I.

ASSESSMENT

II.I NURSING HISTORY

a.) Demographic Data

Ms. CY, a 24-year-old, single, born on October 12, 1984 works as a

sewer in a factory. She resides in R. Aquino Complex, Acacia Lane,
Mandaluyong City with her co-workers and her boyfriend.

b.) Socio-Economic and Cultural Factors

Ms. CY together with her boyfriend is working as a sewer in a factory

where they currently reside. Ms. CY was raised as a Roman Catholic, were
she learned about religious values. She claimed that she lived in Surigao
province in Mindanao with her family including her father, mother and
siblings but went to Manila to earn money to support her family in their daily
expenses. When it comes to health matters, she usually self medicates with
pain relievers and analgesics such as Ponstan, Mefenamic Acid and
Paracetamol. Ms. CY claimed that she also uses herbal medicines and does
not usually go to health care providers and medical professionals to seek
health care.

c.) Environmental factors

Ms. CY resides in R. Aquino Complex, Acacia lane, Mandaluyong City

and occupies the employees’ quarters where she currently works in a factory
as a sewer. The location of their house is easily accessible to hospitals, health
centers and other government institutions. Ms. CY did not report any
problems regarding her environment that interfered to her condition except
that she usually sleeps late because of her work.

II.II CHIEF COMPLAINT

The patient was admitted at Mandaluyong City Medical Center with a chief
complaint of labor pain, (LMP: May 15, 2010; EDC: February 22, 2011; G1P0)
with I.E. findings of Cervical Dilatation = 4cm, 80% effaced, breech, (-) BOW
last September 21, 2010 at around 4:20 a.m.

II.III HISTORY OF PRESENT ILLNESS

Three days prior to admission, there was a (+) intake of Cytotec; 2

tabs P.O.; 1 tab vagina. One day prior to admission, there were (+)
contractions and (+) vaginal bleeding. Ms. CY went to MCMC on September
21, 2010 because of labor pain with initial V/S of (T=36.3, BP=90/60), I.E.
findings of Cervical Dilatation = 4cm, 80% effaced, breech, (-) BOW.

II.V PAST MEDICAL HISTORY

Ms. CY had her menarche at the age of 12 with duration of 3-4 days.
LMP: May 15, 2010; AOG: 18 weeks and 3 days; OB record: G1 P0 T0 P0 A1
L0. She had experienced measles, mumps, and chickenpox as a child. She
also experienced diarrhea, fever, cough, colds. She claimed that she has a
weak resistance and easily gets sick and self-medicates with over the counter
medications like Paracetamol and pain relievers before she became pregnant.
She has completed all her childhood immunizations. She has known allergies
to alcoholic drinks. She was never been hospitalized before.
II.VI FAMILY HISTORY

Ms. CY’s father was a known Hypertensive and her brother had appendicitis.
However, her father has no known maintenance for his condition but
maintains a diet rich in fiber and low fat and low sodium and regularly
exercises in the morning. Moreover, Ms. CY claims that her family members
including her mother and 4 siblings were healthy and no known illness
except for her father and her brother.