Republic of the Philippines
TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, TarlacCityPhilippines 2300
Tel.no.: (045) 493-1865 Fax: (045) 982-0110 website: www.tsu.edu.ph
Awarded Level 2 Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines Inc (AACCUP)
CLINICAL CASE ANALYSIS
Name of Patient Ms. Catriona Wurtzbach, Age: 32 yrs Gender: F
old
Address TARLAC Date
Admitted:
Diagnosis Postpartum bleeding
NURSING HISTORY:
Ms. Catriona Wurtzbach, a 32 year old G4P4 who vaginally delivered a 4,309 grm term
male infant 45 minutes ago. She had an uncomplicated prenatal course, and her only
medications during pregnancy were prenatal vitamins.
Her membranes ruptured at home 48 hours prior to delivery, and she was admitted to
labor and delivery about 2 hours ago in active labor. Her labor progressed quickly, and she
delivered an hour later. The placenta was delivered spontaneously within 5 minutes. Her
estimated blood loss was 400 ml. She had a second-degree perineal laceration that was repaired
under local anesthesia. No type and cross were done. She has no known allergies.
Her most recent vital signs 10 minutes ago were as follows, pulse 88, BP 124/70, RR 20,
Temp. 37.1 degree Celsius, O2 saturation 97%. After 2 hours post vaginal delivery the patient
stated” I do not feel good. I feel sick to the stomach, my head is spinning. I am really crampy.
Can I have something for pain?' The nurse assesses the patient, and the fundus is boggy at 3 cm
above umbilicus, The patient complaints pain in lower abdomen and area around vagina.
Hospital gown soaked with blood; perineal pads saturated with blood.
PATHOPHYSIOLOGY:
A
t term the uterus and placenta receive 500-800mL blood per minute through their low
resistance network of vessels. This high flow predisposes a gravid uterus to significant
bleeding if not well physiologically or medically controlled. By the third trimester maternal
blood volume increases by 50% which increases the body tolerance of blood loss during
delivery. Following the delivery of the fetus, the gravid uterus is able to contract down
significantly given the reduction in volume. This allows the placenta to separate from
uterine interface, exposing maternal blood vessels that interface with the placental surface.
After the separation and delivery of the placenta, the uterus initiates a process of contraction
and retraction, shortening its fiber and kinking the supplying blood vessels, like physiologic
sutures or living ligatures.
DIAGNOSTIC PROCEDURES:
CBC ( this blood test evaluates blood loss, anemia blood replacement therapy and fluid
balance and screens red blood cell status)
PRR & PT ( this test evaluates coagulation ability of the blood)
Ultrasound ( use to perform noninvasive, risk free abdominal examinations, used to detect
tumor, cyst, obstruction and abscesses, information gained from the use of ultrasound.)
MEDICAL MANAGEMENT:
IV fluid
Blood transfusion
Oxygen therapy
Indwelling folley catheter
Oxytocin
Name of Student: Valertio, Stephanie Danielle M
Date Submitted: 04/15/21 C.I.’s Signature
Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
Patients Name: Ms. Catriona Wurtzbach
Age: 32 years-ol
SUBJECTIVE:
“I do not feel good. I feel sick to the stomach, my head is spinning. I am really crampy.”
As verbalized by the patient.
OBJECTIVE:
Vital Signs:
Temperature: 37.1°C
Respiratory Rate: 20 bpm
Pulse Rate: 88 bpm
Blood Pressure: 124/70 mmHg
O2 Saturation: 92%
ASSESSMENT:
Risk for ineffective tissue perfusion related to Hemorrhage.
PLANNNING:
After 8 hours of appropriate nursing intervention and proper health teachings to the
patient will be able to:
-Identify and use appropriate interventions to manage pain/discomfort
-Appear relaxed, able to sleep/rest comfortably
-To know different techniques in alleviating pain
INTERVENTION:
Independent
-Provide rapport with the patient.
-Monitor vital signs.
-Assess and record the type, amount, and site of the bleeding; Count and weigh
perineal pads and if possible, save blood clots to be evaluated by the physician.
-Assess the location of the uterus and degree of the contractility of the uterus/
Massage boggy uterus using one hand and place the second hand above the
symphysis pubis.
-Maintain a bed rest with an elevation of the legs by 20-30° and trunk horizontal.
Dependent
-Start fluid infusion thru an IV-line stat as ordered. Administer parenteral fluids as
prescribed considering the need for an IV fluid challenge with immediate
infusion. Maintain flow rate.
Collaborative
-Instruct the caregiver to report any untoward sign or symptoms
EVALUATION:
-After 8hours of nursing interventions goals are met as evidence of the clients decrease in
pain and discomfort and positive verbal report of the client during the evaluation.
