: Based on the case study below In a tabular form make 1…

: Based on the case study below In a tabular form make 1… : Based on the case study below In a tabular form make 1 NCP including the assessment( subjective and objective), Nanda Diagnosis, Planning( Short and long term goal), Intervention ( independence and collaborative), Rationale and evaluation Case Study Incomplete AbortionGeneral Data This is the case of Patient B.M, 39 years old G7P6 (6006) 7 4/7 weeks AOG, female, Filipino, Roman Catholic, married, currently lives in Mapandan Pangasinan, admitted for vaginal bleeding in Pangasinan Provincial Hospital on November 28,2020 around 12:20 pm.Informant: patient herself with a reliability of 80%Chief complaint Vaginal bleeding, History of Present illness3 days prior to admission, the patient experienced crampy abdominal pain located in the hypogastric area with a pain scale of 7/10. patient took mefenamic 500 mg but the symptoms unrelieved. 2 days prior to admission, while working in her parlor around 8:24 am, the patient experienced heavy vaginal bleeding consuming 3 napkins fully soaked, along with abdominal pain in the hypogastric region that is radiating to the lower back. The patient took Cephalexin 3x a day to relieve the symptoms. 1 day prior to admission, vaginal bleeding with intermittent fever and headache characterized as crampy and bitemporal in location. Paracetamol 500 mg was taken to relieve the symptoms Few hours prior to admission, heavy vaginal bleeding, hypogastric pain, fever with nausea and vomiting along with headache that prompted her for hospitalization.Past Medical History The patient has no previous hospitalization or any surgeries noted. No medical history of cancer, TB, asthma, diabetes and hypertension.Family HistoryPatient’s mother has hypertension, father has rheumatoid arthritis No pertinent medical history of the siblingsPersonal and social HistoryPatient lives in a concrete bungalow house, with 2 bedrooms and 1 cr with her children and husband. The patient is a college graduate currently working in a parlor shop. Patient is a smoker consuming 3 sticks per day, occasional drinker consuming 1 bottle of emperador lights. Diet consists mainly of fish, meat, eggs, vegetables and rice.Obstetric and Gynecological HistoryMENSTRUAL HISTORY • Patient B.M menarche started when she was 18 years old, her menstrual duration is 4-5 days, regular cycle of 28, with lighter menstrual flow on the first day and become gradually heavier towards the end of menses consuming 3 pads in a day. The patient reported of having severe dysmenorrheal on every first day of her menstruation. The patient reported that the dysmenorrhea is severe with a pain scale of 7/10 and mefenamic acid 2x a day was taken to relieve the pain.LMP: October 7, 2020EDD: July 14,2021AOG: 7 4/7 weeksNumber of pregnancy  Place of delivery  Date of birth Type of delivery  complications G1 R1MC 1995  NSD  none G2  R1MC  1998 NSD  none G3 R1MC  2001 NSD  none            G4  R1MC  2003 NSD  none            G5 R1MC 2006  NSD  none            G6  R1MC 2009  NSD  none G7 PPh Gynecologic HistoryNo history of sexually transmitted disease, fibroids, endometriosis, urinary incontinence, pap smear, mammogram, colonoscopy and post coital bleeding.Contraceptive HistoryThe patient reported of using contraceptive pills specifically lady pills for 1 year however discontinued afterward because of nausea.Physical AssessmentGeneral (+) fever(+) crampy abdominal pain,(+) vomiting,(+) headache(+) heavy vaginal bleedingBP: 100/80 mmhgRR; 20cpmTemperature: 36.3CPR:100 bpmAdmitting diagnosis: G7P6 (6006) 7 4/7 week AOG to consider incomplete abortion; non septic, non-induce.LaboratoriesNormal valueshemoglobin  67  120-150 g/lhematocrit  20 37-47 vol %WBC  9.93  5-10 x 10/lPlatelet count  178 150-350Segmenters .46 .50-.70Lymphocytes .37 .20-.40Eosinophils .01  .02-.04Stabs .01 .03-.05Vital SignsBP 90/60 mmhgtemperature 38 ^CRespiratory rate 20 cpmPulse rate 100 bpm  IE: cervix is open with placental fragmentsMedicationsCephalexin 500mg 1 cap 3 x dayMefenamic acid 500mg 1 cap 3 x a dayParacetamol 500mg 1 cap every 4 hours Health Science Science Nursing NURS 101

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