BULACAN STATE UNIVERSITY CITY OF MALOLOS S.Y.

2011-2012

CHN 101-B

PRENATAL CARE

SUBMITTED BY: GROUP 2 LEADER: MEMBER: Dela Cruz, Mary Grace C. 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.

SUBMITTED TO: Rosemarie Bartolome, RN Heinrich Presas, RN Abigail Ramos, RN Daisy Reyes, RN

TABLE OF CONTENTS

I. II. III. IV.

V. VI. VII. VIII. IX. X.

INTRODUCTION ...PAGE 1-2 OBJECTIVES OF THE CASE PRESENTATION ..PAGE 3 SIGNIFICANCE OF THE CASE STUDY ..PAGE 3 SUMMARY / SIGNIFICANT FINDINGS OF ADB .PAGE 4 A. DEMOGRAPHIC/SOCIO-ECONOMIC, CULTURAL AND ENVIRONMENTAL CHARACTERISTICS ...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 y 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 AND OTHER SCREENING PROCEDURE ..PAGE 22 C. VALUES, HABITS,PRACTICES ON HEALTH PROMOTION,MAINTENANCE AND DISEASE PREVENTION ..PAGE 23 APPLICATION OF NURSING THEORY IN THE CARE OF CLIENT .PAGE 23-24 HEALTH CONDITION AND PROBLEM SHEET .. ..PAGE 25 INDIVIDUAL NURSING CARE PLAN PAGE 26-28 IMPLEMENTATION OF NURSING CARE PLAN PAGE 29 y CONDUCT OF HEALTH EDUCATION ..PAGE 29 CONCLUSION PAGE 30 BIBLIOGRAPHY ..PAGE 30

I.

INTRODUCTION

Our client Mrs. C.S ( G4P3) is 35 years old living in Prk. 6 Barangay Palapat, Hagonoy, Bulacan. The last time we visited Mrs. C.S her pregnancy was on the third trimester ( turning 9 months ). She states that after giving birth, she will undergo tubal ligation. Mrs. C.S had three pregnancies with 1 year interval for each child. According to her, all of her children were delivered normally on the hospital and on her present pregnancy; she will do the same thing. She go to a doctor for check-up but not regularly. Mrs. C.S originally lived in Manila, she is a high school graduate and wasn t able to continue her studies ( College ) because of financial problem. She was getting married at the at the age of 20, she do not have any work since then and up to now because she is pregnant. Together with her family, they moved to Barangay Palapat where her husband, Mr. L.S resides. As we go further on this case presentation, we will be able to know the everyday lifestyle of Mrs. C.S but before that we must first to know some important information about prenatal period. PRENATAL PERIOD The term prenatal period refers to the time in pregnancy between conception and birth. The prenatal period last for 40 weeks, which is roughly nine months. The prenatal period is divided into three trimesters, with each trimester lasting approximately three months. During this time, the embryo develops into a fetus and then into a viable human baby. There are many changes in both mother and child during the prenatal period, including weight gain in both physical and hormonal changes. During the third trimester( 28th weeks of AOG 40th weeks of AOG ) where our client, Mrs. C.S has been experiencing, the focus is on the weight of the fetus and there is a period of rapid growth and development. At the end of 28th weeks of Gestational week, the length of the fetus is 35 to 38 cm. and the weight is about 1200gms. The bones are fully formed, but still soft. Lungs are not fully formed, but practice breathing movements occur. The surfactant starts to develop: Male testes descends and on Female clitoris are small. At the end of 32nd weeks, the baby s kick and jabs are forceful on which our client experienced often. The eyes are open and close and sense changes in light. The baby is gaining weight quickly, about lbs. a week. Nails start to extend to the fingers. The baby s length is about 38-43 cm. and weighing 1600gms. At the end of 36th weeks, lanugo and vernixcaseosa completely disappear. The baby is getting bigger and bigger and has less space to move around. The amniotic fluid decreases. The length was now 42-48 cm. and weighing 1800-2700gms. At the end of 40th weeks, the bone ossification of fetal skulls begins. As the woman near her due date, the baby may turn into a head-down position for birth. The length is 48-52 cm. and weighing 3000gms. PRENATAL CARE
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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 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.

II.

OBJECTIVES OF THE CASE PRESENTATION

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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 To give knowledge about the importance and objectives of prenatal care. To formulate significant nursing diagnosis that will help the client resolve her problem. To build trust and establish rapport in dealing with the client in rendering nursing care.

III.

SIGNIFICANCE OF THE CASE STUDY

y y y 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.

IV.

SUMMARY/SIGNIFICANT FINDINGS OF ADB

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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: y A.S female, 16 yrs. Old. y A.S male, 15 yrs. Old y A.S female, 14 yrs. Old 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 isn t 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

Mrs. B.M A/W

Mr. S.S LC

Mrs. J.S A/W

Mr. R.S 40 y/o

Mr. H.S 38 y/o

Mrs. C.S 35 y/o

Mrs. E.L 32 y/o

Mrs. A A/W

Not Recognized

Mr. AL 38 y/o

Not recognized

Not recognized

LEGEND: - MALE FEMALE DECEASED FETUS

A.S 16 y/O

A.S 15Y/O

A.S 14 y/o

9 MONTHS Boy

O.G OLD AGE L.C LUNG CANCER A/W ALIVE AND WELL
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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. 72 Hours Dietary Recall DATE NOTED TIME OF THE DAY MEAL August 23, 2011 Breakfast - 4pcs. Pandesal, 2 glasses of water, 1 fried egg. Lunch Dinner Breakfast Lunch Dinner - bowl of menudo, 1 cup of rice, 4 glasses of water. - 2 pcs. Fried tilapia, 1 cup of rice, 3 glasses. August 24, 2011 - 1 pc. scrambledegg, I cup fried rice, 2 glasses of water - 1 pc. Of Chicken (tinolang manok), 1 cup of rice, 2 glasses of rice. - 1 pc. Of Fried tilapia, 1 cup of rice, 2 glasses of water.

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August 25, 2011

Breakfast Lunch

- 3 pcs. Of tuyo, 1 cup of rice, 3 glasses of water. - 1 cup of rice, 2 pcs. of fried biya, 3 glasses of water.

ELIMINATION PATTERN Bowel Movement Urine Feces Color dark yellow brown Frequency 6-8 times a day Once a day Characteristics slightly turbid firm Odor aromatic foul odor Discomfort no discomfort 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
Feeding Bathing

Score
0 0

Criteria
Level 0 full self-care. Level I requires the use of equipment or device.

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Toileting Home Management Dressing Grooming

0 0 0 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 doesn t have any problem falling asleep but she is usually interrupted because she feels the urge to urinate.

COGNITIVE-PERCEPTUAL PATTERN She doesn t 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 doesn t have any problems in dealing with her children. She feels isolated because she lives far from her neighbors.
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SEXUALLY REPRODUCTIVE PATTERN Mrs. C.S is a G4P3 and she didn t 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.
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3. GROWTH AND DEVELOPMENT ASSESSMENT A. DEVELOPMENTAL ASSESSMENT THEORY STAGE COGNITIVE Formal operations stage (adolescence and adulthood) Occurring in this stage, they In this stage, intelligence begin to share their selves more is demonstrated through intimately with others. They the logical use of symbols explore relationships leading related to abstract toward longer term concept. He or she is commitments with someone capable of deductive and other than a family member. hypothetical reasoning. PSYCHOSOCIAL Young Adulthood ( Intimacy vs. Isolation ) MORAL Post conventional (universal ethical principle orientation) It is the final stage where The person lives it begins at the start of autonomously and defines puberty when sexual moral values and urges are once again principles that are distinct awakened. Adolescents from personal direct their sexual urges identification with group 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. Our client uses rational Our client s energy is She is consistent on her thinking; her reasoning is directed toward full decision making. Her deductive and futuristic. sexual maturity and conscience is working for function and her to do the right one. She 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. By this stage, the person We must encourage Our client s decisions and no longer requires separation from parents behaviors are based on concrete objects to make which lead to internalized rules, on rational judgments. achievement of conscience rather than
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PSYCHOSEXUAL Genital Stage ( puberty onward )

DEFINITION

FINDINGS

Mrs. C.S personal lifestyle develops, she establishes a relationship with a significant others like her husband and had a meaningful social life

REMARK/ANALYSIS

We as a nurse must assist adult s chosen lifestyle and assist with necessary adjustments relating to health.

We must recognize the person s 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 we ve 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 PULSE RATE: 80bpm RESPIRATORY RATE: 27 cpm TEMPERATURE: 37 C AREAS TO BE ASSESSED GENERAL SURVEY Body built, height and weight in relation to the client s age Posture and Galt Overall hygiene and grooming Body and breath odor TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION/ANALYSIS HEIGHT: 4 11 / 59 inches WEIGHT: 62 kgs. BMI: 27.5

Inspection

Proportionate, varies with lifestyle `Relaxed, erect Posture Clean, neat No body odor or minor odor relative to work or exercise; no breath odor No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation

Inspection Inspection Inspection

Endomorph, height and weight proportion to her age. Relaxed and has erect posture Our client is neat and clean No foul body and breath odor No distress noted She has a healthy appearance Cooperative and can follow instructions Cooperative and pleasant,

Normal

Normal Normal Normal

Signs of distress Obvious sign of health or illness Client s attitude Mood and affect

Inspection Inspection Inspection Inspection

Normal Normal Normal Normal

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Quantity and quality of speech Relevance and organization of thoughts INTEGUMENTARY A. Skin Color

Inspection

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

Inspection

Generally uniform in color except in the areas that are exposed to the sun

Presence of edema Temperature Skin Turgor Skin Intactness B. Hair Presence of edema Evenness of growth over the scalp Hair texture and oiliness Amount of body hair C. Nails Fingernail plate shape, toenail texture Tissues surrounding nails Perform blanch test of

Inspection palpation palpation Inspection Inspection Inspection Inspection Inspection Inspection

No edema Uniform; within normal range Skin springs back to previous state No lesion, skin is intact No edema Evenly distributed; thick or thin Silky, resilient hair Variable Convex curvature, angle of the nail plate about 160 ; smooth texture Intact epidermis Prompt return of pink or

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 No lesion, skin is intact Has slight edema Has thick hair, evenly distributed, color black She has silky hair Variable Her nail shape is convex curvature. Has smooth texture. Has intact epidermis The usual color of nails

Normal

Normal Normal Normal Normal Normal Normal Normal Normal Normal

Inspection Inspection and palpation

Normal Normal
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capillary refill D. Skull and face Skull size, shape and symmetry Presence of nodules, masses and depression Facial features Facial movements E. Eyes Inspect the eyes for edemas and hollowness Eye brows for hair distribution Eyelashes for evenness of distribution and direction of curl Eyelids for surface characteristics, ability to blink and frequency of blinking

usual color

returns to pink after 2-3 seconds. No nodules and masses, smooth No nodules and masses, smooth Facial features were slightly asymmetric Has symmetric facial movements No edema 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 Normal

Inspection Palpation

Inspection Inspection

Rounded and smooth skull contour Smooth, uniform consistency; absence of nodules and masses Symmetric or slightly asymmetric facial features Symmetric facial movements No edema Hair evenly distributed, eyebrows symmetrically aligned. Equally distributed; curled slightly outward 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

Inspection Inspection

Normal Normal

Inspection

Normal

Inspection

Normal

Bulbar and palpebral conjunctiva for color, texture and presence of lesions

Inspection

Bulbar conjunctiva is transparent. Palpebral conjunctiva is shiny, smooth and pink.

Normal

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Lacrimal gland Lacrimal sac and nasolacrimal duct Cornea for clarity and texture Corneal sensitivity Pupils for color, shape and symmetry of size Pupil s depict and consensual reaction to light

Inspection and palpation Inspection and palpation 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.

Normal Normal Normal

Inspection Inspection

Inspection

Pupil s reaction to accommodation

Inspection

Peripheral visual fields

Inspection

Six ocular movements

Inspection

Visual acuity

Inspection

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

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F. Ears Auricles color, symmetry of size and position

Inspection

Texture, elasticity and areas of tenderness External ear canal for cerumen, skin lesions, pus and blood Watch tick test G. Nose Shape, size or color and flaring or discharge Nasal cavities

Palpation

Inspection

Inspection

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 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

Color same as facial skin, auricle aligned with the outer cantus of the eye. Mobile, firm and not tender; pinna recoils after being fold. Has dry light brown cerumen and grayish color

Normal

Normal

Normal

She was able to hear ticking in both ears Symmetric and straight; no discharge or flaring; uniform in color Have no discharge and no lesions. Air moves freely as Mrs. C.S breathes through the nares Nasal septum is intact and in midline No tender, masses or displacement of bones and cartilage Maxillary and frontal sinuses are not tender

Normal

Inspection

Normal

Inspection

Normal

Patency of both nasal cavities Nasal septum Tenderness, masses and displacement of bones and carriage Sinuses for tenderness H. MOUTH

Inspection

Normal

Inspection Palpation

Normal Normal

Palpation

Not tender

Normal

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Lips for symmetry of contour, color and texture

Inspection

Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips

Buccal mucosa for color, moisture, texture and presence of lesions Teeth for color, number, condition and presence of dentures Gums for color condition

Inspection

Inspection

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

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 Pink and smooth posterior wall Pink and smooth, no discharge Has pink and smooth posterior wall. Has pink and smooth tonsils; no discharge.

Normal

Normal

Normal

Normal

Normal

Normal Normal

Normal

Inspection Inspection

Normal Normal

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Elicit the gag reflex I.NECK Neck muscles

Perform test on gag reflex Inspection

Present Muscles equal in size; head centered Coordinated, smooth movements with no discomfort Not palpable Central placement in midline of neck; spaces are equal on both sides Not visible on inspection, ascends during swallowing but is not visible

Gag reflex is present. 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. 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

Head movement

Inspection

Normal

Entire neck for enlarged lymph nodes Trachea for lateral deviation

Palpation Inspection

Normal Normal

Thyroid Gland

Inspection and Palpation

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

Normal

Normal

Normal Normal

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Chest for vocal fremitus

Palpation

Thorax

Percussion

Bilateral symmetry of vocal fremitus; fremitus is heard most clearly at the apex of the lungs Percussion notes resonate, except over scapula

Diaphragm excursion

Percussion

Chest using the flat-disc diaphragm of the stethoscope J. ANTERIOR THORAX Breathing pattern Anterior chest for respiratory excursion Tactile fremitus

Auscultation

Excursion is 3 to 5 cm bilaterally in women and 5 to 6 cm in men; diaphragm is usually slightly higher on the right side, Vesicular and bronchovesicular breath sounds 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,

apart an equal distance and at the same time. Bilateral symmetry of vocal fremitus; fremitus is heard most clearly at the apex of the lungs Percussion notes resonate, except over scapula; lowest point of resonance is at the diaphragm. Excursion is 3 to 5 cm. Diaphragm is usually slightly higher on the right side, Vesicular and bronchovesicular breathe sounds on the chest. Quiet, rhythmic and effortless respirations. Full symmetric excursion 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

Inspection Palpation Palpation

Normal Normal Normal

Anterior chest

Percussion

Normal

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dull on areas over the heart and the liver, and tympanic over the underlying stomach. Auscultation 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 Axillary, subclavicular and supraclavicular lymph nodes J. ABDOMEN Skin integrity Contour and symmetry Abdomen for bowel sounds Liver K. MUSCULOSKELETAL Inspection Inspection Inspection Bronchial and tubular breath sounds Rounded shape slightly unequal in size Uniform in color Oval and bilaterally the same; color varies widely

dull on areas over the heart and the liver, and tympanic over the underlying stomach. Bronchial and tubular breath sounds Rounded shape slightly unequal in size Skin is uniform in color Oval and bilaterally same; color is dark-brown Normal Normal Normal

Inspection

Palpation

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

Normal

Inspection Inspection Auscultation Palpation

Uniform in color, silverwhite striae Flat, rounded or scaphoid Audible bowel sounds May not be palpable; border feels smooth

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 Normal Normal Normal

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Muscles for size Muscles and tendons for contractures and tremors Muscle tonicity Muscle strength Skeleton Joint

Inspection Inspection Palpation Testing muscle strength Inspection 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 b. EDC: September 8, 2011 c. AOG: 38 weeks and 1/7 d. LMP: December 01, 2010 e.Trimester: 3rd trimester 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 movement 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 fetal body weight: 2110 grams  Expected date of confinement: September 8, 2011  Sex: Male URINALYSIS NORMAL VALUE Physical Appearance: Color Pale to dark yellow transparency clear Chemical Screening: pH 5-7 Specific gravity 1.000 to 1.030 Glucose Negative Protein Negative Leukocyte Esterase Negative Nitrite Negative Blood(Hemoglobin) Negative Ketones Negative Bilirubin Negative Microscopic Examination: White Blood Cells 5.0-10.0 Red Blood Cells 3.80-5.80

RESULTS Dark yellow Slightly turbid 6 1.015 Negative 1+ Negative Negative Negative Negative Negative 8.4 3.80

REMARKS Normal Normal due to pregnancy Normal Normal Normal Normal due to her pregnancy Normal Normal Normal Normal Normal Normal 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 attends her prenatal check-ups but not regularly. Currently haven t 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

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.

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 Human to Human Relationship Model

THEORIST
Joyce Travelbee

DESCRIPTION
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

Travelbee s theory emphasis on caring stressed empathy, sympathy, rapport, and the emotional aspects of nursng. 1st Stage of Travelbee s Theory: Original Encounter When we first visit Mrs. C.S she ignore us, she didn t want to talk to us and even entertain us. She was not interested on what we are saying. 2nd Stage of Travelbee s Theory: Emerging Identities
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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. rd Stage of Travelbee s Theory: 3 Developing Feelings of Empathy She was now cooperative to us, she entertain us and more confident in answering our questions. 4th Stage of Travelbee s Theory: Sympathy This stage was very helpful to us. We gained our client s trust. She was now having conversation to us about her life. She even allowed us to borrow her check-up s record. th Stage of Travelbee s Theory: 5 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

DATE IDENTIFIED July 01,2011 SOLVED July 22, 2011

1. Do not perform regular check-up

4.0

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

The client stated to us that she do not go to a doctor for a check-up. She stated to us that they 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

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).

July 08, 2011

---

August 25, 2011

----

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VII. INDIVIDUAL NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

BACKGROUND KNOWLEDGE OF HEALTH CONDITION/ HEALTH PROBLEM

GOAL OF CARE/OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

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

After 30 minutes of nursing intervention the client will:  Identify necessary health Maintenance Activities appropriate to a pregnant.  Verbalized understanding of factors contributing to current situation.

 Establish rapport on the client.

 To gain trust and cooperation on the client.  To obtain the baseline data.  To meet the client s changing needs/ abilities and environmenta l concerns.

 Monitor the vital signs.

After 30 minutes of nursing intervention the client will:  Identify necessary health Maintenance Activities appropriate to a pregnant.  Verbalized understanding of factors contributing to current situation.

O:

 Identify ways to adapt things in current circumstances

Lack of financial resources

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ASSESSMENT

NURSING DIAGNOSIS

BACKGROUND KNOWLEDGE OF HEALTH CONDITION/ HEALTH PROBLEM

GOAL OF CARE/OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

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

After 30 minutes of nursing intervention the client will:  Demonstrate behaviors to attain/maintain appropriate weight.  Be free of signs of malnutrition.  Be able to safely prepare and store foods.

Willingness to enhance nutrition

 Review clients knowledge of current nutritional needs and ways client is meeting these needs.  Encourage client s beneficial eating patterns / habits.

 To provide baseline for further teachings and interventions

After 30 minutes of nursing intervention the client will:  Demonstratebe haviors to attain/maintai n appropriate weight.  Be free of signs of malnutrition.  Be able to safely prepare and store foods.

O: Attitude toward eating is congruent with health goals  Review safe preparation and storage of food  Identify ways to adapt things in current Circumstances

 To have a positive feedback which promotes continuation of healthy lifestyle habits and new behavior.  To avoid food-borne illnesses.

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ASSESSMENT

NURSING DIAGNOSIS

BACKGROUND KNOWLEDGE OF HEALTH CONDITION/ HEALTH PROBLEM

GOAL OF CARE/OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

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

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.

unattended vehicle on the garage

 To emphasize importance of periodic evaluation and repair of gas appliances/ Furnace, automobile exhaust system.  Identify/ Encourage relevant safety measures.

 To prevent exposure to carbon monoxide.

After 30 minutes of nursing intervention the client will:  Verbalized knowledge of hazards in the environment.  Correct hazardous situations to prevent/ Reduce risk of suffocation.

 To prevent / Minimize risk of injury.

May be risk for 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

MONEY:  Definition of prenatal care. Manila paper  Purpose of @ Php 5.00 each 10.00 prenatal care  Schedule of Pentel pen ---24.00 prenatal visit  Nutrition 34.00 needed by a pregnant MATERIALS: woman  Tetanus Toxoid  Manila paper Vaccination  Pentel pen Interactive Discussion 15-20 minutes ( 9:30 9:50 am)

After 15-20 minutes of health teaching, the client will be able to answer tha following: 1. What is the definition of prenatal care? 2. What are the advantages of having a prenatal checkup? 3. What is the correct schedule for prenatal visits?

Target Population: Mrs. C.S Lecture

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IX. CONCLUSION/RECOMMENDATION
In doing this case study, we as a group acquired knowledge which was supported by the information we have gathered for this case. We are able to identify and monitor the condition of our client and guide her in prenatal care. For us, we could say that we have been effective health care providers. We have implanted information on how the client can take care of her condition which we can think helped our client.

X. BIBLIOGRAPHY
INTERNET:  http://www.medicalmoment.org/content/risks/jan04/196268.asp  http://www.womenshealth.gov/publications/our-publications/fact-sheet/prenatal-care.cfm#b

BOOKS:     Mary Ellen Zator Estes, Introduction to Health Assessment and Physical Examination, Copyright 2010 Delmar, Cengage Learning Kozier & Erb s, Fundamentals of Nursing, 8th edition, Pearson Education South Asia Pte. Ltd. Copyright 2008 Ann Marriner Tomey, Martha Raile Aligood, Nursing Theorist 6th Edition Marilynn E. Doenges, Mary Frances Moorhouse, Alice Murr, Nurse s Pocket Guide 11th edition, Copyright 2008

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