Patients Profile: Name: Mrs. a Civil Status:

8/14/2019 Patients Profile: Name: Mrs. a Civil Status:

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Patients Profile:

Name: Mrs. A

Civil Status: Single

Location: Brgy. Maahas, Los Banos, Laguna.Date of Birth: November 12, 1990.

Age: 19 year old

Religion: Roman Catholic

History of present illness:

-2 days prior to admission she had experienced abdominal pain. As well asnausea and vomiting.

Date of admission: February 5, 2010.

Admitting Diagnosis:

PU 37 weeks AOG by LMP G1P0

Medications:

Methergin 500mg/TAB

Methergin 1 amp

IV Fluid:D5LR 41-42gtts/min

Overview:

Normal Spontaneous Delivery

Signs and Symptoms:

-Missed Menstrual Period

-Nausea and Vomiting-Headache

-


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Physical Assessment


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ORGAN SYSTEM REVIEW OF SYSTEM

Integumentary Warm and moist skin.

Head Moderately thick hair, no scalp lesions,

no skull deformities Eyes Pale palpebral conjunctiva due to fluid

loss.

Ears The patients auricles color is the same

as the facial skin. It is aligned with the

outer canthus of the eye and not tender

upon palpation. The pinna recoils after it

is folded. The patient has no hearing

aids.The patient has no difficulty in hearing a

normal voice. She is able to hear the

watch tick on both ears.

Neck/Lymph nodes The patient can move her neck without

difficulty. There are no palpable masses

or lumps.

Chest/Breast The patients breasts are rounded in

shape, slightly unequal in sizeand generally symmetric. Her breasts

are uniform in color. The

areola is round. Both nipples are

pointed in the same direction and

dark- brown in color.

Respiratory system She has symmetrical chest expansion

and clear breath sounds. No rales and

wheezes were noted. Cardiovascular system (-) hypertension. S1 and S2 in the

tricuspid and mitral sites are louder than

aortic and pulmonic sites.

Gastrointestinal Client shows no sign of nausea and

vomiting. There is no enlargement of

spleen and liver.

Renal/Urinary system Frequent urination


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ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE SYSTEM


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INTERNAL STRUCTURES

1. Fallopian tube/Oviduct 4 inches long from each side of the uterus (fundus). It

transports the mature ova form the ovaries to the uterus and provide a place for

fertilization of the ova by the sperm in its outer 3rd or outer half.

P

arts:

o Interstitial lies within the uterine

wall

o Isthmus portion that is cut or

sealed in a tubal ligation.

o Ampulla widest, longest portion

that spreads into fingerlike projections/fimbriae and it is where

fertilization usually occurs.

o Infundibulum - rim of the funnel covered by fimbriated cells (hair

covered fingerlike projections) that help to guide the ova into the

fallopian tube.

2. Ovaries Oval, almond sized, dull white sex glands on either side of the uterus

that measures 4 by 2 cm in diameter and 1.5 cm thick. It is responsible for the

production, maturation and discharge of ova and secretion of estrogen and

progesterone.


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3. Uterus The uterus or "womb" is a hollow, muscular organ in which a fertilized

egg, called the "zygote," becomes embedded and in which the egg is nourished and

allowed to develop until birth. It lies in the pelvic cavity behind the bladder and in front

of the bowel. The uterus is lined with tissues which change during the menstrual cycle.

These tissues build under the influence of hormones from the ovary. When the hormones

withdraw after the menstrual cycle, the blood supply is cut off and the tissues and

unfertilized egg are shed as waste. During pregnancy, the uterus stretches from three to

four inches in length to a size which will accommodate a growing baby. During this time,

muscular walls increase from two to three ounces to about two pounds and these

powerful muscles release the baby through the birth canal with great force. The wombshrinks back to half its pregnant weight before a baby is a week old. By the time the baby

is a month old, the uterus may be as small as when the egg first entered.

Layers:

1. Perimetrium outermost layer of the uterus comprised of connective tissue, it

offers added strength and support to the structure.

2. Myometrium middle layer, comprised of smooth muscles running in 3

directions; expels fetus during birth process then contracts around blood vessels to

prevent hemorrhage.

3. Endometrium Inner layer which is visibly vascular and is shed during

menstruation and following delivery.


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PATHOPHYSIOLOGY OF NORMAL SPONTANEOUS

DELIVERY

Sperm travels to search

the mature ovum

Zygote travels from thefallopian tube

to the uterus

Ovulation (release of matureovum from the graafian

follicle)

Fertilization (union of the ovum

and sperm in the ampulla)

Ovum travels into the

fallopian tube

Development of the fetus/embryo &

placental structure until full term

Implantation

( uterus called desidua)


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Preliminary signs oflabor until 37 weeks of

gestationTrue signs of labor until

full dilatation of the

cervix

Expulsion of the fetus

through vaginal birth

Expulsion of the

placenta


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Laboratory Test

Tests Result Normal Interpretation

Haemoglobin 12.6 12-16 Normal

Hematocrit 37.0% 36-51 Normal

WBC 7.9 5.0 10.0 Normal

RBC 4.88 4.0-6.0 x 10L Normal

Segmenter 58% 50-65% Normal

Lymphocytes 22% 23-35% Normal

Platelet count 211 150-450 x 10L Normal


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DRUG STUDY


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Nursing Management

1. Assess the patient to prevent post partum hemorrhage.

2. Monitor Vital Signs.

3. Continue giving medications and IV Fluid as prescribed by the physician.

4. Conduct a health teaching about proper hygiene, how to change napkins andfamily planning.

5. Instruct and advice the patient for the importance of family planning.

Concept Mapping

s- kapag umiihi ako medyo dumudugo pa as verbalized by the patient

o- with moderate vaginal bleeding- with normal breast structure

- with body weakness

a- Altered skin integrity related to surgical incision

p- At the end of the shift the patient will display timely wound healing of the surgicalincision.

i- Assessed site and characteristic of incision

- Instructed to complete the prescribed antibiotic theraphy.

- Encouraged proper perineal care to prevent infections.- Emphasized the importance of frequently changing napkins.

e- Goal partially met, the surgical incision was maintained free from signs of infections.


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Client who has undergoneExploratory Laparotomy with

underlying condition of EctopicPregnancy

Keep fluids within patients reach andencourage frequent fluid intake as

possible.

Maintain accurate I/O and weigh daily.

Administer IV fluids as possible

Discuss factors related to occurrenceof dehydration.

NursingDiagnosis

Risk fordeficient

fluid volumerelated toblood loss

Desired outcomesThe patient will bebe able to maintainfluid balance andunderstand itscausative factorsand findappropriateintervention for it.

Subjective:N/A

Objective:Hematocrit: 35

Hemoglobin: 12

Monitor Vital Sings regularly.


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Client who has undergoneExploratory Laparotomy with

underlying condition of EctopicPregnancy

Administer analgesics as indicated. Thennotify if regimen is inadequate to meet

goal

Use pillows, cloth into the incised areato lessen impact whenever the patient

moves or touches it.

Instruct in usage of relaxationtechniques like deep breathing

exercises to promote proper bloodcirculation.

NursingDiagnosisAcute painrelated toincised

abdominalarea

Desiredoutcome(s):The patient will beable to control thepain and willalso find ways tolessen itsoccurrence.

Subjective:Medyo nananakit ang tiyan ko ngayon.As verbalized by the patient.Objective:Evidence of sutured abdomenFacial expressions seen expressing pain

Encourage diversional activities liketalking to others reading newspaper,

etc.


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Nursing Theory

The theory contains of three independent but interconnected circlesthecore, the care and the cure.

According to the theory, the core is the person or patient to whom nursing

care is directed and needed. It has been mentioned that the core has goals setby the patient herself and not by any other person, and that these goals need tobe achieved. The core, in addition, behaved according to his feelings, and valuesystem.

The cure, on the other hand is the attention given to patients by themedical professionals. It has been explicit in stating that the cure circle is sharedby the nurse with other health professionals. These are the interventions oractions geared on treating or curing the patient from whatever illness or diseasehe may be suffering from. Some interventions in relation to this are prescribingpharmacologic therapies and performing diagnostic tests.

The highlight however is the care model. This is the part of the modelreserved for nurses, and focused on performing that noble task of nurturing thepatients, meaning the component of this model is the motherly care provided bynurses, which may include, but is not limited to provision of comfort measures,provision of patient teaching activities and helping the patient meet their needswhere help is needed.

Lydia HallCare, Core, Cure

Theory

Care Core

Cure


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In relation to Patient LA, the patient serves as the core together with the relativeswhom nursing care is needed and must be given. The patient sets goal for the

relief and this must be achieved according to what the patient feels. On the otherhand, the attention the nurses give to the patient serve as the cure. The patientwill achieve his goal with the help of all the medical team. Lastly, the care whichis the task for the nurses. It focuses on performing the tasks. The nurses will givenecessary interventions and actions that gears in treating and curing the patient(core). These three components, the patient, the attention and the care by thenurse should have balance and each one has benefit to one another not to thepatient only.

Patients Profile: Name: Mrs. a Civil Status:

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