1.

PATIENTS PROFILE:
Name Langbis, Joana
Age 21
Sex Female
Civil status Married
Address Camp 4, Tuba Benguet
Place of Birth Camp 4, Tuba Benguet
Nationality Filipino
Religion Roman Catholic
Occupation Housewife
Admitting Diagnosis Pregnancy uterine, cephalic, delivered
living child, Term birth, G2p2(2002);
Post NSD
Admitting Physician Aileen F. Mallare MD
Date and Time of Admission 10-28-09,/ 09:05 AM

Chief Complain/ Reason for Admission

Chief complain on labor pain.

History of Present Illnesses

Present condition started at the first day prior to admission as irregular

abdominal pain from the sacral area radiating to the abdomen. The patient
immediately sought consult upon admission. Patient’s vital signs were recorded as
170/100 for blood pressure, 25 breaths per minute and had a temperature of 36.7C.

History of Past Medical History

The patient stated that she had no history of any trauma of hospitalization on the
past.

COURSE OF HOSPITALIZATION
DAY 2 October
DATE 29, 2009 NURSING CONSIDERATIONS
> the doctorORDER
DOCTORS ordered a
medicine:
a. oxytocin
October 28, 2009 > Oxytocin is used intravenously, diluted in
b. hyosine
>please admit her to the an isotonic solution used over long period.
OB ward under Dr.
Mallare
>take the vital sign every >monitoring the vital sign should not be
Day 1. TPR every
hour and shiftall the
refer considered to be just a work to rendered but
10:35
abnormalPM it should be a task of a responsible and
the patient delivered a effective health worker.
baby boy
>take vital signs >Vital signs were taken and noted every 30
Intravenous fluid minutes.
>the
D5LRS:Dr. order to
administer
1Liter methergine >a fluids containing electrolytes and nutrients
>the
Timedoctor ordered
administer- to replace and correct electrolyte imbalance
meds:
10:30AM
Antibiotic
Drops/minute-25-30
DAY 3 October 30, 2009 > Continue meds at home and to clean the
Vaginal
> May Go internal
Homeexam >to determine
perineal the progress
area with of 1st stage of
cold water.
labor

MEDICAL INTERVENTION

Medicines Rationale Nursing Intervention

Oxytocin, 2 ampule > It helps in the progress >explain the purpose of

of labor by stimulating the medicine and the
smooth muscles to effect
contract.

Hyosine, 1 tab every one >To relieve the patient
hour from vomiting
Methergine, 1 ampule >helps in blood
coagulation to prevent
excessive bleeding
>give information
concerning the medicine
and educate the patient
about the medicine
>inform the patient what is
the side effects of the drug

DIAGNOSTIC TEST:

A. Bacteriology Result

Bacteriology is a laboratory exam concerning with the study of bacteria on the

vagina. The specimen source was from a vaginal swab. Examination desired was a
positive gram stain. The result was, smear shows few grams, positive cocci appearing
singly and in pairs.

B. Urinalysis
Physical examination
The color was light yellow and the appearance was slightly turbid.

Chemical examination
Result Normal Significance of the Result
Values
PH 6.0 6.5-7.5 The PH of the patient shows that
Sugar negative negative In the urinalysis, during pregnancy,
the urine should not contain sugar.
Negative result is normal.
Protein negative The result shows that there is no
problem. Having a protein in
pregnant urine indicates a
complication such as pre-
eclampsia.

Microscopic examination
On the microscopic examination bacteria and epithelial cells are moderate and
the mucus threads are rare.

THIRTEEN AREAS OF ASSESSMENT

1. PSYCHOSOCIAL

The patient is 21 years old, female, a pregnant woman from Camp 4, Tuba
Benguet. She is a Roman Catholic who has no belief that would interfere in the delivery
of medical and nursing intervention. Patient verbalized her fear about pregnancy smiling
yet she seems so weak in appearance because of pain. Speaks minimal and eye
contact.

2. MENTAL AND EMOTIONAL STATUS

The patient was well oriented, conscious and responds to verbal stimuli by body
language and sometimes by talking. She was oriented to time, place and person.
Regarding to her emotional status, she was easy to be irritate due to her condition.

3. ENVIRONMENTAL STATUS

The patient lives at Camp 4, Tuba, Benguet. She lives with her husband and her
in-laws in their two-story house. They have four bedrooms in their house; one room is
for her and her husband while the other rooms are occupied by her in-laws. The comfort
room is water sealed. Source of water is coming from underground which is utilized for
any purposes. Drinking water is bought at the stores. They burn their garbage in their
backyards.

4. SENSORY STATUS

VISUAL The patient to read with no signs of extra movement. During

assessment, the papillary respond to the light normally. She has
a whitish sclera and pink conjunctivitis. Eyebrows and
eyelashes are evenly distributed.
 AUDITORY Patient is able to distinguish sounds without using any hearing
device.
OFACTORY During assessment, nose color is the same with the color of the
STATUS face. It normally respond to stimuli.
GUSTATORY Tongue is intact, pink in color and no lesions seen during
STATUS assessment. Patient verbalized that she can distinguish
different taste.
TACTILE Patient is able to distinguish hot cold.
LANGUAGE & As verbalized by the patient, she can speak kankanaey, ilokano
PERCEPTION and tagalog. Upon observation, she has a dry lips, complete
teeth, pink in gums and moist.

5. MOTOR STATUS

The patient is able to do her comfort necessities by going at the comfort room
alone or with the assistance of students. Due to frequent abdominal pain, she seems
weak.

6. NUTRITIONAL STATUS

The patient was put on NPO(nothing by mouth) when she was on the onset of true
labor but she has still IV infusion which serves as nutritional supplements.

7. ELIMINATION

During the shift, the patient verbalized that she never defecates. She frequently
urinates.

8. FLUIDS AND ELECTROLYTE STATUS

No dehydration was noted but edema is present et the lower extremities. She was
having an IVF to replace nutrients.

9. CIRCULATORY

Patient’s blood pressure was not in the normal range, it is above normal. She also
has a fast pulse rate with 115 beats per minute.

10. RESPIRATORY STATUS

Breaths per minute was in the normal range(20bts/min). No respiratory tract

infection detected during assessment. No episode of difficulty in breathing.

11. TEMPERATURE STATUS

Temperature was 36. 70C. A pregnant woman is normal to have a high

temperature.

12. ITEGUMENTARY SYSTEM

Patient’s skin appear brown in color under natural sunlight. During assessment,
there were no any lesions found out. Mobility and turgor is normal, no signs that indicate
dehydration. The skin is moist due to perspiration and the temperature is within the
normal range (36.5-37.5). Hair is fairly distributed, silky and normally resilient hair. Nails
are pink in color. Angle between the fingernail and base is about 1600. When palpated
the nail base is firm.

13. REST AND COMFORT STATUS

Before admission at the hospital, she sleep eight hours at night and sleeps also at
day time. As the patient verbalized, her sleeping pattern is irregular due to frequency of
urination.
 Cordillera Career Development College
HEALTH EDUCATION DEPARTMENT
Buyagan, La Trinidad, Benguet

In Partial Fulfillment of the Requirements on the

subject English 204- Technical Writing

Submitted to;
Ma’am Miriam Lagadan

Submitted by:
Jane Enomis
Judith Aquisio
Feby Apnoyan
Jia Rosendo

3-22-10