BIOGRAPHIC DATA

NAME: Ms. Ivy

AGE: 34

GENDER: female

STATUS: single

ADDRESS: J.de Leon la huerta Paranaque city

DOB: July 21,1981

PLACE OF BIRTH: Paranaque

RELIGION: catholic

EDUCATIONAL ATTAINMENT:

OCCUPATION: Businesswomen

LANGUAGE SPOKEN: Tagalog, English

ADDMITING DIAGNOSIS:

ADMITTING PHYSICIAN: Dr.D. Granado

NURSING HISTORY

THE PATIENT IS:

 G2 P1
 LMP 11/18/14
 EDC 8/25/15
 AOG 39 WEEKS
 PAST MEDICAL HISTORY

CHILDHOOD ILLNESS:

 Measles
 Chicken pox
 Common flu

IMMUNIZATION STATUS

 BCG
 OPV
 HEP.B
 Measles Tetox

ALLERGIES: NONE

ACCIDENT AND INJURIES: NONE

HOSPITALIZATION (Cause/organ damage/removed):NONE

MEDICATION: NONE

FAMILY HISTORY

HEALTH STATE AND AGES OF PARENTS:

 Father 59 y/o living healthy

 Mother 57 y/o living healthy

SIBLINGS:

 Brother 29 y/o living healthy

 GORDON’S FUNCTIONAL HEALTH PATTERN

1. PATTERN OF HEALTH PERCEPTION AND HEALTH MANAGEMENT

The Patient is healthy mommy based on how she takes care of herself. She
eats trice a day and exercises before. And she takes a bath every day at least 20-30
mins. in the morning if her baby sleep.

2. NUTRITIONAL AND METABOLIC PATTERN

The patient eats anything without restrictions.is usual diet like eating vegetables
and fruits. She usually eats bread every morning and rice during lunch and dinner.

3.PATTERN AND ELIMINATION

The patient usually voids at least 3x/day usually in the morning when she wake up
and before meals with no discomforts. Color of urine is yellow, they have a proper
toilet and adequate water supply. She is doing house hold works.

4. ACTIVITY OF ELLIMINATION

She is doing exercise sometimes if she had a free, she doing boxing ,tennis in the
afternoon. Her body fells lazy during her pregnancy.no experience
fatigue/weakness, pain after activity.

5. SLEEP AND REST PATTERN

The patient sleeps late in the evening because of her baby. She said her baby
crying and needs to be breastfeed, and change diaper. She naps if she knows her
baby sleep. She usually sleeps for 4-5 hours. She feels that she needs more than
that.

6.COGNITIVE-PERCEPTUAL PATTERN

The patients has no sensory deficits, if she experience pain she manage to sleep
and take medicine to help relieve it.if she has headache she took paracetamol so it
relief and take a rest
7.SELF-PERCEPTION AND SELF –CONCEPT PATTERN

The patient is compatable with her appearance ,when she ask her if she change
about her appearance she said she is nothing to change and she thankful of what
god gave her.

8.ROLE-RELATIONSHIP PATTERN

The patient is good partner to her husband.she is with her family she is able to help
her family financially,and she teach her daughter about values

Her relationship with her child and parent in the most important at present.

9.SEXUALITY-REPRODUCTIVE PATTERN

I ask permission to the patient if she will let me ask the question .

I ask her MENARCHE,LMP and CYCLE of her menstrual period and she let me;

Menarche ;34/yr old LMP;11-18-14 cyche;28 days duration 4-5 day

No.of pads/day 2;3 pads

10.COPING-STRESS TOLERANCE PATTERN

The patient no experienced any discomforts in life if she have her parent is advice
are important for her.

11.VALUE-BELIEF PATTERN

The patient learned to be a good daughter,

 PHYSICAL EXAMINATION

VITAL SIGNS

 Temp.36.8
 Pulse rate: 66beats/min.
 Respiratory rate: 14/min.
 Blood pressure: 110/80

GENERAL SURVEY

 Height:5’7
 Weight:55

SKIN

General color: fair

Texture: Smooth

Turgor: good

Temperature: warm

HEAD

Hair: Normal/even distribution

Scalp: Clean

Lids: symmetrical

Conjunctiva: pink
 LABORATORY

URINALYSIS (JUNE 17, 2015)

COLOR Yellow EPITHELIAL Moderate PUS CELLS 15.17/hpf

CELL
RED
TRANSPAR- Turbid AMORHHOUS Moderate BLOOD 0.2/hpf
ENCY URATES CELLS
CALCIUM
ALBUMIN trace MUCUS moderate OXALATES
THREADS

SUGAR negative BACTERIA few URIC ACID

REACTION Acidic/6.0 RENAL

CELLS
SPECIPIC
GRAVITY 1.030
COMPLETE NORMAL
BLOOD VALUE DIFFERENTIAL COUNT
COUNT

Hemoglobin 127 140- segmenters 0.77 0.55-0.65

170gm/L(M)120-
150gm/L(F)
hematocrit 0.37 0.42-0.52(M)0.37- Stab cells 0.03-0.06
0.47(F)

Red blood 3.9 4.5- lymphocytes 0.15 0.25-0.35

cells 55x10/L(M)3.8-
4.5x10/L(F)
White blood 9,8 eosinophil’s 0.02-0.05
cells 4.5-11.0x10/L

Platelet count monocytes 0.08 0.02-0.08

Blood type/rh BASO Phil’s 0.0-0.01

Bleeding time 2-4min. ESR 0.20mm/hr

Clotting time 2.5min.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIOGNOSIS

Subjective: Pain r/t >to be able to >instruct the pt.to >to provide >encourage to
“sumasakit ang laceration of decrease the take the the pt.comfort eat nutritious
tahi ko”as the delicate level of pain medication on if the pain has food.
verbalized by tissues AMB from 8 to 6 time. decreased
the pt. facial using pain from the pain >emphasized
grimace. scale of 10 to scale goal. the importance
1. of profer
Obj. >positioned pt. >in order to hygiene.
>conscious and Impaired Comfortably. heal or fast
cooperative skin/tissue recovery after
V/S integrity may >lines stretched taking
T:36.8 C be r/t for more comfort. medications.
P:66 beats/mins. mechanical >to promote
R: 14/mins. interruption of comport >keep back dry.
BP:110/80 skin/tissues, >to have
>diaphoresis altered V/S taken and be comport from
>face connotes circulation, recorded. the pain
pain effect of
medication, >To keep >advised the
Diagnosis: accumulation away from mother to
>few hr.PTA— of getting a breastfeed
lumbosacral drainage,and disease such
pain altered as
metabolic pneumonia.
state, possibly >to monitor if
Evidenced by V/S has >nrsg.care
disruption of charged from rendered
skin its baseline
surface/layers and to assess >discharged
and tissues. the pt.’s
conditions
 PHYSICAL EXAMINATION

HEAD/SKULL:

Hair is thick and shiny.no present of lice

EYES/VISION:

No sign of edema on the eyelids

BREAST:

Texture is smooth with no edema.

EARS:

Are equal in size. Smooth with no lesions, lumps or nodules

NOSE:

No congestion

NECK:

No lumps
SKIN:

Skin are smooth

THORAX:

Scapula are symmetric and nonprotruding.shoulder and scapulae are at equal

horizontal position.

ABDOMEN:

Umbilical skin tones are similar to surrounding abdominal skin tones.

EXTREMETIES:

No ankle swelling
ANATOMY AND PHYSIOLOGY (DRAWING)
 PLACENTA:

The placenta is the highly specialized organ of pregnancy that supports the normal
growth and development of the fetus. Growth and function of the placenta are
precisely regulated and coordinated to ensure the exchange of nutrients and waste
products between the maternal and fetal circulatory systems operates at maximal
efficiency. The main functional units of the placenta are the chorionic villi within
which fetal blood is separated by only three or four cell layers (placental
membrane) from maternal blood in the surrounding intervillous space.
OVARY:

The ovaries, a pair of tiny glands in the female pelvic cavity, are the most
important organs of the female reproductive system. Their importance is derived
from their role in producing both the female sex hormones that control
reproduction and the female gametes that are fertilized to form embryos.

UTERUS:

The uterus, also commonly known as the womb, is a hollow muscular organ
of the female reproductive system that is responsible for the development of the
embryo and fetus during pregnancy. An incredibly distensible organ, the uterus can
expand during pregnancy from around the size of a closed fist to become large
enough to hold a full term baby. It is also an incredibly strong organ, able to
contract forcefully to propel a full term baby out of the body during childbirth.

CERVIX:

The cervix is made of cartilage with a thick layer of soft tissue surrounding it. A
front view of the cervix gives it the appearance of a doughnut. The hole in the
center is referred to as the os and the vaginal side of the cervix is known as
the ectocervix.

VAGINAL:

The vagina is an elastic, muscular canal with a soft, flexible lining that provides
lubrication and sensation. The vagina connects the uterus to the outside world. The
vulva and labia form the entrance, and the cervix of the uterus protrudes into the
vagina, forming the interior end.
The vagina receives the penis during sexual intercourse and also serves as a
conduit for menstrual flow from the uterus. During childbirth, the baby passes
through the vagina (birth canal).
The hymen is a thin membrane of tissue that surrounds and narrows the vaginal
opening. It may be torn or ruptured by sexual activity or by exercise.
RECTUM:
Is the concluding part of the large intestine that terminates in the anus,The average
length of the human rectum may range between 10 and 15 cm. Its diameter can be
compared to that of the sigmoid colon (the part of the large intestine nearest the
rectum) at its onset. However, it becomes larger near the anus, where it forms the
rectal ampulla.

ANUS:

The anus is the opening where the gastrointestinal tract ends and exits the body.
The anus starts at the bottom of the rectum, the last portion of the colon (large
intestine). The anorectal line separates the anus from the rectum.
Tough tissue called fascia surrounds the anus and attaches it to nearby structures.
Circular muscles called the external sphincter an form the wall of the anus and
hold it closed. Glands release fluid into the anus to keep its surface moist.
A plate-like band of muscles, called the levator and muscles, surround the anus and
form the floor of the pelvis. A network of veins lines the skin of the anus.

LABIUM MINORA:

The labia minora are a pair of thin cutaneous folds that form part of the vulva, or
external female genitalia. They function as protective structures that surround the
clitoris, urinary orifice, and vaginal orifice.

CLITORIS:

The clitoris is a small projection of erectile tissue in the vulva of the female
reproductive system. It contains thousands of nerve endings that make it an
extremely sensitive organ. Touch stimulation of the nerve endings in the clitoris
produces sensations of sexual pleasure. The clitoris is structurally and functionally
homologous to the penis of the male reproductive system, except that the clitoris
does not contain the urethra and plays no role in urination.
CUES NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIOGNOSIS

Objective: Disturbed Following if 1 >access sleep >high >After 1day of

>presence of sleeping day of nursing pattern percentage of nursing
eye bags. patterns intervention disturbance that sleep intervention
>weakness related to the patient will are associate with disturbances The patient was
and interruption achieve the environment can affect the able to display
restlessness. for optimal recovery of improvement in
>dizziness therapeutics, amount of >observe the the patient sleeping pattern
>taking nap monitor and sleep as obtain feedback as evidence by:
when there is other evidenced by: regarding on the To determine
a chance or if generated usual sleeping usual sleeping >the patient
there is a free awakening Objective: pattern and to does not look
time and excessive >do as much care compare if weak and
stimulation >Verbalization as possible there are any restlessness
>Yawning {noise and of feeling without waking improvements compare to the
lightning} rested up the client and on the past
do as much care sleeping
>decrease the as possible while pattern of the >the present of
presence of eye the client is still patient eye bags have
bags awake been minimize
To avoid or have gone
Goal >explain disturbance
necessity of the during sleep. >decrease of
>improvement disturbances for And also to the usual
if sleeping monitoring vital maximize the yawning
pattern sign and care sleep and rest
when of the client
hospitalization
For patient to
have an
understanding
of the
importance of
care being
done to her
and to
minimize the
complain
 DRUG STUDY

NAME INDICATIO MECHANISM SIDE CONTRA URSING

N OF ACTION EFFECT INDICATIO IMPLACATION
N
Generic >short term >anthracitic CNS: >hypersensiti >assess pt.who
name: relief of mild acid derivative. drowsiness, vity to develop severe
Mefenamic to moderate like ibuprofen insomnia, drug.GI diarrhea and
acid pain inhibits dizziness, inflammation vomiting for
including prostaglandins nervousness, or ulceration. dehydration and
Trade primary synthesis and confusion Safety in electrolyte
name: dysmenorrhe effects platelets headache. children imbalance.
Ponstan a functions. No <1/ty,during
evidence that it GI: severe pregnancy or
Dosage: is superior to diarrhea, lactation is
1 cap aspirin. ulceration, not
every/h and bleeding, established
500 mg/ nausea,
vomiting,
abdominal
cramps, flatus
constipation
hepatic
toxicity.
NAME INDICATION MECHANISM SIDE CONTRA ACTION
OF ACTION EFFECT INDICATION
Generic >prevention >elevates the >mild,transiet >hypersensitivity >ferrous sulfate
name: and treatment serum iron which nausea >severe is an essential
ferrous of iron them to form high >heartburn hypotension component in
sulfate deficiency or trapped in the >anorexia the formation of
anemia’s reticuloendothelial >constipation hemoglobin and
cells for storage >diarrhea enzymes. Its is
>dietary and eventual necessary for
supplement for conversion to a ADVERS effective
iron. usable form of EFFECT: erythropoiesis
iron. and transport or
>dizziness utilization of
>nasal oxygen.
congestion
>muscle
cramps
flushing
NAME MECHANISM INDICATION/CONTRA SIDE EFFECT NURSING
OF ACTION INDICATION RESPONSIBILITY
Generic Cefuroxime is Indication: >GI: diarrhea, >determine history of
name: similar to nausea, hypersensitivity
cefuroxime penicillin. Pharyngitis, tonsillitis, antibiotic reactions to cephalos
infection of the urinary associated phorins,penicillins and
and lower respiratory colitis. history of allergies
tracts and infections particularly to drugs
caused by streptococcus Skin: before therapy is
pneumonia and Rash, pruritus, irritated
S.pyogenes haemophillus urticaria >report on set of loose
influenza, stools
staphylococcus aureus, >absorption of
Escherichia coli. cefuroxime is enhanced
by food.
Contraindication: >notify prescriber about
rashes or super in
>Hypersensitive to drug infection.
>use cautiously in
patients hypersensitive to
penicillin because of
possibility of cross
sensitivity with other
beta lactam antibiotics.
>use with caution in
breast feeding women
and in patient with
history of colitis or renal
sufficiency