Patient Profile

A. Demographic Data Name: PATIENT X Address:Camantiles Urdaneta City Civil status: Single Gender: Female Date of admission: July 28 2011 Admittig Diagnosis: PUFT,39 weeks AOG Admitting Physician:Dr.Tolete B. Chief complaint She was brought to the hospital due to crumping abdominal pain brought about by progressive uterine contraction. C. History of Present illness The patient stated that she noticed that there was a blood in her urine when she voided on July 28 ,2011 at 1:30 pm and the patient stated that after a few minutes,her abdomen starts to contract and experiencing severe pain on her lower back. Several minutes during our interview with the patient, before the actual delivery, duration of abdominal contraction was noted at around 3-5 mins with shifting of intensity from moderate to severe abdominal pain. D. Past History The patient stated that she completed her immunizations,had fever during childhood and does not have ay allergies.She added that she did not encounter any accidents or injuries. At present , she does not have any disease or serious illness that leads to hospitalization E. Family History The patient stated that their is no disease among her family members. F. Obstretric History The patient stated that she has a normal menstruation. She used 4-5 pads a day. Her obstretric scoring is G1P0.

13 REAS OF ASSESSMENT

I.Psychological The patient is Patient x,with obstetrical score of G1P0 20 years old.Filipino and resident from Camantiles Urdaneta City,Pangasinan.She was born in Camantiles.She is plain housewife.She is Roman Chatolic.She is confined in Urdaneta District Hospital II.Mental and Emotional Status The patient is coherent and oriented to time , place and person.she is also responsive to vrbal and noise. III.Environment Status A cabinet was provided to keep all belongings orderly.Acording to her,their faily uses mosquito net at night to protect them from insect bites caused by mosquitoes and cockroaches. IV.Sensory A. Visual Status The patient has no known deficit regarding her visual status.She can always distinguish the person who is in front of her.She has no difficulty reading the newspaper or magazines. B.Auditory Status She can distinguish voice has no deficit regarding hearing C.Olfactory status She can distinguish odors and has no problem with her olfactory sensations. D.Gustatory Status she can distinguish sweet,sour,salty or bitter tastes and has no unusual sensations. E.Tactile Status She can still distinguish different kind of touch.She still has the ability to perceive heat,cold and pain.She can still differentiate common objects by touch.

F.Speech Formulation Her speech organ are intact.She has no deficits in her phonation.She has the ability to understand and initiate speech. V.Motor Status She can move or flex extremities. All joints are active and she has a good posture and she has a muscle strength. Able to perform daily living such as walking. VI.Nutrition Status The patient stated that she usually eats 1 cup of rice every meal and eats 1 serving of vegetable regularly.She drinks approximately 8-10 glasses of water every day and when she got pregnant she drinks 2 glasses of milk everyday. VII.Elimination She defecates once a day and her stool is characterized as a soft and brown in colo,she urinate 3-5 times a day of approximately 200cc in 8 hours shift.Her urine is yellowish in color and clear. VIII. Fluid and Electrolyte Status She drinks approximately 8-10 glasses of water everyday. She urinate 3-5 times a day of approximately 200cc. She was give IVF of D5LRS x 8hrs.Consumed 2 bottles. IX.Circulatory Status She has pulse rate of 70 beats per minute witch is characterized as regular.Her blood pressure was 120/80mmHg while she was on a supine position.She has a capillary refill of 1-2 seconds,Her nails and conjunctiva are pinkish in appearance.She consumed 2-3 diaper every day X.Temperature Status Her body temperature was at 36.9 degrees celsius and was taken via axillary route. XI.Intergumentar Status She has a good turgor and her skin is not pale in appearance, her hair is smooth, she had a good grooming.

XII.Comfort and Rest Status The patient stated that she cant sleep well, she only slept for 3 hrs because often thinks about her babys condition. XIII.Respiratory Rate Her respiratory rate was 19 breaths per mins which is regular. Her skin and lips are not pale.