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Introduction
Abortion is the termination of pregnancy before 20 weeks based upon the date of the first day of last normal menses. It is also the delivery of a fetus-neonate that weighs less than 500 g. The fetus and placenta are likely to be expelled together before 10 weeks, but separately thereafter. When the placenta, in whole or in part, is retained in the uterus, bleeding ensues sooner or later and that is called Incomplete Abortion.

Incomplete abortions involve a moderate to heavy amount of bleeding with an open cervical os, bits and pieces of tissue may be present with the profuse bleeding. Prompt termination of the pregnancy, usually by curettage, is the suggested treatment.

Dilatation and curettage (D&C) refers to the dilatation (widening/opening) of the cervix and the surgical removal of a part of the lining of the uterus and/or the remaining products of conception by scraping and scooping (curettage).

Genetic is the major cause of incomplete abortion. Another etiology that causes congenital uterine anomalies is the environmental factors such as pollution and insufficient nutritional intake of the mother. Another cause of incomplete abortion is cervical incompetence characterized by an asymptomatic dilation of the internal cervical OS, leading to dilation of the cervical canal and external OS during the 2 nd trimester of pregnancy.

According to the studies conducted by World Bank, the Philippines is among the top 10 countries where theres an increasing number of teenage mothers. Seven out of 10 Filipina mothers are adolescents; most of them are below 19 years old. There are 3.6 million young mothers in the Philippines to date. Evidently, these figures translate to a higher incidence of abortion in the country. Every year, an estimated total of 64,000 Filipino youth commit abortion.

While there is a prevalence of pregnancy among teens, it is still intensely unaccepted by the societyespecially by their parents. For this reason and their youth, adolescent mothers-to-be are more prone to stress. They suffer both physically and emotionally.

Dr. Gloria Villena, Obstetrician-Gynecologist at Dr. Jose Fabella Memorial Hospital says that teenage pregnancy is risky because adolescents bodie s are not yet fully-developed; bearing another child inside of them is precarious to their health.

Objectives
General: This study aims for it to understand the cause, manifestations, treatments and prevention of incomplete abortion which will lead to an increase of awareness of energy individual who may have this kind of disease and to the members of the health care team who read this case study.

Specific: to present the definitions of the complete diagnosis that would explain the illness of the patient to determine the past, present and nursing health history of the patient to identify the Gordons Typology of the functional health patterns of the patient to be able to assess the review of systems of the patient to assess the physical condition of the patient in a cephalocaudal manner noting her general physique and patterns of functioning to determine the action and nursing intervention of the drug administered to the patient to formulate an effective Nursing Care Plan for the patient.

Nursing Health History

A) Initial Data Date of Admission Mode of Admission Ward Admitting Diagnosis - December 11, 2011 (4:50am) - conscious and lying on bed - OB Ward - Incomplete Abortion 10 4/7 weeks G2P1 (1011)

B) Demographic Data Patient Name Age Sex Occupation Nationality Marital Status Religion - Patient JAL - 19 years old - Female - Housewife - Filipino - Single - Roman Catholic

C) Chief Complaint

- Profuse Vaginal Bleeding

D) History of Present Illness The morning of December 10, 2011, the patient did some strenuous activities like washing clothes and other household chores. Then that afternoon she seems to have her menstruation without her knowing that it is a vaginal spotting already since she does not know that she is pregnant at that time. The night prior to her confinement she had a profuse vaginal bleeding with blood clumps.

E) Past Health History Medical History: The patient stated the she was not hospitalized before aside from giving birth to her first baby.

Surgical History:

The patient stated that she did not undergo any surgical procedure Wala akong alam na allergy ko, lahat kasi pwede sa akin eh. as verbalized by the patient.

Allergies:

Immunizations:

The patient stated that AMV and TT1 are the immunizations that she does not have.

F) Family Health History She stated that her aunt in the father suffers from hypoglycaemia.

Review of Systems
General Appearance Normal naman ako, feeling ko ganun pa din ang timbang ko.

Breast Yung sa suso ko lang ang medyo masakit, yung nakapa kanina.

Gastrointestinal Tatlong beses na ako umuutot pero hindi pa ako natatae.

Respiratory Normal naman, hindi naman ako nahihirapan huminga.

Genitourinary Minsan lang ang pag-ihi ko, hindi mayat maya

Eyes Minsan kasabay ng hilo, nanlalabo yung mata ko.

Psychological Nanghihinayang ako sa pagkawala ng baby ko.

Gordons Functional Health Patterns

FUNCTIONAL HEALTH PATTERN Beliefs about effect of foods on health and well being can affect food choices (Kozier 7th ed.). It could be seen that the patient has proven the efficacy of the said vitamin that is why she takes it religiously but is hindered temporarily due to financial constraints. Although some people overeat when stressed, depressed, or lonely, others eat very little under the same conditions. (Kozier 7th ed.). It could be inferred that the patient is stressed that is why she increased her food intake or she just wants to rapidly regain her strength. Recovering patients increase their food intake to return to their normal functions as fast as possible. (Kozier 7th ed.) BEFORE ILLNESS DURING ILLNESS ANALYSIS/ INTERPRETATION

1. HEALTH PERCEPTION/ HEALTH MANAGEMNE T PATTERN

For the last six months, Jhovy takes Fern- C for increased protection and stamina. She believes that this vitamin is good for her health.

She stopped taking Fern- C vitamins due to financial constraints.

For the past 6 months, the patient eats 2. NUTRITIONAL/ moderately METABOLIC varying from 3 4 PATTERN times a day. She said she likes to eat salty foods.

In the course of her hospital stay, patient reported an increased intake of food.

3. ELIMINATION PATTERN

Advise patient that GI upset, nausea, vomiting, diarrhea or constipation During her stay in For the past 6 are common side effects the hospital, she months, patient of FE SO4. (Clayton et al does not defecate reports defecating 14th ed.) it could be yet due to lack of every other day. analyzed that the patient urge. could be suffering from constipation as a side effect of one of her drugs. For the past year, Jhovy does not have any formal exercise program; rather, she treats her household chores as her regular exercise regimen. In her stay at the hospital, her activity level was diminished and most of the time she is just lying down since strenuous activities causes pain. A strange environment such as a hospital, with its lights, and activity, can compound pain. (Kozier 7th ed.). This shows that the patients pain may be intensified due to the unfamiliar environment of the hospital. Environment can promote or hinder sleep. Any change for example, noise in the environment can inhibit sleep. (Kozier 7th ed.). As mentioned before, the hospital with its buzzing activities 24/7 could really alter the patients pattern of sleep especially with the constant noise and of course the unfamiliarity of the place also caused the change in the patients pattern of sleep.

4. ACTIVITY/ EXERCISE PATTERN

5. SLEEP REST PATTERN

For the past 2 years, patient tells that she sleeps late at night at around 11 PM and wakes up at 5 AM.

Patient shares that she does not sleep well in the hospital and she is roused from sleep easily.

6. COGNITIVE/ PERCEPTUAL PATTERN

For the last 6 months, Jhovy recounts that she do not have any sensory impairment and is able to function well.

During her stay at the hospital, patient is responsive and cooperative but is a little fatigued and reports dizziness and blurred vision upon sudden changes in movement.

Increased quantity or quality of external stimuli, such as a noisy health care setting, intrusive diagnostic studies and contacts with many strangers could cause sensory overload th (Kozier 7 ed.). The patient may be experiencing fatigue as a result of sensory overload and is also overwhelmed by what had happened to her. Illness and trauma can also affect the self concept. (Kozier 7th ed.). The patients change in pattern was caused by her dizziness which is a common side effect of her drug mefenamic acid. 1. Her dizziness could be a, common side effect of her drug. Explain to patient that she may experience common side effects such as constipation, dizziness, and drowsiness. (Clayton et al 14th ed.)

7. SELF PERCEPTION/ SELF CONCEPT PATTERN

For the past 6 months, the patient shares that she often looks at the mirror to check her appearance signifying a good self esteem and appreciation of ones self.

In the course of her stay at the hospital, she reported a decrease in the frequency of her looking viewing the mirror due to dizziness when she gets up from bed.

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8. ROLE/ RELATIONSHI P PATTERN

For the last 6 months, the patients shares that she is in good terms with her peers and family.

Patient does not notice any change, rather she felt their concern for her welfare.

As an adult, a person who has high self esteem has feelings of significance, of competence, of the ability to cope with life(Kozier 7th ed.). since the patient has a strong support group her self esteem did not decrease rather she felt that she is cared for and is someone important to others.

9. SEXUALITY/ REPRODUCTI VE PATTERN

For the past 6 months, patient confides that she have a sexual intercourse with her partner once a week or none at all in a month.

Healthy minds, bodies and emotions are She was advised necessary for sexual well not to have being. (Kozier 7th ed.). sexual the change in this aspect intercourse for the is very clear, she is next two weeks advised by her doctor to following her D&C avoid form sex until she procedure to fully recovers from her avoid infection complete curettage and to allow procedure, this is to avoid healing. infection and trauma to her reproductive organs. Since her child is not with her, she substituted walking at the corridors of the ward whenever she is bored or stressed. A persons coping strategies often change with a reappraisal of a situation. (Kozier 7th ed.). The change in her coping mechanism is due to adjustment to her current state wherein her child is not with her.

10. COPING/ STRESS TOLERANCE PATTERN

For the last year, patient plays with child whenever she is stressed out.

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11. VALUE/ BELIEF PATTERN

For the past 6 months, patient said that she goes to the church every Sunday and attends mass regularly. Furthermore, she views God as someone, she could pour her heart out to.

Her faith did not waiver a bit; rather, it was strengthened and she believes God has a reason for this episode in her life.

For the client who is ill, faith whether in a higher authority (God, Allah, Jehovah), in oneself, in the health care team, or in a combination of all provides strength and hope (Kozier 7th ed.). The patients faith changed for the better since thru her hospitalization, it was deepened and her faith also gives her an optimistic vibe and views thus facilitating faster recovery and return to normal functions.

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Physical Assessment

General Appearance The patient has a fair body built. Lying on bed. Negative on breaths and body odor, dizziness and facial expression and signs of distress. with normal affect, organization of thoughts.

Skin/Integument o All other findings are within normal limits.

Upon inspection, the skin is fair in color and has normal uniformity. Negative to sign of edema and lesions.

Upon palpation, skin is warm and smooth to touch. the skin has normal skin turgor.

Hair o Scalp is free from scaliness and scars but visible sparse and dandruff.

All other findings are within normal limits.

Upon inspection, hair seems to be silky, resilient and has its normal thickness and growth. Negative to any lesions and masses. Body hair amount is according to normal distribution. no areas of patchy hair loss or excessive hair growth are detectable.

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Nail o All other findings are within normal limits. The patient has normal nail curvature of 1600, has smooth texture and highly vascularised. Tissues surrounding nails are intact. Upon performance of blanch test, nails displayed good capillary refill as evidenced by return of pinkish color in 3 seconds.

Head o All other findings are within normal limits.

Upon inspection, head is normocephalic and symmetrical. Swelling is absent. Head is hard and smooth upon palpation; no lumps lesions creptations and tenderness noted.

Eyes o The patients eyebrows are symmetrically aligned, with evenly distributed hair while eyelashes on both eyes have an even distribution of hair and curls outward. Patients eyelids blink spontaneously. Eyelids are also intact having no unusual discharge.

Upon inspection, both bulbar and palpebral conjunctivas are normal with no lesions noted. Lacrimal glands on both eyes do not manifest swelling upon inspection and palpation.

Upon lighting with penlight, the corneas are clear on both eyes. Iris is brown in color and symmetrical in size for both eyes. Pupils are equally round and also both reactive to light; its consensual reaction is to constrict when its lighted and dilates when it is not.

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Ears o All other findings are within normal limits. The patients ears are equal in size, symmetrical and uniform in color with the facial skin. The pinna is in the level of outer canthus of the eye and recoils after it was folded. Little amount of cerumen are found inside the ear of the patient and with skin flaking and shedding. There are no other unusual discharge and lesions noted upon inspection. No tenderness is felt by the patient upon palpation in the mastoid process.

Nose o All other findings are within normal limits. The patients nose is symmetrical in shape, size and color. Nasal flaring is absent when patient EB breaths. Both nares are patent. Nasal septum is intact and in between the nasal chambers.

Upon inspection in both of the nasal cavities of the patient using a flashlight, redness, swelling and discharges are not present. Cilia also are present and evenly distributed in both nasal cavities. Upon palpation of the nose, there is no tenderness of the frontal and maxillary sinuses.

Lips, Buccal, Mucosa, Teeth and Gums o The patients lips are symmetrical. While inspecting the upper and lower lips, no lesions and thruses were present.

Upon inspection of the teeth, cavities on the right central incisor with crack due to lollipop were seen.

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Upon inspection of tongue, it was at the center when patient protrudes it outward. Lesions are not present on the floor of the tongue. Thruses were not observed in both sides of the cheeks and in the gums.

Neck o All other findings are within normal limits. The patients neck muscles are aligned at the center of the head as it is hold erectly by the patient. Neck movement is smooth and normal without discomfort as patient moves her head from chin to chest and ear towards the shoulder on each side. Lymph nodes are not palpable.

Upon neck palpation, tenderness was not present. The thyroid gland is in the middle, does not have any palpable masses and it moves down as the patient swallows.

Chest o The patient has a symmetrical chest. Spine is vertically aligned, straight, with the right and left shoulders are not at the same height. Neither tenderness nor masses were present on the chest wall. Upon palpation, the patients chest demonstrates bilateral symmetry strong vibrations of tactile fremitus. Friction rub are heard upon auscultation on patients right upper chest. There is also a full symmetric chest expansion while patient breaths in.

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Heart and Central Vessels o All other findings are within normal limits.

No vibration or thrills noted. Jugular veins are not distended. S1 louder at apical area, S2 louder at base of heart. No abnormal heart sounds is heard. Heart rate is 116 beats per minute.

Breast and Axillae o

6

/10 pain in both breasts is noted upon palpation

All other findings are within normal limits. The patients breast is round in shape, slightly unequal in size but generally symmetric, uniform in color, diffuse symmetric horizontal or vertical vascular pattern. Areola is round and bilaterally the same, color is dark brown without masses or lesion. Nipples are round, equal in size, similar in color, soft and smooth.

Abdomen o Upon inspection, abdomen is firm. Symmetrical abdominal movements by respiration were noted. Presence of bowel sounds is heard upon auscultation but weak in the left upper quadrant (LUQ). Upon palpation 8/10 pain in the Epigastric region is present. Liver upon palpation is not enlarged.

Musculoskeletal o Upon inspection and palpation the patient exhibited good ROM in all joints. No evidence of swelling or deformity. The patient has no contractures or tremors present. They are firm upon palpation. Muscle strength is equal in both sides. He moves and walks normally.

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Reproductive o All other findings are within normal limits.

Upon inspection and palpation, no enlargement or tenderness of inguinal lymph nodes, external genitalia without lesions and with minimal lochial discharge.

Neurologic o All other findings are within normal limits.

The patient has a slouch posture and walks normally. She is able to distinguish sharp and dull sensations and able to differentiate hot and cold sensations.

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Pathophysiology
ETIOLOGY

Predisposing Factor: 19 years old Lifestyle activities

disruption in the normal function during pregnancy

Increased production of immune response

fetal membranes and uterine decidua increase prostaglandin levels.

uterine contraction (intense cramps)

Heavy vaginal bleeding

Cervical dilation

embryo is detached from the placenta

Retained fragments

Continuous vaginal bleeding

Incomplete abortion

Delivery of some products of conception

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Surgical Management

The patient had undergone a complete Dilatation and Curettage (D&C) procedure. Dilatation and Curettage refers to the dilation (widening/opening) of the cervix and surgical removal of the part of the lining of the uterus and or contents of the uterus by scraping or scooping (curettage). It was performed to patient to remove tissues or placenta that maybe causing abnormal vaginal bleeding. It is the standard care for incomplete abortion. Furthermore, D&C often involves sedation or general anaesthesia.

Nursing Management

1. Provide appropriate management and prevent complications o Assess and record vital signs, bleeding and pain due to abdominal cramps o Emphasize to patient the importance of taking the prescribed iron supplements and the increase in the intake of dietary iron to help prevent anemia. o Give patients medication on time.

2. Provide client and family teaching o Teach client and her partner to avoid having intercourse for the next two weeks or until after the next menses to promote healing and recuperation. o o Explain to the client and her partner the importance for rest and delay of another pregnancy until the client fully recovers. Address emotional and psychosocial need for both patient and relatives.

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Drug Analysis
DRUG PATIENTS DOSGE CLASSIFICATION 2nd Generation Cephalosporin elimination of bacterial infection GENERIC NAME NURSING INTERVENTION 1. Give oral drug with food to decrease GI upset and enhance absorption. Cefuroxime 2. Inform patient that an upset stomach or diarrhea are common side effects. 1. Monitor post-partum women for BP changes and amount and character of vaginal bleeding. Methylergonovine Maleate 2. Advise patient that these side effects may be experienced such as nausea, vomiting, dizziness, headache or tinnitus. 3. Instruct patient to report DOB, dizziness and headache. 1. Maintain patients fluid intake at 8 to 10 glasses daily Diphenhydramine 2. Monitor patient for these side effects: blurred vision, constipation, urinary retention, dry mucosa of the mouth, throat and nose

Cefuroxime

750mg/IV 5oo mg/tab OD x 7 days

Methergine

/cap IM

Uterine Stimulants controls post partum blood loss and maintains uterine firmness

Diphenhydramine

25mg/ TIV

Anticholinergic Agents used to treat nausea and vomiting associated with pregnancy

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Diazepam

5 mg/ TIV

Benzodiazepines decreases anxiety to Diazepam a manageable level

1. Explain to the patient the need for rising first to a sitting position, equilibrating and then standing to manage the complaints of blurred vision and transient hypotension on arising which are common side effects of the drug. 2. Assist with ambulation if necessary 1. Advise patient to expect common side effects such as clamminess, dizziness, sedation, nausea, vomiting, dry mouth and sweating. 2. Provide patient safety, assurance and comfort. 1. Encourage patient to take medication on the right time and schedule.

Nalbuphine

5mg/ TIV

Opiate Partial Agonists obstetric Nalbuphine and surgical analgesia

Multivitamin

/cap OD

Multivitamin 2. Advise patient that dark colored urine is normal when taking this drug.

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Ferrous Sulfate

/cap OD

Ferrous Salts Elevates the serum iron concentration, which then helps to form Hgb or trapped in the FeSO4 reticuloendothelial cells for storage and eventual conversion to a usable form of iron Nonsteroidal Antiinflammatory Agents reduces pain and inflammation and eliminates fever Mefenamic Acid

1. Give drug with meals (avoid milk, eggs, coffee and tea) if GI discomfort is severe. 2. Advise patient that GI upset, nausea, vomiting, diarrhea or constipation are common side effects. 3. Warn patient that stool may be dark or green. 1. Advise patient to take drug with food, milk, antacids or large amounts of water if GI irritation occurs. 2. Explain to patient that she may experience common side effects such as constipation, dizziness, and drowsiness. 3. Provide patient safety during episodes of dizziness and drowsiness.

Mefenamic Acid

prn for pain

23 Assessment Diagnosis Inference Goal Nursing Intervention > identify the clients perception of the threat represented by the situation. Rationale Evaluation

Subjective: hindi ko alam na buntis ako, kawawa naman ang anak ko. . as verbalized by the patient.

Anxiety related to miscarriage

Objective: Crying Inability to sleep Verbalizati on of sadness

Miscarriage and abortion are both stressful events. Women who had abortions had higher anxiety scores at all measured time points. She feels guilty and wants to grieve over the loss of her unborn child.

After 3 hours of nursing intervention, the client will identify healthy ways to deal with and express anxiety and use resources/ support systems effectively.

> to identify the clients feelings and determine the source of anxiety.

> monitor vital signs.

> to identify physical responses associated with emotional condition.

After 3 hours of nursing intervention, the client was able to deal with her anxiety and was able to use her family support system in coping up with this stressful event in her life.

> observe clients behavior.

> which can point the clients level of anxiety.

>establish a > to avoid contagious therapeutic effect of anxiety. relationship, conveying empathy and unconditional positive regard.

24 >assist the client to identify precipitating factors and new methods of coping disabling anxiety. > to promote self awareness and strengthening of EGO.

25 NURSING INTERVENTION 1. Explain to the patient the need for rising first to a sitting position, equilibrating and then standing to manage the complaints of blurred vision and transient hypotension on arising

CUES Subjective: -Medyo nahihilo ako kapag biglang bumabangon tsaka biglang galaw. -blurred vision

DIAGNOSIS

INFERENCE Sudden change of positions leads to rapid return of venous flow and insufficient drainage of blood thus affecting our balance and coordination since our brain is very sensitive to the level of oxygen, glucose and CSF. Since the CNS is the one affected, its signs and symptoms are usually related to balance and coordination such as dizziness, blurred vision and transient hypotension.

GOALS After eight hours of meticulous nursing intervention the patient would:

RATIONALE 1. Allowing sufficient drainage of blood and of gradual venous return promotes stability and relief of dizziness in relation to sudden movements.

EVALUATION After eight hours of meticulous nursing intervention goal is met as evidenced by:

Risk for injury related to dizziness

Objective: - pallor - clammy skin - wavers when stands abruptly

- verbalize relief of dizziness associated with sudden movements

1. Patients demonstration of proper technique of getting up from bed and of changing positions. 2. Patients verbalization of relief from dizziness associated with sudden change of positions.

VS: - BP: 120/70 mmHg - Temp: 36.3 C - RR: 17 bpm -PR: 91 bpm

- demonstrate proper technique of getting up from bed and of changing positions

2. Assist patient when getting up from bed if necessary

2. Ensures patients safety in the event that the episode of dizziness is severe.

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