A.

Application of the nursing process

1. Fill-up the needed data based on the given scenario/case. Note: Assessment findings of all
other areas must be filled up using fictional data BUT should be within the scope of the case
scenario given.
Conduct a history taking and physical assessment of your patient. using BLUE pen for
normal findings and RED for abnormal findings under Review of Systems (ROS).

General the patient looks pale, tired, and sleepy. Patient is

hypotensive, hypothermic, and tachycardic. Her vital
signs are as follows:

BP: 80/50,

PR: 105 bpm,

CR: 105 bpm,

T: 35.3 degrees Celsius.

Present weight:110 lbs.

Weight Upon admission 127 lbs..

Skin The patient has a fair-colored complexion.The skin is

warm and dry. There is also palmar erythema.With
diaphoresis. The abdomen has striae gravidarum and
appears reddened and linea Negra. Abdomen is soft and
non-tender. The skin around the episiorrhaphy is red and
drains a small amount of seropurulent drainage.
Head, Eyes, Ears, Ø Head is rounded; normocephalic and
Nose, Throat symmetrical.Skull has no nodules or masses and
depressions fundus 1 cm above the umbilicus
and right. Mask of pregnancy is visible on the
face.There is excessive pigment on the face and
neck (Chloasma)

Ø Eyes.The palpebral conjunctiva is pale.The sclera

appeared white.The pupils of the eyes are black
and equal in size.

Ø Ears.Has normal alignment of the pinna.

Ø Nose.The nose has no presence of discharge or

flaring, it's clear.

Ø Throat. No palpable nodules.

Neck The neck muscles are equal in size. No palpable nodules..

There is excessive pigment on the face and neck (Chloasma).
Thyroid is not palpable in the neck.

Breast Breast is hard, larger, and more erectile. It is engorged and

shiny. The chest is symmetrical. she says that she has a hard,
tender, and shiny over the entire breast not just in one spot.
There is no redness, fever, and cracked nipples.

Respiratory The abdomen has striae gravidarum and appears reddened

and linea Negra. Lungs have normal breath sounds without
dyspnea. Clear to auscultation in all lobes

Cardiovascular The chest is symmetrical. There were no visible pulsations on

the aortic and pulmonic areas. There is no presence of
heaves or lifts.Pulse is palpable. Capillary refill actively
returns to its normal color in less than 4 seconds. Cardiac rate
of 105 beats per minute, no signs of crackles, wheezing,
stridor.
Gastrointestinal Able to digest food. The patient is constipated. Abdomen has
audible bowel sounds.

Urinary The patient has a foley catheter inserted draining to a

yellow-colored. Hemorrhoids are present

Urine.no sign of sediment or cloudiness.

Genital Patient had her menarche @ 12 years of age. She had a

regular menstruation 30 days cycle lasting 3-4 days,
moderate to heavy flow. She experienced dysmenorrhea, no
history of bleeding between periods. There is an increased
steady flow of bright red blood and clots from the vagina.
There is also a saturation period. There is a soft and boggy
uterus.

The perineum is edematous with ecchymosis patches

from ruptured capillaries. Cervix feels soft and malleable,
vagina,feels soft with few rugae. Diameter is greater than
normal. A moderate lochia rubra was observed.

Peripheral / Vascular There is an increased steady flow of bright red blood and
clots from the vagina. There is also a saturation period. Leg
pain and varicosities were not noted.

Muskuloskeletal On musculoskeletal, no pelvic girdle pain or back pain.

Extremities have a good range of motion.

Neurologic

There is a low level of Hemoglobin and Red blood cell

Hematologic count;
Endocrine Thyroid is not palpable in the neck.

Psychiatric Narda has this overwhelming sadness, burst into tears, and
feeling down, there is also a feeling of inadequacy, anorexia,
and sleep disturbance. She is also worried about the weight
of her baby