FINAL OUTPUT, 32214.docx

8/10/2019 FINAL OUTPUT, 32214.docx

1/41

I. DEMOGRAPHIC DATA

Date of Interview: March 04, 2014

Initials of

Clients

Name

Position Age e!Civil

tat"sReligion E#"$ation O$$"%ation

Mrs. SG Mother 39 F Married Catholichigh school

graduateHousewife

Client S, 39 ears old, a high school graduate, currentl residing at !agtas

"an#a, Ca$ite, is on 24 4%& wee' of her ( th)regnanc. She wor's as a !aranga

Health *or'er of +aang -aa "an#a, Ca$ite and sells corn when additional

financial needs arise. Her hus/and is currentl une-)loed. "heir fa-il is under

the +e)art-ent of Social *elfare and +e$elo)-ents 4s )rogra-. "heir

-onthl /udget $aries de)endentl on the arising needs of the fa-il. "he /igger

)art of the /udget is allotted on food and education of the children. ll her

children are de)endent on her. 4 of & children are studing. "he eldest alread

has his own fa-il. et to the eldest, so-ehow hel)s financiall through selling

ice crea- so-eti-es.

1


2/41

II. HITOR& O' PREENT I((NE

+r and crac'ed s'in on /oth )edalis area was o/ser$ed and co-)lained / the

client. ccording to the client, she sought -edical ad$ice regarding the stated condition

and it was diagnosed as ec#e-a. +oacillin, an anti/iotic , was )rescri/ed, howe$er,

she discontinue the inta'e due to co-)lain of h)eracidit.

56u-alala ung sugat 7)ag hindi natutuo -a/uti at tuwing -ainit ang )anahon8,

SG stated. 5ilalanggas 'o na lang ng )ina'uluang dahon ng /aa/as8, added / the

client.

III. PAT MEDICA( HITOR&

+uring childhood, SG e)erienced co--on illnesses such as colds, cough, and

flu. She also had chic'en )o /ut unsure if had /een infected / -easles. She is not

sure if she had /een full i--uni#ed.

t the age of 9, SG had her left second ri/ fractured /ecause she fell fro- a tree

while )laing. :ra confir-ed the fracture.

2


3/41

She was hos)itali#ed on the ear 2012 due to high ris' & th )regnanc

co-)licated / ele$ated /lood )ressure. She deli$ered in General ;-ilio guinaldo

Me-orial Hos)ital. fter that she was su/. She has a 2(:da ccle, -enstruating

three ?3@ to four ?4@ das using a/out three ?3@ to four ?4@ full )ads a da.

HITOR& O' PAT PREGNANCIE

Aear'PM "se# after

%regnan$,Gravi#it, Parit, T,%e of Deliver,

Gen#er of

Infant

-/ one 1 0 S+ B Ho-e +eli$er M

-0 one 2 1 S+ B Ho-e +eli$er M

-1 ills?( -onths@ 3 2 S+ B Ho-e +eli$er F

-

n S+ B Ho-e +eli$er F

3


4/41

/2-/ one & S+ B Hos)ital +eli$er F

CDD;" D;GCA

6M AOG GP3GTPA(M EDCe%tem4er

-56 /2-7

s of March 04,2014,

=G E 1 Se)t

31 =ct

30 o$

31 +ec

31 an

2( Fe/

4 Mar

1&1 das

1&1das E /5 5 3 1 wee8s

E > 21 % 30 -onths

GP:

(:&

GTPA(M

(:&:0:0:&:0

EDC :

09 14 2013

:3 & 1

29+/-+/2-5

"he first four )regnancies ha))ened in Ca-arines orte. fter the 3rd

)regnanc, she used )ills for ( -onths. fter the 4th)regnanc, she used in


5/41

C

!n"no#n $ause of death

%

M&

'P

No "no#n information

%Maternal Death

S( 3)

*PN

+P

*PN

%PMaternal Death

,

*PN

-egend:

male

female

Male de$eased

Female de$eased

Female $lient

*PN . hypertensive

M& . myo$ardial infar$tion

). HEREDO+'AMI(IA( HITOR&

/


6/41

nter)retation

"he gra)h a/o$e shows that SG has a fa-il histor of heart )ro/le-s. "his can

/e considered a factor in the de$elo)-ent of her high /lood )ressure.

!oth her grand-other died during fetal deli$er -a'ing her a candidate for

de$elo)ing co-)licated )regnancies.

)I. DE)E(OPMENTA( HITOR&

A. . Piagets Cognitive Develo%ment

For-al o)erations )hase

n this stage, an indi$idual uses rational thin'ing. Deasoning is

deducti$e and futuristic.

*. E. Eri8sons Ps,$;oso$ial Develo%ment

dulthood Generati$it $s. stagnation

n this stage energ is directed towards full seual -aturit and

function and de$elo)-ent of s'ills needed to co)e with the en$iron-ent.

Client shows concerns on her fa-il, / )ro$iding their needs. She

sells sweet corn when there is a need for etra -one.

C. . 're"#s Ps,$;ose!"al Develo%ment

0


7/41

Genital Stage

;nerg is directed toward full seual -aturit and function and

de$elo)-ent of s'ills needed to co)e with the en$iron-ent

Client shows -ore -ature role on her )art, / thin'ing of others thher.

D. . 'owlers %irit"al Develo%ment

ndi$iduati$e:Deflecti$e Faith

)erson in this stage is constructing their own e)licit sste-.

"he show a high degree of self:consciousness

Client shows $er realistic and )ositi$e $iew of )oints in e$er

situations or )ro/le-s she encountering

E. (.


8/41

dolescence

General acco-)lish-ents )er age )eriods.

Client is $er su))orti$e on her four children, though their /ig enough to

carr the-sel$es, still she assisting the- / so-e s-all things.

)II. GORDON -- '=NCTIONA( HEA(TH PATTERN

)II. Gor#ons -- '"n$tional Healt; Patterns

A. Healt; Per$e%tion+ Healt; Management

"he client stated that she )ercei$es herself as a well and health )erson,

5hindi )a na-an 'asi a'o nag:'a'asa'it ng -atitindi. "anging /o, si)on at

lagnat lang na )ang:'araniwan8 as she $er/ali#ed. ccording to her she uses

her/al -edicines in curing such illnesses and


9/41

Mrs. S.G also had a fear in dentists. 5 siguro -a isa o dalawang /eses

lang a'o na'a)ag:)a/unot ng ngi)in noong /ata )a a'o, ero ngaon -as

natata'ot talaga a'o sa -ga ganiang )roseso8 as she $er/ali#ed. t was

o/ser$ed that her u))er two )re:incisors and two incisors are -issingB she does

not su/-it herself to annual dental chec':u).

B. N"tritional+Meta4oli$"he client stated that she eats three ti-es dail, and can consu-e -ore

than ( glasses of water e$erda. ccording to her shes fond eating of salt

foods e$en /efore )regnanc. 5tuwing 'u-a'ain a'o -a )atis,8 as $er/ali#ed

/ the client.Mrs. S.G doesnt ha$e an health )ro/le-s which affects her eating

)attern. Seldo- had she lost her a))etite. She also added that shes drin'ing

-il' e$er -orning and ta'ing ferrous sulfate ?FeS=4@ e$er night for her iron

store su))le-entation.

Diet Preferen$e

MEA( Mar$; 2 Mar$; -2 Mar$; --

*rea8fast1 cu) of -il', :&

)andesal

1 cu) of -il', :&

)andesal

1 cu) of -il', :&

)andesal

("n$;

3 glass of water I

cu) rice, 1 ser$ing

of )a'siw na isda

3 glass of water, 1

cu) rice, 1 ser$ing

of sina/awang

gula

3 glass of water, 1

cu) of rice, 1ser$ing

of )ritong isda w%

ginataang gula

)


10/41

na$8s2 sliced ng -ais, 3

glass water

1 stic' /anana Jue,

2 glass water

1 whole -ais, 2

glass of orange


11/41

She also added that she defecates once a da, -ostl in -orning, fir- in

consistenc and /lac'ish in color which can /e related to her FeS= 4.According

to Pillitteri, (2010), as peristalsis slows and the weight of the uterus presses the

bowel, constipation occur. Client also verbalized that she does not feel an pain

upon defecating and constipation does not occur.

D. A$tivit,+E!er$ise

;arl in the -orning the client starts her da / assisting her children

/efore going to school, doing house chores, then goes in /aranga health center

of -aa .. She considers those as her eercise, including her 5sideline8 which

is selling sweet corn within the /aranga. Clients for- of relaation is /

sociali#ing with her friends through )laing 5!G=8 and ha$ing so-e 5chit:

chats8 with so-e residents of the /aranga. So-eti-es, after those acti$ities,

she goes in the house of her son and ta'es a na).

>1+Da, A$tivit, Ta4le

TimeDa,

Da, - Da, / Da, 7 Da, 5 Da, 0 Da, 9 Da, 1

'e4 /

t;"r

'e4 /?

fri

Mar$; -

sat

Mar$; /

s"n

Mar$; 7

mon

Mar$; 5

t"e

Mar$; 0

we#

1 a-

2 a- Koided Koided $oided

3 a-

4 a- Koided $oided Koided

> a- $oided $oided

a-

11


12/41

& a- Koided Koided

( a- $oided Koided

9 a- $oided

10 a-

11 a- $oided Koided Koided12 nn Koided Koided

1 )- Koided Koided

2 )- $oided Koided $oided

3 )-

4 )- $oided $oided Koided Koided

> )- Koided

)- $oided Koided

& )- $oided Koided

( )- $oided

9 )- Koided

10 )- Koided $oided

11 )- $oided Koided Koided

12 -n Koided $oided

(egen#

slee) : eat : wor'ing

E

wa'ing u) : cleaning :Merienda

: ta'e a /ath L$oided: so-eti-e on that )art,

she urinated

Inter%retation:

12


13/41

"he ta/le shows the se$en ?&@ das acti$it of client S.G. "he color ellow stands

for the ti-e of her slee)B "he green color for the ti-e she wa'es u) in the -orningB "he

s'/lue stands how often she eats in a daB "he color /lue stands for ti-e she ta'es a

/ath. "he color )itch stands for how -an hours she wor's in a da. nd the /luegreen

stands for snac' ti-e. "he 5Koided8 indicates how -an ti-es $oidedin in the whole

twent:four ?24@ hours.


14/41

E. lee%+Rest

1+Da, lee% Diar,

Constr"$ts Da, - Da, / Da, 7 Da, 5 Da, 0 Da, 9 Da, 1

Ho"rs of

lee%9 hrs 9 hrs & hrs & hrs 9 hrs 9 hrs 9 hrs

lee%ing

Time ( )- ( )- 10 )- 10 )- ( )- ( )- ( )-

a8ing

Time4 a- 4 a- 4 a- 4 a- 4 a- 4 a- 4 a-

*e#time

Rit"alsone one one none one one one

'eeling

"%on

wa8ing "%

rested Dested rested rested Dested rested rested

Pro4lem

En$o"ntere

#

none one none none one none none

Inter%retation:

"he clients hour of slee) is sufficient. She feels rested after her slee)

which can /e related to the a/sence of )ro/le- encountered in slee)ing.

14


15/41

'. Cognitive+Per$e%t"al

)on assess-ent, the client shows no signs of a/nor-alities in her

thought and thin'ing )rocess as well as in her senses. 5Hindi )a na-an

nanglala/o ang )aningin 'o. Madali rin na-an a'ong -a'arinig at hindi na-an

a'o na-a-anhid8, the client stated.

She can decide on her own, can read, can write, and can interact with

other )erson. She also can recogni#e )eo)le and things around her.

G. elf+Per$e%tion+elf+Con$e%t

H. Role+Relations;i%

Mrs. S.G has a har-onious relationshi) with her fa-il as how she

descri/es it. She has se$en children and still wor'ing for the- through selling

sweet corns and ser$ing as !H* in the /aranga. Client is still assisting her 'ids

e$er -orning /efore going to school. "hough she has got Juite a -an children,

she ne$er had 7fa$oritis-. Howe$er, she focuses her attention on the needs the

ounger ones who could not do things on their own.

n ter-s of her relationshi) with her hus/and, she descri/es it as a t)ical

one. ro/le-s and -isunderstanding were encountered /ut were ne$er left

unresol$ed.

She added that she does not get a hard ti-e getting along or sociali#ing

with other )eo)le.

1/


16/41

I. e!"alit,+Re%ro#"$tive

Client is on her 24thwee's of )regnanc, and according to her, on the first

tri-ester of )regnanc, the ?her hus/and@ still had intercourse, /ut when she

reached the following tri-ester, the sto) it due to so-e fears. She also added

that u)on doing that, no )ain or disco-fort was e)erienced.

fter her th )regnanc, she was encouraged to undergo tu/al ligation.

She was scheduled twice for ligation /ut did not a))ear on the da of o)eration

due to fear. Still, she is /eing encouraged / the -idwi$es and her co:!H*s to

su/-it herself to the o)eration after gi$ing /irth.

. Co%ing tress

"he client stated that when shes stressed and ha$ing trou/les and

)ro/le-s, she


17/41

G;;D6 ;DC;

1. Body build and height-weight proportionality

Client S.G has an endo-or)hic /od /uild, weighing 9 'g which is not

)ro)ortioned to 1>> c- in height /ecause according to Pilliteri, a bod !ass

inde" of#######.

2. Posture and Gait

Client S.G -o$e-ents is well coordinated and slightl lordotic. ccording to

)illitteri

3. Over-all Hygiene & Grooming

)on assess-ent client S.G a))eared with unfied hair, unclean finger and

toe nails, with drness on her /oth heel and -uddled clothes, her teeth was

o/ser$ed, and has a ca$ities at the u))er incisors. According to $ozier and

%rb&s 'unda!entals in ursing, !aintaining a clean state prevents disease

infection and conta!ination therefore it is advised to eep the bod clean and

practice proper hgiene at all ti!es.

. Body and breath Odor

o unusual /od and /reath odor. According to *ebber + $elle ealth

Assess!ent in ursing -rdedition that no unusual odors should be assess.

or!al findings noted.

!. Obvious sign o" distress#illness

Client S.G a))eared with no signs of an distress, /ut during the assess-ent

her s'in was o/ser$ed of drness es)eciall on her lower etre-ities.

1


18/41

According to Pillitteri, no signs of distress and illnesses indicate absence of

co!plications or an disco!fort for an individual.

$. %ental tatus

)on the o/ser$ation, client S.G can e)ress where she is, ti-e and who

others are and can follow instruction she is a/le to recall )ast e$ents.

'. (ttitude

Client S.G o/ser$ed to /e Coo)erati$e since the ea-iner a))eared,

res)onds to all Juestions, )artici)ates in e$er acti$it, and is coherent.

). (""e*t#mood+ appropriateness o" responses

Client was slightl inacti$e /ecause of her ( th)regnanc

,. uantity and uality o" spee*h

Can s)ea' fluentl and can handle long con$ersations

1./elevan*e and organi0ation o" thoughts

+uring the assess-ent client. S.G was alread e)resses her thoughts

logicall rele$antl, and with sense.

.COMPREHENI)E PH&ICA( EAMINATION

A. )ital igns

3:+a Kital Signs Monitoring

+ate %"i-e Tem%erat"re P"lse RateRes%irator,

Rate

*loo#

Press"re

03%03%14 79.7OC 1? 4%m -? $%m -7232 --Hg

1


19/41

03%04%14 71.-OC 10 4%m /- $%m -7232 --Hg

03%04%14 79.0OC ?/ 4%m - $%m --232 --Hg

According to Pillitteri 200/ aternal and Child ealth ursing th

ed. 3henor!al vital signs of non4pregnant and pregnant wo!en are as follow5

O/%( 45( 4G

on:)regnant regnant

"e-)erature 79.?+71./ 79.?+71./!lood ressure -/23?2 --5390

ulse Date 12 ?2Des)irator Date -/+/2 -/+/2

Inter%retation:

3:+a Kital Sign Monitoring shows that the te-)erature, DD, and D are

at nor-al le$els. "he ! howe$er is higher than the nor-al.

*. Ant;ro%ometri$ Data

Height*eight

!MPre+%regnant %regnant

0 feet / in$; 3 'ilogra- 9 'ilogra- 2.22

1)


20/41

>According to bab.co!, a )regnant wo-an who enters )regnanc should

: 11.2> 'g co-)ared to a nor-al wo-an who needs to

ha$e an increase of 2>.0: 1>.&> 'g.

Com%"tation of *o#, Mass In#e! an# I#eal *o#, eig;t:

*MI%re+%regnan$, Mass in 'g E 3 E 3 E /9.// height in -2 ?1.>>@2 2.402>

I#eal *o#, eig;t+ since SG entered )regnanc o$erweight, she should N 11.2> 'g. Her )re:)regnanc weight is 3 'g and her

latest weight is 9 'g. "herefore, she .2> 'g.

!M SC6;Kalue Inter%retationF-?.0 nderweight

-?.0+/5. or-al *eight/0.2+/. =$erweight

72 =/ese

C. (eo%ol#s Mane"ver fin#ings

Maneu$er Findings -st '"n#al Gri%B "he fetal head is hard, fir-, round

and -o$es inde)endentl of the

trun'. "he /uttoc's is soft

s--etric, has s-all /on

)rocesses, and -o$es with the

trun'. either head nor the /uttoc's

2


21/41


22/41

unifor-it,ede-a, lesions

-oisture,te-). "urgor

andCrac'eds'in on heel

discoloration onother /od)art

?@ 6inea

nigra ?@striae

gra$idaru-

no

defor-ities.

*ar- to

touch asother /od)art.

color

no lesions

no

defor-ities

s'in color

andte-)erature generallthe sa-ethroughoutthe /od

s'in

s)rings/ac' to)re$iousstate

i--ediatel when)inched

illiteri, 200>,>th;dition,age 229

5+iscoloration

of s'in -aresults fro-h)er:)ig-entationduring)regnancusuall foundin face, anda/do-en.8

Hair e$enness of

growth thic'ness,

teture,oiliness,infection

or infestation,/od

hair

s-oothness

dr and

fri## hair

Hair

e$enldistri/uted

!lac' in

color, cutatshoulderle$el.

?:@

)arasitis-

Slightl

oil

Slightl dr

andcoarse.

Hair -ust

/e-oisturi#ed ande$enldistri/uted

andwithout the)resenceof )arasite

S-ooth

and sil'

ail )late sha)e,

teture,/ed color,

surrounding

oor hgiene S--etric

al,

eJual in

length

nail /ed

S--etric

al

eJual in

length

)in'ish in

22


23/41

tissues,scha-roth sign

!lanch test

)in'ish incolor

nails with

har/oreddirt

?:@scha-rothsign

Ca)illar

refill O 3seconds

color

?:@

scha-rothsign

Ca)illar

refill)ro-)treturn of)in' ?lessthan 3seconds@

HEAD6ull and7a*e

si#e, sha)e ,s--etr

facial features ees for

ede-aand

hollowness

nodules,-asses, de)ressions

S'ull

round in

sha)eBnor-oce)halic

s--etric

al facefeatures

no ede-a,

slight

)erior/italdar'ening

o

nodules,no-asses,node)ressions and notenderness

S'ull is

nor-oce)

halic. S--etric

al featuresa))ro)riate for si#e,

head -a

ha$e oddsha)e dueto -oldingof child/irth

o

nodules,no-asses,node)ressions and notenderness

ccording to)illitteriB

Maternal andChil Healthursing >thed.

+ar' circlesunder the ee-a resultfro- distur/edslee)ing)attern.

8yes andision eyebrowsfor distri/ution Palign-ent,

;e/rows

e$enldistri/utedand

;e/rows

e$enldistri/utedand

23


24/41

Jualit P-o$e-ent

eyelashesfor

e$enness ofdistri/ution Pdirection of

curl

eyelidsfor

surfacecharacteristics,)osition inrelation tocornea, a/ilitto /lin' PfreJuenc

bulbar +palpebral*on9un*tivaforcolor, teture,

and lesion

% la*rimalglandsa*,nasola*rimaldu*tforede-a,tenderness %tearing

*orneaforclarit, tetureP sensiti$it

aligned

s--etric

al and-o$e withcoordinatio

n

;elashes

fine,e$enldistri/utedoutwarddirectionor curl.

?:@ eelid)uffiness

/lin'

coordinatel ands--etricall

Con


25/41

pupilsforcolor, sha)e,s--etr ofsi#e, direct and

consensualreaction tolight, Pacco--odation

isual (*uity?near P far$ision test@

isual 7ield

5est 8O% 5est

"rans)are

nt andshincornea

?@

;DD6,

/lac'

s--etric

al

a/le toreadnews)rint

cornea is

trans)arent, shin,s-oothand /lin's

when it istouched

?@

;DD6

20%20

$ision

8ars andHearing

auri*lesforcolor, s--etrand )osition

e:ternal*analfor ceru-en,lesions, )us or

/lood

auri*lesforteture,elasticit andareas of

;ars eJual

in si#e,

s--etric

al

)ositionedalignedwith theoutercantus ofthe ees

ears color

si-ilarwith /ods'in color

?:@

discharge,

few ear

waes areo/ser$ed,

no lesions

;ars eJual

in si#e,

s--etric

al

)ositionedalignedwith theoutercantus ofthe ees

ears color

si-ilarwith /ods'in color

?:@discharge,

few ear

waes areo/ser$ed,

no lesions

2/


26/41

tenderness

6ross earingAcuit 3ests5

nor-al $oicetone andwhis)ered$oice

*atch 3ic3est

3unning 'or3ests5

4 *e/er for/one

conduction 4Dinnes toco-)are airand /oneconductions

uricles

are fir-

Decoil

instantl

?:@tenderness

t. a/le to

hear /othnor-alandwhis)ered

$oice

t. can

a))reciatewatch tic'in /othears

ot

ssessed

uricles

are fir-

Decoil

instantl

?:@

tenderness

or-al

andwhis)ered$oice, aswell aswatchstic'audi/le.

ose andinuses

nosede$iationin sha)e si#e,color, flaring,dischargeB

nasal mu*osafor redness,swelling,growth ordischarge

?:@ nose

de$iation

S--etric

al

?:@ nasal

discharge

?:@ nasal

stuffiness

?:@ lesion.

?:@-ucosalrednessandswelling

?:@ nose

de$iation

S--etric

al

?:@ nasal

discharge

?:@ nasal

stuffiness

?:@ lesion.

?:@-ucosalrednessandswelling

ccording toillitteriBMaternal PChild Healthursing >thed.

local changethat oftenoccurs in theres)iratorsste- is-ar'edcongestion, or5stuffiness,8 ofthenaso)harn,a res)onse to

20


27/41

a tenderness,-asses,dis)lace-entsB

nasalpaten*y ma:illaryand"rontalsinusesfortenderness

e the a/o$esinusesfortenderness

3ransillu!ination3est

?:@

tendernes

s, -assesanddis)lace-ent onnasalca$it

atent

nostrils

?:@

tenderness of

-aillarand frontalsinuses

?:@

tenderness,

-asses anddis)lace-enton nasalca$it

atent

nostrils

?:@

tendernessof -aillarand frontalsinuses

increasedestrogen le$el.

%outh #Oropharyn:

lipsfors--etr,contour, color,teture,-oisture, lesion

teethforalign-ent, loss,dental filingsand cariesB

gumsfor/leeding, color,retraction,lesions,

"he teeth

conditionwaso/ser$edunhealth/ecause)resence

of dentalcarriesandca$ities w%etractedteeth at 1st

and 2ndu))erincisors.

6i)s

s--etrical

+ar' red in

color

Moist

?:@ lesion

"eeth

aligned

?@ dental

carries?u))erincisor,u))er

canine,u))er)re-olarsand lower-olars@

Missing

teeth? etracted

6i)s

s--etrical

+ar' red in

color

Moist

?:@ lesion

"eeth

aligned

?:@ dental

carr

?:@ -issing

ll teeth

should ha$eeru)ted.

Gu-s )in'

:::::::::::::::::::::::::

2


28/41

swelling

tonguefor

)osition, colorP tetureB-o$e-ent, aswell as the/ase of thetongue, -outhfloor andfrenulu-

salivaryglanddu*tsfor

swelling,redness

palatesforcolor, sha)e,teture,)resence of/on)ro-inences

uvulafor)osition P-o/ilit

oropharyn:for color Pteture

tonsilsforcolor,discharge, and

1stand 2ndu))er-olar@

Gu-s are

)in', notenderness, noretractionand no/leeding

"ongue

aligned

centerred incolor,

-o$es

freel

-outh

floors-ooth

?:@ swelling ?:@

tenderness

in'ish

soft )alate

?:@

defor-ities,

?:@/leeding

, swelling,and

lesion

in color,non:tenderand not/leedingnor swelling

"ongue

alignedcenterred incolor,

-o$es

freel

-outh

floor

s-ooth

?:@ swelling

?:@

tenderness

in'ishsoft )alate

?:@

defor-ities,

?:@/leeding

, swelling,and lesionQ

$ula)ositionedat the-idline

=ro)harn

)in'ish

o

2


29/41

si#e

3est for 6ag

7efle"

nodules, lu-)and ecoriatedareas

$ula at

the -idline

=ro)harn

)in'ish o

o/ser$a/lenodules onthesurface

"onsils

not e$ident

ntact

no

discharge

?@ gag refle

?:@ nodules

?:@ lu-)s

?:@

ecoriation

o/ser$a/lenodules onthesurface

"onsils

not e$ident

ntact

no

discharge

?@ gag refle

o

nodules,

lu-)s andecoriatedareas

NEC:3>%-in. no-asses, nolu-)s, notenderness.

6i$er s)an is :12c- in the rightMC6. 6i$er s)an

is 4:(c- in-idsternal lineBnontenderB no-asses S)leens-all area ofdullness at thto10thri/sBt-)anic oninhalationB notnor-all)al)a/leB

nontenderTidnes notnor-all)al)a/le,nontender, no-asses, noincrease ina/do-inal girth,

ccording tolliteri 200>>thed.

5terusincreases itssi#eB it tendsthe a/do-ento /eco-eglo/ular in

sha)e.8

5ccording to)illitteriBMaternal andChild Healthursing >thed.

34


35/41

L 6eo)oldsManeu$er for

=! clients for)resentation,lie,engage-ent,attitude,)osition

1st

-aneu$er

le$el of dullnessdoes not change

1st-aneu$er"he fetalhead is

hard, fir-, round,and -o$esinde)endentl ofthe trun'whilethe /uttoc'sfeelsofter,are s--etric,and theshoulders andli-/s ha$e s-all/on )rocessesB

unli'e the head,the -o$e withthe trun'.2nd-aneu$er"he fetal /ac'will feel fir- ands-ooth whilefetal etre-ities?ar-s, legs, etc.@should feel li'es-all

irregularities and)rotrusions. "hefetal /ac', oncedeter-ined,should connectwith the for-found in theu))er a/do-enand also a -assin the -aternalinlet, lowera/do-en.3rd-aneu$er"he head and isnot acti$elengaged inthe/irthing)rocess, it -a/e gentl )ushed

6eo)oldsManeu$er is)refera/l)erfor-ed

after 24 wee'sgestationwhen fetaloutline can /ealread)al)ated.8

3/
http://en.wikipedia.org/wiki/Fetalhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Buttockshttp://en.wikipedia.org/wiki/Symmetryhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Human_headhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Limb_(anatomy)http://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Buttockshttp://en.wikipedia.org/wiki/Symmetryhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Human_headhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Limb_(anatomy)http://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Fetal


36/41

/ac' and forth.4th-aneu$er"he head of thefetus is well:fleedB it should

/e on theo))osite sidefro- thefetal /ac'.

M=C=(Ooints swelling tenderness,

s-oothness of-o$e-ent,swelling,cre)itation,nodules

/le to

)erfor-D=Meercises,the chest is

s--etric, s)ine

$erticallaligned

Chest wall

intact, notenderness,no -asses.u-/er offingers )er

each hand isfi$e.

o ede-a,

notenderness,no defor-it

/le to )erfor-D=M eercises,the chest iss--etric, s)ine$erticall aligned,

chest wall intact,no tenderness,no -asses.u-/er offingers )er eachhand is fi$e.

ccording todele illiteri,200>, >thedition, )age23

5"o change hercenter ofgra$it and-a'ea-/ulationeasier,)regnantwo-en tend tostand

straighter, withshoulders /ac'and a/do-enforward,createslordosis8

NE=RO(OGIC

%ental tatus: 6anguage: =rientation

: Me-or: ttention S)an %

Calculation

o slurge

s)eech

t. can

identifwhere sheis.

t. can

lert, awa'e,oriented threeti-es. o slurges)eecht. can identifwhere she is.t. can

30
http://en.wikipedia.org/wiki/Human_backhttp://en.wikipedia.org/wiki/Human_back


37/41

;ons*iousnessevel

Glassgow Co-aScale

;ranial erves4 to

/e"le:es: +ee),

su)erficial P)athologic

Gross%otor#Balan*e

> *al'ing Gait

> Do-/erg

> Standing on 1foot w% eesclosed

enu-eratesets ofnu-/ers

Can focus

u)on

inter$iewing

GCS 1>

consciousand aware ofthesurroundings

Can identifthings, candifferentiates-ells, can$iew near orfar, canidentif

Gait

changesha$e /eeno/ser$ed,-anifested/ s-allste)s whilewal'ing

egati$e

Do-/erg

Can stand

on one foot

enu-erate setsof nu-/ersCan focus u)oninter$iewing

GCS 1>conscious andaware of the

/le to wal'straight withoutalteration and aid

Maintains/alance, u)right)osition, and footstance

egati$eDo-/erg

-a swa slightl/ut is a/le to-aintain u)right)osture and footstance

ccording toillitteriB-aternal andChild Healthursing >thed.

5+ifficultiesresult fro-e)andinga/do-en.8

3


38/41

> Heel:toewal'ing

7ine %otor: ))er

;tre-ities> Finger:ose

"est

>lternateSu)ination Pronation of

hands on'nees

> Finger to oseP to D finger

> Fingers:to:fingers

> Fingers:to:thu-/

: 6ower;tre-ities

L Heel downo))osite s'in

L "oe % !all ofFoot to Dsfinger

with slightlswa

Can-aintainheel toewal'ing

Can

re)eatedl

touches thenose

!oth hands

can su)inateand )ronateat ra)id )ace

erfor-s

withcoordination

and ra)idit

Can )erfor-

withaccuracand ra)idit

;ach hand

can ra)idltouches thefinger to

thu-/

;Jual

coordinationof /oth loweretre-ities

Maintain heel toewal'ing along astraight line

De)eatedltouches the nose

lternatelsu)inate and)ronate at ra)id)ace

erfor-s withcoordination andra)idit

erfor-s withaccurac andra)idit

Da)idl touches

each finger tothu-/ with eachhand

+e-onstrates/ilateral eJualcoordination

Mo$es s-oothl,with coordination

3


39/41

ensory7un*tion

L 6ight%+ee)"ouch

L ain Sensation

L "e-)erature

L osition%Tinesthetic

L "actile+iscri-ination

+ifficult of

raising thefoot tostudent

nurse finger

/le to

discri-inatelight or dee)sensation

Can

discri-inatehold to coldte-)erature

Can ra)idl

deter-inethe )ositionof finger

Can

deter-ine

nu-/er offingerstouches the/od )art

"ouch sensation/le todiscri-inate5shar)8 and 5dull8

sensations.

/le todiscri-inate holdto coldte-)erature

/le to deter-inefingers )osition

/le to deter-inenu-/er of fingerstouches /od)art

GENITA(pubi* hair

distri/ution,a-ount,characteristicsBits areas for

)arasites,infla--ation,swelling,lesions

*litoris=urethral andvaginalori"i*es for

Lot

assessed

u/ic S'in intact,no lesions, noinfla--ation, noswelling, nodischarge

ntact anal s'in,anal s)hincterhas good tone

3)


40/41


41/41

Normal %;,siologi$al C;anges

Pat;o+%;,siolog,

Dr"g st"#,

NCP

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