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Wesleyan University- Philippines

Mabini Extension, Cabanatuan City

Case Study
In NCM 103: Care of Clients with problems in Oxygenation-Cardiovascular system Disorder

Submitted by:

Jenilyn Faye M. Orpilla


(Bsn3-4)

Submitted To: Prof. Reuben Q. Ignacio, RN MAN


Concept Instructor

Abnormal Uterine Bleeding, Iron deficiency Anemia Secondary Case Study


Table of Contents
I. INTRODUCTION ..................................................................Error! Bookmark not defined. A. Brief history of the case ......................................................Error! Bookmark not defined. B. Definition of related terms ..................................................Error! Bookmark not defined. II. PATIENTS HISTORY ........................................................................................................ 2 A. Biographic data ..................................................................................................................... 2 B. Chief complaints .................................................................................................................... 3 C. History of present illness ........................................................................................................ 3 D. Past medical / health history ................................................................................................. 3 E. Family medical / illness history.............................................................................................. 3 F. Review of system .................................................................................................................... 3 G. Lifestyle and health practices ................................................................................................. 4 h. Developmental level ............................................................................................................. 5 III. COLLECTING OBJECTIVE DATA .................................................................................. 5 a. Course of confinement ........................................................................................................... 5 i. Medication administered since date of admission ....................................................... 5
ii. IVF , BT and other parenteral medication infused/ administered since date of admission ..... 9

iii. All diagnostic test made to pt since date of admission ................................................ 9 b. Physical assessment .............................................................................................................. 9 IV. LIST OF NANDA BASED OR GORDON BASED NURSING DX .......................... 16 V. PATHOPHYSIOLOGY .......................................................Error! Bookmark not defined.8 VI. NURSING CARE PLAN ....................................................Error! Bookmark not defined.9 References ..................................................................................................................................... 28

I. INTRODUCTION a. Overview Patient A has been admitted in August 22, 2012 5:06am. The patient is 35 weeks pregnant and has been reported with a heavy vaginal bleeding. Her final diagnosis is Abnormal Uterine Bleeding, Iron Deficiency Anemia Secondary. Iron deficiency is the most common deficiency disorder in the world, affecting more than two billion people worldwide, with pregnant women at particular risk. World Health Organization (WHO) data show that iron deficiency anaemia (IDA) in pregnancy is a significant problem throughout the world with a prevalence ranging from an average of 14% of pregnant women in industrialized countries to an average of 56% (range 3575%) in developing countries. Anaemia during pregnancy is a well known and considerable risk factor for both mother and fetus. Fetal consequences are an increased risk of growth retardation, prematurity, intrauterine death, amnion rupture and infection. Prematurity is a consequence of early anaemia during Maternal consequences of anaemia are also well known and include cardiovascular symptoms, reduced physical and mental performance, reduced immune function, tiredness, reduced peripartal blood reserves and nally increased risk for blood transfusion in the postpartum period. b. Definition of Related terms Anemia/ Anaemia- is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. Iron deficiency anemia-(IDA) is an ailment when there is not enough hemoglobin produced by the body to meet its requirement. Iron- The total body iron in a 70-kg man is about 4 Abnormal Uterine Bleeding (AUB) or Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the vagina that is due to changes in hormone levels. Anemia - a decrease in red blood cell (RBC) mass. Red blood cell (RBC)/ Erythrocyte- deliver oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs Cesarean Section- is a surgical procedure in which one or more incisionsare made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has also been performed upon request for childbirths that could otherwise have been natural. Lochia rubra (or cruenta) is the first discharge, red in color because of the large amount of blood it contains. It typically lasts no longer than 3 to 5 days after birth. Hematocrit- (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume fraction (EVF) is the volume percentage (%) of red blood cells inblood. It is normally about 45% for men and 40% for women.[1] It is considered an integral part of a person's complete blood count results, along with hemoglobin concentration, white blood cell count, and platelet count. Hemoglobin- tetramer protein composed of heme and globin. Is the ironcontaining oxygen-transportmetalloprotein in the red blood cells

MCH- "mean cell hemoglobin" is the average mass of hemoglobin per red blood cell in a sample of blood. It is reported as part of a standard complete blood count. MCH value is diminished in hypochromic anemias. MCHC- mean corpuscular hemoglobin concentration, a measure of the concentration of hemoglobin in a given volume of packed red blood cells. It is reported as part of a standard complete blood count. It is calculated by dividing the hemoglobin by the hematocrit. MCV- mean corpuscular volume, or "mean cell volume" (MCV), is a measure of the average red blood cell size that is reported as part of a standard complete blood count. The MCV is calculated by dividing the total volume of packed red blood cells (also known as hematocrit) by the total number of red blood cells. Serum ferritin- Ferritin is a protein found inside cells that stores iron so your body can use it later. A ferritin test indirectly measures the amount of iron in your blood. Total Iron Binding Capacity in the Blood (TIBC)-) is a medical laboratory test that measures the blood's capacity to bind iron with transferrin. It is performed by drawing blood and measuring the maximum amount of iron that it can carry, which indirectly measures transferrin since transferrin is the most dynamic carrier. Transferrin- are iron-binding blood plasma glycoproteins that control the level of free iron in biological fluids. Transferrin saturation: 1550% (males), 1245% (females) Erythropoiesis- is the process by which red blood cells (erythrocytes) are produced. It is stimulated by decreased O2 in circulation, which is detected by the kidneys, which then secrete the hormone erythropoietin.

II. PATIENTS HISTORY A. Biographical Information i. Name: Patient A ii. Age: 43 years old iii. Gender: Female iv. Birthday: March 23, 1969 v. Birthplace: Laur, Nueva Ecija vi. Civil Status: Married vii. Address: #106 purok 1, Laur, Nueva Ecija viii. Phone Number: 0927-4722-559 ix. Educational Level: High school Graduate x. Occupation: None xi. Race/ Ethnic Group: Tagalog xii. Religion: Roman Catholic xiii. Nationality: Filipino xiv. Citizenship: Filipino citizen xv. Language spoken: Tagalog xvi. Source of information: Patient A xvii. Reliability: 99%

b. Chief Complaints: Vaginal Bleeding i. Initial diagnosis: Abnormal Uterine Bleeding ) ii. Final Diagnosis: Abnormal Uterine Bleeding, Iron Deficiency Anemia Secondary c. History of Present Illness: 1 month prior to admission- unusual bleeding described as messy lasting only for 7 days, consuming 2 pads. 15 days prior to admission- vaginal bleeding noted to be profuse, consuming 8 pads fully soaked 3 days prior to admission- vaginal bleeding noted to be profuse, consuming 9 pads fully and with pain in lumbosacral region 2 days prior to admission- still with bleeding, with lumbosacral pain and headache d. Past Medical/ Health History i. Problems at birth- none ii. Childhood illnesses 1978: Measles 1981: Mumps iii. Immunization to date Patient A cannot remember iv. Adult illnesses 2000-2012: Hypotension v. Accidents: None vi. Allergies: None vii. Previous Hospitalization, Medical and Surgical Diagnosis Abdominal Caesarean Section Year 1998 Cause Pregnancy To her First Child

e. Family Medical/ Illness History i. Heredofamilial In her father side, her father is recently been diagnosed with diabetes and an alcoholic drinker. Her Grandmother had Tuberculosis of the bone and also asthmatic. In her mother side; her mother has a history of hypotension, and anemia. Her grandmother had a history of hepatitis and diabetes. f. Review of System 1. Skin, Hair & Nails Skin Pallor Hair- Black Nails- Pinkish 2. Head and Neck Head- No headache reported Neck- No stiffness of neck felt, with melasma at back of neck 3. EENT & Sinuses

Ears- No drainage or ringing ears reported Eyes- Blurred Vision when reading (Farsighted) Nose- No discharges Throat- No pain or hoarseness of voice felt 4. Chest and Lungs Chest- No pain reported Lungs- No shortness of breath or pain reported 5. Breast & Regional Lymphatics Breast- with Milk discharges Feeling of tenderness, and dark areola Regional Lymphatics- Lymph nodes are not enlarged nor tender 6. Heart, Neck Vessels & Central CVS Heart- No pain, distress or palpitations felt Neck vessels- are not distended. Cardiovascular System- No tightness, edema, or orthopnea reported 7. PVS With Varicosities in Right Leg 8. Abdomen No abdominal pain, bowel movements are good, with linea nigra 9. Genitalia and Reproductive System With Vaginal discharge (Lochia rubra) No pain during sexual intercourse reported 10. Anus, Rectum & Prostate Anus- No itchiness or lesion reported Rectum- No itchiness or lesion reported 11. Musculoskeletal System and Extremities No muscle pain, stiffness or swelling felt 12. Neurologic With dizziness and weakness as reported g. Lifestyle and Health Practices- 24H day Description i. Nutrition, diet and Weight management She prefers vegetables, rice and a glass of water in her meal. ii. Activity & Exercise She does household chores as her exercise. She usually at home with her daughter. iii. Rest and Sleep The client takes a 5-6hours of sleep as her rest and she also takes a nap occasionally. iv. Medication and Supplements The Client takes Multivitamins every morning v. Self-concept and self care The client is aware of the complication of her illness and she is willing to cooperate for her health promotion and disease prevention. vi. Social activities The patient visits her neighborhood to catch up latest issues around their town. She also visits her close relatives occasionally.

vii. Spiritual, Cultural, Values and Belief System The patient Goes to Church every Sunday and prays at night and before meals. She believes that everything happens for a reason. viii. Education and work A high school graduate and with no work. Patients A stays at home and do household chores. ix. Stress Level and Management/ Coping Stress Patient A is having a headache and feels dizzy when she is stress or angry at her child. Shes watching television at night before sleep, and talking with her peer group at morning as a way of relieving stress. x. Environment & Neighborhood Patient A lives in a rural area; in a 3 bedroom-house, with a backyard and a garden. The houses in their town are 5 meters apart. With a quiet neighborhood and far from highway. h. Developmental Stage i. Theory: Erik Ericksons Psychosocial Development ii. Generativity vs. Stagnation (Middle adulthood 40-64 years)The client has self confident of raising her child. She is devoted to her family and to their community. She wants her children to be educated and to be good person someday. She is confident of raising her premature child and her first child so that someday, her children will do the same to her. She believes that all of their sacrifices (The client and her husband) are worth it for their family. iii. Comparison of Normal and Abnormal developmental parameter: People extend their concern from themselves and their families to the community and to the world. They may become politically active, work to solve problems, or to participate in far-reaching-community or world based decisions. People with sense of generativity are self-confident and better able to juggle their various lives (as a mother and church member. People without this sense become stagnated or selfabsorbed. Those who have devoted themselves to only one role are more likely to find themselves at the end of middle age with a narrow perspective and lack of ability to cope with change. Women without a sense of generativity may have more difficulty than others accepting a late-in-life pregnancy and a new role of childbearing.

III. COLLECTING OBJECTIVE DATA a. Course of Confinement i. Medications Administered since date of admission Physicians Order Generic Name Brand Name Ascorbic acid 1cap BID P.O. Ascorbic Acid Apo-C, Ascorbicap, Cebid, Cecon, Cenolate, Cemill, C-Span, Cetane, Cevalin, Cevi-Bid, Ce-Vi-Sol, Cevita,

Classification Mechanism of Action

Side Effects GI disturbances in high doses (nausea, vomiting, and diarrhea).

Bright yellow discoloration of urine Adverse Effects Rarely, hypersensitivity reaction Flatulence, constipation Heartburn,

Flavorcee, Redoxon, Schiff Effervescent Vitamin C, Vita-C. Vitamin Vitamin C or L-ascorbic acid, or simply ascorbate (the anion of ascorbic acid), is an essential nutrient for humans and certain other animal species. Vitamin C refers to a number of vitamers that have vitamin C activity in animals, including ascorbic acid and its salts, and some oxidized forms of the molecule like dehydroascorbic acid. Ascorbate and ascorbic acid are both naturally present in the body when either of these is introduced into cells, since the forms interconvert according to pH. Vitamin C is a cofactor in at least eight enzymatic reactions including several collagen synthesis reactions that, when dysfunctional, cause the most severe symptoms of scurvy. Nursing Management Instruct Client to take the medication after meals to avoid GI upset. Instruct client to measure and follow the prescribed dosage of the medication to avoid overdosing. Advise the client that yellow discoloration of urine is normal Nursing Management Instruct the client to discontinue the medication, and refer to the doctor. Instruct the client to discontinue the medication, and refer to the doctor. Instruct the client to take the medication after meals to avoid adverse reactions. Tranexamic acid 500mg, 1cap TID P.O. Tranexamic acid Hemostan, Fibrinon, Cyklokapron, Lysteda, Transamin Anti-fibrinolytic, antihemorrhagic. Haemostatics Tranexamic acid is a synthetic derivative of the amino acid lysine. It exerts its

Physicians Order Generic Name Brand Name Classification Mechanism of Action

Side Effects GI disturbances (Nausea, vomiting, diarrhea) Adverse Effects Hypotension

Headache

Hypersensitivity skin reactions/ allergic reactions Disturbances in color vision Physicians Order Generic Name Brand Name Classification Mechanism of Action

antifibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. Antifibrinolytic drug inhibits endometrial plasminogen activator and thus prevents fibrinolysis and the breakdown of blood clots. The plasminogen-plasmin enzyme system is known to cause coagulation defects through lytic activity on fibrinogen, fibrin and other clotting factors. By inhibiting the action of plasmin (finronolysin) the antifibrinolytic agents reduce excessive breakdown of fibrin and effect physiological hemostasis. Nursing Management Instruct Client to take the medication after meals to avoid GI upset. Nursing Management Take the client Blood pressure before and after taking the medication to identify if hypotension occurs as adverse effects, if so, discontinue the medication and refer to the doctor. Monitor the client after taking the medication and Instruct to take bed rest to avoid injury Instruct the client to discontinue the medication, and refer to the doctor Instruct the client to discontinue the medication, and refer to the doctor Ferrous Fumerate 1cap, TID P.O. Ferrous Fumerate Femiron, Ferretts, Ferro-Sequels, Ferrocite, Hemocyte, Ircon Antianemic/ Supplement Iron is an essential component in the physiological formation of hemoglobin, adequate amounts of which are necessary for effective erythropoiesis and the resultant oxygen transport capacity of the blood. A similar function is provided by iron in myoglobin production. Iron also serves as a cofactor of several essential enzymes, including cytochromes that are

Side Effects stomach upset,


diarrhea, black or darker than normal appearing stools, or temporary staining of the teeth.

Adverse Effects nausea or vomiting, epi-gastric pain.

involved in electron transport. Iron is necessary for catecholamine metabolism and the proper functioning of neutrophils. Nursing Management Instruct Client to take the medication after meals to avoid GI upset. Instruct client not to take with milk or antacids Inform patient the color stool black may be black Inform patient that temporary staining of the teeth is normal Nursing Management Instruct client to take the medication after snack or meal Instruct client to take the medication 2 hours prior to or 4 hours after antacids

Physicians Order Generic Name Brand Name Classification Mechanism of Action

Mefenamic acid 500mg 1capsule, TID P.O. Mefenamic acid Pharex, Mefenemax, Fenamax, Femacid Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Mefenamic acid binds the prostaglandin synthetase receptors COX-1 and COX-2, inhibiting the action of prostaglandin synthetase. As these receptors have a role as a major mediator of inflammation and/or a role for prostanoid signaling in activity-dependent plasticity, the symptoms of pain are temporarily reduced. Instruct patient to avoid alcohol intake when taking this medicine since it can cause increases in stomach irritation. Use caution if the patient has a weakened heart. It may cause increased shortness of breath or weight gain. Do not drive or engage in potentially hazardous activities until response to drug is known. It may cause dizziness and drowsiness.

Side effects: stomach pain or cramps vomiting or upset stomach increased shortness of breath

dizziness and drowsiness

Adverse Effects stomach ulcer or bleeding

dark stools, hematemesis, ecchymoses diarrhea, epistaxis, or rash

Nursing Management Instruct client to immediately tell the health provider about bleeding or stomach ulcer Instruct client to Discontinue the drug promptly, do not use again and Contact the physician. Instruct client to Discontinue the drug promptly, do not use again and Contact the physician.

ii. IVF, BT and other Parenteral Medication infused/administered since date of admission INTRAVENOUS FLUID OREDERED Previous IVF: Rationale: This pulls the fluid into the vascular by osmosis resulting in an LRS 1Liter + KCl 40 meq/L increase vascular volume. It raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy. Potassium chloride is used to prevent or to treat low blood levels of potassium (hypokalemia). Current IVF: Rationale: only IV fluid which is Plain NSS 1Liter for 24hours compatible to Blood Transfusion To follow IVF: Rationale: To facilitate another Blood Plain NSS 1Liter for 24hours Transfusion OTHERS Rationale: To restore blood volume after severe hemorrhage and to restore the oxygen-carrying capacity of the blood Rationale: Stimulating labor when the contractions are considered too weak. Preventing or controlling heavy bleeding following delivery of the child (postpartum hemorrhage).

Blood Transfusion

Oxytoxin

iii. Diagnostic Test since Date of Admission Name of Result Diagnostic Test Complete CBC Hemoglobi 100 n mass Normal Values Female: 110 158 Unit of Measurement Implication

g/dl

Indicates a decrease in Red blood cell

Male: 138 to 182 Hematocrit 0.32 0.37 0.54 fraction of RBC

production.

Indicates a decrease in Red blood cell production Normal.

Leukocyte Count Platelet Count

4.5 10 150 400

/L

463

400 X 10^9/L

An elevated platelet count is an indication that there is an underlying condition that is causing the disorder. Decrease in redness is due to a disproportionate reduction of red cell hemoglobin. Decrease in red blood cell size Decrease in hemoglobin concentration. Indicate a number of medical conditions such as tissue damage (due to trauma or disease), hemolytic anemia (an abnormal breakdown of red blood cells) Indicates poor absorption of Iron, Chronic heavy menstrual bleeding, Poor absorption of iron, Not enough dietary iron or Pregnancy There is a risk for lack of iron

RBC Indices MCH

26

28 32

pg

MCV MCHC LDH SCE

81

82 - 92 32 38 225.00 450.00

fL

31

410.00

U/L

Serum Iron concentration

40

Female: 50 to 170 Male: 65 to 176

g/dL

Serum ferritin

13

Female: 15200

g/L

Male: 30 300 Total Iron Binding Capacity in the Blood (TIBC) 375 250370 g/L In pregnant, the liver increases the production of transferring thus raising TIBC. When TIBC is high, it indicates iron deficiency anemia.

iv. Other relevant events during hospitalization - none. b. Physical Assessment i. General Impression Hygiene- Clean and Groomed appropriately Interaction/behavior- Cooperative attitude as her condition permits Posture- Bedridden and weak facial Expression- Symmetric with movement ii. Height, weight and Vital Signs Height: 5 feet and 3 inches Weight: 126 lbs Vital signs: Temperature: 37.3 C Pulse rate: 88 cpm Blood Pressure: 110/70 mm/Hg Respiratory Rate: 23 bpm iii. Skin

Color of skin- Pallor Color of hair- Black (Normal) Odor- No odor Lesion- No lesion Moisture- Moist Temperature- Warm Texture- Smooth & Soft Turgor- Pinched up skin returns immediately to original position Edema- No swelling, pitting or edema Nails- Has a convex curvature of fingernail plate, 160 Fingernail and toenail bed color are pinkish in color. The tissues surrounding the nails of the client are intact. Presence of capillaries- When blanched test is performed, color of the nail bed of the client returns into pink in less than 4 seconds. Capillary Refill test: 2 seconds (normal)

iv. MSE/ Neurologic

Mental Status: Awake & Alert; oriented to person, place & time Cranial Nerves: II: Visual Acuity- 20/20 with pocket screener, both eyes Visual Fields- intact in all fields II and III: Pupillary Reaction to Light- direct & consensual normal Accommodation- normal PERRLA, pupils, equal, round, reactive to light, and accommodation for both) III, IV, VI: EOM- intact V: Light Touch Face- normal in all 3 divisions VII: Wrinkle Forehead, Close Eyes, Show Teeth- normal VIII: Hearing- normal by rough testing X: Cough- normal (able to cough) XI: Shrug Shoulders and check sternocleidomastoid muscles - normal XII: Protrude Tongue- midline protrusion Motor System: Normal tone Sensory: Able to feel : Light Touch- normal Position Sense- normal Vibration- normal Sharp- normal Reflexes: Deep tendon O Biceps (C5-6)- Responsive o Triceps (C6-7)- Responsive o Brachioradialis- Responsive o Knee (L2-4)- Responsive o Ankle (S1)- Responsive Pathological - Plantar Reflex- none (bilateral down going toes) Coordination: Gait and Balance- normal Finger to Nose- normal Rapid finger movements- normal v. HEENT, Sinuses and Neck Head: Size/Shape- Symmetric, round, erect & in midline ROM/ Head control- Neck movement is smooth & controlled with 45 degree flexion, 55 degree extension, 40 degree lateral abduction, & 70 degree rotation head posture- still and uptight. Face: Appearance- Smooth and controlled movements Symmetry- Symmetrical Movement- abnormal movement noted Eyes: Position- Lower margins at bed cover approximately 2-6mm of iris bottom edge of iris; upper margins of lids Eyelids placement- No swelling, discharges or lesions noted

Sclera/Conjuctiva- No swelling, discharges, lesions or laceration are noted Iris/Pupils Color Black, round, flat and constricted when direct to light Visual Acuity Test- 20/20 vision; Can differentiate colors Ears: o External: Placement- Alignment of pinna with corner of eye within 10 degree angle of vertical position No swelling, discharges and lesions. o Internal: No discharges, lesion, excoriation or presence of foreign body. Mouth: Lips- Smooth & moist, without lesions or swelling Palates- Hard palate is pale or whitish with firm, transverse rugae (wrinkle like folds) Tongue- Pink, moist, a moderate size with papillae Buccal Mucosa- Smooth & moist without lesion Gums- Pink, moist and firm Teeth- 31 adult teeth, white to yellowish in color, shiny tooth enamel, no intact dentures Uvula- Positioned in midline of soft palate Throat/tonsils- Pink and symmetric Nose/sinuses: Structure and patency of nares- Able to sniff through each nostril while other is occluded Color and problem of turbinates - Color is the same as the rest of the face No discharges or tenderness Neck: Mobility- Symmetric Cervical Lymph Nodes- No enlargement or tenderness Temperature- Warm No swelling or tenderness vi. C/ L and Heart Breasts and Nipples- symmetrical--nipples symmetrical and everted No masses, with milky discharges Areola- Equal, round, symmetric, dark brown, smooth,has no lesions Thorax Posterior thoraxo Symmetric, ribs are sloped downward at 45 relative to the spine, muscle development is equal, anteroposterior to transverse diameter in ratio of 1:2 o Spinal alignment- Slightly o Uniform in temperature, no tenderness and masses o Respiratory excursion- Full and symmetric chest expansion o Vocal fremitus- Bilaterally equal, heard mostly at the apex of the lungs o Sounds- Percussion notes resonant except over the scapula, bronchovesicular and vesicular Anterior thorax

Breathing patterns- Quiet, rhythmic effortless Temperature, tenderness, masses- Warm, no tenderness or masses Respiratory excursion- Full and symmetric chest expansion Vocal fremitus- Bilaterally equal, mostly heard at the apex of the lungs o Sounds- Flat sound on the part with heavy muscles and bony prominences, tympani on the stomach, dullness on the liver and spleen, bronchovesicular, vesicular o Trachea- Bronchial sound Axillary, subclavicular and supracvicalar lymph nodes- Absence of masses or lumps Cardiovascular Precordiumo Aortic, pulmonic, tricuspid area- No pulsation o Apical area- With palpable pulsation (point of maximal impulse) o Sounds of tricuspid and apical- S2 is louder than S1 o Sounds of Tricuspid and apical area- S1 is lauder than S2 Carotid arteries- Symmetric pulse volumes, full pulsation, no sound o Visibility- Not visible Lungs respiratory effort: Even, 23bpm, unlabored Percussion and Palpation of Lung Fields- normal resonant percussion Auscultation- clear, normal vesicular breath sounds vii. Abdominal Unblemished skin, uniform in color, no signs of enlargement of the liver and spleen, symmetrical contour Peristalsis movement not visible vascular patterns not visible Audible bowel sounds, not audible vascular and peritoneal friction rubs With suture in viii. Urinary System No Pain or discomfort in response to pressure on the lower back, abdomen, or the area above the pelvic bone, Nogrowths, or abnormalities detected No discharge from the urethra ix. Genitalia and Reproductive External Genitalia- labia, clitoris, urethral orifice & introitus all normal (no sweelin, pus, warts or inflammation) Bimanual Exam- uterus is anterior, midline, smooth, enlarged and tender Fundus in midline, about half way to 2/3 way between umbilicus and symphysis pubis x. Anus Inspection of Cervix and Vaginabulging with straining, normal vagina mucosa, cervix- pink, with lochia rubra, cervix: Spongy and flabby

o o o o

Normal rectal sphincter tone; no rectal masses or tenderness. 0 stool for 3 days. no fissures, no hemorrhoids xi. Musculoskeletal, upper and lower extremities and PVS Musculoskeletal system Muscleso Size, contractures, tremors- Bilaterally symmetric, no contractures and tremors o Tonicity, strength (neck, upper, lower extremities)- Normal muscle tension, adequate strength of themuscles Bones- Uniform in structure, no deformities, tenderness or edema Joints- Absence of tenderness and swelling, has smooth movement, no nodules Range of motion (shoulder and scapula, elbows, hands, acetabulum, popliteal, ankles)- Able to perform the exercises in full range of motion, no tenderness, moves smoothly Upper Extremities >Nails- no cyanosis, or clubbing > palms- pale > muscles- size is proportional > joints (including rom) -interphalangeal- normal Range of motion without deformities - wrists- flexion = 90, = extention 70, radial deviation = 20, ulnar deviation = 50 - elbows- flexion = 160 - radial pulse- 4 / 4, normal and symmetric > Capillary Refill test: 2 seconds (normal) Lower Extremities: >Nails- normal (No cyanosis or clubbing) >Muscles- nl size > Joints (including ROM) Ankle- dorsiflex = 20, plantar flexion = 40, eversion = 20, inversion = 20 Knee- flexion = 130 Hip- flexion = 100, internal rotation = 40, ext rotation = 40 Pulses: Posterior Tibial- 4 / 4 bilateral & equal Dorsalis Pedis- 4 / 4 4 bilateral & equal > Capillary Refill test: 2 seconds (normal)

IV. LIST OF NANDA-BASED OR GORDON-BASED NURSING DIAGNOSIS LIST OF PRIORITIZED NURSING DIAGNOSIS Circulation ,Airway, Breathing 1. Fatigue related to the bloods decreased hemoglobin and diminished oxygencarrying capacity 2. Fluid volume deficit related to blood loss secondary to anemia

BASIS OF PRIORITIZATION Maslow Actual/ Overt/ potential covert Patients verbalization

JUSTIFICATION

3. Risk for infection related to decreased hemoglobin secondary to iron-deficiency Anemia. 4. Disturbed sleep pattern related to hospital noise and lightning secondary to Anemia 5. Imbalanced nutrition: Less than body requirement related to

Fatigue or weakness is patients major chief complaint regarding to her health after her cesarean delivery, and it is also one of the signs and symptoms of Iron deficiency anemia. Theres a severe hemorrhage after her delivery, blood loss results in decreased intravascular volume and needed to be replace immediately to avoid hypovolemia and shock Hemoglobin served as a secondary defense, a decreased in hemoglobin also means theres an easy access of the pathogens to infect the patient especially during her stay in the hospital.

inadequate intake of essential nutrients secondary to Anemia 6. Risk for Ineffective tissue perfusion related to inadequate blood volume secondary to anemia 7. Activity intolerance related to imbalance between oxygen supply and demand in the blood related to generalized weakness secondary to Anemia 8. Risk for Constipation related to insufficient physical activity secondary to Anemia 9. Risk for fall related to generalized weakness secondary to Anemia 10. Sedentary lifestyle related to deficient knowledge of health benefits of proper diet and exercise secondary to anemia

V. PATHOPHYSIOLOGY
MODIABLE FACTORS: Lifestyle: Diet: High in fiber, Low in Iron. In Weight Reducing program Preterm Birth (<38 weeks) Birth delivery via Cesarean section NON- MODIABLE FACTORS: Age: Adult (43 years old) Gender: Female (Pregnant) Heavy Menstruation History of having Anemia

Preterm Birth Blood loss/ Hemorrhage Decreased intravascular volume Depletion of iron stores in bone marrow Serum ferritin will become low (< 20-30 mcg/L) The compensatory increase in iron absorption causes an increase in iron-binding capacity (TIBC/Transferrin level) Serum iron falls to < 50 g/dL and transferrin saturation to < 16%. The serum ferritin receptor level rises (> 8.5 mg/L) Erythropoiesis is impaired Low Hemoglobin (below 12mg/dL) Low Hematocrit (Below 33%) Reduction in oxygen-carrying capacity of Red Blood cell

Small Red Blood cell (Microcytic)

Less Hemoglobin than Average Red Blood cell (Hypochromic)

Signs and Symptoms: Fatigue/ Generalized weakness Headache/ Dizziness Pale skin color or Pallor Sore tongue Light-headedness when you stand up

VI. NURSING CARE PLAN Name: Patient A Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary Date and time: August 22, 2012 (11pm-7am) Assessment Diagnosis Scientific Planning rationale Subjective Fatigue IronLong term Data: related to deficiency Goal: Nanghihina the bloods anemia is After 16 ako mula decreased a Hours of duty kagabi, sobra hemoglobi common a The patient ata kasi n and nemia (lo will be able pagdurugo ng diminished w red To enhance puson ko kaya oxygenblood cell her siguro ako carrying level) knowledge nanghihina. capacity caused by about her Matanda na secondary insufficien disease, and rin kasi ako to Anemia t dietary to facilitate nang intake and health nabuntis as absorption promotion. manifested by of iron. the mother. Short Term One of the Goal: Objective Symptoms After 16 hours Data: of anemia of duty, Pallor, is The patient generalized generalize will be able to weakness, d verbalize the With heavy Weakness understanding lochia rubra and of individual fatigue therapeutic Vital signs: interventions, T: 37.3 C medications

Implementation Independent Intervention: Explain to the client the procedures and its purpose Assess vital signs.

Scientific Rationale

Evaluation

To reduce anxiety of the patient. To prepare the patient for the Procedure. To evaluate fluid status and cardiopulmonary response to activity. To determine the need for doing activities or movement. To increase activity level as tolerated To conserve energy for other task To conserve energy:

Evaluate need for individual assistance or assistive device. Encourage client to do whatever possible Encourage use of assistive devices like wheelchair Instruct patient to sit instead of stand during care and other activities.

The patient is able to improve her activities of daily living as evidenced by the use of assistive devices and support system. The patient is able to verbalize the foods and diet which are rich in iron as evidence by eating 1 egg yolk, 1 small liver and small slice of red meat. Goal met:

RR: 23 bpm PR: 88 cpm BP: 110/70 mm/Hg

and its purposes. Long term objective: After 4 hours of health teaching, The patient will be able to identify foods rich in iron and the patient will be able to verbalize the dosage of her medication. Short term Objective: After 4 hours of health teaching, the patient will be able enhance her activities of daily living as evidenced by report of improved sense of energy.

Provide diversional activities like having her to talk with her relatives Instruct patient to eat Iron rich foods (e.g. liver or animal organs, egg, fish, poultry, leafy vegetables and dried fruits) Instruct patient to increase her fluid intake. Observe and measure fluid losses (e.g. bleeding) Provide Oral care

Pleasurable activities can refocus energy and diminish feelings of unhappiness and sluggishness. To Increase the Total Body iron of the patient. To prevent anemia and to help in producing more red blood cells.

To rehydrate the patient.

To determine replacement needs For patients comfort and to prevent dryness of mucous membrane. To provide optimal skin care and to prevent dryness of skin. To Follow patients therapeutic regimen to

Instruct the Family to bathe the patient every other day. Give/administer medications as

instructed by the doctor. Administer Blood transfusion as ordered by the Doctor. Replace electrolytes as ordered (Inserting IV fluids as ordered)

stabilize her wellness of health. To replace Blood volume loss. To replace electrolytes to prevent dehydration and further complications.

Collaborative Intervention: Refer patient to Radiology Technician for X-ray as ordered by the doctor.

For further evaluation and analysis of the patients disease.

Name: Patient A Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary Date and time: August 23, 2012 (11pm-7am) Assessment Diagnosis Scientific Planning Implementation rationale Subjective Fluid Iron Long term Independent Cues: volume deficiency Goal: Intervention: Medyo deficit during the After 16 hours Explain to the client nanghihina pa related to pregnancy is of duty, the the procedures and rin ako pero blood loss the cause of patient will be its purpose din na tulad secondary abnormal able to enhance ng kahapon, to anemia uterine her knowledge nakakatayo bleeding about her Assess vital signs naman ako during the disease, and to noting blood kahit papano. labor and facilitate health pressure Feeling ko resulting in promotion and lagi naman heavy blood further disease ako uhaw as loss. prevention. Estimate procedural manifested by fluid losses and take the mother. Massive Short Term note possible routes Fluid Goal: of insensible loss. Objective volume is After 16 hours Cues: loss during of duty, The Note complaints and generalized the delivery patient will be physical signs weakness, as a result able to associated with with lochia the patient verbalize the dehydration (scanty, rubra felt weak understanding concentrated urine, and thirsty. of individual confusion, muscle Vital signs: therapeutic weakness, light T: 37.3 C interventions, headedness, RR: 21 bpm medications headache) PR: 91 cpm and its BP: 110/70 purposes. Establishing 24-hour

Scientific Rationale

Evaluation

To reduce anxiety of the patient. To prepare the patient for the Procedure. Changes in vital signs are associated with fluid volume loss or other complications. To monitor and observe other routes of fluid losses Other sign and symptoms may indicate serious complications.

The patient is able to demonstrate a behavior of correcting her fluid deficit as evidenced of increased fluid intake by 500cc. The patient is able to maintain adequate fluid volume as evidenced by adequate urinary output: August 22 output: 220cc August 23 output: 550cc

This prevents peaks and

mm/Hg Long term objective: After 4 hours of health teaching, the patient will be able to demonstrate behavior to correct deficit. Short term Objective: After 4 hours of health teaching, The patient will able To maintain adequate fluid volume as evidenced by adequate urinary output.

fluid replacement needs. Instruct patient to increase her fluid intake. Maintain accurate I &O Provide Oral care

valleys in fluid level To rehydrate the patient.

To observe the progress of the current status of the patient For patients comfort and to prevent dryness of mucous membrane. To provide optimal skin care and to prevent dryness of skin. To reduce pressure on fragile skin and tissue To protect skin and monitor losses. To Follow patients therapeutic regimen to stabilize her wellness of health. To replace Blood volume loss.

Instruct the Family to bathe the patient every other day. Change position frequently Change dressings frequently Give/administer medications as instructed by the doctor. Administer Blood transfusion as ordered by the

Doctor. Administer IV fluids as indicated To replace electrolytes to prevent dehydration and further complications. For further evaluation and analysis of the patients disease.

Collaborative Intervention: Refer patient to Radiology Technician for X-ray as ordered by the doctor.

Name: Patient A Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary Date and time: August 24, 2012 (11pm-7am) Assessment Diagnosis Scientific Planning rationale Subjective Iron Long term Goal: cues: deficiency After 16 hours of Eto medyo Risk for during the duty, the patient nanghihina Infection pregnancy will be able to at related to is the enhance her nagdurugo decreased cause of knowledge about pa rin ang hemoglobi abnormal her disease, and puson ko, n uterine to facilitate pero di na secondary bleeding health promotion kasing lakas to ironduring the and further ng kahapon deficiency labor and disease as anemia. resulting prevention. manifested in heavy by the blood loss. Short Term mother. Goal: Hemoglob After 16 hours of Objective in served duty, the patient Data: as a will able to generalized secondary improve wound weakness, defense, a healing and will vaginal decreased not manifest any bleeding in sign of infection. (lochia hemoglobi rubra) n also Long term means objective: Vital signs: theres an After 4 hours of T: 36.6 C easy health teaching, RR: 21 bpm access of the patient will

Implementation Independent Intervention: Explain to the client the procedures and its purpose Assess vital signs noting blood pressure

Scientific Rationale

Evaluation

To reduce anxiety of the patient. To prepare the patient for the Procedure. Changes in vital signs are associated with fluid volume loss or other complications. To determine possible infection and to avoid further complication

Observe for localized signs of infection at insertion sites of invasive sites (or IVF insertion sites) and wound site. Stress proper hygiene by all caregivers between therapies and clients Emphasize proper use of personal protective equipment (PPE) to visitors as dictated by

A first line of defense against healthcare associated infections (HAIs) For personal protection of yourself and the patient

The patient is able to demonstrate techniques in lifestyle changes as evidence by reciting what will she do after her discharge : Eating foods Rich in iron (lean meat, liver, egg yolk and fish), having 6-8 hours sleep at night, and taking vitamins as prescribed by the doctor. The patient is be able to

PR: 90 cpm BP: 110/70 mm/Hg

the pathogens to infect the patient especially during her stay in the hospital.

able to demonstrate techniques in lifestyle changes to promote safe environment Short term Objective: After 4 hours of health teaching, the patient and her relative will be able to demonstrate behavior to prevent and reduce risk in infection (e.g. hand washing and change of dressing)

the agencys protocol Maintain sterile technique for all invasive procedures Recommend routine shower or scrubs. Instruct the patient and her relative about proper hand washing Change wound dressings using proper technique for changing and disposing of contaminated materials. Cover perineal and pelvic region when using a bedpan. Encourage early ambulation, deep breathing, and coughing and position changes. Maintain adequate hydration, stand or sit To reduce contamination

To reduce bacterial colonization. Basic infection and contamination control. To prevent contamination and reducing the occurrence of infection

demonstrate behavior to prevent and reduce risk in infection as evidence by performing hand washing and maintaining their room clean.

Goal met:

To prevent contamination

For mobilization of respiratory, and for prevention of aspiration/ respiratory infections. To avoid bladder distention and urinary

to void. Provide perineal care

stasis To reduces risk of ascending urinary tract infection For patients comfort and to prevent dryness of mucous membrane. To Follow patients therapeutic regimen to stabilize her wellness of health. To replace Blood volume loss. To replace electrolytes to prevent dehydration and further complications.

Provide Oral care

Give/administer medications as instructed by the doctor. Administer Blood transfusion as ordered by the Doctor. Administer IV fluids as indicated

Collaborative Intervention: Obtain appropriate tissue or fluid specimens for observation and culture and sensitivity test

For further evaluation and analysis of the patients disease.

REFERENCES: Nurses Pocket Guide (by E.A. Davis) Maternal & Child Health Nursing 6th Edition Volume 1&2 (Lippincott-Williams & Wilkins) Handbook of Medical-Surgical Nursing 11th Edition (by Brunner & Suddhart) MIMS Philippine 131st Edition MIMS.com Wikipedia.org (for Definition of terms) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001610/ http://www.medindia.net/drug-price/ferrous-fumarate-combination.htm#ixzz27aEaDdPD http://www.namrata.co/case-study-iron-deficiency-anemia/ http://nursesnanda.blogspot.com/2012/01/nanda-anemia.html http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/iron-deficiency-anemia/ http://www.geburtshilfe.usz.ch/Documents/LehreUndForschung/Publikationen/breymann_bl ood_cells.pdf http://nurseslabs.com/d5lrs-iv-fluid-study/ http://www.globalrph.com/dilp.htm http://www.netdoctor.co.uk/pregnancy/medicines/syntocinon.html http://www.scribd.com/doc/37710190/Anemia-NCP Pathophysiology references: Handbook of Medical-Surgical Nursing 11th Edition (by Brunner & Suddhart) Maternal & Child Health Nursing 6th Edition Volume 1&2 (Lippincott-Williams & Wilkins) http://www.merckmanuals.com/professional/hematology_and_oncology/anemias_caused_by _deficient_erythropoiesis/iron_deficiency_anemia.html http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/iron-deficiency-anemia/ http://www.namrata.co/case-study-iron-deficiency-anemia/ Handbook of Medical-Surgical Nursing 11th Edition (by Brunner & Suddhart) Maternal & Child Health Nursing 6th Edition Volume 1&2 (Lippincott-Williams & Wilkins)