Case Press 2-01
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Transcript of Case Press 2-01
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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