Pamantasan ng Lungsod ng Maynila

(University of the City of Manila)

Gen. Luna, cor. Muralla Sts., Intramuros, Manila
College of Nursing

Maternal and Child Nursing II

OB WARD
(Related Learning Experience)

Submitted by:

Julia Michal P. Angeles

BS Nursing II-2
Group D1

Submitted to:
Prof. Lady Anne De Jesus
I. DEMOGRAPHIC PROFILE

The case presents, Patient LO, a forty-four-year-old Filipino Catholic woman who

was born in Manila city on March 5, 1972. She is a high school graduate. She works as

a manicurist and has a husband who works at a factory in Makati. They have four

children and they are currently living in Cavite city.

II. CHIEF COMPLAINT

“Sobrang sakit nung sa may bandang puson ko” As verbalized by the patient.

III. HISTORY OF PRESENT ILLNESS

Three days prior to confinement, the patient had noted pain on the hypogastric

region with a pain scale of 5/10. She also noted vaginal bleeding and said that she had

consume 2-3. On the day of confinement (December 5, 2016), the patient said that she

experienced abdominal (belly) pain with pain scale of 7/10 and her vaginal bleeding

became heavy.

IV. PAST MEDICAL HISTORY

The patient has no known diseases and positive allergies to food or

medications. She had measles when she was 9-year-old, mumps when she was 7-year-

old and chicken pox when she was 10-year-old. She has not been involved into major

injuries or accidents and the patient’s past hospitalizations include her labor and

delivery to her four children.

V. FAMILY HEALTH HISTORY

The patient’s parents are still living. The patient has no family history of genetic

history of hypertension, asthma, heart diseases, diabetes mellitus and blood dyscrasia.

VI. SOCIAL HISTORY

The patient is 44 years old. She is living together with her husband and their four

daughters. They are residing at Dasmarinas, Cavite. Her daily activities were doing

household chores before going to work. she and her husband are the one who budgets

their money in order for them to survive the daily livings of life. The patient finished 4 th

year high school. She discovered she was pregnant when she suddenly felt sick and

weak, she seems to be sleepy and tired at all times and she was a month and a half

delayed. Because of the symptoms, she felt, she bought a pregnancy test and the result

were positive. She said that despite of being not a well-off family she is happy that she

is going to have a baby again. The patient is a cigarette smoker and consumes 1-2

sticks/day, she said that it is her stress reliever. She does not drink nor do drugs.

VII. OBSTETRICS HISTORY

The patient had her first menstruation or menarche at the age of 11 years old, her

menstruation has a regular or monthly interval and it often lasts for 5days. She also

consumes approximately 4 pads a day and. She does not experience dysmenorrhea
 whenever she has her period. Her first sexual intercourse was when she was 20 years old

and she had 1 sexual partner. The patient’s last menstrual period was October 8, 2016.

She is in her 8th week of gestation. She had her labors in the 1996, 1999, 2001, 2004 all

full term via normal spontaneous delivery at Fabella Hospital. She said that with her current

pregnancy, she did not attend any pre-natal check-up.

IX. GORDON’S FUNCTIONAL HEALTH PATTERNS

Health Pattern Before Admission After Interpretation

Admission
Health Perception – Health Management Pattern
How do you describe your “saktuhan lang, okay na hindi” as verbalized by the “ewan ko,
health? patient parang di
okay” as
verbalized by
the patient
How do you improve or “kumakain naman ako nang maayos tyka mahilig ako “inumin ko
maintain your health? sa gulay at prutas” as verbalized by the patient mga gamot
na binigay
sakin” as
verbalized by
the patient
How do you link lifestyle “di ko maiwasan di mag-yosi eh, lalo na kapag stressed “dahil siguro
choices and health? ako.” as verbalized by the patient sa lifestyle ko
kaya
nangyari
sakin to” as
verbalized by
the patient
How big is the problem in “medyo mahirap kaya nga kahit taga Cavite kami dito “panibagon
financing health care for you? ako nagpaadmit.” as verbalized by the patient g gastos
nanaman”
as
verbalized

Can you name Medications
you are taking and their
purpose?
What is your usual diet?
How’s your appetite?
Can you recall the highest
weight you have?
Usual bowel pattern?
Frequency? Color?
Do you experience any
discomforts: pain, burning,
and difficulty voiding? How do
you manage it?
Do you experience any
discomforts diarrhea,
constipation, bleeding?
How do you describe your
weekly pattern of activity and
leisure, exercise and
recreation?
Do you have any disease that
affects cardio-respiratory
system or musculo-skeletal
system?
by the
patient
“Multivitamins na lang ata ang iniinom ko ngayon.” as
verbalized by the patient
Nutritional – Metabolic Pattern
“Gulay lang pati minsan karne ng baboy, manok, isda,
prutas na din” as verbalized by the patient
“nung sumakit na yung sa may puson ko medyo “wala ako
nawalan ako gana kumain eh” as verbalized by the ganang
patient kumain” as
verbalized by
the patient
“Hindi ko na maalala eh, pero dati pa ‘to 60 kg ako.”
as verbalized by the patient
Elimination Pattern
“Normal pa rin naman, isang beses araw-araw.” as
verbalized by the patient
“Wala naman akong nararamdaman sa pagihi.” as
verbalized by the patient
“oo, nagkaron ako ng bleeding, medyo kinabahan na
nga ako” as verbalized by the patient
Activity - Exercise Pattern
“gawa ng gawaing bahay, kapag may customer edi
lakad dito, lakad dun” as verbalized by the patient
The patient denies any disease affecting the cardio-
respiratory and musculo-skeletal system.
Do you experience
fatigue/weakness, pain after
the activity?
Describe your sleep pattern?
Do you feel tired upon waking
up?
Do you have sensory deficits
(sight, smell, auditory, taste
and vision)? Are they
Corrected?
Do you experience pain?
How do you manage it?
Do you think that there is
anything unusual about your
appearance and self?
How are you feeling?
How do you describe various
roles in life?
Which relationship is most
important to you?
“nakakapagod syempre” as verbalized by the patient
Sleep – Rest Pattern
“Medyo hirap ako matulog, putol putol ba.” as
verbalized by the patient
“Minsan, parang kulang sa tulog.” as verbalized by the
patient
Cognitive – Perceptual Pattern
“Wala naman, di naman Malabo ang mata ko, hindi rin
mahina ang pandinig ko.” as verbalized by the patient
“oo sumakit yung sa may puson ko talaga.” as
verbalized by the patient
Self- Perception – Self- Concept Pattern
“Wala naman, ganyan talaga pag tumatanda
nagbabago ang katawan” as verbalized by the patient
“natatakot ako tyaka nalulungkot: as
verbalized by the patient
Role – Relationship Pattern
“Isa akong ina at asawa.” As verbalized by the “ina at
patient asawa, isang
kapatid din”
as verbalized
by the patient
“Yung pagiging asawa at nanay sa mga anak “pagiging
ko” as verbalized by the patient
isang
mabuting
ina” as
verbalized by
the patient
Sexuality – Reproductive Pattern
Can you say that you are “sakto lang, kami ng asawa ko.” As verbalized by the “ayoko na”
sexually active? patient as verbalized
by the patient
Do you use birth control “Hindi eh, hindi kami gumagamitng contraceptives.” “hinde” as
method? As verbalized by the patient verbalized by
the patient
Coping – Stress Tolerance Pattern
Have you experience any “Oo, pero katuwang ko naman ang asawa ko.” as “eto ang
discomforts in life? What verbalized by the patient sakit para
condition brought it? sakin, ang
sakit
mawalan ng
anak” as
verbalized by
the patient
How do you usually cope with “Tinutulungan ako ng asawa ko sa mga problema ko.” “pinaguusap
problems? as verbalized by the patient an namin ng
asawa ko” as
verbalized by
the patient
To whom would you go if you “Sa asawa ko or sa magulang ko” as verbalized by the “asawa at
have problems? patient magulang”
as verbalized
by the patient
Value – Belief Pattern
What support systems do you “Yung asawa ko at mga magulang ko syempre pati “pamilya ko,
have? mga anak ko” as verbalized by the patient mga anak ko
asawa,
magulang ko
din” as
verbalized by
the patient

X. REVIEW OF SYSTEMS

SYSTEM SUBJECTIVE
Constitutional “Tumaas timbang ko sa pregnancy na ‘to” as verbalized by the client.
HEENT “Maayos pa naman ang mata ko” as verbalized by the client.
Integumentary The client denies rashes or itching.
Cardiovascular The client denies any shortness of breath, cough or pleuritic chest pain.
Respiratory “Normal naman paghinga ko, nagkaubo lang ako nung last week” as verbalized by the
client.
Gastrointestinal “Masakit yung sa may puson ko” as verbalized by the client.

Genitourinary The patient does not have any dysuria, frequency or urgency.
Neurological The patient denies any weakness, dizziness, or headache.
Musculoskeletal “Wala naming masakit sa akin” as verbalized by the client.
Hematologic The patient denies any bleeding or bruising.
Lymphatic “Wala naman akong nakakapang mga kulani” as verbalized by the client.
Endocrine The patient denies excessive sweating, polyuria, heat or cold intolerance.
Allergies The patient denies history of asthma, hives, eczema or rhinitis.

XI. PHYSICAL ASSESSMENT

General Survey: Seen lying on bed, awake, conscious, coherent and communicative.

Normal Findings Actual Findings

Skin
 Inspect skin color. Varies from light to deep brown; from ruddy Brown skin
pink to light ink
 Inspect uniformity of skin color. Generally uniform except in areas exposed to Generally uniform skin color
the sun; are of lighter pigmentation in dark-
skinned people.
 Assess edema, if present. No edema No edema
 Inspect, palpate, and describe Freckles, some birthmarks, some flat and No freckles, has some
skin lesions. raised nevi; no abrasions or other lesions birthmarks
 Observe and palpate skin Moisture in skin folds and the axillae Not excessively dry
moisture.
 Palpate skin temperature. Uniform; within normal range Within normal range
Hair
 Inspect the evenness of growth Evenly distributed hair Evenly distributed hair
over the scalp
 Inspect the thickness or Thick hair Thickness of hair
thinness.
 Inspect hair texture and oiliness. Silky, resilient hair Silky and resilient
 Inspect amount of body hair. Variable Variable
Nails
  Inspect fingernail plate shape to
determine its curvature and
angle.
 Inspect fingernail and toenail
bed color.
 Inspect tissues surrounding nails
 Perform the blanch test of
capillary refill.
Skull and Face
 Inspect the skull for size shape
and symmetry.
 Palpate the skull for nodules or
masses and depressions,
 Inspect the facial features.
Eyes and Visual Acuity
 Inspect the eyebrows for hair
distribution and alignment and
akin quality and movement.
 Inspect the eyelashes for
evenness of distribution and
direction of curl.
 Inspect bulbar conjunctiva.
 Inspect pupils color, shape, and
symmetry of size.
 Inspect PERRLA.
 Pupil’s direct and consensual
reaction to light.
Ears and Hearing
 Inspect the auricles for color,
symmetry of size and position.
 Palpate the auricles for texture,
elasticity, and areas of
tenderness.
 Assess the client’s response to
normal voice tones.
Nose and Sinuses
 Inspect the external nose for any
deviations in size, shape, or
color and flaring or discharge
from the nares.
 Determine the patency of both
nasal cavities.
 Palpate the maxillary and frontal
sinuses for tenderness.
Mouth and Oropharynx
 Inspect outer lips for symmetry
of contour, color, and texture.
 Inspect the tongue movement.
Convex curvature; angle of nail plate about Convex
160o
Highly and pink in light-skinned clients; dark- Pink nail bed color
skinned clients may have brown or black
pigmentation in longitudinal streaks
Intact epidermis Intact epidermis
Prompt return of pink or usual color (less than Returned to usual color after 3
4 seconds) seconds
Rounded; smooth skull Rounded; smooth skull
Smooth, uniform consistency; absence of Smooth; no presence of
nodules or masses nodules or masses
Symmetric or slightly asymmetric facial Symmetric facial features
features; palpebral fissures equal in size
Hair evenly distributed; skin intact Evenly distributed; intact skin;
Eyebrows symmetrically aligned; equal eyebrows are aligned
movement symmetrically
Equally distributed; curled slightly outward Equally distributed, slightly
curled outward
Transparent, capillaries sometimes evident; White sclera
sclera appears white
Black in color; equal in size; normally 3-7 mm Black pupils; equal size; 4mm
in diameter in diameter
Pupil’s equal, round, reactive to light, PERRLA
accommodation
Both illuminated and non-illuminated pupil Direct and consensually
constricts reactive to light
Color same as facial skin Uniform in color, symmetrical
Symmetrical
Mobile, firm, and not tender; pinna recoils Firm and not tender, pinna
after it is folded recoils after it is folded
Normal voice tones audible Able to hear normal voice
tones
Symmetric and straight Nose are symmetric, no
No discharge or flaring discharges or flaring, color is
Uniform color same as other body parts
Air moves freely as the client breathes Breathes normally and freely
through the nares through the nares
Not tender Not tender
Uniform pink color Pink in color, dryness
Soft, moist, smooth texture
Moves freely; no tenderness Moves freely; no tenderness
  Inspect the hard and soft palate
for color, shape, texture and he
presence of bony prominences.
 Inspect the tonsils for color,
discharge, and size.
Neck
 Inspect the neck muscles for
abnormal swellings or masses.
 Palpate the entire neck for
enlarged lymph nodes.
 Inspect the thyroid gland.
Thorax and Lungs
 Inspect the shape and symmetry
of the thorax.
 Inspect breath patterns.
Heart
 Palpate the carotid artery, using
extreme. caution.
 Auscultate the carotid artery.
Breast and Axillae
 Inspect the breasts for size,
symmetry, and contour or shape. generally symmetric
 Palpate the axillary,
subclavicular lymph nodes.
 Palpate the breast for masses,
tenderness, and any discharge
from the nipples.
Abdomen
 Inspect the abdomen for skin
integrity.
 Inspect the abdomen for contour Flat, rounded, or scaphoid
and symmetry.
 Palpate the uterus
Genitals– The patient refused to assess her genitals
Light pink, smooth, soft palate Light pink in color, soft palate
Lighter pink hard palate, more irregular is smooth; hard palate with
texture texture
Pink and smooth posterior wall Pink and smooth
Muscles equal in size; head centered Muscles are equal, head is
positioned in the center
Not palpable Not palpable
Not visible on inspection Thyroid gland not visible
Chest symmetric Chest symmetric
Quiet, rhythmic, and effortless respirations Quiet, rhythmic, and effortless
respirations
Symmetric pulse volumes Symmetric pulse volumes
Quality remains same when client breathes
No sound heard on auscultation No sound heard on
auscultation
Rounded shape; slightly unequal in size; Rounded; slightly unequal;
engorgement
No tenderness, masses, or nodules No tenderness, masses, or
nodules
No tenderness, masses, nodules, or nipple Breasts are engorged
discharge
Unblemished skin Presence of striae and incision
Uniform color wound
Rounded
The uterus should be contracted Contracted uterus

XII. NURSING CARE PLANS

Assessment Nsg Diagnosis Planning Intervention Rationale

S Activity intolerance Within 2 hours Adjust activities To prevent over

- “Kumikirot yung within patient’s exertion
related to pain of nsg
tahi ko” ROM
intervention the
Assist the To protect client and
O client will be
patient with her prevent from further
- post-op pt able to do her activities injury
- facial grimace
- frequent touching daily activites Administer To help the patient
of the incision mefenamic acid relieve or lessen the
with less or no
- weakness as ordered pain
pain