Nursing Case Study
2200 – OB Ward
Submitted By: Liana Monique San Lorenzo
BSN3-2; RLE Group 2
Submitted to: Ms. Vicencio
, NURSING CASE STUDY
ADMISSION DIAGNOSIS:
G2P1 (1001) Pregnancy, Uterine,Term, Cephalic
FINAL DIAGNOSIS:
G2P2 (2002) Pregnancy, Uterine,Term, Cephalic Delivered, Live birth by VSD with right
mediolateral episiotomy and repair
I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1. Client’s initials: H. H. M.
2. Gender (Sex): Female
3. Age, Birthdate and Birthplace: 30 y/o, May 11, 1983, Trece Martires City
4. Marital (Civil) Status: Married
5. Race and Nationality: Filipino
6. Religion: Baptist
7. Address and Telephone Number: B41 L40 Pontevedra Tiera Solana,
Buenavista 3, General Trias, Cavite
8. Educational Background: College Graduate
9. Occupation (usual and present): Japanese Interpreter
10. Usual Source of Medical Care: Clinic – Physician
B. SOURCE AND RELIABILITY OF INFORMATION
The patient was competent to provide information. She was able to speak clearly
and was conscious, coherent and conversant. The patient’s chart was also used as a
secondary source of information.
C. CHIEF COMPLAINTS
“Biglang sumakit ung tiyan ko.”
“humihilab na ung pakiramdam ng tyan ko.”
“Ka-buwanan ko na kasi.”
Page | 1
,D. HISTORY OF PRESENT HEALTH
1 week prior to admission, the patient was expecting birth so she had already prepared
all the needed things including money for her delivery.
On the day of the admission, the patient experienced pain in her abdominal region and
started having contractions. She then immediately decided to go to the hospital because
her pregnancy is already in term and she knew she was about to start labor.
E. PAST MEDICAL HISTORY OR PAST HEALTH
The patient has complete immunization. She said she barely gets sick. She recalled that
she had mumps and chickenpox when she was young, and some occasional fever. Last
2009, the patient was hospitalized because of UTI. The patient’s menarche started
when she was 12 years old, the cycle was regular. Her LMP was on January 23, 2013.
8 Months before admission, the patient had discovered that she is pregnant. The patient
started to suspect that she’s pregnant because of several episodes of morning
sickness, she took a pregnancy test and got a positive result and went to her OB-Gyne
to confirm it. She followed her check-up schedules and her doctor’s health teachings to
have a normal pregnancy.
4 months before the admission, the patient went for an ultrasound and she discovered
that her baby was a girl. She said her current pregnancy was easier than the first. The
patient was taking Ferrous sulfate and Iron supplements as prescribed by her physician.
The patient also did not acquire any sickness during her pregnancy, even fever. Her last
check-up was on September 23, 2013, when she was at 38 weeks AOG which revealed
normal findings.
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, F. FAMILY HISTORY (Family tree or genogram)
Paternal Maternal
UA UA UA UA
UCD UCD UCD UCD
60 57
DM A&W
40 30
A&W A&W
37
A&W
Legend:
UA - Unrecalled age
UCD - Unrecalled cause of death
A & W- Alive and Well
- Male - Deceased
- Female - Deceased
- Client
Synthesis:
The genogram presented in the previous page shows three generation of the
patient’s family. Based on the genogram, the client’s family has a history of endocrine
disorders such as Diabetes Mellitus which she can acquire due to genetics. Other
diseases could be inherited due to the uncertainty in the cause of death of her
grandparents.
Page | 3
2200 – OB Ward
Submitted By: Liana Monique San Lorenzo
BSN3-2; RLE Group 2
Submitted to: Ms. Vicencio
, NURSING CASE STUDY
ADMISSION DIAGNOSIS:
G2P1 (1001) Pregnancy, Uterine,Term, Cephalic
FINAL DIAGNOSIS:
G2P2 (2002) Pregnancy, Uterine,Term, Cephalic Delivered, Live birth by VSD with right
mediolateral episiotomy and repair
I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1. Client’s initials: H. H. M.
2. Gender (Sex): Female
3. Age, Birthdate and Birthplace: 30 y/o, May 11, 1983, Trece Martires City
4. Marital (Civil) Status: Married
5. Race and Nationality: Filipino
6. Religion: Baptist
7. Address and Telephone Number: B41 L40 Pontevedra Tiera Solana,
Buenavista 3, General Trias, Cavite
8. Educational Background: College Graduate
9. Occupation (usual and present): Japanese Interpreter
10. Usual Source of Medical Care: Clinic – Physician
B. SOURCE AND RELIABILITY OF INFORMATION
The patient was competent to provide information. She was able to speak clearly
and was conscious, coherent and conversant. The patient’s chart was also used as a
secondary source of information.
C. CHIEF COMPLAINTS
“Biglang sumakit ung tiyan ko.”
“humihilab na ung pakiramdam ng tyan ko.”
“Ka-buwanan ko na kasi.”
Page | 1
,D. HISTORY OF PRESENT HEALTH
1 week prior to admission, the patient was expecting birth so she had already prepared
all the needed things including money for her delivery.
On the day of the admission, the patient experienced pain in her abdominal region and
started having contractions. She then immediately decided to go to the hospital because
her pregnancy is already in term and she knew she was about to start labor.
E. PAST MEDICAL HISTORY OR PAST HEALTH
The patient has complete immunization. She said she barely gets sick. She recalled that
she had mumps and chickenpox when she was young, and some occasional fever. Last
2009, the patient was hospitalized because of UTI. The patient’s menarche started
when she was 12 years old, the cycle was regular. Her LMP was on January 23, 2013.
8 Months before admission, the patient had discovered that she is pregnant. The patient
started to suspect that she’s pregnant because of several episodes of morning
sickness, she took a pregnancy test and got a positive result and went to her OB-Gyne
to confirm it. She followed her check-up schedules and her doctor’s health teachings to
have a normal pregnancy.
4 months before the admission, the patient went for an ultrasound and she discovered
that her baby was a girl. She said her current pregnancy was easier than the first. The
patient was taking Ferrous sulfate and Iron supplements as prescribed by her physician.
The patient also did not acquire any sickness during her pregnancy, even fever. Her last
check-up was on September 23, 2013, when she was at 38 weeks AOG which revealed
normal findings.
Page | 2
, F. FAMILY HISTORY (Family tree or genogram)
Paternal Maternal
UA UA UA UA
UCD UCD UCD UCD
60 57
DM A&W
40 30
A&W A&W
37
A&W
Legend:
UA - Unrecalled age
UCD - Unrecalled cause of death
A & W- Alive and Well
- Male - Deceased
- Female - Deceased
- Client
Synthesis:
The genogram presented in the previous page shows three generation of the
patient’s family. Based on the genogram, the client’s family has a history of endocrine
disorders such as Diabetes Mellitus which she can acquire due to genetics. Other
diseases could be inherited due to the uncertainty in the cause of death of her
grandparents.
Page | 3
