I INTRODUCTION Our patient is Mrs X, who is 39 years of age. She was born on December 12, 1974.

She was a college graduate & finished the course of education. Her occupation is a teacher at La Paz National High School. Her husband is working as a line man at Tarlac Electric Corporation. On the present, they already have 3 children. She got pregnant for the first time on the year 2002, followed by the second pregnancy on 2005 & the third last January 21, 2013. Shes a mix of Tagalog, Kapampangan & Ilocano. Shes the second child out of the 4 children in their family. She was admitted on the night of January 19, 2013 since she reported that her bag of water had already ruptured. Upon her admission, her cervix was 4cm dilated. After several hours, it increased into 7cm. For the 24 hours, it didnt increase further so the physician ordered that she would undergo LCCS ( Low Cervical Caesarian Section ) delivery. Mrs X delivered a baby girl weighing 3.4 kg.

II OBJECTIVES In this study, we the student nurses will be able to:

1 Establish good relationship with the patient & significant others. Gain knowledge regarding the patients health condition, the cause of the illness, treatment and its prevention.

Assess the present illness and its manifestation to the patient. Recognition of patients problem to be prioritized for the establishment of nursing diagnosis. Plan for the patients care.

Perform of interventions like:

-carrying out measures to prevent complications.

-monitoring patients response to the treatment.

-imparting health teachings.

-identifying risk factors to avoid complications.

7. Encourage patient & significant others to accept the treatments and medications that are appropriate for his condition.

8. The student nurses will be responsible health care team member by interacting and establishing a harmonious and professional relationship with all the other members of the healthcare team.

III NURSING HEALTH HISTORY A. BIOGRAPHICAL INFORMATION Surname: X First name: Y Middle name: Z Age: 39 Sex: Female Birthday: December 12, 1974 Birthplace: Quezon City Address: Caut, Lapaz Tarlac Occupation: High School Teacher B. REASON FOR SEEKING HEALTH CARE Mrs. X seeks for health care because of experiencing some sort of pain brought by labor on the night of the 19th of January 2013. In this, her age of gestation was estimated to be on her 37th week. C. CLIENT EXPECTATION Mrs. X looks forward for having: 1. Successful delivery of the infant. 2. Appropriate health teaching regarding her needs & self-management. 3. Proper rendering of care & carrying-out of interventions during labor & after the delivery of the infant. 4. Efficient treatment as of postpartum period in relieving the pain felt after the procedure. D. PRESENT OF ILLNESS

She was confined and admitted last January 20, 2013, felt worried since the bag of water suddenly ruptured. As for the further assessment, her cervix was dilated upon examination upto the measurement of 7cm. For the succeeding 24 hours way back when she was confined, the measurement wasnt able to increase any further so the attending physician has ordered for a Caesarean section delivery instead of the normal spontaneous delivery.

E. Past Health History Mrs X was last hospitalized when she gave birth to her second child last 2005 & was given medications like antibiotics & pain-relievers. She didnt report any occurrence of any illness. F Family History Mrs X is now a mother of three children. They are residing as a nuclear family. She informed us that her father died of Pneumonia when he was 63. Her mother is still alive & presently has diabetes. Nevertheless, no other diseases were noted. G Immunization Mrs X has received & completed vaccinations when she was a child. Also, she has completed the 5 doses required for Tetanus Toxoid throughout her pregnancy. H Nutrition Mrs X is taking a regular diet. She prefers a lot of vegetables of meat. When shes pregnant she assures she increases her intake of vegetables & meat with a lot of fluids at the same time. I Environmental History Mrs X is residing at Caut, La Paz, Tarlac. Their house is built in a concrete type of way. Their source of water is from a jetmatic but as for their drinking water they are purchasing from a water station. She shared they are planting vegetables on their backyard. Their garbage is collected once in a week. As stated by Mrs X, shes doesnt view anything from their area as a problem. J Psychosocial History Mrs X told us that she has a lot of friends, particularly her co-teachers, even her students & her neighbors. Shes in good-terms with all of her relatives & that of her husbands. She seems to be interactive since shes telling a lot of stories about her life. She cares about the health & happiness of her family & prioritizes to put them all first in everything. K Spiritual Health Mrs X & the rest of her family is a Catholic. They attend the mass every Sunday. They make it to a point to make God as the center in strengthening their bonds.

OBJECTIVE:

At the end of the whole exposure,the nurse will be able to: Established rapport with the patient and his significant others. Established knowledge about the patients illness, its cause, treatment and prevention. Give psychosocial support and therapy. Evaluate all the health teachings that have been given and outcome of the patients condition. Established working relationship with other health care giver who are involved with the patients treatment.

Area/region

Findings

Normal finding

Abnormal findings

Interpretation/analysis

1.vital signs

Temperature

36.3 (laxilla)

36.5 to 37.5

Normal

Normal

Pulse rate

20 bmp

12-20 bmp

Normal

Normal

Respiratory rate

80 bmp

60-100bmp

Normal

Normal

Blood pressure

110/80 mmHg

120/80mmHg

Normal

Normal

2.general survey

The clients body is asymmetrical she has a large abdomen

The patient should exhibit body asymmetry,no obvious deformities and well appearance.

Abnormal for pregnant woman

Large abdomen due to expansion of stomach because of growing and development of the fetus.

General appearance

Mood and manner

Speech

Patients cooperate during interactions and to her medical procedure done. Patients responds to questions and commands easily patients speech is clear and understandable. Patient is awake and coherent .facial change appropriate in accordance to the incision.

Patient should be cooperative and pleasant Patient should respond question and commands easily and understandable . Patient should appear alert and alert facial expression should be appropriate in relation to what is happening and should change naturally

Normal

Normal

normal

normal

Normal

normal

Facial expression

Client breaths effortlessly, without wheezing cough and wheezing she has eye contact

3. Skin Skin in general

Lesions Moisture

Patients skin color is brown on her axilla and on her neck Incision in the abdomen Skin is slightly dry

Breathing should Normal be effortless without cough or wheezing. The patient should nor perspire excessively or show sign of emotional distress such as nail biting and avoiding of eye contact Brown in color Normal

Normal

Temperature

Her palm is cool to touch No tenderness noted

Tenderness

The skin is dry with normal a minimum amount of perspiration Skin surface should normal be cool and equal bilaterally Skin surface be non normal tender

normal

Normal

Normal

Texture

Skin is smooth, even, and firm Skin returns to original contour rapidly.

Turgor

Scars

No scars is present except of her insicion

Skin should feel smooth, even and firm. When skin is released after pinching, it should return to original contour rapidly. No presence of scars

normal

normal

normal

normal

abnormal

Scar because of her present surgery

4.HAIR Color

Hair color is black

Hair varies in color is based on the amount of melanin present.

The body is

Normal

normal

Distribution

Vellus hair is light

Texture

and evently distributed in the body such as the face arms and legs. Terminal hair is found in the eye brows, eyelashes and scalp without baldness. Scalp hair is fine and oily.

covered in vellus hair. Terminal hair is found in the eyebrows. Eyelashes and scalp.

Hair my feel thin, coarse, thick, curly or straight. It should be resilient when traction is applied. Head should be symmetrical and nomocephalic. the skull should be smooth and without masses. The scalp should be intact and without lesions, lice. Facial features should be symmetric The shape of the face can oval, round or slightly square. The patient should be able to move her neck without any complaint, discomfort or weakness.

normal

normal

5.Head and neck head

Head is symmetrical. No masses noted.

normal

normal

scalp

No lesions, lice or dandruff noted.

normal

normal

symmetry

Shape and Features

Facial features and movements are symmetrical. Oval in shape

normal

normal

Normal

normal

neck

Neck muscles in good tone and strength.

Normal

normal

6.EYES Gross Visual Acuity

Patient can read small letters written on a paper at a feets

Patient should be able to read the letters in a receipt at a

normal

normal

eyelids

distance. Eyelids are symmetrical and without any swelling or readness.

Conjunctiva

Sclera

Pupil

7.EARS Voice whisper test

External ear

certain distance The eyelids should be appear symmetrical with no drooping, infections or tumor. Conjunctiva is Conjunctiva pinkish and should appear moist. pinkish and moist. It is without swelling, lesions, exudates, or foreign bodies. Sclera is The sclera should anicteric. be white with some small, superficial vessels and without exudates, lesions, or foreign bodies. PERRLA with The pupils brisk direct and should be deep consensual pupil black, round and constriction from of equal 4mm to 2mm. diameter, pupils are black. ranging from 2 to 6mm. Pupil should constrict briskly to direct and consensual light and to accomodation Patient can hear Patient should his name being be able to repeat whispered from words whispered 2 feet. from a distance of 2 feet. The external ear The Ear should shows normal much the flesh

Normal

normal

normal

Normal

normal

Normal

Normal

Normal

Normal

normal

alignment. Ear color is white which is consistent with his skin color. No impacted cerumen, discharged or lesions noted. External ear is nontender.

of the rest of the patient skin and should be positioned centrally and in proportion to the head. The top of the ears should Cross an imaginary line drawn from the outer cantus of the eyes to the occiput. Cerumen should be moist and not obscure to the tympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules or lesions.