Joule Quijano Case Study of Postpartum Eclampsia

BLOOD PRESSURE CHART

NAME: ___Ms E__________________ CASE NO.: __________________ WARD & BED NO.:
______

DATE April April April April April April

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2021 2021 2021 2021 2021 2021
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Cebu Institute of Technology

University
N. Bacalso Ave., Cebu City Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

I & O MONITORING SHEET

April 26
INTAKE OUTPUT NAME AND SIGNATURE
2021
DATE ORAL IV URINE EMESIS DRAINAGE
Joule Peirre P. Quijano
CIT-U CN SN / Monette
AM 420 0 300 0 0
Pacaña Cañete RN MAN

Joule Peirre P. Quijano

CIT-U CN SN / Monette
PM 1050 0 840 50 0
Pacaña Cañete RN MAN

Joule Peirre P. Quijano

CIT-U CN SN / Monette
NIGHT 520 0 405 0 0
Pacaña Cañete RN MAN

Joule Peirre P. Quijano

CIT-U CN SN / Monette
TOTAL 2000 1545 50 0
Pacaña Cañete RN MAN
April 27
INTAKE OUTPUT NAME AND SIGNATURE
2021
DATE ORAL IV URINE EMESIS DRAINAGE
Joule Peirre P. Quijano
CIT-U CN SN / Monette
AM 850 0 710 0 0
Pacaña Cañete RN MAN

Joule Peirre P. Quijano

CIT-U CN SN / Monette
PM 550 0 420 0 0
Pacaña Cañete RN MAN

Joule Peirre P. Quijano

CIT-U CN SN / Monette
NIGHT 620 0 530 0 0
Pacaña Cañete RN MAN

Joule Peirre P. Quijano

CIT-U CN SN / Monette
TOTAL 2020 0 1660 0 0
Pacaña Cañete RN MAN
 CebU INSTITUTE OF TECHNOLOGY
UNIVERSITY

COLLEGE OF NURSING

ACTIVITY 1: PHYSICAL ASSESSEMNT

ASSESSMENT TOOL

Name of Student: __Joule Peirre P. Quijano____________________ Level _2_Section _N1_

Rating: ______

I. Nursing Health History

A. Biographic Data
Initials of Client/Patient : Mrs. E.
Residence: Labangon Cebu City
Contact Number: 09225856941 Nationality: Filipino
Religion : Roman Catholic Birth of Date:
Age: 22 Sex: Female Civil Status: Single
Educational Attainment: Bachelor of Science in Psychology
Occupation: Guidance Councilor

Name of Hospital: VSMMC ___________________ Ward & Room No.: 105

Date of Admission: April 25 2021 Attending Physician : Dr. Chua
Impression / Admitting Diagnosis: Intrauterine Pregnancy at _44__ weeks
__________________________
Source of Information:
( / ) Patient
( ) Others, (Initials of SO):
Relationship to patient :

B. Admitting Complaint/s
______ Present of pain on the lower abdomen continuous pain including on the back part of the body.
Feeling nauseous.
_____________________________________________________________________________________
___________________________________________________________________

C. History of Present Illness

Symptom: Present of backpain and fatigue. Frequent contractions
Location: Lower abdomen and lower back of the body ______
Character: Sharp and stabbing pain ______
Intensity: Moderate
Timing: 10 to 15 seconds _____________
Aggravating factors: Doing heavy household chores, Cooking
Alleviating factors: Sitting on a sofa. Self massage. Bed Rest
Treatments tried: Applying pain reliever ointment on small amount.

D. Past and Present Medical History (Utilizing Gordon’s Functional Health Pattern).
Questions are being included so that students will be guided with each health patterns. Please
answer the following inquiries in paragraph form or bullet form.

Before During
Gordon’s Criteria Admission Admission
I. HEALTH PERCEPTION HEALTH MANAGEMENT
PATTERN The patient said that Upon admission,
1. How was general description of the client’s it is her the patient went
health prior to hospitalization or responsibility to go through
consultation? consultations and caesarean section
needs to get due to deflexed
hospitalized in order occipito-posterior
to deliver her baby position with the
in. She stated that it vertex above the
is important to take ischial spines of
care of one’s health. her baby. Sutures
are present on
2. Any childhood or past year illnesses (both her lower
physiologic and psychiatric alterations)? Any abdomen.
absences from work if client or patient is working?
After her
The patient stated admission, she
that she completed received
her immunization. pethidine through
3. The most important things the client/patient She has not intramuscular
do to keep healthy? Use of cigarettes, encountered any injection.
alcohol, drugs? illness before. She
still works as a
Guidance Counselor
despite that she is During the
pregnant because admission, tshe
she wants to avoid felt abdominal
absences in work. distention but
after 2 days the
The patient loves to abdominal
workout before and distention
eat healthy meals become less
such as vegetables. sever and she
She used to drink began eating her
lots of water since meals and
she wants to stay drinking
hydrated. She only normally.
drinks alcohol
occasionally. She
never smokes.
 Before During
Gordon’s Criteria Admission Admission
4. Accidents or injuries (home, work, driving)? The patient haven’t The patient had
Any operations, treatments and medications have history of only operation
received? accidents or injuries which she had
before. No history cesarean section
of surgeries. on her lower
5. In past, are there any health suggestions that abdomen.
were easy for the patient to comply? The patient felt
what do you think causes this complaint? The patient used to unrelaxed,
Actions taken when symptoms perceived? Results do relaxation stressed and
of action? techniques after her uncomfortable
hours on work since she had
because she felt post eclampsia
easily tired and on which here
fatigue. She used to highest blood
lay both of her feet pressure is at
on a chair after long 180/90 and had
period of time of further tonic-
standing or walking. clonic
convulsions.
II. HEALTH PERCEPTION HEALTH MANAGEMENT
PATTERN The patient is The patient felt
1. How was general description of the client’s motivated to go for scared after
health prior to hospitalization or consultations and delivering her
consultation? went for baby since this
hospitalization since time it is more
she feels that it is focused on
her responsibility to monitoring her
do so. baby. And she
2. Any childhood or past year illnesses (both expects to have
physiologic and psychiatric alterations)? more
Any absences from work if client or patient consultations.
is working? The patient stated
that she completed After her
her immunization. admission, she
She has not received
encountered any pethidine through
illness before. She intramuscular
3. The most important things the client do to still works as a injection.
keep healthy? Use of cigarettes, alcohol, Guidance Counselor
drugs? despite that she is
pregnant because
she wants to avoid During the
absences in work. admission, tshe
felt abdominal
The patient loves to distention but
3. Accidents or injuries (home, work, workout before and after 2 days the
driving)? Any operations, treatments and eat healthy meals abdominal
medications received? such as vegetables. distention
She used to drink become less
lots of water since sever and she
5. In past, are there any health suggestions she wants to stay began eating her
 that were easy for the patient to comply? hydrated. She only meals and
what do you think causes this complaint? Actions drinks alcohol drinking
taken when symptoms perceived? Results of occasionally. She normally.
action? never smokes. The patient had
only operation
The patient haven’t which she had
have history of cesarean section
6. Family history of illness accidents or injuries on her lower
( ) Diabetes ( ) Hepatitis before. No history abdomen.
( ) Thyroid Disease ( / ) HPN of surgeries. The patient felt
( ) Vision Disorder ( ) Arthritis unrelaxed,
( ) Heart Disease ( ) Seizure stressed and
( ) Mental Illness ( ) Stroke The patient used to uncomfortable
( / ) Cancer ( ) STD do relaxation since she had
( ) Asthma ( ) Blood Dis. techniques after her post eclampsia
( ) Tuberculosis ( ) Kidney Dis hours on work on which here
( ) Others:______________________ because she felt highest blood
easily tired and pressure is at
7. When appropriate: What are things that fatigue. She used to 180/90 and had
are important to the patient in health lay both of her feet further tonic-
care? How can the health care provider be on a chair after long clonic
most helpful? period of time of convulsions.
standing or walking.
8. Any immunizations received?

She become
The most important more conscious
thing from the on her nutritional
patient is the intake.
nutrition intake and
lifestyle.

After her
She completed her admission, she
childhood received
immunizations and pethidine through
completed her intramuscular
immunizations for injection.
her pregnancy.
III. NUTRITIONAL-METABOLIC PATTERN The patient eats 3 The patient still
1. Describe the typical daily food intake? meals a day with eats 3 meals per
Supplements (vitamins, type of one cup of rice and day and drink
snacks)? any meal. She also water normally.
takes vitamins
2. State the weight of the patient in everyday.
relation to the height. What is the Her current
 significance of his weight to his height? The significance weight is 73 kg
weight of the patient since she had
was 54 kg. pregnancy for 9
3. Can the patient consume his food during meal months.
or snack time? If not, why?
4. If the patient has wound, does it heal well or The patient can
poorly? Any skin problems like lesions, The patient can consume her
dryness and dental problems? consume her meal meal or snacks.
or snacks. The patient had
only her scar on
The patient don’t her lower
have any presence abdomen due to
of lesions or skin the surgical
problems or dental procedure of
problems. Cesarean section.
IV. ELIMINATION PATTERN
1. Describe the urine and bowel elimination Her bowel During
pattern? Frequency? Character? elimination would be admission, she
Discomfort? Problem in control? Use of everyday. The had problems on
laxatives as over the counter drug or texture of her stool her bladder but
prescribed? Odor problems? is fine texture. She her urinalysis was
urinates at least clear.
thrice a day. Color of
urine is yellowish to
amber.
Before During
Gordon’s Criteria Admission Admission
2. Any body cavity drainage, suction, and so None None
on that aids the patient in elimination?
IV. ACTIVITY-EXERCISE PATTERN
1. Is there sufficient energy for desired or Yes Not at all
required activities?
Casually. Home Not yet because
2. Does the patient exercise regularly? workout. of her surgical
What type of exercise? stitches.

3. What are the patient’s activities in their Household chores,

spare-time / leisure time? If the patient is a cooking meals, Spending more
child, what play activities does he indulge watch TV shows, time on bed
in? walking outside. doing resting.

4. Perceived ability (code for level) for:

Criteria Rate Criteria Rate Criteria Rate

Feeding Level Gait Level Cooking Level
0 0 0
Bathing Level ROM Level Shopping Level
 1 0 0
Toileting Level Grooming Level Bed mobility Level
0 0 0
Home maintenance Level General mobility Level Posture Level
0 0 0
Dressing Level Hand Grip Level
1 0

Functional Level Codes

*Level 0: full self-care
*Level I: requires use of equipment
or device
*Level II: requires assistance or
supervision from another
person
*Level III: requires assistance or
supervision from another
person and equipment or
device
*Level IV: is dependent and does not
participate

Before During
Gordon’s Criteria Admission Admission
V. SLEEP-REST PATTERN
1. Can the patient rest/sleep? What are the The patient sleeps Had sleeping
usual daily activities of the patient to induce him to well. Read books or problems due to
sleep? watch videos. baby’s hunger
and doing
breastfeeding on
2. Are there sleep onset problems? Aids? her baby.
Dreams (nightmares)? Early awakening? None None
VI. COGNITIVE-PERCEPTUAL PATTERN
1. Any hearing difficulty? Presence of hearing
aid? Location: Left or right or both? None None
2. Is there a problem in vision? Wear glasses?
Last checked? When Last changed? None None
3. Any change in memory lately?
None None
4. Does the patient experience difficulty in
deciding during problems, family issues, None None
etc. ?
5. What are the patient’s strategies to make
decisions easier? None None
6. Any discomfort? Pain? When appropriate:
How do you manage it? None Doing relaxing
techniques and
bed rest.
VII. SELF-PERCEPTION—SELF-CONCEPT PATTERN
1. How will the patient describe self? Patient describes Patient felt more
herself as a happy happy and
mother who wants become more
to have a happy satisfied as she
family carries her baby

2. Changes in way the patient feel about self Patient is conscious Patient is still
or body (since illness started)? on her body image conscious on her
body image
3. Things frequently make the patient angry? Not providing her Not providing her
 Annoyed? Fearful? Anxious? basic needs basic needs

4. Ever feel that the patient lose hope?

None None

Before During
Gordon’s Criteria Admission Admission
VIII. ROLES-RELATIONSHIPS PATTERN
1. Is the patient living alone? With family? Living with her Living with her
family family

Draw the family structure or genogram with emphasis

on the specific heredofamilial diseases.

X X
X X

Cance
r HP
N

Patien
t
 Before During
Gordon’s Criteria Admission Admission
2. Any family problems you have difficulty None None
handling (nuclear or extended)?
The patient is well The patient is
3. Are the family or others depend on the depend on her well depend on
patient for things? How is the patient family. her family.
managing?
Excited The family is
4. How do the family or others feel about happy to see the
illness or hospitalization? The patient can patient’s baby
manage well on her The patient can
5. Are problems with children also the problems manage well on
concern of the patient? Does the patient her problems
have difficulty in handling the problems? The patient have
close friends.
The patient have
6. Is the patient belongs to social groups? Yes close friends.
Close friends? Is the patient lonely? Yes
Yes
7. Are things generally go well at work or Yes
school?
8. Does the income sufficient for their needs?
IX. SEXUALITY-REPRODUCTIVE PATTERN
1. When appropriate to age and situations: The patient feels The patient feels
Does the patient’s sexual relationships satisfied with her satisfied with her
satisfying? Any changes? or problems? Use of sexual relationship sexual
contraceptives? Problems? with her husband. relationship with
They use condom her husband.
before. They use condom
before.
2. If client is female and of age: When 12 years old
menstruation started (menarche)? 12 years old
Duration? Menstrual cycle? August 21 2020

3. Last menstrual period, if with relation?

Menstrual problems? August 21 2020

G__1_ T_0__ P 1 _ A0 L_1__ M_0__

X. COPING-STRESS TOLERANCE PATTERN

1. Is there any big changes in the patient’s There is big changes There is big
life in the last year or two? Any crisis? in her life as stated changes in her
by the patient life as stated by
2. Who is the most helpful in talking things the patient
over? Is this person available to you at The parents of the
present? patients, close The parents of
friends and her the patients,
3. Is the environment tense or relaxed most husband. They’re all close friends and
of the time? When tense, what coping present. her husband.
strategy helps? They’re all
present.
The environment of
 4. How do the person handle stress? Use any the patient is The environment
medicines, drugs, alcohol? relaxed of the patient is
relaxed

5. Is the coping strategies successful? The patient would

always pray if she The patient
has any problems. would always
She vent out with pray if she has
her husband and her any problems.
friends. She vent out with
her husband and
Yes her friends.

Yes

Before During
Gordon’s Criteria Admission Admission
XI. VALUES-BELIEFS PATTERN
1. Important health plans for the future? To become To become
financially stable and financially stable
have a strong and have a
foundation of family strong foundation
2. Is religion important in life? When as stated by the of family as
appropriate: Does this help when patient. stated by the
difficulties arise? Does religion patient.
interfere with health practices? The patient said that
religion is important The patient said
to her since she that religion is
3. Any other values or beliefs that affect the have big faith to important to her
health care delivery system. God. since she have
big faith to God.

None

None
XII. Other concerns: Any other things we haven’t None None
talked about that you would like to mention?
Any questions?

II. Physical Assessment

 1. GENERAL SURVEY: Describe the general appearance apparent age, grooming, hygiene, odors,
nutritional status, level of consciousness, speech, affect, gait, posture, movements, gross
deformities and signs of distress.

Patient’s Findings Review of System/s

Having a good proper hygiene

The patient can communicate well

The patient can move freely

The patient can eat well

2. SKIN. Inspect the color and presence of lesions. Palpate temperature, turgor and texture.

Patient’s Findings Review of System/s

Skin is well intact

Had presence of scar on the lower abdomen Surgical site on the lower abdomen
due to cesarean section as needed
since it is emergency.

3. HEAD, FACE AND NECK

3.1 Head. Inspect size, shape, symmetry, position, hair distribution presence of parasites, lice,
dandruff and lesions

Patient’s Findings Review of System/s

Patient’s head is well symmetrical

No presence of lesions or wounds on the face and

neck

Hair is well intact

 Patient’s head is well symmetrical

No presence of lesions or wounds on the face and

neck

Hair is well intact

Patient’s head is well symmetrical

3.2 Face. Inspect symmetry of nasolabial folds and palpebral fissures. Palpate muscle of
mastication and test sensory function (CN V). Note facial mobility (CN VII).

Patient’s Findings Review of System/s

No presence of masses or tenderness on the face

Face is palpable

3.3 Neck. Inspect, palpate and auscultate thyroid. Palpate lymph nodes and tracheal position.
Note ROM of neck. Test neck muscle strength (CN XI)

Patient’s Findings Review of System/s

No presence of masses or tenderness

Neck is well intact

Jugular vein is present

4. NOSE, MOUTH AND THROAT.

 4.1 Nose and Sinuses. Inspect nasal mucosa, septum and turbinates. Palpate sinuses and nasal
patency. Test sense of smell (CN I).

Patient’s Findings Review of System/s

No presence of masses or tenderness

Nose is well firm and intact

4.2 Mouth. Inspect lips, oral mucosa, teeth, gums and tongue. Test sense of taste (CN VII, IX).
Test mobility of tongue (CN XII) and gag reflex (CN IX, X)

Patient’s Findings Review of System/s

Chapped lips

Complete teeth

Minimal cavities

Present of gag reflex

5. EYES AND EARS

5.1 Eyes. Test visual acuity with Snellen Chart or allowing the client to read a magazine (CN II),
Peripheral vision by confrontation, EOM in 6 cardinal fields (CN III, IV, VI), Corneal light reflex,
Cover/uncover test. Inspect external structures of the eye, test pupillary reaction, and palpate lacrimal
glands / ducts

Patient’s Findings Review of System/s

Eyes both dilate and constrict

Can see near and far area

Eye muscle movement same direction

No present of discoloration on eye area

5.2 Ears. Inspect/palpate external ear, perform whisper tests (CN VIII)

Patient’s Findings Review of System/s

Pinna recoils when folded

Auricles are firm and no tenderness

6. LUNGS
6.1 Inspection. Respiratory effort or rate, anteroposterior-lateral ratio and condition of the skin
in the thoracic.

Patient’s Findings Review of System/s

 Chest both expands equally

Breast are symmetrical

6.2 Palpation. Symmetric chest expansion, presence of tenderness, masses, crepitus and tactile
Fremitus

Patient’s Findings Review of System/s

No presence of masses on breast

No presence of tenderness on both chest

Symmetrical chest expansions

6.3 Percussion. Anterior/posterior/lateral and diaphragmatic excursion.

Patient’s Findings Review of System/s

Present of dullness of left anterior chest due to heart

and right lower chest due to liver
 6.4 Auscultation. Note for breath and adventitious sounds and count apical pulse.

Patient’s Findings Review of System/s

Present sounds of Tracheal, Bronchial,

Bronchovesicular and Vesicular

Loud, high-pitched bronchial breath sounds.

7. CARDIOVASCULAR
7.1 Inspection. Presence of carotid and jugular pulsations.
Patient’s Findings Review of System/s

Present of pulsations on the supraclavicular area

Present of carotid vein and jugular vein on the neck

 7.2 Palpation. Note apical impulse.
Patient’s Findings Review of System/s

Present of pulses on the neck, on the apical pulse and

caroitd artery pulse

7.3 Auscultation.

Patient’s Findings Review of System/s

Audible lub dub sounds or S1 and S2 sounds.

8. MUSCULOSKELETAL
8.1 Inspection and Palpation (Gait, cervical, thoracic and lumbar curves. Palpate spinous
processes and paravertebral muscles on both sides of the spine).

Patient’s Findings Review of System/s

Slight jerking movements on the legs Presence of further tonic–clonic

convulsion as the blood pressure
gets higher at 180/90

8.2 Perform the following tests (If the present condition allows).
 Tests Purpose Client’s Response Significance

Nudge Test Not assessed

Phalen’s Test Not assessed

Tinel’s Test Not assessed

Tests Purpose Client’s Response Significance

Bulge Test Not assessed

Test for ROM Not assessed

Head, spinal cord,

lower extremities

(feet, ankles and

knees)

Upper extremities, Not assessed

 (arms and hands),

shoulders

9. NEUROLOGIC

9.1 Assess mental status and level of consciousness.

Patient’s Findings Review of System/s

Patient is time oriented

Patient knows the place and her surroundings

Patient can cooperate well

9.2 Observe posture and body movements. Be alert for tense, nervous, fidgety, and restless
behavior which reflect apprehension during physical exam.

Patient’s Findings Review of System/s

Posture of the patient is well symmetrical

Shows good standing posture

9.3 Observe facial expressions as well as eye contact and affect. Note also speech (clarity, tone
and pace of speech), dressing (grooming and hygiene), mood (feelings and expressions),
cognitive abilities, orientation, memory and rationalization on issues.

Patient’s Findings Review of System/s

No speech delay
 Can catch up ideas

Can process thoughts well

Patient is happy and active

9.4 Cranial Nerve Test

Name of Nerve Function Client’s Response and Significance

1 Olfactory Not assessed

2 Optic Not assessed

Name of Nerve Function Client’s Response and Significance

3 Oculomotor Not assessed

4 Trochlear Not assessed

5 Trigeminal Not assessed

6 Abducens Not assessed

7 Facial Not assessed

8 Auditory Not assessed

9 Glossopharyngeal Not assessed

10 Vagus Not assessed

11 Accessory Not assessed

12 Hypoglossal Not assessed

10. GENITOURINARY

10.1 Inspection. Note distribution of pubic hairs and presence nits/lice. For female: Observe
perineum, labia, clitoris, urethral meatus, vaginal opening, Bartholin’s glands for lesions,
swelling and excoriation as well as enlarged nodes. For male: Inspect skin of penile shaft
for rashes, lesions or lumps, foreskin, glans penis and meatus for color, location and skin
integrity. Also observe the size, shape and position of the scrotum and its skin, any
presence of hernia.

Patient’s Findings Review of System/s

Not assessed

10.2 Palpate hypogastrium gently for urine retention and presence of abnormal mass or growth

Patient’s Findings Review of System/s

Not assessed

10.3 Auscultate labia or the scrotal area for presence of bowel sounds.

Patient’s Findings Review of System/s

Not assessed
11. ANAL AREA

11.1 Inspect the perianal area for lumps, ulcers, lesions, rashes, redness fissures and thickening
of the epithelium.

Patient’s Findings Review of System/s

Not assessed

11.2 Ask the client to perform Valsalva’s maneuver (bearing down) to note any bulges.

Patient’s Findings Review of System/s

Not assessed

11.3 Palpate the prostate gland (if allowed and with the presence of the clinical instructor) by
using the index finger facing toward the umbilicus. Note the size, shape, consistency and
identify nodules.

Patient’s Findings Review of System/s

Not assessed
 Cebu Institute of Technology
University
N. Bacalso Ave., Cebu City Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Reflection/Wrap-Up

Based on this activity, all I did was to understand the patient case scenario
and highlight the important key words. And from that I plot them based on
the vital signs and did the Gordon’s and indicating the cause or the scenario
of the patient that has a role on it. What I learn from this activity is that vital
signs has a big role when it comes to assessing the patients. That’s because
it is a close monitoring of the patient to check if the patient is stable or not. I
also learned that we as student nurses should look close enough when
assessing the patient to check for findings or abnormalities in order to notify
the physician and the healthcare team to treat right away if there are signs
of complications.
Name of Student: _Joule Peirre Quijano______

Section:_N1____Group: __7____

Cebu Institute of Technology

University
N. Bacalso Ave., Cebu City Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

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