SAINTS JOHN AND PAUL EDUCATIONAL FOUNDATION

Pamana Compound, Halang, Calamba City

COLLEGE DEPARTMENT
BACHELOR OF SCIENCE IN NURSING

Name: Ladeza, Allyson Mae D. Course Title: Related Learning Experience

Year: 3rd year Clinical Instructor: J. Rogado, RN

Data Gathering
The data were gathered in August 1, 2022 at Laguna Medical Center, Sta. Cruz, Laguna. All the data gathering procedures are interview and
using the client’s chart.

Biographical Data
Name: Mary Jane T. Victoria Age: 38 yrs old
Address: Brgy. Tagumpay, Bay, Laguna Birthdate: 08/20/1983
Occupation: Housewife Sex: Female
Religion: Catholic Tel. No.: 09995631429
Nationality: Filipino Civil Status: Married
Spouse Name: Cesario B. Victoria
ADMISSION Attending Physician: Rayzelle Ann Caballero, M.D.
Date: 07/30/2022
Time: 11:40 AM

Chief Complaint: Patient reported vaginal bleeding and admission was recommended.
History of Present Illness: Prior to admission, the patient stated that when she came to the hospital, the staff said to her that
her baby has a low fetal movement and will not be able to live, even if he survives, he will have many complications.

Past Medical History: As stated by the patient, there were no past serious medical history aside from giving birth of her two
daughters via NSD last June 6, 2017 and September 30, 2018.

Family History: According to the patient’s chart and the statement of the patient said that there were no family history affecting her present
illness.

Gordon’s 11 Functional Patterns

Functional Health Pattern
Health Perception/ Health Management The pt still manages to cope with her current situation by diverting her emotions to eating.
"Malungkot kasi last baby na namin 'yun, tapos lalaki pa, kasi 'yung dalawa kong nauna ay
mga babae. Pero pinipilit kong hindi isipin para hindi ako ma-stress, kumakain na lang ako
nang kumakain." as stated by the patient.

She also states that she has no family health history and no allergies to foods and
medications.
Nutritional-Metabolic The pt's weight is normal, and she stated that, "Healthy eating lang ako palagi. Gulay at isda
lalo na 'yung may sabaw dahil hindi naman ako mahilig sa mga unhealthy na pagkain." She
also said that she doesn't have any disease that affects nutritional-metabolic function.
Elimination "Nakakatae naman ako araw-araw, 2 times pa nga. Ngayon lang talaga dahil nga dito." as
stated by the pt.
Activity - Exercise “Nage-exercise ako, walking lalo na sa umaga. Pag siesta naman, ang ginagawa ko ay
matulog o mag-cellphone” as verbalized by the pt.
Cognitive - Perceptual The pt said that she was a college undergrad; and she stopped because she applied as a
factory worker in Taiwan for 10 years. She also stated that she has no sensory deficits.
Sleep - Rest “Palaging 8 hours ang tulog ko, minsan nga sobra pa sa 8 hours.” as stated by the pt.
Self-Perception/ Self Concept “Okay naman ako sa sarili ko ngayon at wala naman akong nararamdaman na kakaiba” as
verbalize by the pt.
Role-Relationship I asked the pt nicely, “how will you describe yourself as a mother?" the pt stated, "Okay
lang. Independent na sila kasi hindi ko na sila kailangan pang bantayan, tapos isang remind
ko lang sa kanila, sinusunod agad nila." Then I followed up a question by, "Who is your role
model?". She said, "Ang nanay ko. Kasi sakaniya ko natutunan kung papaano maging isang
ina." Lastly, I asked her, "Which relationships are most important for you at the present?".
She said, "Kaming mag-asawa, kasi kami 'yung nagtutulungan talaga eh".
Sexuality-Reproductive “’Yung mga plano ko naman sa dalawang anak ko, na-pprovide naman naming mag-asawa. Okay
naman din ako kung ano yung sekswalidad ko ngayon. Masaya naman ako” as verbalized by the pt.
Coping / Stress Tolerance “Nalalagpasan naming ‘yung problema namin pag pinag-uusapan naming magasawa at ipinagdarasal
namin. Sa awa ng Diyos, naaayos naman namin” as stated by the pt.
Value - Belief “Ang naging support system ko ‘yung pamilya ko, pati ‘yung mga kapatid ko, kasi walo kaming
magkakapatid, pang lima ako. Sila ‘yung pinanghahawakan ko ngayon eh. Kasi ang sabi ng nanay ko
sa amin “Basta buo ang pamilya, walang pagsubok na ‘di malalagpasan” as stated by the pt.

Nursing Care Plan

Mild Anxiety

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Mild Anxiety r/t After 8 hours of nursing Assess pt’s/couple knowledge These emotional After the shift, the
“Nagulat at nalungkot to loss of intervention, the pt will and interpretation of events reactions may hinder patient was able to
na lang ako nang presence of the appear relaxed and the surrounding the death of the the couple’s ability relax, shows a good
biglang nagdurugo ako, fetus as level of anxiety is fetus. to process response by managing
kaya napapunta agad evidenced by reduced to manageable information and her anxiety, and was
kami sa ospital. Tapos verbal level. interpret the able to participate well
ayun nga sabi patay na expression of significance of in ADLs.
raw anak ko, 6 months sadness. events.
pa lang daw. Pero
Assess pt’s level of anxiety. Different levels of
tumagal ng 7 months sa
tiyan ko’ as verbalized anxiety will affect
by the pt. the coping
mechanism of the pt.
Monitor vital signs
To identify physical
responses associated
Objective: with both medical
 Conscious and and emotional
coherent conditions.
 Confused Acknowledge awareness of
 Has a dry and pt’s anxiety. Acknowledgement
peeling skin of the pt’s feelings
around her validates the feelings
hands due to her and communicates
hand wringing acceptance of those
feelings.
Instruct to do deep breathing
exercises. This may help the pt
T: 36.6°C
PR: 72 to be at ease and
RR: 19 relax.
BP: 100/70 Listening actively and focus on
the pt discussed her personal
To establish trust
feelings.
and showing interest.
Instruct deep
breathing exercise.
Speak in brief statements using
simple words.
To avoid confusion
and easy to
understood.
Participate in self-care
activities of daily living Note pt’s activity level, sleep
(ADLs), as able. pattern, appetite, and personal
hygiene.
These areas may be
neglected because of
the process of
grieving. Pt may
need assistance in
meeting physical
needs and may need
assurance that is
acceptable to
Provide physical care as continue with usual
needed. Encourage pt to activities.
participate at level of ability.

Demonstrates caring
and nurturing and
helps pt conserve
energy needed to
meet the demands of
the grieving process.

Case: IUFD

08-01-22
S: “Nagulat at nalungkot na lang ako nang biglang nagdurugo ako, kaya napapunta agad kami sa ospital. Tapos ayun nga sabi patay na
raw anak ko, 6 months pa lang daw. Pero tumagal ng 7 months sa tiyan ko’ as verbalized by the pt.

O: Received on bed on supine position conscious and coherent, with initial vital signs taken as follows: T: 36.6°C
PR: 72, RR: 19, BP: 100/70 mmHg

A: Mild Anxiety r/t to loss of presence of the fetus as evidenced by verbal expression of sadness.
P: At the end of 8 hours shift, the pt will appear relaxed and the level of anxiety is reduced to manageable level.
I: > Provide quiet environment
> Assess pt’s/couple knowledge and interpretation of events surrounding the death of the fetus.
> Listen actively and focus on the pt
> Speak in brief statements using simple words

E: After the shift, the patient was able to relax, shows a good response by managing her anxiety.

Discharge Instruction and Health Teaching Sheet

Patient’s Name: Mary Jane T. Victoria Age: 38 Sex: Female Date Admitted: 07-30-22
Address: Brgy. Tagumpay, Bay, Laguna Date & Time of Discharge: 08-01-22/ 2:00PM

DIAGNOSIS: G3P2 (2102) IUFD delivered cephalic preterm stillbirth via NSD
HOME MEDICATIONS

- Cefuroxime 500 mg/tablet, 2x a day

- Mefenamic Acid 500 mg/capsule, 3x a day
- Ferrous Sulfate
- Vitamin C

CRITERIA HEALTH TEACHING

A. Diet  Should be on a neutropenic diet (ie, no fresh fruits or vegetables).
 All foods should be cooked properly.
 Meats should be cooked completely.
 High calorie and high protein drinks.
 Eating less fat and salt
B. Activities  Limit activity to what is tolerable.
 Should refrain from strenuous activities (eg, lifting, exercise)
 People who are immunosuppressed may be advised to avoid public places.
 Severe fatigue may make activities of daily living difficult. Help with activities of daily living from someone else may
be required because of pain, fatigue or dizziness.
C. Medications  Take the medicine on proper route, all home meds are oral
 Take medicine on time.
 Discuss potential benefits and harm that may result from non-adherence.
 Encourage patient to call/report untoward symptom to their physician.
 To comeback for follow-up checkup.
D. Self-Care  Wash your hands often, especially after you change a diaper or go to the bathroom. Wash your hands before you eat.
 Make sure to wash between the folds of your skin. Use an electric shaver to prevent nicking your skin when shaving.
Gently clean between your legs each time you have a bowel movement or urinate.
 Stay away from people who have a cold or the flu.
 Gently brush your teeth and gums using a brush with soft bristles. Do this 2 to 3 times every day. Change the water in
your denture cup daily if you have dentures.