HEALTH ASSESSMENT

Demographic data

Name: Mrs. S.M. G. V

Age: 30 years old

Birth Date: May 5, 1988

Birth Place: Numancia, Aklan

Gender: Female

Height: 5’2”

Weight: 67 Kg.

Marital Status: Married

Current Address: Laguinbanua West, Numancia, Aklan

Nationality/Race: Filipino

Religion: Roman Catholic

Educational Attainment: 2-year HR Graduated

Occupation: Bookkeeper

Monthly Family Income: Php50,000

Admitting Physician: Dr. J.C.

Attending Physician: Dr. J.C

Date and time of Admission: March 4, 2019/4:35pm

Chief Complaint: Abdominal Contractions

Admitting Vital Signs:

Temperature – 36.8 ºC/axilla Pulse Rate- 76 bpm

RR – 20 cpm BP- 120/90 mmHg

O2 Sat-96% FHT-145

Informant

Primary: Client

Secondary: Mother and Sister

Other Sources: Client’s Chart

Admitting Diagnosis: G3 P2 (2002) PU 39 weeks AOG by UTZ, Cephalic in beginning labor

Final Diagnosis: PUFT Cephalic delivery via STAT LSTC, FPD, Maternal Distress, Alive baby
boy AS 8.9, BL 53cm, G3 P3 (3003) GDM

Surgery Performed: STAT Low Segment Transverse Cesarean Section

History of Present Illness:

 In the year 2018 of June, Mrs. S.M.G.V went to clinic of Dr. A to have a check-up with
the chief complaint of dizziness. The patient underwent thorough examination and ordered
pregnancy test and CBG. The result of Pregnancy test was positive, CBG was 190mg/dL and was
diagnosed with diabetes mellitus. In there, Mrs. S.M.G.V was given metformin hydrochloride
500mg twice a day and daily dietary intake as ordered.

On the 4th day of March 2019, Mrs. S.M.G.V went to her private doctor to have a weekly
prenatal check-up. She underwent internal examination and revealed 4cm dilatation without any
feeling of abdominal contraction nor pain. She then went home and packed all the things needed
for child delivery. While at home, she experienced abdominal contractions so she made a call to
Dr. J.C. to check if there are any available VIP room at S.G.H., however there aren’t any
available rooms, so she decided to go to S.J.H.

She travelled together with her folks from Laguinbanua West, Numancia, Aklan going to
Kalibo using a tricycle. When they arrived at the emergency room of SJH at around 4:30pm,
Mrs. S.M.G.V. underwent thorough examination and was admitted by Dr. J.C. The following
were as ordered:

 Please admit to room of choice under my service

 Monitor vital signs q4h and record
 FHT q4h and record
 Refer if FHT if <120 or >100s/min
 DAT, NPO once in active labor
 IVF: D5NM 1L, FD 100cc then x 8hrs
 LABS:
CBC
Urinalysis
HBsAg

 MEDS:
Hyoscine-N-butyl brumine (buscupan) 1amp IV q4h
 MIO Q shift and record
 For trial of labor
 Perineal care
 Please inform Dr. N. F for Pedia
 Dr. J.C. informed of this admission
 For fleet enema
 Refer accordingly
 Dr. Q.S. informed
 On March 5 at around 12 noon, Mrs. S.M.G.V experienced difficulty of breathing

associated with blurring of vision. The patient received medical intervention from Dr.

R.G. (ROD) and Dr. C.J ordered stat LSTCS. At around 1:40 pm the client delivered

alive baby boy.

Past Health History

Immunization

The patient claimed that she was fully immunized.

Childhood Illness

She had experience common illnesses such as colds, runny nose, fever, cough, and measles

Allergies

She has no known allergies both medicine and food.

Medication

She claimed that whenever she gets common illness cough, fever and colds she just take
over the counter drugs such as biogesic 500mg, mefenamic acid and neozep tablet.

Medical Problems or Chronic Illnesses

The patient claims that she is aware that she was diagnosed with diabetes mellitus last
June of 2018 but doesn’t take any maintenance for it.
 Previous Hospitalization
Hospitalized when she delivered her first and second child
Surgeries
No surgeries

Serious Injuries or Accidents

Patient reports no history of serious injury and accidents

Mr.
Mr. M.P.G55
M.P.G55 yrs.
yrs. old
old Mrs.
Mrs. C.D.G
C.D.G 53
53 yrs.
yrs. old
old
Obstetric /Gynecologic
Alive
Alive and
and well
well Alive
Alive and
and hypertensive
hypertensive

According to Mrs. S.M.G.V she delivered her first child on full term via normal

spontaneous delivery at ACMH. Her second child was delivered full term via normal

spontaneous delivery at SGH. The patient claims that she had her first menarche at the age of 13.

Her menstrual period occurs every month which lasts for 3-4 days in duration and usually
Mr.
Mr. E.N.V
E.N.V Mrs.
Mrs. S.G.D
S.G.D
30
30 yrs.
yrs. old
old 28
28 yrs.
yrs. old,
old, Alive
Alive
consumed
Mrs. S.M.G.V approximately 5 pads ofAlive
napkins
Alive and
and a day depending
and on
and well
well
the amount of blood discharge.
30 yrs. old, well
well
+DM
She also experienced dysmenorrhea every first day of her menstrual cycle but doesn’t have and

remedies for it. Her last menstrual period was on June 5, 2019.

C.G.V
C.G.V C.G.V
C.G.V Baby
Baby Boy
Boy
10
10 yrs.
yrs. old
old 66 yrs.
yrs. old
old Alive
Alive and
and
Alive
Alive and
and Alive
Alive and
and well
well
well
well well
well

Family Genogram

Patient’s parents
Patient
Husband
Male children of patient
Female child of the patient
Married
Patient’s siblings
 Ms. M.D.G 27
yrs. old Alive and
well.

PSYCHOSOCIAL HISTORY

Health Beliefs and Practices

  The patient claims whenever they get sick they usually seek medical help in their private
doctor she also believes in traditional healers like “albularyo”

Sleep and Rest Pattern

 She usually sleeps at around 7:00 P.M and wakes up at 4:00 A.M.

Elimination Pattern

 She defecates every day to a brownish, well-formed stool and voids more than 10 times a
day to a clear- colored urine. She has no complaints of difficulty in defecation and
urination.
Role/Relationship Pattern

 Mrs. S.M.G.V lives with his children. They have a good relationship and communication
with each other. She claimed that she seeks some advice from her husband when it
comes to decision making but she has the final decision.

Sexuality Pattern

 The patient verbalized “dati don kung mag uli iya ang asawa it kada siyam nga buean hay
ga labing labing ma lang kami sa una ma lang abi tag permi permi”
 Patient claimed that she uses oral contraceptive (Dianne) for 2 years

Values and Belief Pattern

 Mrs. S.M.G.V is a devoted Roman Catholic. She goes to church every Sunday with her
family.

Social History

 She has a good relationship with her neighbors.

REVIEW OF SYSTEM

General Survey

Post-Operative Assessment

On March 7, 2019, at 10 o’clock in the morning the patient was seen from PR 7. She was
sitting on the bed while racking her baby’s crib. She was wearing a floral violet pajamas with no
contraptions.

Vital signs were as follow:

T: 37 ºC/axilla. CR: 84 bpm

RR: 18cpm BP: 110/70 mmHg

REVIEW OF SYSTEM

INTEGUMENT

Skin

 Skin is light in color, warm to touch.

 She uses soap and lotion for her skin care and takes a bath every day.

Hair

 Hair is medium in length and light brown in color

 Scalp is smooth and clean.
 No flakes and lice observed.
 No mass and lesions present in the scalp.
 Regularly uses shampoo and conditioner for her hair care habit.

Nails
  Fingernails are untrimmed upon inspection.
 Nail beds are pale pink in color without clubbing.
 Has a good capillary refill that returns in 2 seconds.
 Cuts her nails once a week.

Head

 Head is round, symmetric, still and upright.

 Able to turn head smoothly from left to right with resistance without tenderness.
 No nodules and mass felt upon palpation.

Eyes

 Eyes are symmetric, outer canthus of the eye are aligned to the auricles.
 Eyebrows are black in color and fairly distributed.
 Eyelashes appeared to be equally distributed and curled slightly outward.
 Eyelids have no presence of discharges or discoloration and closes symmetrically.
 The sclera is clear, iris is black in color flat and round.
 Pupils are equally round and reactive to light and accommodation.
 Able to perform 6 cardinal eye movements.
 Patient uses reading glass

Ears

 Ears are symmetric; auricles are aligned at the outer canthus of the eyes.
 Pinna recoils when folded.
 No mass and tenderness upon palpation.
 Able to hear the clicking sound of a pen 2 feet away from her.
 Cleans her ears every day.

Nose and sinuses

 Nose is intact, aligned, symmetrical without discharge or redness.

 Both nares are patent, able to blow and sniff through each nostril.
 No tenderness upon palpation on sinuses.

Mouth and Pharynx

 Teeth are incomplete; 1 upper right molar extracted.

 Lips, gums and tonsils are moist and pinkish in color, without lesion and bleeding.
 Tongue is moist, pink, with papillae present.
  Uvula is intact and hangs in the midline.
 Brushes her teeth once a day after meal.

Neck

 Neck is in midline.
 Can perform full range of motion (ROM) and no masses upon palpation.
 Trachea is in midline.

Breast and Axilla

 Breast is lighter in color than the surrounding skin.

 Areola is dark brown in color and is everted.

 No palpable lumps and lesions upon palpation and inspection

 Axilla has no lesion, masses, and rashes present.

 Uses deodorant and shaves axillae once a week.

Lungs

 Respiration is 18 breaths per minutes (cpm), no use of accessory muscle upon breathing.
 No crackles or abnormal sounds heard upon auscultation.
 No mass and tenderness palpated on the anterior and posterior chest.
 Does not smoke or use tobacco.

Heart

 Soles and palms are pale pink in color.

 No abnormal pulsations, no jugular distention.
 No mass and tenderness with palpation on heart landmarks.

Gastrointestinal

 Presence of surgical incision at the lower abdominal incision (6inches) with dressing
applied and covered with binder.
 Abdomen is round in shape.
  Striae gravidarum observed.
 Umbilicus is in midline and inverted.
 Client eliminates every day to a brown well-formed stool.

Peripheral vascular

 Arms are equal in size, no swelling, and no clubbing of finger nails.

 Capillary refill time less than 2 seconds.
 Legs are warm to touch bilaterally and no ulcers or edema noted.
 No apparent varicosities or superficial thrombophlebitis noted.

Genitourinary

 No pubic hair as verbalized by the patient.

 No history of reproductive disease or disorders claim by the patient.
 The patient voids more than 10 times a day to a clear yellowish colored urine.

Musculoskeletal

 There are no deformities on the bones.

 Patient claimed that she is experiencing pain upon movement.

Neurologic

 GCS 15 (E4, V5, M6), oriented with time, place and person.
 She is cooperative and attentive all throughout the assessment.
 Able to answer concretely questions being asked.

CRANIAL NERVES

CRANIAL NERVES RESULT

Cranial Nerve – I (Olfactory) Identifies the smell of Vicks and vinegar.

Patient was able to read printed writing held

Crania Nerve – II (Optic )
at a distance of 12 inches.

Cranial Nerve – III,IV & VI (Oculomotor, Intact. Pupils equally round and reactive to
 light and accommodation, able to perform 6
Trochlear and Abducens)
cardinal eye movements.

Able to sense and distinguish the point of

Cranial Nerve – V (Trigeminal Nerve)
pencil on arm and cheeks.

Able to smile, frown, wrinkle forehead, show

Cranial Nerve – VII (Facial) teeth, puff out cheeks, purse lips, raise
eyebrows, and close eyes against resistance.

Cranial Nerve – VIII (Acoustic nerve) Able to hear ticking sounds of a wrist watch.

Cranial Nerve IX and X (Glossopharyngeal

Intact. Client is able to swallow and cough.
&Vagus)

Client was able to shrugs shoulders and

Cranial Nerve XI (Accessory Nerve) moves head to right and left against
resistance.

Tongue is in midline. Client was able to say

Cranial Nerve XII (Hypoglossal)
letter d, l, n, and t.

Sensory Function Test

 Client was able to feel touch, pain, and temperature on various areas of her body.

 Client was able to identify the direction of movement of her fingers.as

 The client was able to identify the shapes and letters drawn in her hand.

Glasgow Coma Scale

Response
 6- Obeys command fully

5- Localizes pain

4- Withdraws from pain

I.MOTOR RESPONSE 3-Abnormalflexion 6 (Obeys commands fully)

(decorticate)

2-Extensor response
(decerebrate)

1- No response

5- Alert and oriented

4- Confused, yet coherent

II. VERBAL RESPONSE speech
5 (Alert and oriented)
3- Inappropriate words

2- Incomprehensible sounds

1- No sounds

4- Spontaneous eye opening

II. EYE OPENING 3- Eyes open to speech

4 (Spontaneous eye
opening)
2- Eyes open to pain

1- No eye opening

Score: 15