CHANG, Mark Joseph V.

August 20, 2019

N2C – C10

NURSING PROCESS

BIOGRAPHICAL DATA

A female, 30 years old patient named, H.M.G., born on May 13, 1989 at Mandaluyong. She is a
Roman Catholic, married to her husband and is expecting their first baby. Patient H.M.G. is
currently renting a place in San Juan City; it is a rent to own type of residence. She graduated
College with a degree in B.S. Mathematics. She is now working as a store supervisor in one of
the leading drug store in the country.

NURSING HEALTH HISTORY

Chief Complaint: “Nandito lang ako for my follow – up check – up sa O.B. ko”

PRESENT HEALTH HISTORY

Patient H.M.G. is G1P0 with 32 weeks AOG by LMP. Patient does not report any diseases or
illness from the last 6 months. Throughout the interview she mentioned about being anxious on
her physical attributes, she feels like it lower her confidence and self – esteem. She mentioned as
well her re – occurring backaches especially in daylight. She verbalized “Ang sakit sa likod ang
bigat kasi.” Her therapeutic regimen is resting and most often times side lying position. When
she experience edema on her lower extremities, she put her legs on top of pillows; elevated to
subside the edema. She suspected her pregnancy when she noticed a delay on her menstrual
cycle. She immediately tested her own self with a pregnancy test kit and it was indicated
positive.

PAST HEALTH HISTORY

Patient H.M.G. experienced chickenpox and measles during her grade school days. She
completed her vaccines prior to the illness. Vaccines included are: BCG,
Hepatitis B, OPV, DPT, and Tetanus Toxoid. There is no known allergy. She got hospitalized
before her pregnancy due to abdominal pain in the gastric region. She was confined for 34 hours.
Patient does not undergo any surgery.

FAMILY HEALTH HISTORY

Legend:
- female
- male
- patient
- deceased
--- - spouse
- Heart Disease
MENSTRUAL HISTORY

Patient H.M.G. experienced her menarche at the age of 14 years old. It lasted for seven (7) days.
Patient had a regular cycle of her menstruation. She uses 4 – 5 pads a day during her
menstruation. All pads are full with her blood. She does not experience dysmenorrhea.

SEXUAL HISTORY

Patient H.M.G. had her cotarche at the age of 30. She only had 1 sexual partner. They did not use
any contraceptives. They practice their sexual intercourse even during her pregnancy. They
already planned their birth spacing; the patient preferred a 1 – 2 years gap.

OBSTETRICS HISTORY

G1: Patient present pregnancy 32 weeks AOG by LMP. EDD: September, 19, 2019 at the
UERMMMCI. Fetus is in cephalic position; candidate for NSD.

GYNECOLOGIC HISTORY

The patient experienced pain on her lower back before coming in for prenatal check – up. She
verbalized “mabigat”. She also noticed white discharge from her vagina. She characterized it as
“malapot pero walang amoy”. She estimated it as “kalahati ng kutsarita”. The patient is negative
for any STI upon interview. She explained her routine for perineal care; from the perineum to the
anus.

DEVELOPMENTAL HISTORY

The patient at 30 years old is mentally capable of answering question with conviction and humor.

Erik Erikson’s Developmental Theory: Intimacy V.S. Isolation

The patient is on the intimacy part because of her building stronger relationship with her
husband.

PSYCHOSOCIAL HISTORY

The patient at 30 years old is now residing in San Juan. They are occupying a rent to own
residence. She is a B.S. Mathematics graduate and now works in Watsons. She is the one that
plans the food in their household and sometimes cook. She spends 500 pesos a day or more for
their daily grocery. She works out by breast waling for at least 30 minutes before her pregnancy

THEORETICAL FRAMEWORK

Martha Roger’s Adaptation Model can be incorporated with the case of the patient because of
her feeling of anxiousness towards the physical changes due to her pregnancy. With the help of
the model, the patient will be able to adjust to changes on the physical attributes.