CASE PRESENTATION

PREPARED BY: TINU VARGHESE

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}

GENERAL

• The patient is 24 years of age, FEMALE• She is conscious, coherent, with the following

Vital Signs:– BP= 110/59mmHg– PR=100 bpm– RR= 28 cpm– Temp=37. ⁰C– SPO²= 98%

SKIN

• Fair complexion• No palpable masses or

lesions, moist, with good turgor

HEAD

• Maxillary, frontal, and ethmoid sinuses are not tender.

• No palpable masses and lesions• No areas of deformity

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)

EYES

• Pink conjunctivae and no dryness

• Pupils equally round and reactive to light

EARS

• No usual discharges noted

NOSE

• Pink nasal mucosa• No unusual nasal

discharges• No tenderness in sinuses

MOUTH

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

NECK AND THROAT

• No palpable lymph nodes• No masses and lesions

seen

CHEST AND LUNGS•Equal chest expansion•No retraction•Clear breath sounds

HEART

•Regular rythm

ABDOMEN • Globular abdomen

• Leopold’s Maneuver done: fetus in cephalic presentation, head is round and hard, fetal back is facing right side

• USG report: o 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

GENITALS

•Clear Watery discharge per vagina since 2 days.

•No show present

EXREMITIES•Pulse full and equal•No lesions noted

PATIENT HISTORY

PAST MEDICAL HISTORYNo past medical history

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: BP=110/59 mmHg, PR=118 bpm, RR= 28 cpm, Temp=37. ⁰C, SPO²= 98%

PRESENT MEDICAL HISTORYINVESTIGATION:

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 GroupA positive

Antibody screeningNegative

RPR Non- Reactive

Rubella Antibody IgG Positive

Urinalysis Pus cells= 0-1/ hpf, RBC = 0-1/ hpf

HBsAg negative

HIV Negative

PRESENT MEDICAL HISTORYUltrasound 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

NAME OF DRUG DOSAGE ROUTE ACTION

1. Ampicillin1 gm IV antibiotics

2 Inj.Dexamethasone12mg IM corticosreroid

3 Tab .Nifedipine 20mg POCalcium channel blockers

4 Tab .Nifedipine

10mg PO Calcium channel blockers

5 Calcium Tablet600mg PO Calcium supplimentt

6 FeSO4 Tablet100mg PO Iron suppliment

ADDITIONAL MEDICATIONS:1. Oxytocin (Pitocin Mix 10 U in 500 mL of IV

solution, begin infusion at 1 mU/min and increase 1–2

mU/min q 30 min

IV causes the uterus to contract

Meperidine (Demerol) 25 mg IV push (IVP) q 3–4 hr IV opioid analgesic drug

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.

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.

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

To diagnose PPROM, the doctor may do the following tests:

Visual examinationA nitrazine paper test

Fern test

Ultrasound Amnisure

POSITIVE NITRAZINE TEST

POSITIVE FERN TEST

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

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)

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

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.

VIII. NURSING INTERVENTION

Educate the patient to use sterile pads

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.

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

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

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

ASSESSMENT PLANNING IMPLEMENTATION EVALUATIONCUES/ EVIDENCE NURSING

DIAGNOSISGOALS & DESIRED

OUTCOMENURSING 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:

• BP:130/90mmHg

• 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

ASSESSMENT PLANNING IMPLEMENTATION EVALUATIONCUES/

EVIDENCENURSING

DIAGNOSISGOALS & DESIRED

OUTCOME

NURSING ORDER/ACTION

RATIONALE FOR ACTION

EVALUATION

SUBJECTIVE:

Patient says that “I am afraid about the baby’s health

as verbalized by the patient

OBJECTIVE:

Her facial expression shows that she has anxiety

V/S taken as follows:

BP:130/90mmHg

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

1. 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

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.

CONCLUSIONThis 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.

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.

BIBLIOGRAPHY• Maternal and Child Health Nursing by Adele Pillitteri

5th edition; volume 1 page 426- 433;page 329-332• All-in-one care planning resource page 748; by Pamela

L. Swearlngen, RN• Maternal Neonatal Nursing;page 30 by Lippincott

Williams and Wilkins• Luckman and Sorensen’s Medical-Surgical Nursing a

Physiologic Approach 4th edition Volume 1 page 734• Lippincot Manual of Nursing Practice 9th edition• http://www.ualberta.ca/~olsonlab/Am%20J%20Obstet

%20Gynecol%201999%20180(1%20Pt%201).pdf

Thank you!!