I.

Nursing Health History

I.I Biographic Data
Name of Patient: Clara
Age/Sex: 29/F
Date of Birth: 8/24/1984
Religion: Roman Catholic
Nationality: Filipino
Civil Status: Married
No. of Children: 3
Obstetrical Score: G4P3
Occupation: Relief Operation Officer
Educational Attainment: College Graduate
Date & Time of Admission: May 18, 2014
@ 12:47:18 am
Attending Physician: Dra. Paares
Admitting Diagnosis: G4P3 (3013)
Incomplete Abortion
Vital Signs upon Admission:
BP- 100/80 mmhg
Temp. - 36.8 C
RR- 19 cpm
PR- 90 bpm
Height: 155 cm
Weight: 52 kg
Pain Score: 7/10, with facial grimace apparently
noted

I.II Chief Complaint: Vaginal Bleeding

I.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, crampy in nature, radiating to the lower back. Patient noted a sudden gush of blood flowing
accompanied with small meat-like tissues. She felt dizzy and was hyperventilating hence seek consult at Sugod Hospital.
Venoclysis with PLR 1 liter was started and 500 cc was run as fast drip. Tranexamic Acid 500 mg IVTT was also
administered. Upon stabilization of status, she was transported to Chong Hua Hospital for a self-directed admission. She
was then scheduled for completion curettage in the morning. According to the patient, she was not aware that she was
pregnant. Completion curettage under regional anesthesia- spinal was done and completed on May 19, 2014.

I.IV Past History
Patient claimed to be fully immunized. No serious hospitalization was stated aside from her previous pregnancies
wherein she delivered her children in the hospital via spontaneous vaginal delivery. Patient completed prenatal check
ups during that time and did not experience any problems. Patient is taking Kremil S once a day for her gastric ulcer (as
claimed) as maintenance which is a self prescribed medication. During the past months, 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. She
travels daily from one place to another and is working on papers and distribution of relief goods. At the end of the day,
she will always feel stressed out and weak.

I.V Family History of Illness
Patients mother was a known hypertensive, aside from that, no other heredo-familial disease from both side of her
parents is claimed. Her grandparents died of old age.

I.VI Menstrual and Obstetric History
Patient claimed to have an irregular menstrual cycle lasting for 3 days, consuming 2 pads on the first day then 1 pad for
the succeeding days. Her last recalled menstruation was in April 2014. Patient is gravida 4 with parity of 3 all delivered
via NSD and were in a healthy status. There is no history for abortion during her last pregnancies. Her youngest child is
aged 3 y. o.

I.VII Social Data
Patient has her own circle of friends. She is an occasional alcoholic drinker, non-smoker. But because of her job, her
social life was limited and the only interaction she was having was purely professional and work-related.

II. Patterns of Functioning/Gordons Functional Health Pattern
a. Health Perception and Health Management
Patient believe that as long as she feels well and does not easily get ill, shes healthy. Wala koy time karon i-
mind akong health like using vitamins kay busy ko sa akoang work mangud, as claimed. She often self-medicate
for simple coughs, colds, & fever.

b. Nutrition and Metabolism
Patient eat three times a day, but not much. She drinks approximately 1 liter of liquids a day. She does not drink
soft drinks and eat junk foods.

c. Elimination
Patient voids comfortably and without any problem. She defecates once a day, every morning.

d. Activity and Exercise
Patient considers her travelling routine and daily living activities as exercise.

e. Cognition and Perception
Patient is able to understand instructions and is with intact sensory sensation at all extremities.

f. 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.

g. Self-Perception and Self-Concept
Patient has a positive attitude/view towards herself and life.

h. Roles and Relationships
Patient is a good wife and a mother of three. Claimed to have a good rapport with other people.

i. Sexuality and Reproduction
Is satisfied with her current state of sexual pattern. Was feeling down because of the miscarriage that happened
and her inability to noticed the pregnancy.

j. Coping and stress tolerance
Able to cope any difficulties encountered in life with her family as support system.

k. Values and belief
Patient is a Roman Catholic, but due to her job lately, she cannot go to church during Sundays anymore.
III. Review of Systems and Physical Examination

General Appearance


Integumentary


HEENT (Head, Eyes, Ears, Nose, Mouth and Throat)
Head:

Hair:

Face:


Eyes:



Ears:



Nose:


Mouth:


Throat:

Neck

Respiratory






Patient looked stressed
With dirty feet caused by blood

With smooth, fair skin complexion
Pale and cool to touch


Normocephalic, symmetrical

Hair is evenly distributed, black in color, no lice

Symmetrical, no involuntary movements noted,
expression is appropriate to feelings and mood

Brownish in color, with 20/20 vision as claimed,
PERRLA (Pupils Round and Reactive to Light and
Accommodation), non-protruding, with pale
palpebral conjunctiva

able to hear, symmetrical in shape, both are
aligned with the outer cantus of the eyes, no
drainage noted

with nares patent, with pale nasal mucusa, no
nasal discharges noted

with pale dry lips and tongue, 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


Cardiovascular





Chest


Gastrointestinal







Genitourinary





Bowel Elimination

Musculoskeletal




Sexuality/Reproductive Pattern





Neurolosensory/Cognitive/Perception


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, without nipple
discharges

with round abdomen, soft, not distended and
non-tender
with positive bowel sounds
no hemorrhoids, 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, have not
under gone for pap smear & mammogram
does not use birth control measures

Awake, alert and oriented
With memory intact and able to provide
adequate history
Attitude: Cooperative
Mood: Appropriate to situation


IV. Laboratory/Diagnostic Examination Results

COMPLETE BLOOD COUNT 5/19/14 RESULT REFERENCES UNIT
Blood Count
White Blood Cells
Red Blood Cells
Hemoglobin
Hematocrit
Platelet

15.88
3.52
9.6
27.8
225

4.8 10.8
4.2 5.4
12.0 16.0
37.0 47.0
130 - 400

10^3/L
10^6/L
g/dL
%
10^3/L
Blood Indices
MCV
MCH
MCHC
RDW
PDW
MPV

79.0
27.3
34.5
12.9
10.2
9.8

81 99
27.0 31.0
33.0 37.0
11 16
9.0 14.0
7.2 11.1

fL
pg
g/dL
%
%
fL
Relative Differential Count
Neutrophil(%)
Lymphocyte(%)
Monocyte(%)
Eosinophils(%)
Basophils(%)

77.6
19.0
2.6
0.7
0.1

40 74
19 48
3.4 9.0
0.0 7.0
0.0 1.5

%
%
%
%
%
Absolute Differential Count
Neutrophil(#)
Lymphocytes(#)
Monocyte(#)
Eosinophils(#)
Basophils(#)

12.33
3.01
0.42
0.11
0.01

1.9 8.0
0.9 5.2
0.16 1.00
0.0 0.8
0.0 0.2




PROTHROMBIN TIME
RESULT REFERENCES UNIT
Prothrombin Time 5/19/14
Patient
Activity
INR
Control
Control Activity
14.2
87
1.09
13.4
100.0

>70%
<=1.21
Sec
%

Sec
%


BLEEDING TIME & CLOTTING TIME RESULT REFERENCES UNIT
B T Adult (Simplate)
C T (Lee and White)
4 mins. & 10 secs.
5 mins. & 50 secs.
2.3 9.5
up to 15
mins.
mins.


BLOOD TYPING (A, B, 0 & RH) RESULT
ABO Typing
RH factor
B
positive


TEST 5/19/14 RESULT
ANTIBODY SCREENING FOR OTHER BLOOD GROUPS
Antibody Screening

Negative
SCREENING PANEL
Antibody Screening Panel 1
Antibody Screening Panel 2
Antibody Screening Panel 3

Negative
Negative
Negative


URINE ANALYSIS 5/19/14 RESULT REFERENCE RANGE UNIT
Physical Characteristics
Color
Transparency
pH
Specific Gravity

Yellow
Slightly cloudy
7.0
1.015



5 6
1.003 1.035 Random

Chemical Statistics
Protein
Glucose
Ketone
Urobilinogen
Leukocytes
Blood/Hb
Bilirubin
Nitrite


Negative
Negative
15
Normal
Negative
250
Negative
Negative


Negative
Negative
Negative
Up to 2
Negative
Negative
Negative
Negative


mg/dL
mg/dL
mg/dL
mg/dL
wbc/L
rbc/L
mg/dL
mg/dL

Microscopic Findings
Red Blood Cell
White Blood Cell
Bacteria
Squamous Epithelial Cells
Cast

1072
5
17
4
0

0 11
0 17
0 278
0 17
0 1




COMPLETE BLOOD COUNT 5/20/14 RESULT REFERENCES UNIT
Blood Count
White Blood Cells
Red Blood Cells
Hemoglobin
Hematocrit
Platelet


8.80
3.35
9.2
27.4
204

4.8 10.8
4.2 5.4
12.0 16.0
37.0 47.0
130 - 400

10^3/L
10^6/L
g/dL
%
10^3/L
Blood Indices
MCV
MCH
MCHC
RDW
PDW
MPV

81.8
27.5
33.6
13.4
56.6
7.3

81 99
27.0 31.0
33.0 37.0
11 16
26 65
7.2 11.1

fL
pg
g/dL
%
%
fL
Relative Differential Count
Neutrophil(%)
Lymphocyte(%)
Monocyte(%)
Eosinophils(%)
Basophils(%)
LUC (%)

57.6
32.8
4.5
3.0
0.3
1.8

40 74
19 48
3.4 9.0
0.0 7.0
0.0 1.5
0.0 4.0


%
%
%
%
%
%
Absolute Differential Count
Neutrophil(#)
Lymphocytes(#)
Monocyte(#)
Eosinophils(#)
Basophils(#)
LUC(#)

5.07
2.89
0.39
0.27
0.02
0.16

1.9 8.0
0.9 5.2
0.16 1.00
0.0 0.8
0.0 0.2
0.0 0.4


10^3/L
10^3/L
10^3/L
10^3/L
10^3/L
10^3/L

V. Medications, IV Infusions, Blood transfusions, Treatments given

Medications:
1. Doxycycline (Doxin) 100 mg/cap 1 capsule 2x a day by mouth
2. 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, screened and crossmatched, ran for 4 hours. No transfusion
reaction was noted.

Treatments given: Patient undergone completion curettage under spinal anesthesia.

VI. Anatomy and Physiology
Interruption of pregnancy or expulsion of the product of conception before the fetus is viable is called abortion. The
fetus is generally considered to be viable any time after the fifth to sixth month of gestation. The term premature
labor is used when a woman experiences labor after this point in the pregnancy.

UTERUS
The uterus, a pear-shaped muscular organ, is about 7.5 cm (3 inches) long and 5 cm (2 inches) wide at its upper part. Its
walls are about 1.25 cm (0.5 inch) thick. The size of the uterus varies, depending on parity (number of viable births) and
uterine abnormalities (eg, fibroids, which are a type of tumor that may distort the uterus). 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). The uterus lies posterior to the
bladder and is held in position by several ligaments. The round ligaments extend anteriorly and laterally to the internal
inguinal ring and down the inguinal canal, where they blend with the tissues of the labia majora. The broad ligaments
are folds of peritoneum extending from the lateral pelvic walls and enveloping the fallopian tubes. The uterosacral
ligaments extend posteriorly to the sacrum. The uterus has two parts: the cervix, which projects into the vagina, and a
larger inner portion of the fundus narrows to a small canal in the cervix that has constrictions at each end, referred to as
the external os and internal os. The upper lateral parts of the uterus are called the cornua. From here, the oviducts or
fallopian (or uterine) tubes extend outward, and their lumina are internally continuous with the uterine cavity.upper
part, the fundus or body, which is covered posteriorly and partly anteriorly by peritoneum. The triangular

VII. Pathophysiology of the disease

VIII. Prioritized list of nursing problems
1. Deficient Fluid Volume related to excessive blood loss
2. Acute pain related to post-operative incisional site as manifested by positive facial grimace, limited movement,
and a verbal report of abdominal discomfort, 4/10
3. Risk for infection related to depression of immune system secondary to surgical procedure undertaken
IX. Nursing care plan

X. Discharge Plan/Home Management
Medications
Exercise Encourage early ambulation then returning to normal activities of daily living if tolerated.
Have an adequate rest and sleep (8 hours).

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.
Diet Eat a full dietalong with vegetables and fruits
Sexual Activity or Spirituality Advised to avoid sexual intercourse for 2 weeks

XI. Summary of Clients Status or Condition as of last day of contact.
Patient was discharged from PACU and was brought to her room in the floor while blood transfusion
was ongoing. It was the last contact between the patient and me. She was discharged on May 22, 2014
accompanied by husband. Patient is not in pain, not in distress, with the following vital signs of T - 36.4 C, PR
82 bpm, RR 21 cpm, BP 100/60 mmHg on minimum risk. She went home via public vehicle. (Data gathered
from patients chart).