NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY

A Mini Case Study on

INCOMPLETE ABORTION
Submitted by: ARAGON, Mikhail S. BALDIVINO, Apriel Joy D. DADANG, Shermane C. GOROSPE, Irish Kate A. GUIAMAN, Baisarah Q. PANDITA, Mohaima W. RUBI, Beverly Joy A. SUMAMPAO, Diamond M. SUYOM, Jessieden E. BSN 2C Group 3 MTW

March 9, 2011

TABLE OF CONTENTS

I. Introduction .. II. Objectives III. Baseline Information . IV. History of Illness V. Physical Assessment VI. Focus Assessment .. VII. Anatomy & Physiology VIII. Pathophysiology .. .. IX. Doctors Order (Course in the hospital) X. Laboratory Study.. XI. Drug Study .

1 2 3 4 5 7 8 12 14 15 17

XII. Nursing Care Plan . 25 XIII. Prognosis .... 35 XIV. Discharge Summary Plan .... XV. Recommendation 36 37

XVI. Bibliography 38

INTRODUCTION
Human beings are created with reproductive organs, through these women are capable of becoming pregnant and that is, the essence of being a woman. Pregnancy is a step for a couple to have their own children and form a family but it entails many complications that the woman may encounter and hinder to their way of having a family as she go along her pregnancy. These problems, the couple must be prepared and aware of, for them to be able to prevent it. The term "abortion" also called as miscarriage is commonly used to mean all forms of early pregnancy loss. It is at a stage where the embryo or fetus is incapable of surviving independently, generally defined in humans at prior to 20 weeks of gestation. Miscarriage is the most common complication of early pregnancy. In medical contexts, the word "abortion" refers to any process by which a pregnancy ends with the death and removal or expulsion of the fetus, regardless of whether it is spontaneous or intentionally induced. Many women who have had miscarriages, however, object to the term "abortion" in connection with their experience, as it is generally associated with induced abortions. Incomplete abortion is a type of abortion which is inevitable and some of the products of the pregnancy are still present in the uterus. The first abortion symptom is vaginal bleeding, which can range from spotting to being heavier than a period, then the woman will experience pelvic pain and lastly the cessation of pregnancy symptoms including breast tenderness, morning sickness and having to pass urine more frequently than usual. The most common cause of abortion during the first trimester is chromosomal abnormalities of the embryo/fetus, accounting for at least 50% of sampled early pregnancy losses. Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus. Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion. A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide. It is thought that between 10 and 20% of pregnancies miscarry. Most abortions occur in the early weeks of pregnancy. Ultrasound screening for fetal anomaly has shown the incidence of nonviable pregnancy at 10-13 weeks to be 2.8%. The number of abortions per year is approximately 42 million and number of abortions per day is approximately 115,000 worldwide. The number of abortions performed worldwide has decreased between 1995 and 2003 from 45.6 million to 41.6 million, which means a decrease in abortion rate from 35 to 29 per 1000 women. The greatest decrease has occurred in the developed world with a drop from 39 to 26 per 1000 women in comparison to the developing world, which had a decrease from 34 to 29 per 1000 women. Out of a total of about 42 million abortions 22 million occurred safely and 20 million unsafely. According to Prevention and Management of Abortion Complications (PMAC) Programme, substantial numbers of unsafe abortions are performed in the Philippines each year, most in a clandestine fashion and by unskilled practitioners. The most current data (Perez et al., 1997) indicate that, among the estimated 400,000 women annually who are thought to have an induced abortion, one-quarter are hospitalized for complications. During the period 1994-1998, abortion was the third leading cause of hospital discharge in Department of Health facilities in the Philippines. The Department of Health reports that 12% of all maternal deaths in 1994 were due to abortion. When a miscarriage occurs, the tissue passed from the vagina should be examined to determine if it was a normal placenta or a hydatidiform mole. It is also important to determine whether any pregnancy tissue remains in the uterus. If the pregnancy tissue does not naturally exit the body, the woman may be closely watched for up to 2 weeks. Surgery (D and C) or medication (such as misoprostol) may be needed to remove the remaining contents from the womb. After treatment, the woman usually resumes her normal menstrual cycle within a few weeks. Any further vaginal bleeding should be carefully monitored. It is often possible to become pregnant immediately. However, it is recommended that women wait one normal menstrual cycle before trying to become pregnant again.

OBJECTIVES

General objectives:
This case study aims to come up with in-depth understanding of incomplete abortion, for us to be able to come up with the best nursing care plan in the care and for all the aspects that contribute to and affect the condition of patients with the said abortion.

Specific objectives:
To organize patients data to establish good background information. To be able to know the pathophysiological basis of the incomplete abortion. To make and decide on different nursing care plans. To determine the signs and symptoms on the current health history and other manifestations of the patient.

To discuss the normal functioning of reproductive system which is involved on the case of our patient. To take on new or additional responsibilities of the mother who are pregnant. To know the laboratory and diagnostic tests the patient had undergone. To better understand the medication given to the patient. To explain to the patient the cause or reason of having incomplete abortion, laboratory examination, and drug administration. To formulate a discharge plan and prognosis for the continuous health care even at home and recommendation for future further researches.

BASELINE INFORMATION
A. Personal Data

__________________________________
NAME: AGE: SEX: CIVIL STATUS: NATIONALITY: ADDRESS: DATE OF BIRTH: OCCUPATION: RELIGION: Mrs. Troba 34 years old Female Married Filipino Pob. Pikit Cotabato July 26, 1976 Government Employee Roman Catholic

___________________________________________________________ DATE OF ADMISSION: TIME OF ADMISSION: January 31, 2011 12:00 nn

ATTENDING PHYSICIAN: Dr. Rosario Isabel Pader CHIEF COMPLAINT: DIET: Vaginal Spotting x 3days Diet as Tolerated

ADMITTING DIAGNOSIS: Incomplete Abortion OPERATION: OBSTETRICAL SCORE: Dilatation & Curettage G3P1 (1 0 2 1) G1: Abortion, 12th week of pregnancy G2: 2008, Cesarean section

HISTORY OF ILLNESS

Past Illness History

The patient, Mrs. Troba, a 34 year old woman is a government employee who works by processing papers for 5 days in a week. At 7am, she travels from Midsayap to Amas and at 4:30pm she returns to Midsayap. On her first pregnancy, she had an abortion on her third month and was subjected to Dilatation & Curettage at MDC Hospital by Dr. Loria, it was said that it was due to her stressing work that it happened. The patient also said that during that time, her uterus had descended and the doctor needed to return it back to place. After 3 months, she had been pregnant again. The fetus is prone to miscarriage due to weak placental attachment to the uterus, the reason why she had to take Duvadilan. And on July 3, 2008, she gave birth to a baby girl and was delivered through bikini type Cesarean Section at Midsayap Community Doctors Hospital by Dr. Loria.

Family History
Patients mother has hypertension and father has asthma.

Present Illness History

The patient, Mrs. Troba, was on her second month of pregnancy. On January 28, 2011, she started to experience vaginal spotting but was only admitted on January 31, 2011, the third day of her spotting, at Dr. Amado B. Diaz Provincial Foundation Hospital. She had undergone Dilatation and Curettage under the service of Dr. Pader. The abortion was again due to her stressing work. Her uterus had descended again and the doctor returned it back again to place.

PHYSICAL ASSESSMENT
I. GENERAL PHYSICAL SURVEY
A. Appearance and Behavior
1. Age, Sex, and Race 2. Body Build 3. Posture and Gait 4. Hygiene and Grooming -34 years old, Female, Asian -Appropriate for age, Height and Weight -Symmetrical posture and coordinate -Clean and neatly dress, nails are well-trimmed, fixed hair -Appropriate for age, place and climate -No foul smell noted on body and breath -No distress -Physically, mentally, and emotionally fit -Cooperative with treatment and conversation -Coherent, responds appropriately with discussed topics and expressed feelings appropriate to her condition. -Clear, soft and weak, spontaneous and consistent in her stories -Oriented and organized thoughts

5. Dress 6. Odor of the body and breath 7. Signs of distress 8. Apparent state of health 9. Attitude 10. Affect and mood

11. Speech

12. Thought Process

B. Vital Signs Temperature: 37 C Pulse Rate: Respiratory Rate: 21 breaths per minute Heart Rate: 72 beats per minute Blood Pressure: 100/70 mmHg

II. SKIN
Uniformed skin color, slightly dark brown with slightly dark extensors; no edema; has 2mm macule beside her lips; has moist skin & warm to touch; skin returns to normal after 1 second when doing turgor.

III. HEAD
Skull is oval, smooth skull contour, uniform consistency, no tenderness palpated, absence of nodule or mass with symmetrical facial features and movements. Hair is equally distributed.

IV. EYES
Eyebrows are evenly distributed, symmetrically aligned, equal movement, eyelashes are equally distributed, curved, slightly outward. Eyelids skin is intact, closes symmetrically, bilateral blinking, bulbar conjunctiva is clear with tiny vessel, and palpebral conjunctiva is pink with no discharge.

V. EARS
Ears are symmetrical and color same as face, firm and not tender, size is normal-6cm; ears align with the cornea of each eye. Pinna coils after it folded, hearing ability is normal. Presence of mass, lesions, lacerations, bruises, swelling was not seen upon inspection.

VI. MOUTH
Lips are pink, smooth and moist, no lumps; Pink gums, no swelling noted; Has dentures on the upper teeth; Tongue in central location, pink in color, no lesions, moves freely, no tenderness, no palpable nodules, uvula is position on midline of soft palate. Tonsils are not inflamed.

VII. NOSE
Nose is symmetrical and straight, without nasal discharge, uniform in color, not tender, no lesions, nasal septum is intact and located in the midline. External surface of the patients nose is smooth and oily.

VIII. NECK
Patient can move his neck freely without any difficulty. Neck can properly support the head. No lesions, masses, deformities noted upon inspection.

IX. CHEST/LUNGS
Has a respiratory rate of 21 bpm. There were no presence of scars, lesions and masses noted. Breath sounds were clear on both lungs.

X. ABDOMEN
Presence of stretch marks on both right and left lower quadrant,

XI. GENITO-URINARY
Patient verbalized no pain or difficulty upon defecation and urination.

XII. UPPER EXTREMITIES

Patients upper limbs, shoulders and arms were symmetrical. No deformities and swelling noted. No tenderness on the bones of the wrists and fingers. No structural deviations. Patient has IVF of D5LR 1L @ KVO infusing well @ right metacarpal vein.

XIII. LOWER EXTREMITIES

Patients legs are symmetrical. Has no edema noted. Presence of scar on left leg about 6 inches.

FOCUS ASSESSMENT
As of Feb. 1, 2011 SUBJECTIVE: I.Interview A. Maam kumusta nap o kayo? - Okay naman ako ngayon. B. Ilang araw nap o kaong dinugo bago po kayo pumunta sa ospital? - Umabot yun ng 3 days. C. Maam nung buntis po kayo? Ano po ang ginagawa nyo po? - Trabaho lang, liason ako ung nagproprocess ng papers.Baba-akyat ako sa building tapos punta naman sa ibang lugar. Araw-araw akong bumabyahe from Midsayap to Amas D. May mga rest day po ba kayo? - Sunday lang nasa bahay ako.Kasi ang trabaho ko Monday-Saturday 7am-4:30pm for 5 days in a week. E. Ganun po ba. May iniinom po ba kayong gamot sa mga araw ng pagbubuntis nyo? - Oo, mga MX3, Vitagen atsaka Gluta capsule once a day lang. Hindi ko kasi alam na bawal yun sa buntis. F. Pain Scale (0-10) - The day after the procedure: 9/10 - As of the moment: 0

OBJECTIVE.: ABDOMEN I. INSPECTION: a. Upon inspecting the clients skin, striae noted on both lower quadrants of the abdomen, incision noted about 120cm.No presence of palpable lesions noted, umbilicus is sunken and centrally located, and has normal contour and symmetrical abdomen. Has lighter skin than expose skin. b. Has an abdominalcircumference of 31 inches.

s II. AUSCULATION a. Upon auscultating the abdomen of the patient high-pitched bowel sounds with irregular gurgles present in all 4 quadrants. III. PERCUSSION a. Generalized tympany over bowels and tympanic on inhalation noted IV. PALPATION a. Has abdominal girth of 31 inches (79cm)

ANATOMY & PHYSIOLOGY

The Female Reproductive System

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be menopausal.

What parts make-up the female anatomy?

The female reproductive anatomy includes internal and external structures. The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).

Bartholins glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Cervix: the lower one-third of the uterus is the tubular "cervix," which extends downward into the upper portion of the vagina. The cervix surrounds the opening called the "cervical orifice," through which the uterus communicates with the vagina. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. The Wall of the Uterus (3 Layers) a. The outer serous coat called the perimetrium, consists of peritoneum supported by a thin layer of connective tissue; b. The middle muscular coat called the myometrium consists of 12 to 15 mm of smooth muscle. The myometrium increases greatlyduring pregnancy. The main branches of the blood vessels and nerves of the uterus are located in this layer; c. The inner mucous coat called endometrium is firmly adherent to the underlying myometrium. o The endometrium is partly sloughed off each month during menstruation. o It lines only the body of the uterus. The Ligaments of the Uterus a. Transverse Cervical Ligament (Cardinal Ligament) o This extends from the cervix and lateral parts of the vaginal fornix to the lateral walls of the pelvis. b. Uterosacral Ligaments o These pass superiorly and slightly posteriorly from the sides of the cervix to the middle of the sacrum. o They are deep to the peritoneum and superior to the levator ani muscles. o The uterosacral ligaments tend to hold the cervix in its normal relationship to the sacrum. c. Round Ligament of the Uterus o These ligaments are 10 to 12 cm long and extend for the lateral aspect of the uterus, passing anteriorly between the layers of the broad ligament. o They leave the abdominal cavity through the inguinal canal and insert into the labia majora. d. The Broad Ligament o This is a fold of peritoneum with mesothelium on its anterior and posterior surfaces. o It extends from the sides of the uterus to the lateral walls and floor of the pelvis. o The broad ligament holds the uterus in its normal position. o The 2 layers of the broad ligament are continuous with each other at a free edge. o This is directed anteriorly and superiorly to surround the uterine tube. o Laterally, the broad ligament is prolonged superiorly over the ovarian vessels as the suspensory ligament of the ovary. o The ovarian ligament lies posterosuperiorly and the round ligament of the uterus lies anteroinferiorly within the broad ligament. o The broad ligament contains extraperitoneal tissue (connective tissue and smooth muscle) called parametrium. o It gives attachment to the ovary through the mesovarium. o The mesosalpinx is a mesentery supporting the uterine tube. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.

Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall.

What happens during the menstrual cycle?

Females of reproductive age (anywhere from 11-16 years) experience cycles of hormonal activity that repeat at about one-month intervals. (Menstru means "monthly"; hence the term menstrual cycle.) With every cycle, a womans body prepares for a potential pregnancy, whether or not that is the womans intention. The termmenstruation refers to the periodic shedding of the uterine lining. The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase, the ovulatory phase (ovulation), and the luteal phase. There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing hormone, estrogen, and progesterone. Follicular phase This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the following events occur:

Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are released from the brain and travel in the blood to the ovaries. The hormones stimulate the growth of about 15-20 eggs in the ovaries each in its own "shell," called a follicle. These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogen. As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating hormone. This careful balance of hormones allows the body to limit the number of follicles that complete maturation, or growth. As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This dominant follicle suppresses all of the other follicles in the group. As a result, they stop growing and die. The dominant follicle continues to produce estrogen.

Ovulatory phase The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory phase is the midpoint of the menstrual cycle, with the next menstrual period starting about 2 weeks later. During this phase, the following events occur: The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain. B. This causes the dominant follicle to release its egg from the ovary. C. As the egg is released (a process called ovulation) it is captured by finger-like projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube. D. Also during this phase, there is an increase in the amount and thickness of mucus produced by the cervix (lower part of the uterus.) If a woman were to have intercourse during this time, the thick mucus captures the man's sperm, nourishes it, and helps it to move towards the egg for fertilization.
A.

Luteal phase The luteal phase begins right after ovulation and involves the following processes:

Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum.

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The corpus luteum secretes the hormones estrogen and progesterone. Progesterone prepares the uterus for a fertilized egg to implant. If intercourse has taken place and a man's sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now considered pregnant. If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual period begins.

How many eggs does a woman have?

During fetal life, there are about 6 million to 7 million eggs. From this time, no new eggs are produced. The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of birth control pills, and in the presence or absence of regular menstrual cycles.

Embryonic development
Chromosome characteristics determine the genetic sex of a child at conception. This is specifically based on the 23rd pair of chromosomes that is inherited. Since the mother's egg contains an X chromosome and the father's sperm contains either an X or Y chromosome, it is the male who determines the baby's sex. If the baby inherits the X chromosome from the father, the baby will be a female. In such case, testosterone is not made, but the Wolffian duct will degrade and the Mllerian duct will develop into female sex organs. In this case, the female clitoris is the remnants of the Wolffian duct. On the other hand, if the baby inherits the Y chromosome from the father, the baby will be a male. In such case, testosterone will be in charge of stimulating the Wolffian duct in order to develop male sex organs, and the Mllerian duct will degrade.

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PATHOPHYSIOLOGY

Precipitating Factors
Works 5 days in a week Work-related stressor

Predisposing Factors
Age: 34 years old Gender: Female Previous abortion

Abdominal contraction

Abdominal pain

Cervical dilation

Vaginal bleeding for 3 days

Passing of small pieces of pregnancy tissue

Dilatation and Curettage

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NARRATIVE
The modifiable factors of this case study includes the work of Mrs. RM straight for 5 days and her work related stressor while the nonmodifiable factors includes the age, gender and the previous abortion of Mrs. RM. Too much stress and overworked have caused Mrs RM to experience abdominal contraction leading to abdominal pain. With an incomplete abortion, some tissue remains behind inside the uterus. These typically present with continuing bleeding, sometimes very heavy, and sporadic passing of small pieces of pregnancy tissue. Left alone, many of these cases of incomplete abortion will eventually resolve spontaneously, but so long as there are non-viable pieces of tissue inside the uterus, the risks of bleeding and infection continue. Treatment consists of converting an incomplete abortion into a complete abortion. Usually, this is done with a D&C (dilatation and curettage). This minor operation can be performed under local anesthesia and takes just a few minutes. Alternatively, bed rest and oxytocin (10 units) of any crystalloid IV fluid helps the uterus contract and expel the remainder of the pregnancy tissue, converting the incomplete abortion to a complete abortion.

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DOCTORS ORDER (COURSE IN THE HOSPITAL)

January 31, 2011

12 nn
Admit under PHIC NPO (Preparation for D and C) VS q 30 minutes (To monitor closely any changes or unusualities in vital sign) Attach CBC, BT (CBC- To use as a basic information identify patients problem) (BT- because patient is prone to bleeding U/A (To detect substance or cellular material in the urine) IVF: D5LR + 10 u oxytocin @ 20 gtts/min Cefuroxime 1.5g IVTT start now

2:15 pm NPO (To allow for the affected organ to rest) VS q 30 minutes (To monitor closely any changes or unusualities in vital sign) IVF D5LR + 10 units of Oxytocin @ 30 gtts/min (D5LR-To support electrolytes in the body) TF D5NM 1L @ 30 gtts/min (D5LR-To support electrolytes in the body) DAT when fully awake Cefuroxime 750 mg q8 hr IVTT x2 doses Clindamycin 300mg 1cap q12hours MEM 1 tab q8hours MFA 500mg 1cap q8hours Iron 1cap q 12hours

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PROGNOSIS
CRITERIA
Sleep Pattern Nutritional Status Attitude towards treatment regimen

GOOD (3)

FAIR (2)

POOR (1)

JUSTIFICATION
According to Mrs. Troba shes able to sleep,only that sometimes her husband is sleeping on the bed. Mrs. Troba eats vegetable always.

.
Mrs. Troba participates with her treatment such as taking her medications, laboratory exams and assessment. Mrs. Trobas husband always stays with her and some relatives visits her .

Family support

Financial support

Patient has moderately enough financial capacity to provide financial support. Mrs. Troba doesnt manifest any signs of complications and shows good coping response, thus, indicates a good recovery.

Duration of Illness

Affect and Mood

Mrs. Troba was discouraged on her abortion but still participative, cooperative and ready to move on.

Respective Numerical Values: Standard Rating: Poor = 1.0-1.6 Fair = 1.7-2.3 Computation: Formula: Rate x frequency Poor: 1x0 = 0 Fair: 2x4 = 8 Good: 3x2 = 6 2.0 14/ 7 = Good = 2.4-3.0

GENERALPROGNOSIS:
Based on the criteria, our patient has a fair general prognosis with the result of 2.0. She has two prognosis on good, four on fair, and none on poor. Despite of termination of Mrs. Trobas conceptus, she shows hope and readiness to move on.

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DISCHARGE SUMMARY PLAN

Medication Instruct client to follow and take medication prescribed by the physician R: Treatment regimen is important to have faster recovery. Explain to the client the nature of the drugs so as the prescription. R: Knowledge about the medication will make the client aware of what she is taking and may increase her cooperation. Treatment: Cefuroxime 750mg IV every 8 hours ANST (-) x 2 doses Iron 1 cap every 12 hours Clindamycin 300mg 1cap every 12 hours MEM 1tab every 8 hours MFA 500mg 1cap every 8 hours x 4 doses Exercise Encourage to do early ambulation with resumption of normal activity as tolerated. R: Circulation of blood is promoted through regular movement thus help in healing process. Advise client to take adequate rest and sleep. R: To gain back the lost strength and be able to return to its normal state thus allow ample time for healing. Treatment: Explain to the client and family the need for treatment and that it is long process depending on the compliance of the client to the therapeutic regimen. R: To make the client and the family aware to the treatment does not end in the hospital and that their participation is a must in continuation of care. Encourage family member to provide patient emotional support. R: To lessen anxiety and stress felt by the patient. Hygiene Advise to do proper perineal care regularly. R: Appropriate self-care of the perineum reduce risk for bacterial invasion and promotes comfort and cleanliness. Increases sense of wellness. Outpatient Visit Instruct client to visit physician on the dates given for following check-up. R: Follow-up checkup is important for the physician to still monitor the progress of the therapeutic intervention availed by the client. Diet

Educate client about the importance of taking proper diet. R: Adequate information about the action will be gain clients cooperation. Instruct client to take variety of nutritious foods such as fruits and vegetables. R: Promote and maintain a healthy body. Encourage patient to eat protein and vitamin C rich foods R: To promote faster healing and tissue repair.

Sexual Activity Advise that sexual intercourse will be resume after two to four weeks. R: This prevents any complication to occur such as blood clotting, inflammation and scarring.

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RECOMMENDATION
To the Client and his Family: Clients compliance and his familys participation are greatly needed for the continuum of care for the faster healing and recovery of the client. The client must submit himself in taking the medications prescribed by the doctor. Adequate support from the family will boost the morale of the client and help him accept his condition so that he can willingly follow the interventions given. We also recommend that the patient, knowing that shes pregnant, must abstain from doing anything that may harm her child. To the Student Nurses: We have also evaluated ourselves upon doing this case study and we have decided to follow the recommendation of our clinical instructor. To provide tender loving care to the patient is our main goal and continuous monitoring and application of nursing interventions is compulsory for patients recovery. Careful collection of data should be observed to obtain more accurate information.

To the Notre Dame University- College of Health Sciences Our group is proud to belong to such a peace loving school. We recommend that the Notre Dame Universitys College of Health Sciences continue to maintain or improve their high quality of teaching not only on the nursing profession but also on developing the moral aspects of the student nurses through inculcating moral values and giving high emphasis on the FIRES. Other than that, continuous evaluation of our performances and hearing our voices also helps us to realize our mistakes and to face our difficulties, in that way we can maximize our learning.

To the Readers: The group recommends that you, the reader, must also visit other sources of information and not solely base everything on this case presentation alone. Use of variety of sources makes a more complete understanding of a subject matter. Incomplete abortion is just one of the maternal problems that may occur to a woman not taking care of her self as well as her baby or is just unaware of her health. Thats why we recommend every pregnant woman to have your pre-natal check-up and immediately consult your doctor and seek advice when starting to feel abnormalities in your body. They must also choose a good and healthy lifestyle for them to preserve their life and their baby.

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BIBLIOGRAPHY

BOOKS:
Brunner and Suddarths Textbook of Medical-Surgical Nursing (Eleventh Edition) Volume 2 2007 Lippincotts Nursing Drug Guide by Amy Karch Nurses Pocket Guide edition 10 and 11 Nursing Care Plan third edition by Gulanick, Klopp, Galanes, Gradishar, Puzas Handbook of Diseases Third edition Tabers Cyclopedic Medical Dictionary.

WEB LINKS:
http://www.the-human-body.net/female-reproductive-system.html http://www.cchs.net/health/health-info/docs/2400/2418.asp?index=9118 http://www.docstoc.com/docs/19118015 http://www.2womenshealth.com/incomplete-abortion.htm

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ULTRASOUND REPORT
Date: January 29, 2011

Referring physician: Dr. Carlotta Garcia Others Cervix: 4.5 x 5.0 x 3.8 cm Endometrium: 1.3 cm Uterus: 6.3 x 6.0 x 5.4 cm Right Ovary: 2.7 x 2.9 cm (+) Corpus Luteum Left Ovary: 3.7 x 1.6 cm

Transvaginal scan shows normal sited cervix with a gestational sac of approximately 4 weeks 1 day age of gestation by mean-sac-diameter noted at the upper endocervical canal suggestive of abortion in progress. The uterus is slightly enlarged, anteversed with no myometrial lesion. The endometrium is thickened at 1.3cm with heterogeneous echoes within considered retained products of conception. Both ovaries are normal in site and echotexture with corpus luteum on the right (-) free fluid I the cul de sac. Final Impression: Normal sized cervix with abortion in progress, slightly enlarged, anteverted uterus, thickened endometrium with RPOC. Normal ovaries, no adnexal pathology.

Grace S. Caoagdan, MD, FPOGS, FPSUOG (OB-GYNE Sonologist)

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NURSES NOTES
Patient: Mrs. Tobra DATE/TIME
1/31/11 12:00 nn
o o

FOCUS
Potential for Fluid Volume Deficit Infection D=Conscious and coherent, ambulatory, anxious, Naga spotting ko, as verbalized by the patient, G3P1 + mild to moderate vaginal bleeding, afebrile. A=Established rapport, VS taken and recorded, data gathered lab requested, results attached, Perineal pre done, IE done revealed open cervix. ICS dilatation with smelling odor, referred to Dr. Pader, seen by Dr.Pader, carried out, consent to care, consent for procedures + anesthesia occurred D5M 1L + 10 u oxytocin hooked as initial venoclysis & regulated @ 20gtts/min as ordered, monitored patient for further unusualities, for D&C, VS monitored, Cefuroxime 1.5g given IV after revealed a (-) skin test that as ordered pre-op care done, O2 inhalation given with nasal cannula @ 3L/min as ordered, Diazepam 10g given slow IVTT as ordered, Ketamine 0.3g given slow IVTT as ordered, patient able to sleep, D&C stunned, Nubain 10g given IVTT as ordered, retained products of conception, evacuated by D&C operation ended, MEM 1amp given IVTT as ordered, post op care done, VS monitored closely, post op orders made by AP carried out. R=Able to maintain normal fluid volume; no further signs of signs of infection; no further bleeding. >Received patient from DR D=Weakness noted, warm to touch, with complaints of discomfort. A=Placed comfortably on bed, VS checked & recorded, IVF checked & regulated, available meds given, needs attended comfort measures provided, encouraged to take enough rest & sleep, monitored for unusualities. R=Decreased comfort as verbalized. D=Discomfort noted A=Discomfort altered due meds given, comfort measures attended, carried, monitored unusualities. R=Able to rest.

1:00 pm 1:55 pm 2:02 pm 2:10 pm 2:15 pm

3:45 pm

Alteration in comfort

7:00 pm

Altered comfort

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