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A. Personal Data
Mrs. R is a 27 year-old woman who is 7 months pregnant. She is happily married to Mr. J, 27 years old, and they are currently residing at Brgy. 2 San Roque, Paoay, Ilocos Norte, with daughter F, Mr. J’s sister, and Mr. J’s parents. Their type of family is patrilocal as to residence and extended as to composition since they live with the husband’s parents and one sister. 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 checkup, 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. According to Mrs. R, during her first trimester, she experienced morning sickness approximately 2 tbsp, bearable headache with a rank of 4 in a 0-10 painscale which occurs simultaneously and craving for food such as “isaw”. During her second trimester, she experienced easy fatigability and abdominal pain with a rank of 7 in a 0-10 pain-scale at the epigastric area as verbalized, “Haan nak makaanges nu agsakit ti buksit ko ken alisto nak lang nga mabannog.” She also experiences frequent urination 4 times during daytime and 3 times at night as verbalized “normal met ti panagisbuk ken saan nak met maproblemaan”. She received the first dose of Tetanus Toxoid for her present pregnancy last May 2009. She already received 2 during her first pregnancy in 2006 but was not able to continue it so she was required to repeat the vaccination. 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.” With regards to the medications Mrs. R has received since beginning of pregnancy, she takes in OB-min and ferrous sulfate alternately once a day but originally, the prescription was to take OB-min and ferrous sulfate every day. The OB-min was prescribed by a doctor in MMMH & MC while the ferrous sulfate was prescribed in the RHU during his check up also in the 5 th month. The reason why Mrs. R takes these drugs alternately every other day is that she presumes that she might get overdosed and also, according to her, the OB-min drug makes her abdomen grow bigger. The student nurses encouraged then the patient to adhere strictly to the doctor’s order to prevent complications and for better results. Also, as to the ferrous sulfate, the student nurses informed the patient that it is usually prescribed to prevent or treat anemia, increasing the iron stores of the body and replace blood loss during delivery and that it is normal to expect or notice dark stools and sometimes it causes constipation. 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.

2. Past Obstetrical History 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. Common illnesses were experienced by the members of the family which includes fever, cough, colds, stomach ache, diarrhea, and headache. To manage such illnesses, they usually take in over-the-counter drugs such as paracetamol for fever, carboscisteine for cough, neozep for colds, and pain reliever for headache.

According to Mrs. R, they consult “manghihilot” whenever they experience body pains. If both “hilot” and over-the-counter drugs don’t relieve the symptoms , they immediately consult a doctor. 3. Personal Health History: 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. 4. Past Medical History Mrs. R experienced common illnesses such as chicken pox, measles, influenza or flu, stomach ache, colds, cough, diarrhea and mumps. Decoction from guava leaves were used in bathing, as well as, smoke from burning skin of onion and “akot-akot” were used to manage measles, chicken pox and mumps. 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 July 22, 2009 Amount 1 serving 2 cups ½ glass 1 glass 2 servings 2-3 cups 1 glass 4 slices 1 pack 1 glass 1 serving 1 serving Caloric Value (kcal) 80 200 95 64 250 600 130 37 310 290

Canned tuna Rice Milk Water Inabraw Rice Water Bread Biscuit Juice Sardines Noodles

Rice Water

2 cups 2 glasses July 23, 2009 Amount 1 pack 2 cups 1 glass 1 glass 12 ounces 4 slices 1 piece 1 serving 2 servings 2-3 cups 1 glass 1 serving 1 serving 2 servings 2 cups 1 glass July 24, 2009 Amount 2 servings 12 ounces 1 serving 2-3 cups 1 glass 1 serving 2-3 cups 1 glass Total: 7302 kcal

200 2256 Caloric Value (kcal) 290 200 170 140 600 350 122 64 250 16 310 64 200 2776 Caloric Value (kcal) 580 140 350 250 700 250 2270

Pancit canton Rice Milk Water Softdrinks Bread Fried chicken (leg) Adobo Pinakbet Rice Water Papaya with soup Sardines Pinakbet Rice Water

Pancit bihon Softdrinks Tinola Rice Water Ginisang monggo Rice Water

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. Being an overweight could lead to possible diseases such as hypertension and diabetes which may be dangerous because the client is pregnant. 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). 7. Data About Husband 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 Body Temperature: 36.50C per axilla Pulse Rate: 79 beats per minute, regular Respiratory rate: 20 per minute, regular Blood pressure: 100/60 mmHg

2. Head-to-Toe Assessment: Head normocephalic able to do ROM exercises

Hair and Scalp Face Eyes External and internal eyes structures: o o o o o o o with evenly distributed black eyebrows with upper eyelid partially covering the iris with white sclera and black iris with pinkish and upper and lower conjunctiva with symmetrically aligned eyes with intact nerve III, IV and VI PERRLA with symmetrical facial features able to move facial muscles at will no melasma noted scalp lighter in color than complexion free from lice, nits and/or dandruff with evenly distributed black, smooth, and oily hair

Visual field and acuity:

o o o Ears Nose -

able to see objects at 1800 angle while looking at a fixed point pupils equally round reactive to light and accommodation able to read a font-size 12 article at a distance of two feet

with symmetrical earlobes the upper connection of the earlobes are in line with the outer canthus of the eye with minimal cerumen on both ears canal upon inspection with good hearing acuity – able to hear whisper at a distance of two feet

nose in the midline, high bridge, with patent nares nasal septum in the midline

Oral Cavity Lips: o pinkish in color

Tongue: o o pinkish and moist midline in position

-

Teeth o o 29 teeth present with dental carries at lower left 2nd molar

-

Gums o pinkish

Neck able to do ROM exercises trachea in midline

Chest Breast soft, no tenderness noted with dark areola and nipples moves symmetrically when breathing with cardiac rate of 80 beats per minute

Abdomen protuberant fundic height is 22 cm fundus is in halfway between umbilicus and xyphoid process presence of linea nigra and striae gravidarum

Upper Extremities able to do ROM without any assistance with short nails and capillary refill of 1-2 seconds

Lower Extremities able to flex and extend legs no signs of edema with short nails and capillary refill of 1-2 seconds

3. Leopold’s Maneuver The results of Leopold’s maneuver are the following: First, we performed the fundal grip and we palpated a cephalic presentation in relation to the fundus but the general presentation is breech. 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 The results of the roll over test are as follows: 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: Constipation related to inadequate fiber and fluid intake as manifested by passage of hard stools and verbalization of ““natangken ti takkik isu nga kada maikadwa nga aldaw nak lang a tumakki.”

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 Intervention Instruct client to have adequate fluid intake (at least 2-3 liters of water daily within cardiac tolerance), including high-fiber fruit juices Recommend a glass of warm water to be taken 30 minutes before breakfast Encourage her to evacuate her bowels regularly Encourage activity/exercise within limits of individual ability Instruct the client to avoid gasforming foods like rootcrops like camote Rationale To promote passage of soft stool

• • • •

This may act as stimulus to bowel evacuation To avoid fecal impaction To stimulate contractions of intestines Decreases gastric distress abdominal distention the and

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: Noncompliance related to barriers to access secondary to financial issues as manifested by verbalization of “Haan ko malagip diay nagan ti agas kasi haan ko met nga ginatang. Napan nak latta nagpailoten ditoy ayan min. Adu pay ngamin ti gastos ko kadagidiay agas diay maysa nga anak ko kasi adda angkit na.”

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 Interventions with Rationale: • • Nursing Intervention Discuss with the patient importance of the drug regimen. Rationale the Letting the patient know and understand the importance of the drug regimen to encourage the patient to comply. Discuss with the patient the danger Letting the patient know the danger or or risks of noncompliance to regimen. risks of noncompliance can cause fear on her part. She cannot recover from the abnormal condition if she does not comply. Help the patient establish a support Support from relatives or friends can minimize/lessen the burden of buying system. such medications. Help the patient set proper What weighs greater would help the patient prioritize. prioritizations.

• •

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 Interventions with Rationale: • Nursing Intervention Discuss with the patient the disadvantage of attending risky procedures especially to people with inadequate knowledge. Rationale If a person who performs procedures who has insufficient knowledge of the clinical condition can bring about erroneous outcomes, worse injuring the patient and the fetus. physician knows the most Encourage the patient to adhere or The appropriate thing to do for her clinical comply with doctor’s order or condition. prescriptions.

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: Imbalanced nutrition more than body requirements related to excessive intake in relationship to metabolic need as manifested by patients BMI of 29.44

Nursing Goal: After 2-3 days of nursing intervention, the patient will be able to go back or execute normal eating pattern.

Nursing Interventions with Rationale: • • • • • Nursing Intervention Rationale client determine realistic Discuss client’s motivation for weight Helps motivating factors, individual situations. loss. Calculate calorie requirements based This will limit the intake of calories within the normal range that should be given to on physical factors and activity. 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:

Knowledge deficit related to cognitive limitation as manifested by verbalization of “pagsinsinublatek lattan tay pinagtumar ko ngamin maamak nak nga baka maoverdose ak”.

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 Intervention Provide information about the mechanism of action ferrous sulfate and obimin. Discuss with the patient the danger or risks of noncompliance to regimen. Rationale The client will be aware about the importance of both medications.

• •

Letting the patient know the danger or risks of noncompliance can cause fear on her part. She cannot recover from the abnormal condition if she does not comply. Discuss with the patient the Letting the patient know and understand the importance of the drug regimen to importance of the drug regimen. encourage the patient to comply. Advise the client to seek consultation. The patient will be able to clear things out on the drug regimen.

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 *LMP = December 4, 2008 Expected Date of Delivery (EDD)= 12/4/2008 -3+7+1 9/11/2009 *September 11, 2009

McDonald’s Rule Age of Gestation (AOG) in months = fundic height x 2/7 22 x 2/7 6.28 or 6-7 months In weeks = fundic height x 8/7 22 x 8/7 25.14 or 25-26 weeks

Bartholomew’s Rule 31 weeks – halfway between umbilicus and xiphoid process

Obstetrical Data LMP = December 4,2008

First clinic visit = april 17,2009 Month Decembe r January February March April Total # of Days 27 31 28 31 16 133 days

AOG (in weeks) = 133/7 = 19 weeks

Johnson’s Rule Estimated total weight = fundic height – n x k =22-11x155 =1705 grams

Haese’s Rule Estimated fetal length = (# of months)2 (7)2 49 cm

Body Mass Index BMI = = = Weight (Height)2 68 kg. (1.52m)2 29.44 (overweig ht)

Height=

5ft 5ft x 12 = 60 in x 2.54 cm = 152.4 cm

Weight=

58kgs (prior to pregnancy)

DBW =

height – 100; x-10% 152.4 – 100 = 52.4 – 10% of 52.4 = 47.16 or 47 *Range: 42.4 kgs to 51.9 kgs

Physical Activity = 40 kcal (moderate)

TER = DBW x PA = 47 x 40 = 1880 kcal

During Pregnancy, 58 kg + + + 1.35 kg (1st trimester) 2.7 kg (2nd trimester) 1.8 kg (3rd trimester, 1st month)

63.85 kg or 64 kg

Recommended Energy Intake 1880 kcal + 300 kcal 2180 kcal

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