Republic of the Philippines

CAVITE STATE UNIVERSITY (CvSU)

DON SEVERINO DE LAS ALS CAMPUS Indang, Cavite

College of Nursing

NURSING CARE PLAN

In Partial Fulfillment of the Requirement in NURS 50 Maternal and Child care Nursing

Submitted by: Sudario, Carmella Dawn B. BSN 2-1

Submitted to: Mr. Genreigh Genuino RN, MAN

September 22, 2012

INDIVIDUAL ASSESSMENT

I.

Demographic Data Name: Address: Age: Sex: Date of Birth: Nationality: Occupation: Language: Educational Attainment: Religion: Information provided by: Ms. Z City Homes Resort Ville-2, Langkaan-II, Dasmarias, Cavite 19 y/o Female February 11, 1993 Filipino Vegetable Vendor Filipino College Graduate Jehovahs Witness The client who is reliable

II.

Reason for seeking care There reason for seeking health care is to have a pre natal check up.

III.

History of Present Illness The client is well during the time of the interview.

IV.

Past Medical History The client was in a good state of health. The client was always brought to the hospital because of minor accidents like overdosing of vitamins, as verbalized by the mother of the client, when she was a child; she undergone appendectomy when she was 15 years old; there are no allergies reported as the client described; she is taking Clusivol OB and Ferosulfate for her state; she is fully immunized; she starts to have pre natal check up when its already 2 nd trimester of her pregnancy; her last check up was on August 12 2012.

V. Personal And Psychosocial History DIETARY INTAKE Breakfast: Lunch: Snack: Dinner: USUAL DIET The client usually eats rice, meat and vegetables for her diet. EXERCISE She is walking every morning at least 30 minutes to 1 hour as her form of exercise. USUAL ACTIVITIES Her usual activity in a day is watching television, texting, eating, and sleeping. HOBBIES Her hobby is texting and watching television. REST AND SLEEP She sleeps every 11 pm and wakes up at 8 am. ALCOHOL USE/ SMOKE Ms. Z doesnt drink alcohol since she got pregnant and smoke as well. RECREATIONAL DRUG USE The client has no recreational drug use. VI. Gordons Functional Health Pattern A. Health Perception- Health Management The client verbalize that she doesnt suffer vomiting in her pregnancy. She sometimes eats vegetables, meat, and fish. The client drinks ferosulfate and Clusivol OB as prescribed by her ob gynecologist. She doesnt drink milk these past few weeks because of lack of budget. Lastly, she stated also that she thinks her baby inside is healthy because she follows what her OB told her. She is moderately active also. She drinks 1 glass of chocolate, and eats 5 loaves of bread She eats 1 cup of rice, 1 serving of Monggo, and drinks 2 glasses of water 2 pieces of banana and drinks 1 glass of water She eats 1 cup of rice, 1 serving of adobong manok, and drinks 2 glasses of water

B. Nutritional- Metabolic The client eats at least 3 meals a day and drinks 6 glasses of water. She prefers vegetables than meat and fish. She denies drinking alcohol and smoking. C. Elimination The client voids about 8-10x a day characterized as clear and yellow. She also defecates thrice a week as characterized as yellowish to brownish in color and semi solid usually in the morning. Shes having difficulty defecating. D. Activity- Exercise After the client wakes up in the morning, she washes her face and walk for 30 minutes to 1 hour. As verbalized, that was her form of daily exercise. She eats breakfast at 100:00am and walk again after eating. At around 3:00pm, when she feels sleepy she takes afternoon naps. E. Sleep- Rest During the course of interview, client looked relaxed and comfortable, suggesting she is well rested. As verbalized, client sleeps about 9 hours at night. Induce Her usual sleeping time is around 11pm and usually wakes up around 8am. She verbalized no problems in regarding her sleep-wake cycle, denied any use of sleeping aids, but described practice of bedtime rituals like listening to music to help her induce relaxation and comfort during sleep. Dyring the day, she spends about 2-3 hours of afternoon naps to serve as rest periods. F. Cognitive- Perceptual The client was able to answer the questions clearly and concisely. Her senses are still comprehensive, as verbalized. Client was a graduate of BS Computer Science. G. Self-Perception- Self-Concept Client feels good and satisfied about herself. She does not exude self confidence and esteem because of her condition. She describes herself as having low and unsociable personality. She was a little bit shy during the course of the interview. She prefers to be alone when she had a problem and keep it by herself. H. Role- Relationship The client stated that she is a good friend, and an obedient daughter. She verbalized that she sometimes act like a parent and rule over her sibling, being the eldest daughter. She described that she is type of friend that is easily to be leaned.

I.

Sexuality- Reproductive

The client speak that she is contented with her sexuality. She stated that she never encounter major medical problem about her reproductive system but at times she had dysmenorrhea. J. Coping- Stress The client verbalizes that whenever shes stress she walks around there street. She denied drinking medications when coping but she just cries alone and eat a lot. K. Value- Belief The client goes to church before she got pregnant. Shes major priority as for now is to deliver her baby normal spontaneous delivery. She stated also that she believe whenever the pregnant gets beautiful her baby is a girl but if she gets ugly it means its a boy. VII. Review of System System General Integument Skull Eyes Ears Nose and Sinuses Mouth Throat and Neck Breast and Axila Respiratory Cardiac Gastrointestinal Urinary Musculoskeletal Subjective Cues Naramdaman ko, bumigat yung timbang ko Pakiramdam ko parang medyo dry yung balat ko Di naman nanglalagas yung buhok ko Okay naman, nilalagyan ko pa nga ng cutics kuko kahit buntis na ko Wala naman sugat ulo ko o kaya bukol pero nasakit pag minsan Hindi naman malabo ang mga mata ko Malinaw naman pandinig ko Wala naman akong sipon ngayon Kapag may sipon ako, nasakit ulo ko Madalas ako magkasingaw Hindi naman ako nahihirapan lumunok Wala naman ako nararamdaman na kulani sa may leeg ko Nararamdam ko na parang nalaki siya tapos minsan nasakit Hindi naman ako nahihiripan huminga liban na lang kapag nakahiga Nakakaramdam ako ng paninikip ng dibdib kapag minsan Medyo hindi na ko nakain gawa ng sabi ng OB ko huwag na ako magpataba Kulay dilaw nga ihi ko e Nakakaramdam ako minsan ng pananakit ng likod

VIII.

Physical Examination Parts Technique Inspection Palpation Objective Cues white in color (-) lesions (-) hyperpigmentation dry skin warm to touch poor skin turgor evenly hair distribution black, fine hair no parasites evident (-) masses oily and dry round, hard, nails with pink nail beds capillary refill <3 seconds normocephalic aligned facial features (-) masses (-) nodules symmetrical blinking round and equal iris (+) opacity of the left lens non tender lacrimal apparatus symmetric (-) discharges on external ear smooth, elastic (-) tenderness symmetric (-) nasal discharges pink and moist mucosa with no lesions (-) nasal flaring (-) masses (-) tenderness pharyngeal tonsils not inflamed (-) gag reflex (-) lesions on lips, mouth and throat cracked lips symmetric (+) full ROM (-) lesions (-) masses (+) smooth, firm and non tender thyroid (-) enlarged lymph nodes Findings

Skin

Normal

Hair Inspection Palpation Nails Skull and face Inspection Palpation Inspection Palpation Eyes and vision Inspection Palpation Ears and hearing Inspection Palpation Nose and sinuses Inspection Palpation Mouth and oropharynx Inspection Neck Inspection Palpation Lymph Nodes Palpation

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Trachea Breast and Axilla

Palpation Inspection Palpation

Thorax and Lungs Heart

Inspection Auscultation Auscultation

Gastrointestinal Palpation Auscultation Inspection

Musculoskeletal

midline position nipples everted pale brown areola (-) dimpling, discoloration, nipple discharges (-) tenderness (-) axillary lymph nodes enlargement symmetrical thoracic expansion (-) crepitus (-) wheezing (+) apical pulse felt at 5th ICS LMC line normal heart sounds regular rate, normal rhythm normal liver span (-) masses (-) tenderness normoactive bowel sounds steady gait (+) full ROM and muscle strength of upper and lower extremeties

Normal

Normal

Normal Normal

Normal

Normal