PATIENT’S ASSESSMENT

I. Patient’s Profile
Name: Prescila Jabonete Source of Info: Patient
Age: 37 y/o % of Reliability: 95%
Birthday: 4/18/1973
Status: Married
Address: Inobongan San Sebastian, W. Samar
Educ’l Attainment: College Level
Occupation: Housewife
Religion: Roman Catholic
Date & Time Admitted: 09/09/10 @ 6:45 PM
C/C: painless, vaginal bleeding
Attending Physician: Dr. Ychon
Diagnosis/Impression: PU 38 wks AOG, cephalic, marginales delivered by “E” 1 CSTLS with
BTL to alive Bb. Girl AS-7,9, MSAF G6P6 (6006)
Procedure: “E” 1 CSTLS with BTL
II. Health History
Present Illness
6 days PTA patient experienced vaginal spotting not associated with pain. Consumes 1 pad of
napkin per day. Other associated signs and symptoms include fever, headache, dizziness, nausea and
vomiting. No meds taken and consult done.
3 days PTA, vaginal bleeding was noted, still not associated with pain. Fever recurred.
Headache, dizziness, nausea and vomiting are still noted. Patient took paracetamol (Biogesic) 500mg OD
for fever. Fever was relieved the day after. Patient sought consultation at the clinic and was given
unrecalled medicines to prevent bleeding which provided temporary relief.
A day PTA, pt experienced excessive painless vaginal bleeding. Pt sought consultation at EVRMC
and had undergone laboratory exams and transvaginal UTZ and was initially diagnosed with placenta
previa the following day; hence, subsequent admission.
The patient had undergone “E” CS and was diagnosed as to having placenta previa marginales.
Past Health History
Usual illness experiences include fever, cough and colds. Usually take OTC meds such as
paracetamol (Biogesic and Neozep) as relief measure. Had complete Tetanus Toxoid vaccination. No
history of previous operations or injuries. No known allergy to food and medication.
Family History
Patient had 6 living children, 4 boys and 2 girls. All are currently well. Patient’s father died due to
heart attack at the age of 55. Has positive family history of hypertension on paternal side; and anemia
on maternal side.
No other known heredofamilial diseases like DM, tuberculosis and mental illness.
Gynecologic History
Patient had her menarche at the age of 14. With regular monthly menstruation of 3 days, and
consumes 3-4 napkins per day. Usually experiences dysmenorrhea during menstruation and occasionally
takes mefenamic acid as remedy. Patient is breastfeeding her 6 days old baby.
Patient uses Calendar method as means of family planning and denies use of any artificial
contraceptive. No history of any reproductive disorder.
Obstetric History
Patient is a G6P6 (6-0-0-6) with an LMP of December 13, 2009. No previous abortions. No
problems encountered during previous labor and deliveries. Occasionally take paracetamol (Biogesic) for
relief of fever even during pregnancy. Her 5 children were delivered NSVD on good condition. The
youngest daughter delivered via CS.
Psychosocial History
Patient is a housewife and does household chores like washing dishes and clothes, cleaning the
house and cooking. Lives in a semi-concrete house with a potable water source. She is a non-smoker and
an occasional alcoholic drinker. Husband, however, is a smoker.
The family is able to meet their basic needs and is supported well by their relatives financially.
Patient relates well to family members.
II. PATTERNS OF FUNCTIONING AND PHYSICAL EXAMINATION

Patterns of Pre-Hospital Assessment Clinical Inspection Other Sources

Functioning

1. Respiratory -last had cough and colds 2 RR-26 cpm -no CXR
months ago associated with fever.
-Took paracetamol (Biogesic) and -with regular breathing -no O2
Neozep as remedy. Symptoms pattern
were resolved 4 days after -Does not use accessory
-non-smoker (husband however, is muscle in breathing
a smoker)
-with clear breath sound
upon auscultation
-no cough, colds

2. Circulatory -non-hypertensive CBC Ct.

-occasionally experiences dizziness BP-90/60mmHg
(Abnormal
especially when doing strenuous PR- 80 bpm
Findings)
activities and during previous -pale conjunctiva, pale lips
pregnancies -poor capillary refill > 3 sec ↓Hgb- 110 g/L
-unable to recall occurrence of -facial and skin pallor (120-
palpitations and chest pains. -cold, clammy skin 160)=bleeding
-“Malingaw tak ulo”,as ↓ Hct- 0.31
verbalized by the patient (.36-.42)=bleedin
-no edematous parts noted g
↓Lymphocyte-
0.15%=infection
3.Food and Fluid -has thin body appearance
-usually eats 3x a day PO meds taken:
Intake -poor appetite
-prefers eating rice, fish and
-drinks 2-3 glasses of water
vegetables during meals •mefenamic acid
per day
-no known allergies to food and 500 mg 1 cap TID
-cold,clammy skin
medications
-poor skin turgor
-drinks 6-8 glasses of water per •ferrous sulfate
-dry lips
day 1 cap OD HS
-With an IVF of D5LR 1L
- occasional alcoholic beverage
@750 cc level regulated @
drinker; Parenteral meds:
20 gtts/min infusing well@
usually consumes 8-10 glasses per 1. Tramadol
right cephalic vein.
session. 50mg IVTT q6h
–on soft diet
2. MEM 1 amp
IVTT q8h x 3
doses w/ BP
precaution ≥
120/80 mmHg
3. Ranitidine 50
mg IVTT q8h
4. Elimination -usually voids at least 6x per day -Urinates 2-3 times a day in
with yellow-colored urine. minimal amount with
-no voiding difficulties experienced yellow-colored urine. No U/A
-Defecates 1-2 times per day -no dysuria or hematuria No S/E
usually in the morning with brown noted UTZ report:
stool. -has not defecated since -longitudinal lie
admission composite,
- with minimal perspiration anterior high
-no aids used in elimination lying placenta of
grade 3 maturity
-patient has hx of fever Temp. – 36.7(axillary) normohydramios
5. Regulatory
-take paracetamol as medication -cold, clammy skin
Mechanism
- had menarche at 14 -with minimal perspiration
-regular menses of 3 days at the back
-doesn’t take contraceptives -breast engorged
-LMP : 12-13-2009 -no twitching paralysis
noted

6. Hygiene Hair is unkept,appears

-usually takes a bath once a day
unkept
-uses shampoo when available
- long and dirty fingernails,
-changes clothes everyday
-with foul-smelling body
-no known allergy to soap or
odor
shampoo
-with vaginal discharge
- believes that bathing should be
noted.
avoided during menstruation.

7. Exercise and - Patient ambulates with

-does household chores everyday
Locomotion assistance
such as: washing clothes and
-no fractures,contractures,
dishes, cooking and cleaning the
andjoint stiffness noted.
house.
–pt experiences fatigue
- occasionally experiences
dizziness when doing strenuous
activities
-Sleeps for just 2-3 hours at
-usually sleeps at 7:30 pm and
night.
8. Rest and Sleep arise at 5pm
-“Diri ako nangangaturog
-take daytime nap usually at 1-
hin tuhay kay maaringasa
3pm
ngan mapaso”, as
-prefers side-lying position when
verbalized by the patient.
sleeping and uses 1 pillow
-take daytime naps for 30
min – 1 hour
-eyebags noted

9. Communica- -right – handed -EYES : eyelashes evenly

tion and Special -no eyeglasses or hearing aids distributed
Senses used PERRLA
-no visual or auditory disturbances -Whitish sclera
-speaks in Waray -Positive corneal reflex
-Pale conjunctiva
-EARS: symmetrical, in line
with outer canthus of eyes
-no swelling and discharges
presence of earwax
-no swelling and tenderness
 -NOSE:at midline, firm
septum is thick, at midline
-no nasal flaring
-no lesion and discharges
VOICE: speaks on soft,
moderate voice
10. Sensory -no history of convulsions, epilepsy -awake, coherent and
and loss of consciousness oriented with time and
place
-able to respond to
questions well
-no seizures noted
11. Pain and -No pain noted
Discomfort - No meds taken and consult done. -“Maul-ol hin duro ha may Medication
gintahi”,as verbalized by the taken for pain
pt Mefenamic acid
-pain scale of 8 (10 most – 500 mg 1 cap
severe pain) TID
- facial grimace, guarding
12.Recreation -watches t.v. at home for behavior
and Diversion recreation
Likes watching Eat Bulaga at noon -restlessness
-chats with neighbors during spare -usually observed silent and
time seldom talks with SO
- uses cp when bored

13.Religious -attends Sunday masses regularly

14. Coping -talks with family members and -no religious medals worn
Mechanism prays when faced with stressful
situation. - patient talks with
roomates
 PATHOPHYSIOLOGY

Predisposing Factors Precipitating Factors

- Age - hx of placenta previa
- Gender - multiparous women
- Genetic

↑ Progesterone and estrogen level

- Pre-embryonic stage

Production of fertilize ovum

Implantation in the uterus

- Embryonic stage

Placenta arises from tropoblast tissues

Insufficient blood supply

Placenta migrates to where there is rich in blood supply

Placenta resides in the lower

Total Placenta Previa Partial Previa Marginal Previa Low-Lying Previa

(placenta completely covers
the top of the cervix)
(Partially covers the ( placenta touches,but (placenta encroaches
top of the cervix) not cover the top of the the lower segment of
cervix) the uterus but does
not infringe on the
cervical os.

profuse bright red bleeding

painless vaginal bleeding
 DRUG STUDY

Drug Name: mefenamic acid 500 mg 1 cap TID

General Action: anti- inflammatory drug
Specific Action: inhibition of prostaglandin synthesis
Indication: mild to moderate pain
Contraindication: contraindicated to pt with hypersensitivity to drug
Adverse Reaction: CNS: dizziness, headache
CV: edema, fluid retention
EENT: tinnitus
GI: abdominal pain, constipation, decreased appetite, nausea
Nursing Responsibilities: - 10 Rs of drug administration
- Tell pt to take meds with meals to reduce adverse GI reactions
- Teach pt to watch for & report to prescriber stat S/S of GI bleeding.
-Monitor patient regularly. Provide assistance especially during episodes of
dizziness, headache and nausea

Drug Name: ferrous sulfate 1 cap OD

General Action: Iron supplements
Specific Action: produces increase number of erythrocytes
and/or hemoglobin concentration in erythrocytes
Indication:
iron deficiency, bleeding
Contraindication: hemolytic anemia, liver cirrhosis
Adverse Reaction: nausea, Epigastric pain,
vomiting, Constipation, Anorexia, dark-colored stool
Nursing Responsibilities: - 10 Rs of drug administration
-Advise pt. to report constipation
-Teach client that change in stool color is a normal response to medications
-Increase fluid intake
-Advise diet high in fiber
-Monitor patient regularly . Provide assistance especially during episodes of nausea

Drug Name: Tramadol 50mg IVTT q6h

General Action: opiods analgesic
Specific Action: thought to bind
receptors and inhibit reuptake of norepinephrine and serotonin
Indication: moderate to severe pain
Contraindication: contraindicated in pts hypersensitive to drug
Adverse Effect: dizziness, headache, anxiety, visual disturbance, nausea and vomiting, anorexia
Nursing Responsibilities: Reassess pt level of pain at least 30 mins. after administration.
Caution ambulatory pt to be careful when rising and walking.

Drug Name: Ranitidine 50 mg IVTT q8h

General Action: anti- ulcer drug
Specific Action: inhibits action of histamine on the H2 at receptor sites for parietal cells, decreasing
gastric secretion.
Indication: To prevent duodenal and gastric ulcer
Contraindication: contraindicated in patients hypersensitive to drug
Adverse Effects: headache, malaise, blurred vision, jaundice
Nursing Responsibilities: Assess pt abdominal pain.