Case Study 1

URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Philippines-2428
COLLEGE OF HEALTH SCIENCES
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE SUBJECT RLE 107N
CASE STUDY
ON
PLACENTA PREVIA
SUBMITTED BY:
TRICIA B. MATEO
SUBMITTED TO:
SIR RONIEL D. AQUINO
(CLINICAL INSTRUCTOR)
I. PERSONAL DATA
NAME: Patient X
ADDRESS: San Vicente East, Urdaneta City, Pangasinan
AGE: 41
SEX: Female
BIRTHDATE: December 11, 1978
EDUCATIONAL ATTAINMENT: First Year High School
CIVIL STATUS: Married
CITIZENSHIP: Filipino
RELIGION: Roman Catholic
ADMITTING DIAGNOSIS: PUFT Cephalic in Labor G4P3 T/C Placenta Previa
PRINCIPAL DIAGNOSIS: G4P4 (4004) PU 40 weeks, delivered to a live baby
girl LTCS +BTL for Placenta Previa Totalis
ATTENDING PHYSICIAN: OBGYNE Doctor

WARD: Annex A
HOSPITAL: Urdaneta District Hospital
DATE & TIME ADMITTED: 11-9-19/ 6:30 Am
DATE & TIME DISCHARGED: 11-15-19/ 9:30 Am
NO.OF DAYS HOSPITALIZED: 6 days
II. HISTORY OF PRESENT ILLNESS:
Prior to admission, Patient X experienced mild uterine contraction so she decided

to call a midwife at home. The midwife examined the patient and performed internal
examination. Patient X suddenly experienced vaginal bleeding so the midwife brought
her immediately to a hospital for further evaluation.
Upon arriving at the emergency room, nurses performed assessment and since
there is profuse bleeding, patient x was immediately referred to OBGYNE doctor.
Wherein orders were made and carried out. And she was then diagnosed by of PUFT
Cephalic in Labor G4P3 T/C Placenta Previa.
III. HISTORY OF PAST ILLNESS
Patient X was born to a G3P3 mother via NSD. She was full term and was
delivered at home by a trained hilot. There were no birth traumas or defects noted
during delivery. Cough and colds was her usual illness but not that often. Patient X
regularly visits RHU for consultation. According to her, she received vaccinations
during her childhood but she can’t recall those vaccines.
Patient X had no other medical illness, no allergies, no history of previous
surgeries or accidents.
IV. PHYSICAL HEALTH ASSESSMENT
A. GENERAL SURVEY
The patient is well groomed and oriented to time and place as evidence by the
client answering our question appropriately.
The patient has paleness of skin (pallor) while the skin is intact and there is no
presence of reddened areas in the body. The skin is dry.
B. VITAL SIGNS
VITAL INITIAL INTERPRETATION/ LAST INTERPRETATION/

SIGNS ASSESSM ANALYSIS ASSESS ANALYSIS
ENT(11- MENT
9-19) (11-14-
19)
Temperatu 36.5 WBC invade the 37 WBC invade the affected
re affected area to area to combat the
combat the bacteria bacteria from the body
from the body especially the lungs and
especially the lungs increased due to the
and increased due to pyrogen release
the pyrogen release
Pulse Rate 75 Normal 80 Normal
(PR)
Respirator 23 Increased respiration 24 Increased respiration of
y Rate of the patient the patient compensating
(RR) compensating the the decrease oxygenation
decrease oxygenation of the body
of the body
Blood 130/90 Normal 120/80 Normal
Pressure
C. BODY MASS INDEX (BMI)

 20.6 -within the normal range
D. GORDON’S FUNCTIONAL HEALTH PATTERN
FUNCTIONAL BEFORE DURING INTERPRETATION

HEALTH PATTERN HOSPITALIZATION HOSPITALIZATION AND ANALYSIS
Sleep – Rest Pattern Good sleeping Sleep Deprivation Due to acute pain
pattern secondary to LTCS
Cognitive – No presence of pain Acute Pain Due to tissue
Perceptual Pattern until labor trauma secondary
to LTCS
Nutritional Metabolic Body temperature on Hyperthermia Due to infection
Pattern normal range secondary to LTCS
E. HEAD-TO-TOE PHYSICAL ASSESSMENT
PART NORMAL FINDINGS ASSESSMENT INTERPRETATION

/ANALYIS
HAIR Black Black and coarse As the client aged the
dry less white hair elasticity and moisture
of the hair is
decreased
NAILS Nails are cleaned and Normal Nails should be
no manicures cleaned to prevent
further pathogens
contaminating the
food that might lead to
other diseases. Nails
should also not
 Color- pink  Pale manicured because it
tones is needed to be
assessed due to the
lack of oxygenation in
 Shape-  normal the tissues
normally its
160 degrees  It is usually seen
the nail base of in patients with
the skin anemia like low
iron diet and
hypoxia
 There is no
presence of
clubbing of nails
to patients
having anemia
HEAD Head is normally Normal Normal
hard and smooth
without lesions
FACE The face is Normal Normal
symmetric and round
NECK Symmetrical Normal Normal because there
are no presence of
bulging masses
EYE  Test for near  Normal  Patient may read
visual acuity- what the normal
20/20 eye could read
in a near
 Eye  Normal distance
movement-
able to follow  Normal functions
the fingers of the ocular,
from side to trochlear and
side than top trigeminal
to bottom  Normal nerves of the
body and six
 Reactivity to muscles that
light-PERRLA controls the eye
movement
 Normal
 Conjunctiva-  Dilates during an

palpebral object or light is
conjunctiva  Pale distant
 Constrict during
 Color-pinkish an object or light
is near
 Normal
 Decreased
oxygenation of
the tissue
MOUTH No repair or no Presence of a Due to improper
decayed areas chalky white hygiene to the teeth
 Gums and  Pale

teeth-pinkish in  decreased tissue
color, no perfusion
presence of
bleeding and
lesions
 Buccal mucosa  Normal
 Tongue-pink,  Normal  Normal

moist and
moderate six in  Normal
papillae
NOSE  No tenderness,  Normal  Normal
and
symmetrical
 Normal  Normal
 Patency-able to
stiff while the
other nare is
occluded  Normal  Normal
 Internal Nose-
dark pink,
moist and free
from exudates
CLIENTS Normally she should Normal Normal
POSITION be sitting and
breathing easily with
arms in the sides
LUNGS  Chest  Normal  Normal
expansion-
symmetrical
with 5-10 cm
apart
 Fremitus -  Un equal  Presence of lung

symmetrical fremitus consolidation
and air
entrapment
 Breath Sound  Normal
 Normal
 Respiration-  Normal
relaxed and  Normal
effortless. Rate
20 cpm.
 ABDOMEN  Bowel Sound-  Hypoactive  Indicates
4/hr constipation,
borborygmic effect of Feso4
sound/quadran medication of
t the patient
 Post-op pain  Effect of the

 Palpation surgical incision
(LTCS)
V. LABORATORY AND DIAGNOSTIC EXAMINATIONS
A. HEMATOLOGY
November 9, 2019
RESULT NORMAL INTERPRETATION
Hgb 11.4 12-16 g/L  due to bleeding
Hct 34.7 36-47 %  due to bleeding
RBC 5.23 4.2-5.4 10^g/L Normal
PLT 320 150-450 10^g/L Normal
WBC 17.6 5.0-10.0 10^g/L  due to infection
Neutrophils 12.7 2.00-7.50 10^g/L  due to infection
Lymphocytes 3.5 1.00-4.00 10^g/L Normal
Monocytes 0 0.00-1.00 10^g/L Normal
Eisonophils 1.2 0.00-0.50 10^g/L  due to infection
Basophils 0.2 0.00-0.20 10^g/L Normal
MCH 21.71 27-31 pg  due to bleeding
November 10, 2019

Hgb 7.8 12-16 g/L  due to bleeding and 2° to
operation
Hct 24.3 36-47 %  due to bleeding and 2° to
operation
RBC 3.68 4.2-5.4 10^g/L  2° to operation
PLT 263 150-450 10^g/L Normal
Eisonophils 0.3 0.00-0.50 10^g/L Normal
MCH 21-26 27-31 pg  due to bleeding and 2° to
operation
November 11, 2019
operation
operation
PLT 255 150-450 10^g/L Normal
Eisonophils 0.5 0.00-0.50 10^g/L Normal
operation
November 12, 2019

operation
operation
PLT 271 150-450 10^g/L Normal
Monocytes 1.0 0.00-1.00 10^g/L Normal
Eisonophils 0.8 0.00-0.50 10^g/L  due to infection
operation
B. SEROLOGY
 HBsAg - Non Reactive
 Blood Typing - B+
VI. BRIEF DESCRIPTION OF THE DISEASE:
PLACENTA PREVIA
An abnormal implantation of the placenta where instead of it being normally

implanted in the upper uterine segment, all or part of it is located in the lower uterine
segment and overlies or reaches the vicinity of the internal os.
Classification of Placenta Previa:

1. Total Previa- the placenta completely covers the internal cervical os.
2. Partial Previa- the placenta covers a part of the internal cervical os.
3. Marginal Previa- the edge of the placental lies at the margin of the internal
cervical os and may be exposed during dilatation.
4. Low-Lying Placenta- the placenta is implanted in the lower uterine segment but
does not reach to the internal os of the cervix.
Predisposing Factors:
1. Multiparity (80% of affected clients are multiparous)
2. Advanced maternal age (older than 35 years old in 33% cases)
3. Multiple gestations
4. Previous Cesarean birth
5. Uterine Incisions
6. Prior Placenta Previa (incidence is 12 times greater in women with previous
placenta previa)
Complications for the baby include:
 Problems for the baby, secondary to acute blood loss
 Intrauterine growth retardation due to poor placental perfusion
 Increased incidence of congenital anomalies
Clinical Manifestations:
 Painless vaginal bleeding > occurs after 20 weeks of gestation, bright red in
color associated with the stretching and thinning of the lower uterine segment
that occurs in third trimester.
 Adequately contract and stop blood flow from open vessels.
 Decreasing urinary output.
Diagnostic Evaluation:
Placenta Previa is diagnosed using transabdominal ultrasound.

- Transabdominal scans with fewer false positive results
TRANSVAGINAL ULTRASOUND
 If a woman is bleeding she is usually placed in the labor and birth unit or for
cesarean birth because profound hemorrhage can occur during the examination.
This type of vaginal examination knows as the double –set up procedure.
ULTRASONOGRAPHIC SCAN
 If ultrasonographic scanning reveals a normally implanted placenta, an
examination may be performed to rule out local causes of bleeding and a
coagulation profile is obtained to rule out other causes of bleeding management
of placenta previa depends of the gestational age and condition of the fetus and
the amount and cesarean birth.
COMPLETE BLOOD COUNT (CBC)

 To monitor mother’s blood volume
FETOSCOPE
 To monitor fetal heart rate and conditions.
Medical Management:
 Maternal stabilization and fetal monitoring
 Control of blood loss, blood replacement
 Delivery of viable neonate
 With fetus of less than 36 weeks gestation, careful observation to determine
safety of continuing pregnancy or need for preterm delivery
 Hospitalization with complete bed rest until 36 weeks gestation with complete
placenta previa
 Possible vaginal delivery with minimal bleeding or rapidly progressing labor
Nursing interventions:
1. In continuation of the pregnancy is deemed safe for the patient and fetus
administer magnesium sulfate as ordered for premature labor.
2. Obtain blood samples for complete blood count and blood type and cross
matching.
3. Institute complete bed rest
4. If the patient and placenta previa is experiencing active bleeding, continuously
monitor her blood pressure, pulse rate, respiration, central venous pressure,
intake and output, and amount of vaginal bleeding as well as the fetal heart rate
and rhythm.
5. Assist with application of intermittent or continuous electronic fetal monitoring
as indicated by maternal and fetal status.
6. Have oxygen readily available for use should fetal distress occur, as indicated by
bradycardia, tachycardia, late or available decelerations, pathologic sinusoidal
pattern, unstable baseline, or loss of variability.
7. If the patient is Rh-negative and not sensitized, administer Rh (D) immune
globulin (RhoGAM0 after every bleeding episode.
8. Administer prescribed IV fluids and blood products.
9. Provide information about labor progress and the condition of the fetus.
10. Prepare the patient and her family for a possible cesarian delivery and the
birth of a preterm neonate, and provide thorough instructions for postpartum
care.
11. If the fetus less than 36 weeks gestation expect to administer an initial
dose of betamethasone, explain that additional dosage may be given again in 24
hours and possibly for the next 2 weeks to help mature the neonate lungs.
12. Explain that the fetus survival depends on gestational age and amount of
maternal blood loss. Request consultation with a neonatologist or pediatrician to
discuss a treatment plan with the patient and her family.
13. Assure the patient that frequent monitoring and prompt management
greatly reduce the risk of neonatal death.
14. Encourage the patient and her family to verbalize their feelings helps them
to develop effective coping strategies, and refer them for counseling, if
necessary.
15. Anticipate the need for a referral for home care if the patient bleeding
ceases and she’s to return home in bed rest.
16. During the postpartum period, monitor the patient for signs and early and
late postpartum hemorrhage and shock.
17. Monitor VS for elevated temperature, pulse, and blood pressure, monitor
laboratory results for elevated WBC count, differential shift; check for uterine
tenderness and malodorous vaginal discharge to detect early signs of infection
resulting from exposure of placental tissue.
18. Provide or teach perineal hygiene to decrease the risk of ascending
infection.
19. Observe for abnormal fetal heart rate patterns such as loss of variability,
decelerations, tachycardia to identify fetal distress.
20. Position the patient in side lying position and wedge for support to
maximize placental perfusion.
21. Assess fetal movement to evaluate for possible fetal hypoxia.
22. Teach woman to monitor fetal movement to evaluate well-being.
23. Administer oxygen as ordered to increase oxygenation to mother and
fetus.
VII. ANATOMY AND PHYSIOLOGY
Normal Placenta during Childbirth
Process of placental growth and uterine wall changes during pregnancy

1. The placenta grows with the placental site during pregnancy.
2. During pregnancy and early labor the area of the placental site probably changes
little, even during uterine contractions.
3. The semi rigid, non contractile placenta cannot alter its surface area.
Anatomy of the uterine/placental compartment at the time of birth

1. The cotyledons of the maternal surface of the placenta extend into the deciduas
basalis, which forms a natural cleavage plane between the placenta and the uterine
wall.
2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around
the branches of the uterine arteries that run through the wall of the uterus to the
placental area.
3. The placental site is usually located on either the anterior or the posterior uterine
wall.
4. The amniotic membranes are adhered to the inner wall of the uterus except where
the placenta is located.
VIII. PATHOPHYSIOLOGY OF PLACENTA PREVIA:
IX. COURSE IN THE WARD
11-9-19 ADMISSION:
6:30 am
 A 36 year old was admitted in the ER per
ADMISSION wheelchair with chief complaint of profuse
bleeding; vital signs were taken as follows T-
IVF 36.5, BP-130/90, RR-34, PR-75. She was
 D5LR 1L, 500cc FD, seen and examined by OBGYNE doctor.
500cc x 8° FD Consent for admission was signed by her
 PLRS 1L FD husband. D5LR 1L was inserted as venolycsis
 TF-PNSS 1L KVO on her right arm and regulated 500 ml Fast
Drip remaining 500 ml run to 8° FHT and
LABORATORY: labor progress was moitored. Laboratories
 Blood Typing were requested and done. Referred to other
 HBsAg OBGYNE doctor.
 CBC 10:30am
 OBGYNE doctor made orders
MEDICATION:  IVF to 500cc FD, PLRS 1L FD
 Ketorolac 30mg IV q6  Anesthesiologist and pediatrician were notified
 Nalbuphine 5mg IV q4  Abdominal perineal preparation were done
 Ranitidine 50mg IV q8  VS taken and recorded as follows BP 120/90,
 Cefazolin 1gm IV q6 RR 19 bpm, PR 85 cpm
 Indwelling foley cathether was inserted
DIET: NPO aseptically
 Pre-op orders by OBGYNE doctor were made
NURSING INTERVENTION: and carried out
 VS q15x2°, then every  Patient on NPO
hour thereafter  Consent for “E” CS=BTL was secured
 Intake and output q 1°  Risk and complications were explained and
and record accepted by patient
 Transferred to O.R
12:15pm
 In from O.R per stretcher, VS of CR 105 cpm;
BP-120/70; O2 saturation 99%
 S?P LTCS = BTL under sab
 Still on NPO
 Patient maintained flat on bed for 6 hours
with O2 inhalation at 2-3 lpm
 Ongoing IVF were PNSS 1Lx FD on the left
arm, and PLR 1L = 10 IU oxytocin x 8°
 Patient for CBC in AM
2:30 pm
 In from stretcher, conscious, with same IVF
on.
 With complaint of post-op pain rated as 8/10.
 Necessary interventions were done.
 Comfort measures were provided
 Meds ordered were given
11-10-19  IV meds to consume
 Patient complaint that she was not able to
IVF sleep well cause of her incision. Necessarty
 PNSS 1L x KVO interventions were done.
 TF-PNSS 1L x KVO  Patient (-) flatus and BM (-), she was
LABORATORY: instructed to turn to sides, on general liquid
 CBC except carbonated drinks
 IFC was removed aseptically
 New meds were ordered an carried out
MEDICATION:  VS, intake and output were taken and
 Ketorolac 30mg IV q6 recorded
 Nalbuphine 5mg IV q4  Meds given as ordered
 Ranitidine 50mg IV q8
 Cefazolin 1gm IV q6 4:00 pm
 Patient’s temperature was 38°C. She was
New orders: then referred to OBGYNE doctor with orders
 Co-amoxiclav 625mg tab made and carried out. Necessary
q6 interventions were done. Temperature
 Celecoxib 200mg BID decreased. From 38 to 37.2.
 Paracetamol 1 amp 7:30pm
 Patient for BT VS taken T-37.1, BP-130/90,
DIET: General Liquid except RR-20, PR-79
carbonated drinks  1 iu PRBC properly cross matched was hooked
and regulated on the left arm
NURSING INTERVENTION:  VS was taken and recorded, and patient was
 Provide comfort, and strictly monitored for adverse reaction of BT,
environment conducive  IVF consumed and terminated aseptically as
for sleep and rest ordered
 Tepid Sponge Bath  After BT, patient keep rested but still being
 Monitored patient for monitored for post BT reaction.
adverse reaction on
blood transfusion
11-11-19  Patient was advised to ambulate slowly

IVF  Instructed on soft diet
 PNSS 1L x KVO  (-) BM, (+) flatus- instructed to turn to sides
 TF- PNSSx KVO and increase oral fluid intake
 Vital Signs taken and recorded
LABORATORY:  Meds given as ordered
 CBC  Patient provided with comfortable
environment
MEDICATION: 5:00am
 Co amoxiclav 625 mg  New orders were made and carried out
tab q6  Suppository was inserted as ordered
 Celecoxib 200mg BID  Patient may now ambulate fully
New orders:  Patient now on DAT
 NA+ ascorbate 1 cap 7:00 am
BID  1 iu PRBC properly typed and cross matched
was hooked and regulated
DIET: Soft diet, then DAT  VS was taken and recorded, and patient was
strictly monitored for adverse reaction of BT.
NURSING INTERVENTION:  After BT, patient kept rested but still being
 Provide comfort and monitored for post BT reaction.
environment conducive
for sleep and rest.
 Health teachings
 Monitored for any
untoward signs and
symptoms of BT and
post BT
11-12-19  Patient well groomed with IVF intact and

infusing well
IVF  Morning care done
 PNSS 1L x KVO  Meds given as ordered
 TF-PNSS x KVO  Health teachings done
 Patient kept safe and secured
 No new orders made
LABORATORY:  Provide with comfort
 CBC
MEDICATION:
 NA+ ascorbate 1 cap
BID
 Co Amocxiclav 625mg
tab q6
 Celecoxib 200 mg BID
DIET: DAT
NURSING INTERVENTION:
 Provide comfort and
environment conducive
for sleep and rest.
11-13-19  Patient well groomed with IVF intact and

infusing well
IVF  Morning care done
 PNSS 1L x KVO  Meds given as ordered
 Health teachings done
MEDICATION:  Patient kept safe and secured
 NA+ ascorbate 1 cap  May go home
BID  Necessary instructions were explained
 Co AMocxiclav 625mg
tab q6
DIET: DAT
11-14-19  Meds given as ordered

IVF  Health teachings done
 PNSS 1L x KVO  Patient kept safe and secured
 Kept rested
 Still for discharge
MEDICATION:
 NA+ ascorbate 1 cap
BID
 Co AMocxiclav 625mg
tab q6
DIET: DAT
Health teachings
9-15-15  Meds given as ordered

MEDICATION:  Health teachings done
 NA+ ascorbate 1 cap  Patient kept safe and secured
BID  DISCHARGED
 Co Amocxiclav 625mg
tab q6
TAKE HOME MEDS:

 Co Amocxiclav 625mg, 1
tab q6
 Celecoxib 200 mg, 1 cap
2x a day
DIET: DAT
Health teachings

Case Study 1

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URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Philippines-2428

COLLEGE OF HEALTH SCIENCES

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE SUBJECT RLE 107N

SIR RONIEL D. AQUINO

ATTENDING PHYSICIAN: OBGYNE Doctor

II. HISTORY OF PRESENT ILLNESS:

Prior to admission, Patient X experienced mild uterine contraction so she decided

III. HISTORY OF PAST ILLNESS

VITAL INITIAL INTERPRETATION/ LAST INTERPRETATION/

C. BODY MASS INDEX (BMI)

D. GORDON’S FUNCTIONAL HEALTH PATTERN

FUNCTIONAL BEFORE DURING INTERPRETATION

PART NORMAL FINDINGS ASSESSMENT INTERPRETATION

 Conjunctiva-  Dilates during an

 Gums and  Pale

 Buccal mucosa  Normal

 Tongue-pink,  Normal  Normal

 Fremitus -  Un equal  Presence of lung

 Post-op pain  Effect of the

V. LABORATORY AND DIAGNOSTIC EXAMINATIONS

November 10, 2019

November 12, 2019

An abnormal implantation of the placenta where instead of it being normally

Classification of Placenta Previa:

Placenta Previa is diagnosed using transabdominal ultrasound.

COMPLETE BLOOD COUNT (CBC)

Normal Placenta during Childbirth

Process of placental growth and uterine wall changes during pregnancy

Anatomy of the uterine/placental compartment at the time of birth

11-11-19  Patient was advised to ambulate slowly

11-12-19  Patient well groomed with IVF intact and

11-13-19  Patient well groomed with IVF intact and

11-14-19  Meds given as ordered

9-15-15  Meds given as ordered

TAKE HOME MEDS:

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