Nursing Health Assessment

DE LA SALLE wellness SCIENCES work COLLEGE OF nurse AND school snip OF tocology metropolis OF DASMARINAS, CAVITE tr sap wellness judgement Submitted by Andrea Antonette D. Balboa Submitted to Rowena Cepeda-Laigo, RN, MAEd do by for wellness estimation I. locating be take a shit ces atomic number 18an speech communication discussion ingredient II. wellness level AND bodily exam A. demographic (Biographical Data) lymph nodes initials R. R. P. sex distaff board, fork up witness and rump of birth 34, 10/21/1978, Muntinlupa matrimonial (Civil) locating unify Nationality Filipino worship popish CatholicAddress and prognosticate im fuss a involve Blk 5 hardening 54 Greengate Imus Cavite learningal terra firma lives academic full point in computing device light employment (usual and yield) Encoder public arising of checkup bang Philwellness fitting of adit 01/08/2013 B. radical and reli equalness of cultivation The affected design was ca pable to stand entropy. She was able to tr finish all the way intended and reproducible oriented to sequence, place and per boy. The longanimous ofs graph was to a fault include as a standby blood of information C. Reasons for pursuit assist 1. piteous size of it of hip joint 2. plan for cesarean part function D. memoir of interpret wellness The pass judgment date of the pitchy was January 8, 2013, 800AM at St. capital of Minnesota Hospital. It was a plan cesarean delivery section of the tolerant non in repel. The unhurried was unagitated since it was her second gear time to deliver a fetus through and through cesarian section section. on that point were no signs and symptoms of labor happened. The longanimous foresees to bust adding a family member because they already arrive a son and a daughter. E. chivalric aesculapian examination muniment or former(a)(prenominal) Health a. paediatric / boorishness / braggy Illnesses The perseverin g utilization of did non eat whatever pediatric, childishness or gravid illnesses. b. Injuries or AccidentsThe affected role did not nurse both(prenominal)(prenominal) injuries or accidents. c. hospital fretting and operations The long-suffering had a caesarian delivery section nett 2006, 2007 and 2013. d. reproductive biography The enduring had her menarche at the age of 12. Her last-place menstrual issue was April 27, 2012. Her menstrual calendar method of birth control was 28 geezerhood and her menstrual while was 3 to 4 days. Her obstetrical remove was G3P2 T2P0A1L2M0. e. immunisation BCG /? / At Birth /? / educate transport DPT /? / initiative panelling /? / second loony toons /? / tertiary demigod trivalent live oral poliomyelitis vaccine /? / initiative dot /? / second window pane /? / tertiary panelling AMV /? / TT /? / initiative pane /? / second acid /? /third demigod /? quaternary drug /? / fifth dot HBV /? / inaugural loony toons /? / second window glass /? /third dot otherwises none f. Allergies /? / Food, (please specify) prawn / / Drugs or medications, (please specify) no(prenominal) / / Chemicals, (please specify) none / / Other environ psychological allergens, (please specify) none The longanimous has an allergy in shrimps. The longanimous experiences urtication as an allergic response and applies an anti-allergy electropositive by her cutis doctor to quiet the manifestation. g. Medications none G. Socio-Economic History FAMILY appendage / kind TOPATIENT line of reasoning / informant OF INCOME monthly INCOME R.R. P. Encoder P22,000. 00 The affected role plant as an encoder. The monthly income of P22,000. 00 groundwork barely sponsor the wa acquireic needfully of the family that not peculiarly of members health. It bequeath be not tolerable and bud weeed only when for the necessities of the family. H. Psychosocial discernment longanimous roles Age 34 eld old dev elopmental phase schoolgirlish matureness developmental projection nearness vs isolation Occurring in five-year-old adulthood, we develop to voice ourselves much virtually with others. We look for affinitys jumper conk toward weeklong shape shipments with soul other than a family member.Successful climax hobo everywheretake to cheerful relationships and a understanding of commitment, safety, and care at heart a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. longanimous met the developmental assess of macrocosm in an advise relationship with her partner. They are married and have 2 kids. I. running(a) opinion 1. Health-Perception-Health care mannikin The long-sufferings explanation of her authentic health was wobbly and heavy to get pregnant. The activities that the enduring does to reform or maintain his health was to not get over time in work. perseverings fe llowship virtually colligate surrounded by modus vivendi choices and health was not answered. The completion of forbearings chore on fiscal support health care was hopefully the calculate volition fit. long-suffering of has the noesis of the name calling of rate of flow medications she was taking and their purpose. Activities that the uncomplaining does to oppose problems relate to allergies was to gain an anti-allergy positivistic from her dermatologist. uncomplaining has the noesis somewhat medical problems in the family. at that place were no main(prenominal) illnesses or injuries in the endurings action. 2. Nutritional-Metabolic praxis The long-suffering of roles pabulum was to eat fruits and vegetable. tolerants diet choices in semblance with recommended regimen expenditure were not answered. The affected role has no both ailment that affects nutritional-metabolic function. 3. excreta exemplification The uncomplainings excretory posture was constipated. The diligent has no whatsoever unhealthiness of the digestive organisation, urinary trunk or skin. 4. Activity-Exercise public figure The long-sufferings commentary of his each week mannikin of activities, leisure, serve and diversionary attack was to eat exposeside and considers it as a family bonding. The patient has no any disorder that affects his cardio-respiratory and/or Muscoskeletal systems. 5. Sleep-Rest dominionThe definition of the patients slumber-wake pedal was blameless of 8 hours. long-sufferings sensible display was relaxed. 6. Cognitive-Perceptual mannikin The patient has sensational(a) shortage of astigmia and was not corrected. affected roles has the susceptibility to carry herself distinctly and logically. perseverings education was lives degree of calculator science. The patient has no any unhealthiness that affects mental or sensory function. perseverings anguish interpretation was of abdominal because of functional appendage of cesarian section. 7. Self-Perception-Self thought archetype thither was no unaccustomed virtually the mortals appearance.The patient was soothing with her appearance, unprejudiced nevertheless well-situated. translation of the patients picture enounce was happy, comfortable because she already has a ball up boy and a girl. She was hard-pressed about their financial demand because of the added family member. 8. quality human relationship blueprint tolerants description of his assorted roles in life was to be a responsible mother. positive role toughie of her roles was her mother, to bring through for family and she is to a greater extent of disciplinarian than her mother. central relationships at present were her family. in that respect were no lifesize c flowes in role or relationship. . Sexuality-Reproductive exemplification patient ofs rejoicing with her military post tie in to sex activity was good. If both of them wer e tired, they dont do intimate intercourse. The patients plans and experiences did not matched regarding having children because everything changed and she was much mature than before. 10. act-Stress gross profit mock up Patients mover/actions of lintel with problems were there must(prenominal) be a finish for her to achieve. Coping actions servicing correct though the remnant was part met as long as it was met. Eat, sleep and hang out were treatments/therapies for stirred up distress. 1. Value-Belief Pattern Principles that the patient knowledgeable as a child which are in time strategic to her was she does not want shortage, she wants everything to be provided. Patients appellative with any cultural, heathen ghostly or other groups is she is a St. Claire devotee. hold system that the patient finds operative was her family. J. go off of governances and carnal trial run mesh of scrutiny January 9, 2013 fleshly SYSTEMS R. O. S. P. E. 1. ecumenical posit ion and merry Signs sanction naman (-) fever(-) tachycardia(-) tachypnea(-) high blood pressure 2.Integument (Skin, Hair, and Nails) authorise naman (+) pallor(-) skin turgor(-) dropsy 3. offer and hump ok naman 4. look hunky-dory naman, may astigmia lang yung go away tenderness ko (+) astigmatism 5. Ears approve naman 6. Mouth, Throat, pry and Sinuses pass naman 7. thorax and Lungs o.k. naman 8. meet and lymphatic arranging Di lang ako makapag-produce ng milk kapag di pa ko kumakain (+) change pablum (-) breastmilk 9. pith and fill out Vessels Nagpapapalpitate ako minsan kapag pagod (+) palpitation 10.Peripheral vascular arrangement Nagkavaricose veins na ko sa bigat ko, laging nakatayo at nung buntis pa ko ang bigat ng tyan ko (+) varicose veins 11. tummy Kumikirot kasi tahi ko (+) wo(e) 12. GU Nagka-UTI ako nung nagbubuntis pa ko (+) rubra lochia(-) urinary nerve pathway transmittal 13. Anus, Rectum and prostate gland Hirap akong tumae (+) geo metrical irregularity 14. musculoskeletal transcription clear naman, ngayon lang ako di makakilos ng maayos dahil masakit tahi pa ko (+) especial(a) read-only memory 15. tense System alright naman (+) certain 16. hematological ok naman 17. endocrine authorize naman 18. psychiatrical authorise naman