General
To render efficient and effective nursing care by the utilization of the nursing process
Specific
1. To establish rapport with the patient.
2. To acquire knowledge and fully understand the disease process.
3. To gather vital information or data about the patient.
PATIENT’S PROFILE
Name: Anabelle Tud
Birthday: November 10, 1968
Address: District 1 Gigmoto, Catanduanes
Religion: Roman Catholic
Age: 43 years old
Civil Status: Married
Date of Admission: August 13, 2012, 9:30pm
Complaint: RLQ pain
Tentative Diagnosis: PU 32-33 wks, AOG CML, T/C UTI G11P10
Final diagnosis: PU 32- 33 wks AOG, Placenta Previa partialis
Attending Physician: Dr. Romano
Physical examination upon admission: conscious and coherent V/S taken as follows: Blood pressure: 110/70 mmhg Pulse rate: 98 bpm Resp. rate: 20 bpm Temperature: 36.9 *C
Obstetric History
Age of menarche: 15 yrs of age
Interval: monthly
Duration: 3 days flow
Flow: moderate
AOG: 32. 33 FHT: 134 bpm FH: 24 cm
Health History Anabelle tud is a 43 year old woman, married, living in District 1, Gigmoto, Catanduanes.she had her menarche at the age of 15. She has 10 children and currently having her 11th baby. Her last child was born 2 years ago. All of her child was born NSD and she has not been hypertensive since. Curretly, anabelle was on her 8th month of pregnancy. While seating on a bench, she suddenly felt a very severe pain in the right lower quadrant of her abdomen. She didnt ot felt this kid of pain ever in her entire pregnancy. She describes the pain as if she is on labor. She was then admitted to the OB ward-EBMC.
Her urine was tested and she was internally examined by DR. Rendon and found out that he cervix was not dilated. Her urine was positive for UTI.
Initial Physical Examination Upon initial physical examination, Mrs. Anabelle was diaphoretic, with bounding peripheral pulses, hypertensive with a BP of