II.

History of Present Illness:

Client has no chief complaint. She was admitted to OB ward after delivery.

III. Past Health History (from childhood to present):

The patient has never undergone any surgery. No hospitalizations and not experiencing
any current illness. She does not have any food, medicine, latex, environmental allergies. She
never had a flu vaccine from her first child up to the eight child but she has completed her vaccines
when she was a child.

Medication Reconciliation:

During her pregnancy, she is prescribed to take Vitamin C and Ferrous Sulfate by
doctor. After giving birth she is asked to take Calcium supplements and Multivitamins.

IV. Family Health History

The client’s grand-father has Tuberculosis and her mother has hypertension.

C. Lifestyle Patterns:

Client walks every day during her pregnancy and cleaning of the house serves as exercise.
She sleeps at 11:00 p.m. and wakes up at 2 a.m. to assist her husband before going to work and
she tries to go back to sleep again. If her children are not around, she watches the television and
uses her phone for 15-30 minutes.

D. Self-Concept:

She is satisfied with her body image and view of self in the present.

E. Physical or Mental Disability:

Client has no disability and doesn’t need any support functioning.

F. Risk for Abuse:

Client had no physical injury in the past and not afraid of partner, caregiver or family
member.

H. Stress and Coping Mechanisms:

Her coping mechanism for stress is confiding with her husband.

I. Environment:

Client’s house is bungalow type and no presence of hazards.

J. Spiritual:

Client has no religious belief and practices pertaining to health and illness.

K. Interpersonal:
VII. Nutrition

For the client’s 24-hour diet recall, she had pandesal for breakfast, rice and mami soup
for lunch, food given by the hospital for dinner and skyflakes for snack. There are also no
restrictions for her diet according to the doctor. Client has also don’t take caffeinated drinks,
doesn’t smoke, doesn’t drink alcohol and never tried drugs.

VIII. Obstetrical Assessment:

Prenatal History:

The event that prompted her to go to the hospital on November 4 at 11 p.m. was
contractions radiating from lower back down to her lower abdomen.