FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Nursing Program

URIAN HEALTH CENTER

INDIVIDUAL TREATMENT RECORD

Name of Mother: Bonita San Jose Case No.: 1

Birthdate: January 20, 2001 Age: 21
Address: Purok 2 Brgy. Babag Contact: ______________
Spouse: ______________________________________ Civil Status: Single
Educational Attainment: 2nd year college Occupation: ___________
Birthplace: ____________________________________ Religion: Roman Catholic
Blood Type: O Pregnancy Status: G 1 P0 (T0 P0 A0 L0 M0 )

Date Complaint Treatment Remarks

10/05/21 For Pre-natal Check-up Vital Signs:
LMP: May 12, 2021 BP: 120/90 mmHg
EDC: February 19, 2022 Temp: 36.9 C
AOG in Weeks: 20 weeks PR: 90 bpm
AOG in Months: 5 months RR: 17 bpm
nd
Trimester: 2 trimester Weight: ___________
Height: ___________
Health Teachings:
1. Do proper hygiene such as
hand washing.

2. Maintain a Perineal Care.

Wipe the perineal area from
front tot back.

3. Adequate fluid intake 2-4

liters per day if tolerated

4. Avoid caffeine and limit

intake during late evenings
and bedtime.

5. Make her realize its

normal to hormonal
imbalance.
Name of Mother: Jessa Cupin Case No.: 2
Birthdate: December 25, 1990 Age: 31
Address: Langihan Road, Butuan City Contact: ______________
Spouse: Jess Cupin Civil Status: Married
Educational Attainment: High School Graduate Occupation: Saleslady
Birthplace: ____________________________________ Religion: ____________
Blood Type: AB Pregnancy Status: G4 P3 (T2 P1 A0 L3 M0 )

Date Complaint Treatment Remarks

10/05/21 For Pre-natal Check-up Vital Signs:
LMP: June 1, 2021 BP: 100/60 mmHg
EDC: March 8, 2022 Temp: 36.6 C
AOG in Weeks: 18 weeks PR: 71 bpm
AOG in Months: 4 months RR: 19 bpm
Trimester: 2st trimester Weight: 49 kgs
Height: 152 cms
Health Teachings:
1. Raise the head of the bed on
6- to 8-inch blocks. It is
important the foam is firm
enough to truly elevate the
upper body. The wedge
should also extend all the
way to the waist so the
entire chest is elevated..
2. Avoid certain types of acidic
or spicy food along with
tobacco and alcohol.
3. Frequent, small meals
should be eaten rather than
three large meals, and the
last meal of the day should
be early in the evening.
4. Avoid any specific foods that
aggravate heartburn (for
example, coffee, cola, tea,
alcohol, chocolate, fat, citrus
juices, etc.)
5. Chewing gums may also
be helpful, because the
bicarbonate neutralizes
the acid that has refluxed
into the esophagus.
Name of Mother: Andrea Dela Torre Case No.: 3
Birthdate: November 5, 1982 Age: 39
Address:Brngy. Bancasi, Butuan City Contact: ______________
Spouse: Andong Dela Torre Civil Status: Married
Educational Attainment: Occupation: College Instructor
Birthplace: Brngy. Bancasi, Butuan City Religion: Roman Catholic
Blood Type: Pregnancy Status: G6 P5 (T4 P1 A0 L5 M0 )

Date Complaint Treatment Remarks

10/05/21 For Pre-natal Check-up Vital Signs:
LMP: July 22, 2021 BP: 130/100 mmHg
EDC: April 29, 2022 Temp: 36.9 C
AOG in Weeks: 10 weeks PR: 81 bpm
AOG in Months: 2 months RR: 18 bpm
Trimester: 1st trimester Weight: 55 kgs
Height: 155 cms
Health Teachings:
1. Eat small frequent meals to
avoid gastric distention.

2. Increasing carbohydrates is
recommended to relieve
nausea better.

3. Put some sourball candies

or dry crackers such as
saltines in the bedside and
eat a few before rising.

4. Try ginger, raspberry, and

peppermint teas.

5. Avoid lying supine for 2

hours after eating.
Name of Mother: Joy Uy Case No.: 4
Birthdate: Age:
Address: T. Calo Ext. Butuan City Contact: ______________
Spouse: John Uy Civil Status: Married
Educational Attainment: _________ Occupation: Chef
Birthplace: ____________________________________ Religion: Roman Catholic
Blood Type: B Pregnancy Status: G3 P0 (T0 P1 A2 L0 M0 )

Date Complaint Treatment Remarks

10/05/21 For Pre-natal Check-up Vital Signs:
LMP: February 28, 2021 BP: 120/80 mmHg
EDC: November 5, 2021 Temp: 37 C
AOG in Weeks: 31 weeks PR: 85 bpm
AOG in Months: 7 months RR: 18 bpm
Trimester: 3rd trimester Weight: 60 kgs
Height: 150 cms
Health Teachings:
1. Take a prenatal Vitamin at
least once a day to help
supplement a healthy diet
with essential vitamins and
minerals sufficient red blood
cell production.
2. Separate iron supplements
in addition to your daily
prenatal vitamin. Top your
favorite iron-fortified
breakfast cereals with fruits
rich in vitamin C, such as
strawberries, bananas, or
blueberries.

3. Eat the right foods, a food

that good in sources in
minerals including fish,
poultry, eggs, leafy greens,
and also fruits like bananas
and melons.

4. Sprinkle nuts and seeds

over yogurt, oatmeal, or
granola.

5. Try making a green

smoothie with your choice of
leafy greens, fruits, and a
plant-based or dairy milk that
is fortified with iron.
Name of Mother: Rochel Mednoza Case No.: 5
Birthdate: April 12, 1987 Age: 34
Address: Guingona Subdivision Contact:
Spouse: Rod Mendoza Civil Status: Married
Educational Attainment: ______________ Occupation: Housewife
Birthplace: ______________________________ Religion: Roman Catholic
Blood Type: O Pregnancy Status: G6 P5 (T3 P2 A1 L5 M1 )

Date Complaint Treatment Remarks

10/05/21 For Pre-natal Check-up Vital Signs:
LMP: March 26, 2021 BP: 110/70 mmHg
EDC: January 2, 2022 Temp: 37.2 C
AOG in Weeks: 27 weeks PR: 80 bpm
AOG in Months: 6 months RR: 16 bpm
nd
Trimester: 2 trimester Weight: 56 kgs
Height: 156 cms
Health Teachings:
1. Eat a variety of vegetables,
fruits, whole grains, fat-free
or low-fat dairy products,
and protein foods.

2. Choose foods and drinks

with less added sugars,
saturated fats, and sodium
(salt).

3. Limit refined grains and

starches, which are in foods
like cookies, white bread,
and some snack foods

4. Since it is your second

trimester, you need to take
340 extra calories a day.

5. If you are feeling sick, try

eating a piece of whole-grain
toast or whole-grain
crackers.