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I.

INTRODUCTION In Psalms 127:3 it was stated: Behold, children are a heritage from the Lord, The fruit of the womb is a reward. Hence, every pregnancy is a blessing from the Lord but one with multiple birth is even more so. A multiple birth happens when more than one fetus is carried to term in a single pregnancy. Different names for multiple births are used, depending on the

number of offspring. Common multiples are two and three, known as twins and triplets. The most common form of multiple births for humans is twins. Our groups case study focuses on twins. A twin is one of two offspring produced in the same pregnancy. Twins can either be monozygotic ("identical"), meaning that they develop from one zygote that splits and forms two embryos, or dizygotic ("fraternal") because they develop from two separate eggs that are fertilized by two separate sperm.

II. PATIENTS PROFILE

Name: Nationality: Province: Birthday: Age: Religion: Status: Address:

Jackylyn P. Mabitasan Filipino Baayan, Ucab, Itogon Benguet December 27,1980 32 Roman Catholic Married to Willy Mabitasan Baayan, Itogon, Benguet

Marites K. Galapon Millado Filipino Victoria Tarlac December 7, 1969 42 Iglesia ni Cristo Married to Jungie Millado #42 Sunflower Street, St. Joseph Village, Baguio City Tagalog, Kapampangan , Ilokano and English

Language:

Kankanaey,Ilocano,Tagalog

III. NURSING PROCESS 13 AREAS OF ASSESSMENT

1. Psychosocial Status a. Personal History

b. History of Present Illness:

c. Past Medical History: d. Family and Socio-cultural History Analysis: Based on the above statements, Mr. Esquilons social status is not affected by his condition. Even while being in medication and treatment, his condition did not restrain him from interactions outside home. 2. Mental and Emotional Status

Analysis: Mr. Esquilons mental capabilities are still functioning well. He is emotionally stable and reacts accordingly.

3. Environmental Status Analysis: Mr. Esquilon is in a healthy environment. 4. Sensory Perception

Analysis: Mr. Esquilons senses is still normal despite old age. 5. Motor Stability Mr. Esquilons gait does not have any staggering on his legs. He does not need support when standing up and walking. Mr. Esquilon walks a distance of more than 1 kilometer to report to the Barangay Hall and performs his duty every day as a barangay streetsweeper. Analysis: Despite his old age, Mr. Esquilon has no difficulty in coordinating movements as well as performing his day to day activities. 6. Nutritional Status
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Analysis: Mr. Esquilon has a normal nutritional status 7. Elimination status Analysis: He can still urinate and defecate by himself. He can still control his elimination. 8. Fluids and electrolytes status 9. Circulatory Status The circulatory status of Mr. Esquilon is shown in the tables below: a. Pulse Rate Time 11:00 a.m. 2:00 p.m. 3:00 p.m. Pulse Rate 73 82 80 Analysis Normal Normal Normal

Date August 16, 2012 August 17, 2012 August 18, 2012 b. Heart Sounds His heart sound is normal. c. Blood Pressure

Date Time August 16, 2012 11:10 a.m. August 17, 2012 2:08 p.m. August 18, 2012 3:10 p.m. d. General Appearance Analysis: Mr. Esquilon is still physically fit.

Blood Pressure 120/80 120/80 110/90

Analysis normal normal Normal

10. Respiratory status The table below shows the respiratory rate of Mr. Esquilon: Date August 16, 2012 August 17, 2012 August 18, 2012 Analysis: Time 11:15 a.m. 2:13 p.m. 3:16 p.m. Respiratory Rate 24 bpm 22 bpm 20 bpm Analysis Abnormal Abnormal Normal

Temperature status The table below shows the temperature of Mr. Esquilon during our visit: Date August 16, 2012 August 17, 2012 August 18, 2012 Time 11:02 a.m. 2:03 p.m. 3:04 p.m. Temperature 38.5 37.9 37.4 Analysis abnormal Abnormal normal

Analysis: Hence, Mr. Esquilon has a fever during our first days of visit. 11. Integumentary Status
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Analysis: Based from the above information Mr. Esquilons integumentary status is normal. 12. Comfort and Rest Status: Analysis: Mr. Esquilons sleep and rest pattern is normal. 13. Comfort and Rest Status: Analysis: Mr. Esquilons sleep and rest pattern is normal.

IV PATHOPHYSIOLOGY The 2 types of twin pregnancies are dizygotic and monozygotic. Dizygotic twins develop when 2 ovum are fertilized. Dizygotic twins have separate amnions, chorions, and placentas (see the image below).

Diamniotic/dichorionic placentation.

The placentas in dizygotic twins may fuse if the implantation sites are proximate. The fused placentas can be easily separated after birth. Monozygotic twins develop when a single fertilized ovum splits after conception. An early splitting (ie, within 2 d after fertilization) of monozygotic twins produces separate chorions and amnions. These dichorionic twins have different placentas that can be separate or fused. Approximately 30% of monozygotic twins have dichorionic/diamniotic placentas. Later splitting (ie, 3-8 d after fertilization) results in monochorionic/diamniotic placentation (see the image below).

Diamniotic/monochorionic placentation.

Approximately 70% of monozygotic twins are monochorionic/diamniotic. If splitting occurs later (ie, 9-12 d after fertilization), monochorionic/monoamniotic placentation occurs (see the image below).

Monoamniotic/monoamniotic placentation.

Monochorionic/monoamniotic twins are rare; only 1% of monozygotic twins have this form of placentation. Monochorionic/monoamniotic twins have a common placenta, with vascular communications between the 2 circulations. These twins can develop twin-totwin transfusion syndrome (TTTS). If twinning occurs more than 12 days after fertilization, then the monozygotic fertilized ovum only partially splits resulting in conjoined twins. Triplet pregnancies result from various fertilization, splitting, and development scenarios that involve ovum and sperm. For example, triplets can be monozygotic, dizygotic, or trizygotic. Trizygotic triplets occur when 3 sperm fertilize 3 ova. Dizygotic triplets develop from one set of monozygotic cotriplets and a third cotriplet derived from a different zygote. Finally, 2 consecutive zygotic splittings with a vanished fetus can also result in monozygotic triplets. Zygosity in quadruplets and higher order multiples also varies. Although the evaluation of the placenta or placentas after the birth is important in all multifetal pregnancies, the examination may not always help determine zygosity.[2]

V. NURSING PROCESS (SOAPIE)

VI.

DOCUMENTED INTERVIEW Questions for the interview (DONT FORGET NA MAGPAKILALA MUNA) I. A. PATIENTS PROFILE Ano po ang inyong buong pangalan? - Jackylyn P.Mabitasan po. B. Matagal nap o ba kayong naninirahan po dito? C. * Ay hindi ngayon lang kami ditto nong nanganak ako. D. Ano po ang address sa lugar na ito? E. Baayan Ucab Itogon Benguet. F. Ano po ang inyong natapos na pinag-aralan? G. - High school graduate lng ako.. H. Maaari po bang malaman kung ano-ano po ang inyong mga naging hanapbuhay? I. Naging sales lady po ako . J. Ano po ang pinagkakaabalahan po natin ngayon? K. Wala nag- aalaga na ng mga anak. L. Ano po pala ang pangalan po ng mister niyo po? M. Willy Mabitasan po. 8. Puede po ba naming malaman kung paano po kayo nagkakilala ni Mister? HEhe..kinuha nya po yung # ko sa pinsan ko tas don na nag simula nag ttxt na sya KUNG PWEDE DAW MANLIGAW..HEHEHE 9. Ilang taon na po kayong mag-asawa? - 2 YRS nap o. 10. Kailan po kayo nagpakasal? 11. Saan po kayo nagpakasal? -Sa baayan ucab itogon po. 12. Ilan po ang anak ninyo? - Tatlo napo sila. 13. Maaari po bang malaman ang mga pangalan ng inyong mga anak at ang kanilang mga birthday? II. ON HAVING TWINS HISTORY 1. Nabanggit niyo po na mayroon po kayong twins, maari po ba nating pagusapan ang pagkakaroon niyo po ng kambal na mga anak? 2. Before po kayo magpakasal, pinangarap niyo po ba na magkaroon ng kambal na anak? -Ay hindi po.. 3. Karaniwan po ba sa pamilya ninyo ang magkaroon ng kambal na anak o sa lahi ng inyong asawa? -Sa side ko po. 4. So, expected niyo na po ba na maaaring magkaroon kayo ng kambal na anak? - hindi nman po. 5. Dito po sa lugar ninyo, bukod pos a inyo meron pa po bang kambal sa barangay ninyo?
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-ay,,wala po eh.. 6. Ano Po ang pinagkakaabalahan niyo o trabaho niyo bago po kayo mabuntis sa inyong kambal? -Wala sa bahay lng binabantayan ko yung isa kong anak. 7. Huminto po ba kayo sa pagtatrabaho? -Oo 8. Ano po ang naging source of income niyo habang kayo ay buntis at hanggang pagkapanganak ninyo? _ BEFORE PREGNANCY 1. Nasubukan niyo po bang gumamit ng contraceptive o mga pills? 2. *ay,hindi po..never po akong gamamit ng pills.. 3. 4. Paano niyo po nalaman na buntis kayo sa inyong kambal? 5. *nag paultra sound po ako nong 8mnths ako. 6. Kanino niyo po unang ipinaalam na buntis kayo? 7. *Syempr, kay mister hehe.at sa mga kapamilya ko. 8. Sino po ang pinaka-naging katuwang niyo physically, emotionally habang ipinagbubuntis niyo po ang inyong kambal? 9. *Si mister ko .. 10. Ano po ang naging reaction ng inyong mister?.. paano niyo po binanggit sa kanya o sa inyong mga kamag-anak? 11. *syempre.parang na shock siya..hindi naniniwala..pero Masaya nman siya.. 12. Ano pa po bang napansin niyo sa pangangatawan ninyo? 13. *Lumaki yung susu ko tas lumapad yung biwang ko.. 14. Pumasok po ba sa isipan ninyo na kambal ang magiging anak ninyo? 15. *Ay hindi po eh.. 16. Before po kayo nagpa-ultrasound, nagkaroon po ba kayo ng suspetsa na baka kambal ang inyong magiging anak? 17. *Hindi po kasi maliit lng kasi yung tian ko. 18. Ano po yung naging clue ninyo na kambal ang inyong magiging anak? 19. .Wala kasi hindi ko alam nalaman ko lang na kambal nung 8 mnths ako. 20. Paano niyo po nalaman na magkakaanak kayo ng kambal? 21. * Sa ultra sound po. 22. Agad po ba kayong nagpatingin sa doctor? 23. Kailan po kayo nagpa-ultrasound? 24. Pagkatapos ng ultrasound nasabi na po ba agad sa inyo na kambal ang inyong anak at kung ano po ang gender nila? 25. Ano po ang naging reaksiyon niyo ng malaman niyo na kambal ang inyong magiging anak? Meron po ba kayong mga concerns, o nag-alala po ba kayo ng malaman ninyo na magkakaroon kayo ng kambal na anak? 26. *Medjo natakot ako kc ini isip ko kung hiwalay ba sila o ung magkadikit. 27. Nang malaman ninyo na kambal ang inyong anak, ano-ano po ang nirekomenda sa inyo ng doctor? Nasunod niyo po ba lahat ng mga inirekomenda sa inyo? 28. *oo,naman kunting pahinga lang tas wag magpapagod. 29. Ano po ang pangalan ng inyong doctor?.. OB? 30. *Si Dr.Susan chungalao. 31. Ano pong mga test ang ikinonduct sa inyo at sa inyong anak bago po at pagkatapos kayong manganak? DURING PREGNANCY 1. Kumusta naman po ang pagbubuntis niyo pos a kanila? 2. *ok, lng naman po.
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May takot po ba? *syempre meron. Mayroon po ba kayong mga binasang libro tungkol sa pagbubuntis? *oo meron Noong ipinagbubuntis niyo po sila, gaano po kadalas kayong nagpapacheckup sa doctor? 8. *every month. 9. Ano pong mga nirekomenda sa inyo gaya ng gamot o ipinagbawal sa inyo ng doctor? 10. * basta ang sabi wag akong iinom ng mga gamut na hindi nila nirisita.. 11. Ano po yung mga inirekomenda sa inyo na kainin noong kayo ay nagbubuntis at after niyo pong magbuntis?May mga ipinagbawal po ba sa inyong kainin? 12. .wala naming pinag bawal.. 13. Ano po ba ang paborito po ninyong pagkain? 14. * hehe apple at saging po eh. 15. May allergy po ba kayo sa pagkain? 16. * wala naman po. 17. Naka-experience po kayo ng mga komplikasyon habang sila ay ipinagbubuntis ninyo? 18. Wala naman po. 19. Habang ipinagbubuntis niyo sila, nagkaroon po ban g komplikasyon, o nagkasakit po ba kayo, ano po yun? 20. * wala naman,pero pag minsan sumasakit ung ulo ko yun lang. 21. Sa ano niyo po pinaglihi ang inyong mga anak? 22. * hehe wala naman po. 23. Ano-ano po napansin niyo pong pagbabago s katawan niyo habang ipinagbubuntis niyo sila? 24. Ano po ang worst pregnancy moment niyo habang ipinagbubuntis niyo sila? 25. Ano po ang best pregnancy moments niyo habang ipinagbubuntis niyo sila? 3. 4. 5. 6. 7. AFTER PREGNANCY 1. Ilang araw po kayong namalagi sa ospital pagkapanganak niyo po? 2. *4 days po. 3. Maaari po bang malaman kung anu-ano pong mga gamut ang inireseta sa inyo habang kayo ay buntis at pagkapanganak ninyo? 4. Yung mga baby ninyo, anu-ano pong gamut ang ibinigay para sa kanila? 5. Ano-ano pong napansin niyo pong pagbabago sa katawan niyo o sa kalusugan niyo pagkatapos niyo po sialng ipanganak? CURRENT STATUS 1. Kayo po, kumusta naman po kayo, pagkatapos ninyo pong magkaroon ng kambal? 1. Ano po ang masasabi ninyo na pagkakaiba ng pagkakaroon ng kambal na anak sa paisa-isa lang. 2. Bakit po sinasabi nila na kapag magkakaanak daw po ng kambal ay napakadelikado, ano po ba ang delikado sa pagbubuntis ng kambal? 3. Ano po ang masasabi ninyong pinakaproblema sa pagkakaroon ng kambal na anak? 4. Okay lang po ba na manganak sa bahay ang manganganak ng kambal? 5. Ano pong mga advice o tips ang maari niyo pong maibigay sa mga babaeng gusting magkaroon ng kambal na anak? 6. Ano po mairerekomenda ninyo sa mga babae na ipinagbubuntis ay kambal? 7. Puede po bang magtrabaho ang nanay na nagbubuntis ng kambal? 8. Paano niyo po naibabalanse ang oras niyo sa pag-aalaga sa kambal na anak?
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9. Puede pong magkuento po kayo tungkol sa inyong mga babies. Ano po ang pagkakaiba nila sa isat-isa. Ano po ang pagkakapareho? 10. P{aano niyo po nalalaman pagkakaiba ng inyong mga kambal? 11. * Sa ngayun mas payat kasi ung isa tas yung isa nman mataba. 12. Karaniwan po ay dinadamitan ng pareho ang kambal?.. ano po angmasasbi niyo tungkol dito? 13. *para sa akin nagagandahan ako pag magkapahira ang mga damit nila.. 14. Puede pa po ba kayong magkaanak?.. 15. * Ay.hindi na ah nag paligate na ako eh.. 16. Kung magkakaanak po ulit kayo gusto niyo pa rin po ban a kambal ulit next na anak niyo po? haha ai apo..hwag na mahirap ng manganak ng kambal...

OTHER CONCERNS 13 AREAS OF ASSESSMENT 1. Pscycho-social Status ______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _____________________________________________________ 2. Mental and Emotional Status ______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________ 3. Environmental Status ______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________ 3. Sensory Status: a. Vision ___________________________________________________________________ b. Auditory __________________________________________________________________ c. Olfactory _________________________________________________________________ d. Gustatory ________________________________________________________________ e. Tactile ___________________________________________________________________ 4. Motor Status ______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________ 5. Nutritional Status Ano ano pong pagkain ang inirekomenda sa inyo ng doctor na kainan habang ipinagbubuntis niyo po ang inyong kambal? Ngayon po, kumusta naman po ang pagkain natin?
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6. Elimination Paano po ang pagdumi natin noong kayo ay buntis? Noong buntis po ba kayo ay madalas po ba kayong umihi? Gaano po kadalas? Kumusta naman po ang pagdumi at pag-ihi natin noon, may masakit po ba? Nahihirapan po ba kayo? Ngayon po kumusta naman po? Gaano po kayo kadalas umihi ngayon? 7. Fluids and electrolytes status Umiinom po ba kayo ng alak? Noong ipinagbubuntis niyo po sila, madalas po ba kayong uminom ng tubig? Gaano po karami? Ngayon po, kumusta naman po, mga gaano po karaming tubig ang iniinom niyo ngayon? 8. Circulatory Status a) Pulse Rate (60-100 beats per minute ang normal) _____________ b) Heart Sound ______________ c) Blood pressure 120/80 min Hq ang normal ______________ d) General Appearance 9. Respiratory Rate

a) Respiratory Rate (16-20 breathes per minuteang normal) Naninigarilyo po ba kayo noon? 10. Temperature Status ___________ 11. Integumentary Status a) Skin _______________________________________________________________________ b) Nail _______________________________________________________________________ c) Hair _______________________________________________________________________ 12. Comfort and Rest Status Noong buntis po kayo? Ano po exercise ginagawa niyo noong buntis po kayo Ano po ang karaniwan niyong ginagawa upang makapag-unwind o makapagrelax? Ilang oras po kayong natutulog?
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Ngayon po kumusta naman po Ano po karaniwan niyo pong exercise? Ano po ang karaniwan niyong ginagawa upang makapag-unwind o makapagrelax? Ilang oras po kayong natutulog?

OBJECTIVE: 1. To be able to help him cope up with the difficulty of having twins ______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________ ASSESSMENT Body Image disturbance/Role Performance, altered/Personal Identity disturbance/Self Esteem (specify) may be related to situational and maturational crises, fear of failure at life events, biophysical changes, absence of support systems possibly evidenced by self-negating verbalizations, expressions of shame/guilt, hypersensitivity to criticism, fear of rejection, lack of follow-through and/or nonparticipation in care. PLANNING 1. Promote optimal physical/emotional well being of client 2. Monitor vital signs and well being 3. Provide information and review the available options 4. Facilitate positive adaptation to new and changing roles 5. Encourage family/partner participaton in problem solving 6. 1. Identify feelings and methods for coping with negative perception of self/abilities. 2. Verbalize increased sense of self-esteem in relation to current situation. 3. Demonstrate adaptation to changes/events as evidenced by setting of realistic goals and active participation in meeting own needs. INTERVENTION (what did you do to decrease suffering) Nursing intervention with rationale: 1. Establish a therapeutic nurse-client relationship. Rationale: Adolescent client needs a caring, nonjudgmental adult with whom to talk. Important to establish trust and cooperation so that the client is free to hear the information available. 2. Assess use of terms/language used by the client/significant other(s). Rationale: Terminology may be specific to the adolescent culture, and words may have different meanings for client and nurse. 3. Determine developmental level and needs relative to age as early, middle, or late adolescence. Rationale: Cognitive development during this period moves from concrete to
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abstract thinking (formal operations). The younger client may see control of the situation as external and beyond her grasp, and have little ability to understand the consequences of her behavior. With maturity, the abilities to understand possible consequences and to accept individual responsibility develop. 4. Identify clients self-perception as positive or negative. Rationale: Helps client become aware of how she views herself and to begin to increase her self-esteem. Until late adolescence, body image is still formative. The client is dealing with adolescent developmental tasks, establishing an adult identity. Low self-worth may lead to feelings of hopelessness about the future and inability to visualize a successful outcome. 5. Elicit the clients feelings about sexual identity/roles. Rationale: May have difficulty seeing herself as a mother. The adolescent must make a role transition from child/daughter to adult/mother, which can create conflicts for the client and significant other(s). 6. Discuss concerns and fears about body image and transitory changes associated with pregnancy; discuss personal value system. Rationale: Establishes a basis for future learning. Conflicts may exist regarding how client has previously seen herself, what her expectations of pregnancy had been, and what the realities of pregnancy are. By midpregnancy, the enlarging abdomen and the increasing size of breasts and buttocks may prompt the teenager to try to control her appearance by dieting, with adverse consequences for fetal health and her own growth needs. 7. Discuss ways to promote positive self-image (e.g., clothing style, makeup) and recognition of positive aspects of the situation. Rationale: Assists in coping with changes in appearance and presenting a positive image. 8. Discuss appropriate adaptation techniques and the communication skills to implement these techniques. Rationale: Role playing and active listening can be used to learn skills of communication and adaptation. Helps client learn information necessary to development of improved self-esteem. EVALUATION ______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________ .

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VII. DOCUMENTED MANAGEMENT

IX. PHARMACOLOGICAL ASPECT Iron Calcium

X. GLOSSARY

XI. APPENDIX

Quick Facts and Figures about Twins


Chances of having a twin pregnancy naturally is increased by maternal age ( 30+), genetics and number of previous pregnancies. According to the National Center for Health Statistics the number of multiple births ha s increased about 74% since 1980.

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Twin pregnancy is considered full term at 36 weeks and 3 days. The average weight of twins at term is about 5.5 lbs The average or recommended weight gain for average sized mothers of twins is between 35 -45 lbs. Studies have shown that mothers who gain about 24 pounds by week 24 have reduced their chances of giving birth either prematurely or to low birth-weight babies. Women pregnant with twins will have more ultrasounds, tests and prenatal appointments than women pregnant with singletons. 1 in 250 pregnancies can result in identical twins. In some African countries such as Nigeria, the rate of twin pregnancies can be as high as 1 in 20. China has the lowest rate of Twinning in the world.

http://www.motheroftwins.com/factsabouttiwns.html

17 Facts about Twins


References

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XII.
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GENERAL EVALUATION

XIII. ACKNOWLEDGEMENT

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