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- 1. CARE STUDY ON INCOMPLETE ABORTION GENERAL HISTORY Name of Patient: Mrs. Narayani w/o Ghanshyam Age/sex: 27years/female Marital status: Married Hospital registration no.: 2789 Address: Milk man colony, Jodhpur. Religion: Hindu Education: B.A. Graduate Admission date: 23.06.21 Occupation of husband and patient: Patient’s husband is an Engineer and patient is a house wife. Monthly family income: Rs. 30,000 per month Chief complaints with duration: Patient was admitted in the hospital with chief complaints of mild pain in the abdomen and expulsion of fleshy mass per vaginum. History of past medical illness: Patient has no history of past medical illness. History of present medical illness: Patient is admitted in Gynecology ward with chief complaints of vaginal bleeding . History of surgical illness: Patient has no history of any surgery. FAMILY HISTORY: Type of family: Nuclear
- 2. Name of family member Relation with patient Age/sex Occupation education Health status Mrs . Savitri Mother in law 54yrs/female House wife 10th standard Healthy Mr.Rajiv Husband 30yrs/male Engineer B.tech Healthy Mrs. Preeti Self 27yrs/female House wife B.A Healthy Family history of illness: All members in patients family are healthy and do not have any history of illness. Housing: Pucca house Toilet: Closed drainage system Electricity: Present Drinking water: Tap water GRAVIDA PARA ABORTION METHOD OF DELIVERY PUERPERIUM G1 P0 Incomplete abortion with expulsion of mass per vaginum Not delivered Nil PRESENT OBSTETRIC HISTORY: Weight: 52kg Height: 5feet 2 inches Period of gestation: 8weeks Height of fundus: 8cm Number of visits: 2 visits Immunization: Nil No. of living children: Nil Menstrual history: My patients menarche started at the age of 13.she had a normal history of menstruation, with a cycle of 28days , lasting for 4-5days. LMP: 22/10/20 EDD: 29/07/21
- 3. PERSONAL HISTORY: Personal hygiene: Good Oral hygiene: 2 times per day Bath per day:1 time per day Diet: Non-Vegetarian No. of meals per day: 3 times Food preference: Rice and chapati Fluid: 8-10 glasses per day Tea and coffee: Tea-2 times daily Sleepand rest: 8 hours sleep/day Elimination: 1 time/day Urine frequency: Regular During day: 3-4 times During night: 1 time Other habits: No SEXUAL AND MARITAL HISTORY: Age of marriage: 25 years Relationship: Satisfactory Contraceptive: condom OBSERVATION AND EXAMINATION 1. General appearance: Normal Sensorium: Conscious Build: Average Nutrition: Good Physical examination: Weight: 52 kg Height: 5 feet 2 inches Vitals: Temperature:98.7*F pulse: 82/min respiration:26/min BP: 110/70mm Hg
- 4. Head: Normal Hair: Black, well nourished Eyes: Brown, reacts to light Skin color: Pale Teeth/gums: Normal Glands: Not Enlarged Chest: Normal Breast examination: slight tenderness was present. Abdomen: Normal no previous scar marks. Oedema of legs: No Toes and nails: Normal vaginal examination: The following were the findings of vaginal examination: Excessive bleeding was present There was partial expulsion of the products of conception per vaginum Mild uterine contraction was present Operation room notes: Dilatation and curettage: The cervix was dilated and endometrium was scraped away Along with the products of conception using an ovum forceps, under general anesthesia. The entire inner uterine cavity was Scraped with an in and out motion .All products of gestation was removed (a grating sound/feeling was noted).
- 5. SIGN AND SYMPTOMS LISTED IN BOOK PRESENT IN PATIENT History of partial expulsion of fleshy mass per vaginum Present Heavy bleeding Present Dilated cervix Present The size of the uterus is smaller products of Conception Present Cramping/lower abdominal pain Present Incomplete expelled mass Present Patulous cervical os admitting tip of the finger Present INVESTIGATIONS LISTED IN BOOK PRESENT IN PATIENT REMARK Hemoglobin 11.5gm% Normal (11.5-16.5gm%), W.B.C 11,500/cu mm Elevated value than normal(4500-11000/cu mm), eliciting the signs of infection Neutrophils 72% Normal(40-75%) Lymphocyte 24% Normal (20-45%) Eosinophils 01% Normal(1-6%) Monocytes 03% Normal(2-10%) Basophils 00% Normal(0-1%)
- 6. DISEASE ASPECT INTRODUCTION: Maternal mortality occurs due to various pregnancy-related complications, childbirth or later during the puerperium due to hemorrhage, hypertensive disorders of pregnancy, abortion, obstructed labour or puerperal sepsis. It is now well-recognized that antenatal care alone, no matter how good the quality and the coverage, cannot alleviate the major burden of suffering during and around childbirth. For reducing maternal mortality and morbidity, skilled attendance at every birth and provision of emergency obstetric care are essential. Countries that have been successful in bringing down the maternal mortality ratio are those that have ensured that emergency obstetric care is accessible to all women. DEFINITION: According to D.C Dutta: Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500 gm or less when is not capable of independent survival. INCOMPLETE ABORTION: Incomplete abortion: Uterus retains part or all of the placenta. Before the 10th week of gestation, the fetus and placenta usually are expelled together; after the 10th week, separately. Because part of the placenta may adhere to the uterine wall, bleeding continues. Hemorrhage is possible because the uterus doesn't contract and seal the large vessels that fed the placenta. ETIOLOGY: LISTED IN BOOK PRESENT IN PATIENT Genetic factors Absent Endocrine disorders Absent Maternal medical illness Absent Rh incompatibility Absent Bacterial or viral infections Present Cigerratte smoking Absent Alcohol consumption Absent
- 7. PATHOPHYSIOLOGY: In this variety of miscarriage, the cervix opens and there part of the product of conception are expelled. Usually the fetus is passed, and the placenta and membranes are retained. The patient is often more than 12 weeks pregnant, so the placenta is firmly embedded and the slender cord breaks. The bleeding continues and may become profuse, because of the presence of retained products, does not allow for efficient contraction and retraction of the uterus and therefore control of the bleeding. There is pain, as well as backache, the cervical OS is usually open and the uterus remains bulky. MANAGEMENT OF INCOMPLETEABORTION: o If the bleeding is light to moderate and the pregnancy is less than 12 weeks, use your fingers or a pair of ring (or sponge) forceps to remove the products of conception protruding through the dilated cervix. o If the bleeding is heavy and the pregnancy is less than 12 weeks, evacuate the uterus. Manual vacuum aspiration (MVA) is the preferred method of evacuation "Procedure for manual vacuum aspiration for incomplete abortion". Do not carry out evacuation by sharp curettage. If evacuation is not immediately possible, give Tab. Misoprostol 400 mcg orally (repeated once after 4 hours, if necessary) o If the pregnancy is more than 12 weeks:
- 8. Start an Oxytocin drip, i.e. 20 U of Oxytocin in 500 ml of R/L @ 40 drops/minute until the products of conception are expelled. If necessary, give Tab. Misoprostol 200 mcg vaginally every 4 hours until the products of conception are expelled; do not administer more than a total of 800 mcg. Evacuate any remaining products of conception from the uterus. After 12 weeks of pregnancy the foetus is usually expelled in toto but the placenta may be retained, which has to be expelled. If the placenta does not deliver normally, and there is no bleeding, start an Oxytocin drip (as in the case of a delayed third stage of labour with retained placenta). You can keep the patient at the PHC for about 2 hours after starting the Oxytocin drip, waiting for the placenta to be expelled. However, if bleeding occurs, refer immediately to an FRU. If the placenta is still retained, and the woman is bleeding, she needs immediate referral to the FRU. Establish an IV line, start the Oxytocin drip, and refer. In rare cases, even after expulsion of the placenta, the woman may bleed. Such patients too need to be referred to an FRU. Ensure post-abortion follow up of the woman after treatment
- 9. MEDICATION CHART S N Name ofdrug Dose/time Route Action Side effect Nursing responsibility 1 Ceftriaxone 1gm/BD IV Interferes with protein synthesis in bacterial cell wall by binding ribosomal subunits , causing miscreation of genetic code Nausea, vomiting fatigue, dizziness, oliguria, hematurea Check infusion site for redness, swelling, abscess 2 . Diclofenac 75mg/BD IM Inhibit prostaglandin synthesis by decreasing the enzyme needed for biosynthesis Nausea, vomiting fatigue, dizziness Avoid aspirin, alcohol beverages, report if bleeding is present. 3 Methergine 200-400 mcg/12hrly IM Stimulates uterine vascular smooth muscle, causing contractions, decreases bleeding Headache, hypotension, or hypertension, sweating, nausea, vomiting, rash Assess vitals, administer only on 4th stage of labour. 4 Gentamycin 80mg/BD IV/I M Interferes with bacterial protein synthesis Rash, urticaria, scaling, redness Assess allergic reaction, signs of nephrotoxicity, ototoxicity 5 Dextrose5% 5% in 500ml/mai ntenance IV Needed for adequate utilization of amino acids, decreases protein Confusion, loss of consciousness, glycosuria Assess electrolytes, blood glucose. Monitor temperature 4hrly. COMPLICATIONS: Injuries : Uterine, vaginal, urinary bladder or bowel Retention of urine or dysuria Distended abdomen
- 10. Rigid (tense and hard)abdomen Vaginal hematoma Infection/sepsis NURSING MANAGEMENT: it includes the following guidelines to be carried out: Guidelines for complete clinical assessment of a woman with spontaneous abortion Complete clinical assessment History (Ask about and record the • Period of amenorrhea (ask her the date of her LMP) information) • Bleeding (duration and amount) • Abdominal cramping (duration and severity) • Foul-smelling vaginal discharge • Abdominal or shoulder pain • Allergy to drugs • H/o passage of the products of conception/foetus/blood clot • H/o inserting something into the vagina (suggestive of an illegal abortion) Routine physical examination • Check the vital signs (temperature, pulse, respiratory rate, blood pressure) • Examine the general condition of the woman (malnourished) • Look for pallor • Examine the respiratory system, cardiac system and extremities Abdominal examination • Auscultate for bowel sounds (absent in peritonitis due to septic abortion) • Check whether the abdomen is distended (hydatidiform mole, ectopic pregnancy) • Assess the presence, location and severity of pain • Palpate for abdominal rigidity (tense and hard) and guarding (peritonitis, ectopic pregnancy) • Palpate for rebound tenderness
- 11. • Assess the abdominal mass (molar/ectopic pregnancy) Pelvic examination • External pelvic and vaginal examination: * Look for lacerations outside the vagina, or over the external genitalia * Assess the amount of bleeding (light/heavy) * Look for protruding products of conception lying outside the vaginal canal • P/V examination Look for: * Any visible product of conception protruding from the cervical os or visible in the vaginal canal * Foul-smelling vaginal/cervical discharge * Cervical lacerations (indicative of instrumentation; may be suggestive of illegal abortion) * Foreign bodies in the vagina • P/V examination * Assess the amount of bleeding (light/heavy) * Check whether the cervical os is open or closed (to determine the stage of abortion) • Bimanual examination * Estimate the size of the uterus * Palpate for any pelvic masses * Examine for pelvic pain (note severity, location, and what causes the pain: is it present at rest; does it occur/increase with touch and pressure; does it occur/increase on moving of the cervix).
- 12. Investigations : The woman's blood group, especially her Rh status, should be a part of routine investigations during the clinical assessment in cases of abortion. APPLICATION OF THEORY: My patient is a case of incomplete abortion. She requires intense psychological support along with physiological care in order to avoid abortion associated complications. The theory well suited for this case is Orlando’s theory of Nursing Process ORLANDO’S THEORY OF NURSING PROCESS: Orlando's theory was developed in the late 1950s from observations she recorded between a nurse and patient. MAJOR DIMENSIONS OF THE THEORY • Discuss the experience of a patient whose need has not been met. • Nursing role is to discover and meet the patient’s immediate need for help. o Patient’s behavior may not represent the true need. o The nurse validates his/her understanding of the need with the patient. • Nursing actions directly or indirectly provide for the patient’s immediate need. • An outcome is a change in the behavior of the patient indicating either a relief from distress or an unmet need. o Observable verbally and nonverbally. • Function of professional nursing - organizing principle • Presenting behavior - problematic situation • Immediate reaction - internal response • Nursing process discipline – investigation • Improvement – resolution DOMAIN CONCEPTS 1. Nursing – is responsive to individuals who suffer or anticipate a sense of helplessness 2. Process of care in an immediate experience….. for avoiding, relieving, diminishing or curing the individuals sense of helplessness. Finding out meeting the patients immediate need for help 3. Goal of nursing – increased sense of well being, increase in ability, adequacy in better care of self and improvement in patients behavior
- 13. 4. Health – sense of adequacy or well being . Fulfilled needs. Sense of comfort 5. Environment – not defined directly but implicitly in the immediate context for a patient 6. Human being – developmental beings with needs, individuals have their own subjective perceptions and feelings that may not be observable directly 7. Nursing client – patients who are under medical care and who cannot deal with their needs or who cannot carry out medical treatment alone 8. Nursing problem – distress due to unmet needs due to physical limitations, adverse reactions to the setting or experiences which prevent the patient from communicating his needs 9. Nursing process – the interaction of 1)the behavior of the patient, 2) the reaction of the nurse and 3)the nursing actions which are assigned for the patients benefit 10. Nurse – patient relations – central in theory and not differentiated from nursing therapeutics or nursing process 11. Nursing therapeutics – Direct function : initiates a process of helping the patient express the specific meaning of his behavior in order to ascertain his distress and helps the patient explore the distress in order to ascertain the help he requires so that his distress may be relieved. 12. Indirect function – calling for help of others , whatever help the patient may require for his need to be met 13. Nursing therapeutics - Disciplined and professional activities – automatic activities plus matching of verbal and nonverbal responses, validation of perceptions, matching of thoughts and feelings with action 14. Automatic activities – perception by five senses, automatic thoughts, automatic feeling, action
- 14. NURSING CARE PLAN S.No Assessme nt Diagnos is Goal Planning Implementat ion rationale Evaluati on 1 Subjectiv e data:- Patient complaint s of pain in surgical site. Objective data:- On observati on, the patient was restless Acute pain related to mechani sm of abortion To reduce the pain .Plan to assess the site of pain plan to provide drugs prescribed by the doctor .Plan to provide hot compressi ons in lower abdomen .abdominal region was assessed. Slight tenderness was present in lower abdomen. .injection Diclofenac 75mg was administered intramuscular ly, as adviced by the doctor. . hot compression was provided in the lower abdominal region. . Assessmen t provide a baseline informatio n regarding patient .it help to reduce the pain .helps to reduce the pain Patient’s pain was reduced 2 Subjective data: Patient complains of excessive thirst Objective data: On observing the urine output, it was very scanty Fluid volume deficit related to excessiv e blood loss maintain fluid balance . plan to assess the vitals. .plan to start intravenous infusion with .vitals were checked:- temperature- 97.6*F, pulse- 77/min,respirat ion- 22/min,Blood pressure- 100/70mmHg. . intravenous infusion of ringer lactate and oral administration . .provide a baseline data for monitoring change and selecting effective interventio ns .helps in maintainin Fluid balance was maintain ed and bleeding was reduced.
- 15. prescribed drugs for fluid maintenanc e and control bleeding. of liquids were given to the patient. g fluid balance 3 Subjective data: Patient complains of nausea and anorexia. Objective data: On observatio n, it was found that the patient was not taking proper diet. Imbalanc ed nutrition less than body requirem ent related to anorexia, nausea and vomiting Maintain adequate nutrition balance . Plan to assess the dietary pattern of the patient. . plan to provide a balanced diet to the patient. . plan to provide small and frequent meals . Assessed the dietary pattern of the patient. . A balanced diet rich in iron,folic acid and vitamin c was given to the patient. .small frequent meals were provided to the patient. .provide a baseline data for monitoring change and selecting effective intervention s. .promotes early recovery from blood loss. .prevents nausea and promotes effective absorption of meals The patients nutritiona l status is improved . 4 To maintain the body temperat ure . plan to assess the vitals . plan to provide measures to reduce the temperature . . vitals were taken. The temperature was 102*F. .cold sponging was given to the patient. Tab. Paracetamol 500 mg was given to the patient, as prescribed by the physician. . helps to identify minute variation in body mechanics . helps to reduce the body temperature Patients body temperatu re was brought to normal i.e 98.8*F.
- 16. Subj ective data: My patient complaint s of hot flushes all over body. Objective data: On observing the vitals, the patient had elevate body temperatu re up to 102*F. Hyperther mia related to decreased body resistance to infection To reduce the anxiety . plan to assess the knowledge of the patient . plan to provide psychologi cal support to the patient . assessed the knowledge level of the patient . All doubts of the patient were cleared with proper explanation before and after each procedure .It helps to find out the understand ing level of the patient .helps to reduce the anxiety Anxiety of the patient was reduced. Subjectiv e data: Patient asks many questions and worries regarding treatment regimen Objective data: On observati on, it was found that the patient was very anxious Anxiety related to the recovery and various treatment regimens
- 17. HEALTH EDUCATION: • DIET: patient was advised to take nutritious diet including high protein, iron and folic acid rich diet. She was encouraged to take plenty of water. • REST: patient was advised to take proper rest and reduce heavy workload. She was encouraged not to take stress and practice diversional therapies like music, art etc. • PERSONAL HYGIENE: patient was asked to give specific importance to personal hygiene, especially menstrual hygiene. She was also advised to observe the pattern of bleeding, its color and duration, and to report any variation to the doctor immediately. • MEDICATIONS: the patient was encouraged to take medicines regularly on time. • FOLLOW UP CARE: The patient was advised to come to the hospital for follow up check up. She was instructed to meet the physician if any complications occur.
- 18. CONCLUSION: Patient was admitted in the ELR ward as a case of incomplete abortion. she was been treated under Dr. Santosh. At the time of admission, she was having cramping abdominal pain and vaginal bleeding. After the procedure – Dilatation and curettage, and administration of proper medication, the condition of patient got stable.
- 19. BIBILIOGRAPHY: "Fear a factor in surgical births". The Sydney Morning Herald. 2007-10-07. Kiwi Caesarean rate continues to rise - New Zealand news on Stuff.co.nz “ Finger, C. (2003). "Caesarean section rates skyrocket in Brazil. Many women are opting for Caesareans in the belief that it is a practical solution.". Lancet 362 (9384): 628. doi:10.1016/S0140-6736(03)14204-3. PMID 12947949. "C-section rates around globe at ‘epidemic’ levels". AP / msnbc.com. Jan. 12, 2010. http://www.msnbc.msn.com/id/34826186/. Retrieved February 21, 2010. “As there was a cultural taboo against burying an undelivered woman in Roman and German societies, according to Lex Caesarea..." U Högberg, E Iregren, CH Siven, "Maternal deaths in medieval sweden: an osteological and life table analysis", Journal of Biosocial Science, 1987, 19: 495-503 Cambridge University Press “University of Virginia Health System, Claude Moore Sciences Health Library, Ancient Gynecology: Caesarean Section Cesarean Section - A Brief History: Part 1". US National Institutes of Health. 2009-06- 25. http://www.nlm.nih.gov/exhibition/cesarean/part1.html. Retrieved 2010-11-27.