Nantongo Ritah

Aga Khan University

568471

Maternal and Reproductive health Antenatal clinic Portfolio

Nalule Imelda

17TH November 2022.

Case Number: 01 Clinical date: 19th October 2022 Health Facility: Kawempe National

Referral Hospital

Student’s Name: Nantongo Ritah Year 2 Semester 3

Clinical Objectives

• To assess and identify a pregnant woman with no any complications and fit for vaginal

delivery

• To examine the mother from head to toe and rule out any abnormality including the

pelvic assessment for adequacy.

• To take properly take history both objective and subjective and identify the mother’s

nursing concerns

• To prioritize the mother’s nursing concerns and Formulate a nursing care plan.

• To implement the planned nursing care plan and document what has been done

• To health educate the mother on any concerns during pregnant for example the danger

signs of pregnancy, the signs of true labor, and the physiological changes that occur

during pregnancy

• To interpret results of diagnostic examinations including pregnancy tests, urine tests, and

blood tests.

• To administer drugs like tetanus toxoid vaccine and fansider to the mothers

• To orient the mothers around the hospital, and showing them departments like

Emergency and Accidents, labor ward and postnatal ward so that they don’t get stuck

when need arises

• To advise mothers to come with their husbands on the next visits for HIV counseling and

testing and also to advise them to come back for antenatal visits on the given dates.
 • To encourage and advise the mothers to save some money to but the babies needs like

clothes and milk when delivery time comes.

• To assist the midwife in admitting mothers to the maternity unit and caring for them

during the 1st stage of labor.

• To observe and assist in the care of the patient during the 2nd and 3rd stage of labor.

1. Client’s identification data.

a) Client’s first name: Ndagire

b) Ward/ Clinic: Antenatal clinic OP/File No: 661820

c) Age/ year of birth: 25 years d) tribe: muganda

e) Occupation: House wife f) Education level: Certificate

g) Religion: Moslem h) Tel Contact: 0783414126

i) Gravida: 3 Para 2 + 0

2. Social History

a). Marital Status: Married

b) N.O.K (by relationship): Atangmana Levi (Husband) Tel Contact: 0703688900

c) Level of education (N.O.K): Bachelors Occupation: Dentist

d) Physical Address: Nansana Zone: masitoowa Distance from Health Facility: 10km

Means of Transport: Taxi

d) House Condition:

She stays in a rented four bed room house that is well ventilated and big enough for the family

e) Source of food: Market Source of water: Tap at her home

f) Disposal of waste:

Dumps in a sack and picked by the home clean company truck.

Refuse:

The food remains are given to the domestic animals and they use a flush toilet for disposing off

the fecal matter.

History taking:

The mother is a 25 year old female who reports to have one sister and two brothers all alive with

both her parents alive, she is married and stays with her husband with their two children who

were delivered vaginally and they are all normal and doing well health wise. She also reports that

she was a hair dresser three years ago and currently a house wife and her major reason for

coming to the hospital today is to attend the antenatal clinic and also to attend to her complaints

which are lower back pain, nausea and vomiting, loss of appetite and over dozing during day

time.

Vital Observations.

BP: 120/66hmmg

PULSE: 88b/m

RR: 18 b/m

RBS: 6.4milmoles

Temp: 36.4 degrees centigrade

Weight: 58kg.

3. Family History

a) Diabetes Mellitus:

The mother reports no any history of diabetes in their family.

b) Hypertension:

She reports no any hypertensive history in her family.

c) Mental illness:

She reports that her aunt, the follower of her father had a mental illness which she did not specify

and was admitted to Butabika Hospital in 2016 but later she passed away.

d) Sickle cell disease: The mother reports no any history of sickle cell in her family.

e) Others: none

4. Medical History

a) Diabetes mellitus: The mother is not diabetic. b) Hypertension: The mother is not

hypertensive. c) Cardiac disease: The mother has no any cardiac disease

d) TB: The mother has never suffered from TB. e) Anemia: She is mildly anemic.

f) Kidney diseases: She is free from kidney diseases.

g) HIV/AIDS: The mother is negative for HIV/AIDS. h) Syphilis: Negative

i) Herpes Zoster: She has never had a herpes zoster.

j) Sickle cell disease: she is normal k)

Asthma: She reports to have suffered from asthma but then it got cured as she grew up.

l) Epilepsy: She is free from Epilepsy m) Polio: She has never suffered from polio.

5. Surgical History

a) Operations: Yes/No. If yes, when: No.

b) Fractures: Yes/ No. If yes, when: No.

c) Blood transfusion: Yes/ No. If yes, when: No.

6. Menstrual History:

Menstrual Cycle & Contraceptive History: a) Menarche: 13 Years. b) No. of Days: 4

days.

c) Length of Cycle: 28days

 d) FP Method Used: She does not use any family planning method

e) Indication for Use: does not use.

7. Gynecological History

a). D&C: Yes/No. If yes, when: No.

b) Operations on cervix: Yes/No. If yes, when: No.

c) Myomectomy: Yes/ No. If yes, when: No.

d) Evacuation: Yes/ No. If yes, when: No.

e) STD: Yes/ No. If yes, when: No.

8. Past- Obstetric History

ABORTIONS MOTH DELIVERIES CHILD
ER
Below Abov Gestatio Type of Third Puerperiu Alive/S Birth wt Immunizati Health
12 e 12 n delivery stage m B/NND on condition
wks wks
1 None None 9 months Normal Complet Normal Alive 2.5kg Fully Good
delivery ed immunized
2 None None 9months Norma complete Normal Alive 3kg Fully Good
immunized

9. Present obstetric history

Gravida 3 Para 2 LNMP: 18th May 2022 EDD: 25th February 2023. WOA: 25 weeks

and 1day.
 Present Health

Sleeping pattern:

The mother reports to have disturbed sleeping pattern at night with no clear explanation for it,

and over dosing during day time.

Micturition Action: She reports frequent micturition with a pale yellow color.

Appetite: She has no appetite since conception due to nausea and vomiting

Bowel Action: She reports a soft bowel action and does it at least twice a day.

Present Complaints: Nausea and vomiting, back pain, loss of appetite and over dozing during

day time

Medication (Current): Fefo and oral paracetamol.

10. Clinical Findings & Investigations

a) Weight (Kg) 58kg Gait: The mother is able to move without limping and has no any

deformities.

b) Urine (color): Pale yellow. (Odor) she is not sure of the odor. (PH): Not done.

c) Albumen: Not tested for. Sugar: 6.8milmoles. Acetone: Not done.

d) Blood (HB): 10ml/dl Group: B+ HIV status : Negative.

e) Others: none.

11) General Examination:

a) General condition: The mother is a gravida 3 para 2 + 0, she is in a fair general condition,

not fibril, not jaundiced, no edema, but has a mild pallor.

Temperature: 36.4 degrees centigrade Pulse: 88 beats per minute

iv). Respirations: 18 breaths per minute. iv) Bp: 120/ 66mmHg

b) Head:

The mother reports no any trauma to her head, the head is round with well aligned and uniformly

distributed hair, no lesions, and no signs of lice infestation.

c) Neck:

The mother reports no any injury or problem to her neck, the neck is short and round, the trachea

and the thyroid are intact, with no any swollen and palpable lymph nodes, the jugular veins are

not distended, the carotid artery is palpable, and she is able to move the neck in all directions

without difficulties.

d) Chest

The chest contour is flat, mother reports no problems with breathing, the respiratory rate is 18

beats per minute, and it expands uniformly with a symmetrical movement and on auscultation

the heart sounds 1 and 2 are heard with no any added heart sounds.

e) Breasts (i) Size: The breasts are big. (ii) Shape: They are pendulous.

iii) Signs of pregnancy:

The breasts have striae gravidarum, and the secondary areola is also present

iv) Palpation:

On superficial palpation, there is no any tenderness

On deep palpation, there is no any masses or lump felt.

f) Upper limbs:

The mother has two hands both symmetrical, with no any lesions or deformities, she has ten

fingers with all the nails present, short and clean. The radial and brachial arteries are present,

well palpable and she is able to move both the hands in all directions with ease.
g) Lower Limbs:

The mother has two legs both symmetrical, with no any lesions or deformities, she has ten feet

with all the nails present, short and clean no any signs of edema, no varicose veins and she is

able to move both limbs in all directions and walks without difficulties.

h) Abdominal Examination

On inspection,

The abdomen is distended, with signs of pregnancy like strae gravidarum and linear nigra present

without any lesions.

On superficial palpation,

There is no tenderness

On deep palpation,

The liver and the spleen are not palpable, and there is no any organomegaly.

On lateral palpation of the right side of the abdomen, a continuous curve is felt which is

suspected to be the fetal back, on palpation of the left lateral side soft irregular masses are felt

which are suspected to be the fetal limbs and on palpation of the pelvis, a hard round mass is felt

which is suspected to be the fetal head.

And on auscultation, the fetal heart is heard.

Therefore, the presentation is Cephalic, the lie is Right occipital anterior and the fundal height

was 27cm by the tape measure and the fetal heart is 126 b/m.

i) Abdominal scars. Yes/ No. If yes, give reason: No.

ii). Abdominal tenderness: no iii). Liver: not palpable. iv). Spleen: not palpable.

v) Fundal height: 27cm vi) Presentation: Cephalic presentation

vii) Position: Right occipital anterior.

Summary of Abdominal findings

The mother has no organomegally, has signs of pregnancy that is the striae gravidaram and the

linear nigra, no abdominal scars, no abdominal pains, the presentation is Cephalic, the lie is

Right occipital anterior and the fundal height is 27cm.

12) a) Medical Diagnosis: Hyperemesis gravidarum

b) Nursing concerns

➢ Lower back pain

➢ Nausea and vomiting

➢ Lack of sleep at night

➢ Loss of appetite

c) Nursing diagnoses

• Pain in the lower back related to the growing fetus that compresses the back bone

evidenced by the mother’s verbal report rating her pain as 7/10 on a pain scale of 10/10.

• Unpleasant sensation at the back of the throat and epigastrium related to hormonal

changes and abdominal distension evidenced by the mother vomiting whatever she eats

as per verbal report.

• Disrupted sleep patterns related to physical discomfort evidenced by the failure to do

house work and over dozing throughout the day.

Nursing Care Plan:
Assessme Nursing diagnosis Outcomes/goal Interventions/ Rational Evaluatio
nt s implementatio n
n
The Pain in the Short term To administer The pain The
mother lower back goals the prescribed killer mother’s
complains related to the To lower the pain killers to inhibits the pain was
of lower growing fetus mother’s pain the sensation reduced
back pain that to a pain scale mother.(oral of pain by from a
compresses of 3/10 within paracetamol inhibiting scale of
the back bone 30 minutes 1g) transmissio 7/10 to a
evidenced by n of scale of
the mother’s non-nocice 3/10 after
verbal report ptive 30
rating her pain impulses minutes
as 7/10 on a along of
pain scale of primary administe
10/10. afferents ring the
painkiller
Long term
goal
To overcome The mother Sitting in The
the mothers was advised to one mother
pain take the position will have
throughout prescribed strains the minimal
pregnancy pain killers at joints of or no pain
home, avoid the lower througho
sitting for so back and ut her
long and pelvis. pregnanc
carrying heavy y
loads
Nurse/midwifery care:

Creating a rapport with the mother, physical examination and health assessment of the mother

from head to toe to rule out any abnormality, palpation of the fetus, health education of the

mother about the danger signs of pregnancy and signs of true labor and when she is supposed to

come back for the next visit, administering painkillers, Tetanus toxoid vaccine, fansidar and

Ferrous salts with Folic Acid (FeFol)

Nurses’ notes:

19th October 2022.

9:00am to 9:35am:

Obtaining Objective data:

Taking vital Observations of the mother B.p:120/66mmHg, pulse: 88b/m, Temp: 36.4degrees

centigrade, Rbs:6.4milmoles, MUAC: 32cm, body weight:58kg, and then history taking.

Observingly, the mother was smartly dressed, well-groomed and fully conscious, was able to

move without limping, no signs of edema, no jaundice but had signs of mild anemia

Subjective data: The mother was oriented to place, time and person, she is a 25-year-old female

married with 2 children and stays with her husband, she reports to have had 2 normal deliveries

and all her children are doing well health wise and she does not have any complications related

to her past deliveries, she is a house wife and she reports to have last seen her periods on18th

May 2022 and she went to a clinic three weeks from that time to test for pregnancy which was

positive. She reports that she was happy with the news and she loves her pregnancy. She is

currently for antenatal care as a routine and she complains of lower back pain, nausea and

vomiting, loss of appetite and over dozing during day time.

9:35 to 10:05am:

Physical examination of the mother from head to toe and palpation of the abdomen for the fetal

examination which showed that all her systems are ok and the fetus is doing well being in the

right occipital anterior position and presentation being cephalic and the fundal height is 27cm.

10:06am to 11:46am:

Identifying the mother’s nursing concerns and formulating a nursing care goal

Implementation of the care goals and documentation of the findings and all procedures

performed to the mother.

11:47am to12:17pm

Health education of the mother, I health educated the mother about the danger signs of

pregnancy and signs of true labor.

12:18pm to 12:33pm

Administering Tetanus toxoid vaccine and fansidar to the mother and encouraging her to come

back for the next visit which will be 19th December 2022.

Conclusion

I received a 25 years old mother who is a gravida 3 para 2 + 0 following normal deliveries, who

had come for her second antenatal visit, her vital observations were ok, she is doing well

nutrition wise, her fetus is doing well too and she has complaints of nausea and vomiting, back

pain, loss of appetite and disturbed sleep patterns at night which were addressed to the doctor,

nursing concerns were obtained, formulated a care plan which was implemented and evaluated,

treatment and coping mechanisms were advised, administered Tetanus Toxoid vaccine and

Fansidar plus the pain medications, health educated the mother, documented all that was done

and advised her to come back on her next date of visit.

 Drug card for Ferrous salts with Folic Acid (FeFol)

(Precise pharmacology 2nd edition page 379)

Forms Doses Routs of Mode of action Indications Side effects

Name of Available Availabl administration
drug e
Ferrous salts Capsules Oral route Ferrous Prevention of Sensation of
with Folic 5mg and sulfate replenishes iron and fullness,
Acid (Fefol) Suscaps 10mg iron, an essential Folic Acid nausea and
component in deficiencies in vomiting,
Tablets hemoglobin, pregnancy, diarrhea,
myoglobin, and after delivery constipation,
various enzymes. and lactation. severe
It replaces the iron dizziness,
that is usually troubled
found in breathing,
hemoglobin ... rash, itching
or swelling.
Nursing considerations before administering Ferrous salts with Folic Acid (Fefol).

It should not be administered to patients with known hypersensitivity to any of the ingredients.

Ferrous sulfate + folic acid tablets are contraindicated in patients who are taking calcium tablets

as it inhibits the absorption of iron in the blood

It is advisable to take it with orange juice or a vitamin C supplement. Vitamin C is believed to

increase the amount of iron absorbed by the body

Do not administer ferrous sulfate + folic acid tablet to patients who you have:

• Iron overload syndrome;

• Hemolytic anemia (a lack of red blood cells);

• Porphyria (a genetic enzyme disorder that causes symptoms affecting the skin or nervous

system);

• Thalassemia (a genetic disorder of red blood cells);

• Receiving regular blood transfusions.

Teaching plan
Topic: SIGNS OF TRUE LABOUR AND DANGER SIGNS OF PREGNANCY
Date: 16th November 2022 Time: 10:31am
Facilitator: In charge Antenatal clinic.
Participants: Mothers and my fellow colleagues Duration: 30 minutes
Venue: Antenatal clinic Presenter: N.R
Specific Content Teaching Teaching Learning Evaluation
objectives method and activity activity
teaching aid
Explain the These are bad Verbal Explaining Listening Mother was
meaning of signs we get explanation the meaning and being able to
danger signs when we are of dangers attentive explain the
of pregnancy pregnant and signs of meaning of
they are very pregnancy danger signs
dangerous to verbally of pregnancy
the mother in their own
and the fetus. words by the
end of the
teaching
session
Mention the Vaginal Verbal Verbal Listening, Mothers were
danger signs bleeding, explanation explanation Observing, able to
of pregnancy swelling of and the aids and with the and asking mention all
the face and were my aid diagrams questions the danger
the whole phone and a on my phone signs of
body, failure manila chart and a manila pregnancy
to hear the chart
fetal
movements,
(rapture of
membranes)
 power of
waters before
time of labor
Define the These are Verbal Talking and Listening and All mothers
asking
meaning of things that explanation demonstration were able to
questions
signs of true happen to a give a right
labor pregnant definition of
mother and true signs of
indicates that labor in their
it is time for own
delivery. understanding
List the signs (Show) Verbal Asked the Listening and Mothers were
of true labor bloody explanation mothers to Paying able to list all
mucus, and active tell me some attention, the danger
rapture of participation of the signs of Active signs of
membranes of mothers by true labor that participation, pregnancy
Uterine brain they knew, asking and without
contractions storming corrected answering leaving any
that are them and then questions out
frequent and I listed all the
strong in signs of true
nature labor that
they had
missed out
Conclusion: The mothers were attentive and cooperative, understood all that was taught asked
questions where they had not understood and promised to put into action whatever was taught. It
was a very interesting health talk.
References

Nathan, M., Nilliet, N., Jannipher, N. M., Harriet, N., Peace. , C. ,Esther., B. , Florence. N., John, M.M.

(2011). Pricise pharmacology (2nd ed). New King Offset, Kampala

Student’s Signature _________________________________ Date_______________________

Midwife’s Name __________________________________Signature & Date _______________
Supervisor’s Name ________________________________Signature &Date ________________

NB: Include all the care offered to the mother including the teaching and
return date