Bulacan State University

College of Nursing
Malolos City, Bulacan

Written Output

Submitted by:
Fajardo, Alexes Ann A.
BSN-2D

Submitted to:
Mrs. Daisy Reyes, RN.
 NURSING HEALTH HISTORY
A. Personal history
Demographic Data
Name: CPL
Age: 29
Civil Status: Married
Position in the family: Third among four children
Address: Bahay Pari Candaba Pampanga
Date of birth: December 20, 1980
Place of birth: Candaba Pampanga
Nationality: Filipino
Religion: Roman Catholic
Educational Attainment: Computer Science (second level) Baliuag University
Date of admission: January 14, 2010
Date of discharge: January 16, 2010
Initial Diagnosis: G3P2 (2002)
Age of Gestation: 38 weeks
Final diagnosis: G3P3 (3003), NSD + RMLE with repair

B. Reasons for Visit or Chief Complaint

“Manganganak na yata ako, napakasakit ng tiyan ko.” – as verbalized by the client.

C. History of Present Illness

Our clients first menstrual period is on her third year highschool but cannot remember the month. Her periods started irregularly, then eventually became
regeular at seventeen. She had her first baby boy when she was 23 yrs old then after 7 years they had another boy.
Her last menstrual period is on second week of March 2009. Without any occurrence of signs and symptoms our client knew that she is pregnant already and
it was confirmed by the community doctor. Having a history of hypertension, she continue to take medications with the doctors prescriptions.
On the night of January 14, 2010 at 8pm, our client felt that her contractions are getting more frequent and intense. So she went to the hospital anticipating
her third birth with her close neighbor. She gave birth to an alive baby girl 5lbs in weight and 48cm in length by 3am.
D. History of Past Illnesses

She remembers having vaccines as a kid but she doesn't know what it is. She received tetanus toxoid in her pregnancy but can’t remember how many times
she have received the vaccine. She also had chicken pox and mumps when still a kid. She frequently has colds and cough. She also have hypertension and is
currently taking medications to lower blood pressure.

Obstetric History:

Name: CPL
Age: 29 years old
Menarche: 3nd yr high school
TPAL: G3P3 (3003)
Last Menstrual Period: 2nd week of March 2009
Age of Gestation: 38 weeks
E. Family Health Illness History
FP -88 RL + -71
+
MP-85 63 FL-81

+ +

MP+♥ - 53 MP-51 BL-47

FP-60 MP- 58 FP- 56 RL-54 RL-53 YL-41 TL-38
+S

BL-51 RL-45 TL-40

CL-33 CL-30 CL (♣) -29 CL-27

CL (♣)…client
+……….dead
………... high blood
S………. stroke
♥………. heart attack
………male
…….. female
 The client’s age is 29 years old. She has three siblings. Her father died at 51 years old because of stroke. Her mother is still alive but
experiencing high blood pressure. Her father has seven siblings, four of them also experiencing high blood pressure. Her mother has four siblings.
The second sibling died because of heart attack. And the elder brother is experiencing high blood pressure. The client’s grandparents of both sides are
already died because of old age except for her grandmother on her mother side who is also experiencing high blood pressure.

F. Functional Health Pattern

Functional Health Pattern Prior to Hospitalization During Hospitalization

She does self medication when she has fever, cough &
Health Management colds. She also uses herbal medicines like sambong, She didn't take a bath in the hospital.
Pattern oregano and lagundi.

1st day 2nd Day Breakfast Lunch Dinner

3rd Day
Nutritional Metabolic -
ADL: Breakfast ADL:
Lunch Dinner ADL:- -NPO (admission)
Pattern -1 cup sotanghon Feeding-0
-1 cup rice -1 cup rice
Feeding-0 3 pandesal w/ Feeding-0
- ginisang adobong baboy,
Bed mobility-0 Bed2mobility-0 flavored noodles Bed
-1 mobility-0
pritong isda -1 cup sinigng nab
mayonnaise, 1 monggo, cup 1 cup rice, 2
General mobility-0 General mobility-2 -2 glasses of -2glasses of water
General mobility-0 boy with
glass juice rice, 2 glasses glasses of water
Bathing-0 Bathing-2 water Bathing-0 kangkong
of water
Dressing-0 Dressing-0 menudo, 2 cup Dressing-0 -2glasses of water
3 pandesal with ginataang
Toileting-0 -1 nissin cup - 1cup rice -discharged
pancit canton langka,Toileting-2
1 cup rice, 2 glasses Toileting-0
Grooming-0 Grooming-0 noodles bulalo Grooming-0
- 1platitong
1cup coffee rice, 2 baso of water
-2 glasses of menudo
1 glass water tubig
water -2 glasses water
pandesal and 1 fried tilapia, green
coffee 1cup rice, 2 vegetables,
glasses of water bangus fillet, 1
cup rice 2
glasses of water
Characteristics Stool Urine
Elimination Pattern Characteristics Stool Urine
Frequency 1x a day 4x a day
Frequency 1s 2n 3r 1st 2n 3r
t d d d d
Consistency formed Clear
0 0 1 0 4 2
Consistency formed Clear
Odor Foul No odor
Color brownish Orange Odor foul No odor
yellow Color brownish Orange yellow
Discomfort None None
Discomfort None None

Activity/ Exercise Pattern ADL:

Feeding-0
Bed mobility-0
General mobility-0
Bathing-0
DRUG STUDY

Generic Name Route/ Dosage/ Indications/ Contrainications Sideffects Adverse Reactions Nursing Responsibilities
Frequency Purposes
Mefenamic Route: Oral This medication  liver or kidney  Stomach  black stools Instruct client to:
Acid Dosage: 500mg, relieves pain and disease upset  persistent  Take with food or
 i tab reduces  blood disorders  Nausea stomach/ milk to minimize
Frequency:TID inflammation. It is  ulcers  loss of abdominal stomach upset.
used to treat  heart disease appetite pain  Most effective in
headaches,  alcohol use  dizziness  vomit that relieving menstrual
menstrual cramps,  high blood  drowsiness looks like pain if taken at the
muscle aches, pressure  diarrhea coffee earliest sign of pain.
dental pain and  eye disease  headache grounds  Take this medication
athletic injuries.  allergic with 6 to 8 ounces
 allergies  yellowing of
(especially drug the eyes reactions: (180-240ml) of
allergies)  fever with or (symptoms) water.
without chills rash, itching,  Do not lie down for
swelling, at least 30 minutes
 vision
severe after taking this
changes
dizziness, drug.
trouble  This should not be
breathing taken for more than
7 days at a time.
 Report immediately
if any signs and
symptoms of an
allergic reactions
occur.

Ferrous sulfate Route: Oral It is used to treat  iron overload  constipation;  signs of an Instruct client to:
Dosage: 250mg, iron deficiency syndrome  upset allergic  Take ferrous sulfate
i tab anemia (a lack of  hemolytic stomach; reaction: on an empty
Frequency:OD red blood cells anemia (a lack  black or dark- hives; stomach, at least 1
caused by having of red blood colored difficulty hour before or 2
too little iron in the cells) stools; or breathing; hours after a meal.
body).  porphyria (a  temporary swelling of Avoid taking
genetic enzyme staining of the your face, antacids or
disorder that teeth. lips, tongue, antibiotics within 2
causes or throat. hours before or after
 symptoms taking ferrous
affecting the sulfate.
skin or nervous  Take this medication
system) with a full glass of
 thalassemia (a water.
genetic disorder  Do not crush, chew,
of red blood break, or open an
cells) extended-release
 if you are an tablet or capsule.
alcoholic Swallow the pill
 if you receive whole.
regular blood  Shake the oral
transfusions suspension (liquid)
well just before you
measure a dose.
 Use this medication
exactly as directed
on the label, or as
prescribed by your
doctor. Do not use it
in larger amounts or
for longer than
recommended.
 Avoid taking this
medication within 1
hour before or 2
hours after eating
fish, meat, liver, and
whole grain or
"fortified" breads or
cereals.
 Report immediately
if any signs and
 symptoms of an
allergic reactions
occur.

Metronidazole Route: Oral It is an antibiotic  liver problems  Dizziness  Seizures Instruct client to;
Dosage: 500mg, that is used to treat  seizure  headache  loss of  It should be taken
i tab a variety of disorders  diarrhea consciousnes with food or a full
Frequency:TID infections.  any allergies  Nausea s glass of water or
 should not be  stomach pain  tingling of milk to prevent
used during the  change in hands or feet stomach upset
first 3 months taste sensation  unsteadiness  Antibiotics work
of pregnancy  dry mouth  mood/mental best when the
and used with changes amount of medicine
caution during  rash in your body is kept
the last 6  Itching at a constant level.
months  sore throat Do this by taking the
 It is excreted medication at evenly
 Fever
into breast milk spaced intervals
 severe
and using it throughout the day
stomach pain
while breast- and night. Continue
 vomiting to take this
feeding is not
 vaginal medication until the
recommended.
irritation. full prescribed
amount is finished
even if symptoms
disappear after a few
days.
 Avoid alcoholic
beverages
 Report immediately
if any signs and
symptoms of an
 allergic reactions
occur.
Cefuroxime Route: Oral It is used to treat  allergic to any  nausea,  diarrhea that Instruct client to:
Dosage: 500mg, many kinds of drugs vomiting, is watery or  Take this medication
i tab bacterial (especially diarrhea, bloody; exactly as it was
Frequency:BID infections, penicillin) stomach pain;  fever, sore prescribed for you
including severe or  liver or kidney  headache, throat, and  Take cefuroxime
life-threatening disease dizziness; headache tablets with or
forms.  diabetes  fussiness or with a severe without meals.
 heart failure, crying (in blistering,  Use this medication
cancer children); peeling, and for the entire length
 a stomach or  sleep red skin rash; of time prescribed
intestinal problems  seizure by your doctor.
disorder (insomnia); or (black-out or  Report immediately
 malnourishment  vaginal convulsions); if any signs and
 pregnant itching or or symptoms of an
 breastfeeding discharge.  jaundice allergic reactions
mothers (yellowing of occur.
the eyes or
skin).

Captopril Route: Oral It is used to treat  Do not use this  cough;  feeling light- Instruct client to:
Dosage: 25mg, i high blood medication  loss of taste headed,  Take this medication
tab pressure without telling sensation, loss fainting; exactly as it was
Frequency:BID (hypertension), your doctor if of appetite;  urinating prescribed for you.
congestive heart you are  dizziness, more or less  Take each dose with
failure, kidney pregnant or drowsiness, than usual, or a full glass of water.
problems caused planning a headache; not at all;  It is usually taken 1
by diabetes, and to pregnancy.  sleep  fever, chills, hour before meals.
improve survival  kidney disease problems body aches, Follow your doctor's
after a heart attack. (or if you are on (insomnia); flu instructions.
dialysis)  dry mouth, symptoms;  Your blood pressure
 liver disease sores in the  pale skin, should be checked
  heart disease or mouth or on easy bruising on a regular basis to
congestive heart the lips; or bleeding; know the
failure  nausea,  fast, effectiveness of the
 diabetes; diarrhea, pounding, or drug.
 a connective constipation; uneven  Avoid drinking
tissue disease or heartbeats; alcohol.
such as Marfan  mild skin  chest pain; or  Do not use salt
syndrome, itching or  swelling, substitutes or
Sjogren's rash. rapid weight potassium
syndrome, gain. supplements while
lupus,  taking captopril,
scleroderma, or unless your doctor
rheumatoid has told you to.
arthritis.  Report immediately
if any signs and
symptoms of an
allergic reactions
occur.
Aldazide Route: Oral Essential  cute renal  Gynaecomasti  Gastro- Instruct client to:
Dosage: 25mg, i hypertension, insufficiency a may develop intestinal  Taken with food or
tab oedema and ascites  significant renal in association disorders milk to prevent GI
Frequency:BID of congestive heart compromise with the use  Skin and upset.
x 3days failure, cirrhosis of  Addison’s of appendages:  Taken early in the
postpartum the liver, the disease ALDAZIDE. rash, pruritis, day so increase
nephrotic  significant Development dermatitis urination will not
syndrome, hypercalcaemia, of  Nervous distub sleeping.
idiopathic oedema. hyperkalaemia gynaecomasti system  Arrange to monitor
 hypersensitivity a is related to disorders: serum, electrolytes,
to both dose and dizziness, hydration and liver
spironolactone, duration of headache, function during long
thiazide therapy. paraesthesia. term therapy.
diuretics or to Gynaecomasti  Psychiatric  Weigh yourself on a
other a is usually disorders: regula basis to note
 sulfonamide- reversible impotence. if there is 3lbs
derived when  Neoplasm: weight gain a day,
medicines ALDAZIDE breast report it to your
 Safety in is neoplasm, physician
pregnancy has discontinued  Metabolic immediately.
not been  breast and  Report immediately
established enlargement nutritional if any signs and
 Lactation. may persist. disorders: symptoms of an
electrolyte allergic reactions
disturbances. occur.
 Haematologi
cal disorders:
thrombocyto
penia.
 Other
adverse
reactions
reported with
the use of
ALDAZIDE
include
pancreatitis
and
cholestatic
jaundice.

HEALTH TEACHING

Goals and Learning Content Methodology Venue/ Time/ Date Resources Evaluation
Objectives
Goal:
  To teach Contents:  Discussion and Venue: OB-ward Manpower Goal is met.
the mother  Explanations why the mother cannot teaching why Time:2:00pm Bottle
in continue breastfeeding. the client Date: January 16, 2010 The client was able
managing - captopril is a drug that lowers the blood cannot to demonstrate the
breast pressure. This drug can be passed through breastfeed. proper
engorgeme breastmilk and is harmful if ingested by the  Teaching and breastfeeding
ntpain due baby. demonstration technique,
to not  Suctioning of the mothers breast of proper breast suctioning of her
breastfeedi  Bottle feeding techniques suctioning, breast, and burping
ng relate to -choose an appropriate nipple size for your effective bottle of her baby.
taking child, use milk formulas according to feeding and
captopril. doctors advice or something that fills up the burp method. The client was also
baby’s nutritional needs. Also, remember to able to understand
* sterilized the baby’s things before an after why she cannot
Objectives: using them by boiling it for 5mins. continue to
 To relieve - Put a bib on your baby and have a cloth breastfeed through
mothers ready to clean any spit-up milk or formula. answering my oral
breast pain. Now, cradle your baby with his head a bit questions
 To promote higher than the rest of his body. Hold the correctly.
mother an bottle; don't prop it up by itself. This can
baby help prevent choking, extra gas, tooth
bonding decay, and provide bonding time. It’ll also
even if the help you better judge when he's finished
baby is not eating. If your baby slows his eating, try
breastfeedi burping after every 2 oz.
ng.  Burp method
- Your baby needs a burp during or after
feeding and this is how you do it:
Hold her on your lap or rest her on your
shoulder. Gently pat or rub baby's back.
You can also lay baby tummy-down on
your lap, supporting her head, while you pat
her back. Your baby may spit up some milk,
so have a cloth on your shoulder or lap. If
she doesn't burp after a few minutes but
seems comfortable, don't worry. Not every
baby burps after every feeding.