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XAVIER UNIVERSITY Jan 11,2016, was referred to Maternity

ATENEO DE CAGAYAN hospital. IV. HISTORY OF FAMILY ILLNESS


COLLEGE OF NURSING Jan. 15,2016, admitted to Maternity (Check that applies)
NCM 102 RLE
Hospital
Hypertention
Jan.16,2016, delivered the fetus via Coronary Artery Disease (CAD)
OBSTETRIC ASSESSMENT TOOL cesarean section found out that the cord Cerebro-vascular Disease (CVD)
has been tightly knot 3x Diabetes Mellitus
I. GENERAL INFORMATION Kidney Disease
Tuberculosis
Name: Patient AR Age: 19 Current Medications: (Include Dosage, Cancer
Birthday: April 4, 1996 Timing, Route and Indication of use) Others (Specify):
Civil Status: _Single Sex: Female Drug Indication
Dose/Frequency/Route V. Obstetric History(pregnancy,
Religion: R.Catholic Occupation: Student
Labor and Birth)
Income: N/A Address: Mapua Balingoan Cephalexin Infection Para: 1 Gravida: 1 TPAL: 0100
Mis. Oriental Prenatal Coverage: Check-up, vaccines
Informant: patient herself who verbalized 1cap(500mg),TID,PO Place of Prenatal Care: Balingoan Health
quoted words Relation: Tramadol Pain reliever Center
Admission Date: __1/15/16_Time: 12:55PM Total number of visits: 3
Chief Complaint: No fetal movement_ 1cap(50mg),TID,PO Any abnormal finding: have UTI
Pre-pregnancy Weight: 60kg
Attending Physician: Dr. LS Celecoxib Pain,Anti- Weight gain: 3 up to 6kg
Diagnosis: Delivery preterm 33 weeks inflammatory Last Menstrual period: 5/25/15
operative to a dead baby boy in breech 1cap(200mg), BID,PO
EDC: not reflected in the chart
presentation Age of Gestation: 33 weeks
Upon assessment: Actual date of Delivery: 1/16/16 Time: 9:35
II. HISTORY OF PRESENT ILLNESS Vital signs: HR: 74 RR: 22 BP: 110/80 Type of Delivery: cesarean section
Temp: 36.7C If C/S, indication: No fetal movement
Oxygen Sat: 98% Height: 164 cm Weight: Position of fetus: Breech position
___ 3 months of pregnancy had UTI Complications during Labor: N/A
Jan 6,2016, felt that a day before there is no 60 kg BMI: 22.31 Interpretation: normal
Onset and Duration of Labor: N/A
fetal movement so on the day went to III. PAST Episiotomy N/A Lochia N/A Amount N/A
Balingoan Hospital to have check-up, OBSTETRIC/MEDICAL/SURGICAL
ultrasound and found out that there is no HISTORY VI. Gynecologic History
fetal heart beat. Age of Menarche 14 yrs. old
Illness Date
Menstrual Cycle:
Jan. 8,2016, went to NMMC to have the
None Interval/ Length of cycle 28 days
fetus delivered out but stated that ” murag gi Duration of menstrual flow 4 days
induced lang man ko, pero gipasa-pasa Amount of Menstrual Flow moderate
raman ko dadto so wala ra gyapon nakuha” Menstrual Discomfort: “awh wala man”
verbalized by the patient.

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Vaginal discharge(odor,color) ”normal lang Lesions no lesion noted Objectives
jud” Thyroid hypertrophy none
Bleeding between periods ”wala man” Subjective: Palpable lymph nodes palpable
Sexually active yes Sexual concerns/ Headache severity “wala man” Location N/A
difficulties ”wala” Frequency N/A Breast
Recent change in frequency/interest “wala” Fainting spells/dizziness “wala man” Objectives/Subjectives
For how long N/A Tingling/numbness/weakness(location) Breast changes : Areola black
Side Effects if any N/A “Wala man pud” Breastsize enlarged
Previous Miscarriage/Abortion None Others/Comment Presence of colostrum none
Normal Adequacy of breast for feeding N/A
Abnormal signs N/A
VII. ASSESSMENT OF SYSTEMS Eyes/Ears Perform BSE(frequency and schedule)
Objective Objectives N/A
General Appearance and Mental Status Edema in eyelids None Abdomen
Well groomed appearance and is oriented Sclera & Conjunctiva white sclera and pink Objective (antepartum)
Personal hygiene/habits: takes bath 3x a conjunctiva Fundal Height: N/A
day with an over all good personal hygiene Spots before the eyes None Leopold’s Maneuver: N/A
Hair: Hair is tidy,black and shiny Diplopia (double vision) “wala man” Fetal Position: N/A
Clothing/Manner of dress: clothing is Subjective Pelvic Measurement: N/A
appropriate and clean Vision problem: R”wala L”wala”
Body Odor no foul odor is noted Last examination “wala” Circulation
Skin integrity/turgor: skin is intact and has a Ears: Hearing loss/ deficiency: “wala” Ankle/Leg Edema none
good skin turgor, elastic Last Examination:”wala” History of hypertention “wala
Speech: clear slurred Etremeties: Numbness “wala”
unintelligible Aphasic Nose Tingling: “wala”
Nasal Congestion “wala man “ Change in frequency/amount of urine” wala”
Subjective Sense of smell was able to smell the coffee Homan’s sign None
Pain: Precipitating: cesarean incision: “Sakit made by the SO Others/comment
pa akong tahi” Epistaxis “wala man”
Quality of Pain: “ngut-ngot cya” Others/Comment: no abnormalities noted Objectives
Location: Low transverse abdomen Mouth, Teeth and Throat BP: R Lying 110/80 Sitting 110/80
Severity: 6 out of 10 Objectives L Lying 110/80 Sitting 110/80
Time: (onset, frequency, duration) Condition of mouth lips is intact, moist Heart sounds: Rate normal Rhythm regular
”kanang maglihok ko, mag sakit dayon siya” mucous membrane Pulse: carotid 80 Radial 74 popliteal 76
Others/Comment patient commonly just Condition of teeth and gums complete, Temporal 80 Femoral 73 Dorsalis Pedis 73
take rest and lie to prevent feeling of pain yellowish, pink gums Capillary Refill <2sec Color pinkish
Appearance of tongue pink, intact
Head and scalp Gingival gum hypertrophy none Lesion none Cyanosis/pallor None
Symmetry symmetrical Dental hygiene brushes2x/day with Varicosities None
Contour round Distribution equally toothpaste Dental Carries none Nail beds pinkish in color and normal
distributed Thickness thick Excessive Mucous membrane intact and moist
Dryness/Oilness dry Use of hair dye none Neck/Lymph Nodes Others/comment circulation is normal

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Body build endomorph Others/comment the patient has an
Respiration Skin turgor good skin turgor mucuos memb. adequate time for rest even before and
Objective moist/dry moist hernia/masses none during her pregnancy as she mentioned
Respiratory rate: 22 Depth: average Other comment: has a good food and fluid
Symmetry: Symmetrical Nasal flaring: None intake Ego integrity
Use of accessory muscles: None Subjective
Abnormal breath sounds: not noted Elimination Report of stress factor “ di pod ko maka
Cyanosis: None Clubbing of fingers: None Subjective ingon, daghan pero ga tinabanga man gud
Sputum characteristics: wasn’t able to Usual bowel pattern 1xday mi pamilya”
assess Last BM: 1/15/16 Ways of handling stress “ampo”
Others/comment: patient is not experiencing Recent character of stool: semi-solid Financial problems “wala man”
cough Amount moderate Frequency 1x Relationship status “ok rami, naa rman siya
Color brown odor: “normal odor” perminti”
Dyspnea related to: N/A Lifestyle “naa rako permis sa balay man
Cough/Sputum N/A History of GI bleeding “wala” and school”
History of: Hemorrhoids “wala” constipation “wala” Recent changes “wala man”
Bronchitis None Asthma None Laxative use “wala” Feeling of helplessness “dili man”
Tuberculosis none Emphysema none Others BM of client is normal hopelessness “dili man”
Recurrent pneumonia none powerlessness “wala”
Smoker “no” pack/day N/A No. of years N/A Usual voiding pattern “mga katulo” others/comment patient shows little sign of
Use of respiratory aids none Incontinence “wala” urgency “wala” sadness when assessed regarding about
Oxygen therapy none Retention “wala” Frequency 3x the baby, she’s watery eyed
Others/Comment: No respiratory distress Pain/burning/difficulty in voiding none Objective
noted History of kidney/bladder disease UTI Emotional status(check those that apply)
Other comment voiding of patient is normal Calm Anxious Angry
Food/fluid Intake Withdrawn Fearful
Subjective Activity and Rest Irritable Euphoric
Usual diet(type) vegetable Subjective
No.of meals daily 3x/day Usual activities/hobby “tan aw ug salida,
Last meal intake “lugaw, ganiha buntag” unya mag cellphone” Safety
Loss of appetite “wala” Leisure time activities ”magtan-aw lang Allergies/Sensitivity: none
Nausea/vomiting “wala man” gyod ug t.v unya mag luto” Reaction N/A
Dentures 5 upper front teeth Limitation imposed by situation “wala man, History of STD(Date/Type) “wala”
Allergy/Food Intolerance none karon lang nga naa koy tahi” Blood transfusion/ number: “wala”
Heart burn/indigestion “wala” Sleep: History of accidental injuries: None
Mastication/swallowing problem “wala” No. of hours “kasagara 8” naps “dili ko ga Fractures/dislocation “wala”
Changes in weight “ wala, kato raman sa nap” Arthritis/unstable joints “wala”
pag buros” Sleeping aids “wala” Back problems: “wala man pod”
Diuretics use none Difficulty in sleeping “wala man pod ” Changes in moles: None
Feeling on awakening “normal lang siya” Enlarged nodes: None
Objective Unusual bleeding: None
Current weight 60kg height 164cm Prosthesis: None

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Social Interactions

Subjective:
Marital status single(live in) Developmental Milestone
Years in relationship 4yrs
Living with “family” Age Psychosexual Psycho- cognitive
Other support person ” tanan pamilya” social
Role within the family “anak” X
Describe behavior in relation to developmental
Report of problem related to ] X task
illness/condition None
Others/comments patient’s family is very
] 19y/o Time of Value Making
exploration in committed future
supportive as well as her partner wich the relationship plans and
sexual setting for
Teaching/ Learning energy is long term
Subjective present goals.
Dominant language (specify) Bisaya sexually Makes
Literate Educational level College LABORTAROY/DIAGNOSTIC RESULTS active own
Health beliefs/practices “wala naman kayo, (Only abnormal findings highlighted) schedule
kanang normal lang tapos sa hospital sad A. CBC and plans
jud mi ga duol” Hemoglobin = 110g/L =LOW
Hematocrit =0.33 =LOW
VIII. BODY MAP Total WBC = 10.33x10^12/L =HIGH Vital Signs
(Illustrate in the body map how your patient Total RBC =3.66x10^12 =LOW
looks like e.g tubes inserted, bruises, Platelet count =491x10^9/L =HIGH T P R BP
surgical incisions, physical abnormalities, Differential Count Day1 36.7 74 22 110/80
affected areas. Marl with a small “x” where it Neutrophil = 0.66 =Normal
Day2
is located or draw it on the body map then Lymphocyte = 0.30 =Normal
8am 36.2 94 23 110/80
label.) Eosinophil =0.02 =Normal
12nn 36 97 24 110/80
Monocyte =0.02 =Normal
Describe affected areas: B. U/A
Day 1 of assessment IV site on the right none
side of the hand, incision(sutured) due to C. fecalysis
cesarean section on the lower transverse none
part of the abdomen D. X-RAY
Day 2 no IVF, IV marks, and with incision none
(sutured)
OTHERS
Hepatitis= NONREACTIVE

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