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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.