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XAVIER UNIVERSITY Others (Specify): arteriosclerotic heart disease, recurrent

ATENEO DE CAGAYAN II. History of Present Illness: absence seizures, type 1 diabetes mellitus
COLLEGE OF NURSING Patient PT entered pregnancy without any feeling of
NCM 109 RLE shortness of breath. Since 2 weeks ago, she has been V. Obstetric History (Pregnancy, Labor and Birth)
OBSTETRIC PATHOLOGIC ASSESSMENT TOOL extremely fatigued, has mild constant swelling in her ankles, Para: 0 Gravida: 1 TPAL: 0,0,0,0
SN Name: MABOLO,RUFFA MAE LARIETA a persistent cough, inability to walk upstairs without Prenatal Care Coverage: _not mentioned_
NERQUIT,BERN MICHELLE BATUCAN becoming breathless, and orthopnea so severe at night she Place of Prenatal Care: _not mentioned_
PAHUNANG,CHRISTINE AGNES BABALO cannot sleep without four pillows. Total number of visits: _not mentioned_
PAYOT,ANA MARIE TAN NERY Any abnormal findings: _none_
PINEDA,LHEAN ANGELA MACARON Current Medications: (include Dosage, Timing, Route and Pre-pregnancy Weight: _174 lbs_
RAPADAS,MARCO CARABALLE Indication of use): Weight Gain: _6 lbs (0.5 lbs per week)_
ROBERTO,RAMON DARREN GAID Name, dose, timing, route Indication Last Menstrual period _September_
TINGSON, ZYRA digoxin It is used to treat heart EDC: _no data presented_
TOMARONG,JAVE MARK LEGARA failure (weak heart). Age of Gestation: _12 weeks_
UY,FARLAINE FLOR LAO VI. Gynecologic History
Upon assessment: Age of Menarche_13 years old_
Block: NE Vital Signs: HR 96 beats/min RR 22 breaths/min BP 135/88 Menstrual Cycle:
Area of Exposure: _OB-GYN_ mmHg Temp _no data presented_ O2 Sat _no data Interval/ Length of cycle_30_ days
CI: MS. GLENDA P. DE VERA RN, MAN_ presented_ Ht _5’4_ Wt _180lbs_ BMI: _31.88 or 31.9_ Duration of menstrual flow_6_days
I.GENERAL INFORMATION Interpretation of BMI: _obese_ Amount of Menstrual Flow: _moderately heavy_
Name: PT Age: 38 years-old III. Past Obstetric/Medical/Surgical History Menstrual Discomfort: _mild dysmenorrhea_
Birthday: _not mentioned_ Illness Date Vaginal discharge (odor, color): _no data presented_
Civil Status: _Married_ sickle-cell anemia child Bleeding between periods: _none_
Sex: F Religion: _not mentioned_ Occupation: _Massage scoliosis Early adolescence Sexually active _yes_
therapist_ Sexual concerns/difficulties _gonorrhea_
Income: _not mentioned_ Address: _not mentioned_ IV. History of Family Illnesses (Check box that applies) Recent change in frequency/interest _no data presented_
Informant: _not mentioned_ Relation: _husband_ Hypertension Reproductive Tract Surgery: _none_
Admission Date: _8/01/21_ Time: _2:44 pm_ Coronary Artery Disease (CAD) Reproductive Family Planning Methods Used: _diaphragm
Chief Complaint: verbalized “I can’t sleep at night, I am so Cerebro-vascular Disease(CVD) and vaginal foam_
short of breath.” Diabetes Mellitus For how long: _2 years_
Attending Physician: _Farlaine Uy_ Kidney Disease Side Effects if any: _ risk for infection, redness, edema, foul
Diagnosis/Impression: _Iron deficiency anemia and Tuberculosis odor from vaginal discharges_
congestive heart failure_ Cancer Previous Miscarriages/Abortion _none_
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Sclera & Conjuctiva _(-)_ Objective

Spots before the eyes _(-)_ Breasts changes: Areola _no data presented_ Breast Size _no
VII. ASSESSMENT OF SYSTEMS Diplopia(double vision) _(-)_ data presented_ Presence of Colostrum _not mentioned_
Objective Subjective Adequacy of breast for breastfeeding _N/A_
General Appearance and Mental Status: _Extremely worried Vision loss: R _(-)_ L _(-)_ Abnormal signs _(-)_
and tired appearing pregnant female_ Last examination: _no data presented_ Perform BSE (frequency and schedule) _no data presented_
Personal Hygiene/Habits: _not mentioned_ Ears: Hearing loss: _(-)_
Hair _black_ Last Examination: _no data presented_ Abdomen
Clothing/Manner of Dress _neat and clean_ Objective (antepartum)
Body Odor _no data presented_ Nose Fundal Height: _28 cm_
Speech: ______ clear ______ slurred Nasal Congestion _can sniff through each nostril_ Leopold’s Maneuver _not performed_
_______ unintelligible ________ Aphasic Sense of smell: _client is able to sniff through each nostril Fetal Position _no data presented_
Subjective while the other is occluded_ Pelvic Measurement _Deferred_
Pain: Precipitating: _no data presented_ Epistaxis _(-)_
Quality of Pain: _no data presented_ Others/Comments: _none_ Circulation
Radiating at: _N/A_ Severity: _N/A_ Time: (Onset, Others/Comments: _none_ Ankle/Leg edema: _mild constant swelling, Edema 2+ present
Frequency, Duration) _N/A_ Mouth, Teeth and Throat on both legs extending from feet to mid-calf_
Others/Comments _none_ Objective History of Hypertension _none_
Condition of mouth _Oral mucosa is pink and moist with good Extremities: Numbness _(-)_ Tingling: _(-)_
Head and Scalp dentition_ Change in frequency/amount of urine _not mentioned_
Symmetry _symmetrical on each side_ Condition of teeth and gums _no decayed areas, no missing Homan’s sign _not performed_
Contour _round_ Distribution _evenly distributed_ teeth and color and consistency of tissues along gums are Others/Comments: _none_
Thickness _thick_ Excessive Dryness/Oiliness _(-)_ even_
Use of hair dye _none_ Lesions: _(-)_ Appearance of tongue _pink, moist and papillae present_ Objective
Gingival gum hypertrophy _(-)_ Lesions _(-)_ BP: R: Lying _no data presented_ Sitting _ no data presented_
Subjective: Dental hygiene _observes cleanliness of the mouth, brushes L: Lying _no data presented_ Sitting _no data presented_
Headache _(-)_ Location _N/A_ Frequency _N/A_ teeth at least twice a day_ Dental Carries _(-)_ Heart sounds: _accentuated and split, Prominent grade 2
Fainting spells/dizziness _none_ diastolic murmur heard at left sternal margin_
Tingling/numbness/weakness (location) _none_ Neck/Lymph Nodes Rate_96 beats/min_ Rhythm _no data presented_
Others/Comments: _none_ Objective Pulse: Carotid ____ Radial ____ Popliteal ____
Eyes/Ears Thyroid hypertrophy _(-)_ Temporal ____ Femoral ____ Dorsalis Pedis ____
Objective Palpable lymph nodes_(-)_ Capillary refill _no data presented_ Color _not mentioned_
Edema in eyelids _(-)_ Breasts Cyanosis/Pallor _not mentioned_
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Varicosities _none_ Heartburn/Indigestion _Eats ice cubes almost constantly to Activity and Rest
Nail beds: _not mentioned_ relieve heartburn_ Subjective
Mucous membranes _no data presented_ Mastication/swallowing problems _(-)_ Usual activities/hobbies: _not mentioned_
Others/Comments: _none_ Changes in weight _not mentioned_ Leisure time activities _Enjoys talking to chat room on Web
Diuretic use _not mentioned_ site_
Respiration Limitations imposed by conditions _inability to walk upstairs
Objective Objective without becoming breathless_
Respiratory Rate_22 breaths/minute_ Depth _no data Current weight _180 lbs_ Height_5’4_ Body build _no data Sleep:
presented_ Symmetry _symmetric chest expansion_ presented_ Number of hours _3-4 hours_ Naps _not mentioned_
Use of accessory muscles _(-)_ Nasal flaring _(-)_ Skin turgor _skin mobile, with elasticity and returns to Sleeping Aids _4 pillows_
Abnormal Breath sounds: _Rhonchi heard on lung original shape quickly_ Mucous membranes moist/dry _no Difficulty in sleeping _orthopnea so severe at night she
auscultation_ Cyanosis _(-)_ Clubbing of fingers _(-)_ data presented_ Hernia/masses _(-)_ cannot sleep without four pillows_
Sputum characteristics _no data presented_ Other Comments: _none_ Feeling on awakening _receives only 3 to 4 hours because
Others/Comments: _orthopnea so severe at night she cannot of constant waking with shortness of breath_
sleep without four pillows, persistent cough_ Elimination Others/Comments: _none _
Dyspnea related to _Hypoxemia (low 02 level in the blood)_ Subjective
Cough/sputum _none_ Usual bowel pattern _not mentioned_ Ego Integrity
History of: Last BM: _not mentioned_ Subjective
Bronchitis _none_ Asthma _none_ Tuberculosis _none_ Recent: Character of stool _no data presented_ Report of stress factors _Verbalized “I’ll go crazy without
Emphysema _none_ Recurrent Pneumonia _none_ Amount: _N/A_ Frequency: _N/A_ people to talk to. I’m a people person”_
Smoker _does not smoke_ Pack/day _N/A_ Number of years Color: _N/A_ Odor: _N/A_ Ways of handling stress _continue working because her
_N/A_ History of GI bleeding _(-)_ Hemorrhoids _Two 1-cm husband does not earn enough to pay the mortgage on their
Use of respiratory aids _not mentioned_ Oxygen _none_ hemorrhoids present_ house without her help_
Others/Comments: _none_ Constipation _none_ Laxative use _none_ Financial concerns _Her husband does not earn enough to
Others: _none_ pay the mortgage of their house_
Food/Fluid Intake Relationship status _Married_
Subjective Usual voiding pattern: _no data presented_ Incontinence Lifestyle _not mentioned_
Usual diet (type) _regular diet_ No. of meals daily_3_ _not mentioned_ Recent changes _extremely fatigue_
Last meal intake _no data presented_ Loss of appetite _no Urgency _no data presented_ Retention _no data Feelings of helplessness _not mentioned_ Hopelessness _not
data presented_ presented_ Frequency _N/A_ mentioned_
Nausea/vomiting _(-)_ Dentures _not mentioned_ Pain/Burning/Difficulty in voiding _(-)_ Powerlessness _extremely fatigue_
Allergy/Food Intolerance _not mentioned_ History of kidney/bladder disease _(-)_ Others/Comments _none_
Others/Comments: _none_ Objective
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Emotional Status (check those that apply) Teaching/Learning legs extending from feet to mid-calf. Lungs: rhonchi heard on
Calm _____ Anxious ______ Angry _____ Subjective lung auscultation; respiratory rate: 22 breaths/min
Withdrawn ______ Fearful ______ Irritable _____ Dominant language(specify) _English)_
Euphoric ______ Literate _not mentioned_ Educational level _not mentioned_ Laboratory/Diagnostic Results (Include date and interpret in
Health beliefs/practices _not mentioned_ relation to patient’s condition.)
Body Map. (Illustrate in the body map how your patient looks
Safety like e.g. tubes inserted, bruises, surgical incisions, a. CBC
Subjective Physical abnormalities, affected areas. Mark with a small “x” Hemoglobin: 9 gm/dl - low hemoglobin level and has been
Allergies/sensitivity _not mentioned_ where it is located or draw it on the body map and then diagnosed with iron-defficiency anemia.
Reaction _none_ label.)
History of STD(Date/Type) _gonorrhea_ b. U/A
Blood Transfusion/number _not mentioned_ When _N/A_ Negative for protein and glucose - urinalysis of the patient is
History of accidental injuries _none_ CHEST normal, no infection has been detected.
Fractures/dislocations _none_ Prominent grade 2
Arthritis/unstable joints _none_ diastolic murmur c. Fecalysis
Back problems _She developed scoliosis as an early heard at left sternal no data presented
adolescent. She has retainer rods inserted to support her SPINE margin
LUNG
spine_ Scoliosis d. X-ray/ Sonogram
rhonchi heard on
Changes in moles _none_ Enlarged nodes _none_ Unusual ABDOMEN no data presented
lung auscultation,
bleeding _none_ RECTUM increased Fundal height:28
Prosthesis _none_ hemorrhoids cm linea nigra and
striae
Social Interactions
EXTREMITIES
Subjective:
Edema 2+ on
Marital status _married_ Years in relationship _not
both legs
mentioned_ Living with _husband_
Concerns/stresses _her husband does not earn enough
money_ Extended family _not mentioned_
Describe affected areas:
Other support person _not mentioned_
Chest: cardiac enlargement suggested by percussion. Spine:
Role within family structure _wife_
she has retainer rods inserted to support her spine.
Report of problems related to illness/condition _none_
Abdomen: linea nigra and striae present. Rectum: Two 1-cm
Others/Comments _none_
hemorrhoids present. Extremities: Edema 2+ present on both