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Name: Pokemon
Ward: Delivery Room
PATIENTS ASSESSMENT
I. PATIENTS PROFILE
Name: Pokemon
Age: 18 years old
Gender: Female
Status: Single
Occupation: Housekeeper
Religion: Born Again
Date & Time Admitted: August 25, 2016 @ 4:10 pm
Address: Sta. Monica, Puerto Princesa City Palawan
Educational Attainment: High School Graduate
Attending Physician: Patricia Evelyn P. Palaypayon MD
Chief Complaint: G1P0 Vaginal Bleeding
Discharge Diagnosis: G1P1 (0101) Pregnancy Uterine 29 weeks AOG
Delivered by complete breech extract (NSD)
Using marshall maneuver to a live baby boy
Diet: DAT
II. HEALTH HISTORY
A. PRESENT ILLNESS
A day prior to admission, patient was taking a shower and
suddenly the basin full of water above her fall down and she accidentally
catched the basin full of water to her surprised. She didnt felt anything after
the incident, at 7pm she experienced pain on her lower back and started
bleeding profusely. According to the patient, her stepmother massage her
abdomen. She didnt mind that she was bleeding because she thought it was
just nothing.
30 minutes prior to admission, the patient experienced pain that
she rate 7 out of 10. The bleeding continued she thought that she was on
labor, her husband brought her to Ospital ng Palawan at 10am and were
admitted at ER.
experienced cough that would last for a week and she couldnt remember
the medication that she took that time.
She had her first prenatal at 4 months and second prenatal was at 6
months.
C. FAMILY HISTORY
According to the patient she has two sisters and apparently in a
good health. She emphasized that her father has a high blood pressure, her
mother died at age 32 due to hypertension. The patient is the youngest of
three siblings and there is no history of such diseases.
GENOGRAM
Father:
High Blood
Mother:
High Blood
Deceased
September 1, 2016
Alive and
Well
Alive and
Well
FATHER
SISTERS
MOTHER
PATIENT
Patient
OB/GYNECOLOGIC HISTORY
A. MENSTRUAL HISTORY
Menarche of the patient began when she was 13 years old in a regular
cycle of 5-7 days. She uses two packs of feminine napkins, moderately
soaked in her whole menstrual cycle. Patient sometimes experiences
dysmenorrhea during her first to second days of her menstruation.
B. OBSTETRIC HISTORY
G1P1T0P1A0L1 2016 baby boy via NSD preterm, footling breech @
ONP
LMP February 4, 2016
EDC November 11, 2016
C. ANTHROPOMETRIC MEASURE
Head Circumference 27 cm
September 1, 2016
Chest Circumference 23 cm
Abdominal Circumference 22 cm
Body Length 38 cm
Body Weight 1,210 gms
Temperature 36 C
Cardiac rate 157 bpm
Respiration rate 46 cpm
September 1, 2016
GROWTH:
Adolescents are generally in good health, subject neither to disease nor problems of
senescence. Biologically function and physical performance reach their peak from
13-19 years of age, waning after 19.
DEVELOPMENT:
Ms. Pokemon approximately 5 feet and 3 inches weighing 55 kilogram.
THEORY
AGE
Freuds
psychosexual
developmental
theory
(Genital)
Eriksons
Psychosocial
Theory
young adulthood
(ages 18 to 40
yrs)
CHARACTERISTICS
Energy is directed
toward full sexual
maturity and
development of
skills needed to
cope with the
environment.
intimacy vs.
isolation
intimate relationship
with another person
commitment to work
and relationship
Havigursts
Cognitive
developmental
theory
Adolescent
13-18 years old
PRESENTING
CHARACTERISTICS
Developmental
Tasks of
Adolescence:
1. Achieving new
and more mature
relations with agemates of both sexes
2. Achieving a
masculine or
feminine social role
3. Accepting one's
physique and using
the body effectively
4. Achieving
emotional
independence of
parents and other
adults
5. Preparing for
September 1, 2016
DISCHARGE PLAN
Name of patient: Ms. Pokemon
Delivery Room
Age: 18 y/o
Ward:
September 1, 2016
Chief Complaint:
Palaypayon
Nursing
Discharge Instructions
Orders
Medications
Exercise
Treatment
To avoid making
medication errors thus
preventing adverse
reaction.
To regain strength
To hasten recovery
Encourage patient to
continue deep
breathing exercise and
instructed the family
for the exercise
needed.
This is to promote
circulation of blood, and
relaxation also.
To promote involution
September 1, 2016
have sexual
intercourse after 4
weeks.
To prevent newborn
diseases.
Encourage patients
compliance in
treatment.
Emphasized the
importance of
adequate rest and
sleep
Hygiene
To maintain physiologic
functioning
To maintain internal
equilibrium
To avoid infection
It facilitates good
healing and prevents
harboring of
microorganisms that will
cause infection
To avoid infection.
September 1, 2016
OPD
Diet
Spirituality
To increase lactation
To boost immune
system and promote
wound healing.
Suggest patient to
attend Sunday
service/ mass in
church as to boost
spirit and to prevent
distress.
September 1, 2016
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