V.Assessment Tool I.

GENERAL INFORMATION Name: Racoma, Jovi Age: 40 Birthday: July 16, 1972 Civil Status: Married Sex: Female Religion: Roman Catholic Occupation: Housewife Income: None Address: Zone 7, Agusan, CdeOC Informant: Patient Relation: Not applicable Admission Date/Time:9/5/12, 7:00am Chief Complaint: Labor pains, headache Attending Physician: Dr.Bajan Diagnosis/Impression: Pregnancy Uterine Full Term (41 weeks AOG) Vital Signs: HR: 76bpm RR: 23 breaths/min BP: 120/80mmHg Temp: 36.1C O: NA Ht: 48 ft. Wt: 40 kg III. PAST OBSTETRIC/MEDICAL/SURGICAL HISTORY Illness None None Date II. HISTORY OF PRESENT ILLNESS: Patient experienced labor contractions accompanied by abdominal and pelvic pain 10 hours prior to delivery. Current Medication: Name, dose, timing, route Cefalexin, 500mg, q8h, po Mefenamin Acid, 500mg, q8h, po Indication Antibiotic for GU tract infection Pain reliever (mild to moderate pain)

IV. HISTORY OF FAMILY ILLNESS (check illness that applies) Hypertension: CVD:NONE Kidney Disease:NONE Cancer:NONE NONE CAD:NONE Diabetes Mellitus: NONE Tuberculosis:NONE Others:NONE

Actual Date of Delivery: 09/05/2012 Time: 9:45 am Last Menstrual Period: 11/23/2011 Type of Delivery: NSVD Position of Fetus: Cephalic Complications During Labor: None Onset &Duration of Labor: 6 hours & Spontaneous Infants AGPAR Scores: Girl-9 Plans for Feeding: Breastfeeding for the first 6 months VI. GYNECOLOGIC HISTORY Age of Menarche: 16 years old Menstrual Cycle: Interval: 28 days Duration: 5 days Menstrual Discomforts: None Vaginal Discharge: None Bleeding Between Periods: None

V. OBSTETRIC HISTORY (Pregnancy, Labor & Birth) Para: 4 TPAL: 4-0-0-4 Prenatal Care Coverage:6th-9th month of gestation Place of Prenatal Care: Agusan Health Center Total # of Visits: 4 Abnormal Findings: None Pre-pregancy weight: Patient forget her weight before pregnancy Weight Gain: 42 Kg Age of Gestation: 41 weeks EDC: 8/28/12 Gravida: 4

Sexually Active: Yes Sexual Concerns/Difficulties: None Change in Frequency/Interest: None Reproductive Tract Surgery: None Episiotomy: None Lochia: Scanty Amount: approx. 5mL

Personal Hygiene/Habits: Poor hygiene Hair: Thick and oily Clothing/Manner of Dress: Dressed functionally Body Odor: Slight unpleasant odor due to sweat Skin integrity/turgor: No tenting & skin returns to original post Speech: Clear Head & Scalp Symmetry: Symmetrical Contour: Round Thickness: Fairly thick Excessive Dryness/Oiliness: Oily Use of Hair Dye: None Lesions: None Subjective Headache: Present Location: Frontal Frequency: 2 minutes

Complication of Pregnancy: Preterm Excessive Bleeding: None Infection: None Reproductive Family Planning Method Used: Calendar Method For how long: 14 years Side effects: None Previous Miscarriages/Abortions: None VII. ASSESSMENT OF SYSTEMS Objective Gen. Appearance and Mental Status: Appears exhausted but clean and alert

Fainting spells/ dizziness: None Tingling/numbness/weakness (location): None Eyes & Ears Objective Edema in Eyelids: None Sclera & Conjunctiva: Sclera is white, conjunctiva clear Spots before the Eyes: None Diplopia: None Subjective Vision loss R: None L: None Last Examination: Wala ko ka pa checkup Hearing loss R: None L: None

Mouth, Teeth & Throat Objective Condition of the Mouth: Moist, in good condition, No swelling & No redness Condition of Teeth and Gums: Yellowish teeth, and some tooth missing with presence of cavities in some of the remaining tooth Appearance of Tongue: Pinkish, moist Gingival Hypertrophy: None Lesions: None Dental Hygiene: Brushes teeth irregularly Dental Carries: Present in some teeth Neck & Lymph Nodes Objective Thyroid Hypertrophy: None Palpable Lymph Nodes: None Breasts Objective

Last Examination: Wala pud Nose Nasal congestion: None Sense of Smell: Can smell scents and odors Epistaxis: None

Breast Changes Areola: dark brown Breast size: Increase to 35B Presence of Colostrum: Yes Adequacy of Breast for Breastfeeding: If the child asks Abnormal Signs: None Perform BSE: Yes, once a month after morning bath Abdomen Objective Fundal Height:35cm Leopolds Maneuver: Performed at health center Fetal Position: Cephalic Pelvic Measurement: Patient does not remember Circulation Subjective Ankle/Leg Edema: Ankle & feet (non-pitting) History of Hypertension: None

Extremities Numbness: Wala man. Tingling: Wala pud. Change in Frequency/Amount of Urine: One Others/Comments: None Objective BP R Lying: NA L Lying: NA Heart sounds Rate: 76 bpm Rhythm: regular Pulse Carotid: Radial: Femoral: Popliteal: 76 bpm Temporal: R Sitting: 120/80mmHg L Sitting: 120/80mmHg

DorsalisPedis:

Capillary Refill: Immediate (1-2 seconds) Color: Pinkish

Cyanosis: None observed Varicosities: None observed Nail beds: Pinkish in color Mucous Membranes: Moist (appears normal) Others/Comment: None Respiration Objective Respiratory Rate: 23 breaths/min Use of Accessory Muscles: Primarily the diaphragm, and slightly the intercostal muscles Abnormal Breath Sounds: None Clubbing of Fingers: None Cough/Sputum: None Others/Comments: None History of Bronchitis: None Tuberculosis: None Asthma: None Emphysema: None

Smoker: Non-smoker Pack per Day: NA Number of Years: NA Use of Respiratory Aids: None Oxygen: None Others/Comments: None Elimination Subjective Usual Bowel Patters: Everyday, once a day Character of Stool: Solid and brown in color Last BM: 2:00pm 09/5/2012 Laxative Use: None History of Bleeding: None Hemorrhoids: None Constipation: None Diarrhea: None Usual Voiding Pattern: once a day

Recurrent Pneumonia: None

Incontinence: None Urgency: none Retention: none Frequency: Infrequent Activity & Rest Subjective Usual Activity/Hobbies: Housekeeping, laundry Leisure Time Activities: Watching TV Limitation Imposed by Condition: None No. of hours: 2 Sleeping aids: Naps: 5-10 minutes Pillows

Report of Stress Factors:Noise, lack of sleep due to crying baby Ways of Handling Stress: Relaxation, deep breathing, tolerance Financial Concerns: Low family income Relationship Status: Married Lifestyle: Lower class Recent Changes: None Feelings of Helplessness: Sometimes Powerlessness: None Food & Fluid Intake Objective Current Weight: 40 kgs. Height: 48 feet Body Build: Lean Skin Turgor: Elastic Mucous Membranes: Moist Subjective

Difficulty in Sleeping: Yes, due to hospital environment Feelings on Awakening: Refreshing and sometimes restless Others/Comments: None Ego Integrity Subjective

Usual Diet: Diet as tolerated No. of Meals Daily: 2-3 times a day Last Meal Intake: Breakfast Loss of Appetite: None Nausea/Vomiting: None Mastication/Swallowing Problems: None Usual Weight: 40 kgs. Changes in Weight: None Diuretic Use: None Safety Subjective Allergies: None History of STD: None Blood Transfusion: None When: N/A History of Accidental Injuries: None Arthritis/Unstable Joints: None

Social Interaction Subjective: Marital Status: Married Years in relationship: 14 years Living with: Cergio Racoma Concerns/stresses: Problem with family Extended family: Mother(patients side) Role within family structure: Mother Report of problems related to illness/condition: Client reports a problem but refuse to explain further. Others/Comments: None Teaching & Learning Subjective Dominant Language: Visayan Literacy: Literate Educational Level: Grade 6 Health Beliefs/practices: Arbularyo, Hinilot

Body Map

Laboratory/Diagnostic Results (include date and interpret in relation to patients condition.) A. CBC (HbsAg) WBC RBC HEMOGLOBIN HEMATOCRIT MCV MCH MCHC RDW.CV PDW MPV LYMPHOYTES NEUTROPHIL MONOCYTES EOSINOPHILES BASOPHILES PLATELET B. U/A COLOR: CLARITY: YELLOW HAZY 5.8 2.46 6.7 22.3 90.7 27.2 30.0 14.5 8.3 8.6 28.7% 57.4% 10.7% 2.9% 0.3% 243

Description of Affected Areas: Arms and forearms have dark colored rashes due to insect bites. Legs have edema.

PH: 5.0 SPECIFIC GRAV.

1.020

PROTEINSNEGATIVE GLUCOSE NEGATIVE KETONES +4 BACTERIA RARE EPITHELIAL CELLS RARE PUS CELLS 2-4 RBC 25-30