Você está na página 1de 3

STUDENT NAME: Najat Fanchaouy DATE: 11/14/09

Patient’s Initial: R.J

PATIENT’S MEDICAL DIAGNOSIS: First day postpartum


Age: 20

Development stage: Inferiority vs role confusion


Development tasks: Develops a concern, secure, unique sense of self, plans for carrier,
and value system.
Source of Information: Medical Records, and the patient.

Reason for Hospitalization: Scheduled Caesarian-Section

Past Health History: Abnormal Pap smear, (2008), IBS

I. Health Perception/Health Management Pattern:

R.J describes herself as talkative, outgoing person who likes being around people but
hates noisy environments. She is compliant with medications. She engages in healthy
activities such as regular walks and also gets annual checkups. She denies use of tobacco,
and drugs. She hopes that she will be able to care for her baby and family. Before
delivery she met with her obstetrician and understood her situation and the importance of
scheduling the caesarian-section. This changed her due date by 2 weeks

II Nutritional, Metabolic Pattern:

R.J is healthy. She uses to go to the gym three times a week before pregnancy; she eats
health rich diet... She knows that she needs to eat sufficient amounts of calcium, protein
and calories of food from the Food Pyramid.

III Elimination:

R.J voids freely. She didn’t her bowel movements yet. Bowel sounds are active.
IV Activity/Exercise Pattern:

Prior to hospital admission, R.J drove, cleaned the house, and cared for herself and her
family. She stopped working as a waitress at the cheese factory, and stopped going to
school. Prior to hospitalization she was very active with family obligation. She is on bed
because of surgical incision, but she able to accomplish all activity of daily living. She
enjoyed hair dressing; she spends three hour s a day in hair salon working as hairdresser.

V Cognition/Perceptual Pattern:

Pain level: Appears uncomfortable at this time (6/10)

• Alert and Oriented x 3.


• Spoke clearly
• Pleasant

VI Sleep Pattern:

R.J goes to bed at 10.00pm and wakes a 7:30am. She states that she had no problem with
sleeping prior to the hospital admission. R.J sleeps with one pillow, has no difficulty
breathing at night. Now she has troubles falling asleep because she states “I need to feed
the baby every 3 hours”

VII Role/Relationship Pattern:


• Client lives with husband.

VIII Sexuality/Reproductive Pattern:


• Gravida 1

IX Self Perception/Self Concept Pattern:


• Client had good eye contact.

X Activity exercise:
She enjoys swimming, walking in the Park

XI Self Perception/self Concept Pattern:


She had good eye contact
XII Cognitive/perceptual pattern
- Alert
- Spoke clearly
- Pleasant