1.

Patient’s Data, Obstetrical History (EDC, GPTPALM)

 LMP: May 21, 2020; EDC: February 28, 2021

05 21 2020
-3 +7 +1

02 28 2021

 GPTPALM = G5 P3 T1 P3 A1 L3 M1
2. Questions to ask as part of initial interview and history taking, and why do you need to include these
questions as part of your interview

 Demographic Data – “What is your name? How old are you? Where do you live? What is your
civil status? What is your religion? Do you work, if yes, what is your work? Where do you work?
What is your telephone or cellphone number?” RATIONALE: These are basic information
regarding the client and must be taken into consideration since specific interventions depend on
the demographics of the client, specifically age, work and religion.
 Chief complaint – “When was your last menstrual period? Have you experienced nausea,
vomiting, breast changes or fatigue during the early stage of pregnancy? Have you experienced
discomforts like constipation, backpain, or frequent urination during pregnancy? Have you
experienced any danger signs like bleeding, abdominal pain, continuous headache, visual
disturbances, or swelling particularly on hands and face?” RATIONALE: These are asked to
confirm pregnancy. If the patient experiences any of the danger signs, immediate referral to the
physician.
 Family Profile – “How’s your relationship with your husband and family? What are your worries
during this pregnancy? What are your ways to cope up with this concern?” RATIONALE: To
know about the support system the client has especially pregnancy is responsibility not only to
the client but to the whole family. Having a support system will help the client to cope up easily.
 Obstetric History – “Have you experienced any conditions during your previous condition? Any
previous miscarriages or abortion? What was the type of delivery you had before?”
RATIONALE: This information will be used in providing health teachings regarding nutritional
needs of the client to prevent such conditions from reoccurring.
 Gynecologic History – “When was the first time you had your menstruation (menarche)? Do you
have a regular or irregular menstrual cycle? If regular, how many days is your usual cycle? The
long does your menstrual period lasts? How many sanitary napkins do you use per day? Did you
have any past reproductive tract surgery? What is the reproductive planning method you used and
you’re planning to use after pregnancy?” RATIONALE: It is done to determine whether the client
has sexual problems.
 Past and Present Medical History – “Do you have any existing medical problems? What were
your past illnesses? What were your childhood diseases? Have you completed your
immunizations when you were young? Do you have any drug allergies?” RATIONALE: Some
past illnesses like tuberculosis may reactivate during or after pregnancy. Vaccine are not to be
administered during pregnancy except for influenza and poliomyelitis. Allergies present may
affect the fetus.
 Review of System – Ask per system in a cephalocaudal method. RATIONALE: This is to allow
the client to recall diseases she hasn’t mentioned before.
3. Health teaching about nutritional needs + rationale

 Educate the client to increase calorie intake by eating green leafy vegetables, milk, and cereals
and grains which are complex carbohydrates than simple sugars. RATIONALE: This is utilized
for deposition, synthesis and maintenance of new tissue.
 Educate the client to increase protein intake by eating food containing complete proteins like
eggs, fish (in moderation), meat, milk and yogurt. RATIONALE: Protein is necessary for the
fetal grow and development and to increase maternal blood volume.
 Educate the client to decrease fat intake by eating only food rich in omega 3 and consuming corn,
olive, peanut and cottonseed. RATIONALE: Fat causes gastrointestinal discomfort which may
worsen during pregnancy.
 Educate the client to decrease carbohydrates intake especially during the 2 nd and 3rd trimester.
RATIONALE: To prevent excessive fetal growth which may be caused by the increased HPL
level happening during these trimesters.
 Educate the client to increase iron intake especially during the later stage of pregnancy by eating
green leafy vegetables, beef, liver, eggs, nut and whole grains. RATIONALE: Iron is important
especially during the last trimester in preparation for the blood loss during delivery.
 Educate the client to take food rich in calcium and phosphorus like milk, cheese, yogurt and
almonds. RATIONALE: These minerals help in bone and teeth formation and also prevents pre-
eclampsia.
 Educate the client to take food rich in Vitamin C like green leafy vegetables, and papaya.
RATIONALE: Vitamin C is necessary for anti-oxidant and collagen formation. It also
strengthens the immune system.
 Educate the client to take folic acid. RATIONALE: Folic acid prevents complications occurring
in the fetus like neural tube defects.
 Educate the client to prevent unhealthy lifestyles like drinking alcohol and caffeine, and smoking.
These may cause preterm birth and LBW.
4. Explain reason for different signs and symptoms
Briefly explain how they occur during pregnancy
Formulate Nursing Diagnosis based from the signs and symptoms
Health teachings to alleviate signs and symptoms

 Nausea and vomiting

o Scientific Explanation: Nausea and vomiting are often experienced during the 1 st
trimester of pregnancy due to the increased levels of HCG which stimulates corpus
luteum to produce progesterone. This can also be associated with heartburn or pyrosis.
o Nursing Diagnosis: Nutrition imbalanced: less than body requirements related to inability
to absorb nutrients as evidenced by nausea and vomiting
o Interventions or teachings:
a. Advise the client to take dry carbohydrates 30 minutes before getting up in the
morning. Rationale: This is to prevent morning sickness by eating small amounts
of food first thing in the morning.
b. Educate client to increase fluids, but best tolerated between meals. Rationale:
This is to promote faster digestion of food. Drinking during meals may cause
acidity since water dilutes the gastric juices, and also slows down digestion.
 c. Advise the client to take small, frequent meals. Rationale: These meals are easier
to digest.
d. Inform the client to avoid taking fatty or greasy foods. Rationale: Greasy food
contains large amounts of fat which slows down stomach emptying.
 Heartburn (after eating)
o Scientific Explanation: Heartburn occurs due to the increased level of progesterone which
relaxes the cardiac sphincter, making it open and allowing gastric contents to move back
to the esophagus.
o Nursing Diagnosis: Acute pain related to acidic irritation of mucosa as evidenced by
reports of heartburn
o Interventions or teachings:
a. Advise the client to take small, frequent meals. Rationale: These meals are easier
to digest.
b. Inform the client to avoid taking fatty or greasy foods. Rationale: Greasy food
contains large amounts of fat which slows down stomach emptying.
c. Encourage the client to keep an upright position after meals. Rationale: This is
done to prevent reflux.
d. Inform the client to avoid drinking coffee and citric juices, eating tomato
products, and smoking cigarettes. Rationale: Prompts the stomach to produce
more acid, increasing risk of gastric contents being refluxed into the esophagus.
 Muscle cramps (on legs during nighttime)
o Scientific Explanation: Muscle cramps on legs is caused by fatigue, or by the growing
uterus which puts pressure on nerves or blood vessels resulting to decreased circulation.
Calcium and magnesium deficiency, and dehydration may also be one of the causes as to
why muscle cramps is being experienced.
o Nursing Diagnosis: Disturbed sleep pattern related to discomfort as evidenced by muscle
cramps on legs during nighttime which makes the client experience difficulty initiating
sleep.
o Interventions or teachings:
a. Advise the client to elevate her lower extremities frequently. Rationale: This is to
promote circulation.
b. When muscle cramps are experienced, educate the client to lie one’s bac and
hyperextend the affected knee, and inform someone to dorsiflex the foot.
Rationale: Stretching the area that has muscle cramps can help stop the spasm
from occurring.
c. Encourage the client to apply warm compress. Rationale: Heat can soothe tight
muscles.
d. Inform the client to change position frequently. Rationale: This is to avoid
fatigue of muscles.
 Dyspnea (when lying down)
o Scientific Explanation: Dyspnea is experienced during pregnancy due to the growing
uterus which displaces the diaphragm compressing the lungs. This limits the ability of the
lungs to have its maximal expansion.
o Nursing Diagnosis: Ineffective breathing pattern related to body position that inhibits
lung expansion as evidenced by report of dyspnea when lying down.
o Interventions or teachings:
 a. Explain to the client that shortness of breath is a normal discomfort during
pregnancy. Rationale: This is to ensure the client and to lessen her concerns.
b. Encourage the client to lie in left lateral position or sim’s position. Rationale:
Sleeping in left lateral position or sim’s position improves circulation and promotes
maximal lung expansion.
c. Inform the client to use pillows when lying to the side. Rationale: This is to ease
pressure on the hips.
d. Advise the client to call the physician when problems with breathing worsens.
Rationale: This is to prevent further complication for both the mother and the fetus.
 Difficulty defecating
o Scientific Explanation: Constipation is caused by the elevation in progesterone level
resulting to a reduced gastric motility, and the weight of the growing uterus presses
against the bowel.
o Nursing Diagnosis: Constipation related to decrease in gastrointestinal motility as
evidenced by reports of having difficulty in defecating.
o Interventions or teachings:
a. Advise the client to drink eight to ten glasses of water per day. Rationale:
Adequate amounts of fluid is required to keep the fecal mass soft.
b. Advise the client to increase intake of dietary fiber. Rationale: Fibers helps in
easier elimination since it passes through the large intestine resisting digestion in
small intestine.
c. Encourage the client to have regular exercise like walking. Rationale: Exercises
promote peristalsis.
d. Inform the client to avoid using enemas. Rationale: Enemas may initiate labor.
 Hemorrhoids
o Scientific Explanation: Hemorrhoids are one of the discomforts in pregnancy which are
caused by the pressure from the growing uterus pressing against the rectal veins, making
them swollen and painful.
o Nursing Diagnosis: Acute pain related to inflammation and edema of prolapsed varices as
evidenced by verbal reports regarding problems with hemorrhoids.
o Interventions or teachings:
a. Encourage adequate intake of fluids and fiber in diet. Rationale: This is to
prevent constipation.
b. Inform the client to avoid straining at stools. Rationale: Straining increases
pressure on the venous cushion in the lower rectum.
c. Inform the client to avoid spicy foods. Rationale: Spicy food doesn’t necessarily
cause hemorrhoids, rather they irritate anal fissures.
d. Advise the client to rest in modified sim’s position. Rationale: Resting in
modified sim’s position doesn’t compromise maternal venous return and relieves
pressure on the rectal veins.
e. Educate the client to have warm sitz bath. Rationale: This is to decrease irritation
from hemorrhoids and promote comfort.
 Backaches
o Scientific Explanation: Backache is experienced as pregnancy advances and postural
changes are essential to provide balance. The growing uterus may also put pressure on
the pelvis and back causing backache.
 o Nursing Diagnosis: Deficient knowledge related to body mechanics techniques to protect
the back as evidenced by reports of backaches
o Interventions or teachings:
a. Advise the client to squat when picking up things. Rationale: This is to prevent
bending the back.
b. Encourage the client to wear low heels. Rationale: This is to maintain an upright
position and to provide easier balancing.
c. Inform the client to provide warm compress on the affected area. Rationale: Heat
can relieve back pain.
d. Encourage the client to have backrubs or massage. Rationale: It doesn’t only
alleviate pain, but also provides comfort and relaxation.
 Easy fatigability
o Scientific Explanation: Fatigue is usually experienced during early pregnancy because of
increased metabolic demands. Hormonal changes specifically increased progesterone
levels may also be the cause of fatigue since it makes one feel sleepy as well.
o Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and
demand as evidenced by fatigue.
o Interventions or teachings:
a. Encourage the client to have enough rest and sleep in modified sim’s position
with top leg forward. Rationale: Modified sim’s position allows the weight of the
fetus to rest on bed and not on the mother.
b. Educate the client to eat well-balanced meals, and food rich in iron. Rationale:
Iron is needed to make RBCs that carry oxygen throughout the body.
c. Advise the client to wear comfortable clothes and shoes. Rationale:
Uncomfortable outfits can deplete one’s energy
5. Health teachings about lab and diagnostic procedures + importance and purpose

 Complete Blood Count (CBC)

o Importance/purpose: It is done to determine possible health issues that pregnant woman
may develop. This test also monitors the levels of RBCs which carry oxygen in the body
and to the placenta, the levels of WBCs which helps in one’s immunity, and the levels of
platelets which are responsible for coagulation.
o Procedure: The assigned healthcare provider will withdraw a blood sample from a vein in
the client’s arm by inserting a small needle. Then, a small amount of blood will be
collected into a test tube or vial which will be brought to the laboratory.
o Health teachings: In preparation for CBC test, inform the client to fast 8 – 10 hours
before the test. Rationale: Food intake alters CBC results, especially WBC count.
 Urinalysis Test
o Importance/purpose: Urinalysis is done to determine the presence of sugar wherein too
much may indicate need for further testing for gestational diabetes. It is also done to
determine presence of ketones which indicates the nutrition and hydration level of the
client. On the other hand, presence of protein may indicate a potential problem with the
kidneys, while presence of bacteria indicates a possible urinary tract infection requiring
treatment.
o Procedure: It is done by obtaining a small sample of urine (midstream) into a sterile cup.
Then, testing strips are to be dipped in the urine sample to screen for certain indicators.
 o Health teachings: Inform client to drink plenty of water (but not too much) before the
test. Rationale: This is to provide adequate sample which may help in giving accurate
results. Assess the medications being taken by the client. Rationale: Some medications
may alter the results of the urinalysis. Educate the client regarding the technique in
getting the clean catch urine sample. Rationale: This technique helps to prevent any
microorganisms from getting in the sample.
 Ultrasound
o Importance/purpose: It is done to determine any congenital abnormalities, to determine
baby’s sex, monitor the growth of fetus and position and to check for fetal heart rate.
o Procedure: The client will be asked to life down on the examination bed. Then, the
healthcare provider will apply water-based gel on the abdomen and pelvic area. A
transducer will be used to capture images on the ultrasound screen. There are times where
the client will be asked to hold one’s breath or move. Then, the gel will be wiped off and
the client will ask to empty her bladder.
o Health teachings: Inform the client to full her bladder by drinking 2-3 glasses of water an
hour before the procedure. Rationale: Having a full bladder will help in getting a clear
image of fetus and the reproductive organs.
 HIV Test
o Importance/purpose: to detect HIV and provide immediate care reducing the risk of
transferring the virus to the baby.
o Procedure: It is done at the same time as the other routine antenatal blood tests
o Health teachings: Explain the importance of HIV test especially during pregnancy.
Rationale: This is to encourage the client to take the test and also, to alleviate her worries.
o Nursing Responsibilities: The nurse must sterilize the reusable equipment before and
after each use. Rationale: this is to prevent the spread of infection.
 Glucose tolerance test
o Importance/purpose: It measures the ability of the body to use glucose. It is done to
diagnose gestational diabetes or glucose intolerance.
o Procedure: A blood sample will be taken when the client arrives. Then, she will be asked
to drink a small cup of sweet liquid and asked to stay in the room for 1-3 hours for more
blood tests.
o Health teachings: Inform the client to avoid eating or drinking anything aside from sips of
water for 8-10 hours before the said test. Rationale: Fasting helps to ensure accurate
result of blood sugar levels.