Case Abstract

Case Abstract In partial fulfillment in RLE (Summer)

Acute Uterine Bleeding (AUB) Submitted by: Ms. Rochelle O. de Guzman (Student)

Submitted to: Mrs. Marissa May N. Abuan, RN, MAN (Clinical Instructor)

General Objectives: To become efficient and be a good student nurse. To gained more knowledge in handling patient and give nursing care to the clients.

Specific Objectives: • To facilitate in taking necessary actions to solve and prevent the identified problems on her own. • To render primary treatment on her illness. • To help the client in the motivation of her health care provided by the health workers.

Patient’s Profile Name: Santina Address: P-2 Calaocan, Santiago city Age: 37 y/o Birthday: July 15, 1972 Civil status: Married Husband’s Name: Santino No. of Children: 5 Nationality: Filipino Religion: Roman Catholic Occupation: Housekeeper Chief Complain: vaginal bleeding Diagnosis: Acute Uterine Bleeeding Attending Physician: Dr. Dadural

Present Health History The present health history started two weeks PTA, history of catherization at Dubinan Santiago city, because they all know that she was pregnant but they were had a wrong diagnosis a days after the catherization it’s followed by the episode of vaginal bleeding.

Past Health history Prior to her hospitalization it was her first time to be hospitalized, and she denies having allergies to any foods and drugs. She also said that when she suffered from minor illness she just buy over the counter drugs such as neozep, paracetamol, ponstan.

Family Heath History No hereditary disease can be adopted from her father and mother side.

11 Gordon’s Functional Pattern 1. Health Management Pattern •Before:

Health for her is wealth and it is very important for her

and for her family.

She also believes that being able to perform her daily activities and work signifies good health. •During: She still believes that Health is wealth and we should treasure it for a lifetime because being unhealthy will affect our whole way of living.

2. Nutritional metabolic pattern •Before she eats regularly three times a day and drinks at least 8 to 10 glasses of water daily. •But during hospitalization, she cannot eat well due to loss of appetite and worrying to much on her situation but she always drink 6-7 glass of water.

3. Elimination pattern •Before: She urinates 3-4 times a day and stool one times a day. •During: Her bowel movement is normal but she urinates 5-6 times a day.

4. Activity exercise pattern •Before: She considered exercise her daily activities in the house like sweeping the floor; clean the backyard and many more. •During: She is always in her bed and she has no exercise.

5. Cognitive perceptual pattern

Before and during She finished a degree of Bachelor of Science in nursing and

And her Ability is also in normal condition and she says that she can still remember all the things that happened in their life especially those happy moments with his family and relative. she’s working as a volunteer nurse in the hospital.

6. Sleep rest pattern •Before: She sleeps 9pm-5am; 9hours of sleep normal. •During: She can easily sleep because she feels bored. She sleep 10pm-5am and in the afternoon 3pm-4pm.

7. Self-perceptual pattern •Before: She felt happy and fulfilled by doing her responsibilities as a mother to her children and because she can do what she wants.

• But during the hospitalization she felt worthless and sad because she is worried about the sake of her children and about her hospital bills.

8. Role relationship pattern She had a good relationship to her husband and children. But during the hospitalization she cannot perform her role as a mother and wife. 9.

Sexually and reproductive pattern Before: They have no contact for 3months because his husbands are working in the other country.

During: Same, Nothing has changed.

10.Coping stress management Before: When Problem arises she always put in god and usually wants to be alone.

During having her best friend and family at her side still the best coping management.

11.

Value, belief pattern Before: The client is Roman Catholic. Even though she does not go every Sunday at church, she still believes in god that is superior and the most powerful of all. During: Not attending masses, but she always pray and his faith in god is never lessen even though she had encountered many hardship in her life.

TABLE OF CONTENTS General Objective Specific Objective Overview of the disease

Nursing History a. Patient’s Profile b. Present history of illness c. Past health history d. Family history Anatomy and Physiology Drug study Course in the ward Physical assessment Nursing care management

Course in the ward:  d/s admission to ROC  severe consent for admission and management  TPR q 2 shift to record  v/s q 2 and record  IVF D NSLR 11 * 12  Labs: BT

CBC c APC- stat pls.