Wesleyan University- Philippines

Mabini Extension, Cabanatuan City

Case Study
In NCM 103: Care of Clients with problems in
Oxygenation-Cardiovascular system Disorder

Submitted by:

Jenilyn Faye M. Orpilla

(Bsn3-4)

Submitted To:
Prof. Reuben Q. Ignacio, RN MAN
Concept Instructor

Abnormal Uterine Bleeding,

Iron deficiency Anemia Secondary Case Study
Table of Contents
I. INTRODUCTION Error! Bookmark not defined.

A. Brief history of the case

Error! Bookmark not defined.

B. Definition of related terms Error! Bookmark not defined.

II. PATIENTS HISTORY 2

A. Biographic data

B. Chief complaints 3

C. History of present illness 3

D. Past medical / health history

E. Family medical / illness history

F. Review of system 3

G. Lifestyle and health practices

h. Developmental level

III. COLLECTING OBJECTIVE DATA 5

a. Course of confinement

i. Medication administered since date of admission 5

ii. IVF , BT and other parenteral medication infused/ administered since date of admission

iii. All diagnostic test made to pt since date of admission

b. Physical assessment

IV. LIST OF NANDA BASED OR GORDON BASED NURSING DX

V. PATHOPHYSIOLOGY Error! Bookmark not defined.8

VI. NURSING CARE PLAN

References

28

Error! Bookmark not defined.9

16

INTRODUCTION a. Overview

Patient A has been admitted in August 22, 2012 5:06am. The patient is 35 weeks pregnant and
has been reported with a heavy vaginal bleeding. Her final diagnosis is Abnormal Uterine
Bleeding, Iron Deficiency Anemia Secondary.

Iron deficiency is the most common deficiency disorder in the world, affecting more than two
billion people worldwide, with pregnant women at particular risk. World Health Organization
(WHO) data show that iron deficiency anaemia (IDA) in pregnancy is a significant problem
throughout the world with a prevalence ranging from an average of 14% of pregnant women in
industrialized countries to an average of 56% (range 3575%) in developing countries.

Anaemia during pregnancy is a well known and considerable risk factor for both mother and
fetus. Fetal consequences are an increased risk of growth retardation, prematurity, intrauterine
death, amnion rupture and infection. Prematurity is a consequence of early anaemia during
Maternal consequences of anaemia are also well known and include cardiovascular symptoms,
reduced physical and mental performance, reduced immune function, tiredness, reduced
peripartal blood reserves and finally increased risk for blood transfusion in the postpartum
period.

Definition of Related terms

Anemia/ Anaemia- is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin
in the blood.

Iron deficiency anemia-(IDA) is an ailment when there is not enough hemoglobin produced by the body to meet its
requirement.

Iron- The total body iron in a 70-kg man is about 4

Abnormal Uterine Bleeding (AUB) or Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the vagina
that is due to changes in hormone levels.

Anemia - a decrease in red blood cell (RBC) mass.

Red blood cell (RBC)/ Erythrocyte- deliver oxygen from the lungs to the tissues and carbon dioxide from the tissues
to the lungs

Cesarean Section- is a surgical procedure in which one or more incisionsare made through a
mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or,
rarely, to remove a dead fetus. A Caesarean section is usually performed when a vaginal delivery
would put the baby's or mother's life or health at risk, although in recent times it has also been
performed upon

request for childbirths that could otherwise have been natural.

Lochia rubra (or cruenta) is the first discharge, red in color because of the large amount of blood it contains. It
typically lasts no longer than 3 to 5 days after birth.

Hematocrit- (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume

fraction (EVF) is the volume percentage (%) of red blood cells inblood. It is normally about 45%
for men and 40% for women.
count results, along with

[1]

It is considered an integral part of a person's complete blood

hemoglobin concentration, white blood cell count, and platelet count.

Hemoglobin- tetramer protein composed of heme and globin. Is the iron-containing oxygen-transportmetalloprotein
in the red blood cells

MCH- "mean cell hemoglobin" is the average mass of hemoglobin per red blood cell in a sample of
blood. It is reported as part of a standard complete blood count. MCH value is diminished in
hypochromic anemias.

MCHC- mean corpuscular hemoglobin concentration, a measure of the concentration of

hemoglobin in a given volume of packed red blood cells. It is reported as part of a standard
complete blood count. It is calculated by dividing the hemoglobin by the hematocrit.

MCV- mean corpuscular volume, or "mean cell volume" (MCV), is a measure of the average red
blood cell size that is reported as part of a standard complete blood count. The MCV is
calculated by dividing the total volume of packed red blood cells (also known as hematocrit) by
the total number of red blood cells.

Serum ferritin- Ferritin is a protein found inside cells that stores iron so your body can use it later. A
ferritin test indirectly measures the amount of iron in your blood.

Total Iron Binding Capacity in the Blood (TIBC)-) is a medical laboratory test

that measures the blood's capacity to bind iron with transferrin. It is performed by drawing blood
and measuring the maximum amount of iron that it can carry, which indirectly measures
transferrin since transferrin is the most dynamic carrier.

Transferrin- are iron-binding blood plasma glycoproteins that control the level of free iron in
biological fluids. Transferrin saturation: 1550% (males), 1245% (females)

Erythropoiesis- is the process by which red blood cells (erythrocytes) are produced. It is stimulated by
decreased O2 in circulation, which is detected by the kidneys, which then secrete the hormone erythropoietin.

PATIENTS HISTORY
A. Biographical Information

Name: Patient A
Age: 43 years old
Gender: Female
Birthday: March 23, 1969
Birthplace: Laur, Nueva Ecija
Civil Status: Married
Address: #106 purok 1, Laur, Nueva Ecija
Phone Number: 0927-4722-559
Educational Level: High school Graduate
Occupation: None
Race/ Ethnic Group: Tagalog
Religion: Roman Catholic
Nationality: Filipino
xiv. Citizenship:

Filipino citizen

Language spoken: Tagalog

Source of information: Patient A

Reliability: 99%

b. Chief Complaints: Vaginal Bleeding

i. Initial diagnosis: Abnormal Uterine Bleeding

Final Diagnosis: Abnormal Uterine Bleeding, Iron Deficiency Anemia Secondary c. History
of Present Illness:
1 month prior to admission- unusual bleeding described as messy lasting only for 7 days,
consuming 2 pads.

15 days prior to admission- vaginal bleeding noted to be profuse, consuming 8 pads fully
soaked

3 days prior to admission- vaginal bleeding noted to be profuse, consuming 9 pads fully and
with pain in lumbosacral region

2 days prior to admission- still with bleeding, with lumbosacral pain and headache

Past Medical/ Health History

Problems at birth- none
Childhood illnesses-

1978: Measles
1981: Mumps
Immunization to date

Patient A cannot remember iv. Adult illnesses

2000-2012: Hypotension v. Accidents: None

vi. Allergies: None

vii. Previous Hospitalization, Medical and Surgical

Diagnosis
Year
Cause
Abdominal
1998
Pregnancy To her First Child
Caesarean Section

e. Family Medical/ Illness History i. Heredofamilial

In her father side, her father is recently been diagnosed with diabetes and an alcoholic drinker.
Her Grandmother had Tuberculosis of the bone and also asthmatic. In her mother side; her
mother has a history of hypotension, and anemia. Her grandmother had a history of hepatitis
and diabetes.

Review of System
Skin, Hair & NailsSkin Pallor

Hair- Black

Nails- Pinkish

Head and Neck

Head- No headache reported

Neck- No stiffness of neck felt, with melasma at back of neck

EENT & Sinuses

Ears- No drainage or ringing ears reported

Eyes- Blurred Vision when reading (Farsighted)

Nose- No discharges

Throat- No pain or hoarseness of voice felt

Chest and Lungs

Chest- No pain reported

Lungs- No shortness of breath or pain reported

Breast & Regional Lymphatics

Breast- with Milk discharges

Feeling of tenderness, and dark areola

Regional Lymphatics- Lymph nodes are not enlarged nor tender

Heart, Neck Vessels & Central CVS

Heart- No pain, distress or palpitations felt

Neck vessels- are not distended.

Cardiovascular System- No tightness, edema, or orthopnea reported

PVS
With Varicosities in Right Leg

Abdomen
No abdominal pain, bowel movements are good, with linea nigra

Genitalia and Reproductive System

With Vaginal discharge (Lochia rubra)

No pain during sexual intercourse reported

Anus, Rectum & Prostate

Anus- No itchiness or lesion reported

Rectum- No itchiness or lesion reported

Musculoskeletal System and Extremities

No muscle pain, stiffness or swelling felt

Neurologic
With dizziness and weakness as reported

Lifestyle and Health Practices- 24H day Description

Nutrition, diet and Weight management
She prefers vegetables, rice and a glass of water in her meal.

Activity & Exercise

She does household chores as her exercise. She usually at home with her daughter.

Rest and Sleep

The client takes a 5-6hours of sleep as her rest and she also takes a nap occasionally.

Medication and Supplements

The Client takes Multivitamins every morning

Self-concept and self care

The client is aware of the complication of her illness and she is willing to cooperate for her health promotion
and disease prevention.

Social activities

The patient visits her neighborhood to catch up latest issues around their town. She also visits her close relatives
occasionally.

Spiritual, Cultural, Values and Belief System

The patient Goes to Church every Sunday and prays at night and before meals. She believes that everything happens
for a reason.

Education and work

A high school graduate and with no work. Patients A stays at home and do household chores.

Stress Level and Management/ Coping Stress

Patient A is having a headache and feels dizzy when she is stress or angry at her child. Shes watching
television at night before sleep, and talking with her peer group at morning as a way of relieving
stress.

Environment & Neighborhood

Patient A lives in a rural area; in a 3 bedroom-house, with a backyard and a garden. The houses in their
town are 5 meters apart. With a quiet neighborhood and far from highway.

Developmental Stage
Theory: Erik Ericksons Psychosocial Development

ii. Generativity vs. Stagnation (Middle adulthood 40-64 years)-

The client has self confident of raising her child. She is devoted to her family and to their
community. She wants her children to be educated and to be good person someday. She is

confident of raising her premature child and her first child so that someday, her children will do
the same to her. She believes that all of their sacrifices (The client and her husband) are worth it
for their family.

iii. Comparison of Normal and Abnormal developmental parameter:

People extend their concern from themselves and their families to the community and to the
world. They may become politically active, work to solve problems, or to participate in farreaching-community or world based decisions. People with sense of generativity are selfconfident and better able to juggle their various lives (as a mother and church member. People
without this sense become stagnated or self-absorbed. Those who have devoted themselves to only
one role are more likely to find themselves at the end of middle age with a narrow perspective and
lack of ability to cope with change. Women without a sense of generativity may have more
difficulty than others accepting a late-in-life pregnancy and a new role of childbearing.

COLLECTING OBJECTIVE DATA a. Course of Confinement

Medications Administered since date of admission

Physicians Order
Ascorbic acid 1cap BID P.O.
Generic Name
Ascorbic Acid
Brand Name
Apo-C, Ascorbicap, Cebid, Cecon,

Cenolate, Cemill, C-Span, Cetane,

Cevalin, Cevi-Bid, Ce-Vi-Sol, Cevita,

Flavorcee, Redoxon, Schiff Effervescent

Vitamin C, Vita-C.
Classification
Vitamin
Mechanism of Action
Vitamin C or L-ascorbic acid, or

simply ascorbate (the anion of ascorbic

acid), is an essential

nutrient for humans and certain other

animal species. Vitamin C refers to a

number of vitamers that have vitamin C

activity in animals, including ascorbic

acid and its salts, and some oxidized

forms of the molecule

like dehydroascorbic acid. Ascorbate and

ascorbic acid are both naturally present in

the body when either of these is

introduced into cells, since the forms

interconvert according to pH.

Vitamin C is a cofactor in at least

eight enzymatic reactions including

several collagen synthesis reactions that,

when dysfunctional, cause the most

severe symptoms of scurvy.

Side Effects
Nursing Management
GI disturbances in high doses (nausea,

Instruct Client to take the medication

vomiting, and diarrhea).

after meals to avoid GI upset.

Instruct client to measure and follow

the prescribed dosage of the

medication to avoid overdosing.

Bright yellow discoloration of urine

Advise the client that yellow

discoloration of urine is normal

Adverse Effects
Nursing Management
Rarely, hypersensitivity reaction

Instruct the client to discontinue the

medication, and refer to the doctor.

Flatulence, constipation

Instruct the client to discontinue the

medication, and refer to the doctor.

Heartburn,

Instruct the client to take the

medication after meals to avoid

adverse reactions.

Physicians Order
Tranexamic acid 500mg, 1cap TID P.O.
Generic Name
Tranexamic acid
Brand Name
Hemostan, Fibrinon, Cyklokapron,

Lysteda, Transamin
Classification
Anti-fibrinolytic, antihemorrhagic.

Haemostatics
Mechanism of Action
Tranexamic acid is a synthetic derivative

of the amino acid lysine. It exerts its

antifibrinolytic effect through the

reversible blockade of lysine-binding

sites on plasminogen molecules. Anti-

fibrinolytic drug inhibits endometrial

plasminogen activator and thus prevents

fibrinolysis and the breakdown of blood

clots. The plasminogen-plasmin enzyme

system is known to cause coagulation

defects through lytic activity on

fibrinogen, fibrin and other clotting

factors. By inhibiting the action of

plasmin (finronolysin) the anti-

fibrinolytic agents reduce excessive

breakdown of fibrin and effect

physiological hemostasis.
Side Effects
Nursing Management
GI disturbances (Nausea, vomiting,

Instruct Client to take the medication

diarrhea)
after meals to avoid GI upset.
Adverse Effects
Nursing Management
Hypotension

Take the client Blood pressure

before and after taking the

medication to identify if hypotension

occurs as adverse effects, if so,

discontinue the medication and refer

to the doctor.
Headache

Monitor the client after taking the

medication and Instruct to take bed

rest to avoid injury

Hypersensitivity skin reactions/

Instruct the client to discontinue the

allergic reactions
medication, and refer to the doctor
Disturbances in color vision

Instruct the client to discontinue the

medication, and refer to the doctor

Physicians Order
Ferrous Fumerate 1cap, TID P.O.
Generic Name
Ferrous Fumerate
Brand Name
Femiron, Ferretts, Ferro-Sequels,

Ferrocite, Hemocyte, Ircon

Classification
Antianemic/ Supplement

Mechanism of Action
Iron is an essential component in the

physiological formation of hemoglobin,

adequate amounts of which are necessary

for effective erythropoiesis and the

resultant oxygen transport capacity of the

blood. A similar function is provided by

iron in myoglobin production. Iron also

serves as a cofactor of several essential

enzymes, including cytochromes that are

involved in electron transport. Iron is

necessary for catecholamine

metabolism and the proper functioning of

neutrophils.
Side Effects
Nursing Management

stomach upset,

Instruct Client to take the medication

after meals to avoid GI upset.

diarrhea,

Instruct client not to take with milk

or antacids

black or darker than normal

Inform patient the color stool black

appearing stools, or
may be black

temporary staining of the teeth.

Inform patient that temporary

staining of the teeth is normal

Adverse Effects
Nursing Management

nausea or vomiting,

Instruct client to take the medication

after snack or meal

epi-gastric pain.

Instruct client to take the medication

2 hours prior to or 4 hours after

antacids

Physicians Order
Mefenamic acid 500mg 1capsule, TID

P.O.
Generic Name
Mefenamic acid
Brand Name
Pharex, Mefenemax, Fenamax, Femacid
Classification
Nonsteroidal Anti-Inflammatory Drugs

(NSAIDs)
Mechanism of Action
Mefenamic acid binds the prostaglandin

synthetase receptors COX-1 and COX-2,

inhibiting the action of prostaglandin

synthetase. As these receptors have a role

as a major mediator of inflammation

and/or a role for prostanoid signaling in

activity-dependent plasticity, the

symptoms of pain are temporarily

reduced.
Side effects:

stomach pain or cramps

Instruct patient to avoid alcohol intake

vomiting or upset stomach

when taking this medicine since it can

cause increases in stomach irritation.

increased shortness of breath

Use caution if the patient has a

weakened heart. It may cause increased

shortness of breath or weight gain.

dizziness and drowsiness

Do not drive or engage in potentially

hazardous activities until response to

drug is known. It may cause dizziness

and drowsiness.

Adverse Effects
Nursing Management

stomach ulcer or bleeding

Instruct client to immediately tell the

health provider about bleeding or

stomach ulcer

dark stools, hematemesis,

Instruct client to Discontinue the drug

ecchymoses
promptly, do not use again and

Contact the physician.

diarrhea, epistaxis, or rash

Instruct client to Discontinue the drug

promptly, do not use again and

Contact the physician.

ii. IVF, BT and other Parenteral Medication infused/administered since date of

admission

INTRAVENOUS FLUID OREDERED

Previous IVF:

Rationale: This pulls the fluid into the

LRS 1Liter + KCl 40 meq/L

vascular by osmosis resulting in an

increase vascular volume. It raises

intravascular osmotic pressure and

provides fluid, electrolytes and calories

for energy. Potassium chloride is used to

prevent or to treat low blood levels of

potassium (hypokalemia).
Current IVF:

Rationale: only IV fluid which is

Plain NSS 1Liter for 24hours

compatible to Blood Transfusion

To follow IVF:

Rationale: To facilitate another Blood

Plain NSS 1Liter for 24hours

Transfusion

OTHERS
Blood Transfusion

Rationale: To restore blood volume after

severe hemorrhage and to restore the

oxygen-carrying capacity of the blood

Oxytoxin

Rationale: Stimulating labor when the

contractions are considered too weak.

Preventing or controlling heavy bleeding

following delivery of the child (post-

partum hemorrhage).

iii. Diagnostic Test since Date of Admission

Name of
Result
Normal
Unit of
Implication
Diagnostic

Values
Measurement

Test

Complete CBC

Hemoglobi

100
Female: 110
g/dl
Indicates a decrease in
n mass

158

Red blood cell

0.32
Male: 138 to 182

Hematocrit

0.37 0.54

28 32

Leukocyte
9
4.5 10

Count

MCV

81

Platelet

82 - 92

463

150 400

MCHC
31

Count

32 38

LDH SCE
410.00
225.00

RBC Indices

26

MCH

450.00

15200
Serum Iron
40

Female: 50

production.

concentration

fraction of
Indicates a decrease in

to 170

RBC
Red blood cell

Male: 65 to

production
x
/L
Normal.

176

400 X 10^9/L
An elevated platelet

count is an indication
Serum ferritin
13

Female:

that there is an

underlying condition

cell size

Decrease in hemoglobin concentration.

that is causing the

U/L
Indicate a number of
disorder.
medical conditions such
pg
Decrease in redness is

as tissue damage (due to

trauma or disease),
due to a
hemolytic anemia (an

disproportionate

abnormal breakdown of

red blood cells)

reduction of red cell

g/dL
Indicates poor

hemoglobin.

absorption of Iron,

fL

Chronic heavy

Decrease in red blood

menstrual bleeding,

g/L
Poor absorption of iron,

There is a risk for lack

Not enough dietary iron

of iron

or Pregnancy

Male: 30

300

Total Iron
375
250370
g/L
In pregnant, the liver
Binding

increases the production

Capacity in the

of transferring thus
Blood (TIBC)

raising TIBC. When

TIBC is high, it

indicates iron deficiency

anemia.

iv. Other relevant events during hospitalization - none.

b. Physical Assessment
General Impression
Hygiene- Clean and Groomed appropriately

Interaction/behavior- Cooperative attitude as her condition permits

Posture- Bedridden and weak

facial Expression- Symmetric with movement

Height, weight and Vital Signs

Height: 5 feet and 3 inches

Weight: 126 lbs

Vital signs:

Temperature: 37.3 C
Pulse rate: 88 cpm
Blood Pressure: 110/70 mm/Hg
Respiratory Rate: 23 bpm

Skin
Color of skin- Pallor

Color of hair- Black (Normal)

Odor- No odor

Lesion- No lesion

Moisture- Moist

Temperature- Warm

Texture- Smooth & Soft

Turgor- Pinched up skin returns immediately to original position

Edema- No swelling, pitting or edema

Nails- Has a convex curvature of fingernail plate, 160

Fingernail and toenail bed color are pinkish in color. The tissues surrounding the nails of the
client are intact.

Presence of capillaries- When blanched test is performed, color of the nail bed of the client
returns into pink in less than 4 seconds. Capillary Refill test: 2 seconds (normal)

iv. MSE/ Neurologic

Mental Status: Awake & Alert; oriented to person, place & time

Cranial Nerves:

Visual Acuity- 20/20 with pocket screener, both eyes

Visual Fields- intact in all fields

II and III: Pupillary Reaction to Light- direct & consensual normal Accommodationnormal

PERRLA, pupils, equal, round, reactive to light, and accommodation for both)

III, IV, VI: EOM- intact

V: Light Touch Face- normal in all 3 divisions

VII: Wrinkle Forehead, Close Eyes, Show Teeth- normal VIII: Hearing- normal by rough
testing

X: Cough- normal (able to cough)

XI: Shrug Shoulders and check sternocleidomastoid muscles - normal XII: Protrude
Tongue- midline protrusion
Motor System: Normal

Sensory: Able

tone

to feel :

Light Touch- normal

Position Sense- normal Vibration- normal

Sharp- normal

Reflexes: Deep

tendon

O Biceps (C5-6)- Responsive

o Triceps (C6-7)- Responsive

o Brachioradialis- Responsive o Knee (L2-4)- Responsive

o Ankle (S1)- Responsive

Pathological - Plantar Reflex- none (bilateral down going toes)
Coordination: Gait

and Balance- normal

Finger to Nose- normal

Rapid finger movements- normal

HEENT, Sinuses and Neck

Head:

Size/Shape- Symmetric, round, erect & in midline

ROM/ Head control- Neck movement is smooth & controlled with 45 degree flexion, 55
degree extension, 40 degree lateral abduction, & 70 degree rotation

head posture- still and uptight.

Face:

Appearance- Smooth and controlled movements

Symmetry- Symmetrical

Movement- abnormal movement noted

Eyes:

Position- Lower margins at bed cover approximately 2-6mm of iris bottom edge of iris; upper margins of
lids

Eyelids placement- No swelling, discharges or lesions noted

Sclera/Conjuctiva- No swelling, discharges, lesions or laceration are noted

Iris/Pupils Color Black, round, flat and constricted when direct to light

Visual Acuity Test- 20/20 vision; Can differentiate colors

Ears:

External:

Placement- Alignment of pinna with corner of eye within 10 degree angle of vertical position
No swelling, discharges and lesions.

Internal:

No discharges, lesion, excoriation or presence of foreign body.

Mouth:

Lips- Smooth & moist, without lesions or swelling

Palates- Hard palate is pale or whitish with firm, transverse rugae (wrinkle like folds)

Tongue- Pink, moist, a moderate size with papillae

Buccal Mucosa- Smooth & moist without lesion

Gums- Pink, moist and firm

Teeth- 31 adult teeth, white to yellowish in color, shiny tooth enamel, no intact dentures

Uvula- Positioned in midline of soft palate

Throat/tonsils- Pink and symmetric

Nose/sinuses:

Structure and patency of nares- Able to sniff through each nostril while other is occluded

Color and problem of turbinates - Color is the same as the rest of the face

No discharges or tenderness

Neck:

Mobility- Symmetric

Cervical Lymph Nodes- No enlargement or tenderness

Temperature- Warm

No swelling or tenderness

C/ L and Heart
Breasts and Nipples- symmetrical--nipples symmetrical and everted

No masses, with milky discharges

Areola- Equal, round, symmetric, dark brown, smooth,has no lesions

Thorax-

Posterior thorax-

o
Symmetric, ribs are sloped downward at 45 relative to the spine, muscle
development is equal, anteroposterior to transverse diameter in ratio of 1:2
o

Spinal alignment- Slightly

Uniform in temperature, no tenderness and masses

Respiratory excursion- Full and symmetric chest expansion

Vocal fremitus- Bilaterally equal, heard mostly at the apex of the lungs

Sounds- Percussion notes resonant except over the scapula, bronchovesicular and
vesicular
Anterior thorax

Breathing patterns- Quiet, rhythmic effortless

Temperature, tenderness, masses- Warm, no tenderness or masses

Respiratory excursion- Full and symmetric chest expansion

Vocal fremitus- Bilaterally equal, mostly heard at the apex of the lungs

Sounds- Flat sound on the part with heavy muscles and bony prominences, tympani on
the stomach, dullness on the liver and spleen, bronchovesicular, vesicular

Trachea- Bronchial sound

Axillary, subclavicular and supracvicalar lymph nodes- Absence of masses or lumps

Cardiovascular

Precordium-

Aortic, pulmonic, tricuspid area- No pulsation

Apical area- With palpable pulsation (point of maximal impulse)
Sounds of tricuspid and apical- S2 is louder than S1
Sounds of Tricuspid and apical area- S1 is lauder than S2
Carotid arteries- Symmetric pulse volumes, full pulsation, no sound

Visibility- Not visible

Lungs-

respiratory effort: Even, 23bpm, unlabored

Percussion and Palpation of Lung Fields- normal resonant percussion

Auscultation- clear, normal vesicular breath sounds

Abdominal

Unblemished skin, uniform in color, no signs of enlargement of the liver and spleen, symmetrical contour

Peristalsis movement not visible

vascular patterns not visible

Audible bowel sounds, not audible vascular and peritoneal friction rubs

With suture in

Urinary System

No Pain or discomfort in response to pressure on the lower back, abdomen, or the area above the pelvic
bone,

Nogrowths, or abnormalities detected

No discharge from the urethra

Genitalia and Reproductive

External Genitalia- labia, clitoris, urethral orifice & introitus all normal (no sweelin, pus, warts or
inflammation)

Bimanual Exam- uterus is anterior, midline, smooth, enlarged and tender

Fundus in midline, about half way to 2/3 way between umbilicus and symphysis pubis

Inspection of Cervix and Vagina- bulging with straining, normal vagina mucosa, cervix- pink,
with lochia rubra, cervix: Spongy and flabby

Anus

Normal rectal sphincter tone; no rectal masses or tenderness. 0 stool for 3 days.

no fissures, no hemorrhoids

Musculoskeletal, upper and lower extremities and PVS

Musculoskeletal system

Muscles-

Size, contractures, tremors- Bilaterally symmetric, no contractures and tremors

Tonicity, strength (neck, upper, lower extremities)- Normal muscle tension, adequate
strength of themuscles
Bones- Uniform in structure, no deformities, tenderness or edema

Joints- Absence of tenderness and swelling, has smooth movement, no nodules

Range of motion (shoulder and scapula, elbows, hands, acetabulum, popliteal, ankles)- Able
to perform the exercises in full range of motion, no tenderness, moves smoothly

Upper Extremities
>Nails- no cyanosis, or clubbing
palms- pale
muscles- size is proportional
joints (including rom)
-interphalangeal- normal Range of motion without deformities

wrists- flexion = 90, = extention 70, radial deviation = 20, ulnar deviation = 50

elbows- flexion = 160

radial pulse- 4 / 4, normal and symmetric
Capillary Refill test: 2 seconds (normal)

Lower Extremities:

>Nails- normal (No cyanosis or clubbing) >Muscles- nl size

> Joints (including ROM)

Ankle- dorsiflex = 20, plantar flexion = 40, eversion = 20, inversion = 20

Knee- flexion = 130

Hip- flexion = 100, internal rotation = 40, ext rotation = 40 Pulses:

Posterior Tibial- 4 / 4 bilateral & equal Dorsalis Pedis- 4 / 4 4 bilateral & equal

> Capillary Refill test: 2 seconds (normal)

IV. LIST OF NANDA-BASED OR GORDON-BASED NURSING DIAGNOSIS

LIST OF

PRIORITIZED

BASIS OF PRIORITIZATION
JUSTIFI

NURSING

DIAGNOSIS

Circulation

Maslow
Actual/
Overt/
Patients

,Airway,

potential
covert
verbalization

Breathing

1. Fatigue related to the

Fatigue or weaknes

bloods decreased

chief complaint reg

hemoglobin and

after her cesarean d

diminished oxygen-

also one of the sign

carrying capacity

Iron deficiency ane

2. Fluid volume deficit

Theres a severe he

related to blood loss

delivery, blood loss

secondary to anemia

intravascular volum

replace immediatel

hypovolemia and s

3. Risk for infection

Hemoglobin served

related to decreased

defense, a decrease

hemoglobin secondary

also means theres

to iron-deficiency

pathogens to infect

Anemia.

especially during h

hospital.

4. Disturbed sleep

pattern related to

hospital noise and

lightning secondary to

Anemia

5. Imbalanced nutrition:

Less than body

requirement related to

inadequate intake of

essential nutrients

secondary to Anemia

6. Risk for Ineffective

tissue perfusion related

to inadequate blood

volume secondary to

anemia

7. Activity intolerance

related to imbalance

between oxygen supply

and demand in the blood

related to generalized

weakness secondary to

Anemia

8. Risk for Constipation

related to insufficient

physical activity

secondary to Anemia

9. Risk for fall related to

generalized weakness

secondary to Anemia

10. Sedentary lifestyle

related to deficient

knowledge of health

benefits of proper diet

and exercise secondary

to anemia

V. PATHOPHYSIOLOGY

Lifestyle:

MODIABLE FACTORS:

Diet: High in fiber, Low in Iron.

In Weight Reducing program Preterm Birth (<38

weeks)

Birth delivery via Cesarean section

NON- MODIABLE FACTORS:

Age: Adult (43 years old) Gender: Female

(Pregnant) Heavy Menstruation History of
having Anemia

Preterm Birth

Blood loss/ Hemorrhage

Decreased intravascular volume

Depletion of iron stores in bone marrow

Serum ferritin will become low (< 20-30 mcg/L)

The compensatory increase in iron absorption causes an increase in iron-binding capacity (TIBC/Transferrin level)

Serum iron falls to < 50 g/dL and transferrin saturation to <

16%. The serum ferritin receptor level rises (> 8.5 mg/L)

Erythropoiesis is impaired

Low Hemoglobin (below 12mg/dL)

Low Hematocrit (Below 33%)

Reduction in oxygen-carrying capacity of Red Blood cell

Small Red Blood cell (Microcytic)

Less Hemoglobin than Average Red

Blood cell (Hypochromic)

Signs and Symptoms: Fatigue/ Generalized weakness Headache/ Dizziness

Pale skin color or Pallor Sore tongue Light-headedness when you

VI. NURSING CARE PLAN

Name: Patient A
Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary

Date and time: August 22, 2012 (11pm-7am)

Assessment
Diagnosis
Scientific

Planning
Implementation
Scientific Rationale

rationale

Subjective
Fatigue
IronLong term
Independent

Data:
related to
deficiency
Goal:
Intervention:

Nanghihina

the bloods
anemia is
After 16

Explain to the client

To reduce anxiety of

ako mula
decreased
a
Hours of duty
the procedures and its

patient.
kagabi, sobra
hemoglobi
common a
The patient
purpose

To prepare the patie

ata kasi
n and
nemia (lo
will be able

the Procedure.
pagdurugo ng
diminished
w red
To enhance

puson ko kaya
oxygenblood cell
her

Assess vital signs.

To evaluate fluid sta

siguro ako
carrying
level)
knowledge

and cardiopulmonar
nanghihina.
capacity
caused by

about her

response to activity.
Matanda na
secondary
insufficien
disease, and

rin kasi ako

to Anemia
t dietary
to facilitate

Evaluate need for

To determine the nee

nang

intake and
health
individual assistance

for doing activities o

nabuntis as

absorption
promotion.
or assistive device.

movement.
manifested by

of iron.

the mother.

Short Term

One of the
Goal:

Encourage client to do

To increase activity
Objective

Symptoms
After 16 hours
whatever possible

as tolerated
Data:

of anemia
of duty,

Pallor,

is
The patient

Encourage use of

To conserve energy
generalized

generalize
will be able to
assistive devices like

other task
weakness,

d
verbalize the
wheelchair

With heavy

Weakness
understanding

lochia rubra

and
of individual

Instruct patient to sit

To conserve energy:

fatigue
therapeutic
instead of stand during

Vital signs:

interventions,
care and other

T: 37.3 C

medications
activities.

Long term
her to talk with her

objective:
relatives
RR: 23 bpm

and its

After 4 hours

PR: 88 cpm

purposes.

of health

Provide diversional

BP: 110/70

teaching,
activities like having
mm/Hg

Instruct patient to eat

patient will be
The patient

fruits)

Iron rich foods (e.g.

able to
will be able to
liver or animal

verbalize the
identify foods

Instruct patient to

organs, egg, fish,

dosage of her
rich in iron

increase her fluid

poultry, leafy

medication.
and the
vegetables and dried

intake.

Short term

patient will be

Observe and measure

able enhance
Objective:
fluid losses (e.g.

her activities
After 4 hours
bleeding)

of daily living
of health

teaching, the

Instruct the Family to

as evidenced
bathe the patient every

Provide Oral care

by report of
other day.

improved

sense of

Give/administer

energy.
medications as

Pleasurable activitie
refocus energy and
diminish feelings of
unhappiness and
sluggishness.

To Increase the Tota

Body iron of the pati To
prevent anemia a help
in producing m red
blood cells.

To rehydrate the pati

To determine replacement
needs

To provide optimal s
care and to prevent
dryness of skin.

For patients comfor to prevent dryness o mucous membrane.

To Follow patients
therapeutic regimen

Replace electrolytes as ordered (Inserting IV fluids as

ordered)

Collaborative
Intervention:

Refer patient to Radiology Technician for X-ray as

ordered by the doctor.

instructed by the doctor.

Administer Blood transfusion as ordered by the Doctor.

To replace electrolyt prevent dehydration further

complication

stabilize her wellnes health.

To replace Blood vo loss.

For further evaluatio and analysis of the patients

disease.

Name: Patient A
Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary
Date and time: August 23, 2012 (11pm-7am)

Assessment
Diagnosis
Scientific
Planning
Implementation

Scientific Rationale

rationale

Subjective
Fluid
Iron
Long term
Independent

Cues:
volume
deficiency
Goal:
Intervention:

Medyo
deficit
during the
After 16 hours

Explain to the client

To reduce anxiety o

nanghihina pa
related to
pregnancy is
of duty, the
the procedures and
patient.
rin ako pero
blood loss
the cause of
patient will be
its purpose
To prepare the patie
din na tulad
secondary
abnormal
able to enhance

for the Procedure.

ng kahapon,
to anemia
uterine
her knowledge

nakakatayo

bleeding
about her

Assess vital signs

Changes in vital si

naman ako

during the
disease, and to
noting blood
are associated with
kahit papano.

labor and
facilitate health
pressure
volume loss or othe
Feeling ko

resulting in
promotion and

complications.
lagi naman

heavy blood
further disease

ako uhaw as

loss.
prevention.

Estimate procedural
To monitor and obs

manifested by

fluid losses and take

other routes of fluid
the mother.

Massive
Short Term
note possible routes
losses

Fluid

Goal:
of insensible loss.

Objective

volume is
After 16 hours

Cues:

loss during
of duty, The

Note complaints and

Other sign and

generalized

the delivery
patient will be
physical signs
symptoms may indi
weakness,

as a result
able to

associated with
serious complicatio
with lochia

the patient
verbalize the
dehydration (scanty,

rubra

felt weak
understanding
concentrated urine,

and thirsty.
of individual
confusion, muscle

Vital signs:

therapeutic
weakness, light

T: 37.3 C

interventions,
headedness,

RR: 21 bpm

medications
headache)

PR: 91 cpm

and its

BP: 110/70

purposes.

Establishing 24-hour
This prevents peaks

needs.

objective:

After 4 hours

Instruct patient to

of health
increase her fluid
mm/Hg

teaching, the
fluid replacement

Long term

intake.

patient will be

able to

Provide Oral care

Short term

Maintain accurate I

demonstrate

Objective:

&O

behavior to

After 4 hours

correct deficit.

of health

Instruct the Family

teaching,

to bathe the patient

The patient

evidenced by

every other day.

will able To

Change dressings

adequate
frequently

maintain

urinary output.

Change position

adequate fluid
frequently

volume as

Give/administer

medications as

ordered by the

instructed by the

doctor.

Administer Blood

valleys in fluid leve

transfusion as

To rehydrate the pa

To observe the prog of the current status the patient

For patients comfo and to prevent dryn of mucous membra

To provide optimal care and to prevent dryness of skin.

To reduce pressure fragile skin and tiss

To protect skin and

monitor losses.

To Follow patients
therapeutic regimen
stabilize her wellne
health.

To replace Blood volume

loss.

Doctor.

Administer IV fluids
To replace electroly

as indicated
to prevent dehydrat

and further

complications.

Collaborative

Intervention:

Refer patient to

For further evaluati

Radiology
and analysis of the

Technician for X-ray

patients disease.

as ordered by the

doctor.

Name: Patient A
Diagnosis: Abnormal Uterine Bleeding, Anemia Secondary
Date and time: August 24, 2012 (11pm-7am)

Assessment
Diagnosis
Scientific
Planning
Implementation

Scientific Rationale

rationale

Subjective

Iron
Long term Goal:
Independent

cues:

deficiency
After 16 hours of
Intervention:

Eto medyo
Risk for
during the
duty, the patient

Explain to the client

To reduce anxiety of

nanghihina
Infection
pregnancy
will be able to
the procedures and
patient.
at
related to
is the
enhance her
its purpose
To prepare the patien
nagdurugo
decreased
cause of
knowledge about

the Procedure.
pa rin ang
hemoglobi
abnormal
her disease, and

puson ko,

n
uterine
to facilitate

Assess vital signs

Changes in vital sign

pero di na
secondary
bleeding
health promotion
noting blood pressure
associated with fluid
kasing lakas
to ironduring the
and further

volume loss or other

ng kahapon
deficiency
labor and
disease

complications.
as

anemia.
resulting
prevention.

manifested

in heavy

Observe for localized

To determine possibl

by the

blood loss.
Short Term
signs of infection at
infection and to avoid
mother.

Goal:
insertion sites of
further complication

Hemoglob
After 16 hours of
invasive sites (or IVF

Objective

in served
duty, the patient
insertion sites) and

Data:

as a
will able to
wound site.

generalized

secondary
improve wound

weakness,

defense, a

healing and will

Stress proper hygiene

A first line of defens

vaginal

decreased
not manifest any
by all caregivers
against healthcare
bleeding

in
sign of infection.
between therapies and
associated infections
(lochia

hemoglobi

clients
(HAIs)
rubra)

n also
Long term

means
objective:

Emphasize proper use

For personal protectio

Vital signs:

theres an
After 4 hours of
of personal protective
yourself and the patie
T: 36.6 C

easy
health teaching,
equipment (PPE) to

RR: 21 bpm

access of
the patient will
visitors as dictated by

demonstrate

mm/Hg

to infect
techniques in

Maintain sterile

the patient
lifestyle changes
technique for all

especially
to promote safe
PR: 90 cpm

invasive procedures

the
able to

during her

the agencys protocol

environment

BP: 110/70

pathogens

stay in the
the patient and

Recommend routine

proper hand washing

hospital.
Short term

her relative will

shower or scrubs.

Objective:

be able to

Change wound

After 4 hours of

demonstrate

dressings using

Instruct the patient

health teaching,
and her relative about

behavior to
proper technique for

dressing)
prevent and

Cover perineal and

changing and

reduce risk in

pelvic region when

disposing of

infection (e.g.

using a bedpan.

contaminated

hand washing
materials.

Encourage early

and change of
ambulation, deep

breathing, and

coughing and position

changes.

To reduce contaminat

Maintain adequate

hydration, stand or sit

To reduce bacterial
colonization.

Basic infection and

contamination contro

To prevent contamina and reducing the occurrence of infectio

For mobilization of
respiratory, and for
prevention of aspirati
respiratory infections

To prevent contamina
To avoid bladder distention
and urinary

to void.
stasis

Provide perineal care

To reduces risk of

ascending urinary tra

infection

Provide Oral care

For patients comfort

to prevent dryness of

mucous membrane.

Give/administer
To Follow patients

medications as
therapeutic regimen t

instructed by the
stabilize her wellness

doctor.
health.

Administer Blood
To replace Blood vol

transfusion as ordered
loss.

by the Doctor.

Administer IV fluids
To replace electrolyte

as indicated
prevent dehydration a

further complications

Collaborative

Intervention:

Obtain appropriate
For further evaluation

tissue or fluid
analysis of the patient

specimens for
disease.

observation and

culture and sensitivity

test

REFERENCES:
Nurses Pocket Guide (by E.A. Davis)

th

Maternal & Child Health Nursing 6 Edition Volume 1&2 (Lippincott-Williams & Wilkins)
th

Handbook of Medical-Surgical Nursing 11 Edition (by Brunner & Suddhart)

st

MIMS Philippine 131 Edition MIMS.com

Wikipedia.org (for Definition of terms)

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001610/ http://www.medindia.net/drugprice/ferrous-fumarate-combination.htm#ixzz27aEaDdPD http://www.namrata.co/case-studyiron-deficiency-anemia/ http://nursesnanda.blogspot.com/2012/01/nanda-anemia.html
http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/iron-deficiency-anemia/
http://www.geburtshilfe.usz.ch/Documents/LehreUndForschung/Publikationen/breymann_bl
ood_cells.pdf

http://nurseslabs.com/d5lrs-iv-fluid-study/ http://www.globalrph.com/dilp.htm
http://www.netdoctor.co.uk/pregnancy/medicines/syntocinon.html
http://www.scribd.com/doc/37710190/Anemia-NCP

Pathophysiology references:
th

Handbook of Medical-Surgical Nursing 11 Edition (by Brunner & Suddhart)

th

Maternal & Child Health Nursing 6 Edition Volume 1&2 (Lippincott-Williams & Wilkins)
http://www.merckmanuals.com/professional/hematology_and_oncology/anemias_caused_by
_deficient_erythropoiesis/iron_deficiency_anemia.html http://nursingcrib.com/nursing-notesreviewer/maternal-child-health/iron-deficiency-anemia/ http://www.namrata.co/case-study-irondeficiency-anemia/
th

Handbook of Medical-Surgical Nursing 11 Edition (by Brunner & Suddhart)

th

Maternal & Child Health Nursing 6 Edition Volume 1&2 (Lippincott-Williams & Wilkins)