TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

PATIENT HEALTH TEACHING

Cruz, Czarina B.
BSN 2-2 | 2B

Nurse Cza: Good day Ma’am! I’m Czarina Cruz your student nurse for today. May I know your
name and birthday?

PT: Hi I’m CIT born on November 25, 1982.

Nurse Cza: Hello Patient CIT! How are you feeling after your consultation with Dr. Miles?

PT: Nervous as always, I’m always unease about my pregnancy.

Nurse Cza: Okay go on, you can say what you want to say. I’m listening

PT: I also hope that the bleeding will not happen again.

Nurse Cza: We can prevent that from happening again Ma’am. Here are some health teachings
that I can give to you. But as you listen, please sit for a while and make yourself comfortable. If
you have any questions, I can answer them for you

PT: Thank you nurse! Dr. Miles said that I have a Placenta Previa, and Dr. enlightened me on why
am having a bleeding.

Nurse Cza: Oh, I see. If you have any questions don’t hesitate to talk to me Ma’am. So here
are some health teachings that I can give to you. For the bleeding not to happen again, avoid
engaging in activities that can increase your risk of bleeding, such as running, squatting, and
jumping. Also, you need to take a rest and avoid lifting heavy things. About your clothes ma’am
also avoid wearing tight clothes.

PT: Oh, okay go on.

Nurse Cza: About your food intake, just continue on what your diet is like the dry food in the
morning and a combination of fruit, vegetables, lean meat or fish during lunch and supper. Also,
increase your fluid intake and drink your medicine in time.

PT: This is noted Nurse Cza

Nurse Cza: Thank you for listening Ma’am we are always happy to help you and to guide you
to have a better health, for you and your child. If you have any questions, please don’t hesitate to
call us. And if the bleeding happens again call us right away. Your follow up check up will be on
December 20, 2021.

PT: Thank you for this wonderful information, Nurse Cza!

Nurse Cza: You’re always welcome Ma’am! Please take care of yourself, see you on your next
check up! Have a great day ahead
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

DAILY PHYSICAL EXAMINATION REPORT

Name of Patient: CIT Age: 37 Date of Birth: November 25, 1982

Medical Diagnosis: Placenta Previa
Nursing Diagnosis: Ineffective Tissue Perfusion
Assessed by: Cruz, Czarina B. Date of Assessment: December 14, 2021 Time: 1PM

Assessment
Area N AbN Description of Findings & Interpretation
General Appearance ✓ Client has complete extremities, but her motor stability is not normal due to
Posture her backpain.
Hygiene/Grooming ✓ When client arrived in the hospital, she wears presentable clothes.
Nutrition/Diet ✓ Client’s normal diet includes dry food in the morning and a combination of
fruit, vegetables, lean meat or fish during lunch and supper.
Body Size/Habitus ✓
Height: 5’4 ✓ Normal height.
Weight: 59kg ✓ Normal weight.
Supply appropriate data: ✓ Normal.
➢ IBW: 108 - 132 lbs
➢ BMI: 22.3
➢ IRS: ✓ Normal BMI.
✓
Behavior ✓ She is nervous, anxious, febrile, and slightly irritable due to her soaked
sanitary pads.
LOC ✓ The client is conscious and can cooperative when answering questions.
Vital Signs ✓ The client is febrile upon arrival.
Temperature: 38.4°C
Pulse Rate: 86 bpm ✓ Pulse rate is within normal range.
Rhythm: __________
Respiration Rate: 25cpm ✓ Client’s respiratory rate is 25 which leads to being tachypneic. She also stated
Rhythm: ___________ that she is having DOB. Client’s O2 Sat’s is not normal.
Blood Pressure: 110/70mmHg ✓ Blood pressure is within normal range
Skin ✓ Fair complexion.
Color
Temperature ✓ Warm to touch skin.
Turgor ✓ Normal skin turgor.
Texture ✓ Smooth.
Integrity ✓ No broken areas found. No tearing, blisters, wounds. Skin’s integrity is
normal.
Unusual Marks ✓ No unusual marks.
Rashes, Lesions ✓ No rashes found.
Pressure sore: Yes __ No ✓ ✓
Site: ___________________
Edema: Yes ____ No ✓ ✓
Site: _____________________
Type: _____________________
Size/Degree: _______________
Hair ✓ Soft to touch skin.
Texture
Thickness ✓ Not too thick and not too thin.
Color & Distribution ✓ Her hair is black in color, smooth, and distributed fairly.
Hygiene Status ✓ Normal.
Nails ✓ Transparent, smooth and convex
Color & Shape
Hygiene Status ✓ Fingernails and toenails are trimmed and cleaned
Presence of Clubbing ✓ Normal.
Head ✓ Normal.
Shape & Symmetry
Unusual swelling ✓ Normal.
Cranial bruit ✓ Normal.

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6
 Assessment
Area N AbN Description of Findings & Interpretation
Eyes ✓ Normal eye alignment
Size, placement & alignment
Cornea ✓ Translucent, smooth and avascular
Pupils ✓ Pupils are spherical.
➢ Size (mm)
PERRLA ✓ Responsive to light and accommodation in equal amounts. Without
difficulty, the patient can see everything clearly.
Visual Acuity ✓ 20/20 vision, Normal.
Orbital Bruit ✓ Normal.
Other Findings:
________________
Ear ✓ Symmetrical and normal.
Location/Alignment
Pinna, Canals, Drums ✓ No lesions and no swelling.
Hygiene ✓ Normal.
Discharge and Odor ✓ There are serums found and it is normal.
Hearing Acuity ✓ Client can hear normally without having a tough time.
Tinnitus ✓ Normal.
Vertigo/Dizziness ✓ Client experiences dizziness but she does not have vertigo.
Other Findings:
________________
Nose ✓ Client has a pointed nose.
Shape
Symmetry ✓ The client’s nose is in the middle of the face, Normal.
Patency ✓ Normal.
Mucosal Integrity ✓ Normal.
Epistaxis ✓ Normal.
Sinuses ✓ No abnormalities, no swelling and she has a normal sense of smell.

Other Findings:
________________
Lips ✓ No tearing, not dry. Normal.
Integrity
Symmetry ✓ Middle of the face, no abnormalities.
Color ✓ Reddish-pink-to-brown, Normal.
Other Findings:
________________
Mouth ✓ Client brushes her teeth 3x a day. Normal hygiene.
Hygiene
Number & Condition of Teeth ✓ 32 teeth. All of the teeth are clean and normal.
Gums ✓ Pink and firm. No swellings.
Mucosal Integrity ✓ Normal.
Tongue ✓ Pink in color, can identify/ distinguish different taste of foods given to her.
Tonsils ✓ Pink in color and its surrounding area.
Palate ✓ Pale pink color, firm to palpation. Normal.
Parotid Gland ✓ Normal.
Hoarseness ✓ Normal.
Other Findings:
________________
Neck ✓ During auscultation, vascular sound.
Carotid Bruit
Neck Veins ✓ Normal.
Thyroid ✓ Soft, smooth, symmetrical, and non-tender.
Trachea Rigidity/Tenderness ✓ Normal.
Mass/Bruises ✓ No bruises found, no masses. Normal.
Other Findings:
________________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 6
 Assessment
Area N AbN Description of Findings & Interpretation
Chest and Lungs
Shape & Symmetry
➢ Nipple & Areola ✓ Normal, darker than usual and larger.
➢ Mass/Lump ✓ No masses and lump, Normal.
➢ Others: __________
Breathing
➢ Spontaneity ✓ 25cpm
➢ With Ventilator ✓ Normal
➢ With Tracheostomy ✓ Normal
➢ Rhythm ✓ 25cpm, leads into tachypneic.
➢ Depth ✓ 25cpm, leads into tachypneic
➢ Effort ✓ DOB
Use of Accessory Muscles ✓ Normal.
a. Intercostals
b. Abdominal
c. Sternocleidomastoid ✓ Due to her vaginal bleeding, client has a DOB.
d. Trapezius ✓ Normal.
✓ Normal.
Cough ✓ Not coughing.
Sputum Production: Yes __ No: __ ✓
➢ Amount: _____________
➢ Consistency: __________ ✓
➢ Color: _______________ ✓
➢ Odor: _______________
✓
✓
Chest X-ray Result ✓ N/a
Breath Sound (Specify) ✓ No bronchial.
a. Bronchial
b. Crackles
c. Rhonci ✓ No crackles found.
d. Wheezes ✓ No rhonci found.
e. Stridor
f. Crepitus ✓ No wheezes found.
✓ No stridor found.
No crepitus found.
CTT ✓ n/a
Location: __________
Suction: ___________
Water Level: _______ ✓
Quality of Drainage: ___________ ✓
✓
ABG ✓
Other Findings: ________________
Heart ✓
History
With Palpitation
Dyspnea ✓
✓ Client experiences DOB.
Rhythm ✓ Tachypneic since Clients’ RR is 25cpm.
Point of Maximal Impulsec(PMI) ✓ n/a
(PMI is felt at 5th ICS at apex
of heart) Specify:
a. Heaves ✓
b. Clicks
c. Splitting ✓
d. Thrills ✓
e. Callops ✓
f. Muffles
✓
✓
Presence of Heart Sounds ✓ n/a
a. S1
b. S2 ✓
c. S3
d. S4 ✓
✓
Murmurs ✓ 110
a. Systolic
b. Diastolic ✓ 70

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 3 of 6
 Assessment
Area N AbN Description of Findings & Interpretation
Abdomen ✓ Diet includes dry food in the morning and a combination of fruit,
Diet: ____________________ vegetables, lean meat or fish during lunch and supper.
Mode of Feeding: __________
✓
Shape and Symmetry ✓
Umbilicus Protrusion ✓
Bowel Sound (Indicate Sound) ✓
➢ LUQ: __________
➢ RUQ: __________
➢ LLQ: __________ ✓
➢ RLQ: __________ ✓
✓
Abdominal Bruit ✓
Distention ✓
Ascites: Yes: ____ No: ____ ✓
Nausea ✓
Vomitus/Hematemesis ✓
Amount: _______________
Consistency: ____________
Color: _________________
Odor: _________________
Frequency: _____________

Drainage Tube ✓
Abdominal Mass ✓
Abdominal Girth: __________ ✓
Other Findings: ________________
Back
➢ Spine
➢ Paralumbar
Other Findings: ________________
Genitalia
Symmetry ✓ Normal.
Presence of Tenderness ✓ Normal.
Urethral Discharge ✓ n/a
Bleeding ✓ Vaginal bleeding, w partially soaked sanitary pads per day.
Pelvic Pain ✓ Client stated she experiences back pain.
LMP: 6/12/21 ✓ 24 weeks and 2 days, 6months. Normal.
With Dysuria ✓ No discomfort during urination.
With Flank Pain ✓ Client stated she experiences back pain.
Nocturia ✓ n/a
History of Urinary Stone ✓ n/a
History of Impotence ✓ n/a
With Urinary Catheter n/a
Urinalysis Finding: _____________
Peritoneal Dialysis (PD) n/a
a. Date Started
b. Incorporation
c. Cycle Exchange
Amount: _______________
Dwell Time: ____________
Drainage Time: __________
d. PD Return
Color: __________
Flow: __________

Hemodialysis n/a
Frequency: ________________
Last HD: __________________
Amount of Fluid Removed: _____
Next HD: __________________
Place: ____________________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 4 of 6
 Assessment
Area N AbN Description of Findings & Interpretation
Rectal Examination ✓
Anal Inspection
With Hemorrhoids: Yes:__ No: ✓
✓
Location: ______________
Characteristics: _________
Mass ✓
Last Bowel Movement: _________ ✓
Characteristic of Stool: __________ ✓ Brown and soft.
Other Findings: ________________
Nodes ✓ No presence of nodes
Lymphadenopathy
Location
a. Cervical R ___ L ___
b. Axillary
c. Inguinal R ___ L ___
Others ______________

Extremity ✓ Client has complete extremities.

Texture
Capillary Refill ✓ Able to go back before 2 seconds.
Peripheral Pulse (both sides) Normal.
➢ Carotid
➢ Radial
➢ Ulna ✓ Normal.
➢ Brachial ✓ Normal.
➢ Femoral
➢ Posterior Tibial ✓ Normal.
➢ Dorsalis Pedis ✓ Normal.
➢ Popliteal
✓ Normal.
✓ Normal.
✓ Normal.
Clubbing of Fingers ✓ No clubbing of fingers.
Varicosities ✓ None
Thrombophlebitis ✓ None
Cyanosis ✓ None
Joints ✓ None
➢ Erythema
➢ Tenderness
➢ Deformity ✓ None
➢ Swelling ✓ None
✓ Client stated she experiences back pain.
Muscles ✓ None
➢ Bulk
➢ Tone
➢ Tenderness ✓ None
✓ None
Ulcerations ✓ No sore on the skin/ mucous membrane.
Edema ✓ No swelling found.
Other Findings: ________________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 5 of 6
 Assessment
Area N AbN Description of Findings & Interpretation
Hematopoietic n/a
Easy Bruisability
Excessive Bleeding
Anticoagulants
Bleeding Profile
Anemia
Hematology Report
Other Findings: ________________
Neurology n/a
Assessment of Cranial Nerves
➢ CN I (Olfactory)
➢ CN II (Optic)
➢ CN III (Oculomotor)
➢ CN IV (Trochlear)
➢ CN V (Trigeminal)
➢ CN VI (Abducens)
➢ CN VII (Facial)
➢ CN VIII (Vestibulocochlear)
➢ CN IX (Glossopharyngeal)
➢ CN X (Vagus)
➢ CN XI (Spinal Accessory)
➢ CN XII (Hypoglossal)

Motor and Posture ✓ The client was assessed using an upright position, she was not able to walk
properly and experiences backpain. Client also is having a hard time during
the range of motion (ROM).
Sensory Perception ✓ Normal.
Reflexes ✓ Normal.
a. Indicate Type of Reflex______
________________________
b. Pathologic Reflex: Yes__ No__
✓ Normal.
Other Findings: _________________
Patient’s ADL ✓ Can take a bath on her own.
a. Bathing
b. Dressing
c. Elimination ✓ Dresses properly, looks presentable.
d. Mobility and Movement ✓ Client stated that she can defecate at least once every two days, with the
e. Nutrition and feeding feces being brown and soft. She said that she urinates at least three times a
day. The color of her urine is pale yellow, and its transparency is clear.
✓ Due to her backpain, she’s having a rough time
✓ Client’s normal diet includes dry food in the morning and a combination of
fruit, vegetables, lean meat or fish during lunch and supper.

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6
13 Areas of Assessment
Name: Pt. CIT | Placenta Previa
Age: 39 yrs/o
Areas of Assessment Findings
Social Status Pt. CIT is 39 years old, born on November 25,
1982. She is living together with her family, and
she is a housewife. Based on the client’s response
she is caring, approachable, and kind. Within her
household, she is a good, loving, and a responsible
mother to her husband and children.
Mental Status
➢ General Appearance and When she arrives in the hospital, she wears
Behavior presentable clothes. Also, she is nervous, anxious,
febrile, and slightly irritable due to her soaked
sanitary pads.
Norms Analysis
This norm is centered on how we should act in social Pt. CIT has excellent communication skills. The
settings. Once again, there are cues we need to client has a good relationship with her family,
notice when we are out with friends or at social friends, and neighbors.
events that help us fit in and get a closer connection
to the group. (Wengrzyn, 2021)
An Appearance norm is related to dress code and The client is febrile and uncomfortable that leads
code of conduct in the organization. In good to irritability due to her soaked sanitary pads.
organization dress while at work, dress for sports
function or for dinner are laid down. In defense
services such norms are inbuilt in the organizational
culture. (CourseHero, 2021)

➢ Level of Consciousness and
Orientation
The client is conscious and can cooperative when Consciousness is not a process in the brain but a kind The client can easily understand the questions
answering questions. of behavior that, of course, is controlled by the brain
which are being asked. Both her level of
like any other behavior. Human consciousness
emerges on the interface between three components consciousness and orientation are normal.
of animal behavior: communication, play, and the
use of tools. (Psychol, 2018)

It also frequently refers to appropriately Client’s verbal response is normal.

➢ Speech Her way of delivering speech is audible to ear.
pronouncing the words and sounds. Speaking or
pronouncing words in a way that they are clearly
understood is referred to as articulate. (Merriam-
Webster)
Emotional Status She is seen to have an anxiety when she talks about Emotion norms are thought to have a significant When she talks about her pregnancy, she appears
her pregnancy. She had an abortion, and it gave impact on affective experience as well as a wide to be nervous. She had an abortion, which caused
her emotional distress and negative feelings. range of emotion-related actions like facial her a lot of emotional pain and unpleasant
expressions, vocalizations, and gestures, mostly feelings.
through socialization and various attempts at
emotion regulation. (Scheve, 2015)
Sensory Perception
➢ Sense of sight Pupils are spherical and responsive to light and Visual acuity of 20/20 is considered normal or The client’s eyes’ movement are normal and do
accommodation in equal amounts. Without healthy by experts. Simply put, you can see not have any abnormalities.
difficulty, the patient can see everything clearly. something clearly from 20 feet away that you should
be able to see from that
distance. (Grief, 2019)

➢ Sense of Taste Client can distinguish different taste of foods Sweet, sour, salty, bitter, and umami are five basic Client’s sense of taste is normal.
given to her. tastes that tell us something about what we put in our
mouth and help us decide whether to eat it.
(Ajinomoto, 2019)

➢ Sense of Hearing Hearing loss of up to 25 dB is considered normal in

The appearance of the client’s ear is symmetrical
and normal, no lesions and no swelling. She can
hear normally without having a tough time.
Client’s sense of hearing is normal. She can hear
adults. This is how hearing loss is divided: Hearing
normally without having a tough time.
loss is measured in decibels between 26 and 40. 41
to 55 dB is a moderate hearing loss. (Borgia, 2021)

➢ Sense of Smell
The client’s nose is in the middle of the face, there
are no abnormalities, no swelling and she has a
normal sense of smell.
The impulses are sent from the nerves to the brain,
which interprets them as sight (vision), sound Client’s sense of smell is normal.
(hearing), smell (olfaction), taste (gustation), and
touch (gustation) (tactile perception). (Visible Body,
2021)

➢ Tactile The skin contains receptors for pain, touch, pressure,

The client was instructed to close her eyes and tell and temperature. Sensory signals are transmitted Client’s sensory transmission functions well, as
whether we are palpating her with light and deep along rapid sensory pathways, and less distinct manifested by the data presented.
touch. The client was able to distinguish both. signals such as pressure of localized touch are sent
 via slower sensory pathways. (Health Assessment
and Physical Examination, Mary Ellen Zator Estez)

Motor Stability The client was assessed using an upright position, Normal motor stability includes the ability to Client has complete extremities, but her motor
she was not able to walk properly and experiences perform different activities without causing pain and stability is not normal due to her backpain.
backpain. Client also is having a hard time during discomfort. It should be firm and have coordinated
the range of motion (ROM). movements. (Estes, 2017)

Body Temperature Date Temperature Remarks Normal body temperature varies by person, age, During the first day of assessing the client’s body
activity, and time of day. The average normal body temperature, she is febrile.
temperature is accepted as 98.6°F (37°C). Some
studies have shown that the "normal" body
12/14/21 38.4°C Febrile temperature can have a wide range, from 97°F
(36.1°C) to 99°F (37.2°C). (MedlinePlus, 2021)

12/15/21 37.2°C Normal

Respiratory Status Date RR O2 Sat Remarks The number of breaths taken per minute is referred Client’s respiratory rate is 25 which leads to being
to as a person's respiratory rate. At rest, an adult's tachypneic. She also stated that she is having
breathing rate ranges from 12 to 20 breaths per DOB. Client’s O2 Sat’s is not normal.
minute. While resting, a respiratory rate of less than
12/14/21 25cpm 88 Tachypneic 12 or more than 25 breaths per minute is considered
abnormal. (Cleveland Clinic, 2019)

12/15/21 20cpm 94 Normal

Circulatory Status Date BP PR Remarks The American College of Obstetricians and Client’s cs blood pressure and pulse rate are
Gynaecologists (ACOG) state that a pregnant within normal range.
woman's blood pressure should also be within the
healthy range of less than 120/80 mm Hg. (Fletcher,
12/14/21 110/70m 86 bpm Normal 2020)
mHg

12/15/21 110/70m 90 bpm Normal

mHg

Nutritional Status Client’s normal diet includes dry food in the To enhance the nutrition of pregnant women, Nutrional status of the client is normal.
morning and a combination of fruit, vegetables, UNICEF advocates healthy diet, micronutrient
lean meat or fish during lunch and supper. supplements (iron and folic acid or several
micronutrients, and calcium), deworming
prophylaxis, weight gain monitoring, physical
exercise, and rest. (NCBI, 2019)
Elimination Status The client stated that she can defecate at least once
every two days, with the feces being brown and
soft. She said that she urinates at least three times
a day. The color of her urine is pale yellow, and its
transparency is clear.
Reproductive Status At the age of 13, the client experienced her first
menstruation. No recorded sexually transmitted
disease. The client also stated that she had an
abortion, and she is experiencing vaginal bleeding. (about 4 weeks) on average, with a range of 21 to 45
She usually uses 2 partially soaked sanitary pads days (about 1 and a half months) between periods.
per day.
Gravida: 4
Term: 2
Pre-Term: 0
Abortions: 1
Living Birth: 2
Sleep-rest Pattern Client stated that she can sleep properly, and she
does not have any difficulty during sleeping. Also,
she acquires the right amount of proper sleeping.
State of Skin Client has fair complexion and warm to touch
skin. She has normal skin turgor. Her hair is black
in color, smooth, and distributed fairly.
Fingernails and toenails are trimmed and cleaned.
Bowel elimination might range from multiple stools Based on the data, there no abnormalities seen
per day to only two or three stools per week. Most with the client's elimination status.
people have bowel movements every 1 to 2 days.
When gastrocolic and defecation reflexes induce
peristalsis 30 to 45 minutes after a meal, the urge to
defecate is most common. (Nurse key, 2016)
It is important to keep track of how big your clitoris The client is experiencing vaginal bleeding which
is not normal for a pregnant woman.
is and how your labia minora and majora are
developing. Menstruation must occur every 28 days
Menarche occurs on average at the age of 12.4.
(Lacroix, 2020)
Advise that healthy adults need between 7 and 9 The client does obtain the recommended seven to
hours of sleep per night. People over 65 should also nine hours of sleep. Her sleep-rest pattern is
get 7 to 8 hours per night. (Suni & Singh, 2021) normal.
Skin that is well-balanced is referred to as "normal." Client fulfilled the standard on her skin and nails
Eudermic refers to skin that is well-balanced. based on norms.
Although the T-zone (forehead, chin, and nose) is
oily, the skin is balanced in terms of sebum and
hydration, and it is neither too oily nor too dry.
(Biersdorf, 2021)