Name: Sanaani, Yuseph Crispe Awang Clinical Instructor: Marry Ann S.

Mendoza, RN MAN
Year and Section: BSN-2B Date: August 27, 2014


I. Clients Profile:

Name: Momo, Hazel Joy Ollamina
Address: Claret Lane, San Jose Z.C.
Age: 22 years old
Sex: Female
Civil Status: Single
Occupation: Business Manager
Ethnic Group: Bisaya
Dialect: Bisaya
Religion: Roman Catholic
Chief Complaint: For CS
Medical Impression: PU 38 weeks AOG
Pre-ecclampsia with cardiac problem


II. 11 FUNCTIONAL PATTERNS

1. Health Perception Management Pattern

The client verbalized that shes experiencing pre-ecclampsia with cardiac problem. She
also told me that she was admitted three times in the past because of high blood pressure and
her heart problem, her last admission was on January, 2012. Also, when she was seventeen
years old she was on the line for an operation but she refused to. She also verbalized that there
is a history of hypertension in her family and that they also dont practice vices. She also said
that she doesnt do regular check ups.


2. Nutritional Metabolic Pattern

The client verbalized that their daily meal are composed of rice, vegetable, fish and
Sometimes canned goods. They also eat fruits and sometimes meat. As of now she is only
Required to have a soft diet and water only no softdrinks.


3. Elimination Pattern

The client verbalized that she defacates irregularly since she was confined but voids
voids regularly. She also doesnt use any laxatives nor devices to help her defacate.


4. Activity Exercise Pattern

The client verbalized that the only exercise she does is walking. She spends her time
surfing the internet when she has free time.


5. Sleep Rest Pattern

The client verbalized that before, she sleeps for minimum of 8 hours, now due to her
present condition she has now difficulty in sleeping even though there is no disturbance in her
sleep.


6. Cognitive Perceptual Pattern

The client verbalized that she can hear without difficulty and that she also has no
problem with her eyes but her mother has problem with vision, wears eyeglasses and has
check-ups.


7. Self-perception Self-concept Pattern

Client stated that she is quite confident about herself and got no problems interacting with others. client
has been affected with a cardiac problem when she was still young and she believes that this made her strong
as a person, she states that she cant do heavy physical activities because of her condition but now in the
present wherein she has pre-eclampsia she feel much more helpless, but not hopeless


8. Role-relationship Pattern

Client stated that they are a nuclear family. They are 4 in the family and have good
relationships with each other. They speak bisaya at home. She said that her dad is a
construction worker, while she helps managing their present business on construction and
supplies, her mother helps at home and a sibling of her is now a graduating student of
Civil Engineering. Her mother is the one taking care of her now.


9. Sexuality

Client verbalized that she has a regular and normal menstruation period.


10. Coping Stress Tolerance Pattern

The clients mother verbalized that the client sleeps around 10:00 am and she is not allowed to do work.


11. Value Belief Pattern

They embraced the roman catholicism, the mother of Hazel verbalized that Hazel refused to undergo
operation for her heart when she was still 17 years old because she believes that if it's her time to die then
she can't do anything anymore.



III. PHYSICAL ASSESSMENT
Head:
shape - has a symmetrical head shape
hair - the clients hair color is black, the hair is evenly distributed.
scalp - patients scalp is lighter than her skin
Face:
eyes - has evenly distributed hair eyebrows, symmetrically aligned, has equal movement, sclera
appears to be white and clear, has no eye problem.
ears - has redness of ear pinna, no hearing problem.
nose - the nose is in the midline, has no discharges.
oral cavity - teeth are white to yellowish in color , tongue is pink
others - has symmetrical facial movements

Neck:
Chest and Breast:
Back:
Abdomen: under recovery due to CS
Upper and Lower Extremities: proportional , weakened
Genitalia:

a. Physiologic examination
Central Nervous System
level of awareness - the client is slightly drowsy.
attention deficit - the client doesnt maintain eye contact with the interviewer while
interviewing.
communication
verbal ok, audible and understandable
non-verbal cant move that much
coordination -
2. Special Senses
auditory perception normal, patient can hear us clearly
pupillary perception -
speech perception patient can speak clearly
gustatory perception -
visual performance patient is slightly dizzy
tactile perception -
olfactory perception -
3. Respiratory System - The clients respiration rate is 23 beats/min
4. Cardiovascular System
heart rate, rhythm, depth - The clients pulse rate is 84 beats/min
blood pressure - the clients BP is elevated to 150/85
5. Nutritional Status
skin - the clients skin color is light brown, has lesions ,has tears and lacerations, Has
edema.
mucous membrane -
nails -
height -
weight-
temperature - the clients temperature is 36.8 degree Celcius.
6. Elimination Status bowel is not regular, voiding is at normal frequency (after meals)
7. Motor Ability Status gait is not good because patient is experiencing pain in her abdomen,
posture is unstraight also because of same reasons, body movement is slow paced.




b. Laboratory and Diagnosis Test Results
ECG -
2D Echo -
Ultrasound -
Blood Chem-
CBC with blood typing -
HBS Ag -
Urinalysis -
Sodium- Potassium -