Demographic Data

Name: Katherine Hilario Age: 23y/o Gender: Female Status: Live-in Birthday: March 20, 1987 Birthplace: Cavite Religion: Roman Catholic Nationality: Filipino Address: Maria Payo Asuncion Tondo Manila Husbands Name: Sherwin Cungnan Occupation: Installer Educational Background: Primary Level: Binacayan Elementary School Kawit, Cavite

Past Medical History

The patient has a previous history of Caesarian delivery during her first pregnancy. According to the patient, when she was delivered her babies she have a hypertension.

Present Medical History

Patient was admitted June 09 2011 at 12:45 am; with a diagnosis of post CS t/c CHVD with superimposed pre- eclampsia severe.

Family Health History

Obstetric- Gynecology History

The patient is 39 weeks pregnant before the confinement. The patient revealed that her first menstrual period when she was at the age of 11 years old. Then when she was 21 year old she delivered her first baby namely Shello Kurt and Shello Kyle through Caesaraan Delivery, last June 2010. .

Gordon Functional Health Pattern

Pattern Before Hospitalization During Hospitalization

Health Perception

Patient does have her check-up while she was in her pregnancy stage. It only seems that she is aware on her condition. It seems that patient has her regular bowel movement. She states that she had at least once a day bowel movement Patient doesnt have her regular exercise. The only exercise she had is just a simple walking around their house daily.

She have more understand how important to have a regular check-up especially when you are pregnant.

Elimination Pattern

Patient said she had a bowel movement after 48 hours of procedure done. And voided after the removal of catheter. She had her limited movements due to her incision and BP precaution.

Activity Exercise

Cognitive Perceptual

Sleep Rest

Patient doesnt have a complete sleep rest because she have two little baby that they need the attention of their mother.

Her sleep of hours are more lessened because of irritabiliy

Role Relationship

She appreciates the support of her close relatives in changing shift to accommodate her Patient simply expresses her emotions through showing it in her actions. Patient is a Roman Catholic and has a strong belief in GOD She is more sensitive after the CS & giving birth

Coping Stress Tolerance

Value Belief Pattern

She prayed more often to seek GOD guidance.

Physical Assessment Vital Sign taken: BP: 140/100 Temp: 36.5 PR: 78 RR:18 A. Skin Body Parts Head Face edema(+) > Due to retention of fluid Interpretation Normal Swollen Analysis There is no abnormal findings. Because of the accumulation of excess fluid in the body. There is no abnormal findings. There is no abnormal findings. There is no abnormal findings. There is no abnormal findings.

Technique Inspection Inspection

Eyes Neck Ears Nose and Sinuses Mouth and Pharynx Anterior/posterior Chest Breast Nipple and Areola

Palpation Inspection Inspection Inspection Inspection Inspection/ Palpation Inspection/ Palpation

Pale sclera Normal Normal Normal Normal

Breast enlargement Nipple swollen

Engorgement is a common response of the breast to the sudden change in hormones and the presence of increase of volume of milk

Abdomen

Inspection/ Palpation

incisions

Due to Caesarean procedures done

Extremities: Upper Extremities Lower Extremities