I BACKGROUND

A. PATIENTS PROFILE
This case is of a 38-year-old Filipino female patient native to
Butbut, Tinglayan, Kalinga having been blessed with 3 children with
another along the way, all of whom are living under her care. She is
from the Christianity religion under the teachings of the Roman
Catholic, married and is of the ethnic tribe Ifutfut weighing 89 kgs
and is 152 cms tall. She was admitted on the 16 th of September
2019 at 12:00 PM.

B. History of Present Illness

Accordingly, the patient said that she is hypertensive which
may have potentiated her current case. However, it is only now that
she experienced the severe complications of it with the generalized
edema, difficulty of breathing, nape pain, and body malaise.

3 days prior to admission at Luis Hora Memorial Regional

Hospital, she first visited the Bontoc General Hospital for the chief
complaints of body malaise and nape pain where she has an
admitting diagnosis of Dengue Fever due to her low platelet count of
45 when a Complete Blood Count was performed. Hours prior to
admission, she was referred to LHMRH with an admitting diagnosis
of G4P3 (3003) PU 35 wks AOG by LMP, Gestational Hypertension
ruled out Dengue Fever where a blood transfusion of 400 cc was
immediately done along with further examinations. It was in here
where the Dengue Fever was ruled out but another complication was
brought into light when she checked out to be positive for
Pneumonia.

C. Past Medical History

Patient claims to have been hospitalized twice due to body
malaise complaints and there was no record and no knowledge of
any allergy.

D. Family History
Patient claims that her mother is hypertensive but is not
sure if her parents has cardiovascular problems. Her husband as
well has no known diseases just the come and go of flu when it is in
season. Along her and their mother, her older brother (second child)
is also hypertensive.

E. Laboratory Results

Test Result Unit Normal (no) Value Interpretation

Hematocrit 0.39 M: 0.40-0.54 Normal

F: 0.37-0.47

Hemoglobin 141 M:130-180 g/L

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 F: 120-160 g/L

Erythrocytes 3.8 X1012/L M: 4.5-6.2

F: 4.0-5.4

WBC 11.7 X109/L 4.0-10.0

Neutrophils 50.0 55.0-65.0

Lymphocytes 29.0 25.0-35.0

Monocytes 8.0 3.0-6.0

Eosinophils 13.0 2.0-4.0

Basophils 0.0 0.0-1.0

Platelet Count 45 X10 /L 150-450

MCV 104.2 fL 80.0-100.0 Fl

MCH 37.4 Pg 27.0-34.0 pg

MCHC 359 g/L 310-370 g/L

MPV 9.4 fL

RDW-CV 0.018 %

RDW-SD 65.0 fL

PDW 9.4

DCT .35 mL/L

16# .2 %

RRBC # .1 %

Blood Type A
Rh Positive

F. Mental Health Assessment

Patient is a 38-year-old married woman dressed in a hospital
gown with a nasal cannula strapped in her head. Due to her
condition, self-care deficit is apparent as observed by the disheveled
hair, yellowish teeth and strong odor emanating from her plus her
bed which were in a mess when she was first visited for an
interview. Her orientation on time and date is challenged being
confined to bed or at most her room for 8 days and counting in
addition to her dizziness. She only answers when asked and needs
questions to be repeated many times before fully comprehending
and providing an answer as she focuses more on herself and her
pains evidenced by her eyes shutting tightly, face crumpling and
heavy breathing. At most, her thoughts are scattered and would
just repeat her answer from one question to another.

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II Assessment
Psychosocial
A store owner and a housewife living with her husband and
children of whom she has good relationship with, patient is a 38-year-old
with an out-going persona. Prior to admission, patient already needs
ADL’s assistance as walking becomes intolerable due to pain. She is not
alcoholic and a non-smoker, but her husband is- a heavy smoker. Under
Erik Erikson’s Theory of Psychosocial Development, she is under the
stage of Love: Intimacy vs. Isolation whereby she develops intimacy by
seeking companionship and love around her husband as evidenced by
the family they have created.

Elimination
Even in her hospitalization, defecation and urination has never
been a problem as she regularly moves although in the afternoon, and
urinates 2-5 times in an 8-hour shift. Catheter was only inserted when
she was to be wheeled to the operating room.

Date Urine Stool

September 17, 2019 4 1
September 18, 2019 5 0
September 24, 2019 2 1

Activity and Mobility

On the start of her pregnancy until her 23 rd week, mobility was not
a problem. She can still go on with her daily activities without any
assistance and performing still the mundane task of seeing to her
children and husbands’ need and that of her store. Upon admission she
was confined to bed-complete bed rest; elimination was done at her bed.
Even the act of sitting still needs the assistance of her husband as
activity was poorly tolerated.

Rest
A month before her current hospitalization, patient was able to
sleep well. But during her stay in the hospital, her sleep cycle was
disturbed; “kanayunak way mafangofangon kapu san sakit yak
malikatanak way manangos”. This would suggest that sleep and rest is
inadequate at times most specially in day time.

Safety
Due to the generalized edema, back pain and dizziness, client is at
risk of fall and trauma. Patient is also susceptible to infection as
evidenced by the lack of self-care and unwillingness to perform simple
hygiene measures.

Oxygenation
Prior to admission, no complaints on difficulty of breathing was
made by the patient. But due to her elevated blood pressure and
pneumonia, she was placed in an oxygen therapy via nasal cannula.
Below is the list of her respiration status in a 3-day morning shift.

Date Time RR

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September 17, 2019 8 AM 24 bpm

11 AM 22 bpm
September 18, 2019 8 AM 14 bpm

11 AM 14 bpm
September 24, 2019 8 AM 12 bpm

11 AM 16 bpm

Nutrition
When asked about her daily consumption, client claims to eat as
tolerated and would usually have fish and chicken for her meals does
include vegetable in her diet at times.

During her stay in the hospital, Low-Fat-Low-Salt Diet was ordered

for her and it was observed that her water intake is poor. With her height
and weight, computed BMI is 36.18 which suggests that she is
overweight.

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