Nursing health history is the first part of the client’s health status, it is
systematic collection of subjective data provided by the patient’s/significant
other’s verbalizations and supplemental by objective data gathered during
physical assessment. It is needed for solving and determining a patient’s
problem and for the nurse to know what interventions to be applied and
what may be the cause of the illness.
Since our patient cannot really express much of herself due to her
condition, we chose to gather information from her mother whom is very
close to her.
It was on December 28, 2008, Friday, when we chose a case for our
individual case study. During my first encounter with the patient, she was
lying on DR table with #1 IVF of D5LR @ 30 gtts/min. hooked at the left
cephalic vein.
For the patient’s trust, privacy, dignity and respect we gave herm we
decided to hide her name and called her Patient B.
Patient B grew up at Purok 10, Ong Yiu, Butuan City with her family,
and has been used to the Muslim traditions since both of her parents were
Muslims. Patient B finished her secondary level at Agusan National High
School, and was already married at the age of 16 years old to a Muslim who
was then a close relative to their family. She was only 17 years old when she
gave birth to her first child through Cesarean Section (Low Segment
Transverse), because she had a difficulty in delivering the child due to her
age and the lack of knowledge.
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T = 37.2°C
P = 90 bpm
R = 20 bpm
BP=110/80 mmHg
Dr. Calamba, her surgeon gave her the following orders:
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PHYSICAL ASSESSMENT
Head is round in shape. Hair is long, thick and coarse, straight and evenly
distributed. Scalp is smooth and white in color, minimal lesions were noted.
Dandruff and lice were seen.
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C. Assessment of the Eyes
Her eyes are symmetrical, black in color, almond shape. Pupils constricts
when diverted to light and dilates when she gazes afar, conjunctivas are pink.
Eyelashes are equally distributed and skin around the eyes is intact. The eyes
involuntarily blink.
Ears are clean, no ear wax was noted and of the same size and shape.
Patient can hear normally when spoken softly.
With narrow nose bridge, there were discharges noted upon inspection.
No swelling of the mucous membrane and presence of nasal hairs were seen.
She has a complete set of teeth with minimal dental caries noted. Oral
mucosa and gingival are pink in color, moist and there were no lesions nor
inflammation noted. Tongue is pinkish and is free of swelling and lesions.
Presence of uvula was noted and there is absence of swelling.
Lymph nodes noted. Neck has strength that allows movement back and
forth, left and right. Patient is able to freely move her neck.
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No reports of pain during the inhalation and exhalation.
Hands: Medium in size with 5 fingernails in each side. Nails are short,
small dusty particles are present. A capillary refill of 1-2 seconds
was noted.
Size of the feet is undefined with lines on the sole, presence of scars and
lesions. Ten fingers are present. Nails are clean and short. No apparent pain
upon movement therefore indicates negative Homan’s sign. Patient is
ambulatory.
Patient urinates 2-4 times a day and has not defecated yet since her
delivery.
O. Neurological Assessment
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Behavior – Patient is silent but is conscious and coherent upon
interaction. She sits and walks if she wants to.
Reflexes - reflexes were present such as the blinking reflex and deep
tendon reflex.
Release of FSH by
of the endometrium)
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Fertilization (union of the ovum
to the uterus
Implantation
head into the pelvis) >begin and remain irregular the cervix feels
softer like
dilatation
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TRUE LABOR
tation
cervical atrophy)
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Increase risk of fetal death
1000-1500 mL)
LABORATORY RESULTS
Urine Analysis
Normal Interpretatio
Result Significance
Values n
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RBC 5.4 4.5 – 6.0 x 10/L Normal
Indicates
WBC 10.1 5 – 10 x 10/L Increase presence of
infection
Indicates
HgB 116 120 – 140 g/dl Decrease occurrence of
anemia
Indicates hyper
Hct 0.35 0.30 Increase
coagulation
150 – 400 x
Platelet 320 Normal
09/L
DIFFERENTIAL COUNTING
Indicates
Neutrophils 0.86 0.05 – 0.70 Increase infection or
inflammation
Indicates high
Lymphocytes 0.14 0.20 – 0.40 Decrease risk for acquiring
infection
DRUG LIST
November 29,
Dr. Calamba Ranitidine(PREOP) 50mg IV q8h
2008
Ketorolac 30 mg IV q8h x3
November 29,
Dr. Villanueva (Kortezor) doses, followed by
2008
(INTRAOP) 15 mg IV q8h
RIGHT PATIENT
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RIGHT DRUG
RIGHT DOSE
RIGHT TIME
RIGHT ROUTE
RIGHT TO REFUSE
RIGHT TO RATIONALE
RIGHT TO DOCUMENTATION
RIGHT INFORMATION
PROBLEM LIST
Date
Proble Type of Date
Nursing Diagnosis Identifie
m# Problem Evaluated
d
3 November Not
POSTOP Acute pain r/t traumatized
29, 2008 Evaluated
skin tissue
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POSTOP post pregnancy 2° to 29, 2008 Evaluated
cesarean section
DISCHARGE PLANNING
M – Medication
E – Environment
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Home environment must be free from slipping or accident
hazards
T – Treatment
H – Health Teachings
D – Diet
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LEARNING OUTCOMES
Cord care and care of the newborn for cesarean section is more
or less the same as that in normal spontaneous delivery. All the same,
additional attention must be paid. This is because the newborn might have
complications brought about by the procedure. Patent airway and
thermoregulation is two of the main concerns.
Nursingcasestudy.blogspot.com
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