COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY
CITY OF DASMARIÑAS, CAVITE
NURSING HEALTH ASSESSMENT
Andrea Antonette D. Balboa
Rowena Cepeda-Laigo, RN, MAEd
NURSING HEALTH ASSESSMENT
I. Status Post Caesarean Section
II. HEALTH HISTORY AND PHYSICAL EXAMINATION
A. Demographic (Biographical Data)
Client’s initials: R.R.P.
Age, Birthdate and Birthplace: 34, 10/21/1978, Muntinlupa
Marital (Civil) Status: Married
Religion: Roman Catholic
Address and Telephone Number: Blk 5 Lot 54 Greengate Imus Cavite Educational Background: Bachelor’s Degree in Computer Science Occupation (usual and present): Encoder
Usual Source of Medical Care: PhilHealth
Date of Admission: 01/08/2013
B. Source and Reliability of Information
The patient was competent to provide information. She was able to speak clearly; conscious and coherent; oriented to time, place and person. The patient’s chart was also included as a secondary source of information
C. Reasons for Seeking Care
1. “Inadequate size of pelvis”
2. “Scheduled for caesarean section”
D. History of Present Health
The expected date of the delivery was January 8, 2013, 8:00AM at St. Paul Hospital. It was a scheduled caesarean section of the patient; not in labor. The patient was calm since it was her second time to deliver a fetus through caesarean section. There were no signs and symptoms of labor happened. The patient foresees to stop adding a family member because they already have a son and a daughter.
E. Past Medical History or Past Health
a. Pediatric / Childhood / Adult Illnesses
The patient did not have any pediatric, childhood or adult illnesses. b. Injuries or Accidents
The patient did not have any injuries or accidents.
c. Hospitalization and Operations
The patient had a caesarean section last 2006, 2007 and 2013. d. Reproductive History
The patient had her menarche at the age of 12. Her last menstrual period was April 27, 2012. Her menstrual cycle was 28 days and her menstrual duration was 3 to 4 days. Her obstetric score was G3P2 T2P0A1L2M0.
BCG: /✓/ At Birth /✓/ School Entrance
DPT: /✓/ 1st Dose /✓/ 2nd dose /✓/3rd dose
OPV: /✓/ 1st Dose /✓/ 2nd dose /✓/3rd dose
TT: /✓/ 1st Dose /✓/ 2nd dose /✓/3rd dose /✓/ 4th dose /✓/ 5th dose HBV: /✓/ 1st Dose /✓/ 2nd dose /✓/3rd dose
/✓/ Food, (please specify): Shrimp
/ / Drugs or medications, (please specify): None
/ / Chemicals, (please specify): None
/ / Other environmental allergens, (please specify): None
The patient has an allergy in shrimps. The patient experiences hives as an allergic reaction and applies an anti-allergy prescribed by her dermatologist to alleviate the manifestation.
G. Socio-Economic History
FAMILY MEMBER /RELATIONSHIP TOPATIENT| OCCUPATION /SOURCE OF INCOME| MONTHLY INCOME| R.R.P.| Encoder| P22,000.00|
The patient works as an encoder. The monthly income of P22,000.00 can only support the basic needs of the family but not particularly of members’ health. It will be not enough and budgeted exclusively for the necessities of the family.
H. Psychosocial Assessment
Patient’s Age: 34 years old
Developmental Stage: Young Adulthood
Developmental Task: Intimacy vs Isolation
Occurring in young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member. Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression.
Patient met the developmental task of being in an intimate relationship with her partner. They are married and have 2 kids.