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#16 Tandang Sora Avenue, Sangandaan, Novaliches, Quezon City
S.Y. 2009 2010
CASE PRESENTATIONAbruptio Placenta
BLEEDING LOVE
Submitted by:
Oco, Jenny Rose Oreta, Charlotte Jenniffer Reyes, Jinky Rose Sy, William Franz Tumbaga, Jean Claudine
Traquena, Shayne Velasco, Racquel Vergara, Alyssa Dawn Verona, Vercely, Villa, Mario Roberto
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Case Presentation
Abruptio Placenta
TABLE OF CONTENTS
I. INTRODUCTION.. 1
A. Background of the study 1B. Significance of the study 2C. Case Explained... 2D. Objectives 3E. Nursing Theories. 4-6
II. PATIENTS DATA
A. General data 7B. Chief Complaint.. 7C. History of present illness... 8D. Past medical history 8E. Family medical history 8F. Personal and Social history.. 9G. Review of systems.. 10-11
H. Physical examination.. 12-16I. Admitting Diagnosis 16J. Course in the ward. 16-18K. Final Diagnosis 18
III. REVIEW OF RELATED LITERATURE
A. Maternal cigarette smoking as a risk factor 19for placental abruption, placenta previa,
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and uterine bleeding in pregnancy
Case Presentation
Abruptio Placenta
IV. ANATOMY AND PHYSIOLOGY
A. Anatomy and Physiology of the Placenta 20-21
V. PATHOPHYSIOLOGY
A. Pathophysiology of abruption placenta 22B. Written Explanation. 23
VI. LABORATORY PROCEDURE
A. Complete Blood Count 24-26
VII.DRUG STUDY 27
A. Ranitidine Hydrochlorid.. 28B. Ketorolac Tromethamine 29-30C. FERROUS SULFATE
.. 31
D. TRANEXAMIC ACID. 32
E. MEFENAMICACID
F. Cefazolin Sodium
G. Diphenhydramine.
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H. C0-Amoxiclav..
VIII. NURSING CARE PLAN..
A. Pain in incision.B. Anxiety..C. Fever.
IX. DISCHARGE PLAN.X. BIBLIOGRAPHY
Case Presentation
Abruptio Placenta
l. INTRODUCTION
This is a case of a teenage mother who gave birth to a premature baby (37 weeks old) that had serious
complications during pregnancy that lead to premature labor and bleeding. The patient diagnose for abruption placenta.
Abruptio Placenta is premature separation of the normally implanted placenta after the 20th week of pregnancy,
typically with severe hemorrhage .An increase risk of placenta abruption has been demonstrated in patient younger than
20 years old and those older than 35 year old.
Placenta may detach incompletely sometimes just 10 to 20 percent or completely and the cause is unknown
.Women who have high blood pressure, heart disease, diabetes or rheumatoid disease and women who use cigarette and
cocaine are more likely to develop his complication.
A. BACKGROUND OF THE STUDY
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Abruptio placenta remains a major cause of perinatal morbidity and mortality globally, though of most serious
concern in the developing world. As most known causes of abruptio placenta are either preventable or treatable, an
increased frequency of the condition remains a source of medical concern.
Normally the placenta is located in the upper part of the uterus firmly attached to the uterine wall. In abruptionplacenta, the placenta detaches from the uterine wall prematurely, causing the uterus to bleed and reducing the fetus
supply of oxygen and nutrients.
Patients with abruption placenta typically present with bleeding, uterine contractions and fetal distress .A
significance cause of third-trimester bleeding associated with both fetal and maternal morbidity and mortality, abruption
placenta must be considered whenever bleeding is encountered in the second half of pregnancy.
1Case Presentation
Abruptio Placenta
B. SIGNIFICANCE OF THE STUDY
The importance of this study is for us student to know more about abruption placenta, its causes and the
appropriate interventions should undertake to prevent this complication among pregnant women and to further enhance
the knowledge of the public, specially those pregnant mother.
We as student nurse valued more the importance of prenatal check up, In order to avoid abruption placenta and
other pregnancy complication and to lessen the fetal and maternal mortality death. Placenta is the source of life of the
baby in order to achieve the stability of the baby in the womb. Strict monitoring must be observed. It is important thatduring 20-30 weeks of AOG the mother must undergo ultrasound. Just to ensure the safety delivery of both the lives of the
mother and the baby.
C. CASE EXPLAINED
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This case study covers Abruptio Placenta which is the partial or complete separation of the placenta, normally the
placenta is located in the upper part of the uterus firmly attached to the uterine wall. In abruption placenta the placenta
detaches from the uterine wall causing the uterus to bleed and reducing the fetus supply of oxygen and nutrients,
therefore pre-natal check-up are important to the well being of the mother and the baby.
2
Case Presentation
Abruptio Placent
D. OBJECTIVES
GENERAL OBJECTIVE
Understanding regarding Abruption of Placenta.
SPECIFIC OBJECTIVE
To provide proper treatment to patient who had abruption placenta.
Patient Care
Complete Bed Rest
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Knowledge
Explain thoroughly to the patient what is abruption placenta.
Communication Skills
Provide Health Teaching
Provide Therapeutic Counseling
Professionalism
Provide Nursing Care Plan 3
Case Presentation
Abruptio Placenta
E. NURSING THEORIES
Hildegard Peplau Interpersonal Relations Model
(1952)
She defined Nursing as an interpersonal process of therapeutic interactions
Between an individual who is sick or in need of health services and a nurse
Especially educated to recognize, respond to the need for help.
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Dr. Peplau emphasized the nurse-client relationship as the foundation ofnursing practice. At the time, her research
and emphasis on the give-and-take of nurse-client relationships was seen by many as revolutionary. She described the
nurse-patient relationship as a four-phase phenomenon. Each phase is unique and has distinguished contributions on theoutcome of the nurse-patient interaction.
We applied this theory because in order for our patient to trust us, we strongly believe we need to build a good
relationship with our patient to get accurate information and we can give the right care. Patient DORA at a young age
experienced losing her son that she needed someone to talk to. She needs an emotional support so she can face reality
that her son had passed away. By giving her therapeutic interaction it lessen her grief.
4
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Case Presentation
Abruptio Placenta
Self Care Theory
Dorothea Orem (1971)
Individuals, families, groups and communities
need to be taught self-care.
Orem defined Nursing as The act of assisting others in the provision and management
of self-care to maintain/improve human functioning at home level of effectiveness.
The theory focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-
being. It has a strong health promotion and maintenance focus.
This theory applied because nursing is human service and nurses design interventions to provide self-care action
for sustaining health.
We applied this theory in order for patient DORA to have an independent function and health teaching like: self
care, proper hygiene, negative effect of smoking & healthy lifestyle.
5
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Case Presentation
Abruptio Placenta
Martha Rogers
Concept of Science of Unitary Human Beings,
And Principles of Homeodynamics
Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and is
concerned with the nature and direction of human development. The goal of nurses is to participate in the process
of change.
Nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen
the wholeness of the Individual and redirect human and environmental patterns or organization to achieve
maximum health.
We applied this theory to increase patient awareness in her surroundings and environment. Cleaning the environment
will help to prevent spreading of communicable disease.
6
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Case Presentation
Abruptio Placenta
II. PATIENTS DATA
A. GENERAL DATA
Name : Patient Dora
Sex : Female
Age : 18 y/o
Height : 5 ft and 1 inch
Date of Birth : February 04, 1991Address : xxxxxxxx27
Date of Admission : 11-25-2009
Time of Admission : 6:55 P.M.
Place of admission : Dr. Jose Fabella Memorial Hospital
Attending Physician : Dr. xxxxx xxxxx
Case Number : xxx27
B. CHIEF COMPLAINT
Bloody vaginal discharge
7
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Case Presentation
Abruptio Placenta
C. HISTORY OF PRESENT ILLNESS
Two days prior to admission client noticed a scanty dark red vaginal spotting.
A day prior to admission, above symptoms persist with no other accompanying symptoms, client still ignore the
condition until
Few hours prior to admission, client noticed profuse vaginal bleeding this time accompanied with severe abdominal
pain. Client was brought to Fabella for consultation and was advice to go home since it was not her due date but client
refuse since bleeding is profuse, she was observed at the ER and subsequently scheduled for emergency CS and
admitted.
D. PAST MEDICAL HISTORY
Positive history of UTI
Consultation was done and prescribed with amoxicillin 500mg / capsule taken TID for 1 week.
E. FAMILY MEDICAL HISTORY
FATHER MOTHER
Hypertension ( - ) ( - )
Diabetes ( - ) ( - )
Asthma ( - ) ( +)
8
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Case Presentation
Abruptio Placenta
F. PERSONAL AND SOCIAL HISTORY
Patient Dora belongs to broken family; she is the youngest among the 3 siblings. Her father resides at Quezon
Province and her mother resides in Quezon City with her new husband. Her 2 elder brothers have their own families to
take care. Every summer, patient Dora goes to Quezon Province to visit her father. Patient Dora lives with her mother
together with her step-father. They live in a depressed area. During her teenage life she was looking for love and
belongingness, she found it through her peers and set of friends. She learned to smoke and occasional drinking of alcohol
at early age until during her pregnancy.
OB HISTORY
Menarche : 12 years old
Intervals : 28 days cycle
Duration : 3 to 4 days
Amount : 4 to 5 napkins
Sign & Symptoms : ( + ) Dysmenorrhea
9
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Case Presentation
Abruptio Placenta
G. REVIEW OF SYSTEM
REVIEW OF SYSTEM
SKIN
( -) Delayed Skin Tugor( +) Dryness(+ ) Pale
HEENT
(+ ) Headache( +) Dizziness(- ) Sore throat( +) Blurring of vision( +) Flaring of nostrils
RESPIRATORY
(+ ) tachypnea(+ ) difficulty of breathing(- ) cough(+ ) crackles
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Case Presentation
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Abruptio Placenta
CARDIAC ENDOCRINE
( -) tachycardiac( -) murmurs ( -) polydipsia (- ) polyuria
(- ) polyphagia
GASTROINTESTINAL
(- ) nausea
(+ ) abdominal pain
(- ) vomiting
GENITOURINARY
(- ) dysuria
( -) incontinence
MUSKOLOSKELETAL
( +) muscle weakness
( -) fracture
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Case Presentation
Abruptio Placenta
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H. PHYSICAL EXAM
GENERAL SURVEY
(+ ) Conscious ( +) Drowsy( -) Unconscious ( +) Lethargic
( -) Alert
VITAL SIGNS
(120/80 mmHg) BP ( 18 cpm) RR
(89 bpm ) PR (37 C) Temp
SKIN
( +) Warm ( +) Dry
(- ) Cold (- ) Moist
HEENT
Conjunctive
( -) Pink
( +) Pale
NECK(+ ) Supple( -) Tense
12Case Presentation
Abruptio Placenta
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CHEST AND LUNGS
( -) Asymmetrical
(+ ) Symmetrical
HEART
(- ) Adynamic
( -) Dynamic
ABDOMEN
(- ) Scaphold
( -) Distended
EXTREMITIES
( -) Deformities
( -) Cyanosis
RECTAL EXAM
( -) Skin Tag
(- ) Presence of Blood on lactating fingers
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Case Presentation
Abruptio Placenta
General survey
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-pt. dora is short and slim appears to be her age (18y.o)
-Awake, alert and aware of the environment
-Pt. is lethargic,
-feels drowsy and presence of guarding her incision site
Vita signs
120/80 mmHg 18 cpm
89 bpm 37 C
SKIN
-skin is hot and dry
-+ appearance of scars
- pinch up skinfold returns immediately to normal position
-absence of edema
Nail
- clean curved hard nail
Heent
-sclera smooth,white ,glossy and moist
- pale conjunctiva
14Case Presentation
Abruptio Placenta
Neck
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- symmetrical, proportional to head and shoulder
- coordinate and controlled movement
Chest and lungs
- Symmetrical- Regular rate and rhythm- Spine is straight, without lesions or masses- Normal sloping of ribs
Heart
- No lesions, masses and abnormalities
Abdomen
- unable to sit or lie comfortably and pain in moving
extremities
- No deformities
Rectal exam
- Smooth without masses, lesions and tenderness15
Case Presentation
Abruptio Placenta
Muscuskeletal system
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- Can do active ROM
I. ADMITTING DIAGNOSIS
Pregnancy uterine 37 6/7 weeks age of gestation by LMP cephalic in labor Abruptio Placenta, Non reassuring
Fetal Status-Fetal Bradycardia.
J. COURSE IN THE WARD
November 25, 2009
At 6:00 pm the patient admitted due to vaginal bleeding prior to caesarian section the doctor ordered to monitor the
vital signs and fetal heart tone of the baby. With IVF D5LR 1L x 8 and PNSS x 8. The patient is NPO then the doctor
ordered CEFAZOLIN 2mg TID with ANST 30 mins prior to preoperative and requested for CBC. The operation started at
10:45 pm ended up 11:38 pm after the operation the doctor s order to transfuse 2u FWB that properly type and
cross matched, monitor vital signs q1 for BT reaction. Then prepared for therapeutic medication. KETOROLAC 30 mg
IV with ANST as standing dose then 15mg q 8 x 2 more doses, TRAXENAMIC ACID 500mg IV q 8x 3 more dose and
RANITIDINE 50mg IV q 8 x 3 more dose with standing orders such as NALBUPHINE 3mg IV and METOCLOPRAMIDE
10mg PRN for nausea and vomiting.
16
Case Presentation
Abruptio Placenta
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November 26 ,2009
At 12nn the patient received conscious, with pale skin ,dryness and muscle weakness the doctor ordered to monitor
vital signs in every one hour, tea and cracker for her diet with continuous IVF of D5LR 1L run at 30 gtts /min. on her left
metacarpal together with one unit properly matched and cross matched of PRBC on right metacarpal and aftertransfusion doctor ordered for CBC.
Medication given were CO-AMOXICLAV 500mg 1 tablet bid ,FERROUS SULFATE 1tablet bid, MEFANAMIC ACID
500mg capsule q6 .The doctor discontinued the blood transfusion due to febrile reaction of the patient and give
DIPHENHYDRAMINE 50g IV now and PARACETAMOL 500mg P.O. After 30 mins the patient was afebrile then the
blood transfusion was continued.
November 27, 2009
At 12:oo nn pt was on 3 rd BT of 1 u FWB with SN# 562909 type, BT infusing well with no BT reaction and the
doctor ordered to take soft diet and continue oral medication and monitor the vital signs. Medication were given CO-
AMOXCILAV 500MG bid FERROUS SULFATE 1 tablet bid and MEFENAMIC ACID 500MG q6 to decrease pain gradually
so that the pt can walk properly then after transfusion doctor ordered again for CBC.
November 30, 2009
At 12nn the doctor administered the patient to discharge with the medicine of CO-AMOXICLAV 625mg tab BID.
FERROUS SULFATE BID and MEFANAMIC ACID 500mg q8 hour for pain . Advised for follow up check up
17Case Presentation
Abruptio Placenta
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December 3. 2009
Still May Go Home and for follow up check up
December 4,2009
Still May Go Home
K. FINAL DIAGNOSIS
Pregnancy uterine 37 weeks, LOT delivered operatively to alive boy. Abruptio placenta non-reassuring fetal
status (FETAL BRADYCARDIA) G1P1 (1001)
18Case Presentation
Abruptio Placenta
III. REVIEW OF RELATED LITERATURE
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Maternal cigarette smoking as a risk factor for placental abruption,placenta previa, and uterine bleeding in pregnancy.
Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, USA.
The authors carried out an epidemiologic study to evaluate the role of maternal cigarette smoking as a potential risk factor
for placental abruption, placenta previa, and uterine bleeding of unknown etiology in pregnancy. Data for this prospective
cohort study were obtained from women seeking prenatal care at any of the two tertiary, seven regional, or 17 community
hospitals in the province of Nova Scotia, Canada, between January 1, 1986, and December 31, 1993. A total of 87,184
pregnancies (among 61,667 women) were registered in the database. Women who smoked during pregnancy (33%) were
compared with nonsmokers, and all women were followed until the termination of pregnancy. Placental abruption was
indicated in 9.9 per 1,000 pregnancies, while placenta previa and uterine bleeding of unknown etiology were indicated in
3.6 and 58.9 per 1,000 pregnancies, respectively. Women who smoked had a twofold increase in the risk of abruption
(relative risk = 2.05, 95% confidence interval (CI) 1.75-2.40) in comparison with nonsmokers, while the relative risk for
placenta previa was 1.36 (95% CI 1.04-1.79). However, cigarette smoking was not found to be associated with uterine
bleeding of unknown etiology (relative risk = 1.01, 95% CI 0.94-1.08). There was no evidence for an increased risk of
uteroplacental bleeding disorders with increasing numbers of cigarettes smoked. All analyses were adjusted for potentially
confounding factors through logistic regression models based on the method of generalized estimating equations. The
study confirms a positive association between cigarette smoking and placental abruption and a weak association with
placenta previa but not with other uterine bleeding. The distinct pattern of results for placental abruption, placenta previa,
and uterine bleeding of unknown origin suggests that these three uteroplacental bleeding disorders do not have a
common etiology in relation to cigarette smoking.
-Ananth CV, Savitz DA, Luther ER.
19
Case Presentation
Abruptio Placenta
IV. ANATOMY AND PHYSIOLOGY
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The placenta is an organ unique to mammals that connects the developing fetus to the uterine wall. The placenta
supplies the fetus with oxygen and food, and allows fetal waste to be disposed via the maternal kidneys. The word
placenta comes from the Latin forcake, ]in reference to its round, flat appearance in humans. Protherial (egg-laying) and
metatherial (marsupial) mammals produce a choriovitelline placenta that, while connected to the uterine wall, providesnutrients mainly derived from the egg sac. The placenta develops from the same sperm and egg cells that form the fetus,
and functions as a fetomaternal organ with two components, the fetal part (Chorion frondosum), and the maternal part
(Decidua basalis).
STRUCTURES
Placenta averages 22 cm (9 inch) in length and 22.5 cm (0.81 inch) in thickness (greatest thickness at the centerand become thinner peripherally). It typically weighs approximately 500 grams (1 lb). It has a dark reddish-blue or maroon
color. It connects to the fetus by an umbilical cord of approximately 5560 cm (2224 inch) in length that contains two
arteries and one vein. The umbilical cord inserts into the chorionic plate (has an eccentric attachment).
20
Case Presentation
Abruptio Placenta
http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Fetushttp://en.wikipedia.org/wiki/Fetushttp://en.wikipedia.org/wiki/Latinhttp://en.wikipedia.org/wiki/Protheriahttp://en.wikipedia.org/wiki/Metatheriahttp://en.wikipedia.org/wiki/Umbilical_cordhttp://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Fetushttp://en.wikipedia.org/wiki/Latinhttp://en.wikipedia.org/wiki/Protheriahttp://en.wikipedia.org/wiki/Metatheriahttp://en.wikipedia.org/wiki/Umbilical_cord8/6/2019 Bleeding Love Manuscript
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Fever
Pain inincision
Risk forinfection in
incision
Anemia
Riskfor
infection
Bradycardia
Anxiety
V. PATHOPHYSIOLOGY
A. Diagram
22
Case Presentation
Abruptio Placenta
Carbon Monoxideintroduce to the system
Excessive Smoking
Predisposing FactorAge
Lifestyle ETIOLOGY: UNKNOWN
PRECIPITATING FACTORAge: 18 y/o
5-6 packs a year
Vasoconstriction
Total separationof placenta to
the uterine
Decreased resiliency ofblood vessels at
placental bed
CSDelivery
Abruptio Placenta
FetalDistress
Abdominal
Pain
Hemorrhage intothe Decidua Basalis
Torn and rupturedBlood vessels
Abnormalcontraction of the
uterus
FHR Reassuring
DiagnosticTest
Decreased of oxygenneeded by the blood
EmergencyDelivery
Disturbed systemcirculation
POST - OP
WBC
RBCBlood
Transfusionadministration
NeonatalDeath
AllergicReaction
Vaginal Bleeding
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B.Written Explanation
23
VI. LABORATORY AND DIAGNOSTIC PROCEDURES
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COMPLETE BLOOD COUNT November 25, 2009 at 8:52 PM
TEST RESULT NORMAL VALUES UNIT SIGNIFICANCE
HEMOGLOBIN 102 120 170 g/L Note:
Decrease in values may indicate anemia.
HEMATOCRIT 0.30 0.37-0.54 % Not normal
Decrease in values may indicate anemia.
RBC COUNT 3.48 4.1-5.1 x10^12/L Not normal.Decrease in values due to Hemmorhage.
MCV 86 80-96 fLNormal Values
MCH 29 27-31 pgNormal Values
MCHC 34 34-36 g/dL
Normal Values
WBC COUNT 14.7 4.5-11 x10^9/10 Not normal.Increase in values may indicate acute bacterial infection.
DIFFERENTIAL COUNT
NEUTROPHILS 0.80 0.00-0.55 % Not normal.
Increase in values may indicate acute bacterial infection.
LYMPHOCYTES 0.12 0.00-0.34 % Not normal.
May indicate infection if the NEUTROPHILS are elevated. (the mostcommon reason for a low lymphocytes count is an elevation in the
number of granulocytes. Granulocytes increase in many circumstances,with bacterial infections at the top of the list.)
BASOPHILS 0.00 0.00-0.01 %
MONOCYTES 0.07 0.00-0.03 %
EOSINOPHILS 0.01 0.00-0.03 %
PLATELET COUNT 253 150-400 x10^9/L
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COMPLETE BLOOD COUNT November 26, 2009 at 11:39 AM
TEST RESULT NORMAL VALUES UNIT SIGNIFICANCE
HEMOGLOBIN 82 120 170 g/L Note:
Decrease in values may indicate anemia.
HEMATOCRIT 0.24 0.37-0.54 % Not normal
Decrease in values may indicate anemia.
RBC COUNT 2.77 4.1-5.1 x10^12/L Not normal.Decrease in values due to Hemmorhage.
MCV 86 80-96 fLNormal Values
MCH 30 27-31 pgNormal Values
MCHC 35 34-36 g/dLNormal Values
WBC COUNT 15.9 4.5-11 x10^9/10 Not normal.Increase in values may indicate acute bacterial infection.
DIFFERENTIAL COUNT
NEUTROPHILS 0.79 0.00-0.55 % Not normal.
Increase in values may indicate acute bacterial infection.
LYMPHOCYTES 0.15 0.00-0.34 % Not normal.
May indicate infection if the NEUTROPHILS are elevated. (the mostcommon reason for a low lymphocytes count is an elevation in thenumber of granulocytes. Granulocytes increase in many circumstances,with bacterial infections at the top of the list.)
BASOPHILS 0.00 0.00-0.01 %
MONOCYTES 0.05 0.00-0.03 %
EOSINOPHILS 0.01 0.00-0.03 %
PLATELET COUNT 198 150-400 x10^9/L
25
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COMPLETE BLOOD COUNT November 27, 2009 at 12:15 PM
TEST RESULT NORMAL VALUES UNIT SIGNIFICANCE
HEMOGLOBIN 95 120 170 g/L Note:
Decrease in values may indicate anemia.
HEMATOCRIT 0.28 0.37-0.54 % Not normal
Decrease in values may indicate anemia.
RBC COUNT 3.28 4.1-5.1 x10^12/L Not normal.Decrease in values due to Hemmorhage.
MCV 85 80-96 fLNormal Values
MCH 29 27-31 pgNormal Values
MCHC 34 34-36 g/dLNormal Values
WBC COUNT 15.4 4.5-11 x10^9/10 Not normal.Increase in values may indicate acute bacterial infection.
DIFFERENTIAL COUNT
NEUTROPHILS 0.79 0.00-0.55 % Not normal.
Values may increase in acute bacterial infection.
LYMPHOCYTES 0.16 0.00-0.34 % Not normal.
May indicate infection if the NEUTROPHILS are elevated. (the mostcommon reason for a low lymphocytes count is an elevation in thenumber of granulocytes. Granulocytes increase in many circumstances,with bacterial infections at the top of the list.)
BASOPHILS 0.00 0.00-0.01 %
MONOCYTES 0.04 0.00-0.03 %
EOSINOPHILS 0.04 0.00-0.03 %
PLATELET COUNT 256 150-400 x10^9/L
26
Case Presentation
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Abruptio Placenta
VII. DRUG STUDY
DATEORDERED MEDICATION DOSAGE FREQUENCY DATE GIVEN
11/25/09
Cefazolin 2g TID 9:25pm
11/25/09
Diphenhydramine 50mg 1 10:40pm
11/25/09
11/26/09
Ketorolac
Ranitidine
Initial Dose: 30mg
Second Dose: 15mg
50mg
q 8 x 2 more doses
Q8 x 3 more dose
2:00am
8:00 am
11/26/09 Tranexamic Acid 50mg q 8 x 3 more doses 7:00am
11/27/09 Co-amoxiclav
Ferrous Sulfate
Mefenamic acid
625g/tb
1tb
500mg /cap
BID
BID
q 8
27
DRUG INDICATIONS CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATIONS
Generic Name:
Ranitidine
Hydrochlorid
Brand Name:
Zantac
Class:
Histamine2
antagonists
DOSE
50 mg q 8 hrs
ROUTE
IV
Short-term treatment of
active duodenal ulcer
Short-term treatment of
active, benign gastric
ulcer
Maintenance therapy
for duodenal ulcer atreduced dosage.
Short-term treatment for
GERD.
Pathologic
hypersecretory
conditions (Zollinger-
Ellison syndrome)
Treatment of erosive
esophagitis
Treatment of heartburn,
acid indigestion, sour
stomach
Contraindicated with
allergy to ranitidine,
lactation
Use cautiously with
impaired renal or hepatic
function, pregnancy
.
CNS: headache, malaise,
dizziness, somnolence,
insomnia, vertigo
CV: tachycardia,
bradycardia
Dermatologic: rash,
alopecia
GI: constipation, diarrhea,
nausea and vomiting,
abdominal pain, hepatitis
GU: impotence or
decreased libido
Hematologic: leucopenia,
granulocytopenia,
thrombocytopenia,
pancytopenia
Assessment:
1. History: allergy to ranitidine, impaired
renal or hepatic function, lactation,
pregnancy.
2. Physical: skin lesions, orientation, affect,
liver evaluation, abdominal examination,
normal output, renal function tests, CBC
Interventions:
1. Administer oral drug with meals and at
bedtime.
2. Decrease doses in renal and liver failure.
3. Provide concurrent antacid therapy to
relieve pain.
4. Administer IM dose undiluted, deep into
large muscle group.
5. Arrange for regular follow-up including
blood test, to evaluate effects.
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Case Presentation
Abruptio Placenta
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Case Presentation
Abruptio Placenta
DRUG INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING CONSIDERATIONS
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Generic Name:
Ketorolac
Tromethamine
Brand Name:Toradol
Class:
Analgesic
DOSE
30 mg q6
ROUTE
IV
Short-term
management of pain
(up to 5 days)
Ophthalmic: relief ofocular itching due to
seasonal
conjunctivitis and
relief of post-
operative
inflammation after
cataract surgery.
Contraindicated with
significant renal impairment,
during labor and delivery,
lactation, aspirin allergy,
recent GI bleed or perforation
Use cautiously with impaired
hearing; allergies; hepatic
conditions
CNS: headache,
dizziness,
somnolence,
insomnia, fatigue,
dizziness, tinnitus,ophthalmologic effects
Dermatologic: Rash,
pruritus, sweating, dry
skin
EENT: eye irritation,
dry eyes,
conjunctivitis, blurred
vision
GI: Gastric pain,
flatulence,
constipation, diarrhea,
nausea, vomiting,
anorexia, ischemic
colitis, renal and
mesenteric arterial
thrombosis,
retroperitoneal fibrosis,
hepatomegaly, acute
pancreatitis
GU: Impotance,
decreased libido,
peyronies disease,
dysuria, nocturia,
polyuria, priapism,
urinary retention
Assessment:
1. History: renal impairment, impaired hearing,
allergies, hepatic, lactation, pregnancy
2. Physical: skin color and lesions, orientation,
reflexes, peripheral sensation, clotting times,
CBC, adventitious sounds
Interventions:
1. Be aware that patient may be at risk for CV
events, GI bleeding, renal toxicity, monitor
accordingly.
2. Do not use during labor, delivery, or whilenursing.
3. Keep emergency equipment readily available
at time of initial dose, in case of severe
hypersensitivity reaction.
4. Protect drug vials from light.
5. Administer every 6 hrs to maintain serum
levels and control pain.
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RESPIRATORY:
Bronchospasm,
dyspnea, cough,
bronchial obstruction,
nasal stuffiness,rhinitis, pharyngitis
30
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Case Presentation
Abruptio Placenta
DRUG INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING CONSIDERATIONS
GenericName:
FerrousSulfate
Brand Name:
Fer-gen-sol
Class: ironpreparation
DOSE
ROUTE
Oral
.Prevention andtreatment of irondeficiencyanemias
Dietarysupplement foriron
Unlabeled use:Supplemental useduring epoetintherapy to ensureproperhematologicresponse toepoetin
Contraindicated withallergy to any ingredient;sulfite allergy;hemochromatosis,hemosiderosis, hemolyticanemias
Use cautiously withnormal iron balance;piptec ulcer, regionalenteritis, ulcerative colitis.
CNS: CNS toxicity,acidosis, coma anddeath withoverdose
GI: GI upset,anorexia, nausea,vomiting,constipation,diarrhea, darkstools, temporarystaining of theteeth (liquidpreparations)
Assesement
Allergy to any ingredient, sulfite;hemochromatosis, hemosiderosis,hemolytic anemias; normal iron balance;peptic ulcer, regional enteritis, ulcerativecolitis
PHYSICAL: Skin lesions; color; gums; teeth(color); bowel sounds; CBC, Hgb, Hct,serum ferritin and iron levels
Interventions:
Confirm that patient does have irondeficiency anemia before treatment.
Give drug with meals(avoiding milk, eggs,coffee, and tea) if GI discomfort is severeand slowly increase to build up tolerance.
Administer liquid preparations in water orjuice to mask the taste and preventstaining of teeth; have the patient drinksolution with a straw.
Warm patient that stool may be dark orgreen.
Arrange for periodic monitoring of
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hematocrit and hemoglobin levels
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Case Presentation
Abruptio Placenta
DRUG INDICATIONS CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATIONS
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Generic Name:
TRANEXAMI
C ACID
Brand Name:
Cyklokapron
Class:
Antifibrinolyticagent
DOSE
10 mg/kg (usual500-1000 mg) IV2-4 times daily
ROUTE
IV
1.treatment ofexcessivebleeding resultingfrom systemic orlocal
hyperfibrinolysis
2.prophylaxis inpatients withcoagulopathyundergoingsurgicalprocedures
Acquired defective
color vision; active
intravascular
clotting;
subarachnoidhemorrhage;
concurrent factor IX
complex or anti-
inhibitor coagulant
concentrates
Postmarketing and/orcase reports: Deepvenous thrombosis(DVT), pulmonary
embolus (PE), renalcortical necrosis,retinal arteryobstruction, retinalvein obstruction,ureteral obstruction
Assessment:
Dosage modification required in patients
with renal impairment; ophthalmic exam
before and during therapy required if patientis treated beyond several days;
caution in patients with cardiovascular,
renal, or cerebrovascular disease; caution in
patients with a history of thromboembolic
disease (may increase risk of thrombosis);
when used for subarachnoid hemorrhage,
ischemic complications may occur
Intervention:
1.Monitor patient closely for increased risk
of thromboembolic complications.
2.Severe and sometimes fatal
thromboembolic events have been reported
in APL patients receiving the combination
32
Case Presentation
Abruptio Placenta
DRUG INDICATIONS CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATIONS
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GENERIC
NAME:
MEFENAMIC
ACID
BRAND
NAME:
PONSTEL
Class:
anti-pyretic
DOSE:
500 mg tid
ROUTE:
ORAL
>used for therelief of mild tomoderate pain in
acute and chronicconditionsincluding: pain oftraumatic, arthriticor muscular origin;dysmenorrhoea;headache anddental pain.
> reduces bloodloss in
menorrhagiawheremenorrhagia is dueto ovulatorydysfunctionalbleeding. Uterineand otherpathology shouldfirst be excludedbefore prescribingMefenamic acid for
this indication.
>contra-indicated
in patients with
known sensitivityand in patients who
respond to aspirin
and aspirin-like
medicines with
sensitivity reactions
like
bronchoconstriction
, skin rashes and
urticaria.
> contra-indicated
in patients with
peptic ulceration or
having a history of
gastro-intestinal
bleeding and or
inflammatory bowel
disease.
CV:thromboticevents,myocardialinfarction, and
stroke, which canbe fatal
GI: Risk ofUlceration,Bleeding, andPerforation
Assessment:
Assess patient pain before therapy
Monitor for possible drug inducedadverse reaction
Advice patient not to take drug
for more than 7 days
Intervention:
>Patients should promptly report signs orsymptoms of unexplained weight gain or
edema to their
>Patients should be informed of the warning
signs and symptoms of hepatotoxicity (e.g.
nausea, fatigue, lethargy, pruritus, jaundice,
right upper quadrant tenderness, and "flu-like"
symptoms
>Patients should be informed of the signs ofan anaphylactoid reaction (e.g. difficulty
breathing, swelling in the face or throat. 33
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Case Presentation
Abruptio Placenta
VIII. NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
masakit yung tahi ko,makirot siya. Asverbalized by thepatient.
OBJECTIVE:
- facial grimacing
- frequentabdominalguarding
- pain scale, asrates pain as 7,10 as the most
painful and 1 asthe least painful
- restlessness
Altered Comfort:Pain related tosurgical incision asevidenced byabdominal guarding,pain scale of 7/10.
RATIONALE:
Patients commonlyprovide security tothe muscle in pain bguarding it for thisgives them theassurance that painwill not furthercomplicate.
With in 2 hours ofnursing intervention thepain will be reduced asevidenced by:
1. Pain scale,rates pain as 3,10 as the mostpainful and 1 asthe leastpainful.
2. Decreaseabdominalguarding.
3. Decrease facialgrimacing
4. Verbalizationthat pain isreduced
Independent:
1. Providedalternativediversions
2. Monitor vitalsigns every 30mins.
3. Encouragepatient ofverbalizationof pain
Dependent:
1. Assistedpatient indrinkingmedicationsas ordered bythe physician
1. Diverts patientsattention to painand makes thisas copingmechanism
2. Provides abaseline dataand note for
certain changesthat mightmanifest furtherabnormalities
3. Providesimmediate careto avoid furthercomplications
1. Administerpainmedicationas orderedby theDoctor
After 2 hours of nursingintervention the patientspain was reduced asevidenced by:
1. Pain scale, rates
pain as 5, 10 asthe most painfuland 1 as the leastpainful.
2. Decreasedabdominalguarding
3. Distraction of ownself. Reduces painperception
4. To monitor
significant changes
Goal partially met
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Case Presentation
Abruptio Placenta
ASSESSMENT NURSINGDIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
mainit angpakiramdam ko,parang nilalagnatako.
OBJECTIVE:
- teary eyes
- warm totouch
- V/S takenTemperature: 38C
Fever related toallergic reaction inBlood Transfusion asevidenced by increase
of temperature (38c)
RATIONALE:
Anything foreignsubstance thatintroduced into thebody may causeallergic reaction thatmay affect well-being ifan individuals.
With in 1 hour ofnursing interventionfever will decrease
from 38C to 37.0C
1. Perform TSB2. Give
paracetamoltablet asordered.
Independent:
1. Perform TSB
2. Continuousmonitoring of V/S.
Dependent:
1. Discontinue Blood
Transfusiontemporarily.Substitute PNSSuntil the feversubside thencontinue BloodTransfusion
2. Paracetamol givenas ordered by thedoctor.
Independent:
1. To decreasetemperature ofthe patient
2. Provide as abaseline dataand note forcertain
changes thatmight manifestfurtherabnormalities
Dependent:
1. Blood Transfusion isa foreign substancethat could cause anallergic reaction to the
client. PNSS
2. To decreasetemperature of thepatient.
After 1 hour ofnursingintervention thepatients feverwas decreasedas evidenced by:
1.Temperature
of the patientsubsided from
38c to 36.5c
Goal met
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Case Presentation
Abruptio Placenta
ASSESMENT NURSINGDIAGNOSIS
PLANNING INTERVENTION
RATIONALE EVALUATION
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SUBJECTIVE:
-Patientverbalized,Sabi patay nadaw ang anakko.
OBJECTIVE:
-facial tension-voicequivering-trembling/handtremors
Anxiety relatedto death of herson asevidenced bycrying.
Rationale:
Anxiety isrelated to thenarrowing of thepersonsperception ofthe situation.
The personsfocus is limitedto the specific
details of thesituation
Short term
With in 3 hours ofNursing care, thepatient will manifestreduced anxiety asevidenced by:
1.Px demonstratingpositive copingmechanisms.
2.activeparticipation andfocus in instructionsgiven
3.verbalization of
positive thoughts orplans afterhospitalization
Long Term:
With in a week ofnursing interventionpatient will be ableto cope and surpassthe DABDA stages
Diagnostic:
1.Assesedpatients level ofanxiety
Therapeutic:
2. established agood workingrelationship withthe px throughcontinuity ofcare.
3.encouragedpx verbalizationof thoughts and
feelings
Educative:
4. Assisted thepx inrecognizingsymptoms ofincreaseanxiety.
1.To determinethe level ofanxiety and
1. Knowing the levelof anxiety enhancesthe patientsawareness andability to identifyand solve problems.
2. on goingrelationshipestablishes a basisfor comfort incommunicatinganxious feelings.
3. talking aboutanxiety-producingsituations and
anxious feelings canhelp the personperceive thesituation in a lessthreatening manner.Expressing emotionscan enhance the pxcoping strategies.
1.to identifypatientsimprovement on thecoping mechanism.
After 3 hours ofNursing care, the wasable to demonstratepositive copingmechanisms andreduced anxiety asevidenced by:
1. Being able to focuson instructions givenand putting them intoaction in the outmostway the patient can.
2.Verbalization thatthere might be biggerproblems that can
arise and verbalizingthat she is still luckenough to have the lifethat she has now.
3. Being spirituallyhealthy as evidencedby having periods forprayer.
1. Partially met dueto lack of time indoing thenursing
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Case Presentation
Abruptio Placenta
IX. DISCHARGE PLAN
Objectives:
This plan aims to continue treatment and care to the patient by involving significant others to participate plan of
care.
Medications:
Instruct patient to continue her prescribed medicines.
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Treatment:
Instruct patient straineous activity
Health Teaching:
Instruct the patient to clean her wound and change dressing everyday.
Out patient
Follow up appointment
Diet
DAT, Increase fluid intake
Case Presentation
Abruptio Placenta
X. BIBLIOGRAPHY
Sherwin N uland, MD, Bernadine Healy M.D , Susan G. Braun ( 1997) Merck Manual of Medical Information,Home Edition ( Publihed by Merck + company Inc.
Wolff, Weitzel, Zornow, Zsohar (Seventh Edition) Fundamental of Nursing Publishedby J.B Lippincott
company Philadelphia
Barbara Kozier, Glenona Erb, Audrey berman, Shirlee Snyder (2004) Fundamentals of Nursing Concepts,
Process + Practice ( Sevent Edition) Published by Pearson Education South Asia Pte. Ltd.
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Marilyn E. Doenges, Mary Frances, Moor house, Alice C. Murr (2004) Nurses Pocket Guide ( Ninth Edition)
Published by Robert G. Mar tone.
Lippincott Williams + Wilkins (2006 ) Nursing Drug handbook(26th edition) Pblished by Walters Kluwer
Company.