CHAPTER I CASE BACKGROUND AND ASSESSMENT

INTRODUCTION
Pregnancy is an exciting in any parents time. Its a time of change, growth,
discovery and a lot of questions. One of the most important factors of having a healthy
baby is the mothers health especially during the 9 months where the childs
development has already started. The mothers 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 mothers health is being taken for granted.
Complications may occur at any time during pregnancy and can result from preexisting 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

women experience some vaginal bleeding, with

or without

pregnant
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. (wikipedia.org)
During our duty in the University of Southern Mindanao Hospital, we decided to
take the case of Patient Z in which she was diagnosed with threatened abortion
1

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 weve 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 patients 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.

CASE OBJEVTIVES
General Objective:
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

2. Gather all necessary information regarding her and her family members as may be
related to our case study

3. Ascertain clients 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 clients 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. I d e n t i f y t h e d ru g s p re sc ri b e d t o o u r cl i e n t , th e i r a ct i o n , si d e e ffe ct s,
i n d i ca ti o n s , 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

CONCEPTUAL FRAMEWORK OF THE STUDY

Diagram 1. Conceptual Framework
Input
Process
Related Literature about
Threatened Abortion and UTI

Patient Diagnosed with

Threatened Abortion; UTI

Review of Related Literature

Review of Medical Records
Patient Interview
Medical History
Family History
Personal History
Family and Significant others
Interview
Hospital Staff interview
Physical Status Assessment

Output
Case Analysis Paper

Family History for

Threatened abortion

Nursing Care Plan about the case

Proposed Health Teaching
Knowledge about the case
Enhance knowledge and Critical
Thinking Skills about the case
Prognosis of the underlying disease

Hospital Institute Records

SIGNIFICANCE OF THE STUDY

This study is conducted for the purpose of having a thorough about the
reproductive system specially the chosen case of the researchers the Threatened
Abortion. The outcome of the study will lead the researchers to become aware of the
appropriate ways necessary in performing a comprehensive nursing care management
on patients condition, and performing nursing care towards patients wellness. In the
part of clinical instructors, they can assess the level of readiness of their students in
terms of their knowledge, skills and attitude. In connection to this, the College of Health
and Science will also know that the researchers are capable of rendering care to patient
in the hospital setting.

NURSING HEALTH ASSESSMENT

5

A. HEALTH HISTORY
i.

Biographical Data
Patients Name: Patient Z
Age: 19
Sex: Female
Birth Date: October 8, 1993
Birth Place: Dungguan Datu Montawal, Maguindanao
Educational Status: 4th year College
Tribe: Maguindanaon
Religion: Islam
Civil Status: Single
Nationality: Filipino
Address: Dungguan Datu Montawal, Maguindanao
Fathers Name: Yussop
Occupation: Teacher
Mothers Name: Babay
Occupation: Housekeeper
Socio-Economic Status: Middle
Type of Community: Rural

ii. Reason for Seeking Health Care

A night prior to admission the patient experienced right abdominal lower
quadrant so her classmate decided to bring him to the hospital.

iii. Current Health Status

Prior to admission, Patient Z had experienced Urinary Tract Infection. Upon
receiving the patient, her temperature is 36.3 degrees celcius, respiratory rate is 20
cycles per minute, pulse rate is 71 beats per minute and blood pressure of 90/60.
Patient Z is already 19 years old, having a boyfriend and pregnant at this time. She has
a Urinary Tract Infection then diagnosed with Threatened Abortion.
6

iv. Past Health History

Patient Z has been hospitalized one year ago and was diagnosed with Urinary Tract
Infection
v. Gynecologic and Obstetric History
Patient Z never visited any Clinic or Hospital for her prenatal check up.

vi. Family History

The grandparents of Patient Z together with their four offspring have a High
Blood Pressure including her mother. Perhaps her grandparents, aunt and uncle died
because of High Blood Pressure.
Patient Zs parents have four children, three male and one female. Patient Z is 19
years old and the youngest among the four. Her firstborn brother is already 32 years
old, married having one wife and two children and was diagnosed with High Blood
Pressure. The second one is 31 years old, married having one wife and three children.
The third one is 24 years old, married and having two wives and has one child with each
wife and was diagnosed with urinary tract Infection.

vii. Review of Systems

General Health Survey: Fatigue, weakness, usual colds, fevers
Integumentary: Presence of scars,
Head and Neck: Headaches, stiff neck
Eyes: None
Ears: Using of ear-care habits
Nose and Sinuses: Runny nose, sneezing
Mouth and Throat: Sore throats, mouth sores, changes is sense of taste, yellowish
teeth
Respiratory: Cough
Cardiovascular: Palpitations, cold, pain legs while walking
Breast: None
Gastrointestinal: Loss of appetite, nausea, vomiting
Genitourinary: Pain in urination
Female Reproductive: Menarche (12 y.o.), LMP , painful during menstrual, irregular
menses,
Musculoskeletal: None
Neurological: None
Endocrine: None
Immune/ Hematologic: None

B. DEVELOPMENTAL CONSIDERATIONS
i. Psychosexual Development
Table 1. Freuds Psychosexual Development
Stage
Oral

Ages
0 to 1

Anal
Phallic

1 to 3
3 to 6

Latency

6 to 12

Genital

12+

Ideal
Weaning off of breast,
feeding or formula
Toilet training
Resolving Oedipus/
Electra Complex
Developing defence
mechanism
Researching full sexual
maturity

Actual

ii. Psychosocial Development

Table 2. Eriksons Psychosocial Development
Stage
Infancy
(Birth 18
months)

Basic
Conflict
Trust vs.
Mistrust

Early Childhood
(2-3 years)

Autonomy
vs. Shame
and Doubt

Preschool
(3-5 years)

Initiative
vs. Guilt

Ideal
Children develop a
sense of trust when
caregivers provide
reliability, care and
affection.
A lack of this will lead
to mistrust
Children need to
develop a sense of
personal control over
physical skill and a
sense of personal
control over physical
skills and a sense of
independence
Children need to begin
asserting control and
power over the
9

Actual

School Age
(6-11 years)

Industry
vs.
Inferiority

Adolescence
(12-18 years)

Identity vs.
Role
Confusion

Young
Adulthood
(19-40 years)

Intimacy
vs.
Isolation

environment. Success
this stage leads to a
sense of purpose.
Children who try to
exert too much power
experience
disapproval, resulting in
a sense of guilt.
Children need to cope
up with the new social
and academic
demands.
Success leads to a
sense of competence.
While failure results in
feelings of inferiority.
Teens need to develop
sense of self and
personal identity.
Success leads to and
ability to personal
identity. Success leads
to have fidelity to ones
real self, while failure
leads t role confusion
and a weak sense of
self.
Young adults needs to
for intimate, loving
relationships with other
people. Success leads
to strong relationships,
while failures lead to
loneliness and
isolation.

10

iii. Moral Development

Table 3. Kohlbergs Moral Development
Stage
Stage 1

Pre-Conventional
Morality:
Obedience or
Punishment
Orientation

Stage 2

Pre-Conventional
Morality:
Self-Interest
Orientation

Stage 3

Conventional
Morality:
Social Conformity
Orientation

Ideal
This is the stage that all
young children start at
(and a few adults
remain in). Rules are
seen as being fixed
and absolute. Obeying
the rules is important
because it means
avoiding punishment.
As children grow older,
they begin to see that
other people have their
own goals and
preferences and that
often there is room for
negotiation. Decisions
are made based on the
principle of "What's in it
for me?" For example,
an older child might
reason: "If I do what
mom or dad wants me
to do, they will reward
me. Therefore I will do
it."
By adolescence, most
individuals have
developed to this
stage. There is a sense
of what "good boys"
and "nice girls" do and
the emphasis is on
living up to social
expectations and
norms because of how
they impact day-to-day
relationships.
11

Actual

Stage 4

Stage 5

Stage 6

Conventional
Morality:
Law and Order
Orientation

By the time individuals

reach adulthood, they
usually consider
society as a whole
when making
judgments. The focus is
on maintaining law and
order by following the
rules, doing one's duty
and respecting
authority.
Post-Conventional
At this stage, people
Morality:
understand that there
Social Contract
are differing opinions
Orientation
out there on what is
right and wrong and
that laws are really just
a social contract based
on majority decision
and inevitable
compromise. People at
this stage sometimes
disobey rules if they
find them to be
inconsistent with their
personal values and
will also argue for
certain laws to be
changed if they are no
longer "working". Our
modern democracies
are based on the
reasoning of Stage 5.
Post-Conventional Few people operate at
Morality:
this stage all the time. It
Universal Ethics
is based on abstract
Orientation
reasoning and the
ability to put oneself in
other people's shoes.
At this stage, people
have a principled
12

conscience and will

follow universal ethical
principles regardless of
what the official laws
and rules are.
iv. Cognitive Development
Table 4. Piagets Cognitive Development
Stage
Sensorimotor
(Birth 2 years)

Pre-operational
(2-7 years)

Ideal
Differentiates self from
objects.
Recognizes self as agent of
action and begins to act
intentionally.
Achieves object
permanence.
Learns to use language and
to represent objects by
images and words.
Thinking is still egocentric
Classifies objects by a
single feature.

Actual

Concrete
Operational
(7-11 years)

Can think logically about

objects and events.
Achieves conversion of
number, mass and weight
Classifies objects according
to several feautures and
can order them in series
along a single dimension
such as size.

Formal Operational
(11 years and up)

Can think about abstract

propositions and test
hypothesis systematically
Becomes concerned with
hypothetical, the future, and
ideological problems.

13

C. PSYCHOSOCIAL PROFILE
Health Practices and Beliefs: Believes each person is responsible for leading a
lifestyle conducive to health. Realize shes overdue for physical exam, in search of new
primary care provider. Satisfied with past experiences with healthcare providers.
Typical Day: wake up 6 AM , has breakfast,arrived at school at 7 AM and has class till 7
PM, arrived at home at 8 PM, makes dinner, studies, retires between 11PM to 12
midnght.
Activity and Exercise patterns: Walking is her only exercise. Ayoko talaga ng sports.
She verbalized
Sleep/Rest Patterns: Says she is a morning person. Awakens at 6 AM, goes to bed at
12midnight. Has no trouble falling asleep.
Personal Habits: Never smoked or used recreational drugs, has 1cup of coffee a day.
Occupational Health Patterns: Has 12 hours a day for school with 1 hour lunch.
Graduating for this school year, Feels under a lot of pressure at studies.
Socioeconomic Status: Middle
Environment Health Status: Present boarder in Mercado Street, Kabacan, Cotabato
Roles, Relationship, Self-concept: Describes self as fairly attractive with good sense
of humor. Being pregnant is difficult, received support from her boyfriend and friends.
Cultural Influences: No specific cultural influences that could affect healthcare
practices.
Religious/Spiritual Influences: Practicing Islam but doesnt consider self very
religious. No religious influences that would affect healthcare practices.
Family Roles and Relationship: Not yet married, family provides support. Relationship
with parents is distant both physical and emotional.

14

Sexuality Patterns: Sexually active, still dating.

Social Supports: Belong to an organized group or fraternity and sorority.
Stress and Coping Patterns: She says she usually deals with stress by avoiding
problem until it is starting her in the face and she has to deal with it. Studies is stressful,
but she manages it on a day-to-day even she is pregnant.

D. PHYSICAL ASSESSMENT
i. General Survey
Received this 19 years old, maguindanaon female patient, lying on the bed, awake
and responsive with an IVF opon receiving of D5LR 1L. Regulated @ 30 gtts/min
infusing well @ right metacarpal vein under the service of Dr. Engkong. Patient did not
look well, she wear complete dress. She complaint of vaginal bleeding.

ii. Vital Signs

Upon receiving the patient , her temperature is 36.3 degree celcius, Respiration rate
is 20cpm, pulse rate is 71bpm, blood pressure 90/60 mmHg

iii. Anthropometric Measurement

Height: 5 feet and 2 inches
15

Weight: 56 kilograms

iv. Head To Toe Scan

Skin: Patient Z has a dark complexion skin; her skin was dry, and rough and warm
to touch. When the skin is pinched, it would immediately return to its original shape.
There were some hair on the skin of her arm and feet. She has an untrimmed nails
on both hands and feet and there were some presence of dirt.
Head: The skull and the face is symmetrical in shape, hair is evenly distributed
about two approximately 15 inches long. Her hair was dry, and wavy. No presence of
lice, and dandruff. Acne are found in the forehead and in some part of her face. She
is not using any eyewear. Her ears are symmetrical to her face, the external canal
was observed with minimal cerumen. Her nose was observed with no discharge and
with the presence of hair inside. Her mouth is dry with pale colored lips. The gums
are dark, and there is no presence of swelling, and discharge. She as a complete
and well arrange teeth with the presence of dental plaques and carries, poor dental
hygiene is observed.

Neck: There is no presence of masses, swelling, and enlarged lymph nodes on the
neck, and it moves easily without any discomfort.

16

Chest and Lungs: Thorax is symmetrical with no impairment upon respiration.

Upon auscultation, no any abnormal sound is noted. Respiration rate and rhythm is
regular.

Heart: Patient Z has a good normal heart rhythm. She has a normal heart rate
95bpm.

Abdomen: Patient have a flat abdomen even she is pregnant. She is 7 weeks
pregnant.

Genito-Urinary: We were not able to assess closely the patients genitor-urinary

because the patient didnt allowed us because of their custom.

Extremities: On the upper limb portion. Shoulder and arms are observed to have no
swelling, the grooves and head of humerus are firm, it was capable of doing flexion
and extension movements. The elbows have no swelling, no deformities, forearms
are flexed, hands and wrist are cold to touch. No swelling, redness, pallor, bone
enlargement noted on her hands. The nails are untrimmed with presence of dirt. The
lower limb portion like knee and legs dont have any deformities at all. Edema and
inflammation is not present. It was capable of doing flexion and extension
movement. The nails are untrimmed with presence of dirt.

17

E. FOCUSED PHYSICAL ASSESSMENT

i. Inspection
Eyes: No signs of any Eye disorder
Face: Symmetrical

ii. Palpation
Abdomen: Pain is not present during deep palpation
Pulse Rate: 64 beats per minute

iii. Percusion
Abdomen: Direct Percussion is used resulting in thudlike sound with moderate pitch

18

iv. Auscultation
Blood Pressure: 100/70 mmHg
SUMMARY OF PERTINENT FINDINGS
Patient, 19-year old, single experiencing much stress from studies. No significant
physical problems noted. Needs physical exam and lab studies to rule out iron
deficiency anemia or other physical problems. Needs health promotion instruction are:
diet, time, and stress management, expanded use of community resources. Positive
findings include self motivated to seek healthcare; exercises routinely; has family, and
friends, who are source of support; self motivated to further education to expand career
options.

LABORATORY AND DIAGNOSTIC ASSESSMENT

A. HEMATOLOGY
Table 5. Hematology Result
DATE

LAB

RESULT
19

NORMAL

SIGNIFICANCE

03-12-13

Hemoglobin
mass count
Leukocytes
number count
Lymphocyte
Segmenters

100

VALUES
FM-129-140g/L

Below Normal

11.5

5-10 x 10g/L

Above Normal

0.25
0.75

0.23-0.35
0.50-0.70

Normal
Above Normal

SIGNIFICANCE

B. URINALYSIS
Table 5. Urinalysis Result
DATE

LAB

RESULT

03-12-13

Color
Transparency

Yellow
Cloudy

NORMAL
VALUES
Straw
Clear

pH
Sugar
Albumin
Pus cells
RBC

8.0
H
5-10
Abundant

4.5-8
------------------------0-4
0-3 hpf

20

Normal
If urine is cloudy it
could a sign of a
serious illness
such as Urinary
Tract Infection
can include
feeling a constant
need to urinate,
frequent urination,
and burning or
stinging during
urination.
Normal
Normal
Normal
Above Normal
The presence of
rbc in the urine
interpret that the
patient had an
abnormalities of
blood in the urine.

Epithelial cells

Few

21

Asymptomatic of
many renal
disease and
disorders of the
genitourinary
system.
Epithelial cells are
indicative of a
transitional cell
carcinoma. It is
also indication of
contamination in
the vulva of distal
urethra,
inflammation and
possible for
infection.