CASE STUDY I.

INTRODUCTION Preterm labor is defined as the onset of regular contractions with progressive cervical effacement and dilatation that occurs before 37 weeks of gestation. Preterm labor is probably initiated by a single etiologic event, but rather by a group of factors that individually or in combination influence the various pathways involved in control of labor onset. Numerous risk factors for preterm labor have been cited, including multiple gestation; previous labor, exposure to DES, more than one second trimester abortion, infectious causes, smoking, poor maternal weight gain, and maternal age. The most frequently cited risk factor is a history of a previous spontaneous preterm delivery. These clients have an increased risk for preterm delivery in their current pregnancy of about 2.5 times that of a normal delivery. The incidence rate for preterm births account for approximately 8% to 15% of births in the United States. There are 13 million premature infants born worldwide, accounting for the overwhelming majority of perinatal morbidity and mortality (Althabe, 1999). II. OBJECTIVES At the end of the case presentation, the students will be able to: 1. Apply the nursing process plan to and implement care for the woman in preterm labor 2. Discuss the nursing interventions for pregnant women who is experiencing preterm labor 3. Outline common risk factors for preterm labor

III. THEORETICAL FOUNDATION

Myra Estrin Levines Conservation Model can be used in this case since this model focuses on three (3) major concepts. These are Wholeness, Adaptation, and Conservation. Wholeness involves integrity of individuals. Our patient is pregnant which means that it is not only the woman itself that we should be taking care of but also the baby inside her.

She elaborated on how redundancy characterizes availability of adaptive responses when stability is threatened. Adaptation process establishes a body economy to safeguard the individuals stability. The outcome of adaptation is conservation. She explicitly linked health to the process of conservation to clarify the Conservation Model. This views health as one of its essential components. Conservation through treatment, focuses on integrity and the reclamation of oneness whole person. of the

She also gave four principles of Conservation. One of it is the Conservation of personal integrity. This principle includes recognition of the holiness of each person. The primary focus of conservation is keeping together of the wholeness of the individual.

IV. NURSING HISTORY a. BIOGRAPHICAL DATA

Patients name: Ms. R.E Address: Paranaque City Date of birth: 02/15/1981 Occupation: Employee in San Miguel Corporation Source of Health Assistance: Makati Medical Center b. REASON FOR SEEKING HEALTHCARE Uterine contractions 3x in 30 minutes for 2 days c. HISTORY OF PRESENT ILLNESS A day prior to admission, the patient verbalized uterine contractions for 3x in 30 minutes with no watery or bloody discharges wherein she did not mind going to the hospital for a check-up. The next day she was still experiencing the same uterine contractions which was more intense which made her decide to fo to the hospital with her husband for check-up. d. PAST HEALTH HISTORY 2006 2nd trimester of of pregnancy 3rd trimester Excision of the breast on the right side Constipation Experienced dyspnea

pregnancy e. FAMILY HEALTH HISTORY (-)Cancer, (-) Diabetes, (-) Hypertension f. SOCIAL HISTORY Unremarkable V. IMMUNIZATION/ EXPOSURE TO COMMUNICABLE DISEASE

Immunizations were unrecalled by the patient

VI. ALLERGIES Patient has no allergies to any food and any medications

VII.

HOME MEDICATIONS/ALTERNATIVE MEDICINE The patient is taking her supplements which are Calci-aid and Clusivol

VIII.

OBSTETRICAL HISTORY Menarche: @ 12 years old LMP: April 15, 2006 EDC: June 29, 2007 AOG: 32 weeks OB Score: G1P0 (T0P0A0L0)

IX. ANATOMY AND PHYSIOLOGY X. PATHOPHYSIOLOGY

XI. GORDONs FUNCTIONAL PATTERN During Hospitalization

Pattern

Before Hospitalization

Analysis

Health Perception

The day prior to admission, the patient did not mind going to a hospital for a check-up even though she was experiencing uterine contractions because she was at work.

The patient was checked for pelvic ultrasound, routine urinalysis, Complete Blood Count (CBC), sterile vaginal examination, NonStress Test, progress and Fetal Heart Tone right after admission. The patient was held for NPO.

26 years old patient currently works at San Miguel Corporation. She didnt have time to go to a hospital when she experienced the contractions. Anytime, the patient could deliver the baby that is why she was hald for NPO. Mobility of patients having premature uterine contractions is prohibited Mobility of patients having premature uterine contractions is prohibited. The pain and anxiety caused by the contractions disturbed the patients sleep pattern. When The contraction stopped, so do the pain and the anxiety.

Nutritional / Metabolic

The patient has no known allergies to food and medications. Her supplements are CalciAid and Clusivol OB Patient was able to go to the bathroom at work and at home whenever she feels like to.

Elimination

The patient was ordered for complete bed rest without bathroom privileges and was given a bed pan at bed side to urinate on.

Activity / Exercise

The patient is working as Patient was ordered for an executive at San complete bed rest. Miguel Corporation. She has less exercise because of her work The patient works as an executive at San Miguel Corporation and her work requires more time to stay in the office which does contribute to less sleep and rest that the patient is having. Patient can sleep better when last checked on because the contractions stopped occurring.

Sleep / Rest

Cognitive / Perceptual

The patient can verbalize the pain due to contractions. She is anxious about her first pregnancy. They went to the hospital because of continued and more intense contraction

The patient is anxious about her first pregnancy.

Since it is her first pregnancy, she has fears about what might happen to the baby because of the unusual experiences she is having. The patient is a responsible mother with a dependable husband. They have good communication. The patient had her menarche at the right time with a regular monthly cycle. She first got pregnant at 26 years old, not too young, not too old. The patient was able to sleep after the contractions stopped occurring which decreased her level of stress and anxiety.

Role / Relationship

Patient is a working mother and has a husband who took her to the hospital when she needed to. They are both concerned about their first baby. The patient had her menarche at 12 years old with a regular monthly cycle with 4-5 days duration using 3-4 pads per day. She is now 26years old, 37 weeks pregnant with her first baby.

The patient is concerned about her first baby that is why she wanted a careful monitoring of her pregnancy.

She is having premature uterine contractions.

Sexuality / Reproductive

Coping / Stress Tolerance

The patient had anxiety because of pain due to the contractions. She didnt mind it until the next day wherein the contractions havent stopped. To cope up with the stress, they went to the hospital.

Patient is anxious for her first pregnancy and the contractions. After the contractions stopped, she slept to relieve her stress.

Value / Belief

The patient works in preparation for their first baby.

Value for the life of the baby.

Patient values her baby so much.

XII. XIII.

PHYSICAL ASSESSMENT DIAGNOSTIC/LABORATORY EXAMINATIONS

Urinalysis as of May 1, 2007

Category Color Transparency

NV Yellow Clear

Findings Yellow Hazy

Analysis Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. normal normal (+)Infection > A positive leukocyte esterase test results from the presence of white blood cells either as whole cells or as destroyed cells. A negative leukocyte esterase test means that an infection is unlikely. It could be possible for urinary tract infection. Hematuria is the

Nursing Alert >as the uterus grows it presses on the bladder and can prevent complete emptying of urine. This stagnant urine is a likely source for infection. If untreated, these infections may lead to kidney infections. Urinary tract infections in pregnant women should be treated to prevent complications. >advice the importance of increased oral fluid intake to prevent infection. >advice the importance of good

pH (reaction) Specific Gravity Leucocytes Esterase

4.8-7.8 1.015-1.025 -

Neutral (7.0) 1.015 +1

Blood Hemoglobin RBC

0.15

Trace 3.3

WBC

0-2.5

11.6

Epithelial Cell Bacteria

0-2.5 < 1000/ HPF

1.0 467

presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors which erode the urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and lower uri urinary tract infections, nephrotoxins, and physical stress. (+)Infection >Pyuria refers to the presence of abnormal numbers of leukocytes that may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis. normal normal

hygiene to prevent complication and infection. >emphasize the need to complete antibiotic therapy as instructed by the physician.

CBC

Category Hemoglobin Hematocrit RBC

NV 112-144.9 g/l 0.33-0.44 3.70-5.94 10 12/l

Findings Analysis 116 normal 0.34 normal 3.5 >a low red-bloodcell count generally caused by an iron deficiency is extremely common,

Nursing Alert >advice the need for dietary intake that contain food high in iron and folate >advice client to increase fluid

WBC Eosinophils Segmenters/neutrophil s Lymphocytes

5.2-1010 g/l 0.02-0.04 0.55-0.65 0.25-0.35

10.2 0.02 0.66 0.23

Monocytes phagocytic Platelet Count

0.02-0.06 150-45010 g/l

0.09 186

especially in the second and third trimester. (+)infection normal Bacterial infection > There are several factors that may result in low lymphocytes in blood. Low lymphocytes usually results from infection or immunity problems and may sometimes cause a blood disorder. Bacterial infection normal

intake >discuss the need for antibiotic therapy.

XIV. MEDICAL DIAGNOSIS XV. DRUG STUDY

XVI. MEDICAL/ SURGICAL MANAGEMENT XVII. XVIII. NURSING CARE PLAN DISCHARGE PLAN

B- breast Avoid nipple stimulations Instruct client to observe and check for breast tenderness, blisters, and cracks U- uterus

During pregnancy, always observe for uterine contractions Avoid douching to prevent infection that may affect the babys growth

B- bladder Empty bladder frequently to promote comfort and control the bleeding (if there is any) and contractions Always observe proper hygiene to prevent infection

B- bowel Increase eating foods high in fiber to relieve the constipation of the patient Observe hygiene to avoid infection

L- lochia -----

E- exercise Avoid doing too much work to prevent fatigue Should have enough sleep and rest Walk at least 30 minutes a day to promote better circulation Modify physical activities

S- sex Instruct client to avoid intercourse, nut instead try other ways of satisfying partner without the penetration

After delivery, avoid intercourse for about 3 weeks to 1 month to help in faster healing of the episiotomy