Munder, Aljanna-Marie P.

BS Nursing OB Duty
NURSING ASSESSMENT II (Part 2)

CLINICAL APPRAISAL
NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL
DAY 1 DAY 2
5. NEURO-SENSORY
Patient is conscious and active. Patient is conscious but not that active. Patient is conscious but not that Patient is conscious but
a. Mental state Patient answers actively and Five senses are functioning well upon active. Five senses are slightly active. She responds
appropriately to the questions assessment and no history of any functioning well upon assessment well when asked. Five senses
nervous or mental problem. and no history of any nervous or are functioning well and no
asked.
b. Condition of five mental problem. history of nervous or mental
senses: (sight, hearing, problem.
smell, taste, touch)

6. OXYGENATION
a. Vital signs Patient’s vital signs were not T: 36.7 T: 36.7 T: 36.5
assessed and taken during this time.
Temperature R: 19 bpm R: 19 bpm R: 18 bpm
Respiratory rate BP: 120/80 mmHg BP: 120/80 mmHg BP: 110/80 mmHg
Heart rate O2: 98% O2: 98% O2: 99%
Blood pressure PR: 79 bpm PR: 79 bpm PR: 99 bpm
 b. Lung sounds
c. History of Patient has no history of respiratory Patient has no history of Patient has no history of
Respiratory problems. respiratory problems. respiratory problems.

Problems

7. PAIN-COMFORT
a. Pain (location, onset,
Patient claimed to feel mild pain in Patient feels mild pain in her lower Patient feels mild pain in her Patient still feels pain but not
character, intensity,
her lower abdomen and also feels abdominal area associated with uterine lower abdominal area associated that severe. Tolerable and
duration,
discomfort due to uterine contractions. The patient’s sleep is with uterine contractions. The manageable according to her
associated symptoms,
contractions. Patient prompted disturbed due to discomfort. Patient patient’s sleep is disturbed due to statement.
aggravation)
medical assistance from Amai holds her lower abdomen and ask for discomfort. Patient holds her
Pakpak Medical Center. massage (counter pressure) whenever lower abdomen and ask for Administer Paracetamol for
pain is felt for alleviation. massage (counter pressure) pain.
b. Comfort
whenever pain is felt for
measures/Alleviation
alleviation.

c. Medications

Patient usually takes a bath once Patient needs assistance in Patient can do ADL but with
Patient needs assistance in performing
8. HYGIENE AND daily but there are times where she performing ADL. Hygiene is not assistance. Hygiene is
ADL. Hygiene is not prioritized;
ACTIVITIES takes a bath twice during morning prioritized; patient has not maintained through tepid
patient has not showered since
OF DAILY LIVING and in the evening before sleeping. showered since admission. sponge bath only. Brushed
 Patient is perfectly able to perform
ADL independently such as
bathing, eating, sitting, walking,
etc.
9. SEXUALITY
admission. Hence, tepid sponge bath Hence, tepid sponge bath was her teeth twice. She is
was applied. applied. advised to perform early
ambulation, breastfeed the
baby, and take a bath.
.

a. female (menarche,
Patient is a female, married and 26 Patient is a female, married and 26 Patient is a female, married and Patient is a female, married
menstrual
years old. She started menstruating years old. She started menstruating at 26 years old. She started and 26 years old. She started
cycle, civil status,
the age of 13 years old with normal menstruating at the age of 13 menstruating at the age of 13
number of at the age of 13 years old with
menstruating cycle: 7 days in 1 month years old with normal years old with normal
children, reproductive normal menstruating cycle: 7 days with an obstetric status of G1P0. menstruating cycle: 7 days in 1 menstruating cycle: 7 days in
status) in 1 month with an obstetric status month with an obstetric status of 1 month with an obstetric
of G1P0. G1P0. status of G1P1.
b. male (circumcision,
civil
status, number of
children)