CASE PRESENTATION
PREPARED BY:
TINU VARGHESE
DEMOGRAPHIC DATA
• CASE NO:
052125
• NAME: MS. J.J. AGE: 24 Y/O
SEX: FEMALE
• DIAGNOSIS: PRETERM
PREMATURE RUPTURE OF
MEMBRANES (PPROM)
• {Primigravida 33 wks leaking
since 1100H 6/1/2013}
GENERAL
• The patient is 24 years of age, FEMALE
• She is conscious, coherent, with the following
Vital Signs:
– BP= 110/59mmHg
– PR=100 bpm
– RR= 28 cpm
– Temp=37. ⁰C
– SPO²= 98%
SKIN
• Fair complexion
• No palpable masses or
lesions, moist, with good
turgor
HEAD
• Maxillary, frontal, and ethmoid
sinuses are not tender.
• No palpable masses and lesions
• No areas of deformity
LEVEL OF CONSCIOUSNESS AND
ORIENTATION
• Awake and alert
• Oriented to persons
(knows some of our name)
• Place
( she can tell where she is)
• Time
( knows the day, date and always asking the
time)
EYES
• Pink conjunctivae and no
dryness
• Pupils equally round and
reactive to light
EARS
• No usual discharges noted
NOSE
• Pink nasal mucosa
• No unusual nasal
discharges
• No tenderness in sinuses
MOUTH
• Pink and moist oral
mucosa and free of
swelling and lesions
NECK AND THROAT
• No palpable lymph nodes
• No masses and lesions
seen
CHEST AND LUNGS
•Equal chest expansion
•No retraction
•Clear breath sounds
HEART
•Regular rythm
ABDOMEN
• Globular abdomen
• Leopold’s Maneuver done: fetus in cephalic
presentation, head is round and hard, fetal back is
facing right side
• USG report:
o Pregnancy Uterine 33 weeks AOG by fetal Biometry
live, Singleon in cephalic presentation, female fetus,
Good cardiac and somatic activity, posterior
placenta, Grade III, No previa, Adequate Amniotic
Fluid Volume
GENITALS
•Clear Watery
discharge per
vagina since 2 days.
•No show present
EXREMITIES
•Pulse full and equal
•No lesions noted
PATIENT HISTORY
PAST MEDICAL HISTORY
No past medical history
PRESENT MEDICAL HISTORY
• C/O:
Leaking since 1100H 6/01/2013
• MEDICAL HISTORY:
Primigravida with
pregnancy 33 wks by LMP, 37 wks + 1 day
by USG with PROM since 1100H
06/01/2013
• ON EXAMINATION:
BP=110/59
mmHg, PR=118 bpm, RR= 28 cpm,
Temp=37. ⁰C, SPO²= 98%
PRESENT MEDICAL HISTORY
INVESTIGATION:
TEST
RESULT
REFERENCE RANGE
Hgb
10g/dl
11.2-15.7g/dl
WBC
14.04
3.98-10.04
PT
12.1 sec
10.9-16.3sec
Blood Glucose
5.2 mmol/L
3.9-7.8mmol/L
A positive
Blood Group
Negative
Antibody screening
RPR
Non- Reactive
Rubella Antibody IgG
Positive
Urinalysis
HBsAg
Pus cells= 0-1/ hpf, RBC = 0-1/
hpf
negative
HIV
Negative
PRESENT MEDICAL HISTORY
Ultrasound report:

Pregnancy Uterine 37 weeks and 1 day
AOG by fetal Biometry live, Singleton in cephalic
presentation, female fetus, Good cardiac and
somatic activity, posterior placenta, Grade III, No
placenta Previa, Adequate Amniotic Fluid Volume
NAME OF DRUG
1.
ACTION
DOSAGE
ROUTE
1 gm
IV
antibiotics
12mg
IM
corticosreroid
Ampicillin
2 Inj.Dexamethasone
Calcium channel blockers
3
Tab .Nifedipine
20mg
PO
10mg
PO
Calcium channel blockers
600mg
PO
Calcium supplimentt
100mg
PO
Iron suppliment
Mix 10 U in 500 mL of IV
solution, begin infusion at 1
mU/min and increase 1–2
mU/min q 30 min
IV
causes the uterus to contract
Meperidine (Demerol) 25 mg IV push (IVP) q 3–4 hr
IV
opioid analgesic drug
4
Tab .Nifedipine
5
Calcium Tablet
6
FeSO4 Tablet
ADDITIONAL MEDICATIONS:
1. Oxytocin (Pitocin
INTRODUCTION
• During pregnancy, the baby is surrounded in
the uterus by the amniotic sac. The sac is also
called the “bag of waters.” It protects and
cushions the baby.
• Premature Rupture of Membranes (PROM) is
defined as rupture of membranes before the
onset of labor.
• Preterm Premature Rupture of Membranes
(PPROM), which is when the membranes
rupture before 37 weeks.
INTRODUCTION
• The sac contains amniotic fluid and the
developing baby. In PPROM, the amniotic
fluid inside the sac leaks or gushes out of the
vagina. Before term, PPROM is often due to
an infection in the uterus.
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
To diagnose PPROM, the doctor may do the
following tests:
Visual examination
A nitrazine paper test
Fern test
Ultrasound
Amnisure
POSITIVE
NITRAZINE
TEST
POSITIVE
FERN TEST
Amniocentesis to
inject indigo
carmine or evans
blue dye. watch
for vaginal
leakage of blue
fluid to assess for
ruptured
membranes
Risk factors
•
•
•
•
Lack of prenatal care
Smoking during pregnancy
Low body weight
Bleeding from the vagina during the 2nd or 3rd
trimester
• Having had a sexually transmitted disease (STD)
• Having had certain medical procedures such as
amniocentesis (a test that takes fluid from the
amniotic sac) or cerclage (sewing the cervix
closed during pregnancy)
Main symptom:
Fluid leaking or gushing from the vagina
It may be a sudden, large gush of fluid, or it may be a slow, constant trickle of fluid. The
complications that may follow PROM include premature labor and delivery of the fetus,
infections of the mother and/or the fetus, and compression of the umbilical cord (leading to
oxygen deprivation in the fetus).
Other symptoms:
Bleeding from the vagina
Other symptoms:
Pain in the Lower abdomen or in the low back
If you have any of these signs & symptoms, call your healthcare
provider right away
VIII. NURSING INTERVENTION
• Prevent infection and other potential
complications
 Make an early and accurate evaluation of membrane status, using
sterile speculum examination and determination of ferning.
Thereafter, keep vaginal examinations to a minimum to prevent
infection.
 Obtain smear specimens from vagina and rectum as prescribed to
test for betahemolytic streptococci, an organism that increases the
risk to the fetus.
 Determine maternal and fetal status, including estimated gestational
age. Continually assess for signs of infection.
 Maintain the client on bed rest if the fetal head is not engaged. This
method may prevent cord prolapse if additional rupture and loss of
fluid occur. Once the fetal head is engaged, ambulation can be
encouraged.
VIII. NURSING INTERVENTION
Educate the patient to use sterile
pads
VIII. NURSING INTERVENTION
• Provide client and family education
Inform the client, if the fetus is at term, that the
chances of spontaneous labor beginning are
excellent; encourage the client and partner to
prepare themselves for labor and birth.
If labor does not begin or the fetus is judged to
be preterm or at risk for infection, explain
treatments that are likely to be needed.
TREATMENT
• Hospitalization
• Expectant management (in some cases of PPROM, the
membranes may seal over and the fluid may stop leaking
without treatment)
• Monitoring for signs of infection such as fever, pain,
increased fetal heart rate, and/or laboratory tests
• Giving the mother medications called corticosteroids that
may help mature the lungs of the fetus (lung immaturity is a
major problem of premature babies
• Antibiotics (to prevent or treat infections)
• Tocolytics - medications used to stop preterm labor.
• Delivery (if PROM endangers the well-being of the mother
or fetus, then an early delivery may be necessary to prevent
further complication
COMPLICATIONS OF PROM
• Prolapse of the umbilical cord (the baby's cord
drops down interfere with the blood supply to the
baby).
• Infection of the uterus and unborn child.
• Placental abruption (the placenta comes away early
with bleeding and loss of blood supply to the baby).
• Potential increased rates cesarean delivery.
• Premature Birth (PPROM)
• Chorioamnionitis
• Cord compression
• Respiratory distress syndrome
PRIORITIZATION OF NURSING
PROBLEMS
• Risk for infection related to loss of protective barrier
by the fern test.
• Anxiety r/t threat to maternal or fetal well-being
secondary to risk for infection or preterm birth
• Risk for infection related to ascending bacteria
• Risk for injury to fetus secondary to prematurity
• Compromised Family coping secondary to
hospitalization
• Risk for infection: maternal or fetal r/t premature
rupture of membranes
• Risk for injury: maternal or fetal r/t tocolytic drugs
used to delay birth
ASSESSMENT
CUES/ EVIDENCE
SUBJECTIVE:
“I feeing
sudden gush of
fluid from the
vagina” as
verbalized by
the patient.
NURSING
DIAGNOSIS
Risk for infection
related to loss of
protective barrier
by positive fern
test.
PLANNING
GOALS & DESIRED
OUTCOME
Within 12 hours of
nursing intervention
, patient will have
no signs of
infection.
IMPLEMENTATION
NURSING ORDER/ACTION
1. assess the patient from
any signs and symptoms
of infection
RATIONALE FOR ACTION
1. to assess for
infection.
v/S taken as follows:
•
BP:130/90mmHg
•
PR: 118 bpm
OBJECTIVE:
•
RR: 28 cpm
1.Meconium
stained
amniotic fluid.
•
Temp: 37 °C
2.Provide sterile pads
2. prevent infections
2.Amnicator
test result
positive
3.Teach the proper hand
hygiene technique to the
patient.
3. To avoid infections
3. Fetal
tachycardia
FHR 180bp
without
uterine
contraction
4.Vaginal
examinations
should be held to an
absolute minimum, and
sterile technique should
be used.
4. To prevent infections
5.Administer antibiotics
as prescribed.
5. To treat infection
EVALUATION
EVALUATION
After 12
hours of
nursing
intervention,
the goal was
fully met as
evidenced
by:
Patient has
no signs of
infection
ASSESSMENT
CUES/
NURSING
EVIDENCE
DIAGNOSIS
SUBJECTIVE:
Patient says
that “I am
afraid about
the baby’s
health
as verbalized by
the patient
OBJECTIVE:
Her facial
expression
shows that
she has
anxiety
V/S taken as
follows:
BP:130/90mmH
g
PR: 118 bpm
RR: 28 cpm
Temp: 37 °C
Anxiety r/t
threat to
maternal or
fetal wellbeing
secondary to
risk for
infection or
preterm
birth
PLANNING
GOALS &
DESIRED
OUTCOME
Within 12
hours of
nursing
intervention ,
patient will
relief from
anxiety
IMPLEMENTATION
NURSING
RATIONALE FOR
ORDER/ACTION
ACTION
1. Monitor vital signs
(e.g., rapid or irregular
pulse, rapid
breathing/hyperventil
ation, changes in
blood pressure, , or
restlessness
2. Teach the patient for
counting the 10 fetal
movements in 12 hour
periods.
3. Manage environmental
factors, such as harsh
lighting and high volume
of CTG, which may be
stressful to patient
4. instruct client in
relaxation techniques and
encourage participation in
diversional activities
5. Explain the action and
side effects of medication
as prescribed.
Inj. ampicillin 1gm IV
1. To identify
physical responses
associated with
both medical and
emotional
conditions.
2. To reduce anxiety
by giving awareness
of fetal wellbeing.
3. To relieve
psychological stress
due to prolonged
bed rest
4. To reduce anxiety
by relaxation, deep
breathing.
5. To give
knowledge about
the risk of infection
EVALUATION
EVALUATION
After 12
hours of
nursing
interventi
on, the
goal was
fully met
as
evidence
d by:
Patient
relief
from
anxiety
NURSING HEALTH TEACHING
•
•
•
•
•
Remain on modified bed rest
No sexual activity, no tub bath.
Assess for uterine contraction and fetal movement.
Assess for foul smelling vaginal discharge
Wipe front to back after urinating or having a bowel
movement
• Take antibiotics if prescribed.
CONCLUSION
This is a case of a 24 y/o Primigravida with pregnancy 33+
1 wks by LMP, 37 wks + 1 day by USG who came in due to
watery discharge, amnicator test positive. Patient was
advised for expectant management.
Premature Rupture of Membranes (PROM) is defined as
rupture of membranes before the onset of labor. Preterm
Premature Rupture of Membranes (PPROM), which is
when the membranes rupture before 37 weeks.
Premature Rupture of Membranes happens when the
membranes that hold amniotic fluid (the water
surrounding the baby) usually break at the end of the
first stage of labor.
CONCLUSION
Criteria which are fulfilled by the patient,
conservative management rendered such as
investigations, antibiotic coverage
In cases by which this patient will undergo
active labor despite tocolytic medication,
there will be no objection for delivery as long
as all maternal & fetal consequences are
explained properly to the patient.
BIBLIOGRAPHY
• Maternal and Child Health Nursing by Adele Pillitteri
5th edition; volume 1 page 426- 433;page 329-332
• All-in-one care planning resource page 748; by Pamela
L. Swearlngen, RN
• Maternal Neonatal Nursing;page 30 by Lippincott
Williams and Wilkins
• Luckman and Sorensen’s Medical-Surgical Nursing a
Physiologic Approach 4th edition Volume 1 page 734
• Lippincot Manual of Nursing Practice 9th edition
• http://www.ualberta.ca/~olsonlab/Am%20J%20Obstet
%20Gynecol%201999%20180(1%20Pt%201).pdf
Thank you!!
