I.

PERSONAL HISTORY
A. PERSONAL DATA
Name of the Patient: Jessa Abasola
Address: Brgy. Tao- taon, Inopacan Leyte
Age: 23 Sex: Female Date of Birth: September 13, 1996
Civil Status: Single Number of Children: Living Died
Name of Spouse: Occupation:
Educational Attainment: High School level Religion: Roman Catholic
Client’s role in the family: Living Situation: With her family
Last Menstrual Period: May 1, 2019 G:1 T:1 P:0 A:0 L:1 M:
Date of Admission: February 19, 2020
Time of Admission: 3:00 AM Ht: 56 kg Wt: 145 cm
Source of Healthcare: PhilHealth
Attending Physician:
Impression/Diagnosis: G1P1 (1201) PUFT Cephalic EROM x 5 hours NSVD
live Bb. Boy AS-9,10 TMSAK cord coil 1x around neck BW 2420

B. REASON FOR ADMISSION

The patient was admitted due to labor pains.

C. OBSTETRIC HISTORY
a) Menstruation
The patient’s menarche was at the age of 13 with a duration of 3 -5
days. She usually has an irregular cycle with an interval of one month at
most. The patient’s blood flow is moderate. She did not also experience
dysmenorrhea.
b) Family Planning
The patient did not used family planning practice since then and did
not mention future plans regarding family planning practice.
c) Pregnancy

Year Pregnancy Duration Mode of Live Sex/ Place of Status of TT

of Labor Delivery Birth/Still Birth delivery immunization
birth weight
2020 NSVD Live Male/ WLPH TT1
 2420
Birth TT2
kg

D. HISTORY OF PRESENT ILLNESS

The patient is recovering from her delivery and does not have any
present illness.

E. PAST MEDICAL HISTORY

The patient’s childhood illnesses were coughs, runny nose and fever.
She has had tetanus toxoid immunizations for two rounds, one at her four
months of pregnancy and another one at six months. She does not have any
allergies nor have been in any accidents. This is her first hospitalization due to
her pregnancy. The patient has had no blood transfusions done. She has not
been diagnosed with any mental illness nor prescribed and maintained
psychotropic drugs. The patient took folic acid and calcium during her
pregnancy and currently taking mefenamic acid, cefalexin, and multivitamins +
ferrous sulfate after the delivery.

F. FAMILY HISTORY

The patient’s father, who is 44 years old, is alive and well. Her mother,
who is 44 years old, is alive and well. Their family is a blended type. The
patient does not have a spouse and currently has one child. The patient has no
heredo-familial illness.

G. ENVIRONMENTAL HISTORY

The patient lives in an owned house with her parents. They have an
open drainage and a water-sealed toilet. They get their water through water
district while their garbage is disposed through compose pit.

II. GORDON’S REVIEW OF FUNCTIONAL HEALTH PATTERNS

A. H. PERCEPTION & H. MAINTENANCE MANAGEMENT PATTERN
The patient is usually free from sickness aside from the occasional
colds. Her way of maintaining her healthy state is through consumption of
healthy food such as vegetables and fruits. The patient does not use tobacco
nor take any illegal drugs. She drinks alcohol occasionally but eventually stops
 upon knowing her pregnancy. She does not breast self-examination before
and during pregnancy. The patient does not have any problems following
nurse’s and doctor’s orders and suggestions during the hospitalization. She
prefers a quiet and clean hospital environment. The patient believes in the
traditional hilot and alternative medicine or herbal medicine.

B. NUTRITION & METABOLIC PATTERN

Pre-pregnancy, the patient’s typical food intake 3 meals a day that
includes vegetables and rice. She verbalized that she always has good
appetite and does not take supplements. The patient typically consumes 10
glass of water each day. The patient weight is 44 kilograms. The patient heals
well and does not have any skin problems, lesions, and dryness. She has
dental cavities and tooth decay at the second molar in the upper left.
During the pregnancy, the patient’s typical food intake 4 meals a day
during the pregnancy that includes vegetables and rice. She has good
appetite and take supplements like folic acid and calcium. The patient
typically consumes 12 glass of water each day. She verbalizes, she gains
weight during pregnancy compared to her pre-pregnancy weight from 44
kilogram to 56 kilograms.

C. ELIMINATION PATTERN
The patient defecates three times a day with no problems. Her feces
are yellowish to brownish and not too hard nor too soft. No changes noted
before and during the pregnancy. The patient urinates frequently pre-
pregnancy but it increased more during pregnancy, ten times a day for about
one glass, all with no discomfort or problems in control. Her urine is usually
light yellow. She has no excessive perspiration and no odor issues.
During hospitalization, she did not defecate for one day.

D. ACTIVITY-EXERCISE PATTERN
The patient has sufficient energy to do daily activities even during
pregnancy. During pre-pregnancy and pregnancy, the patient did walk every
day for about 15-30 minutes. In her spare time, she usually watches television.
Level 0: Full self-care
Level 1: Requires use of equipment or device
Level 2: Requires assistance or supervision from another person.
Level 3: Requires or supervision from another person and device.
 Level 4: IS dependent and does not participate.

ACTIVITIES BEFORE DURING

HOSPITALIZATION HOSPITALIZATION
Feeding 0 0
Bathing 0 0
Toileting 0 0
Bed mobility 0 0
Dressing 0 0
Grooming 0 0
General Mobility 0 0
Cooking 0 ----------
Home Maintenance 0 ----------
Shopping 0 ----------

E. SLEEP-REST PATTERN
The patient usually has 10 hours of sleep every night. Pre-pregnancy,
she does not have any problems in falling asleep and sleep continuously.
Either way, she wakes up not tired. She takes a nap every afternoon. To relax
herself, the patient does walk.
During the pregnancy, the patient has quite trouble in falling asleep.
She was not able to sleep continuously and wakes up from time-to-time to
urinate. The patient takes 2-3 hours of afternoon nap every day.

F. COGNITIVE-PERCEPTUAL PATTERN
The patient does not have any hearing and vision problems and
change in memory before, during, and after pregnancy. The patient learns
through listening. During pregnancy, she did not experience any pain or
discomfort except during labor and delivery of the baby. Currently, she
experiences pain due to her episiorraphy site but none other than that. She
simply takes medications as prescribed by the doctor.

G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

Even before and during the pregnancy, the patient feels contented
with herself but not most of the time. She noticed she gained weight as
pregnancy started, however did not see it as a problem to her. The patient
does not have anything she wants to change with her body. She gets angry
and annoyed when there are errands which are not followed and need to walk
from the house even during the pregnancy. It helps when talking to the people
close to her.
H. ROLE RELATIONSHIP PATTERN
The patient lives with her family. In terms of family problems, they
currently have none but when they do, they talk it out altogether. When she
was 18 years old, she supports her family financially. Currently, she does not
engage to any work. During her hospital stay, her parents worried and sad
about her on how can she handle during the delivery. The patient does not
have any problems with handling children before, during and after pregnancy.
She has a close group of friends. When she is still working, she did not have
any problems at work and she does not feel out of place in their neighborhood.

I. SEXUALITY-REPRODUCTIVE
The patient’s current sexual partner is her first and only sexual partner
as of date. She gave her first sexual experience to him at the age of 19. They
were sexually active pre-pregnancy in the beginning stage of their relationship
and eventually stop in the later stage of pregnancy. The patient’s menarche
was at the age of 13. Her last menstrual period was on May 1, 2020. She
usually has no dysmenorrhea. Her menstruation last for about 3-5 days. She
has only been pregnant once.

J. COPING-STRESS PATTERN
Before, during, and after the pregnancy, the patient is not usually
tense but if she is, she let things be. Her mother and friends are most helpful
and available when talking things out and when problems arise. In the last two
years, the biggest change in her life was her pregnancy. For the patient, by
just letting things be is successful in relieving stress.

K. VALUE-BELIEF PATTERN
Before, during, and after the pregnancy, the patient doesn’t usually get
the things she likes. For her, family are most important to her. The patient is
not very religious but praying helps her when difficulties arise. The patient
finds staying at the hospital not an interference with her desire to go to church.

L. OTHERS
The patient does not have any particular information she wants to
share nor have any questions for the student interviewers.
III. NURSING HEALTH ASSESSMENT

A. Review
EENT □ Yes □ No
CARDIO-RESPIRATION □ Yes □ No
GASTROINTESTINAL □ Yes □ No
GENITO-URINARY □ Yes □ No
MUSCULO-SKELETAL □ Yes □ No
NERVOUS SYSTEM □ Yes □ No
ENDOCRINE □ Yes □ No
EMOTIONAL □ Yes □ No

B. Physical Assessment
a) General Survey
Received patient on bed, conscious with an ongoing IVF of D5LR 1L
at 20 qtts/min + 20 IU oxytocin infusing well over the left cephalic vein at
300 mL level. The patient was wearing a fitted yet stretchable brown
dress with a pattern on it. Her hair appeared greasy and she had short
nails with a little dirt under them. She did not look pale and her posture
was slightly slouching as she was sitting down. When the student nurses
approached her, she was cooperative with the interview and assessment.
She is alert and responsive and is able to express her feelings and
emotions through words and facial expressions. She experiences slight
difficulty in formulating what she wants to say.

b) Vital signs around 7:30 A.M. on February 19, 2020.

Temp: 36.6◦C, PR: 84 bpm, RR: 18 cpm, BP: 120/90 mmHg

c) Organ System Assessment

i. Integument
Upon inspection, the skin is medium brown in color with no
presence of lesions. Linea negra and striae gravidarum was noted in
the abdomen. Upon palpation, skin turgor returns within 2-3 seconds.
There is no presence of masses and nodules. Upon inspection, the
hair is black, greasy, slightly disheveled, in shoulder-length and evenly
 distributed with a presence of dandruff. There is no signs of alopecia
and signs of infestations noted. Upon inspection, the nails are intact
and thick. The nailbed is pinkish in color and in normal range (160º
curvature). The nails were cut short with a presence of dirt under.
Upon palpation, capillary refill returned in less than 2 seconds. Fingers
and toenails have smooth texture.

ii. Head
Upon inspection, the patient had a symmetrical facial features
and movements. Upon palpations, the skull has smooth contour. No
masses and nodules noted. Upon inspection, the eyes can close
symmetrical. No discharge and discolorations of the eyelids.
Eyebrows and eyelashes are equally distributed. Pupils equally round
reactive to light and accommodation. Does not use reading glasses.
Upon palpations the eyes, no edema, tenderness or masses noted on
the lacrimal gland. Upon inspection in the ears, the same color as the
facial skin was observed and symmetrical in size. There are no
discharges and lesions noted. Presence of cerumen was observed at
the auditory canal. Upon palpation of the ears, no tenderness or
masses on the external ear. Pinna is mobile, firm, and recoils after it is
folded. Upon inspection of the nose, it is symmetric and uniform in
color. Air moves freely as the client breathes through the nares. No
lesions noted. Upon palpations, no tenderness noted in the maxillary
and frontal sinuses. Upon inspection the mouth, the lips are pinkish
and slightly dry. Presence of tooth decay and cavities on her second
molars in the upper left and a missing tooth on both second molars in
lower left and right side noted. There is presence of cavities. Tongue
in the center, pink with whitish coating. The tongue’s strength is intact.

iii. Neck
Upon inspection in the neck, no enlargement of thyroid gland.
Coordinated head movement no discomfort. Upon palpations, no
tenderness, lesions, and nodules noted. No enlargement of lymph
nodes. And able to shrug the shoulder with resistance.

iv. Musculoskeletal – Upper

 The shoulder shrug and turning head against resistance was
performed without difficulty. No lesions and edema were noted in her
arms. The patient has no problems with her range of motion, reflexes,
and sensations. The pulses can be felt.

v. Thorax etc.
Upon inspection in the thorax, it is quiet, effortless respiration.
Upon palpating it, fill symmetric exertion noted. Upon Auscultations,
vesicular breath sounds heard. Upon inspecting the breast, it is
symmetrical. Areola’s are black in color. Milk discharge in he nipples
are observed. Upon palpations, there is no tenderness and presence
of mass nodules.

vi. Cardio
Upon palpations, the apical impulse is felt, regular and
rhythmic. No problematic sounds were heard during auscultation of
the heart. Upon inspections, there is no presence of varicose veins or
spider veins. Upon palpations, there is good capillary refill.

vii. Abdomen
Upon inspection, there is presence of linea nigra and striae
gravidarum. Upon palpating, the fundus of her uterus was on the level
of her umbilical area.

viii. Lower Extremities

Upon inspection, the hair is fairly and equally distributed on her
lower extremities. Upon palpating, there is good capillary refill and
sensations were felt. The patient can sense dull and sharp. The spinal
curvature is straight and no scoliosis observed.

ix. Neurologic

Nerve Classification Assessment

Olfactory Sensory Able to smell alcohol
Optic Sensory Able to read word given.
Oculomotor Motor Pupil equally round and
reactive to light
Trochlear Motor Able to look up and down
Trigeminal Both Able to move jaw
laterally. Able to
distinguish dull object
from sharp object.
Abducens Motor Able to turn eyes laterally
Facial Both Able to smile, frown and
raise her eyebrows when
instructed. Able to
distinguish smooth object
from rough object.
Acoustic Sensory Able to hear the word the
student nurse said
Glossopharyngeal Both Not assessed
Vagus Both Gag reflex observed
Spinal Accessory Motor Able to turn head from
side to side
Hypoglossal Motor Able to stick out tongue

x. Reproductive System
The patient verbalized that episiotomy and episiorraphy was
done. During the assessment, she verbalized that the lochia or the
flow or amount of discharges on the vagina are in mild to moderate.
Further assessment was not done because patient refuse.

xi. Rectum and Anus

This was not assessed because the patient refuses to proceed

with the procedure as well as due to lack of privacy.