JOSE C. FELICIANO COLLEGE

INSTITUTE OF NURSING, MIDWIFE AND NURSING AIDE

DAU EXIT, DAU EXPRESSWAY DAU MABALACAT

PAMPANGA

THREATENED ABORTION(A CASE STUDY IN OBSTETRIC WARD)

BSN II – A (GROUP 1)

SUBMITTED BY:

ABIAN, IVYLYNN

AGUIRRE, ROXANNE

ARCILLA, CHRISTIAN ROI

BACANTE, CIELITO JOHN

CABRERA, JEFFREY

CANIEL, JOSEPH

LIWANAG, JEEANNE

NAVARRO, JOEL

PANGASIAN, CRYSTAL MAY

SUBMITTED TO:

MRS. FLORENCE AWKIT RMT, RN

CLINICAL INSTRUCTOR (OB WARD)

ACKNOWLEDGEMENT

This project would not be made possible without the help and guidance of

our Almighty Father, who conveyed our group adequate knowledge,

sufficient vigor and bravery to face innovative and peculiar defy during the

entire course of this project. Our never-ending thanks to Almighty Father

the most High for the love and care he showered upon us.

Our genuine gratitude to our beloved parents for always supporting us

physically, mentally, emotionally and financially in regards to this venture.

Warmth thanks for entrusting to us their confidence and understanding not

only in times of need but in everyday of our lives. They used to complain

that we are getting too sovereign and matured; however we live in the

ideology that letting go of their children is the hardest part of being a

parent. Though it is not easy for us to acknowledge the fact that we are

getting old bit by bit, we have to separate from them in order to understand

the true essence of being a human, and still our love for them remains the

same. To our dear parents, rest guaranteed that what we are doing right

now will serve as a stepping stone towards a philosophical future and

sagacious life, and that is being a nurse.

INTRODUCTION

Pregnancy is an exciting time in any parent's life. It's a time of change,

growth, discovery and a lot of questions. One of the most important factors

of having a healthy baby is the mother’s health especially during the 9

months where the child’s development has already started. The mother’s

nutrition, activity etc. greatly affect the developing fetus inside her womb

such that any move could put the child at risk resulting to abnormalities,

poor health or even death to the precious being anytime or even during

pregnancy if mother’s health is being taken for granted.

Complications may occur at any time during pregnancy and can result from

pre-existing maternal medical problems or from the pregnancy itself. Early

and consistent prenatal care results in improved fetal and maternal

outcomes, regardless of complications that may occur. One of these

complications, threatened abortion is a condition of pregnancy, occurring

before the 20th week of gestation, that suggests potential miscarriage may

take place.

Approximately 20% of pregnant women experience some vaginal bleeding,

with or without abdominal cramping, during the first trimester. This is

known as a threatened abortion. However, most of these pregnancies go on

to term with or without treatment. Spontaneous abortion occurs in less than

30% of the women who experience vaginal bleeding during pregnancy.

In the cases that result in spontaneous abortion, the usual cause is fetal

death. Such death is typically the result of a chromosomal or developmental

abnormality. Other potential causes include infection, maternal anatomic

defects, endocrine factors, immunologic factors, and maternal systemic

disease.

Estimates report that up to 50% of all fertilized eggs abort spontaneously,

usually before the woman knows she is pregnant. Among known

pregnancies, the rate is approximately 10%. These usually occur between 7

and 12 weeks of gestation. Increased risk is associated with women over

age 35, women with systemic disease (such as diabetes or thyroid

dysfunction), and those with a history of 3 or more prior spontaneous

abortions.

During our duty in the Ob ward at Ospital Ning Angeles (ONA) , we decided

to take the case of Mrs. X in which she was diagnosed with threatened

abortion v/s incomplete abortion because we would like to have a deeper

understanding about this condition so that we could render the care the

patient needed to arrive with a good prognosis. Management should

therefore always be based on appropriate clinical judgment. We would like

to apply all the things that we’ve learned through our lectures for the

benefit of our patient and to enhance our skills as well.

We hope that this case study will enable us, student nurses to better

understanding about the disease process and that we will be more sensitive

in attending to our patient’s need. For the community, we hope that this will

increase the level of awareness among the members of the community so

that it could help in the prevention of further pregnancy complications.

OBJECTIVES

General

This case study aims that the students and the readers will gain knowledge

and further understanding about Threatened Abortion

Specific to be able to:

1. Establish rapport with our client including her family members

2. Gather all necessary information regarding her and her family members

as may be related to our case study

3. Ascertain client’s past and present health history

4. Trace her genogram or family tree

5. Trace the development data of the client

6. Perform physical assessment on client’s condition so as to attain baseline

data

7. Present the definitions of the complete diagnosis that would explain the

illness of our client

8. Study the anatomy and physiology of female reproductive system

9. Trace the Pathophysiology of Threatened Abortion

10. Determine the diagnostic tests our client has undergone including their

implications and nursing responsibilities

11. Identify the drugs prescribed to our client, their action, side effects,

indications, contraindications and nursing responsibilities

12. Identify and prioritize the need of our patient

13. Formulate an appropriate nursing care plan based on the assessment

identify needs and problems of the patient

14. Render health teachings as part of our holistic care to alleviate

problems identified

15. Evaluate complications to nursing practice, education and research

PATIENT’S DATA

Name: Mrs. X

Address: Mt. View Balibago Angeles City

Age: 27 y/o.

Birthday: July 09, 1982

Birthplace: Angeles City

Civil Status: Single

Religion: Iglesia Ni Cristo

Nationality: Filipino

Educational Attainment: High School Graduate

Occupation: Housewife

Date Admitted: February 08, 2010

Time Admitted: 11:00 PM

Ward: OB

Bed no.: 22

Admitting Diagnosis: Pregnancy uterine 8 weeks 3 days AOG G2P1 (1001)

Threatened Abortion v/s Incomplete Abortion

Student Nurse Centered:

After the completion of the case study, the student nurse shall be able

to:

Present a comprehensive and detailed report regarding the patient’s

illness

Have a complete picture of the patient’s physical, psychosocial and

mental status through daily assessment

Have a well-structured nursing diagnosis of the client’s status based

from an integration of data gathered

Understand the factors that might have contributed to the development

of the disease

Provide organized and structured nursing interventions as a response to

the patient’s anticipated needs

Provide relevant information on available alternative therapies and

management

III. Nursing Process

A. Assessment

1. Personal History

a. Demographic Data

Mrs. X is a 27 years old Single Mother. She was born on July 09, 1982 in

Mt. View Balibago Angeles City, she is a Filipino Citizen and a Iglesia Ni

Cristo. She is the 4th child among the 8 children. This is her 2nd Pregnancy

on her G2P1 8 weeks and 3 days Age of Gestation. She has a 1 daughter 7

years of age. During my initial assessment to her she told me that they

living in a good and peaceful community, there surroundings are clean and

she has a good knowledge about what happening to her.

b. Socio Economic and Cultural Factors

Mrs. X is a plain housewife, they are residing at Mt. View, Balibago

Angeles City her husband is currently working as a welder at Ben Side Car

earning P 250 a day. They lived in a commuted place together with her

daughter and niece, during her first time pregnancy she is always

submitting herself for pre natal check up. Including her 2nd pregnancy

because she has experience in her first pregnancy that she always

experiencing vaginal bleeding during her 1st trimester. She is always aware

what happening to her that’s why she never miss to consult the health

center near at her place.

Mrs. X blaming her daily activity that all the household choir she is doing

that, causing her to bleed. All her activity in everyday to washing dishes,

clothes, cleaning the house, cooking and walking about 2 kms just to bring

her daughter in school at the Don Gueco Elementary School. She believes

that she really needed a bed rest during her pregnancy but because of what

there is status right now that they having difficulty financially that there

only source of income is that her husband salary. Sometimes those meds

has been prescribed during her pre natal check up is difficult for her to buy

because of lack of resources in their family.

2. Family Health – Illness History

Mrs. X diseases has a direct connection with the past illnesses. Her 1st

pregnancy she has experience a vaginal bleeding during the 1st trimester,

and also diagnosed Threatened abortion is a vaginal bleeding other than

spotting during early pregnancy is considered a threatened miscarriage. (A

miscarriage may also be referred to as a spontaneous abortion.) Vaginal

bleeding is common in early pregnancy. About 1 of every 4 pregnant women

has some bleeding during the first few months. About half of these women

stop bleeding and have a normal pregnancy.

3. History of Past Illness

Mrs. X has a previous operation via C/S her two ovaries has been

removed and diagnosed with Ovarian Cysts at Angeles Medical Center. Her

family has a history of having an ovarian cysts.

Father

(Arthritis)

Mother

(Ovarian Cysts

1st

Brother4th

Brother

3rd Sister

(Ovarian Cysts)

3rd

Brother2nd

Sister

1st Sister

(Disease)

2nd

SisterMrs. X

4. History of Present Illness

According to the Client in the evening of January 20, 2010, 10pm she

just finish washing her husband clothes and preparing herself to sleep, she

suddenly just feel something coming out on her vaginal part and having

pain in her abdomen. She just noticed that she having a bleeding which she

think it will just diminish for the following days. But the days gone by the

bleeding still not stopping and accompanied with pain on her abdominal

part on the day of January 23 2010 she consulted Dr. Romero Clinic at

Burgos Angeles City and later was ordered to take a UTZ and was seen in

Ultrasound that she has a minimal subchorionic hemorrhage.

In February 08,2010 at 11:00 pm she submitted herself at ONA and

upon assessing her upon admission she has a minimal vaginal bleeding prior

to admission and the UTZ confirm that it has presence of blood cloth in her

intrauterine segment. She was diagnosed with Threatened Abortion v/s

Incomplete Abortion.

5. Physical Examination

PHYSICAL EXAMINATION

February 08, 2010

Upon Admission

Appearance and Behavior: Appears well when not moving but shows

slight facial grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 36.6 OC

PR: 80 BPM

RR: 20 CPM

BP: 100/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

Abdomen: Flabby, soft & non tender

Genitalia: dosed cervix x 1(4) Spotting

February 09, 2010

Actual Physical Examination

Appearance and Behavior: Appears well when not moving but shows

slight facial grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 37.3 OC

PR: 85 BPM

RR: 18 CPM

BP: 90/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

Chest & Lungs: SCE, with retractions

Abdomen: Flabby, soft & non tender

Genitalia: Minimal Vaginal Bleeding

Extremities: full and equal pulses

Diagnostics and Laboratory Tests:

A.)Urinalysis:

Examination

Actual Values

Normal Values

Implication

Rationale

Color Light yellow straw yellow to amber in

color

Normal

>To examine the patient’s urine for sign of renal or urinary tract disease.

> To help discover disease that is not related to renal disorders.

>To demonstrate

the concentrating and diluting ability of the

kidneys.

Transparency/

Appearance

clear clear Normal

pH 7.5 4.5-8 NormalSpecific gravity

1.005 1.005-1.025 Normal

Albumin Negative In normal condition there should be no protein that can be detected.

Normal

Sugar Negative Blood glucose

levels should be 160mg/dL

Presence of sugar in urine may indicate diabetes, chronic kidney disease.

RBC/HPF 0.1 Blood in the urine may sometimes indicate serious urinary tract problems.

Pus cells/HPF

0.2Pus cells and bacteria should be

May be a sign of swelling in the kidney

Epithelial cells

Rare

absent in urine.

and pelvic region, urethral ulceration and chronic specific inflammatory of the bladder.

>To identify drugs or substances that has been taken.

A . phosphate

Rare

Nursing Responsibilities:

1.)Tell the patient that the test is for the detection of renal and urinary tract disorders and assessment for body function.

2.)Notify the patient that the procedure requires a urine sample. Urine must be acquired most likely on the first void in the morning.

3.)Notify the laboratory and physician of any drugs that the patient has taken that may affect the results.

Physical tests

The physical tests measure the color, transparency (clarity), and specific gravity of a urine sample.

COLOR. Normal urine is straw yellow to amber in color. Abnormal colors include bright yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases. For example, red urine may be caused by blood or hemoglobin, beets, medications, and some porphyrias. Black-gray urine may result from melanin (melanoma) or homogentisic acid (alkaptonuria, a result of a metabolic disorder). Bright yellow urine may be caused by bilirubin (a bile pigment). Green urine may be caused by biliverdin or certain medications. Orange urine may be caused by some medications or excessive urobilinogen (chemical relatives of urobilinogen). Brown urine may be caused by excessive amounts of prophobilin or urobilin (a chemical produced in the intestines).

TRANSPARENCY. Normal urine is transparent. Turbid (cloudy) urine may be caused by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria.

SPECIFIC GRAVITY. The specific gravity of urine is a measure of the concentration of dissolved solutes (substances in a solution), and it reflects the ability of the kidneys to concentrate the urine (conserve water). Specific gravity varies with fluid and solute intake. It will be increased (above 1.035) in persons with diabetes mellitus and persons taking large amounts of medication. It will also be increased after radiologic studies of the kidney owing to the excretion of x ray contrast dye. Consistently low specific gravity (1.003 or less) is seen in persons with diabetes insipidus. In renal (kidney) failure, the specific gravity remains equal to that of blood plasma (1.008–1.010) regardless of changes in the patient's salt and water intake.

Biochemical tests

pH: A combination of pH indicators (methyl red and bromthymol blue) react with hydrogen ions (H + ) to produce a color change over a pH range of 5.0 to 8.5. pH measurements are useful in determining metabolic or respiratory disturbances in acid-base balance. For example, kidney disease often results in retention of H + (reduced acid excretion). pH varies with a person's diet, tending to be acidic in people who eat meat but more alkaline in vegetarians. pH testing is also useful for the classification of urine crystals.

Protein: Albumin is important in determining the presence of glomerular damage. The glomerulus is the network of capillaries in the kidneys that filters low molecular weight solutes such as urea, glucose, and salts, but normally prevents passage of protein or cells from blood into filtrate. Albuminuria occurs when the glomerular membrane is damaged, a condition called glomerulonephritis.

Glucose (sugar): The glucose test is used to monitor persons with diabetes. When blood glucose levels rise above 160 mg/dL, the glucose will be detected in urine. Consequently, glycosuria (glucose in

the urine) may be the first indicator that diabetes or another hyperglycemic condition is present.

Blood: Red cells and hemoglobin may enter the urine from the kidney or lower urinary tract. Testing for blood in the urine detects abnormal levels of either red cells or hemoglobin, which may be caused by excessive red cell destruction, glomerular disease, kidney or urinary tract infection, malignancy, or urinary tract injury.

Microscopic examination

The presence of bacteria or yeast and white blood cells helps to distinguish between a urinary tract infection and a contaminated urine sample. White blood cells are not seen if the sample has been contaminated. The presence of cellular casts (casts containing RBCs, WBCs, or epithelial cells) identifies the kidneys, rather than the lower urinary tract, as the source of such cells. Cellular casts and renal epithelial (kidney lining) cells are signs of kidney disease.

B.)Hematology:

Examination Result Normal Range

Implication Rationale

WBC

(White blood cells)

11.3 5-10 Bacterial infection

>To verify infection or inflammation in the body and observe its responses to specific therapies.

RBC

(Red blood cells)

3.83 4.20-6.10 Low RBC is due to

enormous blood loss

which results to anemia.

>To know the amount of RBC in the blood.

Hemoglobin (Hgb)

120 g/dL 115-155g/dL Normal >To recognize the

amount of O2 carrying protein contained within RBC.

Hematocrit(Hct)

0.36 0.36-0.48 Normal >To identify the percentage of blood volume occupied by red blood cells.

ESR

Bleeding time 1’30’ Seg. 0.53

Clotting time 3’45” Lymph 0.47

ABO Type ‘A’

WBC (White Blood Cell): Also referred to as leukocytes, a fluctuation in the number of these types of cells may indicate the presence of infections and disease states dealing with impaired immune system status (cancer, excess stress/catabolism)

RBC (Red Blood Cell): called erythrocytes, their primary function is to carry oxygen (via the hemoglobin contained in each RBC) to various tissues as well as giving our blood that cool "red" color. A decrease in the number of these cells can result in anemia which could stem from dietary insufficiencies. An increase in number can occur when androgens are used. This is because androgens increase EPO (erythropoietin) production and red blood cell division, increasing RBC count. This can increase blood pressure and result in stroke (called a cardiovascular accident, or CVA).

Hemoglobin: Hemoglobin is a carrier of dissolved gases, oxygen and carbon dioxide, in blood, an important part of each red blood cell surface. An increase in hemoglobin can be an indicator of congenital heart disease, congestive heart failure, sever burns, or dehydration. Being at high altitudes, or the use of androgens, can cause an increase as well. A decrease in number can be a sign of anemia, lymphoma, kidney disease, sever hemorrhage, cancer, sickle cell anemia, etc.

Hematocrit: The hematocrit is used to measure the percentage of the total blood volume that's made up of red blood cells. An increase in percentage may be indicative of congenital heart disease, dehydration, diarrhea, burns, etc. A decrease may be indicative of anemia, hyperthyroidism, cirrhosis, hemorrhage, leukemia, rheumatoid arthritis, pregnancy, malnutrition, a sucking knife wound to the chest, etc.

Nursing Responsibilities:

1.)Explain to the patient the necessity of undergoing the test that it helps detect occurrence of anemia and polycythemia.

2.)Notify the patient that the test requires blood samples as well as the person who will perform the venipucture and time.

3.) Inform the patient that the procedure is slight discomfort and he/she may feel a little pain.

4.)After the procedure, apply direct pressure to the venipuncture until bleeding stops.

5.)Refer if venipuncture develops hematoma and monitor the pulses distal to sites.

IV infusion/Blood transfusion:

Date Ordered No. of Infusion Name of Remarks

Infusion Date Consumed

02/08/10 #1 D5LRS 1L x 30gtts/min. with side drip D5 water 500ml + 3 amps. Isoxilan x 30gtts/min with increasing.

TS: 10:50 am

TS: 11pm

Ultrasound Report:

10-18910

Baluyot, Erlinda 27/ R

January 23, 2010 Dr. Mandal

TRANSVAGINAL ULTRASOUND

Within an enlarged uterus is a single live embryo exhibiting good cardiac contractions during time scanning of about 177 beats/ min. The crown rump length measures about 0.53cm equivalent to 6 weeks and 2 days age of gestation. EDD in this scan 09-16-10

Minimal sub chorionic hemorrhage is evident. Right ovary is normal in size with few small follicles. No fecal mass seen. It measures 2.19 x 1.59cm. left ovary is not demonstrated.

Cervix measures 2.35 x 2.29cm with homogenous echo pattern.

Adnexae are unremarkable. Negative cul-de-sac fluid.

IMPRESSION:

Single, live, intrauterine, pregnancy, 6 weeks and 2 days age of gestation.

EDD in this scan 09-16-10 Minimal subchorionic hemorrhage Unremarkable right ovary, cervix and adnexae sonographically.

THE FEMALE REPRODUCTIVE SYSTEM

GENERAL

The organs of the reproductive systems

are concerned with the general process

of reproduction, and each is adapted for

specialized tasks. These organs are

unique in that their functions are not

necessary for the survival of each

individual. Instead, their functions are vital to the continuation of the

human species. In providing maternity gynecologic health care to women,

you will find that it is vital to your career as a practical nurse and to the

patient that you will require a greater depth and breadth of knowledge of

the female anatomy and physiology than usual. The female reproductive

system consists of internal organs and external organs. The internal organs

are located in the pelvic cavity and are supported by the pelvic floor. The

external organs are located from the lower margin of the pubis to the

perineum. The appearance of the external genitals varies greatly from

woman to woman, since age, heredity, race, and the number of children a

woman has borne determines the size, shape, and color. See figure 1-1 for

the female reproductive organs.

TERMS AND DEFINITIONS

These are only a few terms and definitions that will be used in this

lesson. Other terms and definitions will be dispersed throughout the

lesson.

A. Broad Ligaments. Two wing-like structures that extend from the

lateral margins of the uterus to the pelvic walls and divide the pelvic

cavity into an anterior and a posterior compartment.

B. Corpus Luteum. The yellow mass found in the graafian follicle after

the ovum has been expelled.

C. Estrogen. The generic term for the female sex hormones. It is a

steroid hormone produced primarily by the ovaries but also by the

adrenal cortex.

D. Fimbriae. Fringes; especially the finger-like ends of the fallopian

tube.

E. Follicle. A pouch like depression or cavity.

F. Follicle Stimulating Hormone. The follicle stimulating hormone

(FSH) is a hormone produced by the anterior pituitary during the first

half of the menstrual cycle. It stimulates development of the graafian

follicle.

G. Graafian Follicle. A mature, fully developed ovarian cyst containing

the ripe ovum.

H. Hormone. A chemical substance produced in an organ, which,

being carried to an associated organ by the bloodstream excites in the

latter organ, a functional activity.

I. Lactation. The production of milk by the mammary glands.

J. Luteinizing Hormone. A hormone produced by the anterior pituitary

that stimulates ovulation and the development of the corpus luteum.

K. Oocyte. A developing egg in one of two stages.

L. Ovum. The female reproductive cell.

M. Progesterone. The pure hormone contained in the corpora lutea

whose function is to prepare the endometrium for the reception and

development of the fertilized ovum.

N. Reproduction. The process by which an off- spring is formed.

Anterior view of the uterus and related structures

Wall of the uterus

INTERNAL FEMALE ORGANS

The internal organs of the female consist of the uterus, vagina,

fallopian tubes, and the ovaries.

A. Uterus. The uterus is a hollow organ about the size and shape of a

pear. It serves two important functions: it is the organ of

menstruation and during pregnancy it receives the fertilized ovum,

retains and nourishes it until it expels the fetus during labor.

(1) Location. The uterus is located between the urinary bladder and

the rectum. It is suspended in the pelvis by broad ligaments.

(2) Divisions of the uterus. The uterus consists of the body or corpus,

fundus, cervix, and the isthmus. The major portion of the uterus is

called the body or corpus. The fundus is the superior, rounded region

above the entrance of the fallopian tubes. The cervix is the narrow,

inferior outlet that protrudes into the vagina. The isthmus is the

slightly constricted portion that joins the corpus to the cervix.

(3) Walls of the uterus (see figure 1-3). The walls are thick and are

composed of three layers: the endometrium, the myometrium, and the

perimetrium. The endometrium is the inner layer or mucosa. A

fertilized egg burrows into the endometrium (implantation) and

resides there for the rest of its development. When the female is not

pregnant, the endometrial lining sloughs off about every 28 days in

response to changes in levels of hormones in the blood. This process

is called menses. The myometrium is the smooth muscle component of

the wall. These smooth muscle fibers are arranged. In longitudinal,

circular, and spiral patterns, and are interlaced with connective

tissues. During the monthly female cycles and during pregnancy,

these layers undergo extensive changes. The perimetrium is a strong,

serous membrane that coats the entire uterine corpus except the

lower one fourth and anterior surface where the bladder is attached.

B. Vagina.

(1) Location. The vagina is the thin in walled muscular tube about 6

inches long leading from the uterus to the external genitalia. It is

located between the bladder and the rectum.

(2) Function. The vagina provides the passageway for childbirth and

menstrual flow; it receives the penis and semen during sexual

intercourse.

C. Fallopian Tubes (Two).

(1) Location. Each tube is about 4 inches long and extends medially

from each ovary to empty into the superior region of the uterus.

(2) Function. The fallopian tubes transport ovum from the ovaries to

the uterus. There is no contact of fallopian tubes with the ovaries.

(3) Description. The distal end of each fallopian tube is expanded and

has finger-like projections called fimbriae, which partially surround

each ovary. When an oocyte is expelled from the ovary, fimbriae

create fluid currents that act to carry the oocyte into the fallopian

tube. Oocyte is carried toward the uterus by combination of tube

peristalsis and cilia, which propel the oocyte forward. The most

desirable place for fertilization is the fallopian tube.

D. Ovaries (2) (see figure 1-4).

(1) Functions. The ovaries are for oogenesis-the production of eggs

(female sex cells) and for hormone production (estrogen and

progesterone).

(2) Location and gross anatomy. The ovaries are

about the size and shape of almonds. They lie against the lateral walls

of the pelvis, one on each side. They are enclosed and held in place by

the broad ligament. There are compact like tissues on the ovaries,

which are called ovarian follicles. The follicles are tiny sac-like

structures that consist of an immature egg surrounded by one or more

layers of follicle cells. As the developing egg begins to ripen or

mature, follicle enlarges and develops a fluid filled central region.

When the egg is matured, it is called a graafian follicle, and is ready

to be ejected from the ovary.

(3) Process of egg production--oogenesis (see figure 1-5).

(a) The total supply of eggs that a female can release has been

determined by the time she is born. The eggs are referred to as

"oogonia" in the developing fetus. At the time the female is born,

oogonia have divided into primary oocytes, which contain 46

chromosomes and are surrounded by a layer of follicle cells.

(b) Primary oocytes remain in the state of suspended animation

through childhood until the female reaches puberty (ages 10 to 14

years). At puberty, the anterior pituitary gland secretes follicle-

stimulating hormone (FSH), which stimulates a small number of

primary follicles to mature each month.

(c) As a primary oocyte begins dividing, two different cells are

produced, each containing 23 unpaired chromosomes. One of the cells

is called a secondary oocyte and the other is called the first polar

body. The secondary oocyte is the larger cell and is capable of being

fertilized. The first polar body is very small, is nonfunctional, and

incapable of being fertilized.

(d) By the time follicles have matured to the graafian follicle stage,

they contain secondary oocytes and can be seen bulging from the

surface of the ovary. Follicle development to this stage takes about 14

days. Ovulation (ejection of the mature egg from the ovary) occurs at

this 14-day point in response to the luteinizing hormone (LH), which is

released by the anterior pituitary gland.

(e) The follicle at the proper stage of maturity when the LH is

secreted will rupture and release its oocyte into the peritoneal cavity.

The motion of the fimbriae draws the oocyte into the fallopian tube.

The luteinizing hormone also causes the ruptured follicle to change

into a granular structure called corpus luteum, which secretes

estrogen and progesterone.

(f) If the secondary oocyte is penetrated by a sperm, a secondary

division occurs that produces another polar body and an ovum, which

combines its 23 chromosomes with those of the sperm to form the

fertilized egg, which contains 46 chromosomes.

(4) Process of hormone production by the ovaries.

(a) Estrogen is produced by the follicle cells, which are responsible

secondary sex characteristics and for the maintenance of these traits.

These secondary sex characteristics include the enlargement of

fallopian tubes, uterus, vagina, and external genitals; breast

development; increased deposits of fat in hips and breasts; widening

of the pelvis; and onset of menses or menstrual cycle.

(b) Progesterone is produced by the corpus luteum in presence of in

the blood. It works with estrogen to produce a normal menstrual

cycle. Progesterone is important during pregnancy and in preparing

the breasts for milk production.

EXTERNAL FEMALE GENITALIA

The external organs of the female reproductive system include the

mons pubis, labia majora, labia minora, vestibule, perineum, and the

Bartholin's glands. As a group, these structures that surround the

openings of the urethra and vagina compose the vulva, from the Latin

word meaning covering. See Figure 1-6.

a. Mons Pubis. This is the fatty rounded area overlying the symphysis

pubis and covered with thick coarse hair.

b. Labia Majora. The labia majora run posteriorly from the mons

pubis. They are the 2 elongated hair covered skin folds. They enclose

and protect other external reproductive organs.

c. Labia Minora. The labia minora are 2 smaller folds enclosed by the

labia majora. They protect the opening of the vagina and urethra.

d. Vestibule. The vestibule consists of the clitoris, urethral meatus,

and the vaginal introitus.

(1) The clitoris is a short erectile organ at the top of the vaginal

vestibule whose function is sexual excitation.

(2) The urethral meatus is the mouth or opening of the urethra. The

urethra is a small tubular structure that drains urine from the

bladder.

(3) T e. Perineum. This is the skin covered muscular area between the

vaginal opening (introitus) and the anus. It aids in constricting the

urinary, vaginal, and anal opening. It also helps support the pelvic

contents.

f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The

Bartholin's glands lie on either side of the vaginal opening. They

produce a mucoid substance, which provides lubrication for

intercourse.

BLOOD SUPPLY

The blood supply is derived from the uterine and ovarian arteries that

extend from the internal iliac arteries and the aorta. The increased

demands of pregnancy necessitate a rich supply of blood to the

uterus. New, larger blood vessels develop to accommodate the need

of the growing uterus. The venous circulation is accomplished via the

internal iliac and common iliac vein.

FACTS ABOUT THE MENSTRUAL CYCLE

Menstruation is the periodic discharge of blood, mucus, and epithelial

cells from the uterus. It usually occurs at monthly intervals

throughout the reproductive period, except during pregnancy and

lactation, when it is usually suppressed.

The menstrual cycle is controlled by the cyclic activity of

follicle stimulating hormone (FSH) and LH from the

anterior pituitary and progesterone and estrogen from the

ovaries. In other words, FSH acts upon the ovary to

stimulate the maturation of a follicle, and during this

development, the follicular cells secrete increasing

amounts of estrogen (see figure 1-7).

Hormonal interaction of the female cycle is as follows:

(1) Days 1-5. This is known as the menses phase. A lack of signal from

a fertilized egg influences the drop in estrogen and progesterone

production. A drop in progesterone results in the sloughing off of the

thick endometrial lining which is the menstrual flow. This occurs for 3

to 5 days.

(2) Days 6-14. This is known as the proliferative phase. A drop in

progesterone and estrogen stimulates the release of FSH from the

anterior pituitary. FSH stimulates the maturation of an ovum with

graafian follicle. Near the end of this phase, the release of LH

increases causing a sudden burst like release of the ovum, which is

known as ovulation.

(3) Days 15-28. This is known as the secretory phase. High levels of

LH cause the empty graafian follicle to develop into the corpus

luteum. The corpus luteum releases progesterone, which increases

the endometrial blood supply. Endometrial arrival of the fertilized

egg. If the egg is fertilized, the embryo produces human chorionic

gonadotropin (HCG). Thehuman chorionic gonadotropin signals the

corpus luteum to continue to supply progesterone to maintain the

uterine lining. Continuous levels of progesterone prevent the release

of FSH and ovulation ceases.

Additional Information.

(1) The length of the menstrual cycle is highly variable. It may be as

short as 21 days or as long as 39 days.

(2) Only one interval is fairly constant in all females, the time from

ovulation to the beginning of menses, which is almost always 14-15

days.

(3) The menstrual cycle usually ends when or before a woman reaches

her fifties. This is known as menopause.

Ovulation

Ovulation is the release of an egg cell from a mature ovarian follicle

(see figure 1-5 for ovulation). Ovulation is stimulated by hormones

from the anterior pituitary gland, which apparently causes the mature

follicle to swell rapidly and eventually rupture. When this happens,

the follicular fluid, accompanied by the egg cell, oozes outward from

the surface of the ovary and enters the peritoneal cavity. After it is

expelled from the ovary, the egg cell and one or two layers of

follicular cells surrounding it are usually propelled to the opening of a

nearby uterine tube. If the cell is not fertilized by union of a sperm

cell within a relatively short time, it will degenerate.

MENOPAUSE

As mentioned in paragraph 1-6c (3), menopause is the cessation of

menstruation. This usually occurs in women between the ages of 45

and 50. Some women may reach menopause before the age of 45 and

some after the age of 50. In common use, menopause generally means

cessation of regular menstruation. Ovulation may occur sporadically

or may cease abruptly. Periods may end suddenly, may become scanty

or irregular, or may be intermittently heavy before ceasing altogether.

Markedly diminished ovarian activity, that is, significantly decreased

estrogen production and cessation of ovulation, causes menopause.

Description of the Disease

A threatened miscarriage is a condition that suggests a miscarriage might

take place before the 20th week of pregnancy.

A small number of pregnant women have some vaginal bleeding, with or without abdominal cramps, during the first trimester of pregnancy. When the symptoms indicate a miscarriage is possible, the condition is called a "threatened abortion." (This refers to a naturally occurring event, not medical abortions or surgical abortions.)

Miscarriage occurs in just a small percentage of women who have vaginal bleeding during pregnancy.

A miscarriage is the spontaneous loss of a fetus before the 20th week of pregnancy. (Pregnancy losses after the 20th week are called preterm deliveries.)

A miscarriage may also be called a "spontaneous abortion." This refers to naturally occurring events, not medical abortions or surgical abortions.

Other terms for the early loss of pregnancy include:

Complete abortion: All of the products of conception exit the body Incomplete abortion: Only some of the products of conception exit the

body

Inevitable abortion: The symptoms cannot be stopped, and a miscarriage will happen

Infected abortion: The lining of the womb, or uterus, and any remaining products of conception become infected

Missed abortion: The pregnancy is lost and the products of conception do not exit the body

Most miscarriages are caused by chromosome problems that make it impossible for the baby to develop. Usually, these problems are unrelated to the mother or father's genes.

Other possible causes for miscarriage include:

Hormone problems Infection

Physical problems with the mother's reproductive organs

Problem with the body's immune response

Serious body-wide ( systemic) diseases in the mother (such as uncontrolled diabetes)

It is estimated that up to half of all fertilized eggs die and are lost (aborted) spontaneously, usually before the woman knows she is pregnant. Among those women who know they are pregnant, the miscarriage rate is about 15-20%. Most miscarriages occur during the first 7 weeks of pregnancy. The rate of miscarriage drops after the baby's heart beat is detected.

The risk for miscarriage is higher in women:

Older than 35 Who have had previous miscarriages

PATHOPHYSIOLOGY(Client Based)

Precipitating fx: No Predisposing fx:

>8 weeks AOG(occurs during first > Age- common among women over

trimester of pregnancy) 35y/o

> Race- No significant racial differences

During egg implantation, egg slightly separates or tears from the uterus

Blood collects between the chorionic membrane(a membrane that develops

around a fertilized egg) and the wall of the uterus

Blood leaks in the cervix

Mild uterine cramping Minimal vaginal spotting/bleeding

(lower abdomen) Date: (3-4 days) Dates: January 20, 2010

SUBCHORIONIC HEMORRHAGE

(determine by UTZ) Date: January 23, 2010

*Severe SC bleeding can lead to rupture of the subchorionic membrane

Risk for Miscarriage & Stillbirth(THREATENED ABORTION)

DRUGS

Name of drugDate

Ordered/Date Started

Route of administratio

n

General Action

Indication

Client response to

the medication with actual side effects.

GenericName:

dydrogesterone

Trade Name:

Duphaston

DO: 02/08/10

DS:

02/09/10

1:00AM

>10mg/tab,2 tabs TIDe

>Dydrogesterone is an orally active progestogen which acts directly on the uterus, producing a complete secretory endometrium in an estrogen-primed uterus.

> Treatment of progesterone deficiencies (eg, threatened and habitual abortion associated with proven progesterone deficiency, dysfunctional uterine bleeding, dysmenorrhea, endometriosis, secondary amenorrhea, irregular cycles, premenstrual syndrome, infertility due to luteal insufficiency and to counteract the effects of unopposed estrogen on the endometrium in HRT for women with disorders due to natural- or

>Patient response effectively with no side effect noted.

surgical-induced menopause with an intact uterus

Name of drug

Date Ordered/Date Started

Route of administrati

on

General Action

Indication Client response to the medication with actual side effects.

GenericName:

Isoxsuprine HCl

Trade Name:

Duvadilan, Vasodilan

DO: 02/08/10

DS: 02/09/10

8:00AM

>1amp side drip IVF

> Stimulates skeletal beta receptors to produce vasodilation; stimulates cardiac function (increased contractility, heart rate, and cardiac output) and relaxes uterus. At higher doses, inhibits platelet aggregation and decreases blood viscosity

> Uterine hypermotility disorders: Threatened abortion, premature labor & dysmenorrhea. An adjunct therapy in the treatment of arteriosclerosis obliterans, thromboangitis obliterans (Buerger's disease) & Raynaud's disease.

>Patient response effectively with no side effect noted.

DIET

Type of DietDate Ordered:Date Started:

General Description

Indication / Purpose

Client’s Response / reaction to the

diet

DAT DO: 02/08/10

DS: 02/08/10

There is a dietary sodium restriction on patient

To facilitate reduction of sodium in the body, thus reducing edema and ascites.

It also aide in the reduction of conjunction of vascular fluids since sodium attracts water.

The patient is eating at regular diet.

Nursing Responsibilities:

Explain the purpose. Assess for patient condition, how he respond diet. Provide variety of choices of foods low sodium. Be sure patient is taking / eating foods he can tolerate. Explain importance of compliance.

PATIENT TEACHINGS:

1. Avoid alcohol, cigarettes, and illegal drugs,2. Limit caffeine intake3. Avoid contact with toxin (ex. Arsenic, lead, heavy metals,

and organic solvents).4. Control any medical conditions, such as diabetes and

hyperthyroidism..5. Avoid or restricts some forms of activity, or advise a

complete bed rest.6. Avoid having sexual intercourse is usually recommended

until the warning signs have disappeared.7. Advise patients to return upon occurrence of symptoms

such as: profuse vaginal bleeding severe pelvic pain temperature above 38 degree C (100.4 degree F).

8. Advise the patient to avoid intake of highly seasoned and fatty foods.

9. Talk with any physicians before taking medications to ensure they are safe during pregnancy.

10. Advise the patient to take the full course of medications.

DISCHARGE PLAN

Medications:

· Teach patient and her family or significant others the proper dosage and

the right time to take the medication.

· Emphasize to the patient the importance of obediently taking the

prescribed medications and the disadvantages or complications that may

arise if these are not taken properly.

· Inform and discuss the possible side effects and reactions that these

drugs might produce and seek medical attention immediately is these

arise

· Discourage to use of OTC medications or at least inform the physician if

she’s taking other OTC medications. This is essential to prevent any

occurrence of drug interactions.

Exercise:

· Tell client to refrain from straining activities

· Encourage ambulation as a form of light exercise that would help in the

progression of her recovery and wound healing.

· Range of motion. Encouraging the patient to do some exercises would

allow good blood circulation as well as the prevention of the occurrence of

bed sores.

· Encourage patient to do some stretching exercise to prevent stiffness of

the bone due to less activity performed.

· Encourage patient to first sit up and dangle feet before standing from a

lying position to prevent orthostatic hypotention

Treatment

· Discussing the purpose of treatments to be done and continued at home

and report to the health professional when there is bleeding to alleviate

symptoms of the patient’s condition and monitor for her recovery.

· Encourage patient to have a sufficient rest and sleep to maintain internal

equilibrium

· . Provide a safe and comfortable environment because it could make the

patient more relaxed which is also needed to arrived with a good

prognosis

Hygiene:

· Discuss the significance of personal hygiene and proper hand washing in

preventing infections

· Give client some lectures about proper wound care through changing the

dressing as often as possible so as to protect the wound from invasion of

microorganisms as well as to reduce the risk of microorganism

transmission to others.

Outpatient Care:

· A follow up check-up is necessary for wound evaluation and to assess the

progression of wound healing.

Diet:

· Encourage the patient to increased fluid intake and to include fruits and

vegetables rich in vitamin C for the production of milk needed for lactation.

· Taking food rich in protein is also helpful for tissue repair.