INDIVIDUAL ASSESSMENT

I.

Demographic Data Name: Address: Age: Sex: Date of Birth: Nationality: Occupation: Language: Educational Attainment: Religion: Information provided by: Ms. ZM City Homes Resort Ville-2, Langkaan-II, Dasmarias, Cavite 19 y/o Female February 11, 1993 Filipino None Filipino College Graduate Jehovahs Witness The client who is reliable

II.

Reason for seeking care There reason for seeking health care is to have a post partum and neo natal check up.

III.

History of Present Illness The client is quite well during the time of the interview.

IV.

Past Medical History The client was in a good state of health. The client was always brought to the hospital because of minor accidents like overdosing of vitamins, as verbalized by the mother of the client, when she was a child; she undergone appendectomy when she was 15 years old; there are no allergies reported as the client described; she is taking Mefanamic Acid every 6 hours, Ferosulfate twice a day, and Cephalexin every 6 hours for her state; she is fully immunized.

V.

Obstetric- Gynecological History The client stated that she had her menarche when she was 11 years old. Her last menstrual period was Last week of December 2011 and used about 2 pads per day but not much soaked. The usual duration of her menstrual period is 3 days and had an irregular cycle. She doesntexperiencedysmenorrheal whenever she had menstruation.Client ZMs GTPAL is G1T0P1A0L1.

VI. Personal And Psychosocial History DIETARY INTAKE Breakfast: Lunch: Snack: Dinner: USUAL DIET The client usually eats rice, meat and vegetables for her diet. EXERCISE She is walking every morning at least 30 minutes to 1 hour as her form of exercise. USUAL ACTIVITIES Her usual activity in a day is caring for her baby, and eating. HOBBIES Her hobby is caring for her baby. REST AND SLEEP She doesnt have permanent sleeping pattern due to her baby, sometimes she sleep an hour at night. ALCOHOL USE/ SMOKE Ms. Z doesnt drink alcohol and smoke as well since she got pregnant until now. RECREATIONAL DRUG USE The client has no recreational drug use. VII. Gordons Functional Health Pattern A. Health Perception- Health Management The client verbalize that she doesnt suffer vomiting in her pregnancy. She sometimes eats vegetables, meat, and fish. The client drinks Mefanamic Acid every 6 hours, Ferosulfate twice a day, and Cephalexin every 6 hours for her stateas prescribed by her ob gynecologist. She doesnt drink milk these past few weeks because of lack of budget. She is moderately active also. B. Nutritional- Metabolic She drinks 1 glass of chocolate, and eats 5 loaves of bread She eats 1 cup of rice, 1 serving of Monggo, and drinks 2 glasses of water 2 pieces of banana and drinks 1 glass of water She eats 1 cup of rice, 1 serving of adobongmanok, and drinks 2 glasses of water

The client eats at least 3 meals a day and drinks 6 glasses of water. She prefers vegetables than meat and fish. She denies drinking alcohol and smoking. C. Elimination The client voids about 8-10x a day characterized as clear and yellow. She also defecates thrice a week as characterized as yellowish to brownish in color and semi solid usually in the morning. Shes having difficulty defecating. D. Activity- Exercise After the client wakes up in the morning, she always had headache due to her disturbed sleeping pattern. As verbalized, after she gave birth to her baby she doesnt do many household chores. Her daily routine is just taking care of her baby and sleep if theres time. At around 3:00pm, when she feels sleepy she takes afternoon naps. E. Sleep- Rest During the course of interview, client doesnt look relaxed and comfortable, suggesting she is not well rested. As verbalized, client sleeps about 1 hour at night.. She verbalized having problems in regarding her sleep-wake cycle. During the day, she spends her free time if theres any for afternoon naps to serve as rest periods. F. Cognitive- Perceptual The client was able to answer the questions clearly and concisely.Her senses are still comprehensive, as verbalized. Client was a graduate of BS Computer Science. G. Self-Perception- Self-Concept Client feels good and satisfied about herself. She does not exude self confidence and esteem because of her condition. She describes herself as having low and unsociable personality. She was a little bit shy during the course of the interview. She prefers to be alone when she had a problem and keep it by herself. H. Role- Relationship The client stated that she is a good friend, an obedient daughter and now trying to be a great mother even though shes an adolescent and single-parent. She verbalized that she sometimes act like a parent and rule over her sibling, being the eldest daughter. She described that she is type of friend that is easily to be leaned. I. Sexuality- Reproductive

The client stated that she had her menarche when she was 11 years old. Her last menstrual period was Last week of December 2011 and used about 2 pads per day but not much soaked. The usual duration of her menstrual period is 3 days and had an irregular cycle. She doesnt experienced dysmenorrhea whenever she had menstruation.

J. Coping- Stress The client verbalizes that whenever shes stress she walks around there street. She denied drinking medications when coping but she just cries alone and eat a lot. K. Value- Belief The client goes to church before she got pregnant. Shes major priority as for now is to deliver her baby normal spontaneous delivery. She stated also that she believe whenever the pregnant gets beautiful her baby is a girl but if she gets ugly it means its a boy. VIII. Review of System System General Integument Skull Eyes Ears Nose and Sinuses Mouth Throat and Neck Breast and Axila Respiratory Cardiac Gastrointestinal Urinary Musculoskeletal IX. Subjective Cues Okay naman ako, laging alang puyat Pakiramdam ko parang medyo dry yung balat ko Di naman nanglalagas yung buhok ko Okay naman, nilalagyan ko pa ngang cutics kuko ko Wala naman sugat ulo ko o kaya bukol pero nasakit pagminsan lalo na kapag bagong gising Hindi naman Malabo ang mga mata ko Malinaw naman pandinig ko Wala naman akong sipon ngayon Kapag may sipon ako, nasakit ulo ko Madalas ako magkasingaw Hindi naman ako nahihirapan lumunok Wala naman ako nararamdaman na kulani sa may leeg ko Eto nga nag-breast feed ako, masakit lang nung una Hindi naman ako nahihiripan huminga Nakakaramdam ako ng paninikip ng dibdib kapag minsan Laging malunggay pinapakain sa akin para daw yung sa gatas Kulay dilaw nga ihi ko e tapos mahapdi dahil dun sa tahi Wala na ko masyado ginagawa ngayon kundi mag alaga nalang kay baby

Physical Examination Parts Skin Objective Cues white in color (-) lesions (-) hyperpigmentation warm to touch Findings Normal

Hair

Nails Skull and face

Eyes and vision

Ears and hearing

Nose and sinuses

Mouth and oropharynx

Neck

Lymph Nodes Thorax and Lungs Heart

Gastrointestinal

Musculoskeletal

evenly hair distribution black, fine hair no parasites evident (-) masses oily and dry round, hard, nails with pink nail beds capillary refill <3 seconds normocephalic aligned facial features (-) masses (-) nodules symmetrical blinking round and equal iris (+) opacity of the left lens non tender lacrimal apparatus symmetric (-) discharges on external ear smooth, elastic (-) tenderness symmetric (-) nasal discharges pink and moist mucosa with no lesions (-) nasal flaring (-) masses (-)tenderness pharyngeal tonsils not inflamed (+) gag reflex (-) lesions on lips, mouth and throat cracked lips symmetric (+) full ROM (-) lesions (-) masses (+) smooth, firm and non tender thyroid (-) enlarged lymph nodes symmetrical thoracic expansion (-) crepitus (-) wheezing (+) apical pulse felt at 5th ICS LMC line normal heart sounds regular rate, normal rhythm normal liver span (-) masses (-) tenderness normoactive bowel sounds steady gait (+) full ROM and muscle strength of upper and lower extremeties

Normal

Normal Normal

Normal

Normal

Normal

Normal

Normal

Normal Normal Normal

Normal

Normal