RESPIRATORY

Asthma
Asthma is a chronic inflammation of the bronchial tubes (airways) that causes
swelling and narrowing (constriction) of the airways. The result is difficulty breathing.
The bronchial narrowing is usually either totally or at least partially reversible with
treatments.Childhoos asthma is common and often related to allergens but frequently
abates as the child grows.Adult onset asthma is often not recognized as such for
some time and tends to be more permanent.because the air-ways are
overresponsive,an agent that would not cause a health problem in other people can
provoke an asthmatic attack in susceptible person.

COMMON SIGNS AND SYMPTOMS OF ASTHMA INCLUDE:

 Coughing. Coughing from asthma often is worse at night or early in the morning,
making it hard to sleep.
 Wheezing. Wheezing is a whistling or squeaky sound that occurs when you breathe.
 Chest tightness. This may feel like something is squeezing or sitting on your chest.
 Shortness of breath. Some people who have asthma say they can't catch their breath
or they feel out of breath. You may feel like you can't get air out of your lungs.
 Anxiety (asthma is a frightening experience)
 In severe cases the pulse will be >100,respiration rate >25 and peak expiratory flow
rate <50% of normal

 Not all people who have asthma have these symptoms. Likewise, having these
symptoms doesn't always mean that you have asthma. The best way to diagnose
asthma for certain is to use a lung function test, a medical history (including type and
frequency of symptoms), and a physical exam.

 The types of asthma symptoms you have, how often they occur, and how severe they
are may vary over time. Sometimes your symptoms may just annoy you. Other times,
they may be troublesome enough to limit your daily routine.

 Severe symptoms can be fatal. It's important to treat symptoms when you first notice
them so they don't become severe.

 With proper treatment, most people who have asthma can expect to have few, if any,
symptoms either during the day or at night.
TREATMENT:

There are 2 major groups of drugs to treat asthma:

1. Bronchodilator drugs - to relieve bronchospasm and improve symptoms.

2. Anti inflammatory drugs - to treat the airway inflammation and bronchial
hyperresponsiveness, the underlying cause of asthma, i.e. to prevent attacks.

1. Bronchodilators
These drugs treat symptoms of asthma. They should be used as required rather than
regularly. When asthma is severe and difficult to control, bronchodilators may be
taken on regular basis. There are 3 main groups of bronchodilators:
a. Beta2 agonists
b. Anticholinergics
c. Methylxanthines

a. Beta2 agonists

These drugs are the most effective bronchodilators available. They are safe drugs
with few side effects when taken by inhalation. The therapeutic effect is felt within a
few minutes of inhalation. The main side effects are tremors and tachycardia. Oral
slow release preparations and inhaled long acting beta2 agonists such as
Salmeterol /bambuterol are useful for nocturnal asthma.
Examples:

Inhaled beta2 agonist:

salbutamol (Ventolin, Respolin)

terbutaline (Bricanyl)
 
fenoterol (Berotec) 
salmeterol (Serevent) - long acting

Oral long acting beta2 agonist:

salbutamol (Volmax)
  terbutaline (Bricanyl durules)
bambuterol (Bambec)

Oral short acting beta2 agonist:

salbutamol
 
terbutaline etc.

b. Anticholinergic drugs
 Inhaled anticholinergics have lower onset but longer duration of action. They have
very few side effects.
Examples: Ipratropium bromide (Atrovent)

c.Methylxanthines 

These drugs are available in oral and parenteral forms. Their usefulness is limited by
very variable metabolism and a narrow therapeutic window. Sustained release
preparations may be useful in nocturnal asthma.9 
Examples: Nuelin SR, Theodur, Euphylline

Note: Inhaled beta2 agonists are the bronchodilator of choice. As far as possible,
avoid using oral beta2 agonists or xanthines as first line bronchodilator drugs.

2.  Anti-Inflammatory Drug

As asthma is a chronic inflammatory condition, anti-inflammatory drugs should be a

logical treatment for most patients except for those with mildest asthma. Reducing the
inflammatory will decrease bronchial hyperresponsiveness. The types of anti-
inflammatory drugs include:

i. Corticosteroids

Steroids are the main prophylactic drugs in adult asthmatics. They should be taken by
inhalation and the dosage should be kept to a minimum to reduce side effects
(usually local side effects).10 Oral steroids maybe required for severe chronic asthma. 
Examples: Beclomethasone dipropionate (Becotide, Becloforte, Beclomet, Aldecin,
Respocort) Budesonide (Pulmicort)

ii. Sodium cromoglycate (Intal)

This drug is very safe with no significant side effects. It is given by inhalation (power
Spinhaler or metered dose inhaler). It is of greatest benefit in young, atopic patients.

Other treatments 
Anti-histamines including ketotifen have been proven to be of limited efficacy in many clinical
trials in asthma.Hyposensitisation is of limited value in the management of asthma.

Drug Delivery

The inhaled route is preferred for beta2 agonists and steroids as it produces the same
benefit with fewer side-effects as compared to the oral route. The pressurised metered dose
inhaler (MDI) is suitable for most patients as long as the inhalation technique is correct.

For patients with poor coordination, alternative methods for durg inhalation include: 
spacer devices, dry powder devices and breath-actuated pressurised MDI

Although oral treatment is convenient for most patients, the dose required is higher and
therefore side effects are more common.
 NURSING RESPONSIBILITIES
 Sat upright if possible
 Give high concentration oxygen(40-60%)
 Reassured and encourage to try and breath more deaply and steadily
 Assessed carefullt for danger signs
 Treated in accordance with flows charts
 Not left alone until situation is resolved

Complications and sequelae of Asthma from the Diseases Database include:

 Cardiac arrest
 Pneumothorax- Pneumothorax is a condition where air leaks out of the lungs.
 Pectus carinatum
 Short stature
 Eosinophilia
 Respiratory failure
 Pulsus paradoxus
 Bronchospasm
 Chest hyperinflation
 Chest expansion poor
 Cough

MANAGEMENT
Management Of Chronic Asthma
Aims of management
The aims of management are:

        i.     to recognise asthma

        ii.    to abolish symptoms
        iii.   to restore normal or best possible long term airway function
        iv.   to reduce morbidity and prevent mortality

Approach to management
In order to achieve those aims the approach to management should include:

        i.    Education of patient and family

        ii.   Avoidance of precipitating factors
        iii.  Use of the lowest effective dose of convenient medications minimising short
and long
              term side effects.
        iv.  Assessment of severity and response to treatment.
Education of patient and family
This is an important but often neglected aspect in the management of asthma. It is
essential in ensuring the patient’s cooperation and compliance with therapy. As far as
possible patients and their families should be encouraged and trained to actively
participate in the management of their own asthma. Patient education should include
the following information:

       i.        Nature of asthma

       ii.       Preventive measures/avoidance of triggers
       iii.      Drugs used and their side-effects
       iv.      Proper use of inhaled drugs
       v.       Proper use of peak flow meter
       vi.      Knowledge of the difference between relieving and preventive medications

       vii.     Recognition of features of worsening asthma (increase in bronchodilator

                requirement, development of nocturnal symptoms, reducing peak flow
rates).
       viii.    Self management plan for selected, motivated patients or parents.
(Appendix 1)
       ix.      The danger of non prescribed self medication including certain traditional
                 medicines.

Avoidance of precipitating factors

The following factors may precipitate asthmatic attacks:

    i.    Beta blockers - contraindicated in all asthmatics

    ii.   Aspirin and nonsteroidal anti-inflammatory drugs - if known to precipitate
asthma, these
          drugs should be avoided.
    iii.   Allergens, e.g. house dust mites, domestic pets, pollen should be avoided
whenever
           possible.
    iv.   Occupation - should be considered as a possible precipitating factor.
    v.    Smoking - active or passive.
    vi.   Day to day triggers - such as exercise and cold air. It is preferable to adjust
treatment
           if avoidance imposes inappropriate restrictions on lifestyle.
    vii.   Atmospheric pollution.
    viii.  Food - if known to trigger asthma, should be avoided.

Health education
 Teaching the patient and family to recognize the early warnings of an asthmatic attack

 Monitor peak expiratory flow rate at regular intervals and to be aware of any trend such
as a gradual reduction in PEFR which may herald an acute episode
 Teach the correct to use of medication.

 Tell the patient avoid to take smoking.

NEUROLOGICAL
Brain tumor
A brain tumor (or brain tumour) is an intracranial solid neoplasm, a tumor (defined as
an abnormal growth of cells) within the brain or the central spinal canal.

Brain tumors include all tumors inside the cranium or in the central spinal canal. They are
created by an abnormal and uncontrolled cell division, normally either in the brain itself
(neurons,glial cells (astrocytes,oligodendrocytes, ependymal cells, myelin-
producing Schwann cells), lymphatic tissue, blood vessels), in the cranial nerves, in the brain
envelopes (meninges),skull, pituitary and pineal gland, or spread from cancers primarily
located in other organs (metastatic tumors).

SIGNS AND SYMPTOMS.

(1) A brain tumor is usually characterized by a progressive course of symptoms over a period
of time.
(2) Symptoms depend primarily on the location of the mass within the
(3) Symptoms related to increased intracranial pressure will occur.
(a) Decrease in level of consciousness. Confusion.
(b) Headache. Lethargy. Vomiting.
(c) Papilledema--edema of optic nerve.
(d) Alterations in mentation. Aphasia.
(e) Hemiparesis.
(f) Visual field defects.
(g) Sensory defects (smell, hearing). Seizures.

TREATMENT:
Treatment can involve surgery, radiation therapy, and chemotherapy. Brain tumors are best
treated by a team involving a neurosurgeon, radiation oncologist, oncologist, or neuro-
oncologist, and other health care providers, such as neurologists and social workers.
Early treatment often improves the chance of a good outcome. Treatment, however, depends
on the size and type of tumor and the general health of the patient. The goals of treatment
may be to cure the tumor, relieve symptoms, and improve brain function or the person's
comfort.

Surgery is often necessary for most primary brain tumors. Some tumors may be completely
removed. Those that are deep inside the brain or that enter brain tissue may be debulked
instead of entirely removed. Debulking is a procedure to reduce the tumor's size.

Tumors can be difficult to remove completely by surgery alone, because the tumor invades
surrounding brain tissue much like roots from a plant spread through soil. When the tumor
cannot be removed, surgery may still help reduce pressure and relieve symptoms.

Radiation therapy is used for certain tumors.

Chemotherapy may be used along with surgery or radiation treatment.

Other medications used to treat primary brain tumors in children may include:

 Corticosteroids, such as dexamethasone to reduce brain swelling

 Osmotic diuretics, such as urea or mannitol to reduce brain swelling and pressure

 Anticonvulsants, such as evetiracetam (Keppra) to reduce seizures

 Pain medications
 Antacids or histamine blockers to control stress ulcers

Comfort measures, safety measures, physical therapy, and occupational therapy may be
needed to improve quality of life. The patient may need counseling, support groups, and
similar measures to help cope with the disorder.

Patients may also consider enrolling in a clinical trial after talking with their treatment team.

Legal advice may be helpful in creating advanced directives such as a power of attorney.

NURSING RESPONSIBILITIES
(1) Meticulous nursing management and care aimed at prevention of postoperative
complications are imperative for the patient's survival.

(2) Accurately monitor and record all vital signs and neurological signs.
(a) Postoperative cerebral edema peaks between 48 and 60 hours following surgery.
(b) Patient may be lucid during first 24 hours, then experience a decrease in level of
consciousness during this time.
(3) Administer artificial tears (eye drops) as ordered, to prevent corneal ulceration in the
comatose patient.

(4) Maintain skin integrity.

(5) Bone flap may not have been replaced over surgical site; turning patient to the affected
side, if the flap has been removed, can cause irreversible damage in the first 72 hours.
(6) Maintain head of bed at 30ºelevation.

(7)  Perform passive range of motion exercises to all extremities every 2-4 hours.

(8) Maintain body temperature.

(a)  Increases of body temperature in the neurosurgical patient may be due to cerebral
edema around the hypothalamus.
(b) Monitor rectal temperature frequently.
(c) Place patient on hypothermia blanket, as ordered.
(9) Institute seizure precautions at patient's bedside. (Tongue blade, airway.)

(10) Maintain accurate record of intake and output.

(11) Prevent pulmonary complications associated with bedrest.

(a) Cough and deep breath every 2 hours.
(b) Perform gentle chest percussion, with the patient in the lateral decubitus position, if
tolerated.

(12) Continuously talk to the patient while providing care, reorienting him to person, place,
and time.

Complications

 Brain herniation (often fatal)

 Uncal herniation

 Foramen magnum herniation

 Loss of ability to interact or function

 Permanent, worsening, and severe loss of brain function

 Return of tumor growth

 Side effects of medications, including chemotherapy

 Side effects of radiation treatments

MANAGEMENT
(1) Instruct patient and family about the necessity and importance of diagnostic tests to
determine the exact location of the tumor.
(2) Monitor and record vital signs and neurological status accurately q2-4h, or as ordered.
Report changes to professional nurse immediately.
 (3) Institute measures to prevent inadvertent increases in intracranial pressure.
(a) Elevate head of bed 30º.
(b) Stool softeners to prevent straining at stool (which increases intracranial pressure).
(4) Institute seizure precautions at patient's bedside. (Tongue blade airway.)
(5) Supportive nursing care is given depending upon the patient's symptoms and ability to
perform activities of daily living.
(6) Administer all doses of steroids and antiepileptic agents on time.
(a) Withholding steroids can result in adrenal crisis.
(b) Withholding of antiepileptic agents frequently precipitates seizure.

(7) Surgery (craniotomy) is performed to remove neoplasm and alleviate symptoms.

Health education
Emotional Support for Patients and Caregivers
Support for patients and their families is a critical component of treatment and management.
Helpful measures include:

 Any physical impairment that could benefit from home equipment or physical therapy
should be identified and treated.
 Patients should discuss emotional as well as physical issues with their doctors.
Depression, for instance, can be medically treated. Caregivers should also seek help for the
inevitable stress, depression, and tension arising from their difficult role.
 Relaxation techniques, meditation, and spiritual resources may be helpful. Support
groups are beneficial, but mental health professionals recommend separate groups for
patients and their families.
HAEMOTOLOGY
Anemia
Anemia is a medical condition in which the red blood cell count orhemoglobin is less than
normal. The normal level of hemoglobin is generally different in males and females. For
men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and
in women as hemoglobin of less than 12.0 gram/100ml. These definitions may vary
slightly depending on the source and the laboratory reference used.

Symptoms:

Symptoms appear in a number of different forms and are dependent on the severity of the
Anemia, the speed at which the Anemia develops, and any other diseases which may
already be present (such as heart or lung disease).

Some of the more common symptoms include:

 Headache
 Lightheadedness
 Paleness
 Mouth sores
 Chest pain
 Shortness of breath
 Brittle nails
 Decreased/irregular heartbeat
 Weakness and general fatigue

Some types of anemia may have other symptoms, such as:

 Constipation

 Problems thinking

 Tingling
Treatment

Medication:

All drugs can be grouped together by how they work (i.e., their specific mode of action).

Always consult your healthcare provider if you have any questions or concerns about
the medication you have been prescribed.

Drug Type Effect

Erythropoietin A hormone normally produced by the kidney, which causes the bone marrow
to produce red blood cells.
Folic Acid A vitamin required by the bone marrow to produce effective red blood cells.
Iron A vitamin, which is a vital component of the hemoglobin molecule that allows
it to carry oxygen in the blood.
Vitamin B12 A vitamin required by the bone marrow to produce effective red blood cells.
Vitamin C A vitamin required by the bone marrow to produce effective red blood cells

Other Treatment:

Injections - In severe cases, special injections of Iron or Vitamin B12 may be required.

Treatment should be directed at the cause of the anemia, and may include:

 Blood transfusions

 Corticosteroids or other medicines that suppress the immune system

 Erythropoietin, a medicine that helps your bone marrow make more blood cells
 Supplements of iron, vitamin B12, folic acid, or other vitamins and minerals

NURSING RESPONSIBILITIES


Their healthcare provider on a regular basis, to determine response to therapy,
should monitor individuals diagnosed with Anemia. Often, the Anemia has taken
years to develop, so response will not be immediate.
  It is very important that underlying conditions be treated as well. Untreated Anemia
can result in complications that may vary from general fatigue and weakness to
serious heart problems.
 Groups of individuals at high risk of developing Anemia, such as those who are
pregnant and women with heavy menstruation, should ensure they are meeting their
body’s demands for iron and nutrients to avoid developing this condition.
 Food sources containing iron include certain meats, green leafy vegetables, beans,
and almonds. In addition to supplements, many vitamins are found in fruits,
vegetables, and protein sources.
 As a special note, individuals should make sure to keep iron products out of the reach
of children, as iron is the most common cause of poisoning in children.

COMPLICATION
As mentioned earlier, hemoglobin has the important role of delivering oxygen to all parts
of the body for consumption and carries back carbon dioxide back to the lung to exhale it
out of the body. If hemoglobin level is too low, this process may be impaired, resulting in
body having low oxygen level (hypoxia).

MANAGEMENT

Aim of treatment
The aim of treatment should be to restore haemoglobin levels and red cell indices to normal,
and replenish iron stores. If this cannot be achieved, consideration should be given to further
evaluation.

Iron therapy
Treatment of an underlying cause should prevent further iron loss but all patients should
have iron supplementation both to correct anaemia and replenish body stores (B) This is
achieved most .simply and cheaply with ferrous sulphate 200 mg twice daily.Lower doses
may be as effective and better tolerated and could be considered in patients not tolerating
traditional doses. Other iron compounds (e.g. ferrous fumarate, ferrous gluconate) or
formulations (iron suspensions) may also be tolerated better then ferrous sulphate. Ascorbic
acid (250–500 mg twice daily with the iron preparation) may enhance iron absorption We
recommend .that oral iron is continued until three months after the iron deficiency has been
corrected so that stores are replenished

Parenteral iron may be used when there is intolerance or noncompliance with oral
preparations. Intravenous iron sucrose, when given according to the manufacturers’
instructions, is reasonably well tolerated (35% of patients have mild side effects) with a low
incidence of serious adverse reactions (0.03–0.04%)

Bolus intravenous dosing of iron sucrose (200mg iron) over 10 minutes is licensed and more
convenient than a two-hour infusion. Intravenous iron dextran can replenish iron and
haemoglobin levels in a single infusion. but serious reactions can occur (0.6–0.7%) and there
have been fatalities associated with infusion (31 reported between 1976–1996) However, it
can be .given via the intramuscular route when venous access is problematic. Blood
transfusions should be reserved for patients with, or at risk of, cardiovascular instability due
to their degree of anaemia (C), particularly if they are due to have endoscopic investigations
before a response from iron treatment is expected . Transfusions should aim to restore
haemoglobin to a safe level, but not necessarily normal values. Iron treatment should follow
transfusion to replenish stores.

Follow-up
Once normal, the haemoglobin concentration and red cell indices should
be monitored at intervals. We suggest three monthly for one year then again after a further
year. Additional oral iron should be given if the haemoglobin or red cell indices fall below
normal (ferritin levels can be reserved for cases where there is doubt). Further investigation
is only necessary if the haemoglobin and red cell indices cannot be maintained in this way. It
is reassuring to know that iron deficiency does not return in most patients in whom a cause
for IDA is not found after OGD, small bowel biopsy and barium enema
.

Health education
Some nursing cares to consider:

1. Measure temperature of bath water with thermometer because anemia may cause
poor circulation.
2. Provide blankets and warm clothing to increase comfort and aid circulation.
3. Notify physician if excessive vomiting, coughing or straining at stools occurs so that
medication can be prescribed to alleviate symptom.
4. Avoid aspirin-containing products to prevent bleeding.
5. Avoid forceful blowing.
6. Avoid contact on gingival when brushing and flossing teeth.
7. Avoid situations in which trauma may occur, such as shaving with straight-edge razor,
ambulating after taking medication that may cause orthostasis, or using sharp
utensils.
8. Avoid purseful sexual intercourse and use adequate lubrication.
9. Avoid rectal thermometers, suppositories, and enemas.
10. Avoid heating pads or hot water bottles.
11. Iron salts are gastric irritants and should always be taken following meals.
12. Iron preparation taken on empty stomach cause dyspepsia, abdominal
discomfort, and diarrhea
 13. Liquid iron preparations should be well diluted and taken through a straw
(undiluted liquid iron stains teeth).
14. Use of stool softeners or laxative to avoid PRN to avoid straining.
15. Ascorbic acid (Vitamin C) promotes iron absorption, thus iron preparations
should be taken with orange juice.
16. Bowel movements will be black from excess iron excretion.
16. Iron supplements usually given for at least 6 months to restore body stores.
17. Keep skin clean and bedclothes dry.
18. Encourage diet high in protein, vitamins, and minerals.
19. Encourage cool, bland foods; flavored ices and ice cream are well tolerated.
20. Monitor Hb/Hct and assess whether other factors (e.g., nutritional deficiencies,
fluid and electrolyte disorders, depression, etc.) are contributing to symptomatology.
21. Assess activity schedule and suggest daily activities that allow for rest periods.
22. Transfuse whole blood and packed red blood cells as ordered by physician.

OBSTETRICS
Abortion
Abortion is defined as the cessation og pregnancy before the 24th week of pregnancy. This
occur spontaneous or may be induced for therapeutic reasons. Spontaneous abortion

Signs and symptoms of Abortion

Abnormal uterine bleeding may be occur due to various symptoms such as:

1. Pink discharge for several days

2. Cramps
3. Increased vaginal bleeding

Symptoms
Symptoms of a threatened miscarriage include:
 Abdominal cramps with or without vaginal bleeding
 Vaginal bleeding during the first 20 weeks of pregnancy (last menstrual
period was less than 20 weeks ago)
 Note: During an actual miscarriage, low back pain or abdominal pain (dull to
sharp, constant to intermittent) typically occurs, and tissue or clot-like material
may pass from the vagina.

TREATMENT:
Currently exist 3 methods of medication abortion, used for pregnancy termination with
gestational ages up to 22 weeks. All three methods include medicine named Misoprostol
(Cytotec):

1) Misoprostol alone

2) Mifepristone and Misoprostol

3) Methotrexate and Misoprostol

NURSING RESPONSIBILITIES

 Resume normal activity gradually

 Intermittent menstrual-like discharge is to be expected for the next 2 weeks but it
should not be bright res in colour, sanitary pads should be used. She should abtain
from sexual intercourse while the discharge is present
 Some cramping is to be expected but severe diacomfort or fever should be reported
immediately to the doctor
 A menstrual period is to be expected 4-5 weeks after abortion
 Information concercing a follow-up appoiment and how to obtain support and
counselling

Complications

 Anemia
 Infection
 Miscarriage
 Moderate-to-heavy blood loss

MANAGEMENT
 Physicians should recognize the psychologic issues that affect a patient who

experiences a spontaneous abortion. Although the literature lacks good evidence to

support psychologic counseling for women after a spontaneous abortion, it is thought
that patients will have better outcomes if these issues are addressed. The patient and
her partner may be dealing with feelings of guilt, and they typically will go through a
grieving process and have symptoms of anxiety and depression.

 Women who have a spontaneous abortion frequently struggle with guilt over what
they may have done to cause or prevent the loss. Physicians should address the
issue of guilt with their patients and allay any concerns that they may have “caused”
the spontaneous abortion.
 Physicians should encourage the patient and her partner to allow themselves to
grieve. The woman and her partner may grieve differently; specifically, they may go
through the stages of grief in different orders or at different rates. They also should be
aware that friends and family members may not recognize the magnitude of their
loss. Friends and family members may ignore the subject of miscarriage, or they may
make well-meaning comments that try to minimize the event. Connecting the couple
with a counselor who has experience in helping couples cope with pregnancy loss
may be beneficial. Many hospitals offer programs that provide follow-up care and
literature to the woman and her partner. Two national organizations, the
Compassionate Friends (969–0010) and SHARE Pregnancy and Infant Loss Support,
Inc. (
 Most studies have found that a significant percentage of women experience
psychiatric symptoms in the weeks to months after spontaneous abortion. Women
who were found to be especially prone to these symptoms are childless and have lost
a wanted pregnancy. One study showed that women who are managed expectantly
have better overall mental health 12 weeks after a spontaneous abortion.
 Physicians should realize the importance of providing care that is sensitive to the
medical and psychologic aspects of a couple who experiences spontaneous abortion.
Many patients report dissatisfaction with the medical care they receive.The Advanced
Life Support in Obstetrics5  provider course offered by the American Academy of
Family Physicians summarizes issues to discuss with women and their partners after
a spontaneous abortion
Health education
 Tell the patient to expect vaginal bleeding or spotting and to report excessive bright-
red blood immediately or any bleeding that lasts longer than 10 days.
 Advise the patient to watch for signs of infection, such as a temperature higher than
100.5° F (38° C) and foul smelling vaginal discharge.
 Encourage the gradual increase of daily activities to include whatever tasks the
patient feels comfortable doing, as long as these activities don't increase vaginal
bleeding or cause fatigue. Most patients return to work within 1 to 4 weeks.
 Urge 1 to 2 weeks abstinence from intercourse, and encourage use of a
contraceptive when intercourse is resumed.
 Instruct the patient to avoid using tampons for 1 to 2 weeks.
 Be sure to inform the patient who desires an elective abortion of all the available
alternatives. She needs to know what the procedure involves, what the risks are, and
what to expect during and after the procedure, both emotionally and physically. Be
sure to ascertain whether the patient is comfortable with her decision to have an
elective abortion. Encourage her to verbalize her thoughts both when the procedure
is performed and at a follow-up visit, usually 2 weeks later. If you identify an
inappropriate coping response, refer the patient for professional counseling.
 To help prevent elective abortion, medical and nursing personnel need to make
contraceptive information available. An educated population motivated to utilize
contraception would have little need for elective abortion.
 Tell the patient to see her doctor in 2 to 4 weeks for a follow-up examination.

To minimize the risk of future spontaneous abortions, emphasize to the pregnant

woman the importance of good nutrition and the need to avoid alcohol, cigarettes,
and drugs. Most clinicians recommend that the couple wait two or three normal
menstrual cycles after a spontaneous abortion has occurred before attempting
conception. If the patient has a history of spontaneous abortions, suggest that she
and her partner have thorough examinations. For the woman, this includes
premenstrual endometrial biopsy, a hormone assessment (estrogen, progesterone,
and thyroid, follicle-stimulating, and luteinizing hormones), and
hysterosalpingography and laparoscopy to detect anatomic abnormalities. Genetic
counseling may also be indicated.