CASE PRESENTATION

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CASE PRESENTATION

• PREPARED BY TINU VARGHESE

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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

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GENERAL

• The patient is 24 years of age, FEMALE
• She is conscious, coherent, with the following
  Vital Signs
• BP 110/59mmHg
• PR100 bpm
• RR 28 cpm
• Temp37. C
• SPO² 98

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SKIN

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

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HEAD

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

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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)

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EYES

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

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EARS

• No usual discharges noted

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NOSE

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

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MOUTH

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

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NECK AND THROAT

• No palpable lymph nodes
• No masses and lesions seen

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CHEST AND LUNGS

• Equal chest expansion
• No retraction
• Clear breath sounds

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HEART

• Regular rythm

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ABDOMEN

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

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GENITALS

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

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EXREMITIES

• Pulse full and equal
• No lesions noted

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PATIENT HISTORY

• PAST MEDICAL HISTORY
• No past medical history

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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 BP110/59 mmHg, PR118 bpm, RR
  28 cpm, Temp37. C, SPO² 98
•  

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PRESENT MEDICAL HISTORY

• INVESTIGATION
•  

TEST RESULT REFERENCE RANGE
Hgb 10g/dl 11.2-15.7g/dl
WBC 14.04 3.98-10.04
PT 12.1 sec 10.9-16.3sec
Blood Glucose 5.2 mmol/L 3.9-7.8mmol/L
Blood Group A positive
Antibody screening Negative
RPR Non- Reactive
Rubella Antibody IgG Positive
Urinalysis Pus cells 0-1/ hpf, RBC 0-1/ hpf
HBsAg negative
HIV Negative
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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

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NAME OF DRUG DOSAGE ROUTE ACTION ACTION
Ampicillin 1 gm IV antibiotics antibiotics
2 Inj.Dexamethasone 12mg IM corticosreroid corticosreroid
3 Tab .Nifedipine 20mg PO Calcium channel blockers Calcium channel blockers
4 Tab .Nifedipine 10mg PO Calcium channel blockers Calcium channel blockers
5 Calcium Tablet 600mg PO Calcium supplimentt Calcium supplimentt
6 FeSO4 Tablet 100mg PO Iron suppliment Iron suppliment
ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS
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
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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.

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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.

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ANATOMY AND PHYSIOLOGY
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ANATOMY AND PHYSIOLOGY
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To diagnose PPROM, the doctor may do the
following tests

• Visual examination
• A nitrazine paper test
• Fern test
• Ultrasound
• Amnisure

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• Positive nitrazine test

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• Positive fern test

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

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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)

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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
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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.

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VIII. NURSING INTERVENTION

• Educate the patient to use sterile pads

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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.
•  

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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

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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
•  

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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

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ASSESSMENT ASSESSMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/ EVIDENCE NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING ORDER/ACTION RATIONALE FOR ACTION EVALUATION
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 3. Fetal tachycardia FHR 180bp without uterine contraction Risk for infection related to loss of protective barrier by positive fern test. Within 12 hours of nursing intervention , patient will have no signs of infection.  1. assess the patient from any signs and symptoms of infection v/S taken as follows BP130/90mmHg PR 118 bpm RR 28 cpm Temp 37 C 2.Provide sterile pads 3.Teach the proper hand hygiene technique to the patient. 4.Vaginal examinations should be held to an absolute minimum, and sterile technique should be used. 5.Administer antibiotics as prescribed. 1. to assess for infection.  2. prevent infections 3. To avoid infections 4. To prevent infections 5. To treat infection After 12 hours of nursing intervention, the goal was fully met as evidenced by Patient has no signs of infection
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ASSESSMENT ASSESSMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/ EVIDENCE NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING ORDER/ACTION RATIONALE FOR ACTION EVALUATION
SUBJECTIVE Patient says that I am afraid about the babys health as verbalized by the patient OBJECTIVE Her facial expression shows that she has anxiety V/S taken as follows BP130/90mmHg PR 118 bpm RR 28 cpm Temp 37 C Anxiety r/t threat to maternal or fetal well-being secondary to risk for infection or preterm birth Within 12 hours of nursing intervention , patient will relief from anxiety Monitor vital signs (e.g., rapid or irregular pulse, rapid breathing/hyperventilation, changes in blood pressure, , or restlessness   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 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 After 12 hours of nursing intervention, the goal was fully met as evidenced by Patient relief from anxiety
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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.

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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.

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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.

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BIBLIOGRAPHY

• Maternal and Child Health Nursing by Adele
  Pillitteri 5th edition volume 1 page 426-
  433page 329-332
• All-in-one care planning resource page 748 by
  Pamela L. Swearlngen, RN
• Maternal Neonatal Nursingpage 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/Am20J20Obstet2
  0Gynecol20199920180(120Pt201).pdf

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• Thank you!! ?