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Nursing History

BIOGRAPHICAL DATA

Name: LC Age: 26

Address: Blk. 18 Lot 2 3rd St. Taong, Malabon CityDate of Birth: October 7, 1984 Gender: F Marital Status:

Married

Religion: Catholic Occupation: Government

Employee

Insurance Coverage: Philhealth Member

Admitting Medical Diagnosis:

Breech Presentaion

Reason for Seeking Health Care/Chief Complaint:

Scarred uterus in begin labor

Perception of Health Status:

-exercise regularly

-consult the doctor every month

Previous Illness/Hospitalization/Surgeries:

CS Surgery (Breech Presentation)

Family Medical History

Medical History Mother FatherAddiction(Drugs/Alcohol)

- -

Arthritis - -DM - -Mental Disorder - -Cancer - -

Heart Disease - -Hypertension + +Sickle Cell Anemia - -Chronic Lung Disease - -CVA - -Kidney Disease - -

Others:

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Immunizations/Exposure to Communicable Disease:

+mumps , +measles , +sore eyes

Allergies:

None

Home Medications/Alternative Medicines:

-complementary and alternative Vit C (Ascorbic Acid)-Biogesic for headache

PSYCHOSOCIAL HISTORY:

Alcohol use: occational only

Tobacco use: -

Drug Use:

Caffeine Intake:

OBSTETRICAL HISTORY:

Menarche: 12y/o

Menstrual History: 3-5 days; menstrual flow is heavy during the 1st and

2nd day;3rd to 5th day is moderate to scanty

Past surgery on the reproductive tract: Ceasarian section year 2005

Recent Contraceptive Practice:

Natural: None

Artificial: Pills

Last Menstrual Period: December 28, 2010Expected Date of Confinement: September 5, 2011

Age of Gestation:

OB scoring

Gravida: 2

Para: 2

Term: 2

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Prem: 0

Abortion: 0

Living: 2

Multiple Pregnancy: 0

Patterns of Functioning (Gordons Functional Patterns)

Pattern BeforeHospitalization

DuringHospitalization

Analysis

1.Health Perception -exerciseregularly-consult thedoctor everymonth

-walking Because of surgery, sheshould followthe doctorsorder only

2.Nurtritional/Metabolic -7 glasses ofwater-more fruits &vegetable

-4 glasses ofwater

-more on fruits

Fluid intake islessenedbecause of herif infusion.She only relieson food givenby hospital

3.Elimination -10x urinated-3x bowelmovement-no pain & noproblem incontrol

-7x urinated-none

Didnt have theurge todefecate.Voiding islessened due toenvironment

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(psychological)4.Activity/Exercise -shopping

-washingdishes-grooming

-bathing-toileting-homemaintenance-bed mobility-dressing-cooking

- walking-proper hygiene-breastfeeding-cuddling the

baby

Activities arelessened due toincision relatedto pain.

5.Sleep-Rest -6hrs sleep -interruptedsleep

Sleep & restpattern isaltered becauseof medications,

stress &incontinence

6.Cognitive/Perceptual -change inmemory lately-self medicate

-shes still takingmedications butwith prescriptionof the doctor

She enhancedher knowledgeabout hermedications.

7.Role Relationship -extendedfamily-has a goodrelationshipwith

neighbors,communityand relatives-handlesproblems withfamily-insufficientincome

-hospitalizationhave not affecther rolerelationship as amother because

of her familyssupport

8.Sexuality/Reproductive

-patient usescontraceptives-her partner is

satisfied intheir sexualrelationship

9.Coping/StressTolerance

-Only herhusband &mother whowill be the oneto comfort her

-only mothercomforts herbecause herhusband is busy

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-is notdependent onalcohol whenshe hasproblems

10.Value/Belief -the onlyimportant inher life ishealth of herfamily & farfrom anydanger-she attendsmass everySunday

-faith in God

11.Self

Perception/Concept

-sometimes

she has moodswing-sometimesshe hasmemory gap

PHYSICAL ASSESSMENT

Body Part Normal Findings Findings Analysis

BreastRectum

DIAGNOSIS/LABORATORY EXAMINATIONS

ANATOMY & PHYSIOLOGY:

PATHOPHYSIOLOGY

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PRIORITY NURSING DIAGNOSIS/PROBLEM and PRESENTATION OF NURSING

CARE PLANS

1. Risk for Infection

2. Constipation related to decreased activity & fluid intake

3. Disturbed sleep pattern