NURSING HEALTH ASSESSMENT

I.

FINAL DIAGNOSIS G2P2(2002) pregnancy uterine, term, double footling breech delivered, S/P LTCS II, cephalopelvic disproportion by Low Transverse Caesarean Section II under spinal epidural anesthesia

II.

HEALTH HISTORY AND PHYSICAL EXAMINATION

A. Demographic Data Client's initials: J.G.B Gender: female Age, Birthdate, Birthplace: 31, October 16, 1980, Surigao City Marital status: married Nationality: Filipino Religion: Roman Catholic Address and Telephone Number: B19L1 Phase 3 Village Park Subdivision, Langkaan I, Dasmarias City, Cavite, 09183980374 Educational Background: college graduate Occupation: housewife Usual Source of Medical Care: health center Date of admission: October 1, 2012

B. Source and Reliability of Information Patient was fully competent to provide answer to the questions asked. She was conscious, coherent, and was able to speak clearly. C. Chief Complaints 1. Schedule na kasi ng panganganak ko kaya pumunta na ako.

D. History of Present Illness The patient arrived in the hospital feeling good but was a little nervous. It is her second time to give birth via caesarean section and has an OB score of G2P1(1001) . E. Past Medical History

a. Pediatric/Childhood/Adult Illness The patient verbalized that she has never had any serious illness during her childhood or adult life. b. Injuries or Accidents

The patient verbalized that she has not experienced any major injuries or accidents. c. Hospitalization and Operations In 2008, the patient gave birth of her first child via low transverse caesarean section. She has no other hospitalization or operations other than that. d. Reproductive History The clients menarche happened when she was 13 years old, the onset of secondary sex characteristics happened late at around 16 years old. She has a regular menstrual cycle spanning for about 28-30 days a month. Her last menstrual period was on January 6, 2012. The patient verbalized that she and her husband does not use any birth control method. The patient gave birth via caesarean section because the baby does not fit in her pelvic opening e. Immunizations BCG: // At Birth // School Entrance //3rd dose // 3rd dose / / 4th dose / / 5th dose DPT: // 1st dose // 2nd dose OPV: // 1st dose //2nd dose AMV: // TT: // 1st dose // 2nd dose / /3rd dose HBV: // 1st dose //2nd dose // 3rd dose

f. Allergies / / Food: none / / Drugs: none / / Chemicals: none / / Other enviromental allergens: none

g. Medications The patient was prescribed Cefuroxime 500mg 1 tablet q8h for seven days as a prophylaxis for surgical infection. A 500mg capsule of mefenamic acid was also given q6h for seven days to alleviate the pain that the pt might experience from her C/S. Lastly, she was asked to take a tablet of Hemarate q.d for 30 days for nutritional and iron deficiency anemia caused by her pregnancy.

F. Family History

As shown on the genogram, the family doesnt have a hereditary disease however, the childs maternal grandmother and youngest sister has asthma. The patient has a lot of support system since she has 5 other siblings. G. Socio-Economic History Family Member/Relationship to patient Occupation/source of income Overseas worker Monthly income

Not disclosed

According to the patient, her husband that works as an electrician overseas provides ample money to support their needs and even some wants in life. This implies that her and her family are able to take care of their health and seek the help of a health care provider when necessary.

H. Psychosocial Assessment Patient's age: 31 years old Developmental Stage: middle adulthood Developmental Task: generativity vs stagnation

Persons in this stage focus on the next generation. Making contributions

to the society and the next generations by making a family or helping for the betterment of the society. People who get past this stage feels a sense of accomplishment and productivity while those who don't tend to feel unsatisfied with their accomplishments. The patient is in the early part of the stage. As analyzed, she is trying her best to fulfill her roles as a mother, daughter, and wife although her husband and family of orientation isn't around. She tries to be both the mother and the father to both her children to make sure that they grow up as good, obedient children that will contribute to society. All in all, the patient shows signs of generativity.

I. Functional Assessment 1. Health-Perception-Health Management Pattern The patient perceives herself as a healthy individual. Despite this perception, she thinks that she could still improve her health. She has never had any important illness or injuries in her life. When asked what were the medications given to her and what are their purposes, the client was able to respond confidently. 2. Nutritional-Metabolic Pattern The client eats at least three meals a day consisting mainly of meat or fish and vegetables. She drinks more than eight glasses water which is evident in her skin that has good turgor. She also has pink nail beds and has no signs of anemia. Her hair is equally distributed and does not fall off easily. The client has a normal temperature of 36.9C. 3. Elimination Pattern The patient eliminates once a day and feels uncomfortable when she doesn't. She also voids at least 4x a day. According to her, she sweats easily. 4. Activity-Exercise Pattern The client does not exercise but sometimes walks around their village. She devotes her time in taking care of her children and maintaining the household. She thinks that she has enough time to do what she wants weekly but she does not have the motivation to work out. She also verbalized that she doesn't and has never had any heart or respiratory illness and or illnesses that can affect her musculoskeletal system.

5. Sleep-Rest Pattern The client's sleep-rest pattern has changed especially now that she just gave birth. But according to her, she tries to get 8+ hours of sleep. For a brief part of her pregnancy, she experienced waking up at night

to void. During the interview, the patient appeared to be well-rested and relaxed. 6. Cognitive-Perceptual Pattern The patient is a college graduate. There were no signs of deficit in the patient's sensory perception during the physical exam. The patient was also able to comprehend and answer all the questions asked to her during the interview. She was able identify the scale or level of pain that she was feeling on her abdomen. 7. Self-Perception-Self Concept Pattern In general, the patient is happy with herself. She has accepted that her abdomen is slightly protruding and that she will have a scar from her caesarean section. 8. Role Relationship Pattern The patient plays as a mother to her two kids. This is the most important relationship that she has alongside being a wife to her husband and a daughter/sister to her family. She is a hands-on mom who gave up her work to watch children grow up. As a wife, she is still adjusting coping up to the fact that her husband is working in another country even though it has been years since they've been in this set-up for a few years now. As a daughter/sister, she maintains constant communication with her family in Mindanao and tries to help them whenever necessary. 9. Sexuality-Reproductive Pattern The patient verbalized that she is somewhat satisfied with her sexuality. She is a G2P2(2002) who just gave birth to her son. She does not have any diseases affecting her reproductive system. 10. Coping-Stress Tolerance Pattern As a coping mechanism, the client sleeps and/or eats a lot when under a great amount of stress. This action, according to her, somewhat helps her but she knows that it is not the solution to her stressors. Despite all these, she has never received any therapy or treatment for emotional stress. 11. Value-Belief Pattern The patient strongly believes in God and puts Him the center of everything that she does. As of now, she only sees herself taking care of her children and playing the other roles that she has. During her move here from Mindanao, she identified the difference between Caviteos and her hometown. According to her, the people here in Cavite have strong personalities. And as a means of coping or support system, she calls her family in Mindanao regularly.

J. Review of Systems and Physical Examination PHYSICAL SYSTEMS 1. General R.O.S. wala naman problema P.E. >T = 36.8C >BP = 120/80 >PR = 80, normal, >RR = 21, high normal >sleepy Skin: >good skin turgor >(+)hyper pigmentation on nape, armpits, and inguinal area >(+)edema on lower extremities Hair: >hair equally distributed >dark brown thin hair with no evidence of parasites Nails: >Hard nails >pink nail beds >capillary refill >3secs extremities hindi naman sumasakit >symmetrical, ulo ko smooth, firm >normocephalic >(-)lesions on scalp malinaw pa naman >symmertrical mata ko blinking >(+)PERRLA >round and equal iris >bulbular conjunctiva clear with tiny vessels visible >pink palpebral conjuctiva Wala naman problema >(-) discharges on tenga ko medyo madumi external ear lang >passed whisper and Romberg test >(-) tenderness normal lang >(+)dry lips >(+) gag reflex >(-) hoarseness >(-) Enlargement of Tonsils >(-) Gingival bleeding >(-) inflammation of the pharyngeal tonsils normal naman ang >(-)cough production paghinga ko >shallow, fast breathing >symmetrical thoracic expansion >(+) rales on both lung fields

2. Integument

Wala naman ako problema

3. Head and Neck

4. Eyes

5. Ears

6. Mouth, Throat, Nose and Sinuses

7. Thorax and Lungs

8. Breast and Lymphatic System 9. Heart and Neck Vessels

medyo masakit yung dibdib ko. Wala pa din gatas lumalabas sakin wala rin naman ako nararamdamang problema sa puso ko

>(-)crepitus >(-)wheezing >Refused >(-)Breastfeeding >(+) apical pulse felt at 5th ICS LMC line >identical apical and radial pulse at 80bmp >normal heart sounds >regular rate, normal rhythm > (-)jaundice discoloration >(-)Homans sign >capillary refill >3 seconds on lower extremities >bilateral radial pulses strong and equal at 80bmp >(+)tenderness >(-)rashes >no enlarged organs >normoactive bowel sounds @ 5 BS per minute >(-)mass >(+) tympany in all 4 quadrants >(+)post-surgical wound, 10cm in legth, linear, well dressed and has no signs of blood and other secrections >(+) abdominal binder >Refused >Refused >(+) ambulatory >responds to questions and statements >oriented to time, place, and person >CNI: able to smell odor correctly CN III,IV,VI: good EOM CN V: (+) sensation to light touch and pain CN VII: (-)drooping of mouth while head was still; able to raise eyebrows, wrinkle forehead, clench teeth, puff out cheek >CN IX: (+) gag reflex, able to identify taste >CN X: (-)symmetrical elevation of palate, uvula rises while

10. Peripheral Vascular okay naman System

11. Abdomen

medyo masakit pa yung tahi ko lalo na kapag naglalakad ako

12. Genitourinary 13. Anus, Rectum, and Prostate 14. Musculoskeletal 15. Nervous System

wala naman problema Masakit din pag ginagalaw wala naman masakit

swallowing >CN XI: (+)able to shrug shoulders, able to move neck with ease >CN XII: (-) limitation of tongue movements 16. Hematologic 17. Endocrine 18. Psychiatric III. LABORATORY STUDIES AND DIAGNOSTICS Indications Normal Values/Finding s Pt. Blood Type: AB Rh Typing: (+) Major crossmatching: compatible Actual Findings and Interpretations Donors Blood Type: AB Rh Typing: (+) Major cross matching: compatible This shows that the donors blood and the recipients blood are compatible to each other. It means that it is safe to transfer blood from the donor to the recipient. Complete Blood Count: WBC: 5.0-10.0 10^9/L RBC: 4.2-5.4 10^12/L Hemoglobin: 12.0-15.0g/dL Hematocrit: 37.0-47.0% Differential count: Segmenters: 50-70% Eosinophils: 05% Lymphocytes: 20-40% Complete Blood Count: WBC: 23.4 10^9/L RBC: 3.5 10^12/L Hemoglobin: 11.56.3 g/dL Hematocrit: 33.818.9% Differential count: Segmenters: 89% Eosinophils: 1% Lymphocytes: 10% The results show that the patient has a high count of WBC while she has low RBC, hemoglobin, and hematocrit. The patient also has high segmenters and low lymphocytes. Nursing Responsibilities(pre , intra, post) The nurse should accompany the patient to the laboratory with the patients chart on their hand as well. After the procedure, the nurse must monitor the site from which blood was drawn for bruises, edema, or any other abnormalities.

Procedure/Date

Blood Crossmatching

Hematology

This test is performed prior to a blood transfusion to determine if the donor's blood is compatible with the blood of an intended recipient. People must receive blood of the same blood type, otherwise, a serious, even fatal, transfusion reaction can occur. A CBC provides detailed information about three types of cells in your blood: red blood cells, white blood cells, and platelets.

Pretest: identify patient Intratest: Observe standard precautions, and follow the general guidelines. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. Perform a venipuncture. Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation

However, her eosinophils are of normal level.

and secure gauze with adhesive bandage. Promptly transport the specimen to the laboratory for processing and analysis.