ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING

I. PERSONAL DATA:
Name of Patient: A.C. Smith
Civil Status: Married

Gender: Female

Birthdate: March 22, 1977

Age:

37 years old
Address: Mabalacat, Pampanga
Date & Time of Admission: November 13, 2014 at 11:30 pm
Medical Diagnosis: Uterine Myoma

II. HISTORY:
A. Chief Complaint:
The client reports heavy vaginal bleeding, dizziness, vomiting,
headache, and verbalized Masakit na masakit ang likod ko.
B. Brief History:
The client was home when she started feeling dizzy, headache,
and back pain. Her pain scale is 6/10. She vomited 2x at home. She
also noticed blood on her underwear and she described it as dark red.
On her assessment the nurse noticed that she has weak in
appearance, pale lips, and pallor.

III. ASSESSMENT:
A. Vital Signs:
Morning
T: 36.7 celcius
PR: 82 bpm
RR: 18 bpm

BP: 110/70 mmhg

B. Review of System:
a. General Appearance:

The client was seen in a sitting position on bed, conscious, awake and
coherent, oriented
to time, place and person with ongoing IVF #11 0.9% Nacl 1L at
900cc level infusing
well on right metacarpal vein. Vital signs taken as follows:
Temp:

36.7 celsius

Pulse:

82 bpm

RR:

18 bpm

BP:

110/70 mmhg

b. Integumentary:

Skin: The clients skin is pallor in color, smooth, and no presence of

any foul odor. She

has slight poor skin turgor, and skins

temperature is within normal limit.

Hair: The hair of the client is black, thick and evenly distributed.
There are no signs of infection and infestation observed.

Nails: The client has pale nail beds and has the shape of convex
curve.. It is smooth and is intact with the epidermis. When nails
pressed between the fingers (Blanch Test), the nails doesnt return to
usual color in less than 3 seconds.
c. Head:

Head: The head of the client is rounded, normocephalic, and

symmetrical.

Skull: There are no nodules or masses and depressions when

palpated.

Face: The face of the client appeared smooth, uniform consistency,

and with no presence of nodules or masses.

d. Eyes and Vision:

Eyebrows: Hair are evenly distributed; skin intact, symmetrical, and

equal movement.

Eyelashes: Short, equally distributed, and curled slightly outward.

Eyelids: Skin are intact, no discharge, moist and pink, and

involuntary blinks.

Sclera: Appeared white.

Lacrimal Gland: There is no edema or tearing.

Cornea: Transparent, smooth and shiny, and the details of the iris are
visible. The client

blinks when the cornea was touched.

Pupils: Eyes are black and equal in size. The iris is flat and round
PERRLA (pupils equally round respond to light accommodation),
illuminated and non-illuminated pupils constricts.

e. Ears and Hearing:

Ears: The Auricles are symmetrical and has the same color with her
facial skin. When palpating for the texture, the auricles are mobile,
firm and not tender.

Nose: The nose appeared symmetric, straight and uniform in color.

There was no presence of discharge or flaring.

f. Mouth:

The lips of the client are pale, symmetric and have a smooth.

The tongue of the client is centrally positioned. It is pale in color and

slightly dry.

g. Neck:

The neck muscles are equal in size.

The lymph nodes of the client are not palpable.

The trachea is placed in the midline of the neck.

h. Thorax and Lungs:

Lungs/Chest: The clients lungs are clear upon auscultation during

respirations.

Heart: There were no visible pulsations on the aortic and pulmonic

areas.

Abdomen: The abdomen of the client is round and symmetrical, mass

noted on the lower abdomen upon palpation.
i. Breast and Axilla

Breast: The breast is firm, symmetrical, with pink striae, and not

tender.
Areola/Nipple: Areola is brown and nipples are reverted and no

unusual discharge upon palpation of the nipples.

Axillary: Hair noted with adequate distribution and no foul
smelling. Lymph nodes on the axillae are not swollen upon
palpation.

J. Extremities:

Extremities: The extremities are symmetrical in size and length.

Muscles: The muscles are not palpable with the absence of tremors.

Bones: There were no presence of bone deformities, tenderness and

swelling.

Joints: There were no swelling, joints move smoothly and negative in

homans sign.

IV: MANAGEMENT

LIST OF
MANAGEMENT
RENDERED
1. Monitored
vital signs.

DATE
PERFORME
D
11/24/2014

DESCRIPTION

Thermometer
and stethoscope
are used for
vital signs

RATIONALE

Provides baseline
information for
comparison of
changes.

taking.
2. Encouraged
fluid intake and
monitored daily
fluid intake and
output.

11/24/2014

Asked client
how many times To detect signs of
her urine output dehydration.
is per day.

3. Monitored
respirations and
breath sounds.

11/24/2014

Used
stethoscope for
checking.

11/24/2014

Checked if shes
To provide surface
wearing loose
cooling.
fitting clothing.

11/24/2014

The client
To avoid
should have
exhausting the
enough rest and client, this may
sleep.
lead on fluid loss.

4. Loosened
clothing
5. Advised client
to get adequate
rest and sleep.
6. Assessed
characteristic,
severity,
precipitating
factors of pain.

11/24/2014

Indication of
respiratory
distress.

Noted changes
from previous
reports.

To rule out
worsening of
underlying
condition or
development of
complications.

Dependent

An antifibrinolytic.
It works b
preventing blood
clots from breaking
down too quickly. It
helps reduce
excessive bleeding.

Dependent

Its a body mineral.

It is used to treat
iron deficiency
anemia.

7. Administer
analgesics as
ordered.

a. Tranexamic Acid

b. Ferrous Sulfate

IV: REFERENCES
Murr, Alice, Doenges, Marilynn, and Moorhouse, Mary Frances.
(2010). Nurses Pocket Guide. Philadelphia, Pennsylvania: F.A Davis
Company.
http://www.drugs.com