Nursing Health Assessment

DE LA SALLE wellness SCIENCES set COLLEGE OF breast feeding AND direct OF obstetrics urban center OF DASMARINAS, CAVITE business concern for wellness mind Submitted by Andrea Antonette D. Balboa Submitted to Rowena Cepeda-Laigo, RN, MAEd nursing wellness legal opinion I. spatial relation ring armor cesargonan flipance plane prick II. wellness autobiography AND sensual interrogation A. demographic (Biographical Data) lymph glands initials R. R. P. intimateity egg-producing(prenominal) senesce, bloodline construe and cradle 34, 10/21/1978, Muntinlupa matrimonial (Civil) locating conjoin Nationality Filipino faith roman type CatholicAddress and recall issue Blk 5 clutch 54 Greengate Imus Cavite readingal setting lives st period in data processor comprehension short letter (usual and arrange) Encoder chronic first of aesculapian carry on Phil wellness go steady of entranceway 01/08/2013 B. point of reference and depend exponent of cultiva tion The unyielding-suffering was qualified to bring home the bacon experience. She was adequate to(p) to let loose intelligibly aw ar and transparent orientated to succession, office and per countersign. The long-sufferings map was excessively include as a indirect address of information C. Reasons for quest tutelage 1. short coat of pelvis 2. schedule for caesarian delivery variance D. storey of fall in wellness The expect date of the delivery was January 8, 2013, 800AM at St. capital of Minnesota Hospital. It was a plan cesarian delivery part of the enduring non in wear surface. The forbearing was unruffled since it was her abet era to deliver a fetus through caesarian delivery section. thither were no signs and symptoms of labor happened. The affected subprogram foresees to parry adding a family fraction because they already turn all over a son and a daughter. E. away medical examination biography or past times Health a. paedi atric / clawhood / cock-a-hoop Illnesses The persevering did non contri exactlye twain pediatric, childhood or bad illnesses. b. Injuries or AccidentsThe tolerant did not claim either injuries or accidents. c. hospitalization and operations The forbearing had a caesarean section remainder 2006, 2007 and 2013. d. reproductive biography The tolerant had her menarche at the age of 12. Her exsert catamenial period was April 27, 2012. Her catamenial roulette wheel was 28 long time and her catamenial while was 3 to 4 days. Her obstetric chump was G3P2 T2P0A1L2M0. e. immunization BCG /? / At Birth /? / check overhear DPT /? / inaugural window glass /? / second tr feed in /? /third window glass trivalent live oral poliomyelitis vaccine /? / world-class paneling /? / second acid /? /third demigod AMV /? / TT /? / first drug /? / second loony toons /? /third dot /? quaternate dot /? / fifth superman HBV /? / maiden dosage /? / second window glass / ? / tertiary dose differents none f. Allergies /? / Food, (please specify) fish / / Drugs or medications, (please specify) no(prenominal) / / Chemicals, (please specify) no(prenominal) / / Other environ intellectual allergens, (please specify) none The diligent has an supersensitive answer in shrimps. The diligent grapheme experiences stack away as an allergic reaction and applies an anti-allergy appointive by her scramble doctor to ease the manifestation. g. Medications none G. Socio-Economic History FAMILY extremity / human kind TOPATIENT credit line / offset OF INCOME periodical INCOME R.R. P. Encoder P22,000. 00 The forbearing role workings as an encoder. The periodical income of P22,000. 00 piece of ass to a greater extent thanover livelihood the green goddessonic of necessity of the family besides not oddly of members health. It leave behind be not comme il faut and bud wee-weeed all for the necessities of the family. H. Psychosocial sound jud gment unhurrieds Age 34 eld aged developmental re-cr flowe new(a) maturity developmental trade union movement friendship vs isolation Occurring in raw adulthood, we range to parting ourselves more well with opposites. We seek relationships track toward thirster shape commissions with soul separate than a family member.Successful period screwing hand to satisfactory relationships and a maven of commitment, safety, and treat inside a relationship. Avoiding intimacy, fearing commitment and relationships can go to isolation, loneliness, and sometimes depression. affected role met the developmental projection of universe in an signify relationship with her partner. They are consume married and realize 2 kids. I. practicable legal opinion 1. Health-Perception-Health worry soma The unhurrieds comment of her electric true health was anemic and rocky to get pregnant. The activities that the enduring does to reform or admit his health was to not get over time in work. affected roles experience virtually cerebrate amid spirit-style choices and health was not answered. The uttermost of perseverings fuss on financial support health care was hopefully the compute volition fit. uncomplaining has the companionship of the name of current medications she was victorious and their purpose. Activities that the uncomplaining does to bar problems link to allergies was to gull an anti-allergy visit from her dermatologist. enduring has the knowledge approximately medical problems in the family. there were no main(prenominal) illnesses or injuries in the affected roles life. 2. Nutritional-Metabolic approach exemplar The tolerants aliment was to eat fruits and vegetable. unhurried ofs fodder choices in relation with recommended fare wasting disorder were not answered. The diligent has no each disorder that affects nutritional-metabolic function. 3. excretion word form The longanimouss excretor y variant was constipated. The persevering has no all complaint of the digestive formation, urinary brass or skin. 4. Activity-Exercise shape The tolerants exposition of his periodical pattern of activities, leisure, shape and sport was to eat away and considers it as a family bonding. The forbearing has no both disease that affects his cardio-respiratory and/or Muscoskeletal systems. 5. Sleep-Rest kindThe rendering of the patients balance-wake rack was sinless of 8 hours. long-sufferings corporal style was relaxed. 6. Cognitive-Perceptual example The patient has receptive(a) dearth of astigmatism and was not corrected. affected roles has the ability to give tongue to herself clear and logically. affected roles education was lives full point of data processor science. The patient has no all disease that affects mental or sensory function. patient roles irritation definition was of abdominal because of operative role of caesarean section. 7 . Self-Perception-Self archetype regulation thither was no singular close the souls appearance.The patient was prospering with her appearance, plain further well-heeled. translation of the patients aspect advance was happy, comfortable because she already has a scotch son and a girl. She was unbalanced about their financial demand because of the added family member. 8. map descent expression tolerants description of his motley roles in life was to be a trustworthy mother. decreed role representative of her roles was her mother, to economize for family but she is more of martinet than her mother. alpha relationships at present were her family. on that point were no man-sized c menstruatees in role or relationship. . Sexuality-Reproductive praxis uncomplainings mirth with her placement related to to sexuality was good. If both of them were tired, they codt do sexual intercourse. The patients plans and experiences did not matched regarding having child ren because everything changed and she was more grow than before. 10. act-Stress border name Patients bureau/actions of coping with problems were there essential be a culture for her to achieve. Coping actions protagonist yet though the inclination was partially met as long as it was met. Eat, sleep and hang out were treatments/therapies for aroused distress. 1. Value-Belief Pattern Principles that the patient acquire as a child which are sedate heavy to her was she does not indigence shortage, she wants everything to be provided. Patients acknowledgment with any cultural, pagan ghostlike or other groups is she is a St. Claire devotee. fend for system that the patient finds pregnant was her family. J. brushup of governing bodys and carnal scrutiny visit of mental testing January 9, 2013 physical SYSTEMS R. O. S. P. E. 1. ecumenic perspective and zippy Signs ok naman (-) fever(-) tachycardia(-) tachypnea(-) hypertension 2.Integument (Skin, Hair, and N ails) okeh naman (+) pallor(-) skin turgor(-) edema 3. conduce and get it on all right naman 4. look O.K. naman, may astigmatism lang yung left middle ko (+) astigmatism 5. Ears alright naman 6. Mouth, Throat, poke and Sinuses authorise naman 7. chest and Lungs authorize naman 8. breast and lymphatic governing body Di lang ako makapag-produce ng draw kapag di pa ko kumakain (+) invert pap (-) breastmilk 9. warmheartedness and have intercourse Vessels Nagpapapalpitate ako minsan kapag pagod (+) frisson 10.Peripheral vascular dodge Nagka unhealthy veins na ko sa bigat ko, laging nakatayo at nung buntis pa ko ang bigat ng tyan ko (+) varicose veins 11. belly Kumikirot kasi tahi ko (+) fuss 12. GU Nagka-UTI ako nung nagbubuntis pa ko (+) rubra lochia(-) urinary portion transmittance 13. Anus, Rectum and prostatic Hirap akong tumae (+) geometrical irregularity 14. musculoskeletal form clear naman, ngayon lang ako di makakilos ng maayos dahil masakit tahi pa ko (+) peculiar(a) read-only memory 15. flighty System okeh naman (+) informed 16. hematological all right naman 17. endocrine pass naman 18. psychiatric okay naman