Jose Rizal University

College of Nursing

Nursing Process of a 7-month pregnant client

In Partial Fulfillment of the Requirement for

Nursing Care Management 101 – Related Learning Experience
(Friendly Care Clinic)

Submitted by:
Shaneal Alonzo
Jestoni Aure
Joey Bagsarsa
Arviel Berrei
Jerilee Bodota
Kate Lou Cabahug
Von Aarol Calabio
Alma A. Canlas
Brian Armond Casabon
Christine Chan
Alvin Conde

Submitted to:
Mrs. Esperanza Catiis, RN, MAN
Clinical Instructor
Table of Contents

Chapter 1 – Introduction
Objectives

Chapter 2 – Assessment
Nursing Health History
Personal Data of the Patient
Chief Complaints
History of Present Illness
Past Medical History
Family Health History
Social History
Review of System
Physical Assessment
Diagnostic Procedure
Anatomy and Physiology of the Systems affected
a. Pathophysiology
Chapter 3 – Planning
A. List of Prioritized Nursing Diagnoses
B. NCP
C. Drug Study

Chapter 4 – Discharge Planning

Chapter 1 – Introduction

We, group 1 of JRU BSN A314, would like to thank The Friendly Care Clinic for allowing us to
choose a patient for our case. We also thank our clinical instructor, Ms. Catiis, for patiently
teaching us and making sure we learn the most out of our clinical exposure.

Objectives

General Objectives – We did this case study for us to have a deeper understanding of
what physiological changes undergo during pregnancy, thus to give us an idea of how
we could give proper nursing care for our pregnant clients.

Specific Objective - We hope to be able to address the client’s health needs and also to
assess for any health deficit or risks like anxiety, activity intolerance, and fluid volume
deficit.

Chapter 2 Assessment

Personal Data

Name: a.k.a. Sunflower

Age: 29
Occupation: N/A
Educational Attainment: Undergraduate
Birthday: July 9, 1978
Civil Status: Married
Temporary Address: San Juan, Manila
Permanent residence: Dumaguete
Height:
Weight:

G2P1 (T1P0A0L1)
AOG: 32 weeks and 5 days

Final Diagnosis:
Single live uterine fetus, in variable presentation, 32 & 5 days. Placenta posterior, grade 2.
Placenta previa totalis.

Chief Complaint:
“ Nagpapacheck up ako kasi suhi daw ung baby ko.’’

History of Present Illness

She came to the clinic for a pre natal check up. According to her, the last time she had
her last check up, doctor found out that her baby is in breech position. Aside from that, the
client has no other difficulties in her pregnancy.

Past Medical History

The client has given birth previously to baby girl through Normal Spontaneous delivery
and she hasn’t experience any difficulties giving birth to her firstborn.
Family Health History
According to the client, there is no one in the family who has or had any chronic
illness, even hypertension and diabetes. Neither one in the family had complications during
and after pregnancy.

Social History
She and her husband has just moved in san Juan, 6 months ago, due to her husband’s
job. She spends some of her time outside their house dealing with her neighbours. She has no
difficulty getting along with them because she said that people around them are easy to
confide with.

3. Diagnostic Procedures

Ultrasound

Ultrasound is a commonly used procedure that uses sound waves to produce an

image. These sound waves pass through the woman’s abdomen and reflect off the maternal
and fetal structures to form a picture on a monitor.

Ultrasound during pregnancy may be used for the following:

• Early in pregnancy (six to twelve weeks) to confirm a heart beat, identify twins or
triplets, or help predict the due date
• Detailed ultrasound after eighteen weeks, to see if the baby is growing and developing
as it should, and to help make a diagnosis when a fetal abnormality is found
• To locate the fetus and placenta during amniocentesis, which increases the safety of
that procedure
• Along with fetal heart monitoring, when a pregnancy has gone beyond the due date, to
check on the well-being of the fetus and to help with decisions about induction of
labour.

Amniocentesis

Amniotic fluid is the thin watery substance that surrounds the developing fetus in the
uterus/womb. Amniocentesis involves removing a small amount (about 4 teaspoons) of this
fluid with a needle, for testing in the lab. This test can be done after the 15th week of
pregnancy. Amniocentesis is a specific test that is able to tell you if your baby has a normal
number of chromosomes (46). It can find Down syndrome and other major chromosome
abnormalities. A second test is done to measure the amount of alpha-fetoprotein (AFP) in the
amniotic fluid. A higher than normal amount may suggest the possibility of a neural tube
defect, such as spina bifida. Normal results can take up to 3 weeks. Concerns are usually
identified and given to your doctor or midwife within 10-14 days.

Chorionic Villus Sampling

Chorionic villi form as part of the placenta and are made up of cells that develop from
the fertilized egg that has developed into the fetus. Chorionic villi contain the same genes as
the fetus and can be examined to rule out chromosomal disorders. Unlike amniocentesis,
chorionic villus sampling does not provide information about neural tube defects. (this can be
done later by drawing and testing a blood sample from the mother).

Chorionic villus sampling (CVS ) involves taking a small sample of tissue for testing in the lab.
and is usually done between the tenth and twelfth weeks of pregnancy.
4. Anatomy & Physiology

Reproductive System
The reproductive organs are comprised of a vagina, a cervix, a uterus, fallopian tubes and
ovaries. All of these organs work together to help you menstruate, conceive and carry a baby
to term.

The uterus, located in a

woman's abdomen, is a
hollow, elastic reproductive
organ, where a baby
develops during pregnancy.

Labia majora: The labia majora enclose and protect the other external reproductive
organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and
are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting
glands. After puberty, the labia majora are covered with hair.
Labia minora: Literally translated as "small lips," the labia minora can be very small
or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the
vagina (the canal that joins the lower part of the uterus to the outside of the body) and
urethra (the tube that carries urine from the bladder to the outside of the body).
Bartholin's glands: These glands are located next to the vaginal opening and produce a fluid
(mucus) secretion.
Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is
comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce,
which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very
sensitive to stimulation and can become erect.
Vagina: This tube like structure connects your internal reproductive organs with your external
genitalia. It ends at the cervix and is the point of entry for the penis during sex as well as the
final passageway through which a baby exits when it is born. The vagina is a canal that joins
the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth
canal.
Cervix: This part of your reproductive organs is situated between the vagina and
uterus. It secretes mucus that can help or obstruct sperm from fertilizing an egg. The cervix is
the opening that sperm must pass through in order to get to an egg. A baby must also go
through the cervix as it exits the uterus and enters the vagina.
Uterus: Also known as the womb, the uterus is a muscular organ made up of three layers: the
peritoneum (outer layer), myometrium (middle layer)and endometrium (inner lining). An egg
that has been fertilized will implant itself into the endometrium lining and will continue to
develop in the uterus throughout the pregnancy.
Fallopian Tubes: The fallopian tubes extend off the upper sides of the uterus and lead up to the
ovaries. They have 20 to 25 finger-like structures on their ends that hover just above the
ovaries and work to collect the mature egg when it is released. It is in the fallopian tubes that
fertilization of the egg will take place.
Ovaries: Women usually have two ovaries, one on each side of the uterus. Ovaries
are the storing house for your egg follicles; every month, one of these egg follicles will mature
and release an egg into the fallopian tubes. The ovaries are also responsible for producing
estrogen and progesterone, which are vital for proper reproductive function. The ovaries are
small, oval-shaped glands that are located on either side of the uterus. The ovaries produce
eggs and hormones.

Changes in the Reproductive System During Pregnancy

When you become pregnant, the part of your body affected first and the part that undergoes
the most significant changes is the uterus. It increases to 20 times its original weight, and
1,000 times its initial capacity. The amount of its muscle, connective and elastic tissue, blood
vessels, and nerves increases. Its shape changes from elongated to oval by the second month,
to round by midgestation, then back through oval to elongated at term (the end of a normal
nine-month pregnancy).

The uterus softens beginning at the sixth week. It changes position as it increases in size,
ascending into the abdomen by the fourth month and eventually reaching to the liver. It also
becomes more contractile (the tendency to decrease in size), with irregular, painless Braxton
Hicks contractions beginning in the first trimester. You may feel these contractions in the last
weeks of pregnancy, when they are known as false labor.

Other parts of the reproductive system change along with the uterus. The cervix and vagina
have an increased blood supply, which causes a darkening in color apparent by the sixth week.
The amount of elastic tissue increases to prepare the way for the stretching that will be
required during delivery. Secretions increase, and a mucous plug develops in the cervix. The
fallopian tubes, ovaries, and ligaments supporting the uterus all enlarge and elongate. The
ovaries, of course, cease to ovulate.

During the fourth month, the uterus grows into the abdomen, causing the abdominal wall to
expand to accommodate it. The connective and elastic tissues stretch and straighten, creating
thinned areas called striae (stretch marks). While the red of the striae may fade, silver
remnants usually remain after delivery. In 50 percent of women, striae develop in the third
trimester. Late in pregnancy, the internal pressure from the large uterus may even cause the
muscles of the abdominal wall to separate (diastasis).

The Endocrine System and Hormone Function Overview

1. The endocrine system is a major controlling system of the body. Through hormones, it
stimulates such long-term processes as growth and development, metabolism, reproduction,
and body defense.
2. Endocrine organs are small and widely separated in the body. Some are mixed glands
(both endocrine and exocrine in function). Others are purely hormone producing.
3. All hormones are amino acid-based or steroids.
4. Endocrine organs are activated to release their hormones into the blood by hormonal,
humoral, or neural stimuli. Negative feedback is important in regulating hormone levels in the
blood.
5. Blood-borne hormones alter the metabolic activities of their target organs. The ability of
a target organ to respond to a hormone depends on the presence of receptors in or on its cells
to which the hormone binds or attaches.
6. Amino acid-based hormones act through second messengers. Steroid hormones directly
influence the target cell's DNA.

The Major Endocrine Organs

1. Pituitary gland
2. Thyroid gland
3. Parathyroid glands
4. Adrenal glands
5. Pancreatic islets
6. The pineal gland
7. The thymus gland
8. Gonads
Other Hormone-Producing Tissues and Organs
 1. The placenta is a temporary organ formed in the uterus of pregnant
women. Its primary endocrine role is to produce estrogen and
progesterone, which maintain pregnancy and ready
breasts for lactation.
2. Several organs that are generally nonendocrine in overall function, such
as the stomach, small intestine, kidneys, and heart, have cells that
secrete hormones.
Pathophysiology

pituitary gland

anterior lobes posterior

lobes

Protein synthisis antidiuretic

hormones

Thyroid stimulating hormones

oxytocin

hypothalamus

Adrenocortictropic hormones

Gonadotropic hormones

Prolactine hormones
Respiratory System Anatomy & Physiology

The respiratory system consists of the nose, pharynx (throat). larynx (voice box), trachea
(windpipe), bronchi and lungs. Its parts can be classified according to either structure or
function.

Structurally, the respiratory system consists of two parts:

The upper respiratory system includes the nose, pharynx, larynx and associated structures.

The lower respiratory system includes the trachea, bronchi, and lungs.
Functionally, the respiratory system consists of two parts:

The conducting zone consists of series of interconnecting cavities and tubes both outside and
within the lungs – the nose, pharynx, larynx, trachea, bronchi, bronchioles, and terminal
bronchioles—that filter, warm and moisten air and conduct it into the lungs
The respiratory zone consists of tissues within the lungs where gas exchange occurs – the
respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli, the main sites of gas
exchange between air and blood.

• Nose

• Pharynx

• Larynx

• Bronchi

• Bronchioles

• Terminal bronchioles

• Lungs
CO2 exhaled

O2 inhaled
Pathophysiology

Respiratory changes during pregnancy

Respiratory Tract. Hormonal changes to the mucosal vasculature of the respiratory

tract lead to capillary engorgement and swelling of the lining in the nose, oropharynx, larynx,
and trachea. Symptoms of nasal congestion, voice change and upper respiratory tract infection
may prevail throughout gestation. These symptoms can be exacerbated by fluid overload or
edema associated with pregnancy-induced hypertension (PIH) or pre-eclampsia. In such
cases, manipulation of the airway can result in profuse bleeding from the nose or oropharynx;
endotracheal intubation can be difficult; and only a smaller than usual endotracheal tube may
fit through the larynx. Airway resistance is reduced, probably due to the progesterone-
mediated relaxation of the bronchial musculature.

Lung Volumes . Upward displacement by the uterus causes a 4 cm elevation of the

diaphragm, but total lung capacity decreases only slightly because of compensatory increases
in the diameters of the chest, as well as flaring of the ribs. These changes are brought about
by hormonal effects that loosen ligaments.
From the middle of the second trimester, expiratory reserve volume, residual volume and
functional residual volume are progressively decreased, by approximately 20% at term.
Oxygen consumption increases gradually in response to the needs of the growing foetus,
culminating in a rise of at least 20% at term. During labour, oxygen consumption is further
increased (up to and over 60%) as a result of the exaggerated cardiac and respiratory work
load.

Pulmonary changes during pregnancy

Respiratory function is also altered during pregnancy to meet the added oxygen demands of
the fetus. Tidal volume can be increased by 30-40%, expiratory reserve volume can be
reduced up to 40%, functional residual capacity can decline by up to 25%, minute ventilation
can increase by up to 40%, airway resistance in the bronchial tree can decline by 30%-40%,
and total body oxygen consumption can increase by about 10-20%. Dyspnea also occurs.
Mechanical
Diaphragm rises 4 cm
Less negative intrathoracic pressure
Dec FRC-Functional Residual Capacity
volume after passive expiration
Dec ERV-Expiratory Reserve Volume
max volume expired after expiration
Dec RV-Residual Volume
volume after max expiration
No impairments in diaphragmatic or thoracic muscle motion
Lung compliance remains unaffected

- Minute ventilation = RR X Tidal volume

-Tidal Volume-increases
Volume of air Inspired and expired with each breath
- Minute ventilation-increases
Volume inspired or expired in 1 min
- RR- remains unchanged
- Vital capacity-remains unchanged
Max volume that can be forcibly inspired after max expiration

Consumption
O2 consumption Increases 15-20 %
50 % of this increase is required by the uterus
Despite increase in oxygen requirements, with the increase in Cardiac Output and increase in
alveolar ventilation oxygen consumption exceeds the requirements.
Therefore, arteriovenous oxygen difference falls and arterial PCO2 falls.

Physiologic changes

Dyspnea
-increase in desire to breathe
70 % of pregnant women experience this
Occurs during 1st trimester without mechanical factors
No change on PFTs
The lower PCO2 then paradoxically causes dyspnea
The marked change or marked decline in PCO2 results in the sensation of dyspnea

Pulmonary adaptation

Anatomical
Increased chest diameter, subcostal angle changes, increased diaphragmatic excursion with
diaphragm elevated as well

Physiological

Hyperventilation

Increased IC,VC and Minute Volume

Residual volume decreased

Expiratory Reserve Volume decreased

Tidal volume increased by 40%

pO2 increased, pCO2 decreased

arterial pH unchanged

serum bicarbonate reduced

THE CIRCULATORY SYSTEM

Is made of the heart and blood vessels known as arteries and veins. The heart pumps
blood throughout your body through the blood vessels. Blood deliveries oxygen and nutrients
to the body and carries away carbon dioxide and other waste materials.

ANATOMY OF THE HEART

Location and Size

The relative size and weight of the heart give few hints of its incredible strength.
Approximately the size of a person’s fist, the hollow, cone-shaped heart weighs less than a
pound. The heart is located within the bony thorax and is flanked on each side by the lungs.
Its more pointed apex is directed toward the left hip and rest on the diaphragm, approximately
at the level of the fifth intercostal space. Its broader poster superior aspect or base, from
which the great vessels of the body emerge, points toward the right shoulder and lies beneath
the second rib.

PHYSIOLOGY OF THE HEART

As the heartbeats or contracts, the blood makes continuous round trips in and out of
the heart, through the rest of the body, and then back to the heart – only to be sent out
again. The amount of work that a heart does is almost too incredible to believe. In one day it
pushes the body’s supply of 6 quarts or so of blood through the blood vessels over 1000
times, meaning that it actually pumps about 6000 quarts of blood in a single day!

PHYSIOLOGICAL CHANGES

Total body water rises and blood volume increases by 25 to 40 percent to

accommodate the additional needs of the fetus. The rise in blood volume also acts as a
safeguard against blood loss during birth. Blood pressure and pulse typically rise and increase
cardiac output by 20 to 40 percent; this helps propel the greater blood volume around the
body. Because the uterus presses on the pelvic blood vessels, venous return from the lower
limbs may be impaired somewhat, resulting in varicose veins.

The Musculoskeletal System

During pregnancy there is an evident change in the physical appearance of the women’s body.
The most evident change is the substantial weight gain, anywhere from twenty to forty pounds
depending on the individual (Artal and O'Toole, 2003; Paisley et al, 2003). During the
conception period the uterus can expand up to 1000 times, causing an anterior orientation of
the uterus (Hartmann and Bung, 1999). The development of the uterus leads to the visible
‘waddling’ way of walking during the last trimester. The growth of the uterus causes the body
to respond with a shift in the center of gravity. The center of gravity is shifted back over the
pelvis in response, preventing women from falling, the body's safety mechanism. Additionally
the center of gravity usually shifts higher, with this there is an increased strain on the muscles
and ligaments supporting the vertebral column (Wang and Apgar, 1998). The change in the
uterus size, leads to the change in center of gravity, leads to in an increased strain on the back
muscles, hence, the cause of low back pain experienced by most pregnant women. This
musculoskeletal change means pregnant women face difficulty with balance throughout term.
Hyperlordosis is seen resulting in progressive lumbar lordosis and rotation of the pelvis on the
femur (Hartmann and Bung, 1999). This causes an increase in the anterior flexion of the
cervical spine (a hunchback appearance) and adduction of the shoulders (rounding of the
shoulders). There is also an increase in the laxity of ligaments throughout the body, causing a
decreased stability of the joints (Hartmann and Bung, 1999; Wang and Apgar, 1998).
With these changes in mind it is important pregnant women are aware their balance can be
compromised. Care should be taken when choosing the exercises to include in a pregnant
women's exercise protocol. Taking into account the increased strain from the musculoskeletal
changes taking place due to the growing uterus, the exercises chosen should not add
additional unneeded stress on the low back.

Hyperlordosis - 'swayback', excessive curvature of the lumbar spine (lower part of spine,
closest to the buttocks)

Lordosis – the natural curvature of the lumber spine (lower part of spine, closest to the
buttocks)

Laxity - a degree of freedom of movement

Musculoskeletal Changes

Pregnancy is associated with numerous physiological changes. As a result, the physiological

response to exercise is altered. The most significant musculoskeletal Change is progressive
lumbar lordosis, which causes a shift in a woman's center of gravity (COG). As the fetus
grows, the COG is pushed back over the pelvis. To compensate for the change in the COG,
pregnant women tend to increase the anterior flexion of the cervical spine and abduct their
shoulders. Consequently, strain on the cervical and lumbar region of the spine, lower back
pain and general musculoskeletal soreness are common complaints from pregnant women.
In addition to the instability of the musculoskeletal system are hormonal changes. An increase
of estrogen and relaxin augments the elasticity of ligaments. The pelvic region and other joints
become more flexible, which could potentially increase the risk of injury during everyday
activities as well as exercise. Some women may experience a greater degree of complications,
which may alter the amount and type of exercise they can participate in.

Pathophysiology

For about half of all pregnant women, low-back pain is inevitable. Physicians who can specify
what type of back pain the patient has—lumbar, sacroiliac, or nocturnal—can institute targeted
treatment that addresses the relevant pathophysiology. Acetaminophen and certain modalities
such as icing the area are the basis of acute treatment in conjunction with ergonomic
adaptation and a good low-back exercise program. This will help decrease stress on the low
back, making back pain less likely. Before a woman becomes pregnant, encouraging her to
become fit and resolving existing back problems is the key to back pain prevention.

Understanding the normal musculoskeletal changes that occur during pregnancy is useful for
targeting and treating the sites of a patient's back pain.
Lumbar pain. Lumbar pain during pregnancy can stem from multiple sites, most commonly the
facet joints, paraspinal muscles, supporting ligaments, or discogenic sources.
Posture changes that occur during pregnancy help the woman maintain balance in the upright
position as the fetus grows. As pregnancy progresses, the hormone relaxin, which allows
pelvic expansion to accommodate the enlarging uterus, increases tenfold, reaching its peak at
the 14th week (12,13). Joint laxity is more pronounced in multiparous women than it is during
the first pregnancy. In the lumbar spine, joint laxity is most notable in the anterior and
posterior longitudinal ligaments, both of which are pain-sensitive structures. As these static
supports in the lumbar spine become more lax, they can't as effectively withstand shear
forces, and discogenic symptoms and/or pain from the facet joints may increase.
As the abdominal muscles stretch to accommodate the growing fetus, their ability to help
stabilize the pelvis decreases. The burden shifts to the paraspinal muscles, which become
strained at a time when they may be shortened from the increased lordosis of the lumbar
spine.
GI Tract Pathophysiology

Pregnancy

Increase intravenous pressure

Distention and engorgement

Painless, intermittent bleeding

during defecation Vague feeling of anal
discomfort when bleeding occurs

Prolapse of rectal Pain from thrombosis of

mucosa from straining external hemorrhoids

Pathophysiology
Hemorrhoids result from activities that increase intravenous pressure, causing
distention and engorgement. Predisposing factors include prolonged sitting, straining at
defecation, constipation, low-fiber diet, pregnancy, and obesity. Other factors include hepatic
disease, such as cirrhosis, amebic abscesses, or hepatitis; alcoholism; and anorectal
infections. Hemorrhoids are classified as first, second, third, or fourth degree, depending on
their severity. First-degree hemorrhoids are confined to the anal canal. Second-degree
hemorrhoids prolapse during straining but reduce spontaneously. Third-degree hemorrhoids
are prolapsed hemorrhoids that require manual reduction after each bowel movement. Fourth-
degree hemorrhoids are irreducible.
 Pathophysiology of Skin
Changes During
Pregnancy
a.k.a. Sunflower

Pregnancy

Hormonal Changes

Increase in Increase in
Increase in MSH Estrogen and Glucocortoid
Progesterone Hormones

Decrease of
Hyperpigmentation Collagen and
Elastic Fibers

Chloasma/ Darkening of: Loose of Support

Linea Nigra
Melasma -Areolas in Dermis and
-Axillae Epidermis
-Genitals

Rapid Stretching of
Skin

Dermal and
Epidermal Tearing

Striae Gravidarum
Chapter 3 – Planning

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS ANALYSIS

Subjective Cues: Risk for fluid The state in which an Within 8 hrs Encourage having To avoid loss of After 8 hrs of nursing
volume deficit individual is at risk of nursing meals always on appetite intervention the patient’s
related to experiencing intervention the time vomiting decreased
vomiting vascular cellular or occurrence of To provide accurate
intracellur deficit will be Advise to have a ongoing records of
Objective Cues: dehydration (duet to prevented regular weighing weight loss/gain
active regulatory schedule and note
losses of body water the results To stimulate the
in excess of needs or appetite of the client
replacement Provide
capability encouragement and To be able to gain
pleasant eating the toss of the
environment patient

Set time for the To lessen or cure the

client to eat illness of the patient

Administer
medication as
indicated
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Inability for sufficient The patient will regain check vital signs After 8 hours of nursing
Subjective Cues: physiological or it’s strength and be To provide baseline data intervention the patient is
psychological able to do simple monitor cardio respiratory able to do simple task
“Medyo nanghihina ko” energy to endure activities after 8 hours response to activity To monitor her endurance and is able to endure
as verbalized by the required task due to of nursing care to certain activities if desired daily activities
patient fatigue monitory discomfort or pain simple task
during movement/activity
Objective Cues: To monitor activities that
assist patient to do simple must be avoided
>B/P task
>P To prevent to much fatigue
>R document any findings
>T To provide necessary data
if intervention fail
(+) Restlessness
(+) Paleness
(+) Fatigue
(+) grimace
(+) sweating
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Inability to form a Patient will be able to Explore with the client To provide data of coping
Subjective Cues: valid appraisal of express this problem previous method of problems After 8 hours of nursing
stressor or more clearly and will dealing with problems intervention the patient is
“wala akong gana at inadequate choice of be able to respond To help the client established able to make positive
medyo nahihirapan practiced responses well to others after 8 Assist the client in her self actualization responses to other
ako” as verbalize by the due to stress hours of nursing positive appraisal of the people
patient. intervention event and oneself To help the client establish
proper communication to
Objective Cues: Communicate verbally to others.
the client
>b/p To remain free of destructive
Give moral support behavior towards self or
>P others.
Document findings
>R To provide necessary data
when intervention have
>T failed.

(+) Paleness
(+) Anxiety
(+) Grimace
(+) Restlessness
(+)Fatigue
Chapter III Implementation
Medical Management - Drug Study

Classification Adverse effect Medication Contra-indication Nursing intervention

Name of Drug

Iberet Antianemics/Pre & Post Allergic reactions, Treatment & Thalassemia, sideroblastic Pernicious anemia. Patients w/
Natal Vitamins GI effects, prevention of Fe- anemia, hemochromatosis chronic renal failure & receiving
hyperbilirubinemia, deficiency & & hemosiderosis. acetylsalicylic acid.
acneform vulgaris concomitant folic Hematologic remission may
deterioration or acid deficiency w/ occur while neurological
acneform associated deficient manifestations remain
exanthema intake or increased progressive. Serum B12 levels
eruption, bright need for vit B- should be regularly assessed in
yellow urine complex in elderly & patients w/ condition
discoloration, nonpregnant adults. leading to vit B12 depletion.
flushing, dizziness Pregnancy, lactation.
or faintness,
peripheral sensory
neuropathies,
stone formation,
crystalluria &
oxalosis, black
discoloration of
stool.
 Classification Adverse effect Medication Contra-indication Nursing intervention
Name of Drug

OB Max Antianemics/Pre & Post Gastric irritation Pre- & postnatal Thalassemia, sideroblastic Pernicious anemia. Patients w/
Natal Vitamins (take OB-Max on supplement fortified anemia, hemochromatosis chronic renal failure & receiving
full stomach to w/ taurine to meet & hemosiderosis. acetylsalicylic acid.
avoid this). nutritional needs of Hematologic remission may
mothers & for occur while neurological
proper growth & manifestations remain
development of progressive. Serum B12 levels
baby. For proper should be regularly assessed in
mental brain elderly & patients w/ condition
development of the leading to vit B12 depletion.
fetus. Pregnancy, lactation
Chapter IV Discharge Planning

Medication – Aside from the OBMax and Iberet, the client may also be given calcium to
ensure an adequate intake of this essential nutrient. A multivitamin that has folic acid prevents
neural tube defects, calcium is needed for bone and teeth, and iron is needed to prevent
anemia in mother and fetus.

Needed Amount What it does Health Teaching

Vitamin/Mineral What it is for Pregnant
Client

Eat a well-
Folic Acid Sometimes 400 micrograms Folate prevents balanced diet
called folate, is a of folic acid a the baby from that includes rich
B vitamin (B9) day. serious sources of Folic
found mostly in abnormalities of Acid like broccoli,
leafy green the brain and Brussels sprouts,
vegetables like spine. Lack of asparagus, peas,
spinach. Can Folic acid leads chickpeas and
also be found in to inadequate brown rice.
citrus fruits such growth of the
as orange juice, fetus, Other useful
and also beans, underdeveloped sources include
breads, cereals, brain, incomplete fortified
rice, pastas. closure of spinal breakfast
cord, preterm cereals, some
delivery and low bread and some
birth weight. fruit (such as
oranges and
bananas).
 Needed Amount What it does Health Teaching
Vitamin/Mineral What it is for Pregnant
Client

Good sources of
the mineral 1,000 milligrams It helps keep Make sure she
Calcium calcium include (mg) per day your bones and gets enough
milk, cheese and teeth strong. calcium every
other dairy When a woman day: before,
foods, green doesn’t get during and after
leafy vegetables enough calcium the pregnancy.
(such as from her diet, Dairy products
broccoli, the body takes it are the best food
cabbage and from her bones. sources for
okra, but not If a woman calcium like low-
spinach), soya doesn’t get fat or fat-free
beans, tofu, soya enough calcium milk and yogurt,
drinks with in her diet plus hard
added calcium, during cheeses
nuts, bread and pregnancy, the (cheddar, Swiss).
anything made calcium the baby Other good
with fortified needs will be sources are dark
flour, and fish taken from her green leafy
where you eat bones. vegetables (such
the bones, such as broccoli and
as sardines. kale) and tofu
processed with
calcium sulfate.

Needed Amount What it does Health Teaching

Vitamin/Mineral What it is for Pregnant
Client

During Eat a well-

Iron Iron is a mineral The pregnancy balanced diet
found in some recommended women have that includes rich
foods, which is daily intake blood in excess sources of iron
essential for (RDI) of iron volume, so this like beef, liver
good health and during excess blood and kidney, fish,
for physical and pregnancy is 22- requires an vegetables and
mental well- 36mg (10-20mg excess amount fruits,
being. more than that of iron. During
for non-pregnant pregnancy not
women). just the blood
cells of the
mother but the
growing child’s
cells require
oxygen, this is
where again the
demand for the
amount of
oxygen is
fulfilled by iron.
Exercise – Specific exercises may be carried out to help strengthen muscle tone in
preparation for birth. These exercises include:

> Pelvic tilt – Lie on your back with legs hip-width apart, both knees bent, and both
feet on the floor. Place arms alongside body with palms down. Keep head and
shoulders relaxed. Hold abdominals in as you rotate and tilt your pelvic girdle up
toward the ceiling with a smooth and controlled motion. Repeat for 8 times and
progress to 3 sets of 8 times.

> Kegel’s exercise – Kegel's strengthens the pelvic floor muscles that support
the uterus, bowel and bladder and help prevent possible incontinence. For
doing this, all you need to do is pretend you are trying to stop the flow of
urine. Practice this a few times so you understand what muscles you need to
contract, and keep contracting these muscles a number of times during a day.
Contract and hold, and release. Do these exercises in sets of 10, 3-4 times a
day. The longer you hold the muscles and the more regularly you practice this
exercise, the stronger your muscles will get. In addition, this is a great
exercise as it can be done anytime during the day..

>Tailor sit - Sit on a flat, hard surface with your legs crossed in front of you. Tailor
Sitting is also called sitting "Cross-Legged" or "Indian Style."

Treatment – The client experiences nothing more than what is normal for pregnant women so
no special treatment is needed.

Health Teaching – A pregnant woman should drink at least 8 to 10 glasses of fluids each
day. Personal hygiene: daily bathing is important because the pregnant woman generally has
increased perspiration and vaginal mucous. Activity/Rest: She should have some type of
regular physical activity. Fatigue should be avoided. Exercise during pregnancy could reduce
the risk of cesarian birth. She should avoid hyperthermia and drink plenty of water before and
after exercise to prevent dehydration. Advise the client to increase fluid intake and prevent
dehydration. Eat more fibers, encourage regular BM. No mineral oil it will prevent the
absorption of vitamin A, D, E, K. To avoid varicosities elevate the lower extremities 15
minutes. Avoid prolonged standing. Refrain from wearing constricting garments. Backache,
wear low-heeled shoes, use firm mattress, wear maternity girdle.

Outpatient follow up – none

Diet – Eat a balanced diet. Just an additional 300 kcalories a day is needed. The addition of
two milk servings and one meat serving will meet the 300 kcalorie increase as well as the
increased need for calcium and protein.