DE LA SALLE HEALTH SAVOIR INSTITUTE COLLEGE OR UNIVERSITY OF MEDICAL AND UNIVERSITY OF MIDWIFERY CITY OF DASMARINAS, CAVITE NURSING HEALTH EVALUATION Submitted simply by: Andrea Antonette D. Balboa Submitted to: Rowena Cepeda-Laigo, RN, MAEd NURSING OVERALL HEALTH ASSESSMENT I. Status Content Caesarean Section II.
WELL BEING HISTORY AND PHYSICAL EXAMINATION A. Demographic (Biographical Data) Client’s initials: R. R. L. Gender: Woman Age, Birthdate and Birthplace: 34, 10/21/1978, Muntinlupa Significant other (Civil) Position: Married Nationality: Filipino Religion: Roman Catholic
Address and Telephone Number: Japanese 5 Great deal 54 Greengate Imus Cavite Educational Background: Bachelor’s Level in Computer Science Occupation (usual and present): Encoder Usual Method to obtain Medical Care: PhilHealth Date of Admission: 01/08/2013 B. Resource and Reliability of Information The person was proficient to provide data. She was able to speak clearly, conscious and coherent, oriented to period, place and person. The patient’s chart was included as well as a supplementary source of details C. Reasons for Seeking Care 1 . “Inadequate size of pelvis 2 . “Scheduled for caesarean section G.
History of Present Health The expected time of the delivery was January 8, 2013, 8: 00AM at St Paul Medical center. It was a scheduled caesarean section of the sufferer, not in labor. The individual was quiet since it was her second time to deliver a fetus through caesarean section. There were zero signs and symptoms of labor occurred. The patient foresees to stop adding a family member mainly because they already have a son and a child. E. Earlier Medical History or perhaps Past Wellness a. The chidhood / The child years / Mature Illnesses The patient did not include any the chidhood, childhood or adult illnesses. b. Accidents or Mishaps
The patient did not have virtually any injuries or perhaps accidents. c. Hospitalization and Operations The person had a caesarean section last 2006, 3 years ago and 2013. d. Reproductive : History The sufferer had her menarche at the age of 12. Her last menstrual time period was Apr 27, 2012. Her menstrual cycle was twenty eight days and her monthly duration was 3 to 4 days and nights. Her obstetric score was G3P2 T2P0A1L2M0. e. Immunization BCG: as well as? / At Birth /? / School Entry DPT: /? / initial Dose /? / subsequent dose /? /3rd medication dosage OPV: /? / first Dose as well as? / second dose /? /3rd dose AMV: /? / TT: /? / 1st Dose /? / 2nd dosage /? /3rd dose as well as? 4th medication dosage /? / 5th dosage HBV: as well as? / 1st Dose as well as? / 2nd dose as well as? /3rd medication dosage Others: Not one f. Allergic reactions /? as well as Food, (please specify): Prawn / as well as Drugs or medications, (please specify): non-e / as well as Chemicals, (please specify): non-e / as well as Other environmental allergens, (please specify): non-e The patient has a great allergy in shrimps. The individual experiences urticaria as a great allergic reaction and applies an anti-allergy recommended by her dermatologist to alleviate the symptoms. g. Medications None G. Socio-Economic History FAMILY MEMBER /RELATIONSHIP TOPATIENT| PROFESSION /SOURCE OF INCOME| MONTH TO MONTH INCOME| Ur.
R. S. | Encoder| P22, 500. 00| The person works as an encoder. The monthly profits of P22, 000. 00 can only support the basic requirements of the family but not specifically of members’ health. It will probably be not enough and budgeted entirely for the necessities in the family. L. Psychosocial Examination Patient’s Age: 34 years of age Developmental Stage: Young Adulthood Developmental Activity: Intimacy versus Isolation Taking place in small adulthood, all of us begin to reveal ourselves even more intimately with others. We explore interactions leading toward longer term obligations with somebody other than a relative.
Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care in a relationship. Avoiding intimacy, worrying commitment and relationships can lead to isolation, solitude, and sometimes major depression. Patient met the developmental task penalized in an personal relationship with her partner. They are wedded and have a couple of kids. We. Functional Examination 1 . Health-Perception-Health Management Pattern The person’s description of her current health was weak and hard to become pregnant. The activities that the patient does to improve or maintain his health was going to not get over time in work.
Person’s knowledge about backlinks between way of living choices and health had not been answered. The extent of patient’s issue on financing health care was hopefully the budget will suit. Patient has got the knowledge of the names of current medications the girl was choosing and their goal. Activities that the patient really does to prevent concerns related to allergic reactions was to apply an anti-allergy prescribed via her skin doctor. Patient provides the knowledge about medical problems in the family. There was no important illnesses or perhaps injuries inside the patient’s life. 2 . Nutritional-Metabolic Pattern The patient’s nutrition was to consume fruits and vegetable.
Patient’s food options in comparison with advised food intake weren’t answered. The patient has no any disease that affects nutritional-metabolic function. 3. Removal Pattern The patient’s excretory pattern was constipated. You will have no virtually any disease in the digestive system, urinary system or perhaps skin. some. Activity-Exercise Routine The person’s description of his weekly pattern of activities, amusement, exercise and recreation was going to eat exterior and thinks it being a family connecting. The patient has zero any ailment that affects his cardio-respiratory and Muscoskeletal systems. 5. Sleep-Rest Pattern
The description from the patient’s sleep-wake cycle was completed of 8 several hours. Patient’s physical appearance was comfortable. 6. Cognitive-Perceptual Pattern You will have sensory deficit of astigmatism and had not been corrected. Person’s has the ability to express herself plainly and realistically. Patient’s education was bachelors degree of pc science. The patient has no virtually any disease that impacts mental or perhaps sensory function. Patient’s discomfort description was of stomach because of surgical treatment of caesarean section. six. Self-Perception-Self Principle Pattern There were no unconventional about the individual’s appearance.
The person was confident with her physical appearance, simple but comfortable. Description of the patient’s feeling point out was happy, comfortable since she already has a selecting and a lady. She was worried about their very own financial needs because of the added family member. almost eight. Role Romance Pattern Patient’s description of his various roles in every area of your life was to become a responsible mother. Positive function model of her roles was her mom, to save for family but she actually is more of disciplinarian than her mother. Significant relationships presently were her family. There was no big within role or perhaps relationship.. Sexuality-Reproductive Pattern Patient’s satisfaction with her scenario related to libido was good. If both of them were exhausted, they may do sexual intercourse. The patient’s plans and experiences would not matched with regards to having kids because anything changed and she was more grown up than before. 10. Coping-Stress Tolerance Pattern Patient’s means/actions of coping with problems were there must be a goal on her to achieve. Dealing actions support even though the goal was partially met as long as it was achieved. Eat, sleeping and spend time were treatments/therapies for psychological distress. 1 ) Value-Belief Pattern Principles which the patient learned as a child that are still crucial to her was she does not want shortage, she wishes everything to end up being provided. Person’s identification with any ethnical, ethnic religious or different groups is she is a St Claire lover. Support program that the sufferer finds significant was her family. M. Review of Devices and Physical Examination Day of Exam: January 9, 2013 PHYSICAL SYSTEMS| Ur. O. S i9000. | L. E. | 1 . Basic Status and Vital Signs| “Okay naman| (-) fever(-) tachycardia(-) tachypnea(-) hypertension| installment payments on your
Integument (Skin, Hair, and Nails)| “Okay naman| (+) pallor(-) pores and skin turgor(-) edema| 3. Brain and Neck| “Okay naman| | 4. Eyes| “Okay naman, may astigmatism lang yung kept eye ko| (+) astigmatism| 5. Ears| “Okay naman| | six. Mouth, Throat, Nose and Sinuses| “Okay naman| | 7. Torso and Lungs| “Okay naman| | almost eight. Breast and Lymphatic System| “Di lang ako makapag-produce ng milk kapag di pa ko kumakain| (+) inverted left nip (-) breastmilk| 9. Center and The neck and throat Vessels| “Nagpapapalpitate ako minsan kapag pagod| (+) palpitation| 10.
Peripheral Vascular System| “Nagkavaricose problematic veins na ko sa bigat ko, laging nakatayo by nung buntis pa ko ang bigat ng tyan ko| (+) varicose veins| 11. Abdomen| “Kumikirot kasi tahi ko| (+) pain| 12. Genitourinary| “Nagka-UTI ako nung nagbubuntis pa ko| (+) rubra lochia(-) urinary tract infection| 13. And can, Rectum and Prostate| “Hirap akong tumae| (+) constipation| 14. Musculoskeletal System| “Okay naman, ngayon lang ako di makakilos ng maayos dahil masakit tahi pennsylvania ko| (+) limited ROM| 15. Stressed System| “Okay naman| (+) conscious| sixteen. Hematologic| “Okay naman| | 17. Endocrine| “Okay naman| | 18. Psychiatric| “Okay naman| |