TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the
Philippines

CLINICAL CASE ANALYSIS

Name of Patient Ms. Pascua Age: 30 y/o Gender: F
Address Gerona, Tarlac Date Admitted: 02-22-2022
Diagnosis Postpartum Hemorrhage

NURSING HISTORY:

Patient Pascua is a 30-year-old Filipino housewife who lives in Gerona, Tarlac. She was
admitted to the hospital on February 22, 2022, with a chief complaint of excessive bleeding in
her perineum. The nurse finds that the patient's uterus is soft and boggy. The patient's
bladder had shifted to the right side of the abdomen, according to further examination. The
client has an obstetric history of G:1 T:1 P:0 A:0 L:1.

LABOR HISTORY

The baby boy was delivered at 4:30 pm at the delivery room by Normal Spontaneous
Delivery. The fetal heart tones were 134 and regular. The Baby’s head was at +5 station, and
the cervix was 10cm. It was dilated and 100 percent effaced. The placenta is out completely
by Shultz's presentation.

HISTORY OF PAST ILLNESS:

According to the client, her GTPAL was G:1 T:1 P:0 A:0 L:1. Other than that, the client has no
recorded Past Health Illness.

HISTORY OF PRESENT ILLNESS:

The client verbalized that she had been in labor pains and having contractions at 7-to-10-
minute intervals since 6 a.m. The contraction lasted for 30 seconds. She also mentioned that
she'd been experiencing "a lot of false labor". An hour prior to admission her membranes
ruptured.

After giving birth the client used adult diapers to secure the client from bleeding. The patient
was brought into the recovery room via stretcher. However, the patient verbalized and
complains of excessive bleeding in her perineum. The nurse finds that the patient's uterus is
soft and boggy and the bladder has shifted to the right side of the abdomen, according to
further examination. It was noted that her temperature is 36.5 C, Blood pressure
112/80mmHg, Pulse rate is 98bpm, Respiratory Rate is 18 bpm. Upon checking her
laboratory result it showed that her Complete Blood Count (CBC) - Hemoglobin-7.8,
Hematocrit - 0.23 Red blood Cell- 2.6, is in the abnormal values, apart from that,
everything is said within a normal range.
PATHOPHYSIOLOGY:

(Please see the next page)

BOOK BASED PATHOPHYSIOLOGY

Postpartum hemorrhage (more than 500 ml.) is caused by various organic changes such as
injuries of the parturient canal (uterus, cervix, vagina and rarely, perineum), inversion of the
uterus, abnormal separation and expulsion of the placenta, and by functional changes such
as absence of contraction and retraction of the uterine muscle and diseases of the blood
clotting factors and blood vessels. Among them, the most frequent and important cause of
abnormal postpartum hemorrhage is a so-called 'atonic uterine bleeding' which is a diagnostic
term given by clinicians to the cases of postpartum hemorrhage without any pathological
organic changes. However, the term 'atonic uterine bleeding' has been used without criticism
and it remains somewhat equivocal in that. It is often noted in some cases of abnormal
hemorrhage with apparently good contraction of the uterine muscle without any organic
changes, and in cases of normal bleeding with weak contraction of the uterine muscle. On the
other hand, it is generally considered that the following three factors are necessary for the
complete understanding of hemorrhage or hemostasis: 1. Tissue factors (tissue elasticity and
contractility, tissue thromboplastin and tissue plasminogen activator) 2. Blood vessel factors
(blood vessel size, elasticity, contractibility, internal pressure, permeability and, etc.). 3. Blood
clotting factors (all blood clotting factors including thrombocytes). Above three factors are also
necessary for the complete understanding of postpartum hemorrhage, however, at the
present time there have been few trials to explain the causes of postpartum hemorrhage from
these standpoints. As a cause of obstetrical hemorrhage, defibrination syndrome has been
frequently observed in the last decade. There are two possible mechanisms of defibrination;
one is due to the intravascular clotting of fibrinogen as a result of aut extraction of tissue
thromboplastin. Another is due to the enhancement of plasmin enzyme action. Thus, any
given case of postpartum hemorrhage may obviously result from such serious disorders of
the plasmin enzyme system. It is considered, however, that a slight degree of disorder of this
enzyme system may also be a cause of postpartum hemorrhage. In this paper, we have
described such relatively minor disorders of the plasmin enzyme system, as they relate to
pre- or latent defibrination state in connection with postpartum hemorrhage.

CLIENT BASED PATHOPHYSIOLOGY

Ms. Pascua is a 30 y/o Primigravida who just gave birth with prolonged labor(3:00pm-
6:00am). Based on our case scenario, after the birth of Ms. Pascua, she experienced
excessive bleeding. The most common cause of Postpartum hemorrhage is failure of the
uterus to contract. Primary PPH due to uterine atony occurs when the relaxed
myometrium fails to constrict the blood vessels that traverse its fibers, thereby allowing
hemorrhage. Failure of the uterus to contract may be associated with retained placenta or
placental fragments, either as disrupted portions or, more rarely, as a succenturiate lobe.
The retained material acts as a physical block against strong uterine contraction which is
needed to constrict placental bed vessels. In most cases, however, dysfunctional
postpartum contraction is the primary reason for placental retention. The reasons for this
contractile dysfunction are unknown. Because of too much pressure during childbirth, the
pelvic muscles can stretch and become weaker during pregnancy or a vaginal delivery. If
the pelvic muscles do not provide enough support, your bladder might sag or drop and
that is the reason why Ms. Pascua’s bladder has been displaced to the right side of the
abdomen.

DIAGNOSTIC PROCEDURES:
A diagnostic procedure is an examination to identify an individual's specific areas of
weakness and strength in order to determine a condition, disease or illness. A chain
of or stepwise reactions to conclude a test is called Diagnostic Procedure.

CBC TEST. A complete blood count (CBC), also known as a full blood count (FBC), is a set
of medical laboratory tests that provide information about the cells in a person's blood. The
CBC indicates the counts of white blood cells, red blood cells and platelets, the concentration
of hemoglobin, and the hematocrit (the volume percentage of red blood cells). The red blood
cell indices, which indicate the average size and hemoglobin content of red blood cells, are
also reported, and a white blood cell differential, which counts the different types of white
blood cells, may be included.

CBC test result showed:

DIAGNOSTIC EXAMINATIONS
 CBC
  NORMAL VALUES RESULT
HGB 11.5-14.8 g/dl 7.8
HCT 0.34-0.44 % 0.23
RBC 4.20-5.30 x 10 12/L 2.6
WBC 4.50-10 .0 x 10 9/L 10
NEUTROPHIL 0.50-0.70% 0.64
LYMPHOCYTE 0.20-0.40% 0.35
MONOCYTE 0.03-0.08% 0.05
EOSINOPHIL 0.005-0.05% 0.02
BASOPHIL 0.00-0.01% 0.01
MCV 87.0- 102.2fL 96
MCH 25.6-31.3g/dl 27
MCHC 28.2-31.1g/dl 28.9
PLATELET CT 150-450 x 10 9/L 220
BLOOD TYPING: B+  
Interpretation on CBC Test (February 22 ) :

● Hemoglobin count: The results indicate lower than normal range. Low
Hemoglobin count due to excessive bleeding
● Hematocrit level: The result of 0.23% in hematocrit means the percentage of red
blood cells is below the lower limits of normal. The result indicates slightly
elevation but remains below the normal range
● Red Blood Cell count: Low Blood due to excessive blood loss. The result is
below the normal range. White Blood Cell Count: The result indicates within the
normal range.
● Other components of CBC results of the patient were in the normal range.

Nursing Responsibilities
Before
● The nurse must explain the test procedure, its purpose and explain that slight
discomfort may be felt when the skin is punctured.
● Encourage the patient to avoid stress if possible because altered physiologic status
influences and changes normal hematologic values.
● Explain that fasting is not necessary. However, fatty meals may alter some test
results as a result of lipidemia.
After

●
Then the nurse must communicate to the hospital laboratory or to the medical
technologist about the needed procedures that are to be performed and with
regards to the client’s relevant information needed for the laboratory.
● Provide correct information about the findings and results of the examination.
MEDICAL MANAGEMENT:

Medical Management improves the administration of medications given to the client.

DAY 1

IVF (Intravenous Fluid): D5LRS (5% dextrose of lactated ringers) 1L X 30 gtts/min. 8

hrs.
● Intravenous fluids (usually shortened to 'IV' fluids) are liquids given to replace water,
sugar and salt that you might need if you are ill or having an operation, and can't eat
or drink as you normally would. IV fluids are given straight into a vein through a drip.

NURSING RESPONSIBILITIES:
 ○ Assess any allergies to medications.
○ Consider the 10 rights of medication
○ Inform client and significant other regarding the medication.
○ Do not administer unless the solution is clear and the container is
undamaged.
○ Read the label of the medication when it is taken from the medication
cart
○ Check the expiration date of the medication.
○ Properly label the IV Fluid.
○ Check the vital signs
○ Maintain proper hygiene, don gloves, and observe other appropriate
infection control procedures.
○ Assess the client for the possible side effects of the medication.
○ Check for the client’s condition; assess and report immediately if there
are any deviations from normal.
○ Do not administer unless the solution is clear and the container is
undamaged.
○ Discard unused portions.

Oxytocin
● is a hormone that is used to strengthen uterine contractions and also helps to control
bleeding after childbirth.

○ 10 units Oxytocin regulated at 30 drops/min

○ Oxytocin will be mixed in the IV fluid to help prevent further bleeding as it helps
in the uterine contraction.

Nursing Responsibilities

○ Monitor client’s vital signs and input and output

○ Consider the 10 right of medication
○ Side effects such as hyperstimulation, nausea, and hypertension
○ Document the start time, dose, and any changes made during the
administration of the drug
○ Monitor for the frequency, duration, and force of contractions
○ Review the client's medical record for us to make sure that there are no
contraindications in the medication to be administered.
○ Advise patient that contractions will be similar to menstrual cramps, gradually
increasing in intensity

Name of Student: DE GUZMAN, EVANGELINE, FETALCURIN, KATHERINE MAY, GALULO,

NICOLE IMMA, LACSON, MOISES, LAGRIMAS, KRISTAN LLOYD, OGBAC,
VANESSA JHENICA, TORRES, MA. BEA ANGELA
Date Submitted: 02-08-2022 C.I.’s Signature

Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 2