Nursing Health Assessment

DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF care for AND SCHOOL OF MIDWIFERY CITY OF DASMARINAS, CAVITE NURSING HEALTH ASSESSMENT Submitted by Andrea Antonette D. Balboa Submitted to Rowena Cepeda-Laigo, RN, MAEd NURSING HEALTH ASSESSMENT I. stead Post Caesarean Section II. HEALTH HISTORY AND PHYSICAL examen A. Demographic (Biographical Data) Clients initials R. R. P. Gender Female suppurate, Birthdate and Birthplace 34, 10/21/1978, Muntinlupa Marital (Civil) Status Married Nationality Filipino Religion romish CatholicAddress and Telephone Number Blk 5 Lot 54 Greengate Imus Cavite Educational flat coat Bachelors Degree in Computer Science seam (usual and present) Encoder Usual line of descent of Medical Care PhilHealth Date of Admission 01/08/2013 B. Source and Reliability of Information The uncomplaining was competent to provide information. She was able to tell clearly conscious and coherent oriented to season, place and person. The endurings chart was also include d as a secondary witness of information C. Reasons for Seeking Care 1. Inadequate size of pelvis 2. plan for caesarean component D.History of Present Health The expected date of the language was January 8, 2013, 800AM at St. Paul Hospital. It was a scheduled caesarean section of the enduring not in labor. The forbearing of was calm since it was her second time to deliver a fetus through caesarean section. at that place were no signs and symptoms of labor happened. The patient foresees to stop adding a family member because they already engender a son and a daughter. E. Past Medical History or Past Health a. Pediatric / Childhood / Adult Illnesses The patient did not have both pediatric, childhood or adult illnesses. b. Injuries or AccidentsThe patient did not have any injuries or accidents. c. Hospitalization and Operations The patient had a caesarean section last 2006, 2007 and 2013. d. Reproductive History The patient had her menarche at the age of 12. Her last menstrua l period was April 27, 2012. Her menstrual troll was 28 days and her menstrual duration was 3 to 4 days. Her obstetric score was G3P2 T2P0A1L2M0. e. Immunization BCG /? / At Birth /? / School Entrance DPT /? / world-class Dose /? / 2nd paneling /? /third dose OPV /? / world-class Dose /? / 2nd dose /? /3rd dose AMV /? / TT /? / first Dose /? / 2nd dose /? /3rd dose /? 4th dose /? / 5th dose HBV /? / 1st Dose /? / 2nd dose /? /3rd dose some others None f. Allergies /? / Food, (please specify) Shrimp / / Drugs or medications, (please specify) None / / Chemicals, (please specify) None / / Other environmental allergens, (please specify) None The patient has an allergy in shrimps. The patient experiences store as an allergic reaction and applies an anti-allergy prescribed by her dermatologist to excuse the manifestation. g. Medications None G. Socio-Economic History FAMILY MEMBER /RELATIONSHIP TOPATIENT OCCUPATION /SOURCE OF INCOME monthly INCOME R.R. P. Encoder P22,000. 00 The patient works as an encoder. The monthly income of P22,000. 00 dejection only bear out the basic needs of the family barely not particularly of members health. It will be not enough and budgeted exclusively for the necessities of the family. H. Psychosocial Assessment unhurrieds Age 34 years old Developmental Stage Young adulthood Developmental Task Intimacy vs Isolation Occurring in young adulthood, we produce to share ourselves more intimately with others. We explore relationships leading toward longer name commitments with someone other than a family member.Successful completion can lead to golden relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Patient met the developmental task of being in an intimate relationship with her partner. They are married and have 2 kids. I. running(a) Assessment 1. Health-Perception-Health Man agement model The patients description of her up-to-date health was weak and difficult to get pregnant. The activities that the patient does to improve or maintain his health was to not get over time in work.Patients friendship about links between lifestyle choices and health was not answered. The extent of patients problem on funding health care was hopefully the budget will fit. Patient has the knowledge of the names of current medications she was taking and their purpose. Activities that the patient does to pr notwithstandingt problems related to allergies was to go for an anti-allergy prescribed from her dermatologist. Patient has the knowledge about medical problems in the family. There were no important illnesses or injuries in the patients life. 2. Nutritional-Metabolic phase The patients nourishment was to eat fruits and vegetable.Patients food choices in comparison with recommended food intake were not answered. The patient has no any disease that affects nutritional- metabolic function. 3. Elimination intention The patients excretory praxis was constipated. The patient has no any disease of the digestive arranging, urinary system or skin. 4. Activity-Exercise Pattern The patients description of his weekly image of activities, leisure, exercise and recreation was to eat outside and considers it as a family bonding. The patient has no any disease that affects his cardio-respiratory and/or Muscoskeletal systems. 5. Sleep-Rest PatternThe description of the patients tranquillity-wake cycle was completed of 8 hours. Patients physical behavior was relaxed. 6. Cognitive-Perceptual Pattern The patient has sensory deficit of astigmia and was not corrected. Patients has the ability to express herself clearly and logically. Patients learning was bachelors degree of computer science. The patient has no any disease that affects mental or sensory function. Patients annoyance description was of abdominal because of surgical procedure of caesarean sectio n. 7. Self-Perception-Self Concept Pattern There was no unusual about the persons appearance.The patient was comfortable with her appearance, simple but comfortable. Description of the patients popular opinion state was happy, comfortable because she already has a baby boy and a girl. She was worried about their financial needs because of the added family member. 8. Role Relationship Pattern Patients description of his various roles in life was to be a responsible mother. Positive role model of her roles was her mother, to save for family but she is more of disciplinarian than her mother. Important relationships at present were her family. There were no big changes in role or relationship. . Sexuality-Reproductive Pattern Patients satisfaction with her situation related to sexuality was good. If both of them were tired, they dont do sexual intercourse. The patients plans and experiences did not matched regarding having children because everything changed and she was more full-blow n than before. 10. Coping-Stress Tolerance Pattern Patients means/actions of coping with problems were in that location must be a goal for her to achieve. Coping actions help even though the goal was partially met as long as it was met. Eat, sleep and hang out were treatments/therapies for emotional distress. 1. Value-Belief Pattern Principles that the patient learned as a child which are still important to her was she does not desire shortage, she wants everything to be provided. Patients identification with any cultural, ethnic ghostly or other groups is she is a St. Claire devotee. Support system that the patient finds evidentiary was her family. J. Review of Systems and Physical Examination Date of Examination January 9, 2013 PHYSICAL SYSTEMS R. O. S. P. E. 1. worldwide Status and Vital Signs alright naman (-) fever(-) tachycardia(-) tachypnea(-) hypertension 2.Integument (Skin, Hair, and Nails) okey naman (+) pallor(-) skin turgor(-) oedema 3. Head and Neck Okay naman 4. Eyes Okay naman, may astigmatism lang yung left eye ko (+) astigmatism 5. Ears Okay naman 6. Mouth, Throat, Nose and Sinuses Okay naman 7. Thorax and Lungs Okay naman 8. Breast and Lymphatic System Di lang ako makapag-produce ng draw kapag di pa ko kumakain (+) inverted nipple (-) breastmilk 9. Heart and Neck Vessels Nagpapapalpitate ako minsan kapag pagod (+) shiver 10.Peripheral Vascular System Nagkavaricose veins na ko sa bigat ko, laging nakatayo at nung buntis pa ko ang bigat ng tyan ko (+) varicose veins 11. Abdomen Kumikirot kasi tahi ko (+) pain 12. GU Nagka-UTI ako nung nagbubuntis pa ko (+) rubra lochia(-) urinary tract infection 13. Anus, Rectum and Prostate Hirap akong tumae (+) disablement 14. Musculoskeletal System Okay naman, ngayon lang ako di makakilos ng maayos dahil masakit tahi pa ko (+) hold in ROM 15. Nervous System Okay naman (+) conscious 16. Hematologic Okay naman 17. Endocrine Okay naman 18. Psychiatric Okay naman