I.

Personal Data Name: Polea, Clarissa Cabardo Address: Brgy. 1, San Lorenzo (Pob.)Laoag City, Ilocos Norte Hospital Number: 472153 Sex: Female Age: 31 y/o Date of birth: May 27, 1980 Place of birth: Bohol Civil status: Single Religion: Protestant Educational attainment: High School Undergraduate Occupation: Housekeeper Chief complaint: Acute Pain at lower abdomen and lower back with a pain scale of 10/10 3 hours prior to admission Admitting diagnosis: G5P5 (4-1-0-3) Abnormal Uterine Bleeding T/C Endometrial Hyperplasia VS Polyp, Secondary anemia Date and time of admission: December 26, 2011, 11:15 AM Attending physician: Dr. Gisele V. Gonzales Final diagnosis: G5P5 (4-1-0-3) Abnormal Uterine Bleeding T/C Endometrial Pathology Date and time of discharge: December 29, 2011, 8:40 PM Ms. Clarissa Cabardo Polea, 31 years old born on May 27, 1980 in Bohol. She is a High School undergraduate wherein she only reached first year level. She is protestant and a housekeeper. Shes with her live-in partner Mr.Gilbert Isidro, 33 years old and with their children at Brgy. 1, San Lorenzo (Pob.)Laoag City, Ilocos Norte. Her children are Shane Polea, 5 years old and Danica Polea, 3 years old. Mr. Isidro is an electrician and they have been together for 6 years now. She was complaining of acute pain at lower abdomen and lower back with a pain scale of 10/10 3 hours prior to admission and was admitted at the Mariano Marcos Memorial and Medical Center on December 26, 2011 at 11:15 AM with an admitting diagnosis of G5P5 (4-1-0-

3) Abnormal Uterine Bleeding T/C Endometrial Hyperplasia VS Polyp, Secondary anemia. Ms. Poleas attending physician was Dr. Gisele V. Gonzales and had a final diagnosis of G5P5 (4-10-3) Abnormal Uterine Bleeding T/C Endometrial Pathology. She was discharged on December 29, 2011 at 8:40 PM. II. Family member Gilbert Isidro M 33 y/o Clarissa Polea Reica Soria F F 31 y/o 10 y/o Shane Polea F 5 y/o Single Daughter Single Daughter Single Family Background Sex Age Civil status Single Relationship Educational to the client Live-in partner Client attainment College undergraduate High school Housekeeper None Roman Catholic None Protestant Laoag City Danica Polea F 3 y/o Single Daughter None None Protestant Laoag City Protestant Electrician Protestant Occupation Religion Place of residence Laoag City Laoag City Bohol

undergraduate Elementary level Preschooler

The family of Ms. Polea is a cohabitation type of family and is also a patriarchal type because Mr. Gilbert Isidro, the live-in partner of Ms. Polea heads it. They were gifted with two children, Shane who is 5 years old and Danica, 3 years old. Reica who is Ms. Poleas first child with her first partner is now 10 years old and living in Bohol with her father. Mr. Gilbert Isidro is the one who is working for the family and he works as an electrician in his brothers shop. Ms. Polea said that his partner has relatives abroad but none of them are giving them financial support. Every month Mr. Isidro gets an income of Php 20,000. With that income he is the one deciding on how the money will be spent and allocated on their monthly expenses. According to Ms. Polea the income of her partner is adequate to provide all the

necessities and needs of the family for their everyday living. When some unexpected situations occur like when one of the family members would get sick, Ms. Polea said that they get money from their allotment for health services. Their family based from what we have observed, they are open to one another specially that of Ms. Polea and Mr. Isidro but sometimes they are having some conflicts which they can easily solve. For the children, their conflict is usually due to jealousy when one of them has something that the other one doesnt have. But they resolve the problem immediately with adult authority. Even if there are some conflicts within the family it doesnt greatly affect their good relationship to one another as what Ms. Polea said and they are caring for each other. The family doesnt usually go out as what Ms. Polea said but even though they promote their bonding through celebrating birthdays, Fiesta and other occasions such as New Year, Holy Week and Christmas wherein all of them go to mall and buy things the children would want.

Monthly Allotment
3% 2% 2%

10%

Food Current Health services

15%

50%

Savings Clothing Education Water bills

18%

Monthly Family Income = Php 20,000 Breakdown of Expenses for Necessities Needed Every Month

Food Rice--------------------------------------------------------------- Php 1,450/month Meat and Vegetables------------------------------------------- Php 2,710/month Fish -------------------------------------------------------------- Php 1,540/month LPG-------------------------------------------------------------- Php 700/month Grocery---------------------------------------------------------- Php 3,640/month (Snacks, noodles, canned goods, bread, soap, shampoo, milk, detergent bars toothpaste, olay, seasonings, napkin, etc.) Total ----------------------------------------------------------------------- Php 10,040/month Current bills Current-------------------------------------------------------------- Php 2,000/month Internet-------------------------------------------------------------- Php 1,000/month Cable---------------------------------------------------------------- Php 600/month

Total ------------------------------------------------------------------------- Php 3,600/month Health services Services and medicines------------------------------------------- Php 3,000/month

Clothing Clothes ------------------------------------------------------------- Php 630/month

Education School supplies-------------------------------------------------- Php 100/month Allowance-------------------------------------------------------- Php 250/month School fee-------------------------------------------------------- Php 30/month

Total ------------------------------------------------------------------------- Php 380/month Water bills

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Drinking water----------------------------------------------------- Php 200/month Nawasa------------------------------------------------------------- Php 150/month

Total ------------------------------------------------------------------------- Php 350/month Family Monthly Savings = Php 2,000/month With the monthly income of Mr. Isidro of Php 20,000 they are allocating it to food, which includes meat, fish, rice, vegetables, and LPG gas in which they allot Php 10,040 with fifty percent of their total expenses. They allocate Php 3,600 with a percentage of eighteen percent for their current bills which includes their current, internet and cable. For health services they allocate Php 3,000 with fifteen percent and clothing with a total of Php 630 every month with a percentage of three percent, which is taken from the yearly expenses of the family for their clothing which is divided into twelve months. They also allocate for education with Php 380 and water bill with Php 350 with the same percentage of two percent. According to Ms. Polea every month they are saving two thousand pesos with a percentage of ten percent coming from the total income of the family, which they can use for emergency situations. III. Health History The client does not know the names of her late grandmother and grandfather on both sides. She does not have enough information about them because she did not put much attention about knowing her relatives. The clients parents are Mr. Polirico Polea and Ms. Elmira Cabardo. Her mother was diagnosed to have hypertension, diabetes mellitus and heart enlargement. The client doesnt remember the hospital, the doctor who diagnosed and the management done to her mother. On the other hand, her father suffered from sinusitis. The client also claimed that her father had undergone surgery because of accumulation of fluid on his back. The client doesnt know the exact diagnosis and the doctor who diagnosed him. He died 2-3 months after the operation. Mrs. Elmira has three siblings: Veleriana Cabardo and her twin brothers namely Danielito Cabardo and Daniel Cabardo, who is a pastor. The client does not know a lot of information about the siblings of her mother because of loss of communication.

Family Health History

On the other hand, the clients father has no siblings. The client has five siblings namely Francisco who is 35 years old, Ana Lourdes, 29 years old who suffered from goiter and died due to heart failure, Ethel 27 years old, Michelle 24 years old who is currently suffering from sinusitis and Jr. , 22 years old who had undergone appendectomy last 2007. Mrs. Clarissa is the second child of Mr. Polirico and Mrs. Elmira. She is married to Mr. Gilbert Isidro. They have five children namely Reica, 10 years old, Glaiza who died due to cardiovascular defect, Francis, who was born premature, and had undergone to immediate surgery due to imperforated anus and died after 1 month and 1 week due to complications, Shane, 5 years old and Danica who is 2 years old. When the family experiences common illnesses such as cough, colds and fever they used to take over the counter drugs like paracetamol and neozep. But when the family experiences uncommon illnesses they usually go to the hospital. The family does not prefer to consult a quack doctor. As to their beliefs and practices, the family sometimes uses boiled oregano for cough and for mumps; moist akot-akot is applied on the affected part. For chickenpox and measles the family uses dark colored shirts such as black and brown. They also avoid stepping on chicken manure. Past Health History The client claimed that she had received complete immunizations but failed to mention the vaccines. She has a scar on her right deltoid which proves that she had BCG vaccine. On the childhood days of the client, she experienced having chickenpox and measles. They managed it by taking a bath using boiled guava leaves, wearing dark-colored shirts and they also avoid stepping on chicken manure. She also suffered from cough, colds and fever. For these illnesses she takes over the counter drugs such as Mefenamic acid and Paracetamol. When she was in high school she had her check up at Bohol Provincial hospital and had undergone chest X-ray and found out that she had lung spots that is manifested by difficulty of breathing. She was to be admitted but she refused to. She managed it by taking prescribed drug but she failed to name the drug.

The client is not a smoker, drug abuser nor alcoholic. She takes a bath everyday and practices proper role, proper hygiene. She wears appropriate clothing for the present weather. She considers household chores as her form of exercise. She eats meat, fish and vegetables. Present Health History The client was admitted last September 29, 2011 at the provincial hospital due to one month menstruation. She was diagnosed to have enlarged uterus. She described the discharges as red in color, fully saturated and foul in odor. She used regular size napkin (sisters) and changes it eight times a day or consumes one pack. The client also had undergone blood transfusion with 3 units of PRBC due to excessive blood loss and decreased of hemoglobin level. She was discharged last October 1, 2011 and she was given take home medication which is Tranexamic acid. Last November 2011, the client went for consultation at Ranada General Hospital and was reported of ultrasound with recommended endometrial hyperplasia vs. polyp by Dr. Quijano. She was advised to have her follow up check up but she didnt attend the schedule due to financial constraints. On her fifth day after the consultation, bleeding became profuse again. She deny of vomiting fever cough with occupational abdominal pain. She was given Estrogen estradiol 0.625 mg 2 tabs 2x 1 day x 1 week, Medoxy progesterone 10 ml 1 tab 2x 1 day x 1week and Tranexamic acid 500 mg. The client was admitted at MMMH & MC last December 26, 2011 at 11:15AM with a complaint of pain at lower abdomen and lower back with a pain scale of 10 out of 10. The client is experiencing abnormal bleeding 7 days prior to admission and is manifested by profuse bleeding which is characterized by dark red, foul smelling, with clots. She consumes two adult diapers per day. The client was given Tranexamic acid 500g IV q 8, Celecoxib 250g BID PC for hypogastric pain, Cefalexin 500mg TID x 1 week, FeSO4 BID and Mefenamic acid TID for pain. The client claimed that she does not perform self-breast exam. She also claimed that there were no incidents of breast or ovarian cancer in their family. Menstrual History Mrs. Poleas menarche started when she was 13 years old or she was in first year high school. She has 4-day flow period. She doesnt experienced pain during her period. Before, she

uses pasador or a piece of cloth that is about 1.5 inches thick and 6 inches long stitched to her panty and changed it thrice a day. But now she uses sister (night use with wings) as her brand choice for her napkin and changes it once a day. She described her discharges as dark red in color, saturated and foul in odor. She denies experiencing burning sensation upon urination. Sexual History The client had her first coitus when she was 20 years old. They use the missionary or normal position during the intercourse. She claimed that she hasnt tried using any contraceptives. The patient reported that she feels abdominal pain during intercourse. Before, they do sexual intercourse once a month but now she claimed that they dont involve in such activity and their last contact was August 2008 which in that time they decided to make their last baby. Past Obstetric History Date May 24, 2001 AOG 37 weeks Problem Complication Type Normal Spontaneous Delivery/home 2003 37 weeks cardiovascular defect Normal Spontaneous Delivery/ Provincial hospital October 2004 20, 28 weeks premature, decreased amniotic fluid September 27, 37 weeks 2006 imperforated anus Caesarian delivery/ Provincial hospital Normal Spontaneous Delivery/ home of

Delivery/Where

May 10, 2009

37 weeks

Normal Spontaneous Delivery/ home

The clients first baby was born on May 24, 2001 at home through normal spontaneous delivery. The second child was born on 2003 at Provincial hospital through normal spontaneous delivery but died due to cardiovascular defect. The third child was born on October 20, 2004 at provincial hospital through caesarean section. He was born premature (7 months) due to decreased amniotic fluid. He had undergone immediate surgery due to imperforated anus and died after 1 month and 1 week due to immature and weak immunity. The fourth child was born on September 27, 2006 through normal spontaneous delivery at home. The last child was born on May 10, 2009 through normal spontaneous delivery at home. Her three children who are living had received complete immunizations as claimed by the mother. During her pregnancy with her children she claimed that she had received all the immunizations for pregnant women and had her prenatal check-ups at Ranada General Hospital. Her last menstrual period was December 21, 2011. IV. Pathophysiology 1. Anatomy and Physiology The Reproductive System

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be menopausal. The Female Reproductive Organ

The female reproductive anatomy includes internal and external structures.

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The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oilsecreting glands. After puberty, the labia majora are covered with hair.

Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).

Bartholins glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.

Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus.

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Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall. The Menstrual Cycle Females of reproductive age (anywhere from 11-16 years) experience cycles of hormonal activity that repeat at about one-month intervals. (Menstru means "monthly"; hence the term menstrual cycle.) With every cycle, a womans body prepares for a potential pregnancy, whether or not that is the womans intention. The term menstruation refers to the periodic shedding of the uterine lining. The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase, the ovulatory phase (ovulation), and the luteal phase. There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing hormone, estrogen, and progesterone. Follicular cycle, the following events occur:

phase

This phase starts on the first day of your period. During the follicular phase of the menstrual

Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are released from the brain and travel in the blood to the ovaries. The hormones stimulate the growth of about 15-20 eggs in the ovaries each in its own "shell," called a follicle. These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogen. As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating hormone. This careful balance of hormones allows the body to limit the number of follicles that complete maturation, or growth.

As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This dominant follicle suppresses all of the other follicles in the

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group. As a result, they stop growing and die. The dominant follicle continues to produce estrogen. Ovulatory phase

The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory phase is the midpoint of the menstrual cycle, with the next menstrual period starting about 2 weeks later. During this phase, the following events occur:

The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain. This causes the dominant follicle to release its egg from the ovary. As the egg is released (a process called ovulation) it is captured by finger-like projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube. Also during this phase, there is an increase in the amount and thickness of mucus produced by the cervix (lower part of the uterus.) If a woman were to have intercourse during this time, the thick mucus captures the man's sperm, nourishes it, and helps it to move towards the egg for fertilization.

Luteal The luteal phase begins right after ovulation and involves the following processes:

phase

Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum. The corpus luteum secretes the hormones estrogen and progesterone. Progesterone prepares the uterus for a fertilized egg to implant. If intercourse has taken place and a man's sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now considered pregnant.

If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual period begins.

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During fetal life, there are about 6 million to 7 million eggs. From this time, no new eggs are produced.

The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of birth control pills, and in the presence or absence of regular menstrual cycles.

The layers of the Uterus from innermost to outermost are Endometrium which is the lining of the uterine cavity is called the "endometrium". It consists of the functional endometrium and the basal endometrium from which the former arises. Damage to the basal endometrium results in adhesion formation and/or fibrosis (Asherman's syndrome). In all placental mammals, including humans, the endometrium builds a lining periodically which is shed or reabsorbed if no pregnancy occurs. Shedding of the functional endometrial lining is responsible for menstrual bleeding (known colloquially as a "period" in humans with a cycle of about 28 days) throughout the fertile years of a female and for some time beyond. Depending on the species, menstrual cycles may vary from a few days to six months, but can vary widely even
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in the same individual, often stopping for several cycles before resuming. Marsupials and monotremes do not have menstruation while Myometrium mostly consists of smooth muscle. The innermost layer of myometrium is known as the junctional zone, which becomes thickened in adenomyosis. Another layer is the Parametrium which is loose connective tissue around the uterus. The last layer is Perimetrium. It covers the fundus and ventral and dorsal aspects of the uterus.

Readings: The final diagnosis was G5P5 (4103) AUB T/C Endometrial Pathology. It means that any bleeding which is considered excessive in frequency, duration or amount by the patient and as such should be evaluated. The pathophysiology involves hormonal imbalances, pregnancy, structural abnormalities and cancer. AUB is the #1 reason for urgent hospital admission for adolescents and 1/3 of gynecologic outpatient visits and 10% of visits to primary-care provider. AUB affects 50% of menstruating women worldwide at some time and approximately 25% of AUB cases can be traced to an organic cause. Majority of AUB episodes occurs within 5-10 years of menarchy and 5-10 years before menopause begins. Out of 5 women with AUB have no anatomic pathologic condition and it accounts for 500/0 of hysterectomies in US. Risk Factors of AUB are Age, Pregnancy, Obesity, Family member with polycystic ovary syndrome, Hypertension, Diabetes, PCOS and late menopause. The etiology of AUB are Cyst (benign sac that contains fluid, air or other materials), Ectopic Pregnancy (life-threatening pregnancy growing outside the uterus), Endometrial Hyperplasia (thickening of the lining of the uterus), Menorrhagia (heavy bleeding during menstrual period), Miscarriage, Polycsytic ovary syndrome, Some sexually-transmitted diseases, Uterine fibroids or noncancerous tumors of the uterus and Uterine polyps or masses in the abdomen. Manifestations are developed on withdrawal of both estrogen and progesterone following degeneration of the corpus luteum result in the menstrual blood flow through mechanisms mediated by prostaglandins and other multiple factors that are modulated by the sex hormones estrogen and progesterone. It occur as a result of the derangement of the cyclical sex hormonal stimulation orchestrated by follicular development, followed by ovulation and formation of corpus luteum and its degeneration when pregnancy does not occur. Menstrual bleeding occurs mostly from the upper two-thirds of the uterine cavity

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following tissue necrosis of the endometrium associated with disruption of microvasculature, as well as the release of tissue necrosis factors released from migratory leukocytes with deposition of platelet/fibrin thrombi in small blood vessels. The molecular events underlying the endometrial tissue and vascular breakdown are related to the release of proteolytic enzymes from lysosomes of endometrial inflammatory cells. The cyclical hormonal stimulation of endometrial growth by estrogen during the follicular phase of the menstrual cycle, followed by estrogen and progesterone after ovulation, is the mainstay of normal development of the proliferative and secretory endometrium. The management of AUB are Hysteroscopy: A small scope is inserted through the cervix and into the uterus. Air or fluid is injected to expand the uterus and to allow the physician to see the inside of the uterus. Tissue samples may be taken. Anesthesia is used to minimize discomfort during the procedure. In most cases, hysteroscopy is performed along with a D&C. And Dilation and Curettage: In a D&C, the cervix or opening of the uterus is dilated and instruments are inserted and used to remove endometrial or uterine tissue. A D&C usually requires anesthesia. It can sometimes be used as treatment for prolonged or excessive bleeding that is due to hormonal changes and that is unresponsive to other treatments.

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V. VI. Developmental Data According to Erik Erikson, life is constituted of sequence of stages of achievement and each stage signals a certain task that must be achieved. The greater the achievement means the healthier the personality of an individual is. On the other hand, failure to achieve a task influences the individuals ability to achieve the next task and probably will lead to regression. He also views developmental tasks as a series of crises that successful resolution is supportive to the ego while failure to resolve the task is damaging to the ego. Our patient, Ms. Polea, is 31 years old who belong to the stage of middle adulthood since her age is in the 25-60 year old age bracket. Her area of resolution is generativity versus stagnation. Therefore, her primary developmental task is to achieve generativity. It refers to "making your mark" on the world, through commitment extending beyond self or reaching out to others in ways that give to and guide the next generation, creating and accomplishing things that make the world a better place. Extending concern to community and assuming various roles means a positive resolution. Stagnation, on the contrary, is those people who are unable to expand their interests and those who suffer from sense of boredom and impoverishment, thus having difficulty accepting their aging bodies and become withdrawn and isolated. Selfabsorbed, self-concern, lack of interests and commitment would mean a negative resolution. We identified our patients generativity as concern for establishing and guiding the next generation through having and rearing children. And that she was able to somewhat achieve the task appropriate for her age. The notion about generativity is shown through her procreation of family and she assumes the role of a good mother supporting her familys social, emotional and physical aspects. She has also extended her interest to the community. One indication is her expressed concern about the non-therapeutic practices of staff to patients that she had observed during the period of her hospitalization. She is also exercising her right to vote during elections and joining in fiestas but not in cleaning activities in the barangay. Erik Eriksons Psychological Development Theory

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ANALYSIS Ms. Polea had achieved the tasks required at her age under Eriksons theory. Thereby, she is ready to accept challenges and can cope to any problems or changes that may happen with a healthy personality, indicating a positive resolution. Generally, she is on the process of attaining generativity in its optimum level. Robert Havighursts Theory of Developmental Task According to Robert Havighurst, learning is essential to life and that human being continues to learn throughout life. He presented tasks to be achieved at certain age bracket. When a particular task is accomplished by the person successfully happiness is being felt but if not, failure happens with the feeling of discontent and disapproval from people surrounding the client. Ms. Polea, 31 years old, belongs to the middle age which age bracket is from 25-60 years old. According to the theory, our client must achieve adult civic and social responsibility, assisting children to become responsible, relating oneself to ones spouse as a person, adjusting to aging parent, establishing and maintaining an economic standard of living, developing adult leisure time activities, accepting and adjusting to the physiologic changes of middle age. In achieving adult civic and social responsibility our patient claimed that she participates in barangay activities such as fiestas. She also exercises her right to vote during elections. However, she stated that she is not participating in clean and green programs because she is focusing more on managing their house and her family. In terms of rearing her children who are 5 and 2 years old, she teaches them good values such as respecting older people, disciplines them and sets limitations. She also punishes them by smacking their hand or their butt whenever they have wrong doings such as fighting due to jealousy. In relating oneself to ones spouse as a person, according to our patient, even though she and her partner are not married, they are committed to each other like husband and wife. She claimed that they share love and care with each other and to their children. She also claimed that

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there are times of misunderstandings and disagreements but they always resolve them easily with proper communication. In the aspectof accepting and adjusting to the physiologic changes of middle age,our client is aware of the changes such as her increased susceptibility to disease and somehow, accepts the process of aging due to degenerative changes In establishing and maintaining an economic standard of living, our patient assumes the role of home managing. As she claimed that she makesassurance to spend their income for their necessities wisely.

In developing adult leisure time activities, our patients past time is listening to radio and watching television. She is also fond of chatting with her neighborhood friends. In adjusting to aging parent, our patient said that she has already adjusted since her father died when she was younger. ANALYSIS Ms. Polea achieved the expected attitude and behavior at her age, achieving social responsibility, assisting growing children, relating herself to her partner as a person, adjusted to aging parent, establishing and maintaining an economic standard of living, developing adult leisure time activities and accepting and adjusting to the physiologic changes of middle age.This implies that she is physically, mentally, emotionally and socially prepared to face challenges or unexpected events that may occur. Overall, she is still on the course of developing herself to attain tasks to the utmost. GENERAL ANALYSIS: With the two theories presented, we can say that Ms. Polea is developing normally as a middle age adult. It is because she has accomplished the required tasks for her age on both the two theories. Although she has achieved some tasks partially, it is still considered to be normal since the age bracket is from 25-60 years old and that we say that our patient has still time in progressing developmental tasks to the optimal.
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VII. Pattern

Patterns of Functioning of Before illness During illness

functioning Eating -eats 2 cups of rice and a serving of -eats 1 cup of rice and half serving of meat or fish every meal (estimated) -does not eat breakfast -eats 2 times a day meat or fish every meal (estimated) -eatsbreakfast -eats 3 times a day

-eats lunch at 12noon,and dinner at -eats lunch at 12 noon, and dinner at 8pm -dislikes vegetables 8 pm -dislikes vegetables

-likes to eat chicken in Jollibee and -likes to eat chicken in Jollibee and lauriat in Chowking for lunch -no allergies -does not eat snack lauriat in Chowking for lunch -no allergies -does not eat snack

According to our patient, she does not like vegetables and that she only eats meat or fish for her meals. She loves to eat chicken in Jollibee and Lauriat in Chowking and they usually have their lunch at the said establishments. She eats lunch at 12 noon and dinner at 8 pm. Before she experienced her illness, she commonly does not eat her breakfast.She also estimated that she eats 2 cups of rice and a serving of meat or fish for her meals (lunch and dinner). However, after she had her illness, she would eat her breakfast, lunch and dinner with 1 cup of rice and half serving of meat or fish. She has no known food allergies and she does not eat snacks.

Analysis: During her illness, our patients food intake decreased, however, she would eat her breakfast unlike before having an illness. This means that the illness has an impact in her eating
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pattern, which results to decreased amount of food intake, but there is an increase in the frequency. Pattern functioning Drinking -likes and drinks coke about 6-7 glasses a -does not drink coke day -drinks water about 5-6 of Before illness During illness

-dislikes to drink water but drinks 1-2 glasses a day glasses a day According to our patient, she likes to drink coke more than drinking water with 6-7 glasses of coke a day and only 1-2 glasses of water every day. However, during the occurrence of her illness, she avoided to drink coke and drinks 5-6 glasses of water instead. Analysis: During her illness, our patient increased her intake of water and refrained from drinking coke. This implies that the illness has an impact on the drinking pattern of the patient. Pattern functioning Bladder -urinates 5-6 times a day w/ approx. 150-200 - 8-9 times a dayw/ mL per micturation -clear to yellowish color -w/ odor but not strong approx. 150-200 mL per micturation -with the same of Before illness During illness

characteristics as before

-urinates upon waking early in the morning, illness before sleeping and whenever she feels to urinate According to our patient, before she experienced her illness, she would urinate five to six times a day with approximately 150 to 200 mL each urination, with clear to yellowish urine and

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with odor but not very awful. During her illness, she said that she would urinate 8 to 9 times a day. With the same characteristics as before the illness occurred. Analysis: During illness, there is increased frequency of her urination but the amount and characteristics of her urine remained the same.

Pattern functioning Bowel

of Before illness

During illness

-once a day -moves bowel in the morning -usually with brown color -semisolid -with foul odor

-the same

According to our patient, she usually moves her bowel in the morning with foul, brown, semisolid stool. Analysis: There was no change in our patients bowel movement before and during the occurrence of the illness.

Pattern

of Before illness

During illness

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functioning Sleeping -Sleeps at 12 am and wakes at 5 -sleeps at 10 pm and wakes at 6 am am -sleeps about 5 hours -would bath before sleeping -prays before sleeping -sleeps about 8 hours -would sleeping -prays before sleeping only half bath before

According to our patient, before experiencing her illness, she sleeps about 5 hours a day. She would sleep at 12 am and wakes up at 5 am. Before sleeping, she would take a bath. However, during her illness, she only takes a half bath before sleeping. She also sleeps at 10 pm and wakes up at 6 am allowing her to rest for about 8 hours. Analysis: During the illness, the sleeping hours of our patient have increased. Her practice of taking a bath has also changed that she only does half bathing before sleep. This entails that the illness affect our patients sleeping pattern. Pattern functioning Bathing -bathes three times >upon waking up >after chores)hours >before sleeping -uses feminine soap for feminine wash working -bathes once a day >upon waking up (household -half bathesonce a day >before sleeping -uses feminine soap for feminine wash of Before illness During illness

According to our client, before having her illness, she would bath three times a day upon waking up, after doing her tasks and before sleeping. But after her illness arose, she only

23

baths once a day and does half bathing before going to sleep. Before and after the occurrence of her illness, she would use feminine soap for her feminine wash. Analysis: During the occurrence of the illness, our patient decreased the frequency of taking her bath. Hence, it means that her bathing pattern is affected by her illness. VIII. Levels of Competencies 1. Physical Before illness During illness

could do her self care needs such as bathing, can still do activities of daily living combing her hair and dressing herself but easily fatigable

does the cooking and do the household can go to the comfort room chores which serves as her exercise independently or longer but experiences shortness of breath after walking 3m

ANALYSIS: There was a slight alteration on our patients physical level of competency due to the status on her bodys strength that affect her performance and the accomplishment of her activities on her daily living.

IX.

Emotional During illness

Before illness

24

 easily irritated but conversant and still easily irritated but more conversant expressive to what she feels and expressive

immediately resolve problem during answers questions being asked misunderstandings with her husband thru proper communication she gets mad but not to an extent if a problem occur regarding her children

ANALYSIS: There is no significant change in her emotional status. She still manages to express her feelings depending on the situation.

X.

Social During illness same as before

Before illness mingles with neighbors fond of going out of the house watch city activities like fiestas, parades and beauty pageants with children

ANALYSIS: There was no change on our clients social competency.

25

XI.

Spiritual During illness

Before illness

goes to church whenever she wants to or same as BEFORE when shes not busy has a strong faith in God prays when going to sleep

ANALYSIS: There was no significant change in her spiritual competency.

XII.

Intellectual During hospitalization

Before illness

oriented to time, place, person and mental functioning says the same situation can make decisions independently oriented to time, place, person and situation informed about her health condition

ANALYSIS: There is no significant alteration with regards to the intellectual competency of our client. Her mental capacity before and during her illness stays the same.

26

XIII. XIV. Physical Assessment General Survey On December 27, 2011 at exactly 9:00 AM (initial contact with the patient), Clarissa Polea is seen supine on bed with an IVFluid of Plain NSS at 100 cc level regulated at 15 gtts/min. Clarissas stated age is 31 years old and it is congruent to her apparent age. Her weight is 70 kgs. and her height is 55. She has brown general body complexion. Client exhibits body symmetry with no obvious deformity. She is mesomorphic and limbs, trunk and height are proportional. She is ambulatory, regular pace but have more short of breath than normal after walking 3 meters with erect posture and gait is smooth, rhythmic and coordinated with arms swinging at side. No body and breath odors noted. The patient reports feeling of weakness, dizziness, and fatigue. She exhibits diaphoresis and pallor. The client is dressed in light weight clothes appropriate for the current weather. She is well-groomed with clean fingernails. Client is friendly, cooperative, and with pleasant disposition throughout the entire duration of the examination. Smiles appropriately with appropriate facial expressions for particular conditions. Answers questions spontaneously. Speech is understandable, and moderately paced. Client is drowsy, lacks energy, with compromised concentration but she is conversant. Vital signs taken as follows: Temperature-36.7 degree Celsius, axillary Pulse-92 beats per minute, regular, strong Respiration- 22 breaths per minute, regular, shallow Blood Pressure-120/80 mmHg Head-to-toe Assessment Skin pale

27

 good skin integrity dry with no lesions warm to touch good skin turgor Nail clean pale nailbeds 160-degree angle between the nail base and the skin smooth and firms capillary beds refill within 4 seconds Hair and Scalp black hair, curly, coarse and dry hair evenly distributed scalp clean and light in color Head and Face round, normocephalic round face, brown in color symmetric facial features able to move facial muscles symmetrically without any difficulty, pain or discomfort no swelling or unusual movements noted temporal artery elastic, not tender with strong bilateral pulsation no masses, tenderness and depressions noted upon palpation no swelling, tenderness, or crepitation with movement of the temporomandibular joint no bruit sounds upon auscultation of the mandible with intact trigeminal nerve Eyes eyelids symmetrical with no drooping

28

 upper lid margin cover upper portion of the iris and pupil and lower lid margin rests on lower border of the iris able to open both eyes symmetrically no portion of cornea are exposed when the eyes are closed lid margins smooth with lashes evenly distributed sweeping upward from the upper lids and downward from the lower lids eyebrows evenly and symmetrically distributed no swelling or redness appear over areas of the lacrimal gland puncta is visible without swelling or redness bulbar conjunctiva clear and moist lower and upper palpebral conjunctivae pale, clear and free of swelling, lesions, and foreign bodies with white sclera cornea and lens are clear iris round, flat, and evenly colored Pupils Equal Round Reactive To Light and Accommodation (PERRLA) no discharge from puncta upon palpation of nasolacrimal duct with a visual acuity of 20/20 on both eyes good near vision (able to read articles with font size of 12 at a distance of 14 inches from the face) good color vision able to follow the six cardinal fields of gaze Ears symmetrical earlobes tip of auricle diagonally in line in a 10 degree angle with the outer canthus of the eye color consistent with facial color with dry minimal cerumen (white in color) auricle, tragus, and mastoid process not tender no pain noted upon palpation

29

 client passed voice whisper test negative Rombergs test Nose color the same as the rest of the face nose and nasal passages not inflamed mucous membranes intact with patent nostrils nasal mucosa dark pink with intact olfactory nerve Mouth no unusual or foul odor noted lips pale and dry without lesions or swelling tongue is pink, moist, moderate size, and with papillae dorsal surface of tongue slightly rough tongues ventral surface smooth, shiny, and pinkish with visible veins and no lesions with pale buccal mucosa and without lesions with complete set of teeth with dental caries on upper third molar and upper lower molar gums pale, moist, and firm with no lesions or masses uvula fleshy and hangs freely in midline with strong tongue able to distinguish between sweet and salty Throat pinkish without exudates or lesions

30

Neck symmetric with head centered no masses or tenderness noted upon palpation of sternocleidomastoid and trapezius muscles thyroid cartilage, cricoids cartilage, and thyroid gland move upward symmetrically as client swallows no nodularity or tenderness noted upon palpation of thyroid gland trachea in midline jugular vein not distended or enlarged neck movement smooth and controlled can do flexion, extension, lateral bending and rotation of neck able to turn head to each side against opposing force carotid arteries have no blowing or swishing or other sounds heard upon auscultation Lymph Nodes of the Head and Neck no enlargement or inflammation noted in nodal areas upon inspection no swelling or enlargement noted upon palpation of lymph nodes Spine cervical and lumbar spines are concave thoracic spine is convex straight when observed from behind nontender spinous processes; well-developed, firm and smooth no muscle spasm Chest and Lungs skin brown and free of lesions and masses transverse diameter is two times larger than anteroposterior diameter scapulae symmetric and non-protruding

31

 shoulders at equal horizontal positions client is sitting up, relaxed, breathing easily and not using accessory muscles to assist breathing clients respiration is 22 breaths per minute, regular, and shallow with symmetrical chest expansion, a nose breather in sitting position no palpable crepitus fremitus symmetric for bilateral positions anterior and posterior thoracic expansion is 3 cm and symmetric resonance is the percussion tone elicited over lung tissue flat is the percussion tone elicited over the scapula diaphragmatic excursion equal bilaterally and measured 3 cm bronchial is auscultated over trachea and thorax bronchovesicular is auscultated over major bronchi vesicular is auscultated over periphery of lungs Heart and Blood Vessels with a blood pressure of 120/80 mmHg with a pulse rate of 92 beats/minute, regular, and strong with an apical pulse of 92 beats/minute, regular, and strong S1 and S2 are present Breast pendulous breast and axillae have same color with general skin complexion areolas and nipples dark brown and round nipples are equal bilaterally in size and in the same location on each breast no masses noted upon palpation Supraclavicular, Infraclavicular and Axillary Lymph Nodes

32

 no rash or infection noted upon inspection of axillae Abdomen abdominal skin paler than general skin tone rounded umbilicus in midline and dark brown in color with linea nigra and striae gravidarum with vertical scar from Caesarian delivery 10 cm in size normoactive bowel sounds (8 bowel sounds per minute) no friction rub auscultated over liver and spleen tympany percussion tone is heard over stomach and intestines dullness heard over liver and spleen no abdominal pain present Upper Extremities arms bilaterally symmetric no edema or prominent venous patterning brown skin and same bilaterally capillary beds refill in 4 seconds radial pulses have equal strength bilaterally (2+) brachial pulses have equal strength bilaterally negative Allen test (with patent radial and ulnar arteries) elbows are symmetric without deformities, redness, or swelling able to flex, extend, pronate, and supinate arms and elbows wrists symmetric without redness or swelling able to do flexion, hyperextension, ulnar deviation and radial deviation of wrists without pain or difficulties fingers lie in straight line able to abduct, adduct, flex and hyperextend the fingers hands and fingers are symmetric, non-tender, and without nodules

33

 no tingling, numbness, or pain result from Phalens test and from Tinels test no tenderness palpated in anatomic snuffbox Lower Extremities brown in color good skin turgor identical size and shape bilaterally no edema toenails have nail polish dorsalis pedis pulses bilaterally strong posterior tibial pulses strong bilaterally buttocks are equally sized, iliac crests symmetric in height hips stable and non-tender knees symmetric, hollows present on both sides of the patella, no swelling or deformities full ROM of knees but with no pain felt toes point forward and lie flat no pain or nodules noted upon palpation of ankles and feet XV. Ongoing Appraisal Our appraisal to our client to our client Clarissa, Polea was done on the 28th and 29th day of December 2011 after our initial contact to her. 12/28/11 Need Problem 12/29/11

or masakit ang puson at nanghihina ako para hindi ako masyadong likod ko -Grimacing diaphoresis palagi akong pagod face, -Pallor, abnormal heart energy compromised and umiinum ng tubig, hindi ko naman kasi alam na may epekto sa kalusugan -Dry lips and dry skin

guarding behavior and beat, drowsy lack of

34

concentration Management Analgesic Take adequate rest and Increase fluid intake sleep Response Decrease pain

During the 1st day of appraisal, December 28, 2011 our client was seen lying on bed, awake with IV Fluid of PNSS at 700cc level regulated at 15 gtts/min, infusing well. She complained pain at her back and hypogastric. On that same, she was on NPO because she is for diagnostic curettage. At 2:19 pm, she went to DR per stretcher for D&C with an IV Fluid of D5LR 1L. D&C started at 2:25 pm and ended at 2:35 pm. She returned to ward per stretcher, place on bed comfortably at 3:15 pm. And she may have DAt once fully awake. Her vital signs were taken as follows: Body temperature: 33.7C 36.5C

Pulse: 90 92 beats/min Respiration: 19 20 breaths/min 110/80 120/70 mmHg

Blood pressure:

On the 2nd day of appraisal, December 29, 2011 our client was seen lying on bed, awake. She is fair in appearance. The gadget that was attached to her was heplock. That day, she was requested for repeat CBC and once with favorable result, she may go home. The client went home in fair condition accompanied by relatives at 8:40 pm. Her vital signs were taken as follows: Body temperature: 36.4C 36.6C

Pulse: 80 82 beats/min Respiration: 20 21 breaths/min

35

Blood pressure:

110/70 110/80 mmHg

XVI. XVII. Medical Management Date ordered and performed: December 26, 27, and 29, 2011 Complete Blood Count (CBC)

Physician who ordered: Dra. Melody Anne C. Dumlao and Dra. Gisele V. Gonzales

Brief description: A complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red blood cells, white blood cells, and platelets. A CBC helps health professional check any symptoms, such as weakness, fatigue, or bruising, one may have. A CBC also helps them diagnose conditions, such as anemia, infection, and many other disorders. Primarily it is used to study, diagnose and treat blood disorders such as leukemia, anemia and hemophilia, as well as diseases of the organs that produce blood, including the lymph nodes, bone marrow and spleen. The most common test, called COMPLETE BLOOD COUNT (CBC), indicates the Hematocrit (Hct), Hemoglobin (Hgb), red blood cell (RBC) count, white blood cell (WBC) count, differential white cell count, red cell indices and a platelet count may also be included. This laboratory procedure is done to our client in order to confirm any abnormal functioning within the clients cardiovascular system. Hematocrit - The hematocrit is a measurement of the percentage of red cells in the total volume of blood. It is expressed as the percentage of red blood cells in the blood
36

volume. The hematocrit reading is obtained by filling a Winetrobe tube with venous blood to which an anticoagulant has been added. The tube is centrifuged and a reading is taken of the height of the packed cells in the tube. This blood test is used to evaluate blood loss, anemia, blood replacement therapy and fluid balance. Hemoglobin - Hemoglobin is used to evaluate blood loss, erythropoietin ability, anemia and response to therapy. It is the main component of red blood cells. Its main function is to carry oxygen from the lungs to the body tissues and to transport carbon dioxide, the product of cellular metabolism, back to the lungs. One molecule of hemoglobin contains two pairs of polypeptide chains, called globin, and four heme groups, each containing one ferrous iron atom. Each gram of fully saturated Hgb holds l.34 ml of oxygen. Fully arterial blood is bright red color. Venous blood, which transports carbon dioxide, is dark red. Another function of Hgb is to act as a buffer to help maintain acid-base balance. Red Cell Count - The red cell (erythrocyte) count is a determination of the number of red cells found in each cubic millimeter of whole blood. It is used to evaluate anemia and polycythemia and calculates red blood cells indices. The main characteristic of erythrocytes is the presence of hemoglobin, an iron-containing protein that binds oxygen. The life span of a mature RBC is l20 days. As they age, RBCs become more fragile and disintegrate. RBCs are destroyed by a group of phagocytes called macrophages, which are found in the liver, spleen, bone marrow, and lymph nodes. The number of RBCs destroyed every day is equal to the numbers that are released into the circulatory system. White Cell Count - The total white count (WBC) is the absolute number of white blood cells (leukocytes) circulating in a cubic millimeter of blood, which transports them to the parts of the body where they are needed to: 1) defend against invading organisms through phagocytosis, and 2) produce or transport and distribute antibodies to help maintain immunity. It is used to evaluate a number of conditions and differentiates causes of alteration in the total white blood cell count including inflammation, infection and tissue necrosis. Differential White Cell Count - It is used to evaluate a number of conditions and differentiates causes of alteration in the total white blood cell count including

37

inflammation,

infection

and

tissue

necrosis.

There are five types of normal white cells, divided into two main groups: Granulocytes (polymorphonuclear leukocytes) and Agranulocytes (mononuclear leukocytes). The differential white cell count is done to identify the five types of leukocyte cells on a stained slide of peripheral blood. It helps the clinician make a final decision about the patients progress, or to determine the relative numbers of each type of leukocyte. The cells are counted and the differential count is expressed in relative percentage values, which are mathematically correlated to their absolute values. The total of the relative percentage values is 100%.

Purpose: It was done to our client to identify the overall condition of his blood components and serve as basis in the evaluation and to evaluate the effect of Blood Transfusion that was administer to him to normalize the abnormalities in his CBC results.

Results: December 26, 2011 Test Result Reference ranges CBC Hemoglobin Hematocrit RBC Mean cell volume Mean hemoglobin L88.00 L0.30 L3.750 80.30 123-153 0.35-0.44 4.5-5.1 80-100 27-32 Decrease Decrease Deacrease Normal Decrease Significance

cell L21.60

38

MCHC Concentration WBC Differential count Segmenters Lymphocyte Monocyte Eosinophils Basophils Platelet count

L26.90

31-35

Decrease

H13.13

4.50-11.00

Increase

H. 0.78 L.0.14 0.06 0.02 0.00 288

0.50-0.70 0.20-0.40 0.02-0.08 0.01-0.04 0.00-0.01 150-450

Increase Decrease Normal Normal Normal Normal

Bleeding time Clotting time

330 900

2-7 7-15

Prothrombin time Patients time PT control level 1 PT control level 2 PT Activity PT INR L 0.87 2.00-4.50 Decrease 10.40 H 12.60 45.9 RNF 70.00-120.00 Normal 9.8-12.7 Normal

Percent 105.80

39

APTT

33.90

26.00-36.00

Normal

Result: December 27, 2011

Test CBC Hemoglobin Hematocrit RBC Mean cell volume

Result

Reference ranges

Significance

L95.00 L0.31 L3.840 80.20

123-153 0.35-0.44 4.5-5.1 80-100 27-32 31-35 4.50-11.00

Decrease Decrease Decrease Normal Decrease Decrease Normal

Mean cell hemoglobin L24.70 MCHC Concentration WBC Differential count Segmenters Lymphocyte Monocyte Eosinophils Basophils H. 0.71 L.0.19 0.07 0.03 0.00 L30.80 6.80

0.50-0.70 0.20-0.40 0.02-0.08 0.01-0.04 0.00-0.01

Increase Decrease Normal Normal Normal

40

Platelet count

256

150-450

Normal

Result: December 29, 2011 Test CBC Hemoglobin Hematocrit RBC Mean cell volume L101.00 L0.33 L4.030 80.60 123-153 0.35-0.44 4.5-5.1 80-100 27-32 31-35 4.50-11.00 Decrease Decrease Decrease Normal Decrease Normal Normal Result Reference ranges Significance

Mean cell hemoglobin L25.10 MCHC Concentration WBC Differential count Segmenters Lymphocyte Monocyte Eosinophils Basophils Platelet count 0.59 0.28 0.08 0.04 0.01 289 31.10 6.26

0.50-0.70 0.20-0.40 0.02-0.08 0.01-0.04 0.00-0.01 150-450

Normal Normal Normal Normal Normal Normal

Analysis:

41

Based on the procedure, there is a significant low level of hemoglobin, hematocrit and RBC these results are related to the condition of the client wherein there is prolonged bleeding as manifested by vaginal bleeding. This significant loss of blood led the client to have body weakness, restlessness and confusion or altered level of consciousness.

Nursing responsibilities: 1. Check the doctors order. Rationale: To ensure the right medication to be given to the patient 2. Observe 10 R Rationale: For you to be guided 3. Make sure that laboratory request form is available and was already filled up by the physician then forward to the laboratory Rationale: To ensure immediate execution of the doctors order. 4. Tell the patient that the test requires a blood sample and may feel some discomfort from the puncture Rationale: So that the patient will anticipate a mild discomfort at the puncture site 5. Do proper documentation. Rationale: For legal purposes 6. Attached the result of the test to patients chart upon arrival and inform the physician. Rationale: Show that the physician will be notified about the result

Dilatation and Curettage

42

Date ordered and performed: December 27, 2011

Physician who ordered: Melody Anne C. Dumlao

Brief description of procedure: refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage).

Purpose: D&Cs are commonly performed for the diagnosis of gynecological conditions leading to 'abnormal uterine bleeding' to resolve abnormal uterine bleeding (too much, too often or too heavy a menstrual flow); to remove tissue in the uterus that may be causing abnormal vaginal bleeding,

Findings: Obtained endometrial curatives amounting to ____________ Noted uterine humps & dumps EBL: Negligible

Nursing responsibilities: 1. Check the doctors order. Rationale: To ensure the right medication to be given to the patient

43

2. Observe 10 R Rationale: For you to be guided 3. Make sure that laboratory request form is available and was already filled up by the physician then forward to the laboratory Rationale: To ensure immediate execution of the doctors order. 4. Tell the procedure to the patient. Rationale: To gain the cooperation and lessen the anxiety of the patient. 5. Do proper documentation. Rationale: For legal purposes 6. Attached the result of the test to patients chart upon arrival and inform the physician. Rationale: Show that the physician will be notified about the result

BLOOD CHEMISTRY TESTING Date ordered and performed: December 26, 2011

Physician who ordered: Dra. Melody Anne C. Dumlao

Brief Description:

44

 Ordered prior to surgery or a procedure to examine the general health of a patient. This blood test, commonly referred to as a Chem 7 because it looks at 7 different substances found in the blood, is routinely performed after surgery as well. Blood Urea Nitrogen (BUN) BUN is a measure of kidney function. A high level may indicate that the kidneys are functioning less than normal. Normal Values: 825mg/100ml (USA)2.9-8.9 mmol/L (International) Carbon Dioxide (CO2) This test measures the amount of carbon dioxide in the blood. Most carbon dioxide is present in the form of bicarbonate, which is regulated by the lungs and kidneys. The test result is an indication of how well the kidneys, and sometimes the lungs, are managing the bicarbonate level in the blood. Normal Values: 24-30 mEq/L (USA) 24-30 mmol/L (International) Creatinine. Creatinine is produced by the body during the process of normal muscle breakdown. High levels may indicate kidney impairment, low blood pressure, high blood pressure or another condition. Some medications can also cause a higher than normal level of blood creatinine. Low levels may be caused by late stage muscular dystrophy, myasthenia gravis and over hydration. Normal Values: Men: 0.2-0.5 mg/dl (USA) 15-40 umol/L (International) Women: 0.3-0.9mg/dl (USA) 25-70 umol/L (International) Glucose This test shows the level of glucose in the blood. High levels of glucose can indicate the presence of diabetes or another endocrine disorder. Keep in mind that some medications and the timing of the test in relation to meals can radically alter the results. Do not assume that your results indicate a problem until you have consulted with your physician. Normal Values: 70-110 mg/ml (USA) 3.9-5.6 mmol/L (International) Serum Chloride (Cl) This test shows the level of chloride in the blood. Chloride binds with electrolytes including potassium and sodium in the blood and plays a role in maintaining the proper pH of the blood. Chloride levels can vary widely if the patient is dehydrated or overly hydrated, if the kidneys are not functioning properly. Heart failure and endocrine problems can also contribute to abnormal chloride results. Normal Values: 100-106 mEq/L (USA) 100-106 mmol/L (International) Serum Potassium (K) This test shows the level of potassium in the blood. Potassium

45

plays an important role in muscle contractions and cell function. Both high and low levels of potassium can cause problems with the rhythm of the heart so it is important to monitor the level of potassium after surgery. Patients who are taking diuretics regularly may require regular blood tests to monitor potassium levels, as some diuretics cause the kidneys to excrete too much potassium. Normal Values: 3.5-5 mEq/L (USA) 3.5-5 mmol/L (International) Serum Sodium (Na) This portion of the test shows the amount of sodium present in the blood. The kidneys work to excrete any excess sodium that is ingested in food and beverages. Sodium levels fluctuate with dehydration or over-hydration, the food and beverages consumed, diarrhea, endocrine disorders, water retention (various causes), trauma and bleeding. Normal Values: 135-145 mEq/L (USA) 3.5-5 mmol/L

Purpose: It was done to our client to identify the overall condition of his blood components and serve as basis in the evaluation.

Result:

Dx Procedure

Found Value December 26, 2011

Reference Value

Significance

Blood Urea nitrogen Creatinine AST ALT

2.74 61.41 12.53 9.52

1.7-8.3 44.2-150.3 up to 31 up to 34

Normal Normal Normal Normal

46

Sodium Potassium Chloride

141.00 3.70 98.00

136-150 3.4-5.3 96-106

Normal Normal Normal

Analysis: Based on the procedure, there is no significant increase or decrease but on the normal range of the components.

Nursing responsibilities: 1. Check the doctors order. Rationale: To ensure the right medication to be given to the patient 2. Observe 10 R Rationale: For you to be guided 3. Make sure that laboratory request form is available and was already filled up by the physician then forward to the laboratory Rationale: To ensure immediate execution of the doctors order. 4. Do proper documentation. Rationale: For legal purposes 5. Attached the result of the test to patients chart upon arrival and inform the physician.

47

Test Urine analysis Physical exam Urine color Clarity Specific gravity pH Chemical exam Protein Glucose Hemoglobin Ketone Nitrite Bilirubin Urobilinogen Leuko esterase Urinary cells WBC RBC Epithelial cells

Result

Reference ranges

Significance

Reddish Turbid 1.020 6.5

Positive 2 Normal Positive 4 Negative Negative Positive 1 Positive 1 Positive 3

10-15 Numerous Moderate

48

Bacteria Mucus threads Renal cells Yeast cells Urinary casts Hyaline cast Fine granular cast Coarse granular cast Waxy cast Urinary crystals Amorphous phosphates Calcium oxalates Triple phosphates Uric acid

Many Moderate -

1-3 -

0-1

Normal

uratel Moderate

Pregnancy test

Negative Rationale: Show that the physician will be notified about the result.

URINE ANALYSIS AND PREGNANCY TEST (UA & PT)

49

Date ordered and performed: December 26, 2011

Physician who ordered: Melody Anne C. Dumlao

Brief description of procedure: It is performed by collecting a urine sample from the patient in a specimen cup. Usually only small amounts (30-60 ml's) may be required for urinalysis testing. The sample can be either analyzed in the medical clinic or sent to a laboratory to perform the tests. Purpose: Urinalysis is ordered by doctors for a number of reasons such as assessing particular symptoms like abdominal pain. A urine test is used to detect health issues, pregnancy or as a drug test. Result:

Nursing Responsibilities: 1. Check the doctors order. Rationale: To ensure the right medication to be given to the patient 2. Observe 10 R Rationale: For you to be guided 3. Make sure that laboratory request form is available and was already filled up by the physician then forward to the laboratory Rationale: To ensure immediate execution of the doctors order.

50

4. Do proper documentation. Rationale: For legal purposes 5. Attached the result of the test to patients chart upon arrival and inform the physician. Rationale: Show that the physician will be notified about the result.

TRANSVAGINAL ULTRASOUND (TVZ) Date ordered and performed: December 26, 2011

Physician who ordered: Dra. Melody Anne C. Dumlao

Brief Description: TVS is used to look at a woman's reproductive organs, including the uterus, ovaries, cervix, and vagina. Purpose: Transvaginal ultrasound may be done to examine abnormal vaginal bleeding and menstrual problems.

Result:

51

Analysis: The uterus is slightly enlarged, anteverted, anteflexed, with a smooth contour and homogenous echoes. The endometrium is 1.8am hyperechoic and thickened for phase. And its inferior pole is a hyperechoic area, 2.2 x 2 x 1cm, probably an endometrial polyp. Bilateral adnexa are unremarkable.

Nursing Responsibilities: 6. Check the doctors order. Rationale: To ensure the right medication to be given to the patient 7. Observe 10 R Rationale: For you to be guided

52

8. Make sure that laboratory request form is available and was already filled up by the physician then forward to the laboratory Rationale: To ensure immediate execution of the doctors order. 9. Do proper documentation. Rationale: For legal purposes 10. Attached the result of the test to patients chart upon arrival and inform the physician. Rationale: Show that the physician will be notified about the result.

Blood Transfusion (BT)

Date ordered and performed: December 26, 2011

Physician who ordered: Dra. Melody Anne C. Dumlao

Brief Description: It is the administration of whole blood or a component, such as packed red blood cell, and is to replace blood loss through trauma, surgery or disease. Blood for transfusion is obtained from healthy donor/donors whose ABO blood group antigenic subgroups match with those at the recipients and who have an adequate hemoglobin level. Each 500ml of blood collected from a donor is stored in a plastic bag containing citrate phosphate. A unit can be stored under refrigerator for only 3 weeks.

53

Purpose: Blood transfusion was given to our client because there was a decrease in RBC, which is the oxygen-carrying capacity of the blood.

Nursing Responsibilities: 1. Check the Doctors order Rationale: To avoid errors 2. Inform the patient about the procedure, blood product to be given, approximate length of time and desired outcome of transfusion. Rationale: To gain cooperation and to lessen the anxiety of the client regarding the procedure 3. Check blood component and verify patients identity. Rationale: To avoid adverse effect of the blood transfusion if a wrong pack is given to the client. 4. Secure consent. Rationale: For legal purposes. 5. Infuse the blood at desired infusing time and rate. Rationale: To prevent RBC destruction or hemolysis and further circulatory overload. 6. Asses the patency of the tubing. Rationale: To ensure the efficient flow of the blood components. 7. Check for abnormal color, cloudiness, clots and excess air in the blood bag.

54

Rationale: Infusing blood with the said characteristics may cause further complications. 8. Do not permit blood stand up at a room temperature longer than necessary. Rationale: Warm temperature promotes bacterial growth and infusing blood component contaminated with bacteria causes septic reaction. 9. Monitor the client closely and instruct the client or significant others to report unusual symptoms immediately. Rationale: To anticipate the adverse reaction and allergy reaction. 10. Assess vital signs and determine any known allergies or any previous reaction to blood. Rationale: To reserve as a baseline data.

PLAIN NORMAL SALINE SOLUTION (PNSS)

Date ordered and performed: December 26, 2011

Physician who ordered: Dra. Melody Anne C. Dumlao

Brief Description: Plain Normal Saline Solution or PNSS is used after blood transfusion because it is the only compatible diluent or 'cleaner' after transfusion. Its sole content of Sodium and Chloride does not cause blood reactions that may be dangerous to the client. D5LRS

55

for example is discouraged as it has calcium which is a clotting factor. Introducing D5LRS after blood transfusion may cause massive thrombosis or clotting.

Purpose: Intravenously, it is used for hydration, and as a carrier to get other things (drugs, banked blood) into a person. It can also be used for irrigation during surgery, to dilute medications, and to clean wounds out, among other things. It has the same amount of salt as most of our body fluids do (0.9%), so it doesn't cause damage to our cells.

Nursing responsibilities: 1. Check the Doctors Order Rationale: To know the normal regulation of the IV and to avoid error 2. Explain the procedure to the Patient Rationale: To gain cooperation 3. Check for the patency of the IV site Rationale: To check if there is a continuous flow of the IV solution 4. Use strict aseptic technique when caring for a client with IV. Rationale: To prevent contamination 5. Assess the site for any redness, swelling, tenderness, or drainage. Rationale: This may indicate IV dislodgement 6. Change the IV dressing varying from 3-7 days depending on the site. Rationale: To maintain cleanliness

DRUG STUDY

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1. Date Ordered: December 24, 2011 Generic name: Tranexamic acid Brand name: Cyclotrax Classification: Anti-fibrinolytic, antihemorrhagic Dosage, Route, Frequency: 500g IV q 8 Mechanism of Action: A synthetic derivative of the amino acid lysine. It exerts its antifibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. Anti-fibrinolytic drug inhibits endometrial plasminogen activator and thus prevents fibrinolysis and the breakdown of blood clots. The plasminogen-plasmin enzyme system is known to cause coagulation defects through lytic activity on fibrinogen, fibrin and other clotting factors. By inhibiting the action of plasmin (finronolysin) the anti-fibrinolytic agents reduce excessive breakdown of fibrin and effect physiological hemostasis. Desired Effects: Used in treating heavy menstrual bleeding. Adverse Effects: Renal impairment, massive hematuria Nursing Responsibilities: Check the expiration date of the drug Rationale: To know if the drug is still viable. Instruct patient that if she missed to take in the medication, do not take 2 doses at once, just take the next dose at least 6 hours Rationale: Over-dosage Monitor the adverse effects of this drug

57

Rationale: To treat the adverse effect of the drug unto the patient immediately. Take the full course of medication Rationale: To minimize occurrence of resistance

2. Date Ordered: December 26, 2011 Generic name: Celecoxib Brand name: Celexib Classification: NSAIDS Dosage, Route, Frequency: 250g BID PC Mechanism of Action: Thought to inhibit prostaglandin synthesis, impeding cyclooxygenase-2 (COX-2), to produce anti-inflammatory, analgesic, and antipyretic effects. Desired Effects: Treatment of polyps and management of acute pain. Adverse Effects: GI discomfort, nausea, and diarrhea Nursing Responsibilities: Check the expiration date of the drug Rationale: To know if the drug is still viable. Instruct patient that Drug may be hepatotoxic so both of you should watch for signs and symptoms of liver toxicity. Rationale: To avoid liver damage Monitor the adverse effects of this drug Rationale: To treat the adverse effect of the drug unto the patient immediately.

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3.

Date Ordered: December 24, 2011 Generic name: Cefalexin Brand name: Ceporex Classification: Anti-infective, Antibiotic, First-Generation Cephalosporin Dosage, Route, Frequency: 500mg TID x 1 week Mechanism of Action: Cefalexin is a bactericidal antibiotic of the cephalosporin group which is active against a wide range of gram-positive and gram-negative organisms. Desired Effects: Cure the bacterial infections of the genitals. Adverse Effects: Headache, dizziness, lethargy, paresthesias Nausea, vomiting, diarrhea,

anorexia, abdominal pain, flatulence, pseudomembranous colitis, liver toxicity, Nephrotoxicity, Bone marrow depression, and Superinfections Nursing Responsibilities: Check the expiration date of the drug Rationale: To know if the drug is still viable. Give drug with meals; arrange for small, frequent meals if GI complications occur. Rationale: To avoid GI complication Complete the full course of this drug even if you feel better. Rationale: To minimize occurrence of resistance Refrigerate drug. Rationale: The potency of the drug may decrease if not stored in the proper temperature. Instruct the patient that she may experience these side effects: Stomach upset, loss of appetite, nausea (take drug with food); diarrhea; headache, dizziness.

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Rationale: For the patient not to be much worried Report severe diarrhea with blood, pus, or mucus; rash or hives; difficulty breathing; unusual tiredness, fatigue; unusual bleeding or bruising. Rationale: To avoid toward implication like drug interaction Monitor the adverse effects of this drug Rationale: To treat the adverse effect of the drug unto the patient immediately.

4. Date Ordered: December 24, 2011 Generic name: Ferrous Sulfate Brand name: Feosol Classification: Antianemic Dosage, Route, Frequency: 325mg, PO, q day Mechanism of Action: Enters the blood stream and is transported to the organs such as the spleen, liver and bone marrow. Where it is separated out and becomes part of the iron stores. Desired Effects: Prevention/treatment of iron deficiency anemia Adverse Effects: Large doses may aggravate peptic ulcer, regional enteritis, and ulcerative colitis. Severe Iron Poisoning: Vomiting Severe abdominal pain Diarrhea Dehydration collapse Nursing Responsibilities: Explain the purpose of iron therapy to the patient. Advise patient that stools may become dark green or black and that this change is harmless. Instruct the patient to immediately inform the nurse in charge if symptoms of hypersensitivity occur. Hyperventilation Pallor or cyanosis Cardiovascular

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Rationale: For the patient not to be worried. Advice taking in of Eggs and milk. Rationale: Eggs and milk inhibit absorption. Store all forms at room temperature. Rationale: The potency of the drug may decrease if not stored in the proper temperature. Instruct client to inform the physician if unusual effects is experienced. Rationale: To avoid toward complication.

5. Date Ordered: December 24, 2011 Generic name: Mefenamic Acid Brand name: Ponstan SF Classification: NSAIDS Dosage, Route, Frequency: 500 mg, po, TID Mechanism of Action: reduces inflammation and pain by blocking production and release of chemicals that produces it and inhibits prostaglandin biosynthesis Desired Effects: Relief of pain including post- operative pain. Adverse Effects: stomach pain indigestion or heart burn (dyspepsia), nausea, with or without vomiting, diarrhea, constipation, anemia, dizziness, headache, itching, ringing in the ears, (tinnitus), swelling Nursing Responsibilities: Check the expiration date of the drug Rationale: To know if the drug is still viable.

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 May give without regard to food Rationale: For increase absorption Monitor the adverse effects of this drug Rationale: To treat the adverse effect of the drug unto the patient immediately. XVIII. Nursing Care Plan Cues Nursing Diagnosis Subjective: Verbalizati on of Nanghihin a ako, para akong palaging pagod. Activity e Activity After 1-2 Independent: of -Reduce of activities -To prevent n that cause undesired physiologic al changes After days rendering appropriate nursing intervention s, able -To maintain to balance between oxygen supply and demand exhibit good nail and palpebral conjunctiva, demonstrate a in physiologic al signs of intolerance decrease skin beds color, pink the to patient was 1-2 of Inference Goal Intervention Rationale Evaluation

Intoleranc intoleranc days (Level e related rendering to imbalanc oxygen of supply and decreased oxygenI-walk, regular more short breath than normally)

appropriate nursing s, the

intensity level overexertio

pace but e between intervention patient will be able to exhibit good nail and palpebral conjunctiva, demonstrate a skin beds response oxygen color, pink -Monitor supplemental

Objective: Pallor, abnormal heart rate

related to carrying secondary capacity anemia of blood

decrease -Plan care to carefully in -To reduce physiologic balance rest fatigue al signs of periods with intolerance

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and verbalizatio n of Mas

activities

and verbalizatio n of Mas malakas na to of -To leafy increase hemoglobin ako ngayon.

malakas na -Encourage ako ngayon. patient increase intake green and flesh vegetables animal

Dependent: -Provide supplemental oxygen -To maintain balance between oxygen -Provide Blood Transfusion as indicated -To correct anemia Interdepende nt: -Provide s supply and demand

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referral other disciplines such exercise physiologist

to -To develop individually appropriate as therapeutic regimens and manage

and recreation activities specialists as within indicated individual limits

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Nursing Care Plan Cues Nursing Diagnosis Subjective: Verbalization of Nanghihina ako, akong palaging pagod. para Fatigue Fatigue After 1 day Independent: -Assess signs vital -To evaluate After 1 day of rendering appropriate nursing interventions, the patient was able to become alert, -To prevent -Instruct patient methods conserve energy like: 1. Sit instead of stand during daily care and other activities 2. and Combine simplify that to energy level decrease factors can have improved sense of energy, good concentration and verbalization of malakas Mas na Inference Goal Interventions Rationale Evaluation

related to related to of rendering secondary imbalance appropriate anemia between oxygen supply and decreased oxygencarrying capacity nursing interventions, the to alert, sense patient become have of will be able

fluid status and cardiopulmonary response activity to

improved energy, good concentration and verbalization of malakas Mas na

fatigability and

Objective: Drowsy, lack of energy, compromised concentration

of blood

about negatively affect

ako ngayon.

ako ngayon.

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activities 3. breaks activities 4. Avoid or Take during

frequent, short

limit exposure to temperature and humidity -To energy -Encourage nutritionally dense, easy to prepare and consume foods -To -Encourage patient to increase intake of green leafy vegetables and animal flesh increase promote extremes

hemoglobin

Dependent: -Provide Blood -To correct

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Transfusion as anemia indicated

Interdependent: -Refer physical therapy to and for -To stamina, strength, and muscle tone and to enhance sense of well-being improve

comprehensive occupational programmed daily exercises and activities

Nursing Care Plan

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Cues

Nursing Diagnosis

Inference

Goal

Intervention

Rationale

Evaluation

Subjective: Verbalization of Hindi

Risk fluid volume

for Inadequate knowledge about

After 1 day Independent: of rendering -Assess mucous membrane skin -To occurrence of deficit

After 1 day of rendering appropriate nursing interventions, the learn of moist patient the fluid lips, was able to

deficient

the appropriate fluid interventions, patient the will be able at to learn the of importance of moist fluid lips, intake, have smooth skin, demonstrate behaviors of

importance nursing

turgor and oral monitor

ako related to of put

masyadong tubig, ko may sa kalusugan. hindi naman epekto

knowledge intake can the patient risk having deficient fluid volume

umiinom ng deficiency

-Encourage patient increase fluid intake

-To to prevent oral occurrence of deficit

importance intake, have smooth skin,

kasi alam na

Dependent: -Provide

demonstrate behaviors of lifestyle changes prevent development of volume deficit and verbalization of Umiinom na akon ng tamang dami ng tubig na kaylangan ng fluid to

Objective: Dry lips, dry skin

lifestyle changes prevent development of volume deficit and verbalization

to supplemental fluids fluid indicated (e.g., as if parenteral)

-To prevent occurrence of deficit

patient is NPO

of Umiinom Interdependent: na akon ng tamang dami ng tubig na kaylangan ng -Refer Registered Nutritionist to

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katawan ko.

and Dietician

-To provide close supervision on appropriate fluid intake

katawan ko.

Nursing Care Plan Cues Nursing Diagnosi s Subjective: Verbalizati on Masakit ang likod at puson ko of Acute pain One the of After hours rendering nursing intervention the patient will be able to have decreased 3-5 Independent: of -Provide comfort measures (therapeutic touch, quiet environment, and -To client explore methods alleviating promote nonpharmacologi pain nurses cal for assist to After hours rendering appropriate nursing intervention s, the patient was able to have decreased feeling of 3-5 of Inferenc e Goal Intervention Rationale Evaluation

related to sympto g occur

underlyin ms that appropriate condition along l uterine bleeding

(abnorma with the s, bleeding) is pain

repositioning, pain and to

Objective: Grimacing

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face, guarding behavior, diaphoresis

feeling pain, reduced guarding

of presence)

management

pain, reduced guarding

-Encourage diversional activities (e.g. TV/radio) -To patients attention from pain divert

behaviors, reduced diaphoresis and verbalizatio n of Mas mabuti na ang pakiramda m ngayon. ko

behaviors, reduced diaphoresis and verbalizatio n of Mas mabuti ang pakiramda m ngayon.

na -Evaluate and document patients to analgesia ko response

-To determine effectiveness of pain management

Dependent: -Administer analgesics as -To maintain indicated acceptable level of pain Interdepende nt: -Collaborate in -To assist to for

treatment client methods

of underlying explore condition causing pain alleviation of

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and proactive pain management of pain

XIX.

General Evaluation Clarissa is 31 y/o from Laoag City. She was admitted on the 26th day of December with a

chief complaint of pain at the lower abdomen and lower back with a pain scale of 10/10 three hours prior to admission. Upon assessment, it was revealed that the patient show signs of weakness and pain as manifested by pale appearance, grimacing face and minimal vaginal bleeding. Dra. Dumlao ordered her to undergo several diagnostic procedures due to assessed profused bleeding. Diagnostic procedures that she had undergone were complete blood count (CBC), blood chemistry testing and prothrombin time testing. The result of the CBC, blood component levels, decreases and was advised to be managed by a blood transfusion 2u PRBC type O+ and a PNSS of 1L. On the 27th day of December, Dr.Dumlao ordered her to be given medications such as Celecoxib (for the treatment of polyps and management of acute pain) and Cefalexin (treatment for bacterial infection in the genitalia) to manage her condition and was again advised to undergo CBC for the second time and another diagnostic procedure which is transvaginal ultrasound for a better view of her internal genitalia. During Clarissas 3rd day, December 28,2012 Dr. Gisele V. Gonzales requested for a consent on diagnostic curettage and turned her diet on NPO. Later in the afternoon, after her diagnostic curettage, she was brought back at the ward when she was fully awake. Dr. Gonzales also shifted her diet to DAT from NPO. During her stay in the hospital, there were alterations in her eating, bladder elimination and bowel elimination pattern. There were also alteration in the bathing patterns because she

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cannot take a bath alone, instead, she had SB with assistance and sleeping pattern brought by disturbances of the hospital routine. Problems during hospitalization were managed through imparting appropriate health teachings to the patient proving patients comfort and carrying out doctors order properly. Lastly, December 29, 2012, another CBC was ordered by Dr. Dumlao and prescribed to go home if theres a favorable CBC result. Later on the evening, 8:40 pm, the client was discharged with improved condition and given medications such as Cefalexin (500mg, as an antibiotic to be taken thrice a day every after meals), Mefenamic Acid (500mg, as a pain reliever to be taken thrice a day every after meals), and Ferrous sulfate (for anti-anemia, once a day). There were also health teachings imparted such things to be done which is a daily head-to-toe bathing and things to be avoided including agpailot, agsidor, and have a sexual contact.

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