COMPREHENSIVE HEALTH HISTORY

Name of Baby’s Father: Oscar Tejero

Age: 54 years old

Occupation: Fisherman

Chief Complaint: Vaginal Bleeding

Admission date and time: February 16, 2025

HISTORY OF PRESENT ILLNESS

A patient named, M.R. is a 27 years old who was living in Pio Del Pilar, Biri Northern
Samar and have been admitted in Northern Samar Provincial Hospital Obgyne Ward on
February 16, 2025 at 5:30pm with a chief complain of Vaginal Bleeding. According to the
patient, she was experiencing pain on her abdomen and lower back on February 14, 2025 but
she just ignore because it was not her first time to experience abdominal and lower back pain.
February 15, 2025 she attended in pregnancy tracking in brgy. Hall and then when got home
she was doing household chores when suddenly feel pain on her abdomen and start bleeding
at 2pm in the afternoon first it was small amount then in the morning 7am the bleeding
became severe, she suddenly rushed to their hospital and on February 16 afternoon, she was
refer to Northern Samar Provincial Hospital, when arrived she was seen by the Physician.
M.R.M admitting diagnosis is t/c Incomplete Abortion 22 5/7 weeks.

PAST OBSTETRICAL HISTORY

Date: August 05, 2017

Length of Pregnancy: 9 months
D&C: —
Vaginal/C-Section: NSVD
Girl/Boy: Girl (currently 7 y/o now)
Weight: —
Complications: Spotting
PAST HEALTH HISTORY

Patient M.R.M don’t have problem since birth, she was born healthy according and on
her childhood illnesses she had fever and chicken pox when she was in Manila. She don’t
have diabetes, hypertension, any cardiac problem or any problems on her health, she also
don’t undergo any surgeries, no accidents encountered or happened. Her immunizations are
complete according to patient M.R.M.
Patient M.R.M never had a blood transfusion, never smoke but she drinks alcohol she
stated that before when she still not pregnant she consume 2 bottles of hard drink (Tanduay
Rhum) and she loves drinking coffee, she consume 2 cups of coffee per day, 1 in the morning
and in afternoon.

REVIEW OF SYSTEM

Eyes - The eyeballs are in symmetrical normal size and position, eyelids not have redness,
swelling, lumps, or discharge. No drainage is present from the eyes..

Face – The face and lips are pale and dry, it is asymmetric but there is no presence of
swelling, masses or deformities

Extremities – From shoulders to fingertips: equal limb circumference with no edema or

ulcers, and skin color is pale. Delayed capillary refill. Skin temperature warm to touch and
equal bilaterally from shoulders to fingertips. In lower extremities the patient skin color
consistent from upper legs to toes, equal limb circumference with no edema or ulcers. No
presence of cyanosis or pallor on nails. Delayed capillary refill.

Respiratory – The patient’s respiratory has no retractions, no accessory muscle use, chest
rise and fall normally, her respiratory rate are all normal.

GU – The patient has no presence of dysuria or hematuria

MUSCULOSKELETAL – The patient skin color are pale but no skin rash, ulcers or
sweating hair.
GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception and Health Management – According to the patient, the quality of
current health is 7/10 since she was not yet okay and still experiencing lower back pain, in
terms of health importance he scale it of 10/10. The patient’s immunization are complete and
she also had Pfizer vaccine for covid.

Nutritional-Metabolic – Before patient was hospitalized she said that his appetite was good,
their usual food to eat are fish and pork and vegetables on weekend, but on her current health
now he stated that his appetite is maintained since the ration is just small amount, and on her
first admission she was ordered NPO by the Physician. On the other side, can recall on what
food she eat

Elimination – There are no bleeding in stool as per patient said, no diarrhea, and the amount
on how many time she eliminate bowel, she stated once a day and in urination he stated that it
depends, sometimes twice or thrice a day.

Activity and Exercise – The patient favorite leisure time is watching TV and bonding with
her family, doing household chores and walking near in the seashore as her daily routine
exercise

Sleep and Rest – He usually sleep at 9 pm or 10pm and wakes up at 5 or 6am depends on
the schedule work on his husband and school days on her daughter because she’s the one who
prepare for their food, in terms of rest, she rest when gets time to rest. But when she
hospitalized she sometimes experience difficulty in sleeping

Cognition and Perception – The patient ability to understand on things are good.

Roles and Relationships – According to the patient she was close to his siblings, in fact one
of her sister took care of her when she was rushed in NSPH and they even help her when
she’s in need in terms of financial. She is a mother of a 7 year old girl, who is studying grade
1 and a wife of a fisherman. She state that he can freely express her self to the people who
surround her, especially to his husband and family.

Coping and Stress tolerance – The patient stated that her coping mechanism are just
sleeping or diverting her energy on something like watching TV, scrolling on Tilton or taking
care of her daughter or doing household chores.
 LABORATORY TEST

BLOOD TYPING (02-16-2025)

RESULTS:
- ABO Group “O”
- RH Positive

HEMATOLOGY
PARAMETERS RESULTS REF. RANGE
WBC 8.17 3.50 – 9.50 10^3/uL
RBC 4.13 3.80 – 5.10 10^3/uL
PLT 388⬆️ 125 - 350 10^3/uL
MPV 6.2 ⬇️ 6.5 – 12.0 fL
PDW 7.3 ⬇️ 9.0 – 17.0 fL
PLCR 10.6 ⬇️ 11.0 – 45.0%

DISEASE PROCESS
Incomplete abortion is defined by clinical presence of an open cervical os
and bleeding, whereby all products of conception have not been expelled from
the uterus, or the expelled products are not consistent with the estimated
duration of pregnancy. Common symptoms include vaginal bleeding and
abdominal pain. Uncomplicated incomplete abortion can result after an induced
or spontaneous abortion (i.e. miscarriage); the management in both cases is the
same. Incomplete abortion may be managed expectantly, medically or surgically
(vacuum aspiration). Managing uncomplicated incomplete abortion with vacuum
aspiration (when uterine size is less than 14 weeks) includes recognizing the
condition, assessing uterine size, the actual procedure and pain management.
 DRUG ANALYSIS

Drug Mechanism of Indication Contraindication Adverse Drug Interaction Nursing

Action Reaction Responsibilities
Brand Name: Tranexamic acid Used to treat Contraindicated Adverse effects May interact with Assess or Monitor
Tranexamic is a synthetic heavy menstrual in patients with include seizures, this drug include: vs especially
Acid derivative of bleeding in active headaches, “blood thinners” blood pressure
lysine that exerts women. This intravascular backache, (anticoagulants
antifibrinolytic
Generic Name: medicine may be clotting. abdominal pain, such as warfarin, Monitor
effects by
Cyklokapron used by teenage Tranexamic acid nausea, vomiting, heparin), drugs neurologic status
blocking lysine
binding sites on females, but is not is an diarrhea, fatigue, that prevent (pupils, level of
Classification: plasminogen intended for use antifibrinolytic pulmonary bleeding consciousness,
antifibrinolytics molecules, before the start of and may increase embolism, deep (including factor motor activity)
inhibiting the menstruation. the risk of vein thrombosis, IX complex, anti-
Dosage: interaction of Tranexamic acid thromboembolic anaphylaxis, inhibitor Stabilize IV
500mg IV q8 plasminogen with is an events. impaired color coagulant catheter to
formed plasmin antifibrinolytic vision, and other concentrates), minimize
and fibrin agent. It works by visual estrogens, thrombophlebitis.
blocking the disturbances hormonal birth Monitor site
breakdown of control (such as closely
blood clots, which pills, patch, ring),
prevents bleeding. tibolone, Instruct patient to
tretinoin. notify the nurse
immediately if
bleeding recurs
 NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Nursing Rationale Evaluation

Interventions
Subjective: Acute Pain related After 8 hours -Assessed present state -For data baseline After 8 hours rendering
“masuol ak gutok sa to uterine rendering nursing -Monitor vital signs nursing interventions
ilarom banda” as contrations interventions the and observe for -Acute pain often the patient reported
verbalized patient will report nonverbal pain manifests as decrease pain on her
decrease pain and indicators. physiological changes. lower back pain from
Objective: relaxed 8/10 to 6/10 pain scale
-8/10 pain scale rate -Instruct the patient -To reduce muscle rate.
-Limited mobility about deep breathing tension
and relaxation
techniques -Complementary
-Positioning for strategies enhance
comfort (elevating the pain relief and
affected area, using promote comfort
pillows)

Prevents
Encourage movement complications like
and mobility within stiffness and promotes
pain tolerance. faster recovery

Assessment Nursing Diagnosis Planning Nursing Rationale Evaluation

 Interventions
Subjective: Risk for Deficient After 10 hours of -Monitor vital signs Hypotension and After 10 hours of
“” as verbalized Fluid related to nursing interventions (BP, HR) for signs of tachycardia indicate nursing interventions
Vaginal Bleeding the patient will dehydration fluid loss the patient
Objectives: demonstrate -Assess for I/O -Decreased urine demonstrated
RR: 23bpm improved perfusion output (<30 mL/hr) improved perfusion
PR: 63bpm and will experience and dark urine indicate and experience
O2Sat: 92% reduced vaginal dehydration reduced vaginal
Bp- 100/70 mmHg bleeding following -Encourage oral fluid -Helps maintain bleeding following
appropriate medical intake (water, hydration levels appropriate medical
- pale interventions. electrolyte-rich drinks) interventions.
- delayed capillary as appropriate
- weakness -Administer IV fluids
as prescribed -Restores fluid balance
-Assess skin turgor in severe cases.
and mucous -Poor skin turgor and
membranes for dry mucosa indicate
dryness dehydration.
-Administer
prescribed medication -To reduced bleeding

Assessment Nursing Diagnosis Planning Nursing Rationale Evaluation

Interventions
Subjective: Disturbed Sleep After 8 hours of Determine the usual To assess and After 8 hours of
“dire ak nayngaturog Pattern related to nursing interventions sleeping habits and determine rendering nursing
sin maupay kay sak lower back pain the patient will changes appropriate interventions the patient
gutok” as verbalized report improve in interventions reported improved sleep.
sleep pattern
Objectives: Provide comfort
RR: 21bpm bed by maintaining Improve sleeping
PR: 65bpm a clean comfort
O2Sat: 94% environment

-lack of energy Encourage a

-yawning bedtime routine and Deep breathing
-dark circle eyes relaxation exercises.
techniques Progressive muscle
relaxation.

Instruct the patient Reinforces healthy

to avoid screen time sleep behaviors to
(phones, TV) 30-60 promote long-term
minutes before bed. improvement.