PATIENT’S PROFILE

Name: T.S

Age: 24yrs. old

Gender: Female

Date of Birth: August 26, 1995

Civil Status: Married

Address: San Gabriel Village, Tuguegarao City

Nationality: Filipino

Dialect Spoken: Tagalog, Itawes, Ybanag

Religion: Roman Catholic

Educational Attainment: College graduate

Occupation: House Wife

Source of Information: Patient and Maternal Record

Attending Midwife: Janet Beran

L.M.P: January 2019

Ob Score: G1 P1 (10010).
NURSING HEALTH HISTORY

Past Health History

According to patient T.S, she received complete vaccination such as (1 BCG, 3 HEPA B,
3DPT, 3OPV, 1 measles) she claimed that, she had suffered measles during her childhood. She
also said that she seldom experiences fever, cough and colds and take over the counter drugs
such as Paracetamol 500mg and also added water therapy as initial management in overcoming
her cough and colds. According to patient T.S, she doesn’t have an allergy on food. She also
states that she doesn’t drink liquor and smoke.

Maternal History
Patient T.S had her first menarche when she was 15 yrs. old, she states that her
menstruation last for about 5-7 days with moderate pain. In addition to that, she consumes 3-5
pads a day. Patient T. S’s first sexual intercourse with her husband was when she was 23 yrs.
Old. Her first child is a baby girl and 11 months old. According to her, they remain in a
monogamous relationship with her husband.

Her OB Score is G1 P1 (10010). She delivered her first child at full term via CS at Peoples
General Hospital Tuguegarao City on October 12, 2019.

According to the patient her last LMP was on January 2019. She noticed that her menstrual
period was delayed she already assume that she is pregnant; she immediately consulted their
Rural Health Midwife. She visited their RHU midwife regularly for prenatal checkup. She takes
dietary supplement such as Ascorbic acid 500mg Multivitamins +Iron during her pregnancy. She
even drinks supplemental milk like Anmum during her pregnancy. The patient received her 3rd
dose of Tetanus Toxoid on February 26, 2020.

Family History
Patient T. S’s mother has a hypertension and diabetes and her father died because of
Cardiac Disease. She states that both her paternal and maternal side has a history of
Hypertension.
 Date Assessed: September 20, 2020
Time Assessed: 9:30 AM
Vital Signs:
Temperature: 36.5 ℃ Respiratory Rate: 18 cpm
Pulse Rate: 88 bpm Blood Pressure: 120/80 mmhg
General Appearance: Upon assessing, the patient is in a sitting and supine position, awake,
conscious and coherent.

AREA METHOD NORMAL ABNORMAL Rationale

ASSESSED USED FINDINGS FINDINGS
SKIN
 Color Inspection  In Bluish(cyanosis), Changes in color are indicative
white Pallor, Loss of of pathological alterations.
skin: pigmentation,
Light Yellow-
to dark orange(jaundice),
pink Red(erythema),
 In Tan-brown
dark
skin:
light to
dark
brown,
olive
 Texture Palpation Smooth, Soft Localized texture may result in
trauma, surgical wounds, or
lesion.

 Temperatu Palpation/ Warm to touch Hyperthermia and To determine skin temperature.

re Inspection (36.5 to 37.5 Hypothermia Skin temperature reflects the
with C) increase or decrease of blood
thermometer flow.
 Turgor Deep Brings back to Altered turgor To indicate elasticity and
palpation its original increases to risk possible dehydration and
state when for pressure others.
pinch (1-3 sec) ulcers.
 Edema Palpation No edema Presence of To identify if the area has
edema swelling or may due to
inflammation.
 Moisture Palpation Not too dry, Dryness and Moisture is related to the
not too oily excess oil. degree of hydration and
condition of outer lipid layer of
the skin surface.
 Lesions Inspection No lesions Macule, Vesicle, To identify certain skin lesions
 Papule, Pustule, through characterized patterns
Nodule, Ulcer, of features.
Tumor, Atrophy,
Wheal
HAIR Changes in hair color depends
on or either the patient is
 Color Inspection Varies on race already old.
Changes in hair distribution
 Distributio Inspection Evenly Hair loss, hair reflect hormonal changes,
n and distributed thinning due to changes due to aging, poor
quantity hormonal causes nutrition, or use of certain hair
care products.
 Texture Inspection Silky, resilient Dry and kinky, Changes in hair distribution
and presences of split reflect hormonal changes,
thickness ends changes due to aging, poor
nutrition, or use of certain hair
care products.
 Presence Inspection none Presence of To determine the presence of
of Infestation microorganisms bacterial and microorganisms.

HEAD To identify the symmetry and

Presence abnormalities and deformities
 Scalp and Inspection, Round and deformities in area
Symmetry Palpation symmetrical
Presence of
 Texture Palpation Smooth dandruff, alopecia

 Shape Inspection Round Deformity and To identify the shape and size
and Palpation tenderness, of the head with underlaying
hydrocephalus abnormalities
 Nodules/ Inspection No nodules Presence of
Lesions and Palpation and lesions masses and
lesions
FACE

 Symmetry Inspection Symmetrical Facial paralysis, Neurological disorders such as

facial paralysis sometimes
affect the symmetry of the
face.
 Skin in Inspection May vary Decrease/ To determine pathological skin
color according to increase in diseases and to identify area
race; without melanin, skin wherein melanin production is
abrasions/lesio pigmentation lowest.
ns
 Edema Inspection No edema Edema To determine any palpable
 and Palpation abnormalities in the area.
EYES
Asymmetrical positioning or
 Eyebrows Symmetrically eye movement reflects trauma
 Position Inspection aligned or tumor growth.
Alignment

 Visual Inspection Normal is Blindness, To test for the visual acuity of

Acuity 20/20 Myopia, the patient or visual loss
Hyperopia,
Presbyopia,
Astigmatism
 Hair Inspection Symmetrically
Distributio aligned
n

 Color Inspection May vary

according to
race
 Eyelids Inspection Skin is intact, Presence of To determine any discharges or
 Skin no discharges; discharges asymmetry in eye lids.
quality Lids close
symmetrically
 Texture Inspection Smooth and
has the color
of the skin
 Eyelashes Inspection Equally
distributed,
slightly curved
outside
 Sclera Inspection white Jaundice, or any To identify any pathological
eye infection signs
 Conjuncti Inspection Clear, moist, Changes in color of
va and Palpation pink conjunctiva may be due to
local infection, or other
symptomatic abnormality such
as pale conjunctiva due to
anemia.
 Pupils Inspection PEERLA Anisocoria Darkened room normally
ensures brisk response of
 Reaction pupils to light. Pupils is
to light illuminated constricts. Pupil in
another eye should constrict
equally.
  Shape Inspection Round Normal pupils are round,
regular, and equal in size and
shape.
EARS Firm, mobile, To determine any deformity in
no tenderness, both ears.
 Texture, Inspection pinna recoils
Elasticity and Palpation after it is
folded
 Discharge Inspection No discharges Presence of To determine any presence of
s discharges, discharges, infection
yellowish
 Symmetry Inspection Symmetrical asymmetrical To identify the symmetry of
the both ears
 Size Inspection The same with To identify the sizes of the ears
both side
NOSE
Character of discharge and
 Shape, Inspection Symmetrical, Asymmetry inflammation indicate allergies
Size, Intact in the or infection
nasal septum midline
Perforation and erosion of the
 Symmetry Inspection Symmetrical Asymmetry septum and puffiness increase
vascularity of the mucosa
indicate habitual use of drugs.
 Tendernes Palpation No tenderness Presence of Infection, allergy or drug use
s tenderness sometimes causes tenderness.
MOUTH Smooth and Lesions, mouth To determine if there is
 Lips Inspection moist without thrust, presence of lesions and
lesions or hydration
swelling
 Color Inspection pinkish pale To inspect for mouth
discoloration
 Buccal Inspection Smooth and Central cyanosis, To determine if there is
Mucosa moist without mouth cancer presence of lesions and
lesions hydration
DENTITION
 Number of Inspection 32 Impacted teeth Numbers of teeth varies in ages
teeth
 Color Inspection white Yellow due to
tartar
GUMS Pinkish, moist, Pale and dry To determine if there is
 Color and Inspection shinny presence of lesions and
moisture hydration

NECK Inspection Normally

 Position and Palpation located Fracture To determine the location of
 centrally in the the neck and its present
shoulders. structures, thyroid gland and
trachea.
 Reflex Bilateral Difficulty in neck Detects muscle weakness,
symmetry movement strain, and range of motion,
muscle strain, head/nerve
injury.
 Lymph Equal sizes in Swollen lymph Lymph nodes are sometimes
nodes both sides and nodes enlarged from infection or
distributed other diseases such as cancer,
goiter, etc.
THORAX
 (POSTER Inspection Symmetrical Pigeon Chest, To identify thoracic
IOR) Chest Funnel Chest, abnormalities and deformity
 Chest expansion Kyphosis and
Expansion scoliosis
 (ANTERI Inspection Quiet, Crackles, To check for the presence or
OR) and Rhythmic, Gurgles, Friction alterations in breath pattern,
 Breathing Effortless, 16 rub, Wheeze breath sounds
Pattern to 24 CPM
Auscultation Vesicular,
Bronchovesicu
lar and
bronchial.
Percussion Resonant Hyper-resonance
HEART Auscultation 110/70 regular Murmurs, To determine the normal
rhythm and irregular heart systole and diastole of the
soft systolic beat heart, sounds, rate
murmur are
audible
AXILLAE No tenderness, Presence of To check for the presence of
 Mass, Inspection masses and tenderness, tenderness, masses and nodules
Tendernes and Palpation nodules masses and
s nodules
ABDOMEN
 Skin Inspection Uniform with Skin problems Scars reveal evidences that
Color, the rest of the patient undergo previous
scars, body surgery or trauma. Striae
lesions, indicates stretching due to
rashes, tissue from growth, obesity,
stretchmar pregnancy, ascites or edema.
ks
 Texture/ Inspection Smooth Frequent injections cause
appearanc bruising and hardening of
e underlaying tissues due to
patients who undergo injection
 of insulin or heparin. Bruising
also indicates physical abuse,
accident, injury or bleeding
disorders.
 Abdomina Inspection Rounded and Asymmetry, Changes in symmetry or
l Contour/ Symmetry ascites, contour reveal underlaying
Symmetry masses, fluid collection, or
gaseous distension.
 Bowel Auscultation A series of Borborygmi, Normal bowel sounds occur
sounds intermittent, Bruits irregularly every 5-15 sec.
soft, clicks and Absence of sounds indicates
gurgles are cessation of gastric motility.
heard (5-20 Hyperactive bowel sounds not
times/min) related to hunger or a recent
meal indicate diarrhea or early
intestinal obstruction.
Hypoactive or absent of bowel
Percussion Dullness sounds indicate paralytic ileus
Tympanic or peritonitis.
Palpation None Presence of
tenderness and
masses
GENITALIA Inspection Pinkish in Presence of foul To determine the associated
color and discharges, factors that affect the
intact and Vaginitis and genitourinary system.
varies in race other pathological
genital problems.
URINARY Inspection Polyuria,
SYSTEM Oliguria, Anuria,
Nocturia,
Dysuria, Urgency,
Enuresis,
Incontinence,
Retention,
Frequency.
ANUS Inspection Patent, Presence of To identify if the anus is patent
perforate hemorrhoids and any presence of
abnormalities
NAILS Can distinguish signs of illness
 Color of Inspection Pink with Yellow, such in liver, lungs, kidney and
Nail Beds translucent tip discoloration, heart
 Shape Inspection Convex Curling or Can distinguish signs of illness
Curvature clubbing such in liver, lungs, kidney and
angle between heart
nail and nail
bed is about
160
  Texture Palpation Smooth brittle Can distinguish signs of illness
such in liver, lungs, kidney and
heart
 Capillary Palpation and Prompt return Can distinguish signs of illness
Refill Inspection to pink less such in liver, lungs, kidney and
than 3 sec heart
when put
under pressure
UPPER AND General overall view to help
LOWER pinpoint areas in-depth
EXTREMETIES Fractures, assessment.
 Sizes/ Inspection Symmetrical deformities,
Alignment asymmetry,
and lordosis,
Symmetry kyphosis,
scoliosis and
gibbus in spinal
curvature.

 Color Inspection Uniform with Yellow, bluish To check or indicative of such

skin color but that may result to skin problems or skin abrasion
varies to race physical abuses or any chronic inflammation.
 Edema Inspection No edema Presence of Reveals changes due to trauma
and Palpation edema or chronic diseases. Dot
attempt to move joint if
fractured or apparently frozen
by lack of movement over a
long period of time.
 Tendernes Inspection None Presence of Indicates acute or chronic
s/Swelling and Palpation masses and inflammation. ROM causes
tenderness pain or injury.
 Texture Palpation Smooth Presence of To determine for deformities,
lesions,
NEUROLOGIC To identify and assess for
 LOC Interview Conscious Coma, stupor alertness and cooperation of
the patient. Dementia and LOC
can influence ability to
cooperate.
 Mental Interview Oriented Disoriented and To identify if the patient has
Status confusion, mental illness and assess for
lethargy mental stability.
 Speech Interview and Clear and Dysphonia, Differs in dialect /language to
Inspection coherent Aphasia, speak
 ROM Inspection Can perform Alteration reflects neurological
ROM impairment, or injury.
Indicates normal ROM of
joints.