Case Presentation

Psychosocial Assessment 1. Lifestyle Information KMC is a 19 year old, single, a Roman Catholic and lives with her parents, three brothers and uncle at Buga, Leon. She was a second year college student major in Special Education at West Visayas State University but stopped schooling but didn’t tell why. When she was pregnant she lives at Iloilo city with her husband to be. But then, when she was six months pregnant, she went home to Leon to have a rest from all her household chores in the city. During her stay with her parents, she was always accompanied by her mother in a once a month prenatal check-up at a Health Center in Buga. Her last prenatal check-up was August 13, 2009. During pregnancy she confessed that she really like sweets like chocolates and fruits. 2. Normal Coping Patterns When she was under physiological and mental stress, she usually watches TV to relieve her stress. But when she had emotional stress caused by the pregnancy, she usually talks to her mother. She said that her labor was a severe stress that she recently experienced because of the difficulty and pain that she felt during the delivery. Her mother was at her side to comfort her at the ward after her delivery. 3. Understanding of Current Illness She understood that her delivery was very difficult because it was her first. She also said that her labor process was very painful and promised that she will never get pregnant again to avoid experiencing this event again. 4. Personality style KMC shows cooperation on her health care and has no negative traits that may affect her care compliance. She has a pleasant personality, smiling most of the time. 5. History of Psychiatric Disorder KMC has no history of psychiatric disorder. 6. Recent Life Changes KMC considers her recent delivery a big change in her life. After carrying the baby in her womb for approximately 9 months, now she can see the baby besides her sleeping deeply. It was a big shift from her being single to a mother. 7. Major Issues Raise by Current Illness KMC was unable to do her activities of daily living. But a new member was added to their family that gave her pride and confidence. The baby was a blessing for her.

8. Mental Status Appearance

Description: KMC wears neat and clean clothing, has well-combed hair and relaxed position. Her nails are clean and well-trimmed. Converses with good eye contact.

Behavior Description: KMC is calm, alert and awake. She respond to questions appropriately.

Speech Description: KMC’s speech is appropriate, clear and understandable. She shares conversations appropriately. She can understand and speak Hiligaynon, Tagalog and English.

Mood/Affect Description: KMC’s mood is appropriate with her facial expression and she smiles occasionally.

Thoughts Description: Themes in conversation are usually about her situation, her life and her baby. She answers questions appropriately and has sense.

Ability to abstract:not assessed

Memory: Impaired recent memory: No

Impaired Past Memory: No Number of objects able to remember after 5 minutes: not assessed Description: KMC was able to remember recent and past memory without difficulty. She was able to recall her 24-hour diet and the date of her last prenatal check-up that was verified by her mother.

Estimated Intelligence Average

Concentration Easily distractable Able to subtract: not assessed

Orientation Person / time/ place / situation / Judgment Realistic decision making

Yes

No

Description: Not assessed Insight Good Fair

Poor

Description: Not assessed II C. Clinical Inspection 1. Vital Signs T = 36.9°C / axilla PR = 72 beats/min BP = 130/70 mmHg RR = 16 breaths/min 2. Height = 160 cm 3. Weight = 51 kg before delivery 4. Physical Assessment

General Appearance Posture is erect and position is relaxed. Well-developed build of body for age. Neatly dressed in light clothes appropriate for the situation. Clean and trimmed nails. No presence of body and breath odor. No signs of distress in posture and facial expression. Cooperative and answers questions with good eye contact. Speech is fluent, clear and moderately paced. Able to recall recent and past events without difficulty. Apparent age is appropriate to present age. A. Integumentary System Skin color is brown, lighter in palms, soles and nail bed and warm to touch. Discoloration on the lower extremities noted No lesions noted. Hair black, length is 2 inches below the shoulder , wavy, clean and thick. Equal distribution of hair on scalp. Hair is slightly oily and slightly rough. Scalp is pink, with no lesions. Scalp is smooth and nontender. Nails are welltrimmed, clean and form a 160° angle at the base; immobile, hard and smooth with no clubbing. Nail beds are round. Nails are attached to nail beds. B. Neurologic System Eyes are almond-shaped and symmetric. Eyebrows are symmetric and no flakes are noted. No redness, discharge or crusting noted on lid margins. Conjunctivae is pink, smooth and moist. Sclerae is white, moist, with no redness or lesions. No excess tearing on lacrimal apparatus. Cornea is transparent, smooth and moist with no opacities; lens is free of opacities. Irises are round, flat, and evenly colored brownish black. Pupils are equal in size approximately 3 mm in diameter. Ears equal in size bilaterally, smooth. Pinna recoils in less than 2 seconds. Tip of pinna is aligned with the outer canthus of the eye. No discharge, nontender on palpation. Mastoid process is nontender. Cranial Nerves I II

III, IV, VI

Able to identify on each nostril separately (coffee) Able to read SN’s nameplate at a distance of 2 ft. Light reflected on the same location of the iris. Direct and consensual reaction to light when pupils are shun with light. PERRLA noted on both eyes. Able to perform the 6 extraocular movements. Thecovered and uncovered eyes are not wandering

during the cover/uncover test. V Able to identify simple touch equally on both side of the face. Temporomandibular joint is symmetrical and coordinated VII Able to perform facial movement. Facial muscle movements are symmetrical. Able to identify taste (sweet and salty) VIII Able to hear and repeat the word “Joan” and “Marie” on voice test. IX and X Able to identify the different taste and name of substance. Uvula is midline and hanging freely, manifest gag reflex and tonsils are Grade 2 XI Able to perform active ROM of neck muscles (flexion, lateral flexion, hypertension). Equal shoulders against resistance. XII Tongue is able to exert equal resistance KMC was able to identify light touch equally on both sides of the body on the upper and lower extremities. Able to identify sharp and dull pain on upper and lower extremities.KMC is able to identify the arm where light touch is applied (Extinction phenomenon). Able to perform finger to thumb, finger to finger and finger to nose test. Not able to perform the sliding of heel from knee to shin of the other leg due to muscular pain. C. Respiratory System Nose is smooth and symmetrical and medium-sized. Able to sniff and blow through each nostril. Nose has no tenderness and masses. Nasal septum is not deviated. Nasal mucosa, septum and turbinates are moist and pinkish and free of lesions. No discharges are noted. Sinuses (maxillary and frontal) are nontender to palpation and percussion. Trachea is midline. RR = 16 breaths/min. Breath sounds are bronchovesicular on the lung area and vesicular below the lung area. Anterior chest is symmetrical and normal shaped. Breathing pattern is effortless and regular. The trachea manifested bronchial breath sound, the lung area bronchovesicular and below the lung area vesicular. D. Cardiovascular System

Temporal arteries are palpable, strong and regular. Carotid arteries are palpable, strong and regular. Pulsations of precordium are not visible on inspection. Heart sounds are strong and normal. Apical pulse is 72 beats/min. S1 is louder than S2 in apical area. Radial pulse is 72 beats/min. Ulnar, brachial, popliteal and dorsalis pedis pulse are palpable, strong and regular. Capillary refill time on fingers and toes is 2 seconds. E. Gastrointestinal System Lips brownish pink, smooth, moist and without lesions. Buccal mucosa is pink and moist. Thirty-two white teeth present with no cavities. Gums pink without redness and swelling. Tongue protrudes at midline without tremors. Ventral surface of tongue is smooth, moist and pink. Dorsal surface with midline fissure and rough. Frenulum in midline. Hard palate white and bony. Soft palate pink and moist. Midline and symmetric elevation of uvula and soft palate with phonation. Tonsillar pillars pink. Tonsil Grade 2. Jaw alignment is symmetrical. Abdomen is symmetric. Bulges noted. Umbilicus is midline and inverted. Rectum is free of haemorrhoids, masses, tenderness and discharges. F. Endocrine System Thyroid gland is midline, smooth, firm and nontender. Ascends during swallowing. G. Reproductive System Breast bilaterally the same size. Breast color is light brown. No masses noted. Mild discharges noted. Areola is brownish in color. H. Genito-Urinary System KMC has not yet voided four hours after delivery. Genitals is dark brown and nearly black, symmetric . Pubic hair is evenly distributed, thick and curly. I.

Musculoskeletal System Cranium is hormocephalic and proportional to the body. Temporomandibular joint is freely moving and nontender. Cranium is symmetric. Face is oval in shape and symmetric. Neck is midline and symmetrical. Vertebral column is vertically straight. Spinous process are aligned and evenly spaced. No tenderness, swelling and masses upon palpation of joints. Muscle strength is 5/5 in the upper extremity and 3/5 in the lower extremity. No edema present.

J.

Hematopoietic System

Conjuctivae is pinkish and moist. Capillary refill time on fingers and toes is 2 seconds. K. Lymphatic System Axillae no odor noted. Shaved hair on the axillae. Postauricular,subauricular, submandibular, occipital,submental,deep cervical chain, superficial cervical and supraclavicular lymph nodes are nonpalpablee, no masses and tenderness noted. Tonsil is grade 2. II D. Other Sources of Data KMC has no laboratory data.