CASE PRESENTATION

BACALAN, MARIA SHAIRA D.

BOLASTIG, JANINE C.
__________________________________________
STUDENT NURSES (WARD B)
 CASE:

Patient X, a 31 years old pregnant woman, experienced spotting last

December 2022 was admitted to Samar Provincial Hospital (SPH) last
February 6,2023; 11:50 am complaining a vaginal bleeding for five days
associated with abdominal pain, she thought this bleeding is just because
of her Urinary Tract Infection (UTI) that’s why she didn’t get a checked
up.
 Patient Profile:

Patient X was admitted for further evaluation and

management at Ward B, Room 2.
INITIAL VITAL SIGNS

As of February 6, 2023:

BP : 80/60 mmHg
PR : 100 bpm
RR : 21 bpm
Temp : 36.5 °C
PATIENT’S HEALTH HISTORY

- Taking contraceptive pills

- Abdominal pain
- spotting
- Urinary Tract Infection (UTI)
- Ulcer
 HISTORY OF PRESENT
ILLNESS

Vaginal bleeding for 5 days – she was associated with abdominal pain- consumed 3
pads/day.

1 day (PTA) – onset of Vaginal spotting

Morning (PTA) - hypogastric pain associated with profuse vaginal bleeding, consumed 3
pads with passage of meaty tissues.

Abdominal pain - she experienced spotting, when she urinates there are drops of blood .
 DIAGNOSIS

G3 P2 (2-0-0-1) PU 13 3/37 weeks AOG;

T/C Incomplete Abortion
G3P2

• Gravida 3 Para 2
• Which means three pregnancies, 2 live births
 Pathophysiology of Incomplete
Abortion

Partial loss of the products of conception within the first 20

weeks. It’s usually present with moderate to severe vaginal
bleeding, which may associated with lower abdominal and/or
pelvic pain.
Causes of incomplete Abortion

Happens when some pregnancy tissue remains in your womb.

This causes painful symptoms that need medical attention as soon
as possible.
 SUBJECTIVE DATA TAKEN
FROM THE PATIENT

“Gin didinuguan ako lima na ka-adlaw”

“Nasakit tak tiyan”

“Nag spotting ako”

“Pag naihi ako, may patak han dugo”

OBJECTIVE DATA TAKEN FROM THE
PATIENT

Pelvic Ultrasound Result

Impression: Consider incomplete abortion

Vital signs – BP 80/60; PR 100; Temp 36.5 °C; Height (cm) 152;
weight (kg) 55

GU (IE) – blood clot: with profuse bleeding

 NURSING DIAGNOSES

• Bleeding related to incomplete abortion as evidenced by

vaginal bleeding
• Risk for infection related to invasive procedure and
increased environmental exposure
• Knowledge Deficit regarding condition, prognosis,
treatment, self-care and discharge needs related to
unfamiliarity with information resources
 FOCUS DIAGNOSIS

• Bleeding related to incomplete abortion as

evidenced by vaginal bleeding
Nursing Interventions:

• Assess maternal vital signs.

• Assess for signs of hypovolemia.
• Encourage bed rest
• Instruct the SO not to leave the patient.
• Provide health teachings to the patient such as taking the
medications prescribed and diets.
 IV FLUID GIVEN

5% Dextrose in Lactated Ringer’s Solution

 MEDICATION ORDERED
Foralavit – one capsule daily (oral)
Action:
• Ferrous sulfate corrects iron-deficiency anemia by providing iron necessary for the production of
hemoglobin and certain iron-containing enzymes and by resaturating iron storage organs.
Indication:
• Used in the prevention and treatment of iron deficiency anemia and Vitamin B complex
deficiency, prenatal hematinic

Contraindication:
• Care should be taken when given to patients with iron-shortage or iron-absorption diseases,
hemoglobinopathies, and gastrointestinal diseases.

Adverse effect:
• Gastrointestinal irritation and abdominal pain with nausea, vomiting, diarrhea, or constipation.
The feces of patients taking iron salts may be colored black.
MEDICATION ORDERED

Clindamycin- (Oral) 300 (mg) every 6 hours.

Action:
• Bacteriostatic or bactericidal based on drug level and susceptibility of the organism;
suppresses the growth of the susceptible organisms in sebaceous glands by blocking
protein synthesis.
Indication:
• In oral and parenteral formulations, clindamycin is indicated for the treatment of serious
infections caused by susceptible anaerobic bacteria, as well as susceptible staphylococci,
streptococci, and pneumococci
MEDICATION ORDERED

Contraindication:
• Clindamycin is contraindicated in patients who have had an allergic
reaction to it, and it should be used with caution in those who have a
history of regional enteritis, ulcerative colitis, or antibiotic-associated
colitis.

Adverse effect:
• Gastrointestinal irritation and abdominal pain with nausea, vomiting,
diarrhea, or constipation. The feces of patients taking iron salts may be
colored black.
MEDICATION ORDERED

Mefenamic - 500 mg, then 250 mg every 6 hours as needed for 2 to 3 days (Oral)

Action:
• Anthranilic acid derivative. Ibuprofen inhibits prostaglandin synthesis and affects
platelet function. No evidence that it is superior to aspirin. Short-term to the relief of
mild to moderate pain including primary dysmenorrhea.
Indication:
• For the treatment of rheumatoid arthritis, osteoarthritis, dysmenorrhea, and mild to
moderate pain, inflammation, and fever
MEDICATION ORDERED

Mefenamic - 500 mg, then 250 mg every 6 hours as needed for 2 to 3 days (Oral)

Action:
• Anthranilic acid derivative. Ibuprofen inhibits prostaglandin synthesis and affects
platelet function. No evidence that it is superior to aspirin. Short-term to the relief of
mild to moderate pain including primary dysmenorrhea.
Indication:
• For the treatment of rheumatoid arthritis, osteoarthritis, dysmenorrhea, and mild to
moderate pain, inflammation, and fever
MEDICATION ORDERED

Contraindication:
Mefenamic acid is contraindicated in patients with salicylate hypersensitivity or NSAID
hypersensitivity who have experienced asthma, urticaria, or other allergic reactions after
taking aspirin or other NSAIDs. 

Adverse effect:
Bloody urine, bloody, black, or tarry stools, decreased frequency or amount of urine,
Heartburn increased bleeding time, increased blood pressure, increased thirst, indigestion,
itching, skin rash, loss of appetite, lower back or side pain, nausea, pale skin, severe
stomach pain, cramping, or burning
MEDICATION ORDERED

RANITIDINE - 50 mg iv every 8 hours

Action
Competitively inhibits the action of histamine at H2 receptor sites of parietal cells,
decreasing gastric acid secretion.

Indication
Ranitidine is a prescription drug used to treat ulcers of the stomach and intestines and to
prevent intestinal ulcers from coming back after they have healed. Ranitidine is also used to
treat certain stomach and throat problems such as erosive esophagitis, 
gastroesophageal reflux disease or GERD, and Zollinger-Ellison syndrome.
MEDICATION ORDERED

Contraindication:
Hypersensitivity to ranitidine or components of the formulation

Adverse effect:
• Headache
• Malaise
• Vertigo
• Blurred vision
• Jaundice
• Burning and itching at the injection site.
MEDICATION ORDERED

TRANEXAMIC - 500 g IV every 8 hours x 4 doses

Action
Tranexamic acid competitively and reversibly inhibits the activation of plasminogen via
binding at several distinct sites, including four or five low-affinity sites and one high-
affinity site, the latter of which is involved in its binding to fibrin. The binding of
plasminogen to fibrin induces fibrinolysis - by occupying the necessary binding sites
tranexamic acid prevents this dissolution of fibrin, thereby stabilizing the clot and
preventing hemorrhage.
Indication
Taken orally, tranexamic acid is indicated for the treatment of hereditary angioedema,
cyclic heavy menstrual bleeding in premenopausal females, and other instances of
significant bleeding in the context of hyperfibrinolysis
MEDICATION ORDERED

Contraindication
Tranexamic acid is contraindicated in women who are using combination
hormonal contraception containing an estrogen and a progestin.

Adverse Effects

• Pale skin
• trouble breathing with exertion
• unusual bleeding or bruising
• unusual tiredness or weakness
CURRENT STATUS

VITAL SIGNS

BP – 110/74
Temp. 36.6
PR – 87
RR - 20
Thank you and God Bless!