1. 5
CASE STUDY
I.PATIENT’S PROFILE
Name: R.G.B.
Address: Banganan, Aritao, Nueva Vizcaya
Birthday: January 15, 1995
Age: 17 years old
Occupation: None
Marital Status: Single (live-in)
Religion: Roman Catholic
Educational Attainment: College Undergraduate
Ward: OB
Chief Complaint: Labor Pains
Admitting Diagnosis: G1P0, PU 38 5/7 weeks AOG, CIL
Principal Diagnosis: G1P1 (1001) PU, Cephalic delivered spontaneously to live
Baby girl wt. 3240 g , ht. 52cm, AS 8/9
Date/Time of Admission: September 05, 2012, 11:10 AM
Date/Time of Discharge: September 07, 2012, 4:00 PM
2. 6
II. NURSING HISTORY
A. HISTORY OF PAST ILLNESS
Patient stated that when she was young, she had experienced having allergies with
sea foods. Her body was covered with rashes after eating this. Her parents used to
treat this allergy with an anti-histamine oral drug and a topical cream to alleviate the
itchiness which was prescribed by a physician. The patient stated that she completed
her immunization from birth to childhood.
B. HISTORY OF PRESENT ILLNESS
At the night of September 04, 2012 the patient felt minimal contractions but it
stops after few minutes. Until the morning of September 05, 2012 at 4:00 AM she
felt true labor that begins irregularly but become regular and predictable. She felt the
pain in her lower back and sweep around to the abdomen in a wave-like motion. She
also stated that whatever level of activity she does the contraction still continues. She
also felt minimal fluid discharge. When she was unable to tolerate the pain she
decided to go to the hospital accompanied by her mother and live-in partner.
Prior to admission physical assessment was taken with initial vital signs of CR
(85 bpm); RR (20 cpm); BP (120/90 mmHg). FH of 27cm and (-) BOW. At 11:10
am she was admitted after the physician performed IE and found out that she is in
active phase with a cervical dilation of 6cm.
C. OB HISTORY
The patient’s menarche was December 06, 2006. She has 8 days of menstruation
and has a 32 days cycle. She has heavy blood flow during her 1st and 3rd day and a
minimal blood flow on her succeeding days. She easily got angry and irritable during
her menstruation. She also become lazy to do her work and suffered dysmenorrheal.
She’s not taking any medication to relieve the pain of dysmenorrheal.
Patient RGB’s LMP was December 07, 2011. She noticed that she has delayed
menstruation last January 2012 and she taught she’s pregnant. She used a pregnancy
kit to prove her doubt and luckily it is positive. During her first trimester, the patient
has a frequent urination and constipated. She also crave for foods such as mango.
She feels nauseated and vomits afterwards. On her third month of pregnancy she
started to visit the RHU for her prenatal care and received TT1 Vaccine. After 3
months she received her TT2 vaccine. She did not continue to complete her Tetanus
Toxoid Vaccine. During her 2nd and 3rd trimesters she felt discomforts such as
headache, backache, dyspnea, frequent urination, and Braxton hicks contractions.
She usually eats vegetables and foods rich in protein like meat during pregnancy.
Her EDC was computed and dated September 14, 2012. Her Gravida Score is
G1P0, PU 38 5/7 weeks AOG, CIL. She gave birth to a live baby girl wt of 3240g
and length of 52 cm, AS of 8/9. The physician administer local anesthesia (lidocaine)
to the patient before episiorraphy. There is no mcomplication and special treatment
during her delivery and to her baby.
D. SOCIOECONOMIC HISTORY
Her family income ranges from 8,000-11500 pesos monthly. This income came
from her uncle who works in London, from her live-in partner who works as a
tricycle driver and to her father who used to work in their rice farm. The family’s
incomes were distributed accordingly by percentage as shown in the Pie Graph.
3. 7
Family Income
21%
foods
32%
clothing
medication
saving
16%
bills
10% needs of baby
11%
10%
E. ENVIRONMENTAL HISTORY
The patient lives in Banganan, Aritao, Nueva Vizcaya. Their house is made of
concrete materials and well ventilated. Their source of drinking water came from a
water refilling station near them. They also practiced proper segregation of waste
products into biodegradable and non-biodegradable.
F. OCCUPATIONAL HISTORY
Patient R.G.B. was a college undergraduate who worked as a computer clerk in
her aunt’s computer shop. When she got pregnant she was informed of the
teratogenic effects of computers due to radiation which will affect her pregnancy.
Since then she stopped working and stayed at home until she got the baby delivered.
G. FAMILY HISTORY
Both from her mother’s side the patient stated that her grandmother got sick due
to CA and her uncle suffered HTN.
H. LIFESTYLE
The patient describes her day as an ordinary day. She used to help in household
chores with her mother. She is fond of eating frozen products such as hotdog, tocino
and longganisa as her breakfast, meat, and vegetables during lunch and supper. She
loves to eat chocolate, drink milk, fruit juices and carbonated drink such as coke.
When she studied college, she used to smoke and drink alcohol for 3 months. She
quit her vices when she knows that she was pregnant.
I. RECREATIONAL ACTIVITIES
Patient R.G.B. was not fond of liking sports. She spent her leisure time
watching Television movies, and listening to radio, do texting and surfing the
internet sometimes.
