hours complete bed rest,
and prior to the onset of labor. Eighty- providing safety measures Evaluate pulse To asses respiratory
five percent of neonatal morbidity and and promoting a clean oximetry of the insufficiency.
mortality is a result of prematurity. and quiet environment, mother to determine
PPROM is associated with 30-40% of the fetus will be able to oxygen saturation in
preterm deliveries and is the leading receive continuous her body.
identifiable cause of preterm delivery. amount of oxygen
PPROM complicates 3% of all necessary for the Administer IV fluids, as For nutritional support to the
pregnancies and occurs in transportation of indicated. mother and fetus and for
approximately 150,000 pregnancies nutrients. fluid replacement, if vaginal
yearly in the United States. [2] When bleeding occurs.
PPROM occurs remote from term,
significant risks of morbidity and Provide safety To protect client from
mortality are present for both the measure (e.g. raise injuries and to provide the
fetus and the mother. side rails and keeping patient comfort.
off things that are
Reference: sharp and edgy), and
https://emedicine.medscape.com/arti promoting a clean and
cle/261137-overview quiet environment.
Collaborative:
Prepare the patient To help SOs understand the
and family members critical condition of the
for the possibility of mother and have
an emergency CS reassurances of the mother’s
delivery, the delivery current condition.
of a premature
neonate and the
changes to expect in
the postpartum
period. To help the SOs and mother
to prepare physically and
Offer emotional emotionally to the situation.
support and an honest
assessment of the Tell the mother that the
situation. neonate’s survival depends
primarily on gestational age,
the amount of blood lost,
Tactfully discuss the and associated hypertensive
possibility of neonatal disorders- assure her that
death. frequent monitoring and
prompt management greatly
reduce the risk of death.

Allowing them to understand

Encourage the patient clearly the situation.
and her family to
verbalize their
feelings. Help the SOs and mother
cope with the situation
Help them to develop properly.
effective coping
strategies, referring Reference:
them for counselling if https://nurseslabs.com/pret
necessary. erm-labor-nursing-care-
plans/
FDAR
Date Focus
7/22/20 Risk for maternal infection
related to rupture of
amniotic membranes. as
evidenced by onset watery
vaginal discharges
Time DAR
D: Subjective:
-Onset watery vaginal discharge.
A:
-Provide oral and parenteral fluids, as indicated.
-Demonstrate good hand washing techniques.
-Monitor and describe the character of amniotic fluid.
-Monitor vital signs, and white blood cell (WBC) count, as
indicated.
-Encourage perineal care after elimination and prn as
indicated; change underpad/ linen when wet.
R:
Patient demonstrated good handwashing techniques and
perineal care. Risk for infection is reduced.
Discharge Planning

Date Focus Time DAR

5/16/20 Discharges instructions 7am D: With discharge order from attending physician Dr. Seboa

A: A ctivity: The client is assisted in attaining his or her

highest level of mobility possible before
discharge.
M edication:
Cefuroxime (Altoxime) 500 mg 1 tab BID PO/6 days, works by stopping the growth of bacteria.
Nausea, vomiting, diarrhea, strange taste in the mouth, or stomach pain may
occur as side effects. Should be taken orally or by mouth.
Mefenamic Acid (Alfemen) 500 mg 1cap q 6o, used to used to relieve mild to moderate pain. Side
effect includes, diarrhea, constipation, stomach pain, gas, heartburn, nausea,
vomiting, and dizziness. Taken orally.

E nvironment: Stress free, clean and free from infections

T reatment: Instruct the necessity of take home medications, Instruct the client and SO to
monitor for any signs of infection

H ealth Teaching: Teach the client in preventing infections, necessity of complete bed rest,
pelvic rest, temperature monitoring, and healthy diet.

O utpatient Referral: Follow-up at RHU 1 week after discharge through call

D iet: Soft Diet; Balance and healthy meal: Transition to regular DAT
R: Out of the room per wheelchair with improved
condition
Bibliography (a summary of all the resources used)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526377/#:~:text=Levetiracetam%20is%20an%20antiepileptic%20drug,protein%20S V2A
%20in%20the%20brain.
Reference:
Premature Rupture Of Membranes: Birth Injury and Pregnancy Faqs Jesse Reiter
https://nurseslabs.com/preterm-labor-nursing-care-plans/