BULACAN STATE UNIVERSITY UNIVERSITY CITY OF MALOLOS S.Y. 2011-2012
CHN 101-B
PRENATAL CARE
SUBMITTED BY:
SUBMITTED TO:
GROUP 2
Rosemarie Bartolome, RN
LEADER:
Dela Cruz, Mary Grace C.
Heinrich Presas, RN
MEMBER:
De Chavez, Sheila Marie D. De Jesus, Jade M. De Vera, Paula Marie E. Del Rosario, Kristine M. Diaz, Elisha Rose C. Federis, Nerissa Joy Flores, Marjelene G. Garcia, Janette C. Jamakeo, Robheille Kathleen B. Junio, Ma. Jaecelyn S.
Abigail Ramos, RN Daisy Reyes, RN
TABLE OF CONTENTS
I. II. III. IV.
INTRODUCTION...PAGE 1-2 OBJECTIVES OF THE CASE PRESENTATION PRESENTATION ..PAGE ..PAGE 3 SIGNIFICANCE OF THE CASE STUDY..PAGE 3 SUMMARY / SIGNIFICANT FINDINGS OF ADB.PAGE 4 A. DEMOGRAPHIC/SOCI DEMOGRAPHIC/SOCIO-ECONOMIC, O-ECONOMIC, CULTURAL AND ENVIRONMENTAL ENVIRONMENTAL CHARACTERISTICS.. CHARACTERISTICS...PAGE .PAGE 4 B. HEALTH STATUS..PAGE 5 1. GENOGRAM.....PAGE 5 2. NUTRITIONAL ASSESSMENT...PAGE 6-9 y
FUNCTIONAL HEALTH PATTERN.....PAGE 6-9
y
HISTORY OF PRESENT / CURRENT ILLNESS....PAGE 9
HISTORY OF PAST ILLNESS..PAGE 9 3. GROWTH AND DEVELOPMENT....PAGE 10-11 y
DEVELOPMENTAL ASSESSMENT.....PAGE 10-11 4. RISK FACTOR.PAGE 11 5. PHYSICAL ASSESSMENT.PAGE 12-21 6. RESULT OF LABORATORY/DIAGNOSTIC LABORATORY/DIAGNOSTIC AND OTHER SCREENING PROCEDURE..PAG PROCEDURE..PAGE E 22 C. VALUES, HABITS,PRACTICES ON HEALTH PROMOTION,MAINTENANCE PROMOTION,MAINTENANCE AND DISEASE PREVENTION..PAGE PREVENTION..PAGE 23 V. APPLICATION OF NURSING THEORY IN THE CARE CA RE OF CLIENT CLIENT .PAGE .PAGE 23-24 VI. HEALTH CONDITION AND PROBLEM SHEET....PAGE 25 VII. INDIVIDUAL NURSING CARE PLANPAGE 26-28 VIII. IMPLEMENTATION OF NURSING CARE PLANPAGE 29 y
CONDUCT OF HEALTH EDUCATION..PAGE 29 CONCLUSIONPAGE 30 BIBLIOGRAPHY..PAGE 30 y
IX. X.
I.
INTRODUCTION
What
is prenatal care and why is it important?
Prenatal care is the care of woman gets during pregnancy. Getting early and regular prenatal care is important for the health of both mother and the developing baby. In addition, health care providers are now recommending a woman to see a health care provider for preconception care, before she is even trying to get pregnant. Health care providers recommend to take the following steps to ensure the best health outcome for mother and the baby: y
y
y
II.
Getting at least 400micrograms of folic acid every day to help prevent may types of neural tube defects. Health care providers recommend taking folic acid both before and during pregnancy. Being properly vaccinated for certain diseases ( such as chickenpox and rubella ) that could harm a developing fetus. It is important to have vaccinations before becoming pregnant. Maintaining a healthy weight and diet and getting regular physical activity before, during and after pregnancy.
OBJECTIVES OF THE CASE PRESENTATION
Page 2
GENERAL: y y y
To acquire more knowledge about prenatal care. To discuss the importance of prenatal care. To be more confident and independent in rendering nursing care to our client specifically pregnant woman.
SPECIFIC: y y y
III.
To give knowledge about the importance and objectives of prenatal care. To formulate significant nursing diagnosis that will help the client resolve her p roblem. To build trust and establish rapport in dealing with the client in rendering nursing care.
SIGNIFICANCE OF THE CASE STUDY To detect any problems or complications to the mother and to the baby. To avoid potentially serious consequences for both the mother and her baby. To help keep the pregnant woman and her baby healthy. y y y
IV.
SUMMARY/SIGNIFICANT FINDINGS OF ADB
Page 3
A. DEMOGRAPHIC/SOCIO-ECONOMIC, CULTURAL AND ENVIRONMENTAL CHARACTERISTICS
FAMILY STRUCTURE, CAHRACTERISTICS AND DYNAMICS/RELATIONAL PATTERN MEMBERS OF HOUSEHOLD MEMBERS NOT CURRENTLY LIVING WITH THE FAMILY LIVING WITH THE FAMILY
Mr. L.S is the head of the family; he is 35 yrs. Old (construction worker). Mrs. C.S is the mother of three children and currently bearing a 9 months old fetus. Age of gestation: 38 weeks and 1/7 days. Siblings: A.S female, 16 yrs. Old. A.S male, 15 yrs. Old A.S female, 14 yrs. Old y
y y
Eldest daughter of Mrs. C.S currently not living with the family because it attends school at Valenzuela where her sister resides.
SOCIO/CULTURAL CHARACTERISTICS
HOME AND ENVIRONMENT
Mr. L.S is a high school graduate, he works as a construction worker in Palapat, while Mrs. C.S is also a high school graduate and stays at home taking care of their children. Monthly income of the family is about 5,000-10,000 pesos and it came from the work of Mr. L.S. Mrs. C.S states that the family isnt earning enough to provide all the necessities and also not able to save money. According to Mrs. C.S they believed that illness is caused by the physiologic factor such as infection and caused by the changed in weather, and health can be restored by health personnel such as nurses and doctors. Her family actively joins fiesta and religious procession. Mrs. C.S also have a good communication with other members of the family.
They live in small house which is made up of plywood and cement. They all sleep together in one room. They use electricity as their source of light. Their floor is soil and when the rain comes it became muddy.
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B. HEALTH STATUS 1. GENOGRAM
Mr. M.M O.G
Mr. R.S 40 y/o
Mr. H.S 38 y/o
Mrs. B.M A/W
Mrs. C.S 35 y/o
Mr. S.S LC
Mrs. A A/W
Mrs. E.L 32 y/o
Not Recognized
Mr. AL 38 y/o
LEGEND: - MALE -
FEMALE
-
DECEASED
-
FETUS
O.G OLD AGE L.C LUNG CANCER A/W ALIVE AND WELL
A.S 16 y/O
A.S 15Y/O
A.S 14 y/o
9 MONTHS Boy
Mrs. J.S A/W
Not recognized
Not recognized
2. NUTRITIONAL ASSESSMENT y
FUNCTIONAL HEALTH PATTERN HEALTH PERCEPTION/HEALTH MANAGEMENT
According to Mrs. C.S she had an illness such as colds and fever during childhood days. When she gets pregnant she never had illness except on her 1st trimesteron which she experienced nausea and vomiting. Before, she does not have a regular check-up about her pregnancy but after the health teaching, she regularly goes for check-up. She never smokes but sometimes drinks carbonated beverages. She consulted a doctor or rural health team in times of illness. She takes medications as prescribed by the doctor. She easily follows the advice of doctor and nurses. NUTRITIONAL METABOLIC PATTERN
Her usual diet is composed of fish and vegetables. She drinks 8-10 glasses of water a day and occasionally drinks carbonated beverages. Because of her condition she gained weight for about 7 kgs. She has no food and eating discomfort. Her wound heals well. She took medicines such as iron supplement on which doctor prescribed to her. DATE NOTED
August 23, 2011
72 Hours Dietary Recall TIME OF THE DAY
Breakfast Lunch
MEAL
- 4pcs. Pandesal, 2 glasses of water, 1 fried egg. - ½ bowl of menudo, 1 cup of rice, 4 glasses of water. - 2 pcs. Fried tilapia, 1 ½ cup of rice, 3 glasses.
August 24, 2011
Dinner Breakfast
- 1 pc. scrambledegg, I cup fried rice, 2 glasses of water
Lunch
- 1 pc. Of Chicken (tinolang manok), 1 ½ cup of rice, 2 glasses of rice.
Dinner
- 1 pc. Of Fried tilapia, 1 cup of rice, 2 glasses of water.
August 25, 2011
Breakfast
- 3 pcs. Of tuyo, 1 ½ cup of rice, 3 glasses of water.
Lunch
- 1 cup of rice, 2 pcs. of fried biya, 3 glasses of water.
ELIMINATION PATTERN Bowel Movement
Color
Frequency
Characteristics
Odor
Discomfort
Urine
dark yellow
6-8 times a day
slightly turbid
aromatic
no discomfort
Feces
brown
Once a day
firm
foul odor
no discomfort
Mrs. C. S usually perspires when doing household chores but according to her simple chores makes her perspire that much on which she noticed that it was too different since she was not yet pregnant.
ACTIVITY EXERCISE PATTERN
She has sufficient energy for completing desired required activities such as household chores but she do not lift heavy objects since she got pregnant. According to her doing household chores became her form of exercise. During her spare time, she watches television and sometimes takes a nap in the afternoon.
Activities
Score
Feeding
0
Bathing
0
Level 0 full self-care. Level I requires the use of equipment or device.
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Toileting
0
Home Management
0
Dressing
0
Grooming
0
Level II requires assistance or supervision from another person. Level III requires assistance or supervision from another person or device. Level IV independent and does not participate
SLEEP-REST PATTERN
Mrs. C.S has a regular sleeping pattern. She usually sleeps 8-10 hours a day; sometimes she takes a nap in the afternoon. She doesnt have any problem falling asleep but she is usually interrupted because she feels the urge to urinate. COGNITIVE-PERCEPTUAL PATTERN
She doesnt have hearing difficulty and does not wear any eyeglasses. Other senses are in good condition. She has the ability to understand, communicate, remember and make decisions on her own. SELF-PERCEPTION SELF- CONCEPT PATTERN
One thing that changes in her life is her condition now, being pregnant. Even she already had 3 children, she was still very excited for upcoming baby. But according to her this will be her last pregnancy because after she delivers the baby, she will undergo tubal ligation sobrang hirap ng buhay ngayon, kailangan maging praktikal as verbalized by our client. Sometimes she feels alone especially when her husband goes to work and her children to school, she misses her eldest daughter which resides on Manila because of schooling. ROLE- REALTIONSHIP PATTERN
Mrs. C.S is currently living with her husband and their three children, they reside at Purok 6, Palapat Hagonoy, Bulacan. She doesnt have any problems in dealing with her children. She feels isolated because she lives far from her neighbors. Page 8
SEXUALLY REPRODUCTIVE PATTERN
Mrs. C.S is a G4P3 and she didnt take any pills. They do not use any contraceptives but they prefer natural method. She also stated that after her present pregnancy she will undergo tubal ligation. Her menarche eases when she was thirteen years old and her last menstrual period is December 1, 2010. Usually her menstrual period lasts up to 4 days and she changes her menstrual pad three times a day. During her menstrual period she feels pain in her abdomen (dysmenorrhea) and sometimes headache. COPING-STRESS TOLERANCE PATTERN
Her husband is the most helpful in taking things over. They just talk and comfort each other if they encounter problem. She misses her eldest daughter a lot that lives in her sister in Manila. But she manages it because her daughter helps her to ease those feelings. Her daughter makes sure that she went home at least thrice a month. VALUE-BELIEF PATTERN
Mrs. C.S and her family is a catholic and it is very important to her. She believes that with God, all things are possible. God will always be the center of their family especially when there is a problem. 1. HISTORY OF PRESENT/ CURRENT ILLNESS
Mrs. C.S stated that she never had illness during her pregnancy. She was just experienced nausea and vomiting during her 1st trimester which is normal to a pregnant woman.
2. HISTORY OF PAST ILLNESS
Her childhood disease was a communicable one such as colds and fever. According to Mrs. C.S she was fully immunized, kaya siguro hindi ako nagkakasakit, as verbalized by the client. As she remembered, her mother always gave her a medication for fever or colds such as Paracetamol. Page 9
3. GROWTH AND DEVELOPMENT ASSESSMENT A. DEVELOPMENTAL ASSESSMENT THEORY STAGE
PSYCHOSOCIAL
COGNITIVE
PSYCHOSEXUAL
MORAL
Y oung
Adulthood ( Intimacy vs. Isolation )
Formal operations stage Genital Stage Post conventional (adolescence and ( puberty onward ) (universal ethical principle adulthood) orientation) Occurring in this stage, they In this stage, intelligence It is the final stage where The person lives DEFINITION begin to share their selves more is demonstrated through it begins at the start of autonomously and defines intimately with others. They the logical use of symbols puberty when sexual moral values and explore relationships leading related to abstract urges are once again principles that are distinct toward longer term concept. He or she is awakened. Adolescents from personal commitments with someone capable of deductive and direct their sexual urges identification with group other than a family member. hypothetical reasoning. onto opposite sex peers, values. He or she lives with the primary focus according to principles that of pleasure is the are universally agreed on genitals. and that the person considers appropriate for life. FINDINGS Mrs. C.S personal lifestyle Our client uses rational Our clients energy is She is consistent on her develops, she establishes a thinking; her reasoning is directed toward full decision making. Her relationship with a significant deductive and futuristic. sexual maturity and conscience is working for others like her husband and function and her to do the right one. She had a meaningful social life development of skills makes an effort to define needed on which to cope valid values and principles with the environment. without regard to the expectation of others. REMARK/ANALYSIS We as a nurse must assist We must encourage By this stage, the person Our clients decisions and adults chosen lifestyle and no longer requires separation from parents behaviors are based on assist with necessary concrete objects to make which lead to internalized rules, on adjustments relating to health. rational judgments. achievement of conscience rather than Page 10
We
must recognize the persons commitments and support change as necessary for health.
independence and decision making.
social laws, and on selfchosen ethical and abstract principles that are universal, comprehensive, and consistent.
4. RISK FACTOR ASSESSMENT
Before weve done our Health Teaching on Mrs. C.S about prenatal care, she states that she was not able to regularly consult a doctor for check-ups but we were so glad because after the health teaching for the appropriate maternal care, she said that she now regularly visit the doctor for her check-ups. As we go through our Physical Assessment on Mrs. C.S we observed that her nipples are both inverted and when she gets pregnant, she forces herself to breastfeed her child with her right breast. Mrs. C.S also stated her observation regarding her right nipple that it became everted after her second child. Regarding her left nipple, she says that it aches whenever she tries to milk it. She also stated that her left breast sometimes swells. Minsannamamagayungkaliwasigurokasihindimasyadolumalabasyunggatas, konti-kontilang, as stated by our client. Upon our entrance in their gate, we noticed a strong smell of gasoline. Near their gate, we saw their abandoned owner type of jeep and beneath it, we saw traces of gasoline leakage. This is very dangerous for the family, most especially to Mrs. C.S.
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5. PHYSICAL ASSESSMENT
DATE OF PHYSICAL ASSESSMENT: August 25, 2011 BLOOD PRESSURE: 130/90mmHg
HEIGHT: 411 / 59 inches
PULSE RATE: 80bpm
WEIGHT: 62 kgs.
RESPIRATORY RATE: 27 cpm
BMI: 27.5
TEMPERATURE: 37C
AREAS TO BE ASSESSED GENERAL SURVEY
TECHNIQUE
NORMAL FINDINGS
Body built, height and weight in relation to the clients age Posture and Galt
Inspection
Proportionate, varies with lifestyle
Inspection
`Relaxed, erect Posture
Overall hygiene and grooming Body and breath odor
Inspection
Clean, neat
Inspection
Signs of distress Obvious sign of health or illness Clients attitude
Inspection Inspection
No body odor or minor odor relative to work or exercise; no breath odor No distress noted Healthy appearance
Mood and affect
Inspection
Inspection
Cooperative, able to follow instructions Appropriate to situation
ACTUAL FINDINGS
INTERPRETATION/ANALYSIS
Endomorph, height and weight proportion to her age. Relaxed and has erect posture Our client is neat and clean
Normal
No foul body and breath odor
Normal
No distress noted She has a healthy appearance Cooperative and can follow instructions Cooperative and pleasant,
Normal Normal
Normal Normal
Normal Normal
Quantity and quality of speech
Inspection
Relevance and organization of thoughts
Inspection
Understandable, moderate pace; clear tone and inflection Logical sequence, makes sense; has sense of reality
appropriate to situation She has a clear tone and understandable, moderate pace When she speaks it has sense of reality
Normal Normal
INTEGUMENTARY A. Skin
Color
Inspection
Generally uniform in color except in the areas that are exposed to the sun
Her skin color is uniform except in the areas that are exposed to the sun, she has linea nigra with striae gravidum Has slight edema Normal and equally bilateral Has a good skin turgor
Normal
Presence of edema Temperature
Inspection palpation
Skin Turgor
palpation
Skin Intactness
Inspection
No edema Uniform; within normal range Skin springs back to previous state No lesion, skin is intact
No lesion, skin is intact
Normal
No edema Evenly distributed; thick or thin Silky, resilient hair Variable
Has slight edema Has thick hair, evenly distributed, color black She has silky hair Variable
Normal Normal
Convex curvature, angle of the nail plate about 160; smooth texture Intact epidermis Prompt return of pink or
Her nail shape is convex curvature. Has smooth texture. Has intact epidermis The usual color of nails
Normal
Normal Normal Normal
B. Hair
Presence of edema Evenness of growth over the scalp Hair texture and oiliness Amount of body hair
Inspection Inspection Inspection Inspection
Normal Normal
C. Nails
Fingernail plate shape, toenail texture Tissues surrounding nails Perform blanch test of
Inspection Inspection Inspection and palpation
Normal Normal Page 13
capillary refill
usual color
returns to pink after 2-3 seconds.
Rounded and smooth skull contour Smooth, uniform consistency; absence of nodules and masses Symmetric or slightly asymmetric facial features Symmetric facial movements
No nodules and masses, smooth No nodules and masses, smooth
Normal
Facial features were slightly asymmetric Has symmetric facial movements
Normal
D. Skull and face
Skull size, shape and symmetry Presence of nodules, masses and depression
Inspection
Facial features
Inspection
Facial movements
Inspection
Palpation
Normal
Normal
E. Eyes
Inspect the eyes for edemas and hollowness Eye brows for hair distribution
Inspection
No edema
No edema
Normal
Inspection Inspection
Hair evenly distributed, eyebrows were evenly distributed. Eyelashes equally distributed; curled outward Skin intact; no discharge or discoloration; lids closed symmetrically. Has the ability to blink bilaterally.
Normal
Eyelashes for evenness of distribution and direction of curl Eyelids for surface characteristics, ability to blink and frequency of blinking
Hair evenly distributed, eyebrows symmetrically aligned. Equally distributed; curled slightly outward
Bulbar and palpebral conjunctiva for color, texture and presence of lesions
Inspection
Bulbar conjunctiva is transparent. Palpebral conjunctiva is shiny, smooth and pink.
Normal
Inspection
Skin intact; no discharge or discoloration; lids closed symmetrically approximate. Has the ability to blink about 15-20 involuntary blinks per minute Bulbar conjunctiva is transparent and capillaries sometimes evident. Palpebral conjunctiva is
Normal Normal
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Lacrimal gland
Inspection and palpation
Lacrimal sac and nasolacrimal duct Cornea for clarity and texture
Inspection and palpation Inspection
Corneal sensitivity
Inspection
Pupils for color, shape and symmetry of size
Inspection
Pupils depict and consensual reaction to light
Inspection
Pupils reaction to accommodation
Inspection
Peripheral visual fields
Inspection
Six ocular movements
Inspection
Visual acuity
Inspection
shiny, smooth and pink or red. No edema or tenderness over lacrimal gland No edema or tearing Transparent, shiny and smooth; details of the iris are visible Blinks when the cornea is touched Black in color, equal in size and smooth border
No edema or tenderness over lacrimal gland. No edema or tearing.
Transparent, shiny and smooth; details of the iris are visible . Client blinks when the cornea is touched Her pupils are black, equal in size and has smooth borders Illuminated pupil constricts Illuminated pupil (direct response); Nonconstricts; Non-illuminated illuminated pupil constricts pupil constricts (consensual response) Pupils constrict when Her pupils constrict when looking at near object; looking at near object; pupils dilate when looking pupils dilate when looking at far; pupils converge at far; pupils converge when near object is moved when near object is moved towards the nose towards the nose. When looking straight When looking straight ahead, client can see ahead, client can see objects in periphery objects in periphery. Both eyes coordinated, Both eyes coordinated move in unison, with parallel alignment Able to read newsprint She was able to read newsprint
Normal Normal Normal Normal Normal Normal
Normal
Normal Normal Normal
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F. Ears
Auricles color, symmetry of size and position
Inspection
Texture, elasticity and areas of tenderness
Palpation
External ear canal for cerumen, skin lesions, pus and blood
Inspection
Watch
Inspection
tick test
Color same as facial skin, symmetrical; auricle aligned with the outer cantus of the eye Mobile, firm and not tender; pinna recoils after being fold. Dry cerumen, grayish-tan color, sticky or wet cerumen in various shades of brown Able to hear ticking in both ears
Color same as facial skin, auricle aligned with the outer cantus of the eye.
Normal
Mobile, firm and not tender; pinna recoils after being fold. Has dry light brown cerumen and grayish color
Normal
She was able to hear ticking in both ears
Normal
Symmetric and straight; no discharge or flaring; uniform in color Have no discharge and no lesions.
Normal
Air moves freely as Mrs. C.S breathes through the nares
Normal
Nasal septum is intact and in midline No tender, masses or displacement of bones and cartilage Maxillary and frontal sinuses are not tender
Normal
Normal
G. Nose
Shape, size or color and flaring or discharge
Inspection
Nasal cavities
Inspection
Patency of both nasal cavities
Inspection
Nasal septum
Inspection
Tenderness, masses and displacement of bones and carriage Sinuses for tenderness
Palpation
Symmetric and straight; no discharge or flaring; uniform in color Mucosa is pink; clear watery discharge; no lesions. Air moves freely as the client breathes through the nares Nasal septum is intact and in midline Not tender
Palpation
Not tender
Normal
Normal Normal
H. MOUTH Page 16
Lips for symmetry of contour, color and texture
Inspection
Buccal mucosa for color, moisture, texture and presence of lesions Teeth for color, number, condition and presence of dentures
Inspection
Gums for color condition
Inspection
Tongue for color, position, texture and movement
Inspection
Presence of nodules, lumps or excoriated areas Hard and soft palate for color, shape, texture and presence of bony prominences Position of the uvula and mobility while examining palates Oropharynx for color and texture Tonsils for color, discharge and size
Palpation
Inspection
Inspection
Inspection Inspection Inspection
Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips
Lips are color pink (uniform), moist soft and smooth, no lesions and she has the ability to purse her lips Moist, smooth, soft, Moist, smooth, soft, glistening and elastic glistening and elastic texture texture of buccal mucosa 32 adult teeth, smooth 32 adult teeth, smooth white and shiny tooth white and shiny tooth enamel enamel. She has no dentures Pink gums, moist and firm Pink gums, moist and firm texture to gums; no texture to gums; no retractions. retractions. Central position, pink color, Tongue in the center, pink moist slightly rough, moves in color, moist and slightly freely, no tenderness rough without lesions, moves freely. Smooth with no palpable It has no nodule nodules Light pink, smooth, soft She has light pink, smooth, palate; Lighter pink hard soft palate. Hard palate is palate, more irregular more irregular and lighter pink. Positioned in midline of Uvula is in the middle. soft palate
Normal
Pink and smooth posterior wall Pink and smooth, no discharge
Normal
Has pink and smooth posterior wall. Has pink and smooth tonsils; no discharge.
Normal Normal
Normal Normal
Normal Normal
Normal
Normal
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Elicit the gag reflex
Perform test on gag reflex
Present
Gag reflex is present.
Normal
Muscles on the neck are equal in size; head centered. Head movement is coordinated, has smooth movements with no discomfort. No enlargement of lymph nodes Trachea is in central position in the midline of the neck; spaces are equal in both sides. Thyroid gland is not visible on inspection; it ascends during swallowing but is not visible.
Normal
I.NECK
Neck muscles
Inspection
Muscles equal in size; head centered
Head movement
Inspection
Coordinated, smooth movements with no discomfort
Entire neck for enlarged lymph nodes Trachea for lateral deviation
Palpation
Not palpable
Inspection
Central placement in midline of neck; spaces are equal on both sides
Inspection and Palpation
Not visible on inspection, ascends during swallowing but is not visible
Thyroid Gland
Normal
Normal Normal
Normal
I.THORAX
Posterior thorax
Palpation
Shape and symmetry of the thorax
Inspection
Spinal alignment for deformities Posterior chest for respiratory excursion
Inspection Palpation
Skin is intact; uniform in temperature, chest wall intact; no tenderness; no masses Anteroposterior to transverse diameter in ration of 1:2; chest is symmetric Spine vertically aligned Full and symmetric chest expansion
Skin is intact; uniform in temperature, chest wall intact; no tenderness; no masses Anteroposterior to transverse diameter in ration of 1:2; chest is symmetric Her spine is vertically aligned When Mrs. C.S takes a deep breath, my thumb move
Normal
Normal
Normal Normal
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Chest for vocal fremitus
Palpation
Thorax
Percussion
Diaphragm excursion
Percussion
Chest using the flat-disc diaphragm of the stethoscope
Auscultation
apart an equal distance and at the same time. Bilateral symmetry of vocal Bilateral symmetry of vocal fremitus; fremitus is heard fremitus; fremitus is heard most clearly at the apex of most clearly at the apex of the lungs the lungs Percussion notes resonate, Percussion notes resonate, except over scapula except over scapula; lowest point of resonance is at the diaphragm. Excursion is 3 to 5 cm Excursion is 3 to 5 cm. bilaterally in women and 5 Diaphragm is usually to 6 cm in men; diaphragm slightly higher on the right is usually slightly higher on side, the right side, Vesicular and Vesicular and bronchovesicular breath bronchovesicular breathe sounds sounds on the chest.
Normal
Normal
Normal
Normal
J. ANTERIOR THORAX
Breathing pattern
Inspection
Anterior chest for respiratory excursion Tactile fremitus
Palpation
Anterior chest
Percussion
Palpation
Quiet, rhythmic and effortless respirations Full symmetric excursion
Quiet, rhythmic and effortless respirations. Full symmetric excursion
Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue. Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over the areas of heavy muscle and bone,
Bilateral symmetry of tactile fremitus; it decreased over heart and breast tissue. Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over the areas of heavy muscle and bone,
Normal Normal Normal
Normal
Page 19
Auscultation
dull on areas over the heart and the liver, and tympanic over the underlying stomach.
dull on areas over the heart and the liver, and tympanic over the underlying stomach.
Bronchial and tubular breath sounds
Bronchial and tubular breath sounds
Rounded shape slightly unequal in size Uniform in color Oval and bilaterally the same; color varies widely
Rounded shape slightly unequal in size Skin is uniform in color Oval and bilaterally same; color is dark-brown
Round, inverted and equal in size; similar in color, soft and smooth; both nipples point in same direction No tenderness, masses or nodules
Nipples are rounding, inverted and not equal in size. There is a discharge called colostrums. Absence of nodules; not tender.
Deviation from normal
Uniform in color, silverwhite striae Flat, rounded or scaphoid
Uniform in color, silverwhite striae It is big and rounded because of her pregnancy There was a decrease in bowel sounds. Liver is not palpable
Normal
K .BREAST AND AXILLAE
Size, symmetry and contour or shape Skin of the breast Areola for size, shape, symmetry, color, surface characteristics and any masses or lesions Nipples for size, shape, position, color, discharge and lesions
Inspection
Axillary, subclavicular and supraclavicular lymph nodes
Palpation
Inspection Inspection
Inspection
Normal Normal Normal
Normal
J. ABDOMEN
Skin integrity
Inspection
Contour and symmetry
Inspection
Abdomen for bowel sounds Liver
Auscultation
Audible bowel sounds
Palpation
May not be palpable; border feels smooth
Normal Normal Normal
K. MUSCULOSKELETAL
Page 20
Muscles for size
Inspection
Muscles and tendons for contractures and tremors Muscle tonicity Muscle strength
Inspection Palpation Testing muscle strength
Skeleton
Inspection
Joint
Inspection
Equal size on both side of the body No contractures and tremors Normally firm Equal strength on each body side No deformities, tenderness or swelling No swelling and nodule, not tender
Muscles are equal in size on both side of the body. No contractures and tremors Normally firm Equal strength on each body side No deformities, tenderness or swelling No swelling and nodule, not tender
Normal Normal Normal Normal Normal Normal
OB ASSESSMENT a. Menarche: 13 years old
d. LMP: December 01, 2010
b. EDC: September 8, 2011
e.Trimester: 3rd trimester
c. AOG: 38 weeks and 1/7
f.G: 4 P:3 TPAL:3/0/0/3
FUNDIC HEIGHT: 33cm. Fetal heart Rate: 132bpm.
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6. RESULT OF LABORATORY / DIAGNOSTIC AND OTHER SCREENING PROCEDURE PELVIC ULTRASOUND REPORT ( Date: July 22,2011 ) y
Within
an enlarged uterus is a SINGLE FETUS presently seen in cephalic presentation. There is an active fetal m ovement and regular cardiac pulsations noted with 142 beats per minutes. The placenta is implanted at the anterior aspect of the uterus GRADE 2. Amniotic fluid volume index: 11.2 cm. Expected Expected Sex:
fetal body weight: 2110 grams date of confinement: September 8, 2011
Male
URINALYSIS Physical Appearance:
Color transparency
NORMAL VALUE
RESULTS
REMARKS
Pale to dark yellow clear
Dark yellow Slightly turbid
Normal Normal due to pregnancy
5-7 1.000 to 1.030 Negative Negative Negative Negative Negative Negative Negative
6 1.015 Negative 1+ Negative Negative Negative Negative Negative
Normal Normal Normal Normal due to her pregnancy Normal Normal Normal Normal Normal
Chemical Screening:
pH Specific gravity Glucose Protein Leukocyte Esterase Nitrite Blood(Hemoglobin) Ketones Bilirubin Microscopic Examination: White Blood Cells
5.0-10.0
8.4
Normal
Red Blood Cells
3.80-5.80
3.80
Normal
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C. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION BELIEF/PRACTICES
IMMUNIZATION STATUS
ANTENATAL REGISTRATION/ FAMILY PLANNING
Mrs. C.S believes that illness is caused by physiologic factors and weather changes. Also, illness is treated by medications.
All of the family members are completely immunized. And Mrs. C.S states that she received Tetanus Toxoid Vaccinations; no records shown.
Mrs. C.S attends her prenatal check-ups but not regularly. Currently havent undergone ultrasound (as of July 07, 2011). They are family planning acceptor. States that after giving birth, she will undergo tubal ligation.
LIFESTYLE PRACTICES
AWARENESS ON COMMUNITY/DOH HEALTH PROGRAMS
Our client states that they The family is aware of the lack of financial resources. services offered by the Barangay Health Center. They are able to eat nutritious food. Mrs. C.S is neat, clean and clothes well
V. APPLICATION OF NURSING THEORY IN THE CARE OF THE CLIENT THEORY
THEORIST
DESCRIPTION
Human to Human Relationship Model
Joyce Travelbee
Joyce Travelbee published predominantly in the mid-1960s. She died in 1973 at relatively young age. She proposed Human to Human Relationship Theory in her book, Interpersonal Aspects of Nursing. She wrote about illness, suffering pain, hope, communication, interaction, empathy, sympathy, rapport, and
APPLICATION TO NURSING PRACTICE IN THE CARE OF CLIENT Travelbees theory emphasis on caring stressed empathy, sympathy, rapport, and the emotional aspects of nursng. 1st Stage of Travelbees Theory: Original Encounter When we first visit Mrs. C.S she ignore us, she didnt want to talk to us and even entertain us. She was not interested on what we are saying. 2nd Stage of Travelbees Theory: Emerging Identities
therapeutic use of self.
We
introduced our self and explain what the purposes of our visit . We ask her personal information to gather some data and explained to her the importance of what we are doing. 3rd Stage of Travelbees Theory: Developing Feelings of Empathy She was now cooperative to us, she entertain us and more confident in answering our questions. 4th Stage of Travelbees Theory: Sympathy This stage was very helpful to us. We gained our clients trust. She was now having conversation to us about her life. She even allowed us to borrow her check-ups record. 5th Stage of Travelbees Theory: Nurse and Patient attained rapport She was now very open to us. She wants to talk to us regarding on her pregnancy, what was the right thing she must do, how long she must go for a check-up etc.. we gained her trust and attained rapport to her.
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VI. HEALTH CONDITION AND PROBLEM SHEET
HEALTH CONDITION AND PROBLEMS
ACTUAL SCORE
FAMILY NURSING PROBLEMS
SUPPORTING DATA/CUES
1. Do not perform regular check-up
4.0
The client stated to us that she do not go to a doctor for a check-up.
2. Usually prefer eating fried foods
2.7
3. Gas Leakage
1.9
Readiness for Enhanced Capability for Health Maintenance/Health Management Readiness for Enhanced Capability for Health Maintenance/Health Management Failure to Maintain Wellness due to Poor Home/Environmental Condition
DATE IDENTIFIED
SOLVED
July 01,2011
July 22, 2011
She stated to us that they July 08, 2011 usually ate fried foods because it is affordable.
---
As we enter on their gate, we noticed a strong smell of gasoline came from the owner type jeep
----
August 25, 2011
ACTION/S TAKEN, RESPONSES AND EVALUATION OF OUTCOMES We do Health Teaching about Prenatal Care and the goal was met. We
gave her knowledge about healthful eating habits
We tell Mrs. C.S that leakage of gas and strong smell of it is very dangerous for her family especially on her condition (pregnant).
VII. INDIVIDUAL NURSING CARE PLAN
ASSESSMENT NURSING BACKGROUND DIAGNOSIS KNOWLEDGE OF HEALTH CONDITION/ HEALTH PROBLEM
S: hindi
regular ang check up ko eh, wala kasing pera, as verbalized by the client.
Ineffective Health Maintenance related to a pregnant not having a regular check-up due to insufficient resources.
Pregnant
Not having a regular check-up
GOAL OF CARE/OBJECTIVES
After 30 minutes of nursing intervention the client will: Identify necessary health Maintenance Activities appropriate to a pregnant.
INTERVENTION
Establish
rapport on the client.
O:
To gain trust
and cooperation on the client. To
Monitor
the vital signs.
Verbalized
understanding of factors contributing to current situation.
RATIONALE
obtain the baseline data.
After 30 minutes of nursing intervention the client will: Identify necessary health Maintenance Activities appropriate to a pregnant.
To Identify
ways to adapt things in current circumstances
meet the clients changing needs/ abilities and environmenta l concerns.
EVALUATION
Verbalized
understanding of factors contributing to current situation.
Lack of financial resources
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ASSESSMENT NURSING BACKGROUND DIAGNOSIS KNOWLEDGE OF HEALTH CONDITION/ HEALTH PROBLEM
S:Madaling
lutuin ang prito at mas gusto ng mga anak ko, pero mas masustansya pa rin paggulay, as verbalized by the client
Readiness for enhanced nutrition related to expresses knowledge of healthy food
Ineffective NUTRITION
GOAL OF CARE/OBJECTIVES
After 30 minutes of nursing intervention the client will: Demonstrate behaviors to attain/maintain appropriate weight. Be free of signs of
Willingness to enhance nutrition
malnutrition. Be
able to safely prepare and store foods.
INTERVENTION
Review clients
knowledge of current nutritional needs and ways client is meeting these needs. Encourage clients beneficial eating patterns / habits.
O: Attitude toward eating is congruent with health goals
Review safe
preparation and storage of food Identify
ways to adapt things in current Circumstances
RATIONALE
To
provide baseline for further teachings and interventions
have a positive feedback which promotes continuation of healthy lifestyle habits and new behavior. To avoid food-borne illnesses.
EVALUATION
After 30 minutes of nursing intervention the client will: Demonstratebe haviors to attain/maintai n appropriate weight.
To
Be free of signs
of malnutrition. Be able to
safely prepare and store foods.
ASSESSMENT NURSING BACKGROUND DIAGNOSIS KNOWLEDGE OF HEALTH CONDITION/ HEALTH PROBLEM
S:
O: Had
stong smell of gasoline Traces
of gasoline leakage.
Risk for suffocation related to vehicle warming closed garage as manifested by strong smell of gasoline and traces of gasoline leakage.
Vehicle leakage
unattended vehicle on the garage
GOAL OF CARE/OBJECTIVES
After 30 minutes of nursing intervention the client will: Verbalize knowledge of hazards in the environment. Correct
hazardous situations to prevent/ reduce risk of suffocation. May be risk for suffocation
INTERVENTION
To
emphasize importance of periodic evaluation and repair of gas appliances/ Furnace, automobile exhaust system.
Identify/
Encourage relevant safety measures.
RATIONALE
To prevent
exposure to carbon monoxide.
EVALUATION
After 30 minutes of nursing intervention the client will: Verbalized knowledge of hazards in the environment. Correct
To
prevent / Minimize risk of injury.
hazardous situations to prevent/ Reduce risk of suffocation.
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VIII. IMPLEMENTATION OF NURSING CARE PLAN A. Conduction of Health Teaching LEARNING OBJECTIVES
After 15-20 minutes of health teaching, the client will be able to: 1. Gain knowledge regarding the advantages of prenatal care.
LEARNING CONTENT
RESOURCES
STRATEGIES
TIME ALLOTMENT
EVALUATION
15-20 minutes ( 9:30 9:50 am)
After 15-20 minutes of health teaching, the client will be able to answer tha following:
MONEY : Definition
of prenatal care. of Purpose prenatal care of Schedule prenatal visit Nutrition needed by a pregnant woman Tetanus Toxoid Vaccination
Manila paper @ Php 5.00 each 10.00 Pentel pen
Interactive Discussion
---24.00
1.
What
2.
What
3.
What
Target Population:
34.00
Mrs. C.S Lecture
MATERIALS: Manila
is the definition of prenatal care?
paper
Pentel pen
are the advantages of having a prenatal checkup? is the correct schedule for prenatal visits?
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