Wesleyan University- Philippines

Mabini Extension, Cabanatuan City

Case Study In NCM 103: Care of Clients with problems in

Oxygenation-Cardiovascular system Disorder

Submitted by:

Jenilyn Faye M. Orpilla (Bsn3-4)

Submitted To:

Prof. Reuben Q. Ignacio, RN MAN Concept Instructor

Abnormal Uterine Bleeding,

Iron deficiency Anemia Secondary Case Study

Table of Contents

I. INTRODUCTION .................................................................. Error! Bookmark not defined.

A. Brief history of the case ...................................................... Error! Bookmark not defined.

B. Definition of related terms .................................................. Error! Bookmark not defined.

II. PATIENT’S HISTORY ........................................................................................................ 2

A. Biographic data ..................................................................................................................... 2

B. Chief complaints .................................................................................................................... 3

C. History of present illness ........................................................................................................ 3

D. Past medical / health history ................................................................................................. 3

E. Family medical / illness history .............................................................................................. 3

F. Review of system .................................................................................................................... 3

G. Lifestyle and health practices ................................................................................................. 4

h. Developmental level ............................................................................................................. 5

III. COLLECTING OBJECTIVE DATA .................................................................................. 5

a. Course of confinement ........................................................................................................... 5

i. Medication administered since date of admission ....................................................... 5

ii. IVF , BT and other parenteral medication infused/ administered since date of admission ..... 9

iii. All diagnostic test made to pt since date of admission ................................................ 9

b. Physical assessment .............................................................................................................. 9

IV. LIST OF NANDA – BASED OR GORDON – BASED NURSING DX .......................... 16

V. PATHOPHYSIOLOGY ....................................................... Error! Bookmark not defined.8

VI. NURSING CARE PLAN .................................................... Error! Bookmark not defined.9

References ..................................................................................................................................... 28

I. INTRODUCTION

a. Overview

Patient A has been admitted in August 22, 2012 5:06am. The patient is 35 weeks

pregnant and has been reported with a heavy vaginal bleeding. Her final diagnosis is

Abnormal Uterine Bleeding, Iron Deficiency Anemia Secondary.

Iron deficiency is the most common deficiency disorder in the world, affecting more

than two billion people worldwide, with pregnant women at particular risk. World

Health Organization (WHO) data show that iron deficiency anaemia (IDA) in

pregnancy is a significant problem throughout the world with a prevalence ranging

from an average of 14% of pregnant women in industrialized countries to an average

of 56% (range 35–75%) in developing countries.

Anaemia during pregnancy is a well known and considerable risk factor for both

mother and fetus. Fetal consequences are an increased risk of growth retardation,

prematurity, intrauterine death, amnion rupture and infection. Prematurity is a

consequence of early anaemia during Maternal consequences of anaemia are also well

known and include cardiovascular symptoms, reduced physical and mental

performance, reduced immune function, tiredness, reduced peripartal blood reserves

and finally increased risk for blood transfusion in the postpartum period.

b. Definition of Related terms

Anemia/ Anaemia- is a decrease in number of red blood cells (RBCs) or less than

the normal quantity of hemoglobin in the blood.

Iron deficiency anemia-(IDA) is an ailment when there is not enough hemoglobin

produced by the body to meet its requirement.

Iron- The total body iron in a 70-kg man is about 4

Abnormal Uterine Bleeding (AUB) or Dysfunctional uterine bleeding (DUB) is

abnormal bleeding from the vagina that is due to changes in hormone levels.

Anemia - a decrease in red blood cell (RBC) mass.

Red blood cell (RBC)/ Erythrocyte- deliver oxygen from the lungs to the tissues

and carbon dioxide from the tissues to the lungs

Cesarean Section- is a surgical procedure in which one or more incisionsare made

through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one

or more babies, or, rarely, to remove a dead fetus. A Caesarean section is usually

performed when a vaginal delivery would put the baby's or mother's life or health

at risk, although in recent times it has also been performed upon

request for childbirths that could otherwise have been natural.

Lochia rubra (or cruenta) is the first discharge, red in color because of the large

amount of blood it contains. It typically lasts no longer than 3 to 5 days after birth.

Hematocrit- (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume

fraction (EVF) is the volume percentage (%) of red blood cells inblood. It is

normally about 45% for men and 40% for women.[1]

It is considered an integral

part of a person's complete blood count results, along with

hemoglobin concentration, white blood cell count, and platelet count.

Hemoglobin- tetramer protein composed of heme and globin. Is the iron-

containing oxygen-transportmetalloprotein in the red blood cells

MCH- "mean cell hemoglobin" is the average mass of hemoglobin per red blood

cell in a sample of blood. It is reported as part of a standard complete blood count.

MCH value is diminished in hypochromic anemias.

MCHC- mean corpuscular hemoglobin concentration, a measure of the

concentration of hemoglobin in a given volume of packed red blood cells. It is

reported as part of a standard complete blood count. It is calculated by dividing

the hemoglobin by the hematocrit.

MCV- mean corpuscular volume, or "mean cell volume" (MCV), is a measure of

the average red blood cell size that is reported as part of a standard complete

blood count. The MCV is calculated by dividing the total volume of packed red

blood cells (also known as hematocrit) by the total number of red blood cells.

Serum ferritin- Ferritin is a protein found inside cells that stores iron so your body

can use it later. A ferritin test indirectly measures the amount of iron in your

blood.

Total Iron Binding Capacity in the Blood (TIBC)-) is a medical laboratory test

that measures the blood's capacity to bind iron with transferrin. It is performed

by drawing blood and measuring the maximum amount of iron that it can carry,

which indirectly measures transferrin since transferrin is the most dynamic

carrier.

Transferrin- are iron-binding blood plasma glycoproteins that control the level of

free iron in biological fluids. Transferrin saturation: 15–50% (males), 12–45%

(females)

Erythropoiesis- is the process by which red blood cells (erythrocytes) are

produced. It is stimulated by decreased O2 in circulation, which is detected by

the kidneys, which then secrete the hormone erythropoietin.

II. PATIENT’S HISTORY

A. Biographical Information

i. Name: Patient A

ii. Age: 43 years old

iii. Gender: Female

iv. Birthday: March 23, 1969

v. Birthplace: Laur, Nueva Ecija

vi. Civil Status: Married

vii. Address: #106 purok 1, Laur, Nueva Ecija

viii. Phone Number: 0927-4722-559

ix. Educational Level: High school Graduate

x. Occupation: None

xi. Race/ Ethnic Group: Tagalog

xii. Religion: Roman Catholic

xiii. Nationality: Filipino

xiv. Citizenship: Filipino citizen

xv. Language spoken: Tagalog

xvi. Source of information: Patient A

xvii. Reliability: 99%

b. Chief Complaints: Vaginal Bleeding

i. Initial diagnosis: Abnormal Uterine Bleeding )

ii. Final Diagnosis: Abnormal Uterine Bleeding, Iron Deficiency Anemia Secondary

c. History of Present Illness:

1 month prior to admission- “unusual bleeding” described as messy lasting only for 7

days, consuming 2 pads.

15 days prior to admission- vaginal bleeding noted to be profuse, consuming 8 pads fully

soaked

3 days prior to admission- vaginal bleeding noted to be profuse, consuming 9 pads fully

and with pain in lumbosacral region

2 days prior to admission- still with bleeding, with lumbosacral pain and headache

d. Past Medical/ Health History

i. Problems at birth- none

ii. Childhood illnesses-

1978: Measles

1981: Mumps

iii. Immunization to date –

Patient A cannot remember

iv. Adult illnesses

2000-2012: Hypotension

v. Accidents: None

vi. Allergies: None

vii. Previous Hospitalization, Medical and Surgical

Diagnosis Year Cause

Abdominal

Caesarean Section

1998 Pregnancy To her First Child

e. Family Medical/ Illness History

i. Heredofamilial

In her father side, her father is recently been diagnosed with diabetes and an

alcoholic drinker. Her Grandmother had Tuberculosis of the bone and also asthmatic.

In her mother side; her mother has a history of hypotension, and anemia. Her

grandmother had a history of hepatitis and diabetes.

f. Review of System

1. Skin, Hair & Nails-

Skin – Pallor

Hair- Black

Nails- Pinkish

2. Head and Neck

Head- No headache reported

Neck- No stiffness of neck felt, with melasma at back of neck

3. EENT & Sinuses

Ears- No drainage or ringing ears reported

Eyes- Blurred Vision when reading (Farsighted)

Nose- No discharges

Throat- No pain or hoarseness of voice felt

4. Chest and Lungs

Chest- No pain reported

Lungs- No shortness of breath or pain reported

5. Breast & Regional Lymphatics

Breast- with Milk discharges

Feeling of tenderness, and dark areola

Regional Lymphatics- Lymph nodes are not enlarged nor tender

6. Heart, Neck Vessels & Central CVS

Heart- No pain, distress or palpitations felt

Neck vessels- are not distended.

Cardiovascular System- No tightness, edema, or orthopnea reported

7. PVS

With Varicosities in Right Leg

8. Abdomen

No abdominal pain, bowel movements are good, with linea nigra

9. Genitalia and Reproductive System

With Vaginal discharge (Lochia rubra)

No pain during sexual intercourse reported

10. Anus, Rectum & Prostate

Anus- No itchiness or lesion reported

Rectum- No itchiness or lesion reported

11. Musculoskeletal System and Extremities

No muscle pain, stiffness or swelling felt

12. Neurologic

With dizziness and weakness as reported

g. Lifestyle and Health Practices- 24H day Description

i. Nutrition, diet and Weight management

She prefers vegetables, rice and a glass of water in her meal.

ii. Activity & Exercise

She does household chores as her exercise. She usually at home with her

daughter.

iii. Rest and Sleep

The client takes a 5-6hours of sleep as her rest and she also takes a nap

occasionally.

iv. Medication and Supplements

The Client takes Multivitamins every morning

v. Self-concept and self care

The client is aware of the complication of her illness and she is willing to

cooperate for her health promotion and disease prevention.

vi. Social activities

The patient visits her neighborhood to catch up latest issues around their

town. She also visits her close relatives occasionally.

vii. Spiritual, Cultural, Values and Belief System

The patient Goes to Church every Sunday and prays at night and before

meals. She believes that everything happens for a reason.

viii. Education and work

A high school graduate and with no work. Patients A stays at home and do

household chores.

ix. Stress Level and Management/ Coping Stress

Patient A is having a headache and feels dizzy when she is stress or angry

at her child. She’s watching television at night before sleep, and talking

with her peer group at morning as a way of relieving stress.

x. Environment & Neighborhood

Patient A lives in a rural area; in a 3 bedroom-house, with a backyard and

a garden. The houses in their town are 5 meters apart. With a quiet

neighborhood and far from highway.

h. Developmental Stage

i. Theory: Erik Erickson’s Psychosocial Development

ii. Generativity vs. Stagnation (Middle adulthood 40-64 years)-

The client has self confident of raising her child. She is devoted to her family and to

their community. She wants her children to be educated and to be good person

someday. She is confident of raising her premature child and her first child so that

someday, her children will do the same to her. She believes that all of their sacrifices

(The client and her husband) are worth it for their family.

iii. Comparison of Normal and Abnormal developmental parameter:

People extend their concern from themselves and their families to the community and

to the world. They may become politically active, work to solve problems, or to

participate in far-reaching-community or world based decisions. People with sense of

generativity are self-confident and better able to juggle their various lives (as a

mother and church member. People without this sense become stagnated or self-

absorbed. Those who have devoted themselves to only one role are more likely to

find themselves at the end of middle age with a narrow perspective and lack of ability

to cope with change. Women without a sense of generativity may have more

difficulty than others accepting a late-in-life pregnancy and a new role of

childbearing.

III. COLLECTING OBJECTIVE DATA

a. Course of Confinement

i. Medications Administered since date of admission

Physician’s Order Ascorbic acid 1cap BID P.O.

Generic Name Ascorbic Acid

Brand Name Apo-C, Ascorbicap, Cebid, Cecon,

Cenolate, Cemill, C-Span, Cetane,

Cevalin, Cevi-Bid, Ce-Vi-Sol, Cevita,

Flavorcee, Redoxon, Schiff Effervescent

Vitamin C, Vita-C.

Classification Vitamin

Mechanism of Action Vitamin C or L-ascorbic acid, or

simply ascorbate (the anion of ascorbic

acid), is an essential

nutrient for humans and certain other

animal species. Vitamin C refers to a

number of vitamers that have vitamin C

activity in animals, including ascorbic

acid and its salts, and some oxidized

forms of the molecule

like dehydroascorbic acid. Ascorbate and

ascorbic acid are both naturally present in

the body when either of these is

introduced into cells, since the forms

interconvert according to pH.

Vitamin C is a cofactor in at least

eight enzymatic reactions including

several collagen synthesis reactions that,

when dysfunctional, cause the most

severe symptoms of scurvy.

Side Effects

GI disturbances in high doses (nausea,

vomiting, and diarrhea).

Bright yellow discoloration of urine

Nursing Management

Instruct Client to take the medication

after meals to avoid GI upset.

Instruct client to measure and follow

the prescribed dosage of the

medication to avoid overdosing.

Advise the client that yellow

discoloration of urine is normal

Adverse Effects

Rarely, hypersensitivity reaction

Flatulence, constipation

Heartburn,

Nursing Management

Instruct the client to discontinue the

medication, and refer to the doctor.

Instruct the client to discontinue the

medication, and refer to the doctor.

Instruct the client to take the

medication after meals to avoid

adverse reactions.

Physician’s Order Tranexamic acid 500mg, 1cap TID P.O.

Generic Name Tranexamic acid

Brand Name Hemostan, Fibrinon, Cyklokapron,

Lysteda, Transamin

Classification Anti-fibrinolytic, antihemorrhagic.

Haemostatics

Mechanism of Action Tranexamic acid is a synthetic derivative

of the amino acid lysine. It exerts its

antifibrinolytic effect through the

reversible blockade of lysine-binding

sites on plasminogen molecules. Anti-

fibrinolytic drug inhibits endometrial

plasminogen activator and thus prevents

fibrinolysis and the breakdown of blood

clots. The plasminogen-plasmin enzyme

system is known to cause coagulation

defects through lytic activity on

fibrinogen, fibrin and other clotting

factors. By inhibiting the action of

plasmin (finronolysin) the anti-

fibrinolytic agents reduce excessive

breakdown of fibrin and effect

physiological hemostasis.

Side Effects

GI disturbances (Nausea, vomiting,

diarrhea)

Nursing Management

Instruct Client to take the medication

after meals to avoid GI upset.

Adverse Effects

Hypotension

Headache

Hypersensitivity skin reactions/

allergic reactions

Disturbances in color vision

Nursing Management

Take the client Blood pressure

before and after taking the

medication to identify if hypotension

occurs as adverse effects, if so,

discontinue the medication and refer

to the doctor.

Monitor the client after taking the

medication and Instruct to take bed

rest to avoid injury

Instruct the client to discontinue the

medication, and refer to the doctor

Instruct the client to discontinue the

medication, and refer to the doctor

Physician’s Order Ferrous Fumerate 1cap, TID P.O.

Generic Name Ferrous Fumerate

Brand Name Femiron, Ferretts, Ferro-Sequels,

Ferrocite, Hemocyte, Ircon

Classification Antianemic/ Supplement

Mechanism of Action Iron is an essential component in the

physiological formation of hemoglobin,

adequate amounts of which are necessary

for effective erythropoiesis and the

resultant oxygen transport capacity of the

blood. A similar function is provided by

iron in myoglobin production. Iron also

serves as a cofactor of several essential

enzymes, including cytochromes that are

involved in electron transport. Iron is

necessary for catecholamine

metabolism and the proper functioning of

neutrophils.

Side Effects

stomach upset,

diarrhea,

black or darker than normal

appearing stools, or

temporary staining of the teeth.

Nursing Management

Instruct Client to take the medication

after meals to avoid GI upset.

Instruct client not to take with milk

or antacids

Inform patient the color stool black

may be black

Inform patient that temporary

staining of the teeth is normal

Adverse Effects

nausea or vomiting,

epi-gastric pain.

Nursing Management

Instruct client to take the medication

after snack or meal

Instruct client to take the medication

2 hours prior to or 4 hours after

antacids

Physician’s Order Mefenamic acid 500mg 1capsule, TID

P.O.

Generic Name Mefenamic acid

Brand Name Pharex, Mefenemax, Fenamax, Femacid

Classification Nonsteroidal Anti-Inflammatory Drugs

(NSAIDs)

Mechanism of Action Mefenamic acid binds the prostaglandin

synthetase receptors COX-1 and COX-2,

inhibiting the action of prostaglandin

synthetase. As these receptors have a role

as a major mediator of inflammation

and/or a role for prostanoid signaling in

activity-dependent plasticity, the

symptoms of pain are temporarily

reduced.

Side effects:

stomach pain or cramps

vomiting or upset stomach

increased shortness of breath

dizziness and drowsiness

Instruct patient to avoid alcohol intake

when taking this medicine since it can

cause increases in stomach irritation.

Use caution if the patient has a

weakened heart. It may cause increased

shortness of breath or weight gain.

Do not drive or engage in potentially

hazardous activities until response to

drug is known. It may cause dizziness

and drowsiness.

Adverse Effects

stomach ulcer or bleeding

dark stools, hematemesis,

ecchymoses

diarrhea, epistaxis, or rash

Nursing Management

Instruct client to immediately tell the

health provider about bleeding or

stomach ulcer

Instruct client to Discontinue the drug

promptly, do not use again and

Contact the physician.

Instruct client to Discontinue the drug

promptly, do not use again and

Contact the physician.

ii. IVF, BT and other Parenteral Medication infused/administered since date of

admission

INTRAVENOUS FLUID OREDERED

Previous IVF:

LRS 1Liter + KCl 40 meq/L

Rationale: This pulls the fluid into the

vascular by osmosis resulting in an

increase vascular volume. It raises

intravascular osmotic pressure and

provides fluid, electrolytes and calories

for energy. Potassium chloride is used to

prevent or to treat low blood levels of

potassium (hypokalemia).

Current IVF:

Plain NSS 1Liter for 24hours

Rationale: only IV fluid which is

compatible to Blood Transfusion

To follow IVF:

Plain NSS 1Liter for 24hours

Rationale: To facilitate another Blood

Transfusion

OTHERS

Blood Transfusion Rationale: To restore blood volume after

severe hemorrhage and to restore the

oxygen-carrying capacity of the blood

Oxytoxin Rationale: Stimulating labor when the

contractions are considered too weak.

Preventing or controlling heavy bleeding

following delivery of the child (post-

partum hemorrhage).

iii. Diagnostic Test since Date of Admission

Name of

Diagnostic

Test

Result Normal

Values

Unit of

Measurement

Implication

Complete CBC

Hemoglobi

n mass

100

Female: 110 –

158

g/dl

Indicates a decrease in

Red blood cell

Hematocrit

Leukocyte

Count

Platelet

Count

RBC Indices

MCH

MCV

MCHC

LDH SCE

Serum Iron

concentration

Serum ferritin

0.32

9

463

26

81

31

410.00

40

13

Male: 138 to

182

0.37 – 0.54

4.5 – 10

150 – 400

28 – 32

82 - 92

32 – 38

225.00 –

450.00

Female: 50

to 170

Male: 65 to

176

Female:

15–200

fraction of

RBC

x /L

400 X 10^9/L

pg

fL

%

U/L

μg/dL

μg/L

production.

Indicates a decrease in

Red blood cell

production

Normal.

An elevated platelet

count is an indication

that there is an

underlying condition

that is causing the

disorder.

Decrease in redness is

due to a

disproportionate

reduction of red cell

hemoglobin.

Decrease in red blood

cell size

Decrease in hemoglobin

concentration.

Indicate a number of

medical conditions such

as tissue damage (due to

trauma or disease),

hemolytic anemia (an

abnormal breakdown of

red blood cells)

Indicates poor

absorption of Iron,

Chronic heavy

menstrual bleeding,

Poor absorption of iron,

Not enough dietary iron

or Pregnancy

There is a risk for lack

of iron

Total Iron

Binding

Capacity in the

Blood (TIBC)

375

Male: 30–

300

250–370

μg/L

In pregnant, the liver

increases the production

of transferring thus

raising TIBC. When

TIBC is high, it

indicates iron deficiency

anemia.

iv. Other relevant events during hospitalization - none.

b. Physical Assessment

i. General Impression

Hygiene- Clean and Groomed appropriately

Interaction/behavior- Cooperative attitude as her condition permits

Posture- Bedridden and weak

facial Expression- Symmetric with movement

ii. Height, weight and Vital Signs

Height: 5 feet and 3 inches

Weight: 126 lbs

Vital signs:

Temperature: 37.3’ C

Pulse rate: 88 cpm

Blood Pressure: 110/70 mm/Hg

Respiratory Rate: 23 bpm

iii. Skin

Color of skin- Pallor

Color of hair- Black (Normal)

Odor- No odor

Lesion- No lesion

Moisture- Moist

Temperature- Warm

Texture- Smooth & Soft

Turgor- Pinched up skin returns immediately to original position

Edema- No swelling, pitting or edema

Nails- Has a convex curvature of fingernail plate, 160º

Fingernail and toenail bed color are pinkish in color.

The tissues surrounding the nails of the client are intact.

Presence of capillaries- When blanched test is performed, color of

the nail bed of the client returns into pink in less than 4 seconds.

Capillary Refill test: 2 seconds (normal)

iv. MSE/ Neurologic

Mental Status: Awake & Alert; oriented to person, place & time

Cranial Nerves:

II: Visual Acuity- 20/20 with pocket screener, both eyes

Visual Fields- intact in all fields

II and III: Pupillary Reaction to Light- direct & consensual normal

Accommodation- normal

PERRLA, pupils, equal, round, reactive to light, and

accommodation for both)

III, IV, VI: EOM- intact

V: Light Touch Face- normal in all 3 divisions

VII: Wrinkle Forehead, Close Eyes, Show Teeth- normal

VIII: Hearing- normal by rough testing

X: Cough- normal (able to cough)

XI: Shrug Shoulders and check sternocleidomastoid muscles - normal

XII: Protrude Tongue- midline protrusion

Motor System: Normal tone

Sensory: Able to feel :

Light Touch- normal

Position Sense- normal

Vibration- normal

Sharp- normal

Reflexes: Deep tendon

O Biceps (C5-6)- Responsive

o Triceps (C6-7)- Responsive

o Brachioradialis- Responsive

o Knee (L2-4)- Responsive

o Ankle (S1)- Responsive

Pathological - Plantar Reflex- none (bilateral down going toes)

Coordination: Gait and Balance- normal

Finger to Nose- normal

Rapid finger movements- normal

v. HEENT, Sinuses and Neck

Head:

Size/Shape- Symmetric, round, erect & in midline

ROM/ Head control- Neck movement is smooth & controlled with 45

degree flexion, 55 degree extension, 40 degree lateral abduction, & 70

degree rotation

head posture- still and uptight.

Face:

Appearance- Smooth and controlled movements

Symmetry- Symmetrical

Movement- abnormal movement noted

Eyes:

Position- Lower margins at bed cover approximately 2-6mm of iris bottom

edge of iris; upper margins of lids

Eyelids placement- No swelling, discharges or lesions noted

Sclera/Conjuctiva- No swelling, discharges, lesions or laceration are noted

Iris/Pupils – Color Black, round, flat and constricted when direct to light

Visual Acuity Test- 20/20 vision; Can differentiate colors

Ears:

o External:

Placement- Alignment of pinna with corner of eye within 10 degree

angle of vertical position

No swelling, discharges and lesions.

o Internal:

No discharges, lesion, excoriation or presence of foreign body.

Mouth:

Lips- Smooth & moist, without lesions or swelling

Palates- Hard palate is pale or whitish with firm, transverse rugae (wrinkle

like folds)

Tongue- Pink, moist, a moderate size with papillae

Buccal Mucosa- Smooth & moist without lesion

Gums- Pink, moist and firm

Teeth- 31 adult teeth, white to yellowish in color, shiny tooth enamel, no

intact dentures

Uvula- Positioned in midline of soft palate

Throat/tonsils- Pink and symmetric

Nose/sinuses:

Structure and patency of nares- Able to sniff through each nostril while

other is occluded

Color and problem of turbinates - Color is the same as the rest of the face

No discharges or tenderness

Neck:

Mobility- Symmetric

Cervical Lymph Nodes- No enlargement or tenderness

Temperature- Warm

No swelling or tenderness

vi. C/ L and Heart

Breasts and Nipples- symmetrical--nipples symmetrical and everted

No masses, with milky discharges

Areola- Equal, round, symmetric, dark brown, smooth,has no lesions

Thorax-

Posterior thorax-

o Symmetric, ribs are sloped downward at 45º relative to the spine,

muscle development is equal, anteroposterior to transverse

diameter in ratio of 1:2

o Spinal alignment- Slightly

o Uniform in temperature, no tenderness and masses

o Respiratory excursion- Full and symmetric chest expansion

o Vocal fremitus- Bilaterally equal, heard mostly at the apex of the

lungs

o Sounds- Percussion notes resonant except over the scapula,

bronchovesicular and vesicular

Anterior thorax

o Breathing patterns- Quiet, rhythmic effortless

o Temperature, tenderness, masses- Warm, no tenderness or masses

o Respiratory excursion- Full and symmetric chest expansion

o Vocal fremitus- Bilaterally equal, mostly heard at the apex of the

lungs

o Sounds- Flat sound on the part with heavy muscles and bony

prominences, tympani on the stomach, dullness on the liver and

spleen, bronchovesicular, vesicular

o Trachea- Bronchial sound

Axillary, subclavicular and supracvicalar lymph nodes- Absence of

masses or lumps

Cardiovascular

Precordium-

o Aortic, pulmonic, tricuspid area- No pulsation

o Apical area- With palpable pulsation (point of maximal impulse)

o Sounds of tricuspid and apical- S2 is louder than S1

o Sounds of Tricuspid and apical area- S1 is lauder than S2

Carotid arteries- Symmetric pulse volumes, full pulsation, no sound

o Visibility- Not visible

Lungs-

respiratory effort: Even, 23bpm, unlabored

Percussion and Palpation of Lung Fields- normal resonant percussion

Auscultation- clear, normal vesicular breath sounds

vii. Abdominal

Unblemished skin, uniform in color, no signs of enlargement of the liver and

spleen, symmetrical contour

Peristalsis movement not visible

vascular patterns not visible

Audible bowel sounds, not audible vascular and peritoneal friction rubs

With suture in

viii. Urinary System

No Pain or discomfort in response to pressure on the lower back, abdomen, or the

area above the pelvic bone,

Nogrowths, or abnormalities detected

No discharge from the urethra

ix. Genitalia and Reproductive

External Genitalia- labia, clitoris, urethral orifice & introitus – all normal (no

sweelin, pus, warts or inflammation)

Bimanual Exam- uterus is anterior, midline, smooth, enlarged and tender

Fundus in midline, about half way to 2/3 way between umbilicus and

symphysis pubis

Inspection of Cervix and Vagina- bulging with straining, normal vagina

mucosa, cervix- pink, with lochia rubra, cervix: Spongy and flabby

x. Anus

Normal rectal sphincter tone; no rectal masses or tenderness. 0 stool for 3

days.

no fissures, no hemorrhoids

xi. Musculoskeletal, upper and lower extremities and PVS

Musculoskeletal system

Muscles-

o Size, contractures, tremors- Bilaterally symmetric, no contractures

and tremors

o Tonicity, strength (neck, upper, lower extremities)- Normal muscle

tension, adequate strength of themuscles

Bones- Uniform in structure, no deformities, tenderness or edema

Joints- Absence of tenderness and swelling, has smooth movement, no

nodules

Range of motion (shoulder and scapula, elbows, hands, acetabulum,

popliteal, ankles)- Able to perform the exercises in full range of motion,

no tenderness, moves smoothly

Upper Extremities

>Nails- no cyanosis, or clubbing

> palms- pale

> muscles- size is proportional

> joints (including rom)

-interphalangeal- normal Range of motion without deformities

- wrists- flexion = 90°, = extention 70°, radial deviation = 20°,

ulnar deviation = 50°

- elbows- flexion = 160°

- radial pulse- 4 / 4, normal and symmetric

> Capillary Refill test: 2 seconds (normal)

Lower Extremities:

>Nails- normal (No cyanosis or clubbing)

>Muscles- nl size

> Joints (including ROM)

Ankle- dorsiflex = 20°, plantar flexion = 40°, eversion = 20°,

inversion = 20°

Knee- flexion = 130°

Hip- flexion = 100°, internal rotation = 40°, ext rotation = 40°

Pulses:

Posterior Tibial- 4 / 4 bilateral & equal

Dorsalis Pedis- 4 / 4 4 bilateral & equal

> Capillary Refill test: 2 seconds (normal)

IV. LIST OF NANDA-BASED OR GORDON-BASED NURSING DIAGNOSIS

LIST OF

PRIORITIZED

NURSING

DIAGNOSIS

BASIS OF PRIORITIZATION JUSTIFICATION

Circulation

,Airway,

Breathing

Maslow Actual/

potential

Overt/

covert

Patient’s

verbalization

1. Fatigue related to the

blood’s decreased

hemoglobin and

diminished oxygen-

carrying capacity

Fatigue or weakness is patient’s major

chief complaint regarding to her health

after her cesarean delivery, and it is

also one of the signs and symptoms of

Iron deficiency anemia.

2. Fluid volume deficit

related to blood loss

secondary to anemia

There’s a severe hemorrhage after her

delivery, blood loss results in decreased

intravascular volume and needed to be

replace immediately to avoid

hypovolemia and shock

3. Risk for infection

related to decreased

hemoglobin secondary

to iron-deficiency

Anemia.

Hemoglobin served as a secondary

defense, a decreased in hemoglobin

also means there’s an easy access of the

pathogens to infect the patient

especially during her stay in the

hospital.

4. Disturbed sleep

pattern related to

hospital noise and

lightning secondary to

Anemia

5. Imbalanced nutrition:

Less than body

requirement related to

inadequate intake of

essential nutrients

secondary to Anemia

6. Risk for Ineffective

tissue perfusion related

to inadequate blood

volume secondary to

anemia

7. Activity intolerance

related to imbalance

between oxygen supply

and demand in the blood

related to generalized

weakness secondary to

Anemia

8. Risk for Constipation

related to insufficient

physical activity

secondary to Anemia

9. Risk for fall related to

generalized weakness

secondary to Anemia

10. Sedentary lifestyle

related to deficient

knowledge of health

benefits of proper diet

and exercise secondary

to anemia

V. PATHOPHYSIOLOGY

NON- MODIABLE FACTORS:

Age: Adult (43 years old)

Gender: Female (Pregnant)

Heavy Menstruation

History of having Anemia

MODIABLE FACTORS:

Lifestyle:

Diet: High in fiber, Low in

Iron.

In Weight Reducing program

Preterm Birth (<38 weeks)

Birth delivery via Cesarean section

Less Hemoglobin than Average Red

Blood cell (Hypochromic)

Small Red Blood cell (Microcytic)

Low Hemoglobin (below 12mg/dL)

Low Hematocrit (Below 33%)

Reduction in oxygen-carrying capacity of Red Blood cell

Decreased intravascular volume

Blood loss/ Hemorrhage

Preterm Birth

Signs and Symptoms: Fatigue/ Generalized weakness

Headache/ Dizziness

Pale skin color or Pallor

Sore tongue

Light-headedness when you

stand up

Depletion of iron stores in bone marrow

Serum ferritin will become low (< 20-30 mcg/L)

The compensatory increase in iron absorption causes an increase

in iron-binding capacity (TIBC/Transferrin level)

Serum iron falls to < 50 μg/dL and transferrin saturation to <

16%. The serum ferritin receptor level rises (> 8.5 mg/L)

Erythropoiesis is impaired

VI. NURSING CARE PLAN

Name: Patient A

Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary

Date and time: August 22, 2012 (11pm-7am)

Assessment Diagnosis Scientific

rationale

Planning Implementation Scientific Rationale Evaluation

Subjective

Data:

“Nanghihina

ako mula

kagabi, sobra

ata kasi

pagdurugo ng

puson ko kaya

siguro ako

nanghihina.

Matanda na

rin kasi ako

nang

nabuntis” as

manifested by

the mother.

Objective

Data:

Pallor,

generalized

weakness,

With heavy

lochia rubra

Vital signs:

T: 37.3’ C

Fatigue

related to

the blood’s

decreased

hemoglobi

n and

diminished

oxygen-

carrying

capacity

secondary

to Anemia

Iron-

deficiency

anemia is

a

common a

nemia (lo

w red

blood cell

level)

caused by

insufficien

t dietary

intake and

absorption

of iron.

One of the

Symptoms

of anemia

is

generalize

d

Weakness

and

fatigue

Long term

Goal:

After 16

Hours of duty

The patient

will be able

To enhance

her

knowledge

about her

disease, and

to facilitate

health

promotion.

Short Term

Goal:

After 16 hours

of duty,

The patient

will be able to

verbalize the

understanding

of individual

therapeutic

interventions,

medications

Independent

Intervention:

Explain to the client

the procedures and its

purpose

Assess vital signs.

Evaluate need for

individual assistance

or assistive device.

Encourage client to do

whatever possible

Encourage use of

assistive devices like

wheelchair

Instruct patient to sit

instead of stand during

care and other

activities.

To reduce anxiety of the

patient.

To prepare the patient for

the Procedure.

To evaluate fluid status

and cardiopulmonary

response to activity.

To determine the need

for doing activities or

movement.

To increase activity level

as tolerated

To conserve energy for

other task

To conserve energy:

The patient is

able to

improve her

activities of

daily living as

evidenced by

the use of

assistive

devices and

support

system.

The patient is

able to

verbalize the

foods and diet

which are rich

in iron as

evidence by

eating 1 egg

yolk, 1 small

liver and small

slice of red

meat.

Goal met:

RR: 23 bpm

PR: 88 cpm

BP: 110/70

mm/Hg

and its

purposes.

Long term

objective:

After 4 hours

of health

teaching,

The patient

will be able to

identify foods

rich in iron

and the

patient will be

able to

verbalize the

dosage of her

medication.

Short term

Objective:

After 4 hours

of health

teaching, the

patient will be

able enhance

her activities

of daily living

as evidenced

by report of

improved

sense of

energy.

Provide diversional

activities like having

her to talk with her

relatives

Instruct patient to eat

Iron rich foods (e.g.

liver or animal

organs, egg, fish,

poultry, leafy

vegetables and dried

fruits)

Instruct patient to

increase her fluid

intake.

Observe and measure

fluid losses (e.g.

bleeding)

Provide Oral care

Instruct the Family to

bathe the patient every

other day.

Give/administer

medications as

Pleasurable activities can

refocus energy and

diminish feelings of

unhappiness and

sluggishness.

To Increase the Total

Body iron of the patient.

To prevent anemia and to

help in producing more

red blood cells.

To rehydrate the patient.

To determine

replacement needs

For patient’s comfort and

to prevent dryness of

mucous membrane.

To provide optimal skin

care and to prevent

dryness of skin.

To Follow patient’s

therapeutic regimen to

instructed by the

doctor.

Administer Blood

transfusion as ordered

by the Doctor.

Replace electrolytes as

ordered (Inserting IV

fluids as ordered)

Collaborative

Intervention:

Refer patient to

Radiology Technician

for X-ray as ordered

by the doctor.

stabilize her wellness of

health.

To replace Blood volume

loss.

To replace electrolytes to

prevent dehydration and

further complications.

For further evaluation

and analysis of the

patient’s disease.

Name: Patient A

Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary

Date and time: August 23, 2012 (11pm-7am)

Assessment Diagnosis Scientific

rationale

Planning Implementation Scientific Rationale Evaluation

Subjective

Cues:

“Medyo

nanghihina pa

rin ako pero

din na tulad

ng kahapon,

nakakatayo

naman ako

kahit papano.

Feeling ko

lagi naman

ako uhaw” as

manifested by

the mother.

Objective

Cues:

generalized

weakness,

with lochia

rubra

Vital signs:

T: 37.3’ C

RR: 21 bpm

PR: 91 cpm

BP: 110/70

Fluid

volume

deficit

related to

blood loss

secondary

to anemia

Iron

deficiency

during the

pregnancy is

the cause of

abnormal

uterine

bleeding

during the

labor and

resulting in

heavy blood

loss.

Massive

Fluid

volume is

loss during

the delivery

as a result

the patient

felt weak

and thirsty.

Long term

Goal:

After 16 hours

of duty, the

patient will be

able to enhance

her knowledge

about her

disease, and to

facilitate health

promotion and

further disease

prevention.

Short Term

Goal:

After 16 hours

of duty, The

patient will be

able to

verbalize the

understanding

of individual

therapeutic

interventions,

medications

and its

purposes.

Independent

Intervention:

Explain to the client

the procedures and

its purpose

Assess vital signs

noting blood

pressure

Estimate procedural

fluid losses and take

note possible routes

of insensible loss.

Note complaints and

physical signs

associated with

dehydration (scanty,

concentrated urine,

confusion, muscle

weakness, light

headedness,

headache)

Establishing 24-hour

To reduce anxiety of the

patient.

To prepare the patient

for the Procedure.

Changes in vital signs

are associated with fluid

volume loss or other

complications.

To monitor and observe

other routes of fluid

losses

Other sign and

symptoms may indicate

serious complications.

This prevents peaks and

The patient is

able to

demonstrate a

behavior of

correcting her

fluid deficit as

evidenced of

increased fluid

intake by

500cc.

The patient is

able to

maintain

adequate fluid

volume as

evidenced by

adequate

urinary output:

August 22

output: 220cc

August 23

output: 550cc

mm/Hg

Long term

objective:

After 4 hours

of health

teaching, the

patient will be

able to

demonstrate

behavior to

correct deficit.

Short term

Objective:

After 4 hours

of health

teaching,

The patient

will able To

maintain

adequate fluid

volume as

evidenced by

adequate

urinary output.

fluid replacement

needs.

Instruct patient to

increase her fluid

intake.

Maintain accurate I

& O

Provide Oral care

Instruct the Family

to bathe the patient

every other day.

Change position

frequently

Change dressings

frequently

Give/administer

medications as

instructed by the

doctor.

Administer Blood

transfusion as

ordered by the

valleys in fluid level

To rehydrate the patient.

To observe the progress

of the current status of

the patient

For patient’s comfort

and to prevent dryness

of mucous membrane.

To provide optimal skin

care and to prevent

dryness of skin.

To reduce pressure on

fragile skin and tissue

To protect skin and

monitor losses.

To Follow patient’s

therapeutic regimen to

stabilize her wellness of

health.

To replace Blood

volume loss.

Doctor.

Administer IV fluids

as indicated

Collaborative

Intervention:

Refer patient to

Radiology

Technician for X-ray

as ordered by the

doctor.

To replace electrolytes

to prevent dehydration

and further

complications.

For further evaluation

and analysis of the

patient’s disease.

Name: Patient A

Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary

Date and time: August 24, 2012 (11pm-7am)

Assessment Diagnosis Scientific

rationale

Planning Implementation Scientific Rationale Evaluation

Subjective

cues:

“Eto medyo

nanghihina

at

nagdurugo

pa rin ang

puson ko,

pero di na

kasing lakas

ng kahapon”

as

manifested

by the

mother.

Objective

Data:

generalized

weakness,

vaginal

bleeding

(lochia

rubra)

Vital signs:

T: 36.6’ C

RR: 21 bpm

Risk for

Infection

related to

decreased

hemoglobi

n

secondary

to iron-

deficiency

anemia.

Iron

deficiency

during the

pregnancy

is the

cause of

abnormal

uterine

bleeding

during the

labor and

resulting

in heavy

blood loss.

Hemoglob

in served

as a

secondary

defense, a

decreased

in

hemoglobi

n also

means

there’s an

easy

access of

Long term Goal:

After 16 hours of

duty, the patient

will be able to

enhance her

knowledge about

her disease, and

to facilitate

health promotion

and further

disease

prevention.

Short Term

Goal:

After 16 hours of

duty, the patient

will able to

improve wound

healing and will

not manifest any

sign of infection.

Long term

objective:

After 4 hours of

health teaching,

the patient will

Independent

Intervention:

Explain to the client

the procedures and

its purpose

Assess vital signs

noting blood pressure

Observe for localized

signs of infection at

insertion sites of

invasive sites (or IVF

insertion sites) and

wound site.

Stress proper hygiene

by all caregivers

between therapies and

clients

Emphasize proper use

of personal protective

equipment (PPE) to

visitors as dictated by

To reduce anxiety of the

patient.

To prepare the patient for

the Procedure.

Changes in vital signs are

associated with fluid

volume loss or other

complications.

To determine possible

infection and to avoid

further complication

A first line of defense

against healthcare

associated infections

(HAIs)

For personal protection of

yourself and the patient

The patient is

able to

demonstrate

techniques in

lifestyle

changes as

evidence by

reciting what

will she do

after her

discharge :

Eating foods

Rich in iron

(lean meat,

liver, egg yolk

and fish),

having 6-8

hours sleep at

night, and

taking

vitamins as

prescribed by

the doctor.

The patient is

be able to

PR: 90 cpm

BP: 110/70

mm/Hg

the

pathogens

to infect

the patient

especially

during her

stay in the

hospital.

able to

demonstrate

techniques in

lifestyle changes

to promote safe

environment

Short term

Objective:

After 4 hours of

health teaching,

the patient and

her relative will

be able to

demonstrate

behavior to

prevent and

reduce risk in

infection (e.g.

hand washing

and change of

dressing)

the agency’s protocol

Maintain sterile

technique for all

invasive procedures

Recommend routine

shower or scrubs.

Instruct the patient

and her relative about

proper hand washing

Change wound

dressings using

proper technique for

changing and

disposing of

contaminated

materials.

Cover perineal and

pelvic region when

using a bedpan.

Encourage early

ambulation, deep

breathing, and

coughing and position

changes.

Maintain adequate

hydration, stand or sit

To reduce contamination

To reduce bacterial

colonization.

Basic infection and

contamination control.

To prevent contamination

and reducing the

occurrence of infection

To prevent contamination

For mobilization of

respiratory, and for

prevention of aspiration/

respiratory infections.

To avoid bladder

distention and urinary

demonstrate

behavior to

prevent and

reduce risk in

infection as

evidence by

performing

hand washing

and

maintaining

their room

clean.

Goal met:

to void.

Provide perineal care

Provide Oral care

Give/administer

medications as

instructed by the

doctor.

Administer Blood

transfusion as ordered

by the Doctor.

Administer IV fluids

as indicated

Collaborative

Intervention:

Obtain appropriate

tissue or fluid

specimens for

observation and

culture and sensitivity

test

stasis

To reduces risk of

ascending urinary tract

infection

For patient’s comfort and

to prevent dryness of

mucous membrane.

To Follow patient’s

therapeutic regimen to

stabilize her wellness of

health.

To replace Blood volume

loss.

To replace electrolytes to

prevent dehydration and

further complications.

For further evaluation and

analysis of the patient’s

disease.

REFERENCES:

Nurse’s Pocket Guide (by E.A. Davis)

Maternal & Child Health Nursing 6th

Edition Volume 1&2 (Lippincott-Williams & Wilkins)

Handbook of Medical-Surgical Nursing 11th

Edition (by Brunner & Suddhart)

MIMS Philippine 131st Edition

MIMS.com

Wikipedia.org (for Definition of terms)

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001610/

http://www.medindia.net/drug-price/ferrous-fumarate-combination.htm#ixzz27aEaDdPD

http://www.namrata.co/case-study-iron-deficiency-anemia/

http://nursesnanda.blogspot.com/2012/01/nanda-anemia.html

http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/iron-deficiency-anemia/

http://www.geburtshilfe.usz.ch/Documents/LehreUndForschung/Publikationen/breymann_bl

ood_cells.pdf

http://nurseslabs.com/d5lrs-iv-fluid-study/

http://www.globalrph.com/dilp.htm

http://www.netdoctor.co.uk/pregnancy/medicines/syntocinon.html

http://www.scribd.com/doc/37710190/Anemia-NCP

Pathophysiology references:

Handbook of Medical-Surgical Nursing 11th

Edition (by Brunner & Suddhart)

Maternal & Child Health Nursing 6th

Edition Volume 1&2 (Lippincott-Williams & Wilkins)

http://www.merckmanuals.com/professional/hematology_and_oncology/anemias_caused_by

_deficient_erythropoiesis/iron_deficiency_anemia.html

http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/iron-deficiency-anemia/

http://www.namrata.co/case-study-iron-deficiency-anemia/

Handbook of Medical-Surgical Nursing 11th

Edition (by Brunner & Suddhart)

Maternal & Child Health Nursing 6th

Edition Volume 1&2 (Lippincott-Williams & Wilkins)