Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Villa Lucinda Campus, Brgy. Ungot, Tarlac City, Philippines 2300

A Clinical Case Study Presented to the Faculty of the

Department of Nursing
In Partial Fulfillment
of the Requirement of the Subject
NCM 109 RLE

Premature Rupture of Membrane

(PROM)
Submitted By:

Bate, Pearlene Nicole

Bondoc, Jennhel V.
Bulaon, Maria Daniela
Fontanilla, Bietrize Ysabelle T.
Gonzalo, Michaella Disiree
Lagera, Laurisse M.
Malonga, Katrina Joyce
Quiambao, Ralph P.
Soriano, Marc Angelo D.
Vergara, Christian Keith

BSN-2A, GROUP 2
SY. 2022-2023

Submitted to:
Mrs. Flora Tel-equen

1
Table of contents

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CASE SCENARIO

On February 14, 2023, at 3 pm, a 25-year-old female patient came into the emergency
room of Loving Mother General Hospital and Diagnostic Center accompanied by her
significant other, with a chief complaint of vaginal bleeding. Her last menstrual period was in
December 2021, and she was diagnosed with Polycystic Ovary Syndrome (PCOS). Prior to
admission, her vital signs were taken, BP: 140/90 mmHg, RR: 21 bpm, PR: 102 bpm, BT:
37.1 °C. Moreover, she was experiencing minimal labor pain, about 10 to 20 uterine
contractions, and leaking for 2 hours. The attending physician ordered a complete blood count
(CBC) and urinalysis.

CBC disclosed WBC: 9,400 µL, hgb: 10.4 g/dl, hct: 36.4%, and platelet: 200,000 µL.
Urinalysis revealed positive leukocytes and presence of blood in her urine. She had an ongoing
1 liter of D5LRS at 22-23 gtts/min. She was transferred immediately to the delivery room for
cesarean section and gave birth to a 2 kg pre-term baby boy. Her final diagnosis is G1P1,
delivered via c-sec due to PROM for 2 hours, leaking.

I. Introduction

According to Dayal and Hong (2022), Premature rupture of membranes (PROM) is the
term used to describe when the gestational membranes rupture prior to the onset of labor. The
rupture of membranes (ROM) as classified and defined by Jazayeri (2021), Preterm premature
membrane rupture (PPROM) is ROM that occurs before 37 weeks of pregnancy. Another one
is known as Spontaneous preterm rupture of the membranes (SPROM) the rupture of the
gestational membrane that takes place after or concurrently with the beginning of labor before
37 weeks. Any ROM that lasts beyond 24 hours without the occurrence of labor is referred to
as prolonged ROM.

Usually, membranes rupture as a result of mechanical stresses, collagenase activation,

programmed cell death, and other factors that can cause increased intrauterine pressure. The
same mechanisms and early activation of these pathways most likely cause preterm PROM.
Early PROM is connected to underlying pathogenic processes, most likely as a result of
membrane inflammation and/or infection (Jezayeri, 2021). If the sac ruptures, the woman is
more vulnerable to infection and has a higher likelihood of giving birth to the child before
term.

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 In most instances, the root of Premature rupture of membrane is unspecified, but the usual
risk factors are:
• Infections in the uterus, cervix, or vagina.
• Excessive stretching of the amniotic sac (due to polyhydramnios or multiple pregnancy).
• Smoking
• History of operation or biopsies of the cervix.
• History of PROM or PPROM in previous pregnancy/pregnancies.

As reported in the study of Tiruye in 2021, in all pregnancies globally, cases of PROM
ranges from 5% to 15%. As preterm birth is one of the major causes of neonatal deaths, it is
confirmed that PROM contributes more than 40% of preterm deliveries. In 2020, as for the
annual accomplishment report of the Philippine Statistic Authority, 4 registered maternal
deaths were caused by PROM.
A. General objectives:
The conduction of this case study by the student nurses aims to provide knowledge
and information regarding Premature Rupture of Membrane (PROM). At the end of the
study, appropriate nursing interventions will be provided to the client in order to contribute to
the overall physiological maternal and fetal wellbeing.
B. Client-Centered objectives:
• To promote client-student nurse interaction
• To determine and understand the patient’s overall health.
• To determine factors that lead to the client’s condition.
• To provide necessary implementations that are needed by the client.
C. Nurse-Centered objectives:
• To have a better understanding about the possible risk factors contributing to PROM
• To properly interpret patient’s condition
• To improve knowledge and skills related to formulating care plans and diagnoses.
• To implement formulated nursing care plans.

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II. Nursing process

A. Demographic data

Name: Patient X

Age: 25-year-old

Sex: Female

Civil Status: Single

Occupation: Call-Center Agent

Nationality: Filipino

Chief Complaint: Vaginal Bleeding

Date & time of Admission: February 14, 2023, at 3:00 pm

Admitting diagnosis: G1P0 35 weeks 1/7 days

Final Diagnosis: G1P1, delivered via c-sec due to PROM for 2 hours, leaking.

B. Environmental Status

Patient x works at a fast-paced work environment that requires her to manage a handful of
different responsibilities. Patient x is mostly at the office and shares the same space in the
cubicles together with her co-agents. As a call-center agent patient x spends a great deal of her
time sitting at a desk, being in a sedentary position. She remotely interacts with different people
every single day, requiring her to collaborate between employees by providing space and time
for them to interact with each other at the company.

C. Lifestyle

The client was a call center agent, due to a stationary position during hours of working,
physical activities are limited. She occasionally drinks alcohol, and she doesn’t smoke
cigarettes. She stated that she doesn’t get enough sleep because of her work schedule and her
other half was also a call center agent. Also, she said that she prefers to eat fast food and usually
spaghetti, sweets, and fruits during her pregnancy.

5
2. Family history of health and illness

Family genogram

Ms. X’s paternal grandparents are both deceased with an unknown cause, while her
maternal grandfather died due to renal failure. Her maternal grandmother is still alive with a
history of PCOS and diabetes. Her father has a history of hypertension, while her mother has
type 1 diabetes. Lastly, she has a younger sister who is alive and well.

3. History of past illness

The client has a history of pill intake for hormones to promote menstruation, the patient
occasionally intakes alcohol and has a history of hypothyroidism. Prior to admission, the client
was diagnosed with polycystic ovary syndrome (PCOS) and last December 2021 was her
recalled last menstrual period (LMP).

4. History of present illness

Few hours after admission, the patient has a pain with a scale of 1-2 and 10 to 20 uterine
contractions and 2 hours of leaking due to premature rupture of membrane. There is also a
presence of bleeding.

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5. PHYSICAL ASSESSMENT
13 Areas of Assessment
Area of Findings
Assessment
Social Status She could communicate
clearly along with doctors
and nurses in the hospital.
They managed to establish
rapport with Mrs. X.
Mental Status Preoperation: Mrs. X has
a sense of place, time, and
people. She can recognize
the questions or names
being asked. She can
recall both recent and old
events. She responds to
enquiries and provides the
necessary information.
Postoperation: She was
able to remember giving
birth and was a little bit
confused during the
interview after the
operation.
Emotional She is a little bit confused
Status after the surgery and she
looked down because her
premature baby is
currently at the
incubator.
Norms Analysis
The ability to interact Mrs. X’s social
successfully with the status is normal.
people and within the
environment of which
each person is a part, to
develop and maintain
intimacy with significant
others, and to develop
respect and tolerance for
those with different
opinions and beliefs
(Fundamentals of
Nursing: Concepts,
Process, and Practice,
10th Edition, 2018).
The content of the patient Mrs. X is a little
message should make bit confused
sense. The ability to read during the
and write should match interview.
the patient’s educational
level. The patient should
be able to correctly
respond to questions and
to identify all the objects
as requested. The patient
should be able to evaluate
and act appropriately in
situations requiring
judgment. (Health
assessment and physical
examination 3rd edition
by Mary Ellen Zator
Estes).
The early adult period is Mrs X looked
in the stage where despairing during
intimacy and isolation is the interview.
the issue. Intimacy arises
from love while isolation
arises from neglect or
rejection. The presence of
isolation causes the
individual to be detached
and lonely (Avulakunta
& Balasundaram, 2022).
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Sensory Postoperation: ‘Sensory changes occur Mrs. X’s sensory
Perception as a person ages; it may perception is
not happen at the same normal.
Has black eyes, no age for each person,
Sense of Sight presence of lesions or changes may not occur to
discharges, and evenly everyone, or changes
spaced symmetrical may not be the same
pupils. degree for each person.
Normally, vision
Sense of Taste decreases at mid-50s,
She can taste food
hearing decreases at mid-
properly but only allowed
40s, touch decreases at
crackers and food.
mid-50s, taste decreases
Sense of at mid-60s, and smell
Hearing decreases at mid-70s
Her ears are of similar size
and look, no presence of (Brotherson and
nodules or discharges. She Kemmet, 2015, still being
can hear properly in both cited in 2022).'
ears from a near and far
Sense of Smell
distance.

Normal patency is
Sense of observed. She has no
Touch problem breathing.
According to her, her
sense of smell is normal.

She can feel the objects

that she touches and tell
them apart. She does not
feel any weird sensations
on her fingers.
Motor Since she had an
Stability operation, her movements
are limited. She was able
to stand and walk with the
assistance of her husband.
Has upright posture and Her motor
steady gait; walks stability is just
unaided, maintaining normal for a
balance (Kozier & Erb’s pregnant woman
Fundamentals of Nursing who had a
Global Edition, 2021). cesarean section.
However, the plantar
loading would
redistribute as the body
weight increases and the
center of mass relocates
in the late pregnancy. A
decreased step length and
increased step width with
slower walking velocity.
Due to the constantly
upward-transferred
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 center of gravity, the
ability to control trunk
equilibrium declined.
(Mei, Q., Gu, Y. &
Fernandez, J., 2018)

Body Preoperation: The normal range for a Mrs. X’s body

Temperature pregnant woman is temperature is at
consider between 35.3°C the normal range.
37.1 °C
and 37.3°C. (Green LJ,
et. al, 2020).
Postoperation:

36.7 °C
Respiratory Preoperation: 20 bpm A normal respiratory rate Respiration and
Status in a healthy pregnant breathing are
woman is 8 to 24 breaths noted as fine and
Postoperation: 21 bpm per minute during the normal.
third trimester due to
Upon observing her ventilatory changes as
respiration, her shoulders caused by hormonal
rise and fall with the same changes during
level. There are no reports pregnancy. (Green LJ, et.
of difficulty in breathing al, 2020). Respiration has
and Respirations are a regular rhythm, is
regular and rhythmic. silent, and effortless.
(Kozier & Erb’s
Fundamentals of Nursing
Global Edition, 2021)
Circulatory Preoperation: Normal cardiac rate for a Her blood
Status pregnant woman is 64- pressure and
113 beats per minute, cardiac rate is
PR: 102, while the normal blood normal.
BP: 140/90 pressure is within the
range 100/60 mmHg to
Postoperation: 140/90 mmHg. (Green
LJ, et. al, 2020). The
pulse rhythm is noted by
PR: 100, the pattern of the
BP: 120/90 intervals between the
beats. A normal pulse has
equal time periods
between beats, and can be
felt with moderate
pressure, and the pressure
is equal with each beat. A
forceful pulse volume is

9
 full; an easily obliterated
pulse. (Kozier & Erb’s
Fundamentals of Nursing
Global Edition, 2021)

Nutritional As stated by the patient Nutritional status is a The nutritional

Status her favorite food to eat is requirement of health of a status of the
spaghetti, ‘sopas’, sweets, person convinced by the client is
and fruits. She also stated diet, the levels of considered not
that she always eats fast nutrients contained in the normal since she
food. body and normal usually eats
metabolic integrity. foods from fast
Normal nutritional status food like
is managed by balanced spaghetti.
food consumption and
normal utilization of
nutrients (NSRA, 2021).
Elimination She stated that she hasn’t The normal frequency of There is a
Status defecate yet since the bowel elimination varies presence of blood
surgery. She was from several stools per in her urine
catheterized and there is a day to only two or three which is not
presence of blood in her per week. Most adults normal.
urine. experience bowel
elimination every 1 to 2
days. The urge to
defecate most commonly
occurs 30 to 45 minutes
after a meal, when the
gastrocolic and
defecation reflexes
stimulate peristalsis.
(QuickAdvice, 2019)

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Reproductive She stated that her last
Status menstrual period was in
December 2021 and her
estimated date of delivery
is in March 2023. Her
menstruation occurred
when she was 12 years
old, she had an irregular
menstrual period, and she
was taking pills for
hormones to promote
menstruation since she
was diagnosed with
polycystic ovarian
syndrome (PCOS). She
has an OB score of G1P0.
No history of sexually
transmitted disease
Sleep-rest Mrs. C sleeps well, as
Pattern reported. The number of
hours is 7-8 hours and she
stated that she sleeps early
together with her family.
.
State of skin Mrs. X’s skin has no
Appendages pigmentations, no
irritation, no pallor,
jaundice, or cyanosis. She
has impaired skin integrity
related to her cesarean
section. Hair is
distributed, and the nails
are clean.
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A menstrual cycle is The patient’s
defined as being reproductive
“normal” based on four status isn’t
factors described as the: - normal, she had
Frequency of menses irregular
(days) 24–38 days. - menstruation and
Regularity cycle length. she was
Cycle length is the diagnosed with
number of days from the polycystic
first day of bleeding in ovarian
one menstrual cycle to syndrome
the first day of bleeding (PCOS).
in the next. No more than
7–9 days difference
between the shortest to
longest cycles: 7 to 9
days. - Duration (days of
bleeding in a single
menstrual period) 8 days.
- Volume (monthly blood
loss) and the clinical
definition is subjective
and defined as a volume
of menstrual blood loss
that does not interfere
with a woman’s physical,
social, emotional, and/or
material quality of life
(Adapted from (Munro et
al. 2018).
Sleep is a basic human The client most
need; A person needs 7-9 of the time has an
hours of sleep per night appropriate
(Kozier and Erb’s 2018) amount of sleep
and has an
excellent
sleeping pattern.
Skin color varies from The client has
light to deep brown, pink impaired tissue
to light pink and free integrity related
from skin diseases. Hair to her cesarean
is resilient and evenly section. Her hair
distributed. The nail plate and nails are
is normally colorless and considered
has a convex curve. The normal.
angle between the
fingernail and the nail
bed is normally 160
 degrees (Kozier & Erb’s,
2018).

6. LABORATORY AND DIAGNOSTIC PROCEDURES

Test Name Purpose/ Indication Reference Actual Result Nursing

Value Responsibilities
Complete A CBC is a series Hemoglobin Hemoglobin 1. Explain to the
Blood of tests used to = 12.1 to 15.1 = 10.4 g/ dl client the test
Count evaluate the g/dL (Low) procedure.
(CBC) composition and
concentration of the
cellular components Hematocrit Hematocrit 2. Explain that slight
of blood. = 36% to 48 % = 36.2 discomfort may be
felt when the skin is
punctured.
It measures the WBC
WBC = 9,400 µL
following: = 4,500 to (9.4 x 109/L)
• No. of red blood
3. Advise client that
11,000 µL (4.5 he should feel relax as
cells (RBCs) to 11.0 ×
• No. of white possible while blood
109/L). Platelet is being drawn out.
blood cells
= 200,000
(WBCs)
Platelet µL
• Total amount of 4. Advice the client
hemoglobin in = 50,000 to not to pull his hands
the blood 450,000 µL during the procedure.
• Fraction of the
blood composed
of red blood cells 5. Explain that fasting
(hematocrit) is not necessary.
• Mean However, fatty meals
corpuscular may alter some test
volume (MCV) results as a result of
— the size of the lipidemia.
red blood cells
• Platelet count
6. Apply manual
pressure and
dressings over
puncture site on
removal of dinner.

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 7. Monitor the
puncture site for
oozing or hematoma
formation.

8. Instruct to resume
normal activities and
diet.
Urinalysis A urinalysis, or Leukocytes in + 1. Instruct the client
urine test, is a urine = 0 to 10 Leukocytes to wash the area
common medical test leukocytes/μL. in urine between the
in which the urine is vagina’s lips by
examined to either using water
diagnose and + Blood in or a special clean-
monitor various urine catch lit that
illnesses. During a contains sterile
urinalysis, a clean wipes.
urine sample is 2. Instruct the client
collected into a to sit on the toilet
specimen cup and with legs spread
analyzed with a apart and use two
visual exam, a fingers to spread
dipstick test, and a open the lips of
microscopic exam. the vagina. Then
The presence of emphasize to her
cells, bacteria, and to use the first
other chemicals is wipe to clean the
detected and inner folds of the
measured in a labia, wipe from
urinalysis (Smith, the front to back,
2022). then use a second
wipe to clean
over the opening
where urine
comes out just
above the
opening of the
vagina.
3. Explain to the
client on how to
collect the urine
sample. Tell her
to keep her labia
spread open, then
urinate a small
amount into the
toilet bowl then
stop the flow of
urine. Then she

13
 must hold the
urine cup a few
inches from the
urethra & urinate
until the cup is
about half full.
4. Instruct the client
to cover
specimens
tightly, label
properly and send
immediately to
the laboratory.
5. Instruct the client
to observe
standard
precautions when
handling urine
specimens.

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7. PATHOPHYSIOLOGY
Book Based Pathophysiology

15
Patient-Based Pathophysiology

16
B. Planning
Prioritization of nursing problems
Pre-operative Prioritization of Nursing Care Plan
Ranking Diagnosis
1 Deficient fluid volume
related to premature rupture
of bag of water as manifested
by 2 hours of leaking and
vaginal bleeding.
. survival, the patient will not
2 Fatigue related to prolonged
labor process as manifested
by verbalized exhaustion
3 Risk for infection related to
preterm rupture of
membranes
Justification
According to Maslow’s
hierarchy of needs,
physiological needs are
optimum requirement for
survival, and fluid intake is
included in this aspect.
Without a requirement for
be able to improve health
related problems. That is why
deficient fluid volume is at
top priority.
Fatigue is the second
prioritized problem because
if body became weak, all the
optimum requirement for
survival which are included
in Maslow’s physiological
needs will be disregarded.
According to Maslow’s
safety needs, once the
physiological needs are
satisfied, safety needs
become important. Because
to eliminate further onset of
problems, locating and
stopping its source would be
essential.

4 Risk for maternal and fetal Maslow’s safety needs

injury includes medical care, with
an unresolved health
problems, it can affect
overall aspects of the patient
and cause further
complications.
5 Fear related to surgical After fulfillment of both
delivery of the baby as physiological and safety
evidenced by increase in needs, love and
tension and perspiration. belongingness needs become
essential which includes
fear.

17
Post-operative Prioritization of Nursing Care Plan
Rank Nursing Diagnosis
1 Impaired skin integrity related to
mechanical trauma of surgical
incision in the skin secondary to
caesarian section
2 Acute pain related to
postoperative wound as
manifested by facial grimace and
increased pulse rate
3 Disturbed sleep pattern related to
postsurgical procedure as
manifested by restlessness and
frequent yawning
4 Risk for surgical site infection
5 Impaired parenting related to the
inability to perform activities of
daily living secondary to
postpartum blues
Justification
According to Maslow’s hierarchy of needs, the
physiological needs for oxygen and nutrition as well as
nourishment of skin tissues in order to heal needs to be
prioritized. Physiological needs are biological
requirements for human survival. If these needs are
not satisfied the human body cannot function
optimally. Maslow considered physiological needs
the most important as all the other needs become
secondary until these needs are met.
Physiological need for comfort, according to Maslow’s
hierarchy of needs is essential for the survival of a
person. One fifth of women who undergo caesarian
delivery will experience severe pain in the acute
postoperative period, increasing the risk of developing
chronic pain and negatively impact breastfeeding and
newborn care.
Sleep is one of the most essential physiological needs for
the maintenance and regulation of the body. In this
manner, sleep contributes significantly to the mental and
physical well-being of an individual.
According to Maslow’s hierarchy of needs, risk for
surgical site infection is under the second level of human
needs which is the Safety and security needs because this
diagnosis is an anticipated necessity for protection. Once
an individual’s physiological needs are satisfied, the needs
for security and safety become prominent.
The third level of human needs is social and involves
feelings of belongingness and love, according to the
Maslow’s hierarchy of needs. Belongingness, refers to
a human emotional need for interpersonal
relationships. While performing activities of daily
living is bad, impaired parenting will affect both the
baby and the mother’s affection towards each other.
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PRE-OPERATIVE NURSING CARE PLANS

NCP #1: Deficient fluid volume related to premature rupture of bag of water as manifested by 2 hours of leaking and vaginal bleeding.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Deficient fluid After an hour of Independent: Independent: After an hour of

volume related to nursing intervention, • Assess vital • The changes in nursing intervention,
Weakness premature rupture the client will be able signs. vital signs are the client was able to:
of bag of water as to: associated with • Maintain fluid
Objective: manifested by 2 fluid volume volume as
• HR: 102 hours of leaking • Maintain loss. manifested by
bpm and vaginal fluid volume modified vital
• Hct: 36.4 % bleeding. at a functional • Note unusual • These signs signs.
• Hgb: 10.4 level as changes in indicate • Demonstrate a
g/dl . manifested by mentation, sufficient relaxed
• BP: 140/90 stable vital behavior, and dehydration to behavior.
mmHg signs. functional cause poor tissue GOAL MET.
• RR: 21 bpm • Demonstrate abilities. (e.g., perfusion.
• Leaking a relaxed confusion,
• Vaginal behavior. falling, lethargy)
bleeding
• Review
laboratory data. • To evaluate the
body’s response
to bleeding/other
fluid loss to

19
 determine
replacement
needs.
Collaborative:

Collaborative:
• Administer fluids
and electrolytes.
• To replace fluids
and electrolyte
needs.

NCP #2: Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the blood as evidenced by verbalized
exhaustion.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fatigue Short term: Independent Independent: After 6 hours of

related to After 2 hours of • Position the client • To Improve appropriate nursing
“Kahit konting
decreased encouraging client to in comfortable patient’s comfort intervention, the
paglakad at pag
hemoglobin follow the energy sitting position or level. client verbalized
galaw lang po eh
and conservation semi fowlers. understanding of
pakiramdam ko
diminished principles, the client sleep disturbance.
sobrang pagod ko na”
oxygen- will be able to: • Assess the client’s • Demonstrated
as verbalized by the
carrying ability to perform • To know the and
client.
capacity of • Verbalize activities of daily client’s level of established
the blood as reduction of living (ADLs) and fatigue. methods to

20
Objective: evidenced by fatigue, as the demands of help patient
verbalized evidenced by daily living. have
▪ Pale lips
exhaustion. reports of uninterrupted
▪ Restlessness increased • Assist the client in sleep.
energy and planning and • Regulated
▪ Blood
ability to prioritizing • To balance periods patient’s
pressure:
perform activities of daily of activity with rest sleeping
140/90
desired living (ADL). periods which can pattern.
mmHg
activities. help the client GOAL MET.
▪ CBC result: complete desired
activities without
➢ Hemoglobin
adding fatigue
=10.4 g/dl
Long term: levels.
(Low)
• Instruct the client
➢ Hematocrit • After 2-4 about the methods • To help the client
= 36.4 % weeks of that conserve conserve energy
nursing energy such as and reduce fatigue.
interventions, sitting instead of
the client will standing during
be able to activities/ shower
have a and plan the steps
normal level of the activity
of before doing it.
hemoglobin
and • Encourage client to
hematocrit, take frequent • To improve
upon breaks during each client’s condition.

21
checking her task or nap or have
laboratory an adequate sleep.
result.
• Encourage the
client to eat iron • To help increase
rich foods such as hemoglobin count.
red meat, fish,
poultry, chicken,
eggs, beans, and
green leafy
veggies.

Dependent/Collaborative
• Prepare packed red
blood cells as per
doctor’s order. Dependent/Collaborative

• Refer the client • To increase the

and family to an oxygen-carrying
occupational capacity of the
therapist. blood.

• To help the client

and family
evaluate the need
for additional
energy-

22
 conservation
measures in the
home setting.

NCP #3: Risk for infection related to preterm rupture of membranes

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Risk for infection After 1 hour of Independent: Independent: After 1 hour of
“Dalawang oras na related to preterm effective nursing • Assess for signs and • To determine if nursing
pong may rupture of intervention, the symptoms of further medical intervention, the
lumalabas sa ari membranes patient is expected infection. attention is patient is still
ko, sabi po nila to be free from any needed. having signs and
pumutok na daw signs and • Initiate fetal symptoms of
po ang panubigan symptoms of monitoring. • To reduce the risk possible onset of
ko” possible onset of of fetal infection.
infection. compromise Further nursing
Objective: Dependent: intervention is
BP: 140/90 • Administer given.
PR: 102 medications as Dependent:
RR: 21 ordered by the • To prevent further
Temp: 37.1 degree attending physician. complications
Celsius
• Administer IV
Blue nitrazine fluids as ordered. • To reduce the risks
paper test of dehydration

23
 • Prepare patient for
induction of labor
and delivery.

NCP #4: Risk for maternal and fetal injury

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Risk for Within 30 mins Independent: Independent: After 30 mins of
maternal and of nursing nursing intervention
“Nurse, natatakot • Review patient’s • To obtain data
fetal injury intervention the the patient has a
ako baka kung ano history, noting leading to
client and the modified
mangyare samin age, weight, detection of
baby will be free environment to
nung baby ko di ko height, nutritional factors that can
from the risk of enhance safety and
pa naman status, physical affect the
having injury. prevent risk of
kabuwanan.” limitation, and procedure.
injury.
preexisting
conditions that GOAL MET.
Objective Data: may affect .
surgery.
BP: 140/90mmHg • Prevents undue
tension and
RR: 21 bpm • Stabilize patient
dislocation of IV
cart when
T: 37.1°C lines.
transferring
PR: 102 bpm patient to and
from OR table,
using an adequate
number of

24
 personnel for
transfer and
• Impairment of
support of
thought process
extremities.
makes it difficult
for patient to
understand
• Give simple and
lengthy
concise directions
directions.
to the sedated
patient.

• Reduces risk of
electrical injury.
• Protect the body
from contact with
metal parts of the
operating table.
• Prevents
• Position accidental
extremities so trauma, hands,
they may be fingers, and toes
periodically could
checked for inadvertently be
safety, scraped, pinched,
circulation, nerve or amputated by
pressure, and moving table
alignment. attachments.
Monitor

25
 peripheral pulses,
skin color and
temperature.

NCP #5: Fear related to surgical delivery of the baby as evidenced by increase in tension and perspiration.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fear related to surgical After 30 minutes of Independent: Independent: After 30 minutes of
“Nurse, sobrang procedure as evidenced discussing patient’s 3. Fear discussing patient’s
2. Measure
natatakot po by increase in tension fear and counseling can involve fear and counseling
vital signs and
akong and perspiration. the patient should: sympathetic the patient had:
physiological
manganak” as • Appear relax. arousal e.g., • Appeared
responses to the
verbalized by increased heart relaxed.
situation.
the patient. • Verbalize rate,
sense of safety respirations, • Verbalized
Feelings of to current • Stay with the blood pressure. sense of
alarm condition fearful patient safety to
Panic and decide to • Presence of a current
Dread • Demonstrate have significant calm, caring condition.
understanding other be there. person can
Objective: through the provide • Demonstrated
• Discuss the
usage of reassurance understanding
patient’s fearful
through the
feelings and

26
Focus narrowed coping listen to her that patient will usage of
to the source of behaviors. concerns. be safe. coping
fear. behaviors.
Increase in • Promotes .
• Display
perspiration. • Provide atmosphere of • Displayed
lessened fear
Fidgeting information caring and lessened fear.
about the permits GOAL MET.
procedure explanation or
Vital signs
slowly. correction of
taken as
misperceptions.
follows:
• Assist client to
BP: 140/90
learn • Facilitates
mmHg
relaxation, understanding
RR: 21 bpm
visualization, and retention
PR: 102 bpm of information.
and guided
BT: 31.1C imagery skills
• Aids in
reduction of
fear and
enhances
coping skills

27
POST-OPERATIVE NURSING CARE PLANS

NCP # 1: Acute pain related to postoperative wound as manifested by facial grimace and increased pulse rate.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain After 30 minutes of Independent: Independent: After 30 minutes of
"medyo may related to nursing intervention • Encourage patient • Prevent fatigue and nursing
hapdi at kirot postoperative the client will be to have an recover appropriately intervention the
yung tahi ko" as wound as able to: adequate rest. before assuming the new client was able to:
verbalized manifested by role of being a mother.
facial grimace Short term: Short term:
Objective: and increased • Verbalize • Provide comfort • To promote • Verbalize
Facial Grimace pulse rate. decrease of measures, and nonpharmacological pain decrease of
PR: 102bpm pain and quiet environment. management pain and
demonstrate demonstrate
a normal • Monitor skin • Note for signs of a normal
pulse rate. color/ temperature tachycardia, hypertension, pulse rate.
and vital signs. and increased
GOAL MET.
respirations. Changes in
these vital signs often
indicate acute pain and
discomfort.

• Teach and • May help decrease

demonstrate anxiety and tension,
proper relaxation promote comfort, and
techniques like enhance a sense of well-
breathing exercise being.

28
 and position for
comfort as
possible. Use
therapeutic touch,
as appropriate.

• Identify specific
activity
limitations. • Prevents undue strain on
operative site.
Dependent:
• Administer
medications such Dependent:
as • Promotes comfort by
sedative, narcotics, blocking pain impulses.
or preoperative Potentiates the action
drugs. of anesthetic agents.
.
‘

29
NCP #2: Impaired skin integrity related to surgical incision in the skin secondary to cesarean section.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired skin Short term: Independent: Independent: Short term:

integrity related to
“Nurse, After 2 hours of • Provide wound care. • By keeping the After 2 hours of
surgical incision in
nangangati ang the skin secondary nursing incision site clean, interventions, the
tahi ko” as to cesarean section. intervention. the wound care reduces client has engaged in
verbalized by the client will the risk of infection.preventive measures
patient. participate in and treatment
• Use a sterile • Sterile technique
preventive programs.
dressing approach reduces the risk of
Objective data: measures and
while treating infection in impaired
treatment
• Disruption of wounds. tissue integrity. Long term:
programs.
skin surface
• Encourage the use of • To avoid any After 1 week, the
(epidermis)
pressure-relieving pressure injuries patient showed rapid
• Discomfort Long term:
tools such as pillow healing of skin
• Irritable
After 1 week, the and foam wedges. lesions, wounds, or
patient will display pressure sores.
• Instruct the client to • Scratching and
a timely healing of
refrain from rubbing can GOAL MET.
wounds, or
touching or aggravate an injury
pressure sores
scratching the area. and slow recovery.
without
Give out gloves and,
complication.
if required, trim the
nails.
• Early evaluation and
action aid in

30
• Teach the client how preventing the
to check skin and emergence of
wounds and how to significant issues.
keep an eye out for
infection, problems,
and healing.
• Accurate information
lowers the risk of
• Inform the client and
infection and
any family members
improves the
of the value of
patient's capacity to
washing one's hands
manage therapy
and taking care of
independently.
one's wounds.
Dependent:
Dependent:
• To prevent antibiotic
• Instruct the patient
resistance.
to finish the full
course of
Levofloxacin.

31
NCP #3: Disturbed sleep pattern related to postsurgical procedure as manifested by restlessness and frequent yawning.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Disturbed sleep After 30 minutes of Independent: Independent: After 30 of
Patient reports of pattern related to nursing interventions • Advise the mother • To relieve some nursing
physical and mental post-surgical the client will be able to take some time stress and relax for interventions,
restlessness, can’t procedure as to: off for herself some time from her the patient was
focus on her baby manifested by • have a much every day and regular baby care able to:
during the day, and restlessness and healthier avoid taking naps routine. -improve her
inability to fall frequent emotional and during the day. emotional and
asleep at night. yawning physical well- physical
being. • Perform a health wellbeing.
Objective: education • For her to have a
1. Restlessness • manage a regarding better -alternately give
2. Frequent balance management of her understanding of time for herself
Yawning schedule for sutures. what she’s currently and her baby.
herself and her experiencing.
baby. • Reassure and -get enough
provide emotional • For her to be able to sleep and rest
• rest well and support. connect with her properly
get enough friends and have
sleep. some sort of -be more open
emotional help, or vocal about
• express her relief, and her thoughts and
feelings and entertainment as her feelings thus
thoughts more. • Encourage to do well. goals and
light exercises

32
 such as walking • For her to spend outcomes have
during the day. enough energy and been met.
craves rest during GOAL MET.
nighttime.

NCP #4: Risk for surgical site infection

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for After 1 hour of Independent: Independent: After 1 hour of
“Nurse, kanina surgical site providing care, the • Note signs and • Early detection of providing care, the
lang po ako na infection patient will be free symptoms of infection allows patient will be free from
operahan.” as from infection as sepsis, fever, for timely infection as evidenced
verbalized by the evidenced by: chills, treatment and by:
patient. • Verbalization of diaphoresis, and prevention of • Verbalized the
understanding positive blood further relief or reduced
and gained cultures. complications. discomfort,
Objective: knowledge on appear relaxed,
Vital signs taken how to prevent • Identify breaks and able to rest
as follows: surgical site in aseptic • Contamination by properly.
BP: 120/90 infection. technique and environmental or • Verbalized
mmHg • Demonstrate resolve personnel contact understanding
RR: 20 bpm techniques in immediately renders the sterile and gained
PR: 90 bpm preventing upon field unsterile, knowledge on
BT: 36.7 C infection after occurrence. thereby how to prevent
the surgery. increasing the risk surgical site
• Achieve timely of infection. infection.
wound healing

33
-Clean and intact and be free of • Monitor • May indicate • Demonstrated
abdominal pathogenic temperature developing sepsis techniques in
dressing organisms. routinely. Note requiring further preventing
• Identify the presence of evaluation and infection after
interventions to chills, intervention. surgery.
prevent and diaphoresis, and • Respond to
reduce risk for changes in interventions,
infection. mentation. teachings, and
• To minimize the actions
• Clean incision risk of infection. performed.
sites daily with • Attained and
appropriate gained progress
solutions. toward desired
outcomes.
• Reduces the risk GOAL MET.
of spread of
• Practice and bacteria that may
instruct in good cause infection.
handwashing.
• To promote a fast
recovery of the
• Instruct the
surgical site.
client in
techniques to
protect the
integrity of skin,
care for lesions,
and prevention

34
 of spread of
infection.

NCP #5 Knowledge deficit related to infant care as evidenced by verbalization of concerns.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: • Knowledge Within 1 hour of Independent: Independent: After 1 hour of
“Nurse, wala akong deficit related health teaching • Educate the • Let the patient health teaching,
alam sa pag aalaga ng to infant care about infant care, patient about informed about the patient was
sanggol” as verbalized as evidenced the patient will be infant the importance of able to know the
by the patient. by able to: nutrition. infant nutrition to importance of
verbalization • know about avoid infant care and the
Objective: of concerns. infant malnutrition and patient now
• Verbalization of proper other knows how to
infant care nutrition complications. take care of her
• Educate
misconceptions and safety. child.
patient about
• know the • let the patient be GOAL MET.
infant safety.
importance aware of what
infant care. she can and
cannot do to
avoid injury to
the infant and to
• Educate promote infant
patient about safety.
newborn care.

35
 • Assess the • to provide
client's information
readiness and about proper
motivation to newborn care
learn
• the post-partum
period can be a
positive
experience of
education when
given the
opportunity to
assist in the
• Pay attention
development /
to
growth of the
psychological
mother,
status and
malnutrition, and
response to
competence.
cesarean birth
and the role of
motherhood.
• Anxiety related
to the ability to
care for
• Demonstrate themselves and
the techniques their children,
of infant care. disappointment
Observations on the birth

36
 re experience has a
demonstration negative impact
by the client / on learning
partner. ability and
readiness of the
client.

• Helping parents
in mastering new
tasks

C.

37
C. Implementation
1. Drug study
Name of the Drug Route/ Mechanism of Indications Contraindications Side Effects/
Dosage/ Action Adverse
Frequency Reactions
Levofloxacin 1 tab Levofloxacin is a In oral and • diarrhea from an • nausea
bactericidal intravenous infection with • vomiting
antibiotic of the formulations, Clostridium • diarrhea
fluoroquinolone levofloxacin is difficile bacteria • stomach pain
drug class indicated in • diabetes • constipation
that directly adults for the • low blood sugar • heartburn
inhibits bacterial treatment of • glucose-6- • vaginal itching and/or
DNA synthesis. various phosphate discharge
Levofloxacin infections dehydrogenase
promotes the caused by (G6PD)
breakage of DNA susceptible deficiency
strands by bacteria, • low amount of
inhibiting DNA- including potassium in the
gyrase in infections of the blood
susceptible upper • a low seizure
organisms, which respiratory tract, threshold
inhibits the lower • pseudotumor
relaxation of respiratory tract, cerebri, a
supercoiled DNA. skin, skin condition with
structures, high fluid
urinary tract, pressure in the
and prostate. brain
The oral • a painful
formulation is condition that
also indicated in affects the nerves
both adults and in the legs and

38
 children 6 arms called
months of age peripheral
and older for the neuropathy
post-exposure
management of
inhalational
anthrax caused
by Bacillus
anthracis and
for the treatment
and/or
prophylaxis of
plague caused
by Yersinia
pestis.
Bisacodyl 1 tab a Bisacodyl is used on a short- • Hypersensitivity • Abdominal cramping
day, per deacetylated to term basis to • Obstruction or • Electrolyte and fluid
rectal the active bis-(p- treat severe impaction imbalance
hydroxyphenyl)- constipation. It • Symptoms • Excessive diarrhea
pyridyl-2-methane also is used to of appendicitis or • Nausea
(BHPM) by an empty the acute surgical • Rectal burning
intestinal bowels before abdomen • Spinning sensation
deacetylase. surgery and • Vomiting (vertigo)
BHPM can certain medical • Rectal bleeding • Stomach/abdominal pain
stimulate procedures. • Vomiting
parasympathetic Bisacodyl is in a • Weakness
nerves in the class of • Persistent
colon directly to medications nausea/vomiting/diarrhea
increase motility called stimulant • Muscle cramps/weakness
and secretions. laxatives. It • Irregular heartbeat
works by • Dizziness
increasing • Fainting

39
 activity of the • Decreased urination
intestines to • Mental/mood changes
cause a bowel (such as confusion)
movement.
Drug Name: Sinecod Adults: 1 Sinecod Forte is a Symptomatic If a patient is allergic to Somnolence, itchy skin rashes,
Forte tablet 3 valuable cough treatment of butamirate citrate or any nausea, and diarrhea.
times daily suppressant and is cough of various of the other ingredients.
(at least 8 commonly origins.
Generic name: hours available over the
Butamirate Citrate between counter in syrup
doses). To form. The active
be ingredient
swallowed Butamirate Citrate
whole. is an effectual
Maximum cough suppressant
daily dose: and works by
3 tablets lessening the
(150 mg). airway resistance.

40
Drug Name: Mefenamic 500 mg Inhibits synthesis For the Contraindicated Side effects:
Acid PO of prostaglandins treatment of in patients with ulcers, • Diarrhea
in body tissues by rheumatoid stomach bleeding, • Constipation
Classification: inhibiting at least arthritis, hypertension, or NSAID • Headache
Nonsteroidal Anti- 2 cyclooxygenase osteoarthritis, hypersensitivity like • Dizziness
Inflammatory Drugs isoenzymes, dysmenorrhea, aspirin. • Tinnitus
(NSAIDs) cyclooxygenase-1 and mild to • Pyrosis
(COX-1) and -2 moderate pain, • Nausea
Pregnancy Category: (COX-2). inflammation,
C and fever.
Adverse effects:
• Difficulty breathing or
swallowing.
Difficult or painful urination

GENERIC NAME: 30 mg IM The primary Short term Contraindicated with CNS:

Ketorolac action responsible management of significant renal • Headache
for ketorolac’s pain (up to 5 impairment, during labor • Dizziness
anti- days) and delivery, lactation, • Somnolence
BRAND NAME: inflammatory, aspirin allergy, recent GI • Insomnia
Toradol antipyretic and bleed or perforation • Fatigue
analgesic effects • Tinnitus
CLASSIFICATION: is the inhibition of
prostaglandin Use cautiously with Ophthalmologic effects
Nonsteroidal anti- impaired hearing;
inflammatory agents, synthesis by
competitive allergies, hepatic
nonopoid analgesics conditions
blocking of the

41
 enzyme cyclo-
oxygenase.

(COX). Ketorolac
is a non-selective
COX inhibitor

2. Medical Management
Medical Date General Description
Management/ performed
Treatment
Intravenous fluid of Lactated Ringer's and 5% Dextrose
5% of Dextrose in Injection, USP is a sterile, non-
Lactated Ringer’s pyrogenic solution for fluid and
Solution electrolyte replenishment and caloric
supply in a single dose container for
intravenous administration. It contains
no antimicrobial agents.
The Dextrose 5% in Lactated Ringers
Solution (D5LRS) is useful for daily
maintenance of body fluids and
nutrition, and for rehydration.
Incubator An apparatus used to provide a
controlled environment, especially
temperature
Indication/
Purpose
• Treatment that is used to
replace the fluids and
electrolytes in patients with
imbalanced blood fluid to
avoid dehydration.
• The incorporated units of
oxytocin in D5LR are for
induction of labor.
It improves the baby's condition by
regulating the temperature. A baby
can be weaned from an incubator.
Client’s reaction to
treatment
The patient bears the
treatment and there are
no signs of distress or
adverse reactions when
administering the IV
fluid.
The baby bears the
treatment and there are

42
 An incubator helps prevent radiation no signs of distress or
and convection heat adverse reactions.
loss when portholes are opened for
care.

SURGICAL MANAGEMENT

Name of Date Brief description Indication/ purposes Client’s response to Nursing responsibilities, prior
procedure performed operation to, during, and actual surgical
procedure (actual)
Cesarean A surgical procedure in They're performed when • Client can’t Prior to:
Section which a baby is a vaginal delivery is not feel pain
delivered through possible or safe, or when because of • The nurse will set up the tray
incisions in your the health of you or your anesthesia for cesarean section
abdomen and uterus. baby is at risk. • Pain when During:
walking,
sitting, and • Monitors contractions and
urinating advises the physician when
• Soreness in the one is present because
site traction is applied only with
a contraction.
• Assess for signs of infection
if lacerations occurred
during the procedure
After:
• Monitor the patient's vital
signs and pain.

43
 • Monitor urine output, patient
ambulation, and level of
activity.

44
4. Diet
Recommended Diet for post op, c section (PROM).
Ideally, after the operation the mother should be given ice chips and be put under a
liquid diet like coconut milk, smoothies, buttermilk, herbal teas, soups, calcium-fortified drinks,
and fruit juices. These fluids can help ease bowel movements, but these options are not
substitutes for water. Mothers should consume at least 3 liters of water daily until the intestinal
functioning becomes normal. by then, her diet can be changed into semi-solids. we do this to
prevent bloating and gas in our patient. also, at this current stage of diet, we should include
iron, fibers and protein because it is essential at this point. Dehydration, prenatal vitamins, and
pain medications after the operation can cause constipation. Consuming fibers from whole
grains, vegetables, fruits, legumes, and nuts, relieves constipation. New mothers should also
consume enough warm water or nutritional soup.

Protein helps a lot in maintaining the muscle and promoting the growth of new tissues.
Mothers can eat lean proteins to get sufficient nutrition without worrying about additional
unwanted fats. Foods like Greek yogurt, tofu, white meat poultry and eggs, beans, and lentils
are various lean protein sources for diet after C-section who was experienced PROM. Iron
supplements on the other hand are also given to pregnant women during their pregnancy
journey and after it. Women lose a significant amount of blood during delivery. having an iron-
rich food diets like green leafy vegetables, beans, and legumes, helps produce hemoglobin and
reduce the chances of having iron deficiency anemia.

Foods or diets that can cause fatigue, lethargy, and slow recovery to our client should
be avoided. The diet chart after C-section recovery should also be free of anything that takes a
longer duration to digest. Foods or drinks like carbonated drinks, citrus juices, coffee, tea, and
spicy food should be avoided as they increase bloating and gas. Fermented and fried food can
also give heartburn and indigestion. Since mothers are also breastfeeding, such foods can affect
the milk and cause growth problems/complications in the newborn.

45
5. Activity

Activity/Exercise for post op. C-section (PROM)

After a C-section, physical activities are restricted for a significant period of time. Like
any other major surgeries, it usually takes for about weeks for proper recovery and healing after
a C-section. Ideally it should be at least 6 weeks before someone who went post op start doing
exercises again. High-impact exercise, tummy-toning workouts, and long duration of cardio
are definitely not recommended for the first six weeks after a C-section delivery. But if the
patient really wants to indulge in a physical activity before the 6 weeks mark to help boost her
energy and bring back the good shape she had before, she should start with gentle, and low
impact activity like, walking. by walking from time to time after a C section Delivery, it will
help tune up your body slowly. it will progress properly without causing and unwanted health
conditions as long as you won't overwork yourself. light stretches is also a recommended light
exercise to help your body recover. Practicing a Good posture is also recommended if you want
to regain your good body shape before pregnancy.

After 1 to 5 weeks of doing light exercises, once the patient is allowed by her doctor to
finally do physical activities in the upcoming week, one of the recommended exercises is pelvic
floor exercise. Pregnancy puts a lot of strain and pressure on the pelvic floor muscles that
supports the bladder, bowel movement, and the uterus. In addition with that, during surgery
too, the bladder is moved or positioned to safely deliver the baby. This creates a lot of trauma
in those organs and muscles, so it’s really essential and important to focus on strengthening
them. Kegel exercises, squats and bridge are a few examples of pelvic floor exercises that will
help our patient to full recovery. so while it may be the last thing the patient feels like doing
after caring for a baby all night and day, a light walking in the park or even around your house
may be exactly what she needs to feel relieved and happy.

Your mental health will also benefit from postnatal exercise. As exercises can also help
fight postpartum depression and could also promote good sleep for our patient. Just make sure
to not push yourself or overwork yourself too much, as overworking your body after a C-
section delivery can have serious consequences, and complications such as wound infection or
injury.

46
6. Nursing management
Priority: Impaired skin integrity

S “Nurse, nangangati ang tahi ko” as verbalized by the patient.

O • Disruption of skin surface (epidermis)
• Discomfort
• Irritable
A Impaired skin integrity related to surgical incision in the skin secondary to
cesarean section.
P Short term:
After 2 hours of providing wound care the client's wound will participate in
preventive measures and treatment programs.

Long term:
After 1 week, the patient will display a timely healing of wounds, or pressure sores
without complication.
I INDEPENDENT
• Provided wound care.
• Used a sterile dressing approach while treating wounds.
• Encouraged the use of pressure-relieving tools such as pillows and foam
wedges.
• Instructed the client to refrain from touching or scratching the area. Give
out gloves and, if required, trim the nails.
• Taught the client how to check skin and wounds and how to keep an eye
out for infection, problems, and healing.
• Informed the client and any family members of the value of washing one's
hands and taking care of one's wounds.
DEPENDENT
Administered ointment to rectal and groin area as prescribed by the physician.
E Short term:
After 2 hours of interventions, the client has engaged in preventive measures and
treatment programs.

47
 Long term:
After 1 week, the patient showed rapid healing of skin lesions, wounds, or pressure
sores.
GOAL MET

Priority: Acute Pain

S "medyo may hapdi at kirot yung tahi ko"as verbalized by the patient.
O • Facial Grimace
• PR: 102bpm
A Acute pain related to postoperative wound as manifested by facial grimace and
increased pulse rate.
P After 30 minutes of providing comfort measures the client will be able to:

Short term:
• Verbalize decrease of pain and demonstrate a normal pulse rate.

I INDEPENDENT
• Encouraged patient to have an adequate rest.
• Provided comfort measures, and quiet environment.
• Monitored skin color/ temperature and vital signs.
• Taught and demonstrated proper relaxation techniques like breathing
exercise and position for comfort as possible. Use therapeutic touch, as
appropriate.
• Identified specific activity limitations.
DEPENDENT
• Administered ointment to rectal and groin area as prescribed by the
physician.
E Short term:
After 30 minutes of providing comfort measures, the client was able to:
• Verbalize decrease of pain and demonstrate a normal pulse rate.
GOAL MET

48
Priority: Fatigue

S “Kahit konting paglakad at pag galaw lang po eh pakiramdam ko sobrang pagod

ko na” as verbalized by the client.
O ▪ Pale lips
▪ Restlessness
▪ Blood pressure: 140/90 mmHg
▪ CBC result:
➢ Hemoglobin =10.4 g/dl (Low)
➢ Hematocrit = 36.4 %
A Fatigue related to decreased hemoglobin and diminished oxygen-carrying
capacity of the blood as evidenced by verbalized exhaustion.
P Short term:
After 2 hours of encouraging client to follow the energy conservation principles,
the client will be able to:

• Verbalize reduction of fatigue, as evidenced by reports of increased energy

and ability to perform desired activities.

Long term:

After 2-4 weeks of nursing interventions, the client will be able to have a normal
level of hemoglobin and hematocrit, upon checking her laboratory result.
I INDEPENDENT
• Positioned the client in comfortable sitting position or semi fowlers.

• Assessed the client’s ability to perform activities of daily living (ADLs)

and the demands of daily living.

• Assisted the client in planning and prioritizing activities of daily living

(ADL).

• Instructed the client about the methods that conserve energy such as sitting
instead of standing during activities/ shower and plan the steps of the
activity before doing it.

• Encouraged client to take frequent breaks during each task or nap or have
an adequate sleep.

• Encouraged the client to eat iron rich foods such as red meat, fish, poultry,
chicken, eggs, beans, and green leafy veggies.

Dependent/Collaborative
• Preparer packed red blood cells as per doctor’s order.

49
 • Referred the client and family to an occupational therapist.
E After 6 hours of encouraging the client to take frequent breaks during each task or
nap or have an adequate sleep, the client verbalized understanding of sleep
disturbance.
• Demonstrated and established methods to help patient have uninterrupted
sleep.
• Regulated patient’s sleeping pattern.
GOAL MET

Priority: Fear

S “Nurse, sobrang natatakot po akong manganak” as verbalized by the patient.

• Feelings of alarm
• Panic
• Dread
O • Focus narrowed to the source of fear.
• Increase in perspiration.
• Fidgeting
Vital signs taken as follows:
• BP: 140/90 mmHg
• RR: 21 bpm
• PR: 102 bpm
• BT: 37.1C
A Fear related to perceived threat of maternal and fetal well-being as manifested by
increased tension.
P After 30 minutes of discussing patient’s fear and counseling the patient should:
• Appear relax.
• Verbalize sense of safety to current condition
• Demonstrate understanding through the usage of coping behaviors.
• Displayed lessened fear
I INDEPENDENT
• Measured vital signs and physiological responses to the situation.
• Stayed with the fearful patient and plan to have significant other be there.
• Discussed the patient’s fearful feelings and listen to her concerns.

50
 • Provided information about the procedure slowly.
• Assisted client to learn relaxation, visualization, and guided imagery
skills.
E After 2 hours of encouraging the client to follow the energy conservation
principles, the client was able to verbalize reduction of fatigue, as evidenced by
reports of increased energy and ability to perform desired activities.
GOAL MET

Priority: Deficient Fluid Volume

S • Weakness
O • HR: 102 bpm
• Hct: 36.4 %
• Hgb: 10.4 g/dl
• BP: 140/90 mmHg
• RR: 21 bpm
• Leaking
• Vaginal bleeding
A Deficient fluid volume related to premature rupture of bag of water as manifested
by 2 hours of leaking and vaginal bleeding.
P After an hour of administering fluids and electrolytes, the client will be able to:
• Maintain fluid volume at a functional level as manifested by stable vital
signs.
• Demonstrate relaxed behavior.
I INDEPENDENT:
• Assessed vital signs.
• Noted unusual changes in mentation, behavior, and functional abilities.
(e.g., confusion, falling, lethargy)
• Review laboratory data.
Collaborative:
• Administered fluids and electrolytes.
E After an hour of administering fluids and electrolytes, the client was able to:
• Maintain fluid volume as manifested by modified vital signs.

51
 • Demonstrate relaxed behavior.
GOAL MET

Priority: Disturbed sleeping pattern

S • Patient reports of physical and mental restlessness, can’t focus on her baby
during the day, and inability to fall asleep at night.

O • Restlessness
• Frequent Yawning
A Disturbed sleep pattern related to post-surgical procedure as manifested by
restlessness and frequent yawning.
P After 30 minutes of advising the mother to take some time off for herself every
day and avoid taking naps during the day.

• manage a balanced schedule for herself and her baby.

• rest well and get enough sleep.
• express her feelings and thoughts more.
I INDEPENDENT:
• Advise the mother to take some time off for herself every day and avoid
taking naps during the day.
• Perform a health education regarding management of her sutures.
• Reassure and provide emotional support.
E After 30 minutes of advising the mother to take some time off for herself every
day and avoid taking naps during the day, the patient was able to:
• improve her emotional and physical wellbeing.
• alternately give time for herself and her baby.
• get enough sleep and rest properly.
• be more open or vocal about her thoughts and her feelings thus goals and
outcomes have been met.
• GOAL MET

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Priority: Risk for injury

S “Nurse, natatakot ako baka kung ano mangyare samin nung baby ko di ko pa
naman kabuwanan.”
O BP: 140/90mmHg
RR: 21 bpm
T: 37.1°C
PR: 102 bpm
A Risk for maternal and fetal injury.
P • Within 30 minutes of positioning the client’s extremities, the client and
the baby will be free from the risk of having injury..
I INDEPENDENT:
• Advised the mother to take some time off for herself every day and avoid
taking naps during the day.
• Performed a health education regarding management of her sutures.
• Reassured and provide emotional support.
E After 30 minutes of positioning the client’s extremities that client was able to
have a modified environment to enhance safety and prevent risk of injury.
• GOAL MET.

Priority: Risk for infection

S “Nurse, kanina lang po ako na operahan.” as verbalized by the patient.

O Vital signs taken as follows:
BP: 120/90 mmHg
RR: 20 bpm
PR: 90 bpm
BT: 36.7 C
-Clean and intact abdominal dressing
A Risk for surgical site infection
P After 1 hour of providing care, the patient will be free from infection as
evidenced by:
• Verbalization of understanding and gained knowledge on how to prevent
surgical site infection.
• Demonstrate techniques in preventing infection after the surgery.
• Achieve timely wound healing and be free of pathogenic organisms.
• Identify the interventions to prevent and reduce risk for infection.
I INDEPENDENT:

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 • Noted signs and symptoms of sepsis, fever, chills, diaphoresis, and
positive blood cultures.

• Identified breaks in aseptic technique and resolve immediately upon

occurrence.

• Monitored temperature routinely. Note presence of chills, diaphoresis,

and changes in mentation.

• Cleaned incision sites daily with appropriate solutions.

• Practiced and instruct in good handwashing.

• Instructed the client in techniques to protect the integrity of skin, care for
lesions, and prevention of spread of infection.
E After 1 hour of providing care, the patient will be free from infection as
evidenced by:
• Verbalized the relief or reduced discomfort, appear relaxed, and able to
rest properly.
• Verbalized understanding and gained knowledge on how to prevent
surgical site infection.
• Demonstrated techniques in preventing infection after surgery.
• Respond to interventions, teachings, and actions performed.
• Attained and gained progress toward desired outcomes.
GOAL MET.

Priority: Knowledge Deficit

S “Nurse, wala akong alam sa pag aalaga ng sanggol” as verbalized by the patient.

O Verbalization of infant care misconceptions.

A • Knowledge deficit related to infant care as evidenced by verbalization of
concerns.
P Within 1 hour of health teaching about infant care, the patient will be able to:
• know about infant proper nutrition and safety.
• know the importance infant care.
I INDEPENDENT:
• Educated the patient about infant nutrition.
• Educated patient about infant safety.

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 • Educated patient about newborn care.
• Assessed the client's readiness and motivation to learn.
• Paid attention to psychological status and response to cesarean birth and
the role of motherhood.
• Demonstrated the techniques of infant care. Observations re demonstration
by the client / partner.
E After 1 hour of health teaching, the patient was able to know the importance of
infant care and the patient now knows how to take care of her child.
• GOAL MET.

Priority: Risk for Infection

S “Dalawang oras na pong may lumalabas sa ari ko, sabi po nila pumutok na daw
po ang panubigan ko”
O BP: 140/90
PR: 102
RR: 21
Temp: 37.1 degree Celsius

Blue nitrazine paper test

A Risk for infection related to preterm rupture of membranes.
P After 1 hour of administering medications, the patient is expected to be free from
any signs and symptoms of possible onset of infection.
I INDEPENDENT:
•
Assessed for signs and symptoms of infection.
• Initiate fetal monitoring.
DEPENDENT:
• Administered medications as ordered by the attending physician.
• Administered IV fluids as ordered.
• Prepared patient for induction of labor and delivery.

E After 1 hour of administering medications, the patient is still having signs and
symptoms of possible onset of infection. Further nursing intervention is given.
GOAL NOT MET.

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D. Evaluation
A. Methods of Approach
MEDICATION
1. ketorolac
• Indication: Short term management of pain
• Dosage: 30 mg
• Frequency: q6-4 dosage
• Route: IM

2. Sinecod Forde
• Indication: Symptomatic treatment of cough of various
origins.
• Dosage: 250 mg
• Frequency: TID
• Route: Oral

3. Bisacodyl
• Indication: used on a short-term basis to treat constipation.
It also is used to empty the bowels before surgery and certain
medical procedures.
• Dosage: 1 tab
• Frequency: OD
• Route: rectal

4. Mefenamic acid
• Indication: For the treatment of rheumatoid arthritis,
osteoarthritis, dysmenorrhea, and mild to moderate pain,
inflammation, and fever.
• Dosage: 500 mg
• Frequency: OD
• Route: Oral

5. Levofloxacin
• Indication: levofloxacin is indicated in adults for the
treatment of various infections caused by susceptible
bacteria, including infections of the upper respiratory tract,
lower respiratory tract, skin, skin structures, urinary tract,
and prostate.
• Dosage: 500 mg
• Frequency: 1 tab
• Route: Oral
EXERCISE The physician recommended light physical activity per week,
such as walking and kegels exercise. During, after their
pregnancy, and upon discharge planning.

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TREATMENT It was suggested to follow a nutritional diet and provide good care
for the newborn, get plenty of rest.
HEALTH • Do breastfeeding on demand and positions when
TEACHING breastfeeding.
• Perineal care rinsing from front to back and showering each
day.
• Proper wound care.
• It is recommended to maintain a balanced diet.
• Advised to take ferrous sulfate and iron for 3 months
following birth.
• Advised to take rest when the newborn sleeps.
• Advised to increase clean water intake.
• It is recommended to avoid lifting heavy objects for the first
three weeks after birth.
• Advised to take proper cord care, newborn care such as
bathing and changing the diaper.
OUTPATIENT Patient X was recommended to see her doctor one week after
DEPARTMENT giving birth on February 21, 2023 OPD department. The
FOLLOW UP physician will check the development of the newborn. The
immunizations, newborn screenings and tests.
DIET It was advised to take foods that are rich in protein, fruits,
vegetables, and fiber-rich carbs. Proteins like lean meats, beans,
seafood, and eggs.

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III. CONCLUSION

With the comprehensive analysis of the case study, it is determined that preterm
premature rupture of membranes (PPROM) is a pregnancy complication in which the sac
(amniotic membrane) surrounding the baby breaks (ruptures) before week 37 of pregnancy.
Once the sac breaks, the mother have an increased risk for infection and have a higher chance
of having the baby born early. Before term, PPROM is often due to an infection in the uterus.
Typically, unless complications occur, the only symptom of PROM is leakage or a sudden
gush of fluid from the vagina.

In this case, the mother with PCOS had a complication in which the sac surrounding
her baby ruptured even if she was still 35 weeks pregnant. Her complaint of vaginal bleeding,
feeling of minimal labor pain and uterine contractions, high blood pressure and water leaking
for 2 hours caused her to be immediately transferred to the delivery room to give birth via
cesarian section. The patient’s laboratory results revealed that the hematocrit is high, and the
hemoglobin is low, urine is positive of leukocytes and there’s presence of blood in her urine.
PPROM is a high risk for premature birth that requires immediate treatment that is why the
effect of this complication and surgical procedure can be mitigated by providing the client
with appropriate interventions which can help in aiding the needs of both the mother and the
infant.

The student nurses formulated nursing care plans for the patient’s pain, fatigue,
impaired skin integrity, deficient knowledge, risks for infection and injury, sleep deprivation
and fear. It is a responsibility for student nurses to know the nursing interventions and what
type of care should be given to the clients. It is a must to understand and know how to
prioritize the needs of the clients, educate them, and assist them to fully obtain the highest
optimum care that they deserve.

Our responsibility as student nurses doesn’t just end in providing care but it also
extends to giving knowledge on what are the things that the clients need to avoid preventing
complications to arise. All mothers need to take care of themselves during their pregnancy as
their actions brings big impact to the whole well-being of their baby.

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IV. RECOMMENDATION
To the medical allied students
This case study can be a starting point for medical research and a helpful guideline,
particularly in the case of preterm premature rupture of membrane to medical allied students.
Having awareness and understanding with regards to this complication is important to
medical allied students to have a basic understanding of what can be done if encountered in
the clinical exposure, as well as what health teachings to impart to clients and family
members if this complication was encountered. Medical allied students should continue to
broaden their knowledge and skills to formulate appropriate nursing interventions to address
patients’ health needs.

To the health care providers

This case study will give an overview to healthcare providers to continue to help
parents to find ways on how they can be able to surpass complications and find more ways to
help patients throughout the pregnancy and delivery process. It is also recommended to
healthcare providers in order continue educating pregnant women about the things that they
should and should not do during pregnancy to avoid complications, Moreover, this will help
them to gather extra understanding about the case and discover additional proper
management to handle patients with the same case that they may obtain through this study.

To the parents
This study is recommended to parents especially to primigravida mothers to be
mindful of their health and the growing fetus inside the womb. This will help them to prepare
for the pregnancy and participate in management to save the baby from developing further
complications that may put their health at risk. They should also be informed of the risk,
treatment, and effects of the problem in future pregnancies. Hence, taking maternal check-
ups, having a healthy lifestyle, and having a healthy diet and nutrition are recommended to
maintain the mother’s body as well as to promote good growth and development of the baby.
And through this learning, they will be able to know what actions to take and what they
should consider when planning to have another pregnancy again.

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V. Review of related literatures
Premature rupture of membranes (PROM) is described as membrane rupture before the
labor begins. Preterm PROM occurs when a membrane rupture occurs prior to labor and before
37 weeks of gestation (PPROM). PROM complicates about 8% of pregnancies at term. Preterm
PROM complicates about 1% of all deliveries, and it is twice as common in African Americans
(Dayal & Hong, 2022).
PPROM affects about 3% of all pregnancies and accounts for one-third of all preterm
births. Despite its contribution to maternal and neonatal mortality and morbidity, there is little
evidence on the burden of PPROM and its associated factors in the research region (Tsegaye
et al., 2023).
When PROM occurs both at term and preterm, it is linked to serious diseases in both
the mother and the fetus. When it occurs at a preterm age, chorioamnionitis is the most
prevalent of these. PROM affects the prenatal health of newborns; those born from mothers
with the condition have the risk of developing birth asphyxia, neonatal infection, and possibly
neonatal death (Boskabadi & Zakerihamidi, 2019).
The rupture of membrane is caused by a variety of factors that eventually lead to
accelerated membrane weakening. This is due to an increase in local cytokines, an imbalance
in the interaction between matrix metalloproteinases and tissue inhibitors of matrix
metalloproteinases, increased collagenase and protease activity, and other factors that can cause
increased intrauterine pressure (Dayal & Hong, 2022).
In most cases, the cause of PROM is unknown. Some causes or risk factors may be the
following: infections of the uterus, cervix, or vagina; too much stretching of the amniotic sac
wherein this may happen if there is too much fluid, or more than one baby putting pressure on
the membranes; smoking; had a surgery or biopsies of the cervix; and was pregnant before and
had a PROM or PPROM. Most women whose water breaks before labor do not have a risk
factor (Jacobson et al., 2022).

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VI. BIBLIOGRAPHY

References:
• Dayal S, Hong PL. Premature Rupture Of Membranes. [Updated 2022 Jul 18]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK532888/
• Jazayeri, A., MD PhD. (2021, June 26). Premature Rupture of Membranes: Overview,
Premature Rupture of Membranes (at Term), Premature Preterm Rupture of
Membranes. https://emedicine.medscape.com/article/261137-overview
• Jacobson, D., & Dugdale, C. (2022, April 9). Premature rupture of membranes
(A.D.A.M. Editorial team, Ed.). medlineplus.gov. Retrieved February 19, 2023, from
https://medlineplus.gov/ency/patientinstructions/000512.htm
• Tiruye, G., Shiferaw, K., Tura, A. K., Debella, A., & Musa, A. (2021). First published
online October 29, 2021. Prevalence of premature rupture of membrane and its
associated factors among pregnant women in Ethiopia: A systematic review and meta-
analysis. SAGE open medicine, 9, 20503121211053912.
https://doi.org/10.1177/20503121211053912
• American Red Cross (2023). What Does Hematocrit Mean? Retrieved from
https://www.redcrossblood.org/donate-blood/dlp/hematocrit.html
• USCF Health (2018). Hemoglobin. Retrieved from
https://www.ucsfhealth.org/medical-tests/hemoglobin
• USCF Health (2019). WBC count. Retrieved from
https://www.ucsfhealth.org/medical-tests/wbc-count
• National Heart, Lung, and Blood Institute (2022, March 24). Thrombocytopenia.
Retrieved from https://www.nhlbi.nih.gov/health/thrombocytopenia
• Smith, K. (2022). Reviewed: September 14, 2022. Urinalysis: Purposes, Types,
Results. Retrieved from https://www.everydayhealth.com/urine/urinalysis-how-test-
done-what-results-mean/
• Boskabadi, H. & Zakerihamidi, M. (2019). Published: 2019/04/1. Evaluation of
Maternal Risk Factors, Delivery, and Neonatal Outcomes of Premature Rupture of
Membrane. Retrieved from https://jpr.mazums.ac.ir/article-1-170-en.html
• Enjamo, M., Deribew, A., Semagn, S., & Mareg, M. (2022). Published 31 March
2022. Determinants of Premature Rupture of Membrane (PROM) Among Pregnant
Women in Southern Ethiopia: A Case-Control Study. International journal of
women's health, 14, 455–466. https://doi.org/10.2147/IJWH.S352348
• Marianne Belleza, R.N, January 19, 2017 https://nurseslabs.com/category/nursing-
notes/maternal-child-health-nursing/
• https://www.daytoday.health/blog/ultimate-diet-guide-for-c-section-delivery-mothers
• Dr. Anna Targonskaya ,Obstetrician and gynecologist, November 26
2021https://flo.health/being-a-mom/recovering-from-birth/postpartum-
problems/exercises-after-cesarean-delivery

• Premature Rupture of Membranes (PROM)/Preterm Premature Rupture of

Membranes (PPROM). (n.d.). Children’s Hospital of Philadelphia.
https://www.chop.edu/conditions-diseases/premature-rupture-membranes-
prompreterm-premature-rupture-membranes-pprom

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