Demographic Profile Harlene Sitson Patients Name PATIENT PROFILE Birth date: Birthplace: March 24, 1995 Quezon

City Age: 17

Present Place of Residence: 12-A Makabayan St., Barangay Obrero, Quezon City Previous address: Nationality: 1-B Makabayan St., Barangay Obrero, Quezon City Filipino

Languages/Dialect Spoken: Tagalog Marital Status History: Educational Attainment: Occupation & Employment History: Local/Foreign Travel: Sleep habits/Pattern: Handedness: Left Eye glasses: Contact Lenses: N/A Yes None 10-12 hours Sleeping Time: Waking Time: 10:00AM Single 4th Year High School/High School Graduate None

8:00 AM 10:00 AM

Reason for Glasses: N/A Hearing Aide: N/A Dentures: N/A

Dietary Habits/Eating Pattern: She Eats Three times a day Particular Food preference: She said that She has no Food preference, Any food will Satisfy her. Exercise: Kind: Frequency/week: N/A N/A Duration: N/A

Alcohol/Caffeine (Amount/Duration): Tobacco/Drug Abuse (amount/Duration):

Occasional for alcohol, N/A

Living Environment (Type of house, No. of Occupants and Community Setting): Mixed wood and concrete, with 12 occupants and living in a Urban Community Source of Income: Current Medications: Father Ferrous Sulfate

Laboratory Procedure Hemoglobin Mass C

Results 112

Normal Values 120-140

Interpretation Decreased

Analysis Decreased Hemoglobin is caused by the giving birth that the mother had undergone. Decreased Hematocrit is caused by Iron Deficiency because of the Labor

Hematocrit

32

37-47

Decreased

RBC MCHC MCH MCV RDW Blood Type WBC Neutrophils Lymphocytes Eosinophils Platelet MPV RBC Morphology

3.7 34 29.9 86 13.1 A 8.7 60 38 2 Normal 8.6 Normochromic, Normocytic

4.0-4.5 32-37 27.5-33.2 80-94 11-15 5-10 40-75 20-45 1-4 150-440 7.5-11.5

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Urinalysis Lab Procedure Color Turbidity Reaction Specific Gravity Result Light Yellow Clear Acidic 1.030 Normal Value Varying Degrees of yelloW Clear Variable(Usually Acidic) Variable but 1.023 and above usually no significant kidney damage Negative 0-3/ hpf Male- 0-2/hpf Female- 0-5/hpf None None None to Few Cells None None Interpretation Normal Normal Normal Normal Analysis

Sugar RBC WBC Casts Bacteria Epithelial Cells Mucus Threads Crystals

Negative Negative None None None Few None None

Normal Normal Normal Normal Normal Normal Normal Normal

BUBBLESHE Breast

FINDINGS -No Palpable Masses -No Fissures -Breast is Firm and Colostrum is present.

Uterus

Bladder

-Uterus is Firm -3 Finger breadth below the Umbilicus -Bladder is not Distended -Color of urine is light yellow and turbidity is clear. -Urinated Twice -The Client has defecated once -The color of stool is Black, Tarry Stool -Lochia Is present; Lochia Rubra -Moderate In Amount -Dark red in color

ANALYSIS The mothers breast is normal, The breast is firm because it is now releasing Colostrum that is best for baby because colostrum makes the baby more healthy than than powdered milk. Lowering down of the uterus is a sign that the uterus is returning to its non-pregnant status. Bladder is not palpable because the client has already urinated before the assessment.

Bowel

Lochia

Episiotomy

-No Redness -No Edema -No Bluish Discoloration -No Discharge -Pain Graded by 3/10 -it is intact Temp 36.6 RR- 17 PR- 60 BP-120/80 -No pain upon dorsiflexion

Vital Signs

Bowel Movement is not delayed anymore because the baby has now been delivered. Lochia is normal for postpartum Women and will only lasts for about 2 weeks. The color and amount are normal because Lochia Rubra, having a color red and moderate in amount lasts for about 1 to 3 days after pregnancy. No complications found of postpartum patients episiotomy. Stitches are very well intact, no secretion from the episiotomy. The patient has high tolerance thats why she experienced less pain The vital signs signifies the returning of the mother to its non-pregnant state No pain upon dorsiflexion means the patient has no thrombophlebitis -this means that the mother is happy about the pregnancy and this will give a positive effect on the baby and the mother

Homans Sign

Emotions

-The patient verbalized Masaya ako ng Makita ko yung baby ko

Discharge Planning Methods M- edication

E-nvironment

Pain medications as prescribed by physician may be administered. Over the counter medications can also be taken. -Identify self-care activities like cleaning the yard or engaging to community cleaning program to prevent infection -Clean the environment to prevent infection and to provide a comfortable environment to the baby and the mother

Rationale - to help provide comfort and decrease pain -This will help the client in the prevention of infection even though without the help of the nurse therefore decreasing the chance of spreading of infection or being infected. -.this helps in healing and making both the mother and baby happy.

T-eaching

-Sit on a soft surface or a cushion -Wound Care: Carefully wash the incisions with soap and water -Kegels Exercise: This exercise helps your pelvic muscles stronger -Sitz Bath: A sitz bath is a pan that fits on the toilet bowl. Fill it with warm water and sit in it.

- Sitting on a soft surface or a cushion may help the mother in relieving pain. -Wound care will prevent infection of the wound and promote faster wound healing -Kegels exercise helps in preventing pelvic organ prolapsed - This help decrease pain in the perineal area

H-ygiene

- clean the incision site and the perineal area. - To prevent this from taking place, cleansing from front to back will prevent a bacterial infection. When washing the perineum area do not rub with washcloth always pat instead. -Nurses can support these clients in the healing process at followup appointments and during home visits.

- This prevents Contamination and infection in the incision site. - This will prevent making sutures and helps in having a Comfortable feeling. -This will ensure that the client is doing the diagnosis and will also help them for the future diagnosis and they will be able to provide

O-ut Patient

D-iet

S-piritual

-Stay hydrated. Taking vitamins like E, eating protein rich foods, taking foods that are rich in omega 3 and omega 6 will help the Patient - nurses may or should encourage the Patient to get adequate nutrition, rest, relaxation, and exercise.

new nursing care plan if new problems are present -This is to promote faster tissue healing and health -This will promote spiritual Health of the patient

Pain to surgical incision secondary to episiotomy as evidenced by pain scale 3/10 Assessment Subjective: The Client Verbalized medyo masakit pa din pag gumagalaw ako pero nakakaya ko naman kahit papano. Diagnosis Acute pain in the perineal Area due to Episiotomy Planning After 3 to 4 hours of nursing intervention the client will be able to feel comfortable and relieve the pain Intervention -Apply Ice packs or cold Compress by sitz bath 3 to 4 times a day. Rationale -Ice packs and sitz bath may help in relieving of pain. Making the Patient Comfortable. -Fiber and water makes the stool soft and prevent constipation. This makes the defecation process more easier and less painful. Evaluation

-Intake of Fiber rich foods such as apple and drinking a lot of water

Objective: Pain in the perineal area