II. NURSING ASSESSMENT A. BIOGRAPHIC DATA Name: Patient A.R.

S Address: Bunga Menor, Bustos Bulacan Age: 320 years old Sex: Female Race/ Ethnic Origin: Asian Civil Status: Married Occupation: Housewife Religion: Iglesia Ni Cristo Educational Attainment: Bachelor of Science In Business Management Admission Diagnosis: G2P135-36 wks AOG prev. CS, dysfunctional labor arrest in cervical dilatation (4cm) and descent Principal Diagnosis: G2P2 PU delivered PU via LTCS II to an alive baby boy with BW of 3.2 kg Date of Admission: April 25, 2012 Time: 7:10 am Date of Discharge: April 26, 2012 Date of Operation: April 25, 2012 Time started: 9:06am Time ended: 11:15am Health care financing and usual source of medical care: Government & Relatives B. CHIEF COMPLAINT Pumutok na yung panubigan ko, medyo humihilab na din, as verbalized by the patient. C. HISTORY OF PRESENT ILLNESS Pt. A.R.S is 36 weeks pregnant. During April 25, 2012 2:00 am the patient experienced rupturing of her bag of water, she also experienced some abdominal cramps but she ignores it and sleep again. But at 4:30 am she was awaken by an on and off uterine contraction which bother her to go to melverey maternity and general hospital for consultation. Upon consultation her ob discovered that she has dysfunctional labor arrest. Her ob learn that she also had previous CS in santo.nio hospital in her elder 8 years ago. Thats the time she decided for pt. A.R.S to undergo CS to help her deliver safely. She was sent to the operating room at 8:00 am and the operation starts at 9:06 in the morning and lasted for about 1 and a half hour. After the surgery, she was monitored q15 for 1 hour once in the room, and q30 after an also an hour.

Upon handling patient A.R.S(April 26, 2012) a day after her surgery the client actively participates in the interview and cooperates when needed. Upon interview she said that in the 4th month of her pregnancy she had hemorrhoids. She consulted a physician and prescribed her to take balsakonin once a day and daflor 500mg once a day. On the same day the client was discharged with take home medications that includes mefenamic acid -500 mg q 6 for 7 days, Bisacodyl-15 mg once a day, Methergine 200 mcg q8 for 7 days and Ascorbic acid- 500mg/day for 2 weeks. She was advised to go back for follow-up check-up on May 3,2012.

D. HISTORY OF PAST ILLNESS Pt. A.R.S had a previous CS to her son. Upon interview she said that she completed her vaccine of tetanus toxoid ( TT1,TT2,TT3,TT4). She said that she had undergone CS because she is afraid of the pain she may experience if she will go NSD. She stated that she completed her immunizations when she was still a child. These immunizations include: BCG, DPT, MMR and Hepa B vaccines. When she has a fever, she usually just buys Biogesic from a drugstore and does not seek any medical advice / consultation. The client also stated that she does not have any allergies; denies having blood transfusion in the past and does not experience injuries. She also said that her family practices self-medication, having and taking OTC Drugs. She does not believes in Albularyo and Hilot she said that this practices are not allowed in their religion.