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

I. Introduction ..

II. Objectives

III. Baseline Information .

IV. History of Illness

V. Physical Assessment

VI. Focus Assessment ..

VII. Anatomy & Physiology

VIII. Pathophysiology .. ..

12

IX. Doctors Order (Course in the hospital)

14

X. Laboratory Study..

15

XI. Drug Study .

17

XII. Nursing Care Plan . 25

XIII. Prognosis ....

35

XIV. Discharge Summary Plan ....

36

XV. Recommendation

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
A. Personal Data

__________________________________
NAME:

Mrs. Troba

AGE:

34 years old

SEX:

Female

CIVIL STATUS:

Married

NATIONALITY:

Filipino

ADDRESS:

Pob. Pikit Cotabato

DATE OF BIRTH:

July 26, 1976

OCCUPATION:

Government Employee

RELIGION:

Roman Catholic

___________________________________________________________
DATE OF ADMISSION:

January 31, 2011

TIME OF ADMISSION:

12:00 nn

ATTENDING PHYSICIAN: Dr. Rosario Isabel Pader

CHIEF COMPLAINT:

Vaginal Spotting x 3days

DIET:

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
I. GENERAL PHYSICAL SURVEY
A. Appearance and Behavior
1. Age, Sex, and Race

-34 years old, Female, Asian

2. Body Build

-Appropriate for age, Height and Weight

3. Posture and Gait

-Symmetrical posture and coordinate

4. Hygiene and Grooming

-Clean and neatly dress, nails are well-trimmed,

fixed hair

5. Dress

-Appropriate for age, place and climate

6. Odor of the body and breath

-No foul smell noted on body and breath

7. Signs of distress

-No distress

8. Apparent state of health

-Physically, mentally, and emotionally fit

9. Attitude

-Cooperative with treatment and conversation

10. Affect and mood

-Coherent, responds appropriately with discussed

topics and expressed feelings appropriate to her
condition.

11. Speech

-Clear, soft and weak, spontaneous and consistent in

her stories

12. Thought Process

B. Vital Signs
Temperature: 37 C
Pulse Rate:

-Oriented and organized thoughts

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.

5
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
o
o
o
o
o

This is directed anteriorly and superiorly to surround the uterine tube.

Laterally, the broad ligament is prolonged superiorly over the ovarian vessels as
the suspensory ligament of the ovary.
The ovarian ligament lies posterosuperiorly and the round ligament of the
uterus lies anteroinferiorly within the broad ligament.
The broad ligament contains extraperitoneal tissue (connective tissue and smooth
muscle) called parametrium.
It gives attachment to the ovary through the mesovarium.
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.

9
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:

A. 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.
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.

10

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.

11

PATHOPHYSIOLOGY

Precipitating Factors

Predisposing Factors

Works 5 days in a week

Work-related stressor

Abdominal contraction

Abdominal pain

Cervical dilation

Vaginal bleeding
for 3 days

Age: 34 years old

Gender: Female
Previous abortion

Passing of small pieces

of pregnancy tissue

Dilatation and Curettage

12

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.

13

DOCTORS ORDER
(COURSE IN THE

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

14

PROGNOSI
CRITERIA

GOOD
(3)

FAIR
(2)

Sleep Pattern

Nutritional Status

Attitude towards
treatment
regimen

Family support

Financial support

Duration of
Illness

Affect and Mood

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 .
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.
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
14/ 7 =
2.0

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.

35

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.

36

RECOMMENDATIO
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.

37

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

38

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)

33

NURSES NOTES
Patient: Mrs. Tobra
DATE/TIM
E
1/31/11
12:00 nn

FOCUS
o Potential for Fluid
Volume Deficit
o Infection

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

3:45 pm

o Alteration in
comfort

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

7:00 pm
o Altered comfort

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.

34