Case of Vaginal Bleeding
Case of Vaginal Bleeding
Case of Vaginal Bleeding
Client Profile
Name: Patient Z
Birth Date: 1987-10-24
Age: 33
Sex: Female
Nationality: Filipino
Civil status: Married
Ethnic background: Igorot
Address: Bekkel, La Trinidad
Religion: Roman Catholic
October 5, 2021 patient Z gave birth at SLU hospital and during her stay in the hospital patient Z
suddenly experienced vaginal bleeding and was given a liter of PRBC blood transfusion. She stayed in the
hospital for three days for further observation and procedures, then patient Z was discharged October 9,
2021. She was given home medication. After 3 days, she was readmitted at same hospital due to another
episode of vaginal bleeding. 2 units of PRBC blood transfusion given, observed for 2 days. She was
discharged with home medication. On October 16, 2021 patient had another bleeding prompting to
admission at BGHMC. She was given another 2 unit of PRBC blood transfusion.
IV. Past History Illness
Patient had a history of anemia, but no previous hospitalization. She gave birth at St. Louis University
Hospital of the Sacred Heart last October 5, 2021 wherein she had developed uncontrollable bleeding
which leads to blood transfusion. She was admitted at Baguio General Hospital and Medical Center last
October 16, 2021 due to uncontrolled bleeding.
A. General Survey
During the assessment on the first day of rotation, patient Z was received awake lying on bed with an
ongoing IV fluid of PLRS IL x 12 hours infusing well on her left arm. She appeared weak, needs
assistance when assuming activities of daily living like changing clothes and going to the comfort
room. She is conversant and responds to any question asked, she is aware of present situation that led
her to Baguio General Hospital after delivery.
Head Normocephalic; colored hair: brown, fine long and evenly distributed.
Oiliness with no lesions; No pain, lumps or tenderness during palpation and
the position of head is symmetrical with the body. Temporal artery is
nonpalpable.
Eyes Symmetrical; pupils are brown and equally round in both eyes; pupils are
reactive to light; Pale pinkish conjunctiva was observed; smooth and white
moist sclera; eyelids are free from erythema, edema, discharges and lesions;
Ocular movement intact; able to follow penlight with gaze by introducing
Snellen chart; Able to distinguish different colors.
Ears Parallel, symmetrical and proportional to the size of her head; Ear canals are
impacted with cerumen; Nontender pinna and mastoid; absence of lumps or
nodules when palpating.
Nose & Sinuses Nose is patent, proportional and symmetrical on her face; septum located at
the midline with no flaring of the nose noted; Nontender sinuses on palpation
and no pain during percussion; Moist pink, intact and smooth nasal mucosa;
No inflammatory, frontal, sphenoid, ethmoid and maxillary sinuses.
Mouth Intact lips, gums and buccal mucosa; pale moist, intact hard palate and rises
on “ah” word on the soft palate; complete set of yellow, misaligned adult
teeth without dental carries.
Neck Aligned to the midline of the chest and head; Able to move neck in different
directions without complain; carotid pulse is bilaterally symmetrical, full and
strong pulse; No jugular veins distention noted; Thyroid and trachea is
located at the midline.
Chest Symmetrical chest expansion; no decreased tactile fremitus on both lungs;
Clear lungs upon auscultation’ Rises and falls noted during respiration;
Respiration ranges from 16-20 bpm.
Breast Non-inverted dark brown nipples; Negative masses; No lumps and tenderness
noted upon palpation.
Genitals Episiotomy done in the right medio lateral during delivery’ Excessive
discharges of blood as stated by the patient.
Musculoskeletal Weak range of motion and muscle strength of 3/5 on both right and left upper
extremities. Moderate range of motion and muscle strength of 4/5 on lower
extremities.
Integumentary Brown skin color all over the body’ Warm to touch; no edema; good skin
turgor; Nails are well trimmed
C. 13 Areas of Assessment
1. Psychosocial Status:
She lives with her mother, husband and her son. She is a Roman Catholic, an elementary school
teacher in La Trinidad. She is primigravida. According to Erick Erickson’s Psychosocial
development theory, patient’s task is intimacy vs. isolation. This stage occurs during the young
adulthood from the age 19 through 40 years. During this period, the young adults tends to deal
with the sense of identity deepen their capacity to love others and care for them. They also enjoy
adult freedom and responsibility. She expressed concern about the wellbeing of her newborn son.
4. Environmental Status
Patient was admitted at BGHMC Obstetric Ward. The ward is congested. There are
approximately 17 beds with just enough space for visitors to walk by and watchers to sit in. Her
bed is situated inside the main ward at the window side near the nursing station. She has a
bedside table where there is storage of food, water and other essential belongings. Bed rails are
available. There are windows which results to good ventilation. She verbalized that it was
difficult to nap or take rest because of the people passing by. She was easily disturbed by
neighbor’s patient and has lack of sleep when vital sign is taken. She commented that the hospital
staffs are very kind and friendly.
5. Motor status
Prior to hospitalization, patient can do activities of daily living alone without assistance. Upon
admission, she can hardly perform ADLs; she needs assistance in walking and moving to bed.
6. Nutritional Status
Patient stated prior to hospitalization, she eats 4 times a day. She eats cup of rice and not selective
on food. She would eat fruits and vegetables. Upon her hospitalization, her normal diet was
changed to foods which can easily heal her body faster. She finished more than half of her food
on the tray served to her and eats 3 times a day. She has no history of food allergies. She was
encouraged to increase fluid intake and increase food rich in vitamin, iron and protein which she
acknowledged to do. She loves eating fruit mostly banana and watermelon which can also
increase nutrients in the body.
7. Elimination status
Patient verbalized that she defecates daily with a normal characteristic; brown in color. She
usually urinates 5-7 times a day with light yellow color. She urinates and defecates in the comfort
room.
9. Circulatory Status
Heart rate was noted to be high due to low oxygen circulation in the body. No heart murmurs and
regular rhythm. Capillary refill on all extremities are 1-2 seconds indicating low blood circulation
on all extremities. The circulatory status of patient as well as blood pressure is noted below.
During monitoring, the average heart rate for adult is between 60-100 bpm. Patient’s heart rate
ranges from 96-98 bpm which heart is of high quality upon auscultation.
Patient has a brown complexion. She has oily skin and no edema. She has good skin turgor which
goes back immediately within 1-2 seconds.
X. Diagnostic
1. CBC
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