1

PATIENT BIODATA
Name of Patient - Mrs. Purnima Saha

W/O - Akhilesh Saha

Age/ Sex - 33 Yrs/F

Education - 10

Occupation - Housewife

Income - 20000/- month

Marital Status - Married

Religious - Hindu

Address -

Date of Admission -

Diagnosis - Abortion

Ward - Gynae ward

Present Complaints: Patient having complaint of Pain in abdomen,

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

Present Surgical History:

Patient has no any present surgical history

Past Medical History: She was previously admitted in government hospital

for delivery before 5 years.

Past Surgical History: Patients have no any past surgical history.

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

Family tree:

Male

Female

Client
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Socio Economic History:

Mrs. Purnima lives in her own concrete house. There was adequate
electricity & water supply (hand pump) is present. She has 2 rooms in her house
with proper ventilation. Her family income is around 20.000/- month. Her
relation with other member of family & with other relatives is good & healthy.

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

PHYSICAL EXAMINATION -
Anthropometric measurements:
Height - 5 ft
Weight - 44 kg.
Vitals:
Temperature - 98*F
Pulse - 100b / min.
Respiration - 18b/ min.
Blood Pressure - 110/70 mm Hg
General appearance:
Consciousness: conscious
Body build: thin.
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Head:
Hair - Black in Color
Scalp - Itching and dandruff present.
Face - Slight pigmentation
Sinus - Normal
Cranium - symmetrical
Eyes
Visual activity - Normal
Ocular movement - Normal
Lids - Clear
Lacrimal gland - Proper functioning
Conjunctiva - Pale
Sclera - White
Ears
External Structure - Normal
Mucus membrane - No discharge
Tympanic membrane- Normal
Hearing - Normal.
Nose:
Eternal Structure - Short & round
Septum - symmetrical
Mucous Membrane - pink color
Nasal deviation - Normal nasal deviation
Epitasis - not present
Oral Cavity:
Lips - pink color.
Gums - no swelling
Oral cavity - clean, pink color
Teeth - Symmetrical & yellowish.
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Tongue - light pink in color, no erethroplasia present, no white

patches present, Present in center line.
Taste - Normal
Voice - Soft
Neck:
General Structure - Normal
Tracheal sound - Heard
Thyroid and Parathyroid - No enlargement.
Lymph node - No enlargement
Range of motion - All movement present
(Flexion, extension, internal and
External rotation and circumduction.)
Chest and respiratory systems
Chest Shape - symmetrical
Respiration rate - 22 b/min.
General palpation - no palpable mass present, no fluid
Collection
Percussion - No pleural effusion.
Breathe sound - Heard.
Abdomen
Scar marks - absent
Hernias - absent
Masses - absent
Uterus - tenderness is present
Spleen - no spleenomegaly.
Hepatic - no hepatomegaly.
Bladder - normal
Palpation - abnormal mass is palpable on lower
abdomen.
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Back
No lordosis, kyphosis, sclerosis present.
Genitalia & rectal examination
 No pus inflammation.
 No congenital abnormality present.
 Any infection is not present.
 Vaginal discharge present.

Upper & Lower extremities-

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

Drug Rout Indication Action Side effects Nurse

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

4-Administer the
five rights.

5-Always follow
six rights and test
dose should be
done.
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(2)Inj. Peptic ulcer, It is a newer Known 1-Assess the

0- gastro H+ k+ ATP hypersensitivity general condition
Pantoprazol 40m
oesophageal inhibitor of patient.
e g reflux similar in
slow 2-Always follow
Trade potency and
I/V six rights.
name: clinical
efficacy to 3-Check the
pan top omeprazole allergic reaction

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

1)External female genitalia

The external organs of the female reproductive system include the mons pubis,
labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a
group, these structures that surround the openings of the urethra and vagina
compose the vulva, from the Latin word meaning covering. See Figure 1-6.

a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis
and covered with thick coarse hair.

b. Labia Majora. The labia majora run posterior from the mons pubis. They are
the 2 elongated hair covered skin folds. They enclose and protect other external
reproductive organs.

c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia
majora. They protect the opening of the vagina and urethra.

d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the
vaginal introitus.
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(1) The clitoris is a short erectile organ at the top of the vaginal vestibule whose
function is sexual excitation.

(2) The urethral meatus is the mouth or opening of the urethra. The urethra is a
small tubular structure that drains urine from the bladder.

(3) The vaginal introitus is the vaginal entrance.

External female genitalia.

e. Perineum. This is the skin covered muscular area between the vaginal
opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and
anal opening. It also helps support the pelvic contents.

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

glands lie on either side of the vaginal opening. They produce a mucoid
substance, which provides lubrication for intercourse.

1-5. BLOOD SUPPLY

The blood supply is derived from the uterine and ovarian arteries that extend
from the internal iliac arteries and the aorta. The increased demands of
pregnancy necessitate a rich supply of blood to the uterus. New, larger blood
vessels develop to accommodate the need of the growing uterus. The venous
circulation is accomplished via the internal iliac and common iliac vein.

INTERNAL FEMALE ORGANS

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

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

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

MEASUREMENT AND PARTS OF UTERUS:

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

STRUCTURE:
The uterus is held in place by the following ligaments:
a. The broad ligaments
b. The uterosacral ligaments
c. The round ligaments
d. The cardinal (lateral cervical) ligaments
The wall of the uterus consists of the following three layers:
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e. The perimetrium is a serous membrane that lines the outside of the

uterus.
f. The myometrium consists of several layers of smooth muscle and
imparts the bulk of the uterine wall. Contractions of these muscles
during childbirth help force the fetus out of the uterus.
g. The endometrium is the highly vascularised mucosa that lines the
inside of the uterus. If an oocyte has been fertilized by a sperm, the
zygote (the fertilized egg) implants on this tissue. The endometrium
itself consists of two layers. The stratum functionalise (functional
layer) is the innermost layer (facing the uterine lumen) and is shed
during menstruation. The outermost stratum basalis (basal layer) is
permanent and generates each new stratum functionalise.

ABORTION

SPONTANEOUS INDUCED
(Miscarriage) (Deliberate)

ISOLATED RECURRENT LEGAL ILLEGAL

MTP UNSAFE

SEPTIC COMMON

THREATENED INEVITABLE COMPLETE INCOMPLETE MISSED

SEPTIC LESS COMMON

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

b. Pain in back & abdomen.

c. Internal examination reveals the dilated internal os.

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

b. Pain – bleeding is usually painless but there is mild backache & lower abdomen.

3. Inevitable miscarriage
It is a clinical type of abortion where the changes have progressed to a stable
from where continuation of pregnancy is impossible.
Clinical features:-
A. Increase vaginal bleeding.

B. Pain in lower abdomen.

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

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

B. Persistence of vaginal bleeding

C. Internal examination revels –

• Uterus smaller than period of amenorrhea

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• Patulous cervical Os often admitted tip of the finger.

• Varying amount of bleeding.

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

Retrogression of breast change.

Cessation of uterine growth.

Cervix feels firm.

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

Purulent vaginal discharge

Lower abdominal pain & tenderness.

Chills

Diarrhoea & vomiting

Tachypnea

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

ii. Acquired - D &C operation

iii. Others :- multiple gestation

Diagnosis & management of cervical incompetence

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1. History.

2. Internal examination.

3. Speculum examination.

Management: - it includes two types of operations.

1. SHIRODKAR’S OPERATION

2. McDonald’s OPERATION

Diagnostic evaluations of abortion

1. History taking –
 Previous history of abortion.

 Personal & obstetrical history.

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

 Urine for immunological & culture.

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

 Complication of abortion

1) Sepsis & placental polyp.

2) Blood coagulation disorders.

3) Haemorrhage.

4) Injury may occur to the uterus.

5) Renal failure due to spread of infection.

6) Chronic pelvic & back ache.

7) Dyspareunia.

8) Cervical incompetence.

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

 Drugs- diazepam 5mg BD.

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

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

cavity.

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

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

5. Missed abortion:- it include

a. Medical:- oxytocin 10 – 20 units.

b. Surgical :- D & C

6. Septic abortion: - It includes:-

 General measure – Hospitalization is essential for all cases of septic abortion.

 Vaginal swab for culture & drug sensitivity.

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

 D & C is done.

Dilatation & Curettage

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

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

SIGN AND SYMPTOMS:

S. IN BOOK IN PATIENT
NO
.

1. Fleshy mass per vagina  Present.

2. Pain in lower abdomen  Present.
3. Persistence vaginal bleeding  Present.
4. Uterus smaller than period of  Not present.
amenorrhea.
Patulous cervical os
5.  Present.
Chills and rigor
6.  Present.
Tachypnea
7.  Not present.
Impaired mental status
8.  Not present.
Hypothermia
9.  Not present.

INVESTIGATION:
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S. NAME OF THE NORMAL VALUE PATIENT

NO. INVESTIGATION VALUE

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

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

MANAGEMENT:
According to book:
In recent cases
Evacuation of the retained products of conception (ERCP)is done.
She should be resuscitated before any active treatment is undertaken.
EARLY ABORTION: dilatation and evacuation under analgesics or general
anesthesia is to be done. Evacuation of the uterus may be done using MVA also.
LATE ABORTION: the uterus is evacuated under general anesthesia and the
products are removed by ovum forceps or by blunt curette. In late cases
dilatation and curettage operation is to be done to remove the bits of tissues left
behind. The removed materials are subjected to a histological examination.
MEDICAL MANAGEMENT of incomplete miscarriage may be done. Tablet
misoprostol 200µg is used vaginally every 2hours.
 NSAIDs can be used to reduce painful menses.
 Oral contraceptive pills are prescribed to reduce uterine bleeding and
cramps.
 Anemia may have to be treated with iron supplementation.
1. SURGICAL MANAGEMENT:
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According to book:
 Dilatation and evacuation
 Intrauterine instillation of hypertonic solution:
 Extra-amniotic: instillation of 0.1 ethacridine lactate
 Intra-amniotic: instillation of 20% of hypertonic
saline.
 Hyserotomy.

8. NURSING MANAGEMENT:
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I assess the patient according there priority needs. The priority needs of my
patient are given below & I assess my patient for.
1. Assess for pain, pain duration, intensity & level of pain.
2. Assess for self care deficit.
3. Assess for complication.
4. Assess for risk of infection.
5. Assess for anxiety.
6. Assess for nutritional level.
7. Assess for hygiene
8. Assess for knowledge deficiency.

NURSING DIAGNOSIS
1. Pain in lower abdomen related to mass expel from the uterus.
2. Altered body temperature related to infection as evidence by purulent and
smelly discharge.
3. Risk of infection related to vaginal discharge.
4. Activity intolerance related to pain in lower abdomen.
5. Altered sleeping pattern related to pain.
6. Knowledge deficit related to diet, personal hygiene and treatment and its
complications.
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ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL

DIAGNOSIS
Subjective Pain in lower To relieve  To assess the  General condition of Pain is reduced up to
data:-Patient abdomen related the pain of general condition of patient is assessed. some extent as
complaints that to product of the patient. patient.  Level, intensity and evidenced by patient
she having pain conception expel  To assess the level, duration of pain is having good sleep.
in the lower through the intensity and assessed. Patient is
abdomen. uterus. duration of pain. having moderator pain.
Objective data:  To provide the  Comfortable position is
- By observing comfortable position given, with the help of
patient facial to the patient. extra pillow.
expressions and  To provide  Divertional therapy is
by doing per divertional provided to patient.
vaginal Therapy to the Diverting her mind by
examination we patient. verbalizing with patient.
know that  Administer  Analgesic is
patient is having analgesics as administered as
pain. prescribed by prescribed by physician.
physician.
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ASSESSMEN NURSING GOAL PLANNING IMPLEMENTATION RATIONAL

T DIAGNOSIS

Subjective Risk of infection To reduce  Assess the level of  Level of risk of Risk of infection is
data:-patient related to the risk of risk of infection. infection is assessed by reduced to some
complaints of vaginal infection. examining the perineal extent as evidenced
itching and discharge. area. by examining the
redness over  Educate the patient  Patient is educated perineal area.
the perineal about the about the maintenance
area. maintenance of of hygiene.
hygiene.
Objective
data: patient  Advice the patient to  Patient is advised to
looks take plenty of fluids. take plenty of fluids.
discomfort able
and irritated.  Advice to take  Patient is advised to
antibiotics as ordered take antibiotics as
by physician. prescribed by physician.
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ASSESSMEN NURSING GOAL PLANNING IMPLEMENTATION RATIONAL

T DIAGNOSIS
Subjective Activity To improve  Asses the level  Level of activity Activity tolerance
data: patient intolerance related the activity activity intolerance intolerance is assessed is improved to
complaints of to pain in lower tolerance of of the patient. by observing the some extent as
not able to do abdomen. the patient. patient’s activity. evidenced by
daily activities.  Assist the patient in  Patient is assisted in patient’s self care.
daily activities. daily activities by her
Objective data: family
patient looks  Provide active and  Active and passive
depressed and passive exercises to exercises are provided to
lazy. the patient. the patient.
 Educate the patient  Patient is educated to
to take adequate take adequate rest and
rest and healthy healthy diet.
diet.
 Assess the tolerance  Level of tolerance of
level of activities. activities is assessed.
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ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL

DIAGNOSIS
Subjective Altered sleeping To improve  Assess the sleeping  Sleeping pattern of the Sleeping pattern is
data: patient pattern related to the sleeping pattern of client. client is assessed. improved to some
complaints of pain pattern of  Provide calm and  Calm and noise free extent as
sleeplessness. client. noise free environment is provided evidenced by
environment to the to the patient. patient’s facial
Objective data: patient. expression.
Patient looks  Provide well  Well ventilated
lazy and ventilated environment and
depressed. environment and position is provided to
position to the the patient with the help
patient. of extra pillows.
 Provide  Comfortable bedding is
comfortable provided to client.
bedding to the
client.
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Assessment Nursing Goal Planning Implementation Rational

diagnosis
Subjective Knowledge deficit To improve  Assess the level of  Level of knowledge of Knowledge is
data: patient related to the level of knowledge of patient is assessed by improved to some
complaints of treatment and its knowledge patient. asking questions. extent as evidenced
having queries. complications. of patient  Explain to the  Explanation about the by patient answer.
Objective patient about the whole treatment plan
data: patient treatment plans and and follow is provided
looks confused importance of to the patient.
and anxious. follow up.
 Clear the doubts of  All the doubts of the
the patient. patient are cleared.
 Provide
psychological  Psychological support
support to the is provided to the
patient. patient.
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HEALTH EDUCATION
Diet and supplements:
 Educate the mother to take adequate diet. Add vegetables, milk, egg,
fruits and juices in her diet.
 The supplementary diet is also important such as iron calcium and folic
acid.
 Instructed to patient for taking high caloric diet which is rich in protein &
vitamin diet for the early recovery.
 I told to patient for avoid spicy food & fatty diet.
Rest and sleep:
 Encourage client to take adequate rest and sleep.
 Provide calm and quiet environment to client.

Personal hygiene:

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

infection. Daily bathing is very necessary.

Environmental hygiene:

 Educate the mother to keep her surroundings clean.

Follow up care:
 Educate the mother regarding follow up care. I gave the health education
to patient & his relatives.
 I explain the all aspect of disease to patient & his family members.
 I instructed to patient & his family members if they have seen any
complication then immediate contact with doctor.
 26

SARSWATI NURSING
INSTITUTE

CASE STUDY
ON
ABORTION

SUBMITTED TO: SUBMITTED BY:

Mrs. SBINA MAM PALLAVI

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