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C Address: Centro Sur, Camalaniugan, Cagayan Age: 24 Civil Status: Married Occupation: Housewife Educational Attainment: High School Graduate Nationality: Filipino Religion: Roman Catholic


Vital signs BP: 110/80 mmHg Temperature: 36.7 ˚C RR: 21 cpm PR: 78 bpm


General Appearance My patient is about 5’2” in height, brown complexion.

Her look is appropriate to her age. Her weight is 45 kg and when the baby is growing, her weight is also increasing.


Gordon’s 11 Functional Pattern 1. Health Perception-Health Management Pattern a. Past Health History

she eats three times a day and takes snack two times a day. Present Health History My patient was in good health and according to her she doesn’t have serious illness. or in any kind of drugs. d. Family Health History According to my patient. 2. She used drugs over the counter when she’s sick. she has no allergies in foods. once in the morning and once in the afternoon. She have never been hospitalized. she can feed herself and can swallow liquid and sour foods and she can chew. Daily Practices According to her. 3. they don’t have any serious illness or hereditary illness in their family.My patient is in good health condition and according to her. she brushes her teeth three times a day and sometimes she go for dental check-up for dental carries. Her present weight is 50. b. There are no foods that she doesn’t like. She completed her immunization and took exercise to maintain healthy condition and to prevent illness. She doesn’t smoke and drink liquor. c.3 kg but her usual weight is 45 kg. Nutritional-Metabolic Pattern According to her. Sleep-Rest Pattern .

she expresses . on the day she sleeps two hours as her rest. she has no difficulties and even defect. She consider her daily activities in their house as an exercise but only the activities that she can do and appropriate for her to perform during pregnancy. and she says that she urinates five to six in a day and four to six during the night. 8. She has the ability to read and write.According to her. during her first trimester. 7. she complaints of frequent urination. Cognitive-Perceptual Pattern According to her. not too soft and not too hard. taste. The pattern of her bowel movement is every morning. Activity-Exercise Pattern She is always taking a bath everyday and use proper dress. She can smell. 5. Role-Relationship Pattern My patient’s dialect is Ybanag but she can speak Ilocano. 4. Her bowel elimination as she said. 6. and feel touch. She can speak clear. Tagalog and English. the usual color is brown. she doesn’t sleep normally because of frequent urination disturbance. Elimination Pattern As she said. Self-Perception Pattern She was most concern about her pregnancy and the time when she deliver if she can do or not and her goal is to deliver her baby well.

she started her first menstruation when she was 13 years old. Characteristics of Menstruation 1. MENSTRUAL HISTORY A. B. There’s no sexual problem that occurred to her that she told that they don’t do sexual intercourse during the entire pregnancy. 10. Her husband and her parents help in making decisions and finances because they are too young to involve in marriage life. Odor: foul odor . Sexuality-Sexual Function According to her. Menarche The first menstruation occurred at the age of thirteen.Value-Belief System According to her.herself verbally. her husband and her parents help her because of being still young and she’s doing some activities in their house in order to cope up if she is in stress or tense. Color: red 3. My patient and her husband live to her husband’s parents and she turns to her husband and her parents in time of need. 9. 11. II. She didn’t use contraceptives. Duration: 5-7 days 2. Coping-Stress Management In relation making. they are Roman Catholic and they believe and trust Jesus Christ as their source of strengths and they can give their life meaningful.

seldom suffers from dysmenorrhea and once attacked. III.4. Second Trimester At this trimester. 2. AOG: Clinic Visit: ( Aug. 19. EDC: 4-10-10 C. First Trimester Changes in the trimester and discomfort are nausea and vomiting. History of Present Pregnancy A. assess the signs. and . Interval between menses: 30 days C. Physiology and Psychology changes of pregnancy. Consistency: flow was describing scanty and uses five to six sanitary napkins 5. changes in size. she takes medicine to relief and take a rest. and discomfort associated with pregnancy during: 1. 6 weeks and 5 days ) A. shape. Obstetrical Score G1 PO T1 PO AO L1 B. LMP: 7-3-09 B. 2009. MATERNAL HISTORY A. frequency of urination and headache and linea nigra. the patient’s enlargement of breast and abdomen. symptoms. Discomfort and Nursing Measures She feels dizziness.

2009. she suffered from fever. Prenatal Check-up: Yes When: starting August 19. mumps. Changes of her abdomen and breast. the patient sense changes and feels discomfort like backache. She takes drug over the counter when she feels sick. PAST-HEALTH HISTORY A. dizziness.consistency of her uterus. and chicken pox. colds. movement of fetus and frequency urination. stomach pain. her first visit Where: Barangay Health Center By Whom: Midwife IV. Because she knows that for a healthy pregnant mother will produce her body Cough Mumps Colds . one in the morning and one in the afternoon. linea nigra formed and nipples become large. and tingling sensation. Family History (+) Allergy Chickenpox Fever B. Past-Medical History When she was a child. cough. NUTRITION According to her. B. 3. headache. mild frontal headache. Third Trimester At this trimester. she eats three times a day and takes snacks twice a day. V. And she never hospitalized or suffered from serious illness or disease.

she easily eliminates twice a day. VII.healthy for a healthy baby inside her womb and she said her preparation for giving birth upon her pregnancy she will eat foods which are rich in nutrients for her supplement for her body and for her presence of edema and lesions . Face 2. She takes also vitamins like Ferrous Sulfate.occipital prominence Abnormal Finding .inspection . during her first few months or first trimester of her pregnancy. URINATION As she said.inspection .smooth skull .oily Area Assessed 1. BOWEL MOVEMENT According to presence of mass . Hair . she goes for CR a day before meal but sometimes.palpation Normal Finding . so I tell her that she limit to drink water to avoid frequent urinating.evenly . VI. PHYSICAL ASSESSMENT Method Use . VIII.presence of dandruff . she usually urinates five to six times in a day and four to six in a night and she told that her usual urination will disturb her sleeprest problem.

normocephalic . Eyes .3.equal movement .normal visual acuity . Ears .the color of conjunctiva and .palpation distributed . Nose .inspection 5.inspection .straight .palpation sclera is white . and smooth and reflex blinking .has ability to .no presence of mass .no nasal discharge .symmetric . Head .normal hearing .inspection .no discharge presence 6.inspection .equally aligned . shiny.the colors of cornea is transparent.presence of dandruff 4.

palpation obstruction .soft .no swelling .7.lose tooth (molar) 12.slightly rough .not swelling .no signs of 13.inspection .no cracks or blisters .reddish .inspection .no swelling 10. Lips . Tonsils .inspection .has normal sense of taste .inspection .inspection .palpation smell -air moves freely .no signs of bleeding . Tongue .inspection atrophy .presence of dental carries .no mucus 8. Neck .no eruption. Gums .palpation mass . spots or pigmentation .pinkish in color .no nodules 11.pale in color 9.inspection . Teeth . Mouth .no presence of .

palpation .palpation .no presence of mass .reddening .normal 16.inspection .absence of nipple’s discharge . Breast .auscultation .inspection -palpation .inspection .rhythm pattern is regular . Lungs and Thorax .no prosthesis difficulty of swallowing .auscultation breathing pattern .no lesions .no irritations . Heart .no presence of mass .yellow white in color .not tender .shape is symmetrical .nipples are at same direction 15.nipples are not cracked ..

auscultation .FHB: 130 bpm in the right lower quadrant .regular in rhythm .inspection .heart sound is 18.inspection .palpation murmur and wheezes ..presence of linea nigra and 19. Extremities .no presence of murmurs .uniform in color .palpation striae gravidanum .interview clear .no tenderness . Anal .the sound is clear .soft and smooth .palpation fistula .absence of presence of 17.Integument: Skin . Abdomen .inspection .absence of hemorrhoids .

irritated .no irritation .absence of amnesia .21. Neurological .smooth and semi form . Emotional status .uniform in color .observation .smooth .calm .no presence of masses .oriented regarding the time and place .speech is clear .observation 22.uniform temperature or within the normal range .conscious and alert .good balance and proper coordination .

PLANNING:  After nursing intervention (during home visits). INTERVENTIONS:  Instructed and encouraged patient to sit up right. it aid in e respiration   Advised her to limit her activities Encouraged adequate rest periods between activities to prevent tiredness that leads to shortness of breath. .ANTEPARTAL ASSESSMENT:    difficulty of breathing restlessness irritability NURSING DIAGNOSIS:  Ineffective breathing pattern (dyspnea) related to increased pressure on the diaphragm.  Advised mother to add two or more pillows during bed time.  Positioned comfortably EVALUATION:  Goal met as evidenced by: patient was able to identify and learned some techniques to reduce the occurrence of shortness of breath. the patient will be able to identify and learned some teachings to reduced shortness of breath. It allows the weight of uterus to fall away from the diaphragm.

Respected necessity to focus during contractions. . INTERVENTION:      Provided comfort measures such as back massage.INTRAPARTAL ASSESSMENT:      Facial grimace Restlessness Presence of perspiration Irritability Sighing NURSING DIAGNOSIS:  Alteration in comfort. EVALUATION:  Goal met as evidence by: the mother can able to tolerate the pain. PLANNING:  Client will complete labor and birth experiencing tolerable level of discomfort. Encouraged diversional activities like talking. Supported breathing pattern efforts as needed. related to labor contractions. Advised client to have adequate rest periods.

. Encouraged mother to wear shoes with a low heels. Advised her not to bend in lifting objects instead to stoop. heat/cold application.ASSESSMENT:    Irritability Restlessness Perspiration NURSING DIAGNOSIS:  As pregnancy advances. PLANNING:  During visit. Provided comfort measures such as back rub. changing position. lumbar lordosis occurs and postural changes necessary to maintain balance will cause backache/back pain. Demonstrated breathing technique. INTERVENTION:      Instructed mother to avoid standing in a long period of time. patient will be able to verbalize methods that provide relief. EVALUATION:  Mother was able to verbalized methods that may provide relief and reduced irritability.

. Provided client with some relief about expected duration of her sad emotions.   Explored the factors that a concern or worthy to her. Assured her that simple postpartal sadness runs a short natural course. mother will be able to demonstrate adequate selfesteem despite seemingly inappropriate emotions.POSTPARTAL ASSESSMENT:    Lack of eye contact Irritability Restlessness NURSING DIAGNOSIS:  Self-esteem disturbance related to lack of knowledge regarding psychological changes during postpartal period. INTERVENTIONS:  Reviewed client that postpartal sadness is common. EVALUATION:   The mother voices that she understands conflicting emotions commonly occur during postpartal period and probably related to the rapid change in hormone level. PLANNING:  After the visit. knowledge about her reactions can offer a sense of control.

PLANNING:  The mother will be able to perceive enough sleep to feel rested during postpartal period. Provided quite environment and comfort measures EVALUATION:  Goal met .ASSESSMENT:    Restlessness Frequent yawning Exhausted NURSING DIAGNOSIS:  Sleep pattern disturbance related to exhaustion due to excitement for the new member of the family. INTERVENTIONS:   Provided uninterrupted periods of rest.