GUIDED ANSWERS FOR NCM 109 ORAL REVALIDA
CASE # 1 : INCOMPLETE ABORTION
PREDISPOSING FACTOR: FATIGUE
Presence of UTI as shown in Urinalysis Result
PATHOGNOMONIC SIGN / SPECIFIC SIGNS & SYMPTOMS
1. Pain
2. Moderate bleeding
3. Passage of tissue (passage of products of conception) This is an INCOMPLETE one
because there are RETAINED PLACENTAL FRAGMENTS ( that makes it an INCOMPLETE
abortion)
PATHOPHYSIOLOGY: Student must put EMPHASIS that because this is an incomplete
abortion= THERE ARE RETAINED PLACENTAL FRAGMENTS ( as shown also in the
ultrasound report) thereby PATIENT is PRONE to HEMORRHAGE that can lead to
HYPOVOLEMIC SHOCK
RATIONALIZATION for Doctor’s order ( students may include these in nursing intervention)
So you may ask students why these are the MD’s orders:
1.Vital signs Monitoring every 2 hours = To
2. IVF PLRS @ 30 gtts/min= not yet sure if patient is diabetic so Plain LRS instead of D5
that contains more glucose
3.CBC w/blood typing=blood extracted, results for follow up= To monitor RBC and WBC
for presence of infection / blood typing ( in case patient will undergo Blood Transfusion )
4.Routine Urinalysis=Urine specimen sent to lab ( to check for presence of UTI)
5.Schedule patient for Ultrasound/ Sonogram = done prior to transfer to ward ( To check
for status of the embryo)- THIS IS A DEFINITIVE diagnostic procedure to CONFIRM
INCOMPLETE ABORTION and that there is no heartbeat and termination of pregnancy is
evident
6.NPO temporarily= ( in case patient will be scheduled for Dilatation and Curettage)
7.CBR w/o BRP= NOT to strain the patient that may cause further bleeding or
hemorrhage
LABORATORY RESULT: Presence of UTI Pus cells @ 15-20 normal is 1-3 or 0 ( This leads
to predispose patient to incomplete Abortion
INTERNAL EXAM RESULT: for INCOMPLETE = cervix is opened w/moderate bleeding (bec
there are retained placental fragments
For MISSED ABORTION- cervix is CLOSED, but there is no increase in size of the embryo
ULTRASOUND RESULT:- INCOMPLETE – retained placental fragments (red specks in the
ultrasound report is EVIDENT)
MISSED- no increase in size of embryo as shown in the
ultrasound result
Doctor’s order in the OB ward
1.Schedule patient for Dilatation and Curettage= TO REMOVE RETAINED PLACENTAL
FRAGMENTS =To stop hemorrhage and prevent hypovolemic shock
2.Inform anesthesiologist and delivery room = REFERAL to anesthesiologist for GENERAL
ANESTHESIA- DELIVERY ROOM – D and C is performed in DR.
3. Obtain an informed consent – nurse will only obtain the patient’s signature AFTER the
attending physician ALREADY DISCUSSED the PROCEDURE to patient and SIGNIFICANT
OTHERS
4.Maintain patient on NPO – for general anesthesia purposes so patient will NOT VOMIT
that can LEAD to ASPIRATION
5. IVF to follow PLRS 1L @ 30 gtts/min x 8 hours = to keep patient hydrated @ all times
POST OPERATIVE ORDER:
1. Specimen for histopathology = all specimens remove to patient MUST be examined
and result for documentation purposes.
2.VS monitoring every 15 mins for one hour, every 30 mins for 2 hours and hourly till
stable = This is protocol in VS monitoring after every POST OP PROCEDURE
3.Amoxicillin 500 mg/ cap 1 cap every 8 hours = To Prevent POST OP infection
4. Mefenamic acid 500 mg/tablet 1 tab PRN for pain = for POST OP pain
5.Increase oral fluids = To keep patient hydrated @ all times
6.I and O every shift = To monitor hydration status and vomiting episodes post
anesthesia
7.Soft diet when tolerated and shift to DAT = gradual return to DAT to prevent vomiting
since patient was on NPO, when soft diet is tolerated may return to DAT.
Discharge Orders:
1.HOME MEDICATIONS: Continue Amoxicillin for 5 more days= to complete 7 days in
case patient will be discharge on the 2nd-3rd day POST OP.
Mefenamic acid PRN for pain = ask student about what is PRN
and when it is given?
2.No coitus for 2 weeks= To prevent bleeding and infection
3.Pad Count= To check for any STILL RETAINED placental fragments even D&C is
performed already.
4.Avoid lifting heavy objects= To prevent further bleedding
5.DAT= for no vomiting and patient for discharge
6.Increase oral fluids= To maintain hydration and help in the healing process
POSSIBLE NURSING DIAGNOSIS
1.Alteration in comfort: Pain related to mild contractions as evidenced by bleeding caused
retained placental fragments or products of conception
RATIONALE: If there are retained products of conception the uterus has a compensatory
mechanism to produce mild contraction to signal the body that there is moderate uterine
bleeding brought about by retained placental fragments and uterus will remain to be NOT WELL
CONTRACTED prone to BLEEDING/HEMORRHAGE
2.Alteration in Comfort: PAIN related to post D&C as evidenced by pain scale or facial grimace
3. RISK for hypovolemic shock related to presence of hemorrhage as evidenced by retained
placental fragments
4. Risk for deficient fluid volume related to presence of bleeding as evidenced by retained
placenta fragments
5. Anxiety related to the outcome of pregnancy as evidenced by passage of products of
conception
CASE #2 FOR MISSED ABORTION
PREDISPOSING FACTOR FOR THE MISSED- History of missed abortion
Patient is G2P0 9second time of missed abortion
DRUG – MISOPROSTOL – (to open the cervix route must be intravaginally or inserted inside
the vagina FOR FAST opening of the cervix since this is a MISSED ABORTION
BUT MUST BE CONFIRMED FIRST THRU ULTRASOUND ( particularly TVS or TRANSVAGINAL
ULTRASOUND) and not ABDOMINAL ULTRASOUND
NOTE: ask the student WHY? TVS and not abdominal BECAUSE pregnancy is in the FIRST
TRIMESTER and more VISIBLE thru TVS or transvaginal
How done? INSERT a PROBE inside the vagina TO VISUALIZE BETTER the UTERUS
GENETIC COUNSELLING – important on this case Because this is second time for missed
abortion we need to check on the genetic component of the husband and wife.
POSSIBLE NURSING DIAGNOSIS:
FEAR related to outcome of pregnancy as evidenced by failure to increase fundic height
measurement
ANXIETY related to outcome of pregnancy as evidenced by failure to increase fumdic height
measurement
RISK for INFECTION related to missed pregnancy as evidenced by presence of failed
outcome of pregnancy by ultrasound report
Risk for deficient fluid volume related to presence of bleeding as evidenced by retained
products of conception = (THIS is @ RISK eventually if cervix will open)
CASE # 3 PRETERM LABOR
PREDISPOSING FACTOR : HISTORY OF PRETERM DELIVERY ; ( look @ the TPAL scoring there
is PRETERM delivery Preterm :2 deliveries and also UTI based on Urinalysis report ( see LAB
RESULTS)
u 1.Vital signs monitoring hourly esp cardiac rate = ( ask this again for the cardiac rate
since we are going to give steroids = patient might have tachycardia)
u 2.Monitor and record uterine contractions =
u to monitor progress of CONTRACTIONS
u 3.Hook patient to a fetal monitor = to monitor FETAL DISTRESS
u
u 2.IVF D5W1L and incorporate terbutaline sulfate @ 10-15 microdrip/min= Mechanism
of action of TERBUTALINE=This is a TOCOLYTIC DRUG to HALT or STOP CONTRACTION
u 3.CBC w/blood typing=blood extracted, results for follow up
u 4.Routine Urinalysis=Urine specimen sent to lab and for urine culture
u 5.Medications: Give Betamethasone 12 mg IM for 2 doses @ 24 hours apart= TO
INCREASE LUNG SURFACTANT OF THE NEONATE JUST IN CASE WILL BE BORN
PREMATURE =( this is VERY IMPORTANT)
u 6. CBR w/o BRP’s
u 7. Avoid heavy meal but keep patient hydrated at all times = HYDRATION will HELP TO
STOP CONTRACTION
u 8. Notify Neonatal Intensive Care Unit = IN CASE patient will proceed or progress of
labor will PROGRESS it will LEAD to PRETERM BIRTH or DELIVERY and NICU must be
prepared for ADMISSION isolette ( infant incubator ) MUST BE PREPARED AHEAD of
TIME.
NURSING DIAGNOSIS:
Pain related to premature labor contraction as evidenced by facial grimace – ( not
indicated in the case BUT this is automatic if there is LABOR PAIN)
FEAR related to outcome of pregnancy as evidenced by presence of premature labor
contractions
ANXIETY related to outcome of pregnancy as evidenced by presence of premature
contractions
Case # 4 : Premature Rupture of Membranes
Note : JUST TO REVIEW the STUDENT: Ask the student what are the 2 types of membrane
rupture as far as he/she can remember ? answer ; SPONTANEOUSLY and ARTIFICIAL
This type in the case is : SPONTANEOUS but PREMATURE because not yet TERM or 37 weeks
AOG
Ask also the student : WHAT is an important question to ask the patient for PROM?
Answer: TIME of RUPTURE ( to check how much longer the fetus is exposed to infection )
COLOR of the amniotic fluid ( to check for any discoloration) it should be clear
Ask the student what is the meaning of BOW ( -) = BOW means BAG of WATER
Negative means it has already RUPTURED
In this case LABOR and DELIVERY cannot be HALTED or STOP since Amniotic Fluid is already
ruptured
ANTIBIOTIC is an important medical management
Ask what is ANST as a review PRIOR to giving any antibiotics
NURSING DIAGNOSIS:
Pain related to premature labor contraction as evidenced by facial grimace – ( not
indicated in the case BUT this is automatic if there is LABOR PAIN)
FEAR related to outcome of pregnancy as evidenced by presence of premature rupture of
membranes
ANXIETY related to outcome of pregnancy as evidenced by presence of premature rupture
of membranes
*DOCTORS order ALMOST SAME RATIONALE in PRETERM LABOR
Only in PROM there MUST be AN ANTIBIOTIC.
