I.

Nursing Health History

I.I Biographic Data
Name of Patient: Clara

@ 12:47:18 am
Attending Physician: Dra. Paares

Age/Sex:

29/F

Date of Birth:
Religion:

Admitting Diagnosis: G4P3 (3013)

8/24/1984

Roman Catholic

Nationality:

Filipino

Civil Status:

Married

Incomplete Abortion
Vital Signs upon Admission:
BP-

100/80mmhg

Temp. -36.8 C
No. of Children: 3

RR-

19 cpm

Obstetrical Score: G4P3

PR-

90 bpm

Occupation: Relief Operation Officer

Height:

155 cm

Educational Attainment: College

Graduate

Weight:

52 kg

Date & Time of Admission: May

18, 2014

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 dizzyand was
hyperventilating hence seek consult at Sugod Hospital. Venoclysis with PLR 1 liter was started
and 500 cc was run as fastdrip. 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.
Walakoy time karon i-mind akong health like using vitamins kay busy kosaakoang 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 softdrinks 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.

III.

k. Values and belief

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

Integumentary

HEENT (Head, Eyes, Ears, Nose,

Mouth and Throat)
Head:
Hair:
Face:

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

Mouth:

with nares patent, with pale nasal

mucusa, no nasal discharges noted

Throat:

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

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

Eyes:

Ears:

Nose:

Neck
Respiratory

Cardiovascular

Chest

Gastrointestinal

distended and non-tender

Genitourinary

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

Bowel Elimination
Musculoskeletal

Sexuality/Reproductive Pattern

Neurolosensory/Cognitive/Perception

IV.

Laboratory/Diagnostic Examination Results

COMPLETE BLOOD COUNT

5/19/14
Blood Count

RESULT

REFERENCES

White Blood Cells

15.88

4.8 10.8

UNIT

10^3/L

Red Blood Cells

3.52

4.2 5.4

Hemoglobin

9.6

12.0 16.0

g/dL

Hematocrit

27.8

37.0 47.0

Platelet
Blood Indices

10^6/L

225

130 - 400

MCV

79.0

81 99

fL

MCH

27.3

27.0 31.0

pg

MCHC

34.5

33.0 37.0

g/dL

RDW

12.9

11 16

PDW

10.2

9.0 14.0

9.8

7.2 11.1

fL

77.6

40 74

19.0

19 48

3.4 9.0

MPV
Relative Differential
Count
Neutrophil(%)
Lymphocyte(%)

2.6

10^3/L

Monocyte(%)

0.7

0.0 7.0

Eosinophils(%)

0.1

0.0 1.5

12.33

1.9 8.0

Neutrophil(#)

3.01

0.9 5.2

Lymphocytes(#)

0.42

0.16 1.00

Monocyte(#)

0.11

0.0 0.8

0.01

0.0 0.2

Basophils(%)
Absolute Differential
Count

Eosinophils(#)
Basophils(#)

PROTHROMBIN TIME
Prothrombin Time 5/19/14
Patient
Activity
INR
Control
Control Activity

BLEEDING TIME &

CLOTTING TIME
B T Adult (Simplate)
C T (Lee and White)

BLOOD TYPING (A, B, 0 &

RESULT
14.2
87
1.09
13.4
100.0

REFERENCES

>70%
<=1.21

UNIT
Sec
%
Sec
%

RESULT

REFERENCES

UNIT

4 mins. & 10
secs.
5 mins. & 50
secs.

2.3 9.5
up to 15

mins.
mins.

RESULT

RH)
ABO Typing
RH factor

B
positive

TEST 5/19/14
ANTIBODY SCREENING FOR OTHER
BLOOD GROUPS
Antibody Screening
SCREENING PANEL
Antibody Screening Panel 1
Antibody Screening Panel 2
Antibody Screening Panel 3

URINE ANALYSIS
5/19/14
Physical
Characteristics
Color
Transparency
pH
Specific Gravity

RESULT

Yellow
Slightly cloudy
7.0
1.015

RESULT
Negative

Negative
Negative
Negative

REFERENCE
RANGE

UNIT

56
1.003 1.035
Random

Chemical Statistics
Protein
Glucose
Ketone
Urobilinogen
Leukocytes
Blood/Hb

Negative
Negative
15
Normal
Negative
250
Negative
Negative

Negative
Negative
Negative
Up to 2
Negative
Negative
Negative
Negative

1072
5
17
4
0

0 11
0 17
0 278
0 17
01

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

Bilirubin
Nitrite
Microscopic Findings
Red Blood Cell
White Blood Cell
Bacteria
Squamous Epithelial
Cells
Cast
COMPLETE BLOOD COUNT
5/20/14
Blood Count
White Blood Cells
Red Blood Cells
Hemoglobin

RESULT

REFERENCES

UNIT

8.80

4.8 10.8

10^3/L

3.35

4.2 5.4

10^6/L

9.2

12.0 16.0

g/dL

Hematocrit

27.4

37.0 47.0

Platelet

204

130 - 400

MCV

81.8

81 99

fL

MCH

27.5

27.0 31.0

pg

MCHC

33.6

33.0 37.0

g/dL

RDW

13.4

11 16

PDW

56.6

26 65

10^3/L

Blood Indices

MPV
Relative Differential
Count

7.3

7.2 11.1

fL

57.6

40 74

Neutrophil(%)

32.8

19 48

Lymphocyte(%)

4.5

3.4 9.0

Monocyte(%)

3.0

0.0 7.0

Eosinophils(%)

0.3

0.0 1.5

Basophils(%)

1.8

0.0 4.0

5.07

1.9 8.0

10^3/L

Neutrophil(#)

2.89

0.9 5.2

10^3/L

Lymphocytes(#)

0.39

0.16 1.00

10^3/L

Monocyte(#)

0.27

0.0 0.8

10^3/L

0.02

0.0 0.2

10^3/L

0.16

0.0 0.4

10^3/L

LUC (%)
Absolute Differential
Count

Eosinophils(#)
Basophils(#)
LUC(#)

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 isgenerally considered to be viable any time after the fifth to

sixthmonth of gestation. The term premature labor is used when awoman 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
uterosacralligaments 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
Nursing care plan

IX.

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).