General Data

Ê Patient·s Name: Mrs. LH Informant: Mr. JH

(husband)
Ê Address: Baclaran Parañaque Date of Admission: 12-03-09
Ê Age: 25 No. of days in this hospital: 2 days
Ê Sex: Female
Ê Date of Birth: Jan. 18, 1984
Ê Occupation: Secretary
Ê Chief Complaints
Ê ´Sobrang sakit na ng tiyan ko parang manganganak na koµ
as said by the patient.
Ê Strong uterine contraction
Ê 6 cm cervical dilatation
Ê History of present illness:

Ê Before the admission the patient was just staying at

home to rest because she felt that her tummy was so
heavy and the pain of contraction is unbearable. Upon
admission the patient was checked her cervical
dilatation and it comes out that it was 6 cm but her
baby was not totally descended.

Ê Past History

Ê The patient said that she can·t remember any illness

when she was a child and still now. Her only reason to
have a checked up was because she was pregnant.
She said that she takes only vitamins for the baby when
she was pregnant.
Ê System Reviews

Ê Gordon·s Eleven functional Areas

Ê
Ê Health perception ² Health Management
Ê The patient previous health been was good, she says that she is
healthy. She doesn·t have any colds in the past year and she
doesn·t have any absences from work because she was sick. She
doesn·t drink, smoke and take any prohibited drugs.
Ê The patients present health been is good even she deliver her baby.
She said that she is only complaining because of her surgical incision
but she thinks that she just need rest then she can do any activities.

Ê Nutritional Metabolic Pattern

Ê The patient said that she is not eating since two days before the
delivery but after the delivery she eats a lot of foods because she
feels so hungry. The only supplement that she takes is vitamins for the
baby like folic acid and she can·t remember the other drugs. She
drinks a lot of water. She gain weight about 19 kg. The patient said
that after the delivery of her baby her appetite backs to normal.
Ê Elimination Pattern

Ê Mrs. LH said that she defecates once or twice a day

but little amount. She is not using any laxative to help
her defecate. She is frequently urinating but also a
little amount of it. She said that she is not
experiencing an excessive perspiration but when she
was pregnant she experience it every dawn.

Ê Activity & Exercise

Ê Mrs. LH said that her pregnancy hinders her to do a

lot of activities and walking is only exercise that she is
doing. She said that in her spare time she wants to
eat especially with her husband. She has a good
posture and her muscle is firm.
Ê Sleep/Rest

Ê Mrs LH said that until now her incision is still hurts that
she cannot sleep well because of the pain. She can·t
relax so well but she said that it is more relaxed to feel
that her baby is born.

Ê Cognitive ² Perceptual

Ê The patient doesn·t have any hearing difficulties, she

can hear whispered words and she doesn·t have any
hearing aids. She is not wearing eyeglasses. She
cannot notice of the changes of her memory. She
said that she can learn new things, just teach her
then she can learn it. She feels discomfort right now it
just because of her incisions.
Ê Self ²perception

Ê Mrs. LH said that she feels good about her self but now
she·s in pain that makes her not good. There are lot of
changes happen to her body when she was pregnant
and until now after she delivers her baby. She feels angry if
she is annoyed. She never loses her hope. The patient is
relaxed and assertive.

Ê Role-Relationship

Ê She is living with her family, their family structure is nuclear.

She is depending to her husband in comes of decisions.
She is working and she has a lot of friends in there.

Ê Sexuality ² Reproductive

Ê Her sexual relationship is satisfying and she only delivered

her first baby.
Ê Coping/Stress Tolerance

Ê The patient is expecting to have a lot of

changes in her life because she has a baby
and it makes her happy. There are no any
crises happen to her in the last two years. She is
relaxed all the time. Mrs. LH said that there are
no problems that she can·t handle as long as
her husband is there for her.

Ê Values/Beliefs

Ê Mrs. LH said that she gets everything she wants

and she plan for the future to make her
children finish their studies.
Ê Family Assessment
p
  
       
 


     



  ! 
   



 
  

" 
Ê Heredo ² Familial Illness

Ê Developmental History (Psychosocial by

Erickson, Psychosexual by Freud,
Cognitive by Piaget, Moral by Kohlberg
and Spiritual by Fowler)
È
  # $
# %& ! 

'
"' 
(  

 ) 
*% +
(  



)& 

# % ! 
 , 
(

)  

 
(È  

% %


-
"%#
 ! 
 
  
(È)  
&  

 %.%
! 
  - 

 
(È %"


 
 / 0
 %) ! 
 '" 
1"
(
2)

3


1

Ê Physical Examination

Ê Height: 5·4
Ê Weight: 72 kg

Ê Skin
Ê I: Skin color is varies from light to brown and it is generally
uniform except to areas exposed to the sun.
Ê P: Moisture in skin folds and when pinched, skin springs back
to previous state.

Ê Nails
Ê I: Highly vascular and brown in longitudinal streaks, and the
tissue surrounding the skin is intact. When perform the blanch
test of capillary refill it prompt return of pink or usual color.
Ê P: The nails are smooth.
Ê Head and Face
Ê I: The head is rounded. Her facial features and facial
movements is symmetric.
Ê P: It is smooth; absence of nodules or masses.

Ê Eyes
Ê I: Hair in eyebrows and eyelashes is evenly distributed.
The eyelids skin is intact. The lids close symmetrically
and when it is open there is no visible sclera above
corneas. It also blinks bilateral of about 15 to 20
involuntary blinking.
Ê P: No edema or tenderness over lacrimal gland.

Ê Ears
Ê I: Color is same as facial skin, it also symmetrical in size
and the auricle aligned with outer canthus of eye.
Ê P: The auricles are mobile, firm, and not tender.
Ê Nose
Ê I: The nose is symmetric and straight. It is uniform in
color.
Ê P: Not tender and no lesion.

Ê Mouth Pharynx
Ê I: Uniform pink in color and the patient has the
ability to purse lips. The tongue is in the central
position and it can moves freely.
Ê P: No tenderness.

Ê Neck
Ê I: Neck muscle is equal in size and the head is in
center . The head movement s are coordinated
with no discomfort.
Ê P: Lymph nodes are not palpable.
Ê Spine
Ê I: The spine is symmetrically aligned.
Ê P: When the spine is palpated it has a tenderness because of
delivery of her baby.

Ê Thorax/Lungs
Ê I: Anteroposterior to transverse diameter in ratio of 1:2, the spine
vertically aligned.
Ê P: Skin is intact, uniform in temperature.

Ê Cardiovascular/Heart
Ê I: No lift or heave. Veins are not visible.

Ê Breast
Ê I: Well formed.

Ê Abdomen
Ê I: Large abdomen because of pregnancy.

Ê Extremities
Ê I: Moves & symmetrically equal.
Ê PERSONAL / SOCIAL HISTORY

Ê Habits: Watching Television & Eating healthy foods.

Ê Vices: None
Ê Lifestyle: Healthy
Ê Social Affiliation: Co-workers
Ê Client·s usual day like: happy living with husband

Ê ENVIRONMENTAL HISTORY (living/neighbourhood

circumstances)
Ê OB/GYNE HISTORY
Ê FOR FEMALE ONLY (Based from the client ² N/A if
not applicable)

Ê Deliveries: G= 1 P= 1 Operations: NSD clear and

2nd degree of episiotomy
Ê OB Score: T=1 P=0 A=0 L=1
Ê PEDIATRIC HISTORY
Ê MATERNAL AND BIRTH HISTORY
Ê Mother
Ê Complications of delivery: 2nd degree of
episiotomy
$
 '    " p
-  # È 

 

" #"  $
  -p4556 1
" 
 ('
 

   
 "  
   6 1 
 

*

+  



    

 

  -746 
6 "
1

 " 6   
/
     (È 



 
%
  pÈ46  
 

 
" 
   6"

6
,'4  6"

6 556
    %
,84
 
& 4



 4
&4 6 

 È 8&) -p456
6 1 
 ('
 

#66 
  % È
   %   6   %& 

 
  

6
   6 %


 %   1

 %
  

  %
 " -74
 
"  1 )
"


 6   

 6   %
6
 
%   "
 
,'4  6"


%

,84  
1  &




  $' ,p '  È' p  ,  p$ 'pÈ7pÈ'  È' p  7 8 È' p
pÈ  9-È'7 p
%0"4  8   , 4 '4 <
:% 
   < (#
  (#  "
 &  
1   
" %0" 


  &6 
  
  
  
  "
     "    %  
  &

    "% 5% )  %4


 )  
    )%  6   (

      6   
&   %0"4     (

& 
 < " "  
  &;  

  ("   
 ()
"% 5 % 
 
 (È&) %
% 
 " $4   


     (#"     


%0"4 

 )% %     (
( È  4  
 
 

 
  (  %   
    
     

 
  ()
&  &
")  % 
( 
  

 "


w
  

 
 ($
  (È