NURSING

Colegio
Colegio de
de Santa
Santa Lourdes
Lourdes of
of
Leyte Foundation,Inc.
Leyte Foundation,Inc.

CARE
PLAN
Group 1:
Alvero, Glicyl
Cinco, Ronalyn Ashley
De Paz, Michel
Fernandez, Claudine Gaye
Lauzon, Jeneva
Tabontabon,
Tabontabon, Leyte
Leyte Redona, May-Ann Joy
Quemado, Melchor
Toledo, Leceel
 PATIENTS
PROFILE :
A.GENERAL
A.GENERAL IMPRESSION:
IMPRESSION:
Ø
Ø
ØMrs.
Ø Mrs. Venezuela,28
Venezuela,28 years
years old
old
who
who appears
appears older
older than
than her
her
age
age looks
looks pale
pale and
and weak.
weak. She
She
is
is immobile
immobile and
and looks
looks like
like she
she
in
in in
in a
a depress
depress situation.
situation.
Despite
Despite it,
it, she
she is
is very
very
cooperative
cooperative toto me.
me.
B.CHIEF
B.CHIEF COMPLAINT:
COMPLAINT:
ØThe
Ø The client
client was
was delivered
delivered toto
the
the delivery
delivery room
room unconscious
unconscious
for
for she
she was
was having
having a
a stillbirth
stillbirth
and
and delivered
delivered the
the baby
baby via
via
NSVD
NSVD with
with a
a presentation.
presentation.
C.SOURCES
C.SOURCES OF
OF INFORMATION:
INFORMATION:
D.PATIENT’S
D.PATIENT’S PROFILE:
PROFILE:

NAME:
NAME: Venezuela,
Venezuela, Lalaine
Lalaine Pascual
Pascual
AGE:
AGE: 28
28 years
years old
old
B-DAY:
B-DAY: March
March 19,1981
19,1981
B-PLACE:
B-PLACE: Manila
Manila
ADDRESS:
ADDRESS: San
San Jose
Jose East
East Burauen,
Burauen, Leyte
Leyte
RELIGION:
RELIGION: Roman
Roman Catholic
Catholic
NATIONALITY:
NATIONALITY: Filipino
Filipino
OCCUPATION:
OCCUPATION: Home-maker
Home-maker
HUSBAND’S
HUSBAND’S NAME:
NAME: Allan
Allan Venezuela
Venezuela
OCCUPATION:
OCCUPATION: Tricycle
Tricycle driver
driver

ADMISSION
ADMISSION DATE:
DATE: December
December 8,8, 2009
2009
ATTENDING
ATTENDING PHYSICIAN:
PHYSICIAN: Dr.
Dr. del
del Pilar
Pilar
ADMITTING
ADMITTING DIAGNOSES:
DIAGNOSES:
PU
PU 38
38 2/7
2/7 weeks
weeks AOG
AOG breech
breech in
in active
active labor
labor G5P4
G5P4
(4004)
(4004)
OTHER
OTHER Dx:
Dx:
PUFT,
PUFT, breech
breech delivered
delivered via
via breech
breech extraction
extraction to
to a
a
stillborn
stillborn baby
baby boy.
boy.
REASON
REASON FOR
FOR ADMISSION:
ADMISSION: Undelivered
Undelivered head
head of
of the
the baby.
baby.
E.CURRENT
E.CURRENT HEALTH
HEALTH PROBLEM:
PROBLEM:

ØOne
Ø One dayday prior
prior to
to admission
admission thethe client
client had
had
an
an active
active labor
labor in
in their
their house.
house. It It was
was about
about
8am
8am when
when she she feels
feels the
the intense
intense contractions
contractions
and
and urge
urge toto deliver
deliver the
the baby
baby atat 22 am
am by
by a
a
hilot.
hilot. It
It was
was a
a breech
breech presentation
presentation and and
unfortunately
unfortunately thethe baby
baby was
was not
not completely
completely
delivered
delivered thethe head
head was
was still
still attached
attached to to the
the
mothers
mothers vagina.
vagina. So
So they
they decided
decided to to run
run her
her
to
to the
the nearest
nearest hospital.
hospital. When
When theythey arrived,
arrived,
the
the client
client was
was immediately
immediately delivered
delivered to to the
the
delivery
delivery room
room and
and there
there the
the stillbirth
stillbirth baby
baby
boy
boy was
was delivered
delivered via
via NSVD.
NSVD. Proper
Proper
medications
medications and and interventions
interventions werewere given
given
after
after the
the procedure.
procedure.
Ø
Ø
F.PAST
F.PAST MEDICAL
MEDICAL HISTORY:
HISTORY:

ØThe
ØThe client
client verbalized
verbalized “Yana
“Yana la
la ako
ako
nanganhi
nanganhi ha
ha ospital
ospital tungod
tungod la
la hine
hine yana
yana
nga
nga natabo
natabo han
han ak
ak panganak.
panganak.
G.FAMILY
G.FAMILY HEALTH
HEALTH HISTORY:
HISTORY:
ØHer
Ø Her mother
mother side
side and
and her
her husband’s
husband’s
father
father side
side had
had a
a family
family health
health
history
history of
of hypertension.
hypertension. Also
Also lately,
lately,
her
her husband
husband had
had an
an operation
operation on
on his
his
kidney.
kidney.
Ø
Ø
H.MENSTRUAL
H.MENSTRUAL HISTORY:
HISTORY:
Menarche-13
Menarche-13 years
years old
old
PADS
PADS consumed-3
consumed-3 pads
pads
Duration-4
Duration-4 days
days
Associated
Associated signs
signs and
and symptoms-headache
symptoms-headache

I.HISTORY
I.HISTORY OF
OF PAST
PAST PREGNANCIES:
PREGNANCIES:

G1-January
G1-January 20,1998
20,1998 (NSVD-home)
(NSVD-home)
G2-March
G2-March 20,
20, 2001
2001 (NSVD-home)
(NSVD-home)
G3-February
G3-February 26,
26, 2002
2002 (NSVD-home)
(NSVD-home)
G4-May
G4-May 9,
9, 2007
2007 (NSVD-home)
(NSVD-home)

J.HISTORY
J.HISTORY OF
OF PRESENT
PRESENT PREGNANCY:
PREGNANCY:

LMP-March
LMP-March 15,
15, 2009
2009
EDC-December
EDC-December 22,
22, 2009
2009
AOG-38
AOG-38 2/7
2/7 weeks
weeks
PHYSICAL EXAMINATION:
GENERAL
GENERAL APPERANCE:
APPERANCE:
ØConscious
ØConscious and
and can
can communicate
communicate but
but is
is weak
weak and
and with
with fever.
fever.

SKIN:
SKIN:
ØSkin
ØSkin color
color varies
varies from
from dark
dark brown
brown to
to brown
brown with
with pale
pale lips.
lips. Her
Her hair
hair is
is
evenly
evenly distributed
distributed ..

HEAD:
HEAD:
ØNorm
Ø Norm cephalic
cephalic head
head with
with symmetrical
symmetrical facial
facial movements.
movements. No
No obvious
obvious
lesion
lesion /lumps
/lumps palpated.
palpated.

EYES:
EYES:
ØPERLA,
ØPERLA, no
no noted
noted problems.
problems.

EARS:
EARS:
ØThe
Ø The ears
ears are
are aline
aline to
to the
the outer
outer can
can thus
thus of
of the
the eyes,
eyes, no
no noted
noted hearing
hearing
problems.
problems.

NOSE
NOSE &
& SINUSES:
SINUSES:
ØSymmetrical
ØSymmetrical and
and no
no obstructions'.
obstructions'.
NECK:
NECK:
ØThyroid
Ø Thyroid is
is located
located at
at the
the center
center of
of the
the neck.
neck. No
No abnormalities
abnormalities
noted.
noted.

BREAST:
BREAST:
ØPain
Ø Pain due
due to
to accumulation
accumulation of
of breast
breast milk
milk in
in the
the breast.
breast.
Ø
Ø
RESPIRATORY:
RESPIRATORY:
Ø
Ø

CARDIOVASCULAR:
CARDIOVASCULAR:
ØHypertensive
Ø Hypertensive
Ø
Ø
GI:
GI:
ØNo
Ø No noted
noted GI
GI problem
problem