different type of case

1. Group 2

2.  The disorder usually occurs in the third trimester of
pregnancy and gets worse over time. In severe disease, the
risk of poor outcomes for both the mother and the baby
includes: red blood cells breakdown, a low blood platelet
count, impaired liver function, kidney dysfunction,
swelling, shortness of breath due to fluid in the lungs, or
visual disturbances.
 Risk factors for PE include: obesity, prior hypertension,
older age, and diabetes mellitus. It is also more frequent
in women's first pregnancy and if she is carrying twins.
Risk factors for PE include: obesity, prior hypertension,
older age, and diabetes mellitus. It is also more frequent
in women's first pregnancy and if she undergone 2
Cesarean section already.

3.  Name: RSD
 Age: 38 years old
 Address: Quezon City
 Sex: Female
 Marital Status: Single
 Religion: Roman Catholic
 Occupation: Budget and MGT Analyst

4.  Before Hospitalization
◦ The client is aware of her health condition and
obeyed her Physician’s order which is to undergo
another Caesarian Section Delivery because of her
maternal age which is 38 years old and her
history of pregnancy induced Diabetes on her 1st
baby at 33 years old.
 During Hospitalization
◦ Patient came for scheduled Ceasarian Section
with Bilateral Tubal Ligation with history of
watery/bloody vaginal discharge, with good fetal
movement.

5.  Caesarian delivery on 1st and 2nd child
 Patient came for scheduled Ceasarian Section
with Bilateral Tubal Ligation with history of
watery/bloody vaginal discharge, with good
fetal movement.

6.  Addiction (Drugs/Alcohol) Occasional
 Arthritis (-)
 DM Pregnancy induced
 Mental Disorder (-)
 CVA (-)
 Kidney Disease (-)
 Cancer (-)
 Heart Disease (-)
 Hypertension: both parents
 Sickle Cell Anemia (-)
 Chronic Lung Disease (-)
 Others : none

7.  Immunization/Exposure to Communicable
Disease:
◦ With no previous diagnosed communicable disease
and no known immunization.

8.  Alcohol Use: Occasional
 Tobacco Use: No
 Drug Use: No
 Caffeine Intake: Yes

9.  Menarche: Doesn’t Recall
 For Pregnant Client:
◦ OB Score (GPTPALM): G3P2 (20020)
◦ LMP: February 15, 2019
◦ EDC: November 22, 2019
◦ AOG: 38 weeks

10. Pattern Before Hospitalization During Hospitalization Analysis
Health Perception
The patient is aware of her
condition which is very fragile
and sensitive so she keeps herself
and the baby healthy by eating
healthy foods and doing some
exercises and house chores. She
stated that they have a slight
problem in financing health care
services
The patient was able to adapt with
her situation and procedures done
to her. She also understands why
she felt pain in her belly and that
it will take time to heal. She has
no known allergies and their
family has a history of
hypertension.
The patient knows and
understands what the right things
to do and she strictly compromise
for the sake of her and her baby.
Nutritional-
Metabolic
The patient eats less rice and
drinks at least 8 glasses a day and
eats at least 4 times a day. She
sometimes eats snacks but most of
the time she eats fruits and
vegetables. She mentioned that
she sometimes drinks softdrinks.
The patient eats soft diet foods
delivered by the dietary
The patient is able to adapt with
the changes in her diet. She
strictly monitors her intake of
foods and drinks.

11. Pattern Before Hospitalization During Hospitalization Analysis
Elimination Usual pattern is every
2 days and with
frequent urination
pattern.
Usual void is 8 a day
Positive stool during
the first day (1x)
Have voided after the
removal of the
catheter
Eliminated during the
first day of
hospitalization and
was able to switch to
Soft Diet.
Activity/Exercise Participated to Zumba
sessions, with
continuous walking
and commute from
home to work
Bedrest With
Bathroom privilege
The patient has a
limited ROM due to
her previous surgery.

12. Pattern Before Hospitalization During Hospitalization Analysis
Sleep-Rest Sleeping pattern is between
11 pm to 4 am with no
naps during the day due to
her work but was able to
sleep with ease.
Usual time of sleep is at 11
pm and woke up at 6 due to
hunger and nurses’ at
rounds.
The patient is lacking of
good sleep because of her
work and her duty as a
mom.
Cognitive/Perceptual Functioning well and is
working during the days,
with clear perception and
was able to communicate
well.
Is easy to talk to with clear
and good response with
fast and detailed answers to
questions.
The patient has a good level
of understanding and can
communicate well.
Role/Relationship Has a positive relationship
with her family even if she
is not yet married
With good relationship
towards her family ,
accompanied by her live in
partner during
hospitalization
No alterations.

13. Pattern Before Hospitalization During Hospitalization Analysis
Sexuality/Reproductiv
e
No family
planning method
used –
withdrawal
method
Underwent
Bilateral Tubal
Ligation
The patient and
her partner
agreed to do the
procedure since
they are sexually
active.
Coping/Stress Tolerance The patient
verbalized
sleeping, eating,
surfing the net
(Facebook) and
ignore things if
stressed.
Watching TV and
surfing the net.
Patient accepts
present
condition with a
positive attitude.
Value/Belief Roman Catholic , Bigkis, unton Due to her

14. BODY PART FINDINGS ANALYSIS
Eyes Visual acuity- 550 eye
grade
Field of vision – unable to see
widely
Cannot able to see far
away objects without her
glasses
Lips Pale pink and slightly dry Due to post operation
Abdomen Classical caesarean
(horizontal cut incision)
Patient’s choice (previous
cut)
Tender and restricted
movement

17.  Pre-operation Diagnosis:
 history of watery/bloody vaginal discharge, with good fetal
movement.
 Post-operation Diagnosis
◦ Operative delivery term alive girl cephalic, 38 weeks
AOG, G3P3 (20020)