Nursing Health Assessment

DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY CITY OF DASMARINAS, CAVITE NURSING HEALTH ASSESSMENT Submitted by: Andrea Antonette D. Balboa Submitted to: Rowena Cepeda-Laigo, RN, MAEd NURSING HEALTH ASSESSMENT I. Status Post Caesarean Section II. HEALTH HISTORY AND PHYSICAL EXAMINATION A. Demographic (Biographical Data) Client’s initials: R. R. P. Gender: Female Age, Birthdate and Birthplace: 34, 10/21/1978, Muntinlupa Marital (Civil) Status: Married Nationality: Filipino Religion: Roman CatholicAddress and Telephone Number: Blk 5 Lot 54 Greengate Imus Cavite Educational Background: Bachelor’s Degree in Computer Science Occupation (usual and present): Encoder Usual Source of Medical Care: PhilHealth Date of Admission: 01/08/2013 B. Source and Reliability of Information The patient was competent to provide information. She was able to speak clearly; conscious and coherent; oriented to time, place and person. The patient’s chart w as also included as a secondary source of information C. Reasons for Seeking Care 1. â€Å"Inadequate size of pelvis† 2. â€Å"Scheduled for caesarean section† D.History of Present Health The expected date of the delivery was January 8, 2013, 8:00AM at St. Paul Hospital. It was a scheduled caesarean section of the patient; not in labor. The patient was calm since it was her second time to deliver a fetus through caesarean section. There were no signs and symptoms of labor happened. The patient foresees to stop adding a family member because they already have a son and a daughter. E. Past Medical History or Past Health a. Pediatric / Childhood / Adult Illnesses The patient did not have any pediatric, childhood or adult illnesses. b. Injuries or AccidentsThe patient did not have any injuries or accidents. c. Hospitalization and Operations The patient had a caesarean section last 2006, 2007 and 2013. d. Reproductive History The patient had her menarche at the age of 12. H er last menstrual period was April 27, 2012. Her menstrual cycle was 28 days and her menstrual duration was 3 to 4 days. Her obstetric score was G3P2 T2P0A1L2M0. e. Immunization BCG: /? / At Birth /? / School Entrance DPT: /? / 1st Dose /? / 2nd dose /? /3rd dose OPV: /? / 1st Dose /? / 2nd dose /? /3rd dose AMV: /? / TT: /? / 1st Dose /? / 2nd dose /? /3rd dose /? 4th dose /? / 5th dose HBV: /? / 1st Dose /? / 2nd dose /? /3rd dose Others: None f. Allergies /? / Food, (please specify): Shrimp / / Drugs or medications, (please specify): None / / Chemicals, (please specify): None / / Other environmental allergens, (please specify): None The patient has an allergy in shrimps. The patient experiences hives as an allergic reaction and applies an anti-allergy prescribed by her dermatologist to alleviate the manifestation. g. Medications None G. Socio-Economic History FAMILY MEMBER /RELATIONSHIP TOPATIENT| OCCUPATION /SOURCE OF INCOME| MONTHLY INCOME| R.R. P. | Encoder| P22,000. 00| The p atient works as an encoder. The monthly income of P22,000. 00 can only support the basic needs of the family but not particularly of members’ health. It will be not enough and budgeted exclusively for the necessities of the family. H. Psychosocial Assessment Patient’s Age: 34 years old Developmental Stage: Young Adulthood Developmental Task: Intimacy vs Isolation Occurring in young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member.Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Patient met the developmental task of being in an intimate relationship with her partner. They are married and have 2 kids. I. Functional Assessment 1. Health-Perception-Health Manag ement Pattern The patient’s description of her current health was weak and difficult to get pregnant. The activities that the patient does to improve or maintain his health was to not get over time in work.Patient’s knowledge about links between lifestyle choices and health was not answered. The extent of patient’s problem on financing health care was hopefully the budget will fit. Patient has the knowledge of the names of current medications she was taking and their purpose. Activities that the patient does to prevent problems related to allergies was to apply an anti-allergy prescribed from her dermatologist. Patient has the knowledge about medical problems in the family. There were no important illnesses or injuries in the patient’s life. 2. Nutritional-Metabolic Pattern The patient’s nourishment was to eat fruits and vegetable.Patient’s food choices in comparison with recommended food intake were not answered. The patient has no any dise ase that affects nutritional-metabolic function. 3. Elimination Pattern The patient’s excretory pattern was constipated. The patient has no any disease of the digestive system, urinary system or skin. 4. Activity-Exercise Pattern The patient’s description of his weekly pattern of activities, leisure, exercise and recreation was to eat outside and considers it as a family bonding. The patient has no any disease that affects his cardio-respiratory and/or Muscoskeletal systems. 5. Sleep-Rest PatternThe description of the patient’s sleep-wake cycle was completed of 8 hours. Patient’s physical appearance was relaxed. 6. Cognitive-Perceptual Pattern The patient has sensory deficit of astigmatism and was not corrected. Patient’s has the ability to express herself clearly and logically. Patient’s education was bachelor’s degree of computer science. The patient has no any disease that affects mental or sensory function. Patient’s pain d escription was of abdominal because of surgical procedure of caesarean section. 7. Self-Perception-Self Concept Pattern There was no unusual about the person’s appearance.The patient was comfortable with her appearance, simple but comfortable. Description of the patient’s feeling state was happy, comfortable because she already has a baby boy and a girl. She was worried about their financial needs because of the added family member. 8. Role Relationship Pattern Patient’s description of his various roles in life was to be a responsible mother. Positive role model of her roles was her mother, to save for family but she is more of disciplinarian than her mother. Important relationships at present were her family. There were no big changes in role or relationship. . Sexuality-Reproductive Pattern Patient’s satisfaction with her situation related to sexuality was good. If both of them were tired, they don’t do sexual intercourse. The patient’s pl ans and experiences did not matched regarding having children because everything changed and she was more matured than before. 10. Coping-Stress Tolerance Pattern Patient’s means/actions of coping with problems were there must be a goal for her to achieve. Coping actions help even though the goal was partially met as long as it was met. Eat, sleep and hang out were treatments/therapies for emotional distress. 1. Value-Belief Pattern Principles that the patient learned as a child which are still important to her was she does not want shortage, she wants everything to be provided. Patient’s identification with any cultural, ethnic religious or other groups is she is a St. Claire devotee. Support system that the patient finds significant was her family. J. Review of Systems and Physical Examination Date of Examination: January 9, 2013 PHYSICAL SYSTEMS| R. O. S. | P. E. | 1. General Status and Vital Signs| â€Å"Okay naman†| (-) fever(-) tachycardia(-) tachypnea(-) hypertension| 2.Integument (Skin, Hair, and Nails)| â€Å"Okay naman†| (+) pallor(-) skin turgor(-) edema| 3. Head and Neck| â€Å"Okay naman†| | 4. Eyes| â€Å"Okay naman, may astigmatism lang yung left eye ko†| (+) astigmatism| 5. Ears| â€Å"Okay naman†| | 6. Mouth, Throat, Nose and Sinuses| â€Å"Okay naman†| | 7. Thorax and Lungs| â€Å"Okay naman†| | 8. Breast and Lymphatic System| â€Å"Di lang ako makapag-produce ng milk kapag di pa ko kumakain†| (+) inverted nipple (-) breastmilk| 9. Heart and Neck Vessels| â€Å"Nagpapapalpitate ako minsan kapag pagod†| (+) palpitation| 10.Peripheral Vascular System| â€Å"Nagkavaricose veins na ko sa bigat ko, laging nakatayo at nung buntis pa ko ang bigat ng tyan ko†| (+) varicose veins| 11. Abdomen| â€Å"Kumikirot kasi tahi ko†| (+) pain| 12. Genitourinary| â€Å"Nagka-UTI ako nung nagbubuntis pa ko†| (+) rubra lochia(-) urinary tract infection| 13. Anus, Rect um and Prostate| â€Å"Hirap akong tumae†| (+) constipation| 14. Musculoskeletal System| â€Å"Okay naman, ngayon lang ako di makakilos ng maayos dahil masakit tahi pa ko†| (+) limited ROM| 15. Nervous System| â€Å"Okay naman†| (+) conscious| 16. Hematologic| â€Å"Okay naman†| | 17. Endocrine| â€Å"Okay naman†| | 18. Psychiatric| â€Å"Okay naman†| |