#16 Tandang Sora Avenue, Sangandaan, Novaliches, Quezon City S.Y.

2009 2010

CASE PRESENTATION
Abruptio Placenta

BLEEDING LOVE

Submitted by: Oco, Jenny Rose Oreta, Charlotte Jenniffer Reyes, Jinky Rose Sy, William Franz Tumbaga, Jean Claudine Villa, Mario Roberto

Traquena, Shayne

Velasco, Racquel

Vergara, Alyssa Dawn

Verona, Vercely,

Case Presentation Abruptio Placenta

TABLE OF CONTENTS

I.

INTRODUCTION..

1 1 2 2 3 4-6

A. B. C. D. E.

Background of the study Significance of the study Case Explained... Objectives Nursing Theories.

II. PATIENTS DATA

A. B. C. D. E. F. G. H. I. J. K.

General data Chief Complaint.. History of present illness... Past medical history Family medical history Personal and Social history.. Review of systems.. Physical examination.. Admitting Diagnosis Course in the ward. Final Diagnosis

7 7 8 8 8 9 10-11 12-16 16 16-18 18

III. REVIEW OF RELATED LITERATURE

A. Maternal cigarette smoking as a risk factor

for placental abruption, placenta previa,

19

and uterine bleeding in pregnancy

Case Presentation Abruptio Placenta

IV. ANATOMY AND PHYSIOLOGY

A. Anatomy and Physiology of the Placenta

V. PATHOPHYSIOLOGY

20-21

A. Pathophysiology of abruption placenta B. Written Explanation. VI. LABORATORY PROCEDURE A. Complete Blood Count VII. DRUG STUDY A. Ranitidine Hydrochlorid.. B. Ketorolac Tromethamine C. FERROUS SULFATE .. D. TRANEXAMIC ACID

22 23

24-26 27 28 29-30

31

. 32 E. MEFENAMIC ACID F. Cefazolin Sodium G. Diphenhydramine .

H. C0Amoxiclav ..

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

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 abruption placenta, 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. 1
Case 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 that during 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

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

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.

Dr. Peplau emphasized the nurse-client relationship as the foundation of nursing 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 the outcome 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

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 wellbeing. 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

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.

Case Presentation Abruptio Placenta

II. PATIENTS DATA

A. GENERAL DATA

Name Sex Age Height Date of Birth Address

: : : : : :

Patient Dora Female 18 y/o 5 ft and 1 inch February 04, 1991 xxxxxxxx27

Date of Admission Time of Admission Place of admission Attending Physician Case Number

: : : : :

11-25-2009 6:55 P.M. Dr. Jose Fabella Memorial Hospital Dr. xxxxx xxxxx xxx27

B. CHIEF COMPLAINT Bloody vaginal discharge

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 Hypertension Diabetes Asthma (-) (-) (-) MOTHER (-) (-) ( +) 8

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 Intervals Duration Amount Sign & Symptoms : : : : : 12 years old 28 days cycle 3 to 4 days 4 to 5 napkins ( + ) Dysmenorrhea

Case Presentation Abruptio Placenta

G. REVIEW OF SYSTEM

REVIEW OF SYSTEM SKIN ( -) ( +) (+ ) HEENT (+ ) ( +) (- ) ( +) ( +) RESPIRATORY (+ ) (+ ) (- ) (+ ) tachypnea difficulty of breathing cough crackles 10
Case Presentation

Delayed Skin Tugor Dryness Pale

Headache Dizziness Sore throat Blurring of vision Flaring of nostrils

Abruptio Placenta

CARDIAC ( -) ( -) tachycardiac murmurs

ENDOCRINE

( -) (- )

polydipsia polyphagia

(- )

polyuria

GASTROINTESTINAL (- ) (+ ) (- ) GENITOURINARY (- ) ( -) dysuria incontinence nausea abdominal pain vomiting

MUSKOLOSKELETAL ( +) ( -) muscle weakness fracture

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Case Presentation Abruptio Placenta

H. PHYSICAL EXAM
GENERAL SURVEY (+ ) ( -) ( -) Conscious Unconscious Alert ( +) ( +) Drowsy Lethargic

VITAL SIGNS (120/80 mmHg) (89 bpm ) SKIN ( +) (- ) Warm Cold ( +) (- ) Dry Moist BP PR ( 18 cpm) (37 C) RR Temp

HEENT Conjunctive ( -) Pink ( +) Pale NECK (+ ) ( -) Supple Tense 12

Case Presentation Abruptio Placenta

CHEST AND LUNGS ( -) (+ ) HEART (- ) ( -) ABDOMEN (- ) ( -) Scaphold Distended Adynamic Dynamic Asymmetrical Symmetrical

EXTREMITIES ( -) ( -) Deformities Cyanosis

RECTAL EXAM ( -) (- ) Skin Tag Presence of Blood on lactating fingers 13

Case Presentation Abruptio Placenta

General survey

-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 89 bpm SKIN -skin is hot and dry -+ appearance of scars - pinch up skinfold returns immediately to normal position -absence of edema Nail Heent -sclera smooth,white ,glossy and moist - pale conjunctiva 14
Case Presentation Abruptio Placenta

18 cpm 37 C

clean curved hard nail

Neck

- symmetrical, proportional to head and shoulder - coordinate and controlled movement Chest and lungs Heart Abdomen unable to sit or lie comfortably and pain in moving No lesions, masses and abnormalities Symmetrical Regular rate and rhythm Spine is straight, without lesions or masses Normal sloping of ribs

extremities No deformities

Rectal exam Smooth without masses, lesions and tenderness 15

Case Presentation Abruptio Placenta

Muscuskeletal system

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 8 x 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

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 after transfusion 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 COAMOXCILAV 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

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Case Presentation Abruptio Placenta

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)

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Case Presentation Abruptio Placenta

III. REVIEW OF RELATED LITERATURE

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.

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Case Presentation Abruptio Placenta

IV. ANATOMY AND PHYSIOLOGY

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 for cake, ]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, provides nutrients 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 center and 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

DEVELOPMENT The placenta begins to develop upon implantation of the blastocyst into the maternal endometrium. The outer layer of the blastocyst becomes the trophoblast which forms the outer layer of the placenta. This outer layer is divided into two further layers: the underlying cytotrophoblast layer and the overlying syncytiotrophoblast layer. The syncytiotrophoblast is a multinucleate continuous cell layer which covers the surface of the placenta. It forms as a result of differentiation and fusion of the underlying cytotrophoblast cells, a process which continues throughout placental development. The syncytiotrophoblast (otherwise known as syncytium), thereby contributes to the barrier function of the placenta.The placenta grows throughout pregnancy. Development of the maternal blood supply to the placenta is suggested to be complete by the end of the first trimester of pregnancy (approximately 1213 weeks)

FUNCTIONS
The perfusion of the intervillous spaces of the placenta with maternal blood allows the transfer of nutrients and oxygen from the mother to the fetus and the transfer of waste products and carbon dioxide back from the fetus to the mother. Nutrient transfer to the fetus is both actively and passively mediated by proteins called nutrient transporters that are expressed within placental cells. Adverse pregnancy situations, such as those involving maternal diabetes or obesity can increase or decrease levels of nutrient transporters in the placenta resulting in overgrowth or restricted growth of the fetus. When the fetus is born, its placenta begins a physiological separation spontaneous expulsion afterwards (and for this reason is also called the afterbirth). In humans, the umbilical cord is routinely clamped and severed prior to the delivery of the placenta, often within seconds or minutes of birth, a medical protocol known as 'active management of third stage' which has been called into question by advocates of natural birth and 'passive management of third stage. The site of the former umbilical cord attachment in the center of the front of the abdomen is known as the navel.
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Case Presentation Abruptio Placenta

V. PATHOPHYSIOLOGY A. Diagram
Predisposing Factor Age Lifestyle
PRECIPITATING FACTOR ETIOLOGY: UNKNOWN

Age: 18 y/o 5-6 packs a year

Vasoconstriction

Carbon Monoxide introduce to the system

Excessive Smoking

Torn and ruptured Blood vessels Hemorrhage into the Decidua Basalis

Disturbed system circulation

Decreased of oxygen needed by the blood

Decreased resiliency of blood vessels at placental bed RBC WBC Diagnostic Test

Total separation of placenta to the uterine

Allergic Reaction

Blood Transfusion administration

Ane mia Risk for infecti on

Abdominal Pain

Abruptio Placenta Abnormal contraction of the uterus Vaginal Bleeding FHR Reassuring

Fev er Risk for infection in incision Pain in incision

POST - OP

CS Delivery

Emergency Delivery Fetal Distress

Neonatal Death

Anxi ety

Bradycar dia

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Case Presentation Abruptio Placenta

B.Written Explanation

23 VI. LABORATORY AND DIAGNOSTIC PROCEDURES

COMPLETE BLOOD COUNT TEST HEMOGLOBIN RESULT 102 NORMAL VALUES 120 170 UNIT g/L Note:

November 25, 2009 at 8:52 PM SIGNIFICANCE

Decrease in values may indicate anemia. HEMATOCRIT 0.30 0.37-0.54 % Not normal Decrease in values may indicate anemia. RBC COUNT MCV MCH MCHC WBC COUNT 3.48 86 29 34 14.7 4.1-5.1 80-96 27-31 34-36 4.5-11 x10^12/L fL Normal Values pg Normal Values g/dL x10^9/10 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 most common 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 MONOCYTES EOSINOPHILS PLATELET COUNT 0.00 0.07 0.01 253 0.00-0.01 0.00-0.03 0.00-0.03 150-400 % % % x10^9/L Not normal. Increase in values may indicate acute bacterial infection. Not normal. Decrease in values due to Hemmorhage. Normal Values

COMPLETE BLOOD COUNT TEST HEMOGLOBIN RESULT 82 NORMAL VALUES 120 170 UNIT g/L Note:

November 26, 2009 at 11:39 AM SIGNIFICANCE

Decrease in values may indicate anemia. HEMATOCRIT 0.24 0.37-0.54 % Not normal Decrease in values may indicate anemia. RBC COUNT MCV MCH MCHC WBC COUNT 2.77 86 30 35 15.9 4.1-5.1 80-96 27-31 34-36 4.5-11 x10^12/L fL Normal Values pg Normal Values g/dL x10^9/10 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 most common 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 MONOCYTES EOSINOPHILS PLATELET COUNT 0.00 0.05 0.01 198 0.00-0.01 0.00-0.03 0.00-0.03 150-400 % % % x10^9/L Not normal. Increase in values may indicate acute bacterial infection. Not normal. Decrease in values due to Hemmorhage. Normal Values

25

COMPLETE BLOOD COUNT TEST HEMOGLOBIN RESULT 95 NORMAL VALUES 120 170 UNIT g/L Note:

November 27, 2009 at 12:15 PM SIGNIFICANCE

Decrease in values may indicate anemia. HEMATOCRIT 0.28 0.37-0.54 % Not normal Decrease in values may indicate anemia. RBC COUNT MCV MCH MCHC WBC COUNT 3.28 85 29 34 15.4 4.1-5.1 80-96 27-31 34-36 4.5-11 x10^12/L fL Normal Values pg Normal Values g/dL x10^9/10 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 most common 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 MONOCYTES EOSINOPHILS PLATELET COUNT 0.00 0.04 0.04 256 0.00-0.01 0.00-0.03 0.00-0.03 150-400 % % % x10^9/L Not normal. Increase in values may indicate acute bacterial infection. Not normal. Decrease in values due to Hemmorhage. Normal Values

26
Case Presentation

Abruptio Placenta

VII. DRUG STUDY

DATE DRUG ORDERED Generic Name: Ranitidine 11/25/09 Hydrochlorid Brand Name: Zantac 11/25/09 Class: Histamine2 11/25/09 antagonists MEDICATION INDICATIONS Cefazolin Short-term treatment of active duodenal ulcer Short-term treatment of Diphenhydramine active, benign gastric ulcer Maintenance therapy Ketorolac for duodenal ulcer at reduced dosage. Short-term treatment for GERD. Ranitidine Pathologic hypersecretory conditions (ZollingerEllison syndrome) Tranexamic Acid Treatment of erosive Co-amoxiclav esophagitis Ferrous Sulfate Treatment of heartburn, acid indigestion, sour Mefenamic acid stomach DOSAGE CONTRAINDICATION 2g Contraindicated with allergy to ranitidine, lactation 50mg Use cautiously with impaired renal or hepatic function, pregnancy Initial Dose: 30mg . Second Dose: 15mg FREQUENCY ADVERSE EFFECT TID CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo 1 CV: tachycardia, bradycardia Dermatologic: rash, q 8 x 2 more doses alopecia GI: constipation, diarrhea, nausea and vomiting, abdominal pain, hepatitis Q8 x 3 more dose GU: impotence or decreased libido Hematologic: leucopenia, granulocytopenia,doses q 8 x 3 more thrombocytopenia, BID pancytopenia BID q8 DATE GIVEN NURSING CONSIDERATIONS Assessment: 9:25pm

1. History: allergy to ranitidine, impaired renal or hepatic function, lactation, 10:40pm pregnancy. 2. Physical: skin lesions, orientation, affect, liver evaluation, abdominal examination, 2:00am normal output, renal function tests, CBC Interventions: 1. Administer oral drug with meals and at 8:00 am bedtime. 2. Decrease doses in renal and liver failure. 3. Provide concurrent antacid therapy to relieve pain. 7:00am 4. Administer IM dose undiluted, deep into large muscle group. 5. Arrange for regular follow-up including blood test, to evaluate effects.

11/26/09 DOSE 50 mg q 8 hrs

50mg

11/26/09 ROUTE IV11/27/09

50mg 625g/tb 1tb 500mg /cap

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Case Presentation Abruptio Placenta

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Case Presentation Abruptio Placenta

DRUG

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECT

NURSING CONSIDERATIONS

Generic Name: Ketorolac Tromethamine Brand Name: Toradol Class: Analgesic

Short-term management of pain (up to 5 days) Ophthalmic: relief of ocular itching due to seasonal conjunctivitis and relief of postoperative 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 while nursing. 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.

DOSE 30 mg q6 ROUTE IV

RESPIRATORY: Bronchospasm, dyspnea, cough, bronchial obstruction, nasal stuffiness, rhinitis, pharyngitis

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Case Presentation Abruptio Placenta

DRUG Generic Name: Ferrous Sulfate Brand Name: Fer-gen-sol Class: iron preparation

INDICATIONS .Prevention and treatment of iron deficiency anemias Dietary supplement for iron Unlabeled use: Supplemental use during epoetin therapy to ensure proper hematologic response to epoetin

CONTRAINDICATIONS Contraindicated with allergy to any ingredient; sulfite allergy; hemochromatosis, hemosiderosis, hemolytic anemias Use cautiously with normal iron balance; piptec ulcer, regional enteritis, ulcerative colitis.

ADVERSE EFFECT CNS: CNS toxicity, acidosis, coma and death with overdose GI: GI upset, anorexia, nausea, vomiting, constipation, diarrhea, dark stools, temporary staining of the teeth (liquid preparations)

NURSING CONSIDERATIONS Assesement Allergy to any ingredient, sulfite; hemochromatosis, hemosiderosis, hemolytic anemias; normal iron balance; peptic ulcer, regional enteritis, ulcerative colitis PHYSICAL: Skin lesions; color; gums; teeth (color); bowel sounds; CBC, Hgb, Hct, serum ferritin and iron levels Interventions: Confirm that patient does have iron deficiency anemia before treatment. Give drug with meals(avoiding milk, eggs, coffee, and tea) if GI discomfort is severe and slowly increase to build up tolerance. Administer liquid preparations in water or juice to mask the taste and prevent staining of teeth; have the patient drink solution with a straw. Warm patient that stool may be dark or green. Arrange for periodic monitoring of

DOSE

ROUTE Oral

hematocrit and hemoglobin levels

31 Case Presentation Abruptio Placenta

DRUG

INDICATIONS

CONTRAINDICATION

ADVERSE EFFECT

NURSING CONSIDERATIONS

Generic Name:

TRANEXAMI C ACID
Brand Name:

1.treatment of excessive bleeding resulting from systemic or local hyperfibrinolysis 2.prophylaxis in patients with coagulopathy undergoing surgical procedures

Cyklokapron
Class: Antifibrinolytic agent DOSE 10 mg/kg (usual 500-1000 mg) IV 2-4 times daily

Acquired defective color vision; active intravascular clotting; subarachnoid hemorrhage; concurrent factor IX complex or antiinhibitor coagulant concentrates

Postmarketing and/or case reports: Deep venous thrombosis (DVT), pulmonary embolus (PE), renal cortical necrosis, retinal artery obstruction, retinal vein obstruction, ureteral obstruction

Assessment: Dosage modification required in patients with renal impairment; ophthalmic exam before and during therapy required if patient is 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

ROUTE IV

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Case Presentation Abruptio Placenta

DRUG

INDICATIONS

CONTRAINDICATION

ADVERSE EFFECT

NURSING CONSIDERATIONS

GENERIC NAME: MEFENAMIC ACID BRAND NAME: PONSTEL Class: anti-pyretic DOSE: 500 mg tid

>used for the relief of mild to moderate pain in acute and chronic conditions including: pain of traumatic, arthritic or muscular origin; dysmenorrhoea; headache and dental pain. > reduces blood loss in menorrhagia where menorrhagia is due to ovulatory dysfunctional bleeding. Uterine and other pathology should first be excluded before prescribing Mefenamic acid for this indication.

>contra-indicated in patients with known sensitivity and 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:thrombotic events, myocardial infarction, and stroke, which can be fatal GI: Risk of Ulceration, Bleeding, and Perforation

Assessment: Assess patient pain before therapy Monitor for possible drug induced adverse reaction Advice patient not to take drug for more than 7 days

Intervention:

>Patients should promptly report signs or symptoms 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 of an anaphylactoid reaction (e.g. difficulty breathing, swelling in the face or throat. 33

ROUTE: ORAL

Case Presentation Abruptio Placenta

VIII. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS Altered Comfort: Pain related to surgical incision as evidenced by abdominal guarding, pain scale of 7/10. RATIONALE: Patients commonly provide security to the muscle in pain b guarding it for this gives them the assurance that pain will not further complicate. PLANNING INTERVENTION Independent: SUBJECTIVE: masakit yung tahi ko, makirot siya. As verbalized by the patient. OBJECTIVE: facial grimacing frequent abdominal guarding pain scale, as rates pain as 7, 10 as the most painful and 1 as the least painful restlessness With in 2 hours of nursing intervention the pain will be reduced as evidenced by: 1. Provided alternative diversions 2. Monitor vital signs every 30 mins. 1. Pain scale, rates pain as 3, 10 as the most painful and 1 as the least painful. 2. Decrease abdominal guarding. 3. Decrease facial grimacing 4. Verbalization that pain is reduced 1. Diverts patients attention to pain and makes this as coping mechanism 2. Provides a baseline data and note for certain changes that might manifest further abnormalities 3. Provides immediate care to avoid further complications After 2 hours of nursing intervention the patients pain was reduced as evidenced by: RATIONALE EVALUATION

3. Encourage patient of verbalization of pain Dependent: 1. Assisted patient in drinking medications as ordered by the physician

1. Administer pain medication as ordered by the Doctor

1. Pain scale, rates pain as 5, 10 as the most painful and 1 as the least painful. 2. Decreased abdominal guarding 3. Distraction of own self. Reduces pain perception 4. To monitor significant changes Goal partially met

Case Presentation Abruptio Placenta

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE Independent: 1. To decrease temperature of the patient 2. Provide as a baseline data and note for certain changes that might manifest further abnormalities Dependent: 1. Blood Transfusion is a foreign substance that could cause an allergic reaction to the client. PNSS 2. To decrease temperature of the patient.

EVALUATION

SUBJECTIVE: mainit ang pakiramdam ko, parang nilalagnat ako. OBJECTIVE: teary eyes warm to touch

Fever related to allergic reaction in Blood Transfusion as evidenced by increase of temperature (38c)

With in 1 hour of nursing intervention fever will decrease from 38C to 37.0C 1. Perform TSB 2. Give paracetamol tablet as ordered.

1. Perform TSB 2. Continuous monitoring of V/S. Dependent: 1. Discontinue Blood Transfusion temporarily. Substitute PNSS until the fever subside then continue Blood Transfusion 2. Paracetamol given as ordered by the doctor.

After 1 hour of nursing intervention the patients fever was decreased as evidenced by: 1.Temperature of the patient subsided from 38c to 36.5c Goal met

RATIONALE: Anything foreign substance that introduced into the body may cause allergic reaction that may affect well-being if an individuals.

- V/S taken Temperature: 38C

Case Presentation Abruptio Placenta

ASSESMENT SUBJECTIVE: -Patient verbalized, Sabi patay na daw ang anak ko.

NURSING DIAGNOSIS Anxiety related to death of her son as evidenced by crying. Rationale:

PLANNING Short term With in 3 hours of Nursing care, the patient will manifest reduced anxiety as evidenced by: 1.Px demonstrating positive coping mechanisms. 2.active participation and focus in instructions given 3.verbalization of positive thoughts or plans after hospitalization

INTERVENTIO N Diagnostic: 1.Assesed patients level of anxiety Therapeutic: 2. established a good working relationship with the px through continuity of care. 3.encouraged px verbalization of thoughts and feelings Educative: 4. Assisted the px in recognizing symptoms of increase anxiety.

RATIONALE 1. Knowing the level of anxiety enhances the patients awareness and ability to identify and solve problems. 2. on going relationship establishes a basis for comfort in communicating anxious feelings. 3. talking about anxiety-producing situations and anxious feelings can help the person perceive the situation in a less threatening manner. Expressing emotions can enhance the px coping strategies.

EVALUATION After 3 hours of Nursing care, the was able to demonstrate positive coping mechanisms and reduced anxiety as evidenced by: 1. Being able to focus on instructions given and putting them into action in the outmost way the patient can. 2.Verbalization that there might be bigger problems that can arise and verbalizing that she is still luck enough to have the life that she has now. 3. Being spiritually healthy as evidenced by having periods for prayer.

Anxiety is OBJECTIVE: related to the narrowing of the -facial tension persons -voice perception of quivering the situation. The persons trembling/hand focus is limited tremors to the specific details of the situation

Long Term: With in a week of nursing intervention patient will be able to cope and surpass the DABDA stages 1.to identify patients improvement on the coping mechanism. 1. Partially met due to lack of time in doing the nursing

1.To determine the level of anxiety and

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.

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 Published by 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.

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.