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Psychosocial Assessment

1. Lifestyle Information

KMC is a 19 year old, single, a Roman Catholic and lives with her parents, three
brothers and uncle at Buga, Leon. She was a second year college student major in
Special Education at West Visayas State University but stopped schooling but didn’t
tell why. When she was pregnant she lives at Iloilo city with her husband to be. But
then, when she was six months pregnant, she went home to Leon to have a rest
from all her household chores in the city. During her stay with her parents, she was
always accompanied by her mother in a once a month prenatal check-up at a
Health Center in Buga. Her last prenatal check-up was August 13, 2009. During
pregnancy she confessed that she really like sweets like chocolates and fruits.

2. Normal Coping Patterns

When she was under physiological and mental stress, she usually watches TV to
relieve her stress. But when she had emotional stress caused by the pregnancy, she
usually talks to her mother. She said that her labor was a severe stress that she
recently experienced because of the difficulty and pain that she felt during the
delivery. Her mother was at her side to comfort her at the ward after her delivery.

3. Understanding of Current Illness

She understood that her delivery was very difficult because it was her first. She also
said that her labor process was very painful and promised that she will never get
pregnant again to avoid experiencing this event again.

4. Personality style

KMC shows cooperation on her health care and has no negative traits that may
affect her care compliance. She has a pleasant personality, smiling most of the
time.

5. History of Psychiatric Disorder

KMC has no history of psychiatric disorder.

6. Recent Life Changes

KMC considers her recent delivery a big change in her life. After carrying the baby in
her womb for approximately 9 months, now she can see the baby besides her
sleeping deeply. It was a big shift from her being single to a mother.

7. Major Issues Raise by Current Illness

KMC was unable to do her activities of daily living. But a new member was added to
their family that gave her pride and confidence. The baby was a blessing for her.
8. Mental Status

Appearance

Description:

KMC wears neat and clean clothing, has well-combed hair and relaxed position. Her
nails are clean and well-trimmed. Converses with good eye contact.

Behavior

Description:

KMC is calm, alert and awake. She respond to questions appropriately.

Speech

Description:

KMC’s speech is appropriate, clear and understandable. She shares conversations
appropriately. She can understand and speak Hiligaynon, Tagalog and English.

Mood/Affect

Description:

KMC’s mood is appropriate with her facial expression and she smiles occasionally.

Thoughts

Description:

Themes in conversation are usually about her situation, her life and her baby. She
answers questions appropriately and has sense.

Ability to abstract:not assessed

Memory:

Impaired recent memory: No
Impaired Past Memory: No

Number of objects able to remember after 5 minutes: not assessed

Description:

KMC was able to remember recent and past memory without difficulty. She was able
to recall her 24-hour diet and the date of her last prenatal check-up that was
verified by her mother.

Estimated Intelligence

Average

Concentration

Easily distractable

Able to subtract: not assessed

Orientation

Person / time/ place / situation /

Judgment

Realistic decision making Yes No

Description:

Not assessed

Insight

Good Fair Poor

Description:

Not assessed

II C. Clinical Inspection

1. Vital Signs
T = 36.9°C / axilla PR = 72 beats/min
BP = 130/70 mmHg RR = 16 breaths/min
2. Height = 160 cm
3. Weight = 51 kg before delivery
4. Physical Assessment
General Appearance

Posture is erect and position is relaxed. Well-developed build of body
for age. Neatly dressed in light clothes appropriate for the situation.
Clean and trimmed nails. No presence of body and breath odor. No
signs of distress in posture and facial expression. Cooperative and
answers questions with good eye contact. Speech is fluent, clear and
moderately paced. Able to recall recent and past events without
difficulty. Apparent age is appropriate to present age.

A. Integumentary System

Skin color is brown, lighter in palms, soles and nail bed and warm to
touch. Discoloration on the lower extremities noted No lesions noted. Hair
black, length is 2 inches below the shoulder , wavy, clean and thick. Equal
distribution of hair on scalp. Hair is slightly oily and slightly rough. Scalp is
pink, with no lesions. Scalp is smooth and nontender. Nails are well-
trimmed, clean and form a 160° angle at the base; immobile, hard and
smooth with no clubbing. Nail beds are round. Nails are attached to nail
beds.

B. Neurologic System

Eyes are almond-shaped and symmetric. Eyebrows are symmetric and
no flakes are noted. No redness, discharge or crusting noted on lid
margins. Conjunctivae is pink, smooth and moist. Sclerae is white, moist,
with no redness or lesions. No excess tearing on lacrimal apparatus.
Cornea is transparent, smooth and moist with no opacities; lens is free of
opacities. Irises are round, flat, and evenly colored brownish black. Pupils
are equal in size approximately 3 mm in diameter.

Ears equal in size bilaterally, smooth. Pinna recoils in less than 2
seconds. Tip of pinna is aligned with the outer canthus of the eye. No
discharge, nontender on palpation. Mastoid process is nontender.

Cranial Nerves
Able to identify on each nostril
I
separately (coffee)
II Able to read SN’s nameplate at a
distance of 2 ft. Light reflected on
the same location of the iris. Direct
and consensual reaction to light
when pupils are shun with light.
III, IV, VI PERRLA noted on both eyes. Able to
perform the 6 extraocular
movements. Thecovered and
uncovered eyes are not wandering
during the cover/uncover test.
V Able to identify simple touch equally
on both side of the face.
Temporomandibular joint is
symmetrical and coordinated
VII Able to perform facial movement.
Facial muscle movements are
symmetrical. Able to identify taste
(sweet and salty)
VIII Able to hear and repeat the word
“Joan” and “Marie” on voice test.
IX and X Able to identify the different taste
and name of substance. Uvula is
midline and hanging freely, manifest
gag reflex and tonsils are Grade 2
XI Able to perform active ROM of neck
muscles (flexion, lateral flexion,
hypertension). Equal shoulders
against resistance.
XII Tongue is able to exert equal
resistance
KMC was able to identify light touch equally on both sides of the
body on the upper and lower extremities. Able to identify sharp and dull
pain on upper and lower extremities.KMC is able to identify the arm where
light touch is applied (Extinction phenomenon). Able to perform finger to
thumb, finger to finger and finger to nose test.

Not able to perform the sliding of heel from knee to shin of the
other leg due to muscular pain.

C. Respiratory System

Nose is smooth and symmetrical and medium-sized. Able to sniff and blow
through each nostril. Nose has no tenderness and masses. Nasal septum
is not deviated. Nasal mucosa, septum and turbinates are moist and
pinkish and free of lesions. No discharges are noted. Sinuses (maxillary
and frontal) are nontender to palpation and percussion. Trachea is midline.
RR = 16 breaths/min. Breath sounds are bronchovesicular on the lung
area and vesicular below the lung area. Anterior chest is symmetrical and
normal shaped. Breathing pattern is effortless and regular. The trachea
manifested bronchial breath sound, the lung area bronchovesicular and
below the lung area vesicular.

D. Cardiovascular System
Temporal arteries are palpable, strong and regular. Carotid arteries are
palpable, strong and regular. Pulsations of precordium are not visible on
inspection. Heart sounds are strong and normal. Apical pulse is 72
beats/min. S1 is louder than S2 in apical area. Radial pulse is 72 beats/min.
Ulnar, brachial, popliteal and dorsalis pedis pulse are palpable, strong and
regular. Capillary refill time on fingers and toes is 2 seconds.

E. Gastrointestinal System

Lips brownish pink, smooth, moist and without lesions. Buccal mucosa is
pink and moist. Thirty-two white teeth present with no cavities. Gums
pink without redness and swelling. Tongue protrudes at midline without
tremors. Ventral surface of tongue is smooth, moist

and pink. Dorsal surface with midline fissure and rough. Frenulum in
midline. Hard palate white and bony. Soft palate pink and moist. Midline
and symmetric elevation of uvula and soft palate with phonation. Tonsillar
pillars pink. Tonsil Grade 2. Jaw alignment is symmetrical.

Abdomen is symmetric. Bulges noted. Umbilicus is midline and inverted.
Rectum is free of haemorrhoids, masses, tenderness and discharges.

F. Endocrine System

Thyroid gland is midline, smooth, firm and nontender. Ascends during
swallowing.

G. Reproductive System

Breast bilaterally the same size. Breast color is light brown. No masses
noted. Mild discharges noted. Areola is brownish in color.

H. Genito-Urinary System

KMC has not yet voided four hours after delivery. Genitals is dark brown
and nearly black, symmetric . Pubic hair is evenly distributed, thick and
curly.

I. Musculoskeletal System

Cranium is hormocephalic and proportional to the body.
Temporomandibular joint is freely moving and nontender. Cranium is
symmetric. Face is oval in shape and symmetric. Neck is midline and
symmetrical. Vertebral column is vertically straight. Spinous process are
aligned and evenly spaced. No tenderness, swelling and masses upon
palpation of joints. Muscle strength is 5/5 in the upper extremity and 3/5 in
the lower extremity. No edema present.

J. Hematopoietic System
Conjuctivae is pinkish and moist. Capillary refill time on fingers and toes is
2 seconds.

K. Lymphatic System

Axillae no odor noted. Shaved hair on the axillae.
Postauricular,subauricular, submandibular, occipital,submental,deep
cervical chain, superficial cervical and supraclavicular lymph nodes are
nonpalpablee, no masses and tenderness noted. Tonsil is grade 2.

II D. Other Sources of Data

KMC has no laboratory data.