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 neverending 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 4 th 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.
1st Brothe r
2nd Sister
Father
Mother
(Arthritis)
(Ovarian Cysts
3rd Sister (Ovarian Cysts)
Mrs. X
4th Brothe r
3rd Brothe r
2nd Sister
1st Sister (Diseas
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.
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
Implication
clear
Normal Values straw yellow to amber in color clear
Color
Light yellow
Transparency/
Normal Normal
Appearance pH Specific gravity Albumin
7.5 1.005
4.5-8 1.005-1.025
Normal Normal
Negative
Normal
Sugar
Negative
In normal condition there should be no protein that can be detected. Blood glucose levels should be 160mg/dL
RBC/HPF
0.1
Pus cells/HPF Epithelial cells A . phosphate
0.2 Rare Rare
Pus cells and bacteria should be absent in urine.
Rationale
Presence of sugar in urine may indicate diabetes, chronic kidney disease. Blood in the urine may sometimes indicate serious urinary tract problems. May be a sign of swelling in the kidney and pelvic region, urethral ulceration and chronic specific inflammatory of the bladder.
>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.
>To identify drugs or substances that has been taken.
Nursing Responsibilities: Tell the patient that the test is for the detection of renal and urinary tract disorders and assessment for body function. Notify the patient that the procedure requires a urine sample. Urine must be acquired most likely on the first void in the morning. 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
WBC
11.3
Normal Range 5-10
3.83
4.20-6.10
Hemoglobin (Hgb)
120 g/dL
115-155g/dL
Hematocrit(Hct)
0.36
0.36-0.48
(White blood cells)
RBC (Red blood cells)
ESR Bleeding time 1’30’
Seg. 0.53
Clotting time 3’45”
Lymph 0.47
Implication Bacterial infection
Rationale
>To verify infection or inflammation in the body and observe its responses to specific therapies. Low RBC is due >To know the to enormous amount of RBC blood loss in the blood. which results to anemia. Normal >To recognize the amount of O2 carrying protein contained within RBC. Normal >To identify the percentage of blood volume occupied by red blood cells.
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
02/08/10
No. of Infusion
Remarks Date Consumed TS: 10:50 am
#1
D5LRS 1L x 30gtts/min. with side drip D5 water 500ml + 3 amps. TS: 11pm Isoxilan x 30gtts/min with increasing.
Ultrasound Report: 10-18910 Baluyot, Erlinda
Name of Infusion
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 fingerlike 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 15 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 (lower abdomen) Date:
Minimal vaginal spotting/bleeding (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 drug
GenericName:
Date Ordered/Date Started
DO: 02/08/10
dydrogesterone
DS: Trade Name:
02/09/10
Duphaston
1:00AM
Route of administration
>10mg/tab,2 tabs TIDe
General Action
Indication
>Dydrogesterone is an orally active progestogen which acts directly on the uterus, producing a complete secretory endometrium in an estrogenprimed 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 surgicalinduced menopause with an intact uterus
Client response to the medication with actual side effects.
>Patient response effectively with no side effect noted.
Name of drug
Date Ordered/Date Started
Route of administratio n
General Action
Indication
Client response to the medication with actual side effects.
GenericName:
DO: 02/08/10
>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.
Isoxsuprine HCl DS: 02/09/10 Trade Name: Duvadilan, Vasodilan
8:00AM
DIET Type of Diet
Date Ordered: Date Started:
DO: 02/08/10
DAT
DS: 02/08/10
General Description
There is a dietary sodium restriction on patient
Indication / Purpose
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.
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.
Client’s Response / reaction to the diet
The patient is eating at regular diet.
PATIENT TEACHINGS:
1. Avoid alcohol, cigarettes, and illegal drugs, 2. Limit caffeine intake 3. 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
equilibrium
internal
· . 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.
