LORMA COLLEGES CON TEMPLATE

PATIENT HISTORY
RELATED LEARNING EXPERIENCE

STUDENT NAME: BALLON, Karlo C. ROTATION:  7th Rotation AREA: Neonatal Intensive Care Unit (NICU)
YR LEVEL CLINICAL
AND SEC:  BSN 2-BETTY NEUMAN DATES:  July 5, 6, 7, 8, 9 12, 13, 14 INSTRUCTOR:  Marina Jumalon

A. BIOGRAPHIC DATA
- Sharon, a 37-year-old patient.

B. REASONS FOR SEEKING HEALTH CARE

- Admitted in the ER at 10:30 am due to prolapse of the
cord. She is dilated 8 cm with obvious signs of ruptured
membranes, no vaginal bleeding.

C. PRESENT HEALTH HISTORY

- AT 10:45 am FHR, which had been 135, begins to fall. A
prolonged deceleration phase occurs, with no progress
in cervical dilatation. A pulsating umbilical cord is felt
upon palpation. Then FHR dropped to 90, prolonged
deceleration phase continued.
The team decided to have emergency caesarian section.
Operating Room was notified of the emergency case and
NICU staffs were alerted to get ready to receive the
newborn and to anticipate the need for the care of a
high-risk newborn.
At 11:00 am Baby girl Wency was delivered. She did not
cry immediately after delivery.Nurse Guerly immediately
received the neonate. Based from the initial assessment,
the neonate appeared pale and blueish, with weak
pulses, poor perfusion with O2 Sat of 75, decreased
 capillary refill, and persistent bradycardia with CR of 55.
She has also minimal response to stimuli and muscle
tone and respiration is absent. Because of the cord
prolapse, the newborn developed hypovolemic shock
secondary to acute blood loss. APGAR score was checked
which is interpreted by Nurse Guerly as “Severely
Depressed”.

D. PAST HEALTH HISTORY

-Patient is G4 P3

E. FAMILY HEALTH HISTORY

F. LIFESTYLE AND PRACTICES

-She do take some time to do yoga and watch educational videos

1.DESCRIPTION OF TYPICAL DAY

-she go for a walk, or watch TV and
make it a daily routine now.

2.NUTRITION
- She eats i lots of fruits and vegetables, and need to religiously
take her medicines and vitamins.

3. ACTIVITY LEVEL AND EXERCISE

-Limited physical activity.

4.SELF-CONCEPT
-The patient family is very supportive and willing to
accompany her during her pregnancy. Said that she
is a good mother and said that her self-confidence
has declined.

5.RELATIONSHIP
-She has her husband , father and in siblings who is willing to
accompany her during her pregnancy.
6.STRESS LEVEL
-She is in pain, asking so much question and seen scared.

7.ENVIRONMENT
- The patient avoid environment of smoking, video display
terminals, anesthetic gases, antineoplastic drugs and
exposure to lead, selenium and inorganic mercury.

8.EDUCATION AND WORK

-The patient is a house wife.

9.VALUES AND BELIEFS

-The patient is a roman catholic.

10.SLEEP AND REST

-The patient is sleeping 8 hours a day and rest well during the
day.

G. DEVELOPMENTAL STAGE
- Trust vs. Mistrust
The first stage of Erikson's theory of psychosocial
development occurs between birth and 1 year of age
and is the most fundamental stage in life. Because an
infant is utterly dependent, developing trust is based on
the dependability and quality of the child's caregivers.

At this point in development, the child is utterly

dependent upon adult caregivers for everything they
need to survive including food, love, warmth, safety, and
nurturing. If a caregiver fails to provide adequate care
and love, the child will come to feel that they cannot
trust or depend upon the adults in their life.