COLLEGE OF NURSING GUIDE FOR ASSESSING A MATERNITY CLIENT NURSING HISTORY

A. Personal Data Name: MARICEL VARGAS Age: 30 Educational attainment: college level Occupation: housewife Nationality: Filipino Address: #360 mabini st. calumpang Marikina B.MENSTRUAL HISTORY a. Menarche-at what age first menstruation occurred 14 yrs old, when I was got menstruation b. Characteristic of menstruation as to: 1. duration- 3 days only 2. color- red 3. odor- natural 4. consistency5. Internal between menses- 1 month is my interval of menses c. Maternal History 1. History of the present pregnancy A.LMP- nov 18, 2010 is my last menstrual period. EDC- July 3, 2011, my expectation date of confinement. AOGb. physiological & psychological changes of pregnancy, asses the signs, symptoms and discomfort associated w/ pregnancy during the: First trimester- In this period I usually felt vomiting, sleepy and being tiredness. This is the first changes on my body. Second trimester- I Gain more weight, because I always want to eat more foods. I crave for something, and then I don’t like to eat all the foods prepared on me. I felt that I’m too choosy about the foods that I eat. Third trimester- I felt my abdomen is too big enough for me. c. prenatal check-up: yes_/___ No____ When: East avenue medical center d. reaction/feelings regarding the present pregnancy 1. Is it a planned or unexpected pregnancy? It is planned both of me & my husband is deciding to have our own family. e. Reaction/feelings regarding the newly born baby 1. Is there any expectation to as to sex and appearance of the baby? Yes, when we do sex we usually think already about the appearance of our baby.

f. Reaction and feelings about breast-feeding?

Reactions and feelings about family planning 1. inverted. color -it is elastic and saggy. and it became big. consistency. sensation of heaviness and fullness) -When it became big.) 3. it became elastic. we are aware about it. . Abdomen Tone of the abdominal wall . Drug Study Guide-purposeof this session is to expose clients to range the method. and amount) -reddish brown. I hope no problem is occurred. Patterns of Functioning II. drug. g. B. Babies need our milk on the first period when we gave birth. Are they (couple) aware of family planning? Yes. it is slightly brownish. Is the mother aware of the advantage of breast feeding? Yes. Past Health History Refer to your hand out that was given in nursing 101(Fund’s of nsg. Sign of engorgement (pain. Personal & Social History 5. Lochial discharges (color. like not enough budgets to support their financial needs or they are not ready to plan.1. bleeding) -its appearance became enlarge. Nipple discharges -Nothing. dilated. Do they have misconceptions about it? What are these misconceptions? Maybe.My abdomen area is saggy. it is not already firm. Are they in favor? If yes. many amount on my discharges III. Other is not ready to plan so that they got a big mistake on their lives. others used it when they are not ready to have a baby. Family History In my family we have a heart disease. Laboratory Exams -all is undergo observation. it is very important to breast feed your baby because it contains more nutrients than other milk that we bought on groceries. 3. and sometimes it bleed. protruded) nipples -I think my breast is protruded. Clinical Appraisal A head to the assessment of the client with emphasis on the following changes on the following: A. Shape.addresses the entire nursing care planning process. Plan of Care. others think about it. Presence of striae Shape -obligated Presence of operative dressings Fundic height C. maybe they abort the child because they not ready to support the family. veins. size & symmetry of the breasts -It is obligated. We decided to have our own family so that we planned it already. it doesn’t have any discharges on it. Breasts Color and appearance (flat. Appearance of episiotomy incision (fresh. color. V. IV. 2. were they able to try any contraceptive method? Yes. Perineum Appearance. I felt more pain on it and my breast is too heavy and full. c. edematous. I don’t know if it can affect when I deliver my baby 4.

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