Académique Documents
Professionnel Documents
Culture Documents
A. Personal Data
Mrs. R is a former crew at a fast food but now a housewife. On the other
hand, Mr. J is an “all around worker” – construction worker-electrician, and farmer.
Daughter F is 3 years old.
1. Socio-Economic Data
Mrs. R is a plain housewife. She used to work as a crew in a fast food chain
but as requested by her husband, she resigned to devote more time caring for their
first child and to her husband as well. Mrs. R’s husband is a fulltime construction
worker-electrician and earns P1680/week and approximately P7000 four times in a
year as a pig raiser. The 7000 is considered as incentive or salary from the parents.
Also, he is a part time farmer and usually grows corn and garlic. They earn 3000
from corn every season for 3 seasons and 2000 for the garlic once a year. All
income earned from being a farmer are incentives from the husband’s parents who
really own the business. They have a total income of P9970 in a month. It is the
husband’s parents who shoulder the expenses on the farm and piggery inputs and
they only help in the overall management and monitoring.
Mrs. R’s family spends P1000 in a week (4000/month) for food. Since theirs is
considered extended, the nuclear family shares food with the paternal parents and
they eat together as verbalized by the patient “agkakabanga kami ken ages-share
kami ti makan nukwa.” They allot P200 for the electric bill, P200 for medical check-
up, P100 weekly for cell phone load, P200 for transportation, 1500 as total
allowance of their daughter monthly and P500 for medications. Their monthly
expenditures cost approximately P7000. The rest of their income serves as their
savings for emergency purposes and in preparation for her delivery.
B. Pregnancy History
1. Current Pregnancy
Mrs. R’s last menstrual period was last December 4, 2008. She is now on her
31st week of gestation. According to Naegele’s rule, Mrs. R’s expected date of
confinement will be on September 11, 2009. She experienced her first quickening
during her 5th month of pregnancy which was in May 2009. Mrs. R has an obstetrical
scoring of G2P1 and T1P0A0L1.
Mrs. R had her first check up last April 17, 2009 in MMMH and MC and was
diagnosed as verbalized “Nababa ti matres ko kuna ni doctor isu nga inresetaan nak
iti pagpakapet ti ubing.” She did not buy the prescribed medication instead she
went to a manhihihilot as stated “Haan ko malagip dijay nagan ti agas kasi haan ko
met nga ginatang. Napan nak latta nagpailot idtoy ayan min. Adu pay ngamin ti
gastos ko kadigijay agas jay anak ko kasi adda angkit na.”
When asked about Mrs. R’s chief concern, she answered “nu tumakderak
kasla maregreg ta pus-on ko ken nasakit patong ko.”
Mrs. R admitted that she has low blood pressure last month (June 2009) and
experienced headache, as she said, “nababa darak ken nasakit ulok.” Moreover, she
feels constipated because she only defecates every after two days as she stated,
“natangken ti takkik isu nga kada maikadwa nga aldaw nak lang a tumakki.”
Mrs. R is not exposed to any communicable diseases and did not have any
illnesses from the beginning of her pregnancy.
Mrs. R admitted that her current pregnancy was unplanned and she really did
not expect getting pregnant. She had to resign from her work in a fast food chain as
requested by her husband in order to have more time to take care of their first child
and to be ready for her labor.
Despite the unpredicted pregnancy, Mrs. R and her family were happy to
have another child and they hope that the next baby would be a boy. They also plan
that Mrs. R would have her ligation after the delivery.
Mrs. R gave birth to her first child on January 2, 2006. She was at 36th week of
gestation when she gave birth. She had undergone a normal delivery at MMMH
Batac. Unfortunately, she experienced pregnancy induced hypertension and was
transfused with 1000 cc of blood because of postpartum bleeding related to uterine
relaxation to compensate the loss of blood. Mrs. R also experienced edema on her
lower extremities specifically on both thighs down to her feet.
3. Menstrual History
Mrs. R had her menarche when she was 12 years old. According to her, she
has a regular 28 day cycle and usually menstruates for 4 days. The heaviest flow
usually occurs from day 1-3 and changes fully soaked sanitary napkin three times a
day. She has spotting for the last day. She also experiences dysmenorrhea and
treats it by using hot compress and claims relief from it as she verbalized
“mabangbangaran nak met nukwa”. Usually, she notices one small clot on her flow.
C. History
1. Genogram
2. Family History
According to Mrs. R there are certain diseases that are present in their family.
Her father died of lung tumor because of smoking, consuming 1 pack within a day.
He also used to be an occasional drinker of alcoholic beverages and could drink 1-2
glasses of ginebra san Miguel. On the other hand, her mother has a heart disease
and with hypertension that Mrs. R inherited but did not know what her mother does
her heart disease attacks as well as hypertension.
They are 8 siblings in the family. Her second brother was diagnosed with
enlargement of the kidney because of stress and vices such as drinking liquor. The
third one had experienced motor accident and got an injury in the head. While her
other siblings have no major illnesses.
On Mr. J’s side, his father, as verbalized by Mrs. R “adda bara ti ulo na ken
agsaksakit siket na.” Furthermore, he has also vices like drinking liquor and
smoking.
Mr. J had slight attacks of asthma during his childhood days. And according to
Mrs. R, her husband drinks liquor occasionally. Daughter F has asthma which she
inherited from her father.
Mrs. R does not have any vices, but according to her, she occasionally drinks
liquor during her high-school days when she was still a teen-ager. She considers
doing household chores such as washing the laundry as her form of exercise. Also,
she said that she walks for 5-10 minutes with a distance of 5-10 meters daily and
usually relaxes by watching TV every afternoon as she verbalized “maayatan nak
agbuya nukwa ti wowowee nu aldaw.” The student nurses inform the patient that
doing household chores are not forms of exercise and that it is a physical activity
that someone does regularly to become healthy or to promote wellbeing.
She cannot recall whether she received her complete immunization but she
has a scar on her left deltoid implying that she has received a BCG vaccine.
She has no allergy on foods and drugs but she has allergy to dust which leads
to nose irritation and colds. She once had an allergy with a particular detergent
powder which led to roughness and thickening of her palms.
Mrs. R claimed that she accidentally got shot by an “escupeta” on her upper
lip and was operated and hospitalized for 1 week.
5. Nutritional History
The table shows the dietary intake of Mrs. R for the past three days.
Mrs. R eats meals three times a day. Rice is always present every meal and
she claimed that she eats more than her usual meals. Sometimes she drinks milk
and eats her snacks if she likes to. She has healthy meal preferences.
Her actual body weight is 68 kilograms and her height is 152.4 centimeters.
At present she has a BMI of 29.44 which means that she is overweight. Her actual
body weight prior to her pregnancy is 58kgs. Her desirable body weight for her
pregnancy is 64kg. The total recommended energy for her pregnancy is 2180 kcal.
Based from the data gathered, the client is in high-carbohydrate-diet because
of the amount of rice and noodles she is taking in and most probably the reason
why she is overweight.
6. Sexual History
Mrs. R’s first sexual intercourse with her husband happened on April 2004. At
first, according to Mrs. R, there is fear in her as well as excitement towards having a
sexual intercourse, but in the succeeding sexual contact through several years she
gets along with it, and considers it as part of their marriage. The attitude of Mrs. R
depends upon the time were in they would have their sexual intercourse even if she
does not have the desire she just considers it as a need of her husband and also
Mrs. R is less aggressive than her husband.
According to her, they do sexual intercourse two times a week, most of the
time at night. They usually practice withdrawal and sometimes use of condom as
their form of contraception and according to her the pleasure they get (both of
them) is the same according to her. Since her pregnancy, they just do it usually only
once a week. Her last sexual intercourse with her husband happened last week (3 rd
week of July).
Mrs. R’s husband stands 5’5’’ and weighs 55kg. According to Mrs. R as of her
husband’s health status as verbalized by “healthy nga saan” because he is capable
of getting sick. When he knew about her wife’s pregnancy, he did not expect it but
still was happy because they were longing for a baby. He was the one who initiated
and decided for her wife to resign from her job as a service crew concerning the
risks that may occur to her pregnancy and that for Mrs. R to take care of and look
for their first child. With regards to his relationship with her, he is very supportive,
understanding, and loving as verbalized by Mrs. R, “mayat met ti pinagdendenna
mi, haan kam met unay agap-apa ken masolsolbar mi met dagitoy problema mi”.
He is also a responsible husband and father to their child. He makes sure that he
sustains well the needs of the family.
D. Physical Assessment
Mrs. R is a middle-aged woman who stands 5’ and weighs 68 kgs. She has an
endomorphic body built. The client has a good posture, wears no make-up, her hair
is neatly fixed and neatly groomed. She walks and moves freely and shows a joyful
disposition. She was wearing a loosely-fit maternity dress.
1. Vital Signs
2. Head-to-Toe Assessment:
Head
- normocephalic
Face
- no melasma noted
Eyes
o PERRLA
Ears
- the upper connection of the earlobes are in line with the outer canthus of the
eye
- with good hearing acuity – able to hear whisper at a distance of two feet
Nose
Oral Cavity
- Lips:
o pinkish in color
- Tongue:
o midline in position
- Teeth
o 29 teeth present
- Gums
o pinkish
Neck
- trachea in midline
Chest
Breast
Abdomen
- protuberant
- fundic height is 22 cm
Upper Extremities
Lower Extremities
- no signs of edema
3. Leopold’s Maneuver
In the second maneuver, we palpated the fetal back at the right lower
quadrant of the abdomen and at the same time auscultated and counted the fetal
heart tone with the aid of a stethoscope which was 135 beats per minute.
During the Pawlik’s grip, we found out that the fetus is not yet engaged, still
movable. The 4th maneuver was not applied anymore.
4. Roll Over Test
During the first reading for left lateral position it is 90/50; for supine position
it is 90/70 and after resting for 5 minutes the result for the second reading for the
left lateral is 90/50 and for the supine position it is 100/70, and we also get the BP
on sitting position which is 110/50.
Despite the normal result of Mrs. R’s blood pressure, she is still at risk to having
pregnancy induced hypertension because of her history in her first pregnancy.
Nursing Diagnosis:
Nursing Goal:
After 4-5 hours of nursing intervention, the patient will be able to establish normal
pattern of bowel functioning as will be manifested by defecating everyday and
verbalization of “haan nga natangken ti takki kon ken .”
Nursing Interventions with Rationale:
Nursing Evaluation:
After 4 hours of nursing intervention, the patient was able to establish normal
pattern of bowel functioning as manifested by defecating everyday and
verbalization of “haan nga natangken ti takki kon.”
Nursing Diagnosis:
Nursing Goal:
After 1-2 days of nursing intervention, the patient will be able to understand the
importance of compliance to prescribed regimen and be encouraged to adhere to
the prescribed regimen.
Nursing Evaluation:
After 2 days of nursing intervention, the patient was able to understand the
importance of compliance to prescribed regimen and was encouraged to adhere to
the prescribed regimen.
Nursing Diagnosis:
Risk for injury related to cultural factors secondary to health beliefs (hilot).
Nursing Goal:
After 20-30 minutes of nursing intervention, the patient will be able to prevent the
occurrence of injury to mother and fetus as will be manifested by doubts toward
consulting serious abnormal conditions to ordinary hilots.
Nursing Evaluation:
After 30 minutes of nursing intervention, the patient was able to prevent the
occurrence of injury to mother and fetus as manifested by doubts toward consulting
serious abnormal conditions to ordinary hilots.
Nursing Diagnosis:
Nursing Goal:
After 2-3 days of nursing intervention, the patient will be able to go back or execute
normal eating pattern.
• Calculate calorie requirements based This will limit the intake of calories within
on physical factors and activity. the normal range that should be given to
her.
• Work with dietician to assist in Dietician knows the normal intake a
creating or evaluating nutritional pregnant woman should have.
program.
• Provide positive reinforcement or Enhance commitment to program.
encouragement for efforts as well as
act of weight loss.
• Encourage the patient do a light To burn excess fats and calories.
exercise.
Nursing Evaluation:
After 3 days of nursing intervention, the patient was able to go back or execute
normal eating pattern.
Nursing Diagnosis:
Nursing Goal:
After 2-3 hours of nursing intervention, the client will be able to understand the
importance of adhering to the prescribed medication as will be manifested by
following the treatment regimen as ordered by the physician.
Nursing Intervention:
Nursing Evaluation:
After 3 hours of nursing intervention, the client was able to understand the
importance of adhering to the prescribed medication as manifested by following the
treatment regimen as ordered by the physician.
COMPUTATIONS
Fundic Height: 22 cm
Naegele’s Rule
12/4/2008
-3+7+1
9/11/2009
*September 11,
2009
McDonald’s Rule
22 x 2/7
22 x 8/7
Bartholomew’s Rule
Obstetrical Data
Month # of Days
Decembe 27
r 31
January 28
February 31
March 16
April
Total 133 days
Johnson’s Rule
=22-11x155
=1705 grams
Haese’s Rule
(7)2
49 cm
Weight
BMI =
(Height)2
68 kg.
=
(1.52m)2
=
29.44
(overweig
ht)
Height= 5ft
During Pregnancy,
58 kg
63.85 kg or 64 kg
1880 kcal
+ 300 kcal
2180 kcal