Revised 2019

Mindanao State University

COLLEGE OF HEALTH SCIENCES
Marawi City

Name of Student: Fatmah Sarah M. Cornell Clinical Instructor: Prof. Namera Datumanong

Area of Assignment: DR Ward Date Submitted: June 26, 2021

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name: Patient X Address: Tubod, Iligan City Age: 36 years old

Sex: Female Religion: Christianity Civil Status: Married Occupation: Housewife

HABITS

Frequency Amount Period/Duration

1. Tobacco N/A N/A N/A

2. Alcohol Occasionally about 2 glasses before pregnancy
3. OTC-drugs/ non-prescription drugs (methamphetamine/shabu) as needed 1 gram until September 2019

A. CHIEF COMPLAINTS:

Labor pains

B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.

A case of a 36-year-old female who one day PTA noted regular uterine contractions associated with blood vaginal discharge. No watery vaginal discharge noted. This prompt the patient to
sought consultation in their district hospital and was noted with blood pressure elevation at 200/120 mm Hg. Thus, referred to JR Borja General Hospital. The patient was managed with a
case of pre-eclampsia. Blood pressure controlled at 140/90 mmHg. She was then referred to NMMC for further evaluation.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for Pedia)

Childhood illnesses: measles and chicken pox. Immunization unrecalled. She is hypertensive, not diabetic or asthmatic. No cardiac or psychiatric problem. No allergies for foo d and drugs. No
known history of trauma or accidents. The patient has a bad habit of drinking and use of metamphetamine or shabu and has a history of abortion twice.

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases:
Heredo- familial Diseases:
Hypercholesterolemia X
Diabetes X
Kidney Disease X
Heart Diseases X
Tuberculosis X
Hypertension √(Father side)

Alcoholism √ Cancer X
Drug Addiction √ Asthma X
Hepatitis A X Epilepsy X
B X Mental Illness X
C X Rheuma/Arthritis X

Others (pls. specify) X Others (pls. specify) X

D. PATIENT’S PERCEPTION OF:

1. Present Illness

"Henaot unta nga magkaanak ko ug maayo ang kahimtan namong duha, " (Hinihiling ko na sana manganak ako ng maayos at maging maganda ang kalagayan namin ng anak ko.) as
verbalized by the patient.

2. Hospital Environment
 The patient is grateful to the hospital for helping people like her.

E. SUMMARY OF INTERACTION

Throughout the interview, the patient was cooperative and interactive. Therefore, as the assessment ended, the student nurses gathered some information needed for the assessment.

Physical Examination

Name: Patient X Date: 06/22/21

Chief Complaint upon Initial Assessment: Labor Pains Height: 169cm
Chief Complaint upon Final Assessment: Superimposed Preeclampsia Weight: 60kg
Initial Vital Signs: Temp: 36.2 RR: 26 cpm PR: 80 bpm O2Sat: 96% BP: 140/90 mmHg Pain Score: ________ BMI: _______________
Initial Assessment

Patient is awake, sitting on bed, appeared weak, oriented to place and person, cooperative, not in respiratory distress, afebrile, no complaints of nape pain, hooked
with IV fluid at left metacarpal vein. With the vital signs of T: 36.2 RR: 26cpm PR:80bpm BP: 140/90mmHg
GENERAL

H: Head is normocephalic, has a good skull configuration, symmetric with the body. Hair is evenly distributed. No lesion, tenderness and deformities noted. Face is
symmetrical and immobile.
E: Periorbital edema; palpebral conjunctival pallor on both eyes.
E: Pinna is symmetrical. No general deformities observed. No lesions and masses present.
N: Symmetrical with the nasal septum at the middle. No general deformities observed and no discharges present.
HEENT T: Trachea at midline, no lymphadenopathy.

Skin is color brown, dry and warm to touch; hypopigmentation on both lower extremities with dark brown scaly scar on the left ventral leg. Lips and gums are pale.
Partial edentulism and dental caries noted, no oral lesions noted.
INTEGUMENTAR
Y
 Symmetrical thorax, equal chest expansion; breath sounds vesicular.
RESPIRATORY Symmetrical breasts, no discharge, no mass

Pulse rate is 80bpm, blood pressure is at 140/90mmHg. Capillary refill >2 seconds. Pallor noted on both hands and feet. Pitting edema on both lower extremities (+1
to +2). Patient has no known history of cardiovascular illness.
CARDIOVASCULA
R

DIGESTIVE Abdomen is enlarged, globular, and distended with 21 cm fundal height. Bowel sounds barely appreciated. Tenderness noted on the hypogastric and right iliac
region.

EXCRETORY Vagina: presence of scanty reddish vaginal discharges without foul odor.

Patient has an equal muscle size on both sides of the body. No deformities of present on both extremities.
MUSCULOSKELET
AL

Patient is conscious, coherent, and senses are functioning well. The patient responds to question properly, has appropriate feelings and perceptions towards
situation.
NERVOUS
 Absence of goiter and any lumps in the throat. No heat and cold intolerance noted. No abnormal hair growth noted.
ENDOCRINE

ANATOMY AND PHYSIOLOGY

The Circulatory (Cardiovascular) System

The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and pick-up waste materials and toxins for elimination. This system is made up of the heart, the veins,
the arteries, and the capillaries. Circulation is achieved by a continuous one-way movement of blood throughout the body. The network of blood vessels that flow through the body is so
extensive that blood flows within close proximity to almost every cell.

Heart

The heart is a muscular pump that propels blood throughout the body. The heart is located between the lungs, slightly to the left of center in the chest. The heart is broken down into four
chambers including:
• The right atrium, which is a chamber which receives oxygen- poor blood from the veins.
• The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs.
• The left atrium which receives the now oxygen-rich blood that is returning from the lungs.
• The left ventricle, which pumps the oxygenated blood through the arteries to the rest of the body.

Blood Vessels

Blood vessels are broken down into three groups: the arteries which carry blood out of the heart to the capillaries, the veins which transport oxygen-poor blood back to the heart, and the
capillaries which transfer oxygen and other nutrients into the cells and removes carbon dioxide and other metabolic waste from these body tissues.

Blood Pressure

Blood pressure is the force exerted by the blood against the walls of the blood vessels. The output or direct pumping of the heart and the resistance to blood flow in the vessels determines
blood pressure. Resistance is determined by blood viscosity and by friction between the blood and the wall of the blood vessel. Blood pressure = blood flow x resistance.
FEMALE REPRODUCTIVE SYSTEM
 The ovary is the organ that produces ova (singular, ovum), or eggs. The two ovaries present in each female are held in place by the following ligaments:
 o The broad ligament is a section of the peritoneum that drapes over the ovaries, uterus, ovarian ligament, and suspensory ligament. It includes both the mesovarium and
mesometrium. The mesovarium is a fold of peritoneum that holds the ovary in place.
o The suspensory ligament anchors the upper region of the ovary to the pelvic wall. Attached to this ligament are blood vessels and nerves, which enter the ovary at the hilus.
o The ovarian ligament anchors the lower end of the ovary to the uterus.

The following two tissues cover the outside of the ovary:

o The germinal epithelium is an outer layer of simple epithelium.

o The tunica albuginea is a fibrous layer inside the germinal epithelium.

=The inside of the ovary, or stroma, is divided into two indistinct regions, the outer cortex and the inner medulla. Embedded in the cortex are saclike bodies called ovarian follicles. Each
ovarian follicle consists of an immature oocyte (egg) surrounded by one or more layers of cells that nourish the oocyte as it matures. The surrounding cells are called follicular cells, if
they make up a single layer, or granulosa cells, if more than one layer is present.

 The uterine tubes (oviducts) transport the secondary oocytes away from the ovary and toward the uterus (the ovaries consist of primary oocytes, which develop into secondary
oocytes). The following regions characterize each of the two uterine tubes (one for each ovary):
o The infundibulum is a funnel-shaped region of the uterine tube that bears fingerlike projections called fimbriae. Pulsating cilia on the fimbriae draw the secondary
oocyte into the uterine tube.
o The ampulla is the widest and longest region of the uterine tube. Fertilization of the oocyte by a sperm usually occurs here.
o The isthmus is a narrow region of the uterine tube whose terminus enters the uterus.

The wall of the uterine tube consists of the following three layers:

o The serosa, a serous membrane, lines the outside of the uterine tube.
o The middle muscularis consists of two layers of smooth muscle that generate peristaltic contractions that help propel the oocyte forward.
o The inner mucosa consists of ciliated columnar epithelial cells that help propel the oocyte forward, and secretory cells that lubricate the tube and nourish the oocyte.  The
uterus (womb) is a hollow organ within which fetal development occurs.

The uterus is characterized by the following regions:

o The fundus is the upper region where the uterine ducts join the uterus. o the body is the major, central portion of the uterus.
o The isthmus is the lower, narrow portion of the uterus.
o The cervix is a narrow region at the bottom of the uterus that leads to the vagina. The inside of the cervix, or cervical canal, opens to the uterus above through the internal os and
to the vagina below through the external os. Cervical mucus secreted by the mucosa layer of the cervical canal serves to protect against bacteria entering the uterus from the
vagina. If an oocyte is available for fertilization, the mucus becomes thin and slightly alkaline. These are attributes that promote the passage of sperm. At other times, the mucus
is viscous and impedes the passage of sperm.
The uterus is held in place by the following ligaments:

o Broad ligaments o Uterosacral ligaments o Round ligaments o Cardinal (lateral cervical) ligaments

The wall of the uterus consists of the following three layers:

o The perimetrium is a serous membrane that lines the outside of the uterus.
o The myometrium consists of several layers of smooth muscle and imparts the bulk of the uterine wall. Contractions of these muscles during childbirth help force the fetus out of
the uterus.
o The endometrium is the highly vascularized mucosa that lines the inside of the uterus. If an oocyte has been fertilized by a sperm, the zygote (the fertilized egg) implants on this
tissue. The endometrium itself consists of two layers. The stratum functionalis (functional layer) is the innermost layer (facing the uterine lumen) and is shed during
menstruation. The outermost stratum basalis (basal layer) is permanent and generates each new stratum functionalis.
 The vagina (birth canal) serves both as the passageway for a newborn infant and as a depository for semen during sexual intercourse. The upper region of the vagina surrounds
the protruding cervix, creating a recess called the fornix. The lower region of the vagina opens to the outside at the vaginal orifice. A thin membrane called the hymen may cover
the orifice. The vaginal wall consists of the following layers:
o The outer adventitia holds the vagina in position.
o The middle muscularis consists of two layers of smooth muscle that permit expansion of the vagina during childbirth and when the penis is inserted.
o The inner mucosa has no glands. But bacterial action on glycogen stored in these cells produces an acid solution that lubricates the vagina and protects it against
microbial infection. The acidic environment is also inhospitable to sperm. The mucosa bears transverse ridges called rugae.
 The vulvae (pudendum) make up the external genitalia. The following structures are included:
o The mons pubis is a region of adipose tissue above the vagina that is covered with hair.
o The labia majora are two folds of adipose tissue that border each side of the vagina. Hair and sebaceous and sudoriferous glands are present. Developmentally, the labia
majora are analogous to the male scrotum.
o The labia minora are smaller folds of skin that lie inside the labia majora.
o The vestibule is the recess formed by the labia minora. It encloses the vaginal orifice, the urethral opening, and ducts from the greater vestibular glands whose mucus
secretions lubricate the vestibule.
o The clitoris is a small mass of erectile and nervous tissue located above the vestibule. Extensions of the labia minora join to form the prepuce of the clitoris, a fold of skin
covering the clitoris.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
related to vasoconstriction of
“Pkaburug ako na di blood vessels.
mamanakit a leg akn” as
verbalized by the patient.
Objective:
>edema noted on lower
extremeties
Ineffective tissue perfusion
patient will be able to
manifest increased tissue
perfusion as evidenced by:
Within 8hours of duty, the  Monitor vital signs  To identify physical After 8hours of duty, the
particularly blood responses associated patient was be able to
with medical manifest increased tissue
pressure.
conditions.
perfusion as evidenced by:
 Perform assistive
 Blood pressure  ROM promotes  Blood pressure is
passive range of improved blood
within normal range slightly above
motion. circulation.
 Warm and dry skin 
normal range.
 Provide quiet and It conserves
 Capillary refill within energy/lower tissue  Skin is warm to
restful environment.
normal range oxygen demand. touch
 Absence of edema  Antihypertensive help  Capillary refill
 Administer anti-
decrease and control within 4seconds
hypertensive drugs as blood pressure.
ordered.  Edema is still
 Magnesium sulfate
present (from
 Administer prevents or controls
seizures in grade 2 to grade 1)
magnesium sulfate as
ordered. preeclampsia brought
about by vasospasm
secondary to
vasoconstriction of
blood vessels.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for decreased cardiac  Patient will  Check laboratory  To identify The patient’s accomplished
output related to increased participate in data (cardiac contributing factors the interventions and the
“medyo daa bagur-bagur vascular resistance, activities that reduce markers, CBC, goals achieved.
akun” as verbalized by the BP/cardiac workload. electrolytes, BUN and
vasoconstriction, myocardial
patient  Patient will maintain creatinine  Comparison of
ischemic, and ventricular
BP within individually  Monitor and record pressures provides a
Objective: hypertrophy as evidenced by acceptable range. BP. Measure in both more complete
increased blood pressure arms and thighs three picture of vascular
Assist patient: (140/90 mmHg) ties, 3-5 min apart involvement or scope
while patient is at of problem.
 Awake rest, then sitting,
 Sitting on bed then standing for
 Weak initial evaluation.  Presence of pallor;
 Oriented to time and  Observe skin color, cool; moist skin; and
place moisture, delayed capillary refill
 Cooperative temperature, and time may be due to
 Afebrile capillary refill time. peripheral
vasoconstriction or
reflect of cardiac
Vital signs: decompensation and
decreased output.
T- 36.2 c

RR- 26 cpm

PR- 80 bpm
 Note dependent and  May indicate heart
BP- 140/90 mmHg general edema failure, renal, or
vascular impairment.

 Evaluate client  To assess signs of

reports or evidence poor ventricular
of extreme fatigue, function or
intolerance for impending cardiac
activity, sudden or failure.
progressive weight
gain, swelling of
 extremities, and
progressive shortness
of breath.

 Provide calm, restful  It promotes

surroundings, relaxation to the
minimize patient
environmental
activity and noise.
Limit the number of
visitors and length of
stay.

 Maintain activity
restrictions (bedrest,  Lessens physical
or chair rest). Assist stress and tension
patient with self-care that affect blood
activities as needed. pressure and the
course of
hypertension

Implement dietary sodium, These restrictions can help

fat, and cholesterol
restrictions as needed.
manage fluid retention, and
with associated hypertensive
response, decrease
myocardial workload.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
“Myamakala a mga ai akn,” as
verbalized by the patient.
Objective:
Received patient sitting on
bed awake hooked with IV
fluid at left metacarpal vein.
The patient appeared weak.
Pallor noted on both hands
and feet.
•periorbital edema noted
•pitting edema on both lower
extremities
VS:
T: 36.2°C
RR: 26 cpm
HR: 80 bpm
BP: 140/90mmHg
Deficient Fluid Volume as After 8 hours of nursing
evidenced by edema intervention the patient will
formation be able to exhibit
physiological edema with no
signs of pitting.
 Weigh patient  Abrupt, notable
regularly. Tell patient
to record weight at
home in between
visits.
 Differentiate  The presence of
physiological and
pathological edema
of pregnancy. Locate
and determine
degree of pitting.
After 8 hours of nursing
weight gain (e.g., intervention the patient was
more than 3.3 lb. (1.5 able to exhibit physiological
kg)/month in the
edema with no signs of
second trimester or
pitting.
more than 1 lb. (0.5
kg)/wk. in the third
trimester) reflects
fluid retention. Fluid
moves from the
vascular to interstitial
space, resulting in
edema.
pitting edema (mild,
1+ to 2+; severe, 3+
to 4+) of face, hands,
legs, sacral area, or
abdominal wall, or
edema that does not
disappear after 12hr
of bedrest is vital.
Note: Significant
edema may actually
be present in nonpre-
eclamptic patient
sand absent in
patients with mild or
moderated PIH.

 Note signs of  Edema and

progressive or
excessive edema i.e.,
epigastric/RUQ pain,
intravascular fibrin
deposition (in HELLP
syndrome) within the
encapsulated liver are
 cerebral symptoms, manifested by RUQ
nausea, vomiting). pain; dyspnea,
Assess for possible indicating pulmonary
involvement; cerebral
eclampsia.
edema, possibly
leading to seizures;
and nausea and
vomiting, indicating
GI edema.

 Note alteration in  Identifies degree of

Hct/Hb levels. hemoconcentration
caused by fluid shift.
If Hct is less than 3
times Hb level,
hemoconcentration
exists.

 Proper nutrition
 Check on dietary decreases incidence
intake of proteins of prenatal
and calories. Give hypovolemia and
information as hypoperfusion;
needed. insufficient
protein/calories
increases the risk of
edema formation and
PIH. Intake of 80–100
g of protein may be
required daily to
replace losses.

 Monitor intake and  Urine output is a

output. Note urine sensitive indicator of
color, and measure circulatory blood
 specific gravity as volume. Oliguria and
indicated. specific gravity of
1.040 indicate severe
hypovolemia and
kidney involvement.
Note: Administration
of magnesium sulfate
(MgSO4)may cause
transient increase in
output.

 Examine clean,
voided urine for  Aids in identifying
protein each visit, or degree of
daily/hourly as severity/progression
appropriate if of condition. A 2+
hospitalized. Report reading implies
glomerular edema or
readings of 2+, or
spasm. Proteinuria
greater. affects fluid shifts
from the vascular
tree. Note: Urine
contaminated by
vaginal secretions
may test positive for
protein, or dilution
may result in a false-
negative result. In
addition, PIH may be
present without
significant
proteinuria.

 Assess lung sounds  Dyspnea and crackles

and respiratory may mean pulmonary
rate/effort. edema, which needs
immediate
treatment.

 Check BP and pulse.