DATA BASE AND HISTORY

Name of Patient: Relia D. Muaña Sex: Female Age: 22 Religion: Roman Catholic
Civil Status: Single Income: N/A Nationality: Filipino
Date Admission: September 14, 2021 Time: 2:22 PM Informant: Ric Ryan D. Sayago
Temperature: 35.6 Pulse Rate: 64 Resp. Rate: 18 BP: 100/60
Height: 156cm Weight: 57.5kg

Chief Complaint and History of Present Illness

The client is carrying her first pregnancy and is expecting to give birth on October. Her last
LMP was on January 4, 2021. She is currently taking vitamin capsules Folicap, Calvit Gold,
and Hanizyn. On her first month of pregnancy, she drank alcohol because at that time she
didn’t know that she was pregnant. She previously had a discharge on her sixth months of
pregnancy and consulted her pediatrician and told her that it was mucus threads; she currently
has the urgency to urinate everyday maximum of 20 times.
Type of Previous Illness Date Type of Previous Illness Date
N/A N/A

Has received blood in the past: ___ Yes / No; If yes, list dates N/A Reaction __ Yes __ No

Medication Dose / Time of Name of Dose / Time of Last

Name Frequency Last Dose Medication Frequency Dose

N/A N/A N/A

 Admitting diagnosis:
Attending Physician: Doctora Cubillo

Score: _________ Grade: __________

NURSING SYSTEM REVIEW CHART

Name: Relia Mae D. Muaña Date: September 14, 2021
Vital Signs:
Pulse: 64 BP: 100/60 Temp: 35.6 Height: 156cm Weight: 57.5kg
INSTRUCTIONS: Place an (X) in the area of abnormality. Write comment on the space
provided. Indicate the location of the problem in the figure using (X).
EENT:
[ ] impaired vision [ ] blind Mucus Threads
[ ] pain reddened [ ] drainage Lessions
[ ] burning [ ] edema [ ] lesion teeth Itching
[ ] assess eyes, ears, and nose ________________
[ ] throat for abnormality [X] no problem ________________
RESPIRATION ________________
[ ] asymmetric [ ] tachypnea [ ] barrel chest ________________
[ ] apnea [ ] rales [ ] cough ________________
[ ] bradypnea [ ] shallow [ ] rhonchi ________________
[ ] sputum [ ] diminished [ ] dyspnea ________________
[ ] orthopnea [ ] labored [ ] wheezing ________________
[ ] pain [ ] cyanotic ________________
[ ] assess resp. rate, rhythm, depth, pattern ________________
[ ] breathe sounds, comfort [X] no problem ________________
GASTRO INTESTINAL TRACT ________________
[ ] obese [ ] distention [ ] mass ________________
[ ] dysphagia [ ] rigidly [ ] pain ________________
[ ] assess abdomen, bowel habits, swallowing ________________
[ ] bowel sounds, comfort [X] no problem ________________
GENITO-URINARY and GYNE ________________
[ ] pain [ ] urine color [ ] vaginal bleeding ________________
[ ] hermaturia [ X ] discharge [ ] noctoria ________________
[ X ] assess urine freq., control, color, odor, comfort ________________
[ ] gyn-bleeding [ ] discharge [ ] no problem ________________
NEURO ________________
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures ________________
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors ________________
[ ] confused [ ] vision [ ] grip ________________
 [ ] assess motor function, sensation, LOC, strength ________________
[ ] grip, gait, coordination, speech [X] no problem ________________
MUSCULOSKELETAL and SKIN ________________
[ ] appliance [ ] stiffness [ X ] itching [ ] petechiae ________________
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling ________________
[ X ] lesion [ ] poor turgor [ ] cool [ ] deformity ________________
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist ________________
[ ] assess mobility, motion, gait, alignment, joint function ________________
[ ] skin color, texture, turgor, integrity [ ] no problem ________________

NURSING ASSESSMENT 2
SUBJECTIVE OBJECTIVE
COMMUNICATION:

• Hearing loss Comments: No trouble • Glasses  Languages

hearing or any visual
• Visual changes changes verbalized by the • Contact lens  Hearing aide
• Denied client. R L

Pupil Size: Normal  Speech difficulties

Reaction: Constrict to direct illumination and Dilates in the

dark.

OXYGENATION:

• Dyspnea Comments: No smoking Resp.  Regular  Irregular

history, isn’t having any
• Smoking history trouble breathing, no Describe: No signs of wheezing, crackles
• Cough presence of sputum, and
currently isn’t coughing
• Sputum R: ____________________________________________
• Denied L: ____________________________________________

CIRCULATION:

• Chest pain Comments: No chest pain, Heart Rhythm  Regular  Irregular

leg pain, nor numbness of
• Leg pain extremities Ankle Edema: No Edema
• Numbness of Carotid Radial Dorsalis Pedis Femoral
extremities
R: _____________________________________________
• Denied
L: _____________________________________________

Comments: ______________________________________

________________________________________________
 *If applicable ____________________________________

NUTRITION:

Diet Comments: Has not gained  Dentures  None

weight and but has change in
• N  V appetite on her first few
• Recent change in months in pregnancy but Full Partial With Patient
weight and appetite doesn’t have any difficulty in
swallowing Upper   
• Difficulty in
swallowing

• Denied Lower   

ELIMINATION: Comments: Urgency to Bowel Sounds: __________

urinate at most 20 times per
Usual bowel pattern • Urinary frequency day _______________________

________________________ ________________________ Abdominal Distention

• Constipation • Urgency Present  Yes  No

remedies
• Dysuria Urine* (color,
________________________ consistency, odor)
• Hematuria
Date of last BM
• Incontinence _____________________
________________________
• Polyuria _______________________
• Diarrhea character
• Foley in place *if foley bag catheter is in
place
• Denied

MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to follow treatments
(diet, meds, etc.) for chronic health problems (if present).
• Alcohol  Denied
(amount, frequency)
N/A
Last February, drank a bottle of alcohol

• SBE Last Pap Smear: _______________________

LMP: January 4, 2021

SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:  dry  cold  pale
• Dry Comments:  flushed  warm
Itchiness on her
• Itching  moist  cyanotic
right arm
 • Other *rashes, ulcers, decubitus (describe size, location,
drainage) Rashes on her right arm
• Denied

ACTIVITY / SAFETY:  LOC and orientation: Awake

• Convulsion Comments: She Gait:  walker  care  other
can bathe herself
• Dizziness  steady  unsteady
normally, hasn’t
• Limited motion of joints felt any dizziness Sensory and motor losses in face or extremities
and hasn’t
Limitation in ability to experienced any N/A
• Ambulate convulsion
ROM limitations: _____________________________
• Bathe self ____________________________________________
• Other ____________________________________________
• Denied

COMFORT / SLEEP / AWAKE  facial grimaces

• Pain
(location, frequency,
remedies)
• Nocturia
• Sleep difficulties
• Denied
COPING:
Occupation: ALS Volunteer Teacher
Members of household: Mother, Father, and Brother
Most supportive person: Mother
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)
________________ Daily Weight
________________ BP Shift
________________ Neuro VS
________________ CVP / SG Reading
Comments: She  guarding
doesn’t have any
trouble sleeping,  other signs of pain _______________________
or felt any pain
while sleeping. ________________________________________
________________________________________
 side rail release form signed (60+ years) ______
________________________________________
Observed non-verbal behavior: Calm demeanour
during our face-to-face talk, she isn’t nervous and sat
still while I was interviewing her.
Person (Phone Number) 09755895352
________________ PT / OT
________________ Irradiation
________________ Urine Test
________________ 24 hour Urine Collection

Date Ordered Diagnostic / Laboratory Date Done Date I.V. Fluids / Blood Date Disc.
Exams Ordered
 NURSING ASSESSMENT 2
PATHOPHYSIOLOGY

Name of Patient: Relia Mae D. Muaña

Diagnosis: Urge urinary incontinence related to ineffective toileting habits
Score: ___________ Grade: _____________
 DRUG STUDY
Name of Patient: Relia Mae D. Muaña
Name of Specific
Dose /
Drug Date Mechanism of Indication Side Effects / Nursing
Classification Frequency Contraindication
Generic Ordered Action (why drug is Toxic Effects Precaution
Route
(Brand) ordered)
Hanizyn Multivitamins One capsule Treats Iron Iron intolerance Constipation Before using
with iron a day deficiency due Hypersensitivity Diarrhea Hanizyn Capsule,
to poor Nausea inform your
absorption and doctor about your
Vomiting
chronic blood current list of
loss medications, over
the counter
products,
allergies, pre-
existing diseases,
and current health
conditions.
Calvit Gold Multivitamins One tablet a For lactation Hypercalcemia Constipation Before using
with calcium day and prevention Hypersensitivity Diarrhea Galvit Gold
of osteoporosis Hypophosphatemia Burping Tablet, inform
in pregnant your doctor about
Kidney problems Nausea
women your current list
Vomiting
of medications,
over the counter
products,
allergies, pre-
existing diseases,
and current health
 conditions.

Folicap Multivitamins One capsule Stimulates the Intolerance to the Constipation Before using
a day production of drug Diarrhea Folicap Capsule,
red blood cells, Stomachache inform your
white blood doctor about your
cells, and current list of
platelets in medications, over
persons the counter
suffering from products,
certain allergies, pre-
megaloblastic existing diseases,
anemias. and current health
conditions.
 Score: __________ Grade: ___________
NURSING CARE PLAN
Name of Patient: Relia Mae D. Muaña
NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Urge urinary After 8 hrs of Independent: Independent: The patient was able
Itchiness and incontinence nursing Let the client This helps to put to demonstrate
lesions on her right related to intervention, the practice proper the client in more increase bladder
elbow ineffective patient will be posture and allow of a squatting capacity to lessen
Urine has mucus toileting habits able to the client enough position, which the times client
threads on the sixth demonstrate time on the toilet. makes urinating must use the toilet.
month of increase bladder Dependent: easier.
pregnancy capacity to lessen Dependent:
Assist the person to
Urgency to urinate the times client Clothing can be a
change their clothing
at most 20 times must use the barrier to
to maximize toileting
per day toilet. functional
access.
Collaborative: continence if it
Objective: takes time to
Refer gynecologist
RR: 18 remove before
and consultant
BP: 100/60 voiding.
physician if
Pulse: 64 condition worsen Collaborative:
Temp: 35.6 To ensure that
Height: 156cm patient is seeing
Weight: 57.5kg the correct
 providers for the
correct problem.
Score: __________ Grade: __________
 HEALTH TEACHINGS
Name of Patient: Relia Mae D. Muaña
Take 1 capsule of Hanizyn for iron, Calvit Gold for calcium, and Folicap for prenatal
MEDICATION vitmins atleast once a day each either after breakfast or after lunch.

Do antepartal exercise atleast 150 minutes a week in preparation for labor and delivery.
EXERCISE

TREATMENT

OUT-PATIENT
(Check-Up)

Eat less oily foods, drink plenty of water, eat more vegetables (legumes, broccoli and dark,
DIET leafy greens) and fruits.