PATIENT BIODATA

Name of Patient- Mrs. Pawan Devi W/O - Akhilesh Kumar

Age/ Sex - 33 Yrs/F

Education - 10

Occupation - Housewife

Income - 10000/- month

Marital Status - Married

Religious - Hindu

Address - Balaganj, Barabanki

Date of Admission - 10 May 2024

Consultant - Dr. Amrita

Diagnosis - Abortion

Ward - OBS 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 clots.
After investigation she founded as anemic. Hb level was 10.3gm/dl.

Present Surgical History:

Patient has no any present surgical history

Past Medical History:

She was previously admitted in government hospital for delivery before 5 years.

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

Menstrual History:
Menarche: 13 yrs.
Day: 20 to 25 day.
Duration: 10 day.
Rhythm: Irregular
Flow: heavy (4 to 5 pads in first 4 days).
Family History:
 S Name of Age/ Sex Relation Health Status
. Family with
N Member Patient
o
.
1 Mr. preetam 72 yr./M Father in Normal
chand law
2 Mrs.veena 65 yr./F Mother in Normal
devi law
3 Mr.Akhlesh 39yr./M husband Normal
kumar
4 Ms. Pawan 33yr./F Self client
devi
5 Ms.Pooja 10 yr./ daughter Normal

Family tree:

Male

Female

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

Personal history:
Hygiene: Maintained.

Diet: Vegetarian.

Activity and Exercise: Her activity is normal in daily life. She was not doing any exercise in his daily life.

Sleep and Rest: She was sleeping at 6-7 hrs. At night & take rest 1-2 hrs. at day time after taking meal.

Elimination Pattern: She goes for defecation for once or twice in a day and 5- 6times for urination. She has
no complaint of constipation.

Values & believes: She belongs Hindu religion. She believes in god. She participates in every holly festivals.
She doesn't take any fast.

PHYSICAL EXAMINATION -
Anthropometric measurements:

Height - 5 ft
Weight - 44 kg.

Vitals:
Temperature - 98*F

Pulse - 100b / min.

Respiration - 18b/ min.

Blood Pressure - 110/70 mm Hg

General appearance: Consciousness: conscious Body build: thin.

Head:
Hair - Black in Color
Scalp - Itching and dandruff present.
Face - Slight pigmentation
Sinus - Normal
Cranium- symmetrical

Eyes
Visual activity - Normal
Ocular movement - Normal
Lids - Clear
Lacrimal gland - Proper functioning
Conjunctiva - Pale
Sclera - White

Ears
External Structure - Normal
Mucus membrane - No discharge
Tympanic membrane - Normal Hearing

Nose:
Eternal Structure - Short & round Septum -
Symmetrical Mucous Membrane - pink color
Nasal deviation - Normal
Nasal deviation Epitasis - not present

Oral Cavity:
Lips - pink color.
Gums - no swelling
Oral cavity - clean, pink color
Teeth - Symmetrical & yellowish.

Tongue -light pink in color, no erethroplasia present, no white patches present, Present in center line.
Taste - Normal
Voice - Soft

Neck:
General Structure - Normal
Tracheal sound - Heard
Thyroid and Parathyroid - No enlargement.
Lymph node - No enlargement

Range of motion - All movement present

(Flexion, extension, internal and External rotation and circumduction.)

Chest and respiratory systems

Chest Shape - symmetrical
Respiration rate - 22 b/min.
General palpation - no palpable mass present, no fluid Collection
Percussion - No pleural effusion.
Breathe sound - Heard.

Abdomen
Scar marks - absent
Hernias - absent
Masses - absent
Uterus - tenderness is present
Spleen - no spleenomegaly.
Hepatic - no hepatomegaly.
Bladder - normal
Palpation - abnormal mass is palpable on lower abdomen.
Back
No lordosis, kyphosis, sclerosis present

Genitalia & rectal examination

No pus inflammation.
No congenital abnormality present.
Any infection is not present.
Vaginal discharge present.

Upper & Lower extremities-

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

DRUG CHART:

Drug Name Rout e Indication Action Side effects Nurse responsibility

/dosa ge

(1)Inj. I/V UTI Used as broad CNS: headache GI: Assess the general
Maczone 0.5 - 1gm Otitis media spectrum constipation condition of the patient
I /v 6hrly septicaemia antibiotics GU: Check the vital signs
discolouration of urine. Checked the allergic
reaction.
Administer the five
rights.
Always follow six rights
and test dose should be
done.
(2)Inj. 0- Peptic ulcer, It is a newer H+ Known Assess the general
Pantoprazole 40m g gastro k+ ATP hypersensitivity condition of patient.
Trade name: slow I/V oesophageal inhibitor similar Always follow six
reflux in potency and rights.
Pan top clinical efficacy Check the allergic
to omeprazole reaction

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

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

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.

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

Vestibule. The vestibule consists of the clitoris, urethral meatus, and the vaginal introitus.

The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is sexual excitation.

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

The vaginal introitus is the vaginal entrance.

External female genitalia.

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.

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 consist of the uterus, vagina, fallopian tubes, and the ovaries.

UTERUS:
The uterus (womb) is a hollow organ within which fetal development occurs.

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

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

The uterus measures about 8 cm. long, 5 cm wide at the fundus and its walls are about 1.25 cm thick. Its
weight varies from 50-80 gm.
The uterus is characterized by the following regions:
Body (corpus).
Isthmus.
The cervix.
Body :
The fundus is the upper region where the uterine ducts join the uterus.
The body is the major, central portion of the uterus.
Isthmus :
The isthmus is the lower, narrow portion of the uterus.
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:
The broad ligaments
The uterosacral ligaments
The round ligaments
The cardinal (lateral cervical) ligaments
The wall of the uterus consists of the following three layers:
The perimetrium is a serous membrane that lines the outside of the uterus.
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.
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.
Vagina.

Location: The vagina is the thin in walled muscular tube about 6 inches long leading from the uterus to the
external genitalia. It is located between the bladder and the rectum.

Function: The vagina provides the passageway for childbirth and menstrual flow; it receives the penis and
semen during sexual intercourse.

Fallopian Tubes (Two):

Location: Each tube is about 4 inches long and extends medially from each ovary to empty into the superior
region of the uterus.

Function: The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian
tubes with the ovaries.

Description: The distal end of each fallopian tube is expanded and has finger-like projections called fimbriae,
which partially surround each ovary. When an oocyte is expelled from the ovary, fimbriae create fluid
currents that act to carry the oocyte into the fallopian tube. Oocyte is carried toward the uterus by combination
of tube peristalsis and cilia, which propel the oocyte forward. The most desirable place for fertilization is the
fallopian tube.

Ovaries (2):

Functions. The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone
production (estrogen and progesterone).

Location and gross anatomy. The ovaries are about the size and shape of almonds. They lie against the lateral
walls of the pelvis, one on each side. They are enclosed and held in place by the broad ligament. There are
compact like tissues on the ovaries, which are called ovarian follicles. The follicles are tiny sac-like structures
that consist of an immature egg surrounded by one or more layers of follicle cells. As the developing egg
begins to ripen or mature, follicle enlarges and develops a fluid filled central region. When the egg is matured,
it is called a Graffian follicle, and is ready to be ejected from the ovary.

Process of egg production--oogenesis (see figure 1-5).

The total supply of eggs that a female can release has been determined by the time she is born. The eggs are
referred to as "oogonia" in the developing fetus. At the time the female is born, oogonia have divided into
primary oocyte, which contain 46 chromosomes and are surrounded by a layer of follicle cells.

Primary oocyte remain in the state of suspended animation through childhood until the female reaches puberty
(ages 10 to 14 years). At puberty, the anterior pituitary gland secretes follicle- stimulating hormone (FSH),
which stimulates a small number of primary follicles to mature each month.
Figure 1-4. Human ovary.
As a primary oocyte begins dividing, two different cells are produced, each containing 23 unpaired
chromosomes. One of the cells is called a secondary oocyte and the other is called the first polar body. The
secondary oocyte is the larger cell and is capable of being fertilized. The first polar body is very small, is
nonfunctional, and incapable of being fertilized.

By the time follicles have matured to the graffian follicle stage, they contain secondary oocyte and can be
seen bulging from the surface of the ovary. Follicle development to this stage takes about 14 days. Ovulation
(ejection of the mature egg from the ovary) occurs at this 14-day point in response to the luteinizing hormone
(LH), which

The follicle at the proper stage of maturity when the LH is secreted will rupture and release its oocyte into the
peritoneal cavity. The motion of the fimbriae draws the oocyte into the fallopian tube. The luteinizing
hormone also causes the ruptured follicle to change into a granular structure called corpus luteum, which
secretes estrogen and progesterone.

If the secondary oocyte is penetrated by a sperm, a secondary division occurs that produces another polar
body and an ovum, which combines its 23 chromosomes with those of the sperm to form the fertilized egg,
which contains 46 chromosomes.

Process of hormone production by the ovaries.

a) Estrogen is produced by the follicle cells, which are responsible econdary sex characteristics and for the
maintenance of these traits. These secondary sex characteristics include the enlargement of allopian tubes,
uterus, vagina, and external genitals; breast evelopment; increased deposits of fat in hips and breasts;
widening of he pelvis; and onset of menses or menstrual cycle

DESCRIPTION OF DISEASE

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

Incidence -: Around 56 million abortions occur each year in the world, with a little under half done unsafely.
Unsafe abortion causes 47000 deaths & 5 million hospital admission each year.
The WHO recommended safe & legal abortion be available to all women.

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

Genetic factor:- Majority of (50%) early miscarriage are due to chromosomal abnormality.
Endocrine & metabolic factors:- Deficient progesterone secretion from corpus luteum & thyroid abnormalities
also increase miscarriage.
Anatomic abnormality:- It include 3-38%.It has following factors:- Cervical-uterine factors include cervical
incompetence. Congenital malformation.
Uterine fibroid.
Infection :- (5%) Infections are the accepted causes of late as well as early abortions. It include :
Viral – rubella, CMV, HIV Parasitic – Toxoplasma, malaria Bacterial – Chlamydia
Immunological disorders:-
(5-10 %) Autoimmunity natural killer cells present in peripheral blood & that is in uterus are different
function. .
Maternal medical illness:-
Cyanotic heart, hemoglobinopathies are associated with early miscarriage.
Premature rupture of membranes:- it lead to abortion.
Unexplained:-
40 to 60 % cases of abortions are unknown.

Rise of temperature at least 100.4F. Purulent vaginal discharge

Lower abdominal pain & tenderness. Chills
Diarrhoea & vomiting Tachypnea
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:-
Congenital- uterine abnormality
Acquired - D &C operation
Others :- multiple gestation
Diagnosis & management of cervical incompetence
History.
Internal examination.
Speculum examination.
Management: - it includes two types of operations.
SHIRODKAR’S OPERATION
McDonald’s OPERATION
Diagnostic evaluations of abortion
History taking –
Previous history of abortion.
Personal & obstetrical history.
Routine investigation
Blood for Hb, ABO, rh+ group.
Urine for immunological & cult
maging:- it includes USG ,X-ray

Complication of abortion
Sepsis & placental polyp.
Blood coagulation disorders.
Haemorrhage.
Injury may occur to the uterus.
Renal failure due to spread of infection.
Chronic pelvic & back ache.
Dyspareunia.
Cervical incompetence.
Management of abortion AIMS:-
To accelerate the process of expulsion. To maintain strict asepsis.
The management of abortion according to its types :-
Threatened abortion:-
Rest
Drugs- diazepam 5mg BD.

Inevitable abortion:-
General measures:- Methergine 0.2 mg to stop bleeding.
Active treatment:- Dilatation & evacuation followed by curettage of uterine cavity.
Complete abortion:- dilatation & curettage with the help of TVS.
Incomplete abortion:- the evacuation of retained product of conception. Drug Misoprostol 200 ug is use every
4 hourly.

Missed abortion:- it include

Medical:- oxytocin 10 – 20 units.
Surgical :- D & C
Septic abortion: - It includes:-
General measure – Hospitalization is essential for all cases of septic abortion.
Vaginal swab for culture & drug sensitivity.
Drugs:- Analgesics , antibiotic , B.T is done.
D & C is done.
Dilatation & Curettage
D& c is a procedure to remove tissue from inside the uterus & lining of uterus & scarping the content from
uterus.
It is also called sharp curettage & attached with electrical vacuum aspiration.
Indications:-
Abortion
Endometrial carcinoma Infertility.

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

S. IN BOOK IN PATIENT
NO.

1. Fleshy mass per vagina Pain in lower abdomen Present.

2. Persistence vaginal bleeding Present.
3. Uterus smaller than period of amenorrhea. Present.
4. Patulous cervical os Chills and rigor Tachypnea Not present.
Impaired mental status Hypothermia

5. Present.
6. Present.
7. Not present.
8. Not present.
9. Not present.

Complications

S.NO. IN BOOK IN PATIENT

1. Profuse bleeding Sepsis Present Present Not present

2. Placental polyp
3.
INVESTIGATION:

S. NAME OF THE INVESTIGATION NORMAL VALUE PATIENT VALUE

NO.

1. Hb TLC 11.5-16.5 mg/dl 5.3 mg/dl 15,100

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

MANAGEMENT:

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

According to book:
 Dilatation and evacuation
 Intrauterine instillation of hypertonic solution:
 Extra-amniotic: instillation of 0.1 ethacridine lactate
 Intra-amniotic: instillation of 20% of
hypertonic saline.
 Hyserotomy.
8. NURSING MANAGEMENT:
I assess the patient according there priority needs. The priority needs of my patient are given below & I assess
my patient for.
Assess for pain, pain duration, intensity & level of pain.
Assess for self care deficit.
Assess for complication.
Assess for risk of infection.
Assess for anxiety.
Assess for nutritional level.
Assess for hygiene
Assess for knowledge deficiency.

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

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

Personal hygiene:

The maintenance of personal hygiene is very important to prevent the infection. Daily bathing is
very necessary.
Environmental hygiene:

Educate the mother to keep her surroundings clean.

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

BIBLIOGRAPHY

Dutta’s D.C. Textbook of obstetrics. 9th edition. Published by New central book agency (P) ltd.
Chintamoni das lane, Kolkata India.2013.
Rama AV. Textbook of Maternity nursing. 19th edition. Published by wolters kluwer. New
Delhi. 2014.
Howkins and Pourne. Shaw’stextbook of gynecology. 16th edition. Published by reed Elsevier.
New Delhi. 2015.
http://www.momjunction.com/articles/indian-diet-during-pregnancy_00372727/#gref
Lippincott and Wilkins.” Drug handbook’’. 32nd edition. Published by wolter and kluwer. New
York. 2012.
 HIND College OF NURSING
SAFEDABAD, BARABANKI

SUBJECT-Obstetrical and gynecology

CASE STUDY
ON
Abortion

SUBMITTED TO SUBMITTED BY
MRS. SOFIA THERESE MS. SAROJ TIGGA
ASSISTANT PROFESSOR M.Sc. NURSING 1ST YEAR
DEPT. OF OBG HIND COLLEGE OF NURSING