P.E.R.S.O.

N
GENERAL APPEARANCE
January 20, 2019: January 22, 2019

A pregnant woman on her 40’s arrived at OB-ER ambulatory. She seems upset
as evidence by eye lack luster, and facial grimace and a guarding behavior on
her right abdominal upper quadrant. Her hair was tied into bun but quite messy
because of loose strands her on her face, and was wearing appropriate clothes
for the weather.
Patient was seen lying on bed, on Moderate High Back Rest, with an ongoing
IVF of D5LR 1L to run for 8hours regulated at 30-31gtts/min at 500ml level
inserted aseptically on her left dorsum or dorsal hand using gauge 20 IV
cannula, patent and infusing well. She has a facial grimace and with presenting
guarding behavior on her abdomen. Her hair was tied into bun, and wearing
appropriate clothes for the weather (t-shirt, pajama, socks)

PAIN ASSESSMENT: PAIN ASSESSMENT:

Character: Character:

 Squeezing pain  Sharp pain

Onset: Onset:

 January 20, 2019; sudden  Post-Operation (January 21, 2019)

Location: Location:

 RUQ  Pain from incision

Duration: Duration:

 Continuous pain and getting worse when moving, or doing physical  Continuous pain and getting worse when moving, or doing physical
activities such as walking. activities such as walking.

Severity: Severity:

 Using the Universal Pain Assessment Tool, the scale is 8/10-Severe;  Using the Universal Pain Assessment Tool, the scale is 6/10-Moderate;
The pain is quite intense and is causing the patient to avoid, or limit Interferes her concentration, and felt uncomfortable
physical activity, also, cannot concentrate on anything except pain.
Pattern:
Pattern:
 Moving makes it worse, and relieved, when lying on bed and controlled
 “Kapag gagalaw ako sumasakit, pero kapag nagpapahinga ako when given pain medication.
nababawasan yung sakit.”
Associated factors:
Associated factors: The pain affects:

 The pain affects the activities of the patient at home, “Ang sakit po,  “Hindi kasi ako masyadong makatulog dito sa hospital at
hindi nga ako nakapagluto ng baon para sa maga anak kong papasok nararamdaman ko pa rin yung sakit dito sa tyan ko kapag gabi lalo
ng school kasi pumunta na agad ako dito.” kapag gagalaw ako, hindi ako komportable.”

 20-25 minutes of sleep disturbance

 (total 4hrs of sleep with interruption)
 PSYCHOSOCIAL
PRE-ASSESSMENT POST-ASSESSMENT PATHOLOGICAL BASIS RESEARCH

Date: January 20, 2019 Date: January 22, 2019

FAMILY
Type: Nuclear Family
Rank: Mother

Religion: Roman Catholic

SIGNIFICANT OTHER Patients are more compliant with

physicians' orders and more satisfied
Age: 40y/o with the care they receive from those
physicians when their family and
Relationship: Husband
friends are effectively involved in their
care management. (source:
sk.sagepub.com)
FINANCIAL RESOURCES
Educational Attainment: High
School
Occupation: Restaurant Cashier

Primary Source of Health: Income

MOOD and AFFECT:
 Patient was able to express a
wide variety of affects to
display sadness, excitement,
happiness, fear,
embarrassment, etc, and
 appropriately responds to any
type of stimuli.
SPEECH:
Dialect: Tagalog/Ilocano

Observations: She speaks in a

modulated voice

COPING MECHANISM:
 Problem Focused

Patient complies to all instructions of

the doctor.
ORIENTATION: Depression, and anxiety both affects
 Patient was well-oriented as immediate, and recent memory but
evidence by awareness of the not the remote memory. (source:
date, time, and place asked by researchgate.net)
the student nurse.
 Memory was intact as
evidenced by accurate
answers such as:

Immediate: “Nagb-breastfeed
Immediate: “Anong oras po
po kayo?”
kayo dinala rito?”
Recent: “Sino po yung nasa
Recent: “Kelan po kayo unang
tabi niyo nung nagising po
nakaramdam ng pananakit sa
kayo?”
may tiyan?”
Remote: “Naaalala niyo pa po
Remote: “Saan po kayo
ba kung kailan namatay ang
unang nagkakilala ng asawa
lolo ninyo?
ninyo?”
 ELIMINATION
PRE-ASSESSMENT POST-ASSESSMENT PATHOLOGICAL BASIS RESEARCH

ABDOMEN:
Contour: Protruding Contour: Protruding
Fundal height: 32 cm Fundal height: Umbilicus level

 Firm fundus

Incision: 13cm (horizontally/low

transverse cs)

STOOL Consistency: Formed

 Not assessed Color: Brown
Frequency: 1x

URINE: URINE: Due to decreased blood flow to the Any amount of protein in your urine
Second-void sample Hooked to IFC Kidney, which caused temporary over 300 mg in one day may indicate
 Color: Dark Yellow  Color: Amber glomerular damage, will resulted to preeclampsia. However, the amount of
 Clarity: Cloudy/Foamy  Clarity: Slightly foamy spilling of protein to the urine. (source: protein doesn't define how severe the
 Amount: 60ml  Amount: 100ml preeclampsia.org and YY: Osmosis) preeclampsia is or may get.
 Protein 1+ = 30 mg/dl  Trace = 10 mg/dl (source: preeclampsia.org)
 REST AND ACTIVITY
PRE-ASSESSMENT POST-ASSESSMENT PATHOLOGICAL BASIS RESEARCH

SLEEP Characteristics: Interrupted sleep “Hindi kasi ako masyadong makatulog

 Not assessed Total hours of sleep: 4 hours dito sa hospital at nararamdaman ko
pa rin yung sakit kapag gabi lalo kapag
 Presence of eye bags gagalaw ako, hindi ako komportable.”
 Lack of concentration

Due to patient’s uncomfortable

environment, and pain from incision.

ACTIVITY Walking, taking the stairs, and even It is highly recommended that bed rest
Current Activity: lifting or moving supplies will all cause or the restriction of other physical
ADL’s: the blood pressure to increase. activity not be used for the primary
 Bathing – 2  Bathing – 0 prevention of preeclampsia and its
 Dressing – 2  Dressing – 0 complications. (source:
 Toileting – 2  Toileting – 0 Hypertensioninpregnancy)
 Transferring – 3  Transferring – 0
 Feeding – 0  Feeding – 0
Bed rest, therefore, is the best method
of aiding increased evacuation of
BODY FRAME: sodium and encouraging diuresis.
POSTURE: Not assessed POSTURE: Fair Rest should always be in a lateral
GAIT: Not assessed Head forward, abdomen prominent, recumbent position to avoid uterine
exaggerated curve in upper back, and pressure on the vena cava and prevent
slight hallow back. supine hypotension syndrome.
GAIT: Normal gait
 Patient was able to do a heel strike
and toe off in one gait cycle, stance
and swing were properly observed.
(source: iBody academy)
(source: Pillitteri, A. (2010). Maternal
and Child Health Nursing: Care of the
Child Caring and Childrearing Family 6th
Edition. Philadelphia: Lippincott Williams
& Wilkins)

MUSCLE In most cases, bed rest is used to give

Strength and Tone: the body it's best chance to normalize.
 Right Arm – 5 Bed rest will be used with women who
 Right Leg – 5 have conditions related to high blood
pressure in order to decrease stress
 Left Arm – 5
and lower blood pressure. It may also
 Left Leg – 5
be necessary to help increase blood
flow to the placenta. (source:
Patient scored 5 in each extremity
americanpregnancy.org)
which means that she can respond
against full resistance, while the
muscle tone was firm.

Tremor: None

ROM’s:
Patient participated in all of the ROM
exercises instructed by the student
nurse.

Arms: Patient can extend both arms

Elbows: Full resistance
Wrist:
Hands and Fingers:
Knee: Patient can extend, or flex both
knees
MOTOR FUNCTION:
Fine: Patient can type, and send
messages through cellular phone.
She can also use pen to write her
name when the student nurse asked
her to.

Gross: Not assessed Gross: Patient was able to walk from

bed to the bathroom.

SAFETY AND ENVIRONMENT

PRE-ASSESSMENT POST-ASSESSMENT PATHOLOGICAL BASIS RESEARCH

ALLERGIES
Food: None
Medication: None
Environment: None
Eyes: PRE-ASSESSMENT: POST-ASSESSMENT:
 PERRLA not assessed due to
patient’s visual disturbance Due to high blood pressure of the Since patient is still monitored for any
(blurred vision) patient, the retina’s vessels were residual hypertension, and pregnant
affected that caused visual who has PIH during pregnancy and will
disturbance (blurred vision). eventually subside after 6 weeks, it is
 Patient doesn’t use any eye
suggested that sudden stimulation
glasses. (source: webmd.com and YT: Osmosis) such as shining a beam of flashlight for
assessment is to be avoided to prevent
seizure.
 (source: Pillitteri, A. (2010). Maternal
and Child Health Nursing: Care of the
Child Caring and Childrearing Family 6th
Edition. Philadelphia: Lippincott Williams
& Wilkins)

Nose:
 There were no lesions, and
unusual secretion noted.
Mouth:
 There were no lesions, and
unusual secretion noted. Lips
were chapped, and no sign of
cyanosis.
Ear:
 There were no lesions, or
unusual secretion noted on
both ears. Patient doesn’t
wear hearing aid.

 Patient was able to answer in

a low tone questions.
 OXYGENATION
PRE-ASSESSMENT POST-ASSESSMENT PATHOLOGICAL BASIS RESEARCH

RESPIRATION RESPIRATION
 Rate: 24  Rate: 20
 Rhythm: Regular
oscillating cycle of inspiration
and expiration
 Depth: Normal
NAIL:
 Color: Pink
 Capillary Refill: More than 2
second
PERIPHERAL PULSE:
 Rate: 95  Rate: 76

SKIN INTEGRITY: Edema:

Patient has a brown skin and a few Patient has a 13cm incision with a 15 This extra retention of fluid is needed
scars on her arm like oil burn scar. on the abdomen from C-Section to soften the body, which enables it to
She also has minimal pimple scar on delivery. expand as the baby develops. Extra
both cheeks.  Intact Dressing fluid also helps prepare the pelvic
joints and tissues to open for delivery.
 Lateral Transverse
Temperature: 37 C The extra fluids account for
Route: Axilla approximately 25% of the weight
women gain during pregnancy.
EDEMA: Temperature: 36.2 C (source: americanpregnancy.org)
  Patient has a non-pitting Edema is no longer included as a
edema on both lower diagnostic criterion for preeclampsia,
extremities although it is often present, as it is an
expected occurrence in pregnancy and
has not shown to be discriminatory.
(source: Disease and Disorder: A Nursing
Therapeutics Manual)

NUTRITION
PRE-ASSESSMENT POST-ASSESSMENT PATHOLOGICAL BASIS RESEARCH

HOSPITAL DIET: HOSPITAL DIET: It is suggested that weight loss, and

 NPO  Clear liquid to Soft Diet extremely low sodium diets (less than
100 mEq/d) not be used for managing
chronic hypertension in pregnancy.

(source: Hypertensioninpregnancy)

Gag Reflex:
 Intact
FLUID I and O: FLUID I and O:
–within shift –within shift
 I: 850ml  I: 1L
 O: 480ml (approximately)  O: 600ml (approximately)
 Lochia:

 Rubra
 From 7-3hrs duty:
3 maternity pads

SKIN TURGOR:
 Skin goes back immediately
after 1-2 second.
IVF: D5LR x 8hrs IVF: D5LR x 8hrs For fluid and electrolyte replenishment
Site: Left Dorsal and caloric supply in a single dose
container for intravenous
administration.

HEIGHT: 5’5 WEIGHT: 57.1 A BMI of 18.5-24.9 is considered

WEIGHT: 61 BMI: 21 normal; 25-29.9 is considered
BMI: 22.43 overweight; 30-39.9 is classified as
 Mesomorph obese; and over 39 is very obese. If
you have A BMI of below 18.5, you are
thought to be underweight. Being
underweight in pregnancy can make
you more likely to give birth
prematurely, or have a "small-for-
dates" baby. (source:
familyeducation.com)

BMI = kg/m2