Transcript A New Life
1. DEMOGRAPHIC DATA Case number: 187*** Age: 24 Y/O Sex: Female Diagnosis:
G1 P0 11 weeks and 6 days AOG; Incomplete Abortion
2. PHYSICAL ASSESSMENT GENERAL Ambulatory Conscious and coherent Slightly weak (+) dizziness Active vaginal bleeding In pain; presented by grimaced face and guarding the abdominal area.
Vital signs:
B/P
= 90/60mmHg
PR=
90 bpm
T=
36. 5 C
RR=
22 bpm
INTEGUMENTARY
Pale in appearance
Cold and clammy skin
Nail beds slightly bluish in color
HEAD AND NECK
Facial symmetry
No lesions nor masses palpated
No deformity noted
No palpable lymph nodes noted
No nasal flaring, congestion or drainages noted
Pale conjunctiva noted
Dry and pale lips also noted
BODY AND UPPER/LOWER extremities
No physical deformities, contractures nor paralysis noted.
Good range of motion.
GENITOURINARY Profuse vaginal bleeding with soaked pads.
With minimal blood clots.
Cervix closed upon vaginal examination by SOD.
Able to void freely in adequate amount.
No painful sensation during urination as reported.
NEUROLOGIC
Slightly anxious.
Uncooperative in internal examination.
Oriented to time, place and person.
3. PATIENT HISTORY
PAST HISTORY
Consultation done at DAAH under Dra. Sofia dated 17/10/12, investigations done as follows:
LMP: not sure
SERUM B-HCG (QUANTITATIVE) RESULT 58,598 mIU/ ml
Transvaginal Ultrasound
Impression:
•Anembryonic pregnancy 6 weeks and 5 days AOG by MSD •No embryonic pole seen •No yolk sac •Irregularly shaped gestational sac •Normal ovaries with corpus luteum on the right
1 day prior to admission (03/11/12)
(+) vaginal spotting
Hypogastric pain
PRESENT HISTORY G1 P0 11 weeks and 6 days by UTZ
Complaint of:
Profuse vaginal bleeding Hypogastric pain Dizziness Quick scan with UTZ revealed gestational sac at the lower uterine segment.
4. TOPIC PRESENTATION ABORTION Is the spontaneous or induced loss of an early pregnancy.
Any interruption of pregnancy
before a fetus is viable
or that is
less than 20 weeks age of gestation (AOG)
, or that which
weighs less than 500g.
The term
miscarriage
is used often in the lay language and refers to
spontaneous abortion.
TYPES OF SPONTANEOUS ABORTION 1.Threatened Abortion Consists of any vaginal bleeding during early pregnancy without cervical dilatation or change in cervical consistency.
Usually, no significant pain exists, although mild cramps may occur. More severe cramps may lead to an inevitable abortion.
Very common in the first trimester; about 25 30% of all pregnancies have some bleeding during the pregnancy.
Less than one half proceed to a complete abortion.
On examination: blood or brownish discharge may be present in the vagina. The cervix is not tender, and the cervical os is closed. No fetal tissue or membranes have passed.
The ultrasound shows a continuing intrauterine pregnancy.
2. Inevitable Abortion An early pregnancy with vaginal bleeding and dilatation of the cervix.
Typically, the vaginal bleeding is worse than with a threatened abortion, and more cramping is present.
No tissue has passed yet.
On ultrasound, the products of conception are located in the lower uterine segment or the cervical canal.
3. Incomplete Abortion A pregnancy that is associated with vaginal bleeding, dilatation of the cervical canal, and passage of products of conception.
Usually, the cramps are intense, and the vaginal bleeding is heavy.
With passage of tissue within the vagina.
Ultrasound may show that some of the products of conception are still present in the uterus.
4. Complete Abortion A history of vaginal bleeding, abdominal pain, and passage of tissue exists.
After the tissue passes, the patient notes that the pain subsides and the vaginal bleeding significantly diminishes.
The examination reveals some blood in the vaginal vault; a closed cervical os; and no tenderness of the cervix, uterus, adnexa, or abdomen. The ultrasound demonstrates an empty uterus.
Anembryonic gestation (also known as a blighted ovum ) is a pregnancy in which the very early pregnancy appears normal on an ultrasound scan, but as the pregnancy progresses a visible embryo never develops. In a normal pregnancy, an embryo would be visible on an ultrasound by six weeks after the woman's last menstrual period.
Anembryonic gestation is one of the causes of miscarriage of a pregnancy.
5. ANATOMY AND PHYSIOLOGY
MATERNAL/ PARENTAL FACTORS *AGE *POOR NUTRITIONAL STATUS *POOR IMMUNE SYSTEM *W/ UNDERLYING DISEASE OR CONDITION AUTOIMMUNE (APAS) INFECTION HIGH RISK PREGNANCY
EARLY PREGNANCY
RISK FACTORS LIFESTYLE ENVIRONMENTAL FACTORS * EXPOSURE TO RADIATION *TERATOGENS CHROMOSOMAL ABNORMALITIES * USE OF ALCOHOL *PROHIBITED DRUGS *SMOKING MISCARRIAGE SIGNS & SYMPTOMS: *LOWER BACK PAIN *VAGINAL BLEEDING *ABDOMINAL CRAMPS
7. SIGNS AND SYMPTOMS
UTERINE CRAMPING LOWER BACK PAIN
VAGINAL BLEEDING
8. NURSING INTERVENTIONS
Monitor vital signs.
Monitor vaginal bleeding through pad count.
Promote bed rest.
Provide fluid resuscitation.
If considerable amount of blood loss has occurred, aggressive hydration, iron therapy or transfusions may be indicated.
Prevent infection.
Provide emotional support.
9. TREATMENT MEDICAL COMPLETE ABORTION usually needs no further treatment, medically or surgically.
THREATENED ABORTION use of progestogen.
MISOPROSTOL is an effective medical therapy. It increase uterine smooth muscle contractions and soften the cervix to allow passage of products of conception from missed abortion, inevitable abortion, or incomplete abortion. Risks for medical therapy include bleeding, infection, possible incomplete abortion, and possible failure of the medication to work.
SURGICAL Inevitable and incomplete abortions are typically treated surgically with D&C.
Methylergonovine maleate (Methergine) (0.2 mg IM)- given after D&C to contract the uterus. This will also decrease the likelihood that clots will be retained in the uterus. Risks of a D&C include bleeding, infection, possible perforation of the uterus, and possible Asherman syndrome after the procedure.
10. COMPLICATIONS
Hemorrhage High fever due to infection.
Maternal mortality.
Accumulation of clot in the uterine cavity without expulsion due to uterine atony.
11. PRIORITIZATION OF NURSING PROBLEMS A. Fluid volume deficit related to profuse vaginal bleeding secondary to incomplete abortion.
B. Acute pain related to uterine cramping secondary to expulsion of some products of conception.
C. Anticipatory grieving related to loss of pregnancy.
D. Risk for infection related to dilated cervix and open uterine vessels.
12. NURSING CARE PLAN
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION CUES/ EVIDENCE NURSING DIAGNOSIS GOALS AND DESIRED OUTCOME NURSING INTERVENTIONs
SUBJECTIVE: “I felt dizzy and I consumed 5-6 pads today and it’s fully soaked.” OBJECTIVE: *Profuse vaginal bleeding with soaked pad and with minimal blood clots.
*Skin pallor noted.
Fluid volume deficit related to profuse vaginal bleeding secondary to incomplete abortion. After 6-8 hours of nursing intervention the patient will be able to demonstrate improve fluid balance as evidence by minimal vaginal bleeding, good skin turgor, diminish pallor. INDEPENDENT:
Assessed the stability of the patient through monitoring vital signs.
Inserted gauge 18 of cannula at the left metacarpal vein.
Instructed the patient to do pad counts.
*Bluish nail beds.
*Cold and clammy skin.
*Dry oral mucous membranes.
*V/S as follows: BP- 90/60mmHg T- 36. 5 C PR- 90, bpm RR- 22 bpm
Maintained bed rest and assisted in ADL. Schedule activities to undisturbed rest periods.
DEPENDENT:
Administered fluids as ordered.
Hgb, Hct, RBC monitored.
RATIONALE FOR INTERVENTION EVALUATION
Provide baseline data regarding patient’s condition. After 6-8 hours of nursing interventions the goals were met as evidenced by:
Scanty vaginal bleeding.
IV line is needed for the hydration of the patient to replace the blood loss.
Good skin turgor and color.
Fast capillary refill <2 sec To monitor the bleeding and able to assess the blood loss.
Activity increases intra-abdominal pressure that may cause further bleeding and also to promote fast recovery.
V/S stable: BP- 110/70mmHg T- 36. 9 C PR- 80 bpm RR- 20 bpm To replace fluid loss and aids in fast recovery.
Through laboratory results we can see the effectiveness of the theraphy.
13. NURSING HEALTH TEACHING Explained to the patient the need to wait for at least 3-6 months before attempting another pregnancy.
Reinforced or discussed with the couple the methods of contraception to be used.
Instructed the couple to observe for signs of infection such as fever, pelvic pain, and change in character or amount of vaginal discharge and advise to report them immediately.
Explained to the patient the importance of follow up check-up to monitor the presence of bleeding and contraction of the uterus after D&C.
Emphasized the importance of take home medications prescribed by the physician.
14. CONCLUSION
First Trimester/early pregnancy is the most crucial stage of pregnancy in which the mother must have a closed watch or gives much attention to.
Therefore I conclude that Antenatal check-up during pregnancy is important to monitor the status of the fetus and the mother. Any presence of unusual signs and symptoms must be reported immediately.
If in any case pregnancy loss is inevitable immediate action is needed, any delay may result to infection or further complications to mother. As a nurse, we need to encourage pregnant women to have their routine check-ups to prevent any complications during or throughout their pregnancy. Importance of vitamins and other pregnancy supplements should be emphasized. Medical team stands an important role in human well-being. The role of a healthcare provider must not just within the hospital but also in the home wherein provided health teachings must be implemented.
15. BIBLIOGRAPHY
1. Philippine Obstetrical and Gynecological Society (Foundation), Inc.
Clinical Practice Guidelines on Abortion (November 2010) Pages 1-15 2. Lippincott Manual of Nursing Practice 9 th Edition; pages 1316, 1317, 1318 3. Maternal and Child Health Nursing by Adele Pillitteri 5 th Edition; pages 400 409 4. http://www.scribd.com/doc/15991947/Nursingcribcom-Spontaneous Abortion 5. http://nursingcrib.com/nursing-notes-reviewer/maternal-child health/spontaneous-abortion/ 6.http://nursingcrib.com/nursing-notes-reviewer/fundamentals-of nursing/nursing-diagnosis-for-female-reproductive-diseasesdisorders/
7. http://nursingcrib.com/nursing-care-plan/nursing-care plan-dilatation-and-curettage-d-c/ 8. http://emedicine.medscape.com/article/795085-overview 9. http://emedicine.medscape.com/article/795085-clinical 10.http://www.rightdiagnosis.com/m/miscarriage/complic.htm
11. http://arispestanyo.hubpages.com/hub/nursing-care-plan abortion 12. http://www.healthplus24.com/womens health/miscarriage.aspx