Sie sind auf Seite 1von 28

College of Nursing

Silliman University
Dumaguete City

FUNCTIONAL HEALTH PATTERN


and

NURSING CARE PLAN


Submitted to:
MS. JOANNA MARIE B. APAO, RN
Clinical Instructor-OB GYNE NURSERY Rotation

Submitted by:
EREN BELLE H. ASENTISTA
PUBLIUS JOSEANGELO C. BRIONES
MITCHELL REYNALD L. MELITON

FUNCTIONAL
HEALTH PATTERN
NURSING HISTORY

Part I. Demographic Information (3 points)


Name: Connie Zuniega Callao______________ Civil Status: Single______ Sex: Female Religion: Roman Catholic_
Educational Attainment: College Undergraduate Occupation: Housewife_ Nationality: Filipino___________________
Address: Calbo St., Poblacion Tayasan, NO Date & Time of Admission: February 4, 2009 at 9:45 am_____________
Doctor(s) in charge: Dr.Portia Pauline Hachuela, Dr.Cadalin___________ Room & Bed No: POR Bed 6_____________
Chief Complaint(s): for induction of labor, regular prenatal check-up by Dr. Portia Pauline Hachuela_________________

History of present illness:


Prior to hospitalization just today, client started to feel uncomfortable predeeded by uterine contractions which prompted her to ask her family
members to bring her to a hospital and have herself checked. She was then transported from Tayasan to Dumaguete City to be confined to Negros Oriental
Provincial Hospital (NOPH). The Age of Gestation (AOG) = 37 weeks. The expected Date of Confinement (EDC) = February 19, 2009.

General Impression of client (appearance upon first contact):


Received sitting on bed with D5LR 1000ml at 400ml level infusing at 30 gtts/min @ right metacarpal vei as main line and 0.9% NaCl 1000ml @ 860 ml
level infusing at 10 gtts/mon as blood line (KVO) metacarpal at left vein, awake, conscious, coherent and responsive to environment . Upon first contact, client
was weak-looking and apprehensive about her pre-scheduled cesarian delivery as claimed. She talked in a moderate-paced manner during the entire
conversation/interaction. Odor and perspiration was not noted.

USUAL FUNCTION PATTERN INITIAL APPRAISAL ONGOING APPRAISAL ONGOING APPRAISAL


1) HEALTH-MANAGEMENT-HEALTH- FEBRUARY 04, 2009 FEBRUARY 05, 2009 JAFEBRUARY 06, 2009
Admitted last February 4, 2009 at 9:45am,  Received lying on bed with twin babies  Received sitting beside bed,
CONCEPT PATTERN conscious, coherent and ambulatory. on both sides. Awake, coherent, and awake, conscious, coherent and
 Client claims that her health in the past year has
Admitting v/s: T= 36.4⁰C, P= 89 bpm, R = 20 responsive. Oriented to time, place and responsive to environment with D5LR
been good
cpm, BP= 110/80 mmHg. persons, with D5LR 1000cc at 925 cc level 1000cc at 540 cc level infusing @ left
 Client verbalized, “okay ra man pod akong
Attending physician: Dr. Portia Pauline on right metacarpal vein infusing well at 20 metacarpal vein.
panglawas atong niaging tuig”
Hachuela and Dr. Cadalin. gtts/min. V/S:
 Client doesn’t smoke or drink as claimed
General Impression: Received sitting on bed  FBC in place and patent; drained 325cc of  7AM
 Client exercises regularly even before she got
with D5LR 1000ml at 400ml level infusing at dark red urine during the shift. T=36.6⁰C
pregnant
30 gtts/min at right metacarpal vei as main  V/S: P=92 bpm
 Client verbalized, “tig exercise na gyud ko sauna,
line and 0.9% NaCl 1000ml at 860 ml level  7AM R= 20 cpm
katong mabdus nako, akong sigeng buhaton kay
infusing at 10 gtts/mon as blood line (KVO) at T=37.2⁰C BP= 120/70mmHg
mag walking every morning”
left metacarpal vein, awake, conscious, P= 92 bpm  12NN
 Client verbalized, “dili man pod ko daling
coherent and responsive to environment . R= 20 cpm T= 87.4⁰C
matakdan ug ubo ug sip-on pero usahay ubhon ug
Chief Complains: for induction of labor, BP= 120/80mmHg P= 94 bpm
sip-onon pod ko”
regular prenatal check-up by Dr. Portia Pauline  12NN R=20 cpm
 Client did not experience any hospitalization in
Hachuela T= 37.4⁰C BP= 120/70mmHg
the past years as claimed except for her
Doctor’s Order: P= 90 bpm  Doctor’s Order:
miscarriage two years ago where she was
9:45 AM R=20 cpm  IVF TF: D5LR at 20 gtts/mon then
confined in the hospital for three days DC once consumed
 Please admit to OB service BP= 120/70mmHg
 Client verbalized, “ Katong 2007, nag miscarriage  NPO  May have soft diet
Doctor’s Order:
ko dayon na admit ko ug mga 3 days. Aside ana,  Labs  DAT for dinner
 Monitor v/s
wala nay lain” -CBC stat  AP  Start (Clavoxin) Co-amxiciclav 625
 Client did not undergo any operation/surgery as -other labs taken at OPD-attach to chart pls  Flat on bed mg tab – 1 tab BID (once IV ampicillin
claimed since her birth  Start venoclysis  O2 inhalation at 2-3L is consumed)
 Client claims she didn’t experience any skin -main line: D5LR 1L at 30 gtts/min  IVF TF:  Mefenamic Acid 500 g/amp – 1
trauma or any accidents involving the skin in the -blood line: PNSS 1L at KVO -D5LR 1L + 20 T “U” Oxytocin @ 30-33 amp q 6 h, RTC
past  For C/S once with blood or in labor gtts/min  Hemobion 1 amp OD
 Has no known skin allergies as claimed 3:11PM -D5LR 1L + 10 T”U” Oxytocin @ 30  Results of Labortory Findings:
Has no known food/medication allergies as  On bed with FBC in place for C/S once with blood gtts/min  CBC

called for -PNSS 1L @ KVO rate -Hemoglobin 10.6 g% (12-14 g%)
claimed
9:45 AM  For repeat HnH @ 5am (02/05/09) – defer -Hematocrit 30.7 vol% (37-22 vol%)
 Client claims she never contracted any major
 Please admit to OB service  MIO q 4h -WBC Count 8,500T/cumm (5-10
disease or illness in the past years  Please transfuse 1 “U” FWB of patient’s
 NPO T/cumm)
 Client’s second child died because of an abortion blood type properly screen and crossmatch
 Labs -Differential Count
way back in 2007  Please refer accordingly
 Secure consent for the procedure *Neutrophil sed 71
 Client claims she doen’t have any difficulty in  Inform OR staff and Anesthesian POD 6:20 *Lymphocytes 20
following the advice of health care professionals  Inform Pedia POD  May have sips of water *Monocyte 5
(e.g. doctors, nurses, midwives, etc)  Abdominoperineal prep  General liquid with crackers for lunch *Eosinophil 9
 Client claims she exercises regularly, mostly  Consent FBC, drain continuously  Discontinue one line, retain blood set once *Basophil 1
through walking every morning when she got  Crossmatch 1 unit of blood, of patient’s blood is consumed -Platelet Count 123,000
pregnant again with her twins, and even before bloddtype  Consumed IVTT meds  Urinalysis
she was pregnant with her first-born child,  TPR, BP now then q shift -Ketoralac Tramadol -Color Light Yellow
Samantha Nicole  Refer accordingly -Cont IV Ampicillin 1 g x 4 doses -Trabsparency Turbid
Results of laboratory tests:  Repeat CBC 8 hrs post transfusion -Specific Gravity 1.010
 Client caims that the following are some of the
 CBC 1:30AM -Pus 0-3/hpf
heredofamilial diseases that her family has:
-Hemoglobin 11.4 g% (12-14 g%)  TTF: D5LR 1L @ 30 gtss/min -RBC 0-2
Hypertension (HPN) and Diabetes Mellitus (DM)
-Hematocrit 34 vol% (37-22 vol%) -Bisacodyl (Dulcolax) -2 supp/rectam at -Epith Cells abundant
 Client verbalized, “basta akong mahinumduman, -Mucus Cells few
-WBC Count 10.5T/cumm (5-10 T/cumm) 4pm today
naa koy BCG, pero wala nako kabalo sa uban, -Remove FBC at 4pm today -Amorph Urates few
-Differential Count
kung kumpleto ba gyud ko” *PMN 78 (53-70) -Refer if unable to void 4-6 hrs after  Client verbalized,”niarang-arang
*EOS 01 (1-4) removal naman akong paminaw, sakit pa
*Lymphocytes 21 (20-35) -May sit up in bed and dangle legs gamay akong tiyan pero makaya ra”
-Platelet Adequate (150-400 T/cumm) -BP, TPR q shift  Client verbalized, “compared
 GRP “O” Rh positive -Refer accordingly
gahapon, may nalang ning karon nga
 Serology  Results of Labortory Findings:
wala nakoy catheter”
-HbsAg Negative  CBC
 Clinical Chemistry -Hemoglobin 10.6 g% (12-14 g%)
-Glucose Tolerance Test 50 gms 1 hr 109 (90-165 -Hematocrit 30.7 vol% (37-22 vol%)
mg/dl) -WBC Count 8,500T/cumm (5-10 T/cumm)
 Obstetrical History: G3 P1 A1; PU 37 ¼ weeks -Differential Count
AOG *Neutrophil sed 71
 Twin Pergancy (Complete Breech Transverse
*Lymphocytes 20
Lie) in beginning labor *Monocyte 5
Pregnanc Pregnacy Year Gestatio Se *Eosinophil 9
*Basophil 1
y Order Outcome n x -Platelet Count 123,000
(weeks)  Medications:
1. G1 NSVD 199 FT F  Ketoralac 30 mg IVTT q 8 x 3 doses
8  Tramadol 50 mg IVTT q 8 h
2. G2 Abortion  Ranitidine 50 mg IVTT a 8 h x 3 doses
3. G3 Present  Ampicillin 1 gm IVTT q 6 h
Pregnanc
Client verbalized, “kapoy gyud kaayo,
y
ganahan rako maghigda sige”
Contraceptive History: None
Client verbalized, “hapdus kaayo ang
 LMP May 18, 2008
akong feeling, dili gyud ko comportable;
 EDC February 25, 2009
mura siya’g manusok and kasakit”
 AOG 37 weeks
Client verbalized, “sakit gyud akong
 Ultrasound JAN 09
tiyan. Mura cyag puno nga ambot, dili ko
 Prenatal Visits = 2-5
kasabot”
 Health Care Provider = OB Provate

 Immunizations=Tetanus (2 doses)

 BP=110/80mmHg

 Medication(s) = FeSO4

 Dilation = 1 cm

 Effacemtn = 50%

 Membrane Intact

 FHT T1 145, T2 149

 Ultrasound Report: (02/04/09)


 Clinical Dx: pregancy Uterine 34 6/7 AOG by
LMP, ML
 Transabdominal – within the gravid uterus are 2
live fetuses on frank breech-transverse lie (fetal
backdown) with good cardiac and somatic
activities)
-TWIN A - 36 3/7 weeks by Biometry; Placenta is
anterior, Grade II, High Lying,
Normohydramnios; Sonographic Estimated Fetal
weight is appropriate for gestational age; [FHR
131 bpm, BPD 9.4 cm 37 weeks and 4 days, HC
34.4 cm 37 weeks, AC 30.2 cm 34 weeks, SEFW
2.61 kg (Hadlock), FL 7.1 cm 36 weeks and 3
days, Placenta Anterior Gr II, AFI 3.8 cm, Others:
consider di-chronic damniotic placentation]
-TWIN B - 35 2/7 weeks by Biometry; Placenta is
anterior, Grade II, High Lying,
Normohydramnios; Sonographic Estimated Fetal
weight is appropriate for gestational age; [FHR
134 bpm, BPD 91 cm 37 weeks and 6 days, HC
32.0 cm 34 weeks and 5 days, AC 30.6 cm 35
weeks, SEFW 2.48 kg (Hadlock), FL 6.6 cm 33
weeks and 3 days, Placenta Anterior Gr II, AFI 3.8
cm, Others: consider di-chronic damniotic
placentation]
 Urinalysis
Physical and Chemical Ecxamination
-Color Light Yellow
-Transparency Turbid
-Specific Gravity 1.010
-Glucose negative
-Proteinnegative
-pH 6.0
Microscopic Examination
-Pus Cells 0-3/hpf
-RBC 0-2/hpf
-Epith Cells abundant
-Mucus Threads Few
-Amorph Urates Few
Medications
 Ampicillin 1 g IVTT ANST q 6 hrs
 Ranitidine 50 mg IVTT q 8 hrs
Prefers to sit or to lie down most of the time
 Needs/requires help for ambulation/mobility
from significant others/”bantay”
 Presence of lochia or vaginal discharges

 Client verbalized, “kutas ug luya kaayo akong


paminaw” Intravenous Medication(s): Client verbalized, “nikaon ko ug
2) NUTRITIONAL-METABOLIC PATTERN
Client verbalized, “wala ra may nausob kaayo sa -Ketoralac 30 mg IVTT q 8 x 3 doses crackers gnha pero wala ko kahurot,

akong lawas; mura ra man gihapon” -Tramadol 50 mg IVTT q 8 h nihigop pod ko ug gamay nga sabaw”
Food or eating discomfort: NONE -Ranitidine 50 mg IVTT q 8 h x 3 doses Client verbalized, “pwede naman

 On NPO Status for pre-schedules Cesarian -Ampicillin 1 gm IVTT q 6 h hinuon ko mukaon ug lugaw, basta
 Has a complete set of teeth
Delivery Doctor’s Order: general liquid with anything soft rah..”
 No food allergies as claimes
 Intravenous Fluid(s): crackers for lunch Client verbalized, “ni arang-arang
 Client verbalized, “pag mukaon ko, daghan-daghan -D5LR 1000ml at 400ml level infusing at 30 gtts/min With 1 “U” FWB of patient’s blood type naman akong gana pero dili pako
gyud ng kan-on kaysa sud-an; ang ako pod fluid
intake, daghan pod before pako nimabdus” -0.9% NaCl 1000ml @ 860 ml level infusing at 10 infusing @ 20 gtts/min (for 4 hrs) ganahan mukaon ug daghan gyud
 Client claims she eats vegetables a lot gtts/mon as blood line (KVO) Client verbalized, “crackers ra akong kaayo”
 Client verbalized, “bata pako, naanad na man gud Intravenous Medication(s): gipaniodto kay mao may gisulti sa doktor”
ko ug kaon ug utan kay akong mama ug papa, -Ampicillin 1g IVTT ANST q 6 hrs Client verbalized, “wala pa kaayo koy
particular kaayo ana kay highblood man to akong -Ranitidine 50 mg IVTT q 8 hrs gana musimhot ug pagkaon; dili ko daling
 Client verbalized,”Wala gyud pod hinuon koy
mga lolo ug lola sauna, mao ng naanad nako” maganyat mukaon…bag-o man gud kung gi
Has 5 artificial teeth (4 at the upper front protain gana ikaon ron kay mura kog nakuyawan” operahan”

 Skin when touched is smooth, moist and warm.
and 1 molar)
 Odor and perspiration not noted.
 Typical Daily Food Intake:
Breakfast
2 cups rice
1 pc egg
1 glass vegetables
Lunch
2 cups rice
1 pc fish/pork/chicken
1 cup vegetables
1 pc fruit (e.g. banana)
Dinner
2 cups rice, sometimes rice porridge
1 pc fish/pork/chicken
1 cup soup/vegetables
Snacks
Appetizers (e.g. lumpia shanghai, pastries (e.g.
cakes, cookies), bread, banana cue or barbecue
and the like and beverages (e.g. coke, juice)
 Typical Daily Fluid Intake: more than 8 glasses/day
as claimed
 Client verbalized,”kusog ko muinom ug tubig bisag
sauna pa”
 Client verbalized, “bisag unsa ra man akong kaon-
on, wala ra pod koy mga allergies”

3) ELIMINATION PATTERN
 Client verbalized, “wala ra may problema sa akong
pag pangihi ug pag kalibang” FBC in place and patent; drained 325 cc A
BEFORE PREGNANCY of dark red urine during the shift
 Bowel Elimination: Doctor’s Order:
Frequency – 1-3/day  Bowel Elimination: -Remove FBC at 4pm today
Character – brown Frequency – 11/day -Refer if unable to void 4-6 hrs after
Consistency – formed Character – brown, sometimes yellowish removal
Discomfort - none Consistency – formed, sometimes formed Client verbalized, “hapdus kaayo akong
 Urinary Elimination: Discomfort – most of the time none, feels feeling tungod sa cathetr; dili gyud ko
Frequency – at most 4/day uncomfortable because she experiences comfortable; mura siya’g manusok sa
Character – yellow constipation as claimed kasakit”
Discomfort – none  Urinary Elimination:
Control Problem - none Frequency – 6-7/day
Character – yellowish in color
Discomfort – none
Control Problem - none
 Client verbalized, “katong mga pila ka weeks na
ang niagi, mura kog ga constipation kay
maglisod kog kalibang pero nawala ra pod”
 Client verbalized, “dili gyud ko comfortable
karon kay kaning akong catheter, may pagka
hapdus siya nya sakit pod”
4) ACTIVITY-EXERCISE PATTERN
 Client verbalized, “tig exercise gyud ko even before Perceived Ability for: Perceived Ability for:
ko nagmabdus”  Feeding – II  Feeding – 0
 Client verbalized, “tig walking ko every morning”  Bathing – II  Bathing – II
 dili gyud ko tig exercise sukad sauna”  Perceived Ability for:  Toileting – II  Toileting – II
 Client doesn’t drink or smoke as claimed  Feeding – 0  Bed Mobility – II  Bed Mobility – 0
 Perceived Ability for:  Bathing – 0  Grooming – II  Grooming – II
 Feeding – 0  Toileting – 0  General Mobility – II  General Mobility – 0
 Bathing – 0  Bed Mobility – 0 Client verbalized, “kapoy…ganahan rako  Client verbalized,”niarang-arang
 Toileting – 0  Grooming – 0 matulog ug muhigda” naman akong paminaw, sakit pa
 Bed Mobility – 0  General Mobility – 0 Client verbalized, “sakit ug hapdus kaayo gamay akong tiyan pero makaya ra”
 Grooming – 0  Client verbalized, “kapoy akong paminaw, kutas ang feeling kaning naay catheter”  Client verbalized, “compared
 General Mobility – 0 kaayo, labi nag magdungan ug lihok ning Client verbalized, “okay ra man nuon gahapon, may nalang ning karon nga
 Cooking – 0 kaluha…kaluoy sa ginoo, bug-at gyud sila” akong cesarian gabie, wala gani ko kabantay wala nakoy catheter”
 Client verbalized, “usahay kung mag higda ko, nga nanganak na diay ko…after mga 2 hrs,  Client varbalized, “maka lakaw-
 Home Maintenance – 0
magtakilid ko kay bug-at gyud” nakagawas ra pod ko dayon sa delivery lakaw naman ko ginagmay padulong
room” sa CR pero may nalang kaysa
Client verbalized, “nahuwasan gyud ko gahapon, dili na kaayo sakit akong
nga nahumana na ang tanan” tahi sa pag opera”

5) SLEEP-REST PATTERN
 Sleeps at 9-10 PM everyday and wakes up at 6- Client verbalized, “wala gyud koy klarong  Client verbalized, “mas ganhan ko
7AM kaulog gabie, ga mata-mata ra gyud ko matulog ron, pero dili naman kaayo
 Client doesn’t have any difficulty in sleeping or in sige…kung maja piyong man gani ko ron, kapoy pareha gahapon…mas okay
initaing sleep  Sleeps at 11PM and wakes up at 7Am pagka tuod-tuod gamata na pod ko” okay nalang karon, bisag sakit pa

 Client verbalized, “usahay maglisod kog katulog Client verbalized, “dili gyud ko kasabot sa gamay”
 Client verbalized, “matulog ko ug mga 10 sa gabie kay bug-at man gud; samot nag magdungan ug feeling…nakuyawan ra gyud dagway ko”
dayon mumata ko ug mga 7 sa buntag” lihok ang duha …bug-at gyud nya maghigda ko Client verbalized, “ganahan ra ko
 Client verbalized, “tig lantaw gyud kog TV ma gabie sa left side sige” muhigda kay kapoy dayon kutas, luya kaayo
before ko matulog”  Client verbalized, “mas dugay-dugay ko akong lawas”
 Experiences dreams and early awakenings makatulog ron kay bug-at gyud akong paminaw Client verbalized, “naluya gyud ko,
sometimes nya kapoy dayon kutasan ko dayon” ganahan sa ko mupahaway”
 Client verbalized, “panalagsa ra man pod noun ko
damguhon”
 No sleeping problems as claimed
 Doesn’t have any difficulty initiating sleep as
claimed
 Client verbalized, “dili ra man pod nuon ko
maglisod ug katulog, maka tulog ra man pod ko
dayon”

6) COGNITIVE-PERCEPTUAL PATTERN Concentration and alertness as observed  Client verbalized, “mas ganhan ko
 Client verbalized, “tig basa gyud kog libro; labi na
has decraesed compared to yesterday matulog ron, pero dili naman kaayo
nang mga pocket books, kalingawan namo na sa
because of her perceived pain sensations kapoy pareha gahapon…mas okay
college sauna”
 Hears in a oderate vioce well and stress responses as claimed okay nalang karon, bisag sakit pa
 Educational Attainment: College Undergraduate
 Client verbalized, “karon, kutas gyud kaayo Closes eyes from time to time; ;lethargic gamay”
 Client verbalized, “dili man pod nuon ko
akong paminaw, ganahan rako magpundo” Hears in a moderate voice well and is able  Client verbalized,”niarang-arang
kalimtanon kaayo, usahay ra pero dili pod sige”
 Client verbalized, “dili ko ganhan mag lihok- to respond appropriately in a slow-paced naman akong paminaw, sakit pa
 Doesn’t have eyesight/hearing problems lihok” and moderately modulated voice gamay akong tiyan pero makaya ra”
 Doesn’t wear eyeglasses/contact lenses/hearing  Client’s over-all alertness is affected by her Client verbalized, ‘ganahan ra gyud ko  Client verbalized, “compared
aids present condition (her perceived discomfort) muhigda kay kapoy, kutas, luya kaayo akong gahapon, may nalang ning karon nga
 Finds that reading books/newspapers/magazines is lawas” wala nakoy catheter”
the best/fastest way for her to learn
 Loves to watch the TV and keeps an update on new
movies as claimed
 Client verbalized, “Ganahan ko mulantaw ug
movies, labi na nang mga new releases”
 Has no difficulty in seeing (eyesight) and hearing
by far as claimed

7) SELF-PERCEPTION PATTERN
 Client verbalized, “dili man nuon ko dali mangisog; Client verbalized, “dili gyud ko kasabot sa  Client verbalized, “mas ganhan ko
taas kog pasensya” feeling…nakuyawan ra gyud dagway ko” matulog ron, pero dili naman kaayo
 Client perceives herself or body image as just fine  Client verbalized, “karon usahay saputon ko Client verbalized, “ganahan ra gyud ko kapoy pareha gahapon…mas okay
or just average as claimed dayon pero dili pod sige; naa ray times” muhigda kay kaoy, kutas, luya akong lawas” okay nalang karon, bisag sakit pa
 Looks at herself or physical appearance (physique) Client verbalized, “naluya gyud ko, gamay”
as average and just right ganhan sa ko mupahaway”  Client verbalized,”niarang-arang
 Client verbalized, “ang daling maka palagot nako, naman akong paminaw, sakit pa
kanang dili dayon mutuo” gamay akong tiyan pero makaya ra”
 Client verbalized, “compared
gahapon, may nalang ning karon nga
wala nakoy catheter”

Client’s bantay for today: mostly their  Client verbalized, “may ra pod nga
8) ROLE-RELATIONSHIP PATTERN house healpe, her husband nianhi akong usa ka manghod ug
 Family Structure : Nuclear Family
Client verbalized, “wala pa ko gi duaw sa akong mama kay para daghang
 Client verbalized, “7 mi kabuok sa balay. Ako,
 Primary Bantay: Husband/Boyfriend akong mama ug papa, ug sa kamagulangan mubantay sa twins”
akong mama, papa, duha ka manghod nga lake,
 Client verbalized, “kabalo naman sila nga nakong anak kay klayo man gud pod ang  Client’s mom, eldest daughter and
akong baye nga manghod ug akong
manganak ko karong gabie so basig muanhi sila Tayasan nya gaklase man pod si Samantha. younger brother came by to visit and
kinamagulangan nga anak”
ugma” Sa weekend na dagway mi magkita, puhon to look for her and her twins
 Client verbalized, “nakuyawan ko, but at the if maka pauli nami”  Client verbalized, “ni absent gani
Cristolo, 69 same time nalipay pod” Client verbalized, “ga plano gyud mi nga ni si Samantha kay excited na siya
FATHER muoli na pag ma discharge nami diri pero makakita sa iyang mga manghod”
Concordia
-known nausob na pod akong huna-huna…mag stay
, 54 sa lamang mi diri ug one month kay para dili
Hypertensive MOTHER na hassle nya mubalik na pod for check-up”
-has heart
problems

Conni Berni Vince


e e 20 nt 19 Jeha
Callao n, 12

Theo- Si-
Died of dore mon
Samantha
Abortion
Nicole, 10

 Civil Status: Single


 Client verbalized, “almost 11 years naming
gakauban sa akong bana (boyfriend)”
 Client verbalized, “gaplano man unta mi nga
magpakasal pero namatay man gud iyang papa last
year so gi postpone nalang namo next year”
 Is not yet married, but plans to get married soon
as claimed
 Family/Household Structure = NUCLEAR FAMILY
 Her primary “bantay” since labor is her husband
(the kids’ father) and their household helper
 Client verbalized, “daghan kung friends sa amoa…
mga silingan ug mga classmates nako sauna”
 Client claims she has a lot of friends in their
community

9) SEXUALITY-REPRODUCTIVE PATTERN Client verbalized, “pagkahuman sa


 Sex: Female cesarian, after ko nigawas sa delivery room,  Client verbalized, “karon,
 Civil Status: Single na arang-arang na akong paminaw…mura malingaw nalang ko ug lantaw nilang
 LMP: May 18, 2008 kog nahuwasan kay nigawas na ang mga duha”
Obstetrical History: G3P1  Client verbalized, “ang akong ganhan karon, bata pero grabe gyud ka kapoy”  Client verbalized, “ang akong

 Client verbalized, “wala ra man mi gagamit ug basog successful ra ang akong cesarian unya” ipangalan nila…Theodire ug Simon
contraceptives pero para nako, igo na dagway ning kay fan gyud kog Chipmunks. Kung
3 ka anak” naay ika 3, Alvin unta iyang ngalan”
 Client verbalized, ”kating pagkabalo nako nga
mabdus ko, mga 22 months na akong tiyan, wala
man ko gi regla maong ga pregnancy test ko”

10) COPING-STRESS-TOLERANCE
PATTERN Client verbalized, “kaya ra man pod nuon
 Client verbalized, “dili ko daling mangisog; taas kog nakong agwantahon ang kasakit ug  Client verbalized, “mas ganhan ko
pasensya” kahapdus, maluya lang ko dayon” matulog ron, pero dili naman kaayo
 Client verbalized, “ang makapalagot ra gyud nako, kapoy pareha gahapon…mas okay
kanang dili mutuo”  Client verbalized, “ang akong ganhan karon, okay nalang karon, bisag sakit pa
 Client verbalized, “pag naa koy problems, ang first basog successful ra ang akong cesarian unya” gamay”
gyud nga akong buhaton…mag ampo”  Client verbalized,”niarang-arang
naman akong paminaw, sakit pa
gamay akong tiyan pero makaya ra”
 Client verbalized, “compared
gahapon, may nalang ning karon nga
wala nakoy catheter”

11) VALUE-BELIEF PATTERN Client verbalized, “gapasalamat ra pod ko


 Client is a baptized Roman Catholic from birth nga okay ra tanan with God’s help…healthy  Client verbalized, “karon,
 Parents and the rest of her family members and ra pod akong mga anak” malingaw nalang ko ug lantaw nilang
relatives are both Roman Catholics duha”
 Claims she goes to church regularly  Client verbalized, “ang akong ganahan karon,
 Client verbalized, “active ko sa mga church basog successful ra akong cesarian unya”
organizations sa among parish…apil ko anang
singles for christ atong college pero wala na kaayo
ron na active ag organization”
NURSING
CARE PLANS
Cues/Evidences Diagnosis Objectives Interventions Rationale Evaluation
Subjective: At the end of our 2-day Independent: By the end of our 2-day
 Client (Mother) Altered Comfort: pain care, the patient will Monitor vital signs  To monitor and assess care, goals were met as
verbalized, “sakit pa ug related to physiologic manifest decreased pain the over-all and/or general the patient was able to
hapdus akong matris” and psychologic as evidenced by: health status of the client; manifest decreased pain
 Client (Mother) adaptaions and/or to provide baseline data
as evidenced by:
verbalized,”dili changes suring and and comparative
a) Verbalization that pain a)goal met: rates pain as 2
comportable akong evaluation for future
after cesarian is within tolerable limits in a scale of 1-10 (10 being
paminaw, kutas ug findings
labor/delivery as the highest and 1 as the
kapoy kaayo” Reassess patient’s  To determine appropriate
evidenced by b) Rates pain as 2 (in a lowest)
sensation of pain measures to be done
verbalizations of the scale of 1-10, 10 being the -client verbalized, “mas
 Provides non-
highest, and 1 the lowest) niarang-arang ang akong
presence of pain Perform back rub, cold pharmacologic relief and paminaw, maagwanta na ang
Objective: compress and proper distraction from pain kasakit”
c) Decreased facial
 Rates pain as 8 in a scale positioning sensations felt b)goal met: absence of
grimacing
of 1-10; 10 being the  Helps refocus attention facial grimacing
highest and 1 the lowest Aid client in performing and enhance coping c) goal met: increased
d) Increased activity
 Decrease activity toleranc cold compress and proper abilities activity tolerance was
tolerance due to pain positioning  To educate and inform evident
noted e) Shows relaxed facial Aid client in performing the client, the - patient can reposition
 Facial grimacing and expression relaxation techniques (e.g. management of pain herself in the bed without
frequent cloding of eyes deep breathing exercises)  To determine any help and can shift from
noted f) Vital signs within Monitor patient’s possible complication or standing to sitting and lying
positions
Vital Signs: T= 36.4⁰C, P= normal range (T=36.5- response to therapy risk factor
d)goal met: vital signs are
89 bpm, R = 20 cpm, BP= 37.5 C, P=60-100 bpm,
within normal range
110/80 mmHg R= 12-20 cpm, BP=110-
(February 6, 2009 at 7AM
 Episiotomy wound upon 140/60-90)
T=36.6⁰C, P=92 bpm, R= 20
inspection was slightly
cpm, BP= 120/70mmHg and
swollen and red; the
12NN T= 87.4⁰C, P= 94 bpm,
area feels tender as
R=20 cpm, BP=
claimed by patient
120/70mmHg)

Cues/Evidences Diagnosis Objectives Interventions Rationale Evaluation


Subjective: At the end of our 2-day Independent: By the end of our 2-day
 Client verbalized that Sleep pattern care, the patient will  Assess the sleep pattern  Provides initial data for care, goals were met as
she finds it hard to sleep disturbance related to manifest improved sleep of the patient and the basis of interventions the patient was able to
because of the hot non-conducive pattern as evidenced by: determine other factors and care to be given and to manifest improved sleep
temperature environmental that interfere with rest determine possible
pattern as evidenced by:
 Client verbalized, “walay conditions interventions
a) verbalizations of a)goal met: client was able
klaro akong katulog,  Encourage the client to  Sleeping for 6-8 hours
improved sleep/rest to verbalize that she was
sige ra kog mata-mata” pattern sleep at least 6-8 hours every day replenishes and able to sleep well the day
everyday restores energy for the day, after the next day of the
Objective: b)lesser frequency of it provides relief from operation-client
Vital Signs: T= 36.4⁰C, P= yawning stress and comfort to the verbalized,”okay ra man
89 bpm, R = 20 cpm, BP= client akong pagkatulog gabie”
110/80 mmHg c) increased focus  Organize care to allow  This enables the client to b)goal met: lesser
 Narrowed focus minimum disturbances and rest and to get ready for frequency of yawning wa
 Presence of dark circles extra resting/sleep periods the planned noted
around the eyes activities/procedures d)goal met: increased focus
 Frequent yawning noted during the day was observed
 General impression of  Provide adequate rest  To prevent sleep - patient can reposition
periods interruptions and to ensure herself in the bed without
client (upon first
help and can shift from
contact) : Weak-looking comfort of the client
standing to sitting and lying
 Closes eyes most of the positions
time during  Provides information on
 Prefers to sit or to lie  Provide comfort the benefits and
down most of the time measures and a silent advantages of sleeping
environment for an early, with the right
uninterrupted sleeping quantity and quality
time
 This can help facilitate
 Encourage client to sleep
drink milk before sleeping  To determine any
 Monitor patient’s possible risk factor or
response to therapy complication
Cues/Evidences Diagnosis Objectives Interventions Rationale Evaluation
Subjective: At the end of our 2- Independent: By the end of our 2-day
 Client (Mother) Generalized day care, the  Monitor vital signs  To monitor and assess the care, goals were partially
verbalized, “kutas, body malaise patient will have over-all and/or general status met as the patient was
kapoy ug luya kaayo related to the increased energy as of the client and to provide able to have increased
akong paminaw” increased baseline data for future
evidenced by: energy as evidenced by:
findings; taking note of the
enegry a)goal met: client was able
Objective: temperature for an increase
expended during a) reports improved to report an improved sense
Vital Signs: T= 36.4⁰C, P= may indicate infection
cesarian labor sense of energy of energy
89 bpm, R = 20 cpm, BP=  Reassess level of  Provides data for further care
process -client verbalized,“mas niarang-
110/80 mmHg fatigue arang ang akong paminaw,
b) perform ADL’s at
 General impression of  Plan care to allow  This maximizes the client’s maagwanta na ang kasakit”
level of activity
client (upon first individually adequate participation b)goal partially met: the
contact) : Weak-looking rest periods client was able to partially
c) appears rested
 Closes eyes most of the  Provide diversional  Limits ability to block perform ADL’s at her level of
time during activities and competing distractions activity
d) Vital signs within
 Prefers to sit or to lie encourage rest - patient can reposition herself
normal
down most of the time  Perform procedures  Helps regain strength in the bed without help and can
range(T=36.5-
 Needs help in that provide comfort shift from standing to sitting
37.5 C, P=60-100 and lying positions
ambulation/general (e.g. deep breathing
bpm, R= 12-20 c)goal met: vital signs are
mobility exercises)
cpm, BP=110- within normal range
 Monitor patient’s  To determine any possible
140/60-90) (February 6, 2009 at 7AM
response to therapy risk factor or complication
T=36.6⁰C, P=92 bpm, R= 20
cpm, BP= 120/70mmHg and
12NN T= 87.4⁰C, P= 94 bpm,
R=20 cpm, BP= 120/70mmHg)
Cues/Evidences Diagnosis Objectives Interventions Rationale Evaluation
Subjective: At the end of our 2-day Independent: By the end of our 2-day
 Client (Mother) Risk for infection related care, the neonate will  Monitor vital signs q 4 h,  To monitor and assess care, goals were met as
verbalized, “mural age to immature body not develop any sign of as indicated by institution’s the over-all and/or general the neonate was not
ug nihubag ang defenses and to infection as evidenced policy. status of the client and to able to develop any sign
kinatawo sa akong presence of cord stump provide baseline data for
by: of infection as
anak” future findings to be
evidenced by:
compared; taking note of
a) vital signs especially
Objective: the temperature for an
temperature at normal a)goal met: the neonate’s
 Placed in the hallway or increase may indicate
range (36.2-37.2⁰C) temperature was within
alley infection
 To determine presence of normal range
 Hospital environment is  Monitor and assess
b)absence of swelling, b)goal met: there was
crowded because of the continuously the infection.
odor, redness, and absence of swelling and
number of patients and condition/appearance of
tenderness in the perineal redness upon inspection of
people passing by and the perineal area and note
area and the cord stump the neonate’s perineal area
the neonate is placed in for swelling and
and the area surrounding
the alley redness/irritation.
c) mother/relatives the cord
 Has no diaper  Stress the importance  To inform/educate the
understanding the c)goal met: mother was
 Mother wasn’t able to and the need for family members on the
importance of washing able to verbalize the
bathe for 3 days and is handwashing to family importance and
hands before handling the importance of washing
in close proximity to the members prior to handling benefits/advantages of
neonate hands and making sure it’s
baby most of the time the neonate. proper handwashing as
well as its important role in clean before handling the
 Relatives and significant neonate
others are always preventing infection.
 To determine any
-client verbalized,”kung mang
touching the neonate  Monitor the neonate’s
hinlo ta sa atong lawas, maka
without even making response to therapy. possible risk factor or
likay man pod ta sa mga
sure the hands are clean complication. sakit”
 Perineum of infant is
slightly swollen and Collaborative:
appears red  Monitor laboratory  To determine presence of
 Was not submitted to results/findings (e.g.WBC, infection.
cord care for neutrophils, lymphocytes,
institution’s policy monocytes)
states that the
procedure is to be done
upon or prior to
discharge from facility
or institution
 Vital Signs:
 8AM
T=⁰C
P= bpm
R= cpm
BP= mmHg
 12NN
T= ⁰C
P= bpm
R= cpm
BP= mmHg
Presence of cord stump
Skin surrounding the
cord is red and is a bit
swollen
Neonate’s have a non-
stable immune system
Cues/Evidences Diagnosis Objectives Interventions Rationale Evaluation
Subjective: At the end of our 2-day Independent: By the end of our 2-day
 Client (Mother) Risk for fall related to care, the neonate will  Monitor the mom and  To prevent injury/falls care, goals were met as
verbalized, “mahadlok absence of any physical not acquire any injury the SO in their care and in and to assess their the neonate did not
ko maatak akong anak… barrier at the bedside due to falls and will be protecting the neonate. readiness for parenting and acquire any injury due
naa pa gud mi sa for welcoming the neonate
protected from falling as to falls as evidenced by:
hallway nya ang kadak- as a new family member.
evidenced by:
on sa katre, gamay ra”  To prevent injury/falls
a)goal met: the neonate’s
 Client verbalized, “sige  Assess and monitor the and to forsee any events
a) making sure she is mother, father and
ra kog mata-mata kay area continuously for that might cause harm to
watched over by either the grandmother came by to
nakuyawan ko, basig potential hazards and for the neonate.
mom or by another take turns in watching over
maatak akong anak kay possible precautions.  This secures the neonate
significant other her
gamay kaayo ang katre”  Protect the sides with a from falling and getting
chair as much as possible hurt.
b)having improvised b)goal met: during our
and/or make sure the
physical barriers around second duty day, the
Objective: neonate is always
bed (e.g. chair, pillows) mother and the neonate
 Placed in the hallway or protected.  To prevent injury/falls.
was transferred to the
alley  Be at the newborn’s side
c) mother to be very ward, in a better and bigger
 Hospital environment is all the time if mother is
cautious including the bed this time, decreasing
crowded because of the sleeping or just for
significant others on the the chances of the neonate
number of patients and additional protection, and
safety of the neonate in to fall or to get hurt
people passing by and stay near mother and/or
order to prevent  To prevent falls/injury.
the neonate is placed in SO.
falls/injury b)goal met: the mother
the alley  Place neonate at the
was very careful in
 No appropriate or side of the bed wherein
d) mother and significant handling the neonate and
inadequate restraints she will not fall (near the
others always at the in living her alone in bed
around the newborn wall).
neonate’s side without someone to watch
 Absence of side rails over her
 Bed size is not
appropriate and enough d)goal met: the neonate’s
for both the tired mom mother, father and
and the helpless grandmother came by to
neonate take turns in watching over
 Newborns don’t have her
coordinated gait and
balance
 Newborn is
approximately just a
couple of hours old
 They (both the mother
and the neonate) are
placed in the hallway
Cues/Evidences Diagnosis Objectives Interventions Rationale Evaluation
Objective: At the end of our 8-hour Independent: By the end of our 8 day
 Neonate is not provided Risk for ineffective care, the neonate will  Monitor vital signs q 4h  To assess the over-all care, the neonate was
with adequate clothing thermoregulation not manifest signs of or as indicated by and general health care not able to manifest
for protection related to immature ineffective institution’s policy status of the patient and to signs of ineffective
 Newborns have compensatory provide comparable
thermoregulation thermoregulation
immature baseline data for future
mechanisms as evidenced by: as evidenced by:
thermoregulatory findings
mechanisms
a) vital signs within normal  To protect the neonate
a)goal met: vital signs
 Newborns have  Assess, monitor and
range (T= 36.2-37.20C, from sudden within normal range (T=
immature defenses anticipate for possible
P=130-140 bpm, R= 30-40 thermoregulatory changes 36.80C, P=140 bpm, R= 48
 Vital Signs environmental changes
cpm) cpm)
T= 36.20C (e.g. environmental
P= 140 bpm
b) Neonate protected from temperature, drafts, b)goal met: neonate was
R= 46 cpm
drafts and chills chills) protected from drafts and
chills
c) neonate with adequate  Provide client with  To protect the neonate
clothing and head adequate clothing and from sudden c)goal met: neonate was
protection make sure the head is thermoregulatory changes provided with adequate
clothing and head
wrapped or protected
protection
 Monitor neonate’s  To determine possible
response to therapy complication and risk
factors