Narrative Head-to-Toe Assessment on a Pregnant Woman

Date of Assessment: July 16, 2022

Area: Tanza, Boac, Marinduque
Assessed by:
Sosa, Irah Eunice
Ricafrente, Mark Joseph
Fernandez, Kyla Allyza Dolceamor R.
Reynoso, Leamarie Jhaira
Saez, Myere Jilliene

Client’s name is Jasmin Mercene, 32 years old, currently living in Tanza, Boac,
Marinduque. The client is pregnant and is currently in her 3rd trimester (8 months and Gravida
5). The client is a food vendor and sells “bibingka”. Her nature of work is quite tiresome but
according to her, it helps them in their financial problems and also relieves stress.
Based on the client’s initial health history assessment, the client has no present health or
history of present illnesses as well as her family history of specific illnesses. Last 2010, she was
diagnosed with Goiter but is already treated. She also had a history of Urinary Tract infections.
The client also experienced edema during her first pregnancy. The client recently received a
vaccine for COVID-19 last January 2022 with no allergies or reactions are shown during
immunization.
The client’s Estimated Date of Delivery (EDD) is September 6, 2022, based on the
client’s Last Menstrual Period (November 25, 2021). Her last gynecologic check-up was
November 8, 2021, and her latest ultrasound result shows normal fetal activity and active cardiac
pulsations at 141 beats per minute with an adequate amount of amniotic fluid. The fetus has an
estimated bodyweight of 1,370 grams.
The client gained weight over the past 3 months because of her growing fetus and
experiences fatigue from time to time. The client complains of toothache which she can feel usually
once a week and on a scale of 1-10, she rated the pain as 3. The client also complains of her
varicose veins which she described as painful and rated the pain as 7 on a scale of 1-10. Other than
these, the client has no other present illnesses and complaints.
Based on the client’s overall head-to-toe assessment, the client’s general health is well. No
hazards and threats are present in the environment that surrounds their area and adequate and
accessible resources near them. The client will be monitored once a week until her date of delivery
and ensure her health and safety during the course of her pregnancy.