Nursing process

Nursing process for missed abortion

1. Nursing process for the woman experience with missed abortion Prepared by Jwan Kareem Salh Msc.Student

2. Nursing reception To welcome the woman, from her arrival at the health unit, taking responsibility for her, listening to her complaints, allowing her to express her worries, anxieties, understanding the different meanings of missed abortion for that woman and her family. Orient and prepare the patient for medical consultation, physical and gynecological examination. Inform the medical team about the relevant data collected during the nursing consultation

3. Cont …. Explain the conduct according to the type of abortion and need for hospitalization. Support family and friends according to their needs.

4. Nursing history The following data must be collected personal identification (name ,age, race, religion and others). gynecological and obstetrical history . report of the event and identification of the risk of exposure. it is important to investigate signs and symptoms of genitourinary system signs of bleeding; and investigate emotional and social aspects, support the family or significant person .

5. Cont … The interview should be performed using clear language, with objective questions, respecting the client's right to answer or not the questions to report or not what happened, exempting the nurse from making judgments and having prejudiced attitudes. The physical examination must be performed: inspection, auscultation, palpation, percussion.

6. Cont … Past Surgical history and type of surgery . Past medical history Drug history and allergy with food and drug. Monitor V/S, blood test, bleeding and vaginal secretion ( character, colour & volume)

7. Nursing Assessment The presenting symptom of an abortion is always vaginal spotting, and once this is noticed by the pregnant woman, she should immediately notify her healthcare provider. As nurses, we are always the first to receive the initial information so we should be aware of the guidelines in assessing bleeding during pregnancy.

8. Cont … Ask of the pregnant woman’s actions before the spotting or bleeding occurred and identifies the measures she did when she first noticed the bleeding. Inquire of the duration and intensity of the bleeding or pain felt. Lastly, identify the client’s blood type for cases of Rh incompatibility.

9. Nursing diagnosis Risk for deficient fluid volume Vaginal bleeding related to the remain pieces of conception Acute pain related to the loss of pregnancy Risk for infection related to the open of cervix Risk for organ perforation related to the dilatation and curettage

10. Cont.. Anxiety and fear related to the loss of pregnancy social isolation related to the loss of pregnancy

11. Nursing Interventions If bleeding is profuse, place the woman flat in bed on her side. monitor uterine contractions through an external monitor. Also measure intake and output to establish renal function and assess the woman’s vital signs to establish maternal response to blood loss.

12. Cont … Measure the maternal blood loss by saving and weighing the used pads. Save any tissue found in the pads because this might be a part of the products of conception.

13. Cont … In case of hospitalization, explain the reasons to the woman, refer her to the bath and offer change of clothes, if the client wishes In case of retained abortion, orient and prepare the woman for the vaginal use of dilators (misoprostol) according to medical advice. Guide blood collection to determine blood typing. If Rh negative and no further sensitization, administration of anti-D.

14. Cont … Request immediate medical gynecological consultation in the presence of significant signs of infection and major bleeding. Accept and advise family members and/or companions in order to provide support in daily living . Refer to social and psychological care, schedule outpatient return with the nurse, guiding about the follow-up with multidisciplinary team

15. Nursing care in outpatient care The woman should be informed that her fertility may be restored before the onset of menstruation. To indicate that she may be able to become pregnant about 15 days after the abortion. To guide sexual abstinence while occurrence of bleeding. To clarify, guide and offer the woman and her partner contraceptive methods.

16. Cont …. To orient the woman to clarify the causes of the missed abortion when she wishes to become pregnant immediately after the abortion. To offer, stimulate and intervene for psychological follow-up in cases of emotional/sexual change and refer to social service if an economic/social problem is identified.

17. Cont … To inform about outpatient follow-up with multidisciplinary team; To guide on gynecological examination, collection of vaginal secretions and serologies for HIV, hepatitis B and C and syphilis . To guide significant family/person for daily support and ask her presence in service if deem it necessary. To schedule return with nurse, gynecologist and infect ologist.

18. Evaluation The aim for evaluation is inclined towards restoring the maternal blood volume and stopping the source of the bleeding. The client’s blood pressure must be maintained above 120/80 mmHg. The pulse rate should be below 60-100 beats per minute. The client’s urine output should be more than 30 mL/ hr , only minimal bleeding should be apparent for not more than 24 hours.

19. Provide client and family teaching Offer anticipatory guidance relative to expected recovery, the need for rest and delay of another pregnancy until the client fully recovers. Suggest avoiding intercourse until after the next menses or using condoms when engaging in intercourse. Explain that in many cases, no cause for the missed abortion is ever identified.

20. Cont … Expect bleeding for up to two weeks. If concerned regarding heavy or prolonged bleeding, patient to ring EPAU or WAU for advice. Side effects of misoprostol include: nausea, vomiting, fever, diarrhoea , headache, dizziness Expect pain during the passage of pregnancy tissue from the uterus. Take regular analgesia and advise the patient that if pain persists after tissue has passed, she should telephone EPAU (WAU if after hours) to speak with a gynaecology nurse

21. Cont ….. A sac or fetus may be seen in any tissue that is passed. Encourage the patient to keep any tissue passed for histology and bring back in pot provided. However sensitivity is required in giving this advice. Avoid intercourse, tampons, swimming and bathing for two weeks or for duration of bleeding If any signs of sepsis e.g. fever, per vagina (PV) discharge, undue pain, unwell, patient to ring EPAU for advice.

22. Cont … Expect a normal grief reaction. Counselling should be offered to all patients. Call at any time to speak to a nurse (numbers provided). There is an 80% chance of avoiding a dilatation (of cervix) and curettage (of uterus) (D&C) with a good outcome.

23. Role nurses in Medical Management In these medical management would be to assist in every aspect possible. Ensure the wellbeing of both the mother and the fetus. Nurse could initiate care without needing to run after the  physician  and ask for their orders. Nurses should be able to function independently as caregivers and promote their wellness in our own way as nurses.

24. Cont ….. The most vital pieces of information are always handed to us first, so it would be up to us to initiate the first intervention to make or break the condition of the client before a doctor arrives. Nurses are the first line of defense of every hospital, and should live up to that expectation.

25. Nurse’s responsibilities with mifepristone and misoprostol Exclude patients with an allergy to misoprostol or prostaglandins. Contraindications: Known allergy to prostaglandins, mifepristone or misoprostol Pregnancy of unknown location, suspected ectopic or molar pregnancy Known bleeding disorder, concurrent anticoagulants and or haemoglobin (HB) >80 g/L

26. Cont … Intrauterine device in place Adrenal failure Porphyria Patient currently shows signs of: - haemody namically unstable - shock - pelvic infection, sepsis. Precautions: Asthma (avoid if severe/uncontrolled) Ambivalent decision.

27. Cont …. Management is usually to be as an outpatient, coordinated from EPAU. Baseline observations (temperature, pulse, Blood Pressure, oxygen saturation and pain score). As directed by EPAU Standing Order: ○ Mifepristone & Misoprostol - Early Pregnancy Assessment Unit (EPAU). Day 1: Administer mifepristone 200 mg PO at EPAU clinic and give pharmacy re-pack misoprostol 800 microgram to take (vaginal/buccal) at home 24 hours later.

28. Cont … Day2: Misoprostol 800 microgram self medicated at home ( vaginal/buccal). Day 3 : if required, misoprostol 400 microgram to be given in EPAU Clinic Provide ‘Managing your Miscarriage, Options for Your Care’ and a container for POC. The EPAU nurse to telephone the next day (day two) to assess the outcome of the misoprostol treatment