Group1a BSN219 Mothers-Case Final PDF

FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
Morayta, Manila, Philippines
NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

FIRST SEMESTER
A.Y. 2021-2022
A Case of Gravida 1 Para 1 (1001) Term, Cephalic Delivered; Failed Induction of Labor,
Term Birth Living Boy APGAR score of 9/10; Birth weight of 3470 grams, Appropriate for
Gestation at Age; Overt Diabetes Mellitus, Insulin Requiring - Uncontrolled; Chronic
Hypertensive Vascular Disease; Obese II, Urinary Tract Infection - Ongoing Treatment
Presented by:
Leader: Flores, Anne Gabrielle C.
Members:
Cajucom, Cathleen
Clemente, Rafael Z.
Dalisay, Brant Angelo
Dychauco, Stefannel Krain Jamaica B.
Enriquez, Hillary
Ganapin, Jenson Mark
Garcia, Samantha Claire
Guiwo, Meryll Julienne T.
Guiyab, Ana Marie T
BSN 219
Presented to/Submitted to:

Ma’am Concepcion Diciembre
Submitted on:
December 14, 2021

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A.Y. 2021-2022
I. DEMOGRAPHIC PROFILE
Name: Agustin, Johanna Garcia
Address: 1081 Aura St. Panginay, Balagtas Bulacan
Age: 37 Birthdate: October 8, 1984 Birthplace: Balagtas, Bulacan
Gender: Female
Religion: Catholic Race/Ethnic Origin: Asian/NA
Occupation: Pharmacist Educational Attainment: N/A
Marital Status: Married Name of Spouse: Agustin, Mark John Alfred D.
Number of Living Children: 0
Chief Complaints: Elevated Blood Sugar (Possible induction of labor)
Date of Admission: December 1, 2021
Room and Bed Number: Room 629 transferred to 425
Attending/ Admitting Physician: Dr. Joseph Olivar / Dr. Dosado
Admitting / Final Diagnosis: Gravida 1 Para 1 (1001) Term, Cephalic Delivered; Failed
Induction of Labor, Term Birth Living Boy APGAR score of 9/10; Birth weight of 3470 grams,
Appropriate for Gestation at Age; Overt Diabetes Mellitus, Insulin Requiring - Uncontrolled;
Chronic Hypertensive Vascular Disease; Obese II, Urinary Tract Infection - Ongoing Treatment
Medical Insurance: Philhealth
II. NURSING HEALTH HISTORY

A. HISTORY OF PRESENT ILLNESS
1. SIGNS AND SYMPTOMS AND INCLUSIVE DATES
a. UTI
The patient's present Illnesses are UTI, Chronic Hypertension Vascular Disease,
Obese II, and Diabetes Mellitus. The UTI signs and symptoms for bladder
infection include pain or burning while urinating, having frequent urination,
bloody urine, having the urge to urinate even though your bladder is empty,

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A.Y. 2021-2022
experiencing pressure, or cramping. In kidney infection having a fever, chills,

vomiting, nausea, and back discomfort in the lower back or on the side of your
back. The patient having UTI will be undergoing a Urinalysis test and we will look
for red blood cells, white blood cells, and bacteria in the urine. The presence of
white and red blood cells in your urine can suggest the presence of an illness. For
its inclusive date, the urinalysis was ordered December 1, 2021 and the results
were also given the same day. All components are within normal range in
accordance with the reference values except for the client’s High Pus cells which
is 56.5/ uL. A Normal Pus Cells ranges from 0 to 17/ uL
b. CHRONIC HYPERTENSION VASCULAR DISEASE

For the most part, high blood pressure has no warning signs or symptoms, and
many people are unaware that they have it. (The only method to tell if you have
high blood pressure is to take your blood pressure.) Upon admission, December 1,
2021, the client’s vital signs were taken and monitored. The client’s blood pressure
elevated December 2, 2021 which was 140/80 indicating hypertension.
c. OBESE II
Obesity symptoms can have a negative impact on one's daily life. Symptoms are
accumulation of excess body fat, particularly around the waist, breathing problems,
sweating a lot more than usual, Skin difficulties caused by moisture accumulating
in the folds of the skin, difficulty sleeping, inability to accomplish simple physical
chores that one could easily perform prior to weight increase, fatigue ranging from
mild to severe, and pain, particularly in the back and joints. Upon admission,
December 1, 2021, the height, and weight of the patient was documented. As for
the client’s BMI, it is 56.7, indicating her weight is in the obese category for adults
in her height range. Obese ranges from 30.0 and above.

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A.Y. 2021-2022
d. DM (DIABETES MELLITUS)
Some people only have a few symptoms, whereas other people have no symptoms
and are unaware that they have the condition. Signs and symptoms are frequent
urination, Excessive thirst, unexplained weight loss, extreme hunger, sudden
visual changes, tingling or numbness in the hands or feet, more infection than
usual, dry skin, and, last but not least, a constant feeling of exhaustion. Overt
Diabetes Mellitus has been an existing illness of the client for five years. A
Capillary Blood Glucose Test was ordered December 2, 2021 and results were
given the same day. The client’s blood glucose is within normal range if it is solely
based on the blood glucose range (Mathew & Prasanna Tadi, 2021).
2. PRECIPITATING AND ALLEVIATING FACTORS

a. UTI
For UTI risk factors specific to women include a woman's urethra is shorter than a
man's, reducing the distance bacteria must travel to reach the bladder. UTIs are
more common in sexually active women than in non-sexually active women.
Having a new sexual partner raises your risk as well. Women who use diaphragms
for birth control, as well as those who use spermicidal drugs, may be at a higher
risk. Menopause. A decrease in circulating estrogen after menopause causes
abnormalities in the urinary tract, making you more susceptible to infection.
B. CHRONIS HYPERTENSION VASCULAR DISEASE

Here are the factors for chronic hypertension vascular disease include as you
become older, your chances of developing high blood pressure increase. History
of the family. High blood pressure is a condition that tends to run in families.
Obesity is being overweight. Being inactive physically, you are consuming too

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A.Y. 2021-2022
much salt (sodium) in your diet, potassium deficiency in the diet. And having
certain chronic illnesses.
c. OBESE II
In Obese II the greater the number of risk factors, the more likely you are to get
the disease or health problem. If you're obese and have these risk factors, you're
more likely to develop health problems like heart disease, stroke, and kidney
disease: having a family member under the age of 50 with heart disease, being
physically inactive or leading a sedentary lifestyle, and smoking or using tobacco
products of any kind.
Risk factors that increase your Diabetes Mellitus fat distribution, inactivity, family
history, race and ethnicity, blood lipid levels, pre-diabetes, pregnancy-related risk
if you had gestational diabetes while pregnant or gave birth to a kid weighing more
than 9 pounds, you're more likely to develop type 2 diabetes (4 kilograms)., and
polycystic ovary syndrome are all major risk factors, irregular menstruation cycles,
excessive hair growth, and obesity are all symptoms of PCOS, which raises the
risk of diabetes. Darkened skin, generally in the armpits and neck, because this
condition is associated with insulin resistance.
3. EFFECT TO OTHER BODY PARTS/FUNCTION

a. UTI
UTI’s are usually caused when unwanted bacteria enter through the urethra and
begins to multiply. A common symptom is an overwhelming burning sensation
while urinating. Cloudy or bloody urine, along with abnormal frequency, is another
symptom. A foul smell can be associated also with the infection. Feeling tired or

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A.Y. 2021-2022
sluggish with slight fever marks and unusual bodily occurrence should be looked
at. Someone who is older could experience only uneasiness due to age. Lower
back pain and abdomen is a sign of infection. If any of these symptoms occur, a
person should consult a physician immediately (Zieve, 2011). When the upper
urinary tract is involved and/or the severity of the infection is more pronounced,
more generalized symptoms such as fever, chills, nausea, vomiting and abdominal
and back pain may appear. (Morrison, 2021).
b. CHRONIC HYPERTENSION VASCULAR DISEASE

High blood pressure (hypertension) can quietly damage your body for years before
symptoms develop (Mayo Clinic, 2019). Hypertension gradually increases the
pressure of blood flowing through your arteries. As a result, the client may have
damaged and narrowed arteries, aneurysm, Coronary artery disease, Enlarged left
heart, Transient ischemic attack (TIA), Stroke, Dementia, Kidney failure, Damage
to your retina (retinopathy) and Sexual dysfunction. (Mayo Clinic, 2019)
c. OBESE II
Obesity can damage and affect normal bodily functions. Any extra weight is
definitely going to add stain to various organs and cause an adverse impact. Some
of these are Diabetes, Polycystic ovarian syndrome, Gastro-esophageal reflux
disease, Erectile dysfunction , Urinary incontinence, Cellulitis, Stroke , Congestive
heart failure, Pulmonary embolism. (Sabeeka Lambe, 2017)
Diabetes Mellitus can damage and affect normal bodily functions.Risk of
stroke, loss of consciousness, extreme thirst, visual disturbances, sweet-smelling
breath, cataracts and glaucoma, risk of heart disease, risk of infections, fatigue and

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A.Y. 2021-2022
lack of energy, high blood pressure, pancreas malfunction, gastroparesis, excessive

urination, protein in the urine, damaged blood vessels, ketoacidosis, nerve damage,
dry, cracked skin, foot problems are some of the various effects in a person with
diabetes mellitus. (Pietrangelo, 2021)
4. INTERVENTION/ TREATMENT DONE

a. UTI
When it comes to urinary tract infections, antibiotics are usually a first line of
protection. The drugs provided and how long they are administered are determined
by your health state and the type of bacteria discovered in your urine. (Mayo Clinic,
2021) Trimethoprim/sulfamethoxazole (Bactrim, Septra, others), Fosfomycin
(Monurol), Nitrofurantoin (Macrodantin, Macrobid), Cephalexin (Keflex),
Ceftriaxone. Those are some of the most regularly prescribed medications and
treatments for UTI.
B. CHRONIC HYPERTENSION VASCULAR DISEASE

High blood pressure can be controlled and managed by altering your lifestyle. The
treatment for Chronic Hypertension Vascular Disease that you make lifestyle
changes try the DASH (Dietary Approaches to Stop Hypertension) diet, which
emphasizes fruits, vegetables, whole grains, chicken, fish, and low-fat dairy foods,
is a good place to start. Potassium is a mineral that can help prevent and control
high blood pressure. (Mayo Clinic, 2021) Eating a low-salt, heart-healthy diet,
Physical activity on a regular basis, maintaining a healthy weight or, if overweight
or obese, reducing weight, and keeping your alcohol consumption to a minimum.
However, lifestyle adjustments aren't always sufficient. If diet and exercise don't
work, your doctor may prescribe blood pressure medication.

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A.Y. 2021-2022
c. OBESE II
Losing weight through healthy eating, increasing physical activity, and
making other lifestyle changes are all common treatments for overweight and
obesity. Some people may benefit from weight-management programs in order to
lose weight or avoid regaining it. Some obese persons are either unable to drop
enough weight to enhance their health or are unable to maintain their weight loss.
For the treatments of DM this involves blood glucose monitoring, nutritional
management, physical activity maintenance, weight and stress management, oral
medication monitoring, and, if necessary, insulin injections or pump use. It allows
patients to make more consistent and suitable therapeutic and lifestyle changes.
5. EFFECT OF INTERVENTION/TREATMENT
a. UTI
According to (CDC, 2021), UTIs are common infections that happen when
bacteria, often from the skin or rectum, enter the urethra, and infect the urinary
tract. The infections can affect several parts of the urinary tract, but the most
common type is a bladder infection (cystitis). When it comes to UTI treatment, the
use of analgesic such as paracetamol would help to alleviate or ease the UTI-
associated pain. Also, cefuroxime is usually prescribed by the physician after the
delivery of the patient, cefuroxime would likely help to treat infection.
b. OBESE II
The drugs prescribe by the physician doesn’t have any effects on the patient’s
obesity.

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A.Y. 2021-2022
C. CHRONIC HYPERTENSION VASCULAR DISEASE

The drugs prescribe to the patient doesn’t have any effect to the patient’s Chronic
Hypertension Vascular Disease.
The drugs prescribe to the patient have no effect because the drugs are for pain
reliever. Note that the patient can take antibiotics but it increases the risk of having
an infection such as Urinary Tract Infection (Campbell et al., n.d.).
B. PAST HEALTH HISTORY

For the Past Health History of Mrs. Johanna Agustin, she has complete immunizations which are
Hepatitis A, Hepatitis B, Polio, TDAP (tetanus, diphtheria, and pertussis), Pneumonia, Typhoid,
Cholera, Measles, Influenza, Yellow fever, Japanese Encephalitis, (MMR) Mumps and Rubella,
Chickenpox, Rabies, Meningitis, Shingles. She has no childhood illnesses, and for the Past
Illnesses she has had Overt DM (Diabetes Mellitus) for 5 years, latest HbA1c 5.1 was done last
May, CBG 103, on detemir (long acting insulin) 15-0-15 units. On light low salt, low fat, and DM
diet doctor advised to shift insulin to Humalog (insulin lispro) but has not complied. There is no
heredofamilial disease in their family, she has no experience with accidents and injuries as well as
surgical procedures. She didn’t travel locally and abroad. And the recent hospitalization is last
November 11, 2021.
C. OB HISTORY
The 37-year-old female patient is scored as G1P1 T1P0A0L1, as the single baby was delivered
alive at 38 weeks and 6 days, the client’s baby was cephalic in delivery in a failed induction of
labor. The birthweight of the client’s baby is 3470g which is above the 90th percentile for
gestational age with an APGAR score of 9/10. Client’s last menstrual period was March 4, 2021.
Upon calculation, the client’s age of gestation by her last menstrual period was 37 weeks and 5

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A.Y. 2021-2022
days. As for the client’s expected delivery date the calculated delivery date was December 9, 2021
but the baby was delivered December 2, 2021 through low segment caesarian section 1 –
Pfannenstiel (intrapartum) under combined spinal and epidural anesthesia converted to general –
orotracheal intubation.
D. FAMILY HEALTH HISTORY (GENOGRAM WITH LEGEND)
In both families, Diabetes Mellitus and Hypertension are common comorbidities, as seen in the
graph. Evidently, patient Johanna Garcia’s mother has Diabetes Mellitus and has Hypertension.
Patient Johanna Garcia got her diabetic and hypertensive genes from her mother, and now, she
also has Diabetes Mellitus and Hypertension. Mark John A., the husband of patient Johanna A.,
has a father who has Chronic Hypertension Vascular Disease, and Obese comorbidity, and it is
passed to Mark John A. Though, there is a high chance that their son may inherit the Chronic

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A.Y. 2021-2022
Hypertension Vascular Disease and Obese so that the genetic comorbidity is a condition that can
be passed down across generations. Johanna and her parents they’ve been taking their prescriptions
for many years now, and their health and condition are not in the best of shape, and this is also the
reason why they have been consulting various doctors.
III. GORDON'S HEALTH ASSESSMENT

1. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
Findings: Due to her unhealthy lifestyle, the client has rated her health as a three out of 10
since the quarantine began. A healthy person, according to her, is someone who consumes
good foods, drinks enough water, exercises frequently, and is free of medical ailments.
Despite this, she is unable to live a healthy lifestyle due to various circumstances such as
stress, poor eating habits, personal issues, and a variety of other commitments. Her
underlying health issues, such as Diabetes Mellitus, Chronic Hypertensive, Vascular
Disease, Obesity, and Urinary Tract Infection, stress her out and get in the way of her
everyday life. She has been preserving her health for the last several months by taking many
drugs for her Diabetes Mellitus, including Insulin Levemir. She is taking Losartan for her
hypertension. Finally, she is currently on a low salt and low-fat diet to cure her UTI. She
does not use any tobacco products or illicit drugs.
Furthermore, she leads a sedentary lifestyle and is physically inactive due to a lack of time
and drive. She does not undergo regular exams since the epidemic prevents them from going
outdoors, particularly to hospitals and clinics. Her primary health issue has been fatigue
since the start of quarantine. More significantly, she claims to be unconcerned about getting
medical attention since she has done so in the past. During her health assessment on the day
of admission, she reported minimal contraction discomfort.

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A.Y. 2021-2022
Analysis: Health perception and health management patterns describe how the client
perceives health and well-being patterns. In the statement above, the client, guided by the
explanation provided by the nurse, stated a numerical rating of her health perception and its
accompanying reasons (Health Status, Health Perception, 2009). She also stated her
definition of a healthy individual. Further, it also discloses how health is being managed.
Health behaviours can be defined as activities done to maintain, achieve, or regain good
health and prevent disease. They are an essential factor that shapes and directly affects
health, which may be positive or negative. The client's health habits reveal her lifestyle
choices.
Additionally, the health beliefs of the client's family influence the client's health perception.
The family's judgment regarding health care behaviours, prevention, and adherence to
proper management of health and illness problems affect the health practices of the client.
Regular physical activity, adequate sleep, a balanced diet, vaccinations, and proper stress
management are some of the positive health behaviours. As for the minimal pain due to
contraction, the patient is experiencing, and it is called laboring, early signs of laboring.
According to the Web MD, labor refers to your body's natural birthing process. It begins
with your first regular contractions and continues until the birth of your baby and placenta
(2004).
Interpretation: Deviation from Normal
2. COGNITIVE – PERCEPTUAL PATTERN

Findings: The client reported no impairments in her five senses, including sight, taste,
hearing, and smell. Furthermore, the customer is capable of comprehending a wide range
of ideas, concepts, and patterns, particularly those relevant to her career as a Pharmacist. In
this regard, the client is an aural and visual learner. Furthermore, the customer has no

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problems with memory or knowledge retention. She described her exhaustion as being
overworked and often exhausted from juggling many jobs. These repetitious daily duties
physically and psychologically drained her, and she lacked the stamina to complete all of
the responsibilities. According to the client, she does not yet feel excited or interested in
completing her tasks; instead, she feels forced to carry out her obligations without a feeling
of purpose. She often takes brief rests in between jobs to relieve herself of her persistent
exhaustion.
Analysis: The client exhibits a sharp sense of sight, taste, hearing, smell, and touch. Also,
the client can process and retain data and communicate information to receivers. Moreover,
the shift from face-to-face duties to an online setting dramatically affects the lifestyle of the
workers and students, including the client. Work-life balance is not correctly carried out,
which escalates stress from workloads. Hence, increasing risks in physical impairment as
well as mental exhaustion. Moreover, a person who undergoes mild stress would have a
positive effect on their sensory reception, such as interpretation of data, encoding and
decoding messages, thus improving memory and acuity. Hence, the adverse effects of stress
depend on various factors such as its severity, time, duration, and type (Yaribeygi, Panahi,
Sahraei, Johnston, & Sahebkar, 2017).
Interpretation: Deviation for Normal
3. SELF-PERCEPTION – SELF-CONCEPT PATTERN

Findings: The client was concerned that she was leading an unhealthy lifestyle. She has not
been eating correctly, sometimes consuming more than she needs to. Furthermore, since she
is overburdened with work from her job and the thesis she is now working on, she has not
been exercising regularly or engaging in any physical activities, leaving her feeling weak

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A.Y. 2021-2022
and lethargic. Furthermore, the client lacks confidence in her general look since she believes
that the stress she is experiencing affects her entire appearance. She also described herself
as stressed in general. Most of the time, she has breakdowns due to the unbearable stress
she is under, as well as social and environmental pressures. With so much on her plate, she
seldom experiences a feeling of success or pleasure from the tasks she has been assigned.
Furthermore, she is going through all of this while pregnant, and hormones at this point add
to the weight of what she has been going through daily. According to the March of Dimes,
pregnant women's hormones are fluctuating, which significantly impacts their mood. Mood
fluctuations may make dealing with stress harder. Mothers may be worried about what to
anticipate during labor and delivery, as well as how to care for their newborn. If you work,
you may be expected to handle employment responsibilities and prepare your team for your
maternity leave.
Analysis: Increased screen time, particularly internet usage due to the demands of online
settings meetings, and having to go out to work affect a person's mental well-being. These
people have an increased susceptibility to developing depressive symptoms such as anxiety,
low self-esteem and self-confidence, and other mental distress. In correlation with self-
esteem, Hoare, Milton, Foster, and Allender (2016) stated that the other factors associated
with sedentary activity with frequent use of the internet are their body mass index (BMI)
and lacking physical activities, especially for females. According to March of Dimes,
pregnant women's hormones shift, dramatically affecting their mood. Mood swings can
make it challenging to deal with stress. Mothers may be concerned about what to expect
during labor and birth and how to care for their infant. In addition, if they work, they may
be required to manage job obligations and prepare your team for your maternity leave (n.d.).
Interpretation: Deviation from Normal


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4. ROLE - RELATIONSHIP PATTERN

Findings: According to the client, she is currently working as a Pharmacist. She has a good
relationship with her colleagues. As a matter of fact, she views some of her close workmates
as her newfound friends. She also reports being part of various groups and organizations
with her former college friends. She reveals being in contact with her grade school and high
school friends up until now. Occasionally, they go out to buy things, eat good food, and
drink coffee, but none of these have already happened for the past two years due to the
Covid pandemic.
Additionally, she reveals living with her family. She describes her family as caring and
supportive of her. She claims to have had a happy experience with her family and denies
any family problems. When it comes to her role in the family, she does most household
chores.
Analysis: The role-relationship pattern characterizes the client’s roles, responsibilities, and
patterns of relationships with other individuals. Social integration is defined as the act of
being involved in numerous social connections, ranging from romantic relationships to
friendships, while social support is characterized by resources offered by a social circle to
aid individuals in coping with stress (Cherry, 2020). The interview revealed that the client
possesses strong social integration and social support within her circle. The client maintains
a good relationship with her family, friends, and colleagues. According to a study titled
Social Support and Resilience to Stress, social and emotional support is beneficial to
physical and psychological health (Ozbay et al., 2007). Clients with decreased social
integration and social support levels may be linked to various mental health concerns.
Moreover, having a strong social network can impact overall health positively through
having a higher possibility of making healthier choices and behaviours.

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Interpretation: Normal
5. SEXUALITY – REPRODUCTIVE PATTERN

Findings: The client identifies herself as a woman who is aligned to her biological sexuality
(cisgender woman). Moreover, she had her first menstruation at the age of 11 or 12.
Moreover, her last menstruation was on March 14, 2021, Sunday, and she became pregnant
and has just given birth to a healthy baby boy this month of December. Also, she reported
that she experiences menstrual cramps associated with her monthly period. Furthermore,
the client has not experienced any sexual contact for the time being, for she and her husband
practice abstinence because they do not want to complicate the patient's pregnancy
accidentally. In relation to this, she does not have any reproductive diseases or sexually
transmitted diseases.
Analysis: Stress levels are associated with the frequency and regularity of a female's
menstrual cycle. During this period, hormonal imbalance, particularly problems or
disturbance in average hormonal level associated with the production of estrogen and
progesterone, is prominent, which leads to disruption in normal reproductive processes,
thus, experiencing a sudden onset of irregularities in the onset of the menstruation and
mood. Also, stress acts as a repressing force onto the normal functioning of the
hypothalamus, which alters various body functions, such as ovarian dysfunction and
hormonal imbalance (Winderlich, 2010). In addition, according to Mayo Clinic, sexual
intercourse during pregnancy is not prohibited since the fetus inside the woman's womb is
well protected by the amniotic fluid in the uterus, so any sexual activity will not affect the
baby (2020). However, although sexual intercourse is not prohibited, it is encouraged to
abstain from intercourse to be on the safer side.

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6. COPING – STRESS TOLERANCE PATTERN

Findings: The client stated that her source of stress this past few months is demanding
occupation due to the amount of workload. Moreover, she frequently feels tense and anxious
regarding the fast-approaching deadlines and questions the quality of her works. Also, she
does not use any medicine or prescribed drugs to manage her anxious and tense feelings.
Additionally, she does not have vices such as smoking, drugs, and alcohol intake to manage
her stress. Frequently, she has episodes of breakdowns from overwhelming distress. Also,
she feels uneasy and despairing. With this crisis, luckily, she has her very supportive
husband and other relatives and her internet friends; some are also her Facebook friends to
lean on and have someone alongside to endure the sleepless nights, especially during the
stressful times of the quarantine. Also, her family is supportive of her work and the thesis
she is currently working on because she is studying again, Masteral; and makes sure to
provide her with everything she needs as much as possible. Nevertheless, at times, she tends
to dissociate herself from the people around her since she does not want any distractions
that could divert her from her tasks to something else.
Analysis: Social support is necessary for anyone undergoing stressful experiences. The
presence of support systems, such as your friends, and peers, exhibits compassion and
understanding with one another that would help an individual get past a situation or crisis.
Also, the presence of your family, especially those an individual treats as their parent, is
still needed in all phases of life (Ozbay, Johnson, Dimoulas, Morgan, Charney, &
Southwick, 2007). It depicts support and comfort from those whom you value the most.
Hence, self-isolation would increase vulnerability towards psychological problems since
individuals are closing themselves from those who want to reach out. Also, low social
support associated with high stressors would decrease the time to achieve healthy physical

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and emotional well-being (Orzechowska, Zajączkowska, Talarowska, & Calecki, 2013). In

addition, those who experience stress and fatigue lack the ability to find positivity from
hardships, decreasing motivation and enthusiasm.
Interpretation of Findings: Deviation from Normal
7. VALUE – BELIEF PATTERN

Findings: The client's religion is Roman Catholic. Prior to the pandemic, she frequently
attends Sunday masses with her family. Also, she reads bible verses and prays to keep her
motivated and ensure devotion and connection with the Almighty. With this, she considers
herself as a devoted Christian with a strong belief and faith in God. Moreover, the client
strongly believes and depends on Science and research-based medicine and treatment rather
than folk medicine. In her current situation, she has not experienced any changes in her
belief, yet, making her carry on despite the hardships she encounters. Thus, it makes her
remember the purpose of what she is doing and serves as a constant motivation.
Analysis: In religion, those who have the same beliefs usually have a purpose and trust a
greater being above all. With this, it enables these individuals to instill hope in themselves
in spite of the situation they are experiencing. Strong religious and spiritual faith is
correlated with how a person handles stress and other underlying physical conditions. Those
with strong beliefs could quickly adapt and recover from health conditions, enabling easier
access and willingness to health interventions and treatments. Moreover, constant overall
well-being is not ensured, yet, their mindset depicts positivity which allows a lower risk of
disease contraction, making it better for their health (Koenig, H. G., 2012).

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8. NUTRITIONAL – METABOLIC PATTERN
THREE-DAY DIET RECALL
Date: December 1, 2021
MEAL TIME FOOD AMOUNT
Lunch 12:30 pm Water (may have) start sips of water
Crackers ½ pack (30 grams)
Mamon 1 (40 grams)
Snack 3:30 pm ---------- ----------
Dinner 7: 30 pm NPO

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NPO ----------
NPO ----------
NPO ----------
NPO ----------
Estimated total liquid intake: 20 mL through the mouth; 2365mL intravenously
Breakfast 7:00 am ---------- ----------
---------- ----------
---------- ----------

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---------- ----------
Lunch 12:00 pm ---------- ----------
---------- ----------
---------- ----------
---------- ----------
---------- ----------
Dinner 6:00 pm ---------- ----------
---------- ----------
---------- ----------
---------- ----------

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---------- ----------
Estimated total liquid intake: None through the mouth; 2839 mL intravenously
Breakfast 7:00 am ---------- ----------
---------- ----------
---------- ----------
---------- ----------
---------- ----------
Lunch 12:00 pm Water 350 mL


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Milk 180 mL
Yogurt 1 cup
Chicken Noodle 1 bowl

Soup
Dinner 7:00 pm Porridge 1 cup
Orange Juice 80 mL
Water 250 mL
Broccoli 50 grams
Chicken Breast 75 grams
Estimated total liquid intake: 860 mL; 2365 mL intravenously


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Findings: As per the client, recently, she has had an irregular eating pattern due to the
limitations before the procedure (giving birth). Additionally, she follows a diet plan made
explicitly by her dietician as per her physician's advice because of her chronic hypertension
and high blood glucose levels. She has been eating low-calorie, low salt, and low cholesterol
meals for months now. The patient also reported that since her family usually stays at home
nowadays and avoids going outside due to the pandemic, they eat home-cooked meals
prepared by her. These meals usually include sinigang, adobo, tortang talong, nilaga, fried
tilapia, and other usual Filipino cuisines. Aside from this, vegetables are included since the
household aims to eat healthy to avoid any sickness. In addition, she stated that most of her
cooking is bland because she is trying so hard to limit her salt intake. Usually, her husband
reminds her to include fruits on their diet as a snack to keep them healthy instead of any
other snacks. On busy days, with loaded work, thesis dilemmas, and fast-approaching
deadlines, she often eats heavy meals due to stress eating. She only eats a portion of rice
and the dish prepared for her dinner since she does not feel hungry at all.
Moreover, her daily intake of water ranges from 9-11 glasses (2250 mL to 2750 mL) per
day for her beverages. Furthermore, the client does not have any history of allergies and
intolerances in relation to food intake. Also, the client has not experienced any food
poisoning or other diseases associated with food and takes supplements to acquire such
essential amino acids to be included in her diet.
During her stay in the hospital, she was forced to eat "extra bland but nutritious hospital
food," like how she branded the hospital food prepared for her diet as per her physician’s
advice. Although, she could not eat until her doctor cleared her since mothers are not
allowed to eat until they know their peristalsis is functioning well. Peristalsis is a movement
aimed at transporting solids or liquids inside the tube-like structures of the digestive and
urinary systems; it is a wave-like kind of muscular activity.

FIRST SEMESTER
A.Y. 2021-2022
Analysis: Keeping a healthy diet is necessary, especially for pregnant individuals, since it
directly correlates with their pregnancy nutrition. Studies have shown that eating proper
breakfast, regular eating patterns, and sufficient intake of fruits are associated with a better
pregnancy diet in mothers with other health concerns. Moreover, an increase in appetite or
food intake is accessory to high arousal emotions such as tension, distress, and anxiety.
Hence, these emotions are often perceived by anxious mothers in particular that frequently
undergo constant pressure from themselves, their family, and peers. In addition, a slow rate
of digestion is also an effect of stress in the operation response of the sympathetic nervous
system (SNS).
Furthermore, the client's diet-recall pattern shows that she drinks 8-10 cups of water a day
before admission to the hospital.
Additionally, the client takes supplements such as ascorbic acid and ferrous sulfate daily.
The body does not synthesize some nutrients, thus, needing it to acquire from the diet from
various sources, including vitamins and other supplements for proper and enhanced body
regulation. To add up, the mother is not allowed to eat until she farted, and that is the case
for many hospital procedures, to not eat until a patient defecates or farted because peristaltic
movement is being observed. Peristalsis is a movement aimed to transport solids or liquids
along inside the tube-like structures of the digestive and urinary systems, and it is a wave-
like kind of muscular activity (MedlinePlus, 20
9. ELIMINATION PATTERN
Findings: As per the client’s statement, her bowel elimination pattern is regular, more
particularly now that she is laboring, uterus contractions are doubling her trip to the

FIRST SEMESTER
A.Y. 2021-2022
restroom. Furthermore, she reports defecating in the morning or night, usually once or twice
daily. She describes her stool as "brown, normal consistency, smooth, and resembles the
shape of a sausage." She reports having no discomforts, irregularities, pain, or other bowel
control issues. Meanwhile, she characterizes her urinary elimination pattern as frequent,
with around five to six times per day, since her uterine contractions are making her bladder
uncomfortable at times. She details her urine character as "pale yellow in colour and has no
smell." She is also not experiencing any discomforts, irregularities, pain, or any other
concerns relating to urinary control. In addition, she denies using any laxatives or any other
methods to help in excretion. She also does not experience excess perspiration and any
odour problems.
Analysis: The elimination pattern tells about the bowel and bladder excretion patterns.
Leonard (2020) stated that typical stool characteristics are medium to dark brown, soft to
firm in texture, pain-free to pass, has an unpleasant odour, and is eliminated once or twice
daily. The client's stool has similar characteristics to a normal stool. Meanwhile, typical
urine characteristics involve being yellow to amber in colour but may vary depending on
fluid intake and diet, having a mild smell, and being clear or slightly cloudy (Physical
Characteristics of Urine, 2020). Since the client takes up lots of fluids intravenously, her
urine colour is pale yellow with no smell. Additionally, she is not using any laxatives or
other helping procedures for excretion since she can eliminate body wastes without
difficulty on a regular basis.

FIRST SEMESTER
A.Y. 2021-2022
10. SLEEP - REST PATTERN
SLEEP DIARY
DATE: DECEMBER 1-3, 2021 FRIDAY - SUNDAY
Activities Wednesday Thursday Friday
Time went to bed 8:00 pm

8:00 am
7:00 pm
Approximate time to Around 10 minutes 20 minutes 5 mites

fall asleep
Wake up None None None

period/Sleep
interruptions (how
long)
Time woke up the 7:00 am 8::00 AM 5:00 am

next morning
Feeling after waking Refreshed Well-rested Good

up

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A.Y. 2021-2022
Nap (time slept/wake 1 hour None 30 minutes

up; duration)
Activities are done Talked with friends Read a book Listened to a podcast
before bedtime
Findings: According to the client, she can easily fall asleep every night and whenever she
wants to take a nap since it is in her nature, and she also said that it might be because she is
too tired from working all day long, and maybe it is also a pregnancy thing. She also can
maintain a consistent sleeping pattern because she avoids screen time before bedtime.
Every Monday, Wednesday, and Friday, she wakes up at ten in the morning to attend her
classes and sleeps at around three to five in the morning. Meanwhile, every Tuesday and
Thursday, she wakes up at seven in the morning to attend her classes and sleeps at around
one to four in the morning. Every weekend, she wakes up at noon and sleeps at four to six
in the morning. In summary, she gets three to six hours of sleep during the weekdays, while
she gets four to eight hours of sleep during the weekends. She reports feeling tired or listless
even after waking up. She experiences nighttime awakenings sometimes. Furthermore, she
also naps in between her classes at times. She denies snoring, experiencing nightmares, and
using sedatives or other helping procedures to encourage sleep.
Analysis: The sleep-rest pattern details the pattern of sleep and rest, including schedule,
methods to induce sleep, habits, and perceived feelings after waking up. Sleep is defined as
a physiological behaviour wherein consciousness towards environmental stimuli is lowered,
which is significant for survival (Mandal, 2020). Based on Michael Crocetti, a pediatrician

FIRST SEMESTER
A.Y. 2021-2022
at Johns Hopkins Hospital, teenagers require around nine to nine and a half hours of sleep
every night since they are in the midst of the second stage of cognitive maturation. Sleep
helps in intellectual development and physical growth surges. It also aids in the prevention
of significant concerns such as depression or drug abuse. The client usually gets three to six
hours of sleep on weekdays and four to eight hours on weekdays. Insufficient sleeping hours
might lead to a short temper, fatigue, and inability to focus (Watson & Cherney, 2020).
Furthermore, long-term severe health consequences such as weakened immunity and

increased susceptibility to high blood pressure, diabetes, obesity, heart disease, and
depression (Cherney, 2019) might also happen. In relation to this, the client usually wakes
up feeling tired or listless despite being able to rest. According to Santos-Longhurst (2019),
common causes of waking up tired include sleep inertia, blue light exposure, poor sleeping
environment, eating and drinking habits, and sleep disorders. The client also experiences
nocturnal sleep disturbances, which may be linked to puberty and emotional and psychiatric
disturbances such as the existence of stressors, the presence of psychological conditions,
low self-esteem, and a tense personality (Thomas, 2019). Additionally, the client takes a
nap during the afternoon sometimes. Napping can be associated with increased alertness,
reduced stress levels, enhanced cognitive function, more efficiency, and improved health
(Scott, 2020). Now for the part where the patient feels sleepy many times within a day,
studies say that physical and mental changes, in addition to hormonal changes, diminish
your energy levels and make you feel tired. Among these modifications are the following:
elevated estrogen and progesterone levels (which, by the way, act as a natural sedative)
(Knisley, K., 2020).

FIRST SEMESTER
A.Y. 2021-2022
11. ACTIVITY - EXERCISE PATTERN
ACTIVITY DIARY
DATE: December 1, 2021 FRIDAY
Time Activities
7:00 am Woke up, did the morning routine
10:30 am Prepared to go to the hospital
12:30 pm Admitted to the hospital
1:30 pm Did several tests in hospital
6:00 pm Gave birth
7:30 pm Assessed; vital signs
8:00 pm Breastfeed the baby and sleep
DATE: December 2, 2021 SATURDAY
Time Activities

FIRST SEMESTER
A.Y. 2021-2022
7:00 am Woke up, did the morning routine
11:30 am Breastfed the baby
2:00 pm Assessed; vital signs
5:00 pm Consulted a doctor
7:00 pm She walked around her room, did stretching exercises
8:00 pm Slept
DATE: December 3, 2021 SUNDAY
Time Activities
5:00 am Woke up
10:00 am Breastfed
9:00 am Washed up
12:30 pm Ate the first meal of the day


FIRST SEMESTER
A.Y. 2021-2022
1:30 pm Took a nap
4:00 pm Walked around her room, did stretching exercises
4:30 pm Breastfed the baby
5:00 pm Ate snacks
6:00 pm Ate the second meal of the day
7:00 pm Slept
Findings: During the patient’s hospital stay, her day begins at eight in the morning, eats
her first meal at lunch, and the patient is assessed many times throughout the day, and
consults doctors and nurses like every 20 minutes, and ends her day at around three to five
in the morning. Additionally, she describes her lifestyle as ‘not-so-active’ since she does
not do any physical activities aside from minimal stretching due to pregnancy. Her only
exercise is walking from one part of the hospital room. For her leisure and recreation, she
likes watching movies and series, spending time with her family, watching youtube and
TikTok videos, reading books, and napping. Moreover, she sometimes lacks the energy and
motivation to do what she needs and wants to do. She can eat, bathe, groom, dress, move,
eliminate, and do other chores without help from other people.
Analysis: The activity-exercise pattern describes the activities done within the day,
participation schedule, leisure and recreation, energy and motivation to do things, physical

FIRST SEMESTER
A.Y. 2021-2022
state, and meaning of each activity to the client. During weekdays, the client's activities are
dependent on the schedule of her synchronous classes. Most of her activities are reliant on
her family's schedule, recreational activities, and school requirements during weekends. The
client's sleeping time is inconsistent since it varies every day depending on what she needs
and wants to do. As stated in the article What is the Best Time to Sleep and Wake Up? By
Kristeen Cherney (2019), sleeping while it is still dark can aid in getting sufficient sleep
while also making falling asleep easier. Ideally, individuals must go to bed early at night to
wake up early in the morning. Precisely, this pattern corresponds to our inherent proclivity
to align our sleeping patterns with that of the sun's.
Moreover, the client's eating time is inconsistent since she eats depending on her free time
and whether "she feels like it." Two papers published in the Proceedings of the Nutrition
Society reveal that health is not influenced solely by what an individual eats but also by
when an individual eats. Regardless of total calorie content, irregular meals can lead to a
disrupted internal body clock, high blood pressure, obesity, and type 2 diabetes (Masters,
2016). Furthermore, regular physical activity and exercise are associated with many
physical and mental health benefits such as improved mood and reducing feelings of
anxiety, depression, and stress, aiding in weight loss, maintaining strong muscles and bones,
boosting energy, decreasing the risk for chronic disease, enhance skin health, improve brain
function, and help in relaxation and sleep (Semeco, 2021). However, the client is physically
inactive. Leisure and recreational activities are said to reduce stress and depression, enhance
emotional health, reduce isolation and loneliness, enhance social skills, improve heart
health, reduce chronic diseases, and increase life expectancy (Braves, 2020). Fortunately,
the client allows time for the things that she wants to do. However, there are some instances
wherein she lacks motivation and energy to do things. Lastly, the client can function and do
regular activities without receiving help from other people.

FIRST SEMESTER
A.Y. 2021-2022
IV. PHYSICAL ASSESSMENT
GENERAL SURVEY AND INTEGUMENTARY SYSTEM
BODY NORMAL ACTUAL INTERPRETATI

PART/AREA FINDINGS FINDINGS ON and
TO BE ANALYSIS
ASSESSED
Observe for signs of No distress noted The patient shows DEVIATION
distress in posture signs of moderate FROM NORMAL
or facial expression pain on her face and
because of labor Labor is normally the
longest and least
intense phase of
labor. Early labor is
also called the latent
phase of labor. This
period includes the
thinning of the cervix
and dilation of the
cervix to 3-4 cm. It
can occur over
several days, weeks,
or just a few short
hours. (Stickler,
2018)
Observe body build, Proportionate, The body build of the DEVIATION

height, and weight in varies with patient is endomorph, FROM NORMAL
relation to the lifestyle her height is 152 cm
client’s age, lifestyle, and weighs 131 kg. A BMI ranging 30
and health. Her BMI is and above is

FIRST SEMESTER
A.Y. 2021-2022
56.7 categorized as
obesity, therefore,
the patient with a
BMI of 56.7 is
considered obese
(CDCP, 2020).
Obesity is the
presence of
excessive amounts
of adipose tissue in
the body. Factors
that lead to obesity
are physical
inactivity, medical
conditions in the
endocrine, and
unhealthy lifestyle
habits (NHLBI,
2012).
Observe client’s Relaxed, erect I observed that the NORMAL
posture and gait, posture, coordinated patient had a widened
standing, sitting, and movement gait while walking, Widening of gait is
walking. sitting, and standing. normally observed in
pregnant women to
compensate for the
space taken up by the
uterus. (Silbert-Flagg
& Pilliteri, 2018).
Observe client’s Clean, neat I observed that the NORMAL
overall hygiene and physical appearance
grooming. of the patient is clean
and neat from head
to toe.
Note body and breath No body/breath odor The patient did not NORMAL

FIRST SEMESTER
A.Y. 2021-2022
odor. or minor body odor have any body or

relative to work or breath odor.
exercise
Note obvious signs Healthy appearance There were no NORMAL
of health or illness illness/illnesses that
were present.
Assess the Cooperative The patient was NORMAL
client’s attitude. cooperative
throughout the
assessment.
Note the client’s Appropriate The patient was NORMAL
affect/mood; assess to situation cooperative
the appropriateness throughout the
of the client’s assessment.
responses
Listen for quantity, Understandable, The patient NORMAL
quality, and moderate pace, answered the
organization of exhibits thought questions I’ve given
speech association in a moderate and
understandable
manner. She also
portrayed
organization within
her speech as she
answered some
questions will
multiple answers in
the
order it was asked.
Listen for Logical sequence, I asked the patient NORMAL

relevance and makes sense, has about the place we
organization of sense of reality are in, the time and

FIRST SEMESTER
A.Y. 2021-2022
thoughts. date. The patient’s

responses were
logical therefore it
proves that she has
a sense of
reality.
Inspect skin color. Varies from light The skin color of the NORMAL
to deep brown, patient is light brown.
from ruddy pink
to
light pink
Inspect uniformity of Generally uniform The uniformity of the NORMAL
skin color except in areas patient's skin is even, These black spots,
exposed to sun; areas some parts had dark which appear
of lighter areas due to sun strange and
pigmentation in dark exposure, however, uncomfortable, are
skinned choalosma was simply
observed. hyperpigmentation,
Additionally, the also known as
patient also stated chloasma, which is
that she regularly a common
uses sunscreen and occurrence in
lotion. pregnant women
(Ekokotu, 2020).
Inspect, palpate, and Freckles, some There were no NORMAL
describe skin lesions. birthmarks, some flat lesions present on
and raised nevi, no the patient’s skin
abrasion although some
or other lesion birthmarks are
seen.
Observe and palpate Moisture in skin Upon assessment, NORMAL
skin moisture folds and the moisture was
axillae, affected by present on the
different factors patient’s skin.
Although there are

FIRST SEMESTER
A.Y. 2021-2022
were dry areas due

to lack of use of
lotion as stated by
the patient.
Palpate skin Uniform; .Upon palpation of NORMAL
temperature. within normal the forehead,
range the two hands and
feet of the patient
using the back of my
hand and I observed
that the patient’s
temperature is warm
and even at both
sides.
Palpate to assess No edema As I palpate the NORMAL
for presence of patient’s
edema. foot, there were no
signs or presence
of edema.
Palpate to assess When pinched, Upon pinching the NORMAL
for skin turgor skin springs back skin between the
to previous thumb and index
state finger, it springs
back to its normal
state.
Inspect the evenness Evenly distributed The hair of the
of growth over the hair patient is evenly
scalp distributed.
Inspect hair thickness Thick hair The patient has a NORMAL
or thinness. thick hair upon
inspection.
Inspect hair Silky, resilient hair The patient had a NORMAL
texture and smooth hair texture
oiliness and oiliness was

FIRST SEMESTER
A.Y. 2021-2022
present upon
assessment.
Note presence of No infection There were no NORMAL
infections or or infestation presence of
infestations. infections or
infestations.
Inspect amount of Variable The patient’s NORMAL
body hair amount of hair is
variable.
Inspect fingernail Convex curvature; The patient had a NORMAL
plate shape. angle between nail convex nail shape
and nail bed and it adheres to the
usually 160° nail bed at 160
degrees.
Inspect fingernail and Highly vascular The fingernails and NORMAL
toenail bed color and pink in light toenails of the
skinned; dark patient are highly
skinned may be vascular and have a
brown or pink color.
black
Inspect tissues Intact epidermis The tissue around the NORMAL
surrounding nails. the patient's
fingernails and
toenails are intact.
Palpate fingernail and Smooth texture The texture of the NORMAL

toenail texture. patient’s
fingernails and
toenails are smooth.
Perform blanch test Prompt return or pink As I have observed NORMAL

of capillary refill. or usual color, less when I perform the
than four blanch test the
seconds original color which
is pink goes back in

FIRST SEMESTER
A.Y. 2021-2022
color in less than 4

seconds.
HEAD TO NECK ASSESSMENT
BODY NORMAL ACTUAL INTERPRETATIO

PART/AREA FINDINGS FINDINGS N and ANALYSIS
TO BE
ASSESSED
Inspect the head. Head size and shape The patient’s head NORMAL
Inspect for size, vary, especially in shape is varied. It
shape, and accord with ethnicity. is symmetric,
configuration. Usually, the head is erect, in midline
symmetric, round, with a round
erect, and in midline shape. It is
and appropriately
appropriately related related to body
to body size size or also called
(normocephalic). Normocephalic.
No lesions are visible. There was no
lesion seen.
Inspect for Head should be held The patient can NORMAL
involuntary still and upright. hold her head still
movement. and upright.
Inspect the face. The face is symmetric The patient face is NORMAL
Inspect for with a round, oval, symmetric with a
symmetry, features, elongated, or square round appearance.
movement, appearance. No There patient can
expression, and abnormal movements perform different
skin condition noted. expressions
without
involuntary
movements.
Palpate the head. The head is normally The head of the NORMAL
Note consistency. hard and smooth, patient is hard,
without lesions. smooth and has
no lesions.
Palpate the temporal The temporal artery is The temporal artery NORMAL

FIRST SEMESTER
A.Y. 2021-2022
artery, which is elastic and not tender. of the patient is

located between the elastic and not
top of the ear and tender.
the eye.
Palpate the Normally there is no I have asked the NORMAL
temporomandibular swelling, tenderness, patient to open her
joint (TMJ). To or crepitation with mouth fully open
assess the TMJ, movement. Mouth and close while
place your index opens and closes fully palpating the
finger over the front (3 to 6 cm between temporomandibular
of each ear as you upper and lower teeth). joint. The TMJ is
ask Lower jaw moves normal without
the client to open laterally, 1 to 2 cm in swelling,
the mouth each direction. tenderness, nor
crepitation on
movement.
Inspect the neck. Neck is symmetric, I have asked the NORMAL
Observe the client’s with head centered patient to open her
slightly extended and without bulging mouth fully open
neck for position, masses. and close while
symmetry, and palpating the
lumps or masses. temporomandibular
Shine a light from joint. The TMJ is
the side of the neck normal without
across to highlight swelling,
any swelling. tenderness, nor
crepitation on
movement.
Inspect movement The thyroid cartilage, I have asked the NORMAL
of the neck cricoid cartilage move patient to open her
upward symmetrically mouth fully open
structures. Ask the
as the client swallows. and close while
client to swallow a palpating the
small sip of water. temporomandibular
Observe the joint. The TMJ is
movement of the normal without
swelling,
thyroid cartilage,
tenderness, nor
thyroid gland crepitation on
movement.

FIRST SEMESTER
A.Y. 2021-2022
Inspect the C7 (vertebra The C7 of the NORMAL

cervical vertebrae. prominens) is usually patient is visible
Ask the client to visible and palpable. and palpable. It is
flex the neck (chin located at the back
to chest). of her neck that I
could have
effortlessly seen on
her.
Inspect range of Normally neck The patient was NORMAL
motion. movement should be able to flexibly
Ask the client to smooth and controlled touch her shoulder
turn the head to the with 45degree flexion, by her ear on both
right and to the left 55-degree extension, sides flexibly. Also,
(chin to shoulder), 40-degree lateral look at the floor
touch each ear to the abduction, and and ceiling flexibly
shoulder, touch chin 70degree rotation. without suffering.
to chest, and lift the
chin to the
ceiling.
Palpate the trachea. Trachea is midline. The trachea of my NORMAL
Place your finger in patient is in the
the sternal notch. midline.
Feel each side of the
notch and palpate
the tracheal rings.
The first upper ring
above the smooth
tracheal rings is the
cricoid
cartilage.
Ask the client to Glandular thyroid The Glandular NORMAL
swallow as you tissue may be felt rising thyroid tissue wise,
palpate the right side underneath your as I have palpated
of the gland. fingers. Lobes should by my finger
Reverse the feel smooth, rubbery,
technique to palpate and free of nodules.
the left lobe of the
thyroid.
Auscultate the No bruits are There were no NORMAL

FIRST SEMESTER
A.Y. 2021-2022
thyroid only if you auscultated. blowing vascular

find an enlarged sounds resembling
thyroid gland heart murmurs that
during inspection or were perceived. It
palpation. Place the was over a partially
bell of the occluded blood
stethoscope over the vessel of the
lateral lobes of the patient.
thyroid gland. Ask
the client to hold his
or her breath.
Palpate the lymph There is no swelling or The patient has DEVIATION FROM
nodes. enlargement and no swollen lymph NORMAL
tenderness. nodes as palpated.
According to (Nair,
2018), swollen lymph
nodes indicate that the
body is fighting an
infection. (Nair, 2018).
Test distant visual Normal distant visual The patient's NORMAL
acuity. acuity is 20/20 with or distant visual acuity
Position the client without corrective is 20/50 without
20 feet from the lenses. This means that wearing an
Snellen or E-chart the client can eyeglass. - It means
and ask her to read distinguish what the that o Right: 20/50
each line until she person with normal o Left: 20/40 - The
cannot decipher the vision can distinguish patient's distant
letters or their from 20feet away. acuity is 20/20 with
direction. wearing an
Document the eyeglass. With
results. eyeglasses, the
patient can
distinguish what the
person with normal
vision can
distinguish 20 feet
away. o Right:
20/20 o Left: 20/20
Test near Normal near visual The patient near NORMAL
visual acuity. acuity is 14/14 (with or visual acuity is

FIRST SEMESTER
A.Y. 2021-2022
Use this test for without corrective 14/14 with and

middle-aged lenses). This means without corrective
clients and others that the client can read lenses or
who complain of what the normal eye eyeglasses. The
difficulty reading. can read from a patient had no hard
Give the client a distance of 14 inches. time reading a
hand-held vision Rosenbaum eye
chart (e.g., chart from a
Jaeger reading distance of 14
card, Snellen card, inches.
or
comparable chart) to
hold 14 inches from
the eyes. Have the
client cover one eye
with an opaque card
before reading from
top (largest print) to
bottom (smallest
print). Repeat test
for other eye
Test visual fields With normal The patient is able DEVIATION FROM
for gross peripheral peripheral vision, the to the object at a NORMAL
vision. client should see the designated angle in
To perform the examiner’s finger at inferior, superior, Diabetes-related high
confrontation test, the same time the temporal, and nasal blood sugar levels can
position yourself examiner sees it. fields. Also, the harm the tiny blood
approximately 2 feet Normal visual field patient has stated vessels that supply your
away from the client degrees are that she had blurry retina. As your
at eye level. Have approximately as vision throughout pregnancy advances,
the client cover the follows: performing the test. your odds increase.
left eye while you • Inferior: 70 Pregnancy-related
cover your right eye. degrees diabetes can cause
Look directly at • Superior: 50 impaired vision in
each other with your degrees • Temporal: expectant mothers
uncovered eyes. 90 degrees (Neimark, 2019).
Next, fully extend Nasal: 60 degrees
your left arm at

FIRST SEMESTER
A.Y. 2021-2022
midline and slowly

move one finger (or
a pencil) upward
from below until the
client sees your
finger (or pencil).
Test the remaining
three visual fields of
the client’s right eye
(i.e., superior,
temporal, and nasal).
Repeat the test for
the opposite eye.
Perform corneal The reflection of light The light shows at NORMAL
light reflex test. This on the corneas should the same spot on
test assesses parallel be in the exact same both corneas of the
spot on each eye, which patient which
alignment of the indicates parallel indicates parallel
eyes. Hold a alignment. alignment.
penlight
approximately 12
inches from the
client’s face. Shine
the light toward the
bridge of the nose
while the client
stares straight
ahead. Note the light
reflected on the
corneas.
Perform cover test. The uncovered eye The patient’s NORMAL
The cover test should remain fixed uncovered eye
detects deviation in straight ahead. The remained fixed
alignment or covered eye should ahead. As for the
strength and slight remain fixed straight covered eye, it also
deviations in eye ahead after being remained straight
movement by uncovered. fix ahead even
after it was

FIRST SEMESTER
A.Y. 2021-2022
interrupting the uncovered.

fusion reflex that
normally keeps the
eyes parallel.
Ask the client to
stare
straight ahead and
focus on a distant
object. Cover one
of the
client’s eyes with
an opaque card.
As you cover the
eye, observe the
uncovered eye for
movement.
Now remove the
opaque card and
observe the
previously covered
eye for any
movement. Repeat
test on the opposite
eye.
Perform the Eye movement should The patient’s eye NORMAL
positions test, be smooth and movement is
which assesses eye symmetric throughout smooth and
muscle strength and all six directions. symmetric
cranial nerve throughout all six
function. directions.
Instruct the client to
focus on an object
you are holding
(approximately 12
inches from the
client’s face). Move
the object through
the six cardinal
positions of gaze in

FIRST SEMESTER
A.Y. 2021-2022
a
clockwise
direction, and
observe the
client’s eye
movements.
Inspect the eyelids The upper lid margin The patient’s NORMAL
and eyelashes. Note should be between the upper lid margin
width and position upper margin of the iris is between the
of palpebral and the upper margin upper margin of
fissures. of the pupil. the iris and the
The lower lid margin upper margin of
rests on the lower the pupil. The
border of the iris. No lower lid margin
white sclera is seen rests on the lower
above or below the border of the iris.
iris. No white sclera is
Palpebral fissures may seen above or
be horizontal. below the iris. As
for the patient’s
palpebral fissures,
it is horizontal.
Assess the The upper and lower The patient’s NORMAL
ability of lids close easily and upper and
eyelids to meet completely when lower lids meet
close. closed. completely
when she
closes her eyes.
Note the position of The lower eyelid is The lower eyelid NORMAL
the eyelids in upright with no inward of the patient is
comparison with the or outward turning. upright with no
eyeballs. Also note Eyelashes are evenly inward or outward
any unusual distributed and curve turning. Her
• Turnings outward along the lid eyelashes are
margins. evenly distributed
• Color
and curve outward
• Swelling along the lid
Lesions Discharge margins.
Observe for Skin on both eyelids is The skin on NORMAL
without redness, both of the

FIRST SEMESTER
A.Y. 2021-2022
redness, swelling, swelling, or lesions. patient’s

discharge, or eyelids has no
lesions. redness,
swellings or
lesions.
Observe the Eyeballs are The patient’s NORMAL
position and symmetrically aligned eyeballs are
alignment of the in sockets without symmetrically
eyeball in the eye protruding or sinking. aligned in her eye
socket. sockets without
any protruding or
sinking.
Inspect the bulbar Bulbar conjunctiva is The conduction NORMAL
conjunctiva and clear, moist, and is clear, moist,
sclera. smooth. Underlying smooth and the
Have the client structures are clearly patient’s sclera
keep the head visible. Sclera is white. is white.
straight while
looking from side
to side then up
toward the ceiling.
Observe clarity,
color,
and texture.
Inspect the palpebral The lower and upper The upper and NORMAL
conjunctiva. palpebral conjunctivae lower palpebral
are clear and free of conjunctivae of
swelling or lesions. the patient is
clear and is free
of swelling and
lesions.
Evert the upper Palpebral conjunctiva The patient’s NORMAL
eyelid. Ask the is free of swelling, palpebral
client to look down foreign bodies, or conjunctiva is free
with his or her eyes trauma. of swelling,
slightly open. foreign bodies or
Gently grasp the trauma.
client’s upper
eyelashes and pull

FIRST SEMESTER
A.Y. 2021-2022
the lid downward.

Place a cotton-
tipped applicator
approximately 1 cm
above the eyelid
margin and push
down with the
applicator while still
holding the
eyelashes
Inspect the No swelling or redness The lacrimal NORMAL
lacrimal apparatus. should appear over apparatus of the
Assess the areas areas of the lacrimal patient has no
over the lacrimal gland. The puncta is signs of redness or
glands (lateral visible without swelling.
aspect of upper swelling or redness and
eyelid) and the is turned slightly
puncta (medial toward the eye.
aspect
of lower eyelid).
Palpate the lacrimal No drainage should There are no NORMAL
apparatus. Put on be noted from the signs of
disposable gloves to puncta when drainage on the
palpating the patient’s
palpate the nasolacrimal duct. lacrimal
nasolacrimal duct to apparatus.
assess for blockage.
Use one finger and
palpate just inside
the lower orbital rim
Inspect the cornea The cornea is The cornea of NORMAL
and lens. transparent, with no the patient is
Shine a light from opacities. The oblique transparent, has
the side of the eye view shows a smooth no opacities,
for an oblique and overall moist smooth and has
view. Look through surface; the lens is a moist surface.
the pupil to inspect free of opacities. As for the lens,
the lens. it is free of

FIRST SEMESTER
A.Y. 2021-2022
opacities
Inspect the iris The iris is typically The patient’s iris NORMAL
and pupil. round, flat, and is round, flat and
Inspect shape and evenly colored. The evenly colored
color of iris and size pupil, round with a while the pupil is
and shape of pupil. regular border, is round, centered
Measure pupils centered in the iris. and has a regular
against a gauge if Pupils are normally border and it is
they appear larger equal in size (3 to 5 3mm.
or smaller than mm). An inequality in
normal or if they pupil size of less than
appear to be two 0.5 mm occurs in 20%
different sizes. of clients. This
condition, called
anisocoria, is normal.
Test pupillary The normal direct The pupillary NORMAL
reaction to light. pupillary response is response of the
Test for direct constriction. patient is
response by constriction.
darkening the room
and asking the
client to focus on a
distant object. To
test direct pupil
reaction, shine a
light obliquely into
one eye and observe
the pupillary
reaction. Shining
the light obliquely
into the pupil and
asking the client to
focus on an object
in the distance
ensures that
pupillary
constriction is a
reaction to light and
not a near reaction.

FIRST SEMESTER
A.Y. 2021-2022
Assess consensual The normal consensual Constriction NORMAL

response at the same pupillary response is occurs in the
constriction. opposite eye of
time as direct
the patient.
response by shining
a light obliquely
into one eye and
observing the
pupillary reaction in
the opposite eye.
Test The normal pupillary The pupillary NORMAL
accommodation of response is constriction response is
pupils. of the pupils and constriction that
Accommodation convergence of the occurs in the
occurs when the eyes when focusing on pupils of the
client moves his or a near object patient. Also, her
her focus of vision (accommodation and eyes converge as
from a distant convergence). the pen that she
point toa near focuses on gets
object, causing the near.
pupils to constrict.
Hold your finger or
a pencil about 12
to15 inches from the
client. Ask the
client to focus on
your finger or pencil
and to remain
focused on it as you
move it closer in
toward the eyes
Inspect the auricle, Ears are equal in size The patient’s ears NORMAL
tragus, and lobule. bilaterally (normally 4– are equal in size
Note size, shape, 10 cm). bilaterally which is
and position The auricle aligns with about 7cm. The
the corner of each eye auricle aligns with
and within a 10degree the corner of the
angle of the vertical patient’s eye and
position. Earlobes may the earlobes are

FIRST SEMESTER
A.Y. 2021-2022
be free, attached, or attached.

soldered (tightly
attached to adjacent
skin with no apparent
lobe).
Continue inspecting The skin is smooth, The patient’s ears NORMAL
the auricle, tragus, with no lesions, lumps, are symmetrically
and lobule. or nodules. Color is aligned and the skin
Observe for consistent with facial is smooth, has no
lesions, color. Darwin’s lesions, no
discolorations, tubercle, which is a discharges and its
and discharge. clinically insignificant color is consistent
projection may be seen with her facial
on the auricle. No color.
discharge should be
present.
Palpate the auricle Normally the auricle, Upon palpation, NORMAL
and mastoid tragus, and mastoid the auricle,
process. process are not tragus and the
tender. mastoid process
are not tender.
Inspect the external A small amount of A small amount of NORMAL
auditory canal. Use odorless cerumen odorless, flaky and
the otoscope. Note (earwax)is the only yellow earwax is
any discharge discharge normally present. There are
along with the present. Cerumen no other discharges
color and color may be yellow, present.
consistency of orange, red, brown,
cerumen (earwax). gray, or black.
Consistency may be
soft, moist, dry, flaky,
or even hard.
Observe the color The canal walls should The canal walls NORMAL
and consistency of be pink and smooth, are pink, smooth
the ear canal walls without nodules. and has no
and inspect the nodules.
character of any
nodules.
Perform the whisper Able to correctly repeat The patient is able NORMAL

FIRST SEMESTER
A.Y. 2021-2022
test. the two syllable word to correctly repeat

With your head 2 as whispered. the two syllable
feet behind the words whispered.
client (so that the
client cannot see
your lips move),
whisper a
twosyllable word
such as “popcorn”
or “football.” Ask
the client to repeat it
back to you. If the
response is incorrect
the first time,
whisper the word
one more time.
Identifying three out
of six whispered
words is considered
passing the tes
Perform Weber’s Vibrations are heard The patient was NORMAL
test if the client equally well in both able to hear the
reports diminished ears. No lateralization vibrations in both
or lost hearing in of sound to either ear. ears. There is no
one ear lateralization of
sound to either
ear.
Perform the Air conduction sound The air NORMAL
Rinne’s test. is normally heard conduction
Strike a tuning fork longer than bone was heard
and place the base conduction sound (AC longer than
of the fork on the > BC). the bone
client’s mastoid conduction.
process.
Ask the client to tell
you when the sound
is no longer heard.
Move the prongs of
the tuning fork to
the front of the

FIRST SEMESTER
A.Y. 2021-2022
external auditory
canal. Ask the
client to tell you if
the sound is audible
after the fork is
moved.
Perform the Client maintains The patient NORMAL
Romberg test. position for 20 was able to
This tests the seconds without maintain her
client’s equilibrium. swaying or with position
Ask the client to minimal swaying. without
stand with feet swaying
together, arms at movements for
sides, and eyes 20 seconds.
open, then with the
eyes
closed.
Inspect and palpate Color is the same as The nasal NORMAL
the external nose. the rest of the face; structure of the
Note nasal color, the patient is smooth
shape, consistency, nasal structure is and symmetric.
and tenderness. smooth and symmetric; The color of the
the client reports no nose is the same
tenderness. as the rest of the
face and the
patient does not
report
Check patency of Client is able to sniff The patient was NORMAL
air flow through through each nostril able to breathe
the nostrils by while the other is and sniff on either
occluding one occluded. nostril even
nostril at a time though the other
and asking client is occluded.
to sniff.
Inspect the The nasal mucosa is The patient’s NORMAL
internal nose. dark pink, moist, and nasal mucosa is
To inspect the free of exudate. The pink, moist and
internal nose, use an nasal septum is intact free of exudate.
otoscope with a and free of ulcers or While her nasal

FIRST SEMESTER
A.Y. 2021-2022
short wide-tip perforations. septum is intact,

attachment or you Turbinates are dark free of ulcers and
can also use a nasal pink (redder than oral perforations.
speculum and mucosa), moist, and
penlight free of lesions.
Palpate the sinuses. Frontal and maxillary Frontal and NORMAL
When an infection is sinuses are nontender maxillary sinuses
suspected, the nurse to palpation, and no of the patient are
crepitus is evident. nontender to
can examine the palpation, and no
sinuses through crepitus is
palpation, evident.
percussion, and
transillumination.
Palpate the frontal
sinuses by using
your thumbs to
press up on the
brow on each side
of nose
Percuss the The sinuses are not The patient’s NORMAL
sinuses. Lightly tap tender on percussion. sinuses are not
(percuss) over the tender to
frontal sinuses and percussion.
over the maxillary
sinuses for
tenderness.
Inspect the lips. Lips are smooth and The patient’s lips NORMAL
Observe lip moist without lesions are smooth, moist
consistency and or swelling. and have no
color. lesions or
swelling.
Inspect the teeth and Thirty-two pearly The patient has 24 DEVIATION
gums. whitish teeth with teeth. It has some FROM NORMAL
Ask the client to smooth surfaces and dark stains with
open the mouth. edges. Upper molars smooth surfaces It's likely that the dark
Note the number should rest directly on and edges. stains on your teeth
the lower molars and during pregnancy are

FIRST SEMESTER
A.Y. 2021-2022
of teeth, color, and the front The patient has 24 the result of iron
condition. Note any upper incisors should whitish teeth that supplements taken by a
repairs such as slightly override the has smooth pregnant lady. Iron
crowns and any lower incisors. Some surfaces and supplements are vital
cosmetics such as clients normally have edges. for a pregnant woman
veneers. Ask the only 28 teeth if the to take since it is
client to bite down four wisdom teeth do needed to keep the
as though chewing not erupt. fetus and the mother's
on something and blood sugar levels in
note the alignment check ("Teeth
of the lower and Discoloration During
upper jaws. Pregnancy: Causes And
Treatment", 2021).
Put on gloves and No decayed areas; no There are no NORMAL

retract the client’s missing teeth. Clients decayed areas,
lips and cheeks to may have appliances lesions or masses
check gums for on the teeth (e.g., within the patient’s
color and braces). Client may mouth. While the
consistency. have evidence of gums are pink,
repair work done on moist and firm
teeth with tight margins
(e.g., fillings, crowns, to the tooth.
or cosmetics such as
veneers).
Gums are pink, moist,
and firm with tight
margins to the tooth. No
lesions or masses.
Inspect the The buccal mucosa The buccal NORMAL
buccal mucosa. should appear pink in mucosa of the
Use a penlight and light-skinned clients; patient is pink.
tongue depressor to tissue pigmentation
retract the lips and typically increases in
cheeks to check dark skinned clients.
color and
consistency.
Inspect and palpate Tongue should be The patient’s DEVIATION
the tongue. pink, moist, a tongue is leading FROM NORMAL

FIRST SEMESTER
A.Y. 2021-2022
Ask client to stick moderate to bluish color,

out the tongue. size with papillae (little moist that has According to (Hsu et
Inspect for color, protuberances) present. moderate size al., 2019), the high
moisture, size, and A common variation is with papillae and prevalence of thick
texture. a fissured, fissures present. fur, yellow fur color,
Observe for topographic- map–like There are no and a bluish tongue
fasciculations (fine tongue, which is not lesions seen upon in patients with type
tremors), and check unusual in older inspection. 2 Diabetes Mellitus
for midline clients. No lesions are demonstrated that it
protrusion. Palpate present. can be used as a
any lesions present preliminary screening
for induration test for type 2
(hardness). Diabetes Mellitus
early identification.
Assess the ventral The tongue’s ventral The ventral surface NORMAL
surface of the surface is smooth, of the patient’s
tongue. Ask the shiny, tongue is smooth,
client to touch the pink, or slightly pale, shiny, it is pink
tongue to the roof of with visible veins and with visible veins,
mouth, and use a no lesions. and there are no
penlight to inspect lesions present.
the ventral surface
of the tongue,
frenulum, and area
under the tongue
Inspect for The frenulum is The frenulum is in NORMAL
Wharton’s ducts— midline; Wharton’s the midline and
openings from the ducts are visible, with the Wharton’s
submandibular salivary flow or ducts of the patient
salivary glands— moistness in the area. are visible with
located on either The client has no salivary flow and
side swelling, redness, or moistness in the
of the frenulum on pain. area. There is no
the swelling, redness
or pain present.
floor of the mouth.
Observe the sides No lesions, ulcers, or The sides of the NORMAL
of the tongue. Use nodules are apparent. patient’s tongue
a square gauze pad do not have any

FIRST SEMESTER
A.Y. 2021-2022
to hold the client’s ulcers, nodules, or

tongue to each lesions.
side. Palpate any
lesions, ulcers, or
nodules for
induration.
Check the strength The tongue offers The patient’s NORMAL
of the tongue. strong resistance. tongue offers
Place your fingers strong
on the external resistance.
surface of the
client’s cheek. Ask
the client to press
the tongue’s tip
against the inside of
the cheek to resist
pressure from your
fingers. Repeat
on the opposite
cheek.
Inspect the hard The hard palate is pale The hard palate of NORMAL
(anterior) and soft or whitish with firm, the patient is
(posterior) palates transverse rugae whitish, firm with
and uvula. (wrinkle-like folds). transverse rugae.
Ask the client to Palatine tissues are Her palatine
open the mouth intact; the soft palate tissues are intact
wide while you should be pinkish, and her soft palate
usea penlight to movable, spongy, and is pinkish in color,
look at the roof. smooth movable, spongy
Observe color and and smooth.
integrity.
Note odor. While the No unusual or foul There is no NORMAL
mouth is wide open, odor is noted. unusual or foul
note any unusual or odor present upon
foul odor. inspection.
Assess the uvula. The uvula is a fleshy, The patient’s NORMAL
Apply a tongue solid structure that uvula is fleshy,
depressor to the hangs freely in the solid in

FIRST SEMESTER
A.Y. 2021-2022
tongue (halfway midline. No redness structure and

between the tip of or exudate from hangs freely in
and back of the uvula or soft palate. the midline. It
tongue) and shine Midline elevation of is symmetric to
apen light into the uvula and symmetric the soft palate
client’s wide open elevation of the soft and it is free of
mouth. palate. A bifid uvula, exudate and
Note the common redness.
characteristics and in Native
positioning of the Americans, looks like it
uvula. Ask the is split in two or
client to say partially severed
“aaah” and watch
for the uvula and
soft palate to
move.
Inspect the tonsils. Tonsils may be present The patient’s NORMAL
Using the tongue or absent. They are tonsils are present
depressor to keep normally pink and and enlarged to
the mouth open symmetric and may be 1+. There is no
wide, inspect the enlarged to 1+ in exudate, swelling
tonsils for color, healthy clients . No or lesions present.
size, and presence exudate, swelling, or
of exudate or lesions should be
lesions. Grade the present.
tonsils.
Inspect the posterior Throat is normally The posterior NORMAL
pharyngeal wall. pink, without exudate pharyngeal wall
Keeping the tongue or lesions. is pink and is
depressor in place, free of exudate
shine the penlight on and lesions.
the back of the
throat. Observe the
color of the throat
and note any
exudate or
lesions. Before
inspecting the nose,
discard gloves and

FIRST SEMESTER
A.Y. 2021-2022
perform hand
hygiene.
CHEST TO ABDOMEN
BODY NORMAL ACTUAL INTERPRETATI

PART/AREA FINDINGS FINDINGS ON and
TO BE ANALYSIS
ASSESSED
POSTERIOR THORAX
Inspect Scapulae are The scapulae of the NORMAL

configuration. symmetric and non patient is non
While the client sits protruding. protruding and
with arms at the Shoulders and symmetric. The
sides, stand behind scapula are at shoulders and the
the client and equal horizontal scapulae are
observe the position positions. The horizontally
of scapulae and the ratio of symmetric. The
shape and anteroposterior to spinous processes
configuration of the transverse are straight while
chest wall diameter is 1:2. the thorax is
Spinous processes symmetric with the
appear straight, ribs that are sloping
and thorax appears downward at a 45-
symmetric, with degree angle in
ribs sloping relation to the spine.
downward at
approximately a
45 degree angle in
relation to the
spine.
Observe use of The client does not The client does not NORMAL
accessory muscles. use accessory utilize her
Watch as the client (trapezius/ accessory muscles
breathes and note shoulder) muscles to assist in her
use of muscles to assist breathing. breathing.

FIRST SEMESTER
A.Y. 2021-2022
The diaphragm is
the major muscle at
work. This is
evidenced by
expansion of the
lower chest during
inspiration
Inspect the client’s Client should be The client is relaxed NORMAL
positioning. Note sitting up and and sitting upright
the client’s posture relaxed, breathing with her arms at her
and ability to easily with arms at side.
support weight sides or in lap.
while breathing
comfortably.
Palpate for Client reports no There is no NORMAL
tenderness and tenderness, pain, tenderness, pain,
sensation. Palpation or unusual unusual sensation,
may be performed sensations. or crepitus that was
with one or both Temperature palpated. As for the
hands, but the should be equal temperature, it is
sequence of bilaterally. bilaterally equal.
palpation is
established. Use
your fingers to
palpate for
tenderness, warmth,
pain, or other
sensations. Start
toward the midline
at the level of the
left scapula (over
the apex of the left
lung) and move
your hand left to
right, comparing
findings bilaterally.
Move
systematically
downward and out

FIRST SEMESTER
A.Y. 2021-2022
to cover the lateral

portions of the
lungs at the bases.
Palpate for The examiner No crepitus was NORMAL
crepitus. Crepitus, finds no palpable palpated
also called crepitus
subcutaneous
emphysema, is a
crackling sensation
(like bones or hairs
rubbing against each
other) that occurs
when air passes
through fluid or
exudate. Use your
fingers and follow
the sequence when
palpating.
Palpate surface Skin and The patient’s skin NORMAL
characteristics. subcutaneous and subcutaneous
Put on gloves and tissue are free of tissue are free of
use your fingers to lesions and masses. lesions and masses.
palpate any lesions
that you noticed
during inspection.
Feel for any
unusual masses.
Palpate for Fremitus is Upon palpation, the NORMAL
fremitus. symmetric and fremitus is
Following the easily identified in symmetric and is
sequence described the upper regions of easily identified at
previously, use the the lungs. If the upper regions of
ball or ulnar edge of fremitus is not the lungs.
one hand to assess palpable on either
for fremitus side, the client may
(vibrations of air in need to speak
the bronchial tubes louder. A decrease
transmitted to the in the intensity of
chest wall). As you fremitus is normal

FIRST SEMESTER
A.Y. 2021-2022
move your hand to as the examiner

each area, ask the moves toward the
client to say base of the lungs.
“ninetynine.” However, fremitus
Assess all areas for should remain
symmetry and symmetric for
intensity of bilateral positions.
vibration.
Assess chest When the client The examiner’s NORMAL
expansion. takes a deep thumbs move apart
(Diaphragma breath, the symmetrically for 7
tic examiner’s thumbs cm.
Excursion) should move 5 to
Place your hands on 10 cm apart
the posterior chest symmetrically
wall with your
thumbs at the level
of T9 or T10 and
pressing together a
small skin fold. As
the client takes a
deep breath,
observe the
movement of
your thumbs.
Observe use of The client does not The client does not NORMAL
accessory muscles use accessory utilize her accessory
(trapezius/ muscles to assist in
shoulder) muscles her breathing.
to assist breathing.
The diaphragm is
the major muscle at
work. This is
evidenced by
expansion of the
lower chest during
inspiration
Percuss for tone. Resonance is the Upon percussion, NORMAL
Start at the apices percussion tone resonance is the

FIRST SEMESTER
A.Y. 2021-2022
of the scapulae and elicited over percussion tone over

percuss across the normal lung tissue. normal lung tissue.
tops of both Percussion elicits
shoulders. Then flat tones over the
percuss the scapula.
intercostal spaces
across and down,
comparing sides.
Percuss to the
lateral aspects at the
bases of the lungs,
comparing sides.
Percuss for Excursion should be The excursion is NORMAL
diaphragmatic equal bilaterally and equal bilaterally and
excursion. Ask the measure 3–5 cm in measures 4cm on
client to exhale adults. The level of both sides.
forcefully and hold the diaphragm may
the breath. be higher on the
Beginning at the right because of the
scapular line (T7), position of the liver.
percuss the In well-conditioned
intercostal spaces of clients, excursion
the right posterior can measure up to 7
chest wall. Percuss or 8 cm.
downward until the
tone changes from
resonance to
dullness. Mark this
level and allow the
client to breathe.
Next ask the client
to
inhale deeply and
downward until
resonance changes
to dullness. Mark
the level and allow
the client to breathe.
Measure the
distance between

FIRST SEMESTER
A.Y. 2021-2022
the two marks.

Perform this
assessment
technique on both
sides of the
posterior
thorax.
Auscultate for Three types of The bronchial, NORMAL
breath sounds. To normal breath bronchovesicular,
begin, place the sounds may be and the vesicular
diaphragm of the auscultated— sounds are clear.
stethoscope firmly bronchial,
and directly on the bronchovesicular,
posterior chest and vesicular
wall at the apex of
the lung at C7. Ask
the client to
breathe deeply
through the mouth
for each area of
auscultation (each
placement of the
stethoscope) in the
auscultation
sequence so that
you can best hear
inspiratory and
expiratory sounds.
Be alert to the
client’s comfort
and offer times for
rest and normal
breathing if fatigue
is becoming a
problem
NORMAL
Auscultate voice
sounds.
Bronchophony: Voice transmission

Voice transmission

FIRST SEMESTER
A.Y. 2021-2022
Ask the client to is soft, muffled, is soft, muffled,

repeat the phrase and indistinct. The and indistinct. The
“ninetynine” while sound of the voice sound of the voice
you auscultate the may be heard but is heard but the
chest wall. the actual phrase actual phrase
cannot be cannot be
distinguished. distinguished.
Egophony: Ask the Voice transmission Voice transmission
client to repeat the will be soft and is soft and muffled
letter “E” while you muffled but the but the letter “E” is
listen over the chest letter “E” should be distinguishable.
wall. distinguishable
Transmission of
sound is very faint,
Whispered muffled and
pectoriloquy: Ask inaudible.
Transmission of
the client to whisper sound is very faint
the phrase “one– and muffled. It may
two– three” while be inaudible.
you auscultate the
chest wall.
ANTERIOR THORAX
Inspect for shape The anteroposterior The anteroposterior of NORMAL

and configuration. diameter is less than the patient is less
Have the client sit the transverse than the transverse
with arms at the diameter. The ratio diameter.
sides. of anteroposterior
Stand in front of diameter to the
the client and transverse diameter
assess shape and is 1:2.
configuration.
Inspect position of Sternum is The anteroposterior of NORMAL
the sternum. positioned at the patient is less
Observe the sternum midline and than the transverse
from an anterior and straight. diameter.
lateral viewpoint.
Watch for sternal Retraction The anteroposterior of NORMAL
retractions. s not the patient is less

FIRST SEMESTER
A.Y. 2021-2022
observed. than the transverse

diameter.
Inspect slope of Ribs slope The rib is sloping NORMAL
the ribs. downward with downward with
Assess the ribs symmetric symmetric
from an anterior intercostal spaces. intercostal spaces
and lateral Costal angle is and a costal angle
viewpoint. within 90 degrees. within 90 degrees.
Observe quality Respirations are The pattern of NORMAL
and pattern of relaxed, effortless, respirations by the
respiration. Note and quiet. patient is relaxed,
breathing They are of a effortless, and
characteristics as regular rhythm and quiet. It is at a
well as rate, normal depth at a regular rhythm and
rhythm, and depth. rate of 10–20 per normal depth rate
minute in adults. of 20 per minute.
Tachypnea and
bradypnea may be
normal in some
clients.
Inspect intercostal No retractions or There were no NORMAL
spaces. bulging of retractions or
Ask the client to intercostal spaces bulging at the
breathe normally are noted. intercostal spaces
and observe the of the patient.
intercostal spaces.
Observe for use of Use of accessory The accessory NORMAL
accessory muscles. muscles muscles were not
Ask the client to (sternomastoid and utilized by the
breathe normally rectus abdominis) is patient upon
and observe for use not seen with breathing normally.
of accessory normal respiratory
muscles. effort. After
strenuous exercise
or activity, clients
with normal
respiratory status
may use neck
muscles for a short

FIRST SEMESTER
A.Y. 2021-2022
time to enhance
breathing.
Palpate for No tenderness or Tenderness, masses NORMAL
tenderness, pain is palpated and pain were not
sensation, and over the lung area palpated over the
surface masses. with respirations. lung area.
Use your fingers to
palpate for
tenderness and
sensation. Start with
your hand
positioned over the
left clavicle (over
the apex of the
left lung) and move
your hand left to
right, comparing
findings bilaterally.
Palpate for Palpation does not Tenderness is not NORMAL
tenderness at elicit tenderness. present at the
costochondral costochondral
junctions of junctions of ribs.
ribs.
Palpate for No crepitus is No crepitus was NORMAL
crepitus palpated palpated.
Palpate for any No unusual No crepitus was NORMAL
surface masses or surface masses palpated.
lesions. or lesions are
palpated.
Palpate for Fremitus is The fremitus is NORMAL
fremitus. Using symmetric and symmetric upon
the sequence for easily identified in palpation and
the anterior chest the upper regions easily identified in
described of the lungs. A the patient’s lungs
previously, decreased intensity at the upper region.
palpate for of fremitus is
fremitus using the expected toward
same technique as the base of the
for the posterior lungs.

FIRST SEMESTER
A.Y. 2021-2022
thorax. However,
fremitus should
be symmetric
bilaterally.
Palpate anterior Thumbs move The examiner’s NORMAL
chest expansion. outward in a thumb moves
Place your hands on symmetric fashion outward
the client’s from the midline. symmetrically
anterolateral wall from the midline.
with your thumbs
along the costal
margins and
pointing toward the
xiphoid process. As
the client takes a
deep breath,
observe the
movement of your
thumbs.
Percuss for tone. Resonance is the The examiner’s NORMAL
Percuss the apices percussion tone thumb moves
above the clavicles. elicited over normal outward
Then percuss the lung tissue. symmetrically
intercostal spaces Percussion elicits from the midline.
across and down, dullness over breast
comparing sides tissue, the heart,
and the liver.
Tympany is
detected over the
stomach, and
flatness is detected
over the muscles
and bones.
Auscultate for • Bronchial- high • Bronchial- NORMAL
anterior breath in pitch, has high in pitch, has
sounds. Place the harsh or hollow harsh or hollow
diaphragm of the quality, loud quality, loud
stethoscope firmly amplitude, short amplitude, short
and directly on the during during inspiration
and long in

FIRST SEMESTER
A.Y. 2021-2022
anterior chest wall. inspiration and expiration.

Auscultate from the long in •
apices of the lungs expiration. Bronchovesicular
slightly above the • Bronchovesicula - moderate pitch,
clavicles to the r- moderate mixed quality,
bases of the lungs at pitch, mixed moderate
the sixth rib. Ask quality, amplitude, and
the client to breathe moderate same duration
deeply through the amplitude, and during inspiration
mouth in an effort same duration and expiration.
to avoid during • Vesicular-
transmission of inspiration and low in pitch,
sounds that may expiration. breezy quality,
occur with nasal • Vesicular- low soft amplitude
breathing. Listen at in pitch, and long during
each site for at least breezy quality,
one complete inspiration and
soft amplitude
respiratory cycle short in
and long
during expiration.
inspiration and
short in expiration.
BREASTS AND LYMPHATICS
Inspect size and Breasts can be a The patient’s NORMAL
symmetry. variety of sizes breasts are
Have the client and are somewhat proportional to
disrobe and sit with round and her body size, it
arms hanging pendulous. One is also round,
freely. Explain breast may somewhat
what you are normally be larger pendulous and
observing to help than the other. naturally
ease client anxiety. asymmetric.
Inspect color Color varies The color of the NORMAL
and texture. Be depending on the patient’s breast
sure to note client’s skin tone. is consistent with
client’s overall skin Texture is smooth, her skin tone.
tone when with no edema. The texture is
inspecting the breast Linear stretch smooth with no
skin. Note any marks may be seen edema present.
lesions. during and after

FIRST SEMESTER
A.Y. 2021-2022
pregnancy or with
significant weight
gain or loss.
Inspect Veins radiate either The veins of the NORMAL
superficial horizontally and patient radiate
venous pattern. toward the axilla horizontally to
Observe visibility (transverse) or her axillae.
and pattern of vertically with a
breast veins. lateral flare
(longitudinal).
Veins are more
prominent during
pregnancy
Inspect the areolas. Areolas vary from The areolas of NORMAL
Note the color, size, dark pink to dark the patient are
shape, and texture of brown, depending dark brown in
the areolas of both on the client’s skin color, round,
breasts. tones. They are about 5 cm and
round and may vary the small
in size. Small Montgomery
Montgomery tubercles are
tubercles are present.
present.
Inspect the Nipples are nearly The nipples of NORMAL
nipples. Note the equal bilaterally in the patient are Discharge of
size and direction size and are in the nearly equal colostrum for
of the nipples of same location on bilaterally, in the pregnant women is
both breasts. Also each breast. Nipples same location, expected to start
note any dryness, are usually everted, everted with from the second
lesions, bleeding, but they may be discharge of trimester. Therefore,
or discharge. inverted or flat. colostrum the discharge of
Supernumerary colostrum
nipples may appear documented is
along the normal (Silbert-
embryonic “milk Flagg & Pilliteri,
line.” No discharge 2018).
should be present.
Inspect for The client’s There is no NORMAL
retraction and breasts should retraction or

FIRST SEMESTER
A.Y. 2021-2022
dimpling. To rise dimpling present

inspect the breasts symmetrically, and the client’s
accurately for with no sign of breast rises
retraction and dimpling or symmetrically as
dimpling, ask the retraction. she raises her
client to remain hands.
seated while
performing several
different maneuvers.
Ask the client to
raise her arms
overhead; then press
her hands against
her hips. Next ask
her to press her
hands together.
These actions
contract the
pectoral muscles.
Palpate texture Palpation Upon palpation, NORMAL
and elasticity reveals smooth, the texture is
firm, elastic smooth, firm,
tissue. and elastic.
Palpate for A generalized Upon palpation, NORMAL
tenderness and increase in there is
temperature. nodularity and tenderness One of the normal
tenderness may be a present and physical changes
normal finding temperature is that occur in
associated with the within normal pregnancy is the
menstrual cycle or range. increased
hormonal vascularity and
medications. sensitivity of the
Breasts should be a breast to prepare for
normal body milk production.
temperature. The tenderness or
sensitivity felt by
the pregnant patient
is normal (Silbert-
Flagg & Pilliteri,
2018).

FIRST SEMESTER
A.Y. 2021-2022
Palpate for masses. No masses should No masses were NORMAL

Note location, size be palpated. palpated.
in centimeters, However, a firm
shape, mobility, inframammary
consistency, and transverse ridge
tenderness. Also may normally be
note the condition palpated at the
of the skin over the lower base of the
mass. breasts.
Palpate the The nipple may Upon palpation, NORMAL
nipples. Wear become erect and discharges of
gloves to compress the areola may colostrum were Discharge of
the nipple gently pucker in response present. Also, colostrum for
with your thumb to stimulation. A the nipples of the pregnant women is
and index finger. milky discharge is patient became expected to start
Note any usually normal only erect and the from the second
discharge. during pregnancy areola became trimester.Therefore,
and lactation. puckered in the discharge of
However, some response to the colostrum
women may stimulation done. documented is
normally have a normal (Silbert-
clear discharge. Flagg & Pilliteri,
2018).
Inspect and palpate No rash or infection No rashes or NORMAL
the axillae. noted. Lymph nodes infections were
Ask the client to sit on the axilla area palpated. As for
up. Inspect the should not be the lymph nodes
axillary skin for palpable. in the patient’s
rashes or infection. axillae area, they
were not
palpable.
DEMONSTRATE • STEP 1: Look at • STEP 1: NORMAL
BREAST SELF- your breasts in Look at your
EXAMINATION the mirror with breasts in the
your shoulders mirror with your
straight and your shoulders
arms on your straight and your
hips. Check size, arms on your

FIRST SEMESTER
A.Y. 2021-2022
shape and color. hips. Check size,

Notice if they are shape and color.
evenly shaped Notice if they
with no distortion are evenly
or swelling. shaped with no
• Notify your distortion
doctor if you or swelling.
notice: - • Notify your
dimpling, doctor if you
puckering or notice: -
bulging of skin -a dimpling,
nipple that has puckering or
changed position bulging of skin -a
or an inverted nipple that has
nipple - redness, changed position
soreness, rash or or an inverted
swelling. nipple - redness,
• STEP 2: Raise soreness, rash or
your arms and swelling.
determine if you • STEP 2: Raise
see the same your arms and
changes determine if you
• STEP 3: Look see the same
for any signs of changes
fluid coming out • STEP 3: Look
of one or both for any signs of
nipples fluid coming out
• STEP 4: Lie of one or both
down with your nipples
arm behind your • STEP 4: Lie
head. Use 3 down with your
middle finger arm behind your
pads and move head. Use 3
them in a circular middle finger
motion covering pads and move
the entire breast them in a circular
from top to motion covering

FIRST SEMESTER
A.Y. 2021-2022
bottom, side to the entire breast

side from your from top to
collarbone to the bottom, side to
top of your side from your
abdomen and collarbone to the
from your armpit top of your
and cleavage. Use abdomen and
a single pattern from your armpit
for palpating to and cleavage.
cover the whole Use a single
breast. pattern for
• STEP 5: Many palpating to
women says it cover the whole
easiest to do this breast.
in the shower • STEP 5: Many
when skin is wet women says it
and slippery. easiest to do this
Cover the breast in the shower
using the same when skin is wet
hand movements and slippery.
described in Cover the breast
STEP 4. using the same
hand movements
described in
STEP 4.
HEART AND NECK VESSELS
Observe the The jugular venous Upon NORMAL
jugular venous pulse is not observation, the
pulse. normally visible jugular venous
Inspect the jugular with the client pulse is
venous pulse by sitting upright. This discernible while
standing on the position fully the client is at a
right side of the distends the vein, supine position.
client. The client and pulsations may
should be in a or may not be
supine position with discernible.
the the head and

FIRST SEMESTER
A.Y. 2021-2022
torso are on the

same plane. Ask the
client to turn the
head slightly to the
left. Shine a
tangential light
source onto the
neck to increase
visualization of
pulsations as well as
shadows. Next,
inspect the
suprasternal notch
or the area around
the clavicles for
pulsations of the
internal jugular
veins.
Evaluate jugular The jugular vein There is no NORMAL
venous pressure. should not be bulging,
Evaluate jugular distended, bulging, protruding or
venous pressure by or protruding at 45 distention on the
watching for degrees or greater. jugular vein
distention of the when the client
jugular vein. It is sits at a 45-
normal for the degree angle and
jugular veins to be above.
visible when the
client is supine. To
evaluate jugular
vein distention,
position the client in
a supine position
with the head of the
bed elevated 30, 45,
60, and 90°. At each
increase of the
elevation, have the
client’s head turned
slightly away from

FIRST SEMESTER
A.Y. 2021-2022
the side being

evaluated. Using
tangential lighting,
observe for
distention,
protrusion, or
bulging.
Auscultate the No blowing or No blowing, NORMAL
carotid arteries if swishing or other swishing or other
the client is middle- sounds are heard. sounds that were
aged or older or if Pulses are equally heard upon
you suspect strong; a 2+ or auscultation. Also,
cardiovascular normal with no there is no
disease. Place the variation in strength variation in
bell of the from beat to beat. strength from beat
stethoscope over the Contour is normally to beat. As for the
carotid artery and smooth and rapid on contour, it is
ask the client to hold the upstroke and smooth and rapid
his or her breath for slower and less on the upstroke.
a moment so that abrupt on the On the other hand,
breath sounds do not downstroke. The it is slower and
conceal any vascular strength of the pulse less abrupt on the
sounds. is evaluated on a downstroke. The
scale from 0 to 4 pulse strength is at
Pulse 2+.
Amplitude
Scale:
0 = absent
1+ = weak
2+ = normal
3+ = increased
4+ = bounding
Palpate the carotid Arteries are The arteries were NORMAL
arteries. elastic and no elastic and there
Palpate each carotid thrills are noted. were no thrills
artery alternately by palpated.
placing the pads of
the index and
middle fingers

FIRST SEMESTER
A.Y. 2021-2022
medial to the
sternocleidomastoid
muscle on the neck.
Note amplitude and
contour of the
pulse, elasticity of
the artery, and any
thrills (which feel
similar to a purring
cat) .
Palpate the carotid

arteries individually
because bilateral
palpation could
result in reduced
cerebral blood flow.
If you detect
occlusion during
auscultation, palpate
very lightly to avoid
blocking circulation
or triggering vagal
stimulation an
hypotension, or even
cardiac arrest.
HEART
Inspect pulsations. The apical impulse The apical NORMAL
With the client in may or may not be impulse is
supine position with visible. If apparent, palpable at the
the head of the bed it would be in the mitral area and
elevated between mitral area. The has the size of
30° and 45° stand on apical impulse is a 2cm. The
the client’s right result of the left amplitude is
side and look for the ventricle moving small and it lasts
apical impulse and outward during through the first
any abnormal systole. 2/3 of the
pulsations. systole.
Palpate the apical The apical impulse The apical NORMAL

FIRST SEMESTER
A.Y. 2021-2022
impulse. Remain is palpated in the impulse is

on the client’s right mitral area and may palpable at the
side and ask the be the size of a mitral area and
client to remain nickel (1-2 cm). has the size of
supine. Use one or Amplitude is 1cm. The
two finger pads to usually small - like amplitude is
palpate the apical a gentle tap. The small and it lasts
impulse in the duration is brief, through the first
mitral area. You lasting through the 2/3 of the
may ask the client 1st 2/3 of systole systole.
to roll to the left and often less. In
side to better feel obese clients or
the impulse using clients with large
the palmar surfaces breasts, the apical
of your hand. impulse may not be
palpable.
Palpate for No pulsations or There were no NORMAL
abnormal vibrations are vibrations and
pulsations. Use your palpated in the areas pulsations that
palmar surfaces to of the apex, left were palpated at
palpate the apex, left sternal border, or the areas of the
sternal border, and base. apex, left sternal
base. border, or base.
Auscultate heart Rate should be 60- The heart rate of NORMAL
rate and rhythm. 100 bpm with a the patient is 93
Place the diaphragm regular rhythm. A bpm with a
of the stethoscope at regularly irregular regular rhythm.
the apex and listen rhythm, such as
closely to the rate sinus arrhythmia
and rhythm of the when the heart rate
apical impulse. increases with
inspiration and
decreases with
expiration, may be
normal in young
adults.
Auscultate to S1 corresponds with The S1 was NORMAL
identify S1 and each carotid heard loudest at
S2 . Auscultate pulsation and is the apex of the
the first heart loudest at the apex heart and is

FIRST SEMESTER
A.Y. 2021-2022
sound (S1 or of the heart. S2 immediately

“lub”) and the immediately follows followed by the
second heart after S1 and is S2 which is
sound (S2 or loudest at the base of loudest at the
“dubb”) the heart. pulmonic area.
Auscultate for Normally no There were no NORMAL
extra heart sounds are heard A extra heart
sounds. physiologic S3 sounds that was
Use the diaphragm heart sound is a auscultated.
first, then the bell benign finding
to auscultate over commonly heard at
the entire heart the beginning of the
area. diastolic pause in
Note children,
characteristics adolescents and
(e.g., location, young adults (rare
timing) of any after age 40) A
extra sound heard. physiologic S4
Auscultate during heart sound may be
the systolic pause heard near the end
(space heard of diastole in well-
between S1 and S2) conditioned athletes
and adults older
than age 40 or 50
with no evidence of
heart disease.
Auscultate for Normally no No murmurs NORMAL
murmurs. murmurs are were heard upon
A murmur is a heard auscultation.
swishing sound
caused by turbulent
blood flow through
the heart valves or
great vessels. Use
the diaphragm and
the bell of the
stethoscope in all
areas of auscultation
because murmurs

FIRST SEMESTER
A.Y. 2021-2022
have a variety of
pitches Auscultate
for murmurs across
the entire heart area.
ABDOMEN
Observe the Abdominal skin may The color of the NORMAL
coloration of the be paler than the patient’s
skin. general skin tone abdominal skin
because this skin is is paler but
so seldom exposed nothing
to the natural abnormal.
elements.
Note the Scattered fine veins The scattered NORMAL
vascularity of the may be visible. fine veins are
abdominal skin. Blood in the veins visible.
located above the
umbilicus flows
toward the head;
blood in the veins
located below the
umbilicus flows
toward the lower
body.
Inspect for scars. Pale, smooth, There were no NORMAL
Ask about the minimally raised unusual scars
source of a scar and old scars may be observed, except the Striae and linea
use a centimeter seen. presence of striae nigra is caused by
ruler to measure the and linea nigra in the the stretching of the
scar’s length. abdomen related to underlying
Document the pregnancy. connective tissues of
location by quadrant the skin during late
and reference lines, pregnancy. The
shape, length, and observed marks are
any specific normal (Silbert-
characteristics (e.g., Flagg & Pilliteri,
3-cm vertical scar 2018).
in RLQ 4 cm
below the
umbilicus and 5

FIRST SEMESTER
A.Y. 2021-2022
cm left of the
midline).
Presence of C- Positive or There were no NORMAL
section scar negative presence presence of a C-
section scar
since the patient
has not been in a
C-section
surgery before.
Presence of There should be There were no NORMAL
horizontal ridge none observed. observed
across lower horizontal ridge
abdomen across the lower
abdomen.
Assess for Abdomen is free of There are no NORMAL
lesions and lesions or rashes. lesions or rashes
rashes. Flat or raised brown that were present
moles, however, are upon inspection.
normal and may be
apparent
Inspect the Umbilical skin The color of the NORMAL
umbilicus. tones are similar to umbilicus is the
Note the color of surrounding same with the
the umbilical area. abdominal skin surrounding
tones or even abdominal skin
pinkish. tone.
Observe umbilical Umbilicus is The abdominal NORMAL
location midline at the contour is oval
lateral line. with a singleton
pregnancy and a
longitudinal line.
Assess the It is recessed The umbilicus of NORMAL
contour of the (inverted) or the patient is
umbilicus. protruding no more recessed and
than 0.5 cm, and is conical.
round or conical.
Inspect Abdomen is flat, The abdominal NORMAL
abdominal rounded, or contour is
contour. scaphoid (usually rounded and During pregnancy,

FIRST SEMESTER
A.Y. 2021-2022
Sitting at the seen in thin adults; distended. the uterus grows and
client’s side, look Abdomen should takes up more space
across the abdomen be evenly rounded. to accommodate the
at a level slightly fetus. The distended
higher than the abdomen observed
client’s abdomen. in the patient
Inspect the area signifies the
between the lower presence of the fetus
ribs and pubic bone. (Silber-Flagg &
Measure abdominal Pilliteri, 2018).
girth View
abdominal contour
from the client’s
side. Many
abdomens are more
or less flat; and
many are round,
scaphoid, or
distended
Assess abdominal Abdomen is The abdomen of NORMAL
symmetry. symmetric. the patient is
Look at the symmetric.
abdomen as the
client lies in a
relaxed supine
position.
Inspect abdominal Abdominal The abdominal NORMAL
movement when respiratory respiratory
the client breathes movement may be movement is
(respiratory seen, especially in visible.
movements). male clients.
Observe aortic A slight pulsation The aortic NORMAL
pulsations. of the abdominal pulsation is not
aorta, which is visible.
visible in the
epigastrium,
extends full length
in thin people.
Observe for Normally, There were no NORMAL

FIRST SEMESTER
A.Y. 2021-2022
peristaltic peristaltic waves peristaltic waves

waves. are not seen, observed on the
although they patient’s
may be visible in abdomen.
very thin people
as slight ripples
on the abdominal
wall.
Auscultate for A series of A series of NORMAL
bowel sounds. intermittent, soft intermittent, soft
Use the diaphragm clicks and gurgles clicks and
of the stethoscope are heard at a rate gurgles were
and make sure that of 5– 30 per heard upon
it is warm before minute. auscultation. It
you place it on the Hyperactive bowel has a rate of 25
client’s abdomen. sounds referred to per minute.
Apply light as “borborygmus”
pressure or simply may also be heard.
rest the stethoscope These are the
on a tender loud, prolonged
abdomen. gurgles
Begin in the RLQ characteristic of
and proceed one’s “stomach
clockwise, covering growling.”
all quadrants. Listen
for at least 5
minutes before
determining that no
bowel sounds are
present and that the
bowels are silent.
Auscultate for Bruits are not Bruits are not NORMAL
vascular sounds. normally heard heard upon
Use the bell of the over abdominal auscultation of
stethoscope to listen aorta or renal, the abdominal
for bruits iliac, or femoral aorta, renal, iliac
(lowpitched, arteries. and femoral
murmur- like sound) However, bruits artery.
over the abdominal confined to systole
aorta and renal, may be normal in

FIRST SEMESTER
A.Y. 2021-2022
iliac, and femoral some clients

arteries. depending on other
differentiating
factors.
Auscultate for a No friction rub There is no NORMAL
friction rub over over the liver or friction rub
the liver and spleen is present. auscultated over
spleen. the liver and the
Listen over the spleen.
right and left
lower rib cage
with the
diaphragm of the
stethoscope.
Percuss for Generalized Upon percussion, NORMAL
tone. Lightly tympany tympany
and predominates over predominates the
systematically the abdomen abdomen because of
percuss all because of air in
the air that is in the
quadrants the stomach and
intestines. stomach and
Abdominal Dullness is heard intestine of the
percussion pattern over the liver and patient. Dullness was
• Abdominal spleen. Dullness percussed over the
percussion may also be liver and the spleen.
sequences elicited over a And if the abdomen
may non-evacuated
descending colon would be percussed,
proceed
it would
clockwise
or up and predominantly be
down over dull as well, since the
the uterus is taking up its
abdomen space.
Normal
percussion
findings.
• Blue
indicates
dullness.

FIRST SEMESTER
A.Y. 2021-2022
• Orange
indicates tympany
Percuss the span On deep inspiration, The span of the NORMAL
or height of the the lower border of liver at the
liver by liver dullness may midclavicular
determining its descend from 1 to 4 line is 8 cm.
lower and upper cm below the costal
borders. To assess margin. The normal
the lower border, liver span at the
begin in the RLQ at midclavicular line is
the midclavicular 8 -12cm.
line (MCL) and
percuss upward.
Note the change
from tympany to
dullness. Mark this
point: It is the lower
border of liver
dullness. To assess
the descent of the
liver, ask the client
to take a deep
breath and hold;
then repeat the
procedure. Remind
the client to exhale
after percussing
Perform blunt Normally, no Upon NORMAL
percussion on the tenderness is percussion, there
liver and the elicited. is no tenderness.
kidneys.
This is to assess
for tenderness in
difficult-to-palpate
structures. Percuss
the liver by placing
your left hand flat
against the lower
right anterior rib

FIRST SEMESTER
A.Y. 2021-2022
cage. Use the ulnar

side of your right
fist to strike your
left
hand.
Perform light Abdomen is The abdomen is NORMAL
palpation. Light nontender and nontender, soft and
palpation is used to soft. There is no with no guarding
identify areas of guarding. present upon
tenderness and palpation.
muscular resistance.
Using the fingertips,
begin palpation in a
nontender quadrant,
and compress to a
depth of 1 cm in a
dipping motion.
Then gently lift the
fingers and move to
the next area. To
minimize the
client’s voluntary
guarding (a tensing
or rigidity of the
abdominal muscles
usually involving
the entire
abdomen).
Deeply palpate all Palpate for No unusual NORMAL
quadrants to masses. Note their masses were
delineate location, size (cm), palpated.
abdominal organs shape, consistency,
and detect subtle demarcation,
masses. Using the pulsatility,
palmar surface of tenderness, and
the fingers, mobility. Do not
compress to a confuse a mass with
maximum depth (5– an organ or
6 cm). Perform structure.

FIRST SEMESTER
A.Y. 2021-2022
bimanual palpation
if you encounter
resistance or to
assess deeper
structures.
Palpate the liver. The liver is usually The liver is not NORMAL
Note consistency not palpable, palpable and is
and tenderness. To although it may be not tender.
palpate bimanually, felt in some thin
stand at the client’s clients. If the lower
right side and place edge is felt, it
your left hand under should be firm,
the client’s back at smooth, and even.
the level of the Mild tenderness
eleventh to twelfth may be normal.
ribs. Lay your right
hand parallel to the
right costal margin
(your fingertips
should point toward
the client’s head).
Ask the client to
inhale, then
compress upward
and inward with
your finger
Palpate the urinary An empty The urinary NORMAL
bladder. Palpate for bladder is bladder of the
neither patient is not
a distended bladder
palpable nor palpable and
when the client’s tender. nontender.
history or other
findings warrant
(e.g., dull percussion
noted over the
symphysis pubis).
Begin at the
symphysis pubis and

FIRST SEMESTER
A.Y. 2021-2022
move upward and

outward to estimate
bladder borders.
Assess for No rebound There is no NORMAL
rebound tenderness is rebound
tenderness. present. tenderness upon
assessment.
If the client has
abdominal pain or
tenderness, test for
rebound tenderness
by palpating deeply
at 90 degrees into
the abdomen away
from the painful or
tender area then
suddenly release
pressure.
Listen and watch for
the client’s
expression of pain.
Ask the client to
describe which hurt
more - the pressing
in or the releasing -
and where on the
abdomen the pain
occurred
Musculoskeletal
BODY NORMAL ACTUAL INTERPRETATIO

PART/AREA FINDINGS FINDINGS N and ANALYSIS
TO BE
ASSESSED
Inspect the muscles Equal size on The patient has an NORMAL
for size. Compare both sides of equal muscle size on

FIRST SEMESTER
A.Y. 2021-2022
each muscle on one body both sides of the

side of the body to body.
the same muscle on
the other side. For
any
apparent
discrepancies,
measure the
muscles with a tape.
Inspect the muscles No contractures The patient has no NORMAL
and tendons for tightening of the
contractures. muscles, tendons,
skin, and nearby
tissues. Also, the
joints do not shrink
nor become stiff.
Inspect the No The patient has no DEVIATION
muscles for fasciculation or No fasciculation FROM NORMAL
tremors. tremors however shivering Shivering is a typical
Inspect any tremors has been observed. condition for most
of the hands and women during
arms by having the pregnancy, and it can
client hold arms out also be caused by
in front of body. urinary tract
infections (Larson,
2021).
Palpate muscles at Normally firm The patient has a NORMAL
rest to determine firm muscle
muscle tonicity. tonicity.
Palpate muscles Smooth The patient has NORMAL
while the client is coordinated smooth coordinated
active and passive movements movements.
for flaccidity,
spasticity, and
smoothness of
movement.
Test muscle Equal strength on The patient was able NORMAL

FIRST SEMESTER
A.Y. 2021-2022
strength of the each body side with to fight the

head and a grade of 5. resistance created.
shoulders. Additionally, the
muscle strength on
the
sternocleidomastoid
, trapezius and
deltoids of the
patient is equal at
both
sides and has a
grade of 5.
strength of upper each body side with to fight the resistance
extremities a grade of 5. created. Additionally,
the muscle strength of
the upper extremities
of the patient is equal
at both sides and has a
grade of 5.
strength of lower each body side with to fight the resistance
extremities. a grade of 5. created on a supine
position.
Additionally, the
muscle strength of
lower extremities of
the patient is equal at
both sides and
has a grade of 5.
Inspect the No deformities Upon inspection of NORMAL
skeleton for the skeleton, there are
normal structure no deformities or
and deformities misalignments that
were present.
Palpate the bones No tenderness Upon palpation of the NORMAL
to locate any areas of swelling bones of the upper
of edema or extremities (cranial
tenderness. bones, scapula,

FIRST SEMESTER
A.Y. 2021-2022
clavicle, humerus,
radius and ulna,
carpals, metacarpals
and phalanges) and
lower extremities
(femur, patella, tibia,
and fibula),
tenderness and edema
were not present.
Inspect the joint No swelling No There is no swelling, NORMAL
for swelling. tenderness, tenderness, crepitation
Palpate each joint crepitation, or or nodules that were
for tenderness, nodules present upon
smoothness of inspection of joints.
movement, Also, during passive
swelling, movements, the joints
crepitation, and move smoothly.
presence of nodules.
Assess joint Joints are in full The movements are
range of motion range of motion; smooth, with no
of the head no difficulty in tenderness or any
movement; no difficulty and the
tenderness; joints (Neck-Pivot
smooth Joint) were able to
movements. move in full range of
motion.
Assess joint Joints are in full For seated and DEVIATION
range of motion range of motion; standing forward FROM NORMAL
of body trunk no difficulty in flexion and seated In late pregnancy,
movement; no axial rotation, the strategies such as
tenderness; motion of both the increasing the width
smooth thoracic segment and of the base of support
movements. the thoracolumbar and reducing
spine were obstruction from
significantly other body parts were
reduced. Movement used to minimize the
of the pelvis was less effects of increased
affected due to the trunk mass and girths.
partial success of Not all trunk segment

FIRST SEMESTER
A.Y. 2021-2022
minimizing motion was affected

obstruction from the equally. The differing
thighs by placing the effect on individual
feet further apart trunk segment motion
during seated and may lead to altered
standing forward movement patterns
flexion. during functional
tasks (Gilleard et al.,
2002).
Assess joint Joints are in full The movements are NORMAL
of upper no difficulty in tenderness or any
extremities movement; no difficulty and the
tenderness; joints (Shoulder-Ball-
smooth and Socket Joint,
movements. Elbow hinge Joint,
Wrist Condyloid
Joint, and Thumb-
Saddle Joint) were
able to move in full
range of motion.
Assess joint Joints are in full The movements are NORMAL
of lower no difficulty in tenderness or any
extremities movement; no difficulty and the
tenderness; joints(Hip-Ball-and-
smooth Socket Joint, Knee-
movements. Hinge
Joint, Foot Gliding
Joint, and Toe-
Condyloid Joints)
were able to move in
full range
of motion.
MEASUREMENTS
ASSESSMEN BODY PART NORMAL ACTUAL ANALYSIS &


FIRST SEMESTER
A.Y. 2021-2022
T METHOD (CEPHALO- FINDINGS FINDINGS INTERPRETA

USED CAUDAL) TION
Inspection Height 157.48 cm to 152 cm DEVIATION

175.26 cm is the FROM
normal height for NORMAL
the weight of
59.42 kg The ideal body
height for 59.42
kg weight is
between 157.48
cm to 175.26 cm
(Brazier, 2021)
Inspection Weight 42.7 to 57.5 kg is 131 kg DEVIATION

the normal FROM
weight for the NORMAL
height of 152 cm
The ideal body
weight for 152
cm height is
between 42.6 –
53.9 kg (Brazier,
2021)
Inspection BMI 18.5 - 24.9 56.7 DEVIATION

FROM
NORMAL
BMI that ranges

30.0 and above
indicate obesity
(Centers for
Disease Control
and Prevention,

FIRST SEMESTER
A.Y. 2021-2022
2021)
Inspection Temperature Normal body 36°C NORMAL

temperature can
range from 97.8
degrees F (or
Fahrenheit,
equivalent to
36.5 degrees C,
or Celsius) to 99
degrees F (37.2
degrees C) for a
healthy adult
(Silbert-Flagg &
Pilliteri, 2018).
Inspection Respiratory Rate Normal 20 NORMAL

respiration rates
for an adult
person at rest
range from 12 to
20 breaths per
minute(Silbert-
Flagg & Pilliteri,
2018).

FIRST SEMESTER
A.Y. 2021-2022
Inspection Pulse Rate The normal 93 bpm NORMAL

pulse for healthy
adults ranges
from 60 to 100
beats per minute
(Silbert-Flagg &
Pilliteri, 2018).
Inspection Oxygen Normal range is 98% NORMAL

Saturation between 95 and
100 percent
(Silbert-Flagg &
Pilliteri, 2018).
Auscultation Blood Pressure Normal blood 140/80 mmHg DEVIATION

pressure is FROM
systolic of less NORMAL
than 120 and
diastolic of less Elevated blood
than 80 (Silbert- pressure is when
Flagg & Pilliteri, readings
2018).. consistently
range from 120-
129 systolic and
less than 80 mm
Hg diastolic. It is
also called
hypertension
(CDC, 2021).

FIRST SEMESTER
A.Y. 2021-2022
LABORATORY/DIAGNOSTIC EXAMINATIONS
DATE LABORATO NORMAL VALUES ACTUAL CLINICAL

DONE RY/DIAGNO RESULTS INTERPRETATIO
STIC N & ANALYSIS
EXAMINATI (WITH
ON REFERENCE)
December Complete Normal reference All components are

1, 2021 blood count values according to the within normal range
given laboratory chart: in accordance to the
hospital’s reference
RBC Count: RBC Count: values except for the
● 4.50 - 5.50 ● 4.73 x following:
1012/L
Hemoglobin: Hemoglobin: High in Neutrophil
● 120.0 - 140.0 ● 130.0 g/L count:
● 0.721
Hematocrit: Hematocrit:
● 0.370 - 0.470 ● 0.395 L/L Normal Neutrophil
count:
MCV: MCV: ● 0.550 - 0.650
● 80.0 - 100.0 ● 83.5 fL
Analysis:
MCHC: MCHC: Neutrophils are a
● 320 - 380 ● 329 g/L type of white blood
cells wherein it is
MCH: MCH: mostly responsible
● 27.0 - 33.0 ● 27.5 pg for the immune
system’s response
RDW-CV: RDW-CV: since it makes up
● 11.0 - 16.0 ● 14% about 50-70% of the
WBCs that are

FIRST SEMESTER
A.Y. 2021-2022
RDW-SD: RDW-SD: present in our body.

● 35.0 - 56.0 ● 42.6 fL Having high
neutrophil levels is
Platelet Count: Platelet Count: also known as
● 150 - 450 ● 160 x 109/L neutrophilia. The
underlying conditions
MPV: MPV: for neutrophilia are as
● 6.5 - 12.0 ● 11.7 fL follows:
● infection,
PDW: PDW: most likely
● 9.0 - 17.0 ● 16.2 fL bacterial
● noninfectious
WBC Count: WBC Count: inflammation
● 5.00 - 10.00 ● 6.99 x ● injury
109/L ● surgery
● smoking
Neutrophils: Neutrophils: cigarettes or
● 0.550 - 0.650 ● 0.721 sniffing
tobacco
Lymphocytes Lymphocytes ● high stress
● 0.250 - 0.350 ● 0.186 level
● excessive
Monocytes: Monocytes: exercise
● 0.020 - 0.060 ● 0.076 ● steroid use
● heart attacks
Eosinophils: Eosinophils: ● chronic
● 0.030 - 0.050 ● 0.014 myeloid
leukemia
Basophils Basophils In the client's case, it
● 0.000 - 0.010 ● 0.003 was shown in the
Complete Blood
Count results that the
client’s neutrophil
count is higher than

FIRST SEMESTER
A.Y. 2021-2022
the expected amount.

With the neutrophilia
experienced by the
client, it indicates that
an infection is present
in her body (Morris,
2017).
High in Monocyte
count:
● 0.076
Normal Monocyte
count:
● 0.020 - 0.060
Analysis:
Another type of white
blood cell are
monocytes wherein it
also plays a vital role
in the immune
system’s response.
They are also known
as macrophages in
which they eat up and
isolate harmful
microorganisms. The
following conditions
may cause increased
levels on monocyte
counts (Pietrangelo,
2019):

FIRST SEMESTER
A.Y. 2021-2022
● Chronic
inflammatory
disease
● Viral
infections
● Parasitic
infections
● Tuberculosis
● Cardiovascula
r diseases.
In the given CBC
result of the client, it
can be seen that the
monocyte count is
higher than the
normal range. It may
have been related to
the patient’s
admitting diagnosis
of chronic
hypertensive vascular
disease since
cardiovascular
disease is one of the
underlying conditions
that causes high
monocyte count
(SahBandar et al.,
2020).
December Urinalysis Normal reference

1, 2021 values according to the All components are
given laboratory chart: within normal range
in accordance to the
reference values

FIRST SEMESTER
A.Y. 2021-2022
Pus cells: Pus cells: except for the

● 0-17/ uL ● 56.5/ uL following:
Red blood cells: Red blood cells: High Pus cells:

● 0-11/ uL ● 13.7/ uL ● 56.5/ uL
Normal Pus Cells:

Epithelial cells: Epithelial cells: ● 0-17/ uL
● 0-17/ uL ● 22.1/ uL
Bacteria: Bacteria: Analysis:

● 0-278/ uL ● 2118.6/ uL
Pus cells, together
pH: pH: with infectious
● 5.5- 9.0 ● 5.5 agents, cell debris,
and tissue fluid, are
Color: Color: the constituents of the
● Straw Yellow ● Straw pus formed at the site
of infection or injury.
Character: Character: They are neutrophils
● Clear/ cloudy ● Clear that have gotten to
the infection site as
Blood: Blood: part of an immune
● Positive (≤3 ● Negative response to infectious
RBCs) pathogens.
Pyuria can cause the
urine to look cloudy
Bilirubin: Bilirubin: or as if it contains
● Negative ● Negative pus. Pyuria is a
common symptom of
Urobilinogen: Urobilinogen: a urinary tract
● High (> 1.0 ● Normal infection (UTI).
mg/dL) It can be a symptom
of a severe UTI or

FIRST SEMESTER
A.Y. 2021-2022
Ketone: Ketone: sepsis in rare

● Negative ● Negative circumstances.(Samp
son, 2018)
Protein: Protein:
● High (300-500 ● Trace The underlying
mg/d) conditions for pyuria
are as follows:
Nitrite: Nitrite: ● Permanent
● Negative ● Negative kidney
damage
Glucose: Glucose: ● Blood
● Positive ● Negative poisoning
● Organ Failure
Specific Gravity: Specific Gravity:
● 1.005-1.025 ● 1.014 In the client's case, it
was shown in the
Leukocytes: Leukocytes: Urinalysis results that
● Negative ● Positive the client’s Pus cells
(+1) count is higher than
Mucus Threads: Mucus Threads: With the Pyuria
● 0.00-8.0/ uL ● 0.00/ uL experienced by the
client, it indicates that
Urinary Tract
Infection is present in
her body. (Rogers,
2018)
High Red Blood

cells:
● 13.7
Normal Red Blood

cells:

FIRST SEMESTER
A.Y. 2021-2022
● 0-11
Analysis:
The red blood cells in

your body are in
charge of carrying
oxygen from your
lungs to your tissues.
High red blood cells
in urine are also
known as hematuria.
(Cleveland Clinic,
2021).
The possible reasons

for having hematuria
includes:
● Urinary tract
or kidney
infections
● Cancer in
your bladder
or kidney
● Kidney stones
● Prostate
cancer
In the client's case, it

was shown in the
Urinalysis results that
the client’s Red blood
cells count is higher

FIRST SEMESTER
A.Y. 2021-2022
than the expected

amount. With the
Hematuria evident in
the Urinalysis result
of the client, it
indicates that Urinary
Tract Infection is
present in her body.
(Ansorge, 2020).
High Epithelial
Cells:
● 22.1/uL
Normal Epithelial
Cells:
● 0-17
Analysis:
Epithelial cells are

the cells that line the
insides of your body's
surfaces. Skin, blood
vessels, the urinary
tract, and organs are
all places where they
can be found. An
epithelial cell in urine
test examines urine
under a microscope
to determine whether
the quantity of
epithelial cells in

FIRST SEMESTER
A.Y. 2021-2022
your body is within

normal limits.
(Medline Plus,2020).
High epithelial cells

may indicate:
● Urinary tract
infection
● Yeast
infection
● Kidney
disease
● Liver disease
● Certain types
of cancer
According to the
client's case, it was
shown in the
Urinalysis results that
the client’s epithelial
cells are higher than
A high number of
epithelial cells in the
urine is typically an
indication of a minor
infection, such as a
urinary tract infection
(UTI) or a yeast
infection. (Stephens,

FIRST SEMESTER
A.Y. 2021-2022
2018).
High Bacteria
Count:
● 2118.6/uL
Normal Bacteria
Count:
● 0-278
Analysis: Bacteria
are single-celled
organisms that can be
found almost
anywhere: on your
hands, in the ocean,
and in your stomach.
While some are
hazardous, the
majority are not, and
some are even good
for human health.
When bacterial
counts are high —
meaning the number
of colonies of a single
organism is greater
than 100,000 per mL
— bacterial
colonization in urine
is high. (Pappas,

FIRST SEMESTER
A.Y. 2021-2022
2021)
Complications due to
high bacteria count in
urine includes:
● Permanent
Kidney
damage
● Sepsis
● Urethral
narrowing
● Chronic
Kidney
infection
In the given
Urinalysis result of
the client, it can be
seen that the bacteria
count is higher than
the normal range. A
high number of
bacteria in the urine
is typically an
indication of a minor
infection, such as a
urinary tract
infection. (Mayo

FIRST SEMESTER
A.Y. 2021-2022
Clinic,2021).
December Second and General Survey ● Single, live,

1. 2021 Third ● Singleton intrauterine
Trimester pregnancy.
Scan ● The cephalic
presentation
of the baby is
● Cephalic ● Cephalic normal as it is
presentation Presentatio a natural
(head-down) is n occurrence
natural in the 37- from the 37th-
40th week of 40th week of
pregnancy pregnancy
(Iftikhar, 2020). (Iftikhar,
2020).
● The baby’s
Normal fetal heart rate Fetal Heart Rate fetal heart rate
(FHR) (FHR): is within

FIRST SEMESTER
A.Y. 2021-2022
The normal range of FHR ● 138 BPM normal range

is from 120 bpm -160 (Pildner von
bpm (Pildner von Steinburg et
Steinburg et al., 2013). al., 2013).
● The SVP of
Single Deepest Vertical Single Vertical the client is at
Pocket (SDVP) according Pocket (SVP): 1.82, which
to (Lord et al., 2021): ● 1.82 means it is
● Normal range is considered
2cm-8cm below the
● If less than 2cm, it normal range,
is considered to also known as
be oligohydramn
oligohydramnios ios. When
(low amniotic such a
fluid volume) condition
● If greater than occurs, the
8cm, it will be amniotic
considered as membrane of
polyhydramnios the patient is
or increased ruptured
amniotic fluid (Lord et al.,
volume. 2021). hence
an indication
that the
patient’s
water is
breaking and
labor will
follow
(Iftikhar,
2020).

FIRST SEMESTER
A.Y. 2021-2022
Normal AFI ● The client’s

● 5cm - 25cm amniotic fluid
● Less than 5cm Amniotic Fluid index is at
indicates Index (AFI): 5.95cm,
oligohydramnios ● 5.95cm therefore, it is
while greater than still within
25cm is normal range
considered to be (Lord et al.,
polyhydramnios 2021).
(Lord et al.,
2021).
Normal placenta ● Having an

● The placenta, Anteriorly
which nourishes Placenta placed
the baby, may ● Anterior placenta does
attach itself ● Grade III not generally
anywhere. affect the
Although the pregnancy
usual placenta and the fetus
positions are at (Fletcher,
the top or side of 2019).
the uterus. It is However,
also possible for possible
the placenta to blockage may
attach at an occur,

FIRST SEMESTER
A.Y. 2021-2022
anterior position hindering the

which is in front baby’s way of
of your stomach delivery and
(Nall, 2021). cause
● However, having bleeding.
an anteriorly Thus, the
positioned cesarean
placenta may section
have a high risk recommended
for the following and done to
complications the patient
according to Zia (Nall, 2021)
(2013):
-Pregnancy- ● Since the
induced client’s
hypertension placenta grade
-intrauterine is III, it is
growth restriction recommended
-gestational to have a
diabetes cesarean
-placental section rather
abruption than a normal
-intrauterine fetal delivery
death procedure.
Hence, the
Placenta Grading patient’s
● Grade 3 placenta cesarean
is associated with section
it’s anterior procedure.
location, wherein Her placenta
pre-eclampsia, grade is also
meconium-stained normal for the
amniotic fluid, gestational
and intrauterine week of her

FIRST SEMESTER
A.Y. 2021-2022
growth restriction pregnancy

may occur. which is 39
Additionally, weeks
Grade 3 placental (Fouedjio et
maturity before al., 2015).
the 36th week
may result in
some fetal and
maternal
complications.
Therefore, close
monitoring is
needed to prevent
such conditions
(Fouedjio et al.,
2015).
● Vaginal birth is
possible for
pregnant women
with placental
grade of 1 or 2.
However, for
patients with a
placental grade of
3 or 4, it requires
a cesarean section
(Pregnancybirthba
by.org.au, 2020).
● The fetal
biometry
Fetal biometry normal results,
values in mm & cm: including the
At 40 weeks: BPD, HC,

FIRST SEMESTER
A.Y. 2021-2022
● Biparietal Fetal Biometry OFD, AC and

Diameter (BPD): At 40 weeks: NFL, are
8.92-9.87cm ● Biparietal within normal
(89.2-98.7mm) Diameter range
(BPD): At (Anzaku et
● Head 9.93cm al., 2019).
Circumference (99.3mm)
(HC): 31.9- ● Head
35.2cm Circumfere
(319-352mm) nce (HC):
34.88cm
(348.8mm)
● Occipitofrontal ● Occipitofro
diameter (OFD): ntal
10.7-12.6cm diameter
(107-126mm) (OFD):
11.82cm
(118.2mm)
● Abdominal
● Abdominal Circumfere
Circumference nce (AC):
(AC): 34.2- 36.05cm
39.3cm (342- (360.5mm)
393mm)
Normal Femur Length

(NFL)
● 7.18-7.84cm
(71.8-78.4mm) At 36 weeks:
● Femur ● The newborn
Length of the client is
Normal EFW (FL): at 3,759
● The weight of a grams. At 39

FIRST SEMESTER
A.Y. 2021-2022
healthy newborn 7.04cm (1 weeks, it is

at 39 weeks can day) within normal
range from 2,500 ● Estimated range in
grams-4,500 Fetal accordance
grams (Pevzner, Weight with the
2021). (EFW): baby’s
3,759 gestational
grams age (Pevzner,
2021).
● The
Actual Ultrasound biophysical
Normal biophysical Age (AUA): 39 profile score
score: weeks 2 days of the client is
● A score of 8-10 is 10/10. This
normal while a Biophysical score is within
score of 6 is Profile Score normal range
considered to be ● 10/10 and indicates
abnormal. While a ● indicative good fetal
score of 2-4 is of good well-being
alarming and fetal well (Sapoval et
induction of labor being. al., 2021).
or a cesarean ● Score of 2
section must be for each
immediately component
done. Having a including:
score of 0 Amniotic
indicates that fetal fluid, fetal
asphyxia will tone, fetal

FIRST SEMESTER
A.Y. 2021-2022
occur. Therefore, movement,

an urgent fetal
cesarean section breathing,
should be done to and non-
immediately stress test
address the
situation (Sapoval
et al., 2021).
December Non-Stress Normal NST results ● Baseline Analysis:

1, 2021 Test (under FHT: 145
second and ● NST: Reactive bpm In the given NST
third trimester ● FHT: 110-160 ● with result of the client, it
scan) bpm moderate is evident that the
● with moderate variability fetal heart rate count
variability ● with no is within normal
● with no acceleration range, with no
accelerations s accelerations, no
● no declarations of ● no uterine contractions,
active fetal declarations no declarations of
movements of active active fetal
● No uterine fetal movements and it is
contractions noted movements also within the
● No uterine moderate variability.
contractions
notes According to Mayo
● NST: Clinic (2021), a
Reactive nonstress test is a
common prenatal test
that is performed to
assess the health of a
fetus. The baby's
heart rate is

FIRST SEMESTER
A.Y. 2021-2022
monitored during a
nonstress test to
observe how it
responds to the baby's
movements. A
nonstress test is used
to assess the health of
a newborn before
birth. A nonstress test
checks your baby's
heart rate and how it
responds to
movement in order to
provide vital
information about his
or her oxygen supply.
December Capillary Normal blood glucose At 5am The client’s blood

2, 2021 Blood range: ● 93 mg/dL glucose is within
Glucose ● 4 to 6 mmol or normal range if it is
(CBG) Test about 72 to 108 At 3pm solely based on the
mg/dL (Mathew ● 78 mg/dL blood glucose range
& Prasanna Tadi, (Mathew & Prasanna
2021). Tadi, 2021). Due to
the insufficient
information from the
patient’s chart, the
interpretation of the
actual result is
indiscernible.
Although it was
stated in the final
diagnosis of the
patient that diabetes
mellitus is present.
FAR EASTERN UNIVERSITY INSTITUTE OF NURSING
NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE] FIRST SEMESTER
A.Y. 2021-2022
V. DRUG STUDY
Name of client: Agustin, Johanna Garcia. Age: 37 Sex: Female Date: __December 2, 2021__
Room No. 629
Diagnosis: Gravida 1 Para 1 (1001) Term, Cephalic, Delivered; Failed Induction of Labor, Term Birth Living Boy APGAR score of
9/10; Birth weight of 3470 grams, Appropriate for Gestation at Age; Overt Diabetes Mellitus, Insulin Requiring - Uncontrolled;
Chronic Hypertensive Vascular Disease; Obese II, Urinary Tract Infection - Ongoing Treatment
Prescribing Doctor: Joseph Olivar M.D.
DRUG INDICATI CONTRAINDICA MECHANISM OF ACTION SIDE EFFECT / NURSING

ON TION ADVERSE RESPONSIBILIT
EFFECT IES
Cefuroxim Intravenous Hypersensitivity to Frequent: Nursing

ROU ONSE PEA DURATI
e Injection cefuroxime or to ● Oral consideration:
TE T K ON
(IV) any of the candidiasis
Generic excipients. (thrush) ● Assess
name: Surgical ● Mild onset, type,
A.Y. 2021-2022
Cefuroxim prophylaxis Cefuroxime is diarrhea location,

PO unkno 2 to 3
e for contraindicated in ● Mild duration of
wn hours
gastrointesti patients with abdominal pain/inflam
Brand nal, cephalosporin cramping mation.
name: gynecologic hypersensitivity or IV unkno 2 to 3 ● Vaginal Inspect
Zinacef al surgery cephamycin wn minut candidiasis appearance
(including hypersensitivity. es of affected
Therapeuti caesarean Cefuroxime should Occasional: joints for
c Class: section) and be used cautiously ● Nausea immobility,
Second orthopedic in patients with ● Fever deformity,
Binds to penicillin-binding proteins
Generation operations. hypersensitivity to ● Joint pain skin
and inhibits final transpeptidation
Cephalosp 1.5 g with penicillin. condition.
step of peptidoglycan synthesis,
orins the induction Rare: Assess for
resulting in cell-wall death; resists
of ● Allergic allergy to
degradation by beta-lactamase;
Pharmacol anesthesia. reaction sulfa,
proper dosing and appropriate route
ogic This may be ● Thrombop aspirin, or
of administration are determined by
classificati supplemente hlebitis NSAIDs
condition of patient, severity of
on: d with two (contraindic
infection, and susceptibility of
Cephalosp 750 mg ated).
A.Y. 2021-2022
orins doses microorganism

Antibiotics (intramuscul ● Inject
arly) after 8 appropriate
Dosage: hours and 16 dose of
500 hours. reconstitute
mg/tablet d solution
two times a Per Orem directly into
day (PO) a vein over
a period of
750mg IV 250 mg PO 3–5 minutes
every eight every 12 or slowly
hours hours for 7 into the
to 10 days. tubing of a
1.5g IV The freely
12/02/21 Infectious flowing
3:15 pm Diseases compatible
Society of IV solution.
Route: America
Intravenous (IDSA) ● Advise
A.Y. 2021-2022
Injection recommends patients that

(IV) beta-lactams skipping
used for 3 to doses or not
Per Orem 7 days as completing
(PO) alternative the full
therapy for course of
cystitis when therapy may
other agents decrease
cannot be effectivenes
used. For s and
pyelonephrit increase the
is, oral beta- likelihood
lactams that bacteria
should be will develop
used after an resistance
initial and will not
intravenous be treatable
dose of a with
long-acting cefuroxime
A.Y. 2021-2022
antimicrobia or other
l antibacterial
(ceftriaxone s in the
or future.
aminoglycos
ide) for 10 to
14 days.
Beta-lactams
generally
have inferior
efficacy than
other agents.
A.Y. 2021-2022
DRUG INDICATION CONTRAINDIC MECHANISM OF SIDE EFFECT / NURSING

ATION ACTION ADVERSE EFFECT RESPONSIBILITIES
CNS: Nursing
(Acetaminop Per Orem (PO) Acetaminophen is ● agitation (IV), consideration:
R O P D H
hen) contraindicated in anxiety
O N E U A
Paracetamol Oral forms of patients with ● Fatigue ● Follow the 10
U S A R L
acetaminophen hypersensitivity to ● Headache rights of drug
T E K A F
Generic name: or paracetamol it. Moreover, the ● Insomnia administration.
E T T -
Acetaminophe are indicated for IV form of the said ● pyrexia ● Double check if
I L
n/Paracetamol patients who are drug is the seal or
O I
experiencing contraindicated in CV: packaging is
N F
Brand name: mild pain or patients with ● HTN broken or not
E
Tylenol fever. The severe hepatic ● Hypotension intact. Do not
following are the impairment or P < 3 4 2 ● peripheral administer if
Therapeutic dosages for such severe active liver O 1 0 - - edema such is
Class: conditions: disease. h - 6 3 ● periorbital observed.
Analgesics Furthermore, it r 6 h h edema ● It is important to
Adults: should be used with 0 rs rs ● tachycardia be aware when
A.Y. 2021-2022
Pharmacologic 325 to 650 mg caution to patient (IV). calculating daily

m
classification: PO every 4 to 6 that has any type of doses since
in
Para- hours. Or, two liver disease, G6PD GI: many over-the-
s
aminophenol extended-release deficiency, chronic ● Nausea counter (OTC)
Derivatives caplets PO every malnutrition, severe I 5 1 4 2. ● Vomiting and prescription
8 hours. hypovolemia V - 5 - 4 ● Abdominal products contain
Dosage: Maximum, 3,250 (dehydration, blood 3 m 6 - ● Pain acetaminophen.
Post-op order- mg daily unless loss), or severe 0 in h 7 ● Diarrhea ● It is important to
900 mg under health care renal impairment m s rs h ● constipation be critically
intravenously provider (CrCl of in rs (IV). cautious in
Every 6 hours supervision, 30 mL/minute or s preparing,
for 4 DOSES when 4 g daily less). In addition, it GU: prescribing and
(-) ANST (immediate- should also be used The drug produces ● oliguria (IV). administering
(after negative release) may be with critical care in analgesia by the intravenous
skin test) used. For long- patients with long- inhibiting Hematologic: type of
term therapy, term alcohol use prostaglandins and ● hemolytic acetaminophen.
-6:30pm don't exceed 2.6 since therapeutic other substances that anemia Such action is
g daily unless doses may cause sensitize pain ● Leukopenia important to
-12:30am prescribed and hepatotoxicity in receptors. ● Neutropenia prevent errors
A.Y. 2021-2022
monitored these patients. Additionally, the ● Pancytopenia that lead to

-6:00am closely by health Chronic alcoholics acetaminophen or ● Anemia accidental
care providers. should not take paracetamol may overdose and
-12:00pm more than 2 g of relieve fever through Hepatic: death. Be sure
Adjust-a-dose: acetaminophen central action in the ● Jaundice about the dosage
>Adults and For adults with every 24 hours. hypothalamic heat- given to patients
children age GFR of 10 to 50 regulating Metabolic: and do not
13 and older mL/minute/1.73 Most liver injury center. ● hypoalbumine exceed their
weighing 50 m2, give every 6 cases are associated mia (IV) maximum daily
kg or more: hours; if with ● Hypoglycemia limit.
1,000 mg IV GFR is less than acetaminophen or ● Hypokalemia ● It is important to
every 6 hours 10 paracetamol doses ● Hypervolemia consider
or 650mg IV mL/minute/1.73 exceeding 4,000 ● Hypomagnese reducing the
every 4 hours. m2, give every 8 mg/day. mia total daily dose
Maximum hours. For Additionally, such ● hypophosphate and increasing
dose is 1,000 patients cases often involve mia (IV) dosing intervals
mg as a single receiving more than one in patients with
dose and 4,000 continuous acetaminophen- Musculoskeletal: hepatic or renal
mg/day. renal containing product. ● muscle impairment.
A.Y. 2021-2022
replacement With this, drug may spasms, ● Advice the

>Adults and therapy, give cause acute liver extremity pain patient that the
children age every 6 hours. failure that will (IV) administration
13 and older require a liver of
weighing less Intravenous transplant Respiratory: acetaminophen
than 50 kg: Injection (IV) or possibly cause ● abnormal or paracetamol
15 mg/kg IV death. breath sounds is for short-term
every 6 hours Intravenous ● Dyspnea use. Encourage
or forms of Since there are no ● Hypoxia them to seek a
12.5 mg/kg IV acetaminophen studies of ● atelectasi physician if their
every 4 hours. or paracetamol is intravenously ● pleural condition does
Maximum administered to administered effusion not improve
dose is 15 patients who acetaminophen in ● pulmonary after 10 days
mg/kg (up to have pregnant women, it edema (for adults).
750 mg) as a mild to moderate should be used only ● Stridor ● Tell the patient
single dose pain with when necessarily ● wheezing (IV). to consult with a
and 75 adjunctive opioid and clearly needed. physician if their
mg/kg (up to analgesics and as Skin: fever lasts
3,750 well as fever. ● Rash longer than 3
A.Y. 2021-2022
mg)/day. Dosages for such ● Urticaria days or becomes

cases are as ● infusion-site recurrent.
>Adjust-a- follows: pain (IV) ● Warn the patient
dose: Longer ● pruritus. to stop using the
dosing Adults and drug and
intervals and a children age 13 immediately
reduced total and older seek medical
daily dose weighing 50 kg attention if
may be or more: rashes or other
warranted in 1,000 mg IV adverse
patients with every 6 hours or reactions occur
CrCl of 30 650 after
mL/minute or mg IV every 4 administration
less. hours. Maximum or intake.
dose is 1,000 mg
as a single dose
Route: and 4,000
Intravenous mg/day.
Injection (IV)
A.Y. 2021-2022
Adults and
children age 13
and older
weighing less
than 50 kg: 15
mg/kg IV every
6 hours or
12.5 mg/kg IV
every 4 hours.
Maximum dose
is 15 mg/kg (up
to 750 mg) as a
single dose and
75
mg/kg (up to
3,750 mg)/day.
Adjust-a-dose:
Longer dosing
A.Y. 2021-2022
intervals and a
reduced total
daily dose may
be warranted in
patients with
CrCl of 30
mL/minute or
less.
A.Y. 2021-2022

nalbuphine In patients with Contraindicated in Nursing

R O PE D
renal or hepatic patients CNS: dizziness, Considerations:
Generic O N A U
impairment, hypersensitive to headache, sedation,
Name: U SE K R ● Adjust dosage
decrease dosage. drug or its vertigo.
TE T A according to the
nalbuphine components and in
Moderate to TI CV: bradycardia, severity of pain,
those with
Brand Name: severe pain (non- O hypotension. physical status,
significant
opioid-tolerant N and other drugs
respiratory EENT: Dry mouth.
Nubain patients) the patient is
depression, known IV 2- 2- 3-
GI: Nausea, vomiting. receiving.
Therapeutic Adjunct to or suspected GI 3 3 6
● Before
class: balanced obstruction mi mi hrs Respiratory: administering
anesthesia; pre- (including paralytic n n
Opioid respiratory depression. the drug, assess
operative and ileus), and acute or
analgesics the patient's risk
severe asthma in an IM < < 3- Skin: clamminess,
postoperative
, 15 15 6 of opioid abuse,
analgesia; unmonitored diaphoresis.
Su mi mi hrs misuse, and
setting or in the
A.Y. 2021-2022
Pharmacologic obstetric absence of addiction.

bc n n
class: analgesia during resuscitative Regularly
uta
labor and equipment. monitor patients
ne
Opioid
delivery. for development
ou
agonist- Use cautiously and
of these
s
antagonist– at low doses in
behaviors or
opioid partial patients with Binds with opioid
conditions.
agonist preexisting receptors in the CNS,
● Reassess
respiratory altering perception of
Suggested patient’s level of
compromise. and emotional
Dosage: pain at least 15
response to pain.
Use cautiously in and 30 minutes
Adults: For after parenteral
patients with a
patients administration.
history of drug
weighing ● Carefully
abuse and in those
about 70kg, 10 monitor vital
with emotional
to 20 mg signs, pain
instability, head
subcutaneous, level’s,
injury, increased
IM, or IV respiratory
ICP, impaired
every 3 to 6 status, and
ventilation, MI
A.Y. 2021-2022
hours p.r.n. accompanied by sedation level,

maximum, nausea and in all patients
160 mg daily. vomiting, receiving
upcoming biliary opioids,
Adults: 0.3 to
surgery, or hepatic, especially those
3 mg/kg IV
renal, or adrenal receiving IV
over 10 to 15
insufficiency. drug, even those
minutes; then
given
maintenance Drugs may cause
postoperatively.
dose of 0.25 to mood disorders and
Monitor patient for
0.5 mg/kg in osteoporosis.
respiratory depression,
single IV dose
especially within first
p.r.n.
24 to 72 hours of the
Drug Order 1: start of therapy and

after dosage increase.
5 mg diluted
in 10 mL
PNSS (Plain
normal saline
A.Y. 2021-2022
solution) every
6 hours for 4
DOSES
Time
Administered:
-8:30 pm
(12/2/21)
-2:00 am
(12/3/21)
-8:00 am
(12/3/21)
-2:00 pm
(12/3/21)
Drug Order 2:
A.Y. 2021-2022
5 mg
intravenously
every 4 hours
AS NEEDED
for
breakthrough
pain
Time
administered:
-11:00 pm
(12/2/21)
Used Route:
Intravenous
(IV)
A.Y. 2021-2022

CNS: Nursing
> To induce or >Hypersensitivity
● subarachnoid consideration:
R O PE D
Oxytocin stimulate labor. to drug
hemorrhage,
O N A U
Generic name: Adults: Initially, seizure, coma. ● All patient
U SE K R
oxytocin 0.5 to CV: receiving
T T A
>Contraindicated ● arrhythmias, oxytocin IV
1milliunit/minute E TI
when vaginal HTN, PVCs, must be under
IV infusion. O
delivery isn’t hypotension, continuous
Brand name: Increase rate by N
advised (placenta tachycardia observation by
Pitocin 1 to 2
previa, vasa previa, IV 1 U 1 GI: trained
milliunits/minute
invasive cervical M N H ● nausea, personnel who
at 30- to 60-
carcinoma, genital IN K O vomiting have a thorough
minutes intervals
Therapeutic herpes) when U N U GU: knowledge of
unit normal
Class: cephalopelvic T O R ● abruptio the drug
contraction
Oxytocics disproportion is E W placentae, ● · Discontinue
pattern is
present, or when N tetanic uterine oxytocin
established.
A.Y. 2021-2022
Decrease rate delivery requires contractions, infusion

IV 3- U 2-
Pharmacologic
when labor is conversion as in postpartum immediately if
5 N 3
classification:
firmly transverse line. hemorrhage, uterine
M K hr
Exogenous
established. uterine rupture, hyperactivity or
IN N s
hormones
Rates exceeding impaired fetal distress
U O
9 to 10 > Use cautiously, if uterine blood occur.
T W
milliunits/minute at all, in patients flow, pelvic Administer
ES N
Dosage: are rarely hematoma, oxygen to the
with invasive
-D5NSS 1L+ required. increased mother. Mother
cervical cancer and
20 units Oxytocin is a protein
in those with uterine and fetus must
oxytocin > To reduce or produced by the
previous cervical or motility, be evaluated.
- D5NSS 1L+ stimulate pituitary gland of
uterine surgery ● · Drug is used
10 units postpartum mammals including
(including cesarean to induces or
oxytocin bleeding after man. Pitocin is a Hematologic:
section), grand reinforce labor
- Dextrose 5% expulsion of man-made version of ● afibrinogenemi
multiparity, uterine only when
in NSS placenta oxytocin used for a, possibly
sepsis, traumatic pelvis is known
1 liter + 10 stimulating related to
Adults: 10 to 40 delivery, or to be adequate,
units oxytocin contraction of the postpartum
units in 1000 mL overdistended when vaginal
uterus. Oxytocin bleeding,
of lactated uterus. delivery is
A.Y. 2021-2022
Ringer solution, works by increasing pelvic indicated, when

or NSS IV at rate the concentration of hematoma fetal maturity is
Route: needed to sustain calcium inside assured, and
Injection uterine muscle cells that when fetal

Other:
contraction and control contraction position is
>Flow Rate is ● anaphylaxis,
control uterine of the uterus. favorable. Use
125 mL/hr. death from
atony. Also, may Increased calcium drugs only in
oxytocin-
give 10 units IM increases contraction hospitals where
induced water
after delivery of of the uterus. critical care
intoxication,
placenta. facilities and
hypersensitivit
prescriber are
>Incomplete, y reactions.
immediately
inevitable, or
available.
elective abortion
● · Monitor fluid
Adults: 10 units intake and
IV infusion at 10 output.
to 20 milliunits Antidiuretic
(20 to 40 effect may lead

drops)/minute. to fluid
A.Y. 2021-2022
Don’t exceed 30 overload,

units in 12 hours. seizures, and
coma from
water
intoxication
● · Monitor and
record uterine
contractions,
HR, BR,
intrauterine
pressure, fetal
HR, and blood
loss at least
every 15
minutes.
Patient Teaching:
● · Explain use
and
A.Y. 2021-2022
administration
of drugs to
patients and
family.
● Instruct patient
to promptly
report adverse
reactions
A.Y. 2021-2022
DRUG INDICATION CONTRAINDICA MECHANISM OF SIDE EFFECT / NURSING

TION ACTION ADVERSE EFFECT RESPONSIBILITIES
Nursing
Omeprazole >Symptomatic ● Contraindic
ADVERSE considerations:
R O PE D
GERD without ated in
Generic name: EFFECTS:
O N A U
esophageal patients
● May increase
U SE K R
Omeprazole lesions hypersensiti
CNS: risk of CDAD.
TE T A
ve to drug
Adults: 20 mg ● Asthenia Evaluate for
Brand name: TI
or its
PO, as delayed- ● Dizziness CDAD in
O
components
Prilosec release form or ● headache patients who
N
and in
oral suspension, develop diarrhea
Therapeutic patients IV 1h 30 3 GI: that doesn't
daily for 8
Class: receiving r mi da ● abdominal pain improve.
weeks for
rilpivirine- ns- ys
Antiulcer drugs patients who ● Constipation
containing 2
respond poorly ● diarrhea ● False-positive
Pharmacologic products. hrs
to customary ● Flatulence results in
classification:
medical ● Nausea diagnostic
PPIs treatment, ● Vomiting investigations

A.Y. 2021-2022
usually ● Acid for

Dosage:
including an Inhibits proton pump regurgitation neuroendocrine
40mg adequate course activity by binding to tumors may
intravenously of H2 - receptor hydrogen–potassium Musculoskeletal: occur due to
once on antagonists. adenosine ● back pain increased CgA
definitive non triphosphatase, ● weakness. level.

>Erosive
per orem located at the Temporarily
esophagitis
secretory surface of Respiratory: stop omeprazole
Route: (EE)
gastric parietal cells, ● Cough treatment at
Adults: 20 mg to suppress gastric ● URI least 14 days

Intravenous
PO daily. For acid secretion. before assessing
route
recurrent EE or Skin: CgA level and
GERD signs and ● rash consider
symptoms, treat repeating the
for up to 12 SIDE EFFECTS: test if initial
months. CgA level is

● nausea high.
>Pathologic
● vomiting
hypersecretory ● Long-term
A.Y. 2021-2022
conditions ● gas (flatulence) therapy may

cause vitamin
Adults: Initially, ● dizziness
B12 absorption
60 mg PO daily; ● upper problems.
adjust dosage respiratory Assess patient
based on patient infection for signs and
response. If
● acid reflux symptoms of
daily dose
cyanocobalamin
exceeds 80 mg, ● loss of appetite
deficiency
give in divided ● gastric polyps
doses. Doses up
● hip fracture ● Because risk of
to 120 mg t.i.d.
● hair loss fundic gland
have been given.
polyps increases
Continue
with long-term
therapy as long
use, especially
as clinically
beyond 1 year,
indicated.
use drugs for the
>Duodenal shortest duration

ulcer appropriate to
A.Y. 2021-2022
the condition
Adults: 20 mg
being treated.
PO, as delayed-
release form or
● Periodically
oral suspension,
assess patients
daily for 4
for osteoporosis.
weeks.
>Helicobacter ● Monitor patients
pylori infection for signs and
and duodenal symptoms of

ulcer disease, to acute interstitial
eradicate H. nephritis.
pylori with
clarithromycin ● Discontinue
drug if signs or
Adults: 40 mg symptoms of
PO every cutaneous lupus
morning with erythematosus
clarithromycin or SLE develop;
A.Y. 2021-2022
500 mg PO t.i.d. refer patient to

for 14 days. For the appropriate
patients with an specialist for
ulcer at start of evaluation.
therapy, give
another 14 days
of omeprazole ● Drug increases
20 mg PO once its own
daily. bioavailability
with repeated
doses. Drug is
>H. pylori unstable in
infection and gastric acid; less
duodenal ulcer drug is lost to
disease, to hydrolysis
eradicate H. because drug
pylori with increases gastric
clarithromycin pH.
and amoxicillin
A.Y. 2021-2022
● Gastrin level
Adults: 20 mg rises in most
PO with patients during
clarithromycin the first 2 weeks
500 mg PO and of therapy.
amoxicillin
1,000 mg PO, ● Look alike–
each given b.i.d. sound alike:
for 10 days. For Don't confuse
patients with an Prilosec OTC wi
ulcer at start of
therapy, give
another 18 days
of omeprazole
20 mg PO once
daily.
>Short-term
treatment of
A.Y. 2021-2022
active benign
gastric ulcer
Adults: 40 mg
PO once daily
for 4 to 8 weeks.
>Dyspepsia
Adults: 20 mg
once daily for up
to 4 weeks.
A.Y. 2021-2022
DRUG INDICATION CONTRAINDICA MECHANISM OF SIDE EFFECT/ NURSING

Diclofenac ● A ● Hypersensit Route - IV Side Effects : Nursing

nonsteroi ivity to Onset - 30 min Considerations :
Generic name: dal anti- diclofenac.e Peak Effect - 2-3 hrs ● Cardiovascular
inflamma xperiencing Duration - up to 8hrs Thrombotic ● For appropriate
Diclofenac tory asthma, Events patients, assess
Sodium medicine urticaria Analgesic, anti- ● GI bleeding, for aggravation
(NSAID) after taking inflammatory, and ulceration and of asthma.
Brand name: called aspirin. antipyretic effects Perforation ● Analyze
diclofena With are all present in ● Hepatotoxicity therapeutic
Dyloject c moderate to diclofenac. ● Hypertension response by
injection severe renal Diclofenac's ● Heart Failure evaluating pain,
Therapeutic is used to impairment mechanism of action, and Edema joint stiffness,
class: treat in like that of other ● Renal Toxicity joint swelling
mild to perioperativ NSAIDs, isn't totally ● Anaphylactic and mobility.
NSAID moderate e period understood, although reactions ● Nurses should
pain in who are at it involves ● Serious skin advert to the
A.Y. 2021-2022
Pharmacologic humans. risk for cyclooxygenase reactions summary of

classification: It is used volume inhibition (COX-1 ● Hematologic product
+ to treat depletion; and COX-2). In Toxicity characteristics
NSAID individua perioperativ vitro, diclofenac is a provided by the
ls with e pain in the strong inhibitor of manufacturers
Dosage: moderate setting of prostaglandin and to proper
to severe CABG production. In vivo local guidelines.
37.5 mg/mL pain, surgery. effects have been ● Regular full
either Heart observed with dosage possess
Route: alone or failure, diclofenac doses analgesic and
in hypertensio obtained during anti-
Intravenous combinat n, therapy. In animal inflammatory
route ion with renal/hepati models, effects thus
other c prostaglandins making it
opioid impairment, sensitize afferent beneficial for
(narcotic hepatic nerves and amplify continuous pain
) pain porphyria, the effect of associated with
medicati history of bradykinin in inflammation.
ons. GI disease, producing pain.
A.Y. 2021-2022
concomitant Prostaglandins are

use of inflammatory
asipirin or mediators.
anticoagula Diclofenac's route of
nts, elderly, action could be
debilitated attributed to a
pts. decrease in
prostaglandins in
peripheral tissues
because it inhibits
prostaglandin
production.
A.Y. 2021-2022
DRUG INDICATIONS CONTRAINDIC MECHANISM OF SIDE NURSING

ATION ACTION EFFECT/ADVERSE RESPONSIBILITY
REACTIONS
Lactated Solutions Adverse Reaction: ▪ Do not
Generic Action:
Ringer's and containing dextrose administer
Name: Reactions which may
5% Dextrose Inj may be 5% Dextrose in unless
occur because of the
lactated ection, USP is contraindicated in Lactated Ringer's solution is
solution or the
ringer's and indicated as a patients with Injection provides clear and
technique of
5% dextrose source of water, known allergy to electrolytes and container is
administration include
injection electrolytes and corn or corn calories, and is a undamaged
febrile response,
calories or as an products. source of water for .
Brand Name: infection at the site of
alkalinizing hydration. It is ▪ Caution
injection, venous
agent. capable of inducing must be
Lactated
thrombosis or
diuresis depending exercised in
Ringer's in 5%
phlebitis extending
on the clinical the
Dextrose
from the site of
condition of the administrati
Therapeutic injection,
patient. This solution on of
Class: extravasation and
also contains lactate parenteral
hypervolemia.
which produces a fluids,
A.Y. 2021-2022
Intravenous metabolic Side effects of especially

Nutritional alkalinizing effect. Lactated Ringer's those
Products. solution are containing
Route:
sodium
Pharmacologic • chest pain,
Intraveneous ions to
classification: • abnormal heart
patients
Onset: rate,
receiving
• decreased bloo
corticostero
Unknown
Route & d pressure,
ids or
Dosage: Peak: • troubled breath
corticotrop
ing,
hin.
This solution Unknown • cough,
▪ Solution
is for
• sneezing,
Duration: containing
intravenous
• rash,
acetate
use only.
Unknown • itching, and
should be
Dosage is to • headache.
used with
be directed by caution as
a physician excess
and is administrati
A.Y. 2021-2022
dependent on may
upon age, result in
weight, metabolic
clinical alkalosis.
condition of ▪ Solution
the patient and containing
laboratory dextrose
determinations should be
. used with
caution in
patients
with known
subclinical
or overt
diabetes
mellitus.
▪ Discard
unused
portion.
A.Y. 2021-2022
▪ In very low
birth
weight
infants,
excessive
or rapid
administrati
on of
dextrose
injection
may result
in increased
serum
osmolality
and
possible
intracerebra
l
A.Y. 2021-2022
hemorrhage
.
▪ Properly
label the IV
Fluid
▪ Observe
aseptic
technique
when
changing
IV fluid
A.Y. 2021-2022
DRUG INDICATION CONTRAINDICA MECHANISM OF SIDE EFFECT / NURSING

FDA Contraindication Common side NURSING

Generic Approved s & Cautions R O P D effects of RESPONSIBILITIE
Name: Indications • Contraindicate o n e u metoclopramide S
metocloprami d in patients u s a r include:
de Metoclopramid hypersensitive t e k a o headache ● Monitor bowel
e has been to drug and in e t t o confusion sounds.
approved by those with i o trouble sleeping ● Safety and
Brand the FDA pheochromoc o o dizziness effectiveness of
Name: specifically to ytoma or other n o restlessness drug haven't been
• Reglan treat nausea catecholamine P 1 1 o sleepiness established for
• Metozolv and vomiting -releasing O 3 - - o exhaustion therapy lasting
ODT in patients with paragangliom 0 2 2 longer than 12
• Metonia gastroesophage as, tardive - h h Common adverse weeks.
al reflux dyskinesia, or 6 r r effects of ● Drug may cause
Therapeutic: disease or seizure 0 tropicamide include: tardive dyskinesia,
GI Stimulants diabetic disorders. m parkinsonian
A.Y. 2021-2022
gastroparesis • Contraindicate i I. Central Nervous symptoms, and

Pharmacolog by increasing d in patients n System: motor restlessness.
ic gastric for whom I 1 u 1 o Anxiety ● Monitor patient for
classification motility. It is stimulation of V - n - o Drowsiness involuntary
: also used to Gastrointestin 3 k 2 o dystonic reactions movements of
Dopamine control nausea al motility m n h o fatigue face, tongue, and
antagonists and vomiting might be i o r o lassitude extremities, which
in dangerous n w o restlessness may indicate
chemotherapy (those with n o seizures tardive dyskinesia
Dosage:
patients. hemorrhage, I 1 u 1 o suicidal ideation or other
ciliary muscle, obstruction, or M 0 n - o akathisia extrapyramidal
10mg
preventing perforation). - k 2 o confusion adverse effects.
Metoclopramid
patient control 1 n h o depression ● Monitor patient for
e intravenously
of the 5 o r o dizziness fever, CNS
(1:45 pm) refractive m w o extrapyramidal symptoms,
measurement Black Box i n symptoms irregular pulse,
Warning n o fever cardiac
• Drug can Half-life: 4-6 o hallucinations arrhythmias, or
cause hours o headache abnormal BP,
A.Y. 2021-2022
Adjust-a-dose irreversible o insomnia which may

(for all tardive Stimulates motility o tardive dyskinesia indicate NMS.
indications): dyskinesia, of upper ● Monitor patient for
• Refer to even after Gastrointestinal tract, II. Cardiovascular: dizziness,
manufacturer drug is increases lower o bradycardia headache, or
's product stopped. Risk esophageal sphincter o supraventricular nervousness after
information increases with tone, and blocks o tachycardia metoclopramide is
for dosage duration of dopamine receptors o hypotension stopped; these may
adjustments, therapy and at the chemoreceptor o transient indicate
if indicated, total trigger zone. hypertension withdrawal.
for elderly cumulative o heart failure ● Diphenhydramine
patients, for dose; there is or benztropine
patients with no treatment. III. Gastrointestinal: may be used to
hepatic or Discontinue o bowel disorders counteract
renal drug if signs o diarrhea extrapyramidal
impairment and symptoms o nausea adverse effects
or ESRD, in occur. Except from high doses.
CYP2D6 in rare cases, IV. Genitourinary:
poor avoid o incontinence
A.Y. 2021-2022
metabolizers treatment for o urinary frequency

, and with longer than 12 o erectile PATIENT
concomitant weeks. dysfunction. TEACHING:
use with • In addition to
strong tardive V. Hematologic: ● Instruct patient to
CYP2D6 dyskinesia, o agranulocytosis take ODTs 30
inhibitors. drug may o neutropenia. minutes before
cause other food and at
>>To prevent extrapyramida VI. Skin: bedtime and not to
or reduce l signs and o rash repeat dose if
nausea and symptoms, o urticaria. inadvertently taken
vomiting from parkinsonian with food.
emetogenic symptoms, VII. Others: ● Tell patient taking
cancer and motor o loss of libido ODTs to open
chemotherapy restlessness. o prolactin secretion blister pack with
• Metocloprami o gynecomastia dry hands and
Adults: 1 to 2 de isn't o amenorrhea. immediately place
mg/kg IV 30 recommended tablet on tongue,
minutes before for use in let it melt
A.Y. 2021-2022
chemotherapy; children due completely, and

repeat every 2 to the risk of then swallow.
hours for two tardive (Taking it with
doses, then dyskinesia and water isn't
every 3 hours other necessary.) If
for three doses. extrapyramida tablet breaks or
l signs and crumbles, advise
>>To prevent symptoms as patient to throw it
or reduce well as the away and take a
postoperative risk of new tablet out of
nausea and methemoglobi the blister pack.
vomiting nemia in ● Tell patient to
neonates. avoid activities
Adults: 10 to 20 • Galactorrhea, that require
mg IM near end amenorrhea, alertness for 2
of surgical gynecomastia, hours after doses.
procedure. and impotence ● Urge patient to
have been report persistent or
reported with serious adverse
A.Y. 2021-2022
>>To facilitate prolactin- reactions

small-bowel elevating promptly.
intubation drugs, ● Teach patient
Adults and including signs and
children older metocloprami symptoms of
than age 14: 10 de, tardive dyskinesia,
mg IV as a other
single dose over Alert: extrapyramidal
1 to 2 minutes. • NMS has signs and
Children ages 6 occurred symptoms, and
to 14: 2.5 to 5 rarely and NMS. Advise
mg IV as a may be fatal. patient to
single dose If signs and discontinue drug
slowly over 1 to symptoms and to seek
2 minutes. develop immediate medical
(fever, CNS attention if such
Children symptoms, signs and
younger than irregular symptoms occur.
pulse, cardiac Advise patient not to
A.Y. 2021-2022
age 6: 0.1 mg/kg arrhythmias, drink alcohol during

IV or abnormal therapy.
as a single dose BP),
slowly over 1 to discontinue
2 minutes. drug.
• Use cautiously
>>To aid in in patients
radiologic exam with history of
Adults: 10 mg depression,
IV as a single Parkinson
dose over 1 to disease, or
2 minutes. HTN'
>> Delayed Dialyzable drug:

gastric No.
emptying
secondary to Overdose S&S:
diabetic • Drowsiness
gastroparesis • Disorientation
A.Y. 2021-2022
Adults: 10 mg • Extrapyramid
PO 30 minutes al reactions
before each • seizures
meal and at • lethargy (in
bedtime for mild infants and
symptoms. children).
Maximum daily
dosage is 40 mg. PREGNANCY
Or, give 10 mg LACTATION-
IM or by slow REPRODUCTI
IV push over 1 ON
to 2 minutes 30 • There are no
minutes before adequate
each meal studies in
and at bedtime pregnant
for up to 10 days women. Use
for severe during
symptoms; then pregnancy
A.Y. 2021-2022
PO dose may be only if clearly

started and needed.
continued for 2 • Drug appears
to 8 weeks. in human
milk. Use
>>GERD cautiously in
Adults: 10 to 15 breastfeeding
mg PO q.i.d., as women.
needed, 30
minutes before
meals and at
bedtime.

FIRST SEMESTER
A.Y. 2021-2022
VI. ECOLOGIC MODEL

HYPOTHESIS
Low blood sugar caused by medication is known as drug-induced low blood sugar. It's most
frequent in insulin users. It is frequent in diabetics who use insulin or other medications to regulate
their condition, but it can also happen if you're taking certain oral diabetic drugs. Even if diabetes
is adequately managed, the medications used to treat it can cause drug-induced low blood sugar.
The disease can also arise when someone who does not have diabetes takes a diabetes medication.
Non-diabetes drugs might produce low blood sugar in rare situations. Taking too much insulin or
diabetes medication, not eating enough, delaying or skipping a meal or snack, increasing exercise
or physical activity without eating more or modifying your meds, and drinking alcohol are all
common causes of diabetic hypoglycemia. Fatigue, irritability, weakness, blurred vision,
headaches, frequent urination, and increased thirst are all symptoms of blood sugar abnormalities.
These symptoms are your body's way of informing you that your blood sugar levels are abnormally
high.

FIRST SEMESTER
A.Y. 2021-2022
ANALYSIS
As reported by Medical News Today, previous study has shown that stress may contribute to
obesity. Stress has also been related to "comfort eating," in which people resort to meals heavy in
fat and sugar in an effort to make themselves feel better. A hormone generated as a result of stress
called cortisol has also been linked to obesity and the metabolic syndrome, according to research
(2017). Moreover, since stress generates an unstable blood glucose level, when the body is under
stress, it prepares itself by ensuring that there is adequate sugar or energy available. It is believed
that insulin levels are falling, glucagon and epinephrine levels are rising, and more glucose is being
released from the liver (Diabetes Education Online, 2021). The year 2005, according to
Narkiewicz, reveals that obesity has been consistently connected with high blood pressure and
increased cardiovascular risk. According to risk estimations derived from population research,
obesity is directly responsible for at least two-thirds of the prevalence of hypertension. (Masters,
2016) states that frequent irregular meals may put you at risk for obesity, high blood pressure, and
type 2 diabetes, independent of how many total calories you consume. According to the findings
of (Polonsky & Henry, 2016), at least 45 percent of individuals with type 2 diabetes (T2D) fail to
attain appropriate glycemic control (HbA1c 7 percent) in their treatment. Poor drug adherence is
a significant contributor to the problem. Adherence to diabetes medications is notoriously difficult
in people with type 2 diabetes. This is linked with poor glycemic control.
PREDISPOSING FACTORS
A. HOST
• Age: 37
• Sex: Female
• Race/Ethnicity: Asian
• Marital Status: Married
• Religion: Catholic

FIRST SEMESTER
A.Y. 2021-2022
• Occupation: Pharmacist
• Comorbidity: The patient has comorbidity (Diabetes Mellitus, Chronic Hypertensive,
Vascular Disease, Obesity, and Urinary Tract Infection)
• Diet: the client, recently has an irregular eating pattern due to the limitations before the
procedure (giving birth).
• Resistance: lowered Resistance due to pregnancy
B. AGENT
• Nutritive Agent: Low salt diet, lack of vitamins in the body, excessive intake of nutrients
C. ENVIRONMENT
• Healthy Surrounding
• Conducive environment
• Clean water and air
CONCLUSION AND RECOMMENDATION

It is thus concluded that the overall manifestation of the patient's health condition is comprised of
Chronic Hypertensive Cardiovascular Disorder, Class II Obesity, Diabetes Mellitus due to
Unstable blood glucose levels, which was caused by irregular and faulty eating habits, constant
stress, and nonadherence to medication specifically designed for the patient's health condition and
pregnancy state. It was confirmed by the assessment findings via Gordon's Functional Health
Pattern, physical and cognitive assessment, which overwhelmed the host with multifactorial causes
that traverse various pathways, emphasizes on agents in explaining diseases, mirroring reality,
making the patient more susceptible to conditions a pregnant woman is at risk during her
pregnancy, as well as her preexisting health complications.

FIRST SEMESTER
A.Y. 2021-2022
Insulin resistance during pregnancy causes gestational diabetes, according to Rashi C. Waghel and
Jennifer A. Wilson, associate professors at Wingate University in Wingate, North Carolina.
Controlling blood glucose levels aids in the prevention of complications in both mother and baby,
such as preeclampsia and macrosomia. Nonpharmacologic methods, such as diet and exercise, are
often sufficient for many women. Additional drugs, such as insulin, metformin, or glyburide, may
be required for certain women. Women with gestational diabetes are more likely to develop
postpartum diabetes.
Non-pregnant hypertension patients have benefited from lifestyle adjustments such as weight loss
and salt reduction. Due to volume constriction, salt restriction is not recommended in
preeclampsia. Bed rest, on the other hand, has been shown to lower blood pressure, produce
diuresis, and avoid premature labor. It is advised to examine the diet, since it is vital to be more
active and healthier on a regular basis. Drinking lots of water to keep hydrated, eating breakfast to
stimulate metabolism, avoiding skipping meals to maintain energy level, eating a balanced diet to
limit the quantity of high fat, high sugar, and high salt foods, and eating iron-rich foods to prevent
iron deficiency are all part of it (anemia). As a result, the patient will avoid the aforementioned
health concerns.
VII. PROBLEM IDENTIFICATION AND PRIOROTIZATION
NURSING DIAGNOSIS RANK JUSTIFICATION
Unstable Blood Glucose r/t 1 This medical condition is highly

ineffective medication management prioritized as it concerns the
AEB increased blood glucose levels patient's blood glucose, according
to the ABC rule. The blood
transports glucose to all your

FIRST SEMESTER
A.Y. 2021-2022
body's cells for energy production.

Long-term damage to blood
vessels, nerves, and other tissues
can ensue from an unstable blood
glucose level. Hyperglycemia is
the result of having too much sugar
in the body while having low levels
of insulin or the inability of the
body to utilize the insulin supplied
by the pancreas and is further
aggravated by ineffective
medication management. This may
cause the patient to experience
polydipsia, polyphagia, and
polyuria (Wayne, 2017).
Acute pain r/t childbirth (post op) 2 According to the ABC rule, this
aeb pain scale of 5/10 and minimal concern is the second most
lochia important as it covers lochia.
After childbirth, the patient
suffers some level of pain or
discomfort. It may have had
suture to treat a rip or episiotomy,
or the perineum may be bruised. If
the patient had a Cesarean birth, it
would have discomfort at the
incision site, making it difficult to

FIRST SEMESTER
A.Y. 2021-2022
move, cough, or even laugh. The

patient can describe the pain by
rating the pain using the pain
scale. Uterine contractions
discharge blood and tissue after
delivery. Lochia is the term for
the vaginal discharge that lasts for
two to six weeks following
delivery (Newton-Wellesley
Hospital, 2014).
Acute pain r/t labor and delivery 3 If labor is approaching, the cervix
process aeb increased blood may shrink, stretch (efface), and
pressure/verbalization of pain open (dilate). This will ready the
cervix for the baby's birth canal
passage (vagina). The contractions
of the uterine muscles and the
tension on the cervix create pain
during childbirth. Severe
cramping, as well as a sore
feeling, can be felt in the belly,
groin, and back. The contractions
of the uterine muscles and the
tension on the cervix create pain
during childbirth. Severe
cramping, as well as a sore
feeling, can be felt in the belly,

FIRST SEMESTER
A.Y. 2021-2022
groin, and back (Ben-joseph,

2018). According to the ABC
rule, this medical problem is the
third priority as it concerns blood
pressure.
Acute pain r/t inflammation and 4 If there are too many leukocytes
infection of the urinary tract aeb in the urinalysis results, it could
diagnostic test: Leukocytes positive be a sign of infection. Leukocytes
(1+) and high levels of bacteria in are white blood cells that help in
Urinalysis. the fight against infection. When
you have more of these than usual
in your urine, it's often a sign of a
problem somewhere in your
urinary tract. Leukocytes in the
urine are frequently caused by a
urinary tract infection (UTI).
Infections in the lower urinary
system, particularly the bladder
and urethra, are common. The
pain associated with the urinary
tract infection includes fever,
chills, back pain, belly pain, etc.
(Watson,2019)
Imbalanced nutrition: More than 5 According to Maslow's hierarchy

body requirement r/t obese II aeb of needs, this problem is the fifth

FIRST SEMESTER
A.Y. 2021-2022
endomorph, height of 152cm, priority as it is under

weight of 131kgs, and BMI of 56.7 physiological needs. If food
consumption exceeds what the
body can utilize for energy,
several problems are likely to
develop. This implies being
overweight, and it is more likely
to develop cardiovascular disease,
type 2 diabetes mellitus, sleep
disorders, infertility in women,
and aggravated musculoskeletal
problems, which puts a higher risk
for heart disease. The body mass
index (BMI) can be used to
determine whether a person is
obese. It's not the most accurate
approach to assess cardiovascular
risk, but somehow the risk of
heart disease and stroke rises as
the BMI rises (Wayne, 2021)
Risk for bleeding AEB LSCS 1 6 This medical condition is the sixth
priority as it concerns risk of
bleeding, according to the ABC
rule. The placenta is generally
pushed out of the uterus after the
infant is born. These contractions

FIRST SEMESTER
A.Y. 2021-2022
put pressure on the blood arteries

in the region where the placenta
was connected after it is delivered.
The blood veins bleed easily if the
uterus does not tighten firmly
enough. After the delivery of a
baby, postpartum hemorrhage
occurs when there is more
bleeding than usual. With a
cesarean birth, it's more likely. It
usually occurs after the placenta
has been delivered, although it can
occasionally occur later
(University of Rochester Medical
Center, 2021).
Risk for infection as evidenced by 7

recent invasive procedure An SSI that only affects the layers
of your skin where your stitches
are is called a superficial
infection. Bacteria from your skin,
the operating room, a surgeon’s
hands, and other surfaces at the
hospital can be transferred into
your wound around the time of
your surgical procedure. Since
your immune system is focused

FIRST SEMESTER
A.Y. 2021-2022
on recovering from surgery, the

germs then multiply at the site of
your infection. (Watson, 2018).
According to Maslow’s Hierarchy
of Needs, this falls under safety
needs which is considered the
patient’s health due to risk of
infection.
Deficient knowledge related to 8 Pathogenic bacteria in the urinary

unfamiliarity with the nature of system produce urinary tract
Urinary Tract Infection (UTI) as infections (UTI). Bacteria that
evidenced by lack of questions on invade the urinary tract system are
infective and preventive processes. usually eliminated by the body
before causing symptoms.
However, germs can sometimes
overwhelm the body's natural
defenses, resulting in infection. If
signs and symptoms of UTI are
disregarded, there is a higher risk
of complications especially to
pregnant women, elderly, people
with diabetes, kidney problems
and weakened immune system
(Vera, 2021). According to ABC

FIRST SEMESTER
A.Y. 2021-2022
rules, this problem falls under

circulation.
Activity intolerance r/t sedentary 9 According to the Maslow’s

lifestyle aeb deviation from normal Hierarchy of needs, this problem
of health perception and health is the ninth priority as it falls
management pattern under self-actualization. A
sedentary or inactive lifestyle is
one that involves a lot of sitting
and lying down with little or no
physical activity. Having an
inactive lifestyle can affect the
body. This contains poor blood
circulation, burns fewer calories,
loses muscle strength and
endurance, and bones may get
weaker and lose some mineral
content. It also has health risks
like obesity, high blood pressure,
type 2 diabetes, and increased
feelings of depression and anxiety
(Health Risks of an Inactive
Lifestyle, 2016).
Ineffective coping r/t inadequate 10 When they feel as if the

opportunity to prepare for stressors obligations or pressures placed on
them are greater than they can

FIRST SEMESTER
A.Y. 2021-2022
aeb deviation from normal of handle, most individuals become

coping - stress tolerance pattern uneasy. This comes with its own
set of tensions and obligations,
ranging from family, job, and
professional role commitments to
major life tragedies like divorce,
sickness, and the loss of a loved
one. Nonetheless, how a person
reacts to such situations is
influenced by their coping
resources (Wayne, 2017). This
problem is the least priority as it
falls under self-actualization,
according to the Maslow’s
Hierarchy of Needs.
Name of Patient: Agustin, Johanna Garcia Age: 30 years old Sex: Female
Civil Status: Married Room/Bed No.: RM 629
Nursing Diagnosis: Unstable blood glucose levels Assessment date: December 1, 2021 Intervention date: December 1, 2021
Prepared by: Meryll Julienne T. Guiwo Section: BSN 219 Clinical Instructor: Preceptor Concepcion Baltazar
Deciembre
PROBLEM: UNSTABLE BLOOD GLUCOSE R/T INEFFECTIVE MEDICATION MANAGEMENT AEB BLOOD GLUCOSE
ABOVE NORMAL LEVELS.
CUES NURSING ANALYSIS GOAL OF CARE INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS AND
OBJECTIVES
Objective: Unstable Blood Scientific: Goal of Care: Summative:

Glucose r/t
VITAL SIGN ineffective After 3 days of The patient was
medication nursing able to stabilize
BP: In accordance intervention, the her blood glucose
management AEB with Dooenges,
140/80mmHg blood glucose client’s blood level after
M.E., glucose levels will nursing education
above normal Moorhouse,
• Nausea levels. be managed within and counselling
M.F., and the normal blood regarding
• Increased Murr, A.C. of sugar levels for adherence to
thirst. NANDA book diabetic therapeutic
Situational: (2019), 15th individuals; 70 to regimen
• Frequent edition, the
urination Unstable Blood 130 mg/dL before prescribed by her
unstable blood meals, and less physician.
Glucose r/t glucose level
• Uncontrolle ineffective than 180 mg/dL UN
the patient is PAR
GOAL MET:
d blood medication after meals due to MET
glucose susceptible to medication TIAL
management AEB variation in LY
level overt diabetes adherence. MET
serum levels of
• Low-fat diet mellitus due to glucose from
nonadherence to the normal
• Frequent therapeutic range, which Objectives:
hunger regimen and compromises
management plan one’s health. After the nursing
for diabetes. This health intervention, the
condition is patient will be able
HEIGHT: to:
152cm associated with
According to the patient’s
WEIGHT: Diabetes pregnancy, and
131kg American was worsen
Association, with the
BMI: 56.7 ineffective
Diabetes in
Blood glucose pregnancy is on medication
level: the rise globally. management
The majority is since the Independent
Fasting: Gestational patient did not Nursing
93mg/dL Diabetes Mellitus, complied to the Intervention
8 Hours after with the rest being her doctor’s a. Within 20
a. The nurse in a. Having data
a. The patient is
preexisting type 1 advice. minutes of informed and
meal: 78 mg/dL charge will regarding the
nursing educated
and type 2 Diabetes conduct nursing patient’s
diabetes. The Mellitus, intervention, more about
education, further knowledge
growth the patient will her condition,
related to discussing regarding her
of Gestational hyperglycemia be informed Diabetes
Diabetes Mellitus condition is the
Diabetes Mellitus (high and educated Mellitus.
Subjective: blood so that her patient first step to UN
and type 2 glucose) occurs more about her educate the GOA
PARTIALLY MET
will be more MET
(Verbatim) condition. L
diabetes, along when there is knowledgeable patient MET:
“Mas madalas with an excess of regarding her regarding her
po ako umiihi obesity globally, sugar in the diagnosis. present
ngayon…” is cause for worry. blood due to a condition. It is
Type 1 and type 2 lack of insulin also to
diabetes increase in the body. determine
maternal and fetal Diabetes appropriate
“Nauuhaw po risk compared to mellitus, treatment to
ako palagi..” a
GDMGestational hyperglycemia manage the
Diabetes Mellitus, condition, may patient’s
with notable cause nausea, condition
“Bago po ako distinctions increased Independent (Curran, A.,
kumain, parang between the two. appetite and 2021)
nahihilo po Neonatal thirst, a fast
ako…” hypoglycemia and pulse, frequent
neonatal urination, and
hyperbilirubinemi other
“After ko pong a are dangers of symptoms. If
kumain, mas uncontrolled left untreated,
nahihilo pa diabetes in hyperglycemia
ako…” pregnancy. may cause
Diabetes during significant Nursing
pregnancy may health b. After 10 Intervention b. Certain common b. The patient
also raise the complications, minutes of b. The nurse and the risk factors,
“Mas madalas verbalized the
incidence of especially if health patient will such as a family possible reason
po ako
obesity and type 2 medication assessment, he determine the history of why she was not
nakakaramdam
diabetes in kids. given is patient will be elements that may diabetes, a able to adhere to
ng gutom
evidently not able to history of poor
ngayon…” be contributing to her medications,
controlling and verbalize the the client's glucose and understood
All diabetic managing the the possible unstable blood management, why it is
women of patient's blood reason why she glucose levels poor exercise important to
reproductive age glucose level was not able to through habits, eating maintain diabetes
should be advised (Nurses Labs, adhere to her disorders, and a therapeutic
assessment.
about strict 2021). medications, failure to notice regimen.
glucose and will changes in
Dysglycemia is understand UN
management prior glucose GOA PAR
a broad phrase why it is L TIAL
MET
to pregnancy. demands, may
to describe a important to MET: LY
A1C rises during all contribute to
complication maintain MET
the first ten weeks blood glucose
with blood diabetes
of pregnancy are stability issues
sugar stability. therapeutic
associated with an (The University
It could regimen.
increased risk of of Utah, 2018).
encompass
diabetic hypoglycemia
embryopathy, (low blood
specifically sugar) or
anencephaly, hyperglycemia
microcephaly, (high blood
congenital heart sugar)
disease, and Independent
caudal regression Nursing
(2017). Intervention
Insulin
regulates blood c. After 15 c. The nurse will c. A blood glucose c. The patient
sugar minutes of educate the monitoring verbalized and
levels. Insulin i health teaching patient regarding device provides demonstrated all
s a hormone regarding blood glucose a convenient her understanding
that is glucose monitoring and accurate from the nursing
produced in the monitoring device. Ascertain method of education
pancreas. device, the that the determining regarding
Insulin aids patient will to patient understan blood glucose utilization of
tissues in your verbalize and ds how to use her levels. This blood glucose
body in demonstrate own blood gadget must be monitoring
absorbing understanding glucose used correctly in device.
glucose (sugar) from the monitoring order to identify UN
nursing GOA PAR
for energy gadget. unstable blood MET
L TIAL
consumption education of glucose levels MET: LY
(Santos- how the (Curran, A., MET
Longhurst, utilization of 2021).
2018). Patient blood glucose
J.A. has monitoring
Hyperglycemia device.
, and the
anomaly in her
blood glucose
stability,
known as
Collaborative
Dysglycemia,
Nursing
is caused by her
Intervention
diabetes d. The patient
medication—- d. On the second d. Refer the patient d. An
Insulin day of nurse
to an endocrinologist discussed and
counselling, is a diabetes learned with an
Levemir, endocrinologist to endocrinologist
The nurse and specialist.
which is now the patient will scientifically Endocrinologist her medication’s
not managing be able to discuss more on s are experts in mechanism of
her high blood discuss and how the client’s the glands that action.
glucose levels. collaborate anti-diabetic make up the UN
with an medications endocrine GOA PAR
MET
L TIAL
endocrinologis work. (hormone) MET: LY
t, learning system. The MET
specifically pancreatic gland
what are the causes diabetes.
mechanism of The pancreas
action of her generates
medications. insulin, and
insulin issues
are at the core of
diabetic
management
(The University
of Utah, 2018).
Necessary in
verifying the
client's
comprehension
of his treatment
regimen in order
to guarantee
compliance and
adherence, and
it is possible and
feasible if an
endocrinologist
is to discuss
with the patient.
Independent
Nursing
Intervention
e. On the 3rd day e. Educate patient e. An registered e. The patient
(last day) of about the nurse practition have
nursing importance of er must not only comprehended
intervention, adhering to master new the importance of
the patient will prescribed areas of care, following the
have diabetic but also doctor’s
comprehend treatment. demonstrate therapeutic
the importance knowledge and regimen
of following ability in areas specifically made
the doctor’s such as for her health
prescription healthcare condition and
and adhering to policy, system diagnosis.
the therapeutic improvement, UN
regimen studies, GOA PAR
L MET
TIAL
specifically scientific proof MET: LY
made for her practice, MET
health teamwork and
condition and complicated
diagnosis. decision making
(University of
Texas
Arlington,
2019). Patient
education is an
essential part of
a nurse's job.
Health
education
empowers
individuals to be
more self-reliant
and healthier.
When involved
in their
treatment,
patients are
more inclined to
assist in steps
that might
improve their
status. If the
nurse health
education is
efficient and
successful, the
patient will be
more educated
and conscious of
their health.
Efficiency:
The strategies or
interventions
were suitable
within a given
time frame to
solve the patient’s
health concern.
GOA UN
PAR
MET
L TIAL
MET: LY
MET
Appropriateness
:
The strategies or
interventions
were appropriate
to solve the
patient’s health
problem.
GOA UN
PAR
L MET
TIAL
MET: LY
MET
Adequacy:
The number of
strategies or
objectives were
enough to solve
the patient’s
health problem.
GOA UN
PAR
L MET
TIAL
MET: LY
MET
After childbirth, the majority of women suffer some level of pain or discomfort. It may have had sutures to heal a rip or episiotomy, or your
perineum may be bruised. Uterine contractions discharge blood and tissue after birth. After birth, the vaginal flow persists for two to six weeks.
Bleeding is frequently strong and bright to dark red during the first several days following birth. Clots the size of a tiny orange are common.
Name of Patient: J.A Age: 37 years old Sex: Female Civil Status: M Room/Bed No.: 629
Nursing Diagnosis: Acute Pain R/T childbirth (post op) aeb pain scale of 5/10 and minimal lochia
Prepared by: Hillary Enriquez Section: BSN219
CUES NURSING ANALYSIS GOALS AND IMPLEMENTATI RATIONALE EVALUATIO

DIAGNOSIS OBJECTIVES ON N
SUBJECTIVE Acute pain R/T In accordance GOAL COLABORATIVE Fatigue and Demonstrate use
(Verbatim) childbirth (post with Newton- SHORT TERM: INTERVENTIONS discomfort, such as of relaxation,
op) Having Wellesley After the The nurse in charge perineal pain and techniques, and
“Masakit yung uterine Hospital After intervention, the will assess the uterine contractions, divisional
tahi ko” as contractions childbirth, the patient will be uterine distractions, are common after activities.
verbalized by discharge blood majority of relieved of her the acute pain to childbirth. The
UNMET
GOAL MET:
PARTIALLY MET
the patient and tissue after women suffer Acute pain r/t include location, chance of dying from
birth. some level of childbirth post op characteristic, onset, a pregnancy-related
“Masakit yung pain or and minimal lochia. frequency, quality, condition is quite
buong tyan ko, discomfort. intensity, and low. Women with
parang parehas You may have precipitating factors chronic diseases such
labas at loob.” had sutures to and the assigned as heart disease,
As verbalized repair a tear or doctor will be needed obesity, or high
by the patient. episiotomy, or in efforts to support blood pressure, on
your perineum the patient and the other hand, are The patient has
OBJECTIVE (region assistance that must more likely to die or been
Facial Grimace surrounding be given to the be close to dying as a administered an
the vaginal patient. result of pregnancy- intravenous and
Guarding opening) may related problems. If medication for
behaviour be bruised. If you have these risk pain
you had a factors, it's very management,
Presence of Cesarean birth, important to keep and the scale of
episiotomy you will have track of your pain rating of
wound discomfort at her acute pain
the incision postpartum health. has reduced to
Pain scale of site, making it (Mayo Clinic, 2021) 2/10.
5/10 and difficult to
minimal lochia move, cough,
UNMET
GOAL MET:
PARTIALLY MET
or even laugh.
PATIENT’S Uterine
VITAL SIGNS contractions
BP: 140/80 discharge
mmHg blood and
Temp: 36oc tissue after
RR: 20 breaths delivery.
per minute Lochia is the
PR: 93 beats term for the
per minute vaginal
discharge that OBJECTIVES: DEPENDENT A localized pain- Based on the
lasts for two to Within 5 hours INTERVENTION blocking treatment nurse's health
six weeks after the nursing The nurse will be known as an epidural education, the
following intervention, the needing physician’s block can be utilized patient
delivery. patient will order and during childbirth. An verbalized all of
experience less prescription for the epidural block her
If you're contractions patient to be able to involves the injection comprehension
passing a lot of discharge blood administer of one or more completely.
huge clots or and pain within interventions and anaesthetics into a
have an tolerable levels. medications that only tiny space outside the
UNMET
GOAL MET:
PARTIALLY MET
exceptionally physicians’ can spinal cord in the
heavy flow 5 hours after prescribe. Nurse will lower back through a
(soaking nursing administer Epidural catheter (epidural
through a large intervention, block through space). This allows
pad in an hour patient will report Intravenous route in for pharmaceutical
or less), pain scale of 2/10, the middle or lower administration to be
contact your She will be able to back, into the area repeated or
nurse in the use appropriate between the spinal continuous. (Mayo
hospital or divisional activities column and the outer Clinic, 2020)
your doctor. It and relaxation membrane of the
is your body’s techniques. spinal cord (epidural
way of space) of the patient
reminding you Patient's baseline that will relieve the
to rest and take pulse, blood patient’s acute pain
it easy. pressure, related to childbirth.
(Nurseslab, respirations, and
2021) relaxed muscle tone INDEPENDENT
or body posture all INTERVENTION
show signs of better The nurse will
well-being. educate the patient
about all the steps the
patient may take to
avoid the problem
from recurring, as
well as the support
the nurse can provide
the patient in order
for her to be
successful with the
health education. The
patient will receive
health education in
the aim of preventing
a recurrence of the
problem.
EFFICIENCY
All interventions
were
administered at
the most
appropriate time
phasing by the
nurse and the
rest of the
healthcare team
in order to
relieve the
client's pain.
UNMET
GOAL MET:
PARTIALLY MET
APPROPRIAT
ENESS
All of the
treatments that
were
recommended
and
administered to
the patient were
appropriate for
the patient's
diagnosis and
concerns.
UNMET
GOAL MET:
PARTIALLY MET
Prepared by: Ana Marie Guiyab Section: BSN219
CUES Nursing Analysis Goal Intervention Rationale Evaluation
Diagnosis
Goal: Short Term Summative:

Subjective: Acute pain r/t Scientific The client
The patient has labor and Analysis: The client will reported that the
stated “Masakit, delivery process report pain pain
at as evidence by According to management management has
nakakapagaod” increased blood (Labor & methods relieve relieved the pain
when asked pressure/verbali Maguire, pain to a after the
regarding the zation of pain. 2008), labor satisfactory level interventions
contraction pain has two within a day of were performed.
components. intervention Met __
Objective: Visceral pain, Partially Met
Facial grimace which occurs ___
BP: 140/80 during the Unmet ___
mmHg early first
stage and the Dependent Nursing Formative:
second stage Objectives: Intervention Effectiveness:
of childbirth, 1. Educate the 1.1Teach patient pain 1.1Works by 1. After
and somatic patient control options increasing the release the
pain, which regarding available, giving the of endorphins, health
occurs during pain pros and cons of boosting the teaching
the late first manageme each. therapeutic effects of of pain
stage and the nt options pain relief manage
second stage. and other medications. ment
The pain of necessary According to (Tawil options,
labor in the information et al, P. (2018), the
first stage is . positive patient
mediated by reinforcement and will be
T10 to L1 encouragement able to
spinal provide the patient make an
segments. On and support person a informe
the other hand, sense of control and d
the second self-confidence. decision
stage is carried regardin
by T12 to L1 g pain
and S2 to S4 control
spinal options
segments. she
According to would
(Goldman, like to
2018), the Dependent Nursing 1.2The patient is use.
blood pressure Intervention more attentive and Yes __ No ___
can rise over 1.2Provide health can better internalize
normal, when teaching between information when not
the patient is uterine contractions. in pain.
in pain.
However, after
managing the
discomfort, the
blood pressure
will be in a
normal range. 2. The client Independent Nursing 2.1Various types of 2. After
will obtain Intervention pain require different health
optimal 2.1Provide by analgesic teaching
Situational relief of administering approaches. Some , the
Analysis: pain. prescribed pain relief respond well to non- patient
medication. opioid pain relievers was able
Pain, anxiety, while others demand to
and fatigue are a combination of answer
known that non-opioid and low the
influence dose opioid. verbally
labor. The asked
amount of pain question
felt during by a
labor and nurse
delivery is with at
different for least
every woman. five
The level of
pain depends correct
on many answers.
factors,
including the Yes __ No ___
size and
position of the
baby, the Dependent Nursing 2.2It helps the entire
woman's level Intervention healthcare team
of comfort 2.2Document evaluate their pain
with the patient’s response to management
process, and pain management. strategy.
the strength of
her
contractions. 3. The
Then, after client
labor, your will be
back might be able to
a bit sore for a control
day or two. the pain
(US as seen
Department of by her
Health and facial
Human reaction
Services, that the
2021) pain
slowly
relieves.
Yes __ No ___
Efficiency:
The strategies
were suitable
within the given
time frame.
Yes _ _
No ____
Appropriatenes
s:
The selected
strategies/
interventions
were appropriate
to the client’s
needs.
Yes __ No ___
Adequacy:
The specific
learning
objectives and
its contents were
enough to meet
the client’s
needs.
Yes _ _
No ____
Acceptability:
The strategies
intervention was
acceptable to the
client.
Yes ___ No
____
Prepared by: Samantha Claire Garcia Section: BSN219
Cues Diagnosis Analysis Planning Implementation Rationale Evaluation
Subjective: Acute pain r/t According to

inflammation Watson (2020), Goal: OUTCOME
• Acute and infection too many EVALUATION
Pain of the urinary leukocytes in the Upon completing :
tract aeb urinalysis the therapeutic
• Sore diagnostic test: results, could be regimen prescribed Upon
throat Leukocytes a sign of by the physician, completing the
positive (1+) infection. the client will be therapeutic
• Nausea Leukocytes are able to exhibit regimen
white blood enhanced well- prescribed by
• Vomitin cells that help in being and the physician,
g the fight against experience pain the client will be
infection. When reduction. able to exhibit
Objectives: you have more enhanced well-
of these than being and
Vital Signs: usual in your experience pain
urine, it's often a reduction.
BP: sign of a
• 140/80 problem ✔ Met
mmHg somewhere in __ Partially Met
RR: your urinary
• 20bpm tract. Leukocyte __ Unmet
s in the urine are
frequently Why? ____
Temperature:
• 36 caused by a
celsius urinary tract
Objectives:
infection (UTI).
After the nursing
Laboratory UTI can cause
intervention, the
Tests: intense back INDEPENDENT
client will be able
• Urinalys pain as the INTERVENTION:
to:
is infection reaches
the kidneys.
• Blood People will get a. The patient a. The nurse a. According to a. The client was
Test pain in the lower will be able will discuss Vera (2021), able to articulate
• Non- back and groin to how frequent the importance
stress area. Back pain understand important it voiding of emptying the
test comes with two the is to void every 2 to 3 bladder.
• CBG other symptoms: importance frequently. hours to
test high fever and of voiding completely ✔ Met
vomiting. frequently. empty the
bladder is __ Partially Met
Height:
• 152cm encouraged __ Unmet
to prevent
Weight: bladder Why? ____
• 151kg distention,
lower
BMI: bacterial
• 56.7 urine counts,
reduce stasis
of the urine,
and prevent
reinfection. It
would also
reduce the
likelihood of
developing
urinary tract
infections,
cystitis and
protect your
kidneys from
damage.
b. The patient
b. The client b. According to verbalized all
b. The nurse
will be able will educate Vera (2021), his
Increasing
to identify the client fluid understanding
the about the consumption comprehensivel
significance significance to 2 to 3 y based on the
of drinking of increasing liters per day provided health
plenty of fluid aids urine education by the
water. consumption. production, nurse.
dilutes urine,
relieves ✔ Met
bladder
irritation, __ Partially Met
improves __ Unmet
renal blood
flow, and Why? ____
flushes
bacteria from
the urinary
system.
Drinking
water dilutes
your urine
and
encourages
you to
urinate more
frequently,
allowing
bacteria in
your urinary
system to be
flushed out
before an
infection
develops.
DEPENDENT
INTERVENTION:
c. After 4hrs c. The nurse

of nursing will c. According to c. The patient
intervention administer Immunodefic was able to
, the client the iency Clinic receive the
will receive medication (2021), medication and
medications prescribed by medications treatment
, prescribed the doctor should be ordered by the
by the and proceed taken physician in
doctor in with the regularly to charge.
charge. treatment. make sure
that you have ✔ Met
an effective
amount of __ Partially Met
drug in your
body at all __ Unmet
times. When Why? ____
medications
are not taken
regularly, the
level of drug
in the blood
can become
too low to
effectively
stop the virus
from
multiplying.
This gives
the virus a
chance to
mutate and
become
resistant to
the effects of
the drug.
COLLABORATIV
\ E
INTERVENTION:
d. According to
d. The nurse Nurse Study d. The urine
d. The patient will (2021), sample of the
will be able collaborate urinalysis is patient was able
to provide with a important to to be checked by
urine Urologist to confirm if the Urologist on
sample for identify if the infection call.
urinalysis there is still a has been
once the trace of completely ✔ Met
medication infection in treated or if
has been the urine of there is need __ Partially Met
completed. the client. to continue __ Unmet
the same
therapy or Why? ____
shift into a
different
treatment.
Efficiency:
The strategies or
interventions
were suitable
within a given
time frame to
solve the client’s
health problem.
✔ Met
__ Partially Met
__ Unmet
Why? ____
Appropriatenes
s:
The
interventions
chosen were
appropriate for
the patient's
needs.
✔ Met
__ Partially Met
__ Unmet
Why? ____
Acceptability:
The given
interventions
and strategies
are acceptable
for the patient.
✔ Met
__ Partially Met
__ Unmet
Why? ____
Effectiveness:
The nursing
interventions are
effective since
the goal was met
as evidenced by
the patient
exhibiting
enhanced well-
being and pain
reduction.
✔ Met
__ Partially Met
__ Unmet
Why? ____
Adequacy:
The number of
specific learning
objectives and
their content
were sufficient
to meet the
client's
healthcare
needs.
✔ Met
__ Partially Met
__ Unmet
Why? ____
Prepared by: Stefannel Krain Jamaica Dychauco Section: BSN219
Cues Nursing Analysis Goal Intervention Rationale Evaluation
Diagnosis
Subjective
n/a Imbalanced Situational Objective
nutrition: Analysis
Objective More than
body >In this case
>Height: the patient Goal: After the
152cm requirement nursing
r/t obese II could not
have a intervention the
>Weight: 131 aeb body weight
kgs endomorph, healthy
lifestyle due within normal
height of average
>Body build: to various
152cm,
endomorph circumstance
weight of
131kgs, and s such as
>BMI: 56.7
BMI of 56.7 stress, poor
eating habits,
a. The patient
personal
will attain
issues and
desirable body
underlying
weight with Independent:
health issues.
optimal
maintenance of a. The nurse will a. This will help a. After the
health assist the patient the patient achieve client
Scientific in determining a her desirable body enumerates
Analysis weight-control weight. the desirable
strategy that body weight,
>Obesity is incorporates the nurse was
defined as an healthy meals. able to give a
increased strategy to
buildup of body attain body
fat of at least weight and
20% over the
optimal
average
desirable weight maintenance
for age, gender, of health.
and height, or a
BMI of greater
than 27.8 for _Met
men and higher b. The patient
than 27.3 for will practice _Partially
women (4 proper lifestyle Met
Obesity Nursing and behavior
modifications, _Unmet
Care Plans,
2014). such as eating Why?_
habits, food
quantity/quality,
and exercise
program
Collaborative:
b. Identify the the b. active b. After
proper lifestyle and participation will identifying the
behavior enable the patient proper
modification to to practice proper lifestyle and
c. The patient provide a health lifestyle and behavior
will demonstrate education program behavior modification,
a change in food modification the nurse was
habits and able to create
participation in a a health
personal education
workout program.
regimen
_Met
_Partially
Met
_Unmet
Why?_
Dependent:
c. Formulate an c. It's best if the c. After the
eating plan with the plan resembles the patient gave a
patient, taking into patient's typical demonstration
account the patient's eating schedule as to change her
height, weight, age, much as feasible. food habits
gender, and eating It is more and
habits, as well as probable that a participation
energy and nutrient strategy prepared in a personal
requirements and with and agreed workout, the
exercise program. upon by the nurse was able
patient would be to create an
effective. eating plan
that suits the
patient’s
height,
weight, age,
gender, and
eating habits.
_Met
_Partially
Met
_Unmet
Why?_
Process
Evaluation:
Efficiency:
The nursing
interventions
were done in the
given time
frame and
resources:
__ yes
__ no
Why? __
Adequacy:
The nursing
interventions
were sufficient
to the needs of
the client.
__ yes
__ no
Why? __
Appropriateness
:
The nursing
interventions
were appropriate
in treating the
client.
__ yes
__ no
Why? __
Acceptability:
The planned
nursing
interventions
were accepted
by the client.
__ yes
__ no
Why? __
Prepared by: Brant Angelo M. Dalisay Section: BSN219
CUES Diagnosis Analysis Goal & Objectives Intervention Rationale Evalua
tion
Subjecti Risk for Scientific: Goal: Outcome
ve bleeding Evaluation:
AEB The risk for The client will be able to
n/a lower bleeding is alleviate the risk of The client was able
segment applicable as the bleeding within 24 to alleviate the risk
cesarea nursing problem hours. of bleeding within
section 1. because the 24 hours.
client is
Objecti susceptible to __ Met
ve blood loss which __ Partially Met
may compromise
suscepti __ Unmet
the health of the
ble to
client (Doenges,
postpart Why? ___
2018).
um
hemorrh
age
associat
ed with
lower
segment Situational: Objective 1: Intervention 1: Rationale 1:
cesarean After 8 hours of
section The nursing After 8 hours of nursing (independent) Monitoring the nursing
procedur problem intervention, the client stability of vital intervention, the
e. happened will be able prevent Monitor vital signs signs is an excellent client was able
because the blood loss, with little or every hour. way of assessing prevent blood loss,
client recently normal amount of lochia further risk or with little or normal
underwent a discharge and absence of impending problem amount of lochia
lower segment heavy bleeding. in a client discharge and
cesarean section.
(Doenges, 2018). absence of heavy
This is caused by
bleeding.
the probability of
postpartum Monitor the vaginal Lochia is a normal
hemorrhage. discharge every discharge of blood
hour. during postpartum __ Met
which should not be __ Partially Met
confused with
postpartum heavy __ Unmet
bleeding (Sillbert-
Why? ___
Flagg & Pilliteri,
2018).
(dependent)
Preparing PRBC or
Prepare 1 unit of
Packed RBC is
PRBC that is
important because it
properly typed and
is an ideal source of
crossmatched with
blood in emergency
the patient for
situations (Doenges,
possible use as
2018).
ordered by the
physician.
Administration of Oxytocin helps
D5NSS 1L+ 20 units maintain the uterus
oxytocin 125ml/hr as contracted therefore
ordered by the it will prevent
physician. unnecessary
bleeding during
postpartum
(Sillbert-Flagg &
Pilliteri, 2018).
Objective 2:
Intervention 2:
After 8 hours of nursing Rationale 2: After 8 hours of
intervention, the client (independent) nursing
monitoring vital Monitoring the
will be able to maintain intervention, the
signs every hour. stability of vital
normal blood volume, client will be able to
signs is an excellent
with little or normal maintain normal
way of assessing
amount of lochia blood volume, with
further risk or
discharge and absence of little or normal
impending problem
heavy bleeding. amount of lochia
in a client
discharge and
(Doenges, 2018).
absence of heavy
bleeding.
__ Met
__ Partially Met
__ Unmet
Why? ___
Monitor vaginal Lochia is a normal
discharge every discharge of blood
hour. during postpartum
which should not be
confused with
postpartum heavy
bleeding (Sillbert-
Flagg & Pilliteri,
2018).
Oxytocin helps
(Dependent)
maintain the uterus
Administration of contracted therefore
D5NSS 1L+ 10 units it will prevent
oxytocin 125ml/hr. unnecessary
bleeding during
postpartum
(Sillbert-Flagg &
Pilliteri, 2018).
Intervention 3:
Objective 3: Rationale 3: After 8 hours of
(independent) nursing
After 8 hours of nursing Monitoring vital The client needs
information for an intervention, the
intervention, the client signs every hour. client would be able
would be able to be free ideal diet that
improves blood to be free from risk
from risk for postpartum for postpartum
hemorrhage, with little clotting, the
Monitoring vaginal characteristics of hemorrhage, with
to normal amount of discharge every little to normal
lochia and absence of bleeding that
hour. indicates serious amount of lochia
heavy bleeding. and absence of
condition requires
immediate, and heavy bleeding.
Providing health preventive measures __ Met
teaching for to ensure safety.
preventing further __ Partially Met
risk of bleeding after (Doenges, 2018).
__ Unmet
discharge for 30
minutes. Why? ___
Process
Evaluation:
Efficiency:
The nursing
interventions were
done in the given
time frame and
resources:
__ yes
__ no
Why? __
Adequacy:
The nursing
interventions were
sufficient to the
needs of the client.
__ yes
__ no
Why? __
Appropriateness:
The nursing
interventions were
appropriate in
treating the client.
__ yes
__ no
Why? __
Acceptability:
The planned nursing
interventions were
accepted by the
client.
__ yes
__ no
Why?
__
Prepared by: Rafael Clemente Section: BSN219
Diagnosis
Subjecti Cesarean delivery Objective
ve Risk of (CD) is one of the 1.Establishing After 15 minutes
infection as most common Maintain core 1.Establish rapport. rapport can have of assessment the
“kakapa experienced procedures temperature within the ability to nurse identified
nganak by recent performed in the normal range sustain a good the
ko lang invasive United States, working causative/contrib
ng procedure. accounting for Identify underlying relationship with ution of the
cesarean 32% of all cause or contributing the patient. patient.
kaninang deliveries. factors and _Met
hapon” Postpartum importance of _Martially Met
surgical site treatment, as well as _Unmet
infection (SSI), signs/ symptoms Why?_
Objec wound infection requiring further
tive and endometritis is evaluation or
a major cause of intervention.
Recen prolonged hospital
t Low stay and poses a Demonstrate behaviors
segme burden to the to monitor and 2. Assess for the After 10 minutes
nt health care system. promote 2. To assess cesarean incision is the nurse have
cesare SSIs complicate a normothermia. causative/contributing an essential part of reduce the
an significant number factors. the postoperative existing risk
sectio of patients who evaluation. The factors of the
n1 undergo CD – 2- presence of fever, patients
(LSCS 7% will tenderness, _Met
) experience sound erythema, purulent _Martially Met
infections and 2- discharge, or _Unmet
16% will develop induration should Why?_
endometritis. raise a suspicion of
Many risk factors infection.
for SSI have been (Kawakita &
described. These Landy, 2017)
include maternal
factors (such as
tobacco use;
limited prenatal
care; obesity; 3. To reduce existing 3.Creating a similar After 10 minutes
corticosteroid use; risk factors. patient care bundle of health
nulliparity; twin comprised teaching, the
gestations; and evidence-based patient has
previous CD), elements in patients learned about
intrapartum and who undergo CD importance of not
operative factors may decrease the taking antibiotics
(such as incidence of this unless
chorioamnionitis; major specifically
premature rupture complication. Each instructed. The
of membranes; hospital has the patient will state
prolonged rupture opportunity to at least 3 things
of membranes; create its own CD they have learned
prolonged labor, surgical bundle to in the discussion.
particularly decrease surgical _Met
prolonged second site infection. _Martially Met
stage; large (Hyperthermia – _Unmet
incision length; Nursing Diagnosis Why?_
subcutaneous & Care Plan,
tissue 2016).
thickness > 3 cm;
subcutaneous
hematoma; lack of
antibiotic
prophylaxis; 4. Promote health 4. It is important to
emergency teaching about the inform the patient
delivery; and importance of not about the
excessive blood taking antibiotics importance of not
loss), and unless specifically taking antibiotics
obstetrical care on instructed by the unless specifically
the teaching doctor with the instructed with by
service of an patient. the doctor . With
academic this the patient will
institution. be able to
(Kawakita & recognize the
Landy, 2017) indication of not
taking antibiotics.
(Kawakita &
Landy, 2017).
Process Evaluation:
Efficiency:
The nursing
interventions were
done in the given
time frame and
resources:
__ yes
__ no
Why? __
Adequacy:
The nursing
interventions were
sufficient to the needs
of the client.
__ yes
__ no
Why? __
Appropriateness:
The nursing
interventions were
appropriate in treating
the client.
__ yes
__ no
Why? __
Acceptability:
The planned nursing
interventions were
accepted by the
client.
__ yes
__ no
Why? __
Prepared by: Cathleen Cajucom Section: BSN219
Diagnosis
Subjecti Deficient Scientific Goal: Evaluation
ve knowledge Analysis: The client will be able to of Goal:
- related to Urinary Tract understand the definition, The client was able to
Objec unfamiliarit Infection (UTI) causes, risks, symptoms, understand the
tive y with the is a condition treatment, and prevention of definition, causes,
-the nature of wherein the Urinary Tract Infection risks, symptoms,
patient Urinary bladder and through verbalization of treatment, and
did Tract associated learnings and improving her prevention of Urinary
not Infection structures such condition along with it. Tract Infection
ask (UTI) as as the urinary through verbalization
any evidenced tract, are of learnings and
questi by lack of infected with improving her
ons questions on bacteria (Bono condition along with
about infective et al., 2021). Objective it.
how and Although A. Independent:
she preventative bacteria lives 1. After 10 minutes of A. Independe
got processes. on our skin and explaining the nt 1. It is important Outcome
infecte around our laboratory results, 1. The nurse that the patient Evaluation
d nor rectum and the client will be will explain understand her
where genitals, it may informed regarding the results to condition and After 10 minutes of
she possibly enter the presence of UTI the client in how it was explaining the
might in the urethra and verbalize what layman’s determined as laboratory results, the
have and travel to the she understood term for her it plays a vital client was informed
gotten urinary tract. In about the results. to easily role for their regarding the
infecte most cases, the understand recovery. presence of UTI and
d with bacteria get what Deficiency in verbalized what she
Urinar flushed out indicated that knowledge of understood about the
y before reaching she has UTI. their illness results.
Tract the bladder. may affect their Met
Infecti However, there understanding Partially Met
on are still of the illness Unmet
(UTI). occurrences that and prolonging
does otherwise. the condition
Indica One of the most (Nunstedt et
tions common al., 2017).
of bacteria that
prese causes UTI is
nce of the Escherichia
Urina coli. More so, it 2. After 5 minutes of 2. Being aware of
2. Additionally, After 5 minutes of
ry is still health teaching, the the disease
the nurse will health teaching, the
Tract important to client will recite itself and its
briefly client was able to
Infect remember that what UTI is, and symptoms is
explain what recite what UTI is,
ion: hygiene, sexual, four (4) of its important as
UTI is and its and four (4) of its
and even common symptoms. these are the
symptoms. common symptoms.
>Findi medical indicators that
ngs in condition a person has Met
Compl factors play a underlying Partially Met
ete part. This is conditions. Unmet
Blood why it is Therefore, the
Count: important to be awareness of
aware and the patient to
- informed of the disease and
Norm such its signs and
al precautions that symptoms may
Neutr must be done to encourage her
ophil: avoid UTI to consult a
0.550 (McIntosh, physician and
- 2021). get immediate
0.650 attentat
Situational (Felman,
- Analysis: 2018).
Actual In relation to the
Findin client’s case, a
g: medical
0.721 diagnosis of
Urinary Tract 3. After 5 minutes of 3. A patient’s After 5 minutes of
>Findi Infection (UTI) health teaching, the 3. The nurse awareness on health teaching, the
ngs in was provided in client will recite will explain the causes of client was able to
what are the
Urinal the case report three (3) possible possible their diseases recite three (3)
ysis: and is also causes of UTI and 2 causes of UTI may increase possible causes of
evidenced by the associated risks of along with their capability UTI and 2 associated
- laboratory UTI. the risks to manage their risks of UTI.
Norm results of high associated condition Met
al neutrophil count with it. (Söder, 2018). Partially Met
Leuko in the complete Moreover, Unmet
cytes: blood count test having good
Negati along with the risk perception
ve (-) presence of plays an
bacteria and essential role in
- leukocytes in the disease
Actual urinalysis elimination
Leuko (Watson, 2019). since it results
cyte Additionally, to the
Findin pregnant women facilitation of
g: have higher risk preventative
Positi of getting UTIs measures,
ve (+) compared to preventing the
other people. recurrence of
- Symptoms of the disease
Norm such condition along with it
al include (Aerts et al.,
Bacter (McIntosh, 2020).
ia: 2021):
0-278/ • Frequent
uL urge to
urinate 4. After 5 minutes of After 5 minutes of
4. The nurse 4. Taking health teaching, the
- • Pain or health teaching, the will discuss medications
Actual client will recite client recited two (2)
discomfort how UTI can prescribed by
Bacter two (2) different different ways to treat
when be treated. your physician
ia ways to treat UTI. UTI.
urinating and adhering to Met
findin • Sudden urge the orders that
g: Partially Met
to urinate come along Unmet
2118.6 • Cloudy, and with it is
/ uL sometimes important to
even with prevent the
blood, disease from
strong- worsening
smelling (US-FDA,
urine 2018).
• Feeling Encouraging
unwell, achy non-
and tired pharmacologic
• A sensation al ways such as
wherein the increase intake
bladder is of water,
not fully drinking
empty cranberry juice,
Having or urinating
knowledge or when urge
cognitive occurs can help
information is an speed up the
important aspect recovery
to be considered (Sissons,
in health 2019).
restoration,
preservation, and
even in
promotion. 5. After 5 minutes of 5. The nurse 5. Non- After 5 minutes of
Therefore, the nursing will teach pharmacologic nursing intervention,
presence of intervention, the non- al pain therapy the client verbalized
deficiency in client will verbalize pharmacologi means that no two (2) non-
knowledge about two (2) non- cal ways to drug pharmacological
a certain disease pharmacological alleviate medications are ways she can do to
that one is ways she can do to bladder pain used in the alleviate bladder
experiencing alleviate bladder or discomfort process. discomfort.
may have discomfort. when it However, pain Met
contributed to occurs. can still be Partially Met
acquiring it and reduced along Unmet
as well as with providing
prolonging the the patients
condition with a sense of
(Wayne, 2019). control over
In the case of the their pain.
client, there Examples of
were no such include
verbalizations massage,
noted nor positioning,
eagerness to guided
know how the imagery, and
said infection even hot and
was acquired. cold
Additionally, the compresses (El
client did not Geziry et al.,
also ask to be 2018).
taught about the
different
precautionary 6. After 10 minutes of 6. The nurse 6. Preventative After 10 minutes of
measurements nursing will discuss measures such nursing intervention,
she can take to intervention, the about as drinking the client recited four
prevent the client will recite precautionary plenty of water, (4) precautions that
recurrence of the four (4) precautions measures that carefully she can take to
infection. Hence, that she can take to the client can washing the prevent the
the nursing prevent the take to genitals and recurrence of UTI.
diagnosis made, recurrence of UTI. prevent being anus, along Met
Deficient infected again with giving in Partially Met
knowledge by UTI. to urination Unmet
related to urge, urinating
unfamiliarity after sexual
with the nature intercourse and
of Urinary Tract ensuring the
Infection (UTI) sanitation of
as evidenced by the toilet that is
lack of questions being utilized.
on infective and Following such
preventative measures is
processes. important as it
can reduce the
likelihood of a
person
acquiring and
re-acquiring
UTI (Sissons,
2019).
B. Dependent
(Facilitativ B.Dependent:
e)
B. Dependent: 1. The nurse 1. Cefuroxime is The client received
1. The client will will used to treat the medication
receive the administer bacterial ordered by the
medication ordered the drug infections as it physician to alleviate
by the physician to ordered: inhibits bacteria the existing UTI.
alleviate the cefuroxime growth since it is Met
existing UTI. 500mg/tablet a cephalosphorin Partially Met
2x a day Per antibiotic. It is Unmet
Orem to the indicated to
client. patients with
certain bacterial
infections such as
urinary tract
infections
(University of
Illinois, 2017).
The oral dosage
for adults is
around 125mg-
500mg twice
daily (Rxlist). It
is also safe to use
during pregnancy Process Evaluation:
(Ogbru, 2019).
Effectiveness
The nursing
interventions were
effective to the
patient:
___ Yes
___ No
___ Why?
Efficacy
The nursing
interventions were
done in the given
time frame and
resources:
___ Yes
___ No
___ Why?
Appropriateness
The nursing
interventions were
appropriate in treating
the patient.
___ Yes
___ No
___ Why?
Adequacy
The nursing
interventions were
sufficient to the needs
of the patient.
___ Yes
___ No
___ Why?
Acceptability
The planned nursing
interventions were
accepted by the
patient.
___ Yes
___ No
___ Why?
Prepared by: Jenson Mark Ganapin Section: BSN219
Diagnosis
Subjective data: Activity A After 1-2 hours • After 1-2 hours of
• The Tolerance r/t sedentary of nursing • Discuss the • Explain to nursing intervention,
Patient sedentary or inactive intervention, importance the patient the patient will be
rated her lifestyle as lifestyle is the patient will of healthy what are able to verbalize
health evidence by a lifestyle be able to gain lifestyle. the benefits knowledge on
3/10. deviation with a lot understanding of having a importance of health
• Verbalized from normal of sitting about the • Encourage healthy management:
sedentary of health and lying importance of the patient lifestyle.
lifestyle perception down, with having a to perform __ Met
and and health very little healthy physical • Regular __ Partially Met
physically management to no lifestyle and activity. exercise __ Unmet
inactive pattern. exercise. benefits of maintains
due to physical • Introduce healthy • After 1-2 hours of
lack of activity. an activity state and nursing intervention,
time and calendar to repeated the patient will show
drive. Objectives: the patient. exercise an increased tolerance
helps to perform activities:
- The patient • Teach the increase
will be able to patient and activity __ Met
Objective data: verbalize family the tolerance. __ Partially Met
Weight:131 kg knowledge on importance __ Unmet
Height: 152cm importance of of • This
health continuing calendar
management. activities. will help • After 1-2 hours of
the patient nursing intervention,
- The patient to keep the patient will
will show an track or achieve an increased
increased monitor conditioned physical
tolerance to his/her state:
perform physical
activities. activity. __ Met
__ Partially Met
- The patient • This will __ Unmet
will achieve an help/teach
increased not the
conditioned patient and
physical state. its family
to maintain
a healthy
and
conditioned
state.
Prepared by: Anne Gabrielle Flores Section: BSN219
CUES NURSING ANALYSIS GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSI
S
Subjective Data: Ineffective Scientific Goal: Evaluation of

The client coping r/t Analysis: The client will be Goal:
verbalized inadequate Ineffective coping able to distinguish The client was able
--“Madami akong opportunity is the inability to possible problems to able to
ginagawa ngayon to prepare manage, respond that may lead to distinguish possible
sa work ko” for stressors to, or make the patient’s problems that may
--“Nas’stress ako aeb decisions ineffective coping have led to the
sa trabaho ko pero deviation surrounding a r/t inadequate patient’s ineffective
parte naman yon ng from normal stressful situation. opportunity to coping related to
trabaho.” of coping - Stressors and prepare for inadequate
stress everyday demands stressors as well opportunity to
Objective Data: tolerance such as work as name any prepare for stressors
--Facial grimace pattern schedules, school episode that may as well as name any
--Feels tense deadlines, family happen during episode that may
--Fells anxious needs, and more nursing care. happen during
regarding the fast- can compound on nursing care.
approaching top of more serious Objectives
deadlines stressors such as After the nursing
--Questions the divorce or the loss intervention, the
quality of her of a loved one. client will be
works (Wagner, 2021) able to
--Episodes of Because of these
breakdowns from factors, the client
overwhelming fail to make sound
distress. decisions using
--Feels uneasy and inappropriate
despairing resources or none at
all. Coping Independent Outcome
mechanisms break Nursing Evaluation:
down due to stress Intervention
and build pressure
that eventually 1. The client 1. The nurse will 1. According to 1. The client
exceeds problem- will be able to conduct a health Morin (2020), was able to
solving skills. evaluate the teaching about we face evaluate her
(RNlessons, 2020) ability to behavioral and enough stress ability to
understand physiological in life without understand
Work-related stress events and responses to putting more events and
is a growing provide stress and how to on ourselves, provided
problem around the realistic evaluate the but that's realistic
world that affects appraisal of ability to exactly what appraisal of
not only the health situation to understand many of us situation to
and well-being of decrease her events and how do, in one decrease
employees, but also self-pressure. to decrease self- way or her self-
the productivity of pressure. another, pressure.
organizations. sometimes Met [ ]
Work-related stress without even Partially Met [ ]
arises where work realizing it. Unmet [ ]
demands of various The first step
types and toward easing
combinations off of
exceed the person’s yourself is to
capacity and realize when
capability to cope. you might be
(Better Health, making things
2012) harder on
yourself
Considering unnecessarily.
healthy ways to Without
cope and getting blaming
the appropriate care yourself, why
and support can put not learn what
problems in you can do to
perspective and stop the self-
help stressful sabotage and
feelings and be your own
symptoms subside. strongest ally
Nurses, together in stress
with the patients, relief? Here
need to recognize are some of
stress accordingly the best ways
to come up with the to make the
most effective yet most of your
proper strategies life and cut
that work best for down on self-
every patient. imposed
(Wayne, 2016). stress. Also,
she stated that
Situational working hard
Analysis: can lead to
In relation to our less stress if it
client, work-related translates into
stress can be caused greater
by various events. resources and
She stated that her a sense of
source of stress this accomplishm
past few months is ent.
demanding
occupation due to
the amount of
workload.
Moreover, she
frequently feels 2. The client 2. The nurse will 2. Goal setting 2. The client
tense and anxious will be able to assist the client is a powerful was able to
regarding the fast- set realistic in setting tool that can set realistic
approaching and realistic goals improve and
deadlines and achievable and identify her motivation achievable
questions the goals and personal goals at and your goals and
quality of her identify her work. chance of identified
works. Frequently, personal goals success. But her
she has episodes of at work. that’s not personal
breakdowns from always the goals at
overwhelming case. If you work.
distress. Also, she don’t set Met [ ]
feels uneasy and well-defined Partially Met [ ]
despairing. goals, they Unmet [ ]
can harm
Most people often your success
feel uncomfortable and lead to
when they feel like frustration
the demands or and
pressures on them procrastinatio
are more than what n. (Mick,
they can cope with 2021) In an
(Wayne, 2016). article, James
Some signs or Clear talks
symptoms of work- about the
related stress can be Goldilocks
physical, Rule. The
psychological and premise of the
behavioural Goldilocks
include: rule is that
humans are
Physical symptoms: only
- Fatigue motivated
- Muscular when the task
tension at hand is the
- Headaches absolute
- Heart optimum
palpitations level of
- Sleeping difficulty.
difficulties, Clear argues
such as that if
insomnia something is
- Gastrointes too easy, then
tinal you simply
upsets, get bored. In
such as other words,
diarrhea or if your goal is
too simple,
constipatio then your
n motivation
will die off
Psychological because you
symptoms: are, quite
- Depression frankly, not
- Anxiety feeling
- Discourage challenged
ment enough. If, on
- Irritability the other
- Pessimism hand, the task
- Feelings of is far too
being difficult
overwhelm (impossible,
ed and even), then
unable to you become
cope demotivated,
- Cognitive believing that
difficulties, no matter
such as a what you do,
reduced you won’t be
ability to able to
concentrate achieve it.
or make Think about
decisions. playing chess
as an amateur
Behavioral against a
symptoms: Grandmaster.
- An increase Being
in sick days obliterated
or over and over
absenteeis again is likely
m to result in
- Aggression your eventual
- Diminished giving up.
creativity (Clear, 2016)
and
initiative
- A drop in
work 3. The client 3. The nurse will 3. Coping 3. The client
performanc will be able to conduct a health usually was able to
e verbalize how teaching in involves verbalize
- Problems to cope with regards with adjusting to how to
with everyday coping with or tolerating cope with
interperson stressors. everyday negative everyday
al stressors. events or stressors.
relationship realities while Met [ ]
s you try to Partially Met [ ]
- Mood keep your Unmet [ ]
swings and positive self-
irritability image and
- Lower emotional
tolerance of equilibrium.
frustration Coping
and occurs in the
impatience context of life
- Disinterest changes that
- Isolation. are perceived
(Better to be
Health, stressful.
2012) Coping
involves
adjusting to
unusual
demands, or
stressors. This
requires
giving a
greater effort
and using
greater energy
than what's
needed in the
daily routines
of life.
Prolonged
mobilization
of effort can
contribute to
elevated
levels of
stress-related
hormones and
to eventual
physical
breakdown
and illness.
Some
common
coping
mechanisms
may
challenge you
to:
- Lower
your
expectatio
ns
- Ask
others to
help or
assist
you.
- Take
responsibi
lity for
the
situation.
- Engage in
problem
solving.
- Maintain
emotional
ly
supportiv
e
relationsh
ips
- Maintain
emotional
composur
e or,
alternativ
ely,
expressin
g
distressin
g
emotions.
- Challenge
previousl
y held
beliefs
that are
no longer
adaptive.
- Directly
attempt to
change
the source
of stress.
- Distance
yourself
from the
source of
stress.
- View the
problem
through a
religious
perspectiv
e.
(Clevelan
d Clinic,
2021)
4. The client 4. The nurse will 4. According to 4. The client

will be able to encourage the Pillay (2014), was able to
recognize her patient to your strengths recognize
strengths and recognize his or are things you her
weaknesses in her own can leverage strengths
the strengths and on, things you and
workplace. abilities in the can use to weaknesses
workplace. push yourself in the
further. On workplace.
the other Met [ ]
hand, your Partially Met [ ]
weaknesses Unmet [ ]
are not your
downfall.
These are
areas you
need to
improve on. It
is not
something
you lack. It is
something
you need to
develop and
build. Your
biggest
personal
strength
would be
something
that comes
very easily
for you. Take
some time
and think
about what
comes
naturally for
you. It could
be anything.
It is equally
important to
know your
weaknesses as
much as
knowing your
strengths.
Your
weaknesses
hold you back
from
achieving
many great
things.
Weaknesses
are areas that
you have the
power to
improve. It
can be
anything
ranging from
professional
to social
skills. (Pillay,
2014)
5. The client 5. The nurse will 5. Emotional 5. The client

will be able to conduct a health health is more was able to
give at least 7 teaching about about being in give 6/7
activities that the importance tune with activities
will help of mental and your that will
improve her physical emotions. It’s help
mental and activities such as about being improve her
emotional reading a book, able to mental and
health. television a recognize and emotional
movie, outings, handle the health.
listening to the emotions that Met [ ]
radio, crafts, you have as Partially Met [ ]
exercise, sports, they happen Unmet [ ]
games, dinners in a healthy
out, and social way. Some
gatherings. mental health
activities to
encourage
emotional
health
- Make
sleep a
priority
- reading a
book
- watching
a movie
- outings
- listening
to the
radio
- crafts
- exercise
- sports
- games,
dinners
out
- social
gathering
s (Better
Help,
2020)
6. The client 6. The nurse will 6. While stress

will be able to conduct a health is an 6. The client
verbalize and teaching to the automatic was able to
practice the 4 client in regards response from verbalize
A’s (Avoid, on how to your nervous and practice
Alter, Adapt practice the 4 system, some the 4 A’s
& Accept) of A’s (Avoid, stressors arise (Avoid,
stress Alter, Adapt & at predictable Alter,
management Accept) of stress times: your Adapt &
management. commute to Accept) of
work, a stress
meeting with
your boss, or managemen
family t
gatherings, Met [ ]
for example. Partially Met [ ]
When Unmet [ ]
handling such
predictable
stressors, you
can either
change the
situation or
change your
reaction.
When
deciding
which option
to choose in
any given
scenario, it’s
helpful to
think of the
four A’s:
avoid, alter,
adapt, or
accept.
(Robinson,
2011)
7. The client 7. The nurse will 7. Deep

will be able to conduct a breathing can 7. The client
perform demonstration be a helpful was able to
breathing regrading proper strategy to perform
exercise. breathing use if you are breathing
exercise. struggling exercise
with a Met [ ]
difficult Partially Met [ ]
situation. Unmet [ ]
When you
feel your
stress level
rise or begin
to experience
difficult
emotions, you
may notice a
physical
response in
your body.
This could
include things
like increased
heart rate,
higher blood
pressure,
dizziness, and
short quick
breaths. Deep
breathing
exercises can
help to
interrupt the
cycle that
stress has on
your physical
body. When
you practice
deep
breathing,
you may
notice that
your heart
rate and blood
pressure
return to
normal. This
can help you
to gain
control over
the difficult
emotions that
you might be
experiencing.
(Better Help,
2020)
Process
Evaluation:
Effectiveness
The nursing
interventions were
effective to the
patient:
___ Yes
___ No
___ Why?
Efficacy
The nursing
interventions were
done in the given
time frame and
resources:
___ Yes
___ No
___ Why?
Appropriateness
The nursing
interventions were
appropriate in
treating the patient.
___ Yes
___ No
___ Why?
Adequacy
The nursing
interventions were
sufficient to the
needs of the patient.
___ Yes
___ No
___ Why?
Acceptability
The planned
nursing
interventions were
accepted by the
patient.
___ Yes
___ No
___ Why?

FIRST SEMESTER
A.Y. 2021-2022
I. EVIDENCED BASED NURSING

Title of the Study: Poor medication adherence in type 2 diabetes: recognizing the scope of
the problem and its key contributors
Journal: Patient Preference and Adherence, Volume 10, 1299–1307.
https://doi.org/10.2147/ppa.s106821
Authors: Polonsky, W., & Henry, R.
Year: 2016
General Question: Does poor medication adherence correlate with inadequate glycemic
control?
Reconstruction of General Question related to client’s problem identified in the RLE:
Did the client’s poor medication management contributed to the increase of her blood
glucose levels?
A. COPES (CLIENT-ORIENTED PRACTICAL EVIDENCE SEARCH)
CLIENT TYPE & WHAT MIGHT ALTERNATE WHAT YOU

PROBLEM YOU DO COURSE OF WANT TO
ACTION ACCOMPLISH
The focus type of Advise the patient Advise the patient to The pregnant women
client are pregnant to switch to switch to humalog with Type 2
women with Type 2 humalog (insulin (insulin lispro) and Diabetes will
Diabetes (T2D) who lispro) to manage ensure to establish achieve positive
fail to achieve blood glucose. patient–physician medication
adequate glycemic trust and provide the adherence and
control. patient a positive

FIRST SEMESTER
A.Y. 2021-2022
perception on maintain adequate

treatment efficacy. glycemic control.
B. PICO
PATIENT FOCUS INTERVENTION COMPARISON OUTCOME
POPULATION
Pregnant women Utilization of The National Health The National Health
with Type 2 medications and Wellness Survey and Wellness
Diabetes (T2D). available along with of 1,198 patients Survey of 1,198
behavioral with T2D found that patients with T2D
innovations on each 1-point drop in found that each 1-
medication self-reported point drop in self-
adherence and health medication reported medication
management adherence (using the adherence (using
Morisky Medication the Morisky
Adherence Scale) Medication
was associated with Adherence Scale)
0.21% increase in was associated with
HbA1c, as well as 0.21% increase in
4.6%, 20.4%, and HbA1c, as well as
20.9% increase in 4.6%, 20.4%, and
physician, 20.9% increase in
emergency room physician,
(ER), and hospital emergency room
visits, respectively. (ER), and hospital
visits, respectively.

FIRST SEMESTER
A.Y. 2021-2022
CRITICAL REVIEW WITH SUMMARY OF THE LITERATURE

Type 2 diabetes has reached epidemic proportions around the world, and it is expected to
continue to rise. At least 45 percent of type 2 diabetes patients do not attain sufficient glucose
control. Despite the fact that a variety of treatment options are now available for T2D,
morbidity and death are still high due to the disease's chronic poor metabolic control,
particularly poor glycemic control.
Poor glycemic control is caused by a number of causes, including a lack of integrated

treatment in many health-care systems, clinical inertia among health-care practitioners, and
poor patient compliance with self-care guidelines. Patients are more inclined to stick to
pharmaceutical regimens if they can see how the drug they're taking is helping them achieve
some quick and good results.
No single type of intervention was consistently successful for promoting adherence, despite
the large range of intervention content. With that, the majority of therapies have centered on
the broad category of lowering treatment burden focusing primarily on the problem of
medication behavior rather than medication attitudes. The specific Type 2 Diabetes therapies
have frequently been described inaccurately. Educational and/or behavioral support
interventions as one of the examples are described as fundamental pillars in the majority of
adherence therapies. It has several tactics that delineate as a complex intervention. But, the
specifics of how they work or what impediments are being targeted and rarely specified.
Multifaceted interventions, on the other hand, have been found to be more effective than
single-strategy approaches.
Medicine adherence includes taking prescriptions properly. It is the degree to which people
take up their physicians' prescriptions appropriately. Taking medicine properly includes having
prescriptions filled, reading medication instructions, taking the correct amount, taking

FIRST SEMESTER
A.Y. 2021-2022
medication at the appropriate frequency, and being persistent and consistent. Medication
adherence is crucial for people with diabetes to manage their disease and live better lives.
However, at least 45% of patients with type 2 diabetes do not attain appropriate glycemic
control (HbA1c 7%). Poor drug adherence is one of the leading causes. Insufficient glycemic
control increased morbidity and mortality. Higher expenses of outpatient treatment, emergency
department visits, hospitalization, and managing diabetic complications are linked to poor
medication adherence in Type-2 diabetes. Patient demographic factors (e.g., young age, low
education level, and low-income level), critical patient beliefs about their medications (e.g.,
perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking
their medications are all linked to poor medication adherence (e.g., treatment complexity, out-
of-pocket costs, and hypoglycemia). Specific obstacles to medication adherence in Type-2
diabetes, especially those that may be modified, need to be identified; initiatives should target
medication burden reduction and patient medication attitudes. These issues necessitate
alternative behavioral approaches as well as new medication delivery systems (Polonsky, W.H.
& Henry, R.R., 2016). Study after study addresses the challenges of diabetic medication
adherence. The diabetic medication adherence statistics help put noncompliance into
perspective. The following are the dilemmas but not limited to:
According to William H. Polonsky and Robert R. Henry, non-adherence to medication

loses $317 billion yearly (2016). The National Institute of Diabetes and Digestive and Kidney
Diseases says 50% of chronic illness drugs are not used as directed. Most patients with type 2
diabetes have inadequate glycemic control, and over 20% of new prescriptions are never
maintained. Approximately 30% of people with diabetes skip at least one oral
antihyperglycemic medicine every month. Medication non-adherence causes up to 69 percent
of medication-related hospitalizations and at least 125,000 fatalities annually. Only 13.2% of

FIRST SEMESTER
A.Y. 2021-2022
people with diabetes get their blood pressure, cholesterol, and glucose goals (Polonsky, W.H.
& Henry, R.R., 2016).
No, people do not just refuse to take their medication. Nonadherence is not the same as
non-intentional non-adherence. Socioeconomic, health care system, and medical comorbidities
may all affect adherence. Nonadherence may take many forms. First, failure to complete a
prescription or begin therapy. Following this, the patient does not take the drug as
recommended (late or improper doses), rendering it useless. Finally, Persistence: The person
begins taking medicine but ultimately stops.
Non-adherence to treatments has been linked to adverse health consequences for patients.
There have been studies on the economic consequences for healthcare providers, such as
increasing hospitalization and readmission rates, but less on the financial consequences for
pharmaceutical corporations.
Medication non-adherence costs pharmaceutical businesses an estimated $637 billion

annually. Evidently, medication non-adherence is a severe worldwide health problem that
requires urgent attention," 'The ultimate frontier' for pharmaceutical firms — the only area of
their business where they can produce significant top-and bottom-line growth, enhance
outcomes, and save the healthcare system at the same time.
Despite new drug classes, enhanced patient education, and focused adherence programs,
Type-2 diabetes medication adherence remains low. New nonpharmacologic and
pharmacologic techniques are required to improve adherence clinically and sustainably.
Innovative approaches to managing treatment burden and patients' problematic medication
views are required. Novel medications or delivery methods that eliminate the need for daily,
weekly, or even monthly doses should be available soon, allowing for enhanced glycemic

FIRST SEMESTER
A.Y. 2021-2022
control, fewer diabetic complications, and reduced health care expenditures and resource
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FAR EASTERN UNIVERSITY

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

Presented to/Submitted to:

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

II. NURSING HEALTH HISTORY

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

experiencing pressure, or cramping. In kidney infection having a fever, chills,

b. CHRONIC HYPERTENSION VASCULAR DISEASE

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

2. PRECIPITATING AND ALLEVIATING FACTORS

B. CHRONIS HYPERTENSION VASCULAR DISEASE

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

3. EFFECT TO OTHER BODY PARTS/FUNCTION

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

b. CHRONIC HYPERTENSION VASCULAR DISEASE

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

lack of energy, high blood pressure, pancreas malfunction, gastroparesis, excessive

4. INTERVENTION/ TREATMENT DONE

B. CHRONIC HYPERTENSION VASCULAR DISEASE

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

C. CHRONIC HYPERTENSION VASCULAR DISEASE

B. PAST HEALTH HISTORY

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

D. FAMILY HEALTH HISTORY (GENOGRAM WITH LEGEND)

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

III. GORDON'S HEALTH ASSESSMENT

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

Interpretation: Deviation from Normal

2. COGNITIVE – PERCEPTUAL PATTERN

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

Interpretation: Deviation for Normal

3. SELF-PERCEPTION – SELF-CONCEPT PATTERN

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

Interpretation: Deviation from Normal

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

4. ROLE - RELATIONSHIP PATTERN

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

5. SEXUALITY – REPRODUCTIVE PATTERN

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

6. COPING – STRESS TOLERANCE PATTERN

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

and emotional well-being (Orzechowska, Zajączkowska, Talarowska, & Calecki, 2013). In

Interpretation of Findings: Deviation from Normal

7. VALUE – BELIEF PATTERN

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

8. NUTRITIONAL – METABOLIC PATTERN

THREE-DAY DIET RECALL

Date: December 1, 2021

MEAL TIME FOOD AMOUNT

Lunch 12:30 pm Water (may have) start sips of water

Crackers ½ pack (30 grams)

Mamon 1 (40 grams)

Snack 3:30 pm ---------- ----------

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

Estimated total liquid intake: 20 mL through the mouth; 2365mL intravenously

Date: December 2, 2021

MEAL TIME FOOD AMOUNT

Breakfast 7:00 am ---------- ----------

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]

Lunch 12:00 pm ---------- ----------

Dinner 6:00 pm ---------- ----------

NCM -107 CARE OF MOTHER AND CHILD ADOLESCENCE [CE]