Presented by: BSN III GROUP 9 Presented to: Mrs.

Dean

A. General Objectives After establishing Nurse-Patient Interaction, thorough physical assessment, providing care to the client and study of the clients condition, student will gain knowledge, develop skills and enhance attitude through the utilization of the nursing process on the care and management of the patient with Uterine Inversion.

B. Specific Objectives:
On completion of this case study the student will be able to: Understand what is Uterine Inversion Identify its clinical manifestations Recapitulate the anatomy and physiology of the parts involved Determine the health status of the patient through: General and Demographic Data History of Present Illness Past Medical History Family Health History Physical Examination

 Establish a good and therapeutic nurse patient relationship To build trusting relationship with both the patient and significant others Utilize skills in performing physical examination to the patient Analyze laboratory results and correlate it with patients present condition Familiarize self to some medical and diagnostic procedures related to the patients present condition Trace the pathophysiology of the disease Determine the relevance of the drugs or medication to the patient

 Formulate nursing diagnosis and provide necessary nursing management and interventions Determine the rationale behind the applied nursing interventions Render quality-nursing care through implementation of the Nursing Care Plan Evaluate effectiveness of Nursing Care Plan and medical management Provide continuity of care by giving health teachings not only to patient but also as well the Significant Others

Pregnancy corresponds a lot of complications and most of them are serious and fatal. One of the serious complications of pregnancy is Uterine Inversion. The underlying pathophysiologic mechanism for uterine inversion is unknown. Several clinical observations and associations are pertinent. Clinically, the principal factors that predispose to puerperal inversion are a fundally implanted placenta, flaccidity of the myometrium around the implantation site, and a dilated, immediately post partum cervix.

If left untreated, it will risk the mothers health. Early diagnosis and management will give a good prognosis of uterine inversion.

The uterus or womb is a major female hormoneresponsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species. It is within the uterus that the fetus develops during gestation, usually developing completely in placental mammals such as humans and partially in marsupials such as kangaroos and opossums.

 essential

in sexual response by directing blood flow to the pelvis and to the external genitalia, including the ovaries, vagina, labia, and clitoris; needed for uterine orgasm to occur. to accept a fertilized ovum which passes through the utero-tubal junction from the fallopian tube; it implants into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, attaches to a wall of the uterus, creates a placenta, and develops into a fetus (gestates) until childbirth.

 located

inside the pelvis immediately dorsal (and usually somewhat rostral) to the urinary bladder and ventral to the rectum. pear-shaped and about 3 in. (7.6 cm) long. four segments: fundus, corpus, cervix and the internal os

From outside to inside, the path to the uterus is as follows: Cervix uteri - "neck of uterus" External orifice of the uterus Canal of the cervix Internal orifice of the uterus corpus uteri - "Body of uterus" Cavity of the body of the uterus Fundus (uterus)

 Endometrium

lining of the uterine cavity consists of the functional endometrium and

the basal endometrium from which the former arises.

Myometrium

smooth muscle innermost layer of myometrium is known as

the junctional zone, thickened in adenomyosis.

which

becomes

 Parametrium

loose connective tissue around the uterus.

Perimetrium

peritoneum covering of the fundus and

ventral and dorsal aspects of the uterus.

 in

the middle of the pelvic cavity in frontal plane (due to ligamentum latum uteri). The fundus does not surpass the linea terminalis, while the vaginal part of the cervix does not extend below interspinal line. The uterus is mobile and moves under the pressure of the full bladder or full rectum anteriorly, whereas if both are full it moves upwards.

Distinction

More common

Less common

Position tipped

"Anteverted": Tipped forward

"Retroverted": Tipped backwards

Position of fundus

"Anteflexed": Fundus is pointing "Retroflexed": Fundus forward relative to is pointing backwards the cervix

 the

uterus is supplied by arterial blood both from the uterine artery and the ovarian artery.

Definition Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal. Uterine prolapse often affects postmenopausal women who've had one or more vaginal deliveries. Damage to supportive tissues during pregnancy and childbirth, effects of gravity, loss of estrogen, and repeated straining over the years all can weaken your pelvic floor and lead to uterine prolapse.

 Sensation

of heaviness or pulling in your pelvis Tissue protruding from your vagina Urinary difficulties, such as urine leakage or urine retention Trouble having a bowel movement Low back pain Feeling as if you're sitting on a small ball or as if something is falling out of your vagina Sexual concerns, such as sensing looseness in the tone of your vaginal tissue Symptoms that are less bothersome in the morning and worsen as the day goes on

 Pregnancy

and trauma incurred during childbirth, particularly with large babies or after a difficult labor and delivery Loss of muscle tone associated with aging and reduced amounts of circulating estrogen after menopause Tumor in the pelvic cavity Genetics

 One

or more pregnancies and vaginal births Giving birth to a large baby Increasing age Frequent heavy lifting Chronic coughing Frequent straining during bowel movements Genetic predisposition to weakness in connective tissue

 Ulcers. Prolapse

of other pelvic organs.

 Pelvic

exam Questionnaire Imaging tests

 Lifestyle

changes Achieve and maintain a healthy weight, to minimize the effects of being overweight on supportive pelvic structures. Perform Kegel exercises, to strengthen pelvic floor muscles. Avoid heavy lifting and straining, to reduce abdominal pressure on supportive pelvic structures. Vaginal pessary Surgery to repair uterine prolapse

 Maintain

a healthy weight. Practice Kegel exercises. repeatedly squeeze and relax the muscles of your pelvic floor. To perform these exercises, tighten your pelvic muscles as if you're stopping your stream of urine. Hold for a count of five, relax and repeat. Do these exercises several times a day. Control coughing. Don't smoke.

VITAL INFORMATION Name : Layda Montalla Raymundo Ward : Gyne Bed No : P4 Address : Ibabang Yuni, Mulanay, Quezon Age : 31 years old Sex : Female Nationality : Filipino Religion : Roman Catholic Birthday : June 15, 1980 Status : Married

Chief Complaint : Vaginal Bleeding Admission Date : July 17, 2011 Diagnosis : Uterine Inversion vs. Prolapsing Submucous Myoma, Anemia secondary to blood loss Discharge date :

General Appearance Slightly pale and weak in appearance Conscious, coherent and oriented With ongoing IVF of D5LR 1L at 500cc level; inserted at the right metacarpal vein; regulated at 31- 32gtts/min; infusing well Body Structure Body parts look equal bilaterally and are in relative proportion to each other.

Vital Signs Temperature Pulse Rate

Day 1 36.8C 78bpm

Day 2 37.9C 80bpm

Day3 36.7C 83bpm

Respiratory Rate

25breaths 23breaths 23breaths /min /min /min

80/60mm 90/70mm 110/70m Hg Hg mHg

Blood Pressure

Integumentary Skin pale and has a fair skin turgor. Hair evenly distributed dry black hair.

HEENT Head symmetrical with rounded skull contour Eyes evenly distributed, symmetrically aligned and with equal movement. eyelashes are short, evenly spaced and slightly curled outward. eyelids have no swelling. pale palpebral conjunctiva. pupils are brown in color, equally rounded and active to light accommodation. Ears auricle is of equal size and similar in appearance

Nose same color as the face, symmetrical in appearance no changes in nares with respiration nasal septum is intact and on midline no redness or swelling noted on the nasal mucosa no nasal discharges noted Mouth pale and dry lips gums are pinkish in color, moist and has no retractions tongue is in central position, moves freely and has no tenderness Neck no palpable neck mass noted no neck rigidity noted

Thorax and Lungs chest is symmetrical with skin intact chest wall is intact and no tenderness noted clear breath sounds are heard on both lung fields upon auscultation Heart normal heart rhythm. Abdomen soft and nontender. no palpable mass noted. no complaints of abdominal pain

Extremities Upper well flexed with palm slightly warm to touch. has normal sensation with pale nail beds and a capillary refill time of 2-3 seconds Lower negative weakness on both lower extremities. slightly pale nailbeds and capillary refill time of 3 seconds

The patient experience vaginal bleeding 23 days after passing out abortus. Because of severe blood loss leading to anemia, the patient decided to seek consultation and lead to her confinement at Quezon Medical Center.

The patient had never been hospitalized for any disease. She has 3 children alive. And her 4th pregnancy

According to the patient, there is no history of hypertension, DM and cancer in their family.

EXAMINATION

RESULT

NORMAL VALUES

INTERPRETATION

NURSING MANAGEMENT

CBC Hgb Hct WBC Differential Count Neutrophils Lymphocytes Eosinophils Platelet Count

3.3 7.5 9.0 10.4 10.9 - 23.7 27.7 31.3 7,800 7,100 - 5,100 7,100

12 14gm/dL 30 40 %
5,000 10,000/cumm

Anemia Anemia Normal Normal Normal

69 66 63 - 72 31 - 34 37 - 28

251,000

150,000 450,000 135 148 3.5 5.3

Normal

Electrolytes >Na >K

140.3 3.71

Normal Normal

Assessed gen. Condition monitored v/s Placed on semi-fowlers position Encouraged to eat iron-rich and Vit.C rich foods Encouraged to have adequate rest and sleep Encouraged to have adequate OFI

ASSESSMENT

NURSING DIAGNOSIS

GOAL

NURSING INTERVENTIONS

RATIONALE

EVALUATION

O > hgb 3.4gm/dL > slightly pale and weak in appearance > with O2 inhalation via nasal cannula regulated at > with pale conjunctiva > with pale and dry lips > with pale nailbeds

> altered tissue perfusion r/t decreased O2 carrying capacity of the blood as revealed in the lab.result

> at the end of the nursing interventions, the patient will be able to identify ways to improve tissue perfusion

> assessed general condition > monitored vital signs, especially blood pressure

For baseline data BP- 100/70mmHg

> placed on semifowlers position

> instructed on deep breathing exercises > assisted in performing PROM exercises > encouraged on adequate rest and sleep periods encouraged to eat iron-rich foods such as organ meats and green leafy vegetables; and Vit.C rich foods like oranges, dalandan, calamansi, etc. > Encouraged on ambulation

>promotes gravitational blood flow

>

>kept on semifowlers position >seen performing deep breathing exercises >seen exercising arms and legs >seen asleep at intervals

to maximize tissue perfusion promotes sense of well-being

for production of hgb and absorption of iron

> Seen eating adobong atay and dalandan

> to promote circulation of blood

> seen ambulating

ASSESSMENT

NURSING DIAGNOSIS

GOAL

NURSING INTERVENTIONS

RATIONALE

EVALUATION

O > body temp38.3C > with flushed skin > with body weakness > skin warm to touch > irritable at times

> alteration in body temperature; increased r/t disturbance of the thermoregulating center of the brain; hypothalamus

> at the end of the nursing interventions, the patient will be able identify ways to decrease body temperature at normal level

> assessed general condition > monitored vital signs, especially body temperature > provided TSB and instucted SO to continue doing so

For baseline data

>body temp37.4C

>promotes heat loss

>seen SO performing TSB to the pt. >

> provided cool environment

> instructed to wear non-constrictive clothing > kept back dry at all times > encouraged to increase oral fluid intake >encouraged on adequate rest and sleep periods

>

> to prevent further complication

> seen with loose, comfortable clothing >seen with dry towel on the back seen drinking ample amount of water >seen asleep at intervals

>aids in the flushing of pyrogenic microorganism >promotes sese of well-being

>administered antipyretic drugs as ordered

>for pharmacological effect

MEDICATIONS

SPECIFIC ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTIONS

NURSING RESPONSIBILITIES

Cefuroxime 750mg IV q8

> antibiotic 2nd generation > suspected cephalosporin infections

> allergy to cephalosporins or penicillins > use cautiously with pregnancy, lactation, renal failure

> headache, dizziness, lethargy, NVD, abdominal pain, flatulence

> give drug with food > have Vit. K available in case hypothrombin emia occurs > encourage to increase OFI
> monitor body temp > encourage to increase OFI > administer with food > monitor pts response > monitor BP

Paracetamol 500mg/tab q4 for temp 38.0C Diphenhydra mine HCl amp IM

> antipyretic

> fever

>hypersensitivity

> NVD

>antihistamine

> allergy to antihistamine, third trimester of pregnancy, lactation

>drowsiness, sedation, dizziness, disturbed coordination, hypotension, palpitation