PATIENT BIODATA

Name of Patient - Mrs. Pawan Devi

W/O - Akhilesh Kumar

Age/ Sex - 33 Yrs/F

Education - 10

Occupation - Housewife

Income - 10000/- month

Marital Status - Married

Religious - Hindu

Address - Ram Nagar, teh. Rajpura, distt. Patiala PB.

Date of Admission - 19. March. 2019

Consultant - Dr. Sapna

Diagnosis - Abortion

Ward - Gynae ward

Present Complaints: Patient having complaint of Pain in abdomen,

Discomfort, per vaginal bleeding.
Present Medical History: Patient admitted in hospital with complaints of
per vaginal bleeding and pain in abdomen.
History of excessive bleeding per vagina, passage of poc’s.
After investigation she founded as anemic. Hb level was 5.3gm/dl.

Present Surgical History:

Patient has no any present surgical history

Past Medical History: She was previously admitted in government hospital

for delivery before 5 years.
Past Surgical History: Patients have no any past surgical history.

Menstrual History:
Menarche: 13 yrs.
Day: 20 to 25 day.
Duration: 10 day.
Rhythm: Irregular
Flow: heavy (4 to 5 pads in first 4 days).
Family History:
S. No. Name of Family Age/ Sex Relation with Health Status
Member Patient
1 Mr. preetam chand 72 yr./M Father in law Normal
2 Mrs.veena devi 65 yr./F Mother in law Normal
3 Mr.Akhlesh kumar 39yr./M husband Normal
4 Ms. Pawan devi 33yr./F Self client
5 Ms.pooja 10 yr./ daughter Normal

Family tree:

Male

Female

Client
Socio Economic History:
Mrs. Pawan Devi lives in her own concrete house. There was adequate
electricity & water supply (hand pump) is present. She has 2 rooms in her house
with proper ventilation. Her family income is around 10.000/- month. Her
relation with other member of family & with other relatives is good & healthy.

Personal history:
Hygiene: Maintained.
Diet: Vegetarian.
Activity and Exercise: Her activity is normal in daily life. She was not doing
any exercise in his daily life.
Sleep and Rest: She was sleeping at 6-7 hrs. at night & take rest 1-2 hrs. at day
time after taking meal.
Elimination Pattern: She goes for defecation for once or twice in a day and 5-
6times for urination. She has no complaint of constipation.
Values & believes: She belongs Hindu religion. She believes in god. She
participates in every holly festivals. She doesn't take any fast.

PHYSICAL EXAMINATION -
Anthropometric measurements:
Height - 5 ft
Weight - 44 kg.
Vitals:
Temperature - 98*F
Pulse - 100b / min.
Respiration - 18b/ min.
Blood Pressure - 110/70 mm Hg
General appearance:
Consciousness: conscious
Body build: thin.
Head:
Hair - Black in Color
Scalp - Itching and dandruff present.
Face - Slight pigmentation
Sinus - Normal
Cranium - symmetrical
Eyes
Visual activity - Normal
Ocular movement - Normal
Lids - Clear
Lacrimal gland - Proper functioning
Conjunctiva - Pale
Sclera - White
Ears
External Structure - Normal
Mucus membrane - No discharge
Tympanic membrane - Normal
Hearing - Normal.
Nose:
Eternal Structure - Short & round
Septum - symmetrical
Mucous Membrane - pink color
Nasal deviation - Normal nasal deviation
Epitasis - not present
Oral Cavity:
Lips - pink color.
Gums - no swelling
Oral cavity - clean, pink color
Teeth - Symmetrical & yellowish.
Tongue - light pink in color, no erethroplasia present, no white
patches present, Present in center line.
Taste - Normal
Voice - Soft
Neck:
General Structure - Normal
Tracheal sound - Heard
Thyroid and Parathyroid - No enlargement.
Lymph node - No enlargement
Range of motion - All movement present
(Flexion, extension, internal and
External rotation and circumduction.)
Chest and respiratory systems
Chest Shape - symmetrical
Respiration rate - 22 b/min.
General palpation - no palpable mass present, no fluid
Collection
Percussion - No pleural effusion.
Breathe sound - Heard.
Abdomen
Scar marks - absent
Hernias - absent
Masses - absent
Uterus - tenderness is present
Spleen - no spleenomegaly.
Hepatic - no hepatomegaly.
Bladder - normal
Palpation - abnormal mass is palpable on lower
abdomen.
 Back
No lordosis, kyphosis, sclerosis present.
Genitalia & rectal examination
 No pus inflammation.
 No congenital abnormality present.
 Any infection is not present.
 Vaginal discharge present.

Upper & Lower extremities-

Movement - Range of motion (ROM) is normal in
upper & lower extremities.
DRUG CHART:

Drug Rout Indication Action Side effects Nurse

e
Name /dosa responsibility
ge
(1)Inj. I/V UTI Used as CNS: headache 1-Assess the
Maczone ,I/m broad general condition
Otitis media GI: constipation
spectrum of the patient
0.5 -
septicaemia antibiotics GU:
1gm 2-Check the vital
discolouration of
i/v signs
urine.
6hrly
3-Checked the
allergic reaction.

4-Administer the
five rights.

5-Always follow
six rights and test
dose should be
done.
(2)Inj. 0- Peptic ulcer, It is a newer Known 1-Assess the
40m gastro H+ k+ ATP hypersensitivity general condition
Pantoprazol
g oesophageal inhibitor of patient.
e
slow reflux similar in
2-Always follow
Trade I/V potency and
six rights.
name: clinical
efficacy to 3-Check the
pan top omeprazole allergic reaction

(3)
IV Ranitidine Competitivel Blood- Absorption not
Inj Rantac
route (H2receptor y inhibit the Neutropenia, affected by food.
antagonist) action of thrombocytopen
Can be taken
histamine ia.
without regard to
(H2)at
receptor sites CNS-Headache, meal.
of the malaise,
Use continually in
decreasing dizziness.
hepatic
gastric acid GI- Nausea, dysfunction and
secretion. vomiting. renal impairment
Hepatic- patients.
Increased liver
enzyme.
(4) Tab. orall prostaglandi Help in Assess client for
cervical Nausea, Pain,
misoprostol y ns any sign of side
ripening. Blood loss
effects.
Induction of Diarrhoea, Check of blood
abortion and loss etc.
labour also.
 ANATOMY AND PHYSIOLOGY

1)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 posterior 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) The vaginal introitus is the vaginal entrance.

External female genitalia.

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.

1-5. 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.

INTERNAL FEMALE ORGANS

The internal organs of the female consists of the uterus, vagina, fallopian tubes,
and the ovaries.

UTERUS:
The uterus (womb) is a hollow organ within which fetal development
occurs.
The uterus (from Latin "uterus", plural uteri) or womb is a major female
hormone-responsive reproductive sex organ of most mammals including
humans. One end, the cervix, opens into the vagina, while the other is
connected to one or both fallopian tubes, depending on the species. It is within
the uterus that the foetus develops during gestation, usually developing
completely in placental mammals such as humans and partially
in marsupials such as kangaroos and opossums. Two uteruses usually form
initially in a female foetus, and in placental mammals they may partially or
completely fuse into a single uterus depending on the species. In many species
with two uteruses, only one is functional. Humans and other
higher primates such as chimpanzees, along with horses, usually have a single
completely fused uterus, although in some individuals the uteruses may not
have completely fused. The term uterus is used consistently within the medical
and related professions, while the Germanic derived term womb is also common
in everyday usage in the English language.

POSITION: Its normal position is one of the ante version and ante flexion.
The uterus is located inside the pelvis immediately dorsal to the urinary
bladder and ventral to the rectum.
MEASUREMENT AND PARTS OF UTERUS:

The uterus measures about 8 cm. long, 5 cm wide at the fundus and its
walls are about 1.25 cm thick. Its weight varies from 50-80 gm.
The uterus is characterized by the following regions:
1. Body (corpus).
2. Isthmus.
3. The cervix.
1. Body :
The fundus is the upper region where the uterine ducts join the uterus.
The body is the major, central portion of the uterus.
2. Isthmus :
The isthmus is the lower, narrow portion of the uterus.
3. The cervix :
The cervix is a narrow region at the bottom of ht uterus that leads to
the vagina. The inside of the cervix, or cervical canal, opens to the uterus above
through the internal os and to the vagina below through the external os. Cervical
mucus secreted by the mucosa layer of the cervical canal serves to protect
against bacteria entering the uterus from the vagina. If an oocyte is available for
fertilization, the mucus is thin and slightly alkaline, attributes that promote the
passage of sperm. At other times, the mucus is viscous and impedes the passage
of sperm.

STRUCTURE:
The uterus is held in place by the following ligaments:
a. The broad ligaments
b. The uterosacral ligaments
c. The round ligaments
d. The cardinal (lateral cervical) ligaments
The wall of the uterus consists of the following three layers:
e. The perimetrium is a serous membrane that lines the outside of the
uterus.
f. The myometrium consists of several layers of smooth muscle and
imparts the bulk of the uterine wall. Contractions of these muscles
during childbirth help force the fetus out of the uterus.
g. The endometrium is the highly vascularised mucosa that lines the
inside of the uterus. If an oocyte has been fertilized by a sperm, the
zygote (the fertilized egg) implants on this tissue. The endometrium
itself consists of two layers. The stratum functionalise (functional
layer) is the innermost layer (facing the uterine lumen) and is shed
during menstruation. The outermost stratum basalis (basal layer) is
permanent and generates each new stratum functionalise.
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):

(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 Graffian 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 oocyte, which contain 46
chromosomes and are surrounded by a layer of follicle cells.

(b) Primary oocyte 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.

Figure 1-4. Human ovary.

(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 graffian follicle stage,
they contain secondary oocyte 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

DESCRIPTION OF DISEASE

INTRODUCTION:
Abortion is the ending of pregnancy by removing a fetes or embryo
before it can survive outside the uterus.
An abortion is a procedure to end a pregnancy; it uses medicine or
surgery to remove the embryo, fetes, placenta from uterus.
The procedure is done by a licensed health care professional.

Incidence -: Around 56 million abortions occur each year in the

world, with a little under half done unsafely. Unsafe abortion causes
47000 deaths & 5 million hospital admission each year.
The WHO recommended safe & legal abortion be available to all
women.

Definition
An abortion is a termination of pregnancy before the foetus is viable
before & after 28 week of pregnancy is called abortion & it also
called miscarriage.
 Aetiology of abortion

Genetic factor:- Majority of (50%) early miscarriage are due to

chromosomal abnormality.
Endocrine & metabolic factors:- Deficient progesterone secretion
from corpus luteum & thyroid abnormalities also increase
miscarriage.
Anatomic abnormality:- It include 3-38%.It has following factors:-
Cervical-uterine factors include cervical incompetence. Congenital
malformation.

Uterine fibroid.

Infection :- (5%) Infections are the accepted causes of late as well as

early abortions. It include :
Viral – rubella, CMV, HIV

Parasitic – Toxoplasma, malaria

Bacterial – Chlamydia

Immunological disorders:-
(5-10 %) Autoimmunity natural killer cells present in peripheral
blood & that is in uterus are different function. .
Maternal medical illness:-
Cyanotic heart, hemoglobinopathies are associated with early
miscarriage.
G) Premature rupture of membranes:- it lead to abortion.
H) Unexplained:-
40 to 60 % cases of abortions are unknown.


 ABORTION

SPONTANEOUS INDUCED
(Miscarriage) (Deliberate)

ISOLATED RECURRENT LEGAL ILLEGAL

MTP UNSAFE

SEPTIC COMMON

THREATENED INEVITABLE COMPLETE INCOMPLETE MISSED

SEPTIC LESS COMMON

Types of abortion

1. Spontaneous abortion
It is the expulsion or extraction from its mother of an embryo or foetus
weighing 500 gms or less when it is not capable of independent survival before
the 20 weeks of gestation.
Clinical features:-
a. Bleeding per vagina

b. Pain in back & abdomen.

c. Internal examination reveals the dilated internal os.

2. Threatened abortion
It is a clinical entity where the process of miscarriage has started but has not
progressed to a state from which recovery is impossible.
Clinical features:-
a. Bleeding per vagina

b. Pain – bleeding is usually painless but there is mild backache & lower abdomen.
 3. Inevitable miscarriage
It is a clinical type of abortion where the changes have progressed to a stable
from where continuation of pregnancy is impossible.
Clinical features:-
A. Increase vaginal bleeding.

B. Pain in lower abdomen.

C. Internal examination reveals dilated internal Os of the cervix through which the
product of conception are felt.

4 .Complete miscarriage
When the product of conception is expelled enmass, it is called complete
miscarriage.
5. Incomplete miscarriage
When the entire product of conception neither is nor expelled instead a part of
its left inside the uterine cavity, it is called incomplete miscarriage.
Clinical features:-
A. Continuation of pain in lower abdomen.

B. Persistence of vaginal bleeding

C. Internal examination revels –

• Uterus smaller than period of amenorrhea

• Patulous cervical Os often admitted tip of the finger.

• Varying amount of bleeding.

6. Missed abortion
When the fetus is dead & retained inside the uterus for variable period, it is
missed miscarriage or early fetus demise.
Clinical features:-
Persistence of brownish vaginal discharge.

Retrogression of breast change.

Cessation of uterine growth.

Cervix feels firm.

7. Septic abortion
Any abortion associated with clinical evidence of infection of uterus & its
content is called septic abortion.
Abortion is usually considered septic when there are:-
 Rise of temperature at least 100.4F.

Purulent vaginal discharge

Lower abdominal pain & tenderness.

Chills

Diarrhoea & vomiting

Tachypnea

8. Recurrent miscarriage
It is defined as a sequence of three or more consecutive spontaneous abortion
before 20 weeks. It may be primary & secondary.
Cervical incompetence
It is a medical condition in which a pregnant women’s cervix begin to dilate &
thin before her pregnancy has reached term.
Aetiology:-
i. Congenital- uterine abnormality

ii. Acquired - D &C operation

iii. Others :- multiple gestation

Diagnosis & management of cervical incompetence

1. History.

2. Internal examination.

3. Speculum examination.

Management: - it includes two types of operations.

1. SHIRODKAR’S OPERATION

2. McDonald’s OPERATION

Diagnostic evaluations of abortion

1. History taking –
 Previous history of abortion.

 Personal & obstetrical history.

2. Routine investigation
 Blood for Hb, ABO, rh+ group.

 Urine for immunological & culture.

3. Imaging:- it includes USG ,X-ray

 Complication of abortion

1) Sepsis & placental polyp.

2) Blood coagulation disorders.

3) Haemorrhage.

4) Injury may occur to the uterus.

5) Renal failure due to spread of infection.

6) Chronic pelvic & back ache.

7) Dyspareunia.

8) Cervical incompetence.

Management of abortion
AIMS:-
To accelerate the process of expulsion.
To maintain strict asepsis.
The management of abortion according to its types :-
1. Threatened abortion:-
 Rest

 Drugs- diazepam 5mg BD.

2. Inevitable abortion:-
 General measures:- Methergine 0.2 mg to stop bleeding.

 Active treatment:- Dilatation & evacuation followed by curettage of uterine

cavity.

3. Complete abortion:- dilatation & curettage with the help of TVS.

4. Incomplete abortion:- the evacuation of retained product of conception.
Drug Misoprostol 200 ug is use every 4 hourly.

5. Missed abortion:- it include

a. Medical:- oxytocin 10 – 20 units.

b. Surgical :- D & C
 6. Septic abortion: - It includes:-
 General measure – Hospitalization is essential for all cases of septic abortion.

 Vaginal swab for culture & drug sensitivity.

 Drugs:- Analgesics , antibiotic , B.T is done.

 D & C is done.

Dilatation & Curettage

D& c is a procedure to remove tissue from inside the uterus & lining of uterus
& scarping the content from uterus.
It is also called sharp curettage & attached with electrical vacuum aspiration.
Indications:-
Abortion
Endometrial carcinoma
Infertility.

Technique:
 The procedure is under anaesthesia
 Position the client in Lithotomy position.
 The cervix is dilated by Hegar’s dilator up to the size of 6-10 mm.
 The curette is introduced into uterine cavity up to the fundus & scarping the
curette against the endometrium.
 The uterine cavity is explored with polyforcep to remove any polyp present
 F .Uterus is massaged manually to stimulate the contraction.
Nursing management
 Risk for hypothermia related to infection secondary to septic abortion.
 Fluid volume deficit related to bleeding.
 Abdominal pain related to uterine contraction.
 Anxiety related to sudden bleeding secondary to abortion.
 CLINICAL COMPARISION:

S. IN BOOK IN PATIENT
NO.
1. Fleshy mass per vagina  Present.
2. Pain in lower abdomen  Present.
3. Persistence vaginal bleeding  Present.
4. Uterus smaller than period of  Not present.
amenorrhea.
Patulous cervical os
5.  Present.
Chills and rigor
6.  Present.
Tachypnea
7.  Not present.
Impaired mental status
8.  Not present.
Hypothermia
9.  Not present.

Complications
S.NO. IN BOOK IN PATIENT
1. Profuse bleeding Present
2. Sepsis Present
3. Placental polyp Not present
 INVESTIGATION:
S. NAME OF THE NORMAL VALUE PATIENT
NO. INVESTIGATION VALUE

1. Hb 11.5-16.5 mg/dl 5.3 mg/dl

2. TLC 4000-11000 /mm3 15,100 /mm3
3. neutrophil 1.5-4.5 lack/mm3 2.79 lack/mm3
4. Platelet count. 13-45 mg/dl 10mg/dl
5. Urea serum. 0.6-1.3 mg/dl 0.55 mg/dl
6. Serum Creatinine. 70-140 mg/dl 70 mg/dl
7. Blood sugar. 183.0 micro/dl
8. Alkaline phosphate _____________ Negative.
9. Australia antigen.

MANAGEMENT:

According to book:
In recent cases
Evacuation of the retained products of conception (ERCP)is done.
She should be resuscitated before any active treatment is undertaken.
EARLY ABORTION: dilatation and evacuation under analgesics or general
anesthesia is to be done. Evacuation of the uterus may be done using MVA also.
LATE ABORTION: the uterus is evacuated under general anesthesia and the
products are removed by ovum forceps or by blunt curette. In late cases
dilatation and curettage operation is to be done to remove the bits of tissues left
behind. The removed materials are subjected to a histological examination.
MEDICAL MANAGEMENT of incomplete miscarriage may be done. Tablet
misoprostol 200µg is used vaginally every 2hours.
 NSAIDs can be used to reduce painful menses.
 Oral contraceptive pills are prescribed to reduce uterine bleeding and
cramps.
  Anemia may have to be treated with iron supplementation.
1. SURGICAL MANAGEMENT:
According to book:

Dilatation and evacuation

Intrauterine instillation of hypertonic solution:

Extra-amniotic: instillation of 0.1 ethacridine lactate

Intra-amniotic: instillation of 20% of hypertonic
saline.
 Hyserotomy.
8. NURSING MANAGEMENT:
I assess the patient according there priority needs. The priority needs of my
patient are given below & I assess my patient for.
1. Assess for pain, pain duration, intensity & level of pain.
2. Assess for self care deficit.
3. Assess for complication.
4. Assess for risk of infection.
5. Assess for anxiety.
6. Assess for nutritional level.
7. Assess for hygiene
8. Assess for knowledge deficiency.

NURSING DIAGNOSIS
1. Pain in lower abdomen related to mass expel from the uterus.
2. Altered body temperature related to infection as evidence by purulent and
smelly discharge.
3. Risk of infection related to vaginal discharge.
4. Activity intolerance related to pain in lower abdomen.
5. Altered sleeping pattern related to pain.
6. Knowledge deficit related to diet, personal hygiene and treatment and its
complications.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL
DIAGNOSIS
Subjective Pain in lower To relieve  To assess the  General condition of Pain is reduced up to
data:-Patient abdomen related the pain of general condition of patient is assessed. some extent as
complaints that to product of the patient. patient.  Level, intensity and evidenced by patient
she having pain conception expel  To assess the level, duration of pain is having good sleep.
in the lower through the intensity and assessed. Patient is
abdomen. uterus. duration of pain. having moderator pain.
Objective data:  To provide the  Comfortable position is
- By observing comfortable position given, with the help of
patient facial to the patient. extra pillow.
expressions and  To provide  Divertional therapy is
by doing per divertional provided to patient.
vaginal Therapy to the Diverting her mind by
examination we patient. verbalizing with patient.
know that  Administer  Analgesic is
patient is having analgesics as administered as
pain. prescribed by prescribed by physician.
physician.
ASSESSMEN NURSING GOAL PLANNING IMPLEMENTATION RATIONAL
T DIAGNOSIS

Subjective Risk of infection To reduce  Assess the level of  Level of risk of Risk of infection is
data:-patient related to vaginal the risk of risk of infection. infection is assessed by reduced to some
complaints of discharge. infection. examining the perineal extent as evidenced
itching and area. by examining the
redness over  Educate the patient  Patient is educated perineal area.
the perineal about the about the maintenance
area. maintenance of of hygiene.
hygiene.
Objective
data: patient  Advice the patient to  Patient is advised to
looks take plenty of fluids. take plenty of fluids.
discomfort able
and irritated.  Advice to take  Patient is advised to
antibiotics as ordered take antibiotics as
by physician. prescribed by physician.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL
DIAGNOSIS
Subjective Activity To improve  Asses the level  Level of activity Activity tolerance
data: patient intolerance related the activity activity intolerance intolerance is assessed is improved to
complaints of to pain in lower tolerance of of the patient. by observing the some extent as
not able to do abdomen. the patient. patient’s activity. evidenced by
daily activities.  Assist the patient in  Patient is assisted in patient’s self care.
daily activities. daily activities by her
Objective data: family
patient looks  Provide active and  Active and passive
depressed and passive exercises to exercises are provided to
lazy. the patient. the patient.
 Educate the patient  Patient is educated to
to take adequate take adequate rest and
rest and healthy healthy diet.
diet.
 Assess the tolerance  Level of tolerance of
level of activities. activities is assessed.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL
DIAGNOSIS
Subjective Altered sleeping To improve  Assess the sleeping  Sleeping pattern of the Sleeping pattern is
data: patient pattern related to the sleeping pattern of client. client is assessed. improved to some
complaints of pain pattern of  Provide calm and  Calm and noise free extent as
sleeplessness. client. noise free environment is provided evidenced by
environment to the to the patient. patient’s facial
Objective data: patient. expression.
Patient looks  Provide well  Well ventilated
lazy and ventilated environment and
depressed. environment and position is provided to
position to the the patient with the help
patient. of extra pillows.
 Provide  Comfortable bedding is
comfortable provided to client.
bedding to the
client.
Assessment Nursing Goal Planning Implementation Rational
diagnosis
Subjective Knowledge deficit To improve  Assess the level of  Level of knowledge of Knowledge is
data: patient related to the level of knowledge of patient is assessed by improved to some
complaints of treatment and its knowledge patient. asking questions. extent as evidenced
having queries. complications. of patient  Explain to the  Explanation about the by patient answer.
Objective patient about the whole treatment plan
data: patient treatment plans and and follow is provided
looks confused importance of to the patient.
and anxious. follow up.
 Clear the doubts of  All the doubts of the
the patient. patient are cleared.
 Provide
psychological  Psychological support
support to the is provided to the
patient. patient.
 HEALTH EDUCATION
Diet and supplements:
 Educate the mother to take adequate diet. Add vegetables, milk, egg,
fruits and juices in her diet.
 The supplementary diet is also important such as iron calcium and folic
acid.
 Instructed to patient for taking high caloric diet which is rich in protein &
vitamin diet for the early recovery.
 I told to patient for avoid spicy food & fatty diet.
Rest and sleep:
 Encourage client to take adequate rest and sleep.
 Provide calm and quiet environment to client.

Personal hygiene:

 The maintenance of personal hygiene is very important to prevent the

infection. Daily bathing is very necessary.

Environmental hygiene:

 Educate the mother to keep her surroundings clean.

Follow up care:
 Educate the mother regarding follow up care. I gave the health education
to patient & his relatives.
 I explain the all aspect of disease to patient & his family members.
 I instructed to patient & his family members if they have seen any
complication then immediate contact with doctor.
SARSWATI NURSING
INSTITUTE

CASE STUDY
ON
ABORTION

SUBMITTED TO: SUBMITTED BY:

Mrs. SBINA MAM PALLAVI

LECTURER (OBG) MSc. (N) 1ST YEAR