Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines
2300 Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website:
www/tsu.edu

A Clinical Case Study presented to the Faculty of Tarlac State University

College of Science Department of Nursing

In Partial Fulfillment of the Requirements of the Subject

NCM 109 RLE (OB)

Incomplete
Miscarriage
Presented by:
VIACEL G. GAMBOA
MARRON JANE A. GANOTICE
XYRENCE P. GONZALES
HAILYNE JADE MAMUAD
TRIXIE T. MERCADO
KIESHA R. OCAMPO
KIRSTEN JOISE G.
PANGAN NICOLE REIN S.
PINEDA ALEXANDRA MAE
RUFINO JOSEPH G.
SANTOS

Presented to:
Flora M. Tel-Equen, RN, MAN
Pamela C. Pargad, RN
Rowena B. Lamorena, RN
Miriam Thea C. Damasco, RN, MAN
Mary Rose R. Camacho, RN, MSN

March 2023
 I. INTRODUCTION

Spontaneous abortion is a pregnancy that spontaneously terminates before the

fetus reaches a viable gestational age. This is often described as an embryo or fetus that
weighs 500 g or less, or that is less than 22 to 24 weeks of gestational age. Abortions can
occur spontaneously in a wide range of circumstances, such as those that are threatened,
inevitable, incomplete, complete, or missed (Allen and Forcier, n.d.).

According to Redinger and Nguyen (2022), in relation to this case study, an

incomplete abortion is the partial loss of the embryo within the first 20 weeks of pregnancy.
It generally presents as moderate to severe vaginal bleeding, which may be accompanied
by lower abdominal and/or pelvic pain. The causes of abortion are usually unknown,
however, they are most commonly linked to fetal chromosomal abnormalities. The other
causes and risk factors include cervical insufficiency, uterine abnormalities, and infection.

Incomplete septic abortions might result in complications including severe

hemorrhaging or sepsis. Following the management of an incomplete abortion, a number
of further complications could develop, including infertility, psychological effects, uterine
rupture, uterine perforation, subsequent hysterectomy, multisystem organ failure, pelvic
infection, cervical injury, vomiting, diarrhea, and death. Several types of shock, such as
hemorrhagic, septic, and cervical shock, can manifest in patients.

According to a series of papers published in The Lancet, one in every ten women
will suffer a miscarriage over her lifetime, amounting to 23 million pregnancies lost
annually, or 44 every minute worldwide. Risk factors such as age during pregnancy,
smoking, stress, air pollution, and pesticide exposure account for 15% of miscarriages,
according to one of the studies (Kuehn, 2021). In the Philippines, on the other hand, not
enough data was gathered.

GENERAL OBJECTIVES

This case study aims to promote health, provide evidence-based information for
health education, and prevent complications of the condition through the application of
appropriate nursing interventions.

SPECIFIC OBJECTIVES

1. To conduct an accurate physical assessment of the patient who is diagnosed with

incomplete miscarriage.
2. To develop a precise nursing diagnosis.
3. To prioritize and make a nursing care plan based on the clients’ complaints as
evident by subjective and objective data gathered from the assessment.
4. To provide essential and safe nursing interventions with regard to clients’ health
needs.
5. To evaluate the outcome of the nursing intervention rendered to the client.
6. To embark on documentation after probing and understanding the case study
thoroughly.
II. NURSING PROCESS
A. ASSESSMENT
1. PERSONAL DATA
a. Demographic Data

Name: L.M.
Age: 33 years old
Sex: Female
Civil Status: Widow
Religion: Roman Catholic
Occupation: Factory Worker
Position in the Family: Mother
Address: Capas, Tarlac
Date of Birth: February 23, 1990
Place of Birth: Capas, Tarlac
Nationality: Filipino
Chief complaint: Vaginal Bleeding
Date and Time of admission: February 28, 2023, 6:59 pm
Admitting Diagnosis: Incomplete Miscarriage, (G2P1) (1010) 15 weeks 1/7 days
Final Diagnosis: Incomplete Miscarriage, complete by Curettage (G2P1) (1010) 15
Weeks 1/7 Days

b. Environmental Status

Patient L is currently residing at Capas, Tarlac together with her daughter and parents.
Their house is a one-storey, two-bedroom structure, with concrete walls and metal roofs; has one
living room, one kitchen, one dining area, and one bathroom. Their house is located on the edge
of the town near the rice fields. They have windows in every room for ample ventilation, is
surrounded by trees, and away from pollutants.

c. Lifestyle

Patient L is a 33-year-old female. She is a G2P1. She goes to bed around 9:00
PM. and gets up at 5:00 AM. She has no known food or drug allergies. She had no prior
medical conditions, illnesses, or surgeries from her childhood. The patient also indicates
that she had all of her immunizations performed when she was a baby. The patient
states that her typical nutrition intake includes frequent substantial meals, usually three
times a day, that are mostly composed of fats, protein, and carbohydrates. She does
not have a regular exercise routine; she spends eight hours a day at work, and the rest
are spent on household chores, and napping or sleeping. And they usually purchase
mineral water from water stations as their drinking water.
 2. FAMILY HISTORY OF HEALTH AND ILLNESS

On both sides of the family, Patient L's two (2) grandparents are already
deceased. Due to old age, they already passed away. His grandfather on the side of his
mother is hypertensive. With one daughter, patient L is an only child. Patient L did not
inherit hypertension from her mother's side.

3. HISTORY OF PAST ILLNESS

The patient stated that she is fully immunized because she received all of her
immunizations as a child.

The patient indicated that she had common illnesses such as cough, cold, and fever
in some instances of her life, but she managed them with over-the-counter medications
such as solmux for cough, neozep for runny nose, and paracetamol for fever.

The patient had tonsillitis in December 2022, which led her to develop a fever. She had
taken several drug prescriptions, including antibiotics, but she had no idea what the drugs were.

4. HISTORY OF PRESENT ILLNESS

Two days prior to admission, the patient was already experiencing minimal vaginal
bleeding and lower abdominal pain with a pain scale of 3/10. One day prior to
admission, she had increased vaginal bleeding and lower abdominal pain on a 6/10
pain scale. An hour prior to admission she can no longer withstand the pain, she was
immediately taken to the hospital. The patient was awake, in pain, and restless when
she was initially assessed at Loving Mother General Hospital.
5. PHYSICAL ASSESSMENT (IIPA)
Area of Findings
assessment
Social Status The patient was
observed and
interviewed to assess
for social status.
According to her, she is
able to interact well with
her neighbors and co-
workers back home.
However, as she was
being interviewed, she
was hesitant to answer
some of the questions
and does not maintain
eye contact. She is
cooperative but often
displays non-verbal
Norms Analysis
The ability to interact Her social status is
successfully with the not considered
people and within the normal because of
environment of which her hesitance on
each person is a part telling the truth and
of, to develop and occasional negative
maintain intimacy with body languages.
significant others, and
to develop respect
and tolerance for
those with different
opinions and beliefs
(Fundamentals of
Nursing: Concepts,
Process, and
Practice, 10 Edition,
th

cues, such as fiddling 2018).

with her hands and
looking away.
Mental Status The patient was To be deemed Her mental status is
observed and mentally healthy, one not considered
interviewed to assess should be well- normal because of
for mental status. She is groomed, dress her inappropriate
restless and in guarding appropriately, have behavior while being
behavior. She was not decent posture, and assessed.
maintaining eye contact keep good eye
with the students most contact. Additionally,
of the time while being the patient is
questioned. But, she displaying behavior
was aware of what was that is appropriate for
happening around her the situation. The
and responds patient must be
appropriately to the aware of his/her
questions. surroundings and
situation, especially
their name, current
location, and date
(RM Voss, 2020).
Emotional The patient was A normal patient’s Her emotional status
Status observed and emotion correlates to is a normal
interviewed to assess environmental stimuli. response to her loss
for emotional status. Generally, a person is of pregnancy.
She stated that a family calm and happy.
member is always by However, sadness,
her side since her fear, disgust, and
hospitalization. She was anger are normal in
responsive but does not response to certain
hold eye contact, she is situations (AFFP
often looking away 2022).
because of being teary-
eyed, or playing with
her hands.
Sensory Her sensory
Perception perception is
Sense of Sight Her irises are black in Normal distant visual considered normal.
color. Her sclera is acuity is 20/20 with or
white. Using the without corrective
Snellen’s chart at 20 lenses. This means
 feet away, she is able to that the client can
read clearly the letters. distinguish what the
She stated that she person with normal
does not use vision can distinguish
eyeglasses. Pupils are from 20 feet away.
equal and (Health Assessment
accommodate. Using in Nursing, Janet
the penlight when light Weber, 2021, 7th Ed)
is flashed on her pupils,
they are reactive to
light, and
Sense of Taste accommodate. Pink lips are normal
in light-skinned
Lips are pink, smooth, clients, as are bluish
and moist; no lesions or or freckled lips in
ulcerations. Buccal some dark-skinned
mucosa pink and moist, clients, especially
with patchy areas of those of
dark pigment on ventral Mediterranean
surface of tongue, descent. The buccal
gums, and floor of mucosa should
mouth. No ulcers or appear pink in light-
nodules. Gums pink skinned clients; tissue
and moist, without pigmentation typically
inflammation, bleeding, increases in dark-
or discoloration. Hard skinned clients
and soft palates (Health Assessment
smooth, without lesions in Nursing, Janet
or masses. Tongue Weber, 2021, 7th Ed).
midline when protruded,
no lesions, or masses.
The patient’s sense of
taste was assessed by
asking her to taste a
candy and state the
flavor. She stated the
favor of the candy
correctly after a few
Sense of seconds of tasting it. Auricles must be
Hearing symmetrical, with the
Bilateral auricles same color as the
without deformity, face, and not tender.
lumps, or lesions. Auditory canals
Mastoid processes non contain dry cerumen,
tender. Bilateral grayish-tan color; or
auditory canals contain sticky, wet cerumen
scant amount of dark in various shades of
brown cerumen. The brown. Normal voice
patient’s sense of tones and sound
hearing was assessed must be audible in
by whispering words in both ears and must
both of her ears. She be able to repeat the
was able to respond whispered phrases
when being questioned correctly in both ears
and repeated the words (Kozier and Erb’s
whispered in her ears fundamentals of
correctly. Nursing, 2021, 11th
Edition).

Sense of Smell External nose must

be symmetric and
 straight with no
External structure of the discharge or flaring,
nose without deformity, not tender and no
asymmetry, or lesions. Able to
inflammation. Nares breathe and in
patent without swelling, through the nares.
exudate, lesions, or The nasal chamber’s
bleeding. Nasal septum mucosa must be pink,
midline without contain clear, watery
bleeding, perforation, or discharge, and no
deviation. The patient’s lesions (Kozier and
sense of smell was Erb’s fundamentals of
assessed by asking her Nursing, 2021, 11th
to differentiate two Edition).
scents. She has no
problem breathing and
was able to tell apart
Sense of Touch the smell of alcohol and No complaints of
cologne. numbness, peculiar
sensations, paralysis,
The patient’s sense of or an abnormal
touch was assessed by sensation of burning,
asking her to touch and pain, or an electric
hold a few objects. She shock (Kozier and
was able to feel the Erb’s fundamentals of
objects that was Nursing, 2021, 11th
handed to her and she Edition).
stated the absence of
numbing sensations in
her hands.
Motor Stability The patient was Muscles should be Her motor stability is
observed and moved to command if not considered
interviewed to assess the motor function is normal because she
for motor stability. intact. There must be is unable to move on
According to her, she symmetrical her own due to the
feels weakness on the movement and miscarriage and
lower back part of her strength (Morgan, performed surgical
body but is able to 2019). Mobility on procedure.
extend and use her both sides of the body
arms for reaching is generally robust.
nearby objects. She is Asymmetry exists in
unable to face her normal mobility. A
sides, stand, sit or walk normal person can
without assistance due stand upright without
to body weakness. assistance (Nurse
Guide 4th edition by
Marilynn E.
Doenges).
Body The patient’s body Normal body Her body
Temperature temperature was temperature changes temperature is not
35.7°C. Then depending on the within the normal
reassessed after 2 individual, age, range.
hours with a result of activity, and time of
36.6°C (taken post-op). day. The typical
normal body
temperature is 98.6
degrees Fahrenheit
(37 degrees Celsius).
According to some
studies, the normal
body temperature can
 range from 97 ° F
(36.1 ° C) to 99 ° F
(37.2 ° C) (Medicine
plus, 2021).
Respiratory The patient’s respiratory An adult's resting Her respiratory
Status rate was 17 cpm and respiration rate status is within the
SPO2 was 98%; lungs ranges from 12 to 20 normal range.
expanded breaths per minute
symmetrically, and (URMCR, 2021).
there were no signs of Respiration has a
shortness of breath and regular rhythm, is
labored breathing silent, and effortless.
(taken post-op). (Kozier & Erb’s
Fundamentals of
Nursing Global
Edition, 2021).
Circulatory The blood pressure was Normal cardiac rate Her circulatory
Status 110/80 mmHg and for an adult is 60-100 status is within the
pulse rate was 74 bpm; beats per minute normal range.
pulse rhythm was while the normal
regular and even, and blood pressure is
force was normal and 120/80 mmHg. A
strong (taken post-op). normal pulse has
equal time periods
between beats, and
can be felt with
moderate pressure,
and the pressure is
equal with each beat.
A forceful pulse
volume is full; an
easily obliterated
pulse (Kozier & Erb’s
Fundamentals of
Nursing Global
Edition, 2021).
Nutritional The patient was Optimal weight gain Her nutritional status
Status interviewed and her during pregnancy is normal because
BMI was calculated to depends on the she falls under the
assess for nutritional client’s normal BMI
status. Her weight and height and weight. category, and proper
height before Recommended weight gain was also
pregnancy was weight gain in evident because she
approximately 55kg and pregnancy is as was only able to
165.10cm (BMI: follows: underweight reach 15 weeks
Normal); her weight and client, 28–40 lb; AOG.
height after pregnancy normal weight client,
is 58kg and 165.20cm 25–35
(BMI: Normal). She lb; overweight client,
stated that she is able 15–25 lb; twin
to eat a wide range of gestation, 35–45 lb
meal at home, such as (American
meat, poultry, College of
vegetables, fruit, and Obstetricians and
rice, and she drinks 6-8 Gynecologists
glasses of water in a [ACOG], (2020). Low
day. pregnant weight and
inadequate weight
gain during
pregnancy
contribute to
 intrauterine growth
retardation and low
birth weight.
Elimination The patient was Normal bowel Her elimination
Status interviewed to assess movement of a status is normal
for elimination status. person must be 1 to 2 having the
According to the client, times a day and approximate number
she normally defecates voiding in 3 to 4 times of times for
1-2 times each day and a day with an output defecating and
urinates approximately of 1200 to 1500mL a voiding.
4-5 times a day. day (Kozier & Erb’s
Fundamentals of
Nursing Global
Edition, 2021).
Reproductive The patient was Girls can begin their Her reproductive
Status interviewed to assess periods at any age, status is normal
for reproductive status. although the average because she was
The patient’s first is approximately 12 able to have her
menarche came when years (NHS, 2023). menarche and
she was in high school, The number of reproduce, although
around the age of 14. acceptable soaked underwent
There was no history of pads for vaginal miscarriage, and
sexually transmitted bleeding should not bleeding is within
infections mentioned. exceed normal range.
She is a G2P1 with 15 2 maxi-pads per hour
weeks and 1/7 days for for two or more
her miscarriage. Her consecutive hours.
LMP was on November The surge of estrogen
14, 2022. Her bleeding and progesterone
soaks up 1 pad every 2 begins, causing
hours. There was notable changes in
hyperpigmentation of the mammary glands
the areola and nipple. (Maternal and Child
Health Nursing,
Pelliteri, 8th Ed, 2018).
Sleep-rest The patient was The National Sleep Her sleep-rest
pattern interviewed to assess Foundation suggests pattern is not normal
for sleep-rest pattern. that most individuals because she finds it
The patient stated that obtain between 7 and difficult to sleep and
she was experiencing 9 hours of sleep per is often disrupted
difficulty in resting and night in order to have while resting.
sleeping after what enough energy during
happened. She usually the day, and that
have trouble falling naps be no more than
asleep or have her 30 minutes (National
sleep disrupted by Sleep Foundation,
sudden awakening from 2022).
discomfort and pain.
State of Skin The patient was The skin's surface Her skin
appendages observed and should be smooth, appendages are
interviewed to assess without sensitivity, normal because she
for state of skin and firm and even did not reach the
appendages. The (NIH, 2022). Specific week that those skin
patient had normal skin skin changes that changes are
surface and texture. occur during supposed to
There had been no pregnancy include manifest.
report of skin allergy or dark spots on the
deviations. There was breast, nipples, or
presence of striae inner thighs, brown
gravidarum and but no patches on the face,
linea nigra. dark line that runs
from the navel to the
pubic hair, stretch
marks, acne, spider
veins, and varicose
veins (ACOG).
6. LABORATORY AND DIAGNOSTIC PROCEDURES

DIAGNOSTIC/ LABORATORY DATE PURPOSE OF THE RESULTS INTERPRETATION NURSING

PROCEDURE PERFORMED PROCEDURE AND ANALYSIS OF RESPONSIBILITIES
THE RESULTS (PRIOR, DURING
AND AFTER)
COMPLETE BLOOD COUNT February 28, A CBC will help document Hemoglobin According to the PRIOR:
(CBC) 2023 the amount of blood loss Result: 108 g/l patient CBC  Explain to the
and whether anemia is (decreased) results, her patient what
present. If the hemoglobin platelets count CBC is for and
and hematocrit are very Normal: 115/160 was within the its importance.
low and the patient is g/dl normal range.
symptomatic, then However, her DURING:
transfusions would be MCV hemoglobin and  Proper
warranted. The CBC also Result: 65 fL MCV resulted endorsement to
will provide evidence (decreased) below normal medical
regarding an infection, which could technologist and
which, in the case of Normal: 80-90 fL indicate iron help, if
infection, would yield an deficiency and necessary.
elevated white blood cell WBC may also due to
count and a left shift on Result: 12.6x lost of substantial AFTER:
differential. (elevated) amount of blood  Monitor the
(Bryant B. Et.al puncture site for
Normal: 4.5 – 2018). And her any blood clot
11x1000/mm3 WBC count was formation.
higher than  Document
PLATELET normal which procedure in the
Result: 204,000 possibly due to patient record
mcL (normal) the presence of
infection or
Normal: 150,000– inflammation
400,000 mcL (Cleveland Clinic,
2022).
Here are some more tests that are performed for a patient with suspected miscarriage, however, they were not performed on the patient:

DIAGNOSTIC/ LABORATORY DATE PURPOSE OF THE RESULTS INTERPRETATION NURSING

PROCEDURE PERFORMED PROCEDURE AND ANALYSIS OF RESPONSIBILITIES
THE RESULTS (PRIOR, DURING
AND AFTER)
QUALITATIVE HUMAN HCG appears in the blood Result: Lower than PRIOR:
CHORIONIC GONADOTROPIN and urine of pregnant 4,000mIU/mL normal levels of  Explain to the
(HCG) TEST women as early as 10 (low) hCG may indicate patient what
days after conception. a problem with the HCG test is for
Normal: For 13-16
Quantitative HCG weeks LMP pregnancy and its
measurement helps 13,300- including importance.
determine the exact age 254,000mIU/ml miscarriage,
of the fetus. It can also ectopic pregnancy DURING:
assist in the diagnosis of or fetal death.  Proper
abnormal pregnancies, endorsement to
such as ectopic medical
pregnancies, molar technologist and
pregnancies, and possible help, if
miscarriages. necessary.

AFTER:
 Monitor the
puncture site for
any blood clot
formation.
 Document
procedure in the
patient record.
DIAGNOSTIC/ LABORATORY DATE PURPOSE OF THE RESULTS INTERPRETATION NURSING
PROCEDURE PERFORMED PROCEDURE AND ANALYSIS OF RESPONSIBILITIES
THE RESULTS (PRIOR, DURING
AND AFTER)
ULTRASONOGRAPHY Ultrasound is used during Presence of some Presence of some PRIOR:
pregnancy to check the products of products of  Explain to the
baby's development, the conception in the conception in the patient what
presence of a multiple uterus. uterus indicates ultrasound is for
pregnancy, and to help incomplete and its
pick up any abnormalities. miscarriage or importance.
abortion, it may  Instruct the
not only include patient to drink a
the fetus but also full glass of
the placenta and water every 15
any other tissues minutes an hour
that may result and a half before
from a fertilized the procedure to
egg. ensure a full
bladder.
 Instruct the
patient not to
void before the
procedure.

DURING:
 Proper
endorsement to
sonographer
and help, if
necessary.
 Ask the patient
to relax while
the procedure is
ongoing
AFTER:
 Allow the
mother to void.
 Allow the
mother to take
home a
photograph of
the sonogram
image.
 Document
procedure in the
patient record.
7.PATHOPHYSIOLOGY

Book Based Pathophysiology

A miscarriage typically happens when the pregnancy is not progressing normally. A

newborn develops from a male and a female cell through a very intricate process. The
pregnancy won't progress if something goes wrong with the process. A variety of
maternal, placental, and fetal factors, including aging, illness, systemic disease, radiation
exposure, abnormalities of the reproductive system, drug consumption, and premature
separation of the normally implanted placenta, are among the many reasons of
incomplete abortion.

Another cause of miscarriage may be that the developing pregnancy did not embed itself
properly into the lining of the uterus (womb).

As a result, the egg separates from the uterus and bleeds. After, blood will collect
between the uterine wall and chorionic membrane causing uterine cramping with little
vaginal bleeding as a result of collected blood leaking to the cervix, one of the recognized
symptoms of an abortion. Moreover, this pool of blood will result in subchorionic
hemorrhage. This bleeding will lead to a membrane rupture if adequate treatment is not
given, which will stop the blood flow. The embryo receives all the oxygen and nutrition it
needs from the blood and could not survive in the absence of this. The uterus would
identify a non-viable fetus as a foreign body and expel it as a natural response.
Patient Based Pathophysiology
B. PLANNING
Nursing Care Plan Post-Operative
PRIORITIZATION
Ranking Diagnosis
1st Acute pain related to
disruption of endometrial
tissue during the surgical
removal of the uterine
contents as manifested by
verbalization of pain, facial
mask of pain, abdominal
guarding and a pain scale
of 8/10
2nd Grieving related to loss of
the unborn child as
manifested by verbal
expression of distress
3rd Risk for infection related to
performed invasive
surgical procedure
Justification
This has the highest
priority basing from
OFFTERAS. Under the
physiologic needs.,
OFFTERAS is used as the
basis for prioritization
wherein rest and comfort
is affected. Pain is a
subjective feeling that
affects the comfort status
of the patient.
This is the last among the
actual problems. Using
Maslow’s Hierarchy of
needs, esteem needs,
such as confidence,
strength, self-belief,
personal and social
acceptance, and respect
from others, is the fourth
key stage in achieving
contentedness or self-
actualization. Losing a
baby in pregnancy through
miscarriage is linked to
stigma and shame. Many
women still do not receive
appropriate and respectful
care when their baby dies
during pregnancy. The
client is experiencing
emotional distress that
must be attended to and
treated because it can be
the hindrance to the
recovery of the patient.
Using Maslow’s Hierarchy
of needs, safety needs,
such as security of body,
of employment, of
resources, of morality, and
of health, is the second
key stage in achieving
contentedness or self-
actualization. Risk for
infection can be
heightened by anything
that interferes with the
body’s ability to fight off
pathogenic invasions. One
key risk factor is the
breakdown of the body’s
physical defense
mechanisms. This type of
breakdown can be broken
skin due to injury, surgery,
or other invasive
procedures. It can also
take the form of altered
peristalsis, swelling or
stasis of body fluids, or
damage to mucous
membranes.
NCP 1
Nursing
Assessment Planning Nursing Intervention Rationale Evaluation
Diagnosis
Subjective: Acute pain related Short term: Independent: Independent: Short term:
“Masakit dito sa to disruption of Within 1 hour of proper 1. Encourage the use of 1. Relaxation After 1 hour of proper
may bandang ibaba endometrial tissue nursing intervention, the relaxation techniques techniques relieve nursing intervention,
ng tiyan ko, hindi during the surgical patient’s subjective such as deep- muscle and the patient’s
rin ako kumportable removal of the perception is at an breathing exercises, emotional tension, subjective perception
gumalaw.” as uterine contents as acceptable level, as guided imagery, enhance the sense is at an acceptable
stated by the manifested by evidenced by a report of visualization, or of control, and may level, as evidenced
patient verbalization of no more than 2-3 on a music. improve coping by a report of no
Pain score: 8/10 pain, facial mask of 0-10 pain scale; abilities. more than 2-3 on a 0-
pain, abdominal objective measures 10 pain scale;
Objective: guarding and a such as grimacing are 2. Positioning in labor objective measures
(+) Facial grimace pain scale of 8/10 diminished or absent. 2. Position for comfort affects anatomic and such as grimacing
(+) Restlessness and physiologic physiologic were diminished and
(+) Irritability Scientific response; promote responses (i.e., absent.
(+) Guarding Explanation: position changes alters cardiac output,
behavior The operation q30min while the enhances or reduces Goal met.
performed on patient is awake. effectiveness of
T: 36.6°C women involves the uterine contractions,
RR: 17cpm scraping of the synchronizes
PR: 74bpm uterus (womb) abdominal muscle
BP: 110/80 mmHg lining which causes work, and reduces
SPO2: 98% injury to uterine pressure on the
tissues. The cervix preterm fetal head).
(neck) of the uterus Frequent position
(womb) is dilated changes increase
using an instrument comfort and
called a dilator. The circulation and
endometrium (lining relieve fatigue.
of the uterus) or
contents of the 3. Anticipation of pain
uterus are 3. Educate the client may help the client
removed. about the nature of cope with the reality
 discomfort expected. of its presence.
Informing the client
regarding the
forthcoming
procedure is an
effective tool for
reducing
preoperative anxiety,
which contributes to
the perception of
significant pain.

4. Heat or cold
4. Provide additional application may
comfort measures improve circulation,
such as back rub and reduce muscle
heat or cold tension and anxiety
applications. associated with pain.
It may also enhance
the sense of well-
being.

Dependent:
Dependent: 1. Analgesics may be
1. Administer mefenamic prescribed to
acid, as indicated. alleviate the
cramping after the
procedure. Some
cramping or mild
abdominal
discomfort is
considered usual
after D&C.
NCP 2
Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation
Subjective: Grieving related to Within 24 hours of Independent: Independent: After 24 hours of
“Masakit syempre loss of the unborn proper guidance and 1. Encourage 1. To provide continuity proper guidance and
mabigat sa loob” as child as manifested support given, the continuation of of support and support given, the
verbalized by the by verbal patient and her family support system(s) promote recovery patient and her
patient, and the expression of will begin expressing after hospital over a long period of family was able to
denial of distress their grief, acknowledge discharge. time. move forward and
what caused her that grieving takes a accept the reality of
abortion Scientific long time with no 2. Explain that everyone 2. To emphasize that the loss.
Explanation: specific time frames, grieves differently. coping styles vary
Objective: Grieving is an and begin working with Provide space for and with individuals and Goal met.
(+) Restlessness individual’s other support persons communicate support. can differ between
(+) Crying emotional and in and out of the family. women and men.
(+) Lowered voice psychological
(+) Lack of strength response to a loss 3. Grieve with the 3. To emphasize
(+) Physical that may be patient and family, if emotional and
exhaustion perceived or actual. helpful. psychologic support.
Grief is a natural
human response to Dependent:
loss, and it can be Dependent: 1. To support needs of
shown in a variety 1. Refer to a social both intuitive and
of ways, including worker, chaplain, instrumental styles of
physical symptoms, and/or grief coping. They assist
emotional distress, counselor, as needed. with decisions and
and changes in provide support
behavior. The brain related to pregnancy
will send a cascade loss, both in hospital
of stress hormones and after discharge.
and other signals to
the cardiovascular
and immune
systems that can
ultimately change
how those systems
function.
NCP 3
Nursing
Assessment Planning Nursing Intervention Rationale Evaluation
Diagnosis
Subjective: Risk for infection Short term: Independent: Independent: Short term:
N/A related to performed Within 8 hours of 1. Practice and 1. To prevent After 8 hours of
invasive procedure proper nursing demonstrate healthcare- proper nursing
Objective: interventions, the proper hand hygiene associated interventions, the
Scientific client is expected to by staff and visitors. infections, cross- client remained
CBC RESULTS Explanation: remain afebrile, infection, and afebrile, achieved
Hemoglobin One method for achieve timely healing reduce the spread timely healing as
Result: 108 g/l treating the various as appropriate, of antimicrobial appropriate,
(decreased) types of miscarriages verbalize resistance. verbalized
that happen often in understanding of understanding of
MCV daily life is surgical individual exposure 2. Encourage increased 2. To enhance the individual exposure
Result: 65 fL evacuation. and risk factors, and fluid intake. immune system and and risk factors, and
(decreased) However, this identify interventions aids in natural identifed
method is linked to a to prevent and reduce defense interventions to
WBC number of problems the risk of infection. mechanisms. prevent and reduce
Result: 12.6x that raise the risk of the risk of infection.
(elevated) maternal morbidity 3. Encourage the client 3. To promote body’s
and mortality. When to increase intake of mechanism for Goal met.
the uterine protein-rich foods timely healing.
perforation damages and vitamin C-rich
the colon and foods.
requires laparotomy 4. To prevent or limit
to treat, the infection 4. Advice the patient to further
caused by the report if she complications.
perforation might experiences heavy
become quite bleeding or foul-
dangerous. smelling discharge,
lasting dizziness,
fever, cramps lasting
for 48 hours, and
lasting pain.
5. To avoid the
5. Emphasize the recurrence of
necessity of taking infection and
 antibiotics as development of
directed, especially secondary
dosage and length of infections or
therapy. resistant organisms
due to the
unnecessary use of
antibiotics.

6. To know when
6. Monitor the client’s leukocyte counts in
WBC count. the upper limits
because it is more
likely to be
associated with
infection than lower
counts.

Dependent:
Dependent: 1. To provide
1. Administer cefalexin, pharmacological
as indicated. treatment regimen.
 C. IMPLEMENTATION
1. DRUG STUDY

Name of the Route of Mechanism of Indication Contraindication Side Effects and Nursing Rationale
Drug Administration, Action Adverse Effects Responsibilities
Dosage, and
Frequency
Drug Name: Route: Oral Inhibits For the Contraindicated Side effects: Prior:
Mefenamic Acid synthesis of treatment of for patients with  Diarrhea  Get consent  To respect the
Dosage: 500mg prostaglandins mild to ulcers, stomach  Constipation from client. client’s right to
choose and
Brand Name: Frequency: TID in body tissues moderate pain, bleeding,  Headache
by inhibiting at inflammation, hypertension, or  Dizziness be informed
Ponstan
least 2 and fever. NSAID  Tinnitus about the
cyclooxygenase hypersensitivity  Pyrosis medication
Classification: isoenzymes, like aspirin. being given to
Nonsteroidal  Nausea
cyclooxygenase them.
Anti- -1 (COX-1) and Adverse effects:  Ask for any 
Inflammatory -2 (COX-2). To prvent
 Difficulty allergies or look
Drug (NSAID) possible
breathing or at the patient allergic
swallowing chart.
Pregnancy reactions
 Difficult or
Category: C caused by the
painful urination
medication.

Image:  Determine if
client has  It can
stomach increase risk
bleeding or for bleeding in
ulcers. stomach or
intestines.
After:
 Assess every
 To be able to
now and then have a faster
for any possible intervention in
side effects. case of side
effects.
Drug Name: Route: Oral Cephalexin It is used to Cephalexin is Side effects: Prior:
Cephalexin/ Dosage: 500mg binds to treat susceptible contraindicated to  Diarrhea  Review medical  To verify if the
Cefalexin bacterial cell bacterial those patients  Abdominal pain history patient has
Frequency: TID membranes, infections. who have  Clay-colored history of
Brand Name: inhibits bacterial hypersensitivity stools hypersensitivit
Keflex cell wall reactions to  Dark urine y to
synthesis, cephalosporins.  Dizzinness cephalosporin
Classification: leading s and other
 Fever
Cephalosphorin breakdown and conditions that
Antibiotic eventually cell may
Adverse effects:
death.  Acid or sour contraindicate
Pregnancy with this drug.
Category: stomach
 Heartburn  Secure
B  To practice
 Indigestion informed
consent before patient’s
Image:  Dry mouth
administration. rights.
 Muscle pain
 Trouble sleeping
 Cephalexin
should be taken  To prevent GI
with meals. upset.

After:
 Observe and
 To see any
instruct the
adverse
patient to report
effects that
any adverse
may show up
effects or
and to provide
complications
nursing
occur.
interventions.
 Instruct the
 To inform the
patient to finish
patient about
the full course
antibiotic
of the drug.
resistance,
because if the
patient did not
follow the full
course, it may
lead to
 antibiotic
resistance.
Drug Name: Route: Oral Methylergometri It is used to  Hypersensitivit Side effects: Prior
Methylergometri ne acts directly prevent or treat y  Nausea  Monitor vital  Methergine
ne Dosage: 125 on the smooth bleeding from  Hypertension  Vomiting signs apparently is
mcg muscle of the the uterus that  Preeclampsia  Stomach pain (particularly more likely to
cause the
Brand Name: Frequency: TID uterus and can happen  Diarrhea BP) and
increases the after an  Leg cramps uterine diastolic
Ergon
tone, rate, and abortion.  Skin rash response. pressure to
amplitude of rise thus
Classification: rhythmic blood
Adverse effects:
Ergot Alkaloids contractions pressure
 Significant: Hyp
through binding ertension, needs to be
and the During monitored.
Pregnancy myocardial
resultant  Assess
Category: C ischemia, MI;
antagonism of extremities for  Chest pain
ergotism, pleural color, warmth,
the dopamine fibrosis, occurring
Image: D1 receptor. movement, under oral
retroperitoneal pain report
Thus, it induces fibrosis treatment
a rapid and chest pain should require
(prolonged use). promptly.
sustained immediate
 Cardiac
tetanic attention even
disorders: Chest
uterotonic effect if atypical or in
pain,
which shortens the absence
bradycardia,
the third stage of
tachycardia,
of labor and After cardiovascular
palpitation,
reduces blood risk factors.
coronary arterial  Notify
loss. spasm. physician if BP
 Ear and suddenly  The most
labyrinth increases. common side
disorders: Tinnit effect of
us. methylergono
 Gastrointestinal vine
disorders: Naus (Methergine)
ea, vomiting, is high blood
diarrhea, pressure,
abdominal pain. which can
 Immune system sometimes
 disorders: Anap  Provide lead to
hylaxis support with seizure or
ambulation if headache.
dizziness
occurs.  Common side
effects of
 Assess methylergomet
increase of rine is
cramping and dizziness.
stomach pain.
 Since it makes
the muscles in
the uterus
contract,
Methylergomet
 Assess lochia rine also tends
frequently. to cause
stomach pain
and cramps.
 To determine
if the amount
discharged is
progressing to
normal limits

2. MEDICAL MANAGEMENT

MANAGEMENT DATE MEDICAL DESCRIPTION INDICATION/ PURPOSE PATIENT’S NURSING RESPONSIBILITIES

PERFORMED REACTION
Plain Dextrose February 28, Dextrose 5% in Lactated Ringers To maintain the amount of No adverse Prior:
5% in Lactated 2023 @ Solution (D5LRS) is a crystalloid body fluid, electrolytes, reaction  Review physician’s order.
Ringers 7:00pm isotonic IV fluid that provides and calories during a occurred  Look for signs of hypovolemia
Solution 1L fluid supply to maintain the termination of pregnancy, during the
electrolyte level of the body and preventing dehydration treatment. (hypertension, bounding pulse,
41-42 gtts/min
prevent dehydration. and shock. pulmonary crackles, dyspnea, shortness
of breath, peripheral edema, jugular
venous retention, and extra heart
 sounds.
 Properly label the IV fluid.

During:
 Establish IV site while observing aseptic
technique.
 Position the client in a semi-Fowler’s
position.
 Calculate and set the intended flow rate.

After:
 Watch for indicators of continuing
hypovolemia (low urine output, poor skin
turgor, tachycardia, a weak pulse, and
hypotension) since this indicates the
necessity for a continuous infusion.
 Teach the patient and guardian how to
identify the signs and symptoms of fluid
volume overload (hypertension,
bounding pulse, pulmonary crackles,
dyspnea, shortness of breath, peripheral
edema, jugular venous distention, and
extra heart sounds) so they can report it
immediately and medical attention will be
given.
Dextrose 5% February 28, Oxytocin is a hormone that To induce labor, No adverse Prior:
in Lactated 2023 facilitates childbirth by strengthen uterine reaction  Review physician’s order.
Ringers 9:43pm stimulating uterine muscle contractions, and control occurred  Check for contraindications to
Solution 1L c̅ contractions and increasing the bleeding in the patient during the administration, such as hypersensitivity.
Oxytocin 10 IU production of prostaglandins, with an incomplete treatment.
 Monitor the patient’s blood pressure and
which enhance contractions miscarriage.
compare it to the normal value because
even more and allow a pregnant
oxytocin can cause hypotension.
woman to deliver vaginally.
 Inform the mother to expect pain or
Synthetic oxytocin comes in two contractions upon administering
forms: Syntocinon and Pitocin. If oxytocin.
 labor hasn't started
spontaneously, either induce it or During:
enhance contractions. In  Established IV site while observing
addition, to accelerate placental
aseptic technique.
delivery and limit the risk of
excessive bleeding.  Position the client in a semi-fowler's
position.
 Calculate and set the intended flow rate.

After:
 Monitor the patient’s vital signs,
particularly the BP, because
administering oxytocin might cause
hypotension.
 Monitor patient fluids, both intake and
output because it is associated with
water retention and hyponatremia.
 Check and chart the frequency, duration,
and intensity of uterine contractions.
 Watch for hypertonic contraction. To help
the patient with her breathing, as this
type of contraction can frustrate the
woman with her breathing.
 Implement physical agents, relaxation
techniques, and manual therapies
(massage, others) as needed to help
reduce pain during uterine contractions.

3. SURGICAL MANAGEMENT

MANAGEMENT DATE MEDICAL DESCRIPTION INDICATION/ PURPOSE PATIENT’S NURSING RESPONSIBILITIES

PERFORMED REACTION
Dilation and February 28, Dilation and curettage is a minor To clear tissues that No adverse Prior:
Curettage 2023 surgical procedure for the remain in the uterine lining reaction  Review physician’s order.
(D&C) removal of tissue inside the
uterus using a small instrument
(vaginal speculum) or medication
(misoprostol) to open the cervix
and then a curette to remove
uterine tissue.
4. DIET
Type of Diet Date
after a miscarriage or
abortion to avoid infection
or heavy bleeding.
Indication/s
occurred  Instruct the patient to take nothing by
during the mouth for at least 6 to 8 hours prior to
treatment. the scheduled operation.
 Administer pre-op medicines as ordered.
 Explain the procedure briefly to the
patient, and the anesthesia to be given
and its side effects (such as vomiting).
 If ordered, perform enema early morning
on the day of operation if ordered.
During:
 Properly endorse the patient to the
gynecologist or obstetrician.
 Assist during the surgery.
After:
 Instruct the patient to look for signs and
symptoms of complication, such as
infection, uterine perforation, intrauterine
adhesions, and other abnormalities that
may arise after the surgery, and report it
to the nurse for validation and further
evaluation.
 Inform the patient that mild cramping and
spotting or light bleeding are typical side
effects of the surgery.
 Teach the patient not to put anything in
the vagina until the provider says so.
Nursing Responsibilities
 Diet As Tolerated (DAT)
February 28, 2023  Used when the pt. has an appetite
and the ability to eat preferred
foods.
 Pt. can be upgraded to DAT when
fluids are being well tolerated
 A patient must be able to consume
foods from one diet stage before
moving to the next.
 Instruct the patient and family about the
prescribed diet.
 Suggest food that are preferred and well
tolerated by the patient, preferably high in iron
and vitamin C.
 Suggest smaller, more frequent meal.
 Encourage adequate fluid intake. Avoid
drinking sodas, alcohol, and caffeine.
 Inform patient to avoid food that she cannot
tolerate or that causes gas, bloating or
stomach pain.

5. ACTIVITY

Type of activity/Exercise General Indication/Purpose Client’s

Description
Low Impact Exercise Low-impact exercise gets
your heart rate up slowly
and causes less pressure
on your joints than high-
impact exercise. Popular
forms of low-impact
exercise include walking,
yoga, Pilates, swimming,
skating, cross-country
skiing, and golf.
Response
Indications: It allows patients to improved flexibility, reduced
 Patient suffered an injury or have chance of injury, and perform the activities of
come down with an illness. daily living after hospital discharge.
 Patient who undergone surgery.
 Patient who are injured or
recovering from injury.
 Low-impact exercise is considered
to perform if an individual is new to
working out or is managing joint
issues.
 Performed by elders.

Purpose:
Low-impact exercise is an excellent
way to maintain your fitness and get
your body moving without putting too
much stress on your joints.
D. EVALUATION
a. General Condition of Discharge
Following the patient discharge, client received various medications as well as nursing
interventions that eased the pain and health needs of the client. It is vital to continue health
practices to maintain the wellness of the client. Before the discharge process, client was able
to exhibit health practices as guided by the nurse. She can stand but with the assistance of
others due to her previous operation. The patient was advised to have enough rest and
promote a healthy lifestyle for her fast recovery. The tables below show the method
approach that should be followed by the client.

b. Methods of Approach

MEDICATION 1. Cefalexine
Indication: It's used to treat bacterial infections, such as
pneumonia and other chest infections, skin infections and
urinary tract infections (UTIs).
Dosage: 500mg/cap
Frequency: Three times a day for 7days
Route: Oral

2. Methylergometrine
Indication: Methergine (methylergometrine) is a
vasoconstrictor and often used in obstetrics to control
bleeding after a delivery or spontaneous or induced
abortion.
Dosage: 125 mcg/T
Frequency: Three times a day for 3days
Route: Oral

3. Mefenamic Acid
Indication: It is most often used for treating pain of
dysmenorrhea in the short term (seven days or less), as well
as mild to moderate pain including headache, dental pain,
postoperative and postpartum pain.
Dosage: 500 mg
Frequency: Three times a day PRN (as needed)
Route: Oral

EXERCISE The physician recommended low impact physical exercise/activity

per week, such walking, yoga, and other flexibility exercises.

TREATMENT Patient was advised to have enough rest, promote proper self-care,
follow medication regimen, and nutritional diet.

HEALTH  Assist the patient when getting up and walking.

TEACHING  Informed patient to not put anything in her vagina such as tampon or
menstrual cups for 2 weeks.
 Avoid having sex or swimming until the bleeding stops.
 Maintain proper hygiene upon discharge.
 Take the medications properly such as proper dose and frequency
indicated.
 Seek for medical help or return for follow-up when
complications occur.
OUTPATIENT Patient L was informed to return for OB follow-up on March 7,
DEPARTMENT 2023. The physician will check for vaginal bleeding, and health
FOLLOW-UP progress of the patient.
DIET The patient was given the recommendation to follow the DAT diet,
which has a soft texture, low fiber, and is easy to digest. The
purpose is to lessen symptoms that could lead to abdominal pain
and discomfort, such as nausea, diarrhea, and bowel gas.
 III. CONCLUSION

With the comprehensive analysis of the case study, it is determined that a miscarriage
is the loss of a pregnancy before 20 weeks. Miscarriages happen frequently. Most occur
when the uterine fertilized egg does not mature properly. If bleeding has started and the
cervix has dilated, but the uterus still contains pregnancy tissue, the miscarriage is classified
as "incomplete."

A miscarriage that is incomplete when it is diagnosed will typically end on its own
without further treatment. Nevertheless, occasionally the body has problems eliminating the
tissue, and the miscarriage doesn't end until the woman gets medical attention. The
incomplete miscarriage may result in extremely intense bleeding, protracted bleeding, or an
infection if the tissue is not removed. While random genetic issues in the developing fetus
account for 50% to 70% of all miscarriages, there are other reasons and risk factors for
miscarriage.

In this case, the mother was unaware that she is pregnant. Due to a disease, the
patient was prescribed a number of medications as well as drinking alcohol and working
under stress due to her work as a factory worker. Drugs or medication taken in pregnancy
can cross the placenta and impact on the developing baby, while working stressfully,
physically, psychologically, or both, has deleterious effects on pregnancy. Stressful work
increases the risks of miscarriage. The greater the stress, the greater the risks of pregnancy
complications.

It is the duty of nursing students to understand nursing interventions and the

appropriate level of client care. Understanding and knowing how to prioritize the
requirements of the clients is essential, as is educating and assisting them in obtaining the
fullest possible level of care that they are entitled to.

It is part of our duty as student nurses to educate our patients about potential
consequences and what they should do to avoid them. All pregnant women must take care
of themselves because their choices have a significant impact on the overall health of their
unborn child.

IV. RECOMMENDATION

To nursing students
This case study can serve as a springboard for further medical inquiry and as a useful
manual for nursing students, particularly in the context of abortion. Nursing students should
be aware of this complication in order to have a basic concept of what may be done if it is
encountered during clinical exposure and what health lessons to impart to patients and
family members if it is encountered. Students majoring in medical related fields should keep
expanding their knowledge and expertise so they can create effective nursing interventions
to meet the needs of patients.

To healthcare providers
This case study can serve as a springboard for further medical inquiry and as a useful
manual for healthcare providers, particularly in the context of performing laboratory and
diagnostic tests for patient undergoing incomplete miscarriage. It is important to complete
patients’ laboratory and diagnostic tests to properly identify the patient’s condition and to
provide proper treatment and management. Furthermore, these tests will serve as important
record materials for documenting and storing medical procedures done to a certain patient
that might be useful for future purposes.
V. REVIEW OF RELATED LITERATURE AND STUDIES

International
According to Al Wattar et. al. (2019), up to 25% of pregnant women are thought to
experience first trimester miscarriage, the most frequent type of pregnancy loss. The quality
of life for the spouse can be negatively impacted by miscarriage due to its high clinical and
emotional morbidity. By focusing on the needs of the patient, patient-centered care can
lessen the psychological effects of miscarriage, such as heightened anxiety, despair, grief,
and low self-esteem. Several treatments for first-trimester miscarriage were evaluated, such
as expectant management (EXP), sharp dilation and curettage (D+C), electric vacuum
aspiration (EVAC), manual vacuum aspiration (MVA), misoprostol alone (MISO),
mifepristone+misoprostol (MIFE+MISO), and misoprostol plus electric vacuum aspiration
(MISO+EVAC). Among all these, the study concluded that EXP (for non-pharmacological
treatment), and MISO and MIFE + MISO (for pharmachological treatmeant) are the most
effective management for first-trimester miscarriage.
In another study, Agwu et. al. (2020) discussed the comparison of Manual Vaccum
Aspiration (MVA) and Misoprostol as managements of first-trimester incomplete miscarriage
in a low-resource setting. Incomplete miscarriage can be treated safely and effectively with
manual vacuum aspiration, but it is not commonly accessible or cost-effective in rural
regions, especially in low-resource nations. Hence, the study concluded that incomplete
miscarriage can be treated with misoprostol instead of manual vacuum suction. There was
no statistically significant difference in the efficacy of the two treatment modalities, despite
the increased failure rate of medical treatment. Nonetheless, medicinal treatment was more
cost-effective than surgical treatment and was related with higher client acceptability and
satisfaction.
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