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I.

Demographic Data

Name: Patient X
Sex: Female
Birth Date: 41 years old
Birth Place: Negros Province
Marital Status: Single
Nationality: Filipino
Address: San Antonio 1
San Pablo City, Laguna
Educational Background: High School Undergraduate
Occupation: None
Usual Source of Income:
Admission Diagnosis: Hydatidiform mole, G7P6

II. Source and Reliability of Information

All source of information are collected from Panlalawigang


Pagamutan ng Laguna dated January 15 and 16, 2011. The data
presented in this case presentation are collected from the patient’s chart
and through interview of the patient.

III. Reason for Seeking Care/Chief Complaint


Hematology Report

Date: 1/11/11

Time: 10:15am

Procedure Result Normal Values Significance Nursing


Implication

Hemoglobin 90g/L 110 – 165 g/L Decrease

Hematocrit .27 cv/L 0.35 – 0.50 cv/L Decrease

Blood Typing “B” Rh (+)

Clotting Time 3’ 59’’

WBC 6.6 x 10g/L 5.0 – 10.0 x 10 Normal


g/L
Segmenters 65.2% 43.0 – 76.0 % Normal

Lymphocytes 31.2% 17.0 – 48.0 % Normal

Monocytes 3.6% 4.0 – 10.0 Decrease


Hematology Report

Date: 1/14/11

Time: 3:18pm

Procedure Result Normal Values Significance Nursing


Implication
Hemoglobin 78 g/L 110 – 165 g/L

Hematocrit .22 cv/L 0.35 – 0.50 cv/L

Blood Typing

Clotting Time

WBC 4.9 x 10 g/L 5.0 – 10.0 x 10


g/L
Segmenters 54.9% 43.0 – 76.0 %

Lymphocytes 41.6% 17.0 – 48.0 %

Monocytes 3.5% 4.0 – 10.0

Urinalysis
Macro

Procedure Result Normal Values Significanc Nursing


e Implication
Color Yellow Yellow Normal

Transparency Turbid Clear, Transparent

Reaction Acidic Acidic Normal

Albumin +

Sugar Negative Normal

Micro

Procedure Result Normal Values Significanc Nursing


e Implication
Pus cells 35 – 38 0-5 Abnormal

RBC 8 – 12 0-5 Abnormal

Bacteria + Many

Epithelial Cells #

Crystals #

Amorphous Water #
Blood Chemistry

Date: 1/12/11

Type Result Normal Values Significance Nursing


Implication

BUN 15.9mg/dl 8.0-25.0mg/dl Normal

Creatinine 0.5mg/dl 0.5-1.7mg/dl Normal

Total 120.5mg/dl Up to 200mg/dl Decrease


Cholesterol

Triglycerides 92.8mg/dl 35-135mg/dl Normal

High Density 20.9mg/dl 33-75mg/dl Decrease


Lipoprotein

Low Density 81.0mg/dl 60-160mg/dl Normal


Lipoprotein
Drug Study

Generic Classification Dosage and Indication/ Side – effects Mechanism of Nursing Responsibilities
Name/ Brand Frequency Contraindication Action
Name
Magnesium Antiepileptic 5g q15 IM - to control CNS: Cofactor of many - Give IM route by deep IM injection of
Sulfate Electrolyte hypertension weakness, dizziness, enzymes systems the undiluted (50%) solution for adults,
Laxative fainting, sweating involved in dilute to a 20% solution for children.
- IV: neurochemical
hypomagne CV: transmission and - Do not give oral magnesium sulfate
semia, palpitation muscular with abdominal pain, nausea, or
replacemen excitability; vomiting.
t theraphy GI: prevents or controls
excessive bowel seizures by - Maintain urine output at a level of
-IV or IM: activity, perianal blocking 100mL every 4hr during parenteral
Preeclampsia irritation neuromuscular administration.
or eclampsia transmission;
Metabolic: attracts and retains - Monitor bowel function; if diarrhea
flushing, sweating, water in the and cramping occur, discontinue oral
hypotension, intestinal lumen drug.
depressed reflexes, and distends the
flaccid paralysis, bowel to promote
hypothermia, mass movement
ciculatory collapse, and relieve
cardiac and CNS constipation.
depression -
parenteral