A.

GENERAL INFORMATION
Name :

E.R.

Ward: OB

Rank:

EDW

Age:

29

Birthdate: 13 Sept 86

Weight:

63 kg

Height: 52

BMI: 22

Chief Complaint: Sumasakit ang tiyan at sa bandang likod ko, pero nawawala minsan.
Admission Date: 12 0920H January 2016
Admitting Diagnosis: Gravida2 Para1 (1001) Pregnancy Uterine 32 6/7 weeks AOG ,
Cephalic in threatened preterm labor, previous Low Transeverse Cesarean Section
secondary to double cord coil (tight) mitral valve prolapse.
LMP: 28 May 2015
AOG : 33 weeks 4 days
EDD: 05 March 2016

B. HEALTH HISTORY
1. History of Present Illness
2 days prior to admission ER was sleeping when she experienced uterine contaction
occurring two to three times every hour. 3 hours prior to admission, ER suddenly felt
continuous pain at abdominal area radiating to lower back and was then brought to
VLGH.
2. Past Medical History
ER had Measles when she was 10 years old. She was also diagnosed with Mitral
Valve Prolapse at the age of 16. ER had no known previous hospitalization except last
June 2010 when she underwent Cesarean Section at Ala Valley Hospital, South
Cotabato. She also stated that she had completed her immunizations and had no known
allergies to food and medication.
3. Menstrual History
ER had her first menstruation when she was 14 years old. She had an irregular cycle
menstruation with a duration of 3 to 4 days. A total of 2 to 3 pads per day were used and
fully soaked. During her menstruation, she experienced dysmenorrhea, headache and
numbness of the lower extremity.

4. Obstetrics History
Gravida 2 Para 1 (Term 1, Preterm 0, Abortion 0, Living 1); ER delivered her first
baby last 2010 through Cesarean Section at Ala Valley Hospital, the baby was double
cord coiled but normal in condition with APGAR Score of 8 and weighed 7.6 pounds.

5. Prenatal History
ER had her last menstruation period on 28 May 2015 and one month after she had a
pregnancy test and the result was positive. She had her first prenatal check up at a
private clinic in Angeles City, Pampanga last July 2015.On her first trimester, ER only
experienced morning sickness. She visited her OB-GYNE; urinalysis was done and
revealed having Urinary Tract Infection, she was then advised to increase her oral fluid
intake and was prescribed with Bonamine. On her second trimester, ER experienced
numbness of her whole body for 3 days and felt pain at abdominal area occurring 3 times
per hour. ER

visited her OB-GYNE , ultrasound was done and revealed cephalic

presentation of the fetus with good fetal heart tone. Urinalysis was also done and still
revealed Urinary Tract Infection, Cefalexin for one week, Neurovion once a day and
Ascorbic Acid was prescribed. ER also felt irregular uterine contractions occurring 6 to 8
times per hour lasting for 10 to 15 seconds in which she visited her physician and was
advised for complete bed rest and was prescribed with Duvadilan three times a day for 2
weeks. On her third trimester, ER experienced increase uterine contractions and was
prescribed with 8 doses of Dexamethasone.

D. GORDONS FUNCTIONAL HEALTH PATTERNS

1. Health Perception-Health Management Pattern
For RIG, being healthy is being able to carry out tasks given while illness for him is the
opposite.RIG practiced a healthy lifestyle by joing taebo takbo during Tuesday and Thursday

and smokes at a 1 pack per day and drinks alcohol occasionally. Self-treatment and usage
of over the counter drugs such Biogesic and Alaxan was used by RIG. Turmeric tea, an
herbal supplement was also tried. He visited a doctor when he experienced worsening of his
condition and strictly adhered to the advises.
For ER, being healthy is being able to function well while illness for her is the
opposite. ER practiced a healthy lifestyle by walking if she had available time and did not
smoke or tried drinking alcoholic beverages. Self-treatment and usage of over the counter
drugs was practiced by ER. MX3 Capsule, a food supplement was also tried. She visited an
OB-GYNE when she knew she was pregnant and strictly adhered to the advises.
2. Nutritional- Metabolic Pattern
RIG had a good appetite. He ate his meals prepared by their mess hall three times a
day and was able to drink 6- 8 glasses of water. When deployed, RIG most of the time ate
pancit canton and always drink carbonated beverages such as Coca- Cola. RIG did not have
any food preference; he said he ate almost everything and he weighed 86 kilograms then.
During admission, he still had good appetite; he adhered to his low salt, low cholesterol diet
and loses weight at 79 kilograms.
Prior to pregnancy, ER had good appetite. She ate her meals three times a day,
loved coffee and was able to drink 6- 8 glasses of water. ER did not have any food
preference; she said she ate almost everything and she weighed 58.5 kilograms then.
During pregnancy, she still had good appetite; did not have craving for specific food and ate
nutritious foods like vegetables and fruits. She hated the smell of coffee. On her fourth
month of pregnancy, ER gained weight at 61.5 kilograms.
3. Elimination Pattern
RIG did not have problem with defecation, he defecated once everyday and during
morning. He said that his stool was usually yellow to brown in color and semi-formed
depending on what he ate for that day. RIG never used laxatives whenever he experienced
difficulty defecating, he just increased his fluid intake and foods rich in fiber such as
pineapple.
RIG had a problem with his bladder elimination. He was able to urinate more than 5
times in large amount per day and usually it is tea to yellow in color. He experienced
eliminating foamy urine always and what he did was increasing the amount of his fluid
intake. During his hospitalization, Furosemide was administered and his frequency of
urination was increased to 14 times per day and was yellow to clear in color. Foamy urine is
still observed.
ER had problem with defecation, she defecated once every other day and during morning.
She said that her stool was usually golden brown depending on what she ate for that day.
Usually, she had a hard stool especially if her fluid intake is inadequate. During pregnancy,
ER observed that she had hard stools and had difficulty defecating. She never used
laxatives when constipated; she just increased her fluid intake and ate papaya.

ER did not have problem with her bladder elimination. She was able to urinate more
than 7 times a day. Usually, her urine was amber yellow in color, sometimes yellow-orange
and mostly clear.
4. Activity- Exercise Pattern

Before, RIG was able to perform vigorous physical activity. He exercised

through participating in taebo and road-runs and occasionally playing basketball. His
leisure activities include listening to music and going to the mall and watching movie.
During hospitalization, leisure activities include watching television and
listening to music.
Prior to pregnancy, ER was able to do her activities of daily living like doing
household chores and taking care of her son. Her leisure activities include watching
television programs, listening to music and going to the mall. During pregnancy, she was
advised to avoid strenuous activities and be on complete bed rest. ER then minimized her
ADLs and asked help with her brother-in-law if she wanted something to be done.
5. Cognitive- Perceptual Pattern
RIG had corrective eyeglasses since 2013. He did not have problem regarding her
touch, taste and smell. RIG is a college graduate and able to read and speak English,
Tagalog and his dialect Ilonggo and Bisaya. He was able to decide things on her own and
with the help of his family.
ER had corrective eyeglasses since 2009. She did not have problem regarding her
touch, taste and smell. ER is a college graduate and able to read and speak English,
Tagalog, and her dialect which is Ilonggo. She was able to decide things on her own and
with the help of her family.
6. Sleep and Rest Pattern

RIG usually sleeps 6 to 8 hours per day. He often goes to bed at 2100H or
2200H then wakes up early at 0300H or 0400H. He usually takes nap for 3 hours
starting at 1400H to 1700H when not in operation. He claimed that he feel rested
upon waking up.
During admission, though there were interrupted sleeps, he claimed that he
still feel rested upon waking up.
ER worked as a call center agent; mostly she slept during daytime at 10 a.m. She
usually had 4 hours of sleep and felt tired upon waking up. Her bedtime rituals include:
taking a bath and listening to music. During her 5 th month of pregnancy, she resigned from
her job and was able to have almost 8 hours of sleep.

7. Self-Perception- Self-Concept Pattern

ER considered herself to be functioning effectively. She had a good relationship with
the people in their neighborhood. She claimed that she is emotionally stable and able to face
problems with her family. As a mother, she felt satisfied especially that her role to bear a
child is fulfilled.
8. Role Relationship Pattern
ER is happily married to her military husband and able to perform her role as a
mother to her 5 years old son. She had a good relationship with her brother and sister and
maintained a constant communication being the eldest in the family. She also had a good
relationship with her parents who are both healthy and lives in South Cotabato. All were
supportive with her pregnancy.
9. Sexuality-Reproductive Pattern
Prior to pregnancy, ER was actively engaged in sexual activity with her husband.
They are both satisfied and were not able to encounter problems. When she knew she was
pregnant and was advised to avoid strenuous activity, she explained it to her husband and
they were able to understand it and avoided having sex.
10. Coping and Stress Tolerance Pattern
When angry, ER solved the problem with the help of her family. When she is
anxious, listening to music is done to feel comfortable and minimize anxiety. During her
pregnancy, stress is avoided.
11. Values-Belief Pattern
ER, an Adventist, practiced her belief faithfully. Her husband, a Roman Catholic
respected her practices like not eating pork, shrimp, duck and other foods that are not
allowed in her religion.

H E AD Q U AR TE R S
ARMED FORCES OF THE PHILIPPINES MEDICAL CENTER
VICTORIANO LUNA GENERAL HOSPITAL
NURSING SERVICE DIVISION
NURSING EDUCATION AND TRAINING BRANCH
Camp Colonel Victoriano K Luna, V. Luna Avenue, Quezon City

Nursing Process of
EDW ER (OB Ward)

Submitted by:
P2LT SERAFIN J TORQUIDO JR NC

Submitted to:
LTC MARIA TERESA B RUDIO NC

25 January 2016

Cardiac Problems

C. FAMILY HISTORY
GENOGRAM
PATERNAL
FAMILY

MATERNAL
FAMILY

LEGEND:

GRAND
PARENTS

Deceas
ed
Female
Male

PARENT
S

ER

Cardiac
Problem

ER

Hypertension

Asthma

CHILD