FAREASTERNUNIVERSITY Sampaloc,Manila INSTITUTEOFNURSING

OSPITALNGSAMPALOC OBWard Sept.3,4,5,10,11,12,17,18,192012 InPartialfulfilment Oftherequirementsforthe SubjectNCM106 SubmittedBy: Furton,AlyzaE. (BSN311/Grp.41B) SubmittedTo: MaamAnnaGayDeGuzman (ClinicalInstructor)

I.BiographicData Name:Mrs.JCL Address:326KundimanSt.SampalocManila Age:25yearsold Gender:Female CivilStatus:Married Birthday:April27,1987 PlaceofBirth:Sampaloc,Manila EducationalAttainment:Highschoolundergraduate Nationality:Filipino Religion:RomanCatholic Occupation:Housewife DateandTimeAdmitted:September5,2012,8:00am Ward:OBGyneward Room#:414B Complaint:Hypogastricpain FinalDiagnosis:65P4(4014)PU391/7wksAOG,cephalicdeliveredviaNSDtoalivebabyboy,BW:3.1kgBL:50cm AdmittingPhysician:Dra.Pamitta AttendingPhysician:Dr.Godeloson II.NursingHistory PastMedicalHistory Patientschildhooddiseasesincludefever,cough&colds.Sheneverhadanyseriousdiseasesbefore sincechildhood.PatienthadnohistoryofHypertension,DiabetesMellitus,AsthmaandPTB.Thereisnohistory ofsurgery,accidentandtrauma.ShehasnoallergiestofoodanddrugsandshehadbeenhospitalizedthreetimesinMa. ClaraLyingInClinicfordeliveryofherfirstthreechildrenandmanagementofabortioninherfirstpregnancyatFabella.She hadcompleteimmunization(1BCG,3DPT,3OPV,3HEPAB&1AMVbeforehereachedtheageof1. HermedicationscurrentlytakenincludeMefenamicacid,FerrousSulfateandAmoxicillin. HistoryofPresentIllness ThepatientwasadmittedatOspitalngSampaloclastSeptember5,2012at08:00amwiththechief complaintofhypogastricpain.TheadmittingdiagnosisisG5P4(3013)PU391/7wksAOGcephalicin imminentdeliveryandherattendingphysicianisDra.Pamitta.ThemedicationsgivenareAmoxicillin, FerrousSulfateandMefenamicacid. Familyhistory Thepatientsfamilydoesnthaveanyproblemsorfamilydiseases.ThepatienthasnofamilyhistoryofDiabetes Mellitus,Hypertension,asthma,CardiovascularDiseases,twinningandothercongenitalanomalies. OB/GynecologicHistory A.MenstrualHistory Menarcheofthepatientbeganwhenshewas12yearsoldinaregularcycleof57days.Sheusestwopacksoffeminine napkins.Patientsometimesexperiencesdysmenorrheaduringherfirsttoseconddaysofhermenstruation.Patientisnot yetinamenopausalstage.

 B.ObstetricHistory G12003,spontaneousabortionatFabella G22005,LFTbabyboyviaNSDatMa.ClaraLIC;nocomplication G32007,LFTbabyboyviaNSDatMa.ClaraLIC;nocomplications G42010,LFTbabygirlviaNSDatMa.ClaraLIC;nocomplications G52012,LFTbabyboyviaNSDatOspitalngSampaloc;nocomplications. C.GynecologicalHistory Therewerenoprevioussurgicalproceduresdoneandpreviousgynecologicalproblemsexperiencedbythepatient.She doesnotexperienceanybleeding.Sheverbalizedthathervaginaldischargesisreddishincolor.Shedoesntalso experiencesvaginalitching. D.ContraceptiveHistory PatientandherhusbanddontuseartificialmethodsofcontraceptionbutverbalizedthattheyuseWithdrawalmethodas theirnaturalfamilyplanningmethod.Theyveagreedtothemethodanduseiteversincetheygotmarried. E.SexualHistory Firstsexualintercoursehappenedwhenshewas15yearsold.Sheclaimedthatheronlysexualpartnerwasherhusband. Sheandherhusbandaresexuallyactive.Therewerenosexuallytransmittedinfectionsexperiencedbythepatient. SocialandEnvironmentalBackground Thepatientisahousewifelivingwithherhusbandandchildrenintheirhousewithtworooms.Sourceofwaterfordrinking purposescomesfromNawasa.Waterfordomesticpurposescomesfromthedeepwell.Garbageiscollectedregularly. Patientisanonsmokerandnonalcoholicbeveragedrinker.Nohistoryoftravel. III.PATTERNSofFUNCTIONING NUTRITION Findings: Beforehospitalization,shesaidsheusuallyatepansit,andbreadforherbreakfast.Sheeatsrice withmeatlikefishandchickenforherlunchanddinner.Herhusbandsaidthatshefrequentlydranksoft drinksandatesaltyfoodwhenshedidntknowthatsheispregnant.Duringherhospitalization,herdiet wasDAT.SheatenoodleswithbreadanddrinkwaterlastSeptember5,2012. NormsandStandard: Variousdailyfoodguideshavebeendevelopedtohelphealthypeoplemeetthedailyrequirementsof essential nutrients and to facilitate meal planning. Food group plans emphasize the general types or groups of foods rather than the specific foods, because related foods are similar in composition and oftenhavesimilarnutrientvalues.Forexample,allgrains,whetherwheatoroats,aresignificantsource of carbohydrate, iron, and the B vitamin thiamine. Daily food guides that are currently used include DietaryGuidelinesforAmericansandtheFoodGuidePyramids. Source:FundamentalsofNursing.KozierandErb.2008.Pp1246. Analysis: Thehospitalsmealisverymuchnutritiousthanthepatientsmealwhenshewasathome.

SLEEPANDREST Findings: Beforehospitalization,sheslept8hrs./day.Antukinakoeh,nagigisingakotaposinaantoknanaman maya maya. But she feels satisfied with her sleep. During hospitalization, on her first day, she experiencedsleepingasearlyas9am.Shesaidshewokeupbecauseshefeltvoiding. NormsandStandard: Mosthealthyadultsneed7to9hoursofsleepanight.However,thereisindividualvariationas some adults may be able to function well with 6 hours of sleep and others may need 10 hours to functionoptimally.(FundamentalsofNursing8theditionbyKozierandErbpp.1168) Analysis: There is a little problem on this pattern because she sometimes cannot sleep due to the environmentandnaturescall. ELIMINATION Findings: Before hospitalization, she had difficulty in urinating because she felt pain everytime she urinated.Madalas akong umihi pero untiunti lang. She said that the color of her urine was lightly yellow.Duringhospitalization,shewasassistedbyherhusbandsothatshecangototheCRandshefelt alittlepainandshesaidthatthecolorisyellow. NormsandStandard: Voidingorurinationallrefertotheprocessofemptyingtheurinarybladder.Thisoccurswhen the adult bladder contains between 250 and 450 mL of urine. Each person must take 810 glasses of watereveryday.Thefrequencyofdefecationishighlyindividual,varyingfromseveraltimesperdayto twoorthreetimesperweek.Manypeoplebelievethatregularitymeansabowelmovementeveryday. (FundamentalsofNursing8theditionbyKozierandErbpp.1326and1325). Analysis: ThisisthepatternwhereIhaveseenalotofproblems.Shehaddifficultyinurinatingbecauseof thepainshefelteverytimesheurinates.Sheurinatedfrequentlybutshesaidonthefirstdaythatits toolittle. HEALTHILLNESS Findings: Mrs. JCL was hospitalized because of the pain she felt last Sept. 5, 2012. .My patient is a multigravidawithAOG391/7weeks.ShesaidNahihiloakotuwingumagamalibansasakitkosalikod tsakapuson,walanaakongibangsakitnamatandaan. NormsandStandard: Healthisahighlyindividualperception.Manypeopledefineanddescribehealthasthefollowing: Beingfreefromsymptomsofdiseaseandpainasmuchaspossible Beingabletobeactiveandtodowhattheywantormust Beingingoodspiritsmostofthetime Thesecharacteristicsindicatethathealthisnotsomethingthatapersonachievessuddenly. Source:FundamentalsofNursing.KozierandErb.2008.Pp295.

Analysis: Theclientneedstohavemoreresttoregainherenergy. ACTIVITYEXERCISE Findings: Mypatientisnotactive.Shesaidshehasnoexerciseexceptthatshedoesalittlehouseholdchores. NormsandStandard: Make an activity or exercise for at least 30 minutes. (Fundamentals of Nursing 8th edition by KozierandErbpp.1105) Analysis: Theclientneedstohaveexerciseespeciallywithhercondition. IV. PHYSICALASSESSMENT Mrs.JCL,25yrsold Norms ActualFindings Interpretationand analysis Generalappearance 1. Posture/Gait Relaxed,erect Tense and weak Tense;weakness posture;coordinated posture/ gait are movement caused by the pain and the body weakness felt by the patient. 2. overall Haspoorhygiene, Clean,neat Poor hygiene is hygiene notedlongnailsand caused by the way of hasbadbreath living of people and other environmental factors. 3. signsof Frowning,notedsigns Facial expression is Nodistressnoted often the first distress ofdistress indicationofpain,and it may be the only one. (Kozier Fundamentals of nursingpage982) Unrelievedpain 4. Noteobvious Weakness Healthyappearance Has been noted to signsof have a potentially healthor harmful effect on the illness persons well being a (e.g.skincolor

orbreathing) 5. Verbal behavior 6. Nonverbal Behavior

natural response to pain is to stop activity; tense muscle or muscle weakness, and withdrawn from pain provoking activities. (Kozier Fundamentals of Nursingpage1195) Understandable, understandable;able Normal moderatepace;clear toanswerquestions toneandinflection; exhibitsthought association There are wide Cooperative;ableto Cooperative variations in followinstruction nonverbal responses to pain. For clients who are very young, aphasic, confused, or disoriented, non verbalexpressionmay be the only means of communicating pain. (Kozier fundamentals ofNursingpage1202) Normalrange:36 37.9C Pyrexia:3840.9C Adultpulseaverage: 80(60100) T=36.6C PR=73bpm Increase in temperature is the first response of the body to infection or inflammation. Fear and anxiety as wellastheperception of severe pain stimulate the sympathetic nervous systemthecausesthe pulseratetoincrease. (Kozier Fundamentals of Nursing page 538 and1193)

Measurements Temperature Pulserate

Respiratoryrate Bloodpressure BodyPart Skin

AdultRespiratory average:16(1220) Normal:<120/<80 Prehypertension:120 139/808 HPN,stageI:140 159/9099 HPN,stageII: >160/>100

RR=17cpm BP=100/60

There are many factors that affects the respiratory rate, someofwhicharethe exercise (increase in metabolism), stress (readies the body for fight or flight), and lowered oxygen concentration at increasealtitudes. (Kozier Fundamentals ofNursingpage548) Early in the onset of acute pain, the sympathetic nervous system is stimulated, resulting in increased inbloodpressure,PR, RR, pallor etc. The body cannot sustain the increased sympathetic function over a prolonged period,andtherefore, the sympathetic nervous system adapts, making physiologic responses less evident or even absent. (Kozier fundamentals of Nursingpage1202) Interpretationand analysis Normal

Norms Varies from light to deep brown; from ruddytolightpink; Skin color is generally uniform except in areas exposed to the sun; no edema; freckles, birthmarks, some flat and raised nevi; no abrasions or

Actualfindings Brown color; color is uniform; no edema noted; moisture in skin folds; is temperature 36.6C;warm to touch;

 Hair SkullandFace Eyestructureand VisualAcuity EarsandHearing NoseandSinuses

lesions; moisture in skin folds and in the axillae, skin temp.is uniform and within normal range. Skin turgorspringsbackto previous state when pinch. Evenly distributed hair; thick hair; silky, resilient hair, no infection or infestation Skull is rounded shape; symmetric facialmovements Eyebrows hair evenly distributed; Eyebrows symmetrically aligned; eyelashes is equally distributed; curlyslightlyoutward; skin intact; no discharge; no discoloration; lids close symmetrically; approximately 1520 involuntary blinks per minute; bilateral blinking;Noedemaor tenderness over lacrimalglands;pupils black in color; equal insize; Color same as facial skin; Auricle aligned with outer canthus of the eye; auricles are mobile, firm and not tender upon palpation; Symmetric and

Evenly distributed hair; no infection or infestation Skull is rounded shape; symmetric facialmovements Eyebrows hair is evenly distributed and symmetrically aligned. No discharge and discoloration. No edema or tenderness over lacrimal gland. Equalinsize Color is same as the facial skin; auricle is aligned with outer canthus of the eye; auricles are mobile, firm and not tender uponpalpation; Symmetric and

Normal Normal Normal Normal Normal

 Mouthand Orophrynx Neck ThoraxandLungs HeartandCentral Vessel BreastandAxillae Abdomen

straight;Nodischarge orflaring;nottender; no lesions; mucosa is pink; Outer lips are uniformincolor;soft, moist,smoothtexture Neckmusclesisequal in seize; head lymph centered; nodes are not palpable; trachea is placed centrally in midline of the neck; thyroid gland is not visible upon inspection Notassessed Notassessed Notassessed Notassessed

straight; positive swellingonleftnostril and discharge; tender uponpalpation; Outerlipsareuniform in color; soft, moist, smoothtexture Neckmusclesisequal insize;headisaligned at the center; lymph nodes not palpable; trachea is in central position; thyroid glandisnotvisible; Notassessed Notassessed Notassessed Notassessed

Normal Normal

NEWBORNPHYSICALASSESSMENT BabyBoyLopiga ASSESSMENT NORMS GeneralAppearance Headdisproportionately Brieflydescribe largeforthebody,neck (ex,darkhair,pink, looksshort,chinrestson flexed) chest,prominent abdomen,sloping shoulders,narrowhips, roundedchest Weight& Measurement 1.Weightinclude 25004000g(5lb,8oz.,8

FINDINGS Headislargerthan chest;necklooks short,prominent abdomenand roundedchest.

INTERPRETATION Normal

3.1kgs

Normal

range&average 2.Heightinclude range &average 3.Temperature Axillary Rectal(optional) 4.HeadCircumferance 5.ChestCircumference Posture:briefly describe

Skin 1.Color 2.Texture 3.Turgor

lbs.13oz.) 4852cm(1822in.) 36.437.2C(97.599F) 36.637.2C(97.899F)36.8 C (98.8F)desired 3237cm(12.514.5in.) 2cm Greaterthanchest Circumference 32.5cm,12cmlessthan headWiderthanitislong Bodyusuallyflexed,hands maybetightlyclenched, andneckappearsshort becausechinrestson chest. Consistentwithrace. Europeanpinktinged, AfricanorNativeAmerican palepinkwithyellow tinge,Asianpinktorosy red,yellowtinge. Smooth,soft,flexible,may havedray,peelinghands and feet. Elastic,returnstonormal shapeafterpinching

50cm 35.4C 33cm 34cm

Normal Newbornsoftenhave troubleregulatingtheir ownbodytemperature. Ifit'slow,itmeans they'recoldandneed tobewarmedup. Normal Normal

RosyRed Dryskin Returnstonormal shapeafterpinching

Normal Dryskininbabies occursbecausetheskin isstillimmature.After ninemonthsimmersed inamnioticfluid,a newborn'sskinneeds timetoadjusttothe outsideworld. Normal

 4.Pigmentation 6.NormalVariations Ex.Rashes,ETrash, Mongolianspots, birthmarks,bruises, petechiae. HeadAssessment 1.Generalappearance 2.Size(relatedtobody) 3.CommonVariations Defineandexplainthe differencesbetween CaputSuccedaneum& Cephalhematoma.

Clear,miliaacrossbridge ofnose,forehead,orchin will disappearwithinafew weeks Mongolianbluespots commonoverdorsalarea andbuttocksindark skinnedinfants Round,symmetric,and moveseasilyfromleftto rightandupanddown, softandpliable Greaterthanchest circumference,headone fourth ofbodysize Molding Caputsuccedaneum(long laborandbirthdisappears in1week, cephalhematoma(trauma duringbirth,maypersist upto3months)

Havemiliaonthe bridgeofthenose. Doesnthaveany Mongolianspots

Hair 1.Texture 2.Distribution

Smoothwithfinetexture variations,dependson ethnic background Scalphairhighover eyebrows(Spanish Mexicanhairlinebegins midforeheadtoneck)

Normal Newbornsoftenhave temporarypimplesor blotchesthatsoon disappearasthey adapttolifeoutside thewomb. Roundandsymmetric Normal Headisgreaterthan chestcircumference Normal Hascaput succedaneum Normal.Caput succedaneumisa circularswellingand bruisingofthescalp usuallyseenontopof theheadtowardthe back,whichisthepart ofthescalpmostoften leadingtheway throughthebirthcanal. Thiswillfadeovera fewdays. Smoothhair Normal Scalphairhighover Normal eyebrows.

Face 1.Symmetry 2.Movement

Eyes 1.Generalplacement and Appearance 2.Color

Nose 1.Generalappearance 2.Anysneezing?

Symmetricmovementof all facialfeatures,normal hairline,eyebrows& eyelashespresent Makesfacialgrimaces Symmetricwhenresting andCrying Brightandclear;even placement,slight nystagmus(involuntary cycliceyemovement) Bluegrayorslateblue gray Browncoloratbirthin dark skinnedinfants Mayappearflattenedasa resultofbirthprocess Sneezingcommontoclear nasalpassages

Symmetricmovement Symmetricwhen crying Brightandcleareyes Blackcoloratbirth

Normal Normal Normal Normal

Flat Hasseensneezing

Mouth 1.Symmetry 2.Tongue Ears 1.Positiononhead relativetoeyes

Symmetryofmovement andStrength Tonguefreemovinginall directions,midline Topofear(pinna)should beparalleltotheouter andinnercanthusofthe

Symmetricin movement Tonguefeemovingin alldirections Earisparalleltothe innercanthusand outercanthusofthe

Normal Normal.Sneezingis alsocommonin newborns.Thisisa normalreflexandisn't duetoaninfection, allergies,orother problems. Normal Normal Normal

 Neck 1.Appearance

eyes Short,straight,creased with skinfolds,posteriorneck lackslooseextrafoldsof skin Regularrateandrhythm, nofunctionalmurmurs, 120160bpm Nofunctionalmurmurs Nothrills Vibrationcreatedby turbulenceoffluidpassing throughanincompetent valve Cylindricwithsome protrusion,appearslarge in relationtopelvis Noprotrusionsof umbilicus (but,commoninAfrican descent) Twoarteriesandonevein Present Normalskincolorare pigmentedindarkskinned infants Smegmaunderlabia

eyes Shortneck Normallytheneck looksshortin newbornsbecauseit tendstogetlostinthe chubbycheeksand foldsofskin. Normal Normal Normal

Heart 1.Auscultateheart soundsforoneminute &describe 2.Anymurmur 3Anythrills Defineathrill.

Regularrateand rhythm,135bpm Nomurmursheard Nothrills

Abdomen 1.Appearance 2..Umbiculus 3.Numberofvessels Genitals Female 1.Generalappearance 2.Discharge

Largeandrounded Noprotrusionsof umbilicalcord Twoarteriesandone vein RosyRed Hassmegmaunder labia

It'snormalforababy's abdomen(belly)to appearsomewhatfull androunded. Normal Normal Normal Duetotheeffectsof maternalhormones,

ButtocksandAnus 1.Symmetry Extremities&Trunk 1.Generalappearance 2.Symmetry 3.Arms(equal) 4.Legs 5.Feet

Symmetric

Activity 1.Cry(pitch)

Symmetric Shortandgenerallyflexed, ShortandGenerally flexed extremitiesmove symmetricallythrough Symmetric rangeofmotionbutlack full extention Symmetric Equalinlength Equal Legsequalinlength Legsshorterthanarmsat EqualinLength birth Footisinstraightline Positionalclubfootbased Footisinstraightline onpositioninutero Moderatetoneandpitch, Moderatetoneand strongandlusty pitch

mostnewborngirlswill haveavaginal dischargeofmucusand perhapssomeblood thatlastsforafew days. Normal Normal Normal Normal Normal Normal Normal

PROBLEMPRIORITIZATION
DATE RANKED 1 NURSING PROBLEMS IDENTIFIED IneffectiveHealth Maintenance relatedtopoor hygiene. CUES JUSTIFICATION

SubjectiveCues: Bihiralangakomaghugasng kamayasclientverbalized. ObjectiveCues: *Bodyormouthodor *SoiledClothing *Poorhygiene(LongNails)

DisturbedSleep Patternrelatedto anxiety/fear.

SubjectiveCues: Lagiakongnahihirapansa pagtulogpagkapanganakkoas clientverbalized. ObjectiveCues: *Interruptedsleep *Restlessness *Irritability *Yawning

Thisproblembelongstothe physiologicalneedsof MaslowsHierarchyofNeeds. Thisproblemisahigh modifiablebecauseittakesa longtimewhichisabout1 weektosolvebecauseit affectsmainlytheclients attitudeandwillingness.This problemcoversalltheaspect ofhumanlifebecauseitisall aboutmaintaininghealth.Itis alsoahealththreatening problemandifitisnotsolved, theclientwillnotbeableto surpassotherproblemsboth actualandpotentialone. Amongtheproblems,we chooseittobethefirsttoher priority.Werankeditfirst becauseitismoreimportant thingsratherthantheothers. Inordertosolvethisproblem, itneedstheclientsattitudes, timeandcooperation.Itis alsonecessarythatanurse musthavetheknowledgeand attitudetoencouragethe clienttomaintainherhealth. Disturbed sleep pattern is considered as an actual problem because it is usually present within the client. It is also considered as high modifiable because it takes a lotoftimetosolvethistypeof problem.Italsobelongstothe Physiologic level of Maslows HierarchyofNeedsbecauseit is considered as deviation from sleep of individual and

*Alteredfacialexpression

sleep is a basic need to survive. This problem is also considered as lifethreatening because it usually results to the malfunctioning of different body parts or systems of the body. One example is that the client cannot perform her duties well and cannot make good decisionsifsheisexperiencing lack of sleep. We also prioritized this among the other problems because she thinks that once this problem is solve it will reduce the problem that she has experiencing right now and she can easily maintain her health. Enough sleep, good nutrition and lowstress environment is all she needs to regain her energy so that shecanfaceallthenewsetof workloads for the following day. In order to solve this problem, it needs the knowledge and time of the nurse/healthcare provider to discuss the benefits and effects of having a proper amountofsleepandnutrition. It also requires the effort and cooperation of the client to haveagoodresult.