Case of Vaginal Bleeding

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I.

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

II. Chief Complain


Vaginal bleeding
III. History of Present Illness

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.

V. Family Health History


Patient also explained that his father suffered respiratory infection, and colon cancer other than that, her
family has no any medical history.

VI. Developmental History


Patient Z is the youngest out of the other siblings. She is 29 years old with the task of developing her
intimacy recording to Erik Erikson’s family and they will probably develop feelings of isolation. She
has no problem with self-image and concept. She is a college graduate with a course of Teacher
Education.
VII. Social and Environmental History
According to patient, she lives in a house with her husband, and her mother as well. Houses are not
congested. She commutes daily using the public utility jeep for her transportation going to work. The
house was made of materials such as cement and wood. The house is composed of 4 separate rooms.
Water used daily is being supplied by La Trinidad water district while the source of drinking water is
purified water delivered by station nearby. The patient visits Barangay Clinic for health problems that are
unresolved by home remedies and rest. As a family that belongs to middle class, access to health care
facilities and management is not too much of a problem since she is an elementary teacher at Bekkel
Elementary School and at the same time her relatives also help her with her financial expenses like
hospital bills.

VIII. Lifestyle and Health Practices


She doesn’t smoke and drink liquor, as an Elementary Teacher she is aware about proper nutrition and
diet. Patient Z stated prior to hospitalization, she eats 4 times a day. She eats rice and not selective on
food. She would eat fruits and vegetables. Upon hospitalization, her normal diet was changed to food
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 drinks 6-8 glass of water a day.

IX. Health Assessment

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.

B. Head to Toe Assessment

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.

2. Mental and emotional status:


According to Alfred Adler’s inferiority and superiority complexes, patient falls under the inferior
complex which is an exaggerated feeling of weakness and inadequacy. Adler thought that lack of
self-worth, a doubt and uncertainty could cause inferiority. Patient expressed feeling of being
depressed, she is conscious, coherent, oriented about what led her to the hospital. She is
conversant; she can speak English, Ilocano and Tagalog. She is able to recognize the nurses and
doctors upon visiting and she acknowledges health teaching during the nursing interventions. She
verbalized her feelings and concern regarding nutrition related to her current condition.
3. Sensory Status
She doesn’t wear any device for her vision. The orbital area appears clear, the color of her iris is
brown and pupils are reactive to light with symmetrical constriction dilation when stocked by
light. Eyebrows are symmetrical. Eyelashes are equally distributed, no discharges on eyelids. She
is able to distinguish objects and colors from a distance of not more than 6 feet her movement by
introducing Snellen chart. The lips are symmetrical in shape, light brown gums. There is no tooth
carries noted. Tongue is pink, she was able to distinguish taste and differentiate flavors like when
she tastes a coffee. No difficulty in swallowing. When observed well, oral mucosa is moist and
pinkish. Her ears are symmetrically proportional to the size of the head with firm cartilage and
presence of impacted cerumen. There are no lesions, deformities and tenderness upon palpation.
She can properly hear what you verbalize by introducing whispering test, all discussion made and
she is able to respond accordingly and her nose is located at the midline, bilaterally symmetrical
and proportional to the face. No discharges and no nasal flaring noted. According to the patient,
she has no history of nose infections. She can also determine and distinguish scents and fresh
odors of certain items on both nares such as rubbing alcohol, perfumes and other scented items.
In assessment of her sense of touch, patient was able to distinguish on both extremities cold from
hot by using a sharp and dull end when the tip of the pen and the cap of marker are placed on her
left arm and lower extremities. She was also instructed to close her eyes while performing a
tactile differentiation test that includes distinguishing different objects like pen, cup of water,
books and pillows.

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.

8. Fluid and Electrolytes status


Patient was receiving an ongoing IVF of PLRS1L x 12 hours infusing well on her left hand.
During intervention, patient drinks more than 6-8 glass of water daily.

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.

Oct. 17, 2021 Oct. 18, 2021 Oct. 19, 2021


8am HR: 97 HR: 97 HR: 98
10am HR: 98 HR: 96 HR: 98
2pm HR:98 HR: 98 HR:98

10. Respiratory Status


Varying respiratory rate is caused by her body trying to compensate and release acidity through
expiration of carbon dioxide; she has no difficulty in breathing, no chest indrawing or use of
accessory muscle, no grunting and no wheezing.

Oct. 17, 2021 Oct. 18, 2021 Oct. 19, 2021


8am 16 bpm 19 bpm 19 bpm
10am 16 bpm 17 bpm 18 bpm
2pm 17 bpm 18 bpm 19 bpm

11. Temperature Status


Patient skin is warm to touch. Normal axillary temperature is within 36.4- 37.5 °C. Her
temperature is within ranges from within 36.4- 37.6 ° C taken through axilla.
Oct. 17, 2021 Oct. 18, 2021 Oct. 19, 2021
8am 36 °C 36.1 °C 36.4 °C
10am 26.9 °C 36.4 °C 36.3 °C
2pm 36.5 °C 36.7 °C 36.5 °C

12. Integumentary Status

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.

13. Rest and Comfort


Prior to hospitalization, patient sleeps 6-8 hours a day, uninterrupted. During her
hospitalization. She has lack of sleep when the nurse gets viral signs.

X. Diagnostic
1. CBC

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