7 COMPREHENSIVE CASE STUDY

PATIENT’S DATA
I. ASSESSMENT

A. General Data

Patient's Initials: B. A

Address: N/A

Sex: Female

Date of Birth: 01-july-1998

Place of Birth: Riyadh, Saudi Arabia

Civil Status: Married

Occupation: Homemaker

Date of Admission: January 7, 2024

Order of Admission: Emergency

No. of Days in this Hospital: 2 days

B. HIEF COMPLAINTS

A. Presenting Complaints

1. Para 0 + 1, pregnant 22 weeks and 4 days

2. Leaking membranes since yesterday

3. Pregnant with triplets, 2 IUFD at 16 weeks

4. Complaints of bloody vaginal water leaking

C. HISTORY OF PRESENT ILLNESS

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The patient, a 25-year-old pregnant female at 22 weeks and 4 days of gestation, presented with a chief complaint

of leaking membranes since yesterday. Notably, she had a history of a previous pregnancy with triplets, two of

which experienced intrauterine fetal demise (IUFD) at 16 weeks. The patient reported the occurrence of bloody

vaginal water leakage, prompting concern for the current pregnancy.

D. PAST HISTORY

Category Details

Childhood Illness/es No significant childhood illnesses reported.

Adult Illness/es No significant adult illnesses reported.

Immunization Up-to-date immunization history not provided.

Previous Hospitalization No history of previous hospitalizations reported.

Operation/s No history of previous surgeries reported.

Injuries No history of significant injuries reported.

Medications prior to Dextrose/Normal Saline, Ampicillin, Metronidazole, Erythromycin

confinement (discontinued on January 7, 2024, 2:29 AM)

Allergies No known allergies reported.

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E. FAMILY ASSESSMENT

Relation Age Sex Occupation Educational Attainment

Husband 28 Male Engineer Bachelor's Degree

Unborn Triplets N/A N/A N/A N/A

Other Family Members N/A N/A N/A N/A

F. HEREDITARY (FAMILY ILLNESS)

Hereditary Category Family Member Illness/Condition

Maternal Grandmother Hypertension, Diabetes

Paternal Father No reported hereditary illnesses

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G. PHYSICAL EXAMINATION (Date and Time) January 7, 2024, 11:50 AM

Height: 160 cm

Actual Height: 163 cm

Actual Weight: 68 kgs

Ideal Body Weight: 65 kgs

Anthropometric Measurements (For pediatric 0-3 years old)

Head Circumference: N/A

Chest Circumference: N/A

Abdominal Circumference: N/A

Vital Signs

Temperature: 37.2°C

Pulse Rate: 80 beats per minute

Respiratory Rate: 18 breaths per minute

Blood Pressure: 120/80 mmHg

Regional Examination (Presence or absence be used as noted)

Head 

 Normocephalic and atraumatic

 Eyes:
 Pupils equal, round, and reactive to light and accommodation (PERRLA)
 Neck:
 Supple without masses or stiffness
 Chest:
 Symmetrical chest expansion, no deformities or masses
 Abdomen:
 Soft, non-tender, no palpable masses
 Extremities:
 No cyanosis, clubbing, or edema
 Neurological:
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  Alert and oriented, normal cranial nerves

A. SKIN (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Even skin tone, warm to Possible signs of compromised blood circulation

Skin appears pale with touch, no lesions or and tissue perfusion. Further investigation
evident bloodstains abnormalities needed.

B. NAILS (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Nails are
cyanotic and Pink nail beds, smooth texture, Indicative of potential oxygenation issues; warrants
brittle no clubbing or abnormalities thorough examination and monitoring.

C. HEAD AND FACE (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Swelling on the Symmetrical facial features, no Possible trauma or localized inflammation; further
forehead asymmetry or swelling evaluation recommended.

D. EYES (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Clear conjunctiva, white

Conjunctival pallor, sclera, normal pupillary Indicative of potential anemia or underlying eye
bloodshot appearance response condition; necessitates ophthalmic assessment.

E. EARS (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Redness and tenderness Normal color, no Possible infection or inflammation; requires

behind the left ear tenderness, intact earlobes otologic examination.

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F. NOSE (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Nasal congestion and Patent nostrils, no Signs of respiratory distress; warrants

clear discharge discharge, normal airflow evaluation and intervention.

G. MOUTH AND PHARYNX (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Dry and cracked Moist mucous membranes, Potential dehydration and oral health concerns;
lips, swollen gums pink gums, no swelling hydration and dental consultation recommended.

H. NECK (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Full range of motion, no

Limited range of tenderness, supple neck Possible musculoskeletal or cervical spine
motion, tenderness muscles issues; further examination advised.

I. SPINE (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Mild scoliosis, tenderness Straight spine, no Possible spinal curvature; orthopedic

on palpation tenderness or deformity assessment recommended.

J. THORAX AND LUNGS (Inspection, Palpation, Percussion, and Auscultation)

Actual Findings Normal Findings Interpretation/Analysis

Decreased breath sounds Equal breath sounds, Suggestive of pleural effusion or respiratory
on the left side, dullness to resonant percussion, no distress; immediate intervention and imaging
percussion abnormalities needed.

K. ABDOMEN (Inspection, Auscultation, and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Abdominal distension, Soft, non-tender, no Potential gastrointestinal issues; gastrointestinal

tenderness on palpation distension, normal bowel consultation and imaging recommended.

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Actual Findings Normal Findings Interpretation/Analysis

sounds

L. EXTREMITIES (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

Peripheral edema in both No edema, warm skin, Indicative of potential circulatory or cardiac issues;
lower extremities normal capillary refill requires cardiovascular evaluation.

M. GENITALS (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

No abnormalities noted No abnormalities noted Normal genital examination findings.

N. ANUS AND RECTUM (Inspection and Palpation)

Actual Findings Normal Findings Interpretation/Analysis

No apparent abnormalities No apparent abnormalities Normal findings on rectal examination.

O. NEUROLOGIC EXAMINATION

Actual Findings Normal Findings Interpretation/Analysis

No focal neurological deficits No focal neurological deficits Normal neurologic

observed observed examination.

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 II. PERSONAL / SOCIAL HISTORY

Category Details

Habits Non-smoker, occasional caffeine consumer

Lifestyle Sedentary lifestyle, limited physical activity

Social Affiliation Engages in social activities with close family

Client's usual day like Home-centered, involvement in household activities

Rank/Order in the Family Firstborn

Travel (last 6 months) No significant travel history within the last 6 months

Educational Attainment Bachelor's Degree in [Field of Study]

III. ENVIRONMENTAL HISTORY

 Residence:

 Lives in a suburban area in Riyadh, Saudi Arabia.

 Occupation:

 Homemaker, actively involved in household responsibilities.

 Living Conditions:

 Well-ventilated home with access to clean water and sanitation facilities.

 Exposure to Environmental Risks:

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 No reported exposure to occupational or environmental hazards.

 Support Systems:

 Strong support from immediate family members.

IV. OB/GYNE HISTORY

*FOR FEMALES ONLY (Based on the client. N/A if not applicable.)

Category Details

Menarche (age) 13

When Regular cycles

Amount & Characteristics Moderate flow

Duration 5-7 days

Associated symptoms Mild cramping

Deliveries Details

G (Gravida) 1

P (Para) 0

Operations None

OB Score Details

T (Term Births) 0

P (Preterm Births) 0

A (Abortions) 0

L (Living Children) 0
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 OB Score Details

V. PEDIATRIC HISTORY

Maternal and Birth History

Category Details

Birth Date January 7, 2024

Birth Weight 2.8 kg

Type of Delivery Vaginal delivery

Condition after Birth Stable

Mother

Complication of Delivery None

Anesthesia Drug During Labor Not applicable

Exposure to Teratogenic Agents During Pregnancy

Neonates Details

Neonatal History No reported complications

Feeding History Breastfeeding

Type of Feeding Exclusive breastfeeding

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Pathophysiology

Inevitable Abortion
High CPR Levels and
Membrane Rupture
FIGO Protocol for
Pathophysiology Termination of
Pregnancy

Inflammatory Response

Infection Risk

Genetic Abnormalities

Hormonal Imbalances

Uterine Structural Medication (Misoprostol)

Uterine Contractions
Abnormalities
Expulsion of Products
Fig 1: Theoretical Based Diagram of Inevitable Abortion

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 THEORETICAL BASED

1. Pathophysiology of Inevitable Abortion:

 Inevitable abortion is often associated with disruptions in the normal physiological processes of pregnancy.

Factors such as genetic abnormalities, hormonal imbalances, or structural abnormalities in the uterus may

contribute to the occurrence of inevitable abortion (La et al., 2021).

2. High CPR Levels and Membrane Rupture:

 Elevated C-reactive protein (CPR) levels often indicate an inflammatory response in the body. In the context of

pregnancy, high CPR levels may be associated with infections, potentially leading to membrane rupture.

Infections can ascend from the lower genital tract, affecting the amniotic fluid and contributing to adverse

pregnancy outcomes (Brunham & Paavonen, 2020).

3. FIGO Protocol for Termination of Pregnancy:

 The International Federation of Gynecology and Obstetrics (FIGO) protocol for the termination of pregnancy

involves a systematic approach to ensure the safety of the patient. This protocol typically includes the use of

medications such as misoprostol to induce uterine contractions and facilitate the expulsion of the products of

conception (Melamed et al., 2021)

B. CLIENT BASED

1. Personal and Obstetric History:

 The client's history of a previous pregnancy with triplets, including two intrauterine fetal demises (IUFD) at 16

weeks, suggests a potential predisposition to obstetric complications. The history of leaking membranes and the

current complaint of bloody vaginal water may be linked to these previous complications.

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2. Current Complaint and Investigations:

 The leaking membranes and bloody vaginal water may be indicative of a compromised fetal membrane integrity,

leading to an inevitable abortion. The high CPR levels highlight the presence of an inflammatory response,

emphasizing the potential risk of infection affecting the membranes and the need for intervention.

3. Collaborative Decision-Making with Healthcare Professionals:

 The involvement of multiple healthcare professionals, including Dr. Mohamad Nazer Mhd Ezzat Alatar and Dr.

Yasser AlKateb, suggests a collaborative approach to patient care. The agreement on the need for termination of

pregnancy aligns with established protocols and emphasizes the urgency of the situation.

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 IV. LABORATORY, RADIOOGY & CYTOLOGY RESULTS OR FINDINGS

Test Date Normal Value Result Interpretation/Significance

07-Jan- WBC: 4,000- WBC: Elevated white blood cell count

CBC 2024 11,000/mm³ 12,500/mm³ indicative of infection

07-Jan- Elevated C-Reactive Protein,

CPR 2024 <0.5 mg/L 1.2 mg/L indicating inflammation

07-Jan-

Serum Analysis 2024 [Normal Range] [Results] [Interpretation]

07-Jan- No evidence of bacterial infection in

Blood Culture 2024 No growth No growth blood

07-Jan-

Urinalysis 2024 Normal Normal No signs of urinary tract infection

07-Jan- Triplets

Ultrasonography 2024 - detected Confirming triplet pregnancy

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 Advanced Women’s Health Care
PRACTICUM I
Clinical Portfolio
V. DRUG STUDY (Client Base)

Date Generic Brand Side Effect/ Nursing Consideration/

Ordered Name Name Classification Indication Action Adverse Reaction Patient Teaching

Stimulates

Induction of uterine Uterine cramping, Monitor for bleeding,

labor, contractions, bleeding, provide pain management,

07-Jan- Termination of softens the gastrointestinal educate on possible side

2024 Misoprostol Cytotec Prostaglandin pregnancy cervix effects effects

Monitor uterine response,

fluid balance, and

Induction of Uterine maternal well-being.

labor, Control Stimulates hyperstimulation, Educate on potential side

07-Jan- postpartum uterine water intoxication, effects and symptoms

2024 Oxytocin Pitocin Uterotonic bleeding contractions nausea requiring attention

07-Jan- Erythromycin Erythrocin Antibiotic Prophylaxis for Inhibits Nausea, vomiting, Assess for allergies,

2024 infection in bacterial abdominal cramps, monitor gastrointestinal

PPROM protein side effects, administer

 Advanced Women’s Health Care
PRACTICUM I
Date Generic Brand Clinical Portfolio Side Effect/ Nursing Consideration/

Ordered Name Name Classification Indication Action Adverse Reaction Patient Teaching

with food if possible.

Educate on completing

the full course of

synthesis diarrhea antibiotics.

Advanced Women’s Health Care
PRACTICUM I
Clinical Portfolio
 Advanced Women’s Health Care
PRACTICUM I
Clinical Portfolio

List of Priority Problems:

1. Infection Risk due to Premature Rupture of Membranes (PPROM):

 Assessment: Elevated C-Reactive Protein (CPR) and signs of infection.

 Intervention: Initiation of prophylactic antibiotic therapy (Erythromycin).

 Evaluation: Monitor vital signs, laboratory results, and overall clinical status for signs of

infection.

2. Uterine Hyperstimulation during Termination of Pregnancy:

 Assessment: Use of uterotonic medications (Misoprostol, Oxytocin) may lead to

hyperstimulation.

 Intervention: Continuous monitoring of uterine contractions, fetal heart rate, and maternal

well-being.

 Evaluation: Adjust medication dosage as needed, ensuring a safe and effective termination

process.

3. Psychological Impact of Pregnancy Loss and IUFD:

 Assessment: Previous loss of two fetuses at 16 weeks and the current inevitable abortion.

 Intervention: Emotional support, counseling, and involvement of a mental health professional

if needed.

 Evaluation: Regular assessment of the patient's emotional well-being and coping mechanisms.
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 Advanced Women’s Health Care
PRACTICUM I
Clinical Portfolio
VI. Nursing Care Plan

Nursing

Cues/Needs Diagnosis Planning Intervention Rationale Evaluation

Prophylactic

antibiotics reduce the

- Administer risk of infection.

prophylactic Regular monitoring Assess for signs

Short-Term Goals: antibiotics enables early of infection,

Prevent infection (Erythromycin). - detection and stability in vital

Risk for Infection during pregnancy Monitor vital signs intervention. signs, and

related to termination. Long- and laboratory Education empowers patient

Patient with Premature Rupture Term Goals: Ensure results. - Educate the patient to understanding of

PPROM and of Membranes overall maternal on signs of recognize signs of preventive

elevated CPR (PPROM) well-being. infection. infection. measures.

Uterine Risk for Uterine Short-Term Goals: - Continuous Monitoring helps Monitor uterine

hyperstimulation Hyperstimulation Ensure safe monitoring of detect contractions,

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 Nursing

Cues/Needs Diagnosis Planning Intervention Rationale Evaluation

termination without

uterine

hyperstimulation. uterine contractions hyperstimulation

Long-Term Goals: and fetal heart rate. early. Dosage fetal heart rate,

Minimize - Adjust dosage of adjustments prevent and adjust

related to complications during uterotonic complications while medication

during Termination of pregnancy medications as ensuring effective dosage

termination Pregnancy termination. needed. termination. accordingly.

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 Nursing

Cues/Needs Diagnosis Planning Intervention Rationale Evaluation

- Engage in

therapeutic Emotional support is

Short-Term Goals: communication. - crucial in the Assess

Provide emotional Involve mental grieving process. emotional well-

support and health Professional being,

Grieving related to counseling. Long- professionals as assistance enhances participation in

Psychological Pregnancy Loss Term Goals: needed. - Offer coping strategies. counseling, and

impact of and Intrauterine Facilitate coping support groups and Support groups the patient's

pregnancy loss Fetal Demise mechanisms and counseling provide a sense of ability to cope

and IUFD (IUFD) emotional healing. services. community. with the loss.

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 VII. ONGOING APPRAISAL
Ongoing appraisal involves continuous assessment and adjustment of the patient's

care plan to meet evolving needs. Regular monitoring of vital signs, laboratory

results, and emotional well-being is essential. Collaboration with the healthcare team

ensures a comprehensive approach to care. Adjustments in medication, interventions,

and support strategies are made based on the patient's response and changing

circumstances.

VIII. DISCHARGE PLAN

COMPONENTS OF DISCHARGE PLAN METHOD

Medication: Provide prescribed medications with clear instructions. M

Exercise: Recommend postpartum exercises per healthcare provider guidance. E

Treatment: Outline any ongoing treatments or follow-up appointments. T

Health Education: Educate on signs of infection, uterine hyperstimulation, and

emotional well-being. H
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OPD Follow-up: Schedule outpatient department visits for continued care. O

Diet: Provide dietary recommendations for postpartum recovery. D

Spiritual: Supportive resources for emotional and spiritual well-being. S

References
Brunham, R. C., & Paavonen, J. (2020). Reproductive system infections in women:
lower genital tract syndromes. Pathogens and disease, 78(5), ftaa022.

La, X., Wang, W., Zhang, M., & Liang, L. (2021). Definition and multiple factors of
recurrent spontaneous abortion. Environment and Female Reproductive
Health, 231-257.

Melamed, N., Baschat, A., Yinon, Y., Athanasiadis, A., Mecacci, F., Figueras, F., ...
& Hod, M. (2021). FIGO (international Federation of Gynecology and
obstetrics) initiative on fetal growth: best practice advice for screening,
diagnosis, and management of fetal growth restriction. International Journal
of Gynaecology and Obstetrics, 152(Suppl 1), 3.

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