NCM 109b

Care of Mother and Child at Risk or with Problems (Acute and Chronic)
(Related Learning Experiences)

NURSING CASE ANALYSIS - GYNE

Submitted by:
II-B | Group 4
Salvador, Ma. Claudette Syza B.
Sonajo, Jeshamia A.
Suguitan, Trisha Lei L.
Tagle, Mikylla Angela C.
Tapia, Patricia Mae M.
Tayamen, Joash Mickoy M.
Torida, Ellie Merrace L.
Villacorte, Ibrahim L.
Yanos, Stephen C.
Zapata, Yaella Mariz P.

Submitted to:
Prof. Romelee T. Calili
Prof. Wilma F. Catillo
Ms. Jilliane Althea G. Cacayorin
Ms. Maria Cielo B. Garcia
Clinical Instructors

Date Submitted:
April 30, 2024
 TABLE OF CONTENTS

I. ASSESSMENT
A. Personal Data
B. Pathophysiology
C. Family Background
D. Health History
E. Developmental Data
F. Patterns of Functioning and Levels of Competencies
G. Physical Assessment
H. On-Going Appraisal
I. Medical Management
II. NURSING CARE PLAN
III. GENERAL EVALUATION
IV. REFERENCES

2
 I. ASSESSMENT
A. PERSONAL DATA

Name: Gloria Valenzuela

Hospital Number: 1026538
Sex: Female
Age: 38
Date of Birth: 03/29/1986
Place of Birth: Vintar, Ilocos Norte
Civil Status: Married
Religion: Roman Catholic
Educational Attainment: High School Graduate
Occupation: Vendor/Seller
Address: Visaya, Vintar, Ilocos Norte
Chief Complaint: Vaginal Bleeding
Admitting Diagnosis: G5P4 (4004) incomplete abortion, early, nonseptic;
non induced; advanced maternal age
Date and Time of Admission: 03/17/2024 - 5:25 A.M
Attending Physician: Jezzica R. Balagso, MD.
Final Diagnosis: G5P4 (4014) complete abortion, early, nonseptic; non
induced; advanced maternal age
Date and Time Discharge: 03/19/24 - 3:54 P.M.

3
 B. PATHOPHYSIOLOGY

ANATOMY AND PHYSIOLOGY

A. REPRODUCTIVE SYSTEM

The production and transportation of gametes (sex cells) and the facilitation of
fertilization are the reproductive system's main tasks in order to secure the survival of the
species, according to Tortora and Derrickson (2017). The system in females comprises the
vagina, uterus, cervix, fallopian tubes, and ovaries. The fallopian tubes carry the eggs that are
produced and released by the ovaries to the uterus. During pregnancy, fetal development
takes place in the uterus.

1. Ovaries
i. Function. The ovaries are the female gonads responsible for oogenesis – the production
of eggs (female sex cells) and for hormone production (estrogen, progesterone,
inhibin, and relaxin).
ii. Location and Gross Anatomy. The ovaries are about the size and shape of almonds.
They lie against the lateral walls of the pelvis, one of each side. They are enclosed and
held in place by the broad ligament. The ovarian ligament anchors the ovaries to the
uterus and the suspensory ligament attaches them to the pelvic wall. Each ovary
contains a hilum, the point of entrance and exit for blood vessels and nerves along
which the mesovarium is attached.

iii. Histology of the Ovary. Each ovary consists of the following parts:
1. Germinal epithelium – a layer of simple epithelium that covers the surface of
the ovary.
2. Tunica albuginea – a whitish capsule of dense irregular connective tissue
located immediately deep to the germinal epithelium.
3. Ovarian cortex – consists of ovarian follicles surrounded by dense irregular
connective tissue that contains collagen fibers and fibroblast-like cells called
stromal cells.

4
4. Ovarian medulla – consists of more loosely arranged connective tissue and
contains blood vessels, lymphatic vessels, and nerves.
5. Ovarian follicles – consist of oocytes in various stages of development, plus
the cells surrounding them. The surrounding cells nourish the developing
oocyte and begin to secrete estrogens as the follicle grows larger.
6. Mature (graafian) follicle – large, fluid-filled follicle that is ready to rupture
and expel its secondary oocyte, a process known as ovulation.
7. Corpus luteum (yellow body) – contains the remnants of a mature follicle
after ovulation. The corpus luteum produces progesterone, estrogens, relaxin,
and inhibin until it degenerates into fibrous scar tissue called the corpus
albicans (white body).

Iv. Oogenesis and Follicular Development.

Figure 1: Summary of Oogenesis and Folicular Development

(Source: Tortora & Derrickson, 2017)

5
a. During early fetal development, primordial (primitive) germ cells migrate from
the yolk sac to the ovaries. There, germ cells differentiate within the ovaries
into oogonia. Oogonia are diploid (2n) stem cells that divide mitotically to
produce millions of germ cells. Even before birth, most of these germ cells
degenerate in a process known as atresia.
b. A few, however, develop into larger cells called primary oocytes that enter
prophase of Meiosis I during fetal development but do not complete that
phase until after puberty. During prophase, as oocyte maturation requires a
large amount of ATP for continuous transcription and translation, the
availability of the right number of functional mitochondria is crucial.
Dysfunctional oocyte mitochondria produce many reactive oxygen species
(ROS) which leads to oxidative stress to the oocyte cell.
c. During the oocyte’s arrested stage of development (prophase), each primary
oocyte is surrounded by a single layer of flat follicular cells, and the entire
structure is called a primordial follicle.
d. Each month after puberty until menopause, gonadotropins (FSH and LH)
secreted by the anterior pituitary further stimulate the development of several
primordial follicles into primary follicles.
e. Each primary follicle consists of a primary oocyte that is surrounded in a later
stage of development by several layers of cuboidal and low-columnar cells
called granulosa cells. As the primary follicle grows, it forms a clear
glycoprotein layer called the zona pellucida between the primary oocyte and
the granulosa cells. In addition, stromal cells surrounding the basement
membrane begin to form an organized layer called the theca folliculi.
f. With continuing maturation, a primary follicle develops into a secondary
follicle.
g. The secondary follicle eventually becomes larger, turning into a mature
(graafian) follicle. While in this follicle, and just before ovulation, the
chromosome of primary oocyte lines at the center and pulled away by spindle
fibers, thereby completing meiosis I and producing two haploid (n) cells of
unequal size —each with 23 chromosomes.

6
 h. Once a secondary oocyte is formed, it begins meiosis II but then stops in
metaphase. Preovolatory follicle produces ROS in part by regulating
angiogenesis. This appropriate amount of ROS facilitates the rupture of the
mature (graafian) follicle releasing its secondary oocyte in the process known
as ovulation.
i. In the uterine tube, if fertilization does not occur, the cells degenerate.
However, if sperm are present in the uterine tube and one penetrates the
secondary oocyte, meiosis II resumes, and the fertilized egg becomes a zygote.
The secondary oocyte splits into two haploid cells, again of unequal size. Thus,
the primary oocyte ultimately gives rise to three haploid polar bodies, which
all degenerate, and a single haploid ovum.

2. Cells in Reproductive System

a. Deoxyribonucleic Acid

Figure 2: Nucleic Acid

i. Anatomy. DNA is an organic chemical of complex molecular structure that codes

genetic information for the transmission of inherited traits. Each strand of a DNA
molecule is composed of a long chain of monomer nucleotides. The nucleotides of DNA
consist of a deoxyribose sugar molecule to which is attached a phosphate group and one
of four nitrogenous bases: adenine, guanine, cytosine and thymine. The nucleotides are

7
 joined together by covalent bonds between the phosphate of one nucleotide and the
sugar of the next, forming a phosphate-sugar backbone from which the nitrogenous
bases protrude. One strand is held to another by hydrogen bonds between the bases.
Within a cell, DNA is organized into dense protein-DNA complexes called chromosomes.
Telomeres, a region of repetitive DNA sequences, protect the end of the chromosome
from becoming frayed and tangled. Telomerase, an enzyme, is responsible for elongating
telomeres by de novo addition of TTAGGG sequences onto 3' chromosome ends to
prevent replicative cellular senescence (Lee, J., 2022).

Figure 3: Telomere

ii. DNA Methylation. DNA methylation is an epigenetic mechanism involving the transfer of
a methyl group onto the C5 position of the cytosine to form 5-methylcytosine. DNA
methylation regulates gene expression by recruiting proteins involved in gene repression or
by inhibiting the binding of transcription factor(s) to DNA. During the pre-implantation
embryonic development, while the cell of the zygote continuously divides, DNA methylation
is occurring in order to control gene expression during cell proliferation. By modulating gene
expression, DNA methylation is able to alter signaling pathways that affect cellular processes
such as cell cycle, DNA repair, cell growth, and proliferation. Cell proliferation is important for
successful blastocyst implantation (Dhar, G., 2021).

8
b. Cell Membrane’s Prostaglandin

i. Description. The prostaglandins are made up of unsaturated fatty acids that contain a
cyclopentane (5-carbon) ring and are derived from the 20-carbon, straight-chain,
polyunsaturated fatty acid precursor arachidonic acid.
Arachidonic acid is a key component of phospholipids, which are themselves
integral components of cell membranes. In response to many different stimuli, including
various hormonal, chemical, or physical agents, a chain of events is set in motion that
results in prostaglandin formation and release. These stimuli, either directly or indirectly,
result in the activation of an enzyme called phospholipase A2. This enzyme catalyzes the
release of arachidonic acid from phospholipid molecules.

ii. Function. Through prostaglandin receptors, prostaglandins can cause many effects in
almost every part of the body. Prostaglandins can cause vasodilation or vasoconstriction
in vascular smooth muscle cells, activate or inhibit platelet aggregation, induce labor, and
regulate hormones. They can also act in the central nervous system to cause fever and
influence pain perception. In menstruation, the destruction of endometrial cells releases
prostaglandins responsible for uterine contractions to release the uterine lining (Malik &
Dua, 2022).

3. Uterus

i. Function. It is the site of implantation of a fertilized ovum, development of the fetus

during pregnancy, and labor.

ii. Location and Gross Anatomy. Situated between the urinary bladder and the rectum,
the uterus is the size and shape of an inverted pear. Anatomical subdivisions of the uterus
include (1) a domeshaped portion superior to the uterine tubes called the fundus, (2) a
tapering central portion called the body, and (3) an inferior narrow portion called the
cervix that opens into the vagina. Between the body of the uterus and the cervix is the
isthmus, a constricted region about 1 cm (0.5 in.) long. The interior of the body of the
uterus is called the uterine cavity, and the interior of the cervix is called the cervical canal.

9
The cervical canal opens into the uterine cavity at the internal os (os = mouthlike opening)
and into the vagina at the external os.

iii. Histology of the Uterus. The uterus consists of three layers:

Figure 4: Anterior view of the Uterus with Left-side Partially Sectioned

a. The perimetrium is a serous membrane that lines the outside of the uterus.

b. The myometrium consists of several layers of smooth muscle and imparts the bulk of
the uterine wall. During labor and childbirth, coordinated contractions of the
myometrium in response to oxytocin from the posterior pituitary help expel the fetus
from the uterus. Prostaglandins, a lipid with hormone-like properties, also has a role
in mediating uterine contractions.

c. The endometrium is the highly vascularized 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 functionalis
(functional layer) is the innermost layer (facing the uterine lumen) and is shed during

10
 menstruation. The outermost stratum basalis (basal layer) is permanent and
generates each new stratum functionalis.

Branches of the internal iliac artery called uterine arteries supply blood to the
uterus. Uterine arteries give off branches called arcuate arteries that are arranged in
a circular fashion in the myometrium. These arteries branch into radial arteries that
penetrate deeply into the myometrium. Just before the branches enter the
endometrium, they divide into two kinds of arterioles: Straight arterioles supply the
stratum basalis with the materials needed to regenerate the stratum functionalis;
spiral arterioles supply the stratum functionalis and change markedly during the
menstrual cycle. Blood leaving the uterus is drained by the uterine veins into the
internal iliac veins. The extensive blood supply of the uterus is essential to support
regrowth of a new stratum functionalis after menstruation, implantation of a fertilized
ovum, and development of the placenta.

Iv. Implantation. About 6 days after fertilization, the blastocyst loosely attaches to the
endometrium in a process called implantation. Implantation consists of three stages: (a)
the blastocyst contacts the implantation site of the endometrium (apposition); (b)
trophoblast cells of the blastocyst attach to the receptive endometrial epithelium
(adhesion); and (c) invasive trophoblast cells cross the endometrial epithelial basement
membrane and invade the endometrial stroma (invasion), which occurs in two phases or
waves (Kim, S., 2017).

The ‘first wave’ of trophoblast invasion occurs between days 7 and 10 post-
conception, starting shortly after the blastocyst hatches out of the zona pellucida. During
this time, the blastocyst actively invades the tissues of the uterus. By day 10
postconception, the blastocyst is completely buried within the endometrial lining. For the
next few weeks, the placenta is not yet hemochorial and the blastocyst is fed by secretions
from the endometrial glands under conditions that are both hypoxic and hypoglycemic.
Indeed, high levels of oxygen or glucose at this stage will damage the developing embryo.
At 8–10 weeks of gestation, the placental extravillous cytotrophoblast cells (EVCTs) change

11
their adhesion molecule expression and stream out of the placental villi to invade the full
thickness of the decidualized endometrium (decidua) and the inner third of the
myometrium. These cells invade the maternal spiral arteries, attracted in part by the high
oxygen tension and by active recruitment by uterine natural killer (uNK) cells and
macrophages, and remodel these vessels by destroying the muscle layer and replacing the
endothelial lining with a pseudo-endothelium of fetal origin. This process—known as the
‘second wave’ of trophoblast invasion—is usually complete by 18 weeks of gestation and
is critical for the establishment of the definitive uteroplacental circulation (Kim, S., 2017).

Figure 5: Three Stages of Implantation

v. Decidualization. Decidualization refers to the functional and morphological changes that

occur within the endometrium to form the decidual lining into which the blastocyst
implants. These changes include the recruitment of leukocytes and, importantly, the
differentiation of endometrial stromal fibroblast cells (ESCs) into DSCs. It is the ability of
ESCs to differentiate into this alternative cell state that appears to be the key element in
the decidual transformation. DSCs are not simply modified ESCs; they are a distinct cell
type resulting from terminal differentiation and the genetic reprogramming of ESCs. This
reprogramming includes the downregulation of genes involved in the pro- inflammatory
response and in resisting tissue invasion along with increased expression of genes that
promote cellular proliferation, foster tolerance, and facilitate tissue invasion (Ng, S. et al,
2020).

vi. Amniotic Sac. During the second week of development, with the embryo implanted in
the uterus, cells within the blastocyst start to organize into layers: the amnion, the yolk
sac, the allantois, and the chorion. The amnion fills with amniotic fluid and eventually

12
 grows to surround the embryo. The yolk sac supplies some nutrients absorbed from the
trophoblast and also provides primitive blood circulation to the developing embryo for the
second and third week of development. The last of the extra-embryonic membranes is the
chorion, the one membrane that surrounds all others, which is related to the growth and
development of placenta.

B. ENDOCRINE SYSTEM

The endocrine system also controls body activities by releasing mediators, called
hormones.

Hypothalamic-Pituitary-Gonadal Axis

1. Gonadotropin hormone-releasing hormone (GnRH)

I. Secreting gland. GnRH is a hormone produced and secreted by the hypothalamus.
Hypothalamus is located deep in the brain hidden between the cerebral hemispheres.

Ii. Function. GnRH is the key regulator of the reproductive axis. Its pulsatile secretion
determines the pattern of secretion of the gonadotropins follicle stimulating hormone (FSH)
and luteinizing hormone (LH), which then regulate both the endocrine function and gamete
maturation in the gonads.

2. Luteinizing Hormone (LH)

i. Secreting gland. LH is a glycoprotein hormone that is co-secreted along with follicle
stimulating hormone (FSH) by the gonadotrophin cells in the adenohypophysis (anterior
pituitary gland). The anterior pituitary is the front lobe of the pituitary gland, which is a
small, pea-sized gland located at the base of the brain below the hypothalamus.

Ii. Function. In females, luteinizing hormone (LH) triggers ovulation, the release of a secondary
oocyte (future ovum) by an ovary. LH stimulates formation of the corpus luteum (structure
formed after ovulation) in the ovary and the secretion of progesterone (another female sex
hormone) by the corpus luteum.

13
iii. Luteinizing Hormone, Corpus Luteum, and Progesterone. The transformation of the
ruptured follicle into the corpus luteum occurs under the influence of luteinizing hormone
(LH). The presence of LH stimulates the corpus luteum to release progesterone. If fertilization
does not occur, the level of LH in the blood slowly falls and the corpus luteum will degenerate
within 10 to 14 days. If the oocyte is fertilized, then the corpus luteum remains. It produces
progesterone, estrogen and relaxin, acting to prepare the uterus, in particular the
endometrium, to support the developing embryo. Progesterone also inhibts prostaglandin
(PG) formation, which helps maintain myometrial quiescence and prevents the onset of
uterine contractions The corpus luteum persists until the placenta becomes a fully developed
endocrine organ, at which point it is no longer needed and slowly atrophies into fibrous scar
tissue (corpus albicans). This degeneration of the corpus luteum into a corpus albicans occurs
at around 2 months of pregnancy (Mytilinaios, D., 2023).

Thyroid Stimulating Hormone (TSH)

i. Secreting Gland. Thyroid-stimulating hormone, which is also known as thyrotropin, is
secreted by thyrotrophic cells of the anterior pituitary.

ii. Function. TSH functions by letting the thyroid know whether it has to produce more or less
thyroid hormones.

iii. Thyroid Hormone and Implantation. Thyroid hormone plays an important role in the
process of implantation and early development of the fetus through its effect on the
endometrium and placenta, which can be used to regulate the invasion of the extra villus
trophoblast by affecting the matrix metalloproteinase. Thyroid hormones and hormone
receptors regulate the endometrium receptivity, which is the stage where all the actors,
including thyroid hormones, cooperate to prepare and allow the implantation window of the
blastocyst, with variations during the menstrual cycle (Kbodmehri, R., 2021).

Melatonin
i. Secreting Gland. Melatonin, an amine hormone derived from serotonin, is secreted by the
pineal gland. The pineal gland is a small endocrine gland attached to the roof of the third

14
ventricle of the brain at the midline. Part of the epithalamus, it is positioned between the two
superior colliculi, has a mass of 0.1–0.2 g, and is covered by a capsule formed by the pia mater.
The gland consists of masses of neuroglia and secretory cells called pinealocytes.

Ii. Function. Melatonin appears to contribute to the setting of the body’s biological clock. It
is also a potent antioxidant that may provide some protection against damaging oxygen free
radicals.

Adrenal Cortisol
I. Secreting Gland. Cortisol, also known as the “stress hormone”, is a steroid hormone
produced and released by the adrenal glands. Adrenal glands are the endocrine glands on top
of the kidneys.

Ii. Function. Cortisol plays many important roles including regulating the body’s stress
response, controlling metabolism, suppressing inflammation, regulating blood sugar,
regulating blood sugar and helps control the sleep-awake cycle.

Insulin
I. Secreting Gland. Insulin is a peptide hormone secreted in the body by beta cells of islets of
Langerhans of the pancreas.
Ii. Function. Insulin helps the body use glucose for energy and manage blood sugar levels.

C. CARDIOVASCULAR SYSTEM

The human circulatory system is a complex network of blood vessels, including

arteries, veins, and capillaries, driven by the heart, responsible for transporting nutrients,
oxygen, hormones, and waste products throughout the body. Circulation patterns are clearly
established by the fourth week of embryonic life. It is critical to the survival of the developing
human that the circulatory system forms early to supply the growing tissue with nutrients and
gases, and to remove waste products.

15
Placenta.

As a fully developed organ, the placenta provides nutrition and excretion, respiration,
and endocrine function. It receives blood from the fetus through the umbilical arteries.
Capillaries in the chorionic villi filter fetal wastes out of the blood and return clean,
oxygenated blood to the fetus through the umbilical vein. Nutrients and oxygen are
transferred from maternal blood surrounding the villi through the capillaries and into the fetal
bloodstream (Biga, l et al. 2019). Aside from providing nutrition and oxygen to the product of
conception, placenta also works by producing several important hormones like lactogen,
estrogen and progesterone.

D. IMMUNE SYSTEM

The immune system defends the body from infection. It contains a complex network
of cells, chemicals, tissues and organs. During an infection, the immune response can result
in symptoms such as fever, inflammation, and fatigue. These symptoms are signs that the
body is actively fighting off the infection.

i. Fever. A fever is a natural defense mechanism that helps the body fight off infections. It is
triggered by the release of certain chemicals called pyrogens, which are produced by the
immune system in response to the presence of pathogens. These pyrogens act on the
hypothalamus, the part of the brain responsible for regulating body temperature, causing it
to increase.
The increase in body temperature during a fever serves several important functions.
First, it inhibits the growth and reproduction of many types of bacteria and viruses, as these
pathogens have a narrow temperature range in which they can survive and reproduce. By
raising the body’s temperature, a fever creates an inhospitable environment for these
disease-causing organisms.
Additionally, a fever stimulates the immune system. Higher body temperatures
enhance the function of immune cells, encouraging them to work more efficiently and
increasing the production of antibodies.

16
Ii. Inflammation. Immune system releases chemicals to increase blood flow to the affected
area. This rush of blood brings white blood cells to the site of infection, which help to fight off
the pathogen.

Ii. White blood cells. White blood cells are responsible for identifying and destroying
pathogens, such as viruses and bacteria, that can cause infection. They do this by recognizing
specific markers on the surface of these pathogens and producing antibodies to neutralize
them. When an infection occurs, white blood cells are recruited to the site of infection to
eliminate the pathogen. They can engulf and destroy pathogens through a process called
phagocytosis, or release chemicals that kill the pathogens directly. Neutrophils engulf and
destroy pathogens through phagocytosis. Lymphocytes produce antibodies and coordinate
immune response. Monocytes develop into macrophages that engulf and destroy pathogens.
Eosinophils release chemicals to defend against parasites and allergens. And basophils,
release chemicals that promote inflammation.

READINGS

DEFINITION
Spontaneous abortion, also known as miscarriage, is a medical term for any nonviable,
intrauterine pregnancy with either an empty gestational sac or a gestational sac containing
an embryo or fetus without fetal heart activity (Harvard Medical School, 2021). A viable fetus
is usually defined as a fetus of more than 20 to 24 weeks of gestation or one that weighs at
least 500 g. A fetus born before this point is considered a miscarriage. A miscarriage is an early
miscarriage if it occurs before week 16 of pregnancy and a late miscarriage if it occurs
between weeks 16 and 20.

Classification
According to Harvard Medical School (2021), miscarriages and possible miscarriages are
categorized in several ways:

17
 1. Threatened miscarriage – A miscarriage is considered threatened or possible, when
any bleeding from the uterus occurs before 20 weeks but the cervix is closed and there
is evidence of continued fetal heart activity.
2. Inevitable miscarriage – there is bleeding from the uterus and the cervix is opening,
but neither the fetus nor placenta has passed out of the woman's body yet. The
membranes around the fetus may or may not have ruptured (broken).
3. Incomplete miscarriage – when a portion of the pregnancy tissue (fetus or pregnancy
sac and placenta) has passed out of the uterus prior to 20 weeks gestation, but some
of the placental or fetus remains in the uterus.
4. Complete miscarriage – all the membranes around the fetus and the placenta are
expelled completely and the cervix closes prior to 20 weeks.
5. Missed miscarriage – a missed abortion refers to a miscarriage in which the fetus has
died. This means no heart beat is present when either a heartbeat has been noted
before or when the fetus is of a size in which a heartbeat would always be expected
in a healthy pregnancy. However, neither the fetus nor the placenta has been expelled
from the uterus.
6. Recurrent miscarriage – a woman is said to have recurrent miscarriage after three or
more miscarriages in a row.
7. Blighted ovum or an embryonic gestation – this occurs when a gestational sac forms
inside the uterus, but no fetus is present after seven weeks.

INCIDENCE
Global
• According to the Global Burden of Disease Study 2019 (Wang, Y. et al) results, an
estimated 23 million miscarriages occur every year worldwide, translating to 44
pregnancy losses each minute. The pooled risk of miscarriage is 15.3% of all recognized
pregnancies.
• The population prevalence of women who have had one miscarriage is 10.8%, two
miscarriages is 1.9%, and three or more miscarriages is 0.7% (Wang Y. et al, 2019).
• Chromosomal abnormalities account for up to 60% of all cases of miscarriage. (Shaker.
M. & Smith, A., 2022).

18
 • Approximately 80% of all cases of pregnancy loss occur within the first trimester
(Prager, S. et al, 2021).
• The most common risk factor for spontaneous abortion in the first trimester is
advanced maternal age. Women aged 35 to 40 years experience pregnancy loss at a
rate of 20% to 40% of clinically recognized pregnancies and women aged 45 years
experience pregnancy loss at a rate of 80% (Shaker. M. & Smith, A., 2022).

National
There is limited data on the incidence and prevalence of spontaneous abortion in the
Philippines.
• According to Buenaventura, H. (2021), roughly 10 to 15 percent of known pregnancies
end in miscarriage.
• One of three Filipinas have had at least one pregnancy loss in their lifetime (Elicay, K.,
2018).
Local
There are no published studies that specifically report the incidence or prevalence of
spontaneous abortion in Ilocos Norte, Phillipines.

RISK FACTORS/ETIOLOGIES

A. Non-modifiable
1. Advanced Maternal Age (AMA). AMA is associated with reduced fertility and an
increased incidence of pregnancy complications, including miscarriage. The impact of
AMA in pregnancy (Ye, X. et al., 2023) are discussed below:

a. Impact of AMA on the Female Reproductive System

a.1. Uterus – Implantation and Decidualization
Aging affects the uterus as the endometrium loses its ability to support
implantation and growth of an embryo. The implantation of the embryo in the
uterus is the first step of a successful pregnancy. The coordinated action of

19
 progesterone and estrogen secreted by the corpus luteum establishes the
receptivity of the uterus to implantation.

In the aged uterus, abnormal methylation and expression of imprinted

genes may reduce the successes of implantation due to decrease cell proliferation
. In older female, the expression of estrogen and progesterone receptors in the
endometrium decreases with age, as does progesterone secretion; consequently,
the uterus of the aged female also becomes less responsive to steroid hormones.
These changes affect the decidual response to a great extent, which inevitably
leads to reproductive failure.

a.2. Ovaries – Follicles and Oocytes

The decline in ovarian function with age has been characterized by a gradual
depletion of ovarian follicles and a reduced ability to produce oocytes capable of
fertilization and further development. Moreover, there are many biological
pathways thought to be responsible for age-related decline in oocyte quality, such
as age-related mitochondrial defects, the incidence of embryo aneuploidy and
chromosomal missegregation that are positively correlated with age.

b. Impact of AMA on the Endocrine System

b.1. Progesterone
Progesterone levels naturally declines with age.The pathogenesis behind
miscarriage in the setting of low levels of progesterone is due to the loss of
proliferation of the endothelial lining in the endometrium to make a thickened
endometrium, resulting in an impaired ability of the endometrium to allow for
proper implantation of a fertilized egg. When the ineffectively implanted egg
slightly separates, bleeding collects between the chorionic membrane and the wall
of the uterus. Enlarged subchorionic hematoma may cause the placenta to pull
away from its attachment site on the uterus causing blood to leak to the cervix.
Mild uterine cramping on the lower abdomen with minimal vaginal
spotting/bleeding then proceeds. This may set off a domino effect in which the

20
membranes (amniotic sac) ruptures prematurely. Detachment of placenta will also
lead to the disruption of blood flow to the fetus resulting to compromised state,
endometrial sloughing, or worse, fetal death (Bondick, C., 2022).
Low progesterone allows secretion of prostaglandin F2α and prostaglandin
E2 in the uterus during endometrial sloughing. Increased prostaglandin are
detected through Enzyme Linked Immunosorbent Assay (ELISA) test with
reference range of 35 to 115 pg/mL (Mayo Clinic Laboratories, n.d.). These
prostaglandins are involved in increasing myometrial contractions, cervical
dilation and vasoconstriction, leading to uterine ischemia and production of
anaerobic metabolites. This results in the hypersensitization of pain fibers, and
ultimately pelvic pain (Itani, R. etal., 2022).
In uterine contraction and cervical dilation, it is either the products of
conception will be completely expulsed that would lead to decreased bleeding due
to effective uterine contraction or incompletely expulsed and could cause the
uterus to ineffectively contract. If the latter would be the case, bleeding will
proceed as a result of ineffective uterine contraction with manifestations as
decrease in blood pressure.
The characteristic clinical manifestations of RPOC include one or more of
the following: uterine bleeding, pelvic pain, fever, and/or uterine tenderness
(Carusi, D., 2023). When microorganism is introduced, infection occurs, which is
characterized by fever, foul vaginal discharge, increased white blood cells (WBC),
crampy abdominal pain, and tender uterus (Prager, S. et al., 2023). When
microorganisms gain access to the maternal bloodstream, they can spread rapidly
to every organ system in the body, causing maternal death (Wall, L. et al, 2022).
b.2. Melatonin
As an antioxidant in follicles, melatonin reduces oxidative stress and protects
oocytes and granulosa cells by removing reactive oxygen species (ROS) produced
in follicles during ovulation. The abundance of endogenous melatonin decreases
with age, leading to excessive accumulation of ROS. This leads to oxidation of DNA
bases resulting to DNA damage. Damage to DNA bases decreases the quality of
embryo, thus, triggering apoptosis.

21
 c. Impact of AMA on the Placenta
Premature senescence of the placenta is caused by AMA. Senescence of the
placenta is characterized by reduced telomerase activity, increased DNA damage
and DNA oxidation. Senescence can be triggered by critically short or uncapped
telomeres. Telomeres, which is maintained in cells by telomerase, are found at the
ends of chromosomes to protect them from inappropriate DNA fusion and DNA
breaks. Senescence leads to loss of tissue repair capacity accompanied by a
damaging state of chronic inflammation, resulting to loss of placental integrity
(Cox, L. et al, 2017). Senescence can also occur without critically short telomeres
when cells encounter stressors including oxidative stress that can cause telomere
dysfunction, telomere uncapping or other DNA damage. Indeed, ROS-induced
telomere shortening/uncapping has been observed in oocytes and/or
preimplantation embryos leading to apoptosis or senescence (Chen, Z. et al, 2021).

2. Race. The risk of miscarriage for black African or black Caribbean women is 43% higher
than for white women. According to Johnson, T. (2022), black women are less likely to
seek adequate prenatal care for any number of reasons. These may include lack of
insurance, lack of financial and educational resources, lack of nearby health facilities,
fear of mistreatment, and more. Even the perception of racial discrimination in society
at large can delay prenatal care.

3. History of Miscarriage
The risk of miscarriage increase with the number of miscarriages in the past
pregnancies. According to Ford, H. (2019), the most common reason behind recurrent
miscarriage are anatomic and immunologic etiologies.

a. Anatomic Etiology
The uterine septum is the congenital uterine anomaly most closely linked to
recurrent pregnancy loss (RPL). Abnormalities in the vascularization of the
septum’s endometrium and the architecture of the septum’s musculature, seem
to have an impact on the later vascular stages of implantation, the receptivity of

22
 the uterine septum to the invading trophoblast and on the normal uterine
contractility and motility (Daniilidis, A. et al, 2022).

b. Immunologic Etiology
Antiphospholipid syndrome (APS), secondary to Lupus or Thrombophilia, is an
autoimmune disorder characterized by thrombotic events that may cause RPL.
This syndrome contributes to the uteroplacental thrombosis, vascular
insufficiency, and, more importantly, inflammation that impairs the uterus
function to support pregnancy (Yang, Z. et al, 2020).
Thrombophilia is a condition in which the blood can form into clots too quickly.
It impairs placenta function by causing venous thrombosis (blood clot on vein).

4. Thyroid Problems
Thyroid hormones play a role in the regulation of the menstrual cycle and the
preparation of the uterine lining for implantation. Imbalances in thyroid function may
disrupt these processes, making it more difficult for a fertilized egg to implant in the
uterine wall. Thyroid dysfunction during early pregnancy can also interfere with the
development of the embryo and placenta, increasing the risk of miscarriage.
Thyroid disorders are associated with an increased risk of pregnancy
complications, including preeclampsia, gestational diabetes, preterm birth, and
placental abnormalities. These complications can indirectly increase the risk of
miscarriage or other adverse pregnancy outcomes.

5. PCOS
` Several mechanisms underlying increased risk of miscarriage in women with
PCOS are increase androgens/luteinizing hormone, impaired fibrinolysis, endometrial
dysfunction, and obesity leading to insulin resistance (Kamalanathan, S., 2023)
IR might affect early miscarriage through downstream physiological changes.
IR or hyperinsulinemia may affect the secretion of androgen, and excess androgen can
aggravate endocrine disorders and follicular dysplasia, which may further result in
poor quality eggs and embryos. Besides, from an in vivo study, hyperandrogenism and
insulin resistance could induce mitochondria-mediated damage and result in an

23
 imbalance between oxidative and antioxidative stress responses in the gravid uterus,
which correlates with high abortion risk (Chen, Y., 2022).

6. Chromosomal Abnormalities
The meiotic spindle is a critical component of eggs that is involved in organizing
the chromosome pairs so that proper division of pairs can occur as the egg is
developing. When the chromosomes line up in a straight line on the spindle, the
division process should proceed normally. However, with a disordered arrangement
on an abnormal spindle, the division process may be uneven – resulting in an
unbalanced chromosomal situation. Older eggs are significantly more likely to have
abnormal spindles – which predisposes to development of chromosomally abnormal
eggs (Advanced Fertility Center of Chicago, 2022).

7. Psychological Trauma
The association between psychological stress and miscarriage could result, at
least in part, from activation of the hypothalamic-pituitary-adrenal axis by recruitment
of hypothalamic neurones which secrete corticotrophin-releasing hormone,
increasing pituitary secretion of adrenocorticotrophic hormone secretion and hence
of adrenal cortisol. This hormone has direct effects on decidual and placental
metabolism but also interacts with progesterone signalling. Stress-related early
pregnancy failure could also result from suppression of the hypothalamic-pituitary-
gonadal axis. Although generally considered a “stress hormone”, prolactin production
is decreased by stress in early pregnancy. Since prolactin stimulates progesterone
secretion, the reduced levels will decrease progesterone synthesis. Stress also inhibits
pituitary human chorionic gonadotropin secretion compounding the effect of
prolactin on progesterone release from the corpus luteum. These mechanisms are
relevant because progesterone activity is crucial for the maintenance of pregnancy;
low levels in early of gestation predicting miscarriage (Qu,F., 2017).

8. Infection
Multiple mechanisms can be utilized by pathogens to cross the placental
barrier. Plasmodium, enters the host via the maternal circulation and can infect and

24
 multiply in the trophoblast, even though its natural target cells are red blood cells.
However, this mechanism of crossing the placental barrier is specific to malaria.
Listeria monocytogenes uses two bacterial surface proteins called internalin A and B
to invade the placenta, after passing from the intestinal barrier to the maternal
circulation. The acronym ‘TORCH’ (Toxoplasma gondii, other, rubella virus,
cytomegalovirus, herpes simplex virus) refers to pathogens directly associated with
the development of congenital disease and includes diverse bacteria, viruses and
parasites. The placenta restricts vertical transmission during pregnancy and has
evolved robust mechanisms of microbial defence. TORCH pathogens access the intra-
amniotic space and overcome the placental defences that protect against microbial
vertical transmission. The presence of pathogenic organisms in the placenta induces a
maternal immune response (placental inflammation, fever) to infection that could
result in miscarriage (Giakoumelou, S. 2018).
Immune Response to infection includes placental inflammation and fever.
Placental inflammation is revealed through microscopic exam characterized by
infiltration of neutrophils in chorionic plate, placental membranes, or umbilical cord.

• Hypertension
Unmanaged chronic hypertension in pregnancy is linked to increased risk
of gestational diabetes, placental abruption, preeclampsia, and intrauterine growth
restriction. There is no information linking chronic hypertension to first-trimester
miscarriage, but given that the above conditions are linked to increased risk of
stillbirth, chronic hypertension could be considered a risk factor for late pregnancy
loss.
It eventually leads to high blood pressure directly in the arteries and may, in
turn, lead to pregnancy loss and incomplete abortion.

B. Modifiable
• Work-related Factors
Physical demands, such as lifting weights, standing for prolonged periods of
time, repeatedly bending at the waist, could increase the chance of miscarriage. This
is associated with the uterine contractions triggered by intense physical activities, as

25
 well as reduced blood flow to the uterus brought by the prolonged periods of standing.
Work places also has increased risk of accidents and trauma (CDC, 2023).
Workplace Stress: High levels of job-related stress, anxiety, or psychological
pressure can impact maternal health and potentially increase the risk of miscarriage.
Chronic stress may contribute to hormonal imbalances, immune system dysfunction,
and other physiological changes that can affect pregnancy outcomes (CDC, 2023).
Shift Work and Irregular Hours: Shift work, particularly night shifts or irregular
work schedules, may disrupt normal circadian rhythms and sleep patterns. Disruptions
to the body's internal clock can have adverse effects on reproductive health and
fertility, potentially increasing the risk of miscarriage and other pregnancy
complications (CDC, 2023).
Occupational Hazards: Certain occupations carry inherent risks that may be
detrimental to pregnancy, such as exposure to infectious agents, ionizing radiation,
electromagnetic fields, or workplace violence. Occupational accidents or injuries can
also pose immediate threats to maternal and fetal health (CDC, 2023).

• Physical Trauma
Trauma could cause of miscarriage, which could be in the form of blows and accidents.
These forms of trauma have direct effect causing placental sloughing and fetal death
(Qu et al, 2017).

• Lifestyle Factors (sleeping, vices, eating etc.)

A biological plausibility for an influence of both obesity, alcohol intake and
smoking on risk of pregnancy loss exists. For example, overweight/obesity is linked to
a pro-inflammatory state, while smoking increases the amount of circulating free
radicals and results in vasoconstriction, and both lifestyle characteristics are therefore
likely to influence placentation and potentially embryo implantation and development
(Magnus, M., 2022).

• Obesity.
Obesity is associated with high blood pressure which can complicate pre-
eclampsia. Research has also shown that obesity could be a surrogate for pre-

26
 gestational and gestational diabetes which is a risk factor for spontaneous abortion.
In addition, obesity could also make diabetes harder to manage, thus increasing the
risk of complications in the first 13 weeks of pregnancy.
It amplifies the complications related to incomplete abortion. It increases the
risk of insulin resistance and thyroid dysfunction. It also degrades the quality of
oocytes. Insulin resistance or hyperinsulinemia is associated with hormone changes
and follicular dysplasia, which leads to decrease production of oocytes.

• Pregnancy Interval
Research suggests that both short and long pregnancy intervals may be
associated with an increased risk of miscarriage, although the exact mechanisms are
not fully understood (DaVanzo, J. et al, 2017)..
After giving birth, the uterus undergoes a process called involution, where it
returns to its pre-pregnancy size and shape. A uterus that has not fully recovered may
not provide the optimal environment for implantation and early fetal development.
Pregnancy and childbirth can deplete maternal nutrient stores and increase
nutritional demands on the body. A short pregnancy interval may not allow sufficient
time for the mother to replenish her nutrient stores and recover from the physical
demands of the previous pregnancy (DaVanzo, J. et al, 2017)..
Pregnancy and childbirth cause significant hormonal fluctuations in the body,
including changes in estrogen, progesterone, and other hormones that are essential
for maintaining a healthy pregnancy. A short pregnancy interval may not allow enough
time for hormonal levels to return to baseline before conception occurs again.
Disruptions in hormonal balance may affect the implantation process and increase the
risk of miscarriage (DaVanzo, J. et al, 2017).

• Exposure to Radiography
By producing free radicals, ionizing radiation causes cellular damage by
interfering with chemical bonds between molecules regulating critical cellular
processes and events. This process generally leads to DNA mutation or cell death and
sometimes causes damage to essential cellular enzymes (Kumar, R. (2023).

27
 In addition, one study examined human embryonic tissues to assess the
association between Magnetic field (MF) exposure and embryonic growth, and
observed an increased risk of impaired embryonic bud growth and apoptosis
associated with exposure to higher MF level, providing some direct evidence of
adverse biological impact of MF exposure on embryonic development (Li, D. et al.,
2017).

• Exposure to Teratogenic Drugs

At a molecular level, phenobarbital, produces free radicals and causes DNA
base transversion while macroscopically, resulting in impaired growth, motor
development, and fetal mortality. The teratogenicity of valproic acid is exerted via the
inhibitory actions of folate and histone deacetylase through increased accumulation
in embryonic circulation and by the production of reactive oxygen species (ROS).
Carbamazepine is metabolized into carbamazepine-10,11-epoxide, damages DNA,
and can be associated with craniofacial defects, abnormal IQ, and growth retardation.
Phenytoin gets bioactivated by embryonic prostaglandin H synthase to a free radical,
resulting in DNA oxidative damage (Tsamantioti, E. et al, 2024).

DISEASE PROCESS

Spontaneous abortion, also known as miscarriage, is a medical term for any nonviable,
intrauterine pregnancy with either an empty gestational sac or a gestational sac containing
an embryo or fetus without fetal heart activity (Harvard Medical School, 2021). Different risk
factors lead to abortion, these are classified according to modifiability, hence, there are non-
modifiable and modifiable risk factors.
For the non-modifiable risk factors, these are age, race, history of miscarriage, thyroid
problems, polycystic ovary syndrome (PCOS), chromosomal abnormalities, psychological
trauma, infection, and hypertension. Modifiable risk factors, on the other hand, are work-
related factors, physical trauma, lifestyle (including sleeping, vices, and eating, pregnancy

28
interval, exposure to radiography and exposure to teratogenic drugs. These risk factors results
to etiologies which leads to miscarriage.
Aging affects the overall systemic function. AMA is associated with decline overall
body functions. In miscarriage, decline of functions that are important to consider are the
decrease production of progesterone by corpus luteum/placenta, decrease melatonin
production by the pineal gland, decrease telomerase activity, and impaired mitochondrial
function. Decrease in production of progesterone affects the proliferation of the endothelial
lining in the endometrium, thus further affecting the ability of the product of conception to
implant properly. This ineffective implantation results to sub chorionic bleeding, which is
manifested by signs and symptoms of mild uterine cramping on lower abdomen; hematoma
seen via transvaginal ultrasound and minimal vaginal bleeding/spotting. Enlarged sub
chorionic hematoma may cause the placenta to pull away from its attachment site on the
uterus causing blood to leak to the cervix. Direct trauma can also increase the risk of
separation of the implanted product of conception. This may set off a domino effect in which
the membranes (amniotic sac) ruptures prematurely. Detachment of placenta will also lead
to the disruption of blood flow to the fetus, which is aggravated when the patient has diseases
that causes thrombotic events, resulting to compromised state, endometrial sloughing, or
worse, fetal death (Bondick, C., 2022); thus miscarriage.
Impaired mitochondrial function produces many reactive oxygen species (ROS), this is
aggravated by the decrease melatonin production. Increase ROS leads to oxidative stress to
the oocyte cell. This damages the DNA which leads to production of low-quality oocytes which
are prone to apoptosis or death of product of conception; thus miscarriage.
Increased ROS production leads to abnormal DNA methylation, which affects the cell
proliferation. Decreased cell proliferation contributes to ineffective implantation. Increased
ROS production, aggregated by decreased telomerase activity, which is also an effect of AMA,
also causes placental senescence. This causes tissue damage and inflammation which can be
detected through microscopic examination. Due to damage in the placenta, disruption of
blood flow to product of conception happens compromising the fetus leading to fetal death
and endometrial sloughing; thus miscarriage.
Microorganism can also lead to miscarriage. This is true to patients who have
infections, such as urinary tract infection, TORCH. If microorganisms reach the product of
conception, and the product of conception is having abnormal development due to

29
chromosomal abnormalities, immune response will occur, which is characterized by increased
WBC, fever and placental inflammation revealed through microscopic exam. Immune
response in the uterus leads to rejection of the product of conception leading to fetal death
and endometrial sloughing; thus, miscarriage.
The destruction of endometrial cells or the endometrial sloughing, releases
prostaglandins which then in turn cause vasoconstriction, uterine contraction and cervical
dilation. The increase secretion of prostaglandin is detected through Enzyme Linked
Immunosorbent Assay (ELISA) test with reference range of 35 to 115 pg/mL.
Vasoconstriction results to uterine ischemia and production of anaerobic metabolites
which leads to hypersensitization of pain fiber, thus, the pain felt by the patients of
miscarriage.
The uterine contraction and cervical dilation may lead to complete or incomplete
expulsion of product of conception depending on the effectivity of contraction. In complete
expulsion, the effective contraction of uterus compresses the uterine blood vessels,
decreasing the vaginal bleeding. In the incomplete expulsion, the uterine contraction is
ineffective in compressing the blood vessels leading to increased bleeding and blood loss. This
is manifested by vaginal bleeding, and urinalysis results of presence of blood in urine and RBC
in urine (3-5/HPF). The blood loss decreases the venous return and cardiac output, which can
be assessed by the manifestation of low blood pressure. Next on the disease process is the
constriction of peripheral vessels, increased cardiac contractility and activation of renin-
angiotensin-aldosterone system. Which results to increased heart rate and blood pressure,
cold clammy skin and pallor. Without intervention the mentioned compensatory mechanism
fails thus blood loss continues, which decreases the blood pressure. This leads now to
decrease tissue perfusion in all parts of the body thus maternal death.
In line with the retained fragments in incomplete miscarriage, when microorganisms
are introduced, infection happens which is manifested by the fever, foul vaginal discharge,
increased WBS and increased Leukocyte detected though urinalysis, cramping abdominal pain
and tender uterus. If the microorganisms will go to systemic circulation, maternal death can
happen.

30
MANIFESTATIONS
General
1. Vaginal Bleeding
2. Fetal Tissue Passing
3. Pain and Discomfort – usually lower back pain (often worse than normal menstrual
cramps)
4. Cervical Dilation
5. Nausea and Vomiting
6. Fever and Chills
7. True Contraction
8. White-pink mucus coming from the vagina

Specific to Category
Table 1: Manifestations of the Different Categories of Miscarriage
Diagnostic Criteria Signs Others
Threatened - Minimal bleeding - Amenorrhea with Uterine size vs AOG:
abortion - With or without signs of pregnancy Compatible
cramping - Presence of
- Closed internal cervical lumbosacral and Bag of Water (BOW):
os hypogastric pain Intact
- Normal sonographic - Vaginal bleeding
findings from scanty to Fetal Heart Tone: Present
moderate,
continuous or Internal Examination:
intermittent Cervix is closed and
uneffaced
Inevitable - Progressive cervical - Similar with Uterine size vs AOG:
abortion dilation without passage threatened abortion Compatible
of tissue - Associated uterine
- Heavy, profuse cramping pains Bag of Water (BOW):
bleeding Ruptured

31
 - Severe cramping - Profuse vaginal
- Dilated Cervical Os bleeding Fetal Heart Tone: Present

Internal Examination:
Cervix is dilated and
effaced
Complete - History of bleeding, - (-) uterine Uterine size vs AOG:
abortion cramping, and passage contraction Incompatible
of tissue
- Dilated Internal Bag of Water (BOW): Not
Cervical Os appreciated
- Minimal current
bleeding Fetal Heart Tone:
- TVUS: empty uterus Absent sign of Pregnancy
with normal
endometrial stripe Internal Examination:
Cervix is closed
Incomplete - Ability to pass a ring - Present sign and Uterine size vs AOG:
abortion forceps through internal symptoms of Incompatible
cervical os pregnancy
- passing of tissue - Presence of Bag of Water (BOW):
lumbosacral pain Rupture
- Profuse vaginal
bleeding Fetal Heart Tone:
- uterine contractions Absent

Internal Examination:
Cervix is dilated
Missed - (+) Sonographic - Presence of Signs Uterine size vs AOG:
abortion evidence of a nonviable and symptoms of Incompatible
pregnancy

32
 pregnancy without - Absent uterine Bag of Water (BOW):
bleeding or cramping contraction Intact/Ruptured
- Abnormal UTZ - Spotting or no
findings: bleeding at all Fetal Heart Tone:
o Gestational sac - Continuous brown Absent
is irregularly vaginal discharge
shaped or after cessation of Internal Examination:
collapsing bleeding Cervix is closed
o (-) yolk sac
o (-) fetus and FHT
Septic - Temperature of 38 C or - Presence of signs Uterine size vs AOG:
abortion higher at least 24 hours and symptoms of +/-
and unattributed to any pregnancy
cause - Lower abdominal Bag of Water (BOW):
- History of mechanical pain and cervical +/-
interference with motion tenderness
pregnancy - (+/-) uterine Fetal Heart Tone:
- (+) Septic cervical contraction (severe, +/-
discharge constant, diffuse
- Tender uterus, abdominal pain) Internal Examination:
parametrium, adnexa - Foul cervical Cervix is dilated
discharge
- (+/-) bleeding

33
SCHEMATIC DIAGRAM

34
35
 A. Family Background

Table 2: Demographic Data

Family Sex Age Civil Relationsh Educational Occupation Religion Place of

member Status ip to the Attainment Residence
Client

Gloria Female 37 Separated Client High School Housewife Roman Brgy. Visaya,
Vlenzuela Graduate Catholic Vintar, IN

Rodolfo Male 38 Separated Husband College Skilled Roman Penablanca,

Valenzuela Graduate Constructio Catholic Cagayan
n Worker

Elmer Male 51 Single Partner High School Farmer Roman Brgy. Visaya,
Crisanto Graduate Catholic Vintar, IN

Juan Male 15 Single Mother High School N/A Roman Brgy. Visaya,
Valenzuela Student Catholic Vintar, IN

Juana Female 13 Single Mother High School N/A Roman Brgy. Visaya,
Valenzuela Student Catholic Vintar, IN

Juanita Female 9 Single Mother Elementary N/A Roman Brgy. Visaya,

Valenzuela Student Catholic Vintar, IN

Ian Male 1 Single Mother N/A N/A Roman Brgy. Visaya,

Crisanto Catholic Vintar, IN

The table above shows the demographic data of the immediate family members of
Gloria. The Valenzuela family is a cohabiting family, with six members in the household, since
Rodolfo is living in Cagayan. Gloria is separated from her husband, Rodolfo, and is currently
living with her partner, Elmer, together with her children from her husband, Juan, Juana and
Juanita, and her baby with Elmer, Ian. Altogether, the six members live in a two-storey semi-
concrete house with three bedrooms, a living room, a kitchen, and a comfort room.

Three of the family members, Gloria, Rodolfo and Elmer, specifically, work to provide
for the family’s needs. The client earns a monthly salary of Php 2,550 by managing the ‘Coop’

36
grocery store in their barangay owned by the Pantawid Pamilyang Pilipino Program (4Ps). On
the other hand, Elmer earns a monthly wage of Php 5,000 by working at their neighbors' farm.
Rodolfo, the client's separated husband, employed as a construction worker, also provides
Php 7,000 per month for their children's education and other expenses. In total, the family
has a monthly income of Php 14,550, which, according to the client, is always inadequate to
meet their monthly needs.

In addition, they receive Php 5,100 every two months from the 4Ps, equating to a
monthly amount of Php 2,550. Moreover, they also receive financial assistance from relatives
in Manila, specifically the client's sister and aunt, offering approximately Php 2,000 monthly,
although this sum may vary. According to the client, these financial aids are utilized to meet
the family's expenses alongside their total monthly income. With all of these as financial
sources, there is still inadequacy of their budget as per client’s verbalization, “agkurang nu
dadduma ta nangingina met ti magatang ita nga panawenen.”

During periods of financial strain, which most of it arises from the children’s needs,
the client borrows money from relatives or neighbors or opt to her last resort which is
informing her separated husband about it. According to the client, in the previous year, they
had borrowed money two times from their relatives ranging from Php 300 to 1,000 for family
groceries and borrowed Php 10,000 from CardBank insurance company. The client stated that
the family does not have allocated emergency funds or a designated health service budget.
The family addresses their emergency needs with the same strategy during financial
difficulties, which is by borrowing money from their relatives or to the CardBank insurance
company. Sometimes, she also cuts back the children’s daily allowance, which the children,
fortunately, understand. To pay for the loans, Crisanto finds additional work such as fishing
in the river nearby or working in construction, which pays a lot more than farming. As what
the client assessed, these coping strategies, although involving loans, are effective in coping
up for financial difficulties in the present month. “Nu adda di mi mabayadan ti kaetoy nga
bulan, ipasaruno mi nga bulan lattan.” This suggests that the family has fatalistic resignation
or ‘bahala na’ mentality.

According to a study conducted by Casiño (2018), bahala na is often viewed negatively

since Filipinos often used it as a means of punishment during difficult or emergency situations.

37
The fatalistic inclination of bahala na, where Filipinos put everything up to kapalaran or fate,
is a negative aspect. Hong (2023) claims that bahala na may not be a symbol for cosmic
fatality, which is connected to the uneven distribution of power. Lack of agency specifically is
a byproduct of an unfair framework, and it is lack of agency that reproduces and perpetuates
the structure. Individuals with a “bahala na” attitude may be less likely to adhere to medical
advice or treatment regimens because they believe that their health outcomes are
predetermined. This can lead to poorer health outcomes and exacerbate existing health
conditions.
The Philippine Institute for Development Studies (PIDS, 2022), identified low income
(but not poor) as greater than or equal to 10,957 Php but less than 21,194 Php. With the
family total income of 14,550 Php , the family is classified as low income. According to Hu
(2021), there exists a correlation between social class and self-reported physical and mental
health, with lower social classes typically reporting poorer health. This relationship is partially
mediated by health self-management. Individuals from lower social classes often face
challenges in managing their health, such as limited access to nutritious food and difficulties
in assessing their own health status. Consequently, these disparities contribute to inequalities
in physical and mental health between higher and lower social classes.

Figure 6: Budget Allocation

38
 The client serves as the budget allocator in their household and the main decision
maker as to health services. The family's expenditure is primarily directed towards their
children's education, allocating Php 350 daily, divided among the three children, which in total
is Php 7,000 monthly. Another significant expense is their monthly food budget of Php 6,500,
covering a variety of essentials like dried goods, wet goods, and canned items. The client's
partner has a vice, costing the family Php 1,740 monthly, as he consumes three packs weekly,
Php 145 per pack. Their transportation costs amount to Php 1,200 per month for their
motorcycle fuel. They also have a loan of Php 10,000 from CardBank, with weekly payments
of Php 350 amounting to Php 1,400 monthly. Utility bills for electricity and water come to Php
550 monthly, toiletries expense is Php 460 monthly, the clothing expenses are Php 100 every
2 months equating to a monthly budget of Php 50. Additionally, they allocate Php 200 for
communication expenses each month.
Despite their financial management, the family does not seem to be worried about
their lack of emergency and health service budget. This gap could pose significant challenges
during unforeseen emergencies or health issues requiring medical attention. The family's
expenditure on vices stands out as an area where funds could be redirected . According to
Better Health Channel (2012), smoking costs money as well as affecting your health.
Cigarettes are expensive and quitting can save you money now, as well as saving on future
health costs. Instead of indulging in these vices, reallocating the budget towards an
emergency fund would not only promote healthier lifestyles, mitigating potential health
issues, but also provide a safety net for future family emergencies.

In their household, the members have a close relationship with one another. Usually,
they eat all together at lunch and dinner. In the morning, Elmer goes to the farm early, hence,
the kids eat breakfast together with Gloria before they go to school. Despite Elmer and the
children being unrelated, he still treats them as his own. Fortunately, the kids are also close
to their father-figure, since their mother instilled in them the importance of respect. Despite
not living with the children, Rodolfo contacts his children via the Messenger social platform.
In terms of misunderstanding between the client and her spouse, the spouse usually talks to
Gloria once she is already in a calm state. They practice to voice out their thoughts to each
other, an attitude the client stated that they want to impart to the children. According to

39
Elmer, this attitude, which he observed from his late parents, is effective in maintaining family
relationships by avoiding bigger fights. For the family’s social activities, their form of bonding
is through eating together and watching television together after dinner. The family values
quality time together, often sharing stories and experiences during dinner, reflecting a sense
of equality among all members, as expressed by the client “Kanayon kami met ag kakadwa
nu kada adda ubraen or papanan mi. Nu kuma adda free time mi ket mapan kami agdidigus
dijy dam”.

Family relationships affect an individual's growth and well-being in the long term
through behavioral, physiological, and psychosocial mechanisms. According to Jabbari's
study, 2023, there is a correlation between negative family dynamics and poor sleep
outcomes, elevated heart rate, and elevated blood pressure, all of which increase the risk of
developing hypertension. This suggests that family dynamics have an impact on both
cardiovascular health and sleep health. Evidence linking mutuality among family members to
improved sleep outcomes in kids was also discovered in the same study.

Living in Vintar, Ilocos Norte, they are all raised in the rich Ilocano culture such as the
family eating together in a meal and having gratitude for the past, wherein they prioritize
family and community over individualistic pursuits. This embodies their strong bonds and
support for one another. According to the Centers for Disease Control and Prevention (CDC,
2023), social connectedness helps communities thrive and support the community member’s
well-being, health, safety, and resilience. Moreover, with the presence of bayanihan within
their community, harmonious relationships are built. According to the patient, this is also
strengthened with the community’s gossiping, which creates a unique bond within a group.
Individuals who maintain stable, supportive relationships are inclined to prioritize healthy
behaviors and experience improved mental and physical health outcomes. Moreover, such
individuals demonstrate enhanced resilience in coping with challenges, including stress,
anxiety, and depression. One important value that Gloria wants to impart to her children is
the importance of close family ties. This has been evident within their family, hence, she
wants her children to practice this as well.

In conclusion, the Valenzuela family’s budget allocation reflects that basic needs such
as education and food of the family is their top priority. However, according to the Office of

40
Disease Prevention and Health Promotion, 2023, inadequate health insurance coverage is one
of the largest barriers to healthcare access, as it limits adults to less likely receive preventive
services. Similarly, children without health insurance coverage are less likely to receive
appropriate treatment for conditions like asthma or critical preventive services such as dental
care, immunizations, and well-child visits that track developmental milestones. As for the
family’s interpersonal relationship, they have demonstrated close family relationships and
dynamics that influence a patient's health behavior and decision-making process. This is
supported by the study of Jabbari, 2023, wherein it stated that interpersonal interactions
among family members have lasting impacts and influence the development and well-being
of an individual through psychosocial, behavioral, and physiological pathways. Thus, family
dynamics and the quality of family relationships can positively or negatively impact health.
For the culture, the family’s adherence to the rich ilocano culture strengthens their sense of
identity and community belonging, enhancing their social connections and support networks.

41
 B. Health History

i. Family Health History

Figure 7. Genogram
The figure above shows the genogram of the client’s family. In the first generation,
starting on the paternal side, Fernando was diagnosed with jaw cancer by a physician in 2001
and passed away at the age of 72. However, since Gloria and Fernando were not living under
the same roof, the client is unaware of the medications and management given to her
grandfather. Fernando is married to Susan, 88 year-old, who is still alive. Susan is diagnosed
with hypertension by Dr. Marjorie Sierra at Mariano Marcos Memorial Hospital and Medical
Center (MMMH&MC). According to the client, Susan currently has maintenance for her
hypertension, which are losartan (Cozaar) 50mg tablet taken orally once a day (OD) after her
breakfast, and amlodipine (Norvasc) 5mg tablet taken orally OD after dinner. Aside from
hypertension, Susan was diagnosed at MMMH&MC in 2005 by Dr. Alfonso with Stage II breast

42
cancer affecting her left breast. The client's grandmother had a breast-conserving procedure
that same year, often known as a partial mastectomy or lumpectomy, with the intent of
removing the cancer and preserving as much of the normal breast as possible. Moreover,
radiation therapy started around a month following the surgery. According to the client,
Susan has been going to treatment for three weeks, five days every week. On the maternal
side in the first generation, Lito died of an unknown disease at an unknown age. Marissa
claimed that her husband died from a simple cough and cold until it became severe and can
no longer be cured by herbal medicine such as lagundi and oregano leaves, which is the
management they can only afford. On the other hand, Marissa, who is 80-year old, lives in
Sanchez Mira, Cagayan. According to the client, Marissa, was diagnosed with osteoporosis by
a physician at Northern Cagayan District Hospital in 2009, at the age of 65. Her prescribed
medications include 500mg of calcium carbonate (Vonwelt), which she takes orally twice daily
(BID) after meals, and 70mg of alendronate (Aldren), which she takes 30 minutes before meals
and only once a week as per the doctor's orders. Marissa utilizes herbal medicine, specifically
650mL of extracted ginger, to treat osteoporosis as well as common colds and coughs. The
ginger leaves are simmered for three to five minutes in three cups (710mL) of water. Then,
they let it cool for at least five minutes after boiling. She drinks roughly 250 milliliters twice a
day till her cough and cold disappear. Since she thought it worked and her cold and cough
only lasted three days, Marissa has carried on doing this up until this point whenever she is
sick.
In the second generation on the paternal side, Grace is the first child of Fernando and
Susan. The client only remembered that her aunt died due to Anemia, but was unable to recall
the medications she took. The second child, Allan, 59 years old, has currently no known
diseases and only experienced common childhood illnesses, as claimed by the client. Other
than a fractured left arm sustained in a bicycle accident when he was eight years old, which
was treated at the closest hospital in Cagayan, Ronald, the third child, had no other known
disease. Lovi, 46, was diagnosed with breast cancer at the age of 40 in 2018 and had
undergone surgery in Hong Kong for her condition. Unfortunately, the client does not know
the medications taken by her aunt. On the maternal side, Nora, 60, the client’s mother, was
diagnosed with hypotension in the year 2017 at MMMH&MC, but was unable to recall her
physician. She takes ferrous sulfate (Ferustab) 325mg in tablet form taken OD orally after
meals and cinnarizine (Gorizine) 25mg tablet to be taken orally three times a day (TID) after

43
meals. Currently, she consults regular checkups at Vintar Rural Health Unit (RHU) for her
monthly check up. Manuelito, the second child, was diagnosed with jaw cancer in the year
2009 at Dr. Domingo S. De Leon General Hospital. Manuelito underwent chemotherapy that
lasted for 3 years but eventually stopped due to financial reasons. The client was unable to
determine the medications taken by her uncle and was unable to recall how old Manuelito
was when he died. The third child, Vilma, 58, was diagnosed with osteoporosis (Sciatica) at
MMMH&MC in Batac City, last May 2023. According to the client, her aunt experienced pain
sensation particularly on the back, hands and feet. Unfortunately, the client was also unable
to determine the other medications prescribed to Vilma aside from Vitamin B12 (Pharex B-
complex) 100mg in tablet form, prescribed by the doctor that was to be taken orally once a
day in the morning. Vic, Bong, Joko and Ace live in Claveria, Cagayan and have no known
disease.
In the third generation, Anton, the first child of Allan and Nora, also the client’s eldest
brother, died at the age of 8, hence, the client claims that she was not able to clearly recall
the details of her brother’s death since she was only three years old when it happened. The
client, Gloria, the second child, has four children, currently residing in Vintar, Ilocos Norte.
Aga, the third child at 36 years old, and Anna, the fourth child at 28 years old, have no
diagnosed diseases. The youngest sibling, Anjo, 24, is currently living with their Mother, Nora,
and has no known disease. As for Gloria’s children, all her four children, Juan, Juana, Juanita
and Ian do not have a currently diagnosed disease.
According to Gloria, all of her uncles and aunts including her grandparents on both
sides had no known childhood illnesses aside from common colds, cough and fever except for
Vic, who suffered from chicken pox, and Anjo, who suffered from sore eyes. Vic managed his
chicken pox by following traditional practices from his grandmother, which is wearing a black
long-sleeved shirt and avoid wearing sando and clothes that has bright color in order to that
their belief that the chickenpox disappears instantly which later on claimed that this
traditional practice was effective according to the client as it helps to relieve the itchiness
brought by the chickenpox. Anjo manages his sore eyes using cotton balls soaked with warm
water to clean and rinse the yellowish discharge coming from both of her eyes. Moreover her
mother Nora, buys over the counter drug named EyeMo, a lubricating tear drops for eyes
intended to relieve itchiness caused by the sore eyes. Other than these management, Gloria
states that they are not seeking medical attention in any healthcare facilities due to financial

44
reasons and fear of spending too much money just for illnesses that can be cured using
traditional practices.
As to vaccinations, the client can only provide the COVID-19 immunizations of some
family members. Susan received only one dose of COVID-19 vaccine from Johnsons&Johnsons
pharmaceuticals in the year 2021. She did not receive any booster dose due to the belief that
the vaccine may bring serious illness that may lead to death. Allan, Ronald, and Lovi received
two doses of Sinovac vaccine and one booster shot. On the maternal side, Marissa received 2
doses of Astrazenica vaccines. Nora, the mother of the client, received two doses of the
COVID-19 vaccine Sinovac and received one booster shot of Pfizer. In the present, the client
received immunization against the COVID-19 virus, in which she received two doses and one
booster of Sinovac.
As for the client’s children, Gloria stated that Juan, Juana, Juanita, and Ian, all had the
necessary childhood vaccinations. Specifically, one dose of BCG and Hepatitis B, as well as the
IPV, three doses of Pentavalent, OPV, and PCV, and two doses of MMR. Moreover, they also
received two doses of Pfizer COVID-19 vaccine in the year 2021. Ian has also been
administered a single dose of BCG and Hepatitis B vaccines, along with the IPV, three doses
of Pentavalent, OPV, and PCV vaccines, and two doses of MMR. In addition, a dose of
Rotavirus and Hep A was also administered.
Analysis:
Cancer is the most common hereditary disease that is identified in the family of the
client. This implies that the children of the client had higher chances of inheriting the disease.
The importance of prevention of cancer can reduce the possibility of having cancer. Cancer
prevention strategies are designed to lower the chance of developing cancer and reduce the
morbidity of established cancer. There are three levels of cancer prevention. Eliminating or
mitigating cancer risk factors by adopting healthy behaviors and lifestyles, such as avoiding
tobacco and alcohol use, exercising, eating a healthy diet, and applying sunscreen to protect
against UV exposure, belongs to primary prevention and is the easiest and most effective way
of preventing cancer for the general public. Secondary prevention includes screening to
identify precancerous lesions and taking intervention measures to prevent disease
progression to malignancy. Tertiary prevention refers to reducing or controlling the
symptoms and morbidity of established cancer or the morbidity caused by cancer therapy (Gu
et. al, 2020)

45
 According to the World Health Organization (2017), immunization has been shown to
effectively prevent and eliminate life-threatening infectious illnesses all around the world. A
person who has been vaccinated becomes immune or resistant to an infectious illness
because vaccinations activate the body's own immune system, providing the best protection
against diseases. Immunization helps to promote economic growth by preventing sickness,
disability, and mortality. During epidemics, the public health system spends time identifying
probable contacts, collecting and analyzing blood samples, educating the public, organizing
outbreak response, and allocating funds for hospital treatments. Immunization reduces the
cost on the health-care system and, in particular, on the poorest families. Adherence to
routine vaccinations is critical in reducing vulnerability to vaccine-preventable infections and
subsequent breakout (Hobani and Alhalal, 2022).
The client’s families health beliefs and practices reflect on how they perceive their
different familial diseases. This results in non-compliance to health services, believing in faith
healers, and continuously practicing folk remedies that there are no scientific benefits to the
body. One of the examples of folk remedies are oils, creams and medicines from different
sources such as plants and animals (Rondilla et al., 2021).
Acquisition of such products is attributed to satisfaction from prior experience,
distrust in the current healthcare system, family tradition, and intention to supplement
existing medical treatment. This implies that the role of health education from healthcare
providers is important in order to stop the continuous promoting of these beliefs and
eliminate as much as possible that prevent life threatening situations.

ii. Past Health History

When Gloria was in Grade 1, she had experienced mumps or ‘gabbi’ as per
verbalization. She described it as a raised hand-size bump in the lower jaw that is painful
which causes her to have difficulty in swallowing along with a feverish feeling. As a
management to this illness, they make use of traditional practices taught by her grandmother.
An acot-acot is a brown, mud-like circular object that houses a type of black insect. The acot-
acot is crushed and mixed with approximately water to form a paste after which it is applied
to the affected area. This is done at least one to two times a day. It is her grandmother's belief
that the acot-acot minimizes the swelling and cools down the area since it is their belief that

46
the mumps are caused by the hot environment. She considers it to be effective since her
illness only lasted for 3 days and the size of the bump gradually decreases each passing day.
As for fevers, she would experience elevated body temperature accompanied with
body pain and weakness. During her childhood, the client recalls that her mother would place
a cold cloth on her forehead since it is believed to absorb the heat. She would replace the
cloth 2-3 times a day. Her mother would also give a warm carbonated drink, namely Royal, as
it is her mother’s belief that it boosts her energy for faster healing. She also recalls taking
syrup medications, although she does not remember the name of those medications. She
deemed it to be effective since she would heal after 3-4 days. In her adolescence until
adulthood, when experiencing fever, she treats the illness by taking Paracetamol 3 times a
day, as taught to her by her mother. She claimed it to be effective since her fever would only
last for 3-4 days.
When having coughs and colds, she experiences symptoms of stuffy nose, sneezing
and coughing. In her childhood, her mother’s resort was to give her medications. Although
she does not remember the specific drugs taken and frequency, she remembers taking syrup
medications. She deemed it effective since her symptoms would subside. In her adolescence
and adulthood, her management of the illness is to take Neozep 2 times a day, as advised by
her mother. Her illness would only last for a 4 days to 1 week, hence she claims the treatment
to be effective.
In instances where she has diarrhea, she experiences frequent bowel movement of
about 3-4 times and describes the stool consistency to be watery and loose. She manages the
illness by taking Diatabs 1-2 times a day, which was taught by her mother. Her diarrhea would
last for 1-2 days. She claimed it to be effective after taking the medication, since her passage
of stool would be lessened in terms of frequency or almost stopped immediately. She would
also drink only warm water, advised by her mother as well, as she believes that it helps with
digestion. With the accompaniment of the medication she took, she also believed it to be
effective.
When she was 30 years old, she had boils or busali as per verbalized. The boil is located
at her left elbow and is characterized by a bump in the skin with a remarkable white center
that is about 1.5 cm with the surrounding area looking red, and is accompanied with
tenderness which she rated to be eight out of ten. It is taught by her elders to apply ice in the
area and replace ice as frequently as possible each time the previous melts. It is also their

47
belief to crush a gumamela flower and apply the extracted juice to the area then wrap it with
a cloth to let the bolis absorb the extract. This is done 2 times a day. They believe that by
doing so, the boils will shrink and the healing will hasten. Although the client is not fully
convinced with this practice, she claimed that management done is effective since her boils
healed after a week.
During her 4th pregnancy, at age 36, she was diagnosed with Gestational Diabetes
(GD) on May 23 2022, then later on with Pregnancy-induced Hypertension (PIH) on June 17,
2022 by Dr. Castillo at Gov. Roque B. Ablan Sr. Memorial Hospital. The client was not able to
recall her medications for her GD, but for her PIH, she was prescribed 2 tablets of methyldopa
(Aldomet) 2 tablets for every 8 hours for 10 days. As to surgeries, the client stated that she
has not undergone any procedures.
The client claimed to be complete with childhood vaccinations, however she wasn't
able to name her vaccinations nor present her vaccination card, although she has a visible
vaccination mark on her right upper deltoid arm. For her Covid-19 vaccine, she had received
the vaccination in their local Rural Health Unit (RHU) in Vintar. She had received 2 doses of
Pfizer-BioNTech–the first dose in 2020 and the second dose in 2021, while she had her
booster shot in 2022 with the same brand. She has no known allergies to food, medications
or environmental elements.
Her diet is mostly composed of green leafy vegetables cooked in a dinengdeng dish
which she claims to consume on a day to day basis. She is not fond of overly sweet and salty
meals, and foods that are fish smelling or malansa as per verbalized. Although she tries to
incorporate meat dishes alternately. The client has no vices for alcohol consumption and
smoking. She considered her pattern of activity to be semi-active since her daily routine is to
tend to her family needs in the morning, then open the Coop grocery store where she stays
to work during the day, and in the evening she would do house chores.
Traditional medicines are a part of our culture that is commonly practiced by older
generations. It is the knowledge of our ancestors that was discovered through experience and
later on became a tradition that is passed down years later, hence the widespread use.
However, some of these practices have no concrete evidence or scientific study that verifies
their potency. This is attributed to the earlier generation beliefs which are influenced by
superstition and environmental factors since it is their main source available at the time.
Despite popular opinion, traditional medicine products can be damaging to health and should

48
not necessarily be used in combination with different kinds of treatment (WHO, 2023). As a
defense, plants produced chemical defenses known as physiologically active secondary
metabolites, which can be hazardous to humans and other animals. It is therefore incorrect
to assume that plant extracts are safe, aside from those DOH-approved herbals. Furthermore,
acute poisoning from traditional medical treatments is not uncommon, however because of
information gaps and confidentiality issues, researchers find it challenging to assess exact
potential toxicity (Wyk & Prinsloo, 2020).
Not only traditional medication, but self-medication as well, have an impact
contributing to the deterioration of health and could endanger life. It is a cost-effective and
convenient way of treating a wide variety of illnesses. It involves use of over-the-counter
drugs that are medically studied, hence it is believed to be safe for consumption. Although it
is true, it still has its own danger especially when taken inappropriately and excessively. When
self-medicating, taking an improper amount might not be effective enough to relieve
symptoms. However, taking too much medicine can result in a dangerous overdose (Gateway,
n.d.). While taking medicine to treat symptoms might seem beneficial, Tarr (2024) argues that
medication can mask symptoms of a more serious health issue.
Immunization and vaccination is one of the proven best primary prevention to any
vaccine-preventable diseases. By stimulating the immunological response of the body, the
individual is protected from the disease which prevents the distribution and further spread of
infection. The immune systems of vulnerable populations, such as children, pregnant women,
and the elderly, are compromised, increasing their susceptibility to infectious infections. They
thus have a greater difficulty fighting off these infections, which raises the possibility of severe
sickness or even death (WHO, n.d.).
The client's adherence to traditional health practices may lead her to apply such
methods to her children, despite her inability to explain the reason behind them. While she
believes in the effectiveness of these practices, their validity lacks scientific evidence, raising
potential health concerns. Hence, health education on the possible dangers of traditional
practices and medicines is essential to encourage clients to consult professional health care
providers to avoid further complications to illness and achieve optimum health. In addition,
encouraging an active lifestyle, such as regular walking, can significantly enhance overall well-
being and promote better health outcomes.

49
 iii. Present Health History
The client had her first menstruation when she was 12 years old on January 2-6, 1998.
According to the client, she was about to go to school when she found out that there was a
small patch-like blood present in her underwear in which she asked her mother and was told
that she is having her first menstruation. She was advised to rub her underwear on her face
in order to prevent having pimples. In addition, her mother discouraged her from consuming
foods like coconut and anything sour in the belief that eating these foods can cause clumping
of her menstruation blood in which she claimed that these superstitions are effective. She has
had a regular menstrual flow ever since. In the present, the client’s last menstrual period was
on January 6, 2024. Her period usually lasts for about 3-4 days. On the first day, she described
the bleeding scanty. She would use 1 regular sized sanitary napkins, which were observed to
be partially soaked and appear only as spottings. During the second day, the bleeding
becomes heavier than the previous. She uses about 2 regular size sanitary napkins in a day
and during every change, the sanitary napkin is observed to be moderately soaked. The
situation is similar on the third day. And for the last day, her menstruation flow would return
to being scanty hence she would only use 1 regular sized napkin throughout the day. The
client reports pain in the first few days of her menstruation and rated it to be 4 out of ten.
She usually manages the pain through sleeping which she deemed effective because upon
waking up the pain would have subsided.
According to the client, her last period of menstruation was on January 6, 2024. Gloria
noticed that her period appears to be delayed for the past two months hence, she suspected
that she might be pregnant due to the fact that she had a monthly regular period. To confirm
her suspicion, the client took a pregnancy test on March 11, 2024, which had a positive result.
Aside from surprise she was worried since she had an altered sleeping and eating pattern
during the last week of February because they held a funeral reception for a relative.
The next day, upon bathing, March 12, she noticed a small vaginal blood discharge
that was less than 1 cm in diameter according to the client. The passage of scanty vaginal
blood discharge as they termed as paksay is thought to be normal since she experienced the
same scenario during her previous pregnancies and her friends testimonies of experiencing
the same, hence the client was unalarmed on the situation. The spotting continued until the
next day, March 13, with the same quantity of blood discharge.

50
 On March 14, the bleeding became more heavy, to which she had to use a pantyliner
during the day. Upon changing, the client identified the small amount discharged on her
underwear. On the following day, March 15, the bleeding became profuse and the client used
2 regular sized napkins during the day, which were observed to be fully soaked every after
change. Along with the bleeding, she observed a small red clump that is about 3-4 cm in size
in her second change of sanitary napkin. On March 16, the bleeding was the same as the
previous day; however, she felt pain in her lower back which she described to be a sudden
and short lasting for only 2 seconds with a pain scale of 2 out of 10. During night time, starting
from 9 pm to 12 am the next day, March 17, she had severe bleeding and changed napkins 3
times. At the time, she felt anxious and alarmed to which she decided to be hospitalized. At
1 am she was rushed to Gov. Roque B. Ablan Sr. Memorial Hospital. Upon arrival in the health
care facility, the client was interviewed and had an internal examination. According to the
client, her physician told her that she was 3 cm dilated already. However, she was told that
there were no anesthesiologists available at their facility at the moment to do a Manual
Vacuum Aspiration hence she was referred to Mariano Marcos Memorial and Medical Center
and was admitted on March 17 at 5:25 a.m. in the morning with chief complaint of vaginal
bleeding.

Analysis:
Menarche refers to a female adolescent's first menstrual cycle. Menarche normally
occurs between the ages of 10 and 16, with an average age of onset of 12.4 years. It is
indicative of normal female reproductive health and wellbeing. Most women view menarche
as their body's crucial declaration of fertility (Lacroix et al., 2023). It is usually accompanied
by traditional myths such as rubbing the underwear on your face with the first blood from
your menstrual period in the belief that this helps to avoid having pimples for lifetime.
Moreover, consuming foods like coconut and anything sour in the belief that eating these
foods can cause clumping of the menstruation blood. A study by Sakhi et al. (2023), stated
that there are no medical restrictions on the types of foods that menstruating people can or
should eat, and dietary restrictions can put them at risk by limiting nutrient intake. In addition,
the National Nutrition Council (NCC) clarifies that wiping the face with first menses so you
won’t get pimples is a false information, and very unsanitary. Fact is that hormonal changes,
genes, diet and no proper hygiene are causes in having pimples. Even though these period

51
myths are amusing, many women and girls continue to believe them today. These period
myths and stigma should end. During this monthly cycle, a woman's body and health is prone
to bacteria and infection. Putting proper hygiene when having a period is the topmost concern
and priority. Girls should manage their health and well-being when having a Period (National
Nutrition Council [NCC], 2022).
Miscarriage is generally defined as the loss of a pregnancy before viability or before
20 weeks of gestation. Given that the client was 37 years old when she became pregnant with
her supposed fifth child, her current maternal age is a risk factor in her pregnancy. In line with
the study of Magnus et al. (2019), emphasizing that maternal age is the strongest known risk
factor. The risk of miscarriage is slightly elevated in the youngest mothers and then rises
sharply in older mothers. Moreover, Gloria’s actions during the time of her miscarriage shows
lack of knowledge about the possible complications of completely ignoring the signs of her
condition. As supported by the study of Quenby et al. (2021), the complications of miscarriage
are both physical, such as bleeding or infection, and psychological. Psychological
consequences include increases in the risk of anxiety, depression, post-traumatic stress
disorder, and suicide.
The client's age and past history of multiple pregnancies increase the potential of
pregnancy problems due to factors like altered reproductive physiology with age in the
mother and more stress on the body from previous pregnancies. Targeted family planning
education is essential for reducing such risks and promoting the best possible health
outcomes. This education should cover fertility awareness, contraceptive alternatives, and
the significance of spacing pregnancies. To guarantee safety, it is also important to educate
mothers to report any signs or symptoms of pregnancy issues, such as scanty or profuse
bleeding to physicians immediately.

52
 iv. OB History

The client's obstetric history is summarized by the score G5P4(4014), indicating a total
gravidity of five and a parity of four. Her first child was born when she was 22, followed by
the second at 24, the third at 28, and the fourth at 36. Her most recent pregnancy occurred
at the age of 37. All four deliveries were normal spontaneous deliveries (NSD) at Governor
Roque B. Ablan Sr. Memorial Hospital in Laoag City. Unfortunately, the fifth pregnancy ended
in miscarriage at 10 1/7 weeks.

In the initial four pregnancies, she initiated exercise as a component of her prenatal
routine during the sixth month. This involved taking daily walks around her neighborhood,
covering a distance of about 20 meters. This practice, instilled by her mother, was believed to
facilitate a smoother delivery. Throughout her pregnancies, she abstained from consuming
herbal beverages but ensured adequate hydration by consuming a minimum of nine cups of
water daily, equivalent to 2,160 mL, she simply thought that drinking water could lead to
wellness, especially during her pregnancy. As she verbalized, "kaadwek latta nukwa danom
kon, mga siyam nga baso kada aldaw". Moreover, she mentioned that she craved tinuno a
sili for her first child. While pregnant with her third child, she craves macaroni but dislikes any
sort of fish. She expressed that "awan cravings ko iddi buntis nak kenyada" with her second
and fourth children.

On her prenatal check-ups, she regularly follows her schedule at the Gov. Roque B.
Ablan Sr. Memorial Hospital's Outpatient Department (OPD) of Obstetrics and Gynecology
throughout the pregnancies. With her first child, she received monthly check-ups at Vintar's
Rural Health Unit (RHU). However, Dr. Heidi Marita Albano, the RHU's physician, directed her
to a provincial hospital due to the client’s plan to deliver at the hospital. Subsequently, the
client was advised that she visit the provincial hospital for her monthly check-ups. For this
reason, the client attends monthly check-ups at Gov. Roque B. Ablan Sr. throughout all
pregnancies. In addition, the client reported that the first three pregnancies wer attended by
Dr. Maribel Albano, while the fourth pregnancy was by Dr. Norielle Castillo. The client recalled
taking her medication on a regular basis and said, "Agpapada amin na agasko pwera tay
mayka uppatko a pinagbuntis ."

53
 In her fourth pregnancy, she adhered to a regimen of ferrous sulfate with folic acid
(Ameciron) 300 mg/350 mcg tablet once daily (OD) and calcium carbonate (Albicum) 500 mg
tablet three times daily (TID) orally. However, due to pregnancy-related conditions such as
gestational diabetes and pregnancy-induced hypertension (PIH) diagnosed by her physician,
Dr. Castillo, she received additional medications. Gestational diabetes was diagnosed on May
23, 2022, followed by PIH on June 17, 2022. While the client cannot recall the specific
medications for gestational diabetes, her physician advised her to monitor her daily diet,
particularly sugar intake. For the management of PIH, she took two tablets of methyldopa
(Aldomet) orally every eight hours for ten days and was instructed to ensure adequate rest.
However, due to the delivery of her fourth child, she was only able to take the medication for
five (5) days before being discontinued.

Moreover, according to the client, she did not experience any problems related to
urination, vaginal itching or discharge, mid-cycle spotting, and pain during intercourse. But
throughout her pregnancies, she experienced brown spotting about 1 mL at an early stage of
pregnancy approximately in her second month. She mentioned, "Paksay," reiterating
"agspospotting nak nukwa," to further clarify.

In regards to sexual activity, the client has a husband before her current partner,
during which they had three children together. She mentioned that their sexual encounters
occurred infrequently, approximately once a week, and typically involved the man-on-top
position. Conversely, with her current partner, they share one child and engage in sexual
activity more frequently, typically one to two times per week, also favoring the man-on-top
position.

There were no drug allergies or vices mentioned. In addition, the client’s paternal side
has a history of breast cancer particularly, her aunt and grandmother. However, the client is
not aware about breast self-examination, as she reported, “haanko ammo ubraen eta”.
Moreover, she did not undergo any pap smear or mammogram.

Analysis:

High parity can lead to various medical conditions. In the study of Adams et al. (2022)
titled “High Parity is Associated with Increased Risk of Cervical Cancer: Systematic Review and

54
Meta-analysis of Case–Control Studies”, high parity has long been suspected of being
connected with an increased risk of cervical cancer. The increased risk of cervical cancer
among women with high parity is thought to be linked to a high rate of cervical abnormalities
during pregnancy, a high detection rate of HPV among pregnant women, and some studies
also suggest vaginal parity causes local changes to cervical cells as a result of traumas during
birth.

Pregnancy-related physical activity is essential for promoting the health of the fetus.
In the research conducted by Connolly et al. (2019), walking is the most popular form of
exercise during pregnancy because it has several health advantages for both the mother and
the unborn child. Moreover, as noted by Lake (2021), pregnant women who regularly worked
out experienced a lower risk of cesarean delivery, less pain and discomfort during labor, and
a quicker recuperation after giving birth.

In pursuant of the study of Wang et al. (2022) titled, "Number of Parous Events Affects
the Association Between Physical Exercise and Glycemic Control Among Women with
Gestational Diabetes Mellitus: A Prospective Cohort Study", multiparous women are more
likely than primiparas to develop gestational diabetes mellitus (GDM). Multiparous women
have been linked to an increased risk of both GDM and its recurrence in subsequent
pregnancies.

Pregnancy-induced hypertension (PIH) is often caused by abnormal insulin secretion

or islet dysfunction and/or tissue resistance to insulin which may aggravate or cause various
complications during pregnancy. Thus, hyperglycemia is an independent risk factor for PIH.
Blood pressure and general physiological health are still significantly influenced by lifestyle
and wellbeing. Consequently, the emphasis of lifestyle and wellness guidelines is on
encouraging people to adopt more health-promoting habits, such as regular exercise, a
balanced diet, enough sleep, preventative care, and enhanced resilience.

The client is more vulnerable to negligence because of her lack of understanding about
screening equipment, particularly breast examinations, given her family history. The necessity
of early detection has led to a number of screening programs aimed at reducing the disease's
morbidity and death (Boyd & Pippin, 2023). A crucial component of early detection is clinical

55
breast examinations. Proponents and breast cancer awareness organizations persist in
supporting the contentious practice and work to enlighten the public about its proper use,
which is essential for individuals.

The ability of individuals and couples to anticipate and attain their desired number of
children and the spacing and timing of their births is referred to as family planning by the
World Health Organization (WHO). The most appropriate method of birth control varies
depending on an individual's age, sexual activity frequency, number of sexual partners, desire
to have children in the future, and family history of certain diseases. Ensuring access to
preferred contraceptive methods for everyone benefits numerous human rights, including
the right to life and liberty, freedom of opinion, expression, and choice, the right to work and
education, and the right to significant health and other benefits (WHO, 2023).

C. Developmental Data
A. Robert Havighurst’s Developmental Task Theory (Biopsychosocial Model
of Development)
Robert Havighurst emphasized that learning is basic and that it continues throughout
life span. He proposed that all individuals from infancy to old age progress through a series of
developmental stages, comprising a series of developmental tasks. According to Havighurst,
developmental task is a task which arises from a certain time in life of an individual, successful
achievement of which leads to his happiness and to success with later task, while a failure
leads to unhappiness in the individual, disapproval by the society, and difficulty with later
task.
According to Havighurst’s Developmental Tasks Theory, the developmental tasks at
each stage are influenced by a person’s biology (physiological maturation and genetic
makeup), his/her psychology (personal values and goals), as well as his/her sociology (specific
culture to which the individual belongs). The stages of Havighurst’s Developmental Task
Theory are the following (Psychology, 2021):
● Infancy and Early Childhood (0-6 years old);
● Later Childhood (6-12 years old);
● Adolescence (13-18 years old);

56
 ● Early Adulthood (19-30 years old);
● Middle Age Adulthood (30-60 years old); and
● Later Adulthood (60 years old and above).

Gloria is currently 37-years-old, therefore she belongs under the middle age
adulthood (30-60 years old) category of Havighurst’s Developmental Task Theory. According
to the theory, she is expected to meet the developmental tasks which are as follows:
1. Achieving adult civic and social responsibility
2. Establishing and maintaining an economic standard of living
3. Assisting teen-age children to become responsible and happy adults
4. Developing adult leisure, time activities
5. Relating oneself to one’s spouse as a person
6. Accepting and adjusting to the physiological changes of middle age
7. Adjusting to aging parents.

Task Not Partially Fully Justification

Achieved Achieved Achieved
1. Achieving ✓ Gloria is a member of 4P’s in their
adult civic community. In addition, she is an
and social active member of her community,
responsibilit participating in barangay activities
y like clean up drive and disaster
preparedness sessions.
2. Establishing ✓ Gloria, as a 4P’s member, works in
and the grocery store founded alongside
maintaining with other 4P’s members. Gloria
an economic considers them as financially
standard of unstable since their only constant
living source of income is her earning from
working in the grocery store and her
partners income from farming.

57
3. Assisting ✓
After working hours, Gloria spends
teenage
time with her children to which she
children to
takes advantages to impart life
become
values. She guides her children in
responsible
building necessary attributes through
and happy
assigning them house chores, letting
adults
them budget their allowance, and
encouraging self-care practice.

4. Developing ✓
Gloria spends quality time with her
adult leisure-
neighbors and relatives during her
time
free time through activities like
activities
having meals together and attending
social events.

5. Relating ✓ Gloria and her partner prioritize open

oneself to and honest communication.
one’s spouse According to her, they create a safe
as a person space for each other to express their
feelings and emotions. For instance,
when Gloria is feeling stressed,
Crisanto actively listens to her
concerns and offers support and
encouragement. He validates her
emotions and provides a comforting
presence. Also, they deeply respect
each other. Gloria is glad to her
partner despite him not being the
biological father of her three
children, he still treats them as his
own.

58
 6. Accepting ✓
Gloria accepts the fact that her age is
and
advancing. However, the client has
adjusting to
not perceived any physiological
the
changes in her body yet. She added
physiologic
that she can still perform her daily
changes or
living activities including her usual
middle age
household chores.

7. Adjusting to ✓ Gloria said that she is doing her best

aging to guide her children. As her age is
parents increasing, she is teaching her
teenage children to become
independent in their decisions.

Analysis
According to Havighurst, some developmental tasks are primarily focused on physical
growth, while others are based on individual ideals and ambitions, and yet others are
influenced by socio-structural and cultural variables. According to the theory, the main
developmental task of middle adulthood is to establish and maintain a satisfactory living and
working environment. This includes achieving economic stability, contributing to society, and
finding personal fulfillment in one's work and social roles. Middle adulthood is also a time for
reassessing life goals and values, as well as adjusting to physical changes and aging.
Gloria was able to fully achieve developmental task #1, #3, #4, #5 and #7, with partial
achievement of developmental task #2 and #6. According to Havighurst's theory of
developmental tasks, establishing and maintaining an economic standard of living is a crucial
aspect of adult development. This task involves achieving financial independence, providing
for oneself and one's family, and ensuring economic stability. Gloria was able to partially
achieve this task because being a member of 4P’s suggests that she may face challenges in
achieving economic stability due to limited financial resources. Also, the fact that Gloria is
working in a grocery store founded alongside other 4P's members indicates an effort to
generate additional income beyond the conditional cash transfer program. Gloria

59
characterizes their financial status as unstable, since they mainly depend on her partner's
farming income and income from their grocery store. Their dependence on a limited source
of income draws attention to a possible weakness in their economic standing because it could
not be enough to meet their needs on a regular basis. While Gloria is engaged in work and
entrepreneurship to improve her economic situation, the instability of her income suggests
that she may not have fully achieved financial independence or stability. Thus, based on
theory, Gloria's situation reflects a partial achievement of the developmental task of
establishing and maintaining an economic standard of living.
In Havighurst's theory of developmental tasks, accepting and adjusting to the
physiological changes of middle age is a significant aspect of middle adulthood development
which involves recognizing and adapting to the physical changes that come with aging, such
as changes in strength, endurance, and appearance. Gloria seems to have come to terms with
the fact that she is getting older, based on her statement that she accepts this fact. She
partially achieved this developmental task, nevertheless, even though she believes that she
has not yet noticed any physiological changes in her body.
In conclusion, according to Havighurst's developmental theory, middle adulthood is a
time for establishing and maintaining a satisfactory living and working environment, which
includes achieving economic stability, contributing to society, and finding personal fulfillment.
Gloria was able to fully achieve most of the developmental tasks of middle adulthood, such
as contributing to society and reassessing life goals, but only partially achieved others, such
as establishing economic stability and accepting physiological changes. These achievements
and partial achievements reflect Gloria's ongoing process of growth and adaptation to the
challenges and opportunities of middle adulthood.

Implication
Gloria was able to fully achieve most of the task this suggests that she is still in the
process of achieving all the task. According to Havighurst, being able to meet and to adjust in
middle adulthood leads to satisfaction. Gloria was able to achieve adult civic and social
responsibility that reflects a mature and responsible approach to one's role in the broader
community (Fuligni, 2018). In establishing and maintaining an economic standard of living,
partial achievement of this task means she is struggling to maintain a stable financial
situation. This can lead to ongoing concerns about meeting basic needs, saving for the future,

60
and providing for dependents (Shayan et al., 2022). Thus, Gloria needs to adjust their
spending and saving habits, and explore opportunities for career advancement or additional
income sources. Moreover, partial achievement in adjusting and accepting to the physiologic
changes or middle age indicates Gloria’s need for understanding on age-related changes,
promoting healthy lifestyle choices, and providing support for coping with any physical
challenges that may arise (Infurna et al., 2020).

B. Lawrence Kohlberg’s Theory of Moral Development

The Theory of Moral Development by Lawrence Kohlberg holds that moral reasoning,
which is the basis for ethical behavior, has six identifiable developmental stages. He followed
the development of moral judgment beyond the ages originally studied by Piaget, who
claimed that logic and morality develop through constructive stages. Kohlberg expanded
considerably on this groundwork, determining that the process of moral development was
principally concerned with justice and that its development continued throughout the
lifespan, even spawning philosophical implications of his research (Kurt, 2020).
Kolberg uses stories about moral dilemmas in his studies, and was interested in how
people would justify their actions if they were put in a similar moral situation. He would then
categorize three levels: pre-conventional, conventional, and post-conventional. His theory is
based on constructive developmental stages; each stage and level is more adequate at
responding to moral dilemmas than the last.
1. Pre-Conventional
● Stage 1: Obedience and Punishment
● Stage 2: Individual Interest
2. Conventional
● Stage 3: Interpersonal Accord and Conformity
● Stage 4: Authority and Maintaining Social Order
3. Post-Conventional
● Stage 5: Social Contract
● Stage 6: Universal Ethical Principle

Gloria is 37 years old and is expected at the last level of moral development, post-
conventional morality. She is expected to be at Stage 5: Social Contract and Stage 6: Universal

61
Ethics. In order to determine her level of moral development, a storytelling technique was
utilized and presented to her a moral dilemma which is related to Heinz dilemma. The
scenario goes as follows:
As a mother, you see your child on a deathbed. There was one drug that the doctor
thought might save her life. It is a drug that is rare to produce. There was this person who
discovered it near the hospital. The drug was so expensive to make, but the discoverer was
charging ten times what the drug cost him to produce. The discoverer paid 1,000 pesos for the
drug and charged 10,000 pesos. You as a mother of the child have only 2,000 pesos which is
less five times what it cost. Although you’ve already said that you can pay later for the cost,
the discoverer didn’t want it. Should you as a mother break into the discoverer’s area to steal
the drug? Why or why not?
Task Not Partially Fully Justification
Achieved Achieved Achieve
d
Stage 5: Social ✓
According to Gloria, although stealing
Contract
is a wrong act and it is against God's 10
Commandments and the law, she will
Task: An
steal the drug which only can save her
individual
child even if it is against the law. She
becomes aware
mentioned, being a mother, she will do
that while rules
everything for her child to live even if it
and laws might
costs me to her jailed.
exist for the
good of the
greatest
number, there
are times when
they will work
against the
interest of

62
 particular
individuals.
Stage 6: ✓ Gloria verbalized, “napatpateg ti biyag
Universal Ethical ngem kwarta para kenyak kase adda
Principles amin karapatan tay amin a ag biyag.”
Gloria stated that money can be
Task: Believes earned again but life is irreplaceable.
that there are She added that if it is her conscience to
high moral steal the drug for her child to be save.
principles than
those
represented by
social rules and
customs

Analysis
The Third Level of Moral Development or Post-Conventional Morality states people
decide based on what they think is right rather than just following the rules of society in which
people at this level of morality have their own ethical principles and values and don’t just do
what society tells them to do (Mcleod, 2024). These are ill-defined and abstract, but people
might include things like the necessity of protecting life at all costs and the value of human
dignity. Moreover, moral reasoning is based on individuals rights and justice, while individual
judgment is based on an individual’s chosen principles.
Gloria was able to fully achieve stages 5 and 6 in Post-Conventional Level. In Stage 5,
which is the Social Contract stage, Gloria acknowledges the importance of rules and laws for
the greater good but also recognizes that there are situations where these rules might conflict
with individual interests. She demonstrates this by indicating that she would steal the drug
for her child's sake, even though it is against the law. This shows an understanding of the
problem of moral decision-making and the ability to consider the needs of individuals in
addition to societal rules.

63
 In Stage 6, which is the Universal Ethical Principles stage, Gloria was able to fully
achieve the task by recognizing that there are moral principles beyond societal rules and
customs. She emphasizes the value of life over material possessions, stating that money can
be earned again but life is irreplaceable. She also mentions that her conscience guides her
decision to steal the drug, indicating an internalization of ethical principles that go beyond
external rules. Thus, according to Kohlberg, a person is prepared to act to defend principles
even if it means going against the rest of society in the process and having to pay the
consequences of disapproval and or imprisonment (Mcleod, 2024).

Implication
At Stage 5, individuals recognize that rules and laws are important for the greater good
but also understand that there are times when these rules may conflict with individual rights
or needs. Fully achieving this stage means Gloria is able to balance societal norms with
individual rights and is willing to challenge unjust laws or rules when necessary according to
Kohlberg. Stage 6 or the Universal Ethical Principle represents the highest level of moral
development, where individuals are guided by universal ethical principles that transcend
societal norms and rules. People at this stage have a deep sense of justice, human dignity,
and respect for all individuals. They are willing to act according to their conscience, even if it
means going against societal expectations or laws. Kohlberg states that people work on
disobeying laws that are unfair which Gloria's decision was.

D. Patterns of Functioning and Levels of Competencies

i. Pattern of Functioning

Eating Pattern

Before Illness During Illness

(March 12-17, 2024)

● Client is not selective to food choices ● Client prefers more vegetables.

however she prefers foods that are
sweet, sour or spicy such as barbeque,
palabok from fast food, and vegetables

64
 ● She likes foods that are prepared ● She still likes foods that are prepared
cleanly and well-cooked clean and well cooked.
● Dislikes foods that are served raw, such ● She avoids raw foods
as kinilaw
● She is not allergic to any food ● She has no allergies to food eaten
● Client eats about 1-2 cups of rice each ● Client eats 1 cup of rice every meal
meal
● Eats breakfast at 8-9 am, lunch at 12 nn, ● March 17, 2024, client didn’t have
afternoon snacks at 3-4 pm, and eats breakfast and dinner
dinner at 7-8pm

Analysis
Based on the patient's information, their food preferences remained consistent
before and during the illness, as they preferred clean, well-cooked foods and avoided raw
dishes. This indicates a stable food preference despite the illness. Additionally, there were no
changes noted regarding food allergies, suggesting that the illness did not cause any new
allergic reactions.

During illness, the body may not be able to use food to build itself up as effectively, as
the body recognizes that it can no longer use as much food as before. As stated in the study
by Vaillant et al. (2022), a patient's food intake decreases in the acute phase of the condition.
Therefore, according to Terblanche et al. (2022), maintaining a healthy diet and good
nutrition can support and improve recovery by providing the body with the essential nutrients
it needs to repair and maintain key functions during and after periods of illness.

65
 Drinking Pattern

Before Illness During Illness

(March 12-17, 2024)

● Client likes to drink Coke and Mogu- ● She drinks soft drinks (Coke Sakto) once
mogu, but she prefers water over soft a day
drinks
● Never drank alcohol beverages ● She didn’t drink any alcohol beverages
● She has no allergies to drinks ● She has no allergies to foods eaten
during illness
● She takes 5-6 glasses of water a day ● Her water intake increases from 6-8
(approximately 1.25 to 1.5 liters) glasses (approximately 1.5 to 2 liters)
● She drinks water every after meals and ● She still drinks every after meals and
when thirsty when thirsty

Analysis
Based on the client's eating pattern, there are no significant changes to alcohol
consumption or food allergies, except for fluid intake. Before the illness, the client drank 5-6
glasses of water a day. During the illness, she increased her water intake to 6-8 glasses,
approximately 1.5 to 2 liters a day, and also consumed a bottle of soft drinks a day.

According to Kalman & Lepeley (2020), increasing fluid intake can reduce the effects
of blood volume on hydration status, which plays important roles in physiological and
biochemical functions. Beverages such as carbohydrate electrolyte solutions and
carbohydrate protein beverages are beneficial for enhancing rehydration. The American
College of Obstetricians and Gynecologists (2020) recommends drinking 8 to 12 cups (64 to
96 ounces) of water every day during pregnancy. This aids digestion, helps form the amniotic
fluid around the fetus, and helps nutrients circulate in the body while aiding waste
elimination. Additionally, Hooper et al. (2022) stated that increasing fluid intake to more than
1.5 liters alongside lifestyle changes reduces the need for healthcare visits and
hospitalizations.

66
 Bladder Pattern

Before Illness During Illness

(March 12-17, 2024)

● She urinates at about 6-8 times a day ● Client urinates about 6-8 times day
(500-750 ml) (approximately 750 ml)
● Her urine color varies from clear to ● Her urine color changed to slightly
yellow yellow to yellow

Analysis
The patient's frequency of urination remained consistent before and during the
illness, with about 6-8 times a day. This suggests that the illness did not significantly affect the
patient's bladder pattern. However, the volume of each void increased during the illness, from
500-750 ml before to approximately 750 ml during the illness. This increase in volume could
be attributed to factors like changes in fluid intake or hydration status. Additionally, the urine
color changed from clear to slightly yellow to yellow during the illness, which may indicate
alterations in hydration status, diet, or the presence of certain medications or metabolic
processes associated with the illness.
Normally, fresh urine ranges in color from pale to dark yellow and appears clear. The
typical volume of urine produced in 24 hours ranges from 750 to 2000 ml. However, in the
case of a urinary tract infection, the urine may appear cloudy instead of clear (Tabassum &
Khurshid, 2020). During the illness, the client's urine changed from slightly yellow to yellow.
The normal color of urine is attributed to the presence of a pigment called urochrome, but
variations in urine color can occur based on its concentration and chemical composition. The
client's urine color remains within the normal range and does not show any abnormalities. In
addition, Flores et al. (2023) stated that the optimal function of urination in eliminating waste
products, regulating fluid balance, and evaluating kidney functions reduces the risk of
acquiring illness.

67
 Bowel Elimination Pattern

Before Illness During Illness

(March 12-17, 2024)

● She defecates 1-2 times a day ● She defecates once a day

● Her stool varies from soft to hard ● Her stool still varies from soft to hard
consistency with yellow-brownish color consistency with yellow-brownish color

Analysis
Patient’s frequency of bowel movements decreased from 1-2 times a day before the
illness to once a day during the illness. This change could be due to various factors, such as
changes in diet and activity level. The consistency of the stool remained consistent, ranging
from soft to hard, before and during the illness which implies that the illness did not
significantly impact the client's stool consistency. Also, the color of the stool remained
consistent, with a yellow-brownish color before and during the illness. This indicates that
there were no significant changes in the client's diet or digestive health that affect stool color.

According to the study of Borkoles et al. (2022), they found out that changes in dietary
habits, such as increased intake of fiber-rich foods, can lead to changes in bowel frequency
and consistency. Medical University of South Carolina (2022) stated that people have normal
frequency of from three times a day each after meal but most commonly, people defecate
one per day and at about the same time of day. As to color and consistency of stool, normal
stool usually is medium-brown, smooth, and not too soft or firm (Pratt & Gillespie, 2023).
Thus, the client's bowel elimination pattern appears to be within the normal range, as they
are defecating 1-2 times a day, which is considered normal frequency. The variation in stool
consistency from soft to hard and the yellow-brownish color are also typical characteristics of
stool.

68
 Sleeping Pattern

Before Illness During Illness

(March 12-17, 2024)

● She sleeps 6-7 hours a day from 10-11 ● She sleeps 6-7 a day from 10-11 pm to
pm to 5 am 5pm, but on March 16 she slept only
two hours
● Sometimes, takes a nap for 1-2 hours in ● She takes a nap for 30 minutes in the
the afternoon afternoon
● She uses her phone to help fall asleep ● She uses only her phone to get sleep
by watching videos and listening to
radio
● Sometimes, her 4th child will interrupt ● Her 4th child will interrupt her sleep 1-2
her sleep 1-2 times, about 20-30 times when the child gets hungry, but
minutes, when the child gets hungry. on March 16, 2024, didn’t sleep well
After she fed her child, she will due to vaginal bleeding
eventually go back to sleep

Analysis
The patient's sleep duration remained relatively consistent before and during the
illness, averaging 6-7 hours per day. However, there was a significant change on March 16,
2024, when she slept only two hours, possibly due to the vaginal bleeding, indicating a
disturbance in her sleep pattern. Her napping habits also remained consistent, with a nap
duration of 1-2 hours before the illness and 30 minutes during the illness, suggesting that her
need for daytime rest did not change significantly. While the patient used her phone to help
fall asleep before the illness, she continued to rely on it during the illness. However, there is
no mention of the effectiveness of this method during the illness compared to before. As
mentioned, her 4th child continued to interrupt her sleep 1-2 times when hungry, both before
and during the illness. However, the mention of poor sleep on March 16, 2024, due to vaginal
bleeding indicates a specific disruption that may have affected her overall sleep quality.
Sleep habits and problems are influenced by physical, mental, and environmental
factors such as age, gender, job, lifestyle, emotional tension, and noise. Both the quantity and

69
quality of sleep play an important role in an individual’s psychological and physical well-being
(Lawson et al., 2019). Sleep is essential for our bodies to repair and regenerate our cells,
maintain a strong immune system, and feel mentally alert and focused. Lack of sleep over an
extended period can lead to a range of health issues, including increased stress, depression,
and a weakened immune system. According to Suni & Suni (2024), interrupted sleep involves
frequent awakenings during the night, disrupting the sleep cycle whose effects include
daytime sleepiness, cognitive decline, mood disturbances, and health risks. Thus, optimizing
sleep routine and sleep environment can help prevent sleep interruptions.

Bathing Pattern

Before Illness During Illness

(March 12-17, 2024)

● Client takes a full bath with cold water ● She still takes a full warm bath once a
once a day usually at 7 am in the day
morning or after lunch as she feels
refreshed
● Takes a cold half-bath with cold water ● She takes a warm half-bath before
before sleeping sleeping
● She uses toothpaste, shampoo, bathing ● She uses only toothpaste, shampoo and
soap, and feminine wash bathing soap

Analysis
Patient’s frequency of bathing remained consistent before and during the illness, with
the client bathing once a day. However, there was a change in the water temperature
preference, from cold to warm baths, indicating a possible preference for comfort or
symptom relief during the illness. The client's use of bathing products changed slightly during
the illness, with the exclusion of feminine wash. This change could be due to personal
preference or a need to simplify the bathing routine during illness. Lastly, there was no
significant change in the timing of the full bath, as it still occurred once a day. However, the

70
timing of the half-bath before sleeping was not mentioned during the illness, which could
imply a change in routine or priorities during the illness.

According to Frysh (2023), two to three times is enough and better to maintain good
health. There was a notable change in the bathing routine during illness, with fewer full baths
and more half-baths due to hospitalization. Despite the illness, the client maintained a level
of hygiene by continuing to bathe. According to Centers for Disease Control and Prevention
(2022), regularly washing parts of the body and hair with soap and water. prevents infection.
Also, establishing a good personal hygiene routine can help you reduce your risk for health
conditions and may also improve your self-esteem (Holland, 2018). As to change water
preference from cool to warm bath, warm bath exerts sufficient hyperthermic action to
induce vasodilation and increase blood flow, supplying more oxygen and nutrients to the
periphery (Goto et al., 2018).

ii. Levels of Competencies

Physical Competency

Before Illness During Illness

● She can perform her activities of ● Client is capable of performing ADL

daily living independently, such as independently and doing household
bathing, brushing of teeth, combing chores during the course of bleeding
of hair, managing her bowel and
bladder, dressing and undressing
herself without discomfort
● She is capable of doing household ● During hospitalization, she cannot do
chores such as cooking, washing household chores
dishes, laundering clothes, and
cleaning independently without
discomfort

71
Analysis
The patient's ability to perform activities of daily living independently remained
consistent before and during the illness, indicating a good level of physical competency in
terms of self-care. According to the client she can perform her activities of daily living
independently such as brushing her teeth, combing her hair, and so on. She also mentioned
that she is capable of doing household chores such as cooking, cleaning, washing dishes, and
doing the laundry. Before the illness, the patient could perform household chores
independently without discomfort. However, during the illness, there was a change in the
ability to perform these tasks. While the patient could still manage activities of daily living
during the course of bleeding, they were unable to do household chores during
hospitalization. This change suggests a temporary limitation in physical competency, due to
the effects of the illness or the need for rest and recovery during hospitalization. Thus, the
patient's physical competency remained unchanged in terms of activities of daily living but
was temporarily compromised in terms of household chores during hospitalization. Most
people are able to continue working when pregnant. This indicates a good level of physical
ability and functional independence and Gloria is able to maintain her own personal hygiene
and contribute to household tasks effectively. The safety of the job during pregnancy depends
on what the person does for a living, their health status, and the complications encountered
during pregnancy (Marcin, 2021). Thus, according to the National Institute for Occupational
Safety and Health (2023), Physical demands at work could increase your chances of
miscarriage, preterm birth, or injury during pregnancy.

Emotional Competency

Before Illness During Illness

● She was surprised when she took the ● Gloria was worried about her
pregnancy test and when her children left in their house
pregnancy test came back positive
because she believed her husband
had practiced withdrawal.

72
 ● Also she stated “manen” when asked ● She feels sad when she finds out she
what she felt when she found out has had a miscarriage
that she is pregnant and feels
worried about her pregnancy since it
was unplanned

Analysis
Before the illness, the patient expressed surprise and worry about her unplanned
pregnancy, indicating a mix of emotions including shock, disbelief, and concern. This implies
a complex emotional response to the pregnancy, which is not uncommon in unplanned
situations. As to emotional response to miscarriage, during the illness, the patient feels sad
about her miscarriage. This is a common emotional response to pregnancy loss and reflects
the grief and sadness that many women experience in such situations.

It was stated that she was worried about her pregnancy since her pregnancy was
unplanned. Among the women who reported that their pregnancy was unplanned, more of
those who reported feeling unhappy were pregnant with a second or subsequent child. The
unplanned, ambivalent and unplanned, unhappy groups were more likely to report poor
social support, and more limited social contact than the planned group (Barton et al., 2017).
Moreover, according to the research of González-Ramos et al. (2021), unplanned pregnancies
can evoke a range of emotions, including surprise, shock, worry, and anxiety. These emotions
are often influenced by individual circumstances and beliefs about pregnancy. Also, early
pregnancy loss results in a shocking and traumatic event for women and their families and it
induces an intense period of emotional distress. Furthermore, the emotional impact of
miscarriage is frequently underestimated, and it can be difficult for women and partners to
find acknowledgement from friends, family, or health care providers. Thus, understanding
and addressing the emotional aspects of pregnancy and pregnancy loss in patients is
important.

73
 Social Competency

Before Illness During Illness

● Client takes a pregnancy test last March ● Gloria didn’t inform her husband or
11, 2024 and was positive children she found from her napkin
that there is bleeding and only
inform his husband when the
amount of bleeding increased
● She only informs her husband that she ● During hospitalization, she can only
is pregnant talk her children using messenger

Analysis
Before the illness, the patient's social competency was demonstrated by her decision
to inform only her husband about the pregnancy, suggesting a level of trust and intimacy in
their relationship. However, during the illness, there was a delay in communication regarding
the bleeding, as she did not inform her husband or children immediately. This may indicate
feelings of distress, uncertainty, or difficulty in communicating about sensitive issues related
to the illness. During hospitalization, the patient's ability to communicate with her children
using Messenger indicates an effort to maintain social connections and support despite being
hospitalized. This shows the importance of technology in facilitating communication and
maintaining social connections, especially during times of illness or separation. Thus, the
patient's social competency before the illness involved effective communication with her
husband about the pregnancy. However, during the illness, there were challenges in
communication regarding the bleeding, and reliance on technology was needed to maintain
social connections during hospitalization.

According to Junge et al (2020), developing social competence is essential for future

functioning in society and for reducing risk of behavioral and emotional problems. Gloria's
challenges in communication during her illness may indicate poor social competence, which
can lead to difficulties in processing social information and adapting to situations, potentially
contributing to behavioral and emotional problems (Hukkelberg et al., 2019). Social support

74
during pregnancy can alleviate these pressures, benefiting the well-being of both mother and
child (Al-Mutawtah et al., 2023). Her experiences also suggest social embarrassment, leading
to fear of social activities and avoidance of situations where she felt uncomfortable as stated
by (Henry et al., 2020). Thus, supporting Gloria in overcoming these challenges is crucial for
her emotional well-being and social functioning.

Intellectual Competency

Before Illness During Illness

● The client is aware of time, place, and ● Client saw a small dot of blood in her
people panty liner but didn’t consult the
physician since she thought this as
“paksay”
● She fully understands the given ● She still fully understands the given
directions and has the capacity to directions and has the capacity to
make decisions under various make decisions under various
circumstances circumstances
● She has the capacity to answer ● She still has the capacity to answer
questions and come up with questions and come up with
solutions to the problems she runs solutions to the problems she runs
across across

Analysis
Gloria's intellectual competency remained intact before and during her illness. She
was aware of her surroundings, could follow instructions, make decisions, and solve problems
effectively. However, her decision not to consult a physician about the small dot of blood in
her panty liner due to her interpretation of it as "paksay" (a local term) might indicate a
cultural belief or misunderstanding. This highlights the importance of cultural competence in

75
healthcare to ensure that patients' beliefs and practices are respected and understood. Thus,
Gloria's intellectual functioning did not appear to be significantly affected by her illness.
During the first 12 weeks of pregnancy, vaginal bleeding can be a sign of miscarriage
or ectopic pregnancy (National Health Service, 2020). Research indicates that a woman’s
lifestyle during pregnancy influences her child’s health and development. Therefore, women
need to possess sufficient knowledge regarding the elements of a healthy lifestyle during
pregnancy. women’s knowledge of lifestyle-related factors during pregnancy differs with
regard to particular topics and socio-economic factors. Particular focus on certain topics, such
as the benefits of early familiarization with breastfeeding, normal ranges of gestational
weight gain with regards to the initial BMI of the woman, is required during antenatal
counseling (Nawabi et al., 2022).

Spiritual Competency

Before Illness During Illness

● She goes to church every Sunday; she ● The patient’s faith has become
has a strong faith in God stronger, and still adheres to the
routines she used to practice before
developing her condition
● She would pray before going to sleep ● She still prays before going to sleep
and after waking up and after waking up

Analysis

Before the illness, Gloria's spiritual competency was evident through regular church
attendance, indicating a strong faith. During the illness, despite facing challenges, she
continued to pray regularly, suggesting resilience and a deepening of her faith. The patient's
faith has become stronger during the illness, highlighting the role of spirituality in coping with
adversity. This aligns with numerous studies that suggest religious practices and beliefs can
provide comfort and support during difficult times.

76
 Pregnancy and childbirth involve physical, mental, social, and spiritual aspects. While
physical, mental, and social dimensions are easily recognized in healthcare, spirituality is also
crucial. Studies show that spirituality can help individuals cope with existential pain and
adversities (Dirce Stein Backes et al., 2022). During her illness, Gloria's faith grew stronger as
she held on to her beliefs. She continued to pray, which aligns with research suggesting that
spirituality can help patients overcome illness and strengthen their well-being. According to
Hu et al. (2019), patients are exploring strategies such as having a strong spirituality to
overcome their illnesses as well as strengthen their physical, social, and psychological well-
being. Moreover, positive beliefs, comfort, and strength gained from religion, meditation, and
prayer can contribute to well-being and may even promote healing (Rich, 2020). Overall,
Gloria's spiritual resilience during her illness highlights the positive impact of spirituality on
health and well-being.

E. Physical Assessment
i. General Appearance

Upon initial interaction, the client appears to be physically well while in a fowler’s
position. When asked questions, the client is responsive and coherent when answering and
maintains eye contact. She has an ongoing D5LR’s 1L @ 100cc/h IVF in the dorsum of her left
hand. The client has a large round body with a well-groomed appearance and brownish skin
color.

Vital Signs

Temperature: 36.1˚ C

Respiratory Rate: 16cpm

Pulse Rate: 71bpm

Blood Pressure: 100/70mmHg

O2 Sat: 95%

The vital signs of the patient are within normal range, there are no signs of
hypotension, considering she lost blood during the delivery, and the temperature is normal.

77
There are no signs of tachypnea and tachycardia. Overall, the client is in a good condition
with a minimal 4 / 10 pain scale.

Height: 160cm

Weight: 65kg

BMI: 25.4kg/m^2 - Overweight

ii. Head to Toe Assessment (Inspect, Palpate, Percuss and auscultate)

Head
• Head is round and normocephalic
• Hair is black, clean, and evenly distributed
• Hair is dry with no signs of lice or any foreign bodies
• Face is symmetric and round
• No swelling, masses and nodules noted
• No swelling, crepitation, and tenderness in the Temporomandibular Joint (TMJ)

Eyes
• Eyes are symmetric
• Eyeball is not protruding and sinking
• Sclera is white
• Conjunctiva is pinkish
• Iris is round, flat, and black
• Cornea is transparent with no opacities
• Pupils are equal and erect
• Pupils are reactive to light and accommodation
• Pupils constrict and converge when object is placed near the eyes
• Light on corneas is in exact same spot upon performing corneal light reflex
• No delayed perception upon the examine of gross peripheral
• No drainage upon palpating lacrimal gland

78
Ears
• Ears are bilaterally equal
• Auricles align with the corner of each eye
• Tympanic membranes are clear
• External auditory canal has dry, odorless, and yellowish cerumen
• Auricles are small, nontender, with no lesions and discoloration
• Tragus are nontender and not swelling
• Mastoid process is not tender

Nose
• Color of the nose is the same as the rest of the face
• Nasal structure is smooth and symmetric
• Nasal septum is intact and free of ulcers or perforations
• Nasal mucosa is dark pink, moist, and free of exudate
• Nasal septum is intact and free of ulcers and perforations
• No tenderness upon palpation
• Frontal and maxillary sinuses are nontender with no crepitus evident
• Sinuses are nontender
• A red glow transilluminates the frontal and maxillary sinuses

Mouth
• No foul smell noted
• Lips are cracked and dry
• Lips are brownish to pinkish in color without lesions and swelling
• A total of 26 teeth were noted
• 2 teeth are missing (2nd left and 3rd right upper molar)
• Teeth are yellowish
• Gums are pink, moist, and firm with tight margins to the tooth
• No lesion and masses on gums
• Buccal mucosa is pink
• Tongue is pink and moist without lesions
• Frenulum is in midline

79
• Hard palate is pale with firm rugae
• Uvula is symmetric and hangs freely in the midline
• Wharton’s ducts are visible with salivary flow
• Tonsils are pink and symmetric, with no signs of swelling and lesion, and graded 1+
• Throat is pink, with no exudates or lesions
• The tongue exhibits significant resistance
• Soft palate is pinkish, movable and smooth

Neck
• Neck is symmetric, with head centered and without bulging masses
• Thyroid cartilage and cricoid cartilage move upward symmetrically
• Movement of neck is smooth
• C7 (vertebrae prominens) is visible and palpable
• Lymph nodes are not bulging and nontender
• No swelling, masses and tenderness in trachea
• No swelling, masses and tenderness in thyroid gland

Chest
Breast
• Hyperpigmentation on nipples and areola
• Minimal white discharge
• Breasts not engorged
• No tenderness upon palpation
• No mass palpated

Anterior Chest
• Anteroposterior to transverse diameter has a ratio of 1:2
• Breathing pattern in normal rate, depth and rhythm
• No bulging or any retraction in intercostal spaces
• Not using of accessory muscles in breathing
• No tenderness, sensation, masses, lesions, fremitus, and anterior chest expansion

80
Posterior and Lateral Chest
• Anteroposterior to transverse diameter has a ratio of 1:2
• Scapulae are symmetric and non-protruding
• Shoulders and scapula are at equal horizontal positions
• Thorax appears symmetric, with ribs sloping downward at approximately a 45-degree
angle in relation to the spine
• No tenderness, sensation, crepitus, masses, lesions, and fremitus in the chest
• No rash or infection in axillae upon palpation of the axillae
• No palpable nodes, not tender and movable in the central area

Abdomen
• Color of the abdomen is dark brown especially in the lower quadrant
• Scattered veins are visible
• Striae are visible
• No scars and lesions or rashes were noted
• Umbilicus is in the midline
• Umbilical area has a brown color
• Umbilical is inverted
• Abdominal is distended
• Abdomen is symmetric
• Uterus is hard and round

Perineum
• Pinkish perineum
• Minimal whitish-yellow discharge noted (Lochia Alba)
• No foul smell
• Vaginal spotting
• Minimal uterus cramping

Upper extremities
• Arms are bilaterally equal
• Arms are smooth and brownish in color

81
• Arms have no masses and varicosities
• Lesion is present in right deltoid
• Skins are intact and there are no reddened areas
• Fingernails are clean
• Pink tone in the fingernails
• Fingernails and toenail are attached to nail bed
• Lymph nodes in both arms are not tender and not swelling
• Radial pulse is 2+ palpated bilaterally
• Capillary refill test of 1 second on fingernails

Lower extremities
• Legs are bilaterally equal
• Legs are dry and brownish in color
• No masses, lesions, and varicosities
• Striae are visible in upper thigh
• Toenails are spoon nails, jagged and unclipped
• Pale tone in the toenails
• Equally hair distribution
• No edema, pitting edema noted
• Both legs are warm
• Normal ROM of the hips
• Capillary refill test of 1 second on toenails

Analysis
After conducting a comprehensive assessment of the client, no abnormalities or
significant changes were detected except for the minimal cramping of the uterus and minimal
bleeding in the vagina during the evaluation. According to Romm (2020), an incomplete
abortion involves vaginal bleeding, cramping (contractions), cervical dilatation, and
incomplete passage of the products of conception. The cramping may be rhythmic or labor-
like, although less intense than a full-term labor. At this point, the baby has already died and
has either been passed or is part of the retained tissue. Some obstetricians will manage

82
incomplete abortions medically with oxytocin to help control the bleeding and misoprostol to
help the uterus contract and complete the process of abortion (Redinger and Nguyen, 2020).

F. On-going Appraisal

Course of Confinement (March 17, 2024)

The client, Gloria, was admitted precisely at 5:25 a.m. on March 17, 2024 at Mariano
Marcos Memorial Hospital and Medical Center (MMMH&MC), with vaginal bleeding as the
chief complaint and admitting diagnosis of G5P4 (4004) incomplete abortion; and G5P4 (4014)
complete abortion; early, nonseptic; non induced; advanced maternal age.

Upon arrival at the Outpatient Department of Obstetrics and Gynecology Department

(OPD-OB), the client underwent an internal examination (IE) by the physician, Dr. Dianne
Shayne Faylogna. Prior consent was obtained for both admission and therapeutic
management. Following that, the client received a drip of intravenous fluid (IVF) containing
1000mL of 5% Dextrose in Lactated Ringer's Solution (D5LRS) along with ten (10) units of
oxytocin at a rate of 42gtts/min for eight (8) hours. Moreover, the client was advised for
nothing per orem (NPO) temporarily. Then, prior to the procedure, signed consent was
obtained for manual vacuum aspiration (MVA). At precisely 6:04 a.m., Dr. Balagso ordered
laboratory tests which were carried out. The tests included a urinalysis and hematology,
specifically complete blood count (CBC) and blood typing. At about 6:10 a.m, to relieve
moderate to severe pain, a 1mL of ketorolac tromethamine (Toradol) with a dosage of 30mg
was given via intravenous (IV), following a negative anti-sensitivity test. The client was then
endorsed to the Department of Nuclear Medicine at the Surgical Annex Building's third floor.

Later that day, the client was brought to the operation room. Pre-operative risk
assessment results featured a height of 145cm and a weight of 52.5kg, as well as the
cardiopulmonary (CP) clearance status. Her preoperative diagnosis and postoperative
diagnosis were G5P4 (4004) incomplete abortion; and G5P4 (4014) completed abortion; early,
nonseptic; non induced; advanced maternal age; S/P MVA under paracervical block.

83
 Under the supervision of the physician, Dr. Jezzica Balagso, the MVA procedure under
paracervical block started at 6:21 in the morning. The client was in the dorsal lithotomy
position for the surgery. IE was done once more. Furthermore, the cervix was then located
via a posterior vaginal retractor. Subsequently, an antiseptic solution of peroxide iodine was
used to clean the vaginal vault. After grasping and clamping the cervix's anterior lip with
tenaculum forceps, the lateral posterior cervix was then injected with a paracervical block. A
hysterotomy procedure was done approximately 8cm into the uterus. Then, a cannula was
placed inside the uterus. The procedure proceeded with MVA using a back-and-forth method
until with gritty sensation and bubbly blood passing through the cannula. Immediately
following the procedure, an obtained specimen approximately 15cc of tan white mealy
material admixed with blood clots was sent for histopathological analysis. The procedure was
finished at exactly 6:30 a.m. and the client was transferred to the Post-Anesthesia Care Unit
(PACU) for observation.

Dr. Balagso added an order at 6:33 a.m. for the following medications: 500mg of
cefuroxime (Zinacef) tablet to be taken orally BID for seven (7) days; 325mg of ferrous sulfate
(Ferricore) tablet to be taken orally OD; 500mg of mefenamic acid (Myrefen) tablet to be
taken orally TID for pain; and methylergometrine maleate (Methergine) tablet to be taken
orally TID for three (3) days.

Vital signs were measured and recorded during her stay at the PACU for every fifteen
minutes in one (1) hour. The first vital signs notably a temperature of 36.5 degrees Celsius, a
pulse rate of 80 beats per minute (bpm), a respiratory rate of 18 cycles per minute (cpm), a
blood pressure of 120/80 mmHg, and oxygen saturation of 95%. All throughout the
monitoring process of vital signs, the results were normal. She was also kept under constant
observation for excessive vaginal bleeding. In addition, a well-contracted uterus was then
characterized. She was recommended to remain in bed and continue her D5LR’s IVF with ten
(10) units of oxytocin. The client was then instructed to massage her uterus for the purpose
of preventing the profuse bleeding.

Urinalysis and hematology results were released at 7:25 in the morning. The results of
the urinalysis are graded +3 for blood and +2 for leukocyte esterase. Moreover, low levels of
hemoglobin, red blood cells (RBCs), and lymphocytes, as well as, high of segmenters were

84
found in the results of the hematology test; low levels of mean platelet volume (MPV) and
platelet distribution width (PDW) were found in the results of the platelet count. Additionally,
hematological results showed that the client is blood type B positive.

The client experienced pain in the pelvic area following the surgical treatment.
Subsequently, the patient was administered mefenamic acid (Myrefen)for pain. Gloria, the
client, showed a positive response to the medication given to her because her pain level
decreased from a rate of 4—moderate pain, which can be ignored occasionally—to a rate of
1—mild pain, where the pain is barely noticeable. The Allina Health Pain Assessment Scale,
which uses a 0–10 pain scale, served as the basis for the pain assessment. She further added
that "iddi nagtumar ak kadeta nga oras bummaba dagos tay sakit a marikriknak."

At roughly 9:00 a.m., approval was obtained for a bilateral tubal ligation (BTL).
Subsequently, the physician then gave the client a NPO order, effective starting from 12 noon
onwards. At 10:05 a.m., a transvaginal ultrasound (TVS) was carried out. There was minimal
bleeding recorded within the same time.

In the following time, she was transferred to Gynecological Ward in room 408 and bed
4 on March 17, 2024 at approximately 10:10 in the morning.

The client was advised to take her ferrous sulfate (Ferricore), to prevent anemia, tablet
orally at 11:00 a.m., and was told to take adequate rest and increase fluid intake. These
strategies additionally enable the client to prepare for forthcoming BTL.

At 12 p.m., the client resumed NPO, and her vital signs were taken and recorded, with
the following results: temperature - 36.4 degrees Celsius; pulse rate – 79 bpm; respiratory
rate - 18 bpm; blood pressure - 110/70 mmHg; and oxygen saturation - 96%.

At 1:30 p.m., the client’s IVF was consumed. Thus, a second IVF D5LR’s 1L and 10 “u”
of oxytocin was hooked, set to 42 gtts/min, and infused successfully.

At 4 p.m., the client’s vital signs were taken and recorded as follows; temperature -
36.4 degrees Celsius; pulse rate - 82 bpm; respiratory rate - 17 bpm; blood pressure - 110/70
mmHg; and oxygen saturation - 96%. There was still minimal bleeding noted.

85
 At 8 p.m., the client’s vital signs were taken and recorded as follows; temperature -
36.4 degrees Celsius; pulse rate – 77 bpm; respiratory rate - 15 cpm; blood pressure - 100/70
mmHg; and oxygen saturation - 96%. There was still a small amount of bleeding visible.

At 10:00 p.m., the client’s IVF was consumed. Thus, a third IVF D5LR’s 1L and 10 “u”
of oxytocin was hooked, set to 42 gtts/min, and infused successfully.

Day 1 (March 18, 2024)

During the first day of appraisal, the client was observed lying on the bed with an
ongoing IVF D5LRS 1L attached to her left hand with a drip of 42gtts/min at 100mL level.

At 7:30 a.m., the client’s IVF was consumed. Thus, a fourth IVF D5LR’s 1L and 10 “u”
of oxytocin was hooked, set to 42gtts/min, and infused successfully. The client has no further
complaints of pain but there is still some light vaginal bleeding.

At precisely 8 a.m., her initial vital signs were as follows: temperature - 36.1 degrees
Celsius; pulse rate – 71 bpm; respiratory rate - 15 cpm; blood pressure - 100/70 mmHg; and
oxygen saturation - 95%.

At exactly 9:25 in the morning, a physical examination was performed after the vital
signs had been assessed. In the physical assessment, the uterus appeared to be well-
contracted, and there is a minimal white discharge in the breast, and a small amount of
reddish vaginal bleeding totaling 5mL. It was advised to massage the uterus to prevent
excessive bleeding. Additionally, dry, cracked lips were observed. While the client was still in
NPO, wet cotton used to pat the client's dry lips.

The IVF was stopped at 10:30 a.m. due to swelling in the client's left hand. At around
10:35 a.m., an intravenous (IV) injection was administered. in the client's right metacarpal,
where the attending nurse provided care. Afterwards, the D5LRS 1L at 700 ml level with 42
gtts/min was then continued.

Furthermore, the client's abrupt rejection of her bilateral tubal ligation (BTL) led to
the discontinuation of the NPO. Henceforth, at 11:20 a.m., the client issued a refusal consent

86
form for her BTL, in which she indicated that she chose to use contraceptive pills for family
planning. As therefore, the client received health teaching that comprises;

(1) Educating the client about family planning;

(2) Providing information about the benefits of BTL on family planning; and

(3) Advising the client and significant other to other family planning alternatives, such
as using contraceptive pills and condoms.

At 12 p.m., the client’s vital signs were taken and recorded as follows; temperature - 36.2
degrees Celsius; pulse rate - 79 bpm; respiratory rate - 18 cpm; blood pressure - 100/70
mmHg; and oxygen saturation - 97%. There was still a small amount of vaginal bleeding visible.
Subsequently, the client also takes her ferrous sulfate (Ferricore) tablet and
methylergometrine maleate (Methergine) tablet orally.

The ultrasound report, which revealed normal results, was obtained at around 2:30
p.m. starting at 7 a.m. up to 2:00 p.m., it was noted that the total input was 650 mL, consisting
of 350 mL of oral water and 300 mL of IVF input. With two frequencies of urination, the
estimated volume of urine output was 300 mL, and no stool was recorded.

The client signed a discharge form at 3:10 in the afternoon. The attending nurse
reminds the client about the adherence to medications, and a follow-up check-up at MMMH
& MC's Outpatient Department of Ob-Gyne on March 21, 2024, three (3) days after the
discharge.

G. Medical Management
i. Laboratory Examinations and Diagnostic Procedures

A. URINALYSIS
According to Milani and Jialal (2023), urine analysis, also called urinalysis, is a
diagnostic procedure that evaluates the physical, chemical, and microscopic properties of
urine to assess overall health and diagnose various medical conditions. In connection to the
client’s condition, urinalysis plays a crucial role in the preoperative evaluation of the client

87
undergoing manual vacuum aspiration (MVA) following a miscarriage. It serves as a
comprehensive diagnostic tool, enabling healthcare providers to assess the client's overall
health status and detect any underlying conditions that could impact the procedure or
recovery (Faacc, 2022). Through urinalysis, healthcare providers can identify urinary tract
infections (UTIs), which, if left untreated, may increase the risk of complications during the
MVA procedure or postoperative period (Habak, 2023). Additionally, urinalysis can unveil
abnormalities such as hematuria, proteinuria, or the presence of urinary stones, signaling
potential kidney issues or other conditions necessitating further evaluation or management
before proceeding with the MVA (Saleem, 2022). Moreover, through this laboratory
procedure, they were able to confirm that the client really tested positive in pregnancy. By
addressing these concerns preoperatively, healthcare providers can mitigate risks, optimize
client safety, and ensure the success of the MVA procedure, ultimately facilitating a smoother
recovery process for the client.

Table 3: Urinalysis Result

Date
LABORATORY REFERENCE SIGNIFICANCE
EXAMINATION Date ordered: Date ordered: RANGE
03/17/24 - 2:33 03/17/24 - 6:04
AM AM

Date of Date of
specimen specimen
collection: collection:
03/17/24 - 2:36 03/17/24 - 6:13
AM AM

Physical Examination

Color Light Yellow Yellow Pale Yellow to Normal

Amber > healthy renal
function and
hydration

Character Clear Clear Clear to Slightly Normal

Hazy > absence of
renal
complications

88
Chemical Exam

PH 7.0 6.5 5.0 - 7.0 Normal

> suggests a
balance acid-
base status

Specific Gravity 1.010 1.015 1.005 - 1.025 Normal

> indicates
appropriate
hydration
status and
kidney
function

Glucose Negative Negative Negative Normal

> no indication
of diabetes or
significant
metabolic
disturbances

Leukocyte Positive 2 Positive 2 Negative Increased

> indicates
presence of
urinary tract
infection or
inflammation

Nitrate Negative Negative Negative Normal

> reduced the
likelihood of
complications
related to
bacterial
infection

Protein Negative Negative Negative Normal

> no evidence
of renal
dysfunction

Blood Positive 3 Positive 3 Negative Increased

> suggests
urinary tract
bleeding

Ketone Negative Negative Negative Normal

89
 > adequate
carbohydrate
intake and
metabolism

Bilirubin Negative Negative Negative Normal

> no evidence
of liver
dysfunction

Urobilinogen Negative Negative Negative Normal

> proper liver
function

Microscopic Exam

WBC 3-5/HPF 6-8/HPF 0.0 - 3.0 Increased

> indicates the
presence of
urinary tract
infection

RBC 3-5/HPF 3-5/HPF 0.0 - 2.0 Increased

> suggests
urinary tract
bleeding

Epithelial Cells Few Few Few Normal

> imply minor
shedding of
cells from
urinary tract
lining

Bacteria Numerous Numerous None Seen Increased

> suggests
urinary tract
infection

Mucous Rare Rare Rare Normal

Threads > reflects
minimal mucus
production
from the
urinary tract

Amorphous Rare Rare Rare Normal

Urates > indicates

90
 minimal
crystalline
sediment
formation and
no significant
metabolic
abnormalities

Pregnancy Test Positive Positive - Normal

> indicates
persistent hCG
levels,
suggesting the
possibility of
retained
products of
conception

The abnormal results of the urinalysis, particularly the increased levels of leukocytes,
blood, white blood cells (WBCs), red blood cells (RBCs), and bacteria, suggest urinary tract
complications following the client's miscarriage and before undergoing manual vacuum
aspiration. The presence of elevated leukocytes indicates an immune response, suggesting
potential inflammation or infection within the urinary tract (MacGill, 2023). This is related to
the traumatic nature of the miscarriage process, which has caused irritation or introduced
bacteria into the urinary tract. Additionally, the increased presence of bacteria further
supports the indication of urinary tract infection. If left untreated, urinary tract infections can
progress and lead to more severe complications, such as kidney infection or systemic
infection. According to (Nall, 2023), the elevated levels of blood, WBCs, and RBCs in the urine
are indicative of possible hemorrhage or inflammation within the urinary tract. This is related
to the miscarriage itself, as the process can sometimes involve significant bleeding. However,
it is essential to differentiate between normal post-miscarriage bleeding and abnormal
hemorrhage, as excessive bleeding can lead to complications such as anemia or infection.
Overall, these abnormal urinalysis findings highlight the importance of further evaluation and
prompt intervention to address potential urinary tract complications. This may involve
additional diagnostic tests, such as urine culture and sensitivity testing, to identify the specific
pathogens involved and guide appropriate antibiotic therapy. Close monitoring of renal

91
function and overall health is crucial to prevent further complications and support the client's
recovery following miscarriage and manual vacuum aspiration.

Table 4 : Nursing Responsibilities for Client’s Urinalysis

Nursing Responsibilities Rationale

1. Confirm the identity of the client. To maintain client safety.

2. Assessing the client's readiness and To determine the appropriate timing and
ability to provide a urine sample, approach for urine collection, ensuring
and obtain consent. client comfort and cooperation.

3. Explain the procedure to the client. To build trust and reduce anxiety.

4. Provide education to the client on To promote their understanding and

the purpose of the urine analysis, improve client compliance.
potential implications of abnormal
results, and any follow-up actions
required based on test findings.

5. Provide instructions for collecting a To maintain the integrity of the specimen

clean catch urine specimen, and ensure accurate test results.
including washing hands, cleaning
the genital area, and collecting
midstream urine in a sterile
container.

6. Ensure privacy during specimen To maintain client confidentiality.

collection.

7. Ensure proper sanitation and To prevent contamination of urine

hygiene practices in the collection specimens and maintain a clean and safe
area. environment for clients and healthcare
providers.

8. Accurately label the urine specimen To ensure proper identification and

with the client's name, date, time of tracking.
collection, and any other required
information.

9. Ensure timely transport of the urine To maintain specimen integrity.

specimen to the laboratory for

92
 analysis, following appropriate
storage and transportation
protocols.

10. Record details of urine collection, To maintain accurate medical records.

including client instructions
provided, specimen labeling, and
any observations or deviations from
normal procedures, in the client's
medical record.

11. Provide guidance on lifestyle factors To reduce risk of introducing bacteria into
that may affect urinary health, such the urinary tract.
as hydration, diet, and personal
hygiene practices.

12. Educate the patient about any To enhance medication adherence and
prescribed medications, including treatment efficacy.
antibiotics.

13. Advising the patient on proper To prevent buildup of bacteria.

hygiene practices to prevent urinary
tract infections, such as wiping from
front to back, maintaining genital
hygiene, and avoiding irritants.

B. COMPLETE BLOOD COUNT

According to the National Library of Medicine (2022), a complete blood count (CBC) is
a blood test that evaluates overall health and detects various conditions such as anemia,
infection, and leukemia. This test measures red blood cells, white blood cells, hemoglobin,
hematocrit, and platelets. The purpose of this procedure is to identify blood disorders,
infections, immune system disorders, and other medical conditions. Fasting is not required
before this procedure; however, it is recommended that the client have enough rest and wear
a short-sleeved shirt that easily pulls up to expose the lower half of the arm. This procedure
may cause mild pain and bruising at the needle insertion site, but the symptoms will quickly
disappear. Abnormal values in results do not necessarily indicate a medical condition, but may

93
be due to diet, activity level, medications, menstruation, inadequate water in the body, and
other factors that can affect results there.

According to Mcgready et al. (2024), incomplete abortion frequently results in

prolonged vaginal bleeding and subsequent anemia. Considering the client reported scanty
vaginal bleeding from March 16, 2024, to March 17, 2024, at the time of admission, a
complete blood count was requested on March 17, 2024, at 6:04 AM. In the case of the client,
this procedure was performed on March 17, 2024, at 6:31 AM, which serves as a substantial
diagnostic procedure to evaluate the client's overall health and assess factors such as red
blood cells, hematocrit, and hemoglobin levels, which could indicate the severity of the
client's bleeding (Naqvi, 2021). Uterine sepsis can also occur due to the retained products of
conception. For early detection, a complete blood count was requested to completely
evaluate whether there is an intrauterine infection arising from fetal or placental tissue.
Furthermore, one of the main uses of CBC in the patient's condition is to monitor how the
patient responds to treatment, such as manual vacuum monitoring, as well as any side effects
the patient may have experienced (Kampfrath, 2021). The results of this procedure, therefore,
act as a guide for medical professionals to determine the appropriate intervention that needs
to be carried out.

Date ordered: March 17, 2024 - 6:04 A.M.

Date of Specimen Collection: March 17, 2024 – 6:31 A.M.

Date of release: March 17, 2024 – 7:25 A.M.

Table 5: Complete Blood Count

Laboratory examination Found value Normal value Significance
Complete Blood Count - - -
Hemoglobin (cal6000) 121.00 g/L 123 - 153 g/L Decreased
>suggests low oxygen
level within the blood
Hematocrit (cal6000) 0.37 0.35 - 0.44 Normal
>indicates the
percentage of red
blood cells volume
within blood is normal

94
RBC (cal6000) 4.05 x 1012/L 4.5 - 5.1 x 1012/L Decreased
>suggests vitamin B6,
B12, or folate
deficiency
MCV (cal6000) 91.00 fL 80 - 100 fL Normal
>implies red blood cell
size is within normal
value
MCH (cal6000) 29.90 pg 27 - 32 pg Normal
>signifies adequate
amount of hemoglobin
per red blood cells
MCHC (cal6000) 32.80 g/dL 31 - 35 g/dL Normal
>indicates amount of
hemoglobin per unit
volume is adequate
RDW (cal6000) 13.00 % 12 - 16 % Normal
>implies that red blood
cells are in similar size
WBC (cal6000) 9.58 x 109/L 4.50 - 11.00 x Normal
109/L >indicates that
production of wbc is
adequate and the
immune system is
functioning well
Differential Count - - -
(cal6000)
0.77 0.50 - 0.70 Increased
Segmenters (cal6000) >indicates
inflammation within
Lymphocyte (cal6000) the body

0.16 0.20 – 0.40 Decreased

>suggests mild
Monocyte (cal6000)
infection
Eosinophil (cal6000)
Basophil (cal6000) 0.04 0.02 – 0.08 Normal
>implies the ability to
fight against bacterial
infection

0.02 0.01 – 0.04 Normal

95
 >indicates that the
immune response can
act against parasitic
infection

0.01 0.00 – 0.01 Normal

>implies active
response to allergens
Platelet Count (cal6000) 396.00 x 109/L 150 – 450 x 109/L Normal
>implies platelet count
have the ability to stop
bleeding
MPV (cal6000) 8.40 fL 9.2 – 12.2 fL Decreased
>indicates low
production of platelets
PDW (cal6000)
9.10 fL 9.7 – 15.1 fL Normal
>signifies that platelet
size is within the
normal range

Blood Typing - - -
ABO Blood Typing - - B
RH Typing - - POSITIVE

According to Mayo Clinic (2022), a slightly low hemoglobin level does not always imply
signs of a disease or illness. Low hemoglobin counts are commonly low to women with
menstrual period and pregnant women as it is associated with blood loss due to heavy
menstrual or vaginal bleeding. In line with the client’s condition, hemoglobin level of 121.00
g/L, identified as low, is caused by continuous vaginal bleeding experienced by the client from
March 16 to March 17, 2024, that results to loss of red blood cells and hemoglobin faster than
they can be reproduced. Additionally, the study of Anabela et al., (2023) found out that
maternal hemoglobin level was not associated with the case of the client, which is the
incomplete abortion.

96
 The primary function of red blood cells is to transport oxygen to the body's tissues. In
relation to the CBC results, the client's red blood cell count is 4.05 x 1012/L. It is identified as
having low RBC levels. According to Braunstein (2022), the client's low red blood cell counts
are caused by severe vaginal bleeding, which exceeds the production of new RBCs. As a result,
this condition impairs the body's ability to deliver adequate oxygen and nutrients throughout
the client's body.

Neutrophils are white blood cell components that contribute to the body's response
to infection and the reconstruction of damaged tissues. According to Naeim et al. (2018),
elevated neutrophil levels in the peripheral circulation are a reaction to ongoing processes,
including inflammation. With the client's ongoing vaginal bleeding, her neutrophil count
jumped to 0.77, compared to the normal range of 0.50 to 0.70. The inflammation accelerated
neutrophil production, shortened their maturation period in the marrow, and allowed
immature neutrophils to enter the circulation, resulting in an increase in neutrophil levels in
the blood.

Lymphocytes, a type of white blood cell crucial to the immune system, play a pivotal
role in identifying and targeting specific threats, such as inflammatory and infectious agents
(Cleveland Clinic, 2022). Prior to the completion of the manual vacuum aspiration procedure
on the client, a complete blood count was ordered on March 17, 2024, at 6:04 a.m. The
examination revealed a slight decrease in lymphocyte count, resulting in 0.16, which falls just
below the normal range. According to Brennan (2021), diminished lymphocyte levels are often
associated with mild infections. Furthermore, in the context of the client's situation, it is
mentioned that surgical procedure can lead to a decrease in peripheral blood T and B
lymphocytes. This decline in lymphocytes post-surgery is attributed to heightened lymphocyte
apoptosis, a natural immune response aimed at combating infections. Hence, the observed
decrease in lymphocyte count in the client's CBC results is attributable to the recent surgical
procedure she underwent.

According to Wach et al. (2021), the mean platelet volume (MPV) serves as a reflection
of platelet size and is considered a potential indicator of inflammation and platelet activity.
Platelets play a critical role in hemostasis by adhering to sites of injury or bleeding, forming a
temporary plug that halts bleeding. In line with the CBC findings for the client, it is noted that

97
while the platelet count falls within the normal range at 396.00 x 10^9/L, the mean platelet
volume measures at 8.40 fL, indicating a below-normal level. Reduced MPV levels typically
indicate an increased proportion of older platelets, suggesting a slowdown in bone marrow's
production of these blood components. The decrease in platelet production within the bone
marrow is attributed to low hemoglobin levels in red blood cells, which are responsible for
transporting iron throughout the body (Florida Department of Health, 2022). As highlighted
by Kampfrath (2021), diminished mean platelet volume or an abundance of aged platelets
can contribute to persistent bleeding, a symptom experienced by the client. Therefore, the
observed low mean platelet volume (MPV) in conjunction with the client's CBC results may
signify a potential underlying cause for the ongoing bleeding experienced.

NURSING RESPONSIBILITIES RATIONALE

1. Confirm the identity of the client. To maintain client safety.

2. Assessing the client's readiness and To determine the appropriate timing and
ability to provide a blood sample, approach for urine collection, ensuring
and obtain consent. client comfort and cooperation.

3. Explain the procedure to the client. To build trust and reduce anxiety.

4. Provide education to the client on To promote their understanding and

the purpose of the complete blood improve client compliance.
count, potential implications of
abnormal results, and any follow-up
actions required based on test
findings.

5. Ensure proper sanitation and To prevent contamination of blood

hygiene practices in the collection specimens and maintain a clean and safe
area. environment for clients and healthcare
providers.

6. Administer IV fluids as ordered. To increase the intravascular volume in

instances of trauma or acute blood loss.

7. Administer iron supplement as To supply an adequate amount of iron

ordered. needed and reduce the risk of iron
deficiency.

98
 8. Instruct the client to not take iron To prevent decreased bioavailability of iron
supplements with antacids and from the iron supplements.
tetracyclines unless prescribed.

9. Educate client to include dietary To improve the production of hemoglobin

sources of iron such as lean meat and help maintain iron levels.
and dark leafy vegetables.

10. Encourage patient to engage in light To improve overall cardiovascular health

to moderate physical activity as and increase red blood cell production.
tolerated.

11. Educate patient on signs and To inform client when to alert the
symptoms of infection. healthcare members when signs and
symptoms of infection are present.

12. Encourage client to always observe To reduce the risk of infection.

proper hygiene practices.

13. Encourage client to ask questions To assess the level of knowledge and
regarding the intervention and anxiety of the client. This also help the
condition. client to cope more effectively with what is
happening.

C. ULTRASOUND
Ultrasound, or ultrasonography, is a medical imaging technique that uses high-
frequency sound waves to create real-time images of internal body structures (Krans, 2019).
These sound waves bounce off organs and tissues, producing echoes that are captured and
converted into visual images. Ultrasound is widely used for diagnosing and monitoring various
medical conditions without exposing clients to radiation.
Following a manual vacuum aspiration (MVA) procedure due the miscarriage of the
client, ultrasound imaging was performed to assess the outcome and ensure the uterus is
emptied. The procedure was done on March 18, 2024. This imaging modality served several
critical purposes in the benefit of the client. First, it confirmed the completeness of the
procedure by visualizing the uterine cavity and ensuring the removal of all contents, including
any residual products of conception (Pacheco, et.al., 2020). This confirmation is essential for
ensuring the client's health and preventing potential complications associated with
incomplete evacuation, such as infection or continued bleeding. Additionally, ultrasound

99
helped detect any retained fragments or tissue that may necessitate further intervention,
such as additional aspiration or medication to facilitate expulsion (Quarato, et.al., 2023). By
identifying and addressing these remnants promptly, that will mitigate the risk of
complications and promote optimal recovery for the client. Moreover, ultrasound enabled
the assessment of potential complications like uterine perforation or excessive bleeding,
facilitating prompt management if needed (Togioka and Tonismae, 2023). Detecting these
complications early through ultrasound allows for timely intervention, reducing the risk of
adverse outcomes and ensuring the client's safety. Based on ultrasound findings, the
physician can tailor subsequent treatment, whether through medication, repeat aspiration,
or surgery, to address any remaining issues or complications. This personalized approach
ensures that the client receives appropriate care based on their specific needs and
circumstances. Importantly, the results of the ultrasound guide client counseling, providing
clarity on the procedure's success, remaining concerns, and expectations for recovery and
follow-up care. By involving clients in these discussions and ensuring they understand the
significance of the ultrasound findings, healthcare providers empower them to make
informed decisions about their health and participate actively in their care.

100
Table 6: Ultrasound Result

UTERUS Position: Anteverted

Texture: Heterogeneous
Corpus: 6.16 x 5.31 x 5.17 cm
Findings: No focal mass seen.

CERVIX Size: 2.87 x 2.75 x 3.42 cm

Findings: Intact endocervical canal

ENDOMETRIUM Texture: Hyperechoic, non-linear

Thickness: 0.83 cm
Findings: Intact subendometrial halo

RIGHT OVARY:
Size: 3.62 x 2.45 x 4.73 cm (Volume: 8.02 ml). Lateral to the uterus.
Findings: Normal size and echotexture with corpus luteum noted.

LEFT OVARY:
Size: 2.77 x 1.81 x 0.99 cm (Volume: 2.60 ml). Lateral to the uterus.
Findings: Normal size and echotexture with several follicles noted.

OTHERS: No free fluid in the cul de sac.

IMPRESSION:
NORMAL SIZED ANTEVERTED UTERUS.
THIN ENDOMETRIUM.
NORMAL OVARIES WITH CORPUS LUTEUM, RIGHT.

The ultrasound findings offer deeper insights into the client's post-procedural
condition. The observation of a normal-sized anteverted uterus signifies that the evacuation
process effectively removed any remaining fetal or placental tissue, allowing the uterus to
return to its typical size and position within the pelvis. This normalization of uterine size is
crucial for the restoration of normal uterine function and subsequent reproductive health
(Supermaniam, 2019). The presence of a thin endometrium holds significance in the context
of post-miscarriage recovery. The thinning of the endometrial lining is a natural response to
the evacuation procedure and reflects the beginning stages of endometrial regeneration. This
process is essential for preparing the uterine lining for potential future pregnancies (Blanco-
Breindel, 2023). While a thin endometrium may initially raise concerns, it is generally
considered a normal and expected finding during the early stages of post-miscarriage

101
recovery. Furthermore, the identification of normal ovaries with a corpus luteum, particularly
on the right side, provides reassurance regarding ovarian function and hormonal balance. The
presence of a corpus luteum indicates recent ovulation and the initiation of the luteal phase
of the menstrual cycle (Oliver, et.al., 2023). Despite the recent miscarriage and evacuation
procedure, the ovaries continue to function normally, maintaining the intricate hormonal
interplay necessary for reproductive health. Overall, these ultrasound findings suggest
ongoing post-miscarriage recovery characterized by the normalization of uterine size, the
early stages of endometrial regeneration, and the preservation of ovarian function. While the
thin endometrium may reflect the recent trauma to the uterine lining, its presence alongside
normal ovarian activity suggests a promising outlook for subsequent attempts for
reproduction.

Nursing Responsibilities Rationale

1. Verify the client's identity. To maintain client safety.

2. Monitor vital signs such as blood To help detect any signs of postoperative
pressure, heart rate, respiratory complications such as hemorrhage,
rate, and temperature. infection, or hypovolemia.

3. Explain the procedure or what will To build trust and reduce anxiety.
happen.

4. Ensure the client has a empty To provide better image quality and clarity
bladder and instruct to void before during the examination.
the procedure.

5. Instruct the client to change into a To promote client comfort and dignity.
gown and ensure they are in the
appropriate position for the
procedure.

6. Assist in the setup of sterile drapes, To reduce the risk of infection during the
instruments, and equipment. procedure.

7. Explain post-procedure care To promote adherence to post-procedure

instructions and any potential side instructions and help them recognize and
effects or complications to the report any abnormal symptoms.
client.

102
 8. Observe the client for signs of To reduce the risk of adverse outcomes.
discomfort, bleeding, or other
complications during and after the
procedure.

9. Assist the client with getting To promote client comfort and recovery.
dressed, offering fluids, and
monitoring for any lingering effects
such as dizziness or pain.

10. Provide emotional support and To help alleviate anxiety, grief, and distress.
counseling.

11. Promote self-care and discharge To empower to participate actively in their

instructions. recovery.

12. Document the details of the To support continuity of care, and ensure
procedure, including any accountability.
complications or deviations from the
expected course.

ii. Treatments

A. MANUAL VACUUM ASPIRATION

Manual vacuum aspiration (MVA) is a medical procedure used for uterine evacuation
in cases of miscarriage, abortion, or diagnostic sampling (Chung, et al., 2024). It involves the
use of handheld device to create suction and gently remove uterine contents, offering
advantages such as reduced invasiveness, lower complication rates, and the ability to perform
it in our client settings with minimal anesthesia.

Following a miscarriage, there are retained products of conception (tissue from the
pregnancy) in the uterus. These remnants can lead to complications such as infection or
continued bleeding if not removed. Hence MVA was performed to the client on March 17,
2024 which started at 6:21 AM conducted by Dr. Balagso, in order to allow healthcare
providers to gently and efficiently evacuate the uterus, ensuring that all remaining tissue is
removed. By completing the miscarriage process, MVA not only reduces the risk of

103
complications but also provides emotional closure for the client, allowing them to move
forward with their recovery process both physically and emotionally. Additionally, MVA is
preferred over other methods due to its minimally invasive nature, lower risk of
complications, and offers convenience and comfort for the client.

NURSING RESPONSIBILITIES RATIONALE

1. Assess the client’s medical history, To identify any potential risks or

including any allergies, previous contraindications to the procedure.
surgeries, and current medications.

2. Obtain informed consent from the To ensure that the client has the necessary
client before the procedure. information to make an informed decision
about their care.

3. Ensure that all necessary equipment To reduce the risk of procedural er rors.
for the procedure is prepared and
functioning properly.

4. Provide detailed instructions to the To promote active participation and

client regarding the procedure. cooperation, reduce anxiety.

To create a supportive environment where

5. Provide emotional support and clients feel heard, respected, and cared for,
empathy to clients undergoing MVA, helping to reduce anxiety and promote a
acknowledging their feelings and sense of comfort and trust.
concerns.

To provide support and reassurance

6. Assist the client in assuming a throughout the procedure to help reduce
comfortable position for the anxiety and discomfort.
procedure.

To allow for early detection and

7. Continuously monitor the client's intervention in case of complications.
vital signs, including blood pressure,
heart rate, and oxygen saturation,
before, during, and after the
procedure.

To ensure that the procedure is performed

8. Assist the healthcare provider efficiently and accurately.
during the MVA procedure by
providing instruments, maintaining a

104
 sterile field, and managing suction
equipment as needed.

To help minimize discomfort and anxiety.

9. Assess the client's pain level and
administer appropriate pain relief
measures, such as local anesthesia
or analgesics, before and during the
procedure.

To monitor and care help detect and

10. Monitor the client closely after the address any complications promptly.
MVA procedure, assessing for any
signs of complications such as
excessive bleeding, infection, or
pain.

To ensure accountability, and provides a

11. Accurately document the MVA legal record of the care provided.
procedure, including the client's pre-
procedure assessment, vital signs,
medications administered,
procedure details, any complications
or adverse events, and post-
procedure instructions.

B. IVF THERAPY

Intravenous fluid therapy involves the administration of fluids directly into a client's vein
(O’Carroll, 2023). These fluids typically contain water, electrolytes (such as sodium and
potassium), and sometimes additional components like glucose or medications. Intravenous
fluid therapy is used to restore or maintain hydration, correct electrolyte imbalances, provide
nutrition, deliver medications, and support organ function in various medical conditions such
as dehydration, surgery, severe infections, or critical illness. The type and rate of intravenous
fluids administered depend on the client's condition, fluid status, and treatment goals as
determined by healthcare professionals.

105
 Following a manual vacuum aspiration (MVA), which is a procedure used to remove
uterine tissue in relation to the client’s incomplete miscarriage or abortion, intravenous fluid
therapy 5% Dextrose in Lactated Ringer's Injection (D5LRs) 42 gtts/min is employed to support
the client's physiological needs and aid in recovery. Firstly, IV fluids helped maintain or restore
hydration status, particularly important that the client has experienced fluid loss due to
bleeding during the miscarriage process. Hydration is crucial for supporting organ function
and promoting recovery (News Medical, 2024). Additionally, IV fluids aided in stabilizing the
client’s blood pressure and circulation, ensuring adequate tissue perfusion and oxygen
delivery. This is especially important in cases of significant hemorrhage or fluid loss. IV fluids
also helped prevent or alleviate hypotension, which can occur due to factors such as pain or
blood loss during the procedure. Moreover, the IV fluid therapy facilitated the administration
of anesthesia for MVA, ensuring its effectiveness and safety. Lastly, IV fluid therapy provided
a means of delivering medications and essential nutrients to support the client's overall well-
being and recovery. Ketorolac (Toradol) 30 mg was administered through IV before the
procedure.

During the MVA procedure, there may be minor blood loss or fluid shifts, even though the
procedure is performed under local anesthesia. This can lead to dehydration or fluid
imbalance, especially as the client had been fasting prior to the procedure. Intravenous fluid
therapy helped replenish lost fluids and electrolytes, restoring the body's hydration status
and ensuring optimal organ function (Castera and Borhade, 2023). Moreover, intravenous
fluids served as a supportive measure to stabilize the client's cardiovascular system (Malbrain,
et.al., 2020). The MVA procedure can be physically and emotionally taxing, potentially leading
to fluctuations in blood pressure or heart rate. Intravenous fluids helped maintain adequate
blood volume and blood pressure, which is crucial for tissue perfusion and oxygen delivery to
vital organs. By stabilizing the cardiovascular system, intravenous fluid therapy contributed
to the client's overall comfort and reduces the risk of complications during and after the
procedure. Additionally, intravenous fluid therapy helped mitigate the potential side effects
of anesthesia, such as nausea or dizziness (Sullivan, 2023). By providing hydration and
electrolyte balance, IV fluids alleviated post-anesthesia symptoms and facilitated a smoother
recovery process for the client. This supportive measure promotes client well-being and
enhances their experience during the post-procedural period. In summary, intravenous fluid

106
therapy plays a multifaceted role in managing the client who has undergone manual vacuum
aspiration. It addresses fluid loss, supports cardiovascular stability, and mitigates the effects
of anesthesia, ultimately optimizing the client's recovery and ensuring her comfort and safety
throughout the procedure and beyond.

NURSING RESPONSIBILITIES RATIONALE

Verify doctor’s order. To serve as a guide for initiation of IV

therapy which ensures client safety and
quality care delivery.

Verify the client's identity. To reduce risks of errors.

Obtain informed consent from the client To ensure that the client has the necessary
before the procedure. information to make an informed decision
about their care.

Ensure that all necessary equipment for the To reduce the risk of procedural errors.
procedure is prepared and functioning
properly.

Provide detailed instructions to the client To promote active participation and

regarding the procedure. cooperation, reduce anxiety.

Evaluate the patient's preparedness for IV To measure the level of knowledge and
procedure. preparedness of the patient to the
procedure.

Calculate and regulate IV flow rate. To ensure patient safety and accurate
quality care delivery

Inform patient to limit mobility in the To prevent swelling in the venipuncture site
venipuncture site. due to movement of needle or catheter
within the vein.

Assess IV site for deviations from normal. To ensure the IV site is patent when
initiating new fluid or medication.

Monitor the effectiveness of IV therapy. To ensure that the IV line is protected and
well-cared of.

Document the procedure. To provide members of the healthcare

team to be well informed.

107
 iii. Drugs

1. DRUG NAME:

Generic Name: cefuroxime

Brand Name: Zinacef

Classification: Antibacterial

Dosage: 500 mg/tab

Frequency: BID x 7 days

Route: Oral

Date and Time the Drug was Ordered: 3/17/24 - 6:33 am

MECHANISM OF ACTION:

Cefuroxime, a second-generation cephalosporin antibiotic, exerts its mechanism of

action by binding to penicillin-binding proteins (PBPs) located on the bacterial cell wall,
inhibiting the final stages of bacterial cell wall synthesis. This interference disrupts the cross-
linking of peptidoglycan strands, leading to the formation of weak and defective cell walls.
Consequently, bacterial cells become susceptible to osmotic pressure changes, undergo
osmotic instability, and eventually undergo cell lysis or rupture. Additionally, cefuroxime
triggers the activation of autolytic enzymes within bacterial cells, further degrading the
peptidoglycan layer and promoting cell lysis. The bactericidal activity of cefuroxime, which is
concentration-dependent, results in the eradication of susceptible bacteria (Omole et al.,
2024).

DESIRED EFFECT:

To prevent infections by targeting and eliminating introduced bacteria during the

manual vacuum aspiration (University of Illinois, 2023).

108
DRUG COMPUTATION:

D= 500mg

S= 500mg

q= 1 tab
𝐷
xq
𝑆

𝟓𝟎𝟎𝒎𝒈
x 1 tab
𝟓𝟎𝟎𝒎𝒈

= 1 tab

NURSING RESPONSIBILITIES RATIONALE

Check the doctor’s order. To ensure client safety and quality care
delivery.

Observe 12 R’s of drug administration. To ensure client safety, accuracy, and

effectiveness in medication management.

Verify the client's identity. To reduce risks of errors.

Take the client’s blood pressure. To serve as a baseline data.

Assess if the client has taken drugs that may To optimize treatment efficacy.
decrease the medication effectiveness such
as probenecid, warfarin and loop diuretics.

Inform the client the need and importance To help the client understand the purpose of
of adherence to the drug to manage their treatment and the role that the drug
conditions. plays in managing their condition.

Administer medication at the right time and To maximize the effectiveness of the
right dosage. treatment and prevent treatment failure.

Educate clients to avoid alcohol while taking To prevent adverse reactions.

this drug because severe reactions can
occur.

Inspect IM and IV injection sites frequently To detect signs of phlebitis early and prevent
for signs of phlebitis. complications.

Monitor input and output pattern. To prevent dehydration or fluid overload.

109
 Report loose stools or diarrhea promptly. To assess severity of fluid loss and intervene
to prevent dehydration.

Educate client of the possible adverse To help the client recognize and monitor for
reactions of the drug. symptoms that may indicate a reaction.

Tell the client to report a history of allergic To avoid any adverse reactions.
reactions to penicillins and cephalosporins.

Instruct client to report immediately to the To detect early serious adverse reactions.
nursing staff if rash, chills or fever develops.

Document the drug's name, time and date of To serve as a record of the care provided.
administration on the client’s chart.

2. DRUG NAME:

Generic Name: ferrous sulfate

Brand Name: Ferricore

Classification: Iron Preparation

Dosage: 325 mg/tab

Frequency: OD

Route: Oral

Date and Time the Drug was Ordered: 3/17/24 - 6:33 am

MECHANISM OF ACTION:

Upon ingestion, ferrous sulfate dissociates into ferrous ions in the acidic environment
of the stomach and is absorbed into the bloodstream via specialized transporters including
Divalent Metal Transporter 1 (DMT1) and Ferroportin. Once in circulation, ferrous ions bind
to transferrin and are transported to tissues and organs, where they are utilized for
hemoglobin synthesis within bone marrow precursor cells. This supports erythropoiesis, the
process of red blood cell production, which may be compromised in the setting of iron
deficiency. By providing an exogenous source of iron, ferrous sulfate helps restore iron levels,
alleviate symptoms of anemia, and promote recovery following miscarriage-associated blood
loss (Nguyen and Tadi, 2023).

110
DESIRED EFFECT:

To replenish iron stores depleted during the process of miscarriage and manual
vacuum aspiration, preventing anemia (BuzzRx, 2020).

DRUG COMPUTATION:
𝐷
= 𝑆x q

𝟑𝟐𝟓𝒎𝒈
=𝟑𝟐𝟓𝒎𝒈 x 1 tab

= 1 tab

NURSING RESPONSIBILITIES RATIONALE

Check the doctor’s order. To ensure client safety and quality care
delivery.

Observe 12 R’s of drug administration. To ensure client safety, accuracy, and

effectiveness in medication management.

Verify client’s identity. To reduce risks of errors.

Assess for allergy to any ingredient, sulfite; To prevent adverse reactions.

hemochromatosis, hemosiderosis,
haemolytic anemias.

Monitor blood studies. To serve as a baseline assessment of the

client’s iron status and hematological
parameters.

Administer the right drug in the right dose To maximize the effectiveness of the
and route at the right time. treatment and prevent treatment failure.

Instruct client not to crush, chew or cut To minimize the risk of gastrointestinal
tablets and capsules. irritation.

Avoid taking the drug with eggs, milk, tea, To prevent decreased therapeutic
coffee, or cereal. effectiveness.

Do not take the drug with antacids and To prevent decreased bioavailability of iron
tetracyclines unless prescribed. from ferrous sulfate.

Warn the client that stool may be dark or To reassure that the change in stool color is
green. normal.

111
 Report severe GI upset, lethargy, rapid To detect early signs of adverse reactions.
respirations and constipation.

Document and record. To serve as a record of the care provided.

3. DRUG NAME:

Generic Name: mefenamic acid

Brand Name: Myrefen

Classification: Nonsteroidal anti-inflammatory drug

Dosage: 500 mg/tab

Frequency: TID x PAIN

Route: Oral

Date and Time the Drug was Ordered: 3/17/24 - 6:33 am

MECHANISM OF ACTION:

It inhibits the enzymes cyclooxygenase (COX)-1 and COX-2 and reduces the formation
of prostaglandins and leukotrienes. Mefenamic acid also acts as an antagonist at
prostaglandin receptor sites. It has analgesic and antipyretic properties with minor anti-
inflammatory activity (Khansari and Halliwell, 2019).

DESIRED EFFECT:

To help reduce cramping and inflammation, alleviating discomfort after a manual

vacuum aspiration procedure following a miscarriage (University of Illinois, 2019).

112
DRUG COMPUTATION:

D: 500mg

S: 500mg

q: 1
𝐷
= 𝑆x q

500𝑚𝑔
= x 1 tablet
500𝑚𝑔

= 1 tablet

NURSING RESPONSIBILITIES RATIONALE

Check the doctor’s order. To ensure client safety and quality care
delivery.

Observe 12 R’s of drug administration. To ensure client safety, accuracy, and

effectiveness in medication management.

Verify client’s identity. To reduce risks of errors.

Assess the client's pain before therapy. To determine the appropriate dose and
provide a baseline for measuring
therapeutic efficacy.

Monitor for possible drug induced adverse To rapidly modify the treatment in managing
reactions such as stomach pain, nausea, the adverse effect.
vomiting and diarrhea.

Advise client not to take drugs for more than To reduce the potential risk for digestive
7 days. tract disorders such as bleeding, ulcers, and
kidney damage.

Encourage clients to report immediate To attend the intervention needed and

persistence or failure to relieve pain. prevent further complications.

Do not drive or engage in potentially To prevent injury for the client.

hazardous activities until response to drugs
is known.

113
 4. DRUG NAME:

Generic Name: methylergometrine maleate

Brand Name: Methergine

Classification: Ergot alkaloids

Dosage: 0.2mg

Frequency: TID

Route: Oral

Date and Time the Drug was Ordered: 3/17/24 - 6:33 am

MECHANISM OF ACTION:

Methylergometrine acts directly on the uterine smooth muscle, increasing the tone,
pace, and amplitude of rhythmic contractions by binding and antagonizing the dopamine D1
receptor. Thus, it causes rapid and prolonged tetanic uterotonic action, shortening the third
stage of labor and reducing blood loss (Ohwovoriole, 2021).

DESIRED EFFECT:

To promote uterine contraction and prevent or treat bleeding from the uterus that
can happen after childbirth or an abortion, such as the condition of the patient (National
Library of Medicine, 2022).

DRUG COMPUTATION:

D: 0.2mg

S: 0.2mg

q: 1 tablet
𝐷
= 𝑆x q

0.2𝑚𝑔
= x 1 tablet
0.2𝑚𝑔

= 1 tablet

114
NURSING RESPONSIBILITIES RATIONALE

Check the doctor’s order. To ensure client safety and quality care
delivery.

Observe 12 R’s of drug administration. To ensure client safety, accuracy, and

effectiveness in medication management.

Verify the client's identity. To reduce risks of errors.

Monitor for blood pressure and heart rate. To avoid complications such as hypertensive
crisis or stroke.

Assess for any contraindication such as To prevent the occurrence of severe allergic
hypersensitivity and lactation. responses, including anaphylaxis, which is
life-threatening.

Encourage client to report for nausea, To rapidly modify the treatment in

vomiting, severe abdominal pain, numbness managing the adverse effect.
or tingling of extremities, or increases
bleeding.

Inform the client that the medication can To prevent injury for the client.
cause dizziness and low blood pressure.

Advise the client that the medication may To prevent unnecessary doctor visits and
cause menstrual-like cramps. concerns because they understand that
cramps are a common and expected side
effect of methergine.

115
 5. DRUG NAME:

Generic Name: ketorolac tromethamine

Brand Name: Toradol

Classification: Nonsteroidal Anti-Inflammatory Drug

Dosage: 30mg

Frequency: Single Dose

Route: Intravenous

Date and Time the Drug was Ordered: 3/17/24 - 6:10 a.m.

MECHANISM OF ACTION:

The primary role of Ketorolac is the inhibition of the enzyme cyclooxygenase so that
prostaglandins are not formed. This drug may have other actions that contribute to their anti-
inflammatory actions, including reducing the motility of leukocytes and inhibition of various
other enzymes (Mahmoodi and Kim, 2022).

DESIRED EFFECT:

To provide short-term treatment of moderate to severe pain after surgery such as

manual vacuum aspiration (Medscape, 2019).

DRUG COMPUTATION:

D: 30mg

S: 30mg

q: 1 mL
𝐷
= xq
𝑆

30𝑚𝑔
= x 1 mL
30𝑚𝑔

= 1mL

116
NURSING RESPONSIBILITIES RATIONALE

Check the doctor’s order. To ensure client safety and quality care
delivery.

Observe 12 R’s of drug administration. To ensure client safety, accuracy, and

effectiveness in medication management.

Verify the client's identity. To reduce risks of errors.

Asses for rhinitis, asthma, and urticaria. To prevent the risk of developing
hypersensitivity reactions.

Assess for rash periodically during therapy. To prevent the occurrence of severe allergic
responses, including anaphylaxis, which is
life-threatening.

Monitor for blood pressure before and To avoid complications such as fluid
periodically during therapy. retention, hypertensive crisis or stroke.

Advise client to avoid driving or engage with To serve as a precaution because the drug
other activities that require alertness until may cause drowsiness or dizziness.
response to the medication is known.

Encourage client to immediately consult a To prevent the occurrence of severe allergic

health care provider if rash, visual changes, response that can lead to complications.
tinnitus, weight gain, or influenza-like
symptoms.

117
 H. Nursing Care Plans

Nursing Care Plan 1

NURSING ASSESSMENT
SUBJECTIVE
● “Kasla agcracramps toy ayan matres ko” as verbalized by the patient
OBJECTIVE
● Pain scale of 4/10

NURSING DIAGNOSIS
Acute pain related to tissue trauma related to manual vacuum aspiration as evidenced
by a pain scale of 4/10, and verbalization of “kasla agcracramps toy ayan matres ko”.

NURSING INFERENCE
During MVA, instruments are inserted through the cervix into the uterus to remove
uterine contents. This process involves manipulation of the cervical and uterine tissues, which
can cause minor trauma or irritation. The cervix, in particular, is a sensitive area with a rich
supply of nerves, and manipulation of this area can elicit a pain response. Tissue trauma
during MVA can lead to the activation of nociceptors, which are sensory receptors that detect
tissue damage and transmit pain signals to the brain, thus, acute pain.

NURSING GOAL
After 1-2 hours of nursing interventions, the client will verbalize reduced pain on a
scale of 2/10 and appear relaxed.

NURSING INTERVENTION

NURSING INTERVENTIONS RATIONALE

INDEPENDENT

Evaluate pain, noting characteristics, To assess level of comfort and reduce risk
location, and intensity on a 0-10 scale. of complications.

118
 Observe for non-verbal cues. To observe the level of pain and reveal
underlying anxiety or stress.

Assess the client’s vital signs, noting To detect early signs of complications.
tachycardia, hypertension, and increased
respiration.

Provide a quiet environment. To allow the patient to rest and recuperate

after the procedure.

Encourage the use of relaxation techniques To help reduce pain perception and
such as deep-breathing exercises, guided promote comfort.
imagery, visualization, or music.

Educate the patient about the nature of To help patient understand what to expect
discomfort expected. during the recovery process.

Provide additional comfort measures such To alleviate discomfort and promote

as back rub and heat or cold applications. relaxation.

DEPENDENT

Administer pain medications, as prescribed. To provide relief from acute pain.

NURSING EVALUATION
After 2 hours of nursing interventions, the client reported a reduced pain, from a pain scale
of 4/10 to 1/ 10 rating and appeared relaxed.

119
Nursing Care Plan 2
NURSING DIAGNOSIS
Risk for decreased cardiac output related to low hemoglobin level

NURSING INFERENCE
The protein that is found in red blood cells and it carries oxygen to all parts of a human
body is called hemoglobin. When there is insufficient hemoglobin concentration in the blood,
referred to as anemia; it means that there will be less amount of hemoglobin left to carry the
oxygen molecules released by the lungs. Consequently, the heart muscle may receive less
oxygen from blood pumped into the right atrium via right ventricle because of defective
contraction which is also caused by insufficient oxygen supply to it due to reduced oxygen
content in it as a result of less amount of this gas available while generating energy for its
work, thus risk for decreased cardiac output

NURSING GOAL
After 20 to 25 minutes of nursing intervention, the patient will understand how to
manage low hemoglobin levels.

NURSING INTERVENTION

INTERVENTION RATIONALE

Encourage the patient to stick to their To help raise hemoglobin levels and
treatment regimen as advised by their reduce the risk of complications.
healthcare provider, including taking iron
supplements or other medications.

Educate the patient on the significance of a to support the production of red blood
well-rounded diet abundant in iron, vitamin cells.
B12, and folate

Emphasize the need to hydrate more by To help maintain blood volume and
consuming enough fluids, especially plain circulation, which can support cardiac

120
 water. function.

Encourage the patient to engage in regular To improve cardiovascular health and

physical activity as tolerated. circulation

NURSING EVALUATION
After 20 minutes of nursing intervention, the patient demonstrated comprehension
of the strategies for managing low hemoglobin levels.

121
Nursing Care Plan 3
NURSING ASSESSMENT:
Subjective
● Refusal to Bilateral Tubal Ligation (BTL) treatment

NURSING DIAGNOSIS:
Deficient Knowledge related to inadequate participation of care planning as evidenced
by refusal of Bilateral Tubal Ligation (BTL) treatment.

NURSING GOALS:
After 2-3 hours of rendering appropriate nursing interventions the patient will
verbalize understanding of condition, disease process and treatment and initiate necessary
lifestyle changes and participate in treatment regimen.

NURSING INTERVENTIONS:
Interventions Rationale
INDEPENDENT
Discuss the client’s perception of need. To let the client feel competent and
Relate the information to the client’s respected.
personal desire, needs, values and beliefs.
Review information the client already knows To arouse interest and limit the sense
and move to what the client does not know, of being overwhelmed.
progressing from simple to complex.
Provide written information or guidelines and To facilitate learning.
self-learning modules (e.g. family planning
booklet) for the client to refer to as
necessary.
COLLABORATION

Provide access information for the client for To answer questions and validate
the contact person. information post discharge.

Identify available community resources and To assist with problem-solving, provide

support groups. role models, and support personal
growth/change.

122
Nursing Evaluation: Goal met. After 25 minutes of rendering nursing interventions, the
patient exhibited increased interest and assumed responsibility for their own learning as they
looked for information and asked questions.

I. General Evaluation

Gloria, a 38 year old female from Visaya, Vintar, Ilocos Norte, was admitted at Mariano
Marcos Memorial Hospital and Medical Center (MMMH&MC) last March 17, 2024 at 5:25a.m.
due to vaginal bleeding with an admitting diagnosis of G5P4 (4004) incomplete abortion,
early, nonseptic; non induced; advanced maternal age. The admitting physician was Jezzica R.
Balagso, MD. Moreover, the final diagnosis was G5P4 (4014) complete abortion, early,
nonseptic; non induced; advanced maternal age.

Upon arrival at the Outpatient Department of Obstetrics and Gynecology Department

(OPD-OB), the client underwent an internal examination (IE) by the physician, Dr. Dianne
Shayne Faylogna. Prior to the procedure, signed consent was obtained for manual vacuum
aspiration (MVA). Then, Dr. Balagso ordered laboratory tests including urinalysis and
complete blood count(CBC), which were carried out. After that, the first dose of ketorolac was
administered which was used to manage the patient’s pain and discomfort, followed by a
negative anti-sensitivity test in order to confirm if the patient is not allergic or sensitive to the
medications or materials to be used during the procedure. The client was then endorsed to
the Department of Nuclear Medicine at the Surgical Annex Building's third floor.

Under the supervision of the physician, Dr. Balagso, the MVA procedure under
paracervical block started at 6:21 a.m. and finished at exactly 6:30 a.m. Then, the client was
transferred to the Post-Anesthesia Care Unit (PACU) for observation. Consequently, she was
transferred to the Gynecological Ward in room 408 and bed 4.

Upon assessment, she reported an acute pain of 4/10 in the abdominal area which she
compared as period cramps, and has light vaginal bleeding. According to the client at that
time, she felt minimal uterus cramping in a pain scale of 4/10 which distracts her and feels

123
discomfort, however, she still manages to show a calm expression and aura. The pain occurs
as the uterus continues to contract and expel any remaining tissue, which is a normal part of
the healing process and also due to the body adjusting back to its pre-pregnancy state. It’s
usually temporary and can be managed with pain medications prescribed and with rest. Also,
there was a minimal bleeding and this is due to residual tissue shedding and the natural
healing process of the uterine lining. It's normal for some spotting or light bleeding to
continue for a few days to a week after the procedure as the uterus heals and returns to its
normal state.

Then, the client consented for a bilateral tubal ligation (BTL), however, later that day, she
rejected it. Henceforth, the client issued a refusal consent form for her BTL, in which she
indicated that she chose to use contraceptive pills for family planning. Therefore, she received
health teaching.

On March 18, 2024, Gloria was discharged at 3:10 p.m. with take-home medications
ordered by Dr. Balagso such as 500mg of cefuroxime (Zinacef) tablet to be taken orally BID
for seven (7) days; 325 mg of ferrous sulfate (Ferricore) tablet to be taken orally OD; 500 mg
of mefenamic acid (Myrefen) tablet to be taken orally TID for pain; and methylergometrine
maleate (Methergine) tablet to be taken orally TID for three (3) days. Furthermore, the
patient was advised to have a follow-up check-up at MMMH & MC's Outpatient Department
of Ob-Gyne on March 21, 2024, three (3) days after the discharge.

124
 REFERENCES
Adams, R., Chen, J., Han, J., Li, B., Li, H. Sun, T., Tang, Y., Wang, R., & Yang, Q. (2022,
September). ScienceDirect.
https://www.sciencedirect.com/science/article/pii/S2095254622000448?__cf_chl_t
k=XUTPPTX6iWzfWPqEGcZdsCy0Xd34rrPuWacB7bBHkB8-1712648821-0.0.1.1-1386
Advanced Fertility Center of Chicago (2022). Female Age and Miscarriage and Fertility.
https://advancedfertility.com/client-education/causes-of-infertility/age-and-
fertility/#:~:text=The%20main%20reason%20for%20the,abnormal%20karyotype
Al-Mutawtah, M., Campbell, E., Kubis, H. P., & Erjavec, M. (2023, November 10). Women’s
experiences of social support during pregnancy: a qualitative systematic review. BMC
Pregnancy and Childbirth, 23(1). https://doi.org/10.1186/s12884-023-06089-0
American College of Obstetricians and Gynecologists. (2020, October). How much water
should I drink during pregnancy? Www.acog.org. https://www.acog.org/womens-
health/experts-and-stories/ask-acog/how-much-water-should-i-drink-during-
pregnancy#:~:text=During%20pregnancy%20you%20should%20drink
Anabela, et al. (2023). Association between maternal hemoglobin level and incomplete
abortion at RSUP Dr. Hasan Sadikin Bandung 2017-2019. International Journal of
Integrated Health Sciences, 11(1). https://doi.org/10.15850/ijihs.v11n1.3284
Barton, K., Redshaw, M., Quigley, M. A., & Carson, C. (2017). Unplanned pregnancy and
subsequent psychological distress in partnered women: a cross-sectional study of the
role of relationship quality and wider social support. BMC Pregnancy and Childbirth,
17(1). https://doi.org/10.1186/s12884-017-1223-x
Better Health Channel. (2012). Smoking - the financial cost. Vic.gov.au.
https://www.betterhealth.vic.gov.au/health/healthyliving/smoking-the-financial-
cost
Betz, D. and Fane, K. (2023, August 14). Human Chorionic Gonadotropin.
https://www.ncbi.nlm.nih.gov/books/NBK532950/
Biga, L. et al (2019). Embryonic Development.
https://open.oregonstate.education/aandp/chapter/28-2-embryonic-development/
Blanco-Breindel, M. F., Singh, M., & Kahn, J. (2023, June 7). Endometrial receptivity. StatPearls
- NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK587449/

125
Bondick CP, M Das J, Fertel H. Subchorionic Hemorrhage. [Updated 2023 Jul 31]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK559017/
Borkoles, E., Krastins, D., van der Pols, J. C., Sims, P., & Polman, R. (2022, October 10). Short-
Term Effect of Additional Daily Dietary Fibre Intake on Appetite, Satiety,
Gastrointestinal Comfort, Acceptability, and Feasibility. Nutrients, 14(19), 4214.
https://doi.org/10.3390/nu14194214
Boyd, R. & Pippin, M. (2023, August 17). Breast Self Examination. StatPearls.
https://www.ncbi.nlm.nih.gov/books/NBK565846/
Braunstein. (2022). Anemia Due to Excessive Bleeding. Merck Manuals Consumer Version;
Merck Manuals. https://www.merckmanuals.com/home/blood-
disorders/anemia/anemia-due-to-excessive-bleeding
Brennan, D. (2021, May 11). What Are Lymphocytes? WebMD. https://www.webmd.com/a-
to-z-guides/what-are-lymphocytes
Britannica, T. Editors of Encyclopaedia (2024, February 3). lymphocyte. Encyclopedia
Britannica. https://www.britannica.com/science/lymphocyte
Budler, M. & Cilar, L., (2022). Physical activity during pregnancy: a systematic review for the
assessment of current evidence with future recommendations. BMC Sports Science,
Medicine and Rehabilitation, 14(1). https://doi.org/10.1186/s13102-022-00524-z
Buenaventura, H. (2021). Signs and Causes of Miscarriage.
https://hellodoctor.com.ph/pregnancy/being-pregnant/pregnancy-problems/signs-
miscarriage/
Carusi, D. (2023). Retained products of conception in the first pregnancy.
https://www.uptodate.com/contents/retained-products-of-conception-in-the-first-
half-of-pregnancy#H1
Centers for Disease Control and Prevention. (2023). Physical Job demands – Reproductive
Health. https://www.cdc.gov/niosh/topics/repro/physicaldemands.html
Centers for Disease Control and Prevention. (2022, December 1). Personal Hygiene. Retrieved
April 27, 2024, from https://www.cdc.gov/hygiene/personal-hygiene/index.html
Centers for Disease Control and Prevention. (2023, October 3). Alcohol use in pregnancy.
Centers for Disease Control and Prevention.
https://www.cdc.gov/ncbddd/fasd/alcohol-use.html

126
Chen, Y., Guo, J., Zhang, Q., & Zhang, C. (2022). Insulin Resistance is a Risk Factor for Early
Miscarriage and Macrosomia in Patients With Polycystic Ovary Syndrome From the
First Embryo Transfer Cycle: A Retrospective Cohort Study. Frontiers in endocrinology,
13, 853473. https://doi.org/10.3389/fendo.2022.853473
Chen, Z. et al (June 2021). Advanced maternal age causes premature placental senescence
and malformation via dysregulated α-Klotho expression in trophoblasts.
https://onlinelibrary.wiley.com/doi/full/10.1111/acel.13417
Chung, J. P. W., Law, T. S. M., Ng, K. H., Ip, P. N. P., & Li, T. (2024). Intrauterine adhesion in
ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum
aspiration (EVA): a randomized controlled trial. BMC Pregnancy and Childbirth, 24(1).
https://doi.org/10.1186/s12884-024-06328-
Chung, P. H. (2024, January 9). Urinalysis and Urine Culture. MSD Manual Consumer Version.
https://www.msdmanuals.com/home/kidney-and-urinary-tract-disorders/diagnosis-
of-kidney-and-urinary-tract-disorders/urinalysis-and-urine-culture
Cleveland Clinic. (2022, June 20). Lymphocytes: Function, Definition, Levels & Ranges.
Cleveland Clinic. https://my.clevelandclinic.org/health/body/23342-lymphocytes
Cox, L. et al (2017). The Role of Cellular Senescence in Ageing of the Placenta.
https://www.sciencedirect.com/science/article/abs/pii/S0143400417301182
Daniilidis, A., Papandreou, P., & Grimbizis, G. F. (2022). Uterine septum and reproductive
outcome. From diagnosis to treatment. How, why, when?. Facts, views & vision in
ObGyn, 14(1), 31–36. https://doi.org/10.52054/FVVO.14.1.002
DaVanzo, J. et al. (2017). Effects of interpregnancy interval and outcome of the preceding
pregnancy on pregnancy outcomes in Matlab, Bangladesh.
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2007.01338.x
Dhar, G. A., Saha, S., Mitra, P., & Nag Chaudhuri, R. (2021). DNA methylation and regulation
of gene expression: Guardian of our health. The Nucleus : an international journal of
cytology and allied topics, 64(3), 259–270. https://doi.org/10.1007/s13237-021-
00367-y
Dhingra. (2021, March 21). Ferrous Sulfate. BuzzRx. Retrieved April 29, 2024, from
https://www.buzzrx.com/ferrous-sulfate/uses
Dirce Stein Backes, Eronis Borges Gomes, Rosiane Filipin Rangel, Maria, K., Luciano Samaniego
Arrusul, & Josiane Lieberknecht Wathier Abaid. (2022). Meaning of the spiritual

127
 aspects of health care in pregnancy and childbirth. 30. https://doi.org/10.1590/1518-
8345.5980.3774
Elicay, K. (2018). What Causes a Miscarriage?
https://www.smartparenting.com.ph/pregnancy/getting-pregnant/miscarriage-
causes-symptoms-a00228-20180305
Faacc, T. K. P. D. (2022, September 28). Urinalysis (UA test) - testing.com. Testing.com.
https://www.testing.com/tests/urinalysis/
Flores, J. L., Cortes, G. A., & Leslie, S. W. (2023, September 13). Physiology, Urination.
StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK562181/
Florida Department of Health. (2022, June 12). What Is Hemoglobin? Florida Department of
Health. https://www.floridahealth.gov/AlternateSites/DOH_LMS_Resources/WIC/az-
hematology/CourseFiles/page4462.html#:~:text=More%20specifically%2C%20thoug
h%2C%20it
Ford, H. B., & Schust, D. J. (2009). Recurrent pregnancy loss: etiology, diagnosis, and therapy.
Reviews in obstetrics & gynecology, 2(2), 76–83.
Frysh, P. (2023, September 17). How Often Should You Shower? WebMD.
https://www.webmd.com/beauty/shower-how-often
Fuligni, A. J. (2018, December 18). The Need to Contribute During Adolescence. Perspectives
on Psychological Science, 14(3), 331–343.
https://doi.org/10.1177/1745691618805437
Giakoumelou, S., Wheelhouse, N., Cusch ieri, K., Entrican, G., Howie, S. E., & Horne, A. W.
(2018). The role of infection in miscarriage. Human reproduction update, 22(1), 116–
133. https://doi.org/10.1093/humupd/dmv041
González-Ramos, Z., Zuriguel-Pérez, E., Albacar-Riobóo, N., & Casadó-Marín, L. (2021,
December). The emotional responses of women when terminating a pregnancy for
medical reasons: A scoping review. Midwifery, 103, 103095.
https://doi.org/10.1016/j.midw.2021.103095
Goto, Y., Hayasaka, S., Kurihara, S., & Nakamura, Y. (2018, June 7). Physical and Mental Effects
of Bathing: A Randomized Intervention Study. Evidence-Based Complementary and
Alternative Medicine, 2018, 1–5. https://doi.org/10.1155/2018/9521086

128
 Gu, K. J., & Li, G. (2020b). An overview of cancer prevention: Chemoprevention and

immunoprevention. Journal of Cancer Prevention, 25(3), 127–135.

https://doi.org/10.15430/jcp.2020.25.3.127

Habak, P. J., & Griggs, R. P., Jr. (2023, July 4). Urinary tract infection in pregnancy. StatPearls -
NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK537047
Haque, N., & Tariq, N. (2019). Short term oral methylergonovine maleate prophylaxis for
status migrainosus. case series and review of literature. Frontiers in Neurology, 10.
https://doi.org/10.3389/fneur.2019.00201
Harvard Medical School (January 2021). Miscarriage. Harvard Health Publishing.
https://www.health.harvard.edu/a_to_z/miscarriage-a-to-z
Henry, C., Ekeroma, A., & Filoche, S. (2020, June 12). Barriers to seeking consultation for
abnormal uterine bleeding: systematic review of qualitative research. BMC Women’s
Health, 20(1). https://doi.org/10.1186/s12905-020-00986-8
Holland, K. (2018, May 18). Creating a Personal Hygiene Routine: Tips and Benefits. Healthline.
https://www.healthline.com/health/personal-hygiene#takeaway
Hong, Y. (2023). Powerlessness and A Social Imaginary in the Philippines: A Case Study on
Bahala na. DOI: 10.7252/Journal.01.2020S.08
Hooper, L., Abdelhamid, A., Ajabnoor, S. M., Esio-Bassey, C., Brainard, J., Brown, T. J., Bunn,
D., Foster, E., Hammer, C. C., Hanson, S., Jimoh, F. O., Maimouni, H., Sandhu, M.,
Wang, X., Winstanley, L., Cross, J. L., Welch, A. A., Rees, K., & Philpott, C. (2022,
February). Effects of fluid and drinking on pneumonia mortality in older adults: A
systematic review and meta-analysis. Clinical Nutrition ESPEN, 47, 96–105.
https://doi.org/10.1016/j.clnesp.2021.11.021
Hu, Y., Jiao, M., & Li, F. (2019, November 26). Effectiveness of spiritual care training to enhance
spiritual health and spiritual care competency among oncology nurses. BMC Palliative
Care. https://doi.org/10.1186/s12904-019-0489-3
Hukkelberg, S., Keles, S., Ogden, T., & Hammerstrøm, K. (2019, November 9). The relation
between behavioral problems and social competence: A correlational Meta-analysis.
BMC Psychiatry, 19(1). https://doi.org/10.1186/s12888-019-2343-9

129
Infurna, F. J., Gerstorf, D., & Lachman, M. E. (2020, May). Midlife in the 2020s: Opportunities
and challenges. American Psychologist, 75(4), 470–485.
https://doi.org/10.1037/amp0000591
Itani, R., Soubra, L., Karout, S., Rahme, D., Karout, L., & Khojah, H. M. J. (2022). Primary
Dysmenorrhea: Pathophysiology, Diagnosis, and Treatment Updates. Korean journal
of family medicine, 43(2), 101–108. https://doi.org/10.4082/kjfm.21.0103
Jabbari B, Schoo C, Rouster AS. Family Dynamics. [Updated 2023 Sep 16]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK560487/
Jeon, B., & Baek, J. (2023). Menstrual disturbances and its association with sleep disturbances:
a systematic review. BMC Women’s Health, 23(1). https://doi.org/10.1186/s12905-
023-02629-0
Johnson, T. (December 2022). Why are Black Mothers at Higher Risk for Miscarriage?
https://www.webmd.com/baby/features/why-black-mothers-higher-risk-miscarriage
Junge, C., Valkenburg, P. M., Deković, M., & Branje, S. (2020, October). The building blocks of
social competence: Contributions of the Consortium of Individual Development.
Developmental Cognitive Neuroscience, 45, 100861.
https://doi.org/10.1016/j.dcn.2020.100861
Kabodmehri, R., Sharami, S. H., Sorouri, Z. Z., Gashti, N. G., Milani, F., Chaypaz, Z., &
Ghalandari, M. (2021). The relationship between thyroid function and ovarian reserve:
a prospective cross-sectional study. Thyroid research, 14(1), 22.
https://doi.org/10.1186/s13044-021-00112-2
Kalman, D. S., & Lepeley, A. (2020, April). A Review of Hydration. Strength & Conditioning
Journal, 32(2), 56–63. https://doi.org/10.1519/ssc.0b013e3181c21172
Kamalanathan, S., Sahoo, J. P., & Sathyapalan, T. (2023). Pregnancy in polycystic ovary
syndrome. Indian journal of endocrinology and metabolism, 17(1), 37–43.
https://doi.org/10.4103/2230-8210.107830
Kampfrath, T. (2021, June 18). Complete Blood Count (CBC) - Understand the Test & Your
Results. Testing.com. https://www.testing.com/tests/complete-blood-count-cbc/
Kampfrath. (2022, September 28). Urinalysis (UA Test) - Testing.com. Testing.com. Retrieved
April 29, 2024, from https://www.testing.com/tests/urinalysis/

130
Khansari, P. S., & Halliwell, R. F. (2019). Mechanisms underlying neuroprotection by the NSAID
mefenamic acid in an experimental model of stroke. Frontiers in Neuroscience, 13.
https://doi.org/10.3389/fnins.2019.00064
Kim, S. M., & Kim, J. S. (2017). A Review of Mechanisms of Implantation. Development &
reproduction, 21(4), 351–359. https://doi.org/10.12717/DR.2017.21.4.351
Koyyada, A., & Orsu, P. (2020). Role of hypothyroidism and associated pathways in pregnancy
and infertility: Clinical insights. Tzu chi medical journal, 32(4), 312–317.
https://doi.org/10.4103/tcmj.tcmj_255_19
Krans, B. (2019, December 12). What is an Ultrasound?
https://www.healthline.com/health/ultrasound
Kumar R, De Jesus O. Radiation Effects On The Fetus. [Updated 2023 Aug 23]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK564358/
Kurt, S. (2020, August 17). Stages of Moral Development - Lawrence Kohlberg - Educational
Technology. Educational Technology. https://educationaltechnology.net/stages-of-
moral-development-lawrence-kohlberg/
Lacroix, A. E., Gondal, H., Shumway, K. R., & Langaker, M. D. (2023, March 11). Physiology,
Menarche. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK470216/
Lawson, H. J., Wellens-Mensah, J. T., & Attah Nantogma, S. (2019). Evaluation of Sleep
Patterns and Self-Reported Academic Performance among Medical Students at the
University of Ghana School of Medicine and Dentistry. Sleep Disorders,
2019(1278579), 1–8. https://doi.org/10.1155/2019/1278579
Lee, L., Ma, W., Davies, S., & Kammers, M. (2022). Toward Optimal Emotional Care During the
Experience of Miscarriage: An Integrative Review of the Perspectives of Women,
Partners, and Health Care Providers. Journal of Midwifery & Women’s Health, 68(1).
https://doi.org/10.1111/jmwh.13414
Lerma, E. (2023). Urinalysis: Reference Range, Interpretation, Collection and Panels.
EMedicine. https://emedicine.medscape.com/article/2074001-
overview?form=fpf#a2

131
Li, DK., Chen, H., Ferber, J.R. et al. Exposure to Magnetic Field Non-Ionizing Radiation and the
Risk of Miscarriage: A Prospective Cohort Study. Sci Rep 7, 17541 (2017).
https://doi.org/10.1038/s41598-017-16623-8
MacGill, M. (2023, December 18). What do leukocytes in the urine
mean?https://www.medicalnewstoday.com/articles/313751#:~:text=Summary-
,Leukocytes%20in%20the%20urine%20can%20indicate%20an%20infection%20or%2
0inflammation,cases%2C%20may%20require%20intensive%20interventions.
Magnus, M. C., Hockey, R. L., Håberg, S. E., & Mishra, G. D. (2022). Pre-pregnancy lifestyle
characteristics and risk of miscarriage: the Australian Longitudinal Study on Women's
Health. BMC pregnancy and childbirth, 22(1), 169. https://doi.org/10.1186/s12884-
022-04482-9
Mahmoodi, A. N., & Kim, P. Y. (2022, April 9). Ketorolac. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK545172/
Malik K, Dua A. Prostaglandins. [Updated 2022 Nov 21]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK553155/
Marcin, A. (2021, March 18). Working While Pregnant: Restrictions, Long Hours, More.
Healthline. https://www.healthline.com/health/pregnancy/working-while-pregnant-
2#safety
Mayo Clinic. (24 May 2022). Low hemoglobin count Causes. Mayo Clinic.
https://www.mayoclinic.org/symptoms/low-hemoglobin/basics/causes/sym-
20050760#:~:text=A%20low%20hemoglobin%20count%20can%20also%20be%20du
e%20to%20blood
Mcgready, et al. (2024). Obstetrics in the Tropics (24th ed., pp. 1188–1204). Elsevier EBooks.
https://doi.org/10.1016/b978-0-7020-7959-7.00083-x
Mcleod. (2024, January 17). Kohlberg’s Stages Of Moral Development. Simply Psychology.
Retrieved April 26, 2024, from
https://www.simplypsychology.org/kohlberg.html#:~:text=Level%203%20%E2%80%
93%20Postconventional%20Morality&text=Postconventional%20morality%20is%20
when%20people,society%20tells%20them%20to%20do.
Medical University of South Carolina. (2022). Bowel Habits & Aging. MUSC Health. Retrieved
April 27, 2024, from https://muschealth.org/medical-services/geriatrics-and-

132
 aging/healthy-aging/bowel-
habits#:~:text=People%20have%20%22normal%22%20frequency%20of,the%20same
%20time%20of%20day.
Medscape. (2019, September 28). Ketorolac dosing, indications, interactions, adverse effects,
and more. Medscape.com. https://reference.medscape.com/drug/ketorolac-343292
Milani, D. and Jialal, I. (2023, May 1). Urinalysis.
https://www.ncbi.nlm.nih.gov/books/NBK557685/
Miles, K. (2021). Frequent urination during pregnancy | BabyCenter. BabyCenter.
https://www.babycenter.com/pregnancy/your-body/frequent-urination-during-
pregnancy_237
Mollard, E., & Cottrell, C. (2023). Lifestyle and the hypertensive disorders of pregnancy in
nulliparous women in the United States: a secondary data analysis of the nuMom2b.
BMC Pregnancy and Childbirth, 23(1). https://doi.org/10.1186/s12884-023-05522-8
Mytilinaios, D. (2023). Corpus Luteum.
https://www.kenhub.com/en/library/anatomy/corpus-luteum
Naeim, F., Nagesh Rao, P., Song, S. X., & Phan, R. T. (2018, January 1). Chapter 63 -
Granulocytic Disorders (F. Naeim, P. Nagesh Rao, S. X. Song, & R. T. Phan, Eds.).
ScienceDirect; Academic Press.
https://www.sciencedirect.com/science/article/abs/pii/B9780128098431000632
Nall. (2023, April 20). Why Are There Red Blood Cells in My Urine? Healthline. Retrieved April
29, 2024, from https://www.healthline.com/health/rbc-in-urine
Naqvi, S. (04 January 2024). Incomplete Abortion: Signs, Symptoms, Causes, Diagnosis and
Management. Www.carehospitals.com. Retrieved April 24, 2024, from
https://www.carehospitals.com/raipur/blog-detail/obstetrics-and-
gynecology/incomplete-abortion.
National Health Service. (2019). Red blood cell count. NHS.
https://www.nhs.uk/conditions/red-blood-count/
National Health Service. (2020, December 3). Vaginal bleeding. Nhs.uk.
https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/vaginal-
bleeding/
National Institute for Occupational Safety and Health. (2023). Physical Demands (lifting,
standing, bending) - Reproductive Health | NIOSH | CDC. Center for Disease Control

133
 and Prevention. Retrieved April 27, 2024, from
https://www.cdc.gov/niosh/topics/repro/physicaldemands.html
National Library of Medicine. (2022, April 4). Complete Blood Count (CBC): MedlinePlus Lab
Test Information. Medline Plus. https://medlineplus.gov/lab-tests/complete-blood-
count-cbc/
National Library of Medicine. (2022). Lenvatinib. MedlinePlus. Retrieved January 25, 2022,
from https://medlineplus.gov/druginfo/meds/a601077.html
National Nutrition Council (2022, September 22). Misconceptions on Menstrual Period.
https://nnc.gov.ph/regional-offices/mindanao/region-ix-zamboanga-
peninsula/8815-misconceptions-on-menstrual-period
Nawabi, F., Krebs, F., Lorenz, L., Shukri, A., Alayli, A., & Stock, S. (2022). Understanding
Determinants of Pregnant Women’s Knowledge of Lifestyle-Related Risk Factors: A
Cross-Sectional Study. International Journal of Environmental Research and Public
Health, 19(2), 658. https://doi.org/10.3390/ijerph19020658
News-Medical. (2024, February 12). Healthy hydration: The science and importance of
drinking water. https://www.news-medical.net/health/Healthy-Hydration-The-
Science-and-Importance-of-Drinking.aspx
Ng, S. W., Norwitz, G. A., Pavlicev, M., Tilburgs, T., Simón, C., & Norwitz, E. R. (2020).
Endometrial Decidualization: The Primary Driver of Pregnancy Health. International
journal of molecular sciences, 21(11), 4092. https://doi.org/10.3390/ijms21114092
Nguyen, M., & Tadi, P. (2023, July 3). Iron supplementation. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK557376/
Nynas, J., Narang, P., Kolikonda, M. K., & Lippmann, S. (2019, January 29). Depression and
Anxiety Following Early Pregnancy Loss. The Primary Care Companion for CNS
Disorders. https://doi.org/10.4088/pcc.14r01721
Office of Disease Prevention and Health Promotion (2023). Access to health Services - Healthy
People 2030 | Health.gov.https://health.gov/healthypeople/priority-areas/social-
determinants-health/literature-summaries/access-health-services#cit3
Ohwovoriole, T. (2021, June 14). What to know about methergine (Methylergonovine).
Verywell Family. https://www.verywellfamily.com/methergine-uses-precautions-
and-side-effects-5114521

134
Oliver, R., & Pillarisetty, L. S. (2023, January 1). Anatomy, abdomen and pelvis, ovary corpus
luteum. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK539704/#:~:text=The%20corpus%20luteu
m%20is%20a,a%20mature%20ovum%20during%20ovulation.
Omole, A. E., Awosika, A. O., & Patel, P. (2024, January 11). Cefuroxime. StatPearls - NCBI
Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK599503/
Pacheco, A., et.al. (2020, January 24). Hysteroscopic Management of Retained Products of
Conception: A Single Center Observational Study.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7020944/
Prager, S. et al (2023). Septic Abortion; Clinical Presentation and management.
https://www.uptodate.com/contents/septic-abortion-clinical-presentation-and-
management#H1086268377
Prager, S., Dalton, V., Allen, R. (2021). Early Pregnancy Loss. The American College of
Obstetrician and Gynecologists. https://www.acog.org/clinical/clinical-
guidance/practice-bulletin/articles/2021/11/early-pregnancy-loss
Pratt, E., & Gillespie, C. (2023, December 18). Bristol Stool Chart for Healthy Poop. Health.
https://www.health.com/condition/digestive-health/bristol-stool-chart
Psychology. (2021, April 18). What is the Havighurst Developmental Tasks Theory? The
Psychology Notes Headquarters. Retrieved April 24, 2024, from
https://www.psychologynoteshq.com/development-tasks/?expand_article=1
Qu, F., Wu, Y., Zhu, YH. et al. The association between psychological stress and miscarriage:
A systematic review and meta-analysis. Sci Rep 7, 1731 (2017).
https://doi.org/10.1038/s41598-017-01792-3
Quarato, C., et.al. (2023, February 23). A Review on Biological Effects of Ultrasounds: Key
Messages for Clinicians. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10001275/
Ramulondi, M., de Wet, H., & Ntuli, N. R. (2021). Traditional food taboos and practices during
pregnancy, postpartum recovery, and infant care of Zulu women in northern KwaZulu-
Natal. Journal of Ethnobiology and Ethnomedicine, 17(1).
https://doi.org/10.1186/s13002-021-00451-2
Redinger, Ashley, and Hao Nguyen. “Incomplete Abortions.” PubMed, StatPearls Publishing,
2020, www.ncbi.nlm.nih.gov/books/NBK559071/.

135
 Rich. (2020, September 23). Spirituality and Health. familydoctor.org. Retrieved April 27,
2024, from https://familydoctor.org/spirituality-and-health/
Rondilla, N. A., Rocha, I. C. N., Roque, S. J., Lu, R. M., Apolinar, N. L. B., Solaiman-Balt, A. A.,
Abion, T. J., Banatin, P. B., & Javier, C. V. (2021). Folk Medicine in the Philippines: A
Phenomenological Study of Health-Seeking Individuals. International Journal of Medical
Students, 9(1), 25–32. https://doi.org/10.5195/ijms.2021.849
Romm, Aviva. “Incomplete Abortion - an Overview | Sciencedirect Topics.”
Www.sciencedirect.com, 2020, www.sciencedirect.com/topics/medicine-and-
dentistry/incomplete-abortion.
Sakhi, R., Jalalzai, S., Ahmadi, Z., Almaszada, R., Zarghoon, F. N., Mohammadi, R., Ahmad, H.,
Mazhar, S., Faqirzada, M., & Hamidi, M. (2023). Knowledge, beliefs, and practices
related to menstruation among female students in Afghanistan. International Journal
of Women’s Health, Volume 15, 1139–1149. https://doi.org/10.2147/ijwh.s410660
Saleem, M. O., & Hamawy, K. (2022, August 8). Hematuria. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK534213/
Shaker, M. & Smith, A. (September 2022). First Trimester Miscarriage. Elsevier.
https://www.sciencedirect.com/science/article/abs/pii/S0889854522000407?via%3
Dihub
Shayan, N. F., Mohabbati-Kalejahi, N., Alavi, S., & Zahed, M. A. (2022, January 21). Sustainable
Development Goals (SDGs) as a Framework for Corporate Social Responsibility (CSR).
Sustainability. https://doi.org/10.3390/su14031222
Suni, E., & Suni, E. (2024, March 12). Interrupted Sleep: Causes & Helpful Tips. Sleep
Foundation. https://www.sleepfoundation.org/sleep-deprivation/interrupted-sleep
Supermaniam, S., & Thye, W. L. (2019). Intramural fibroid and fertility—to operate or not.
Gynecology and Pelvic Medicine, 2, 31. https://doi.org/10.21037/gpm.2019.11.01
Tabassum, N., & Khurshid, S. U. (2020). Analysis of urine as an indicator of specific body
conditions in pregnant women in rural mountainous region .
https://www.researchgate.net/profile/Nazia-Tabassum-
Sheikh/publication/374230444_Analysis_of_urine_as_an_indicator_of_specific_bod
y_conditions_in_pregnant_women_in_rural_mountainous_region/links/6514c88d2c
6cfe2cc212b381/Analysis-of-urine-as-an-indicator-of-specific-body-conditions-in-
pregnant-women-in-rural-mountainous-region.pdf

136
Terblanche, E., Jackson, J., Wetherden, J., Russell, E., & Lewis, R. (2022, April). Dietetic-led
nutrition interventions provided to patients recovering from critical illness from
COVID-19 in a large London teaching Hospital from March 2020 to April 2021. Clinical
Nutrition ESPEN, 48, 486–487. https://doi.org/10.1016/j.clnesp.2022.02.030
Togioka, B. and Tonismae, T. (2023, July 29). Uterine Rupture.
https://www.ncbi.nlm.nih.gov/books/NBK559209/
Toboła-Wróbel, K., Pietryga, M., Dydowicz, P., Napierała, M., Brązert, J., & Florek, E. (2020).
Association of Oxidative Stress on Pregnancy. Oxidative medicine and cellular
longevity, 2020, 6398520. https://doi.org/10.1155/2020/6398520
Tsamantioti ES, Hashmi MF. Teratogenic Medications. [Updated 2024 Jan 10]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK553086/
University of Illinois. (2019, August 21). Mefenamic Acid, Oral capsule. Healthline.
https://www.healthline.com/health/mefenamic-acid-oral-capsule
University of Illinois. (2023, February 19). Cefuroxime, oral tablet. Healthline.
https://www.healthline.com/health/cefuroxime-oral-tablet
Vaillant, M. F., Agier, L., Martineau, C., Philipponneau, M., Romand, D., Masdoua, V., Behar,
M., Nesseler, C., Achamrah, N., Laubé, V., Lambert, K., Dusquesnoy, M. N., Albaladejo,
L., Lathière, T., Bosson, J. L., & Fontaine, E. (2022, January). Food intake and weight
loss of surviving inpatients in the course of COVID-19 infection: A longitudinal study of
the multicenter NutriCoviD30 cohort. Nutrition, 93, 111433.
https://doi.org/10.1016/j.nut.2021.111433
Wach, J., et al. (2021). Mean Platelet Volume/Platelet Count Ratio and Risk of Progression in
Glioblastoma. Frontiers in Oncology, 11(2234-943X).
https://doi.org/10.3389/fonc.2021.695316
Wall, L. L., & Yemane, A. (2022). Infectious Complications of Abortion. Open forum infectious
diseases, 9(11), ofac553. https://doi.org/10.1093/ofid/ofac553
Wang, Yadi, et al. "Epidemiological Trend of Maternal Abortion and Miscarriage, 1990–2019:
Results from the Global Burden of Disease Study 2019." Available at SSRN 4264303.
World Health Organization: WHO. (2023, September 5). Family planning/contraception
methods. https://www.who.int/news-room/fact-sheets/detail/family-planning-
contraception

137
Yang, Z. et al. (October 2020). Prevention of recurrent miscarriage in women with
antiphospholipid syndrome: A systematic review and network meta-analysis.
SageJournals. https://journals.sagepub.com/doi/10.1177/0961203320967097
Ye, X., Baker, P., Tong, C. (December 2023). The Updated Understanding of Advanced
Maternal Age. ScienceDirect.
https://www.sciencedirect.com/science/article/pii/S2667325823003746

138