PRE-ASSESSMENT POST ASSESSMENT

September 13, 2019 September 20, 2019

PSYCHOSOCIAL
TYPE OF FAMILY TYPE OF FAMILY
 Extended Family  Extended Family
SIGNIFICANT OTHERS SIGNIFICANT OTHERS
 Mr. Clean  Mr. Clean
RELATIONSHIP TO PATIENT RELATIONSHIP TO PATIENT
 Husband  Husband
COPING MECHANISM COPING MECHANISM
 Problem focused  Problem focused
Fight Fight
RELIGION RELIGION
 Roman Catholic  Roman Catholic
DIALECT DIALECT
 Ilocano/Tagalog  Ilocano/Tagalog
PLACE OF CONFINEMENT PLACE OF CONFINEMENT
 Region II Trauma Medical Center  Region II Trauma Medical Center
FINANCIAL RESOURCES FINANCIAL RESOURCES
 Income from accumulated tricycle fare.  Income from accumulated tricycle
 Support from her younger sister and the fare.
siblings of her husband.  Support from her younger sister and
the siblings of her husband.
LEVEL OF CONSCIOUSNESS LEVEL OF CONSCIOUSNESS
 The patient is alert and awake, coherent.  The patient is alert and awake,
coherent.
GENERAL APPEARANCE GENERAL APPEARANCE
 The patient was in sitting position,  The patient was in sitting position,
awake and alert awake and alert
AFFECT AFFECT
 Broad Affect  Broad
Patient express wide range of emotions Patient express wide range of
during assessment emotion during assessment
ORIENTATION ORIENTATION
 The patient is aware on date and time  The patient is aware on date and
MEMORY time
 Intact MEMORY
 Intact

SPEECH SPEECH
 Clear and audible  Clear and audible
NON-VERBAL BEHAVIOUR NON-VERBAL BEHAVIOR
 Patient maintains eye contact, smiles,  Patient maintains eye contact,
and frown appropriately smiles, and frown appropriately
ELIMINATION
STOOL STOOL
 Frequency: Once a day  Frequency: Once a day
 Pattern: Everyday  Pattern: Everyday
 Consistency: semi form  Consistency: Semi form
 Amount: moderate  Amount: moderate
 Color: Black tarry  Color: black tarry
 Precipitating factor: None.  Precipitating factor: None.
URINE URINE
 Frequency: 7-8 times a day  Frequency: 9-10 times a day
  Color: Light Yellow  Color: Light Yellow
 Clarity: Slightly turbid  Clarity: clear
 Specific Gravity: 1.010  Specific Gravity:
 Odor: aromatic  Odor: aromatic
 Lab analysis:  Lab analysis:
 No pain upon urination.  No pain upon urination

ABDOMEN ABDOMEN
 Color: fair skin  Color: fair skin
 Fundic Height: 25 cm  Abdominal girth: 27 cm
 Contour: Globular  Contour: Globular
 Appearance: absence of linea nigra and  Appearance: Absence of linea nigra
stretch mark. and stretch mark.
 FHT:  FHT:
REST AND ACTIVITY
CURRENT ACTIVITY LEVEL CURRENT ACTIVITY LEVEL
 Patient seen sitting while reading  Patient seen sitting while reading
pamphlets related to pregnancy. pamphlets related to pregnancy.
ADL’s  Bathing- independent
 Bathing- independent
 Dressing- independent
 Dressing- independent
 Feeding- independent
 Feeding- independent
 Toileting- independent
 Toileting- independent
SLEEP PATTERN SLEEP PATTERN
 Position  Position
Side-lying Side-lying
 Hours of sleep  Hours of sleep
6-7 hours  6-7 hours

BODY FRAME BODY FRAME

 Mesomorph  Mesomorph
POSTURE POSTURE
 lordotic  lordotic
GAIT GAIT
 Waddling gait  Waddling gait
COORDINATION COORDINATION
 Patient is coordinated and can perform  Patient is coordinated and can
rapidly alternating movement, and point- perform rapidly alternating
point movement evaluation. movement, and point-point
movement evaluation.
BALANCE BALANCE
 Patient can balance her body upon  Patient can balance her body upon
standing and walking standing and walking
MUSCLE MUSCLE

Strength: Strength:
 Right arm- 5  Right arm- 5
 Left arm- 5  Left arm- 5
 Right leg- 5  Right leg- 5
 Left leg- 5  Left leg- 5

5- Active motions against full resistance. 5- Active motions against full resistance
 4- Active motion against some resistance.
3- active resistance against gravity.
2- Passive ROM (gravity removed and
assisted by examiner)
1- Slight flicker of contraction.
1- No muscular contraction.
4- Active motion against some resistance
3-Active resistance against gravity
2-Passive ROM (gravity removed and
assisted by examiner)
1-slight flicker of contraction
0-No muscular contraction.

Mass/Tone: Mass/Tone:
 Firm  Firm
Tremors: Tremors:
 No tremors  No tremors

Motor Function: Motor Function:

 Fine: Can pick up things  Fine: Can pick up things
 Gross: Able to flex and extend upper  Gross: Able to flex and extend
extremities upper extremities

Range of Motion Range of Motion

 She can perform ROM exercises  She can perform ROM exercises
 Arms:  Arms:
Can extend arms Can extend arms
 Elbows:  Elbows:
Full resistance on elbow Full resistance on elbow
 Wrists:  Shoulders:
The client is able to bend the both wrists Able to shrug
down and back  Wrists:
 Hands and Fingers: The client is able to bend wrists
The client was able to move both hands down and back
and fingers  Hands and Fingers:
 Knee: The client was able to move both
The client can extend or flex both knee hands and fingers
 Knee:
The client can extend or flex both
knee

SAFETY AND ENVIRONMENT

ALLERGIES ALLERGIES
 Medication: None  Medication: None
 Food: None  Food: None
 Environment: None  Environment: None
EYES/VISSION: EYES/VISSION:
 Pupils: PERRLA  Pupils: PERRLA
 Glasses: No eye glasses  Glasses: No eye glasses

HEARING AID HEARING AID

 No hearing aid  No hearing aid
 No hearing impairment  No hearing impairment
MUCOUS MEMBRANE MUCOUS MEMBRANE
Lips: Moist Lips: Moist
Oral activity: moist, pinkish Oral activity: moist, pinkish
OXYGENATION
AIRWAY CLEARANCE AIRWAY CLEARANCE
 Nose: no secretion; Clear  Nose: no secretion; Clear
 Mouth: No lesion and secretions noted;  Mouth: No lesion and secretions
 Clear noted; Clear
RESPIRATION RESPIRATION
 Rhythm: Regular  Rhythm: Regular
 Rate: 17 cpm  Rate: 17 cpm
 Depth: Normal  Depth: Normal
 Position assumed: Sitting position  Position assumed: Sitting position
 Use of accessory muscle: No  Use of accessory muscle: No
SKIN INTEGRITY: SKIN INTEGRITY:
 Skin and lips are normal; no lesions  Skin and lips are normal; no lesions
 Skin color: Fair  Skin color: Fair
SKIN TURGOR: SKIN TURGOR:
 Goes back within 2 sec  Goes back within 2 sec
TEMPERATURE TEMPERATURE
 RATE: 36. 7 C  RATE: 36. 7 C
 ROUTE: axilla  ROUTE: axilla

NAILS NAILS
 Color: Pinkish  Color: Pinkish
 Shape: Flat  Shape: Flat
 Capillary Refill:  Capillary Refill:
Blanch Test Blanch Test
-goes back within 2 sec -goes back within 2 sec
PERIPHERAL PULSE PERIPHERAL PULSE
 Rhythm: Regular  Rhythm: Regular
 Location: Wrist (Radial)  Location: Wrist (Radial)
 Rate: 70 bpm  Rate: 85 bpm
 Strength: Normal  Strength: Normal

BLOOD PRESSURE BLOOD PRESSURE

-110/80 bpm -110/70
PAIN PAIN
 No Pain  No Pain
NUTRITION
HOSPITAL DIET RESTRICTIONS HOSPITAL DIEAT RESTRICTIONS
 Therapeutic Diet:  Therapeutic Diet
-Low Fat diet
 Fluid Intake  Fluid Intake

 Gag reflex: Intact  Gag reflex: Intact

Height: Height:
 154.9 cm  154.9 cm

WEIGHT: WEIGHT:
 61 kg  61 kg

BMI: BMI:
 20.3  20.3