 BIOGRAPHICAL DATA:

Name: Marian Joy Besas

Address: Marilao, Bulacan
Birthdate: September 12, 1996 Age: 22 y/o Occupation: Housewife

Sex: Female Civil Status: Live-in Religion: Catholic

Phone number: 090565898
Provider of History: Client
Place of Birth: Marilao
Language: Tagalog
Educational Attainment: College Undergraduate
Occupation of Live in Partner: Helper (Trucking Company)
Obstetric score: G2,P2 (2002)
Chief Complain: Labor Pain
Significant other/ Support Person: Husband
Date of Interview: July 29, 2019

 REASON/S FOR SEEKING HEALTH CARE:

Reason for Seeking Health Care
Mrs. M went to the hospital on July 19, 2019 because of labor pain, and she delivered on 3:46
am to alive baby girl with birthweight of 3510g.
Feelings about seeking healthcare
Upon interviewing she stated that “parang wala lang normal lang yung pakiramdam sakin, kaso
puro sakit lang yung nararamdaman ko nung mga oras na ‘yon” as verbalized.

 HISTORY OF PRESENT HEALTH CONCERN

Character
She experienced like stabbing pain, “Para siyang tinutusok tusok na parang pinipiga na hindi ko
maipaliwanag yung sakit basta masakit na masakit siya” as verbalized by the client. And it is
getting worse as times passed by.
Onset
It started on Friday afternoon at exactly 2pm after doing housework.
Location
She pointed her hypogastric region and states that it radiates to her lower back and that is the time
that her husband bring her to the hospital
Also stated that “pati pagitan ng hita ko sobrang sakit”.
Duration
Labor pain lasts for 10-15 minutes, then it takes about two hours to feel the pain again.
Severity
She rated the pain in a scale of 9, to the point that no one can speak to her and cry because of pain.
 Pattern
She stated that it gets worse when “humihilab and naninigas yung tiyan ko, nawawala wala naman
siya tapos babalik na naman yung sakit pagkatapos ng dalawang oras” as verbalized.
Associated Factors
She said that before the pain was being felt she just finished doing her routine in their home which
is washing their clothes, then when the pain goes on and off she continue doing it again.

 PAST HEALTH HISTORY

Problems at birth
Mrs. B doesn’t have any problems at birth
Childhood illnesses
During her childhood, she had mumps and only experienced common cold, cough and flu.
Immunizations
She had a complete dose of vaccines.
Adult illnesses
When she was 17 years old she had chickenpox, cold, cough and flu.
Surgeries
She had appendectomy last March 20, 2018 when she was 21 years old.
Accidents
She haven’t involved to any accident she stated.
Prolonged pain
She had experienced prolonged pain when her gums was swollen and affect almost half of
her face that lasts for 1 and half week.
Allergies
She claims that she has allergies on seafood, when excessive intake. And in some medications
such as antibiotics. “nagkakaroon ako ng rushes sa balat kapag nasobrahan ako ng kain ng mga
sea foods” as verbalized.
Physical, emotional, social and spiritual weaknesses
She said that when she got pregnant she cannot do travel from Bulacan to Manila while
riding in her husband’s motorbike. She also suffered depression, due to the separation with her
first live-in partner, to the point that she couldn’t eat for a day. She also claims that even she is
pregnant her faith with God didn’t change, instead she go to the church every Sunday.
Physical, emotional, social and spiritual strengths
She claims that even she’s pregnant she can still do her routine in their house but it is
limited. She cannot do lifting heavy objects considering she is pregnant. She stated that her
husband and her first born was the source of her energy, her life and her happiness. Together with
her first born she can do socialize with others. During her pregnancy it more strengthens her faith.
  HEALTH HISTORY

Family health History

Mrs. M’s mother is Sarah Candano, she can’t even recall the age. But she claims that it is
still alive. She does not know where it lives because her mother and father was separated long time
ago when she was 14years old only.
Her father is Danilo Magisa, she also don’t know where is her father, she stated that “huling
kita ko lang sakanila nung bata pa ako eh kaya hindi ko na matandaan”.
On her maternal side she stated that all of her relatives are already dead. Her grandfather
died because of tuberculosis, but recently her aunt, Segundina Candano, died because of old age.
She stated that she doesn’t have nephew on her mother’s side.
On her paternal side, both of her grandparents are already dead and doesn’t even know their names.
She had no ideas about her father’s family side.
Mrs. M had 3 children all of them are girls, first born is Irish Jade Diez, 15 years old,
studying as grade 10 student at Carlos F. Gonzales High School and a working student, second
born is Julien ann Diez 10 years old, a grade 5 student. She had miscarriage on her third pregnancy,
in fact she doesn’t even know that she is pregnant during that time “nangangahoy kasi ako noon,
nag-iigib rin ako ng tubig nagulat nalang ako dinudugo ako, pumunta ako ng ospital at doon ko
lang nalaman na buntis pala ako ng tatlong buwan”. She had undergo dilatation and curettage. Her
last born is baby Luisa Diez.

Obstetrical History
She stated that she had her menarche when she was 43 years old and her menstrual cycle goes
in a regular manner with 5 to 7 days duration. During her menstrual cycle, she experiences heavy
flow on her first and second day and uses about 4 sanitary pads a day.
Her thelarche started the same age as she had her menarche.
She had her coitarche at the age of 17 years old with her last boyfriend before her husband now
and had her first born when she was 22 years old.
She couldn’t recall her last menstrual period. Her OB score is gravida 4 para 3 with three term,
no preterm, 1 miscarriage, 3 living children, and no multiple birth.
As obtained in the interview, she had all her 3 living daughters delivered in a normal
spontaneous delivery at their house in full term, but baby Luisa is the only one who delivered at
the hospital, in full term also and with no complications while giving birth.
For her miscarriage, she mentioned that she undergo Dilatation and Curettage (Raspa).

 REVIEW OF SYSTEMS
General Appearance
Mrs. G is wearing a gray shirt and printed pajamas. She is conscious and coherent. Maintains eye
contact upon interviewing, speaks clear but there’s instance that she cannot understand my
questions and tended to repeat it to her. She has a wide body frame, had no deformities.
Vital signs:
Blood pressure: 110/80 mmHg
Temperature: 36.7 degrees Celsius
Pulse rate: 88 beats per minute
Respiratory Rate: 24 breaths per minute
Skin
Skin is dark brown, no presence of jaundice, not cyanotic, had a bit of discolorations due
to her chicken pox’s scar, have a rough and dry skin on both lower and upper extremities, no edema
seen.
Head/ hair
Her head is normacephalic upon palpation no tenderness and any unusual mass being
palpated. She has short black hair a little bit oily, no dandruff and lies seen on her scalp and hair,
little bit hair loss no alopecia areata.
Face
She had an oily face, had a visible dark spots because of her chicken pox’s scars.
Ears
Her ears are symmetric with each other, no drainage seen, hearing acuity is fine as well.
Eyes
Her eyes are both round in shape, brownish in color, no redness and drainage seen.
Conjunctiva is slightly pale and no inflammation.
Nose
She had Filipino typed of nose, no discharge seen, can breathe normally through her both
nostrils. No blockage during inhalation and exhalation.
Mouth
Her lips are black in color although she is not using cigarette, and appears dry. She has
incomplete set of teeth on the upper front part, there are also a dental caries seen, it is yellowish in
color. And there is presence of halitosis.
Thorax and Lungs
Mrs. M does not use any accessory muscles to assist her breathing but she had a respiratory
rate of 24bpm, upon asking her if she experiencing difficulty of breathing she answered “hindi
okay lang ako” as verbalized.
Breast
Her nipples are dark in color, had a stretch marks on both breast.
Upper extremities
She had dirt under nails. A capillary refill time of 2-3 seconds, her hand is warm to touch
but little bit rough in texture.
Abdomen
She had a prominent striae gravidarum all over her abdomen, her umbilicus is round and
have seen dirt on it.
Lower extremities
I haven’t seen any swelling and edema on her feet, but seen a lot of stretch marks on the
back part of her knee. Had seen a scars on her lower legs, and toenails are appear dirty.
  LIFESTYLE AND HEALTH PRACTICES
Description of a typical day
Upon interviewing Mrs. B she stated that she spends her whole day in doing housework,
preparing the food for breakfast, getting ready for her husband’s materials for his work
including his lunch, and taking care of her child. She wakes up at around 5am, and prepares
for everything. At exact 10am she prepares for their lunch and ate at exactly 11:30am before
she bring her daughter to the school.
Nutrition and weight management
She stated that she is much prefer in foods she prepare rather than eating processed foods.
She do prepared foods more of vegetables, fish and fried foods in serving. “yung pwedeng
ipambaon sa school tsaka sa trabaho yung niluluto ko talaga” as verbalized.
24 hour dietary intake
In every day, she only ate 3 times- during breakfast lunch and dinner. She usually
consumes 2 cups of rice every meal and prefers to eat vegetables and meat foods. She usually
takes her breakfast at 6:30 in the morning. Her lunch is usually 11:30, her dinner would be
around 7 in the evening with her whole family.
For her fluid intake, she drinks up to 2-3 liters of water every day.
Who purchase and prepares meals
She claims that she is the one who prepares and purchase their daily foods from the market
near them and accompanied with her husband.
Activities on a typical day

Sleep and rest pattern

She usually sleep at around 10pm and wakes up at around 5 in the morning, she also takes a
nap for 30 minutes to 2 hours in the afternoon just to have her body rest. When she’s not pregnant
her sleeping hours is usually 5 hours, but during her pregnancy she stated that she felt discomfort
while sleeping but tend to have a complete 8hours of sleep every day.
Use of medications and other substances
Mrs. B takes vitamins such as Stresstabs and Fern C, doesn’t use any kind of alcoholic and
with nicotinic substances.
Self-care Responsibilities
She usually takes a bath in the morning and before going to sleep “para fresh bago matulog”
as she verbalized. She spends 30minutes for bathing and uses a cold water or buhay na tubig from
their “nawasa”. She uses shampoo, and safeguard soap for the body and face, she did not use any
perineal/ feminine wash. She also used deodorant and brush her teeth right after bathing but do
not brush her teeth after meals.
She stated that she is not able to put makes up on even baby powder and lipstick “kahit
umaalis ako ng bahay ganito lang itsura ko natural lang” as verbalized.
She stated that she defecate once a day when she was pregnant up until now, her observation
towards her feces is that its usual color is brown, semi-formed in consistency.
She experiencing frequent urination when she was pregnant for about 8 to 10 times a day.
Social Activities for fun and relaxation
She stated that she had no time for relaxation and social activities, she also claims that her
ways of relaxing is by watching television at home.
She doesn’t have any activities contributing to her community.
Relationship with the Family, Significant Others, and Pets
She had a happy and strong family. She considered her family as gift from god and her
treasures. When problems arise between her and her husband her first born is the problem solver,
she loves her family more than herself she stated.
They have also a strong relationship with their neighborhood.
They have ducks in their home and her husband is responsible for taking care of it.
Values, Religious Affiliation, and Spirituality
Mrs. M stated that her mother taught her the values of being respectful to the elderly, and “dapat
daw marunong kami sa gawaing bahay, at ‘yon rin yung tinuturo ko sa mga anak ko” as she stated.
They usually go to the church every Sunday, and prays before eating their meals and before going
to sleep.
Finances
When it comes to finances, her husband and her first born is their provider. The income of her
partner would be used to pay the bills which includes water, electric, and buys for their basic
necessities. While her daughter’s salary would eventually go to daily expenses of her in daily
school, when it has extra money she gave her mother at least 500 pesos as her pocket money.
Stressors in life
She stated that her stressors is her husband and her daughters.
Residency, Type of Environment, Neighborhood and Environmental Risks
They live as a nuclear family- consisting of her, her partner, and their 3 daughters.
Their house is a semi-concrete, with plywood, with 1 bedrooms that all of them occupied it, a
comfort room, and a kitchen. It is built near highway.
Their access towards health center, schools, church, malls and other landmarks requires them
to ride a tricycle or a jeepney.
The surrounding environment is well maintained. There are no pest seen nearby nor stray dogs
and cats. Some mosquitoes and flies are observed but is not that disturbing.
Waste segregation is also being practiced in their area. But the garbage truck cannot reach their
house to collect it, so they are required to go to it, neither they burnt it near their house.“kapag
hindi nakokolekta yung basura naming sinisigan ko nalang” as verbalized by the client.
  HEALTH TEACHINGS IMPARTED
After having the interview with Mrs. M, I have told her few things that might help her.
Nutrition
Encourage to eat foods rich in iron like green leafy vegetables and meat organs.
Proper hygiene
I advised Mrs. M the right management for herself as well to her baby’s wellness. That
took a bath right after discharge from the hospital and change her diaper and washed it with
feminine wash it is to prevent of having infections and promote comfortable feeling to the client.
Continue breastfeeding at home
Instructed Mrs. M the right position when feeding her baby, it is to prevent aspiration, and
breastfeeding is the most important matter for the baby’s first year of life. Also emphasized the
benefits from both mother and baby.
Health History
&
Physical
Assessment

Submitted to: Mrs. Elizabeth Bantique

Submitted by: Allyssa Mae Mempin
BSN II-B