I.PATIENT PROFILE Mrs. LM, is a 36 years old female, residing at Salvacion ,Bayombong,NuevaVizcaya.Her birthday is on February 2,1976.She is married to Mr.

KM ,whose occupation is farming. Mrs. LM is a Filipino and she is a Roman Catholic. She was admitted last January 13,2013 at 12:28 in the afternoon, with the admitting diagnosis of G5P4(4004) Abortion Incomplete, Induced by Catheterization,non-septic, and with the principal diagnosis of G5P4(4-0-1-4) Abortion Completed Curettage,non-septic,induced by catheterization.The one who admitted and consulted her are Minnie Darling Padre M.D and Marissa P. Cruz M.D.

II.HISTORY OF PRESENT ILLNESS Two days prior to admission, the patient, Mrs.LM experienced vaginal bleeding and body weakness that promt her to go the hospital.On the 13th day of January,2013 at Veterans Regional Hospital, she had undergone principal operation, completed curettage evades IV sedation under the service of Dr. Cruz.

III. HISTORY OF PAST ILLNESS Mrs. LM experienced hypertension last December,she said that she went to their Barangay Clinic for her to know her blood pressure .The result of her BP is not within the normal range which is 140/100 mmHg.She didnt also took any medication because she didnt consult to a doctor.Aside from hypertension ,the patient also experienced minor illnesses, such as common colds,fever,cough and headache and she took in over the counter drugs.

IV.FAMILY/SOCIAL HISTORY The father of Mrs.LM have a history of asthma, but she did'nt experienced this even in her childhood stage she also verbalized that their house is concrete and it was made up of cement and it is a one story building.They also have garden at their backyard planted with vegetables which is one of the sources of their food.

V.OBSTETRICAL HISTORY Mrs. LM menarche was happened when she was 13 years old with regular interval, duration of 5 days ,and a frequency of 1 fully soaked sanitary napkin.Her LMP was October 27,2012 so her EDC is on August 13,2013 and AOG of 11weeks.The patient has a GRAVIDA PARA SCORING of (G5 P4 T4 A1 L4) , when she was pregnant ,she go to their clinic for prenatal visit. In her 5 pregnancies she only visited three times and acquired two times immunization of tetanus toxoid. She said that she took ferrous sulfate prescribed by the midwife assigned in their barangay clinic.

HISTORY OF PREVIOUS PREGNANCY NO. OF TYPE OF PREGNANCY DELIVERY 1.Baby Boy NORMAL DELIVERY 2. Baby Boy NORMAL DELIVERY 3.Baby Girl NORMAL DELIVERY 4.Baby Boy NORMAL DELIVERY VI.BRIEF DESCRIPTION ABORTION-the termination of pregnancy by the removal or expulsion from the uterus of a fetus, or embryo prior to viability. INCOMPLETE ABORTION- characterized by expulsion of only part of the products of conception usually the fetus, severe uterine cramping and bleeding with cervical dilatation. The pregnancy still remain in the uterus. Most of the time, a miscarriage that is "incomplete" at the time of diagnosis will run its course without further intervention, but sometimes the body has trouble passing the tissue from the pregnancy and the miscarriage remains incomplete until the woman seeks treatment. An incomplete miscarriage diagnosis is not the same as a missed carriage, a nonviable pregnancy in which the baby is no longer developing but the cervix remains closed and no bleeding has begun. RISKS FACTOR Abnormal PAP smear Age over 30 years PLACE OF DELIVERY HOME DELIVERY HOME DELIVERY HOME DELIVERY HOME DELIVERY BIRTH ATTENDANT Trained hilot Trained hilot Trained hilot Trained hilot OUTCOME alive alive alive alive

 Age under 15 years Alcohol use Caffeine use Drug abuse Heavy smoking Obesity Placenta previa Preeclampsia Urinary tract infections Vaginitis Venereal disease

SYMPTOMS Initial symptoms of miscarriage include: Vaginal spotting in pregnancy Lower abdominal pain May be interpreted as a painful menstrual period Painful intercourse This may progress to: Vaginal bleeding in pregnancy Passing blood clots from the vagina Passing tissue from the vagina Moderate to severe abdominal pain

Uncommon symptoms of miscarriage include: Fever Vomiting Fatigue Rapid heart rate PHYSICAL FINDINGS Physical findings in women with a miscarriage may include: Abdominal tenderness Dilated cervix Tissue in the vagina Vaginal bleeding Rapid pulse

Tests used to evaluate miscarriage may include: Pelvic ultrasound Pregnancy ultrasound Serum HCG level Maternal Rh factor TREATMENT Treatment for a miscarriage usually includes bedrest, and dilation and curettage. Treatment options for miscarriage may include: Intravenous fluids Oxygen therapy Close blood pressure monitoring Bedrest

 RhoGAM: For women with Rh negative blood type Dilation and curettage: Procedure to remove unwanted tissue from the uterus. DILATATION AND CURETTAGE A woman may require a dilation and curettage, or D and C, after a miscarriage. A dilation and curettage is a surgical procedure, during which the inner lining of the uterus is removed. Before this can be done, the cervix needs to be opened, or dilated. This allows surgical instruments to enter the uterus. One of the surgical instruments, called a curette, is used to gently scrape away the lining.

VII. ANATOMY AND PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM

FEMALE EXTERNAL GENITALIA MONS PUBIS- a fatty pad covered with skin and pubic hair located just above the vaginal lips. The fat and pubic hair act as a cushion during intercourse to prevent bruising caused by impact between the pubic bones of each partner. LABIA MAJORA- soft, fatty, skin covered tissue that encloses and protects the rest of the vulva. The outer lips swell with blood during sexual intercourse. LABIA MINORA- produce secretions from oil glands to keep the vaginal opening moist. They contain many nerve endings that are stimulated during sex. VESTIBULE- release mucus around the vaginal opening for lubrication during sexual PUDENDAL CLEFT- space between labia majora CLINICAL PERINEUM- region between the vagina and the anus PREPUCE- fold skin over the clitoris where the labia minora unites.

 CLITORIS- most sensitive part of the entire genital area. The sole function of this tiny pea sized structure is to bring pleasure to the female during sexual arousal. URETHRA- carries urine (from the bladder) out of the body, and in males it also carries semen from the testes through the penis (for sexual ejaculation). VAGINA- female organ for copulation and functions to receive the penis during intercourse

FEMALE INTERNAL GENITALIA CERVIX- It widens during child birth to allow the passage of a baby. The cervix also allows the passage of menstrual fluid from the uterus. UTERUS- a. Houses and nourishes fetus until sufficiently mature to function outside the mothers body b. Uterine muscles propels fetus outside. FALLOPIAN TUBE- a. Provides passageway for ovum as it travels from ovary to uterus. b. Site of Fertilization. OVARY- a. Endocrine glands that secrete estrogen and progesterone. b. Contain ova within follicles for maturation during the womans reproductive life.

VIII.LABORATORY RESULT

Date performed: January 13,2013 TEST HEMOGLOBIN RESULT 59 REFERENCE M-135-180g/l F-120-160g/l SIGNIFICANCE The result is not within the normal range,so it will result to anemia. The result is not within the normal range, so it will result to anemia

HEMATOCRIT

19

M-40-54 F-37-47

Date performed: January 14, 2013 TEST HEMOGLOBIN RESULT 88 REFERENCE M-135-180g/l F-120-160g/l SIGNIFICANCE The result is not within the normal range,so it will result to anemia The result is not within the normal range,so it will result to anemia The result is within the normal range. The result is within the normal range. The result is within the normal range. The result is within the normal range.

HEMATOCRIT

27

M-40-54 F-37-47

WBC NEUTROPHILS LYMPHOCYTES PLATELET

8.7 0.68 0.21 315

5-10x10 g/l 0.40-0.70 0.20-0.40 150-400 x 10 g/l

IX.PHYSICAL ASSESSMENT FORM ASSESSMENT

Her husband and 4 children acts as the significant others of Mrs.LM Conscious and Coherent

CLINICAL BASIS
The family serves as inspiration and cater the needs of the patient. She knows where she is and able to socialize with other people and can answer questions being asked. Weakness is due to decrease level of oxygen of the blood. Due to the poor environmental ventilation/hospital setting and excessive noise where in the patient cant able to rest properly. She can accept her condition Strongly facing the problem

P S Y C O S O C I A L

Body weakness

Looks irritable and restless

Coping mechanism: Problem focused: Fight for her problem Religion: Roman Catholic

Primary language: ilocano Primary sources of healthcare,and financial resources related to health Affect: Appropriate Orientation: well oriented to time, place and events Memory Remote:

The patient has no problem about her religion regarding the treatment and administration of medicines. The patient speaks ilocano,but she can also understand tagalog. The patient go to their barangay health center as their primary source of healthcare,and farmng is their financial source related to healthcare.And sometimes her parents support her also through financial and emotional. The facial expression of the patient correspond to what she feels. She knows what happened to her before going to the hospital,who accompanied her to go,and what prompted her to go to the hospital. can be able to remember her previous pregnancies.

Recent:

Immediate:

can able to remember her age and birthday (the patient is 36y/o,and her bday is on February 2,1976)

FORM

ASSESSMENT Speech: clear

CLINICAL BASIS She is able to produce audible sounds in moderate pace that exhibit thought ,with relevance to the questions being asked.

E L I M I N A T I O N

Stool Pattern: Once Consistency: n/a Color: yellow with brown Amount: n/a Urine Pattern: 2-4 x a day Urinalysis: Pattern: 3 x a day but in minimal amount Color:yellow Specific gravity: 01.01 transparency: clear PH-6.0

Abdomen: globular Abdomen Inspection: no scar noted, fair skin. Her abdomen is globular and contour.

Due abdominal distention

Toileting ability;can go to CR without assisstant

FORM

ASSESSMENT Sleep pattern: Sleep approximately 6-8 hours/day has a slight sleep pattern disturbance

CLINICAL BASIS There is an inadequate sleep pattern due to interruption for the monitoring of her vital signs.

R E S T A N D A C T I V I T Y

Current activity level: lying on bed with left side lying position

This position makes the patient to be more comfortable enough and to avoid difficulty of breathing.

The patient doesnt need any assistant in her ADLS (eating, urinating , brushing , performing personal hygiene)

The patient has enough strength to perform her ADLS.

FORM Airway

ASSESSMENT

CLINICAL BASIS

Nose: no obstruction Mouth: no obstruction

The airway is clear The airway is clear

Respiration Rate:20cpm Depth: normal Rhythm: regular Position assumed: supine

Taking V/S are use for baseline data and to know whether if V/S is still within the normal range.

O X Y G E N

Skin: light brown Lips: pink Nails: pinkish Capillary Refill; 1-2 sec. Peripheral pulses Location: radial Rate : 73 bpm, Rhythm: regular Equality: equal on both sides BP: 120/80 mmHg

Due to Normal circulation of oxygen

Edema: none O2 therapy: none

Bp monitoring should be done to be able to assess for Hypertension The patient does not use oxygen inhalation

FORM

ASSESSMENT Diet: On DAT

CLINICAL BASIS To provide adequate and proper nutrition

IVFs

N U T R I T I O N

Solution: D5LRS 1 L (0.9% sodium chloride) Regulation: 30 gtts/minute Site: left hand

To replenish water loss and support circulating volume of blood and tissue Perfusion These abilities are still intact and can be a good reference for intervention, manifests good defense against aspiration.

Ability to: Chew: yes Swallow: yes Tolerate food: yes Gag reflex: intact

X.COURSE IN THE WARD DATE AND TIME January 13,201312:28pm FOCUS In to OB-ER NURSES NOTES D-in to OB-ER, 36y/o female patient,G5P4(4014) Abortion Incomplete,induced by catheterization,nonseptic with chief complaint of 2 days vaginal bleeding ,seen and examined by Dr. Cruz with initial BP of 110/80 mmHg. A-vital signs monitored,assisted to IE table for examination. 12:32pm For completion curettage D-for completion curettage as ordered by Dr. Cruz A-consent for operation and anesthesia secured and maintained on NPO; inserted D5LRS 1L and 10 U oxytocin as IVF aseptically. 12:40pm Diagnostics D-for CBC ,typing HBSAG

12:58pm 1:00pm

Anesthesia induced Procedure started

D-IV sedation by Dr. Galima D-completion curettage started by Dr. Cruz. A-instrument needed to serve D-specimen out completely A-place on sterile specimen bottle and labelled properly for histopathology . D-procedure ended A-perineal care done

1:03pm

Specimen

1:05pm

Procedure ended

1:30pm

Trans-in

D-in from DR via stretcher; with bearable post operation pain A-assisted on bed safely hooked to O2 inhalation via NC, vital signs continuosly monitored, recorded and watched for signs and symptoms of uterine atony and bleeding. R-with well contracted uterus and minimal lochial discharge. D-Hgb 59, Hct 19 D-blood is available for transfusion A-secured consent took properly ,typed cross matched and screened blood ,vital signs monitored. D-awake on bed with pale appearance, negative bleeding noted,with ongoing IVF of D5LR.

3:30pm 6:00pm

Referral Blood typing (39844)

January 14,2013 7:00am

3:00pm

D-awake on bed with slight vaginal bleeding.

January 15,2013 7:00am

D-BP 110/80 mmHg D-received awake on bed with ongoing IVF of D5LR.

FORM Allergies

ASSESSMENT

CLINICAL BASIS

S A F E

Food: none Medication: none Environment: none

The patient has no allergies on foods , medication and on environment.

Vision: 20/20

The patient can see an image of 20 feet distance from her that a normal person can see.

Eyes: ocular muscles intact

Eyes equally round and react to light

E N V I R O N M E N T

Eye glasses: none

None

Conjunctiva: pale in appearance

Due to anemia

Pupils: equally round and reactive to light and accommodation (PERRLA)

When the penlight was being focused nearly to her eyes, it constricts and when the light is far, his eyes dilated. Her eyes also follow the light when it is being focused to his eyes

INDIVIDUAL CASE STUDY

(Incomplete Abortion, induced by catheterization, non-septic) Submitted by: RIYAH B. NADERA
MIDWIFERY 2

Submitted to: ROLITA GRACE V. GARCIA

RN,RM