PRENATAL

CARE
NCMA217 RLE
CASE PRESENTATION

Amurao, Lindzy Aguisanda, Geneva

Antiporda, Alex Barrios, Maritoni

GROUP 1
Bendijo, Honney Bere, Gillianne
 CASE
SCENARIO

Liz Calhorn, an 18-year-old, is about 20 weeks pregnant (can’t remember date of last menstrual period).
Although she says she knows she should have stopped smoking before pregnancy, she has not been able
to do this yet. Twice during the pregnancy(at the 4th and 10th week), she drank beer at summer
picnics. Today, at a clinic visit, she tells you she has felt her fetus move. She states, “Feeling the baby
move made me realize there’s someone inside me, you know what I mean? It made me realize it’s time I
started being more careful with what I do.” Liz works at a fast-food restaurant. Boyfriend (father of fetus)
is supportive but has no money to offer her for support. Patient states, “I’m not getting married. Just not
ready for that level of commitment yet.”
01
ACTUAL NDx
Problems identified by the nurse that are already in existence
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Ineffective childbearing Short Term Goal: Independent: Independent: Short Term Goal:
process associated with After the nursing
The patient stated that: substance misuse: • Within 4 hours of • Monitor vital signs • To obtain baseline data interventions, the patient
smoking and drinking nursing intervention the was able to:
• She knows she should alcohol during pregnancy, patient will obtain • Discuss how alcohol • The patient hasn't yet
have stopped smoking as evidenced by patient sufficient knowledge and cigarettes have realized that drinks and • Obtain sufficient
before pregnancy, she verbalization that she about her pregnancy harmed your life in a nicotine are causing her knowledge about her
has not been able to do wasn't able to stop yet and the impact of careful and problems. It is easier to pregnancy and the
this yet harmful substances nonjudgmental manner. admit that substance impact of harmful
• Patient stated that she such as drinking and abuse has had harmful substances such as
drank beer at summer smoking on her and her consequences when the drinking and smoking on
picnics twice during her baby's health. patient is in pain her and her baby's
pregnancy (at the 4th health. 
and 10th weeks). Long Term Goal: • Discuss the impact of an • The patient may decide
As verbalized by the unhealthy lifestyle on to stop drinking if they Long Term Goal:
patient: After two weeks of nursing the mother and the are informed of the Within 2 weeks of nursing
• "Feeling the baby move intervention, the patient will fetus. detrimental intervention the patient was
made me realize there's be able to: consequences of able to:
someone inside me, you • Report a progressive alcohol on pregnancy.
know what I mean? It shift in her lifestyle that When a client becomes • Report a gradual
made me realize it's is suited for her and her pregnant, identifying change in her lifestyle
time I started being baby (adequate rest, potential issues will aid that is suitable for her
more careful with what I sleep, and exercise) in the planning of the and her baby
do". • Decrease of alcohol and fetus's future needs and • Decrease of alcohol and
• “I’m not getting married. tobacco intake concerns. tobacco intake
Just not ready for that
level of commitment • Encourage the client to • Provides proof of not GOAL MET
yet.” have a prenatal checkup consuming alcohol or
and the significant other smoking cigarettes.
Objective Data: to keep an eye on their
lifestyle
• The patient is about 20
weeks pregnant
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

  • Encourage family • Having a support

members to assist and
support the client.
system will provide
positive results in terms
of preventing the use of
cigarettes and alcohol,
as well as assisting the
patient in recovering
quickly.

Dependent: Dependent:

• Provide prenatal • Providing prenatal

vitamins prescribed by
the physician.
vitamins to patient will
give their body the
vitamins and minerals
needed for a healthy
pregnancy.

• To lessen the addiction

• Administer  the use of of nicotine and prevent
nicotine replacement further complications to
therapy (gum, lozenges, the fetus.
mouth spray, an
inhalator, or 16-hour
patches) as prescribed
by the physician.
Collaborative:
Collaborative:
• This will help to
• Collaborate with a determine the optimal
nutritionist dietitian to nutrition plan for the
ensure the development patient.
of healthy eating habits
and lifestyles.
 02
POTENTIAL NDx
Situations in which problems might occur but are not currently in existence
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Risk for prenatal growth Short Term Goal: Independent: Independent: Short Term Goal:
The patient stated that: disruption related to
inadequate nutrition, as • After 4 hours of nursing • Assess patient’s vital • Monitoring patients' vital • After 4 hours of nursing
• She knows she should well as alcohol and nicotine intervention, the client signs signs will help us to intervention, the patient
have stopped smoking consumption. will learn the keep on track on the now fully understands
before pregnancy, she significance of prenatal patient's situation. the effect of smoking
has not been able to do care and will gain and alcohol intake
this yet knowledge on how • Note use of alcohol, • To educate the patient during pregnancy
• Patient stated that she alcohol and nicotine nicotine and other about increased through verbalization
drank beer at summer consumption may affect drugs. maternal pregnancy and has shown interest
picnics twice during her one’s life. complications and in participating in
pregnancy (at the 4th negative effects on the activities related to
and 10th weeks). Long Term Goal: development of fetus maintaining a healthy
• "Feeling the baby move and to prevent further pregnancy.
made me realize there's • After two weeks of complications.
someone inside me, you nursing intervention, the Long term Goal:
know what I mean? It patient will be able to • Discuss the importance • To ensure quality and
made me realize it's report a gradual of regular prenatal continuity of care to After two weeks of
time I started being adjustment in her check-ups client receiving nursing care, the
more careful with what I lifestyle that is patient was able to:
do". appropriate for her. • Determine cultural • Physicians will provide
• “I’m not getting married. beliefs about accurate medication that • Describe a progressive
Just not ready for that • Patients will show childbearing self-care. will help the patient to adjustment in her
level of commitment interest in participating have a healthy lifestyle that is
yet.” in activities related to pregnancy. appropriate for her.
maintaining a healthy • show interest in
Objective Data: pregnancy such as • Discuss common acts • A woman's best defense participating in activities
water workouts, brisk that are harmful to a against fetal injury is to related to maintaining a
• The patient is about 20 walking, and Lamaze at pregnant woman's understand what healthy pregnancy such
weeks pregnant 3rd trimester. health, such as smoking constitutes dangerous as water workouts, brisk
  and consuming alcohol. practices during walking, and Lamaze at
pregnancy. 3rd trimester.

GOAL MET
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Discuss the benefits of • Knowing what makes a
eating healthy foods healthy diet can help
while pregnant to assist guarantee that a fetus
the fetus development. gets enough nutrients.

Dependent: Dependent:

• Provide prenatal • Providing prenatal

vitamins prescribed by vitamins to patient will
the physician. give their body the
vitamins and minerals
needed for a healthy
pregnancy.

• Administer  the use of • To lessen the addiction

nicotine replacement of nicotine and prevent
therapy (gum, lozenges, further complications to
mouth spray, an the fetus.
inhalator, or 16-hour
patches) as prescribed
by the physician.

Collaborative: Collaborative:

• Collaborate with a • Aids in determining

dietitian individual dietary
requirements. Provides
another resource for
learning about the
importance of nutrition in
both non-pregnant and
pregnant women.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Health Promotion: Health Promotion:

• At each prenatal visit, • It will allow for early

instructing the patient to action to avoid issues
report and monitor any from arising.
unexpected symptoms.

• Facilitate positive • It contributes to the

circumstance adaption successful completion of
by actively listening, the psychological work
accepting, and problem- of pregnancy.
solving.

• Encourage the patient to • Quitting smoking has

quit smoking by referring been shown to minimize
them to a community the significant negative
program or support effects of smoking on
group, as needed. the fetus.
THANK YOU!