ROMERO D.

ROMERO P.
RUFINO L.
SADDI E.
SANCHEZ D.
SANTOS A.

GROUP B
A 45-year-old obese, multiparous (G3P3) female with
no other past medical history and an uncomplicated
prenatal course, presents with twins at 40 weeks'
gestation. Her prior vaginal deliveries were
uncomplicated. She experiences a tumultuous labor of
many hours with delivery by Cesarean section because
of fetal distress. Shortly after delivery, she suddenly
complains of shortness of breath. Her oxygen
saturations fall from 98 to 74%, blood pressure falls to
86/50 mmHg, and she suffers a generalized seizure.
You also note oozing at her IV insertion sites and
increased bloody vaginal discharge. 
1. What is the pathophysiology of Amniotic Embolism? Formulate a concept map
highlighting the clinical presentation based on the scenario. 
2. Formulate guided questionnaire that you will include in history taking the
patient. If you visited her prior to the emergency admission.  

Do you have any

allergies to Do you have any Have you had
medications or illness or disease? surgery lately?
foods?

Is there any
Have you had any
medications that GTPAL
accidents?
you are taking?
3.What is your role as  If an emergency caesarian section is required, our
a nurse if a patient responsibility as nurses is to prepare the patient for the
procedure. Then, phone the OR and let them know
needed an emergency about the emergency caesarian section so they can
caesarian section and prepare. For joint work, contact other departments
you are the one who such as anesthesiology. The doctor will inform the
carried out the order patient's family about her condition, explain the
surgery, and obtain agreement from her family,
of attending physician. particularly her husband if she is married. However, in
Explain based on your the Philippines, nurses are sometimes the ones who
understanding.   request that the family sign the consent form.
ASSESSMENT
Subjective:
“Nahihirapan akong
huminga” as verbalized by
the patient.
 
Objective:
- SaO2: 74%
- BP: 86/50mmHg
- Generalized seizure
- Oozing at the IV site
- Increased bloody
vaginal discharge
4. FORMULATE A 3 NCP BASED ON SCENARIO PLOTTED ALSO IN
FDAR CHARTING. 
DIAGNOSIS PLANNING INTERVENTION EVALUATION
Ineffective breathing Within 30 minutes of - Monitor and record vital signs After 30 minutes of
pattern related to rendering nursing - Assess breath sounds, respiratory rate, rendering proper
decreased oxygen interventions, the depth and rhythm. nursing interventions,
supply patient will be able to - Observe for the use of accessory muscles the patient was be able
maintain an effective - Elevate the head of the patient. to maintain an effective
breathing pattern - Encourage deep breathing exercises breathing pattern as
- Administer supplemental oxygen as evidenced by absence of
ordered. dyspnea.
- Administer prescribed medication as
ordered.
- Encourage adequate rest periods
between activities
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Objective: Risk for infection Within 1 hour of - Monitor signs and symptoms After 1 hour of
- SaO2: 74% related to tissue nursing of infection. rendering proper
- BP: 86/50mmHg trauma interventions, the - Monitor the nutritional status, nursing interventions,
- Generalized seizure patient will be able weight and history of weight the patient was be able
- Oozing at the IV site to alleviate the loss to alleviate the
- Increased bloody problems related - Monitor the characteristics of problems related with
vaginal discharge with the infection. urine. the infection
- Assess the intactness of
amniotic membranes
- Encourage adequate rest
periods between activities
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Objective: Risk for injury Within 8 hours of - Place the bed in After 8 hours of
- SaO2: 74% related to loss of nursing the lowest rendering proper
- BP: sensory interventions, the position. nursing
86/50mmHg coordination and patient will be able - Put pads on the interventions, the
- Generalized muscular control to prevent injury by bed rails and the patient was able to
seizure maintaining the floor demonstrate
- Oozing at the treatment regimen - Turn head to side behaviors that
IV site to control seizure during seizure reduced the risk
- Increased and suction factors from
bloody vaginal airway as injury.
discharge indicated.  
- Administer
supplemental
oxygen as
ordered.
- Administer
prescribed
medication as
ordered.
DATE FOCUS DATA/ACTION RESPONSE
03/04/2022 Ineffective breathing pattern related to decreased oxygen D
supply Subjective:
“Nahihirapan akong huminga” as verbalized by the patient.
 
Objective:
- SaO2: 74%
- BP: 86/50mmHg
- Generalized seizure
- Oozing at the IV site
- Increased bloody vaginal discharge
 
A
- Monitored and record vital signs
- Assessed breath sounds, respiratory rate, depth and rhythm.
- Observed for the use of accessory muscles
- Elevated the head of the patient.
- Encouraged deep breathing exercises
- Administered supplemental oxygen as ordered.
- Administered prescribed medication as ordered.
- Encouraged adequate rest periods between activities
 
R
- After 30 minutes of rendering proper nursing interventions, the patient was be
able to maintain an effective breathing pattern as evidenced by absence of
dyspnea.
 
Date Focus Data/Action Response
03/04/2022 Risk for infection related to tissue D
trauma - SaO2: 74%
- BP: 86/50mmHg
- Generalized seizure
- Oozing at the IV site
- Increased bloody vaginal discharge
 
A
- Monitored signs and symptoms of infection.
- Monitored the nutritional status, weight and history of weight
loss
- Monitored the characteristics of urine.
- Assessed the intactness of amniotic membranes.
- Encourage adequate rest periods between activities
 
R
- After 1 hour of rendering proper nursing interventions, the
patient was be able to alleviate the problems related with the
infection
Date Focus Data/Action Response

03/04/2022 Risk for injury related to loss of sensory D

coordination and muscular control
- Generalized seizure
- SaO2: 74%
- BP: 86/50mmHg
- Oozing at the IV site
- Increased bloody vaginal discharge
A
- Placed the bed in the lowest position.
- Placed pads on the bed rails and the floor
- Turned the head of the patient to the side during
seizure and suctioned airway as indicated.
- Administered supplemental oxygen as ordered.
- Administered prescribed medication as ordered.
R
- After 8 hours of rendering proper nursing interventions,
the patient was able to demonstrate behaviors that
reduced the risk factors from injury.
5. FORMULATE A SAMPLE ENDORSEMENT VIA VIDEO PRESENTATION.
ASSUMING THAT YOUR SHIFT IS FROM 11PM TO 7PM AND 7AM-3PM.
GUIDED BY ISBAR METHOD.
  Good afternoon, Nurse Sanchez, I’m Ella Joyce attending nurse from ICU. I would like to discuss our care plan for our patient. She
  suddenly complaints of shortness of breath after the delivery. There’s an l oozing at her IV insertion sites and increased bloody vaginal
S discharge.

  Patient is 45 yo, female with no other past medical history. She has an
  uncomplicated prenatal course, presents with twins at 40 weeks' gestation. Her prior vaginal deliveries were uncomplicated. She experiences
B a tumultuous labor of many hours with delivery by Cesarean section because of fetal distress.

  - Position the patient in a high fowler position

  - Provided oxygen via nasal cannula
A - Regulated the IV fluid
- Administered medication
- Encouraged deep breathing exercises

   
  I would like to recommend the patient for continuous monitoring of her vital sign until the next shift.
R