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Name: Sanaani, Yuseph Crispe Awang Clinical Instructor: Marry Ann S. Mendoza, RN MAN

Year and Section: BSN-2B Date: August 27, 2014

I. Clients Profile:

Name: Momo, Hazel Joy Ollamina

Address: Claret Lane, San Jose Z.C.Age: 22 years old

Sex: Female

Civil Status: Single

Occupation: Business Manager

Ethnic Group: Bisaya

Dialect: Bisaya

Religion: Roman Catholic

Chief Complaint: For CS

Medical Impression: PU 38 weeks AOG

Pre-ecclampsia with cardiac problem

II. 11 FUNCTIONAL PATTERNS

1. Health PerceptionManagement Pattern

The client verbalized that shes experiencing pre-ecclampsia with cardiac problem. She

also told me that she was admitted three times in the past because of high blood pressure and

her heart problem, her last admission was on January, 2012. Also, when she was seventeen

years old she was on the line for an operation but she refused to. She also verbalized that there

is a history of hypertension in her family and that they also dont practicevices. She also said

that she doesnt do regular check ups.

2. NutritionalMetabolic Pattern

The client verbalized that their daily meal are composed of rice, vegetable, fish and

Sometimes canned goods. They also eat fruits and sometimes meat. As of now she is only

Required to have a soft diet and water only no softdrinks.

3. Elimination Pattern

The client verbalized that she defacates irregularly since she was confined but voids

voids regularly. She also doesnt use any laxatives nor devices to help her defacate.

4. ActivityExercise Pattern

The client verbalized that the only exercise she does is walking. She spends her time

surfing the internet when she has free time.

5. SleepRest Pattern

The client verbalized that before, she sleeps for minimum of 8 hours, now due to her

present condition she has now difficulty in sleeping even though there is no disturbance in her

sleep.

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6. CognitivePerceptual Pattern

The client verbalized that she can hear without difficulty and that she also has no

problem with her eyes but her mother has problem with vision, wears eyeglasses and has

check-ups.

7. Self-perception Self-concept Pattern

Client stated that she is quite confident about herself and got no problems interacting with others. client

has been affected with a cardiac problem when she was still young and she believes that this made her strong

as a person, she states that she cant do heavy physical activities because of her condition but now in the

present wherein she has pre-eclampsia she feel much more helpless, but not hopeless

8. Role-relationship Pattern

Client stated that they are a nuclear family. They are 4 in the family and have good

relationships with each other. They speak bisaya at home. She said that her dad is a

construction worker, while she helps managing their present business on construction and

supplies, her mother helps at home and a sibling of her is now a graduating student of

Civil Engineering. Her mother is the one taking care of her now.

9. Sexuality

Client verbalized that she has a regular and normal menstruation period.

10. CopingStress Tolerance Pattern

The clients mother verbalized that the client sleeps around 10:00 am and she is not allowed to do work.

11. ValueBelief Pattern

They embraced the roman catholicism, the mother of Hazel verbalized that Hazel refused to undergo

operation for her heart when she was still 17 years old because she believes that if it's her time to die then

she can't do anything anymore.

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III. PHYSICAL ASSESSMENT

Head:

shape - has a symmetrical head shape

hair - the clients hair color is black, the hair is evenly distributed.

scalp - patients scalp is lighter than her skin

Face:

eyes - has evenly distributed hair eyebrows, symmetrically aligned, has equal movement, sclera

appears to be white and clear, has no eye problem.

ears - has redness of ear pinna, no hearing problem.

nose - the nose is in the midline, has no discharges.

oral cavity - teeth are white to yellowish in color , tongue is pink

others - has symmetrical facial movements

Neck:

Chest and Breast:

Back:

Abdomen: under recovery due to CS

Upper and Lower Extremities: proportional , weakened

Genitalia:

a. Physiologic examination

Central Nervous System

level of awareness - the client is slightly drowsy.

attention deficit - the client doesnt maintain eye contact with the interviewer while

interviewing.

communication

verbalok, audible and understandable

non-verbalcant move that much

coordination -

2. Special Senses

auditory perceptionnormal, patient can hear us clearly

pupillary perception -

speech perceptionpatient can speak clearly

gustatory perception -

visual performancepatient is slightly dizzy

tactile perception -

olfactory perception -

3. Respiratory System - The clients respiration rate is 23 beats/min

4. Cardiovascular System

heart rate, rhythm, depth - The clients pulse rate is 84 beats/min

blood pressure - the clients BP is elevated to 150/85

5. Nutritional Status

skin - the clients skin color is light brown, has lesions ,has tears and lacerations, Has

edema.

mucous membrane -

nails -

height - weight-

temperature - the clients temperature is 36.8 degree Celcius.

6. Elimination Statusbowel is not regular, voiding is at normal frequency (after meals)

7. Motor Ability Statusgait is not good because patient is experiencing pain in her abdomen,

posture is unstraight also because of same reasons, body movement is slow paced.

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b. Laboratory and Diagnosis Test Results

ECG -

2D Echo -

Ultrasound -

Blood Chem-

CBC with blood typing -

HBS Ag -

Urinalysis -

Sodium- Potassium -