A.

BIOGRAPHIC DATA

1. Patient A 6. Asian
2. Laguna 7. Single
3. 20 8. Unemployed
4. N/A 9. N/A
5. Female 10. N/A

B. COMPREHENSIVE HISTORY

I. PRESENT ILLNESS:

Patient A is pregnant and is experiencing symptoms such as nausea, vomiting, headaches,

fatigue, breast tenderness, mild cramps, light spotting, and a right sided pain due to cyst after
her after her last menstrual period on November 3, 2018. She weighed 121 pounds and had a
BMI of 18.44 before pregnancy. For her most recent monthly visit, she weighs 115 pounds
which is 6 pounds weight loss from her initial prenatal monthly visit and has now a BMI of only
17.48 which is already considered as underweight and she has not effectively gained weight
during the first trimester of her pregnancy. The patient stated patient’s dietary intake is very
little as she claims that she often does not have an appetite, and even when an appetite is
present, she eats very little. The patient is currently just taking her prenatal vitamins in the
gummy form, which the doctor has approved.

II. PAST HISTORY

She has no past obstetric history, and she has a past medical history that includes gallbladder
disease, frequent dehydration, and underwent cholecystectomy in 2014 due to her gallbladder
disease. She used to take salbutamol for her asthma, and has a mental health history of anxiety
and depression but she no longer on medication for it. She used to smoke and does not drink,
and she also stopped taking prescription medication that could potentially cause any harm to
the baby.

III. FAMILY HISTORY

Patient A mother suffers from peptic ulcer disease, while her father has a history of viral
hepatitis. Her maternal grandmother has a history of thyroid disorder, and her fraternal
grandmother had a cholecystectomy is her mid 30’s. She also discussed her mother’s sister has
an extensive history dealing with a heart disorder. The father’s family medical history was not
obtained during the appointment.
IV. DIAGNOSTIC TEST AND LABORATORY TEST

There was no diagnostic nor laboratory tests was conducted.

V. DRUG STUDY

DRUG Mechanism of Action Indication/ Nursing

Contraindication responsibilities

Brandname: It relieves nasal Indication:  Assess lung

Proventil congestion and To control and sounds, PR
reversible prevent reversible and BP before
Genericname: bronchospasm by airway obstruction drug
Albuterol relaxing the smooth caused by asthma or administration
muscles of the chronic obstructive and during
Classifications: bronchioles. The pulmonary disorder peak of
Bronchodilators relief from nasal (COPD); quick relief medication.
congestion and for bronchospasm;  Observe fore
Route: bronchospasm is for the prevention of paradoxical
PO – orally made possible by the exercise-induced spasm and
Dosage:
following mechanism bronchospasm; long- withhold
2-4 mg
that takes place term control agent medication
Frequency:
when Salbutamol is for patients with and notify
q4h
administered. chronic or persistent physician if
bronchospasm condition
occurs.
Contraindications:  Administer PO
Hypersensitivity to medications
adrenergic amines with meals to
and to fluorocarbons minimize
gastric
irritation.
VI. TEACHING PLAN

Patient A dietary intake is very little and is experiencing weight loss during pregnancy. A
consultation with a dietician is recommended. The patient should be educated on the
importance of having a balance-nutrition diet and regular exercise, and follow the advice of the
physician such as taking prenatal vitamins to keep the mother and baby healthy
.
VII. NURSING CARE PLAN

CUES NURSING GOALS AND NURSING IMPLEMENTATIO EVALUATIO

DIAGNOSIS DESIRED INTERVENTION N N
OUTCOME w/ Rationale

Subjective: Risk for The patient Document the Provide The patient
Patient A Imbalance will actual weight information on is able to
stated that Nutrition: acknowledg of the patient. the importance understand
she often Less than e she is Rationale: of healthy and the
does not body underweigh Patient may be well-balanced importance
have an requiremen t and is at unaware of diet. of proper
appetite, t due to risk for actual weight and well-
and even loss of health loss, and for Promote balanced
when an appetite. problems. the record to improvement of diet.
appetite is be accurate. appetite by
present, Verbalize having sufficient The patient
she eats and Monitor the food intake. is able to
very little. demonstrat patient’s identify and
e selection weight. Advised patient create a
of ideal
Rationale: To to see a dietician meal plan
Objective: foods and determine to improve to support
Weight – activities for
type, amount, health. the
115 pounds pregnant and pattern of nutritional
woman to food intake as needs and
BMI – again facilitated by boost the
17.48; weight. accurate health
underweigh documentation system of
t The patient s. her and the
will have a baby.
healthy and Set appropriate
balanced short-term and The patient
weight for long-term is expected
pregnancy. goals. to achieve
Rationale: and
Improvement maintain
in nutritional normal
status varies on weight
time. Patient during the
may lose pregnancy.
interest in the
whole process
without short-
term goals.