NURSING AND OB HISTORY

I. BIOGRAPHIC DATA

PATIENTS NAME : M.J Jimenez ADDRESS: Salangan, San mig. Bulacan AGE: 22 DATE OF BIRTH: 03/06/1989 SEX: F STATUS: single RELIGION: Catholic EDUCATIONAL STATUS: college undergraduate NATIONALITY: Filipino TME/DATE OF ADMISSION: October 11 2011 CHIEF COMPLAINT: humilab yung tiyan ko parang manganganak na ata ako. Labor pain HISTORY OF PAST ILLNESS: Patients first prenatal check-up was started at three month with attending physician and with regular prenatal check-ups thereafter. At 8 months Age of Gestation, patient had increase blood pressure with highest BLOOD pressure of 140/100 mmHg, usual BP was 110/80mmHg. HISTORY OF PRESENT ILLNESS: Prior to her admission she pain in abdomen because she is cesarean section, her blood pressure increase after 2 days she admit. After her cesarean birth she felt pain and lack of movement. HISTORY OF PAST MEDICAL HISTORY: The patients said that she has no any history of past medical history FAMILY HEREDITARY: Sides of her mother has a hypertension and Father there's no any family hereditary.
HISTORY OF ALLERGY: NONE IMMUNIZATION: COMPLETE PREVIOUS HOSPITALIZATION: NONE ACUTE OR CHRONIC INFECTION: NONE INFECTIOUS DISEASE: NONE PREVIOUS INJURY: NONE

o OB HISTORY MENSTRUAL HISTORY MENARCHE: 12 Y/O AMOUNT OF PADS/DAY: 3 pads

AOG: 38 6/7 wks EDC: September 8, 2011 LMP: January 1, 2011 DELIVERIES: G1 P0 OB SCORES: T1 P0 A0 L0 # OF PREGNANCY: 1 ADMITTING DIAGNOSE: Gestational HPN uncontrolled UTI 38-39 weeks G1P0 OTHER DIAGNOSE: G1 P0 (1000) pregnancy uterine delivered FINAL DIAGNOSE: Gestational hypertension, pregnancy uterine delivered operatively OPERATION: LTCS I

Gordons Level of Functioning

Pattern 1.Health PerceptionHealth Management Before Patient goes to the health center once upon when she got pregnant. All in all, she thinks she is in a healthy state. During Patient is concern about her 1st cesarean section thinking that it may be detrimental to her health. Interpretation Patient cannot function normally anymore like before because of her hospital confinement and condition. Her body image changed after the surgical procedure done. Patients nutritional and metabolic status has been changed due to her confinement.

2. NutritionalMetabolic Management

3.Elimination Pattern

Prior to confinement, patient loves eating instant foods and fatty foods like fries and burgers. She also loves condiments like patis, vinegar, and soy sauce. She basically loves eating whatever she likes. Bowel: Patient defecates 1-2 times a day, usually morning and in the afternoon. Stool is brown in color and well-formed. Bladder: Patient voids usually 6-8 times a day. Urine is yellow in color. No pain when voiding. Her leisure time would include bonding with her friends and family.

During her hospitalization, the patient is on diet as tolerated. She eats fruits like apples and oranges. She eats bread instead of rice. She said she lost her appetite since her onset of labor. Bowel: Patient defecates once a day but not on a regular basis. Stool is soft, minimal in amount and brown in color. Bladder: Patient voids 3-4 times a day without pain and discomfort. Patients activities in the hospital are ambulation, breastfeed to her baby, taking a bath or personal hygiene.

Bowel: There was a change in the frequency and amount.

Bladder: There was a change in the frequency and amount. During patients confinement in the hospital, there is a limitation in her activities of daily living and a disruption in her leisure and recreation pattern

4.Activity, Leisure, and Recreation Pattern

Patient puts herself to sleep by watching television programs. She usually sleeps at around 11pm to 6am. She feels rested when sleeping and thinks that her energy is sufficient for her activities. 6.Cognitive Patient is a college Perceptual Pattern undergraduate. She can read and write. She can speak and be understood by others. 7. Self-Perception / Patient is a friendly Self-Concept Pattern person; she loves to socialize with her friends in their neighborhoods. She considers herself as holistic human being as long as she is healthy, complete, and his family is always there. 8. Role Relationship Patient can understand English, Tagalog. She has 4 siblings. And they're bonding was good. 9. Sexuality/ Patient didnt tell me Reproductive about the Pattern sexuality/reproductive pattern Ill respect her to didnt tell me. 10.Coping and Stress When patient is Tolerance stressed, she sings in the karaoke and eats comfort foods like burgers, fries, and her favorite sizzling sisig. When it comes to problems, she lets herself think immediately for a solution.

5.Sleep and Rest Pattern

Due to her uncomfortable condition and pain, patient complains of difficulty of sleeping and short period of sleeps.

Patients slept and rest pattern changed when she was admitted. She cannot put herself to sleep anymore due to present condition and pain plays a big factor for her sleep disturbances. No changes/ alterations.

Patients present condition is not a hindrance to her cognitive- perceptual pattern. During the times of her confinement, she doesnt think that she is a holistic person anymore. However, she is positive that she will be okay after confinement.

There is a slight change in her selfperception due to present condition

The patients family is supportive to the patient. She is happy with their presence and support. Patient reserved her right to privacy.

Normal/ No alterations.

Patient reserved her right to privacy.

The recent hospitalization of the patient was stressful and source of anxiety. However, she is positive that she will be able to cope up with current condition.

Patient accepts present condition with a positive attitude.

11.Values- Belief Pattern

Patient is a Roman Catholic. She has a strong faith to God and goes to mass every Sunday with her family and her boyfriend.

She follows a therapeutic regimen and her strong faith to God accounts for her fast recovery.

Due to her confinement, patient is trusting God that she will be discharge soon and will recover without any complications.

PHYSICAL ASSESSMENT
A. General Physical Assessment Patient is an 22 year old female, stands 52. She is conscious and coherent upon interaction but answers only the questions she is comfortable with. BODY PARTS HEAD Skull Hair Rounded, smooth skull contour Smooth, absence of nodules evenly distributed, thick hair, Silky. Varies from light brown to deep brown Rounded, Smooth Normal Normal NORMAL FINDINGS FINDINGSACTUA L FINDINGS INTERPRETATION

SKIN

Slightly pale

Deviation because of blood loss

EYE S Eyebrows Evenly distributed, skin intact, symmetrically aligned, equal movement. Evenly distribute skin Intact Normal

Eyelashes Eyelids

Slightly curved Toward Equally distributed, curled, slightly toward Skin intact, no discharged, no Skin intact, no discoloration discharged, no discoloration Firm and not tender, pinna recoiled after its folded Straight, no discharge/flaring uniform color Firm and not tender, pinna recoiled after its folded no discharge/flaring uniform color

Normal Normal

EARS

NORMAL

NOSE

Normal

MOUTH LIPS Uniform pink color, smooth texture, moist, soft

Dry, rough texture

Deviated from normal because of dehydration caused by pregnancy

BREAST & AXILLA Breast Even at the chest wall Skin uniform in color Skin smooth & intact No tenderness & Nodules Even at the chest wall Skin uniform in color Skin smooth & intact Tender upon palpation Normal Normal Normal Deviation from normal due to development of milk.

ABDOMEN

Unblemished skin, flat, rounded

Presence of scar in the Deviated from abdomen normal caused by passed CS delivery through classical incision

DISCHARGE PLANNING
1. M Medication
Take home medication as prescribed by the Physician Sultamocillin 1 tab TID Methergin 1 tab BID Rutolax

2. E Environment
Instructed patient to stay in calm, quiet environment Home environment must be free from slipping or accident hazards

3. T Treatment
Informed patient to have a follow-up check up after 1- 2 weeks

4. H Health Teaching
Informed patient to avoid lifting heavy objects for 1-2 weeks Stressed the importance of perineal cleanliness Encouraged client to have hot sitz bath Instructed patient to increase intake of protein-rich foods to promote faster wound healing Instructed to promote adequate fluid intake Discouraged patient to participate in strenuous activities that might precipitate stress and trauma to the wound Instructed patient to promote breastfeeding

5. O Observable Signs and Symptoms

Observe for dehiscence and evisceration Instructed patient to report to physician any signs of infection Instructed patient to report any case of hemorrhage or abnormal bleeding

6. D Diet
Encouraged client to increase intake of fiber to avoid constipation Instructed to increase fluid intake Instructed to increase intake of nutritious foods such as fruits and vegetables