MINDANAO INSTITUTE OF HEALTHCARE PROFESSIONALS, INC.

Marawi City

PHYSICAL ASSESSMENT

NAME OF STUDENT: GROUP 6 SCORE:

_
AREA OF ASSIGNMENT: OB Ward CLINICAL INSTRUCTOR: DAIRY ALMANOR
DATE OF SUBMISSION: ____________________

PATIENT’S PROFILE

Name: Patient Y Age: 20 Sex: Female Status: Married

Address: Lalabuan Tamparan Lanao Del Sur Religion: Muslim

HEALTH HABITS
Frequency Amount Period/Duration
1. Tobacco x x x
2. Alcohol x x x
3. OTC drugs/non-prescription drugs: OD 1 tablet PRN
Biogesic

A. Chief Complaints: Labor pain

B. History of Present Illness: (location, onset, intensity, duration, aggravation and alleviation, associates symptoms, previous treatment and result, social and
vocation, responsibilities and diagnosis.)

A 20 years-old patient, female, Muslim, and currently residency at Lalabuan Tamparan Lanao Del Sur, prior to admission at Tamparan District Hospital.
Experienced labor pain in anterior umbilical region due to the labor birth with a pain scale rate of 6/10, The pain was inconsistent and lasts for about 1 to 2 hours
and the pain aggravated every time when she sit and the pain alleviated when she’s start to walk, with an associated symptoms of contractions, and backache. The
patient said that she’s only takes biogesic every time she has a headache. The patient said that she’s always with her co-worker being the companionship because
the work of the patient was saleslady, she’s spending her time a lot in her work due to the overtime salary because of the bill payment in their house.

C. History of Past Illness: (previous hospitalization, injuries, procedures, infectious diseases, immunization/health maintenance, major illness, allergies, medications,
habits, birth and developmental history, pattern of sleep, exercise and nutrition.)
The patient was hospitalized with peptic ulcer and admitted last year at Tamparan District Hospital and has no previous injury and procedure, has no
infectious disease, the patient has an immunization of first dose TT1 has no allergies in food, environment or medication. The patient loves to do the household
 chores. She was born through vaginal delivery without any developmental abnormalities. The patient usually sleeps at 9:00 PM to 5:00 AM, her exercise routine
was jogging and walking every early morning. According to the patient she always eats with vegetable as her appetizer.

D. Family History with Genogram

Legend:

Male

female tuberculosis

Allergies

patient Dead

Acquired diseases: Heredo – familial Diseases:

Hypercholesterolemia x Diabetes x
Kidney Disease x heart disease x
Tuberculosis / Hypertension x
Alcoholism x Stroke x
Drug Addiction x Cancer x
Hepatitis A x Arthritis x
B x Rheumatism x
C x Allergies /
Others (Pls. Specify) x Asthma x
Epilepsy x
Mental Illness x
Others (Pls. Specify) x
E. Patient Perception of:

Present Illness: “Medyo masakit so tiyan akn” as verbalized by the patient.

Hospital Environment : “Marsik so tiles ago mado so CR iran saya” as verbalized by the patient.
E. Summary of Interaction

DAY-1 INITIAL CONTACT (01-24-2024)

In our initial contact with our patient, we made sure that before we starting the assessment, we established the trust first by introducing ourselves and
explaining the purpose of our assessment to the patient to build the rapport relationship. Then we asked the permission to her and she said yes and after that we
started to do our assessment by asking her some queries particularly her illnesses and familial disease, we also started to take her head-to-toe assessment, The
patient was very cooperative we will also inform our patient to take her rest because we will visit her tomorrow to continue our assessment.

DAY- (01-25-2024)

During our second day assessment we observed that the patient’s cooperation was improved she was very kind to us and every time she answered our
questions, she was always giving us smile and in exchanged to her kindness we gave her the gratitude what she deserved. We also informed her that we will
continue our assessment tomorrow so she can take her rest.
 REVIEW OF SYSTEM

Name of Patient: Patient Y Date: January 25,2024

Vital Signs
Temperature: 36 c Height: 5’4
Pulse: 64 bpm Weight: 55kg
Respiration: 19 cpm Blood Pressure: 90/70mmHg

received patent sitting on bed, awake In black dress with blue veil with ongoing IVF of D5LR volume left 450ml regulate at right arm patient
1. GENERAL and infusing well, and she has a Healthy appearance and She has good mental status, her senses are all functioning

2. HEENT H- The head of the patient is symmetrical and rounded, the patient claimed no history of head injury. Hair is black and long and are evenly
distributed. There are no nodules or masses and depressions when palpated the skull of the patient. The patients face appeared smooth and has
uniform consistency and no presence nodules and masses.

E- Eyes are well dilated and normal. Eyebrows hair are evenly distributed. Eyelashes appeared to be equally distributed and curled slightly
outward. On her eyelids there were no presence of discharge, no discoloration and lids close symmetrically with involuntary blinks. The
pupils of the eyes are black and equal in size. Using penlight, the pupil constricts reacted on the light.

E- The auricles are symmetrically and has the same color with her facial skin. The auricles are aligned with the outer canthus of eye. When
palpating for the texture, the auricles are mobile, firm and not tender.

N- The nose appeared symmetric, straight and uniform in color. There was no presence of discharge flaring. When lightly palpated, there was
no tenderness and lesions, as assess

T- The tongue of the patient is centrally positioned. It is pink in color and moist. Has no difficulty of swallowing, no tenderness was noted,
palate is light and smooth. Hard palate is also pink in color and free from lesion, teeth upward is 16 and down is 14
3. Integumentary The patient’s skin is uniform in color, dark skin unblemished and no presence of any foul odor, patient skin is dry and warm to touch. Her hair
is long black in color and are evenly distributed.she had dandruff upon inspection. The patient has a light pink nail and has a shape of convex
curve. It is smooth and is intact with epidermis. When nail is pressed between the fingers (blanch test), the nails return to its usual color within
less than 3 seconds. And there's Presence of dark spots noted on her arms, and there was noted to her abdomen Stretch marks curve. It is
smooth and is intact with epidermis. When nail is pressed between the fingers (blanch test), the nails return to its usual color within less than 3
seconds. And there's Presence of dark spots noted on her arms, and there was noted to her abdomen Stretch marks
The patient’s respiratory rate is 19cpm. The chest is symmetrically equal. No difficulty or shortness of breathing and no deformities noted.
4. Respiratory Upon using stethoscope, the auscultate of the lungs, there is no presence of abnormal lung sound. There is no history of any respiratory
problem among the family members. Her body thorax is within the normal range.
 The patients pulse rate is 64 bpm. Blood pressure of 90/80mmHg. No observed irregularities upon the observation, symmetric radial pulse in
5. Cardiovascular both upper extremities, no chest pain noted and no murmurs sound.

The mouth of the patient is symmetrical. Abdomen has unblemished skin integrity with uniform color all over the surface of the abdomen.
6. Digestive The Patients has no allergies on food and has no difficulty of swallowing, and she has a stretch mark due to her pregnant.

The patients urinate 3-4 times a day, yellowish in color, no pain upon urination, defecates 1-2 times a day, brown in color. Patient no history
7. Excretory of kidney problem stones

Patient can sit and raise. The patient’s muscle is equal in size of the body, smooth coordinated movements, 100% of normal full movements
8. Musculoskeletal against gravity and full resistance. No deformities or swelling, joint move smoothly.

Physically, patients appear healthy. The patient is alert, coherent and cooperative during assessment, mood is appropriate in her present
9. Nervous situation.

Patient’s weight is 55kg no thyroid enlargement, no swelling on neck noted, no tenderness upon palpation. Patient’s temperature is about 3 6.5
10. Endocrine degree Celsius. No pain on neck upon palpation, no masses noted.

NURSING ASSESSMENT II

Name of Patient: Age:

Chief Complaint: Sex: Female
 Impression / Diagnosis: Inclusive Dates of Care:
Diet: None Allergies: None
Type of Operation:

Normal Pattern Before Hospitalization Clinical Appraisal

Initial Day 1 Day 2
   
1. Activities – Rest

a. Activities
b. Rest
c. Sleeping Pattern

 
2. Nutritional- Metabolic

a. Typical Intake
(food or fluid)
b. Diet
c. Diet Restriction
d. Weight
e. Medication/ Supplement
food

Normal Pattern Before Hospitalization Clinical Appraisal

 Initial Day 1 Day 2

3. Elimination
a. Urine ( Frequency, color,
Transparency)
b. Bowel ( frequency, color,
transparency)

.
4. Ego- Integrity

a. Perception of self

b. Coping Mechanism

c. Support System

d. Mood/ Affect

5. Neuro- Sensory

a. Mental State
b. Condition of 5 senses:
(sight, hearing, smell,
taste, touch)

Normal Pattern Before Hospitalization Clinical Appraisal

 Initial Day 1 Day 2
6. Oxygenated and Vital Sign

a. Respiratory rate
b. Pulse rate
c. Temperature
d. Blood pressure
e. Lung sound
f. History of respiration

7.Pain Comfort
a. Pain(location,onset
Intensity,duration
Associated symptoms,
aggravation)
b. Comfort
measure/alleviation
c. medication

8.Hygiene & Activities of

Daily living
9.Sexually
a. Female
(menarch,menstrual
cycle,civil status number
of children,reproductive
organ)
b. Male(circumcision,civil
status,number of children)
 LABORATORY AND DIAGNOSTIC PROCEDURES

Name of Procedure Result Normal Value Nursing Implication

Hematology 10.4 5-10x10^9/L

The result is above the normal range.
WBC 4.04 F 4.2 - 5.4 x12/2 Leukocytosis can indicate infection,
inflammation, tissue damage or burns,
RBC 36 0.37- 0.47 dehydration, thyroid storm, leukemia, stress, or
steroid use.
Hematocrit 140 4-11 x 10⁹/L Nursing Implication:
1. Eating Vitamin C will help regulate the
Hemoglobin 407 150- 450x 10 9/L levels of white blood cells in your body. Fruits
like lemons, oranges, and lime are rich in
Platelets 79 40-70% vitamin C, and so are papayas, berries, guavas,
and pineapples.
Neutrophils 0.17 0.25- 0.40 2. Medications to reduce stress or anxiety.
3. Anti-inflammatory medications the result
Lymphocyte 0.03 0.01- 0.03 4. Encourages observation of infectious
control procedure like proper handwashing.
0.01 0.01- 0.04
Monocytes The results are within the normal range.
Yellow Pale yellow/ yellow The result is within normal ranges.
Eusinophils
Clear Clear/ cloudy The result is within normal ranges
Urinalysis The result is within the normal ranges
1-2 /hpo The results are above the normal range
Color The result is below the normal range.
Few Lymphocytes, you are at higher risk of
Transference infections.
Nursing implications:
Pus cell 1. Eating the right amount of protein can boast
your lymphocytes production.
Epithelial cells Like eggs, white fish, cottage cheese, beans and
shellfish
Bacteria 2.maintain healthy weight
3.activy pursue hygiene
4.Encourage patient to eat foods rich in iron like
mango, liver, ampalaya,

The result is within normal range.

The result is within normal range.

The result is within normal range.

The results are within the normal range

 SUMMARY OF INTRAVENOUS FLUID

Date / Time Started Intravenous Fluids & Volume Drop Rate Number of Hours Date / Time

1/24/2024 1D5LR 1L 21gtts/min 12hours 9:20 am

21ggts/min 12hours 9:00 am

1/25/2024 2D5LR 1L
 SUMMARY OF MEDICATION

Date / Time Medication Remarks

01/ 24/2024
Hyoscine butylbromide 20mg IVTT Q2hr Butylscopolamine GIVEN AND RECORDED
injectable
( 20 mg in mL ampule )
3:54 pm
 ANATOMY AND PHYSIOLOGY

Fallopian tube - enabling sperm to reach your egg and transporting a

fertilized egg to your uterus.

Ovary - produce eggs for fertilization and they make the hormones estrogen and progesterone.

Uterus - nurturing the fertilized ovum, which passes through the fallopian tube.

Cervix - It allows fluids to leave and enter your uterus.

Vagina - provides a passageway for blood and mucosal tissue from the uterus during a woman's monthly period.

Fallopian tube - enabling sperm to reach your egg and transporting a fertilized egg to your uterus.

Ovary - produce eggs for fertilization and they make the hormones estrogen and progesterone.

Uterus - nurturing the fertilized ovum, which passes through the fallopian tube.

Cervix - It allows fluids to leave and enter your uterus.

Vagina - provides a passageway for blood and mucosal tissue from the uterus during a woman's monthly period.
Skin - Provides a protective barrier against mechanical, thermal and physical injury
and hazardous substances.
Subcutaneous - It helps to insulate the body from cold, cushions deep tissues
from blunt trauma, and serves as a reserve source of energy for the body.
Fascia - provide support for surrounding tissues, help reduce friction,
and play a supportive role for the tissues and organs.
Muscle - attached to bones or internal organs and blood vessels,
are responsible for movement.
Peritoneum- serves to support the organs of the abdomen and acts as a conduit for
the passage of nerves, blood vessels, and lymphatics.
Uterus - is to nourish the developing fetus prior to birth.

NURSING CARE PLAN

 CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Subjective: Acute pain related After 8 hours of Monitoring the vital signs of the •For baseline data, Vital signs •After 8 hours of proper
The patient to labor pain as nursing interventions, patient and pain scale changes during onset of pain, for nursing interventions,
verbalized that her evidenced by patient should future comparison after the patient verbalized a
tummy was in pain patient facial manifest a decrease •Acknowledge and accept the client’s interventions. decrease in pain with a
with a scale rate of appearance of pain pain scale of 6 out of pain. pain scale of 4/10 as
6/10 scale of 6 out of 10 10 manageable of •Nurses have the duty to ask their evidenced by
with the lower pain scale. •Determine the patient 's level of pain. clients about their pain and
examination •Encourage DBE believe their reports of pain. (-) facial grimace
Objective: D-eep (-) verbal report pain
B-reathing •Utilize the numeric pain scale to (-) body malaise
BP: 110/60 mmHg E-xercise determine the patient's pain. The
PR: 66 bpm patient's pain level is assessed BP: 90/70 mmHg
RR: 20 cpm •Educate the patient about the pain frequently to determine the need PR: 64 bpm
Temp: 35.5°c management. for intervention. RR: 19 cpm
Temp: 36.0
(+) Facial grimace • Discuss pain relief options. •Promote patient relaxation and
(+) Verbal report comfort.
pain.
(+) body malaise •Patient can help effectively
(+) With pain scale manage their pain with additional
of 6/10 knowledge.

•The mother should be in charge

of her labor plan. The nurse can
discuss and explain options for
pain relief and help the mother
decide what is best for them.
DIAGRAM OF PATHOPHYSIOLOGY
(Actual on Patient’s Case)
 MEDICAL MANAGEMENT

ACTUAL
01/24/24
> Secure consent to care
> Vital sign monitor q4hrs
> Admitted in ward
> Monitor Urinalysis
> Monitor Hematology
> CBG monitor
> ECG monitor
> Monitor Serology

MEDICATION
> Hyoscine butylbromide 20mg IVTT Q2hr butylscopelamine injectable ( 20 mg in ml ampule )
> 1D5LR 1L/ 21 gtts/min
> 2D5LR 1L/ 21 gtts/ min

IDEAL

> Immediate threat of patience

> Evaluate of the vital signs
> Evaluate of capillary refill, skin color and pulse pressure
> Assessment of increased capillary permeability
> Measurement and assessment of the urine urinalysis

01/25/24
 The patient go home by doctor order
NURSING MANAGEMENT
 DISCHARGE PLAN

Patients Name: Patient Y Date of Discharge:

Condition upon Discharge: Nature: Home per Request ( ) Discharge Against Medical Advice ( )
MGH ( )

Medication

Exercise

Diet

Health Teaching

Schedule for next visit