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I. DEMOGRAPHIC DATA
Date of Interview: March 04, 2014
Initials of
Clients
Name
Position Age e!Civil
tat"sReligion E#"$ation O$$"%ation
Mrs. SG Mother 39 F Married Catholichigh school
graduateHousewife
Client S, 39 ears old, a high school graduate, currentl residing at !agtas
"an#a, Ca$ite, is on 24 4%& wee' of her ( th)regnanc. She wor's as a !aranga
Health *or'er of +aang -aa "an#a, Ca$ite and sells corn when additional
financial needs arise. Her hus/and is currentl une-)loed. "heir fa-il is under
the +e)art-ent of Social *elfare and +e$elo)-ents 4s )rogra-. "heir
-onthl /udget $aries de)endentl on the arising needs of the fa-il. "he /igger
)art of the /udget is allotted on food and education of the children. ll her
children are de)endent on her. 4 of & children are studing. "he eldest alread
has his own fa-il. et to the eldest, so-ehow hel)s financiall through selling
ice crea- so-eti-es.
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II. HITOR& O' PREENT I((NE
+r and crac'ed s'in on /oth )edalis area was o/ser$ed and co-)lained / the
client. ccording to the client, she sought -edical ad$ice regarding the stated condition
and it was diagnosed as ec#e-a. +oacillin, an anti/iotic , was )rescri/ed, howe$er,
she discontinue the inta'e due to co-)lain of h)eracidit.
56u-alala ung sugat 7)ag hindi natutuo -a/uti at tuwing -ainit ang )anahon8,
SG stated. 5ilalanggas 'o na lang ng )ina'uluang dahon ng /aa/as8, added / the
client.
III. PAT MEDICA( HITOR&
+uring childhood, SG e)erienced co--on illnesses such as colds, cough, and
flu. She also had chic'en )o /ut unsure if had /een infected / -easles. She is not
sure if she had /een full i--uni#ed.
t the age of 9, SG had her left second ri/ fractured /ecause she fell fro- a tree
while )laing. :ra confir-ed the fracture.
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She was hos)itali#ed on the ear 2012 due to high ris' & th )regnanc
co-)licated / ele$ated /lood )ressure. She deli$ered in General ;-ilio guinaldo
Me-orial Hos)ital. fter that she was su/. She has a 2(:da ccle, -enstruating
three ?3@ to four ?4@ das using a/out three ?3@ to four ?4@ full )ads a da.
HITOR& O' PAT PREGNANCIE
Aear'PM "se# after
%regnan$,Gravi#it, Parit, T,%e of Deliver,
Gen#er of
Infant
-/ one 1 0 S+ B Ho-e +eli$er M
-0 one 2 1 S+ B Ho-e +eli$er M
-1 ills?( -onths@ 3 2 S+ B Ho-e +eli$er F
-
n S+ B Ho-e +eli$er F
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/2-/ one & S+ B Hos)ital +eli$er F
CDD;" D;GCA
6M AOG GP3GTPA(M EDCe%tem4er
-56 /2-7
s of March 04,2014,
=G E 1 Se)t
31 =ct
30 o$
31 +ec
31 an
2( Fe/
4 Mar
1&1 das
1&1das E /5 5 3 1 wee8s
E > 21 % 30 -onths
GP:
(:&
GTPA(M
(:&:0:0:&:0
EDC :
09 14 2013
:3 & 1
29+/-+/2-5
"he first four )regnancies ha))ened in Ca-arines orte. fter the 3rd
)regnanc, she used )ills for ( -onths. fter the 4th)regnanc, she used in
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C
!n"no#n $ause of death
%
M&
'P
No "no#n information
%Maternal Death
S( 3)
*PN
+P
*PN
%PMaternal Death
,
*PN
-egend:
male
female
Male de$eased
Female de$eased
Female $lient
*PN . hypertensive
M& . myo$ardial infar$tion
). HEREDO+'AMI(IA( HITOR&
/
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nter)retation
"he gra)h a/o$e shows that SG has a fa-il histor of heart )ro/le-s. "his can
/e considered a factor in the de$elo)-ent of her high /lood )ressure.
!oth her grand-other died during fetal deli$er -a'ing her a candidate for
de$elo)ing co-)licated )regnancies.
)I. DE)E(OPMENTA( HITOR&
A. . Piagets Cognitive Develo%ment
For-al o)erations )hase
n this stage, an indi$idual uses rational thin'ing. Deasoning is
deducti$e and futuristic.
*. E. Eri8sons Ps,$;oso$ial Develo%ment
dulthood Generati$it $s. stagnation
n this stage energ is directed towards full seual -aturit and
function and de$elo)-ent of s'ills needed to co)e with the en$iron-ent.
Client shows concerns on her fa-il, / )ro$iding their needs. She
sells sweet corn when there is a need for etra -one.
C. . 're"#s Ps,$;ose!"al Develo%ment
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Genital Stage
;nerg is directed toward full seual -aturit and function and
de$elo)-ent of s'ills needed to co)e with the en$iron-ent
Client shows -ore -ature role on her )art, / thin'ing of others thher.
D. . 'owlers %irit"al Develo%ment
ndi$iduati$e:Deflecti$e Faith
)erson in this stage is constructing their own e)licit sste-.
"he show a high degree of self:consciousness
Client shows $er realistic and )ositi$e $iew of )oints in e$er
situations or )ro/le-s she encountering
E. (.
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dolescence
General acco-)lish-ents )er age )eriods.
Client is $er su))orti$e on her four children, though their /ig enough to
carr the-sel$es, still she assisting the- / so-e s-all things.
)II. GORDON -- '=NCTIONA( HEA(TH PATTERN
)II. Gor#ons -- '"n$tional Healt; Patterns
A. Healt; Per$e%tion+ Healt; Management
"he client stated that she )ercei$es herself as a well and health )erson,
5hindi )a na-an 'asi a'o nag:'a'asa'it ng -atitindi. "anging /o, si)on at
lagnat lang na )ang:'araniwan8 as she $er/ali#ed. ccording to her she uses
her/al -edicines in curing such illnesses and
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Mrs. S.G also had a fear in dentists. 5 siguro -a isa o dalawang /eses
lang a'o na'a)ag:)a/unot ng ngi)in noong /ata )a a'o, ero ngaon -as
natata'ot talaga a'o sa -ga ganiang )roseso8 as she $er/ali#ed. t was
o/ser$ed that her u))er two )re:incisors and two incisors are -issingB she does
not su/-it herself to annual dental chec':u).
B. N"tritional+Meta4oli$"he client stated that she eats three ti-es dail, and can consu-e -ore
than ( glasses of water e$erda. ccording to her shes fond eating of salt
foods e$en /efore )regnanc. 5tuwing 'u-a'ain a'o -a )atis,8 as $er/ali#ed
/ the client.Mrs. S.G doesnt ha$e an health )ro/le-s which affects her eating
)attern. Seldo- had she lost her a))etite. She also added that shes drin'ing
-il' e$er -orning and ta'ing ferrous sulfate ?FeS=4@ e$er night for her iron
store su))le-entation.
Diet Preferen$e
MEA( Mar$; 2 Mar$; -2 Mar$; --
*rea8fast1 cu) of -il', :&
)andesal
1 cu) of -il', :&
)andesal
1 cu) of -il', :&
)andesal
("n$;
3 glass of water I
cu) rice, 1 ser$ing
of )a'siw na isda
3 glass of water, 1
cu) rice, 1 ser$ing
of sina/awang
gula
3 glass of water, 1
cu) of rice, 1ser$ing
of )ritong isda w%
ginataang gula
)
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na$8s2 sliced ng -ais, 3
glass water
1 stic' /anana Jue,
2 glass water
1 whole -ais, 2
glass of orange
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She also added that she defecates once a da, -ostl in -orning, fir- in
consistenc and /lac'ish in color which can /e related to her FeS= 4.According
to Pillitteri, (2010), as peristalsis slows and the weight of the uterus presses the
bowel, constipation occur. Client also verbalized that she does not feel an pain
upon defecating and constipation does not occur.
D. A$tivit,+E!er$ise
;arl in the -orning the client starts her da / assisting her children
/efore going to school, doing house chores, then goes in /aranga health center
of -aa .. She considers those as her eercise, including her 5sideline8 which
is selling sweet corn within the /aranga. Clients for- of relaation is /
sociali#ing with her friends through )laing 5!G=8 and ha$ing so-e 5chit:
chats8 with so-e residents of the /aranga. So-eti-es, after those acti$ities,
she goes in the house of her son and ta'es a na).
>1+Da, A$tivit, Ta4le
TimeDa,
Da, - Da, / Da, 7 Da, 5 Da, 0 Da, 9 Da, 1
'e4 /
t;"r
'e4 /?
fri
Mar$; -
sat
Mar$; /
s"n
Mar$; 7
mon
Mar$; 5
t"e
Mar$; 0
we#
1 a-
2 a- Koided Koided $oided
3 a-
4 a- Koided $oided Koided
> a- $oided $oided
a-
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& a- Koided Koided
( a- $oided Koided
9 a- $oided
10 a-
11 a- $oided Koided Koided12 nn Koided Koided
1 )- Koided Koided
2 )- $oided Koided $oided
3 )-
4 )- $oided $oided Koided Koided
> )- Koided
)- $oided Koided
& )- $oided Koided
( )- $oided
9 )- Koided
10 )- Koided $oided
11 )- $oided Koided Koided
12 -n Koided $oided
(egen#
slee) : eat : wor'ing
E
wa'ing u) : cleaning :Merienda
: ta'e a /ath L$oided: so-eti-e on that )art,
she urinated
Inter%retation:
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"he ta/le shows the se$en ?&@ das acti$it of client S.G. "he color ellow stands
for the ti-e of her slee)B "he green color for the ti-e she wa'es u) in the -orningB "he
s'/lue stands how often she eats in a daB "he color /lue stands for ti-e she ta'es a
/ath. "he color )itch stands for how -an hours she wor's in a da. nd the /luegreen
stands for snac' ti-e. "he 5Koided8 indicates how -an ti-es $oidedin in the whole
twent:four ?24@ hours.
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E. lee%+Rest
1+Da, lee% Diar,
Constr"$ts Da, - Da, / Da, 7 Da, 5 Da, 0 Da, 9 Da, 1
Ho"rs of
lee%9 hrs 9 hrs & hrs & hrs 9 hrs 9 hrs 9 hrs
lee%ing
Time ( )- ( )- 10 )- 10 )- ( )- ( )- ( )-
a8ing
Time4 a- 4 a- 4 a- 4 a- 4 a- 4 a- 4 a-
*e#time
Rit"alsone one one none one one one
'eeling
"%on
wa8ing "%
rested Dested rested rested Dested rested rested
Pro4lem
En$o"ntere
#
none one none none one none none
Inter%retation:
"he clients hour of slee) is sufficient. She feels rested after her slee)
which can /e related to the a/sence of )ro/le- encountered in slee)ing.
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'. Cognitive+Per$e%t"al
)on assess-ent, the client shows no signs of a/nor-alities in her
thought and thin'ing )rocess as well as in her senses. 5Hindi )a na-an
nanglala/o ang )aningin 'o. Madali rin na-an a'ong -a'arinig at hindi na-an
a'o na-a-anhid8, the client stated.
She can decide on her own, can read, can write, and can interact with
other )erson. She also can recogni#e )eo)le and things around her.
G. elf+Per$e%tion+elf+Con$e%t
H. Role+Relations;i%
Mrs. S.G has a har-onious relationshi) with her fa-il as how she
descri/es it. She has se$en children and still wor'ing for the- through selling
sweet corns and ser$ing as !H* in the /aranga. Client is still assisting her 'ids
e$er -orning /efore going to school. "hough she has got Juite a -an children,
she ne$er had 7fa$oritis-. Howe$er, she focuses her attention on the needs the
ounger ones who could not do things on their own.
n ter-s of her relationshi) with her hus/and, she descri/es it as a t)ical
one. ro/le-s and -isunderstanding were encountered /ut were ne$er left
unresol$ed.
She added that she does not get a hard ti-e getting along or sociali#ing
with other )eo)le.
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I. e!"alit,+Re%ro#"$tive
Client is on her 24thwee's of )regnanc, and according to her, on the first
tri-ester of )regnanc, the ?her hus/and@ still had intercourse, /ut when she
reached the following tri-ester, the sto) it due to so-e fears. She also added
that u)on doing that, no )ain or disco-fort was e)erienced.
fter her th )regnanc, she was encouraged to undergo tu/al ligation.
She was scheduled twice for ligation /ut did not a))ear on the da of o)eration
due to fear. Still, she is /eing encouraged / the -idwi$es and her co:!H*s to
su/-it herself to the o)eration after gi$ing /irth.
. Co%ing tress
"he client stated that when shes stressed and ha$ing trou/les and
)ro/le-s, she
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G;;D6 ;DC;
1. Body build and height-weight proportionality
Client S.G has an endo-or)hic /od /uild, weighing 9 'g which is not
)ro)ortioned to 1>> c- in height /ecause according to Pilliteri, a bod !ass
inde" of#######.
2. Posture and Gait
Client S.G -o$e-ents is well coordinated and slightl lordotic. ccording to
)illitteri
3. Over-all Hygiene & Grooming
)on assess-ent client S.G a))eared with unfied hair, unclean finger and
toe nails, with drness on her /oth heel and -uddled clothes, her teeth was
o/ser$ed, and has a ca$ities at the u))er incisors. According to $ozier and
%rb&s 'unda!entals in ursing, !aintaining a clean state prevents disease
infection and conta!ination therefore it is advised to eep the bod clean and
practice proper hgiene at all ti!es.
. Body and breath Odor
o unusual /od and /reath odor. According to *ebber + $elle ealth
Assess!ent in ursing -rdedition that no unusual odors should be assess.
or!al findings noted.
!. Obvious sign o" distress#illness
Client S.G a))eared with no signs of an distress, /ut during the assess-ent
her s'in was o/ser$ed of drness es)eciall on her lower etre-ities.
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According to Pillitteri, no signs of distress and illnesses indicate absence of
co!plications or an disco!fort for an individual.
$. %ental tatus
)on the o/ser$ation, client S.G can e)ress where she is, ti-e and who
others are and can follow instruction she is a/le to recall )ast e$ents.
'. (ttitude
Client S.G o/ser$ed to /e Coo)erati$e since the ea-iner a))eared,
res)onds to all Juestions, )artici)ates in e$er acti$it, and is coherent.
). (""e*t#mood+ appropriateness o" responses
Client was slightl inacti$e /ecause of her ( th)regnanc
,. uantity and uality o" spee*h
Can s)ea' fluentl and can handle long con$ersations
1./elevan*e and organi0ation o" thoughts
+uring the assess-ent client. S.G was alread e)resses her thoughts
logicall rele$antl, and with sense.
.COMPREHENI)E PH&ICA( EAMINATION
A. )ital igns
3:+a Kital Signs Monitoring
+ate %"i-e Tem%erat"re P"lse RateRes%irator,
Rate
*loo#
Press"re
03%03%14 79.7OC 1? 4%m -? $%m -7232 --Hg
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03%04%14 71.-OC 10 4%m /- $%m -7232 --Hg
03%04%14 79.0OC ?/ 4%m - $%m --232 --Hg
According to Pillitteri 200/ aternal and Child ealth ursing th
ed. 3henor!al vital signs of non4pregnant and pregnant wo!en are as follow5
O/%( 45( 4G
on:)regnant regnant
"e-)erature 79.?+71./ 79.?+71./!lood ressure -/23?2 --5390
ulse Date 12 ?2Des)irator Date -/+/2 -/+/2
Inter%retation:
3:+a Kital Sign Monitoring shows that the te-)erature, DD, and D are
at nor-al le$els. "he ! howe$er is higher than the nor-al.
*. Ant;ro%ometri$ Data
Height*eight
!MPre+%regnant %regnant
0 feet / in$; 3 'ilogra- 9 'ilogra- 2.22
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>According to bab.co!, a )regnant wo-an who enters )regnanc should
: 11.2> 'g co-)ared to a nor-al wo-an who needs to
ha$e an increase of 2>.0: 1>.&> 'g.
Com%"tation of *o#, Mass In#e! an# I#eal *o#, eig;t:
*MI%re+%regnan$, Mass in 'g E 3 E 3 E /9.// height in -2 ?1.>>@2 2.402>
I#eal *o#, eig;t+ since SG entered )regnanc o$erweight, she should N 11.2> 'g. Her )re:)regnanc weight is 3 'g and her
latest weight is 9 'g. "herefore, she .2> 'g.
!M SC6;Kalue Inter%retationF-?.0 nderweight
-?.0+/5. or-al *eight/0.2+/. =$erweight
72 =/ese
C. (eo%ol#s Mane"ver fin#ings
Maneu$er Findings -st '"n#al Gri%B "he fetal head is hard, fir-, round
and -o$es inde)endentl of the
trun'. "he /uttoc's is soft
s--etric, has s-all /on
)rocesses, and -o$es with the
trun'. either head nor the /uttoc's
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unifor-it,ede-a, lesions
-oisture,te-). "urgor
andCrac'eds'in on heel
discoloration onother /od)art
?@ 6inea
nigra ?@striae
gra$idaru-
no
defor-ities.
*ar- to
touch asother /od)art.
color
no lesions
no
defor-ities
s'in color
andte-)erature generallthe sa-ethroughoutthe /od
s'in
s)rings/ac' to)re$iousstate
i--ediatel when)inched
illiteri, 200>,>th;dition,age 229
5+iscoloration
of s'in -aresults fro-h)er:)ig-entationduring)regnancusuall foundin face, anda/do-en.8
Hair e$enness of
growth thic'ness,
teture,oiliness,infection
or infestation,/od
hair
s-oothness
dr and
fri## hair
Hair
e$enldistri/uted
!lac' in
color, cutatshoulderle$el.
?:@
)arasitis-
Slightl
oil
Slightl dr
andcoarse.
Hair -ust
/e-oisturi#ed ande$enldistri/uted
andwithout the)resenceof )arasite
S-ooth
and sil'
ail )late sha)e,
teture,/ed color,
surrounding
oor hgiene S--etric
al,
eJual in
length
nail /ed
S--etric
al
eJual in
length
)in'ish in
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tissues,scha-roth sign
!lanch test
)in'ish incolor
nails with
har/oreddirt
?:@scha-rothsign
Ca)illar
refill O 3seconds
color
?:@
scha-rothsign
Ca)illar
refill)ro-)treturn of)in' ?lessthan 3seconds@
HEAD6ull and7a*e
si#e, sha)e ,s--etr
facial features ees for
ede-aand
hollowness
nodules,-asses, de)ressions
S'ull
round in
sha)eBnor-oce)halic
s--etric
al facefeatures
no ede-a,
slight
)erior/italdar'ening
o
nodules,no-asses,node)ressions and notenderness
S'ull is
nor-oce)
halic. S--etric
al featuresa))ro)riate for si#e,
head -a
ha$e oddsha)e dueto -oldingof child/irth
o
nodules,no-asses,node)ressions and notenderness
ccording to)illitteriB
Maternal andChil Healthursing >thed.
+ar' circlesunder the ee-a resultfro- distur/edslee)ing)attern.
8yes andision eyebrowsfor distri/ution Palign-ent,
;e/rows
e$enldistri/utedand
;e/rows
e$enldistri/utedand
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Jualit P-o$e-ent
eyelashesfor
e$enness ofdistri/ution Pdirection of
curl
eyelidsfor
surfacecharacteristics,)osition inrelation tocornea, a/ilitto /lin' PfreJuenc
bulbar +palpebral*on9un*tivaforcolor, teture,
and lesion
% la*rimalglandsa*,nasola*rimaldu*tforede-a,tenderness %tearing
*orneaforclarit, tetureP sensiti$it
aligned
s--etric
al and-o$e withcoordinatio
n
;elashes
fine,e$enldistri/utedoutwarddirectionor curl.
?:@ eelid)uffiness
/lin'
coordinatel ands--etricall
Con
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pupilsforcolor, sha)e,s--etr ofsi#e, direct and
consensualreaction tolight, Pacco--odation
isual (*uity?near P far$ision test@
isual 7ield
5est 8O% 5est
"rans)are
nt andshincornea
?@
;DD6,
/lac'
s--etric
al
a/le toreadnews)rint
cornea is
trans)arent, shin,s-oothand /lin's
when it istouched
?@
;DD6
20%20
$ision
8ars andHearing
auri*lesforcolor, s--etrand )osition
e:ternal*analfor ceru-en,lesions, )us or
/lood
auri*lesforteture,elasticit andareas of
;ars eJual
in si#e,
s--etric
al
)ositionedalignedwith theoutercantus ofthe ees
ears color
si-ilarwith /ods'in color
?:@
discharge,
few ear
waes areo/ser$ed,
no lesions
;ars eJual
in si#e,
s--etric
al
)ositionedalignedwith theoutercantus ofthe ees
ears color
si-ilarwith /ods'in color
?:@discharge,
few ear
waes areo/ser$ed,
no lesions
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tenderness
6ross earingAcuit 3ests5
nor-al $oicetone andwhis)ered$oice
*atch 3ic3est
3unning 'or3ests5
4 *e/er for/one
conduction 4Dinnes toco-)are airand /oneconductions
uricles
are fir-
Decoil
instantl
?:@tenderness
t. a/le to
hear /othnor-alandwhis)ered
$oice
t. can
a))reciatewatch tic'in /othears
ot
ssessed
uricles
are fir-
Decoil
instantl
?:@
tenderness
or-al
andwhis)ered$oice, aswell aswatchstic'audi/le.
ose andinuses
nosede$iationin sha)e si#e,color, flaring,dischargeB
nasal mu*osafor redness,swelling,growth ordischarge
?:@ nose
de$iation
S--etric
al
?:@ nasal
discharge
?:@ nasal
stuffiness
?:@ lesion.
?:@-ucosalrednessandswelling
?:@ nose
de$iation
S--etric
al
?:@ nasal
discharge
?:@ nasal
stuffiness
?:@ lesion.
?:@-ucosalrednessandswelling
ccording toillitteriBMaternal PChild Healthursing >thed.
local changethat oftenoccurs in theres)iratorsste- is-ar'edcongestion, or5stuffiness,8 ofthenaso)harn,a res)onse to
20
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a tenderness,-asses,dis)lace-entsB
nasalpaten*y ma:illaryand"rontalsinusesfortenderness
e the a/o$esinusesfortenderness
3ransillu!ination3est
?:@
tendernes
s, -assesanddis)lace-ent onnasalca$it
atent
nostrils
?:@
tenderness of
-aillarand frontalsinuses
?:@
tenderness,
-asses anddis)lace-enton nasalca$it
atent
nostrils
?:@
tendernessof -aillarand frontalsinuses
increasedestrogen le$el.
%outh #Oropharyn:
lipsfors--etr,contour, color,teture,-oisture, lesion
teethforalign-ent, loss,dental filingsand cariesB
gumsfor/leeding, color,retraction,lesions,
"he teeth
conditionwaso/ser$edunhealth/ecause)resence
of dentalcarriesandca$ities w%etractedteeth at 1st
and 2ndu))erincisors.
6i)s
s--etrical
+ar' red in
color
Moist
?:@ lesion
"eeth
aligned
?@ dental
carries?u))erincisor,u))er
canine,u))er)re-olarsand lower-olars@
Missing
teeth? etracted
6i)s
s--etrical
+ar' red in
color
Moist
?:@ lesion
"eeth
aligned
?:@ dental
carr
?:@ -issing
ll teeth
should ha$eeru)ted.
Gu-s )in'
:::::::::::::::::::::::::
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swelling
tonguefor
)osition, colorP tetureB-o$e-ent, aswell as the/ase of thetongue, -outhfloor andfrenulu-
salivaryglanddu*tsfor
swelling,redness
palatesforcolor, sha)e,teture,)resence of/on)ro-inences
uvulafor)osition P-o/ilit
oropharyn:for color Pteture
tonsilsforcolor,discharge, and
1stand 2ndu))er-olar@
Gu-s are
)in', notenderness, noretractionand no/leeding
"ongue
aligned
centerred incolor,
-o$es
freel
-outh
floors-ooth
?:@ swelling ?:@
tenderness
in'ish
soft )alate
?:@
defor-ities,
?:@/leeding
, swelling,and
lesion
in color,non:tenderand not/leedingnor swelling
"ongue
alignedcenterred incolor,
-o$es
freel
-outh
floor
s-ooth
?:@ swelling
?:@
tenderness
in'ishsoft )alate
?:@
defor-ities,
?:@/leeding
, swelling,and lesionQ
$ula)ositionedat the-idline
=ro)harn
)in'ish
o
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si#e
3est for 6ag
7efle"
nodules, lu-)and ecoriatedareas
$ula at
the -idline
=ro)harn
)in'ish o
o/ser$a/lenodules onthesurface
"onsils
not e$ident
ntact
no
discharge
?@ gag refle
?:@ nodules
?:@ lu-)s
?:@
ecoriation
o/ser$a/lenodules onthesurface
"onsils
not e$ident
ntact
no
discharge
?@ gag refle
o
nodules,
lu-)s andecoriatedareas
NEC:3>%-in. no-asses, nolu-)s, notenderness.
6i$er s)an is :12c- in the rightMC6. 6i$er s)an
is 4:(c- in-idsternal lineBnontenderB no-asses S)leens-all area ofdullness at thto10thri/sBt-)anic oninhalationB notnor-all)al)a/leB
nontenderTidnes notnor-all)al)a/le,nontender, no-asses, noincrease ina/do-inal girth,
ccording tolliteri 200>>thed.
5terusincreases itssi#eB it tendsthe a/do-ento /eco-eglo/ular in
sha)e.8
5ccording to)illitteriBMaternal andChild Healthursing >thed.
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L 6eo)oldsManeu$er for
=! clients for)resentation,lie,engage-ent,attitude,)osition
1st
-aneu$er
le$el of dullnessdoes not change
1st-aneu$er"he fetalhead is
hard, fir-, round,and -o$esinde)endentl ofthe trun'whilethe /uttoc'sfeelsofter,are s--etric,and theshoulders andli-/s ha$e s-all/on )rocessesB
unli'e the head,the -o$e withthe trun'.2nd-aneu$er"he fetal /ac'will feel fir- ands-ooth whilefetal etre-ities?ar-s, legs, etc.@should feel li'es-all
irregularities and)rotrusions. "hefetal /ac', oncedeter-ined,should connectwith the for-found in theu))er a/do-enand also a -assin the -aternalinlet, lowera/do-en.3rd-aneu$er"he head and isnot acti$elengaged inthe/irthing)rocess, it -a/e gentl )ushed
6eo)oldsManeu$er is)refera/l)erfor-ed
after 24 wee'sgestationwhen fetaloutline can /ealread)al)ated.8
3/
http://en.wikipedia.org/wiki/Fetalhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Buttockshttp://en.wikipedia.org/wiki/Symmetryhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Human_headhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Limb_(anatomy)http://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Buttockshttp://en.wikipedia.org/wiki/Symmetryhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Human_headhttp://en.wikipedia.org/wiki/Torsohttp://en.wikipedia.org/wiki/Limb_(anatomy)http://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Pelvimetryhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Fetal -
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/ac' and forth.4th-aneu$er"he head of thefetus is well:fleedB it should
/e on theo))osite sidefro- thefetal /ac'.
M=C=(Ooints swelling tenderness,
s-oothness of-o$e-ent,swelling,cre)itation,nodules
/le to
)erfor-D=Meercises,the chest is
s--etric, s)ine
$erticallaligned
Chest wall
intact, notenderness,no -asses.u-/er offingers )er
each hand isfi$e.
o ede-a,
notenderness,no defor-it
/le to )erfor-D=M eercises,the chest iss--etric, s)ine$erticall aligned,
chest wall intact,no tenderness,no -asses.u-/er offingers )er eachhand is fi$e.
ccording todele illiteri,200>, >thedition, )age23
5"o change hercenter ofgra$it and-a'ea-/ulationeasier,)regnantwo-en tend tostand
straighter, withshoulders /ac'and a/do-enforward,createslordosis8
NE=RO(OGIC
%ental tatus: 6anguage: =rientation
: Me-or: ttention S)an %
Calculation
o slurge
s)eech
t. can
identifwhere sheis.
t. can
lert, awa'e,oriented threeti-es. o slurges)eecht. can identifwhere she is.t. can
30
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;ons*iousnessevel
Glassgow Co-aScale
;ranial erves4 to
/e"le:es: +ee),
su)erficial P)athologic
Gross%otor#Balan*e
> *al'ing Gait
> Do-/erg
> Standing on 1foot w% eesclosed
enu-eratesets ofnu-/ers
Can focus
u)on
inter$iewing
GCS 1>
consciousand aware ofthesurroundings
Can identifthings, candifferentiates-ells, can$iew near orfar, canidentif
Gait
changesha$e /eeno/ser$ed,-anifested/ s-allste)s whilewal'ing
egati$e
Do-/erg
Can stand
on one foot
enu-erate setsof nu-/ersCan focus u)oninter$iewing
GCS 1>conscious andaware of the
/le to wal'straight withoutalteration and aid
Maintains/alance, u)right)osition, and footstance
egati$eDo-/erg
-a swa slightl/ut is a/le to-aintain u)right)osture and footstance
ccording toillitteriB-aternal andChild Healthursing >thed.
5+ifficultiesresult fro-e)andinga/do-en.8
3
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> Heel:toewal'ing
7ine %otor: ))er
;tre-ities> Finger:ose
"est
>lternateSu)ination Pronation of
hands on'nees
> Finger to oseP to D finger
> Fingers:to:fingers
> Fingers:to:thu-/
: 6ower;tre-ities
L Heel downo))osite s'in
L "oe % !all ofFoot to Dsfinger
with slightlswa
Can-aintainheel toewal'ing
Can
re)eatedl
touches thenose
!oth hands
can su)inateand )ronateat ra)id )ace
erfor-s
withcoordination
and ra)idit
Can )erfor-
withaccuracand ra)idit
;ach hand
can ra)idltouches thefinger to
thu-/
;Jual
coordinationof /oth loweretre-ities
Maintain heel toewal'ing along astraight line
De)eatedltouches the nose
lternatelsu)inate and)ronate at ra)id)ace
erfor-s withcoordination andra)idit
erfor-s withaccurac andra)idit
Da)idl touches
each finger tothu-/ with eachhand
+e-onstrates/ilateral eJualcoordination
Mo$es s-oothl,with coordination
3
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ensory7un*tion
L 6ight%+ee)"ouch
L ain Sensation
L "e-)erature
L osition%Tinesthetic
L "actile+iscri-ination
+ifficult of
raising thefoot tostudent
nurse finger
/le to
discri-inatelight or dee)sensation
Can
discri-inatehold to coldte-)erature
Can ra)idl
deter-inethe )ositionof finger
Can
deter-ine
nu-/er offingerstouches the/od )art
"ouch sensation/le todiscri-inate5shar)8 and 5dull8
sensations.
/le todiscri-inate holdto coldte-)erature
/le to deter-inefingers )osition
/le to deter-inenu-/er of fingerstouches /od)art
GENITA(pubi* hair
distri/ution,a-ount,characteristicsBits areas for
)arasites,infla--ation,swelling,lesions
*litoris=urethral andvaginalori"i*es for
Lot
assessed
u/ic S'in intact,no lesions, noinfla--ation, noswelling, nodischarge
ntact anal s'in,anal s)hincterhas good tone
3)
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Normal %;,siologi$al C;anges
Pat;o+%;,siolog,
Dr"g st"#,
NCP