INTRODUCTION

Postpartum hemorrhage (PPH) has been defined by the World Health Organization (WHO) as
blood loss greater than or equal to 500 mL within 24 hours after birth; severe PPH is blood loss greater
than or equal to 1,000 mL within 24 hours. Estimates vary, but the WHO suggests that PPH occurs in
10.5% of postpartum women, which equates to nearly 14 million women annually. PPH accounts for
one-third of all maternal deaths, with 99% of these deaths occurring in low- and middle-income
countries (LMICs) in women who give birth outside of a hospital setting. The most common cause of
primary PPH is uterine atony, the failure of the uterus to contract after delivery of the placenta. Other
causes of PPH include genital tract trauma, uterine rupture, retained placental tissue, and maternal
bleeding disorders.

Patient P.Y a twenty five years old mother, residing in Barangay Alipao, Alegria Surigao Del
Norte was admitted at Surigao Medical Center last November 20, 2019 at exactly 8:47 am with chief
complain of vaginal bleeding. Patient P.Y was diagnosed POSTPARTUM HEMORRHAGE.

We chose the case of Patient P.Y to gain more knowledge and experience in the field of
nursing to establish holistic approach to the S.O and to the patient promoting for optimal health of the
patient’s condition. Enhance critical thinking and skills that can be useful in the future as to provide
appropriate nursing care to our clients. Also this output will be useful for future purposes related to the
case of POSTPARTUM HEMORRHAGE.

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 REVIEW OF RELATED LITERATURE

Obstetric hemorrhage is the most common and dangerous complication of childbirth. This was
redefined in 2017 by the American College of Obstetrics and Gynecology as cumulative blood loss
greater than 1000 mL with signs and symptoms hypovolemia within 24 hours of the birth process,
regardless of the route of delivery.  While this was change was made with the knowledge that blood
loss at the time of delivery is routinely underestimated, blood loss at the time of vaginal delivery
greater than 500 mL should be considered abnormal with the potential need for intervention. Primary
postpartum hemorrhage is bleeding that occurs in the first 24 hours after delivery, while secondary
postpartum hemorrhage is characterized as bleeding that occurs 24 hours to 12 weeks postpartum.

Hemorrhage is preventable in many cases with prenatal, labor and delivery, and postnatal
interventions. Active management of the third stage of labor (AMTSL) is a multi-step procedure that
has recently gained acceptance and global policies support its scale-up. In addition to other
interventions, AMTSL includes administering an uterotonic after the delivery of the baby and before
the delivery of the placenta to increase contraction of the uterus and prevent hemorrhage. The
uterotonic oxytocin reduces PPH by more than 60%. If hemorrhage occurs either in the absence of
AMTSL, or despite it, uterotonics can also be used to reduce the need for blood transfusions.
However, blood transfusions may still be necessary management to save the lives of as many as 3% of
cases of women with severe PPH. Transfusions are widely recognized as an effective intervention to
manage PPH, particularly those attributed to the most frequent cause—uterine atony . In common
global practice, blood transfusions are viewed as “best delivered” in well-equipped and well-staffed
facilities. For most cases of PPH, then, which frequently occur at some distance from a health facility,
obtaining a blood transfusion, even from a ready donor, necessitates rapid referral and transport from
the delivery site. Blood transfusions are part of the package of comprehensive emergency obstetric
care interventions that the United Nations recommends in at least one facility for every 500,000
people. Although the current facilities theoretically meet recommended levels, these facilities are not
always equitably distributed within countries.

Moreover, some designated facilities have been found to be missing the required blood
transfusion capabilities. Blood safety is also a widespread concern among the facilities in low-resource
settings that offer blood transfusions. Rapid tests exist for blood typing and for the most common

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transfusion-transmissible infections, but the use of such tests is still relatively new to low-resource
settings. Addressing the health systems challenges to ensure widespread availability of safe blood for
transfusion, including the facilities, trained staff, cold chain, and transport for women in need, should
be part of a long-term health systems development plan. However, solutions are needed more
immediately to prevent women from dying of PPH. Because of these limitations, a seemingly obvious
solution for PPH restoring lost blood at the very site of the emergency is not always a first-line
response. In fact, the WHO makes only assessing the need for blood transfusion, not the transfusion
itself, part of its recommended PPH care pathway.

Signs and Symptoms

Symptoms generally include heavy bleeding from the vagina that doesn't slow or stop over
time. Initially there may be an increased heart rate, feeling faint upon standing, and an increased
respiratory rate. As more blood is lost, the woman may feel cold, blood pressure may drop, and she
may become unconscious. Signs and symptoms of circulatory shock may also include blurry vision,
cold and clammy skin, confusion, and feeling sleepy or weak.

Risk Factors

Severe postpartum hemorrhage (PPH) is an important cause of maternal death and severe
maternal morbidity. Compared with vaginal delivery, women undergoing cesarean delivery incur the
highest risk of PPH and hemorrhage-related morbidity. Furthermore, evidence suggests that PPH
during is occurring more frequently. In the United States, between 1994 and 2006, the rate of atonic
PPH increased 160% among women undergoing after induction and 130% among women undergoing
no induced.

The International PPH Collaborative group, which comprises an international panel of clinical
epidemiologists, has called for more studies using clinically rich data to better understand relevant,
and potentially preventable, risk factors associated with PPH. Once risk factors for PPH are identified,
clinical predictive rules could be developed. Implementation of predictive rules into clinical practice
could optimize patient outcomes by improving the planning and timely mobilization of staffing and
resources before bleeding onset. For example, when an “at-risk” pregnant patient is identified before

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delivery, providers would have the opportunity to order and prepare blood products, obtain additional
venous access, and prepare additional equipment for PPH management. High-risk pregnant patients
could also receive enhanced postpartum surveillance for excessive blood loss. Finally, for high-risk
patients awaiting pre-labor, arrangements could be made for delivery in an obstetric center with the
necessary staff and resources for providing effective PPH management.

Identifying risk factors for PPH during has been challenging because key differences exist in
patient, obstetric, and intrapartum characteristics for women who undergo pre labor versus after onset
of labor or induction of labor hereafter referred to as intrapartum. Based on data from 2 population-
wide studies in Norway, the risk of PPH is reported to be higher for women undergoing intrapartum
compared with pre labor.  Although intrapartum factors, such as chorioamnionitis and oxytocin
exposure, may explain why the risk of atonic PPH is higher after labor induction, to the best of our
knowledge, only 3 studies have investigated risk factors for PPH for women who underwent elective
and non-elective or emergency. Only 1 study differentiated women by the presence or absence of labor
before. To determine whether the presence and strength of the associations between individual risk
factors and severe PPH vary among women undergoing pre labor or intrapartum, stratified analyses
are needed according to subtype. The primary objectives of this observational study were to perform 2
case-control studies to identify independent predictors for severe PPH within each of the following sub
populations: pre labor and intrapartum.

Complication

Complications from postpartum hemorrhage include orthostatic hypotension, anemia, and

fatigue, which may make maternal care of the newborn more difficult. Post-partum anemia increases
the risk of post-partum depression. Blood transfusion may be necessary and carries associated risks. In
the most severe cases, hemorrhagic shock may lead to anterior pituitary ischemia with delay or failure
of lactation (i.e., postpartum pituitary necrosis). Occult myocardial ischemia, dilutional coagulopathy,
and death also may occur. Delayed postpartum hemorrhage, bleeding after 24 hours as a result of
sloughing of the placental eschar or retained placental fragments, also can occur.

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Prognosis

The prognosis depends on the cause of the PPH, its duration, the amount of blood loss,
comorbid conditions, and the effectiveness of treatment. Prompt diagnosis and treatment are essential
to achieving the best outcome for any given patient. Most reproductive-age women will do well if
managed promptly in a setting with operative and blood-product resources available.
Consequences include the sequelae of hemorrhage; aggressive fluid resuscitation; blood-product
exposure; and procedures done to control uterine, cervical, vaginal, or peritoneal hemorrhage. 

Prevention

Oxytocin is typically used right after the delivery of the baby to prevent PPH. Misoprostol may
be used in areas where oxytocin is not available. Early clamping of the umbilical cord does not
decrease risks and may cause anemia in the baby, thus is usually not recommended.

Active management of the third stage is a method of shortening the stage between when the
baby is born and when the placenta is delivered. This stage is when the mother is at risk of having a
PPH. Active management involves giving a drug which helps the uterus contract before delivering the
placenta by a gentle but sustained pull on the umbilical cord whilst exerting upward pressure on the
lower abdomen to support the uterus (controlled cord traction).

Another method of active management which is not recommended now is fundal pressure
during the delivery of the placenta. A review into this method found no research and advises
controlled cord traction because fundal pressure can cause the mother unnecessary pain. Allowing the
cord to drain appears to shorten the third stage and reduce blood loss but evidence around this subject
is not strong enough to draw solid conclusions.

Nipple stimulation and breastfeeding triggers the release of natural oxytocin in the body,
therefore it is thought that encouraging the baby to suckle soon after birth may reduce the risk of PPH
for the mother. A review looking into this did not find enough good research to say whether or not
nipple stimulation did reduce PPH.

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Medication Treatment

The treatment of patients with PPH has 2 major components: (1) resuscitation and management
of obstetric hemorrhage and, possibly, hypovolemic shock and (2) identification and management of
the underlying causes of the hemorrhage. For the purpose of discussion, these components are
discussed separately; however, remember that successful management of PPH requires that both
components be simultaneously and systematically addressed.

Prevalence

Approximately 3% to 5% of obstetric patients will experience postpartum

hemorrhage. Annually, these preventable events are the cause of one-fourth of maternal deaths
worldwide and 12% of maternal deaths in the United States. A systematic review reported the highest
rates of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with an overall rate globally of
10.8%.The rate in both Europe and North America was around 13%. The rate is higher for multiple
pregnancies (32.4% compared with 10.6% for singletons), and for first-time mothers (12.9% compared
with 10.0% for women in subsequent pregnancies).The overall rate of severe PPH (>1000 ml) was
much lower at an overall rate of 2.8%, again with the highest rate in Africa (5.1%). PPH accounts for
one-third of all maternal deaths, with 99% of these deaths occurring in low- and middle-income
countries like Philippines in women who give birth outside of a hospital setting.

Epidemiology

Postpartum hemorrhage is the leading cause of morbidity and mortality in childbirth.  PPH
occurs in approximately 1% to 6% of all deliveries.  Uterine atony, the primary cause of PPH,
accounts for 70% to 80% of all hemorrhage.

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Etiology

Primary causes of postpartum hemorrhage include uterine atony, genital tract lacerations,
retained placenta, uterine inversion, abnormal placentation, and coagulation disorders. Uterine atony,
or lack of effective contraction of the uterus, is the most common cause of postpartum hemorrhage.

Secondary causes of postpartum hemorrhage include retained products of conception,

infection, subinvolution of the placental site, and inherited coagulation deficits.

PPH has many potential causes, but the most common, by a wide margin, is uterine atony, i.e.,
failure of the uterus to contract and retract following delivery of the baby. PPH in a previous
pregnancy is a major risk factor and every effort should be made to determine its severity and cause. In
a recent randomized trial in the United States, birth weight, labor induction and augmentation,
chorioamnionitis, magnesium sulfate use, and previous PPH were all positively associated with
increased risk of PPH. 

Abstract

Postpartum hemorrhage is common and can occur in patients without risk factors for
hemorrhage. Active management of the third stage of labor should be used routinely to reduce its
incidence. Use of oxytocin after delivery of the anterior shoulder is the most important and effective
component of this practice. Oxytocin is more effective than misoprostol for prevention and treatment
of uterine atony and has fewer adverse effects. Routine episiotomy should be avoided to decrease
blood loss and the risk of anal laceration. Appropriate management of postpartum hemorrhage requires
prompt diagnosis and treatment. The Four T's mnemonic can be used to identify and address the four
most common causes of postpartum hemorrhage (uterine atony; laceration, hematoma, inversion,
rupture; retained tissue or invasive placenta; and coagulopathy). Rapid team-based care minimizes
morbidity and mortality associated with postpartum hemorrhage, regardless of cause. Massive
transfusion protocols allow for rapid and appropriate response to hemorrhages exceeding 1,500 mL of
blood loss. The National Partnership for Maternal Safety has developed an obstetric hemorrhage
consensus bundle of 13 patient- and systems-level recommendations to reduce morbidity and mortality
from postpartum hemorrhage.

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 NURSING HEALTH HISTORY

Biographic Data

Hospital : Surigao Medical Center

Case No. : 99247

Ward : PR-28

Name of Patient : Patient P.Y

Age : 25 years old

Sex : Female

Civil Status : Common Law Wife

Address : Alipao, Alegria, Surigao Del Norte

Occupation : None

Date of Birth : April 14, 1994

Religion : Roman Catholic

Height : 153 cm

Weight : 52 kg

Gravida : 1st pregnancy

Term : Full term (38 weeks)

Pre-term : None

Abortion : None

Living :1

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Admission of Date

Mode of Transmission : Ambulatory

Date and Time of Admission : November 20, 2019 at 8:47 am

Vital Signs upon Admission

 Heart Rate : 104 bpm

 Respiratory Rate : 13 cpm
 Body Temperature : 38.1 degree Celsius
 Blood Pressure : 130/70 mmHg
 Weight : 53 kg

Admitting Physician : Catherine C. Jumawan, MD

Attending Physician : Fe Melva Mantilla Bugas, MD

Chief Complaint : Vaginal Bleeding

Impression : Markedly Thickened Endometrial

Cavity with Mixtures of Echogenic and
Sonolucent Densities Probably Blood
Clots

Final Diagnosis : PPH – Postpartum Hemorrhage

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 CLIENT HEALTH HISTORY

History of Patients Illness

Patient P.Y is a 25 years old female, a Roman Catholic and a Filipino, born on April 14, 1994.
A new mother and currently living with her family in Barangay Alipao, Alegria Surigao Del Norte.
She delivered her first child on November 17, 2019 in Tubod Hospital, Surigao Del Norte. Major
reason for seeking health care is due to vaginal bleeding on the morning of November 20, 2019 just 3
days after her labor.

Treatments/Medication:

Prescribed: None

OTC: None

Past Illness/Hospitalization:

At the age of 9 she experienced chicken pox, at 7 she was also experienced mumps and
measles at age of 5.

Allergies

She has an allergy to sea foods especially in sea urchin and prawn.

NUTRITIONAL METTABOLIC PATTERN

Before hospitalization the patient would take her breakfast 7 in the morning with a cup of
milk and usually meals are vegetables, have lunch during noon, will have a dinner mostly 8 in
the evening and drinks up to 2500-3000 mL of water per day.
During hospitalization the patients appear losing of appetite and ate her meal only half from
her food.

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ELIMINATION PATTERN

Before hospitalization the patient habit defecate 1 time a day brown, soft and form stool. The
patients also urinate 5 – 7 times per day, clear yellow urine.
During hospitalization the patients has diarrhea she defecate almost 4 times a day greenish
brown with watery stool. The patients also urinate up to 1400mL per day.

ACTIVITY EXERCISE PATTERN

Before hospitalization she always woke up early in the morning at 6:30am usually. Take bath
every day. Eat breakfast and getting ready for household chores and taking care of her baby.
Doesn’t have chest pain, fatigue, wheezing, stiffness, cramps, or joint pain or swelling with an
activity. During evening she would have dinner with his family at 7:30 pm.
During hospitalization she often asleep due to fatigue, bath through tepid sponge bath and
rarely move due to pain.

SEXUALITY-REPRODUCTION PATTERN

She is already aware of family planning,

SLEEP-REST PATTERN

Before hospitalization she doesn’t have enough sleep. She often woke up at 1 am because
she’s breastfeeding her baby. Never uses sleep medications.
During hospitalization she often asleep due to medication, weakness and fatigue.

SENSORY-PERCEPTUAL PATTERN

Vision: Doesn’t have any difficulty on her vision

Hearing: Doesn’t have any difficulty in hearing
Smell: Doesn’t have difficulty with smell, pain, postnasal drip, sneezing and nosebleed
Touch: no difficulty in touching
Taste: no difficulty in tasting foods

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COGNITIVE PATTERN

Speech clear without slur or stutter and follows verbal cues. She can recall past weekly events.
Makes major decision on her own.

ROLE-RELATIONSHIP PATTERN

The patient is already a mother of one. Has a good relationship with her common law husband,
siblings and parents. No conflict in any person in their community.

SELF-PERCEPTION-SELF-CONCEPT PATTERN

Describe herself as a friendly and happy person and likes outdoor activities like bonding with
her family and relatives at the beach.

COPING-STRESS TOLERANCE

The major stressors in her life are the house hold chores and not enough financial needs for her
family and her baby. She is coping up with her stress through talking to her family and friends
about her problems.

VALUE-BELIEF PATTERN

A Roman Catholic and attended mass every Sunday with her family. She believes that Jesus
Christ is our savior and prayer is the only communication through God.

PHYSICAL EXAMINATION

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General Physical Survey

The patient is properly groomed. Lying comfortably on bed, conscious, coherent, and oriented.

Sunken eyeballs noted, with oxygen inhalation @ 2Lpm via nasal cannula, with an IVF of D5LR 1L

@ 500cc level @ 30gtt/min hooked @ left cephalic vein, febrile, appears fatigue, thin and has pale

skin. The patient’s vital signs are the following; Blood Pressure: 130/60 mmHg, Pulse rate: 102 beats

per minutes, Respiratory rate: 16 cycle per minutes and Temperature: 38 degree Celsius.

Mental Status Examination

Conscious, coherent, and oriented; client responds appropriately. Able to recall when and who
visits a while ago for immediate memory. She can recall her name. Attentive and able to memorize,
think, read, reason and pay attention.

Skin

The patient’s skin color is pale, warm and dry to touch. Poor skin turgor noted. No edema. No
lesions or flaking.

Head and Face

No scalp lesions or flaking. Head symmetrically rounded upon palpation. Function of CN V,

pt. identifies light touch and sharp touch to forehead, cheek and chin. Her bilateral corneal reflex is
intact. Masseter muscles contract equally and bilaterally. Function of CN VII pt. smiles, frowns, shows
teeth, blow cheeks, and raises eyebrows as instructed.

Eyes

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 Sunken eyeballs noted. Eyebrows sparse with equal distribution. No scaliness noted. Lids
brown, without edema, or lesions noted. Sclera without increased vascularity or lesions noted.
Palpebral and bulbar conjunctiva pale without lesions noted. Irises uniformly black. Pupils are equally
rounded and react to light and accommodation.

Ears and Nose

Ears have no deformity, lumps or any lesions. Ears and mastoid process are non-tender.
Auricle aligned with outer canthus of eye about 10 degrees from vertical. Pinna recoils after it is
folded.

Whisper test: Client identifies words clearly. Nose is symmetrical and straight upon palpation. Nares
patent. No tenderness, masses, and displacement of bone cartilages. No redness, swelling, and
abnormal discharge on the nasal mucosa.

Mouth and Throat

Lips are pale and dry to touch, cracked lips. Teeth are complete and no teeth anomalies upon
inspection. Tonsils appear to be normal. No swelling on uvula.

Neck

Neck is symmetrical without masses and scars. Lymph nodes are non-palpable. Trachea is in
center placement in midline of neck.

Arms, Hands, and Fingers

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 Arms are equal in size and symmetry bilaterally; brown; warm and dry to touch without edema,
bruising, or lesions noted. No lesions and bruising on hands. Three flexion creases present in palm.
Fingernails are finely cut, clean and clear. No clubbing.

Posterior and Lateral Chest

Posterior lateral diameter is 1:2 ratios. Respiration rate is 16 cycle per minutes. Symmetrical
expansion on posterior thorax.

Anterior Chest

Chest symmetry is equal. Anterior lateral diameter is 1:2 ratios. Shape and position of sternum
is level with ribs. Position of trachea is in midline. No pain or tenderness in the anterior thorax.
Symmetrical expansion on anterior thorax.

Breasts (Female)

Skin is the same color as the abdomen/back. Swelling breast due to lactation, no ulcerations, or
nodules noted.

Heart

Apical pulse rate is 102 beats per minutes. No gallops or murmurs, or rubs.

Abdomen

Abdomen is uniform in color upon inspection. No rashes or lesions. No evidence of

enlargement of liver and spleen upon inspection and palpation. The hypogastric area has tenderness
due to the patient’s condition and hyperactive sounds were heard due to GI disturbance. The uterus
appears boggy and not well contracted

Legs, Feet and Toes

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 Skin intact, fair warm and dry to touch without edema. Lymph nodes are non-palpable. No
edema palpated. Toenails are finely cut, clean and clear. No clubbing.

Genitalia (Female)

Presence of bleeding and inflammation of the genital area.

Musculoskeletal and Neurologic examination

No edema noted at upper extremities. Active resistive range of motion against some resistance
noted. No deviations, inflammations, or bony deformities. Client responds appropriately. Oriented to
time and place and also oriented to people around. Able to recall when and who visits a while ago for
immediate memory. Patients can recall her name. Attentive and able to memorize, think, read, reason
and pay attention. Takes incoming information and move it into the bank of knowledge.

Cerebral and motor function: Rapidly opposes fingers to thumb bilaterally without difficulty.
Alternates pronation and supination of hands rapidly without difficulty. Heel to shin intact bilaterally.

Sensory status: Superficial light- and deep-touch sensation intact on arms, legs, neck, chest, and back.
Position sense of toes and fingers intact bilaterally.

REVIEW OF SYSTEMS

Integumentary System

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 Patient has no history of edema and burns. No history of scalp lesion or flaking pigmented
lesion, jaundice, cellulititis, and adenopathy.

Head, Eyes, Ears, Nose and Throat (EENT)

Head: Patient has no history of injuries and light headiness, vertigo.

Eyes: Patient has no conjunctivitis, visual problem, edema, lesion, scaliness, and sore eyes.

No history of double vision (Diplopia).

Ears: Patient has no history of ear infection, draining ears, lumps or lesion.

No discharged (Otorrhea). No history of ear pain (Otalgia).

No history of ear ringing (Tinnitus).

Nose: Patient has no history of Nasal bleeding (Epistaxis), nasal stuffiness.

No nasal discharged (Rhinorrhea), laryngitis.

Throat: Patient has no history in swelling of uvula, tonsillitis, sore throats.

No bleeding gums (Gingival Hemorrhage)

Gastrointestinal System
Patient has no history of nausea, diarrhea, and constipation. No history of bright red stools
(Hematochezia). No history of black tarry stools (Malana), stool incontinence (Encopresis).

Musculoskeletal System
No history of edema at both low extremities. No deviation, inflammation, or bony deformities.
No joint pain. No muscle pain.
Neurological System
Patient has no history of memory loss, seizure, dizziness, sensation changes such as numbness
and coldness.

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Urinary System
Patient has no history of any urinary tract infection. No pain in urination. No discharge.

Reproductive System
No history of bulging or masses in inguinal area. No discharge.

Hematologic or Lymphatic
Patient has no history of lymph node enlargement. No history of easy bleeding or bruising.

Endocrine
No history of Diaphoresis. No polyuria

Psychiatric
No history of depression, memory change, or suicide attempts.

LABORATORY RESULTS

HEMATOLOGY

COMPLETE BLOOD COUNT

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 November 20, 2019

TEST RESULT NORMAL UNIT SIGNIFICANC RATIONALE

VALUES E
RED BLOOD 2.64 4-6 10^12/L Decreased Anemia
CELL
HEMOGLOBIN 7.6 12-17 g/dL Decreased Anemia
HEMATOCRIT 24.2 37-54 % Decreased Anemia
MCV 91.5 87 ± 5 Fl Normal
MCH 28.8 29 ± 2 Pg Normal
PLATELET 359 150-450 10^9/L Normal
COUNT
RDW 13.9 11.6-14.6 % Normal
WHITE BLOOD 15.7 4.5-10 10^9/L Increased Infection
CELLS
TEST RESULT NORMAL VALUES UNIT
LYMPHOCYTE 14.0 20-40 % Decreased Lymphocytopenia
SEGMENTERS 88.7 50-70 % Increased Neutrophilia
MID CELL 4.7 1.0-7.0 % Normal
BLOOD TYPE “B”
RHPOSITIVE
CLOTTING 6’19” 3-6 Increased Lack of Vitamin K
TIME MINUTES
BLEEDING 3’15” 1-3 Normal
TIME MINUTES

ANALYSIS:
The result of the exam with the white blood cells count increased to 15.7 that may indicate that
the immune system is working to destroy an infection. Hemoglobin count decreased to 7.6 that may
indicate Iron deficiency that cause severe anemia. Red blood cell count decreased to 2.64 that may
indicate erythropoietin deficiency due to blood loss. Hematocrit count decreased to 24.2 that may
indicate insufficient supply of Red blood cells due to infection. Lymphocyte count decreased to 14.0

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that may indicate lymphocytopenia. Segmenters increased that respond to a bacterial infection and the
mid cell is normal.

HEMATOLOGY REPORT

NOVEMBER 22, 201

PARAMETER RESULT REF. RANGE UNIT SIGNIFICANCE RATIONALE

1. WBC 18.55 3.50-9.50 10^9/L Increased Infection

2. Neu% 75.0 40.0-75.0 % Normal
3. Lym% 8.6 20.0-50.0 % Decreased Lymphocytopenia
4. Mon% 2.0 3.0-10.0 % Normal
5. Eos% 2.4 0.4-8.0 % Normal
6. Bas% 0.3 0.0-1.0 % Normal
7. *ALY 0.1` 0.02.0 % Normal
8. *LIC 0.9 0.0-2.5 % Normal
9. RBC 3.62 3.80-5.80 10^12/L Decreased Anemia
10. HGB 10.4 11.5-17.5 g/Dl Decreased Anemia

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 11. HCT 29.6 35.0-50.0 % Decreased Anemia
12. HMT 81.8 82.0-100.0 fL Normal
13. MGH 28.7 27.0-34.0 Pg Normal
14. MCHC 35.1 31.6-35.4 g/dL g/dL
15. RDW- 12.5 11.0-16.0 % %
CV
16. PLT 412 125-350 10^9/L Increased Thrombocytosis

ANALYSIS:
The result of the exam with the white blood cells count increased to 18.55 that may indicate that
the immune system is working to destroy an infection. Hemoglobin count decreased to 10.4 that may
indicate Iron deficiency that cause severe anemia. Red blood cell count decreased to 3.62 that may
indicate erythropoietin deficiency due to blood loss. Hematocrit count decreased to 29.6 that may
indicate insufficient supply of Red blood cells due to infection. Lymphocyte count decreased to 8.6
that may indicate lymphocytopenia. Segmenters increased that respond to a bacterial infection and the
mid cell is normal

21
 HEMATOLOGY REPORT

NOVEMBER 25, 2019

PARAMETER RESULT REF. RANGE UNIT SIGNIFICANCE RATIONALE

1. WBC 18.55 3.50-9.50 10^9/L Increased Infection

2. Neu% 75.0 40.0-75.0 % Normal
3. Lym% 24.0p 20.0-50.0 % Normal
4. Mon% 2.0 3.0-10.0 % Normal
5. Eos% 2.4 0.4-8.0 % Normal
6. Bas% 0.3 0.0-1.0 % Normal
7. *ALY 0.1` 0.02.0 % Normal
8. *LIC 0.9 0.0-2.5 % Normal
9. RBC 4.01 3.80-5.80 10^12/L Decreased Anemia
10. HGB 33.0 11.5-17.5 g/Dl Decreased Anemia
11. HCT 33.0 35.0-50.0 % Decreased Anemia
12. HMT 81.8 82.0-100.0 fL Normal
13. MGH 28.7 27.0-34.0 Pg Normal
14. MCHC 35.1 31.6-35.4 g/dL g/dL
15. RDW- 12.5 11.0-16.0 % %
CV
16. PLT 385 125-350 10^9/L Increased Thrombocytosis

ANALYSIS:
The result of the exam with the white blood cells count increased to 11.4 that may indicate that
the immune system is working to destroy an infection. Hemoglobin count decreased to 33.0 that may
indicate Iron deficiency that cause severe anemia. Red blood cell count decreased to 4.01 that may
indicate erythropoietin deficiency due to blood loss. Hematocrit count decreased to 33.0 that may
indicate insufficient supply of Red blood cells due to infection. Platelets count increased that may
indicate thrombocytosis.

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 BLOOD CHEMISTRY

NOVEMBER 22, 2019

TEST RESULT REFERENCE/UNIT SIGNIFICANC RATIONALE

E
POTASSIUM 2.89 (L) 3.50- 5.30 Decreased Hypokalemia
Mmol/L

23
ANALYSIS: The result of the test in potassium count is low or decreased that may cause
hypokalemia or the level of potassium in blood is too low.

24
 BLOOD CHEMISTRY

NOVEMBER 25, 2019

TEST RESULT REFERENCE/UNI SIGNIFICANC RATIONALE

T E
POTASSIUM 2.75 (L) 3.50- 5.30 Decreased Hypokalemia
Mmol/L

ANALYSIS: The result of the test in potassium count is low or decreased that may cause hypokalemia
or the level of potassium in blood is too low.

25
26
 STOOL EXAM

November 20, 2019

RESULT SIGNIFICANCE RATIONALE

COLOR GREENISHBROWN Normal
CONSISTENCY WATERY Abnormal Diarrhea
RBC 0-2 /hpf Abnormal Occult Blood
WBC 0-1 /hpf Normal
BACTERIA ENTAMOEBAHISTO Abnormal presence of bacteria
LYTICA CYST

Analysis:

Stool exam show a Greenish brown in color due to presence of bile pigment. WBC decreased
because of infection and many bacteria in the stool of the patient.

CROSSMATCHING

PATIENTS BLOOD TYPE: “B” RH TYPE: “POSITIVE”

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DONOR’S BLOOD TYPE: “B” RH TYPE: “POSITIVE”

VOLUME: 500ML

BLOOD PRODUCT (S) OR COMPONENT: FRESH WHOLE BLOOD

SOURCE: CRHBB

EXPIRATIONDATE: DECEMBER 21, 2019

SERIAL NUMBER: NVBSP 20190292657

SEGMENT NUMBER: 00502219

CROSSMATCHING RESULT: COMPATIBLE @ 3:45PM

ULTRASOUND SECTION

NAME: PATIENT P.Y AGE: 25

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GENDER: FEMALE CASE NO: 99247

DATE TAKEN: 11/20/2019

EXAMINATION: TVS – TRANSVAGINAL ULTRASOUND

INTERPRETATION:

The uterus is enlarging (post-partum) measuring 13.9x7.6x10.5 cm. The

endometrial cavity thickness measures 1.8 with mixtures of echogenic and sonolucent desities.

No focal mass noted. The posterior cul-de-sac is empty. No masses noted at both adnexae.

IMPRESSION: MARKEDLY THICKENED ENDOMETRIAL CAVITY WITH MIXTURES

OF ECHOGENIC ANS SONOLUCENT DENSITIES PROBABLY BLOOD CLOTS.

REFERRED BY PHYSICIAN: DR. BUGAS

CECILIO B. BENITEZ, MD., F.P.C.R., F.U.S.P

RADIOLOGIST/SONOLOGIST

Anatomy and Physiology

29
The female reproductive system is designed to carry out several functions. It is made up of internal
organs and external structures. It produces the female egg cells necessary for reproduction, called the
ova or oocytes. It functions to produce gametes and reproductive hormones, just like the male
reproductive system; however, it also has the additional task of supporting the developing fetus and
delivering it to the outside world. The system is designed to transport the ova to the site of
fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes.
The next step for the fertilized egg is to implant into the walls of the uterus, beginning the initial stages
of pregnancy. If fertilization and/or implantation does not take place, the system is designed to
menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system
produces female sex hormones that maintain the reproductive cycle. Unlike its male counterpart, the
female reproductive system is located primarily inside the pelvic cavity.
The human female reproductive system contains two main parts: the uterus and the ovaries, which
produce a woman’s egg cells.

KEY POINTS

 A female’s internal reproductive organs are the vagina, uterus, fallopian tubes, cervix, and
ovary.

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  External structures include the mons pubis, pudendal cleft, labia majora and minora, vulva,
Bartholin’s gland, and the clitoris.
 The female reproductive system contains two main parts: the uterus, which hosts the
developing fetus, produces vaginal and uterine secretions, and passes the anatomically male
sperm through to the fallopian tubes; and the ovaries, which produce the anatomically female
egg cells.

KEY TERMS
Ovary: A female reproductive organ, often paired, that produces ova and in mammals secretes the
hormones estrogen and progesterone.
Oviduct: A duct through which an ovum passes from an ovary to the uterus or to the exterior (called
fallopian tubes in humans).
Vulva: consists of the female external genital organs.
Oogenesis: The formation and development of an ovum.
The human female reproductive system (or female genital system) contains two main parts:
1. Uterus
 Hosts the developing fetus
 Produces vaginal and uterine secretions
 Passes the anatomically male sperm through to the fallopian tubes
2. Ovaries
 Produce the anatomically female egg cells.
 Produce and secrete estrogen and progesterone
These parts are internal; the vagina meets the external organs at the vulva, which includes the labia,
clitoris, and urethra. The vagina is attached to the uterus through the cervix, while the uterus is
attached to the ovaries via the fallopian tubes. At certain intervals, the ovaries release an ovum, which
passes through the fallopian tube into the uterus.
If, in this transit, it meets with sperm, the sperm penetrates and merges with the egg, fertilizing it. The
fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then
implants itself in the wall of the uterus, where it begins the process of embryogenesis and
morphogenesis. When developed enough to survive outside the womb, the cervix dilates and
contractions of the uterus propel the fetus through the birth canal (vagina).

31
The ova are larger than sperm and have formed by the time an anatomically female infant is born.
Approximately every month, a process of oogenesis matures one ovum to be sent down the fallopian
tube attached to its ovary in anticipation of fertilization.
If not fertilized, this egg is flushed out of the system through menstruation. An anatomically female’s
internal reproductive organs are the vagina, uterus, fallopian tubes, cervix, and ovary.
The external components include the mons pubis, pudendal cleft, labia majora, labia minora,
Bartholin’s glands, and clitoris.
Ovaries
The ovaries are the ovum-producing organs of the internal female reproductive system.

KEY POINTS
 In addition to producing ova, the ovaries are endocrine organs and produce hormones that act
during the female menstrual cycle and pregnancy.
 Ovaries secrete estrogen and progesterone.
 Each ovary is located in the lateral wall of the pelvis in a region called the ovarian fossa.
 The ovaries are attached to the uterus via the ovarian ligament (which runs in the broad
ligament).
 Usually, the ovaries take turns releasing eggs every month; however, if one ovary is absent or
dysfunctional then the other ovary releases eggs every month.
 There are two extremities to the ovary, the tubal extremity and the uterine extremity.

KEY TERMS
 Intraperitoneal: Located within the inner layer of the peritoneum (serous membrane that
forms the lining of the abdominal cavity).
 Corpus luteum: A temporary endocrine structure in female ovaries that is essential for
establishing and maintaining pregnancy.
 Libido: A person’s overall sexual drive.
 Follicle: A spheroid cellular aggregation found in the ovaries that secretes hormones that
influence the stages of the menstrual cycle.
 Ovary: A female reproductive organ, often paired, that produces ova and in mammals secretes
the hormones estrogen and progesterone.

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The ovary is an ovum-producing reproductive organ, typically found in pairs as part of the vertebrate
female reproductive system. Ovaries in females are analogous to testes in males in that both are
gonads and endocrine glands. Ovaries secrete both estrogen and progesterone. Estrogen is responsible
for the appearance of secondary sex characteristics of females at puberty and for the maturation and
maintenance of the reproductive organs in their mature functional state. Progesterone functions with
estrogen by promoting menstrual cycle changes in the endometrium.

ANATOMICAL FEATURES

The ovaries are located in the lateral wall of each side of the pelvis in a region called the ovarian fossa.
The fossa usually lies beneath the external iliac artery and in front of the ureter and internal iliac
artery.
In humans, the paired ovaries lie within the pelvic cavity on either side of the uterus, to which they are
attached via a fibrous cord called the ovarian ligament. The ovaries are tethered to the body wall via
the suspensory ligament of the ovary. The part of the broad ligament of the uterus that covers the
ovary is known as the mesovarium. The ovary is the only organ in the human body which is totally
invaginated into the peritonium, making it the only intraperitoneal organ.
There are two extremities to the ovary, the tubal extremity and the uterine extremity. The tubal
extremity is the end to which the Fallopian tube attaches via the infundibulopelvic ligament. The
uterine extremity points downward and is attached to the uterus via the ovarian ligament.

PHYSIOLOGY AND FUNCTION

33
The ovaries are the site of egg cell production and also have specific endocrine function.

Oogenesis
The ovaries are the site of gamete (egg cell, oocyte) production. The developing egg cell (or oocyte)
grows within the environment provided by ovarian follicles. Follicles are composed of different types
and number of cells according to their maturation stage, which can be determined by their size. When
oocyte maturation is completed, a luteinizing hormone (LH) surge secreted by the pituitary gland
stimulates follicle rupture and oocyte release.
This oocyte development and release process is referred to as ovulation. The follicle remains
functional and transforms into a corpus luteum, which secretes progesterone to prepare the uterus for
possible embryo implantation. Usually each ovary takes turns releasing eggs each month. However,
this alternating egg release is random. When one ovary is absent or dysfunctional, the other ovary will
continue to release eggs each month.

Endocrine Function
Ovaries secrete estrogen, progesterone, and testosterone. Estrogen is responsible for the secondary sex
characteristics of females at puberty. It is also crucial for the maturation and maintenance of the
mature and functional reproductive organs. Progesterone prepares the uterus for pregnancy and the
mammary glands for lactation. The co-actions of progesterone and estrogen promote menstrual cycle
changes in the endometrium. In women, testosterone is important for the development of muscle mass,
muscle and bone strength, and for optimal energy level. It also has a role in libido in women.

Uterus
The uterus is the largest and major organ of the female reproductive tract that is the site of fetal growth
and is hormonally responsive.

KEY POINTS

 The body of the uterus is connected to the ovaries via the fallopian tubes, and opens into the
vagina via the cervix.

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  Two Müllerian ducts
usually form initially in a female fetus, but in humans they completely fuse into a single uterus
during gestation.
 The uterus is essential in sexual response by directing blood flow to the pelvis and to the
external genitalia, including the ovaries, vagina, labia, and clitoris.
 The reproductive function of the uterus is to accept a fertilized ovum which passes through the
utero-tubal junction from the fallopian tube.
 The lining of the uterine cavity is called the endometrium.

KEY TERMS

 Linea terminalis: Part of the pelvic brim, which is the edge of the pelvic inlet.
 Adenomyosis: A condition characterized by the breaking through of the endometrium into the
muscle wall of the uterus.
 Uterus: An organ of the female reproductive system in which the young are conceived and
develop until birth; the womb.

Endometrium: The mucous membrane that lines the uterus in mammals and in which fertilized eggs
are implanted.
Fallopian tubes: The fallopian tubes, also known as oviducts, uterine tubes, and salpinges (singular
salpinx) are two very fine tubes lined with ciliated epithelia, and lead from the ovaries of female
mammals into the uterus via the utero-tubal junction.

35
The uterus or womb is a major female hormone -responsive reproductive sex organ of most mammals
including humans. One end, the cervix, opens into the vagina, while the other is connected to one or
both fallopian tubes, depending on the species. It is within the uterus that the fetus develops during
gestation, usually developing completely in placental mammals such as humans.
Two Müllerian ducts usually form initially in a female fetus and, in humans, they completely fuse into
a single uterus depending on the species. The uterus consists of a body and a cervix. The cervix
protrudes into the vagina. The uterus is held in position within the pelvis by condensations of
endopelvic fascia, which are called ligaments. These ligaments include the pubocervical, transverse,
cervical, cardinal, and uterosacral ligaments. It is covered by a sheet-like fold of peritoneum, the broad
ligament.
The uterus is essential in sexual response by directing blood flow to the pelvis and to the external
genitalia, including the ovaries, vagina, labia, and clitoris. The reproductive function of the uterus is to
accept a fertilized ovum which passes through the utero-tubal junction from the fallopian tube. It
implants into the endometrium, and derives nourishment from blood vessels which develop
exclusively for this purpose.
The fertilized ovum becomes an embryo, attaches to a wall of the uterus, creates a placenta, and
develops into a fetus (gestates) until childbirth. Due to anatomical barriers such as the pelvis, the
uterus is pushed partially into the abdomen due to its expansion during pregnancy. Even during
pregnancy, the mass of a human uterus amounts to only about a kilogram (2.2 pounds).
The uterus is located inside the pelvis immediately dorsal (and usually somewhat rostral) to the urinary
bladder and ventral to the rectum. The human uterus is pear-shaped and about three inches (7.6 cm)
long. The uterus can be divided anatomically into four segments: The fundus, corpus, cervix and the
internal os.

Female Duct System

The Fallopian tubes, or oviducts, connect the ovaries to the uterus.

KEY POINTS
 The Fallopian tube allows passage of the egg from the ovary to the uterus.

36
  The lining of the Fallopian tubes are ciliated and have several segments, including the
infundibulum, ampullary, isthmus, and interstitial regions.
 Interspersed between the ciliated cells are peg cells, which contain apical granules and produce
the tubular fluid that contains nutrients for spermatozoa, oocytes, and zygotes.
 Occasionally, the embryo implants into the Fallopian tube instead of the uterus, creating an
ectopic pregnancy.

KEY TERMS
Oviduct: A duct through which an ovum passes from an ovary to the uterus or to the exterior.
Fallopian tubes: Also known as oviducts, uterine tubes, and salpinges (singular salpinx), two very
fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into the uterus via
the uterotubal junction.
Ovarian follicle: The basic units of female reproductive biology, each composed of roughly spherical
aggregations of cells found in the ovary.
The Fallopian tubes, also known as oviducts, uterine tubes, and salpinges (singular salpinx), are two
very fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into the
uterus via the uterotubal junction. In non-mammalian vertebrates, the equivalent structures are the
oviducts. These tubes allows passage of the egg from the ovary to the uterus.
The different segments of the fallopian tube are ( lateral to medial):
 The infundibulum with associated fimbriae near the ovary
 The ampullary region that represents the major portion of the lateral tube
 The isthmus, which is the narrower part of the tube that links to the uterus
 The interstitial (intramural) part that transverses the uterine musculature
The tubal ostium is the point at which the tubal canal meets the peritoneal cavity, while the uterine
opening of the Fallopian tube is the entrance into the uterine cavity, the uterotubal junction.

37
Vagina

The vagina is the female reproductive tract and has two primary functions: sexual intercourse and
childbirth.

KEY POINTS

 The vagina is situated between the cervix of the uterus and the external genitalia, primarily the
vulva.
 Although there is wide anatomical variation, the length of the unaroused vagina of a woman of
child-bearing age is approximately 6 to 7.5 cm (2.5 to 3 in) across the anterior wall (front) and
9 cm (3.5 in) long across the posterior wall (rear).
 During sexual arousal the vagina expands in both length and width.
 A series of ridges produced by the folding of the wall of the outer third of the vagina is called
the vaginal rugae.
 Vaginal lubrication is provided by the Bartholin’s glands near the vaginal opening and the
cervix.
 The hymen is a membrane of tissue that surrounds or partially covers the external vaginal
opening.

38
KEY TERMS

 Vulva: The vaginal opening to the uterus.

 Clitoris: A small, sensitive, and elongated erectile organ at the anterior part of the vulva in
female mammals, homologous with the penis.
 Skene’s glands: Glands located on the anterior wall of the vagina, around the lower end of the
urethra, that drain into the urethra and near the urethral opening. These may be near or part of
the G-spot.
 Vagina: A fibromuscular tubular tract which is the female sex organ and has two main
functions, sexual intercourse and childbirth.

The vagina, a female sex organ, is a fibromuscular tubular tract that has two main functions: sexual
intercourse and childbirth. In humans, this passage leads from the opening of the vulva to the uterus,
but the vaginal tract ends at the cervix.

ANATOMY OF THE VAGINA

The vaginal opening is much larger than the urethral

opening. During arousal, the vagina gets moist to
facilitate the entrance of the penis. The inner texture of
the vagina creates friction for the penis during
intercourse.
The vaginal opening is at the caudal end of the
vulva behind the opening of the urethra. The
upper quarter of the vagina is separated from the
rectum by the rectouterine pouch. The vagina
and the inside of the vulva are a reddish-pink
color, as are most healthy internal mucous
membranes in mammals. A series of ridges
produced by the folding of the wall of the outer
third of the vagina is called the vaginal rugae.
These transverse epithelial ridges and provide the vagina with increased surface area for extension and
stretching.

39
Vaginal lubrication is provided by the Bartholin’s glands near the vaginal opening and the cervix. The
membrane of the vaginal wall also produces moisture, although it does not contain any glands. Before
and during ovulation, the cervix’s mucus glands secrete different variations of mucus, which provides
an alkaline environment in the vaginal canal that is favorable to the survival of sperm.
The hymen is a membrane of tissue that surrounds or partially covers the external vaginal opening.
The tissue may or may not be ruptured by vaginal penetration. It can also be ruptured by childbirth, a
pelvic examination, injury, or sports. The absence of a hymen may not indicate prior sexual activity.
Similarly, its presence may not indicate a lack of prior sexual activity.

FUNCTION OF THE VAGINA

The vagina’s primary functions are sexual arousal and intercourse as well as childbirth.

Vulva
The vulva is the external genitalia of the female reproductive tract, situated immediately external to
the genital orifice.

KEY POINTS
 Major structures of the vulva include the labia major and minora, mons pubis, clitoris, bulb of
vestibule, vulva vestibule, vestibular glands, and the genital orifice (or opening of the vagina).
 The vulva is rich in nerves that are stimulated during sexual activity and arousal.
 The vulva also contains the opening of the female urethra and thus serves the vital function of
passing urine.
KEY TERMS
 Labia minora: The two inner folds of skin within the cleft of the labia majora.
 Vulva: The vaginal opening to the uterus.
 Mons pubis: A fleshy protuberance over the pubic bones that becomes covered with hair
during puberty.
 Labia majora: The two outer rounded folds of adipose tissue that lie on either side of the
opening of the vagina.
The vulva consists of the external genital organs of the female mammal. Its development occurs
during several phases, chiefly during the fetal and pubertal periods.

40
As the outer portal of the human uterus or womb, the vulva protects its opening with a “double door”:
the labia majora (large lips) and the labia minora (small lips). The vulva also contains the opening of
the female urethra, and thus serves the vital function of passing urine.
In human beings, major structures of the vulva are:
 The mons pubis
 The labia majora and the labia minora
 The external portion of the clitoris and the clitoral hood
 The vulval vestibule
 The pudendal cleft
 The frenulum labiorum pudendi or fourchette
 The opening (or urinary meatus) of the urethra
 The opening (or introitus) of the vagina
 The hymen
Other notable structures include:
 The perineum
 The sebaceous glands on labia majora
 The vaginal glands (Bartholin’s glands and paraurethral or Skene’s, glands)
The soft mound at the front of the vulva, the mons pubis, is formed by fatty tissue covering the pubic
bone. The mons pubis separates into two folds of skin called the labia majora, literally “major (or
large) lips.” The cleft between the labia majora is called the pudendal cleft, or cleft of Venus, and it
contains and protects the other, more delicate structures of the vulva. The labia majora meet again at
the perineum, a flat area between the pudendal cleft and the anus. The color of the outside skin of the
labia majora is usually close to the individual’s overall skin color although there is considerable
variation.

The inside skin and mucus membrane are often pink or brownish. After the onset of puberty, the mons
pubis and the labia majora become covered by pubic hair. This hair sometimes extends to the inner
thighs and perineum, but the density, texture, color, and extent of pubic hair coverage vary
considerably due to both individual variation and cultural practices of hair modification or removal.
The labia minora are two soft folds of skin within the labia majora.

41
The clitoris is located at the front of the vulva where the labia minora meet. The visible portion of the
clitoris is the clitoral glans, roughly the size and shape of a pea. The clitoral glans is highly sensitive,
containing as many nerve endings as the analogous organ in males, the glans penis. The point where
the labia minora attach to the clitoris is called the frenulum clitoridis. A prepuce, the clitoral hood,
normally covers and protects the clitoris; however, in women with particularly large clitorises or small
prepuces, the clitoris may be partially or wholly exposed. The clitoral hood is the female equivalent of
the male foreskin and may be partially hidden inside of the pudendal cleft.

The area between the labia minora is called the vulval vestibule, and it contains the vaginal and
urethral openings. The urethral opening (meatus) is located below the clitoris and just in front of the
vagina. This is where urine passes from the urinary bladder.

The opening of the vagina is located at the bottom of the vulval vestibule toward the perineum. The
term introitus is more technically correct than “opening,” since the vagina is usually collapsed, with
the opening closed unless something is inserted. The introitus is sometimes partly covered by a
membrane called the hymen. The hymen will rupture during the first episode of vigorous sex, and the
blood produced by this rupture has been traditionally seen as a sign of virginity. However, the hymen
may also rupture spontaneously during exercise or be stretched by normal activities such as use of
tampons. Slightly below and to the left and right of the vaginal opening are two Bartholin glands
which produce a waxy, pheromone-containing substance, the purpose of which is not yet fully known.

42
Perineum
The perineum is the region between the genitals and the anus, including the perineal body and
surrounding structures.

KEY POINTS
 The perineum refers to both external and deep structures.
 Perineal tears and episiotomy often occur in childbirth with first-time deliveries, but the risk of
these injuries can be reduced by preparing the perineum through massage.
 The perineum is an erogenous zone for both males and females.
KEY TERMS
 Lower rabbus: The term for perineum often used in the UK.
 Perineum: The region of the body inferior to the pelvic diaphragm and between the legs. It is a
diamond-shaped area on the inferior surface of the trunk which includes the anus and, in
females, the vagina.
 Episiotomy: A surgical incision through the perineum made to enlarge the vagina and assist
childbirth.
 Perineal body: A pyramid-shaped fibromuscular mass in the middle line of the perineum at the
junction between the urogenital triangle and the anal triangle.
In human anatomy, the perineum is the surface region between the pubic symphysis and coccyx in
both males and females, including the perineal body and surrounding structures. The boundaries vary
in classification but
generally include the
genitals and anus. It is an
erogenous zone for both
males and females.
The term perineum may
refer to only the
superficial structures in
this region or be used to
include both superficial
and deep structures. The

43
term lower rabbus is used colloquially in the UK to describe this structure. Perineal tears and
episiotomy often occur in childbirth with first-time deliveries, but the risk of these injuries can be
reduced by preparing the perineum through massage.
The perineum corresponds to the outlet of the pelvis. Its deep boundaries are:
 The pubic arch and the arcuate ligament of the pubis
 The tip of the coccyx
 The inferior rami of the pubis and ischial tuberosity, and the sacrotuberous ligament
The perineum includes two distinct regions separated by the pelvic diaphragm. Its structures include:
 Superficial and deep perineal pouches
 Ischioanal fossa, a fat-filled space at the lateral sides of the anal canal bounded laterally by
obturator internus muscle, medially by pelvic diaphragm and the anal canal.
 Anal canal
 Pudendal canal, which contains internal pudendal artery and the pudendal nerve
Mammary Glands
A mammary gland is an organ in female mammals that produces milk to feed young offspring.
 Mammary glands are not associated with the female reproductive tract, but develop as
secondary sex characteristics in reproductive-age females.

 The basic components of a mature mammary gland are the alveoli, hollow cavities, a few
millimeters large lined with milk-secreting cuboidal cells and surrounded by myoepithelial cells.

 Alveoli join up to form groups known as lobules, and each of which has a lactiferous duct that
drains into openings in the nipple.

 Secretory alveoli develop mainly in pregnancy, when rising levels of prolactin, estrogen, and
progesterone cause further branching, together with an increase in adipose tissue and a richer
blood flow.

Key Terms

 Wnts: Morphogenic signaling proteins that regulate cell-cell interactions.

 beta-1 integrin: One of the regulators of mammary epithelial cell growth and
differentiation.

44
 mammary gland: A gland that secretes milk for suckling an infant or offspring.
 lactiferous duct: The components that form a branched system connecting the lobules of the
mammary gland to the tip of the nipple.

45

Predisposing factors:
 Age: 25 years old
 Sex: Female
 Induction of Labor
 Postpartum Complication
 Lives in rural area
(Alipao, Alegria SDN)
Retained Placental Fragments
Inability of the uterus to
 Infection
 Hyperthermia (fever)
Metronidazole 500mg/tab
Paracetamol 500 mg/tab
Laceration of the Perineum
Pain
Ketorolac 500mg/tab
Mefenamic acid 500mg/tab
PATHOPHYSIOLOGY
Precipitating factors:
 Poor uterine contractions
 Retained Placental Products
 Tear in the uterus
 Infection
 Incomplete Placental
Removal
Uterine Atony
contract fully
D5LR with 10
units of Oxcytocin
Presence of perineal
trauma
KCl 500mg/tab
Uterine Bleeding Occurs
Decreased Hemoglobin level
Decreased Hematocrit level
Decreased Red Blood Cell
Increased Platelets
Administration of Fresh
whole blood via BT 46
 Postpartum Hemorrhage
Dilatation & Curettage Blood Loss >500 ml

If left untreated: If treated:

If infection is severe If infection is prevented

Peritonitis Restore fluid and electrolyte

balance
Improved sense of energy
Serious fluid volume deficit

Hypovolemic shock Well live

Death Well

LEGEND:

= Disease Process

= Client Manifestation

= Clinical Manifestation

= Treatment/management

= If Left Untreated

= If treated

= Death

= Well

47
 Pathophysiology

The predisposing factors aforementioned which are prolonged labor, retained placenta
products, chorioamnionitis, hydramnios, obesity and raised body mass index, caesarian delivery and
induction of labor are mostly one of the reasons as to why a patient develop postpartum hemorrhage.
The precipitating factors which are the placental abruption, placental previa, overdistended uterus,
multiple pregnancies, preeclampsia, infection, blood clotting disorders, tear in the cervix or vaginal
tissues significantly implies about the conditions that may increase the risk of having postpartum
hemorrhage.
The process of obtaining the said problem started as when the patient P.Y. was admitted at
SMC, having an identification of the problem as Severe Anemia secondary to Late Postpartum
Hemorrhage secondary to Retained Secundines. With this admitting diagnosis, an impression was
made that patient P.Y. has a thickened Endometrial Cavity with mixtures of Echogenic and Sonolucent
Densities probably blood clots that correlates to the chief complaint from the patient P.Y.’s chart.
With the underlying condition of patient P.Y, a collaboration was initiated and it was decided
that an operative procedure will be made to check and clean possible blood clots that were
accumulated inside and as the operative procedure was successfully done it was found out that the
patient P.Y. has Puerperal Sepsis, an infection of the genital tract occurring at any time between the
onset of rupture membranes or labour.
The resulted values that was based from Hematology Analysis Report indicate that patient P.Y
has a low level of potassium in blood known as hypokalemia that usually results from (vomiting,
diarrhea, adrenal gland disorders, or use of diuretics), has high white blood cell count which can only
mean as an indication of another problem such as (infection, stress, inflammation, trauma, allergy or
certain disease), low hemoglobin level that implies patient P.Y. has iron deficiency that caused severe
anemia to occur, low hematocrit level due to having a bleeding specifically vaginal bleeding, and a
high level of platelet due to the occurrence of infection or other condition such iron-deficiency anemia
or simply insufficient iron in the body causing to have a condition known as thrombocytosis, an
excessive number of platelets in the blood.

DRUG STUDY

48
No.1

Generic name: Paracetamol Contraindications

Brand name: BIOGESIC Hypersensitivity to acetaminophen or

phenacetin; use with alcohol
Dosage: 500 mg/tab 1 tab

Route: Oral
Adverse effect
Frequency: PRN
 Hematologic: Hemolytic anemia,
Classification: Analgesic, Antipyretic
leukopenia, neutropenia, pancytopenia,
Mechanism of action: thrombocytopenia.
Paracetamol may cause analgesia by inhibiting  Hepatic: Liver damage, jaundice
CNS prostaglandin synthesis. The mechanism  Metabolic: Hypoglycemia
of morphine is believed to involve decreased  Skin: Rash, urticuria
permeability of the cell membrane to sodium,
Nursing Responsibility
which results in diminished transmission of
pain impulses therefore analgesia.  Assess patient’s fever or pain: type of
pain, location, intensity, duration,
Indications:
temperature, and diaphoresis.
To relieve mild to moderate pain due to things  Assess allergic reactions: rash,
such as headache, muscle and joint pain, urticaria; if these occur, drug may have
backache and period pains. It is also used to to be discontinued.
bring down a high temperature. For this reason,  Teach patient to recognize signs of
paracetamol can be given to children after chronic overdose: bleeding, bruising,
vaccinations to prevent post-immunization malaise, fever, sore throat.
pyrexia (high temperature). Paracetamol is  Tell patient to notify prescriber for
often included in cough, cold and flu remedies pain/ fever lasting for more than 3 days.

DRUG STUDY

No. 2 Generic name: Metoclopromide

49
Brand name: PLASIL

Dosage: 10 mg (1 amp.) caution in Parkinson's disease since, as a

dopamine antagonist, it may worsen symptoms.
Route: IV
It is contraindicated for people with a
Frequency: q 8°x3 doses suspected bowel obstruction, in epilepsy, if a

Classification: Anti-emetics stomach operation has been performed in the

previous three or four days, if the person has
Mechanism of action:
ever had bleeding, perforation or blockage of
Metoclopromide blocks dopamine receptors the stomach, and in newborn babies.
and makes GI cells more sensitive to
Adverse effect
acetylcholine, leading to increase GI activity
and rapid movement of food through upper GI  CNS: Drowsiness, extrapyramidal
tract. reaction, restlessness, anxiety,
depression, irritability
Indications:
 CV: Arrthymias, hypertension,
Prevention of chemotherapy-induced emesis, hypotension
treatment of postsurgical and diabetic gastric  GI: Constipation, diarrhea, dry mouth,
stasis, facilitation of small bowel intubations in nausea
radiographic procedures, management of
Nursing Responsibility
esophageal reflex, treatment and prevention of
postoperative nausea and vomiting when  Assess for extrapyramidal symptoms
and tardive dyskinesia (more likely in
nasogastric suctioning is undesirable.
older patients).
 Assess for gastrointestinal complaints,
Contraindications: such as nausea, vomiting and
constipation.
Metoclopramide is contraindicated  In oral administration, for better
in pheochromocytoma. It should be used with absorption allow 30 minutes to one
hour before eating.

DRUG STUDY

No. 3 Generic name: Pantroprazole

50
Brand name: PROTONIX Adverse effect

Dosage: 40 mg (1 vial)  changes in vision

Route: IV  diarrhea (watery and severe; may also

be bloody)
Frequency: OD
 yellow skin/eyes
Classification: Proton pump inhibitors  abdominal pain

Mechanism of action  dark urine

 clay-colored stools
Is to inhibit the final step in gastric acid
 loss of appetite
production
Nursing Responsibility
Indications
 Advice female patients to notify health
Proton pump inhibitors are used to treat
care professional if pregnancy is
conditions such as stomach ulcers, intestinal
planned/suspected or if breast feeding.
ulcers, and gastroesophageal reflux disease
 Decrease in abdominal pain heartburn,
(GERD, reflux esophagitis) by reducing the
gastric irritation, and bleeding in patient
amount of acid the stomach produces.
with GERD, may require up to 4 weeks
Contraindications of therapy.

Protonix is contraindicated in patients with  Healing in patients with erosive

known hypersensitivity to any component of esophagitis.

the formulation or any substitited

benzimidazole. Hypersensitivity reactions may
include anaphylaxis, anaphylactic shock,
angiodema, bronchospasm, acute interstitial
nephritis and urticaria.

DRUG STUDY

No. 4 Brand name: RACECADOTRIL

Generic name: Hidrasec Dosage: 100 mg/1cap

51
Route: Oral such as erythema multiforme.Tender red lumps
under the skin, usually on the calves(erythema
Frequency: TID
nodosum).
Classification: Anti-diarrheal

Mechanism of action
Adverse effect
It inhibits the enzyme enkaphalinase in the
 Swelling of face, tongue, lips or
small intestine, thereby reducing the intestinal
eyelids.
hypersection of water and electrolyte induced
 Severe skin rash such as rash, hive
by cholera toxin or inflammatory.
 Drowsiness
 Vomiting
Indications  Nausea

It inhibits the enzyme enkaphalinase in the Nursing Responsibility

small intestine, thereby reducing the intestinal
 Assess for extrapyramidal
hypersection of water and electrolyte induced
symptoms and tardive dyskinesia
by cholera toxin or inflammatory.
(more likely in older patients).
Contraindications  Assess for gastrointestinal

Stop using Hidrasec and see your doctor if you complaints, such as nausea,

get any of these. Swelling of the face, tongue, vomiting and constipation.

lips or eyelids. Severe skin rash  In oral administration, for better

absorption allow 30 minutes to one
hour before eating.
 Rinse mouth frequently to combat
dryness.

DRUG STUDY

No. 5 Dosage: 500 mg/tab 1 tab

Generic name: Mefenamic Acid Route: Oral

Brand name: PONSTAN Frequency: q 6°

52
Classification: Nonsteroidal anti-inflammatory cramps, flatus, constipation, hepatic
drugs (NSAIDs) toxicity.
 Hematologic: Prolonged prothrombin
Mechanism of action
time, severe autoimmune hemolytic
It inhibits the enzyme enkaphalinase in the anemia (long-term use), leukopenia,
small intestine, thereby reducing the intestinal eosinophilia, agranulocytosis,
hypersection of water and electrolyte induced thrombocytopenic purpura,
by cholera toxin or inflammatory. megaloblastic anemia, pancytopenia,
Indications bone marrow hypoplasia.
 Urogenital: Nephrotoxicity, dysuria,
Mefenamic acid is used to treat painful
albuminuria, hematuria, elevation of
conditions such as arthritis, pain associated
BUN.
with heavy menstrual bleeding, and pain after
 Skin: Urticaria, rash, facial edema.
surgical operations.
 Spec Senses: Eye irritation, loss of
color vision (reversible), blurred vision,
Contraindications ear pain.
 Body Whole: Perspiration.
Mefenamic acid is contraindicated in the
 CV: Palpitation.
following patients: known hypersensitivity
 Respiratory: Dyspnea; acute
(e.g. anaphylatic reactions and serious skin
exacerbation of asthma;

reactions) to mefenamic acid/any components

of the drug product.

Adverse effect

 CNS: Drowsiness, insomnia, dizziness,

nervousness, confusion, headache.
 GI: Severe diarrhea, ulceration, and
bleeding; nausea, vomiting, abdominal

53
 bronchoconstriction
sensitive to aspirin).
Nursing Responsibility
(in patients  Monitor blood glucose for loss of
glycemic control if diabetic.
 Do not breast feed while taking this
drug without consulting physician.

 Assessment & Drug Effects

 Assess patients who develop severe

diarrhea and vomiting for
dehydration and electrolyte
imbalance.
 Lab tests: With long-term therapy
(not recommended) obtain periodic
complete blood counts, Hct and
Hgb, and kidney function tests.

 Patient & Family Education

 Discontinue drug promptly if
diarrhea, dark stools, hematemesis,
ecchymosis, epistaxis, or rash occur
and do not use again. Contact
physician.
 Notify physician if persistent GI
discomfort, sore throat, fever, or
malaise occur.
 Do not drive or engage in potentially
hazardous activities until response to
drug is known. It may cause
dizziness and drowsiness.

DRUG STUDY

No. 6 Generic Name: Metronidazole

54
Brand Name: FLAGYL  first trimester of pregnancy

Actual Dose: 500 mg/ 1 tab

Adverse Reactions
Route: Oral
 CNS: seizures, dizziness, headache
Frequency: TID
 EENT: Tearing(topical only)
Classification: Antibiotic, Antibacterial,
 GI: abdominal pain, anorexia, nausea
Antiprotozoal
and vomiting, diarrhea, dry mouth,
glossitis
 Derm: rashes, urticarial, mild dryness,
Mechanism of action
skin irritation
Inhibits growth of amoebae by binding to
 Hemat: leukopenia
DNA, resulting in loss of helical structure,
 Local: Phlebitis at Iv site
strand breakage, inhibition of nucleic acid
 Neuro: peripheral neuropathy
synthesis and cell death.
 Misc: superinfection


Indication Nursing Responsibilities

 Acute infection with susceptible  Observe the 10 Rs before giving the

anaerobic bacteria drug.
 Acute intestinal amoebiasis  Instruct to take drug with food or milk
to decrease GI upset

Contraindication  Inform that drug may turn urine brown,

don’t be alarmed
 Active organic disease of the CNS
 Drug Allergy
 Blood dyscrasia

Before

 Assess pts. Infection

 watch carefully for edema because it
 hypersensitivity
may cause sodium retention
 hypersensitivity to parabens

55
  assess skin for severity areas of local  may cause dizziness/ light headedness
adverse reactions
 record number and character of stools
 assess pt’s and family’s knowledge of
drug therapy

During

 give drug with meals to minimize GI

distress
 to treat trichomoniasis, give drug for
7days instead of 2-g single dose
 use only after T.vaginalis has been
confirmed by wet smear
 Tablets may be crushed for pt’s. with
difficult swallowing
 do not use aluminium needles or hubs,
color will turn orange/rust

After

 tell pt. that metallic taste and dark or

red brown urine may occur
 instruct pt. to take oral form with meals
to minimize reactions
 instruct to complete full course of
therapy
 Tell pt. not to use alcohol or drugs that
contain alcohol.

DRUG STUDY

No. 7 Generic name: Potassium Chloride

56
Brand name: KCl prolonged diuresis, diabetic acidosis. Effective
in the treatment of hypokalemic alkalosis
Dosage: 500mg/1 Tab
(chloride, not the gluconate).
Route: Oral
Contraindications  
Frequency: TID
Severe renal impairment; severe hemolytic
Classification: Electrolytic and water balance
reactions; untreated Addison’s disease; crush
agent; replacement solution
syndrome; early postoperative oliguria (except
during GI drainage); adynamic ileus; acute
dehydration; heat cramps, hyperkalemia,
Mechanism of action
patients receiving potassium-sparing diuretics,
Principal intracellular cation; essential for digitalis intoxication with AV conduction
maintenance of intracellular isotonicity, disturbance.
transmission of nerve impulses, contraction of
cardiac, skeletal, and smooth muscles, Adverse effect
maintenance of normal kidney function, and
 GI: Nausea, vomiting, diarrhea,
for enzyme activity. Plays a prominent role in
abdominal distension
both formation and correction of imbalances in
 Body Whole: Pain, mental confusion,
acid–base metabolism.
irritability, listlessness, paresthesias of
extremities, muscle weakness and
Indications
heaviness of limbs, difficulty in

To prevent and treat potassium deficit swallowing, flaccid paralysis

secondary to diuretic or corticosteroid therapy.  Urogenital: Oliguria, anuria

Also indicated when potassium is depleted by  Hematologic: Hyperkalemia

severe vomiting, diarrhea; intestinal drainage,  Respiratory: Respiratory distress
fistulas, or malabsorption;  CV: Hypotension, bradycardia; cardiac
depression, arrhythmias, or arrest;
altered sensitivity to digitalis
glycosides. ECG changes in
hyperkalemia: Tenting (peaking) of T
wave (especially in right precordial

57
 leads), lowering of R with deepening of F); may result from any therapeutic
S waves and depression of RST; dosage, and the patient may be
prolonged P-R interval, widened QRS asymptomatic.
complex, decreased amplitude and  The risk of hyperkalemia with
disappearance of P waves, prolonged potassium supplement increases (1)
Q-T interval, signs of right and left in older adults because of
bundle block, deterioration of QRS decremental changes in kidney
contour and finally ventricular function associated with aging, (2)
fibrillation and death. when dietary intake of potassium
suddenly increases, and (3) when
kidney function is significantly
Nursing Responsibility compromised.
 Assessment & Drug Effects
 Patient & Family Education
 Monitor I & O ratio and pattern in
patients receiving the parenteral  Do not be alarmed when the tablet
drug. If oliguria occurs, stop carcass appears in your stool. The
infusion promptly and notify sustained release tablet (e.g., Slow-
physician. K) utilizes a wax matrix as carrier

 Lab test: Frequent serum for KCl crystals that passes through

electrolytes are warranted. the digestive system.

 Monitor for and report signs of GI  Learn about sources of potassium

ulceration (esophageal or epigastric with special reference to foods and

pain or hematemesis). OTC drugs.

 Monitor patients receiving  Avoid licorice; large amounts can

parenteral potassium closely with cause both hypokalemia and sodium

cardiac monitor. Irregular heartbeat retention.

is usually the earliest clinical  Do not use any salt substitute unless
indication of hyperkalemia. it is specifically ordered by the

 Be alert for potassium intoxication physician. These contain a

(hyperkalemia, see S&S, Appendix

58
 substantial amount of potassium and
electrolytes other than sodium.
 Do not self-prescribe laxatives.
Chronic laxative use has been
associated with diarrhea–induced
potassium loss.
 Notify physician of persistent
vomiting because losses of
potassium can occur.
 Report continuing signs of
potassium deficit to physician:
Weakness, fatigue, polyuria,
polydipsia.
 Advise dentist or new physician that
a potassium drug has been
prescribed as long-term maintenance
therapy.
 Do not open foil-wrapped powders
and tablets before use.
 Do not breast feed while taking this
drug without consulting physician.

DRUG STUDY

59
No. 8 Contraindication

Generic Name: Ketorolac  This drug should be use cautiously

with patients who have impaired
Brand Name: TORADOL
hearing, allergies, and
Actual Dose: 30 mg/ 1 amp. cardiovascular/gastrointestinal/hepat
Route: Oral ic conditions.
 It is contraindicated during labor and
Classification: Nonsteroidal anti-inflammatory
delivery and mothers who gives
drugs (NSAIDs)
breastfeeding to their baby.
 Contraindicated to patients who

Mechanism of action wears soft contact lenses.

 Contraindicated to patients who use
Used as anti-inflammatory that inhibits
NSAIDS simultaneously.
leukotriene and prostaglandin synthesis. This
 Contraindicated to patients who
drug should only be used in a short term basis
have a history of gastrointestinal
especially in the treatment of pain (up to five
bleeding or peptic ulcer.
days). It is also used for ophthalmic relief of
 Contraindicated to patients who are
ocular itching brought by seasonal
suspected or confirmed
conjunctivitis and in cases of postoperative
cerebrovascular bleeding.
inflammation after cataract surgery.

Adverse Reactions
Indication
 Respiratory: Rhinitis, hemoptysis,
Indicated for tje shirt-term (<_5 days) dyspnea
management of moderately severe acute pain  GI: GI pain, diarrhea, vomiting, and
that requires analgesic at the opioid level, nausea
usually in a postoperative setting.
 CNS: Dizziness, fatigue, insomnia,
headache

60
  Hematologic:Neutropenia, leukopenia,
decreased Hgb or Hct, bone marrow
depression
 Dermatologic: Sweating, dry mucous
membrane, pruritus
Nursing Interventions/Considerations:
 Don’t forget to assess first the patient
before administering this drug: know the
history (e.g. allergies, renal impairment,
etc.) and physical condition of the
patient (reflexes, ophthalmologic and
DRUG STUDY
audiometric evaluation, orientation,
clotting times, serum electrolytes, etc.)
 In case of hypersensitivity, be sure that
emergency equipment is available.
 Drug vials should be protected from
light.
 To maintain serum levels and control
pain effectively, administer it every six
hours.
 Report any signs of itching, swelling in
the ankles, sore throat, easy bruising, etc.
61
No. 9

Generic name: Oxytocin

Brand name: PITOCIN Adverse effect

Dosage: 10 units/ml (1 amp.)  Nausea

Route: IV  Hypertension
 Vomiting
Frequency: PRN
 Anoxia
Classification: Uterine Active Agents
Nursing Responsibility
Mechanism of action
 Continuously monitor constraction,
Produce phasic contraction characteristics of fetal and maternal heart rate, and
normal delivery. Promotes milk ejection reflex maternal blood pressure and ECG.
in nursing mother.  Discontinue infusion if uterine

Indications hyperactivity occurs.

 Monitor patient extremely closely
Iniation or improvement of uterine
during first and second stages of
contractions to achieve early vaginal delivery
labor because of risk of cervical
for maternal of fetal reasons.
laceration, uterine rupture and
Control of Postpartum Bleeding or maternal and fetal death.
Hemorrhage.  Assess fluid intake and output.
Watch for signs and symptoms of
Contraindications
water intoxication.
Hypersinsivity to drug when vaginal delivery.
Cephalopelvic disproportion is present.

NURSING CAREPLAN #1

Assessment

62
 Objective:

 Changes in the mental status.

 Concentrated urine.
 Delayed capillary refill >3 seconds
 Decrease in the red blood cell count (hematocrit: 24.2)
 Decrease blood pressure (hypotension). BP: 100/70mmHg
 Dry skin/mucous membrane (Pale skin, sunken eyeball)

Nursing diagnosis: Deficient Fluid Volume related to excessive blood loss.

Planning: After `1-2 days of nursing intervention the patient will demonstrate improvement in the
fluid balance as evidenced by a good capillary refill, adequate urine output, and good skin turgor.

Nursing intervention Rationale

INDEPENDENT

Assessed and recorded the type, amount, and site The amount of blood loss and the presence of
of the bleeding; Counted and weighed perineal blood clots will help to determine the appropriate
pads and saved blood clots to be evaluated by the replacement need of the patient.
physician.

Monitored vital signs including systolic and Increased heart rate, low blood pressure, cyanosis,
diastolic blood pressure, pulse and heart rate. delayed capillary refill indicates hypovolemia and
Checked for the capillary refill and observed nail impending shock. Decrease fluid volume of 30-
beds and mucous membranes. 50% will reflect changes in the blood pressure.

Measured a 24-hour intake and output. Observed This will help in determining the fluid loss.
for signs of voiding difficulty.
A urine output of 30-50 ml/hr or more indicates an

63
 adequate circulating volume. Voiding difficulty
may happen with hematomas in the upper portion
of the vagina causing pressure in the urethra.

Maintained a bed rest with an elevation of the legs The position increases venous return, making sure
by 20-30° and trunk horizontal. a greater availability of blood to the brain and
other vital organs. Bleeding may be decreased
with the bed rest.

DEPENDENT

Blood transfusion (1 bag 500 ml fresh whole This is important for rapid or multiple infusions of
blood) fluids and blood products to increase circulating
volume and enhance clotting.
IVF (D5LR + 10 units oxytocin)
Oxytocin increase contractility of the boggy uterus
and myoterium, and stop hemorrhage in the
presence of atony.

Evaluation: Goal met, the patient was able to demonstrate improvement in the fluid balance as
evidenced by a good capillary refill, adequate urine output, and good skin turgor.

NURSING CAREPLAN #2

Assessment:

Subjective: “Grabe man ka paso sa ija lawas ma’am” as verbalized by the S.O

Objective:

64
  Body temperature above the normal range (39.4 degree Celsius)
 Hot, flushed skin
 Increased heart rate (104bpm)
 Increased respiratory rate (23 cpm)
 Loss of appetite
 Malaise or weakness

Nursing diagnosis: Hyperthermia related to illness.

Planning: After 1-2 hours of nursing interventions the patient will maintain body temperature within
normal range.

Nursing intervention Rationale

INDEPENDENT

Provided Tepid sponge bath. To decreased temperature by means through

evaporation and conduction.

Provided clean and cool environment To make the patient comfortable.

Monitored vital sign. High temperature indicates infection.

DEPENDENT

Administered Paracetamol 500mg/tab every 4 To relieve mild to moderate pain due to things
hours. such as headache, muscle and joint pain, backache
and period pains. It is also used to bring down a
high temperature.

Evaluation: Goal met, the patient was able to maintained body temperature within normal range.

65
66
 NURSING CAREPLAN #3

Assessment:

Subjective: “Sakit ako tijan ma’am” as verbalized by the patient.

Objective:

 loose liquid stool (entamoeba histolytica cyst)

 abdominal cramps
 nausea
 increased bowel sound

Nursing diagnosis: Diarrhea related to Infection

Planning: After 1-2 days of nursing intervention, patient will report reestablish and maintain normal
pattern of bowel functioning.

Nursing intervention Rationale

INDEPENDENT

Auscultated the abdomen. To determine the location, and characteristic of

bowel sound.

Limited caffeine, high fiber foods, and fatty foods. To prevent gastric irritation.

Encouraged patient to restrict solid food intake. To allow for bowel rest and reduce intestinal
workload.

DEPENDENT

Administered anti-diarrheal medication Hidrasec

67
500mg/tab. To decrease G.I. motility and minimize fluid
loosed.

Evaluation: Goal met, the patient was able to report maintain normal pattern in bowel functioning.

NURSING CAREPLAN #4

68
Assessment:

Subjective: “Luja ako lawas ma’am” as verbalized by the patient.

Objective:

 Lethargy
 Alteration in concentration
 Drowsiness
 Deceased performance
 Restlessness

Nursing diagnosis: Fatigue related to physical condition.

Planning: After 8 hours of nursing intervention, patient will report improved sense of energy.

Nursing intervention Rationale

INDEPENDENT

Assessed vital signs. To evaluate fluid status and cardiopulmonary

response to activity.

Determined presence/degree of sleep disturbance. Fatigue can be a consequence of, and/or

exacerbation by, sleep deprivation.

Assessed the patient’s ability to perform activities Fatigue can limit the patient’s ability to participate
of daily living (ADL). in self-care and perform is or her role
responsibility.

Assessed the patient’s emotional response to To assess in evaluating the impact on the patient’s

69
fatigue. life.

Encouraged the patient to use assistive devices. To use assistive device can minimize energy
expertiture and prevent injury with activities

Evaluation: Goal met, the patient was able to improved sense of energy.

NURSING CAREPLAN #5

Assessment

Objective:
 Altered respiratory rate outside of acceptable parameters

70
  Skin discolorations
 Capillary refill >3 seconds
 Pale skin
 Dyspnea
 Dysrhythmias
Nursing diagnosis: Ineffective Tissue Perfusion related to decreased hemoglobin concentration in
blood.
Planning: After 2-3 days of nursing intervention the patient will maintain maximum tissue perfusion
to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within
patient’s normal range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of chest
pain.
Nursing Intervention
DEPENDENT
Assessed for probable contributing factors
related to temporarily impair arterial blood
flow. Some examples included compartment
syndrome, constricting cast, embolism,
indwelling arterial catheters, positioning,
thrombus, and vasospasm.
Reviewed laboratory data (ABGs, BUN,
creatinine, electrolytes, international normalized ratio,
and prothrombin time or partial thromboplastin time) if
anticoagulants are utilized for treatment.
Checked respirations and absence of work of
Breathing
Recorded BP readings for orthostatic changes
(drop of 20 mm Hg systolic BP or 10 mm Hg
diastolic BP with position changes).
Used pulse oximetry to monitor oxygen saturation
and pulse rate.
Checked for pallor, cyanosis, mottling, cool
or clammy skin. Assess quality of every
pulse.
Rationale
Early detection of the source facilitates quick,
effective management
Blood clotting studies are being used to conclude or
make sure that clotting factors stay within therapeutic
levels. Gauges of organ perfusion or function.
Irregularities in coagulation may occur as an effect of
therapeutic measures
Cardiac pump malfunction and/or ischemic
pain may result in respiratory distress.
Nevertheless, abrupt or continuous dyspnea
may signify thromboembolic pulmonary
complications
Stable BP is needed to keep sufficient tissue
perfusion. Medication effects such as altered
autonomic control, decompensated heart failure,
reduced fluid volume, and vasodilation are among
many factors potentially jeopardizing optimal BP
Pulse oximetry is a useful tool to detect
changes in oxygenation
Nonexistence of peripheral pulses must be
reported or managed immediately. Systemic
vasoconstriction resulting from reduced
cardiac output may be manifested by
71

Monitored intake, observe changes in urine output.
Recorded urine specific gravity as necessary.
Dependent
Blood Transfusion (1 bag 500 mL fresh
whole blood)
Administered IV fluids (1L D5LR)
diminished skin perfusion and loss of pulses.
Therefore, assessment is required for constant
comparisons
Reduced intake or unrelenting nausea may
consequence in lowered circulating volume,
which negatively affects perfusion and organ
function. Hydration status and renal function
are revealed by specific gravity measurements
Sufficient fluid intake maintains adequate
filling pressures and optimizes cardiac output
needed for tissue perfusion

Evaluation: Goal met, the Patient was able to maintained maximum tissue perfusion to vital organs,
as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal
range, balanced I & O, absence edema, normal ABGs, alert LOC, and absence of chest pain.

NURSING CAREPLAN #6

Assessment

Subjective: “Dili pa ko maka lihok-lihok ma’am ug kinahanglan nako ug alalay” as verbalized

by the patient.

Objective:

 Generalized weakness
 Decreased ability to move.
 Immobilized (first 24 to 48 hours after a bleeding episode)
 Irritability
 Restlessness

Nursing diagnosis: Activity intolerance related to bed rest (postpartum).

72
Planning: After 2-3 days of nursing intervention the patient will maintain optimal physical mobility
as evidenced by normal range of motion (ROM) and activities of daily living within ability.

Nursing intervention Rationale

INDEPENDENT

Assessed for limited ROM, contractures, and bony Recurrent bleeding of the joints can lead to bone
changes in the joints when bleeding has stopped. destruction, permanent deformities, and crippling.
This data gives the baseline for evaluating further
constraints from bleeding

Assisted with the progression to active exercised Non-weight bearing exercise facilitates optimal
as tolerated. ROM without stimulating re bleeding. Extra
weight should be avoided until swelling has
subsided.

Provided assistive devices when needed. The chronic joint deformity is a common
complaint.

Referred for physical therapy, occupational Electrical stimulation of the muscles around the
therapy, and orthopedic consultations, as required. joints prevents muscle atrophy. Active
physiotherapy helps in regaining joint movement
and preventing fibrous build up.

Evaluation: Goal met, the patient was able to maintain optimal physical mobility as evidenced by
normal range of motion (ROM) and activities of daily living within ability.

73
74
 NURSING CAREPLAN #7

Assessment

Subjective: “nagool ko mg huna2 basin dili nako ma tuman ang akong obligasyon sa
ako bata” as verbalized by patient.

Nursing diagnosis: Altered Parent-Infant Attachment related to Anxiety associated with the parent
role.

Planning: After 4–5 days of nursing intervention the patient will express comfort with the parenting
role.

Nursing intervention Rationale

INDEPENDENT

Discussed client’s view of infant care To provide information about how a client
responsibilities and parenting role. perceive these role changes that will help in
identifying areas of learning need.

Explained the factors that lead to the separation of To minimize anxiety and feelings
mother and infant brought about by the
of helplessness related to the mother’s inability to
postpartum hemorrhage.
assume the role expected to her

Encouraged contact with infant (e.g., photos, To reassure the mother of the health status of the
information from the other people who have seen infant and of the proper care being given to the
the infant) until the client can see and start to care infant.
for the infant.

Evaluated the attachment process, bonding To provide information on the physical,

75
behaviors, and parenting capability once client psychological and physiological capabilities of the
assumes care of her infant. parent.

Evaluation: Goal met, the patient was able to express comfort with the parenting role.

NURSING CAREPLAN #8

76
Assessment

Subjective: “wala ko kasabot sa akong gi bati ma’am nagool ko para sa akong problema” as
verbalized by the patient.

Objective:

 Increased apprehension, uncertainty, feelings of helplessness.

 Expressed concerns due to the changes in the life events.
 Sympathetic stimulation.
 Restlessness and distressed.
 Impaired attention.

Nursing diagnosis: Anxiety related to Situational crisis.

Planning: After 8 hours of nursing intervention the Patient will identify health ways to deal with and
express anxiety.

Nursing intervention Rationale

INDEPENDENT

Stayed with the client by providing a calm, To help in maintaining emotional control in
empathic and supportive attitude. response to the changing physiological status.
Helps in lessening interpersonal transmission of
feelings.

Assisted in developing skills (e.g.,awareness of To eliminate negative thoughts and to promote

negative thoughts, saying “Stop” and replacing it wellness.
with a positive thought)

Evaluated physiological responses to postpartum Changes in the vital signs may be due to
hemorrhage (e.g. restlessness, irritability, physiologic responses, but they can be aggravated

77
tachypnea, tachycardia, hypotension) by psychological factors

Evaluated the psychological responses of the This can help in determining the plan of care.
client to the postpartum hemorrhage and Client’s view of the event may be twisted,
perception of the events happening. aggravating her levels of anxiety

Evaluation: Goal met, the patient was able to identify health ways to deal with and express anxiety.

NURSING CAREPLAN #9

78
Assessment

Subjective: “ma’am wala ko nasayod sa hinungdan gyud nganong ng dugo kog taman” as
verbalized by the patient.

Objective:

 Statement of misconceptions.
 Request for information needed.
 Inappropriate behaviors.
 Verbalizing in accurate information
 Questioning members of health care team.

Nursing diagnosis: Deficient Knowledge related to unfamiliarity with information resources.

Planning: After 8 hours of nursing intervention patient will verbalize in simple terms the signs and
symptoms and implications of her disease condition.

Nursing intervention Rationale

INDEPENDENT

Assessed the client’s level of knowledge, ability to Provides information necessary to develop an
learn. Talked and listened to the client in a calm individual plan of care and engage in problem-
demeanor. Provided time for questions and solving techniques. Reduces anxiety and stress,
clarifications. which can block learning, and provides
clarification and repetition to enhance
understanding.

Explained predisposing factors and treatment To provide information in helping the client cope
related to the cause of hemorrhage. up with the situation

79
Determined the availability of personal Fatigue related to hemorrhage will slow down the
resources/support groups. Explained the client’s resumption of normal activities,
importance of having an adequate rest, healthy necessitating problem solving and dependence on
living and pacing of activities. others for a period of time

Explained long term implications of postpartum This will give the autonomy to the client to make
hemorrhage such as uterine atony, infertility if informed decisions and to begin resolve feelings
hysterectomy is done, or risk of having about current and past events
a postpartum hemorrhage in the future
pregnancies.

Explained short term implications of postpartum It can reduce anxiety and provides a realistic time
hemorrhage such as an interruption in the process frame for resumption of bonding and infant/self-
of mother-infant bonding and inability to assume care activities.
care of self and infant as soon as desired

Evaluation: Goal met, the patient was able to verbalize in simple terms the signs and symptoms and
implications of her disease condition.

NURSING CAREPLAN #10

Assessment

Objective:

80
  Overall felling of sadness
 Extreme Fatigue
 Increased anxiety
 Restlessness
 Irritability

Nursing diagnosis: Risk for Postpartum Depression related to child birth.

Planning: After 4-5 days of nursing intervention, patient will exhibit good coping mechanism

Nursing intervention Rationale

INDEPENDENT

Assessed vital signs To evaluate patient’s status

Assisted in developing skills (e.g., awareness of To eliminate negative thoughts and to promote
negative thoughts, saying “Stop” and replacing it wellness.
with a positive thought)

Evaluated physiological response to postpartum Changes in the vital signs may be due to
hemorrhage (e.g. restlessness, irritability, physiologic responses, but they can be aggravated
tachypnea, tachycardia, hypotension) by psychological factors

Evaluated the psychological response of the client This can help in determining the plan of care.
to the postpartum hemorrhage and perception of Client’s view of the event may be twisted,
the events happening. aggravating her levels of anxiety

Recommended support groups to patient so she This help open up her feelings towards her family.
can have a system where she can share her
feelings.

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 Evaluation: Goal met, after 4-5 days of nursing intervention, patient reported overcome postpartum
depression.

DISCHARGE PLAN

MEDICATIONS:

 Inform the S.O. about the possible side effects of the medication
(Mefenamic, Hidrasec, Metronidazole, Potassium chloride, Ketorolac, metoclopramide).
 Inform the S.O about the importance of compliance to prescribed medications and
consequences.
Mefenamic acid 500 mg/1 tablet every 6 hours
Hidrasec 100 mg /1cup 3x a day

82
 Metronidazole 500 mg/1tablet (thrice a day) per meal
PCM (BIOGESIC) 500 mg/1tab every 4 hours

ENVIRONMENT

 Wash hands with soap after going to the toilet and before eating or preparing food.
 Avoid contact with soil

TREATMENT

Treat painful condition such as pain associated with heavy menstrual bleeding with Mefenamic acid
500 mg/1 tab every 6 hours. Hidrasec 100 mg/1 cap 3 times a day treatment of symptoms of acute
diarrhea. Treat a certain type of intestinal problem with metoclopramide 500mg/tab then thrice a day.

HEALTH TEACHINGS

Activities

 Bed rest upon arrival at home from the hospital.

 Light exercise every morning.
 Eventually the patient can return to its normal activities of daily living.

Hygiene

 Cut and keep your nails clean

 Proper hand washing is necessary
 Take care of drinking water - either option for mineral water or water boiled for 20
minutes.

OPD- FOLLOW-UP:

 Return again after a week for follow up check-up at OPD December 14, 2019.

83
DIETARY MANAGEMENT:

 Diet as tolerated but encouraged to have clear liquids such as water, juice and tea to rehydrate.
 Oral rehydration or electrolyte solutions may help.
 Drinking small amounts at frequent intervals is better accepted in cases of nausea.
 Light soups, toast, rice and eggs are good foods; eat foods high in fiber and carbohydrates.

SPIRITUAL

 Continue religious practices.

 Always pray for fast recovery.

APPENDICES

IVF CHART

Date #of Bottle Solution Volume Additive Rate of Time

Drop
Left Hand

11/20/19 1 1L PLR 30gtts 3:30 pm

11/20/19 1 1L D5LR + 10 units 20 gtts
oxytocin
2 1L D5LR + 10 units 10 gtts 9:25 pm
oxytocin

84
11/21/19 1 1L D5LR + 10 units 80 cc/hr
oxytocin
11/21/19 1L D5LR + 10 80 cc/hr 4:00 pm
units oxytocin

11/22-19 3 1L D5LR + 10 units 80 cc/hr 6:25 am

oxytocin
Right Hand
11/21/19 1 1L PNSS 80 cc/hr 2:45 pm

11/20/19 1 O2 Inhalation (nasal cannula) 2Lpm

11/20/19 2 O2 Inhalation (nasal cannula) 2Lpm 9:40 pm

VITAL SIGNS

DATE TIME BP HR RR TEMP.

11/20/19 11 am 130/70 104 13 38.1

12 nn 130/60 102 16 38.3

4 pm 140/80 100 22 39.4

8 pm 120/80 99 21 38.1

12 mn 110/70 84 19 37

4 am 120/80 95 20 38.3

11/21/19 8 am 140/80 94 20 31.4

12 nn 120/80 91 20 36

1 pm 120/90 90 21 36.4

85
 2 pm 120/80 92 22 37.4

3 pm 120/90 91 22 38.3

4 pm 120/90 91 22 37.7

8 pm 100/80 79 20 37.3

10 pm 100/80 85 20 36

10:15 pm 110/80 62 20 37

10:30 pm 100/80 69 20 37.1

10:45 pm 100/80 66 20 37.1

11 pm 100/70 70 20 37.1

11:30 pm 110/80 84 20 36

12 mn 110/80 90 20 36

1 am 120/80 65 20 36

2 am 120/70 73 20 36

4 am 110/70 84 20 36

11/22/19 8 am 120/80 84 20 36.7

9:20 am 110/80 69 26 36.5

9:40 am 110/70 70 20 36.5

9:55 am 110/60 75 22 36.5

10:10 am 110/60 79 16 36.6

10:25 am 110/60 82 27 36.6

10:40 am 110/70 75 27 36.6

10:55 am 110/70 92 21 36.6

11:10 am 110/80 91 20 36.7

11:25 am 110/80 90 26 36.7

11:40 am 110/80 88 22 36.5

12:10 nn 110/80 90 22 36.5

86
 4 pm 120/80 68 22 36

8 pm 110/60 85 20 36.8

12 am 110/80 89 20 36

4 am 110/90 83 20 36

11/23/19 8 am 120/80 88 21 36.6

12 nn 100/80 75 20 36.4

4pm 140/90 63 23 36.1

8 pm 140/80 65 20 36

12 mn 120/80 70 20 36

4 am 120/70 60 20 36

11/24/19 8 am 110/80 100 20 36

12 nn 110/90 92 20 36

4 pm 120/90 69 20 36

8 pm 110/80 64 20 36

12 mn 120/80 61 20 36

4 am 140/80 68 20 36

11/25/19 8 am 120/80 74 20 36

12 nn 120/80 79 20 36

4 pm 110/80 81 20 36

8 pm 120/70 68 20 36

12 mn 130/80 78 20 36

4 am 130/70 74 20 36

11/26/19 8 am 140/70 77 20 36

12 nn 110/70 78 20 36.2

4 pm 140/90 68 20 36

8 pm 110/70 65 20 36

87
 12 mn 120/60 78 20 36.6

4 am 100/70 85 20 36

11/27/19 8 am 100/80 92 20 36

8 pm 110/80 82 20 36

11/28/19 8 am 90/80 84 20 36

11/29/19 8 am 110/90 86 20 37

11/30/19 8 am 100/80 78 21 36

12 nn 90/60 67 21 35.6

4 pm 110/80 72 21 36.5

12/01/19 8 am 100/60 73 20 36

12 nn 100/60 70 20 36

4 pm 100/60 70 20 36

12/02/19 8 pm 110/80 84 20 36

12 mn 100/70 75 20 36

4 am 100/60 75 20 36

12/03/19 8 am 110/50 92 20 36

12 nn ___ ___ ___ ___

4 pm ___ ___ ___ ___

8 pm 100/70 90 20 36

12mn 100/70 86 20 36

4 am ___ ___ ___ ___

12/04/19 8 am 100/70 60 20 36.5

12nn 110/70 64 17 36.8

88
 I AND O SHEET

Date Credit Consume Oral Total Urine Vomitus Bm Total

d fluid Taken Output Output
taken
11/20/19 PNSS- 50
950 400 1000 400 - 1x 450+
650 1XBM
D5LR-
350
7PM PNSS- 30
- 980 600 1060 1400 - - 1400
7AM 430
D5LR-
920
11/21/19 PNSS- 70
850 - 990 600 - 4 600
920
D5LR-
NH
PNSS- 250
600 400 1650 1300 - 3x 1300+
1000 3BM
D5LR-
NH

BLOOD TRANSFUSION SHEET

Name: Patient P.Y Age: 25 Case No.: 138918

Attending Physician: Dr. Bugas Gender: F Room: TPR21

UNIT DATE BLOOD SOURCE, CHECK START TIME FLOW TIME REMAR

89
NO. SERIAL NO., ED BY ED BY STARTE RATE ENDED & KS
SEGMENT NO., D SIGNATUR
EXPIRATION E
DATE, BLOOD
TYPE & VOLUME
1 11/21/19 CRHBB; 9:30 am 80cc/hr 3:30pm
NVBSP
20190292668;
Q0502159;
DEC. 21,2019;
B+;
480 ml

2 11/21/19 CRHBB; 9:00 pm 80cc/hr

NVBSP
20190292662;
Q0502373;
DEC. 21, 2019;
B+;
410 ml

CFAC

COLOR FREQUENCY AMOUNT CHARACTERISTICS

11/6/18 BROWNISH 10 MEDIUM SOFT WATERY WITH
(7AM) BLOOD STREAK
11/6/18 BROWNISH 10 FEW SOFT WATERY
(7PM)

90
11/7/18 YELLOW 10 MODERATE WATERY
(7AM)
11/7/18 YELLOW 3X MODERATE SOFT
(7PM)

GENOGRAM

91
 LEGENDS:

Mother, diabetes and UTI Father, alive and well

Grandmother, alive and well Siblings, alive and well

Grandfather, alive and well

92
 Grandmother, alive and well Patient, Postpartum Hemorrhage
Grandfather, alive and well

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