7 COMPREHENSIVE CASE STUDY
PATIENT’S DATA
I. ASSESSMENT
A. General Data
Patient's Initials: J.M.
Address: 123 Main Street
Sex: Female
Date of Birth: 01/15/1997
Place of Birth: Jeddah
Civil Status: Married
Occupation: Unemployment , housewife
Date of Admission: | 4/1/2024
Order of Admission: Emergency
No. of Days in this Hospital: 1
B. chief compliant
Pregnant women term complain of
Pain in lower abdomen since 4 days
Warty viginal discharge since 5 hr.
C. History of Present Illness
PT. pregnant G2P1+ 0 39 week and 6 day came to emergency room (ER). C/O watery vaginal discharge clear for
5 hr. with good fetal movement and mild pain . LMP 4/4 2023, hypothyroidism on medication
PV( per vagina ) exam done : 2 cm cervical dilatation and 60% effaced with water pooling
.
D. Past History
Childhood Illness/es: No specific information regarding the patient's past
childhood illnesses is mentioned in the given case
scenario.
G. PHYSICAL EXAMINATION (Date and Time)
Adult Illness/es: The patient has a past medical history of
Height: hypothyroidism.
170 cm However, no other adult illnesses are
mentioned.
Actual Height: 165 cm
Immunization: No information regarding the patient's past history of
Actual Weight: 70 Kg
immunizations is provided in the given case scenario.
Previous Hospitalization: The case scenario states that the patient is "surgically
Ideal Body Weight: 63 Kg
free," indicating that the patient has not undergone any
Anthropometric Measurementsprevious surgeries0-3
(For pediatric or hospitalizations.
years old)
Operation/s: the patient is reported to be "surgically free," suggesting
Head Circumference: no -history of previous operations.
Injuries: No information regarding the patient's past history of
Chest Circumference: -
injuries is given.
Medications taken prior to confinement: The case scenario states that the patient is on 50 mcg of
Abdominal Circumference: -
medication for hypothyroidism. However, no other
Vital Signs information about prior medication history is provided.
Allergies: The patient is reported to have "No Known Drug
Temperature: Allergy." 37 c0
E.Pulse Rate:
Family Assessment (Tabulated) 120 beats per minute
Respiratory Rate:Relation
Name Age Sex 50
Occupation breaths per minute Attainment
Educational
Blood Pressure: 70/40 mmHg
Regional Examination (Presence or absence be used as noted)
The patient is a pregnant woman who presented to the emergency room with the chief complaint
of vaginal watery discharge. The onset of the complaint was five hours prior to coming to the ER.
.F.The patient reported
Hereditary that the discharge was clear and had good fetal movements
(Family Illness)
OBSTETRICAL
Maternal: EXAMINATION
INSPECTION
No heredity disease or twin pregnancy in her family
• Skin condition—healthy & no discoloration.
•
Paternal: Linea nigra is prominent.
• of heredity
No history Striae gravidarum
disease visible at lower abdomen
• Episiotomy wound present.
PALPATION
Palpate the lower uterus Firm and round signifies cephalic presentation
Fundal height is 15 c.m i.e. at the level of umbilicus
Auscultation
Measure fetal HR for one minute was 110-160bpm
No uterine contraction noted
Indicate findings using bulleted form, brief and concise and utilize IPPA techniques.
A. Skin (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
Inspect the skin for any Skin is smooth, dry, and intact. Lina nigra is normal during
abnormalities, no rashes Skin is cool and has a moderate pregnancy because of hormonal
stretch marks (striae gravidarum) amount of turgor. change and feds normally after
is present and linea nigra darkens There are no lesions or infections. childbirth
was visible
B. Nails (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
Nails are straight and smooth.
he nails is smooth and slightly The nail bed is pink. nails are in a healthy condition,
curved shape There are no ridges, pits, or with no significant abnormalities
pink color, nail surface smooth separations in the nails. detected.
C. Head and Face (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
No lesions or deformities No lesions or deformities No lesions or deformities is a
No asymmetry No asymmetry good sign.
No edema No edema No asymmetry is a good sign.
No edema is a good sign.
D. Eyes (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
Open and reactive eyes are a good sign.
Open and reactive Open and reactive Clear cornea is a good sign.
Clear cornea Clear cornea Round pupil with no irregularities is a
Round pupil with no irregularities Round pupil with no irregularities good sign.
No discharge No discharge No discharge is a good sign.
E. Ears (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
Patent external ear canal Patent external ear canal Patent external ear canal is a good
Tympanic membrane intact Tympanic membrane intact sign.
No discharge No discharge Tympanic membrane intact is a good
sign.
No discharge is a good sign.
F. Nose (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
No lesions or deformities No lesions or deformities No lesions or deformities is a good
No obstruction No obstruction sign.
No discharge No discharge No obstruction is a good sign.
No discharge is a good sign.
G. Mouth and Pharynx (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
No lesions or inflammation No lesions or inflammation No lesions or inflammation is a good
No asymmetry No asymmetry sign.
No edema No edema No asymmetry is a good sign.
No edema is a good sign.
H. Neck (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
No masses or tenderness No masses or tenderness No masses or tenderness is a good
No lymph nodes No lymph nodes sign.
Supple Supple No lymph nodes is a good sign.
Supple is a good sign.
I. Spine (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
No deviations No deviations No deviations is a good sign.
No tenderness No tenderness No tenderness is a good sign.
No deformities No deformities No deformities is a good sign.
J. Thorax and Lungs (Inspection, Palpation, Percussion and Auscultation)
Actual Findings Normal Findings Interpretation/Analysis
No deviations or deformities No deviations or deformities No deviations or deformities is a
No tenderness or masses No tenderness or masses good sign.
Normal breath sounds Normal breath sounds No tenderness or masses is a good
sign.
Normal breath sounds are a good
sign.
K. Abdomen (Inspection, Auscultation and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
Soft, non-distended abdomen Soft, non-distended abdomen A soft, non-distended abdomen is a
No masses or tenderness No masses or tenderness good sign.
Bowel sounds present Bowel sounds present No masses or tenderness is a good
sign.
Bowel sounds present is a good sign.
L. Extremities (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
No deformities or swelling is a good
No deformities or swelling No deformities or swelling sign.
No tenderness or masses No tenderness or masses No tenderness or masses is a good
Normal peripheral pulses Normal peripheral pulses sign.
Normal peripheral pulses are a good
sign.
M. Genitals (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
Cervical os is dilated to 4 cm Cervical os is closed A dilated cervical os is a sign of
Effacement is 80% Effacement is 0% labor.
amniotic fluid clear Amniotic fluid is clear Effacement is a sign of labor.
N. Anus and Rectum (Inspection and Palpation)
Actual Findings Normal Findings Interpretation/Analysis
No lesions or inflammation No lesions or inflammation No lesions or inflammation is a good
No masses or tenderness No masses or tenderness sign.
No masses or tenderness is a good
sign.
O. Neurologic Examination
Actual Findings Normal Findings Interpretation/Analysis
Cranial nerves II-XII intact Cranial nerves II-XII intact Intact cranial nerves and normal
Motor function intact Motor function intact motor, sensory, and reflex function
Sensory function intact Sensory function intact indicate a healthy nervous system.
Reflexes intact Reflexes intact
II. PERSONAL / SOCIAL HISTORY
Habits: No Cigarette smoking.
No Alcohol consumption.
Lifestyle: Exercise: Regularly.
Diet: Healthy.
Sleep: Regular pattern.
Stress levels: Low.
Social Affiliation: Marital status: Married.
Occupation: Unemployed.
Social support system: Moderate.
Client's usual day like: Wake-up time: 6:00 AM.
Morning routine: Breakfast.
Afternoon schedule: Childcare.
Evening routine: Dinner and Relaxation.
Bedtime: 10:00 PM.
Rank/ order in the family: Firstborn.
Travel (for the last 6 months only): Domestic travel (within the country): Yes.
International travel: No.
Educational Attainment: High school diploma/GED
III. Environmental History
No history of exposure to teratogens or environmental hazards.
No history of chronic medical conditions, such as diabetes or hypertension.
No history of recent vaginal infections or trauma.
IV. OB/GYNE HISTORY
* FOR FEMALES ONLY (Based from the client. N/A if not applicable.)
Menarche (age): 12 years When: Amount & Characteristics: Regular menstrual cycles of 28-30
days, with a normal flow and no dysmenorrhea_ Duration: 7 days _
Associated symptoms: No history of vaginal infections or trauma
Deliveries: G2 P1 Operations: no
OB Score: Bishop score: 7 T1 P1 A0 L0
V. PEDIATRIC HISTORY
Maternal and Birth History
4/4/2021
Birth Date:
3 kg
Birth Weight:
Vaginal
Type of Delivery:
The baby's condition was healthy
Condition after Birth:
*Mother
Complication of Delivery: Excessive bleeding
No
Anesthesia Drug During the Labor:
Exposure to Teratogenic Agents During Pregnancy: No
*Neonates
The Apgar scores at one and five minutes were 7
Neonatal History: and 9 respectively.
Initially the baby received nutritional through Oral
Feeding History: feeds.
Breastfeeding.
Type of Feeding:
VI. PATHOPHYSIOLOGY
A. Theoretical Based (Please Indicate References)
Premature rupture of membranes ( PROM ) refers to the rupture of the amniotic sac before the onset of
labor. The pathophysiology of PROM is multifactorial and not fully understood. However, several
mechanisms have been proposed to explain this condition.
One of the theories suggests that the weakening and degradation of the fetal membranes, specifically the
amnion and chorion, may contribute to PROM. This degradation can be caused by various factors, such as
inflammation, infection, mechanical stress, or biochemical changes. Inflammatory processes within the
gestational tissues, such as chorioamnionitis, can induce the release of pro-inflammatory cytokines and
matrix metalloproteinases (MMPs), which can weaken the structure of the membranes and lead to their
premature rupture(Geurtsen et al., 2019).
Another proposed mechanism involves the disruption of the collagen network within the fetal membranes.
Collagen provides strength and elasticity to the membranes, and any disruption in its integrity can
compromise their structural integrity and increase susceptibility to rupture(Hüner et al., 2023).
Hormonal factors may also play a role in the pathophysiology of PROM. The gestational tissues produce
prostaglandins, particularly prostaglandin E2 (PGE2), which can stimulate the production of MMPs and
weaken the fetal membranes. Additionally, hormonal imbalances, such as an imbalance in the ratio of
estrogen to progesterone, have been suggested to contribute to the weakening of the membranes and
subsequent rupture.
The pathophysiology of PROM involves a complex interplay of various factors, including both
modifiable and non-modifiable factor
Non-modifiable factors:
Gestational Age, Previous History
Cervical Insufficiency: Weakness or incompetence of the cervix can predispose to PROM
Multiple Gestations: The presence of twins, triplets, or other multiple pregnancies is
associated with a higher risk of PROM
Maternal Age: Teenage mothers and women of advanced maternal age have a slightly higher
risk of PROM
Genetic Factors: Certain genetic factors may contribute to an increased susceptibility to
PROM, but specific genes and mechanisms are still being researched
Modifiable factors
Infection: Infection of the reproductive tract, such as bacterial vaginosis or sexually
transmitted infections, can increase the risk of PROM. Inflammatory processes can weaken the
fetal membranes, leading to rupture
Smoking: Smoking tobacco during pregnancy is associated with an increased risk of PROM.
Substance Abuse: Illicit drug use, such as cocaine or methamphetamine, can increase the risk
of PROM
Nutritional Factors: Inadequate maternal nutrition, particularly a deficiency in certain
micronutrients like vitamin C and E, has been associated with an increased risk of PROM
Cervical Procedures: Invasive cervical procedures, such as cervical cerclage or repeated
cervical exams, may increase the risk of PROM due to mechanical stress on the membranes
Uterine Distension: Conditions like polyhydramnios (excessive amniotic fluid) or multiple
gestations can put increased pressure on the fetal membranes, increasing the risk of PROM
Environmental Factors: Exposure to certain environmental toxins or pollutants may contribute
to the risk of PROM
signs and symptoms associated with PROM :
*Gush or Leakage of Fluid: The most common and characteristic symptom of PROM is the sudden
gush or continuous leakage of fluid from the vagina. This fluid is typically clear and odorless
Abdominal Pressure or Pain: Some women may experience abdominal pressure or discomfort after
PROM. This can be due to the loss of the amniotic fluid that previously provided support to the
uterus.
Changes in Fetal Movement: Following PROM, there may be changes in fetal movement patterns.
Some women may notice a decrease in fetal movements, while others may perceive an increase
due to the absence of fluid cushioning.
Contractions: PROM can sometimes trigger contractions
B. Client Based
When a patient arrives at the emergency room (ER) with PROM (premature rupture of membranes),
the signs and symptoms observed( lower abdomen pain , warty vaginal discharge , decrease fetal
movement ) he diagnosis of PROM is typically made based on a combination of the patient's history,
physical examination findings, and clinical assessment. The healthcare provider may perform a
speculum examination to evaluate the fluid leakage and assess the characteristics of the amniotic
fluid .admit patient in labor ward for management and start antibiotic
VII. LABORATORY, RADIOOGY & CYTOLOGY RESULTS OR FINDINGS
Laboratory/
Normal Value Result Interpretation/
Radiology/
Significance
Cytology
(Date)
|
Ultrasound Helps determine
Assessment of fetal Normal fetal gestational age,
growth, amniotic fluid growth, adequate monitor fetal well-
volume, cervical length amniotic fluid being, and assess
volume, short cervical insufficiency.
cervix (may be
associated with
PROM)
complete blood WBC=4-10 k\ml WBC = 13 k\Ml increased WBC
count (CBC) RBC = 4-5 m\ml RBC = 4.5 M\ml count (leukocytosis)
Hb= 12-15 g\dl Hb = 13 g\dl may indicate an
Platelet =125-450 k\ml infection, as the
body's immune
GBS testing may be response is activated
Group B conducted if it was not Normal cont.
Streptococcus previously done during
(GBS) Testing: the pregnancy. GBS is indicate an infection
high vaginal a bacteria commonly GBS + of bacteria
swab found in the
reproductive tract, and
if present, it can
increase the risk of
infection
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VIII. DRUG STUDY (Client Base)
Drugs
(Date Ordered,
Side Effect/ Adverse Nursing Consideration/
Generic Name, Indication Action
Reaction Patient Teaching
Brand Name,
Classification,
Generic Nam Broad-spectrum antibiotic Rash, nausea, diarrhea, Monitor for signs of
Ampicillin Prophylaxis against to prevent bacterial vomiting allergic reaction.
Brand Name : chorioamnionitis infection
Unasyn (ampicillin Teach patient about
sodium/sulbactam sodium) potential side effects and
is a combination antibiotic importance of completing
indicated for the treatment the full course of
of infections medication,
2 g IV every 6 hours Administer the
medication as doctor
order by folling the
protocol
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IX. LIST OF PRIORITY PROBLEM
1.
Preventing infection : This is crucial, as PROM can increase the risk of ascending
infections that can harm both the mother and the baby. Antibiotics are often given to
prevent or treat infections.
2. Monitoring fetal well-being : Close monitoring of the baby's heart rate CTG and
every 6 hr. movement is essential to assess their health and development.
If labor Paine stared close observation and monitored baby for any signs of distress
3. Determining the timing of delivery : The decision of whether to deliver the baby
immediately or try to prolong the pregnancy depends on the gestational age, presence
of complications, and other factors. In this cases, corticosteroids may be given to help
mature the baby's lungs before delivery.
If labor dose not occur spontaneously within 24 hours then induction of labor with
oxytocin start.
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X. Nursing Care Plan
Cues/Needs Nursing Diagnosis Planning Intervention Rationale Evaluation
Risk for anxiety Early intervention can
Maternal fear due to related to fear threat Explain PROM clearly reduce anxiety and Patient verbalizes Patient uses
possibility of baby of change in health and answer questions promote coping. understanding of relaxation
risk status of Mather and honestly. PROM and techniques
baby ( PROM ) Provide emotional support Knowledge empowers expresses less effectively. Free
and reassurance. the patient to make anxiety. from anxiety
informed decisions.
Encourage relaxation
techniques and stress Relaxation improves
management methods well-being and
reduces stress-related
complications.
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X. Nursing Care Plan
Cues/Needs Nursing Planning Intervention Rationale Evaluation
Diagnosis
Potential for Risk for infection Patient will remain afebrile Monitor vital signs Early detection of Mother states /
chorioamnionitis related to loss of with white blood cell every 2-4 hours, infection allows shows are free of
due to exposed protective barrier as (WBC) count within particularly for prompt any signs of
amniotic sac evidence by positive normal range temperature. treatment. infection normal
nitrazine test WBC count.
Assess for foul- Good hygiene
smelling vaginal measures reduce No signs or
discharge, uterine risk of ascending symptoms of
tenderness, or fetal infection. chorioamnionitis
tachycardia. present
Antibiotics
Encourage frequent prevent or treat
hand washing and established
proper perineal infection
hygiene.
Administer antibiotics
as ordered
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X. Nursing Care Plan
Cues/Needs Nursing Planning Intervention Rationale Evaluation
Diagnosis
Individualized
Acute pain related Patient will report pain Assess pain level and pain management Patient reports
Discomfort and pain to uterine controlled to a tolerable characteristics at improves patient decreased pain
due to frequent contractions and level regular intervals. comfort and well- intensity and
uterine contractions PROM being. improved
Offer non- comfort.
pharmacological pain Non-
relief measures like pharmacological Patient utilizes
massage, warm methods are non- non-
compresses, and invasive and pharmacological
relaxation techniques. reduce side and/or
effects. pharmacological
Administer analgesics pain relief
as ordered following Pharmacological effectively
facility policy agents provide
relief when other
measures are
insufficient
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XI. ONGOING APPRAISAL
ongoing appraisal in patients with PROM is a dynamic process that requires close
monitoring, timely adjustments in management, and effective communication to ensure
optimal outcomes for both mother and baby.
XII. DISCHARGE PLAN
Antibiotics , iron , calcium
M - Medication
Take Rest and can start normal exercise after 2week of delivery
E - Exercise
Hydration , Hygiene and perianal Care
T - Treatment
Educate the patient about the signs and symptoms of infection,
H - Health Education such as fever , seek medial advice if any complication
Adequate fluid intake . maintain personal hygiene , provide
exclusive breast feeding of baby
Schedule follow-up appointments with your healthcare provider
O - OPD Follow-up as instructed . flow the immunization schedule for baby
Maintain a healthy and balanced diet
D - Diet
Engage in practices that provide you with spiritual comfort and
S - Spiritual peace, such as prayer, meditation, or spending time in nature.
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