I.

Patient’s Profile
Name: Patient X
Age: 29
Sex: Female
Address: Pinsao, Pilot Project, Baguio
Birthdate: September 16, 1990
Birthplace: Natonin, Mountain Province
Occupation: businesswoman
Status: single
Religion: Roman Catholic
Date of admission: November 20, 2019
Chief complaint: Labor pain
Admitting diagnosis: G2P1 (1001) Pregnancy uterine 38 2/7 weeks AOG cephalic in beginning of labor
previous LSCS 1X for arrest of descent ( GI: 2013, Bontoc, General, Hospital)

II. History of Present Illness

One day prior to admission, patient went for her prenatal check-up, no subjective complaint such as
labor pain, vaginal discharge, nor bleeding. Then ultrasound was done revealing single, live intrauterine
pregnancy, cephalic in presentation, 39 weeks, 6 days age of gestation by smog ram with an estimated
fetal weight of 4.2 kg. The patient was advised to elective cesarean section on November 20, 2019. No
medications given. Few hours prior to admission, the patient sought consult in BGH-MC and
subsequently admitted for elective cesarean section.

III. History of Past Illness

Patient lives in Salamague, Bugallon, Pangasinan, with her husband, mother, and three children who
were, 15, 12, and 6 years old. According to the patient their house is far from the site where to commute
to town and it serves as her exercise since she goes to the market almost every day.

The patient is not a smoker neither any of her housemates; however, she had been exposed to second
hand smoke from their neighbor. She drinks liquor moderately and started drinking at the age of 18.
According to her she consumes gin about 1-2 shot glass of approximately 25 ml each shot glass, with
water, about every three times a month. The patient also had no known drug abuse usage.

Patient is fond of salty foods such as, dried fish as it is what is most available. According to her she
consumes about 2-3 dried fish per meal, about three times a week. She is also fond of food that are
seasoned with fish sauce and alamang. Patient also consumes about 2-3 lecheflan, approximately 15
grams each in a week.

Patient had been hospitalized when she was 12 years old at a Hospital in Pangasinan. She had urinary
tract infection during her high school days, but had not reoccurred until at present. Patient gave birth at
home to her three children with the help of a hilot. According to her she did not experience any severe
bleeding after any of the three home delivery. She did not also consulted a physician or a midwife after
birth. According to her she was given enough time recover after birth before she returned to doing
household chores. As well, she only do light household chores even after she have recovered already. She
is previously using pills as a contraceptive for the last 6 years.

IV. Family History

The patient’s family had no history of cancer of any type. However, the mother of the patient had
been diagnosed with diabetes mellitus and hypertension. She is living with three children, her mother and
husband at Salamague, Bugallon, Pangasinan. The patient also lived in a family with no one smoking,
and with a member with moderate liquor consumption.

V. 13 Areas of Assessment
A. Psychological status
Patient X is a 35 year-old female and married. She lives with her husband, mother, and three children.
The patient and her family is Roman Catholic and have no practices or beliefs which might affect to
providing health care. The patient appears to be right for her age and gender. The patient is well groomed
as soon as she can sit and stand to perform personal hygiene.

B. Mental and emotional status

The patient is oriented that she is in the hospital. The patient is conscious, alert and coherent. She is
responsive to verbal stimuli, noise, light, touch and pain stimuli. She is oriented to current time, date and
place. She acts according to her age. She has good perception about her health and is aware that her diet
prior to hospitalization needs to be changed. She is very cooperative and prevents some things to further
cause damage to her health. The patient very receptive to the health teachings I give and is interactive
during the discussion. No social concerns or fears were noted.

C. Environmental status
Patient’s bed is clean, including her bedside table and surroundings. The ward have well light, and
ventilation. She is not comfortable during sleep due to acute pain related to incision on the abdomen as
well as the noise from the announcement of the hospital and noise from other patients. The food and
water or side table is placed at the left side of the patient and is accessible for her needs. Patient is in the
GYNE ward, together with her mother and sometimes her husband during the 5 days stay in the hospital.

D. Sensory status
There is no known visual deficit such as color blindness. She have difficulty distinguishing a voice from a
distance of about 1 meter. You have to make your voice louder when speaking in that distance and you
have to remove your mask when talking to her. No corrective auditory device noted. The patient is able to
discriminate an odor from the other. The patient is able to discriminate sweet, sour, salty and bitter tastes
from each other. About the patient’s tactile status, patient was able to discriminate sharp and dull, light
and firm touch, able to perceive heat, cold, pain in proportion to stimulus, able to differentiate common
objects by touch.

E. Motor status
On her first day in the ward, her movements are limited and needs full assistance with her activities. She
have improved on the second day, wherein she can now sit but still with minimal assistance. She can walk
to the restroom but needs assistance as she verbalized that she have nausea whenever she stands to walk,
and this had improve on the third day wherein she can go to the restroom to perform hygienic measures
such as washing her perineal area. She have a good posture and no noted deformities such as lordosis,
kyphosis, and scoliosis.

F. Nutritional status
On the first day the patient was on NPO. The next day the patient is on soft diet as to she is just from an
operation and her digestive system had not return completely to its normal functioning. The patient
appetite is good, and drinks about 750 mL during the entire shift of 8 hours. Her food preference are
conge and papaya. There is no culture or religious dietary restriction reported by the patient. The patient
is able to swallow in her food and medications as well. The patient denied any indigestion and vomiting.

G. Elimination status
The patient eliminates in a toilet bowl on her second day in the ward. She verbalized that the stool is
brownish and is solid like. She drinks about 750 ml of water in 8 hours. She verbalized that she frequently
urinates during her stay at the hospital. She urinated about 2-3 times during my shift. The patient claimed
absence of special problem like urinary and bowel retention, urinary incontinence and diarrhea.

H. Fluid and electrolytes status

The patient usually drinks about 750 mL of water during the 8 hours shift, and urinates 2-3 times the
whole 8 hours shift. She has an ongoing IVF of PLRS x 1LX 8 hours and had 3 of them. Her skin turgor
is normal and she has moist mouth. No signs of dehydration noted.

I. Temperature status
The patient’s temperature is taken from the axillary. She is not warm to touch and there is no sign of
diaphoresis.
March 2 36.3-36.4 C
March 3 36.3-36.4C
March 4 36.5-36.7C
March 5 36.5-36.7C
March 6 36.1-37C
March 7 36.3-37C
 J. Respiratory status
No abnormal breath sounds noted upon auscultation. No signs of respiratory distress noted.
March 2 19-20
March 3 16-20
March 4 16-18
March 5 17-20
March 6 18-19
March 7 18-20

K. Cardiovascular status
Patients pulse rate has regular rhythmic pattern. No heart murmurs heard upon auscultation. The patient’s
capillary refill is 1-2 seconds.
BP CR SPO2
March 2 120-130/70- 55-75 93-97
80
March 3 110-120/80- 66-86 97-98
90
March 4 110-130/70- 78-92 98-99
80
March 5 120-130/70- 84-92 98-99
80
March 6 110-120/80- 78-92 98
90
March 7 120-130/70- 66-86 97-98
80

L. Integumentary status
Skin color is brownish and has a good skin turgor that goes back within 1- 2 seconds. Patient have a
vertical incision site, approximately 5 cm in length. Nails and hair are well kept by the patient. There are
no odorous secretions or oily secretions noted. No psoriasis and rashes noted.

M. Rest and comfort status

Patient claims to have difficulty sleeping due to pain in the incision site. She also verbalized that she is
not comfortable with her abdominal binder, as she experience nausea and dizziness. In the ward, she has
about 4 hours sleep during the day and at home she has about 6-8 hours of sleep.

VI. Brief Description of the Disease

VII. Course in the Ward

IX. Laboratory and Diagnostic Test
URINALYSIS
URINALYSIS CHEMICAL EXAMINATION
November 12, 2019 3:29 PM
Urine chemical examination was indicated to the patient, because the patient has chief complain of lower
abdominal enlargement and pain, which may be that the attributed to having kidney diseases.
Result Reference Physical result Reference range
range examination
color yellow Lt. Yellow- Transparency Slightly
Amber turbid
Chemical Result Reference Chemical Result Reference range
examination range examination
Specific gravity 1.02 1.00-1.005 Glucose Negative 0-5.5
pH 6.0 6-7 Ketone Negative Negative
Leuko esterase Negative Negative Urobilinogen Normal 0-7
Nitrite Negative Negative Bilirubin Negative 0
Urine Protein +3 Negative Erythrocyte +2 <9
Ascorbic acid - Negative micro Albumin -
Creatinine 17.7 0-0.9 Calcium 2.5 0-1.0

 Urine protein- can be a sign of kidney disease when filters damaged by kidney disease may let
proteins such as albumin leak from the blood into the urine.
 Creatinine clearance- High levels of creatinine in the urine can indicate diabetes, high muscle
tone, or problems with the kidneys.
 The calcium level in urine is used in evaluating risk for kidney stones, which high calcium levels
in the urine resulted in the development of a kidney stone.
The patients diet with regards to being fond of salty foods, justify the results.

COMPLETE BLOOD COUNT

March 3, 2020
Complete blood count was indicated to the patient because she had underwent a surgical operation that
involves incision and may risk her for blood loss. Given the increased blood loss, it is routine practice to
obtain a post-operative complete blood count (CBC) on the first day to evaluate for post-operative
anemia. All the results are within the normal range.
Test name Result Reference range
Hemoglobin 125 120-160 g/L
Hematocrit 0.39 0.37-0.47 L/L
WBC Count 7.64 5.0-10.0 10^9/L
Differential count
Neutrophils 60 50-70
Lymphocytes 32 20-40
Monocytes 7 0-10
Eosinophils 1 0-7
Basophils 0 0-1
Total 100
RBC Count 4.47 4.4- 5.48 10^12/L
Platelet count 265 150-400 10^9/L
RBC INDICES
MCV 87.80 80-100 fL
MCH 28 27-31 pg
MCHC 319 310-360 g/L
RDW-CV 12.30 11-16%
RDW-SD 37.90 35-56 fL
MPV 9.50 6.5-12 fL

X. Nursing Prioritization of Problems

PRIORITIZED ACTUA POTENTIA JUSTIFICATION
PROBLEM L L
Acute pain 1 ✓ This problem is the placed in this order of
related to priority because the pain can affect the
operative cooperation of the patient throughout the
procedure treatment. Pain can also make the patient
uncomfortable in which basing it from Maslow’s
hierarchy of needs the pain can affect the
patient’s perception of his/her safety, by thinking
it would cause her other complications. In
addition, the uncomfortableness of the patient
may affect the other needs like the social needs,
by not able to talk comfortably with other
people, thus it needs to be addressed after the
ABC are normalized
Impaired skin 2 ✓ This problem is prioritized in this order because
integrity related if your patient has surgical incision, according to
to surgical Maslow’s hierarchy of needs esteem is on the
incision fourth level which you can achieve after you
have addresses the others factors.
Risk for 3 ✓ Physical mobility requires sufficient muscle
impaired strength and energy, along with adequate skeletal
physical stability, joint function, and neuromuscular
mobility related synchronization in which can be possible if the
to decreased basic needs are fulfilled. The problem has to be
muscle strength. addressed in this prioritized manner because the
basic needs are to be fulfilled first to able the
patient fulfill the higher order needs in the
Maslow’s hierarchy of needs. The patient has
impaired physical mobility because of decreased
muscle strength in which to have a good muscle
strength for physical mobility the basic need
should first be fulfilled.