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NURSING PROCESS
I. ASSESSMENTA. General Data
Patients Initials : P.L.A.N.M Informant : Aunt
Address : Pandacan, Manila Date ofAdmission : June 18, 2011
Age : 21 y.o Order ofAdmission : Ambulatory
Sex : Female No. ofdays in hospital :
Date of birth : July 25, 1989
Place of birth : Manila
Civil status : Married
Occupation : N/A
B. Chief ComplaintsWatery Discharge
C. History of Present IllnessOne month PTA watery discharge with occasional uterine contractions with no
bloody show, consult done with AP : closed cervix, Dx advisedultrasound Px still with
persistent watery vaginal discharge consuming 1 panty liner per day still with no
hypogastric pain with uterine contractions, no bloody show, still no consult done, no
medications given 2 weeks PTA, patient consulted OGC due to persistence of watery
discharge, still consuming 1 panty liner per day with no bloody show, good fetal
movement, on consult: revealed closed intact BTW UAdone revealed UTI, given
amoxicillin 50mg TID x 7days.
One month before admission in Manila Doctors Hospital, the client experienced
occasional uterine contractions with no bloody show, consult done and found closed
cervix and advised to have ultrasound, still with persistent watery vaginal discharge
consuming 1 panty liner per day still with no hypogastric pain with uterine
contractions, no bloody show, still no consult done, no medications given 2 weeks
before admission, patient consulted Obstetric Gynecology Clinic because of persistence
of watery discharge and the patient is still consuming 1 panty liner per day with no
bloody show, good fetal movement, on consult, revealed closed intact
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D. Past History1. ChildhoodIllness/es : Chicken pox, mumps, sore eyes, fever, cough and colds2. Adult Illness/es : Heart disease, Kidney disease, UTI3. Immunization : Patient said that she is completely immunized but cannot avail her
baby book.
4. Previous Hospitalization : Heavy menstrual flow (thought to be miscarriage) [2009],Difficulty in breathing (December 2010), heart disease (2009), Liver disease (2009)
5. Operation/s : Coterize (2010), Raspa (2007)6. Injury : sprain at the right ankle (2006)7. Medications taken prior to confinement : Obimin, Hemerate, Calcium (Vitamins for
pregnancy)
8. Allergies : Unrecalled antibiotics, hard liquor (vodka and tequila) & Korean spicyfoods (the client cannot recall the names of the food but usually fishes & noodles)
E. System ReviewsA.)HEALTH PERCEPTION AND HEALTH MANAGEMENT
When asked about the clients definition of what is health, she toldus
that you have to eat plenty of fruits, fish and vegetables, less pork and beef,
must take multivitamins and have at least 8 glasses of water and 8 hours of
sleep. She rated her own health as 6/10 because she said that she had a couple
of complications for the past years like problems with her kidney. She assumed
that her abdomen increased in size like that of a 2-months-pregnant-woman
and that it was connected with her kidney disease. She thought she was
pregnant. She also said that she went in Manila Doctors Hospital to have a
check-up but the physician said that there was nothing wrong with her
abdomen, also there arent any presence of pain or tenderness. She did not take
any medications but went to an albularyo & the albularyo told her that her first
husband caused this. She did not take any rituals or other medications from the
albularyo. She said that her abdomen decreased in size after 4 days and then it
was on its normal size again. She also had heart problems when she was back
there in Korea & consulted a cardiologist. She didnt know the exact name of the
complication and the medications that were given to her because of language
barriers. She only said that her employer told her that she has to go back to the
Philippines because she is sick. She also discontinued taking the medications
after she has consumed all the medications. She also verified that she has low
potassium when she has consulted a doctor in MDH too anddescribes that
when she cries because of her problems with love life and family, she feels
numbness on her body & a tickling sensation.It starts first on her hands then up
to her arms, to her face anddown to her legs. She estimated to have
experienced it for 30 minutes, and she said that she took Calciumdurole and
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cannot remember the dosage and how many times per day she takes it. She also
had UTI on 2007 for 2 weeks. The medications she took were amoxicillin and
was taken three times a day. She also toldus that she simply eats whatever
random food is on the table, sometimes tuyo, tinola, sinigang, adobo and other
Filipino dishes. We asked her about her pregnancy condition, she said that she
felt normal because she experiences what any other pregnant woman
experiences like morning sickness and being temperamental and she never
misses a check up or appointment with her doctor. She said that she drinks
liquor and smokes 4-6 cigarette sticks per day even though she was pregnant.
We also asked her if she knows the consequences of her actions and she said
yes but cant help it because she was so stressed because of financial problems
like paying her electricity, water and food expenses. She also said that she is
anemic & takes ferrous sulfate when she was 13. She does self breast
examination once a month when she was on Korea on year 2009 but not doing
it anymore here in the Philippines because she said that she does many things
and always forget about doing it. She takes a bath 2x a day, in the morning and
late in the afternoon when she is on her house but since she is in Manila
Doctors Hospital now, she only bathes herself once a day because it is colddue
to the air condition. She also doesnt perform hand hygiene before meals only
alcohol.
B.NUTRITIONALAND METABOLIC PATTERN
She has knowledge of proper nutrition. She also stated the three foodgroups
Go, Grow and Glow. The patient likes pork, any dishes with pork anddesserts and other
sweets but she doesnt like vegetables. The patient has decreased in weight from 110
lbs to 70lbs. She also said that her appetite depends on the food served. She has eating
discomfort like when the environment is not clean. She stated that Depende sa
paligid.. The patient doesnt heal well immediately. She doesnt have any skin problems
except for her CS stitch due to her recent operation. She said that she doesnt have any
dental problems right not but she toldus, Meron dati, may butas ako sa ngipin, kaso
nadala na a mga dentist, dina ako nagpabunot ulit kasi masakit.
She eats 5 times a day, breakfast, lunch, dinner accompanied by 2 snacks on the
afternoon. The patient consumes only 3 cups of rice every time she eats her meal. She
only drinks water every time she takes her medication and every after meals. She mostly
eats bread. The patient also says that she cooks her own food and for her son. She said
that they have food budgeting Oo shempre dumagdag na anak ko eh.. She smokes
cigarettes after eating. She drinks liquor about 10 bottle but depends upon the
occasion. She said that when she and her spouse were together like before, they eat a
lot in the restaurants and fast food.
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C.ELIMINATION PATTERN
The client defecates two times a day but not every day. She estimated that she
defecates 2 times every 2 days. She said that it is solid and there are no difficulties. She
urinates about 15 times a day and said that she didnt have a problem with it except
when she had her UTI. She described it as light yellow in color and not very pungent inodor except from prolong standing of course. She also said that she doesnt have
excessive and foul-smelling perspiration and odor. She doesnt also perform habits or
rituals to help ease her defecation andurination.
D.ACTIVITY-EXERCISE PATTERN
She doesnt do any exercise because she is lazy to do so but she prefers to lay in
bed.It feels relaxing according to her. She does the laundry, cleaning the house &
looking after her children. She works as a vocalist on their band in Korea. The client has
enough energy during her work but she stated Wag lang mamamaos.. She works in
the evening andusually sleeps in the morning after her work.In weekdays, she works at
6pm 12am and in weekends she works at 5pm 3pm. But sometimes she likes to go
out for strolling.
E. SLEEP-REST PATTERNWhen asked about the number of hours of sleep, she said that sometimes it is 8
hours more or less. She stated that she also takes naps on the afternoon like at 3 or 4pm
andusually wakes up at night or early in the next morning. She also said that even
though she oversleeps, she feels like her sleep was not enough and that she doesnt feel
refreshed and satisfied. She also emphasized that she doesnt experience any difficultyin sleeping anddoesnt take any medications and rituals prior to sleeping. She also
stated that the kind of environment that she was sleeps on was very comfortable
because she is surrounded by her family and many relatives. She also said that she
wakes up every night just to void. When asked if she experiences nightmares, she told
us that she doesnt usually have nightmares, but if she does as the client jokes - she sees
the face of her husband.
F. COGNITIVE-PERCEPTUAL PATTERNOur client is a high school graduate. She can speak and understand Filipino
but few when it comes to English. She also knows how to speak and understand in
Korean because she works there on the year 2009. She hears without difficulty. She
doesnt have any hearing difficulty and doesnt use hearing aid. She is near sighted
and use contact lenses when she is in Korea. She also said - Ewan ko, natututunan ko
by experience. Natututunan ko pag nakikipagusap Although she doesnt know the
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grade.Her last eye check up was in 2010. She didnt have any changes in her memory,
smell and taste.
G. SELF-PERCEPTIONAND SELF-CONCEPTShe described herself as maayos. She feels good most of the time. The patient sees
herself in relation to other people better than them. She says that she is unique. She
doesnt express herself in other people that she is not close and comfortable with only
to her friends and family. Her goal in the next 5 years of her life is magpayaman and
umasenso sa buhay kasi may anak eh.. She plans to return to her work as a vocalist in
Korea this January 2012. The client is a very happy person., as she described. She
stressed that if someone hurts her son, shell be angry. She feel annoyed to the people
who are lazy. She feel tearful and sad when shes far away from her family and
especially her son. She said Yung anak ko lang ang nagpapawala ng pagod ko. Yung
kahit anong lungkot at pagod mo galling trabaho, pag hinalikan ka lang ng anak mo,
mawawala na.. She doesnt notice if her mood changes, her family just notices it.
H. ROLE RELATIONSHIP PATTERNShe has an extended type of family. She lives with 6 families but she is not with her
parents and siblings. Her two sons are the most important in her life. She says that shes
a good mother to her children and she added Gagawin ko ang lahat para sa kanila..As
a daughter she states Pasaway ako eh.. She is not that gooddaughter to her parents.
Shes fulfilled playing the role of a mother to her children.If she had problems, she
prays Pag may problema ako, nagdadasal lang ako, umiiyak ako sa kanya.. Her family
is dependent to her. Sometimes ser tito arranges some family activities like outing as
swimming and partying at the disco anddrinking alcohol with them. She never likes to
be alone, she wants to be in a group surrounded with happy people.
I. SEXUALITY-REPRODUCTIVE PATTERNShe stated that 13 was her age of menarche. She consumes 2-3 pads usually on
her secondday which she describes as her gripo day because of heavy menstrual flow.
She stated that her menstruation duration is 4 to 5 days per month. She stated that sheis regular and have her menstruation occur every 28 days to count. She doesnt
experience dysmenorrhea every time only a few times. She also doesnt experience
dizziness, headache or vomitingduring her period. Her flow has sometimes blood clot
on it especially on her secondday. She was also admitted to the hospital once when she
was still a teenager because her menstruation flow was really heavy and that she had
mistaken it to be a miscarriage since she has a boyfriend and is sexually active that time.
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The client said that at the age of 16, she became sexually active. She uses Dianne
contraceptive pills.
J. COPING-STRESS TOLERANCE PATTERNWhen asked about the meaning of stress, she gave an answer saying
that stress is something that can make a person depressed and sad but can
make him or her stronger. The client stated that she has been stressed for over
one year straight because of complications with her husband mainly in
communications and misunderstandings since they have longdistance
relationship and that her husband and the client spoke different dialects
without mastery ofusage of each others language. The things that she does
when she is stressed are throwing of things because of anger, go out with her
friends on an outing
usually swimming, visit her relatives, cry, drink, smoke cigarettes. She also said
that most of her companion when she is stressed are her family and it really
helps to confess to them her problems that causes her stress. She feels better
after sharing her problems that causes her stress. She feels better after sharing
her problems and she also noted that she doesnt keep her problems to herself
instead, shares them to her loved ones. She took disuldrin once to make herself
at ease temporarily. She said that she has experienced chestpain when she is
really very depressed and cant help crying and she said that minsannamamanhid, ayun na nga sabi ngduktor ko dati dahil rin raw yun sa mababa
potassium ko, nakakaramdam rin ako ng hirap sa paghinga dhail sa pag iyak
pero nawawal ren naman pag tumatahan nako at umiinom ng tubig, dahil na rin
siguro yon sa sakit ko raw sa puso, literal at hindi literal.
H. VALUE-BELIEF PATTERN
She thinks that vitamins makes a person healthy and she added Pero
sabi nila sex daw nakakataba depende na lang ren siguro kung hiyang ka. Health is important toher, she added Kapag nawala yan, wala na talaga.. She states that if there are things that she
wants pinagsisikapan ko talaga para makuha ko, ayun na nga nagabroad ako. Her sons were
the most important people in her life. She believes in God. Her religion is Iglesia ni Kristo. She
says that religion is important in her life because without God were nothing.As verbalized by
the client. But she doesnt believe in the superstitious but said that wala naming masama pag
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di ka sumunod.. She also experienced to consult a quack doctor for her health sinusumpa
kasi daw ako ng tatay nguna kong anak.
F.) FAMILY ASSE
SSME
NT Name Relation Age Occupati
Sex
Dianne cousin 23 N/A F
Linda grandmother 74 Construction F
Tatay uncle 38 N/A M
G.) HEREDO
* Family Illness
Mothers side
Fathers side.
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H.DEVELOPMENTALHISTORY
Theorist Age Task Patient descriptionErik Erickson YoungAdults, 19 to 40
years
Intimacy vs.Isolation
-Once people have
established their
identities, they are
ready to make long-term commitments to
others, they become
capable of forming
intimate, reciprocal
relationships and willing
to make sacrifices and
compromises that such
relationships require.If
people cannot form
these intimate
relationships, perhapsbecause of their own
needs- a sense of
isolation may result.
Sigmund Freud puberty onward Genital stage-Physical sexual changes
reawaken repressed
needs. Direct sexual
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feelings towards others
lead to sexual
gratification.
Jean Piaget adolescence Formal Operations-This stage brings
cognition to its final
form. This person no
longer requires
concrete objects to
make rational
judgements.At his
point, he is capable of
hypothetical and
deductive reasoning.
Teaching for the
adolescent may be
wideranging because
he'll be able to considermany possibilities from
several perspectives.
Lawrence Kohlberg Adolescence Stage 4: Maintainingsocial order
-The respondent becomes
more broadly concerned
with society as a whole.
Now the emphasis is on
obeying laws, respecting
authority & performing
ones duties so that thesocial order is maintained.
James Fowler Adolescence -The person is not fullyconscious of having
chosen to believe
something, the beliefs are
not the result of any type
of analytical thought.Any
attempts to reason with a
person about her beliefs,
any suggestion of
demythologizing his
beliefs is seen as a threat.
Most people in this stage
see themselves a s
believing what everybody
else believes and would
be reluctant to stop
believing it because of the
need they feel to stay
connected with their
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C.) SkullInspection: There are no presence ofdandruff & itchiness.No history of loss of consciousness &
seizure. Dizziness experienced sometimes since admission and also headache.No facial pain and
head injury. The skull shape is rounded and smooth in contour. The outher canthus of the eye
are also symmetrical. The client is able to frown, puff, raise and lower both eyebrows, close eyes
tightly, and smile with teeth flashed.
Palpation: There are no lumps, bumps & depressions palpated.No nodules and masses found.
D.) EyesInspection: She said that her family has history of cataract eye problems but didnt know where
it started. She does not visit the ophthalmologist or takes in eye medications. She has used
contact lenses and frequently cleanses it with the solution during her stay in Korea year 2009.
She said that her eyes were a bit blurred by did not know the exact grade of her eyes. Her
eyebrows were evenly distributed, it is also similar in alignment as the other eyebrows. The eye
lashes were also evenly distributed and are all curled slightly upward. The upper and lower lids
has no presence of lesions. Both bulbar and palpebral conjunctiva is pink in color, smooth in
texture and also no presence of lesions. There are few capillaries visible when the client was
asked to look up, down and sideways both.In consensual reaction, the clients pupils both
constricted when the pen light was used. The clients trigeminal or 5th
cranial nerve was also
intact because she has corneal sensitivity when the tip of the cotton touched her cornea. Both
the clients pupils were black in color, rounded in shape and symmetrical in size. The cornea was
shiny and moist and also smooth.Accommodation was performed and the results were, the
clients pupils constrictedupon looking at a near object and when the client was asked to look at
a father object, both pupils dilated.Also when the penlight was moved near her nose, in the
middle, both pupils converged. The clients peripheral vision is also working. The light reflex fell
also symmetrically on both sides of the pupils. The client is able to read the newsprint when her
arms were stretched.
Palpation: The upper and lower lids has no masses and tenderness. There were also no
tenderness felt when the lacrimal gland, lacrimal sac and nasolacrimal duct were all palpated
and no tearing was visible.
E.) Ears and hearingInspection: There are no other family history of hearing problems and hearing loss except for old
age and there are no presence of ear problems and pain on the client. The auricle was inspected
and turned out to be light brown in color, symmetrical in location with the other which is
described as slightly elevated than both of the outer canthus of the eyes. Otoscope was used
and there are no presence of liquid or solid cerumen, the tympanic membrane was seen and
described as pearly grey. The client is able to hear the ticking of a second handed wrist watch
and also can hear a whisper behind her. Tuning fork were also used for Webers test which
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resulted negative because the client is able to feel the vibration and can hear equally the sound
with both ears and resulted to positivity in Rinnes test because the air conduction was greater
than the bone conduction; 8sec : 10sec.
Palpation: The auricles is elastic because it recoils back after it is pinned. There are no
tenderness when palpated through the ear area including the tragus.
F.) Nose and SinusesInspection: There are no allergies on the nose, has history ofdifficulty in breathing and was
brought in Manila Doctors Hospital (December 2010), no further injuries, nosebleeds,
medications and changes in sense of smell except when she has colds. The external nose were
low bridge, brown and smooth in texture, no discharge from the nares. The client has patency
on both nostrils when asked to cover one and breath to the other nostril and vice versa without
difficulty. The internal nose doesnt have any other discharge or drainages except for clear and
watery discharges, there are no redness, swelling and lesions. The nasal septum was located on
the middle of both nostrils.No lesions and is intact.
Palpation: No tenderness palpated on the external of the nose. There are also no tenderness nor
masses when the maxillary, frontal, ethmoid and sphenoid sinuses were palpated.
G.)Mouth and OropharynxInspection: The client doesnt have dental check ups. Her last visit according to her is when she
was still 9 years of age. There are also no presence of singaw.No dentures used and
medications of treatments. The outer lips are moist, no lesions, symmetrical, smooth and
pinkish brown in color. The inner lips are also smooth, lesion-free, no singaw and moist. The
teeth andgums were also intact and appears to be lesion-free. The tongue is positioned on the
center of the mouth and is pink in color with thin whitish coat.It has no lesions. The client is also
able to protrude and move sideways, her tongue without any difficulty. The lingual frenulum is
positioned on the center at the floor of the mouth and is intact with the tongue. There are no
presence of lesions or masses at the floor of the mouth. There are also no swelling or redness on
the gums. The hard palate is more pinkish than the soft palate which appears to be lighter in
pink shade. Both dont have lesions or other drainages or discharges. The soft palate is
smoother in texture than the hard palate. The uvula is also located on the center position, no
swelling or redness and lesions. The oropharynx is not inflamed and pink in color. The client also
has gag reflex.
Palpation: No tenderness was palpated on the tongue.
H.)NeckInspection: There are no presence of neck lumps, neck pain or stiffness, thyroid problems and
medications or radiations. The client also is able to move her head freely and both
sternocleidomastoid and trapezius muscles were functioning because the client is able to move
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her head towards the ches, then her ears near her shoulders on both sides which all determines
the function of the sternocleidomastoid muscle and is able to hyperextend the neck- that is, the
chin is pointedupwards which in turns, determines the function of the clients trapezius muscle.
The client is also able to resist by shrugging of her shoulder and facing to the left and right. The
thyroidglanddoesnt have visible masses and the client is able to swallow without difficulty.
There are also no enlargement of the thyroidgland.
Palpation: There are also no enlarged lymph nodes palpated and no tenderness and other
masses. The trachea is also located in the center of the neck, no masses were also palpated
when the client was asked to swallow.
I.) Thorax and lungsInspection: The client doesnt have history of cancer, Tuberculosis, and currently has no cough
and sneezing. The spinal alignment doesnt have abnormal curvatures. There is also smooth
respiration without obstruction. The breathing patterns were effortless and soundless
Palpation: The posterior thorax doesnt have tenderness and smooth anddoesnt have any
lesions. The vocal fremitus was equal in vibration.
Percussion:
Auscultation: The client is able to breathe clearly with no bruits upon auscultation.
J.) Heart/CardiovascularInspection: The client has heart disease as indicated on the Health management / health
perception pattern in Gordons. Her family also has high cholesterol levels, There is also history
of stroke, heart attack and heart failure. So far there are no presence of lifts or heaves on the
precordium.No jugular veins were visible at the side of the neck.
Palpation: The carotid artery has a thrusting quality in pulsations.
Auscultation: The s1 can also be heard louder on the aortic area and the s2 on the pulmonic.
There is also 56 heart beats per minute recorded.
II.) Personal history
Habits : Do the laundry, clean the house, care and Rank/Order in the family: second eldest
daughter
look out for her son, text, browse the internet, Travel : Korea (2019-2010)
watch tv and sleep. Educational attainment : High school
graduate
Vices : smoke cigarettes anddrink liquor
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Lifestyle : Active
Usual day: Working in the house or singing on a gig
Social affiliation: none
III.) Environmental History
She lives in Pandacan, Manila anddescribed her environment as magulo, maingay,
parati may nag-aaway kadalasan mag-asawa at malayo ang nilalakad ko bago ako makasakay sa
tricycle or jeep o kaya bus.
IV.) OB/GYNE HISTORY
Menarche (age) : 13 years old when: unrecalled
Amount and characteristics: heavy flow
during the secondday & darkish red in
color
Duration: 4-5 days
Deliveries :
G =
P =
OPERATIONS:
T =
P =
A =
L =
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