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CASE PRESENTATION

PREPARED BY:

TINU VARGHESE

DEMOGRAPHIC DATA CASE NO: 052125 NAME: MS. J.J. AGE: 24 Y/O SEX: FEMALE DIAGNOSIS: PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)

{Primigravida 33 wks leaking since 1100H 6/1/2013}

GENERAL
The patient is 24 years of age, FEMALE She is conscious, coherent, with the following Vital Signs:
BP= 110/59mmHg PR=100 bpm RR= 28 cpm Temp=37. C SPO= 98%

SKIN Fair complexion No palpable masses or lesions, moist, with good turgor

HEAD

Maxillary, frontal, and ethmoid sinuses are not tender. No palpable masses and lesions No areas of deformity

LEVEL OF CONSCIOUSNESS AND ORIENTATION


Awake and alert Oriented to persons (knows some of our name) Place ( she can tell where she is) Time ( knows the day, date and always asking the time)

EYES Pink conjunctivae and no dryness Pupils equally round and reactive to light

EARS
No usual discharges noted

NOSE
Pink nasal mucosa No unusual nasal discharges No tenderness in sinuses

MOUTH Pink and moist oral mucosa and free of swelling and lesions

NECK AND THROAT No palpable lymph nodes No masses and lesions seen

CHEST AND LUNGS


Equal chest expansion No retraction Clear breath sounds

HEART Regular rythm

ABDOMEN
Globular abdomen

Leopolds Maneuver done: fetus in cephalic presentation, head is round and hard, fetal back is facing right side
USG report:

o Pregnancy Uterine 33 weeks AOG by fetal Biometry live, Singleon in cephalic presentation, female fetus, Good cardiac and somatic activity, posterior placenta, Grade III, No previa, Adequate Amniotic Fluid Volume

GENITALS

Clear Watery discharge per vagina since 2 days. No show present

EXREMITIES
Pulse full and equal No lesions noted

PATIENT HISTORY
PAST MEDICAL HISTORY
No past medical history

PRESENT MEDICAL HISTORY


C/O: Leaking since 1100H 6/01/2013 MEDICAL HISTORY: Primigravida with pregnancy 33 wks by LMP, 37 wks + 1 day by USG with PROM since 1100H 06/01/2013 ON EXAMINATION: BP=110/59 mmHg, PR=118 bpm, RR= 28 cpm, Temp=37. :C, SPO= 98%

PRESENT MEDICAL HISTORY


INVESTIGATION:
TEST
Hgb WBC PT Blood Glucose Blood Group Negative Antibody screening RPR Rubella Antibody IgG Urinalysis HBsAg HIV Non- Reactive Positive Pus cells= 0-1/ hpf, RBC = 0-1/ hpf negative Negative

RESULT
10g/dl 14.04 12.1 sec 5.2 mmol/L A positive

REFERENCE RANGE
11.2-15.7g/dl 3.98-10.04 10.9-16.3sec 3.9-7.8mmol/L

PRESENT MEDICAL HISTORY


Ultrasound report: Pregnancy Uterine 37 weeks and 1 day AOG by fetal Biometry live, Singleton in cephalic presentation, female fetus, Good cardiac and somatic activity, posterior placenta, Grade III, No placenta Previa, Adequate Amniotic Fluid Volume

NAME OF DRUG

DOSAGE 1 gm

ROUTE IV IM

ACTION antibiotics corticosreroid

1.

Ampicillin
12mg

2 Inj.Dexamethasone

Calcium channel blockers 3 Tab .Nifedipine 20mg 10mg 4 5 Tab .Nifedipine Calcium Tablet 600mg 100mg PO PO Calcium supplimentt Iron suppliment PO PO Calcium channel blockers

FeSO4 Tablet

ADDITIONAL MEDICATIONS: 1. Oxytocin (Pitocin

Mix 10 U in 500 mL of IV solution, begin infusion at 1 mU/min and increase 12 mU/min q 30 min

IV

causes the uterus to contract

Meperidine (Demerol) 25 mg IV push (IVP) q 34 hr

IV

opioid analgesic drug

INTRODUCTION
During pregnancy, the baby is surrounded in the uterus by the amniotic sac. The sac is also called the bag of waters. It protects and cushions the baby. Premature Rupture of Membranes (PROM) is defined as rupture of membranes before the onset of labor. Preterm Premature Rupture of Membranes (PPROM), which is when the membranes rupture before 37 weeks.

INTRODUCTION
The sac contains amniotic fluid and the developing baby. In PPROM, the amniotic fluid inside the sac leaks or gushes out of the vagina. Before term, PPROM is often due to an infection in the uterus.

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

To diagnose PPROM, the doctor may do the following tests:

Visual examination A nitrazine paper test


Fern test

Ultrasound Amnisure

POSITIVE
NITRAZINE TEST

POSITIVE
FERN TEST

Amniocentesis to inject indigo carmine or evans blue dye. watch for vaginal leakage of blue fluid to assess for ruptured membranes

Risk factors
Lack of prenatal care Smoking during pregnancy Low body weight Bleeding from the vagina during the 2nd or 3rd trimester Having had a sexually transmitted disease (STD) Having had certain medical procedures such as amniocentesis (a test that takes fluid from the amniotic sac) or cerclage (sewing the cervix closed during pregnancy)

Main symptom: Fluid leaking or gushing from the vagina


It may be a sudden, large gush of fluid, or it may be a slow, constant trickle of fluid. The complications that may follow PROM include premature labor and delivery of the fetus, infections of the mother and/or the fetus, and compression of the umbilical cord (leading to oxygen deprivation in the fetus).

Other symptoms:

Bleeding from the vagina

Other symptoms:

Pain in the Lower abdomen or in the low back

If you have any of these signs & symptoms, call your healthcare provider right away

VIII. NURSING INTERVENTION


Prevent infection and other potential complications
Make an early and accurate evaluation of membrane status, using sterile speculum examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection. Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, an organism that increases the risk to the fetus. Determine maternal and fetal status, including estimated gestational age. Continually assess for signs of infection. Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapse if additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged.

VIII. NURSING INTERVENTION


Educate the patient to use sterile pads

VIII. NURSING INTERVENTION


Provide client and family education
Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent; encourage the client and partner to prepare themselves for labor and birth.
If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are likely to be needed.

TREATMENT
Hospitalization Expectant management (in some cases of PPROM, the membranes may seal over and the fluid may stop leaking without treatment) Monitoring for signs of infection such as fever, pain, increased fetal heart rate, and/or laboratory tests Giving the mother medications called corticosteroids that may help mature the lungs of the fetus (lung immaturity is a major problem of premature babies Antibiotics (to prevent or treat infections) Tocolytics - medications used to stop preterm labor. Delivery (if PROM endangers the well-being of the mother or fetus, then an early delivery may be necessary to prevent further complication

COMPLICATIONS OF PROM
Prolapse of the umbilical cord (the baby's cord drops down interfere with the blood supply to the baby). Infection of the uterus and unborn child. Placental abruption (the placenta comes away early with bleeding and loss of blood supply to the baby). Potential increased rates cesarean delivery. Premature Birth (PPROM) Chorioamnionitis Cord compression Respiratory distress syndrome

PRIORITIZATION OF NURSING PROBLEMS


Risk for infection related to loss of protective barrier by the fern test. Anxiety r/t threat to maternal or fetal well-being secondary to risk for infection or preterm birth Risk for infection related to ascending bacteria Risk for injury to fetus secondary to prematurity Compromised Family coping secondary to hospitalization Risk for infection: maternal or fetal r/t premature rupture of membranes Risk for injury: maternal or fetal r/t tocolytic drugs used to delay birth

ASSESSMENT
CUES/ EVIDENCE SUBJECTIVE: I feeing sudden gush of fluid from the vagina as verbalized by the patient. OBJECTIVE: 1.Meconium stained amniotic fluid. 2.Amnicator test result positive NURSING DIAGNOSIS Risk for infection related to loss of protective barrier by positive fern test.

PLANNING
GOALS & DESIRED OUTCOME Within 12 hours of nursing intervention , patient will have no signs of infection.

IMPLEMENTATION
NURSING ORDER/ACTION RATIONALE FOR ACTION

EVALUATION
EVALUATION

1. assess the patient from any signs and symptoms of infection v/S taken as follows: BP:130/90mmHg PR: 118 bpm RR: 28 cpm Temp: 37 C

1. to assess for infection.

After 12 hours of nursing intervention, the goal was fully met as evidenced by: Patient has no signs of infection

2.Provide sterile pads 3.Teach the proper hand hygiene technique to the patient.

2. prevent infections

3. To avoid infections

3. Fetal tachycardia FHR 180bp without uterine contraction

4.Vaginal examinations should be held to an absolute minimum, and sterile technique should be used. 5.Administer antibiotics as prescribed.

4. To prevent infections

5. To treat infection

ASSESSMENT CUES/ NURSING EVIDENCE DIAGNOSIS


SUBJECTIVE: Patient says that I am afraid about the babys health as verbalized by the patient OBJECTIVE:

Anxiety r/t threat to maternal or fetal wellbeing secondary to risk for infection or preterm birth

PLANNING GOALS & DESIRED OUTCOME Within 12 hours of nursing intervention , patient will

IMPLEMENTATION NURSING RATIONALE FOR ORDER/ACTION ACTION


1. Monitor vital signs (e.g., rapid or irregular pulse, rapid breathing/hyperventil ation, changes in blood pressure, , or restlessness

EVALUATION EVALUATION

1. To identify physical responses associated with both medical and emotional conditions. 2. To reduce anxiety by giving awareness of fetal wellbeing. 3. To relieve psychological stress due to prolonged bed rest 4. To reduce anxiety by relaxation, deep breathing. 5. To give knowledge about the risk of infection

relief from anxiety

2. Teach the patient for counting the 10 fetal movements in 12 hour periods. 3. Manage environmental factors, such as harsh lighting and high volume of CTG, which may be stressful to patient 4. instruct client in relaxation techniques and encourage participation in diversional activities 5. Explain the action and side effects of medication as prescribed. Inj. ampicillin 1gm IV

Her facial expression shows that she has anxiety


V/S taken as follows: BP:130/90mmH g PR: 118 bpm RR: 28 cpm

After 12 hours of nursing interventi on, the goal was fully met as evidence d by:

Patient relief from anxiety

Temp: 37 C

NURSING HEALTH TEACHING


Remain on modified bed rest No sexual activity, no tub bath. Assess for uterine contraction and fetal movement. Assess for foul smelling vaginal discharge Wipe front to back after urinating or having a bowel movement Take antibiotics if prescribed.

CONCLUSION
This is a case of a 24 y/o Primigravida with pregnancy 33+ 1 wks by LMP, 37 wks + 1 day by USG who came in due to watery discharge, amnicator test positive. Patient was advised for expectant management. Premature Rupture of Membranes (PROM) is defined as rupture of membranes before the onset of labor. Preterm Premature Rupture of Membranes (PPROM), which is when the membranes rupture before 37 weeks. Premature Rupture of Membranes happens when the membranes that hold amniotic fluid (the water surrounding the baby) usually break at the end of the first stage of labor.

CONCLUSION
Criteria which are fulfilled by the patient, conservative management rendered such as investigations, antibiotic coverage In cases by which this patient will undergo active labor despite tocolytic medication, there will be no objection for delivery as long as all maternal & fetal consequences are explained properly to the patient.

BIBLIOGRAPHY
Maternal and Child Health Nursing by Adele Pillitteri 5th edition; volume 1 page 426- 433;page 329-332 All-in-one care planning resource page 748; by Pamela L. Swearlngen, RN Maternal Neonatal Nursing;page 30 by Lippincott Williams and Wilkins Luckman and Sorensens Medical-Surgical Nursing a Physiologic Approach 4th edition Volume 1 page 734 Lippincot Manual of Nursing Practice 9th edition http://www.ualberta.ca/~olsonlab/Am%20J%20Obstet %20Gynecol%201999%20180(1%20Pt%201).pdf

Thank you!!

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