Name of the patient: Conchita Bagtas Santos Assessment A.

Nursing History Nursing Diagnosis Deficient fluid volume related to blood loss as evidenced by heavy vaginal bleeding and decreased hemoglobin and hematocrit results. Rationale Predisposing factors: 49 yrs. old with G6P4 with 4024 TPAL. The patient was hospitalized due to heavy vaginal bleeding. Lab results: decreased hemoglobin (Hgb) and hematocrit (Hct). Goal After 1-2 days of the nursing intervention, the patient will be able to: experience or maintain adequate fluid volume will have a stable vital signs especially Blood Pressure have the normal hemoglobin (Hgb) and Hematocrit (Hct) level.

Nursing Interventions and Rationale Monitor vital signs, noting in increased in pulse and respiration, decreased blood pressure (BP). Rationale: Dehydration and hypovolemia requires prompt intervention to prevent impending shock. Monitor active fluid loss. Rationale: Maintain accurate input and output Drink the prescribed amount of fluids. Rationale: Oral fluid replacement is indicated for mild fluid deficit. Provide proper ventilation. Rationale: To avoid other fluid loss through excessive sweating (hyperhidrosis).

Age: 49 yrs. old Female

Past History: +Hpn (Hypertension) (2012) maintained amlodipine 5mg/tab, tab OD, UBP 120/80 mmHg; HBP 160/90 mmHg +blood transfusion (2010)

G6P4 =4024 (TPAL)

B. Subjective NONE C. Objective Chief Complaint: Heavy Vaginal Bleeding Sept. 10, 2012 Vital Signs 7am: BP 120/80 P.R. 74 R.R. 20 Temp 36 C 8am: BP 130/80 P.R. 64 R.R. 20 Temp 36 C Blood Group B Blood Rh - Positive

D. Laboratory Exams

Nursing Interventions and Rationale

Instruct client to eat green leafy vegetables. Rationale: To increase hemoglobin level.

SPECIMEN: BLOOD COAGULATION RESULT UNIT REFERENCE ASSAY RANGE PROTHROMBIN 12.7 SECS 10.3 14.1 TIME NORMAL 12.0 SECS CONTROL PROTHROMBIN 1.0 RATIO INTERNATIONAL 1.0 0.8 1.3 NORMALIZED RATIO ACTIVATED PTT 27.8 SECS 27.0 45.4 NORMAL 36.5 SECS CONTROL BLOOD CHEMISTRY S.I. TEST RESULT FEMALE REFERE NCE RANGE CREATININE 0.73 mg/dL 0.5 1.2 SODIUM 141.00 mmol/L 137 147 POTASSIUM 3.63 mmol/L 3.8 - 5 (low) RESULT CONVETIONAL REFERE FEMALE NCE RANGE 64.5 umol/L 44.20 106.08 141 mmol/L 137.00 147.00

3.6

mmol/L

3.80 5.00

Evaluations The goals are met when the patient: has a stable vital signs (BP, P.R. R.R. and temperature.) normal hemoglobin and hematocrit level. experiences adequate fluid level. understand the importance of eating foods rich in iron such as liver, green leafy vegetables, egg yolks and dried fruits.

COMPLETE BLOOD RESULT UNIT REFERENCE COUNT RANGE HGB 67 g/L 120 170 RBC 3.90 x10^12/L 4.0 -6.0 HCT 0.23 0.37 0.54 MCV 58.40 6^3 87 + -5 MCH 17.10 pg 29 + -2 MCHC 29.30 g/dL 34 + -2 RDW 21.30 11.6 14.6 MPV 9.40 fL 7.4 10.4 PLATELET 466 x10^9/L 150 450 WBC 7.80 x10^9/L 4.5 10.0 DIFFERENTIAL COUNT NEUTROPHILS 0.69 0.50 0.70 METAMYELOCYTES BANDS 0.01 0.00 0.05 SEGMENTERS 0.68 0.50 0.70 LYMPHOCYTES 0.31 0.20 0.40 MONOCYTES 0.00 0.07 EOSINOPHILS 0.00 0.05 BASOPHILS 0.00 0.01

Submitted by: Liza Marie C. Adarn e 2-NUR1, RLE 1

Submitted to: Mrs. Ma. Elena Ramirez