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Nursing Health History
I.I Biographic Data
Name of Patient: Clara

@ 12:47:18 am
Attending Physician: Dra. Paῆares



Date of Birth:

Admitting Diagnosis: G4P3 (3013)

Roman Catholic



Civil Status:


Incomplete Abortion
Vital Signs upon Admission:


Temp. -36.8 ̊C
No. of Children: 3


19 cpm

Obstetrical Score: G4P3

90 bpm

Occupation: Relief Operation Officer


155 cm

Educational Attainment: College


52 kg

Date & Time of Admission: May
18, 2014

Pain Score: 7/10, with facial grimace
apparently noted

I. Patient noted a sudden gush of blood flowing accompanied with small meat-like tissues.II Chief Complaint:Vaginal Bleeding I. consuming 2 pads on the first day then 1 pad for the succeeding days. Nutrition and Metabolism .VII Social Data Patient has her own circle of friends. b. non-smoker. 2014. Venoclysis with PLR 1 liter was started and 500 cc was run as fastdrip. No serious hospitalization was stated aside from her previous pregnancies wherein she delivered her children in the hospital via spontaneous vaginal delivery.III History of Present Illness 6 hours prior to admission. patient was talking with her friends near their backyard when she felt a sudden onset of hypogastric pain. aside from that. She was then scheduled for completion curettage in the morning. II. She felt dizzyand was hyperventilating hence seek consult at Sugod Hospital. I.IV Past History Patient claimed to be fully immunized. she will always feel stressed out and weak. She is an occasional alcoholic drinker. Her last recalled menstruation was in April 2014. Health Perception and Health Management Patient believe that as long as she feels well and does not easily get ill. But because of her job.VI Menstrual and Obstetric History Patient claimed to have an irregular menstrual cycle lasting for 3 days. At the end of the day. patient stated that she was lacking sleep due to her job assignment which would only take mostly for 2 hours with small naps during the day. Patient completed prenatal check ups during that time and did not experience any problems. Patterns of Functioning/Gordon’s Functional Health Pattern a. She often self-medicate for simple coughs. Her youngest child is aged 3 y. her social life was limited and the only interaction she was having was purely professional and work-related. she was transported to Chong Hua Hospital for a self-directed admission. Patient is gravida 4 with parity of 3 – all delivered via NSD and were in a healthy status. Her grandparents died of old age. colds. I.I. Upon stabilization of status. crampy in nature. I.spinal was done and completed on May 19. she was not aware that she was pregnant. There is no history for abortion during her last pregnancies.V Family History of Illness Patient’s mother was a known hypertensive. o. & fever. she’s healthy. “Walako’y time karon i-mind akong health like using vitamins kay busy kosaakoang work mangud. During the past months. radiating to the lower back. Tranexamic Acid 500 mg IVTT was also administered.” as claimed.Completion curettage under regional anesthesia. Patient is taking Kremil – S once a day for her gastric ulcer (as claimed) as maintenance – which is a self prescribed medication.According to the patient. no other heredo-familial disease from both side of her parents is claimed. She travels daily from one place to another and is working on papers and distribution of relief goods.

Patient eat three times a day. Mouth and Throat) Head: Hair: Face:  Patient looked stressed  With dirty feet caused by blood  With smooth. Cognition and Perception Patient is able to understand instructions and is with intact sensory sensation at all extremities. Claimed to have a good rapport with other people. Review of Systems and Physical Examination General Appearance Integumentary HEENT (Head. Elimination Patient voids comfortably and without any problem. i. f. j. Sleep and Rest Patient stated that she was lacking sleep due to her job assignment which would only take mostly for 2 hours with small naps during the day. Values and belief Patient is a Roman Catholic. every morning. III. h. Coping and stress tolerance Able to cope any difficulties encountered in life with her family as support system. Sexuality and Reproduction Is satisfied with her current state of sexual pattern. e. g. k. fair skin complexion  Pale and cool to touch  Normocephalic. Was feeling down because of the miscarriage that happened and her inability to noticed the pregnancy. Ears. c. she cannot go to church during Sunday’s anymore. Nose. She drinks approximately 1 liter of liquids a day. Self-Perception and Self-Concept Patient has a positive attitude/view towards herself and life. Activity and Exercise Patient considers her travelling routine and daily living activities as exercise. She defecates once a day. but due to her job lately. Roles and Relationships Patient is a good wife and a mother of three. symmetrical  Hair is evenly distributed. She does not drink softdrinks and eat junk foods. black in color. no lice . d. Eyes. but not much.

PERRLA (Pupils Round and Reactive to Light and Accommodation). expression is appropriate to feelings and mood  Brownish in color. no involuntary movements noted. Symmetrical. with pale nasal mucusa. without nipple discharges  with round abdomen. no drainage noted Mouth:  with nares patent. soft. no nasal discharges noted Throat:  with pale dry lips and tongue. not Eyes: Ears: Nose: Neck Respiratory Cardiovascular Chest Gastrointestinal . symmetrical in shape. with complete set of teeth  no swelling of tonsils noted  no tracheal deviation noted  Respiratory rate within normal limits  Respiratory movements symmetrical and unlabored  Breath sounds clear without adventitious sounds  Percussion tones resonant and palpable  with cold extremities  with varicosities at both legs  with 3-4 seconds capillary refill  with +2 pulse amplitude (brachial and radial)  with weak pulse @ lower extremities  with slightly symmetrical breast. non-protruding. with 20/20 vision as claimed. with pale palpebral conjunctiva  able to hear. both are aligned with the outer cantus of the eyes.

Laboratory/Diagnostic Examination Results COMPLETE BLOOD COUNT 5/19/14 Blood Count RESULT REFERENCES White Blood Cells 15. have not under gone for pap smear & mammogram  does not use birth control measures  Awake.8 – 10. alert and oriented  With memory intact and able to provide adequate history  Attitude: Cooperative  Mood: Appropriate to situation Bowel Elimination Musculoskeletal Sexuality/Reproductive Pattern Neurolosensory/Cognitive/Perception IV.8 UNIT 10^3/µL . hernia or rectal mass noted  in a full diet orally  claimed to loss weight for the last 6 months since her new job for about 6 kg  with scarce vaginal hair  no lesions  with minimal vaginal discharges (serosanguineous blood) in diaper  able to void normally with no discomfort noted  with regular BM. usually in the morning  ambulatory  with full and equal strength of both upper and lower extremities  with sensation intact  irregular menstrual cycle  menarche at the age of 13  does not perform breast self-exams.distended and non-tender Genitourinary  with positive bowel sounds  no hemorrhoids.88 ↑ 4.

2 – 5.2 Basophils(%) Absolute Differential Count Eosinophils(#) Basophils(#) PROTHROMBIN TIME Prothrombin Time 5/19/14 Patient Activity INR Control Control Activity BLEEDING TIME & CLOTTING TIME B T Adult (Simplate) C T (Lee and White) BLOOD TYPING (A.0 – 1. B. mins.0 – 0.5 33.6 ↑ 40 – 74 % 19.0 % Eosinophils(%) 0. & 50 secs.0 – 14.0 – 47.1 0.01 0. RESULT .3 27.0 ↓ 81 – 99 fL MCH 27.Red Blood Cells 3.9 – 5.8 0.400 MCV 79.2 87 1.1 fL 77.6 ↓ 10^3/µL Monocyte(%) 0.0 Neutrophil(#) 3.0 % MPV Relative Differential Count Neutrophil(%) Lymphocyte(%) 2.7 0.2 – 11.11 0.9 – 8.09 13.2 Lymphocytes(#) 0.16 – 1.42 0.6 ↓ 12.52 ↓ 4.0 – 37.0 g/dL RDW 12.5 % 12. & 10 secs.0 19 – 48 % 3.0 REFERENCES >70% <=1.0 % Platelet Blood Indices 10^6/µL 225 130 .0 – 31.2 9.0 – 16.00 Monocyte(#) 0.0 – 0.4 100.3 – 9.4 – 9.4 Hemoglobin 9. 0 & RESULT 14.8 ↓ 37.33 ↑ 1.0 % 9.21 UNIT Sec % Sec % RESULT REFERENCES UNIT 4 mins.9 11 – 16 % PDW 10.0 g/dL Hematocrit 27.0 – 7. 5 mins.8 7.01 0. 2.0 pg MCHC 34.5 up to 15 mins.

015 RESULT Negative Negative Negative Negative REFERENCE RANGE UNIT 5–6 1.4 10^6/µL 9.8 – 10.0 g/dL .2 12.0 – 16.003 – 1.0 1.RH) ABO Typing RH factor B positive TEST 5/19/14 ANTIBODY SCREENING FOR OTHER BLOOD GROUPS Antibody Screening SCREENING PANEL Antibody Screening Panel 1 Antibody Screening Panel 2 Antibody Screening Panel 3 URINE ANALYSIS 5/19/14 Physical Characteristics Color Transparency pH Specific Gravity RESULT Yellow Slightly cloudy 7.80 4.8 10^3/µL 3.35 4.2 – 5.035 Random Chemical Statistics Protein Glucose Ketone Urobilinogen Leukocytes Blood/Hb Negative Negative 15 Normal Negative 250 Negative Negative Negative Negative Negative Up to 2 Negative Negative Negative Negative 1072 5 17 4 0 0 – 11 0 – 17 0 – 278 0 – 17 0–1 mg/dL mg/dL mg/dL mg/dL wbc/µL rbc/µL mg/dL mg/dL Bilirubin Nitrite Microscopic Findings Red Blood Cell White Blood Cell Bacteria Squamous Epithelial Cells Cast COMPLETE BLOOD COUNT 5/20/14 Blood Count White Blood Cells Red Blood Cells Hemoglobin RESULT REFERENCES UNIT 8.

07 1.16 – 1.0 – 0.0 % Monocyte(%) 3.8 19 – 48 % Lymphocyte(%) 4.9 – 8. Medications.2 10^3/µL Lymphocytes(#) 0.3 7.400 MCV 81.4 37.8 81 – 99 fL MCH 27.89 0.6 33.0 – 0. screened and crossmatched.0 – 47.0 g/dL RDW 13.8 10^3/µL 0.6 26 – 65 % 10^3/µL Blood Indices MPV Relative Differential Count 7. Ibuprofen + Arginine (Faspic) 40 mg 1 tab 3x a day by mouth IV Infusions: Left Arm: PNSS 1L @ 10 ml/hour Right Arm: PLR 1L + 20 units oxytocin @ 120 ml/hour Blood Transfusion done with 1 unit PRBC B+ typed.8 0.2 10^3/µL 0.0 10^3/µL Neutrophil(#) 2.27 0.0 % 5.00 10^3/µL Monocyte(#) 0.0 0. Treatments given Medications: 1.4 – 9. IV Infusions.6 40 – 74 % Neutrophil(%) 32. No transfusion reaction was noted.5 27. The fetus isgenerally considered to be viable any time after the fifth to .1 fL 57.0 – 31.0 – 0.4 11 – 16 % PDW 56.2 – 11.4 10^3/µL LUC (%) Absolute Differential Count Eosinophils(#) Basophils(#) LUC(#) V.39 0.3 0. VI.0 pg MCHC 33. Anatomy and Physiology Interruption of pregnancy or expulsion of the product of conception before the fetus is viable is called abortion. Treatments given: Patient undergone completion curettage under spinal anesthesia.0 – 4.16 0. Doxycycline (Doxin) 100 mg/cap 1 capsule 2x a day by mouth 2.5 % Basophils(%) 1. Blood transfusions.0 % Platelet 204 130 .0 – 7.0 % Eosinophils(%) 0.5 3.9 – 5.0 – 37.02 0.0 – 1. ran for 4 hours.Hematocrit 27.

which projects into the vagina.sixthmonth of gestation.4 ̊C. where they blend with the tissues of the labia majora. PR – 82 bpm. The term “premature labor” is used when awoman experiences labor after this point in the pregnancy. which are a type of tumor that may distort the uterus).upper part. A nulliparous woman (one who has not completed a pregnancy to the stage of fetal viability) usually has a smaller uterus than a multiparous woman (one who has completed two or more pregnancies to the stage of fetal viability). BP – 100/60 . The size of the uterus varies. UTERUS The uterus. and a verbal report of abdominal discomfort. a pear-shaped muscular organ. 4/10 3. is about 7. Diet Eat a full dietalong with vegetables and fruits Sexual Activity or Spirituality Advised to avoid sexual intercourse for 2 weeks XI. which is covered posteriorly and partly anteriorly by peritoneum. fibroids. the fundus or body. The uterus has two parts: the cervix. Pathophysiology of the disease VIII. X. Acute pain related to post-operative incisional site as manifested by positive facial grimace. Treatment Health Teaching Daily perineal care with chlorhexidine (GynePro) Outpatient(follow up consultation) To comeback at OPD for follow up check up after 1 week upon discharge.5 inch) thick. She was discharged on May 22. 2014 accompanied by husband. and their lumina are internally continuous with the uterine cavity. the oviducts or fallopian (or uterine) tubes extend outward. with the following vital signs of T -36.5 cm (3 inches) long and 5 cm (2 inches) wide at its upper part. Prioritized list of nursing problems 1. Patient is not in pain. Patient was discharged from PACU and was brought to her room in the floor while blood transfusion was ongoing. depending on parity (number of viable births) and uterine abnormalities (eg. Summary of Client’s Status or Condition as of last day of contact. limited movement. From here. and a larger inner portion of the fundus narrows to a small canal in the cervix that has constrictions at each end. Discharge Plan/Home Management Medications Exercise Encourage early ambulation then returning to normal activities of daily living if tolerated. Risk for infection related to depression of immune system secondary to surgical procedure undertaken Nursing care plan IX. The round ligaments extend anteriorly and laterally to the internal inguinal ring and down the inguinal canal.25 cm (0. RR – 21 cpm. referred to as the external os and internal os. The upper lateral parts of the uterus are called the cornua. Its walls are about 1. Have an adequate rest and sleep (8 hours). not in distress. The uterosacralligaments extend posteriorly to the sacrum. The broad ligaments are folds of peritoneum extending from the lateral pelvic walls and enveloping the fallopian tubes. The triangular VII. The uterus lies posterior to the bladder and is held in position by several ligaments. It was the last contact between the patient and me. Deficient Fluid Volume related to excessive blood loss 2.

She went home via public vehicle. (Data gathered from patient’s chart). .mmHg on minimum risk.