University of San Agustin

General Luna St., 5000 Iloilo City, Philippines

www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT

Name: Red Angela O. Dinson Course & Year: BSN 2-B

Asynchronous Activity Day 2

History of Present Illness:

A 26-year-old woman comes to the office because of a 3-day history of lower abdominal pain. She is 18
weeks pregnant by dates. The patient describes the pain as sharp, steady, and radiating across her lower
abdomen bilaterally. Last night she developed new nausea and vomiting. She has not been able to keep
down any food or drink this morning. She had a normal bowel movement yesterday. She says she felt
cold and shivering this morning, followed by feeling warm; however, she did not check her temperature.
She denies vaginal bleeding.

Review of Systems:
General: Patient feels generally weak and ill but was in her usual state of health until 3 days ago. She has
gained approximately 5 lbs (2.3 kg) in the pregnancy so far.
Skin: She denies rash.
HEENT: Her mouth feels dry. No headache, nasal congestion, or sore throat.
Pulmonary: She denies cough or shortness of breath.
Cardiovascular: She denies chest pain or palpitations.
Gastrointestinal: She has had a decreased appetite for 1 day and has been unable to keep any food or drink
down this morning due to nausea and vomiting. She has not had diarrhea or constipation.
Genitourinary: She reports a frequent urge to urinate and a sensation of incomplete bladder emptying for
the past 3 days. No dysuria or hematuria. She is G1P0A0 and has been seeing an obstetrician for all
routine visits and testing. No vaginal bleeding.
Musculoskeletal: She reports mild diffuse low back pain. No generalized muscle aches.
Neurologic: Noncontributory
Psychiatric: Noncontributory

Past Medical History

Medical history: Mild intermittent asthma diagnosed in childhood requiring only occasional rescue
inhaler use, no hospitalizations for asthma. She is otherwise healthy.
Surgical history: Wisdom teeth removed at age 18.

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT
Medications: Albuterol inhaler as needed, about once a month. Daily prenatal vitamin.
Allergies: No known drug allergies.
Family history: Mother is healthy at age 50. Father is 53 years old with high blood pressure.
Social history: Patient is employed as an engineer. She exercises 3 days/week. She drinks 2 glasses of
wine per week but stopped when she found out she was pregnant. She does not smoke or use any illicit
drugs. She has not had any recent travel. She is monogamous with 1 male partner.

Physical Examination
General appearance: Well-developed female, appears tired and ill but in no apparent distress.
Vital signs:
Temperature: 38.8° C
Pulse: 120 beats/minute
BP: 110/76 mm Hg
Respirations: 20/minute
Skin: Hot, diaphoretic. No rash or cyanosis.
HEENT: Dry mucous membranes, no scleral icterus or conjunctival injection, neck is supple, no
adenopathy.
Pulmonary: Breath sounds are equal bilaterally with good air movement in all fields. There are faint
inspiratory crackles present on the left side heard more at the base. No wheezing.
Cardiovascular: Mild tachycardia with regular rhythm; no murmurs, rubs, or gallop. No peripheral
edema.
Gastrointestinal: Bowel sounds normal. Abdomen soft, diffusely tender across the lower abdomen
bilaterally with no guarding, rigidity, or rebound. No tenderness in the upper quadrants, gravid, non-
tender uterus 2 cm below the level of the umbilicus. No inguinal or femoral hernias. Rectal examination
non-tender, stool brown, heme negative.
Genitourinary: Normal external genitalia, no cervical motion tenderness, scant thin white discharge from
the cervical os, which appears closed. Fetal heartbeat regular at 150 beats/minute.
Musculoskeletal: No swelling, tenderness or deformity of joints or extremities. Positive costovertebral
angle tenderness bilaterally.
Neurologic: Unremarkable
Mental status: Alert and oriented, with fluent and coherent speech.

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT
Laboratory and Diagnostics
Test Results
Results of appropriate testing return and show the following:
Blood:

Test Result Results (SI Units)

Hemoglobin 12.5 g/dL 125 g/L

WBC count 17.0 x 103/µL 17.0 X 109/L

Platelet count 150 x 103/µL 150 X 109/L

Basic metabolic profile:

Test Result Results (SI Units)

Sodium 137 mEq/L 137 mmol/L

Potassium 3.9 mEq/L 3.9 mmol/L

Creatinine 0.7 mg/dL 62 micromol/L

Glucose 78 mg/dL 4.3 mmol/L

BUN 23 mg/dL 8.2 mmol/L

Urine:

Test Result
Leukocyte esterase Positive

Blood Positive
Ketones Positive

Bacteria Numerous

WBCs 30-50 per high power field

Nitrites Positive

Leukocyte esterase Positive

Protein Negative

STD panel Urine gonorrhea/chlamydia/trichomoniasis negative

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT
Ultrasonography:
Renal/bladder ultrasound: No hydronephrosis noted. Incidentally noted intrauterine fetus with heartbeat of
156 beats/minute.

Learning Guide:
1. Based from the scenario above, formulate questions you will be asking Sandra that would give you
all the data needed to make her OB history. REMEMBER that your questions must be derived only
from the data given above. Write your questions below.
After you have formulated your questions, put them together and develop an OB History of patient
Sandra, using the format presented in the module
OBSTETRICAL HISTORY

I. Patient’s Baseline Data

What is your name? What is your highest level of education? College
graduate
How old are you?26 years old
Are you married? Married (Monogamous)
Where were you born?
What concerns do you have about visiting this
What do you do for living
clinic?

II. Family History

Does anyone in your family have health problems like asthma or high blood pressure?
✓ Mother is healthy at the age of 50. Father is 53 years old with high blood pressure.

III. Past Medical History

In general:
✓ How are you today? Do you feel weak? Tired? Or fine?
✓ Did you gain or loss any weight?
Skin:

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT
✓ Does your skin have any rashes?
HEENT
Does your head hurt?
✓ Do you ever have trouble getting your food down?
✓ Do you have a dry mouth or not?
✓ Do you have stuffy nose?
Pulmonary
✓ Have you been having trouble getting enough air lately?
✓ Are you coughing?
Cardiovascular
✓ Have you been having chest pain or heart palpitations?
Digestive
✓ How's your appetite been the last few days?
✓ Have you ever felt sick and thrown up?
✓ What have you been eating the last few days?
✓ Have you ever had diarrhea or trouble going to the bathroom?
Genitourinary
✓ Do you have to go to the bathroom soon after you go to the bathroom?
✓ Is it hard for you to empty your bladder all the way?
✓ Does it hurt or are you having trouble going to the bathroom?
✓ Have you noticed any blood in your urine?
✓ Do you have any discharge from your womb?
Musculoskeletal system:
✓ Does your lower back hurt?
✓ Do you have any aches or pains in your muscles?
Do you have any medical problems?
Have you ever been to a doctor or hospital?
Have you had any medical procedures done on you?

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT
Do you take any medicines that a doctor has given you? If so, what is the amount and how often?
Have you ever had a severe allergic reaction to medications or foods?
How do you usually work out?
Do you drink alcoholic drinks?
Do you smoke?
Do you have a record of your most recent medical examination and diagnostic test?

➢ The patient was diagnosed with mild intermittent asthma during childhood that require occasional
rescue inhaler use, no hospitalizations for asthma. She is otherwise healthy. For past surgical
history, the client’s wisdom tooth was removed when she was just 18 years old. Patient
medications are albuterol inhale prn, about once a month and a vitamin for prenatal daily. The
patient has no drug allergies. She is an engineer, exercise three days a week. Drinks 2 glasses of
wine per week but stopped when she found out she was pregnant. Does not smoke or elicit drugs
and no recent travels. Monogamous.

IV. Pertinent Menstrual History

➢ It was not stated in the case scenario

V. History of Past Pregnancies

➢ The patient is G1P0AO. First time being pregnant

VI. History of Present Pregnancy

VII. Physical Examination
VIII. Prenatal History
IX. Health Teachings

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT
2. Given the sample Laboratory Results below, make a Laboratories Study using the format.
Blood:
PARAMETERS NORMAL RESULTS INDICATION SIGNIFICANCE
VALUES

Hemoglobin 12-18 g/dl 12.5 g/dL Normal Normal Hemoglobin doesn’t

mean free from anemia, anemia
can occur in iron deficiency

WBC count 3.5-5.72 x 17.0 x High May indicate a range of

103//µL 103/µL conditions, including infections,
inflammation, injury and
immune system disorders.

Platelet count 150-400 x 150 x Normal A lower-than-normal platelet

103/µL count is referred to as
thrombocytopenia. After a cut
or other form of bleeding
episode, this condition may
cause you to bleed profusely.
The term "thrombocytosis"
refers to an elevated platelet
count. They may restrict blood
flow, which is dangerous since
it can make your blood cut
more severely than it should.

Basic Metabolic Profile:

PARAMETERS NORMAL RESULTS INDICATION SIGNIFICANCE

VALUES

Sodium 136 to 144 137 mmol/L Normal A blood test for sodium is used
mmol/L to find out how much sodium is
in the blood. Sodium is a
mineral that is especially
important for nerve and muscle
function. Foods and drinks
contain sodium, which gets into
the bloodstream. It leaves the
body when you pee, poop, or
sweat. Also, low salt levels in
the blood could be a sign of
kidney disease, dehydration, or
another health problem.

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT

Potassium 3.7 to 5.2 3.9 mmol/L Normal A serum potassium blood test
mmol/L measures how much potassium
is in the blood. It is used to find
diseases that are linked to
having too much potassium. A
high level of potassium in the
blood can be a sign of kidney
disease, high blood pressure, or
heart disease. It can also be
used to keep track of diseases
like diabetes or kidney disease
that have already been
diagnosed.
Creatinine 70.72 to 62 Low The creatinine testing indicates
106.08 micromol/L how well the kidneys are doing
micromol/L their job of cleaning the blood
of waste.If your creatinine level
is high, it could mean that your
kidneys aren't working well.

Glucose 3.55 to 5.55 4.3 mmol/L Normal Glucose is called blood sugar.
mmol/L Blood sugar levels that are too
high are often linked to
diabetes.
BUN 2.14 to 7.14 8.2 mmol/L High The blood urea nitrogen test
mmol/L (BUN) is a common blood test
that tells you a lot about how
well your kidneys are working.
With a BUN test, you can find
out how much urea nitrogen is
in your blood.

Urine:

PARAMETERS NORMAL RESULTS INDICATION SIGNIFICANCE

VALUES

Blood Negative Positive Abnormal Urine blood is

usually not a
serious problem.
Red or white
blood cells in
your urine may

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT

sometimes signify
a number of
illnesses,
including a
urinary tract
infection (UTI),
renal disease, or
liver disease.

Ketones None Positive Abnormal People who are

more likely to
develop high
levels of ketones
are frequently
monitored with a
urine test for
ketones.

Bacteria None Numerous Abnormal Bacteria in the

urine are linked to
both
asymptomatic and
symptomatic
urinary tract
infections (UTI)
WBCs 3-5 per 30-50 per high power field Abnormal White blood cells
high power in the urine may
field indicate kidney or
urinary tract
irritation brought
on by bacterial
infection.

Nitrites Negative Positive Abnormal The nitrates test is

non-specific but
may identify
UTIs. Nitrites are
often not detected
in urine. Nitrites
and urinary
nitrates are
byproducts of
urine bacteria. If
the nitrite test is
positive, the

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT

urinary tract is
infected with
bacteria such as
Escherichia coli,
Klebsiella,
Proteus,
Enterobacter,
Citrobacter, and
Pseudomonas.

Leukocyte Negative Positive Abnormal A positive

esterase leukocyte esterase
test shows that
you have pyuria.
Pyuria is often a
sign of a UTI.

Protein Negative Negative Abnormal You can detect

kidney damage
early with the use
of a protein in
urine test,
allowing you to
make alterations
to protect your
kidneys.

STD panel None Urine Abnormal A gonorrhea test

gonorrhea/chlamydia/trichomoniasis is done to identify
negative whether you are
infected with the
disease. It is
sometimes done
in conjunction
with a chlamydia
test, which is an
STD test.

3. Identify atleast 3 Nursing Problem base on the scenario and rate it according to its prioritization.
1. Acute pain related to lower abdominal pain – Most priority
2. Risk for imbalance Nutrition – Second priority

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 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph
COLLEGE OF NURSING, NUTRITION & DIETETICS
NURSING DEPARTMENT
3. Urinary Retention for pregnancy – Least priority.

4. Formulate a comprehensive nursing care plan that will address the identifies nursing problem of the
case study.
DIAGNOSIS GOAL INTERVENTION RATIONALE EVALUATION
Acute pain After 1 hour Independent:
related to lower of nursing
abdominal pain intervention 1. Assess the 1. Utilizing the Goal Met, the
As evidence by: the patient client’s patient pain using patient reported
will be eased description of pain assessment pain on a scale
Subjective: from pain such as tool determined from 0 to 10.
abdominal quality, nature, the choice of Patient is now
The patient pain. severity of pain intervention. relieved from any
describes the pain 2. Monitor vital 2. To gather pain.
as sharp, steady, signs. baseline data
and radiating
across her lower Dependent:
abdomen
bilaterally. 1. Administer 1. It is soothing
analgesics such on your stomach
as and assist in
Acetaminophen relieving your
(Tylenol) discomfort.

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