DEMOGRAPHIC DATA Name: Patient Dense Age: 35 y/o Address:Burgos St.

Cauayan Isabela Religion: Methodist Status: Married Occupation: Labandera Admitted at: Cauayan Medical Specialist Hospital Principal Diagnosis: Abortion incomplete Post op: abortion complete Procedure: Dilatation and curettage G3P3 Surgeon: Dra. Susan Tan Initial vs: T:37.3, PR: 80, RR:24, BP:90/60 NURSING HISTORY PAST MEDICAL HISTORY According to the patient, she was hospitalized last 2002 and 2005 due to giving birth to her children. No other illnesses or reasons that would cause her to be hospitalized. PRESENT MEDICAL HISTORY 2 weeks prior to admission, the patient experience mild vaginal bleeding without pain but she ignored it . Five (5) days prior to admission, the patient noticed mild to moderate vaginal bleeding with pain on her abdomen. 1 hour Prior to admission, the patient experience severe vaginal bleeding with intermittent pain so her family confined her at CMSH at exactly 11:00 am. Her initial vital signs are T:37.3, PR: 80, RR:24, BP:90/60.

FAMILY HISTORY: According to the patient, she had a history of Hypertension on her father side but doesnt have any history of DM, allergy, asthma, cancer SOCIAL HISTORY: The patient works as a labandera in their barrio. After doing the laundry, she goes home immediately to take a rest. Every weekend she spends her time taking care of her children while his husband is working in the farm. She doesnt smoke or even drink liquor. The patient doesnt finish her studies in high school due to financial problem but she can read and write.

GORDONS FUNCTIONAL HEALTH PATTERN Health Perception and Health Management Pattern The patient has a minimal knowledge about her case because she didnt finish her studies due to financial problem. Mrs.Dense chose to work harder than usual without consulting her condition to the physician. According to her, health is very important especially when you are pregnant in order to keep you both alive Nutritional Metabolic Pattern Prior to admission the patient eats varieties of food but she prefers to eat vegetables. She consumes 3 regular meals a day with approximately 2 cups of rice. Occasionally, she consumes about 1 bottle of softdrink a day but she can consume 7 glasses of water. The patient doesnt drink liquor nor smoke. During hospitalization, the patient was on DAT. She consumes about half cup of rice each meal and drinks 7 glasses of water a day. She said she has a poor appetite due to her condition. Elimination Pattern Before hospitalization, the patient urinates 3-4 times a day and defecates once a day. During hospitalization, the patient urinates 2-3 times a day and defecates every other day Activity-Exercise Pattern Before hospitalization, the patient spends her time In washing the clothes of her amo ad it serves this as her exercise. After that, she goes home immediately to take a rest. E

During hospitalization, the patient spends her time lying on bed. She was advise to take a rest and ordered some activities that is necessary for her condition and those that are restricted for few weeks like sexual intercourse, heavy lifting, etc. SLEEP REST PATTERN Before hospitalization the patient sleeps at night around 9pm and wakes up at 5:00am to cook food for her children . She doesnt have any sleep disturbance because she is tired from work During hospitalization, the patient has difficulty sleeping because of the hospital routine like vital sign monitoring . She also reports of pain after the procedure d and c Cognitive Perceptual Pattern The patient didnt finish her studies in high school due to financial problem but she can read and write. The patient answers coherently and directly. She is aware on her present condition and environment in fact she is willing to continue her medications because she wanted to return on normal condition. Self Perception The patient had a fear of losing her baby again the next time she gets pregnant. According to her there was no change in her senses except on eating foods because she has poor appetite. Role Relationship Pattern Before hospitalization, the patient performs her role well as a mother and wife. She did the household chores and takes care of her children During admission, the patient cannot perform her role as a mother because of her condition. She said she wanted to return in normal condition again. Sexuality Reproductive Pattern The patient is sexually active. Her husband used condom as a contraceptive method for family planning. Coping Stress Pattern According to the patient, whenever she has a problem she tells it immediately to her husband. If she is stress fro work, she just takes a rest and listen to the radio and sometimes she takes a nap. Value Belief Patttern The patient is Roman Catholic. She don believe in ghost and superstitious beliefs. Sometimes she used herbal medicines lie oregano.

LABORATORY RESULT HEMATOLOGY Hemoglobin hematocrit WBC segmenters lymphocyte eosinophil monocyte NORMAL VALUES Male:130-180 g/l Female: 110-160g/l Male:40-54 Female: 37-47 5-10 x 109 50-65% 25-35 1-3% 3-7% RESULT 129 g/l 38.5 5 72.1 21.4 6.5 6.5 INTERPRETATION normal normal normal d/t infection d/t infection d/t infection normal