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A 17 years old, G1P2(1002) Women in Normal Spontaneous Deliv

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joshua mari pabillo

on 25 May 2014

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Transcript of A 17 years old, G1P2(1002) Women in Normal Spontaneous Deliv

BULACAN STATE UNIVERITY
MALOLOS CITY, BULACAN
COLLEGE OF NURSING

A CASE STUDY ABOUT
A 17-year old, G1P2(1002) Woman undergone Normal Spontaneous Delivery
due to Premature Rupture Membrane of Membrane
Submitted by:

BSN 2A- Group 3
Gomez, Ma. Saleth V.
Gonzales, Jean Jayzzel G.
Laquindanum, Filley Therese N.
Lucas, Mary Riza B.
Mendiola, Apple Gleiz
Oligan, Kim N.
Pabillo, Joshua Mari B.

Submitted to: Level III Clinical Instructors

Introduction
Objectives
GENERAL OBJECTIVES
• This case study aims to broaden the knowledge, promote skills and comprehend attitude to the patient and especially to the nursing students who might have handled cases or will handle this kind of delivery. To provide the necessary nursing care and proper intervention for the wellness of patient having Premature Ruptured of Membrane (PROM). We would have to identify nursing problems and the corresponding nursing considerations and managements involved for promotion and maintenance of the patient's health.

SPECIFIC OBJECTIVES
Student Centered
After the case study, the students will be able to:
Knowledge:
• Be familiar in the necessary assessments for the patient who has had Premature Ruptured of Membrane (PROM).
• Be able to acquire the necessary knowledge with regards to the client's medication and understand the importance of complying with it.
• Improve about the ideal nursing interventions for the patients undergoing Premature Rupture of Membrane (PROM).

Skills:
• Render the necessary nursing care in the hospital needs for the client undergoing Premature Rupture of Membrane (PROM).
• Administer properly the medications for the client.
• Apply skills learned from school to hospital settings.

Attitude:
• Build confidence in case when handling similar case in the future.
• Observe and understand the behavior of the client.
• Build up a good rapport with the client conducive to good health.

Client Centered
After the case study, the client will be able to:
Knowledge:
• Develop awareness for the client’s condition.
• Understand the underlying causes of PROM.
• Identify possible complications of undergoing PROM.
Skills:
• Cooperate with the management depending on the doctor's orders.
• Comply with the special needs of the client
• Learn how to do proper wound care regarding her surgery.
Attitude:
• Improve discipline in order to manage her condition.
• Comply with the treatments for promotion of fast recovery.
• Build trust with the hospital personnel.

NURSING HEALTH HISTORY

BIOGRAPHICAL DATA:

Name: Ms. RR
Address: San Antonio Guagua Pampanga
Marital Status: Single
Birthdate: Nov. 2, 1996
Place of Birth: Guagua Pampanga
Nationality: Filipino
Occupation: None
Religion: Born Again Christian
Education Attainment: High School Graduate
OB SCORE: G1P2 (0102)
Date of Admission: April 28, 2014
Date of Discharge:
Admitting Diagnosis: Premature Rupture of Membrane
CC: Pain in lower abdomen


PRESENT ILLNESS:

According to our client, she started having pain in her lower abdomen and it persisted from lower abdomen to the lumbar area last April 28, 2014. She was admitted to the hospital at 6am, she was in her 36 weeks of gestation and 4/7 days. She was admitted to the delivery room for Normal Spontaneous Delivery and gave birth to a baby boy at 7:45am. She is G1P2(1002)


PAST ILLNESS:

Our client remembers that she had received all of her childhood immunization from BCG, DTap, Measles, MMR, Varicella. She got her menarche when she was in grade 6 or 12 years old. She only got 2 shots of her tetanus toxoid, although she cannot remember when she got her first dose. She remembers her last was April 23, 2014. She stated that she goes to her monthly check up regularly in the center. Last April 23, 2014 her bag of water broke and went to the barangay center, and it adviced her that it was a natural thing. She described that it looked like water and during night time it was strongest. Until she felt pain in her lower abdomen on early April 28, 2014 and decided to go JBLMRH OB Emergency Room.




Significance of the Study
Genogram
Anatomy
Physical Assessment
Functional Health Pattern
Growth and Development
Theoretrical Application
Diet
Activities and Exercise
Drug Study
1. Health Perception/ Health Management Pattern
Prior to Hospitalization

Our client stated that she walks everyday as her exercise during her pregnancy. She doesn’t have any bad habit like drinking and smoking. This was her second hospitalization. The first one was because of Urinary tract infection (UTI). She had already her second dose of her tetanus toxoid vaccines.


During Hospitalization

“Malaking kaibahan talaga pagnasa hospital ka, lalo na kung may nararamdaman ka. Pero Masaya ako ngayon dahil nanganak na ako at nakita ko na sila. Pero di ko pa rin maiwasan na magalala dahil sa kalagayan ng mga anak ko ngayon”, as verbalized by the client.

2. Nutritional and Metabolic Pattern
Prior to Hospitalization
April 25
Breakfast:
2 glasses (600ml) of water
1 cup of rice
1pc of fried galunggong

Lunch:
1 saucer of monggo
1 ½ cup of rice
3 glass (800 mL) of water
1 pc of banana

Dinner:
I slice of paksiwnabangus
3glasses (800ml) of water
1 cup of rice Breakfast:
2 glasses (600ml) of water
1 bowl of goto with boiled egg



April 26
Breakfast:
2 glasses (600ml) of water
1 bowl of goto with boiled egg

Lunch:
1 saucer of pakbet
1 ½ cup of rice
3 glass (800 mL) of water

Dinner:
1 saucer of miswang malunggay
1 cup of rice
3glasses (800ml) of water


April 28
Breakfast:
2 glasses (600ml) of water
1 pack of biscuit

Lunch:


Dinner:
1 cup nilagangbaboy
1 glass of water (300ml)
½ cup of rice

During Hospitalization
April 29
Breakfast:
1 cup of milk
1 Pack of biscuit

Lunch:
1 pcfried tilapia
1 cup of rice
2glass (600 mL) of water

Dinner:
1 saucerGinataangkalabasa
2glasses (800ml) of water
1 cup of rice
1 cup milk


April 27
Breakfast:
1 pc fried egg
1 cup of rice
2 glasses (600ml) of water

Lunch:
1 saucer nilagangbaboy
1 cups of rice
2 glasses (600ml) of water

Dinner:
1 slice of fried chicken
1 cup of rice
1 glass (200ml) of water

She eats foods that are good for her and to her baby. She stated that she eat whatever her mother prepared for her.
Our client eats what the hospital serves them and it’s nutritious. On april 28 our client suffering from severe pain because of labor. At around 7am she was admitted to labor room and at 11am she give birth to her twins.
3. Elimination Pattern
Prior to Hospitalization
Our client feel pain during urination and but doesn’t feel pain when defecating. Her urine is cloudy in color. She urinate 8 to 9 times a day or more because of pregnancy mostly at night. Her stool is aromatic and brown in color.
During Hospitalization
She stated that there’s no changes in the color and odorof her urine, but the amount and frequency of her urination was change and it’s lesser than before
4. Activity/ Exercise Pattern
Prior to Hospitalization
Our client doesn’t have any work. She only stay at home and doing the household chores like sweeping and mopping the floor. She can only do walking every morning as her exercise. She can do more on sleeping and watching television.

0-feeding 0-grooming 0-home maintenance
0-bathing 0-general mobility
0-toileting 0-cooking
0-bed mobility 0-dressing

Level 0- Full self care
Level I- Requires use of equipment/ device
Level II- Requires assistance or supervision
Level III- Requires assistance or supervision from another person/ device
Level IV- is dependent and does not participate

During Hospitalization
Our client can do more on resting because of labor and delivery.

0-feeding 0-grooming
II-bathing II-general mobility
II-toileting II-dressing
0-bed mobility

Level 0- Full self care
Level I- Requires use of equipment/ device
Level II- Requires assistance or supervision
Level III- Requires assistance or supervision from another person/ device
Level IV- is dependent and does not participate

5. Sleep/ Rest Pattern
Prior to Hospitalization
During Hospitalization
The client sleeps at around 9 or 11pm because she can’t sleep early. She takes a nap at around 10am and 1pm for 2 hours. At night she is interrupted because of urination. She approximately has 8hours of sleep
The client had a big different when it comes of sleeping because of her hospitalization and giving birth. She have more time to rest and sleep.
6. Cognitive/Perception Pattern
Prior to Hospitalization
The client stated that she has no problem in eyesight and can hear clearly. She can still read a newspaper without using an eyeglass. She usually listen to the radio and watch television. She has the ability to communicate with other people and she doesn’t have any difficulty understanding a word from others.
During Hospitalization
Our client can communicate with us and to the other patients in the ward. She is very attentive and answers our questions.
7. Self Perception/Self-Concept Pattern
Prior to Hospitalization
Our client stated that her attitude is based on how she is treated by others. She is trying her best to be a good wife and soon a mother to her children. She said that her mother give her some advice of motherhood.
During Hospitalization
Our client is happy because she already saw her babies. She is also anxious because of the current condition of her babies.The client also stated “Nung di pa ako nabubuntis sexy pa ko kaso ngayon tumaba na ng kaunti. Tsaka nagka stretch marks ako.”
8. Role-Relationship Pattern
Prior to Hospitalization
She has a good relationship with her family. At first when they knew that she was pregnant her mother and father feel bad and angry because of her study. At the same time she already accepted by her in-laws.
“Ngayong nasa hospital ako mas naramdaman ko ang suporta at pagmamahal nila sa akin at higit sa mga anak ko”, as verbalized by the client. She seem happy and in depted
During Hospitalization
9. Sexuality-Reproductive Pattern
Our client menarche was on her 12 year of age and haveregular menstruation. She stated that, she had a great time with her husband. They have coitus in 3rd time before get pregnant. They using condom as protection and they also try withdrawal.
Prior to Hospitalization
The patient is G1P2(0102) score. The patient is primi. The patient decides not to get pregnant again until they can already handle the full responsibility of being a parent.
During Hospitalization
10. Coping-Stress Tolerance Pattern
Prior to Hospitalization
Our client has the support of her husband and specially her mother. During her pregnancy her youngest brother died and he was her closest sibling of all, during this time all of her family member support and guide to relief her sadness. Social network have a lot of help to relief her boredom.
“Malaki ang pasasalama ko sa nanay at tatay ko, maging sa asawa’t mga kapatid dahil sinuportahan nila ako hanggang sa manganak ako”, as verbalized by the client
During Hospitalization
11. Value/Belief Pattern
Prior to Hospitalization
Our client is a Born Again Christian. She always when to church every Sunday with her family. She said that they believe in “hilot“ and “balis”.
During Hospitalization
“Ngayon nasa hospital na ako di nako makakaattend ng service, pero palagi pa rin naman ako nagdadasal sa panginoon para magpasamalat at humingi ng gabay” as verbalized by the client.
DIAGNOSTIC PROCEDURE/LABORATORY
MEDICAL MANAGEMENT
Prioritization
Nursing Care Plan
Conclusion
This case study focused on Premature Rupture of Membrane of a pregnant woman and her conditions and why it happened to our client. PROM have different predisposing factors on why it happens and we were able to cite information about it. In this case study, we were able to identify health problems and prioritize and apply appropriate nursing interventions and health teaching to promote better health for the mother and the baby. We were able to evaluate a care plan and determine which ones were effective and which plans need improving. Our client complied and understood everything we have informed her about the PROM.

April 29, 2014
April 29, 2014
April 28, 2014
April 29, 2014
April 28, 2014
April 29, 2014
April 28, 2014
April 29, 2014
April 28, 2014
Summary of Physical Assessment

Elevated Temperature
Posture is not relaxed.
Has uncoordinated movement.
With hair infestation.
Only 30 permanent teeth are present.
With linea nigra.

Definition
Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation.

Spontaneous premature rupture of the membranes (SPROM) is ROM after or with the onset of labor. At term, programmed cell death and activation of catabolic enzymes, such as collagenase and mechanical forces, result in ruptured membranes. Preterm PROM occurs probably due to premature activation of these pathways. Early PROM is also linked to inflammation and/or infection of the membranes.

PROM increases risks for perinatal infection and umbilical cord compression due to oligohydramnios. When PROM occurs at term, there is a low risk for severe neonatal complications with delivery of a noninfected and nonasphyxiated infant.



FETAL MEMBRANE ANATOMY AND PHYSIOLOGY

The fetus develops within the amniotic sac. The amniotic sac is surrounded by the fetal membranes. These membranes consist of a thin inner amnion layer lining the amniotic cavity and a thicker outer chorion that is directly opposed to maternal decidua. The amnion fuses to the chorion near the end of the first trimester of pregnancy. The amnion has greater tensile strength than the chorion. Together, the amnion and chorion are stronger than either layer independently.

As the pregnancy progresses, there are structural weakening of the fetal membranes. Membrane remodelling is more evident near the internal cervical os. Contractions subject the amniochorionic membranes to additional physical strain that can lead to membrane rupture.

Pathogenesis of preterm rupture relates to increased apoptosis of membranes' cellular components and to increased levels of specific proteases in membranes and amnionic fluid. Much of the membranes' tensile strength is provided by the extracellular matrix within the amnion. Interstitial amnionic collagens, primarily types I and III, are produced in mesenchymal cells and are the structural component most important for its strength.

In pregnancies with PPROM, the amnion exhibits a higher degree of cell death than that in the term amnion. Many cases of PPROM result from activation of collagen degradation, alterations in collagen assembly, and cell death all leading to a weakened amnion.

Infection causes a significant proportion of PPROM cases. The inflammatory response leads to membrane weakening.



ETIOLOGY OF PREMATURE RUPTURE OF THE MEMBRANES

Risk factors associated with preterm PROM
• Infections involving the urogenital tract
• Low socioeconomic status
• Uterine overdistention
• Second- and third-trimester bleeding
• Low body mass index
• Preterm labor
• Cervical incompetance
• Maternal cigarette smoking
• Cervical conization or cerclage
• Pulmonary disease in pregnancy
• Connective tissue disorders (e.g., Ehlers-Danlos syndrome)
• Nutritional deficiencies of copper and ascorbic acid


Preterm PROM has also been linked to infections involving the urogenital tract. Ascending colonization and infection are integral to the pathogenesis of preterm PROM in many cases. Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis have each been associated with preterm PROM. Although vaginal group B β-hemolytic streptococcus (GBS) colonization does not appear to be associated with preterm PROM, cervical colonization may be associated. Bacterial vaginosis has been associated with spontaneous preterm births, including preterm PROM.

Pathophysiology
This is a case study about Mrs. RR a 17 year-old, G1P2(0102) woman in Normal Spontaneous Delivery, from San Antonio Guagua Pampanga. She was admitted at Jose B. Lingad Memorial General Hospital last April 28, 2014, at 7;45 am because of the pain on her lower abdomen. At her 28 weeks AOG, she delivered a preterm twin baby boy.
Prelabor rupture of membranes (PROM), or premature rupture of membranes, is a condition that occurs in pregnancy, and is defined as rupture of the membrane of the amniotic sac and chorion more than one hour before the onset of labor, which, in turn, is defined by the ACOG as uterine contractions of sufficient frequency and intensity to result in progressive effacement and dilation of the cervix.[1] PROM is considered prolonged when it occurs more than 18[2] or 24[3] hours before labor. PROM is considered preterm when it occurs before 37 weeks gestation, and is called Preterm Premature Rupture of Membranes (or PPROM).
According to World Health Organization, Preterm premature rupture of membranes (pPROM) occurs in 1%–3% of all pregnancies and is responsible for approximately one third of all preterm births (1, 2). A tenfold increase in neonatal infection has been noted in uncomplicated cases of premature rupture of membranes (PROM) compared with neonates in general (3). After membranes have been ruptured for more than 24 hours, the incidence of neonatal infection is approximately 1%, and when clinical chorioamnionitis is present, the incidence of neonatal infection increases to between 3% and 5%. According to Department of Health, Perinatal morbidity and mortality in the Philippines compare to national statistics, the results at this institution are expectedly lower, which shows that 38% of pregnant women suffers PROM in the Philippines.

We, students chose the case of Mrs. RR as our case to be studied. This case helps the group to design a nursing care plan appropriate for the patient’s condition. We could also provide information and health teaching to the postpartum patient. We gain new learning from the experience in conducting the case study. This case study would also equip the group with knowledge, skills and attitude on how to manage future patients with the same condition.
Thank you!!! :)
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