OUTCOME PRESENT STATE TEST

Name: Jessa G. Date Admitted: March 2, 2023

Age: 23 Chief Complaints: Nausea and vomiting/ Prenatal checkup
Sex: Female Admitting Diagnosis: Prenatal checkup
Civil Status: Single Attending Physician: Midwife. Lilia
Address: Pamaong St. Ward/Area: OB-ER RHU

CLIENT IN CONTEXT ASSESSMENT INTERVENTIONS RATIONALE EVALUATION

Patient History: Subjective Cues:

Established rapport. To ensure The patient will
compliance of the maintain hydration as
A case of 4 months ‘’Magsuka suka ko a. Introduce self. patient. evidenced by
pregnant mother from kada buntag niya b. Explain adequate intake and
Pamaong St. who malipung sad ko purpose. output, vital signs and
visited to RHU for usahay ’’as skin turgor. The goal
prenatal check up. verbalized by the partially met.
patient.

History of Present
Illness: Objective Cues: Provide the patient
routine oral care as Establishing routine
needed. oral care will
decrease unpleasant
Consult to RHU for BP-121/73 mmHg. feelings and odor in
prenatal check up and the mouth.
for her medication. Temp- 36.5
HR- 97 bpm
Small frequent meals
History of Past Illness: RR- 17 bpm Encourage the patient can stabilize blood
to eat small frequent sugar levels, satisfy
Weight- 65.9 kg meals.
Non-hypertensive and Height- 158cm appetites and provide
non diabetic. nutrients throughout
the day.
Nursing Diagnosis:
Don’t consume
Alcoholic beverages .
Risk for Deficient
Fluid Volume as
evidenced by nausea Assess the patient It will determined if
and vomiting. fluid status . the patient had good
No food allergies skin turgor or bad, dry
skin and mucous
membrane.
Currently taking vit.
D3
Monitoring intake and
Assess and monitor output is one way for
Socio-economic the nurse to assess
Status: the patient intake and
output . adequate fluid intake.

A pregnant woman
living a the wisdom
boarding house a Monitoring the
sales lady. electrolytes,
Monitor lab values. haemoglobin and
hematrocit, BUN and
Organ Involved: creatinine we will able
to know signal of
hydration issues.
Digestive System
particularly the GI
track since the patient
are experiencing
nausea and urging to
vomit.