NURSING ASSESSMENT II
Name of Patient: Casan, Casmer I.
Chief Complaint: Pain on the incisional site associated with dizziness
Dx: G11 PI1 (11-008) Pregnancy uterine 37 weeks and 1 day by LMP
G11 P11 (12-0-0-9) Pregnancy uterine delivered spontaneously cephalic term alive baby boy BW 29 AS 8.9
Impression / Diagnosis: 10 low transverse cesarean section with BTL
Diet: DAT
Type of Operation: Cesarean section
Normal Pattern Before Hospitalization
1. Activities – Rest a. Previously, the patient's a.
activities before
hospitalization are doing
household chores such as
a. Activities cleaning in the morning,
b. Rest washing clothes, and cooking.
c. Sleeping Pattern b. The patient usually rests in her
free time. b.
c. The patient sleeps around 9pm
and wakes up at 4am.
c.
2. Nutritional a. The patient usually eat 2 cups a.
Metabolic of rice with fish and
vegetables and drinks 8
glasses of water a day. b.
b. She likes to eat fruits such as c.
Initial
She perceived herself as
weak with insufficient
energy to perform required
activities, she spent most of
the time lying on the bed and
she could not get up from
bed.
She spends most of her time
sleeping or resting on the
bed.
The patient doesn't have a
sleeping pattern due to the
hospital setting, her sleeping
was always disturbed.
The patient was only
allowed to eat liquid food
such as porridge.
Soft diet
Soft diet
Age: 37 years old
Sex: Female
Inclusive Dates of Care: January 19-20, 2024
Allergies: NONE
Clinical Appraisal
Day 1 Day 2
a. The patient could somehow sit
properly on the bed and spent
most of her time talking with
her family and other patients
inside the ward.
b. She spent most of her time
sitting or lying on the bed.
c. According to the patient, she
could not find a suitable
position for sleep. She tries to
take naps during the day to
regain energy.
a. This time the patient was on
DAT. She ate rice with
chicken and porridge.
b. DAT
c. The patient diet restrictions are
a. Typical Intake oranges, watermelon, and also d. Not taken gas forming food.
vegetables. e. Medication given are: d. Not taken
(food or fluid) c. No diet restriction - Ferrous sulfate e. Medication given are:
b. Diet d. A weight of 66 kg - Ferrous sulfate
c. Diet restriction e. She takes over-the-counter
d. Weight drugs such as Paracetamol
e. Medication/
Supplement food

Normal Pattern Before Hospitalization Clinical Appraisal

Initial Day 1 Day 2

3. Elimination a. The patient usually voids at
least more than 10 times a
day. Urine was usually from
a. Urine (frequency, clear to yellowish color.
color, b. The patient usually defecates
transparency) once a day. It is often times
formed and brown in color.
a. The patient had a catheter a. The patient had a catheter and
and urine output of 300ml; urine output of 400ml; urine is
urine is yellow in color and yellow in color and is
is transparent. transparent.
b. The patient had not b. During assessment, the patient
defecated the entire day. had not defecated.

b. Bowel (frequency,
color,
transparency)
4. Ego Integrity
a. Perception of Self
b. Coping Mechanism
c. Support System
d. Mood / Affect
5. Neuro – sensory
a. Mental State
b. Condition of 5 despite her situation.
Senses:
(sight, hearing, smell,
taste, touch)
a. The patient usually had a
feeling of worriedness during
her pregnancy.
b. The patient usually coped with
stress by praying, and sharing
her problems with her
husband.
c. The patient’s support system
is her family.
d. According to the patient, she
sometimes feels happy one
minute to feel irritable the
next.
a. The patient was mentally
healthy and happy and acts to
situations appropriately
b. Not taken
a. The patient tries to smile
when talked to despite her
condition
b. Talking with her family and
resting is considered a
coping mechanism.
c. Her husband and family are
acting as her support system.
d. The patient was
approachable, and she
doesn’t seem irritable and
friendly.
a. The patient is talkative,
oriented on time, place and
person.
b. No reported problems
related to sight; pupils react
to light by testing papillary
reaction to light. She has no
problem regarding her
hearing, assessed by weber
test and rinne test. Has a
normal sense of touch
assessed by light-touch
sensation and also has a
normal sense of taste
assessed by eating porridge.
Has a normal sense of smell
assessed by odor
identification.
a. According to her she is a calm
person and can maintain her
patience despite her situation.
b. Talking with her family and
resting is considered a coping
mechanism.
c. Her husband and family are
acting as her support system.
d. The patient was approachable,
and she doesn’t seem irritable
and friendly.
a. The patient is talkative,
oriented on time, place and
person.
b. No reported problems related
to sight; pupils react to light by
testing papillary reaction to
light. She has no problem
regarding her hearing, assessed
by weber test and rinne test.
Has a normal sense of touch
assessed by light-touch
sensation and also has a
normal sense of taste assessed
by eating porridge. Has a
normal sense of smell assessed
by odor identification.
 Normal Pattern Clinical Appraisal
Before Hospitalization
Initial Day 1 Day 2

6. Oxygenated and Not taken a. RR: 19 cpm a. RR: 20 cpm

Vital Signs b. PHR: 99 bpm b. PHR: 119 bpm
c. Temp: 37.0 degree celsius c. Temp: 37.2 degree celcius
d. BP : 120/80 mmHg d. BP: 120/70 mmHg
a. Respiratory Rate
e. The patient has a vesicular e. The patient has a vesicular
b. Pulse Rate
normal lung sounds. normal lung sounds.
c. Temperature
f. No history of respiratory f. No history of respiratory
d. Blood Pressure
problems. problems.
e. Lung Sounds
f. History of
Respiratory
Problems
 a. The patient usually a. The patient was complaining a. The patient verbalized she
7. Pain Comfort experienced abdominal of dizziness but it was doesn’t feel any pain/dizziness
cramps due to her condition; it intermittent; aggravated by anymore but still has body
begin at 12 midnight, the day
sitting. weakness .
before she was admitted. Also
a. Pain (location, experiencing lower back pain b. Alleviated by resting or/and b. Alleviated by resting or/and
onset, intensity, that lasted for 10 minutes sleeping. lying in bed and sleeping.
duration, aggravated by sitting. c. Medication given was: c. N/A
b. Alleviated by lying on bed - Mefenamic Acid
associated
or/and sleeping.
symptoms, c. N/A
aggravation)
b. Comfort
Measures /
Alleviation
c. Medication

Normal Pattern Before Hospitalization Clinical Appraisal

Initial Day 1 Day 2

 a. The patient usually wakes up
8. Hygiene & to do household chores then
Activities of Daily gets some rest and usually
Living takes a bath everyday, and
brushes her teeth once or
thrice a day. She cuts her nails
every 1 week.
a. Due to her condition, she
spends most of her time
resting, and sleeping. The
personal hygiene of the
patient is performed and
maintained by the patient's
SO, the SO helps the patient
change clothes.
a. Due to her condition, she
spends most of her time
resting, and sleeping. The
personal hygiene of the patient
is performed and maintained
by the patient's SO, the SO
helps the patient change
clothes.

a. Patient’s menarche when she
was 14 years old, married and
37 years old, currently has an
9. Sexually ll living children.
a. Patient’s menarche was she a. Patient’s menarche was she
was 14 years old, married was 14 years old, married and
and 37 years old, currently 37 years old, currently has an
has an ll living children ll living children

a. Female (menarche,
menstrual cycle,
civil status, number
of children,
reproductive organ.

b. Male
(circumcision, civil
status, number of
children)