The United Methodist Church Ecumenical Christian College College of Nursing Mangga II, Matatalaib Tarlac City

In Partial fulfillment On The Requirements In The Subject Nursing Care Management 102(RLE)

Premature Rupture of Membrane

Gonzales, John Michael Randy Cayanan, Jenifer BSN II-A

December 19, 2011

Chapter I: Introduction 4-6

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a. Current Trends b. Reason for choosing such case for Presentation c. Objective

Student-Center Client-Center Chapter II Nursing Assessment 7-17 a. Personal History i. ii. iii. iv. v. b. c. d. e. f. Demographic Data Socio-Economic and Cultural Factors Typical Day Life style 24 hours Diet Recall page

Pertinent Family History History of Past illness History of Present illness Physical Examination Diagnostic and Laboratory page page

Chapter III: Anatomy and Physiology 18-20 Chapter IV :The Patient and Her illness 21-22 a. Schematic Diagram of Pathophysiology Book base Client base b. i. ii. iii. Synthesis of the disease Definition of The Disease Predisposing and Precipitang Factors Sign and Symtoms Chapter V: The Patient and Her Care page 23-35 A, Medical Management i. Intravenous fluid ii. Drugs

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iii. Diet iv. Activities b. Nursing Management i. SOAPIE ii. Nursing care plan Chapter VI: Client Daily Progress Chart a. Clients Daily Progress Chart Chapter VII Discharge Plan 36-37 Chapter VIII : Learning Derived 38 Chapter IX: Conclusion and Recommendation 39 BIBLIOGRAPHY 40 page page page page

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CHAPTER I. INTRODUCTION This paper is a discussion about the case of Patient X 21 years old who was diagnosed to have Premature Rupture of Membrane. She was admitted at Tarlac Provincial Hospital on November 21,2011 with chief complaint of Labor pain

Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when there is rupture of the membranes (rupture of the amniotic sac and chorion) more than an hour before the onset of labor. PROM is prolonged when it occurs more than 18 hours before labor. PROM is preterm (PPROM) when it occurs before 37 weeks gestation. Risk factors for PROM can be a bacterial infection, smoking, or anatomic defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the rupture can spontaneously heal, but in most cases of PROM, labor begins within 48 hours. When this occurs, it is necessary that the mother receives treatment to avoid possible infection in the newborn.
Although the fetus is almost always mature at between 36-40 weeks and can be born without complication, a normal pregnancy lasts an average of 40 weeks. At the end of 40 weeks, the pregnancy is referred to as being "term." At term, labor usually begins. During labor, the muscles of the uterus contract repeatedly. This allows the cervix to begin to grow thinner (called effacement) and more open (dilatation). Eventually, the cervix will become completely effaced and dilated. In the most common sequence of events (about 90% of all deliveries), the amniotic membrane breaks (ruptures) around this time. The baby then leaves the uterus and enters the birth canal. Ultimately, the baby will be delivered out of the mother's vagina. In the 30 minutes after the birth of the baby, the placenta should separate from the wall of the uterus and be delivered out of the vagina.

Maternal risk factors for a premature rupture of membranes include chorioamnionitis or sepsis. Association has been found between emotional states of fear in a population and prelabor rupture of membranes at term. Fetal factors include prematurity, infection, cord prolapsed, or malpresentation Page | 4

At the province of Tarlac City, according to Tarlac Provincial Hospital, premature rupture of membrane cases are not usually occurs. The group decided to choose this case for us to enhance our knowledge about the case. With this case. We able to understand about the possible complication of labor and can apply our knowledge on how to assess a patient suffering from labor pain.

A. Current Trends (Premature Rupture of Membrane)

Preterm premature rupture of the chorioamniotic membranes is a common obstetric complication, occurring in approximately 12% of pregnancies. The management of patients with preterm premature rupture of membranes (PROM) is controversial, but most physicians advocate expectant management, especially in cases of extreme prematurity. Expectant management in the setting of preterm PROM has been associated with increased incidence of maternal-fetal infections, cord prolapse, pulmonary hypoplasia, and fetal distress. Evidence from prior studies also suggests that women exposed to prolonged preterm PROM are at increased risk of placental abruption. The role of bacterial colonization and amniotic fluid infection in the pathophysiology of placental abruption is also poorly understood. Most notably, acute chorioamnionitis, an infection caused when pathogens from the vagina and cervix gain access to the placental-fetal membranes, is suspected of preceding membrane rupture. Some earlier studies have suggested that intrauterine infection, especially chorioamnionitis, weakens the membranes, leading to premature rupture, whereas others believe that the ascending infection is the consequence of preterm PROM. In addition, there is evidence that oligohydramnios in preterm PROM increases the risk of abruption. Although the sequence of events linking preterm PROM, intrauterine infections, and oligohydramnios to the risk of abruption is, at best, speculative, we hypothesized that women with both preterm PROM and with a diagnosis of intrauterine infections or oligohydramnios would be at greater risk of developing abruption when compared with women with any 1 of these complications alone.
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The management section reviews current opinions regarding prophylactic antibiotic therapy in the prevention of preterm birth, adjunctive antibiotic therapy in the treatment of preterm labor with and without rupture of membranes, and antibiotic therapy of intra-amniotic infection
b. Reason of Choosing such case for presentation

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The group choice this because we want to further our knowledge about Premature Rupture of Membrane and our group wants to learn more about the facts and proper nursing intervention about the disease

This case study will help the group in understanding the disease process of the patient. This would also help the group in identifying the disease process of the patient with premature rupture of membrane by identifying such needs and health problems of the patient associated with the disease and understanding why such needs and health problem arise the group can now formulate an individualized care plan for the patient that would address these needs and problems effectively. Effect management of the problem identifies will help the patient to recover faster and maintain a holistic sense of wellness even while in the hospital. This case study would also equip the group with knowledge skill and attitude on how to manage future patients with premature rupture of membrane

b. Objective Student Centered After the 1 week exposure and case study/ presentation the group will be able to: 1. Gain new information about Premature Rupture of Membrane and its etiology, patho physiology clinical manifestation as well as the standard medical and Nursing management so that they may apply this newly acquired knowledge to their patient as well as similar in the future 2. Learn new clinical skill as well sharpen our current clinical skill required in the management of the patient with Premature Rupture of Membrane 3. Properly and skillfully administer nursing management and medical treatments needed by the patient

Client Centered At the End of the case study, the client will 1. Understand sufficient health information to help the patient cope with Premature rupture of membrane.

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2. Be aware of the things she needs to modify in order to maintain a healthy body and life style and to prevent further complication brought about by her present illness. 3. Be aware of the treatment regimen and follow this strictly 4. Be more concerned about her health status to avoid illness

Chapter II Nursing Assessment A. Personal History

I.

Demographic Data

Name: Age: Sex: Civil Status: Religion: Address: Date of birth:

Patient X 21 y/o Female Married Roman Catholic Tibag, Tarlac City March 12, 1990
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Place of birth: Nationality: Chief Complaint: Diagnosis: Date of Admission: Admitting Physician:

Balanti, Gerona Tarlac Filipino Labor Pain Premature Rupture of membrane November 21, 2011(6:54; 49 Am)d Dra. Zarate

II.

Social Status

Mrs. X is 21 y/o, she is married. She has a two children, two girls. She stated that she has a good relationship with her neighbors according to her she does not usually participate in the community activities. She usually consults in Hospital, but sometimes seeks advice to the faith healers. According to her it will not cause her harm.

III.

Typical day

Her day starts around 6:00 in the morning, patient X prepares food for her child and fixed the things that her child needs for school. At lunch, she fried fish with fried egg plant. The food she usually eats during snack time are biscuit and glass of orange juice. Then at midnight she eats 2 piece of pandesal at coffee IV. Life style

Patient started to smoke during her high school life. She eat three times a day. She loves to eat salty foods, and claimed that she cannot eat without sauce on her foods like alamang fish sauce and soy sauce. She doesnt usually drink water but instead soft drinks or occasionally and only consumes 1-2 bottles of beer. According to the
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patient she usually used her free time to watch programs at the television. She drinks alcohol occasionally and a permission of her husband.

v. Recall Morning meal: 2 piece of Pandesal Lunch meal: and 1 cup of rice Snack: 1 glass of orange juice Dinner and 1 cup of coffee

24 hour Diet 1cup of Coffe and 1 piece of fried fish 1 piece of biscuit and 2 piece of pandesal

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b. Pertinent Family History

Male-

Female-

DM- Diabetes mellitus HTN-Hypertension

uti- Urinary tract infection patient- X-

HTN uti

DM

HTN

DM

ut i

ut i

21 yrs old Ms X UTI

Interpretation

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There are possible hereditary Disease that the client could acquire from her Parents And Grand Parents c. History of Past Illness Mrs X has history of UTI when She Got Pregnant in her 2nd Child and She was under gone Cesarean Surgery before. She stated that she completed her immunization

d. History of Present illness 2 days prior to admission, she had sudden gush of Fluid to her Vagina and fever. Persistent of this above symptoms led to consultation hence admission she was diagnose Labor pain upon Admission

e. Physical Assessment

General Physical Assessment NAME: Aiza T. Yumul AGE: 21 VITAL SIGNS: 1 .Temperature: 37.5 degree celcius 2. Pulse Rate: 73 3. Respiratory Rate: 23 4. Blood Pressure: 120 / 80 HEIGHT: 54 feet WEIGHT: 58 kilogram SEX: female DATE: Nov 21, 2011

BODY PARTS ASSESSED

ACTUAL FINDINGS

INTERVENTION/ ANALYSIS

APPEARANCE AND MENTAL STATUS

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Body built height and weight in relation to the clients age, health and life style. Clients over all hygiene and grooming Body breath and odor

Proportionate, varies with life style

Stands:164.59cm weights: 58 kg proportionate with age and lifestyle Not Well groomed, and has poor hygiene There is no presence of body odor and no mouth odor No signs of distress Has healthy appearance Understandable

No deviations to normal

Clean, neat

With deviations to normal No deviations to normal

No body odor or minor body odor, no breath odor No distress noted Healthy appearance Understandable; moderate pace; exhibits thought organization

Signs of distress, in posture in facial expression Signs of health illness Quantity and quality of speech

No deviations to normal No deviations to normal No deviations to normal

INTEGUMENTARY SKIN Skin color, uniformity of color Varies light to deep brown; from ruddy pink to light pink; from yellow overtone to olive No edema Moisture in skin folds and axillae Uniform, within in normal range When pinched, skin springs It varies light to deep brown, generally uniform in color except from the area expose to sun No presence of edema Has moisture in skin folds and axillae Within normal range Has good skin turgor No deviations to normal

Presence of edema Skin moisture

No deviations to normal No deviations to normal No deviations to normal No deviations to normal

Skin temperature Skin turgor

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back to its previous state NAILS Finger nail plate shape to determine its curvature and angle Finger nail and toenail bed color Convex curvature, angle of nail plate about 160 degrees Highly vascular and pink in light skinned clients; dark skinned clients may have brown and black pigmentation in longitudinal steaks Smooth texture Convex curvature, about 160 degrees nail plate angle Finger nails are light in color; toenails look pink No deviations to normal

No deviations to normal

Finger nails and toenail texture

Toenails are thick and fingernails are thin and split no deformities

With deviations to normal

With dirty long nail Tissues surrounding nails Blanch test of capillary refill Intact epidermis Prompt return of pink usual color (generally less than 4 sec.) Has intact epidermis Returns to pink 4 seconds No deviations to normal No deviations to normal

SKULL Skull size, shape and symmetry Rounded; normocephalic Rounded, normocephalic, symmetrical and smooth in contour No nodules, masses or depressions No deviations to normal

Nodules, masses and depressions

No nodules, masses or depression

No deviations to normal

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presents SCALP Color and appearance Areas of tenderness HAIR Evenness of growth, thickness or thinness Texture and oiliness over the scalp FACE Facial features, symmetry of facial movements Symmetrical facial movements and features; pimples and blackheads are present EYES EYEBROWS Hair distribution , alignment, skin and quality movement EYELASHES Hair distribution and direction of curl EYELIDS Surface characteristics, position in relation to the Skin intact; when eyes closed, both eyelids Equally distributed; curled outward Hair evenly distributed, symmetrically aligned; equal movement Hair is evenly distributed, thick hair strands Presence of small amount of oil, silky Lighter than skin color No tenderness

present

Lighter than skin color No tenderness

No deviations to normal No deviations to normal

Hair is evenly distributed, thin hair strands Presence of small amount of oil silky

No deviations to normal

No deviations to normal

Face is symmetry

No deviations to normal

Hair evenly distributed, symmetrically aligned; equal movement

No deviations to normal

Equally distributed; curled outward

No deviations to normal

Skin intact; when eyes closed; both eyelids

No deviations to normal

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cornea, ability to blink and frequency of blinking

completely meet; when eyes are opened, small portion of the sclera, iris and cornea covered

completely meet; when eyes are opened , small portion of the sclera, iris and cornea are covered

CONJUNCTIVA Color, texture and presence of lesion in bulbar conjunctiva Moist; has presence of capillaries; no foreign body present; pink reddish in color; no lesions Moist; has presence of capillaries; no foreign bodies present; pink reddish in color; no lesion No deviations to normal

SCLERA Color and clarity Clear and a bit reddish but ultimately colored white Presence of whitish fluid around it No deviations to normal

CORNEA Clarity and texture IRIS Shaped and color Round, colored deep brown and flat Round, colored deep brown and flat No deviations to normal Transparent; shiny, convex curvature Presence of whitish fluid around No deviations to normal

PUPILS Color, shape, and symmetry of size Black in color, round, 4mm in diameter, smooth border Illuminated pupil constricts (direct response) non illuminated pupil constrict (consensual Black in color, round, 3mmin diameter, smooth border Pupil constricts when looking at far object and dilates when the objects is moved No deviations to normal

Light reaction and accommodation

No deviations to normal

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response); pupil constricts when looking at far object, and it dilate when the object is moved toward nose EARS AURICLES Color, symmetry and position Color same as the facial skin; symmetric; aligned to the outer cantus of the eye Elastic, firm, recoils after folded, not tender

toward nose

Color same as the facial skin; symmetric; aligned into the outer cantus of the eye Elastic, firm, recoils, after folded, not tender

No deviations to normal

Texture, elasticity and areas for tenderness EXTERNAL EAR CANAL Presence of cerumen, skin lesions, pus and blood

No deviations to normal

There is small amount of cerumen present; no skin lesion, pus or blood NOSE

There is impacted cerumen present, no skin lesion, pus or blood

No deviations to normal

Deviation in shape, size, or color, and flaring or discharge from nares Presence of redness, swelling, growths and discharge in the nasal cavities Nasal septum between nasal chambers

Symmetric and straight, no discharges/ flaring, uniform in color No discharge, a bit moist, no lesion, pink in color Intact in the midline

Symmetric and straight, no discharge/ flaring, uniform in color With nasal Discharge

No deviations to normal

With deviations to normal

Intact and in the midline

No deviations to normal

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Patency of both nasal cavity Tenderness , masses, displacements of bone and cartilage LIPS Symmetry of contour, color and texture

Air moves freely on nares (breathing) Not tender; no lesion

Air does not moves freely on nares (cold) No tender, no lesion

With deviations to normal No deviations to normal

Symmetrical in contour; soft; moist; able to pout

Symmetrical in contour; soft; moist; able to pout THORAX

No deviations to normal

ANTERIOR THORAX Breathing pattern Rhythmic; quiet and effortless breathing No difficulty of breathing No deviations to normal

F. Diagnostic and Laboratory Result Diagnostic Test Hematology( CBC) Result Date Ordered Result Indication or Purpose to identify persons who may have an infection to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as Result Normal values M: (140170g/L) F( 123153g/L) Analysis and Interpretati on

Hemoglobin (128.0g/L)

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leukemia, anemia Hematocrit (0.374) M (0.4150.504 vol %) F (0.3590.446 vol %) (35-47x10 12/L) (80-96 fl) (33.435.5%) (27.5-33.2 pg) (4.511x10/L) (0.550.63%) (0.230.35%)

RBC MCV MCHC MCH WBC (22.0) Polys (0.874) Lympho (0.058) MXD (0.068) Mono

(0.04-0.08 %)

Platelets (232,000) E OSIN BASO ESR

(150450,000) (0.01-0.08 %) (00-0.12 %) Male (0-10mm/ hr) Female (020mm/hr)

Blood Type

A RH (+) Page | 18

Clotting Time Bleeding Time Others

(5-15 mins) (2-8 mins) GSAG NMREACTIVE

NURSING RESPONSIBILITIES: 1. Positive identify the patient using at least two unique identifies before providing care, treatment or service 2. Inform the patient this test can assist diagnosis and monitor therapy 3. Obtain a history of the patient complaints, including a list of know allergens, especially allergies or sensitive to latex 4. There are no food, Fluid or medication restriction unless by medical direction

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CHAPTER III ANATOMY AND PHYSIOLOGY

Female Reproductive System

The female reproductive system (or female genital system) contains two main parts: the uterus, which hosts the developing fetus, produces vaginal and uterine secretions, and passes the anatomically male person's sperm through to the fallopian tubes; and the ovaries, which produce the anatomically female person's egg cells. These parts are internal; the vagina meets the external organs at the vulva, which includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the Fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryo genesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina. The ova are larger than sperm and have formed by the time an anatomically female person is born. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation.

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Internal The internal reproductive organs of human female are composed of the ovaries, the fallopiantubes, the cervix, and the vagina. Vagina In human female, the vagina is composed of a fibro muscular tube-like component that leads from the uterus to the external part of the body. This is true to all female mammals, in some reptiles, and to the cloaca in female birds. In female insects and other invertebrates, vagina is the terminal part of their fallopian tubes. In ejaculation or the climax of coitus or commonly known as sexual intercourse, the semen from the male is deposited in the vagina of the female. Pubic hairs which grow around the outer part of the vagina serve as protection against infection during puberty. Cervix This is the lower and narrow part of the uterus. Sometimes the cervix is called the neck of the uterus. It connects the end portion of the vagina inside
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to the uterus. Its shape is like a cone and cylindrical protruding through the upper anterior portion of the vaginal wall. Almost half of its entire length may be visible but the rest is lying above the vagina and are hidden from view. Outside of the vagina, there is a thick layer of skin where the baby comes out during delivery. Uterus Uterus, commonly known as the womb, is the major organ for reproduction of female humans. This organ protects the developing embryo, provides nutrition to it, and supports waste removal of the embryo (during the first until the eighth week) and fetus (eighth until delivery). During birth the uterus contracts. These contractions are responsible in pushing the fetus outward during delivery. There are three suspensory ligaments within the uterus which stabilizes its position and restricts its movements. The uterosacral ligaments restricts the anterior and inferior body movements. The posterior movement is restricted by the round ligaments, while the inferiormovements are restricted too by the cardinal ligaments. The shape of the uterus is pear-shaped. It is a muscular organ which houses the fertilized ovum and develops the same until childbirth. When fertilization does not occur, the egg which is not embedded on the uterine wall is flushed from the uterus, a process called menstruation. If the egg is fertilized, it is implanted into the endometrium or the walls of the uterus. The nourishment of the embryo is passed through the blood vessels connected to it. From a fertilized ovum, it becomes an embryo, then develops into a fetus and is carried in the womb, a process called gestation, until child birth or delivery.

Fallopian tube The pair of tubes connecting the ovaries to the uterus in female mammals is called the fallopiantubes. When the egg cell or ovum matures, the follicle and the walls of the ovaries shall break down. This rupture shall cause the ovum to be released into the fallopian tube then traveling to the uterus which is made possible by the cilia or hair-like structures inside the uterus. Its trip can take hours or days. When it meets a sperm and is fertilized, it implants itself in the endometrium upon reaching the uterus. This is the beginning of pregnancy. Ovary These are the pair of organs which are located proximal to the lateral walls of the pelvic cavity. The ovaries produce the egg cells or ova and secrete hormones. Ovulation is the process where an egg cell is released and made available for fertilization. The ovulation period is periodic in nature and
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affects the length of the menstrual cycle. With the ovulation, the ovum is transported via the oviduct or commonly known as the fallopian tube to the uterus. Usually, the ovum is fertilized in the oviduct. Then the fertilized egg is moved to the uterus by the action of the hair-like structures called cilia which are abundant in the fallopian tubes.

Chapter IV: The Patient and Her Illness a. Pathophysiology

Modifiable
Urinary tract Infection Aminiocentsis Placenta Previa Abruptio Placenta

NonModifiable
Age Gender Pregnancy

Before or After 37 weeks AOG

Rupture of membrane

Leakage of Amniotic Fluid Infection (Chorioamnionitis)

Fetal Infection

Maternal Infection
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Sepsis

Fever Cord Prolapse

Fever/ Death Cord Compression

b. Synthesis of Disease

Oligohydramnios

Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when there is rupture of the membranes (rupture of the amniotic sac and chorion) more than an hour before the onset of labor. PROM is prolonged when it occurs more than 18 hours before labor. PROM is preterm (PPROM) when it occurs before 37 weeks gestation. Risk factors for PROM can be a bacterial infection, smoking, or anatomic defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the rupture can spontaneously heal, but in most cases of PROM, labor begins within 48 hours. When this occurs, it is necessary that the mother receives treatment to avoid possible infection in the newborn Premature rupture of membranes (PROM) is a condition in which fluid leaks from your amniotic sac before labor begins. Labor is when you begin having contractions (uterus tightens and relaxes) in order to deliver (push out) your baby. Your amniotic sac is located in your uterus (womb) and holds your unborn baby. The amniotic sac contains fluid that cushions your baby and allows him to move around. This fluid also takes away his body waste and helps to protect him from infection. Usually, the membranes (amniotic sac tissue) rupture and cause the fluid to leak out after labor has started. Ask your caregiver for more information about labor. PROM can happen very close to your due date, or it can happen earlier in your pregnancy. With PROM, you are likely to deliver your baby soon, often within a few hours or days. When PROM happens before 37 weeks, it is called preterm PROM (PPROM). PROM and PPROM can cause serious health problems for you, such as infection. It can also cause problems for your unborn baby, such as difficulty breathing. PROM that happens close to your due date may not cause any
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problems. With treatment, you have a better chance of having a safe delivery. Treatment may also prevent problems for you and your baby

CHAPTER V: THE PATIENT AND HIS CARE a. Medical Management i. Intravenous Fluid

NUMB ER 1

DATE INFU SE Nov 21,20 11

AMOU NT 1 Liter 30 gtts/mi n

GENERAL DISCRIPTION
5% Dextrose in Lactated Ringers Solution w/ TRAMADOL Classification: Hypertonic

Nonpyrogenic, pare nteral fluid, electrolyte and nutrient replenished

INDICATI ON OR PURPOS E Treatment for persons needing extra calories who cannot tolerate fluid overload. Treatment

NURSING RESPONSIBILITIES
>Do not administer u n l e s s s o l u t i o n i s clear and container is undamaged

> Solution containing

acetate should b e used with caution as excess administration may result in metaboli c alkalosis Page | 25

of shock

> Solution

Analgesic (centrally acting)

containing dextrose should be used with caution in patients with known subclinical or over t diabetes mellitus Relief of modera te to moderatel y severe pai n Hypersensitivity to tramadol ; pregnancy ; acute intoxication with alcohol, opioids, psycho tropic drugs or other centrally acting analgesics; lactation; seizures

NUMB ER 1

DATE INFU SE Nov 21,20 11Nov 24, 2011

AMOUN T 1 Liter 30 gtts/min

GENERAL DISCRIPTIO N

INDICATION OR PURPOSE D5NM is D5NM indicated for parenteral Normosol-M and maintenance 5% Dextrose W/ of routine TRAMADOL daily fluid and Hypertonic electrolyte requirements Non pyrogenic with minimal , parenteral carbohydrate fluid,

NURSING RESPONSIBILITIES >Do not administer u n l e s s s o l u t i o n i s clear and container is undamaged. > Caution must bee x e r c i s e d i n t h e administr ation of parent eral fluids,e s p
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electrolyte and nutrient replenished

calories from dextrose .Magnesium in the formula may help to prevent iatrogenic magnesium deficiency

ecially those containing sodiu m ions to patie nts Receiving corticosteroids o r corticotrophin. >Solution containing acetate should b e used with caution as excess administration ma y result in metabol i c alkalosis.

Analgesic (centrally acting)

Relief of moderate to moderately severe pain

Hypersensitivity to tramadol ; pregnancy ; acute intoxication with alcohol, opioids, psycho tropic drugs or other centrally acting analgesics; lactation; seizures

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Drug Name Cephalexin Hydrochlori de

Brand Name Keftab, Biocef

Classificatio n Cephalospor ins

Route & Dosage Adult 250mg to 1g P.O q 6 hours or 500 mg q 12 hours

Indication A betaHemolytic streptococ ci, Respirator y tract, GI tract skin, soft tissue bone and joint infection and otitis media cause by Escherichi a Coli

Adverse Reaction CNS: Dizziness Head ache, Fatigue Agitation GI: Pseudo membran ous colitis GU: Genital pruritus, Candidiasi s

Contra Indication Contra indicated in patient hypersensitive to Cephalosporin

Nursing Responsibility 1. Use cautiously in patient hypersensitive to penicillin because of possibility of cross sensitivity 2. Obtain specimen for culture and sensitivity test before giving first dose 3. Ask patient about past reaction to cephalosporin or penicillin theraphy before giving first dose

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Drug Name Ferrous Sulfate

Brand Name

Classificati on

Route & Dosage Adult 50 to 100 mg. P.O of elemental iron T.I.D

Indication Iron Deficienc y

Adverse Reaction GI: nausea, epigastric pain, Vomiting, constipati on, blackstool , Diarrhea, Anorexia

Contra Indication Contra indicated in patient w/ Hemosiderosi s, peptic ulcer

Nursing Responsibility 1. Use cautiously on long term basis

Feosol, Mol Hematinics Iron

2. Tell patient to take w/ juice

3. Advise patient to report constipation and change in stool color or consistency

Drug

Brand

Classificatio

Route &

Indication

Adverse

Contra

Nursing Page | 29

Name Bisacodyl

Name Dulcolax, Fleet Laxatives

n Laxatives

Dosage Adult and Children 12 and older 10 to 15 mg. P.O in evening or Before Breakfast

Chronic Constipati on/ Preparatio n for Childbirth, Surgery

Reaction CNS: muscle weakness w/ excessive use dizziness, faintness GI: nausea, Vomiting Abdominal Cramps

Indication Contra indicated in patient hypersensitive to drug or its Components

Responsibility 1. Give drug at times that dont interfere with schedule activity or sleep 2. Before giving for constipation determine whether patient has adequate fluid intake, exercise and diet 3. Tablets and Suppositories use to surgery before barium enema

Drug

Brand Name

Classificatio

Route &

Indication

Adverse

Contra

Nursing Page | 30

Name Ketorolac

Toradol

n Nonsteroida l Anti inflammator y drugs

Dosage Adult for Patient younger than Age 65 60mg I.M 30 mg I.V

Short Term managem ent of moderatel y severe, acute pain for single dose treatment

Reaction CNS: drowsiness sedation, dizziness, headache CV: Edema, hypertensi on. palpitaions

Indication Contra indicated in patient hypersensitive to drug and in those w/ active peptic ulcer disease

Responsibility 1.Ketorolac isnt recommended for children 2. Use cautiously in patient w/ hepatic or renal impairement 3. correct hypovolemia before treatment w/ ketorolac

Drug Name

Brand

Classificatio

Route &

Indication

Adverse

Contra

Nursing Page | 31

Omeprazol

Name Losec/ Prilosec

n Anti Ulcer Drugs

Dosage Adult 20 mg P.O daily for 4 weeks for patient poorly responsive to customary medical treatment

Symptoma tic gastro esophagea l reflux disease (GERD)

Reaction GI: diarrhea, abdominal pain nausea Respirator y: Cough upper respiratory

Indication Contra indicated in patient hypersensitive to drug and its components

Responsibility 1. Dosage adjustment arent needed for patients with renal or hepatic impairment 2. Omeprazole increases its own bio availability with repeated doses. 3. Instruct patient not to perform hazardous activities if dizziness occurs

Drug Name

Brand

Classificatio

Route &

Indication

Adverse

Contra

Nursing Page | 32

Acetaminop hen

Name Paracetamo l

n Non Narcotic analgesic and Anti pyretic

Dosage 325 to 650 mg P.O q 4 to 6hrs

Mild pain or fever

Reaction Hematolog ic: hemolytic anemia, neutropeni a, leucopenia Hepatic: liver damage jaundice Metabolic hypoglyce mia Skin: Rash urticaria

Indication Contra indicated in patient hypersensitive to drug and its components

Responsibility 1. Use cautiously in patient w/ history of chronic alcohol use 2. Advice patient that drug is only for short term and to consult prescribe if giving to children for longer than 5 days 3. Acetaminophen may produce false positive decrease in glucose levels in home monitoring system

B. Nursing Management
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SOAPIE Name of Student: Client: Ms X Subjective Data Hindi ako makatulog dahil sa higaan Objective Data >reported 2hrs of sleep > patient looks pale > patient look restless >Facial grimace >Difficulty moving >weak looking > Bp- 130/80 > RR- 20 cpm >PR 102 bpm >temp- 36.1 C >weak appearance >with IVF D5LR 1 L infusing at Left hand KVO >Arranged care to provide for interrupted period for rest >instruct in relaxation technique like music therapy Age: 21 years old Assessment Sleep deprivation related uncomfortable sleep environment Plan After 8 hours of rendering Nursing interventions, patient will be able to increase sleep hrs from 2-4hrs continuous sleep Sex: Female Interventions >Advised the patient to take a bath > Arrange her linen to provide comfort upon sleep > advised to change her current clothing Evaluation Goal met. Patient able to increase sleep hrs from 2hrs to 4hrs of continous sleep Date: Nov 21

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Assessmen t Subjective Data: Masakit ang tahi ko as verbalized by the Patient

Nursing Diagnosi s Pain related to post surgical incision as manifest ed by a pain scale of 7/10 (+) Facial Grimace and Elevated Bp 130/80

Planning

Intervention

Rationale

Evaluation

Objective Data: Pain Scale 7/10 0 being the lowest and 10 being highest

After the Shift of proper nursing interventi on the patient should manifest a decrease In pain scale 7/10 to 4/10 or lower

Asseess the patient perception level of understandi ng and needs

-To identify and assess the nursing interventi on to be done

Obtain clients baseline v/s including pain scale

(+) facial Grimace Eleva ted Bp

Encourage client verbal report during and after each

-To assess the effectiven ess of nursing interventi on and obtain baseline for future compariso n

After the Shift w/ proper nursing interventio n goal met as evidence of the clients decrease In pain scale from 7/10 to 4/10 (-) facial grimace and normalizati on of Bp

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130/80 From normal range 90/80 to 120/ 80

nursing intervention

-because pain is high subjective

Position the client to where she is comfortable

-To provide comfort

Administer analgesic as prescibed

-To Divert Attention from pain

-Alleviate Pain

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Chapter VI: Clients Daily Progress

a. Clients Daily Progress Days Nursing Problem Pain related Post Surgical incision
Sleep deprivation related uncomfortable sleep environment

Admission Nov 21, 2011

2nd day Nov 22, 2011

3rd day Nov 23, 2011

4thday Nov 24,2011

SEVERE SEVERE

MILD MILD

MILD MILD

NORMAL NORMAL

Vital Sign

BP 130/80 RR 20 PR 86 TEMP 37.1 D5LR 30 gtts/min

BP 120/90 RR 21 PR 80 TEMP 36.5 D5NM 30 gtts/min

BP 120/80 RR 22 PR 88 TEMP 36.1 D5LR 30 gtts/min

BP 110/700 RR 19 PR 81 TEMP 36.0 D5LR 30 gtts/min

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Medical Management IVF

Drugs
Cephalexin Ferrous Sulfate Bisacodyl Ketorolac Omeprazol Acetaminophen

GIVEN GIVEN GIVEN GIVEN GIVEN GIVEN

GIVEN GIVEN _ GIVEN GIVEN GIVEN

GIVEN GIVEN _ GIVEN GIVEN

GIVEN GIVEN _ GIVEN GIVEN

GIVEN

GIVEN

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CHAPTER VII: DISCHARGE PLAN

Patient General Condition upon Discharge

The patient felt comfortable during the assessment of the doctor and did not complain any pain. There is no sign of discomfort and she was able to verbalize her feeling during her confinement

Medication

MEDICATION Cephalexin Mefenamic acid Ferrous Sulfate

AMOUNT 500mg 500mg 500mg

FREQENCY Every 6hrs Every 6hrs Once a day

DURATION For 10 days For 10 days For 15 days

1. Instruct the patient and the Family to follow the take home medication as prescribed by the physician Rationale: Treatment regimen is important to have faster recovery

2. Explain each purpose of medication Rationale: Knowledge about what medication will make the client become aware of what is she taking and for the family to participate more in the client treatment

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3. Instruct the client not to take over-the-counter drugs without the doctors knowledge Rationale: non Prescribe drugs may have an antagonistic effect or synergistic effect in any drug theraphy

HEALTH TEACHINGS 1. Take her temperature at least 4 times a day 2. Maintain any activity restriction 3. Return to the hospital if she has fever Follow up check up (OPD) 1. Inform the client that follow-up check-up is important to have continuous monitor and care even after attainment of the course of the medical theraphy Diet 1. Patient was instructed to eat soft diet and avoid salty foods 2. Instructed to increase fluid intake for fluid replacement

Chapter VIII Learning Derived Page | 41

This case study will help the group in understanding the disease process of the patient. This would also Help the group in identifying such needs and health problem of the patient associated with the disease And understanding why such needs and health problem arise, the group can now formulate an Individualized care plan for the patient that would address these needs and problem effectively. Effective management of the problem identified will help the patient to recover faster and maintain a Holistic sense of sense of wellness even while in the hospital. This case study would also equip the group With knowledge, skill and attitude on how to manage future patients with the same or similar disease. They also learned how to effectively connect disease to each other in creating their pathophysiology for their patients.

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Chapter IX. Conclusion and Recommendations

In this case, the group learned on how to think critical and to create a care plan effectively for their patients. They also learned that it should be vital to assess the condition of the patient in order to provide the best possible care to the patient. The group recommends to the patient that she should adhere strictly and comply with the treatment procedures administered to cure her disease. The group also would like to recommend health information and teachings in order to promote a healthy lifestyle and to avoid further disease and complication

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BIBLIOGRAPHY A. BOOKS.

1.

MATERNAL AND CHILD HEALTH NURSING BY PILLITTERI 2. Premature Rupture of Membranes By Patrick Duff - Hirsutism By R. Jeffrey Chang (Clinical Obstetrics and Gynecology, Vol. 34, No. 4, December 1991)

B. WEBSITES 1. http://nursingcrib.com/case-study/premature-rupture-of-membranes-prom/ 2. http://medicaldictionary.thefreedictionary.com/premature+rupture+of+membranes 3. http://www.umm.edu/pregnancy/000143.htm

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