Rillera, Chantel G.

BSN 2F-D

1. Psychosocial and Psychological Status

Patient X is admitted in the hospital because of her elevated blood pressure and induction of
labor. She is married for 12 years and residing in Malaysia for 4 years. She and her husband do not
have vices. Her husband went back to Indonesia 2 months ago after staying in Malaysia for 5 years.
He planned to come back in Malaysia once his papers renewed. Her children are taken care by her
mother in Indonesia.
Patient X is scared of any possible complications for her and her baby. She does not even have a
husband for moral support but her religious belief kept her cheerful and optimist despite the situation.
On the other hand, her mother’s family side is diabetic and hypertensive. Her father died on 2007
because of renal failure. All of her siblings are alive and well.

2. Mental and Emotional Status

Although patient states that she is scared, she still appears jolly and positive. She was conscious,
alert, and able to answer questions comfortably. She well oriented with time, place, date, and
cooperative with the treatments given. Also, she calls help to nurses when she is in need of help.

3. Environmental Status
Patient X is admitted and placed in OB ward with quiet environment, an adequate lighting,
and air ventilation. Patient requested to be placed in a room with big window so she can view outside
and her request was granted,

4. Sensory Status
a. Visual Status
Patient passed PERRLA eye test, she can read Snellen chart from a distance of 6 meters,
and can demonstrate 6 cardinal gazes with ease.
b. Auditory
She does not have hearing aids or any audio device. She is also positive in Rene and
Weber test. She can hear whisper from a distance of 3 meters as well as loud noises from
afar.
c. Olfactory status
She was instructed to shut her eyes and distinguish pleasant and unpleasant odors. She
was able to differentiate the smell of coffee scent from alcohol scent.
d. Gustatory status
She can determine the taste of sweet, sour, salty, and bitter flavors.
e. Tactile status
She can tell apart a rough wall from a smooth paper. She can sense changes in
temperature and discern hot from cold. She can also feel pain but no numbness.

5. Motor Status
She was able to perform 5 ROM against gravity and resistance in both her upper and
lower extremities. She can walk in straight line with no swaying and she doesn’t need
assistance.

6. Thermoregulatory Status
Date Time Temperature
Initial Vital Signs/Upon
Admission:
November 29, 2010 1:30 pm 36.6
Upon Physical Examination:
November 29, 2010 2:30 pm 36.4
 7. Respiratory Status

Date Time RR SPO2

Initial Vital
Signs/Upon 1:30 pm 20 93.4
Admission:
November 29, 2010
Upon Physical
Examination:
November 29, 2010 2:30 pm 20cpm 94.3

8. Circulatory Status
Reference: She was referred from antenatal clinic during follow up in PPUKM on
29/11/2010. During her follow up checkup, her vital sign showed she was afebrile, pulse rate of
90beats per minute and blood pressure was noted 160/100mmHg. She doesn’t have any
abnormalities in her urine.

Her blood pressure upon admission is 142/92mmHg lying and 152/104mmHg standing. Her
pulse rate was 90beats per minute and respiratory rate was 20breath per minute. She was afebrile.
Her current weight was 69kg. There was no pedal edema noted.

Date Time CR Capillary BP

Initial Vital
Signs/Upon
Admission:
November 29, 1:30 pm 90bpm 9.5 160/100mmHg
2010
Upon Physical
Examination:
November 29, 2:30 pm 90bpm 10.5 142/92mmHg
2010 lying and
152/104mmHg
standing

9. Nutritional Status
The patient does not have any food allergies and her appetite was good. She was able to
swallow her food and ingest her medications easily. She also does not need assistance when she
eats, she is presented with foods low in sodium, low in sugar, and low fat to avoid complications
in her case.

10. Elimination status

She doesn’t have urine frequency reduction and she doesn’t wake up at night just to relieve.
She defecates 3 times a day trouble free. Both her urination and defecation were good without
bleeding and any difficulties. Lastly, there was no usual vomiting,

11. Sleep, Rest and Comfort Status

 She stated that her usual sleeping time is 6-7 hours. She’s asserted that she doesn’t experience
sleep disturbance and no insomnia.

12. Fluid and electrolytes status

She has good skin turgor, and drinks 10 glass of water every day. Upon administration, she
was injected with IV fluid to help hydration, electrolyte, and blood sugar level.

13. Integumentary Status

She was not pale or jaundiced. Her breast was symmetrical and bilaterally in size. Her nipple
was not hyper pigmented or retracted and there was no discharge. Upon palpation, mass is
absent and her breast was tender. Linea nigra and striae gravidum is noticeable in her abdomen.
Her abdomen was soft and non-tender. Clubbing and peripheral cyanosis was missing upon
inspection. Inspection of the mouth showed that there was no central cyanosis.
She has no rashes on her skin as well as lesions. She has a scar on her upper abdomen, she
stated that she got it from an accident few years ago. Her nails are trimmed and cleans. Swelling
on her skin is also absent.