Case Abstract

In partial fulfillment in RLE

(Summer)

Acute Uterine Bleeding

(AUB)
Submitted by:
Ms. Rochelle O. de Guzman
(Student)
Submitted to:
Mrs. Marissa May N. Abuan, RN, MAN
(Clinical Instructor)
General Objectives:
To become efficient and be a good
student nurse. To gained more knowledge in
handling patient and give nursing care to the
clients.

Specific Objectives:
• To facilitate in taking necessary actions
to solve and prevent the identified
problems on her own.
• To render primary treatment on her
illness.
• To help the client in the motivation of
her health care provided by the health
workers.
 Patient’s Profile

Name: Santina
Address: P-2 Calaocan, Santiago city
Age: 37 y/o
Birthday: July 15, 1972
Civil status: Married
Husband’s Name: Santino
No. of Children: 5
Nationality: Filipino
Religion: Roman Catholic
Occupation: Housekeeper
Chief Complain: vaginal bleeding
Diagnosis: Acute Uterine Bleeeding
Attending Physician: Dr. Dadural
Present Health History

The present health history started two weeks

PTA, history of catherization at Dubinan
Santiago city, because they all know that she
was pregnant but they were had a wrong
diagnosis a days after the catherization it’s
followed by the episode of vaginal bleeding.

Past Health history

Prior to her hospitalization it was her first
time to be hospitalized, and she denies having
allergies to any foods and drugs. She also said
that when she suffered from minor illness she
just buy over the counter drugs such as neozep,
paracetamol, ponstan.

Family Heath History

No hereditary disease can be adopted from
her father and mother side.
 11 Gordon’s Functional Pattern

1. Health Management Pattern

•Before: Health for her is wealth and it is very important for her

and for her family.

She also believes that being able to perform her

daily activities and work signifies good health.

•During: She still believes that Health is wealth and we should

treasure it for a lifetime because being unhealthy will affect our whole way of
living.

2. Nutritional metabolic pattern

•Before she eats regularly three times a day and
drinks at least 8 to 10 glasses of water daily.
•But during hospitalization, she cannot eat well
due to loss of appetite and worrying to much on
her situation but she always drink 6-7 glass of
water.
3. Elimination pattern
•Before: She urinates 3-4 times a day and stool
one times a day.
•During: Her bowel movement is normal but she
urinates 5-6 times a day.
4. Activity exercise pattern
•Before: She considered exercise her daily
activities in the house like sweeping the floor;
clean the backyard and many more.
•During: She is always in her bed and she has no
exercise.
5. Cognitive perceptual pattern
 Before and during She finished a degree of Bachelor of Science in nursing and

And her Ability is also in

she’s working as a volunteer nurse in the hospital.

normal condition and she says that she can still remember
all the things that happened in their life especially those
happy moments with his family and relative.

6. Sleep rest pattern

•Before: She sleeps 9pm-5am; 9hours of sleep
normal.
•During: She can easily sleep because she feels bored. She sleep 10pm-5am
and in the afternoon 3pm-4pm.

7. Self-perceptual pattern
•Before: She felt happy and fulfilled by doing her
responsibilities as a mother to her children and
because she can do what she wants.

• But during the hospitalization she felt worthless

and sad because she is worried about the sake of her children and about
her hospital bills.

8. Role relationship pattern

She had a good relationship to her husband and
children.
But during the hospitalization she cannot perform
her role as a mother and wife.
9. Sexually and reproductive pattern
Before: They have no contact for 3months because his husbands are working in
the other country.

During: Same, Nothing has changed.

 10.Coping stress management
Before: When Problem arises she always put in god and usually wants to be alone.

During having her best friend and family at her

side still the best coping management.

11. Value, belief pattern

Before: The client is Roman Catholic. Even
though she does not go every Sunday at church,
she still believes in god that is superior and the
most powerful of all.
During: Not attending masses, but she always pray and his faith in god is never
lessen even though she had encountered many hardship in her life.

TABLE OF CONTENTS

General Objective

Specific Objective

Overview of the disease

 Nursing History
a. Patient’s Profile
b. Present history of illness
c. Past health history
d. Family history

Anatomy and Physiology

Drug study

Course in the ward

Physical assessment

Nursing care management

Course in the ward:

 d/s admission to ROC
 severe consent for admission and management
 TPR q 2 shift to record
 v/s q 2 and record
 IVF D NSLR 11 * 12
 Labs: BT
CBC c APC- stat pls.