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Introduction:
onset of labor at or beyond 37 weeks' gestation. The membranes that hold amniotic fluid
(the water surrounding the baby) usually break at the end of the first stage of labor.
However, in about 10% of pregnancies after 37 weeks, the membranes will break before
labor. PROM occurs in about 10 percent of all pregnancies. PPROM (before 37 weeks)
The cause of PROM is often unknown. Some causes are thought to be: uterine or genital
the uterus and amniotic sac, which sometimes occurs with multiple fetuses or too much
suture to hold the cervix closed, most women whose membranes rupture before labor
The most important symptom of PROM is fluid leaking from the vagina. It may leak
slowly or may gush out. Sometimes when it leaks out slowly, women mistake it for urine.
Although some of the fluid is lost when the membranes rupture, the baby continues to
risk of PPROM is that the baby is very likely to be born within one week of the
the placental tissues called chorioamnionitis, which can be very dangerous for mother
and baby. Other complications that may occur with PROM include placental abruption
(early detachment of the placenta from the uterus), compression of the umbilical cord,
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
uterus, antibiotics (to prevent or treat infections), tocolytics - medications used to stop
preterm labor, and delivery (if PROM endangers the well-being of the mother or fetus,
Unfortunately, there is no way to actively prevent PROM. However, this condition does
have a strong link with cigarette smoking and mothers should stop smoking as soon as
possible.
This case study is conducted with the following aims and objectives of the study:
• To plan necessary care to be rendered to the patient while in the hospital and also
My Patient, Jesary Espiritu, has been hospitalized last June 22, 2008 at 2 am in Gabriela
Silang General Hospital with the chief complains of lumbosacral pain and according to
her it is also because of continuous leaking of vaginal fluid (amniotic fluid) that she
thought as water. She was rushed in the hospital for all they knew is that she will already
deliver the baby. Her Admitting diagnosis was Premature rupture of membranes and the
admitting physician was Dra. Eugenio. It was June 23 when she delivered a baby girl
through a caesarean section. She was then discharged after staying one week in the
hospital.
VI. Anatomy and Physiology:
- in the human embryo the earliest stages of the formation of the amnion have not been
observed; in the youngest embryo which has been studied the amnion was already present
as a closed sac and appears in the inner cell-mass as a cavity. This cavity is roofed in by a
single stratum of flattened, ectodermal cells, the amniotic ectoderm, and its floor consists
of the prismatic ectoderm of the embryonic disk - the continuity between the roof and
floor being established at the margin of the embryonic disk. Outside the amniotic
ectoderm is a thin layer of mesoderm, which is continuous with that of the somatopleure
and is connected by the body-stalk with the mesodermal lining of the chorion.
When first formed the amnion is in contact with the body of the embryo, but about the
fourth or fifth week fluid (liquor amnii) begins to accumulate within it. This fluid
increases in quantity and causes the amnion to expand and ultimately to adhere to the
inner surface of the chorion, so that the extra-embryonic part of the celom is obliterated.
The liquor amnii increases in quantity up to the sixth or seventh month of pregnancy,
after which it diminishes somewhat; at the end of pregnancy it amounts to about 1 liter. It
allows of the free movements of the fetus during the later stages of pregnancy, and also
protects it by diminishing the risk of injury from without. It contains less than 2 per cent.
of solids, consisting of urea and other extractives, inorganic salts, a small amount of
protein, and frequently a trace of sugar. That some of the liquor amnii is swallowed by
the fetus is proved by the fact that epidermal debris and hairs have been found among the
The Chorion
- the chorion consists of two layers: an outer formed by the primitive ectoderm or
trophoblast, and an inner by the somatic mesoderm; with this latter the amnion is in
contact. The trophoblast is made up of an internal layer of cubical or prismatic cells, the
proliferation and forms numerous processes, the chorionic villi, which invade and destroy
the uterine decidua and at the same time absorb from it nutritive materials for the growth
of the embryo. The chorionic villi are at first small and non-vascular, and consist of
trophoblast only, but they increase in size and ramify, while the mesoderm, carrying
branches of the umbilical vessels, grows into them, and in this way they are vascularized.
Blood is carried to the villi by the branches of the umbilical arteries, and after circulating
through the capillaries of the villi, is returned to the embryo by the umbilical veins. Until
about the end of the second month of pregnancy the villi cover the entire chorion, and are
almost uniform in size, but after this they develop unequally. The greater part of the
chorion is in contact with the decidua capsularis, and over this portion the villi, with their
contained vessels, undergo atrophy, so that by the fourth month scarcely a trace of them is
left, and hence this part of the chorion becomes smooth, and is named the chorion læve;
as it takes no share in the formation of the placenta, it is also named the non-placental
part of the chorion. On the other hand, the villi on that part of the chorion which is in
contact with the decidua placentalis increase greatly in size and complexity, and hence
LOCATION &
STRUCTURE FUNCTION
DESCRIPTION
Breasts Upper chest one on each side Lactation milk/nutrition for newborn.
of milk).
females.
pelvic region
condom
The innermost layer of uterine Contains glands that secrete fluids that
Endometrium
wall. bathe the utrine lining.
Myometrium Smooth muscle in uterine wall. Contracts to help expel the baby.
VIII. Management
A. Medical Surgical
- the patient undergone caesarean section last June 23, 2008 and began at 1:40
p.m. and ended at 2:25 p.m. a baby girl was delivered at 1:45 p.m. with Dra. Eugenio as
Caesarean Section
-(surgery done)
deliver one or more babies. It is usually performed when a vaginal delivery would lead to
well.
• The lower uterine segment section is the procedure most commonly used
today; it involves a transverse cut just above the edge of the bladder and
commenced.
emergency.
• A caesarean hysterectomy consists of a caesarean section followed by the
Porro CS.
Indications
Caesarean section is recommended when vaginal delivery might pose a risk to the mother
• multiple births
• contracted pelvis
• prior problems with the healing of the perineum (from previous childbirth or
Crohn's Disease)
However, different providers may disagree about when a caesarean is required. For
example, one obstetrician may feel that a woman is too small to deliver her baby, another
might well disagree. Similarly, some care providers may be much quicker to cite "failure
to progress" than others. Disagreements like this help to explain why caesarean rates for
some physicians and hospitals are much higher than are those for others. The medico-
legal restrictions on VBAC, vaginal birth after caesarean, have also increased the
caesarean rate.
As scheduled caesarean sections have become a rather safe operation, there has been a
Risks
Statistics from the 1990s suggest that less than one woman in 2,500 who has a caesarean
section will die, compared to a rate of one in 10,000 for a vaginal delivery. However the
mortality rate for both continues to drop steadily. The UK National Health Service gives
the risk of death for the mother as three times that of a vaginal birth. However, it is not
possible to directly compare the mortality rates of vaginal and caesarean deliveries as
women having the surgery are often those who were at a higher risk anyway.
A study published in the June 2006 issue of the journal Obstetrics and Gynecology found
that women who had multiple caesarian sections were more likely to have problems with
later pregnancies, and recommended that women who want larger families should not
seek caesarian section as an elective. The risk of placenta accreta, a potentially life-
threatening condition, is 0.13% after two c-sections, and increases to 2.13% after four
and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk
Babies born by caesarean sometimes have some initial trouble breathing. In addition,
because the baby may be drowsy from the pain medication administered to the mother,
A caesarean section is a major operation, with all that it entails, including the risk of post-
operative adhesions. Pain at the incision can be intense, and full recovery of mobility can
take several weeks or more. A prior caesarean section increases the risk of uterine rupture
If a CS is performed under emergency situations, the risk of the surgery may be increased
due to a number of factors. The patient's stomach may not be empty, increasing the
anesthesia risk.
Anaesthesia
The mother has the option of receiving regional anaesthesia (spinal or epidural) or
general anaesthesia for caesarean section. Regional anaesthesia has the advantage of
allowing her to remain awake for the delivery and avoids sedation of the newborn. Pain
General anaesthesia for caesarean section is becoming less common as scientific research
has now clearly established the benefits of regional anaesthesia for both the mother and
baby. General anaesthesia tends to be reserved for emergencies where the mother or
baby's life is immediately threatened or other high-risk cases. The risks of general
anaesthesia for mother and baby are still extremely small overall.
If the mother already has an epidural in this epidural can often be used for the caesarean
section. Multiple recent studies have now shown that epidurals in labour do not increase
the caesarean section rate (Meta analysis 2005 Anim-Somuah, Cochrane Review) but
they may increase the risk of a forceps or instrumental delivery. At least one study
however, has found that the risk of c-section doubles if the epidural is placed before the
mother has reached 5cms cervical dilation. For this reason many UK hospitals are
reluctant to give epidural anaesthesia before this stage. Epidurals placed after 5cms
dilation is achieved do not affect chance of c-section. Epidurals traditionally have been
known to slow down the progress of labour, but recent work has shown that they may
actually speed up the labour process (COMET Study, Lancet 2001). This is because in
women who are tense, exhausted and in pain labour can slow, and the "break" provided
by the epidural which allows many women to sleep for a few hours, allowing her to relax
enough to dilate fully and gather strength for the second (pushing) stage of labour. Deep
transverse arrest, where the baby's head becomes lodged in the birth canal, can be a
complication of epidural anaesthesia because the tone of the pelvic floor, which helps to
turn the baby's head as it passes through the pelvic bones, can be reduced or lost. To
experienced care-givers will often instruct the labouring woman not to push until the
head is visible during contractions, ensuring it has already turned to pass under the pubic
arch.
XII. Bibliography:
Book Sources:
Doenges, Marilyn E. et al. Nurse’s Pocket Guide. F.A. Davis Company, 2004.
Doenges, Marilyn E. et al. Nursing Care Plans. F.A. Davis Company, 2002.
Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and
Sia, Maria Loreto J. Outline in Obstetrics A Textbook and a Reviewer. Quezon City:
Internet Sources:
http://en.wikipedia.org/wiki/Caesarian_section
http://search.yahoo.com/search?p=diagnostic+procedure+for+Premature+rupture+of+membrane
&vc=&fr=yfp-t-501&toggle=1&cop=mss&ei=UTF-8&fp_ip=PH
http://www.caesarian.eu/
http://www.emedicine.com/med/topic3246.htm
http://www.merck.com/mmpe/index.html
http://www.moondragon.org/obgyn/pregnancy/placenta.html
http://www.moondragon.org/obgyn/pregnancy/prom.html
V. Diagnostic Procedures
A. Ideal
• Ultrasound
computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to
view internal organs as they function, and to assess blood flow through various vessels.
• Amniocentesis
-a medical procedure during which a long, thin needle is inserted through the
abdominal and uterine walls, and into the amniotic sac. A sample of amniotic fluid is
• Cervical cerclage
-a procedure in which the cervix is sewn closed; used in cases when the cervix starts
-a complete blood count (CBC), also known as full blood count (FBC) or full blood
exam (FBE) or blood panel, is a test requested by a doctor or other medical professional
that gives information about the cells in a patient's blood. A lab technician (diploma
holder) or technologist (bachelor holder) performs the requested testing and provides the
requesting Medical Professional with the results of the CBC. A CBC is also known as a
"hemogram".
The cells that circulate in the bloodstream are generally divided into three types: white
blood cells (leukocytes), red blood cells (erythrocytes), and platelets or thrombocytes.
Abnormally high or low counts may indicate the presence of many forms of disease, and
hence blood counts are amongst the most commonly performed blood tests in medicine,
as they can provide an overview of a patient's general health status. A CBC is routinely
Methods
• Samples
A phlebotomist collects the specimen, in this case blood is drawn in a test tube containing
laboratory.
In the past, counting the cells in a patient's blood was performed manually, by viewing a
slide prepared with a sample of the patient's blood under a microscope (a blood film, or
The blood is well mixed (though not shaken) and placed on a rack in the analyzer. This
instrument has many different components to analyze different elements in the blood. The
cell counting component counts the numbers and types of different cells within the blood.
Blood counting machines aspirate a very small amount of the specimen through narrow
tubing. Within this tubing, there are sensors that count the number of cells going through
it, and can identify the type of cell; this is flow cytometry. The two main sensors used are
light detectors, and electrical impedance. One way the instrument can tell what type of
blood cell is present is by size. Other instruments measure different characteristics of the
precise. However, certain abnormal cells in the blood may be identified incorrectly, and
require manual review of the instrument's results and identify any abnormal cells the
In addition to counting, measuring and analyzing red blood cells, white blood cells and
platelets, automated hematology analyzers also measure the amount of hemoglobin in the
blood and within each red blood cell. This information can be very helpful to a physician
who, for example, is trying to identify the cause of a patient's anemia. If the red cells are
smaller or larger than normal, or if there's a lot of variation in the size of the red cells, this
data can help guide the direction of further testing and expedite the diagnostic process so
Automated blood counting machines include the Beckman Coulter LH series, Sysmex
XE-2100, Siemens ADVIA 120 & 2120, and the Abbott Cell-Dyn series.
Counting chambers that hold a specified volume of diluted blood (as there are far too
many cells if it is not diluted) are used to calculate the number of red and white cells per
litre of blood.
To identify the numbers of different white cells, a blood film is made, and a large number
of white cells (at least 100) are counted. This gives the percentage of cells that are of each
type. By multiplying the percentage with the total number of white blood cells, the
The advantage of manual counting (using helper tools like Grid cell counter) is that blood
cells that may be misidentified by an automated counter can be identified visually. It is,
however, subject to human error and sampling error because so few cells are counted
Red cells
• Total red blood cells - The number of red cells is given as an absolute number per
litre.
• Hematocrit or packed cell volume (PCV) - This is the fraction of whole blood
o Mean corpuscular volume (MCV) - the average volume of the red cells,
based on whether this value is above or below the expected normal range.
reticulocytosis.
• Red blood cell distribution width (RDW) - a measure of the variation of the RBC
population
White cells
• Total white blood cells - All the white cell types are given as a percentage and as
neutrophils is not segmented, but has a band or rod-like shape. Less mature
neutrophils - those that have recently been released from the bone marrow into the
bloodstream - are known as "bands" or "stabs". Stab is a German term for rod.
• Lymphocytes - Higher with some viral infections such as glandular fever and.
In adults, lymphocytes are the second most common WBC type after neutrophils.
In young children under age 8, lymphocytes are more common than neutrophils..
regional enteritis
reaction.
as leukemia of lymphoma.
A manual count will also give information about other cells that are not normally present
Platelets
• Platelet numbers are given, as well as information about their size and the range
Interpretation
Certain disease states are defined by an absolute increase or decrease in the number of a
erythrocytosis or
Red Blood Cells (RBC) anemia or erythroblastopenia
polycythemia
Test Values
WBC 12.4 x 10^ 9/L 4 – 10 High If high,
leukocytosis
If low, leukopenia
If high,
Lymph# 1.1 x 10 ^ 9/L .8 – 4.0 Normal
lymphocytosis
If low,
lymphocytopenia
granulocytosis
If Low,
granulocytopenia
leukocytosis
If low, leukopenia
granulocytosis
If Low,
granulocytopenia
erythrocytosis or
polycythemia
If low, anemia or
erythroblastopenia
Erythrocytosis
If low, anemia
MCV 93.2fL 82 – 95 Normal
If high,
thrombocytosis
If low,
thrombocytopenia
BLOOD TYPE: O
IV. PERSON ASSESSMENT:
urinated.
R labor pain.
-BP-130/90mmHg
-no wounds
O no cough.
-Hct count-40.6%
-on NPO.
June 24,2008
-During orientation, she lies on her bed and
tolerance.
afternoon.
-no allergies to food and drugs.
prescribed.
abdominal area.
-BP-130/90mmHg
IV)
O -rapid breathing
-Respiration- 37cpm
-Hct count-40.6%
Educational Attainment: High School Graduate at Vigan National High School West
Occupation: Saleslady
Hospital Profile:
Ward: OB Ward
OB History: G1P0
Vital Signs:
FHT: 138
Past Illnesses:
My patient, Jesary Espiritu has an OB history of G1P0, started to have
menstruation when she was 14 years old and according to her she received complete
kinyak.” During assessment, she told me that there were no severe diseases that she
experienced before but just simple headache and fever and during her childhood years,
she had had chicken pox and measles, she also added that she never experienced to be
confined in the hospital. When I asked the patient if there are diseases relating to
pregnancy or reproductive system in their family, she answered none and added, “ni
tatang ko lang ti malagip ko nga nagasaksakit idi ngem asthma met ken adda TB na,
naconfine idi ngem diay ngato (medical ward) ken ni manong ngem gapu met diay saka
Present Illnesses:
It was afternoon of June 21, 2008 (Saturday) when my patient experienced pain
on the part of her abdomen radiating on her back. She then rested for a while thinking
that it would relieve the pain and told me, “idi Sabado ket nasakit ngem haan unay ngem
di dumteng ti Domingon ket alla kumaro metten diay sakit nan.” According also to her it
was still Thursday 4 days before she was admitted she experienced leakage of fluid from
her vagina and experienced continuous urination. Due to persisting pain and leakage of
fluid she thought that she will already deliver her baby so her mother rushed her at
Gabriela Silang General Hospital last June 23 at dawn and admitted at the same day.
When I handled her as my patient, June 23, morning, she was already in labor and
experiencing increased episodes of lumbosacral pain. During assessment, she told me that
she experienced drinking alcohol but only in a little amount and told me, “bassit met
laeng ken diay sigarilyo diak met pinadpadas.” She had experienced prenatal check-up
twice during her pregnancy and regarding her diet, she eats everything. She also does
some heavy works before like washing their clothes and lifting heavy objects. She was
transferred to Delivery room at 9:05 am on the same day she was admitted but transferred
to Operating Room qt 1:40 p.m. and delivered a baby girl at 1:45 p.m. trough a caesarean
section.
VII. Pathophysiology:
A. Algorithm
RISK FACTORS:
pH of Vagina
* Increased WBC
Impairment
Fetal Hypoxia
XI. Summary and Copy of Updates:
fluid during pregnancy between 36-40 weeks. The cause of PROM is unknown but the
Complications of PROM:
• Infections
Management of PROM:
• Hospitalization
• If PROM occurred at term and labor does not begin in 24 hours, labor induction is
Frequency:
and the signs of PROM like leakage of vaginal fluid was first experienced 4 days before
she was run in the hospital. She gave birth to a baby girl last June 23, 2008 thru a
caesarean section and discharged after one week of staying at the hospital.
B. Explanation:
fluid during pregnancy between 36-40 weeks of pregnancy. The cause of Premature
membranes results from over distention of the membranes and this causes leakage of
Amniotic Fluid and that causes many complications. This leakage causes an alteration on
the pH of vagina because the amniotic fluid is alkaline and in turn increases risk for
maternal infection. Amniotic fluid serves as the cushion between the fetal parts and the
fetal membranes so the decreased amount of it causes an increase pressure between the
membranes and fetal parts that leads to potter like syndrome on the fetus when delivered.
Yet another complication for the fetus to stay in the non-fluid environment is the
compression of umbilical cord by fetal parts and also cord prolapse (extension of the cord
out of uterine cavity into the vagina) a condition that can interfere with fetal circulation
If PROM is diagnosed without infection, they prolong pregnancy to provide more time
for fetal lungs to develop and mature. But if PROM is diagnosed with infection mother
goes antibiotic therapy and labor induction to prevent fetal infection and sepsis.
C. Promotive and Preventive:
*TT2: One month after TT1. gives 3years protection to the mother and protects
*TT3: Six months after TT2. gives 5 years protection to the mother anom
neonatal tetanus.
*TT4: One year after TT3/next pregnancy. Gives ten years protection to the
*TT5: One year after TT4 and gives lifetime protection to the mother and infants
are protected.
• Consult her health care provider if she feels any unusual signs of pregnancy
• Undergo labor induction if PROM occurred at term and labor does not begin in 24
following:
beans or nuts
1 serving of cooked meat is equivalent to:
• 30g or 30 cm cube
week
Egg 1piece 3-4 times a week
Milk 1 glass whole milk (equivalent to 4 tablespoons of
*Source: Nutritional Guidelines for Filipinos, 2000. Food and Nutrition Research
M- edications:
E- xercise
- active range of motion on extremities (flexion and extension) since patient undergone
T- reatment:
- must continue medications and should follow all the orders of the physician.
H- ealth Teachings:
- take a rest.
O- PD
- have follow up check up every 2 weeks for the first month with her baby after
D- iet
Name Ordered Dose Mechanism of Action Indication Contraindication Adverse Reaction Nursing
Responsibility
Tramadol -100mg slow IV every -centrally acting -relief of moderate to -contraindicated in -potential for abuse -reassess patient’s level
Hydrochloride 8 hours synthetic analgesic not moderately severe patients with -anaphylactoid of pain at least 3o
impairment. dependence.
Name Ordered Dose Mechanism of Action Indication Contraindication Adverse Effects Nursing
Responsibility
Hydralazine 25mg IV Acts directly on Parenteral: severe -contraindicated with -headache -assess hypersensitivity
muscle to cause when drug can be hydralazine hypotension -give oral drug with
vasodilatation, primary given orally or when -use cautiously with -nausea and vomiting food to increase
arteriolar, maintains or need to lower Bp is CVAs or severe renal -rashes bioavailability (drug
increases renal and urgent. impairment and in -lupuslike syndrome should be given in a
consistent response to
therapy)
immediately after
opening ampule.
Hydralazine changes
solutions should be
discarded.
-withdraw drug
gradually especially
experienced marked BP
reduction. Rapid
a possible sudden
increase in BP.
Name Ordered Dose Mechanism of Action Indication Contraindication Adverse Effects Nursing
Responsibility
Paracetamol 1 ampule IV PRN -thought to produce -relief of mild pain or -contraindicated in -rashes -many OTC and
epatotoxicity in these
patients.
Objectives
Cues: -after 30 minutes Independent: June 23,2008 8:50
S: Pain due to uterine contractions, of rendering >assessed pain reports, >indicates need for a.m.
P: Chronic Pain
“Nagsakit met stretching of cervix and perineum nursing noting location, intensity, interventions and may After 30 minutes
ditoy ayan ti and due to pressure of fetal interventions to frequency and time of signal development of of rendering
verbalized by the
S: Lumbosacral
decreased pain rather that waiting until medications is improved but was slightly
patient. and reports of level is severe. with timely intervention. decreased due to
pain
O: decreased >Performed palliative >promotes relaxation/ nursing
Facial Grimace
>facial grimace intensity of pain measures like massage on decreases muscle tension. interventions done
pain Collaborative:
(Tachypnea): 37
cpm
Assessment Nursing Diagnosis Scientific Background Nursing Objectives Nursing Interventions Rationale Evaluation
Cues: Independent June 25, 2008 7:45
S: After a day > Promoted surface > Cold application entails a.m.
P: Hyperthermia
“Nagbara toy of rendering nursing cooling by means of heat dissipation via After a day of
mairkriknak,” as interventions, the tepid sponge bath, evaporation and rendering nursing
verbalized by the
E: Related to
client’s body immersion, application conduction. Thus, heat is interventions, the
infection secondary
patient. temperature will of local ice packs lost thereby subsiding client’s body
to preterm rupture of
O: subside as would be especially on the groin or fever. temperature subsided
membranes without
>Fever- 37.9oC at manifested by a body axilla. as manifested by a
accompanying labor.
8 a.m. 38.10C at temperature ranging > Provided proper body temperature of
10:00 a.m.
S: >fever from 36.5 to 37.5 ventilation (opening > to create a cool 37.4 degrees Celsius,
last June 24,2008) >Increased absence of flushed > Placed the client on means of convection. and warm-to-touch
physician such as
antipyretic (Paracetamol
directly on the
hypothalamic heat-
regulating center to
S: Insufficient After 1-2 days of >Assisted patient in all > to preserve strength June 24, 2008 11:40
P: Activity
Reports of fatigue: physiological energy to rendering Nursing her activities an and prevent injury. Bed a.m.
Intolerance
“Nagsakit met gamin, endure daily activities interventions, patient instituted bed rest. rest is encouraged to After 1 day of
agkakapsotak payen E: Related to due to weakness and can already report prevent cord prolapse. rendering nursing
diak pay makapigsa generalized weakness labor pains. measurable increase in >Promoted comfort > enhances ability to interventions, patient
nga aggarawen,”as and Bed rest. activity tolerance as measures and provide participate in activities. reported measurable
patient.
S: Verbalization of
verbalization of >Provided positive > helps to minimize tolerance e.g. sitting,
weakness
O: strength, “kayak met ti atmosphere while frustration and walking in near
Tachycardia
Increased Respiratory agpagna pagnan.” acknowledging rechannel energy. distance and verbalized
Weak in appearance
Rate (Tachypnea): 37 difficulty of situation “ kayak et ti agpagnan
Presence of pain
cpm for the client. ti asideg.” Goal was
to thrombosis and
pulmonary embolus.
gradually
Assessment Nursing Diagnosis Scientific Background Nursing Objectives Nursing Interventions Rationale Evaluation
Cues: Independent:
P: Knowledge
S: Knowledge deficit due After 1-2 days of >Verified client’s level > provides opportunity June 24, 2008 8:00
Deficit
Inadequate knowledge to unfamiliarity of her rendering nursing of knowledge about her to assure accuracy and a.m.
evidenced by the E: Related to first knowledge about her knowledge base for rendering nursing
verbalization of patient time of pregnancy and condition will increase future learning. interventions, her
as: “Apai gamin ta unfamiliarity on her to be evidenced by >Determined >provides insight knowledge about her
kastoy, nakasaksakit condition. cooperation to nursing motivation/expectations useful in developing condition is increased
met haan mo man pay interventions and for learning. goals and identifying as evidenced by
informed choices.
Collaborative:
problem solving.