Nursing Case Study

NURSING CASE STUDY ADMISSION DIAGNOSIS: G2P1 (1001) Pregnancy, Uterine,Term, Cephalic FINAL DIAGNOSIS: G2P2 (2002) Pregnancy, Uterine,Term, Cephalic Delivered, Live birth by VSD with right mediolateral episiotomy and repair I. HEALTH HISTORY A. DEMOGRAPHIC (BIOGRAPHICAL DATA) 1. 2. 3. 4. 5. 6. 7. Client’s initials: H. H. M. Gender (Sex): Female Age, Birthdate and Birthplace: 30 y/o, May 11, 1983, Trece Martires City Marital (Civil) Status: Married Race and Nationality: Filipino Religion: Baptist Address and Telephone Number: B41 L40 Pontevedra Tiera Solana, Buenavista 3, General Trias, Cavite 8. Educational Background: College Graduate 9. Occupation (usual and present): Japanese Interpreter 10. Usual Source of Medical Care: Clinic – Physician B. SOURCE AND RELIABILITY OF INFORMATION The patient was competent to provide information. She was able to speak clearly and was conscious, coherent and conversant. The patient’s chart was also used as a secondary source of information. C. CHIEF COMPLAINTS “Biglang sumakit ung tiyan ko.” “humihilab na ung pakiramdam ng tyan ko.” “Ka-buwanan ko na kasi.” Page | 1 D. HISTORY OF PRESENT HEALTH 1 week prior to admission, the patient was expecting birth so she had already prepared all the needed things including money for her delivery. On the day of the admission, the patient experienced pain in her abdominal region and started having contractions. She then immediately decided to go to the hospital because her pregnancy is already in term and she knew she was about to start labor. E. PAST MEDICAL HISTORY OR PAST HEALTH The patient has complete immunization. She said she barely gets sick. She recalled that she had mumps and chickenpox when she was young, and some occasional fever. Last 2009, the patient was hospitalized because of UTI. The patient’s menarche started when she was 12 years old, the cycle was regular. Her LMP was on January 23, 2013. 8 Months before admission, the patient had discovered that she is pregnant. The patient started to suspect that she’s pregnant because of several episodes of morning sickness, she took a pregnancy test and got a positive result and went to her OB-Gyne to confirm it. She followed her check-up schedules and her doctor’s health teachings to have a normal pregnancy. 4 months before the admission, the patient went for an ultrasound and she discovered that her baby was a girl. She said her current pregnancy was easier than the first. The patient was taking Ferrous sulfate and Iron supplements as prescribed by her physician. The patient also did not acquire any sickness during her pregnancy, even fever. Her last check-up was on September 23, 2013, when she was at 38 weeks AOG which revealed normal findings. Page | 2 F. FAMILY HISTORY (Family tree or genogram) Paternal UA UCD Maternal UA UCD UA UCD UA UCD 60 DM 57 A&W 40 A&W 30 A&W 37 A&W Legend: UA - Unrecalled age UCD - Unrecalled cause of death A & W- Alive and Well - Male - Deceased - Female - Client - Deceased Synthesis: The genogram presented in the previous page shows three generation of the patient’s family. Based on the genogram, the client’s family has a history of endocrine disorders such as Diabetes Mellitus which she can acquire due to genetics. Other diseases could be inherited due to the uncertainty in the cause of death of her grandparents. The said diseases could be prevented by modification of lifestyle and proper exercise. Page | 3 G. SOCIO-ECONOMIC FAMILY MEMBER / RELATIONSHIP TO PATIENT H. H. M. (Patient) K. H. M. (Son) M. B. H (Brother). OCCUPATION / SOURCE OF INCOME Japanese Interpreter ‘ N/A Office Worker MONTHLY INCOME 12,000 / Month N/A 10,000 / Month The client’s family is an extended type. Her husband is a seaman and he is already 6 months away from home. The salary of her husband was not disclosed. The patient has been working as a Japanese Interpreter for 17 Years and says that her pay is enough for her family’s needs. Her brother also lives with them and helps in paying the bills. H. DEVELOPMENTAL HISTORY Patient's Age: 30 years old Developmental Stage: Young Adulthood Developmental Task: Intimacy vs. Isolation Relationships are important to person included in the young adults age group. It is the time where they want to start a family, have lasting friends and a strong family relationship. Young adults need to form intimate, loving relationships with other people to make them feel successful and on track. Success leads to strong relationships, while failure results in loneliness and isolation. As for the patient’s case, the patient has a loving husband, whom she loves as well and she says that she still feels butterflies “kinikilig” due to her husband. She said that she was lucky and she loves her son and her soon to be daughter so much. She said she was also contented with her family and friends. Page | 4 I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS AND PE Date of Examination: ________October 2, 2013___ ______ PHYSICAL SYSTEMS R.O.S. “Okay naman ako.” a. Vital signs: BP: 130/80 Pulse: 88 RR: 21 Temp: 67.7 oC Feels and looks relaxed; cooperative and purposeful Speech is in moderate tone Client appears to be her stated chronologic age With ongoing D5LR 1L to run for 8 hours. inserted at left metacarpal vein, infusing well General/Overall Health Status “Wala naman akong rashes.” b. Integument P.E. “Meron akong stretch marks.” SKIN Inspection: Skin is fair in complexion (-) rashes on all skin area (-) flushing Moist skin (-) Edema Palpation: skin is warm to touch Good skin turgor HAIR Inspection: Shiny Hair Page | 5 With evenly distributed hair along the scalp Good hair distribution Palpation: Smooth and silky to touch NAILS Inspection: Fingernails and toe nails are clean and trimmed Pinkish nails Palpation: Nails form 160° angle at base, hard, smooth and immobile (+) smooth cuticles With good capillary refill of 2 seconds c. Head “Hindi naman masakit ang ulo ko.” Inspection: Head is round and symmetrical; appropriate to the size of the body (-) lesions on the scalp Face is oval and symmetric Normocephalic Palpation: Smooth and hard skull Good ROM of TMJ (-) lumps, masses and tenderness (-) head depressions or elevations d. Eyes “Hindi naman Malabo ang mga mata ko.” Inspection: Visual fields intact Symmetrical blinking Page | 6 Conjunctiva and sclera appear moist and smooth (+) PERRLA No discharges e. Ears “Wala ako problema sa pandinig.” Palpation: No drainage noted when nasolacrimal duct is palpated Inspection: Equal in size bilaterally Auricles aligned with the corner of each eye within a 10-degree angle of vertical position No discharges Palpation: Skin smooth (+) firm cartilages Recoils easily when folded No tophi ‘No tenderness upon palpation f. Nose and Sinuses “Wala naman akong sipon.” Inspection: Nose is smooth and symmetric Nose has same color as the face Client was able to identify odors presented (orange and perfume) (+) red glow; frontal and maxillary sinuses transilluminate (-) lesions (-) epistaxis (-) nasal flaring (-) nasal discharge Page | 7 Palpation: (-) nasal tenderness Percussion: (+) hollow tone on sinuses g. Mouth and Throat “Wala akong ubo.” Inspection: Lips are pink, smooth and moist without lesion or swelling Buccal mucosa appears pink, and moist without exudates Complete teeth Gums are pinkish without redness or swelling Tongue is pink with and moist Tongue hasno swelling and lesions Frenulum in the midline with visible veins Midline and symmetric elevation of the uvula and soft palate with phonation (-) tonsillitis h. Neck “Hindi naman masakit kapag ginagalaw ko.” Inspection: No lesions No enlargement of lymph nodes. Full ROM Palpation: Palpable thyroid gland, goes up when swallowing No swelling and tenderness. Page | 8 i. Breast and Axillary “Okay lang naman.” Inspection: Breast skin pale pink with pink areola Prominent Montgomery tubercles Nipples everted bilaterally Hyperpigmented nipples and areola (+)Excretion of colostrum j. Respiratory ”Hindi naman ako kinakapos sa hininga.” Palpation: No masses or tenderness palpated Inspection: Chest expansion symmetric Scapula are symmetric and prominent Sternum in midline and level with ribs Palpation: (-) tenderness (-) masses Percussion: Resonant k. Cardiovascular “okay naman.” Auscultation: No adventitious sounds present Lung sounds are clear on both lung fields. Inspection: (-) jugular vein distention and nonvisible (-) varicose veins on both legs near popliteal area (-) abnormal discoloration of the palms and soles of the Page | 9 feet Palpation: Carotid pulse equal bilaterally, 3+ PR = 88 bpm, 3+ BP = 130/80 mm Hg (+) apical pulse felt at 5th ICS LMCL With good capillary bed refill of 2 seconds 3+ radial pulses and in other sites are easy to palpate l. Gastrointestinal “medyo masakit ung tyan ko. Pero kaya ko pa.” Auscultation: Heart sound are rhythmic, regular beating Apical heart rate = 85 beats/min, regular rate and rhythm (-) extra heart sounds No splitting of heart sound, snaps, clicks or murmurs noted Inspection: (-) lesions on the abdominal area (-) rashes (-) abdominal discoloration Abdomen is globular, smooth, no lesion and no scar noted Umbilicus in midline (+) Striae (+) Linea nigra Palpation: No tenderness in any quadrant Engaged fetal position Page | 10 m. Urinary “Wala namang nasakit pag naihi.” n. Genitalia “Wala namang akong problema.” o. Musculoskeletal “wala naman akong problema sa pag galaw ko.” p. Neurologic “Kung minsan nakakalimot pero naalala ko rin” Inspection: Amber colored urine, clear (-) hematuria (-) dysuria Patient refused Inspection: Full ROM of TMJ with no pain, tenderness, clicking or crepitus Patient is ambulatory Full ROM on extremities Inspection: Patient is alert and awake throughout the course of interview; relaxed, cooperative and purposeful; oriented to time, place and person (+) good eye contact Cranial nerves: CN I – identifies correct scents CN II – Clear vision CN III – Pupils constrict to light CN IV – Eyes can move freely and coordinately CN V – full TMJ ROM CN VI – Good bilateral eye movement CN VII – able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows and close eyes against resistance Page | 11 CN VIII – able to hear whispers CN IX – no difficulty in swallowing CN X – (+) Gag reflex CN XI – can shrug his shoulders against resistance CN XII – Tongue moves easily Performs repetitive alternating movements of finger-to-nose at smooth, good pace Sensory system: identifies light touch, dull and sharp sensations to forearm Stereognosis and graphestesia intact Inspection: Nopresence of hematomas “Di naman ako pasain” q. Hematologic “Di naman ako pawisin” Inspection: (-) tremors (-) ABN hair distribution (-) diaphoresis r. Endocrine 2. LABORATORY STUDIES/DIAGNOSTICS Procedure / Date Indication Normal Values/ Findings Actual Findings Nursing Responsibilities/ Implications (Pre, Intra, Post) Page | 12 3. OTHER ASSESSMENT TOOLS (Scale, Sheet, Grade, Level, etc.) Date (s) taken Comprehensive Actual Content/Legend Actual Result August 13, 2013 Level 0 – Full Self Care Feeding – Level 0 Functional Level Code Level 1 – requires use of requirements or device Bathing – Level 0 Level 2 – requires assistance or supervision from another person Level 3- requires assistance or supervision from another person or device Level 4 – Is dependent and does not participate Toileting – Level 0 Bed Mobility – Level 0 Dressing – Level 0 Grooming – Level 0 General Mobility – Level 0 Cooking – Level 0 Home Maintenance – Level 0 Shopping – Level 0 The patient was graded as Level 0 in Functional Level Code since she can take care of herself fully prior to hospitalization. J. FUNCTIONAL ASSESMENT (including ADL) 1. Health-Perception-Health Management Pattern The patient has a good image of her health. She says that she takes care of her body to be able to work efficiently, and to be able to take care of her son and her future baby. She makes sure that she eats good food and does every measures needed to gain a healthy body. 2. Self-esteem, Self concept/Self-perception Pattern Page | 13 The patient said that she is contented with who she is. She doesn’t want to change anything about herself because she is okay with how she looks like. Though she said she feels uneasy because she has gained weight in the course of her pregnancy, she said that she could just burn the excess fats off, and has full confidence on herself. 3. Activity – Rest Pattern The said that most of her usual activities for the last 9 months are walking around her village early in the morning she said that it helps her prepare herself for her labor. During her free time, she reads books about pregnancy and home and living magazines. She alkso likes watching television shows like America’s Next Top Model and Arrow. 4. Sleep/Rest Pattern patient said that she sleeps around 9 pm wakes up around 4:30 pm because she works in Carmona. She said that even though sometimes she couldnot get an 8 hour sleep, she said that she feels relaxed and refreshed upon waking up. 5. Nutritional/Elimination The patient said that she loves vegetables more than meat. She hates fatty meat and like to buy lean meat from the market. She said that she eats various food during the course of her pregnancy and has a liking in eating fresh oranges. The patient has no bowel problems. She says that she is not constipated and she said that she makes sure that she eats foods high in fiber to keep her colons clean. Also, there is no problem in the patent’s urination. She said that her urine is mostly yellow and clear and no pain is present during urination. She says that she always drinklots of water because she learned her lesson when she got UTI last 2009. 6. Sexuality and Reproductive Pattern According to the patient, she is not using any family planning method that’s why she got pregnant. Her menstruation started when she was 12 years old and she said that she often gets dysmenorrhea. Her LMP was last January 23, 2013. She said that after her delivery, she would then go to her doctor and ask which birth control method suits her best, but she said that she prefers oral contraceptives. 7. Interpersonal Relationship Page | 14 The patient verbalized that she was happy with the relationships she has made. May it be with her friends or with her close family. She said that she is mostly a happy person and likes a good laugh. She said that she likes hanging out with her friends, eating out with her family and likes bonding moments. She also has no problems with her neighbors and she feels relieved that her neighbors and her are all friends so there is no conflict. 8. Personal Habits The client said that she has never smoked but drinks alcohol at parties, when she is not pregnant. She said that she never even have thought of using illegal drugs and she said that she values her health too much to engage in those kind of vices. 9. Coping and Stress Management The patient said that she is the type of person who likes to express her feelings and vent things out when she is in trouble or sad. Although she also said that it all depends on the situation. She said that if other people could not help her even if they listen to her problems, she would then keep the problem to herself; and if the problem is needed to be said, then she will. 7. Environmental Hazards The patient said that the place she lives in is safe, has a low crime rate, and are very much accessible. She resides in a subdivision so there are very few cars passing the streets. Her only problem was the noise from her neighbors when they use the karaoke. II. PROBLEM LIST A. ACTUAL or ACTIVE Problem No. 1 Problem Impaired Comfort Date Identified Oct 2, 2013 Date Resolved/Remarks Oct 2, 2013 Patient’s pain was addressed. But the pain was only Page | 15 natural because the patient is in labor. 2 Anxiety related to stress of labor Oct 2, 2013 Oct 2, 2013 -The patient said that she somehow feels scared of what may happen but she said that she has full trust with the hospital staff. B. HIGH RISK or POTENTIAL Problem No. Problem 1 Risk for Ineffective breathing pattern related to breathing exercises 2 Risk for fluid volume deficit related to decrease in oral fluid intake and increase in diaphoresis during labor. Date Identified Oct 2, 2013 Oct 2, 2013 Page | 16 IV. ANATOMY AND PHYSIOLOGY REPRODUCTIVE SYSTEM The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization.Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next step for the fertilized egg is to implant into the walls of the uterus, beginning the initial stages of pregnancy. If fertilization and/or implantation does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. The female reproductive anatomy includes parts inside and outside the body. EXTERNAL The function of the external female reproductive structures (the genitals) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include: Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholin's glands: These glands are located beside the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called Page | 20 the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect. INTERNAL Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to adeveloping fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall. THE MENSTRUAL CYCLE Females of reproductive age experience cycles of hormonal activity that repeat at about onemonth intervals. With every cycle, a woman's body prepares for a potential pregnancy, whether or not that is the woman's intention. The term menstruation refers to the periodic shedding of the uterine lining. (Menstru means "monthly.'') Page | 21 The average menstrual cycle takes about 28 days and occurs in pha ses: the follicular phase, the ovulatory phase (ovulation), and the luteal phase. There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing hormone, estrogen, and progesterone. Follicular Phase of the Menstrual Cycle This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the following events occur: Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH), are released from the brain and travel in the blood to the ovaries. The hormones stimulate the growth of about 15 to 20 eggs in the ovaries, each in its own "shell," called a follicle. These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogen. As estrogen levels rise, like a switch, it turns off the production of folliclestimulating hormone. This careful balance of hormones allows the body to limit the number of follicles that mature. As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This dominant follicle suppresses all of the other follicles in the group. As a result, they stop growing and die. The dominant follicle continues to produce estrogen. Ovulatory Phase of the Menstrual Cycle The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory phase is the midpoint of the menstrual cycle, with the next menstrual period starting about two weeks later. During this phase, the following events occur: The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain. This causes the dominant follicle to release its egg from the ovary. As the egg is released (a process called ovulation), it is captured by finger-like projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube. Also during this phase, there is an increase in the amount and thickness of mucus produced by the cervix (lower part of the uterus). If a woman were to have intercourse during this time, the thick mucus captures the man's sperm, nourishes it, and helps it to move towards the egg for fertilization. Page | 22 Luteal Phase of the Menstrual Cycle The luteal phase of the menstrual cycle begins right after ovulation and involves the following processes: Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum. The corpus luteum secretes the hormone progesterone. Progesterone prepares the uterus for a fertilized egg to implant. If intercourse has taken place and a man's sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now considered pregnant. If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual period begins. How Many Eggs Does a Woman Have? The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of birth control pills, and in the presence or absence of regular menstrual cycles. THE FETAL DEVELOPMENT First trimester (week 1-week 12) At four weeks: baby's brain and spinal cord have begun to form. The heart begins to form. Arm and leg buds appear. baby is now an embryo and one-twenty-fifth inch long. Page | 23 At eight weeks: All major organs and external body structures have begun to form. Baby's heart beats with a regular rhythm. The arms and legs grow longer, and fingers and toes have begun to form. The sex organs begin to form. The eyes have moved forward on the face and eyelids have formed. The umbilical cord is clearly visible. At the end of eight weeks, the baby is a fetus and looks more like a human. It is nearly 1 inch long and weighs less than one-eighth ounce. At 12 weeks: The nerves and muscles begin to work together. The baby can make a fist. The external sex organs show if the baby is a boy or girl. A woman who has an ultrasound in the second trimester or later might be able to find out the baby's sex. Eyelids close to protect the developing eyes. They will not open again until the 28th week. Head growth has slowed, and the baby is much longer. Now, at about 3 inches long, the baby weighs almost an ounce. Second trimester (week 13-week 28) Page | 24 At 16 weeks: Muscle tissue and bone continue to form, creating a more complete skeleton. Skin begins to form. You can nearly see through it. Meconium (mih-KOH-nee-uhm) develops in the baby's intestinal tract. This will be the baby's first bowel movement. The baby makes sucking motions with the mouth (sucking reflex). The baby reaches a length of about 4 to 5 inches and weighs almost 3 ounces. At 20 weeks: The baby is more active. The mother might feel slight fluttering. The baby is covered by fine, downy hair called lanugo (luh-NOO-goh) and a waxy coating called vernix. This protects the forming skin underneath. Eyebrows, eyelashes, fingernails, and toenails have formed. The baby can even scratch itself. Your baby can hear and swallow. Now halfway through the mother’s pregnancy, the baby is about 6 inches long and weighs about 9 ounces. At 24 weeks: Bone marrow begins to make blood cells. Taste buds form on the baby's tongue. Footprints and fingerprints have formed. Real hair begins to grow on the baby's head. The lungs are formed, but do not work. Page | 25 The hand and startle reflex develop. The baby sleeps and wakes regularly. If the baby is a boy, his testicles begin to move from the abdomen into the scrotum. If the baby is a girl, her uterus and ovaries are in place, and a lifetime supply of eggs have formed in the ovaries. The baby stores fat and has gained quite a bit of weight. Now at about 12 inches long, the baby weighs about 1½ pounds. Third trimester (week 29-week 40) At 32 weeks: The baby's bones are fully formed, but still soft. The baby's kicks and jabs are forceful. The eyes can open and close and sense changes in light. Lungs are not fully formed, but practice "breathing" movements occur. The baby's body begins to store vital minerals, such as iron and calcium. Lanugo begins to fall off. The baby is gaining weight quickly, about one-half pound a week. Now, the baby is about 15 to 17 inches long and weighs about 4 to 4½ pounds. Page | 26 At 36 weeks: The protective waxy coating called vernix gets thicker. Body fat increases. The baby is getting bigger and bigger and has less space to move around. Movements are less forceful, but the mothar can will feel stretches and wiggles. The baby is about 16 to 19 inches long and weighs about 6 to 6½ pounds. Weeks 37-40: By the end of 37 weeks, The baby is considered full term. The baby's organs are ready to function on their own. As the mother nears due date, the baby may turn into a head-down position for birth. Most babies "present" head down; At birth, the baby may weigh somewhere between 6 pounds 2 ounces and 9 pounds 2 ounces and be 19 to 21 inches long. Most full-term babies fall within these ranges. But healthy babies come in many different sizes. CHANGES THAT OCCURS IN THE MOTHER Pregnancy is associated with normal physiological changes that assist fetal survival as well as preparation for labour. It is important to know what 'normal' parameters of change are in order to diagnose and manage common medical problems of pregnancy, such as hypertension, gestational diabetes, anaemia and hyperthyroidism. Pituitary FSH/LH fall to low levels. ACTH and melanocyte-stimulating hormone increase. Prolactin increases. Thyroid and parathyroid Thyroxine-binding globulin (TBG) concentrations rise due to increased oestrogen levels. T4 and T3 increase over the first half of pregnancy but there is a normal to slightly decreased amount of free hormone due to increased TBG-binding. Page | 27 TSH production is stimulated, although in healthy individuals this is not usually significant. A large rise in TSH is likely to indicate iodine deficiency or subclinical hypothyroidism. Serum calcium levels decrease in pregnancy, which stimulates an increase in parathyroid hormone (PTH). Colecalciferol (vitamin D3) is converted to its active metabolite, 1,25dihydroxycolecalciferol, by placental 1α-hydroxylase. Adrenal and pancreas Cortisol levels increase in pregnancy, which favours lipogenesis and fat storage. Insulin response also increases so blood sugar should remain normal or low. Peripheral insulin resistance may also develop over the course of pregnancy and gestational diabetes is thought to reflect a pronounced insulin resistance of this sort. Cardiovascular system Progesterone reduces systemic vascular resistance by about 20% early in pregnancy. Postural hypotension may result. Diastolic and systolic blood pressure tend to fall during mid pregnancy and then return to normal by week 36. Venous return in the inferior vena cava can be compromised in late pregnancy if a woman lies flat on her back. This is relieved by lying in the left lateral position. Increased circulating angiotensin II encourages water and sodium retention, leading to an increased plasma volume (to 50% by 30 weeks) and predisposing to oedema. This enables increased uterine blood flow to meet growing nutritional and oxygenation needs of the fetus. It also enables blood loss (average 500 ml) at delivery to be met without physiological decompensation. Advise women not to take up unaccustomed, vigorous exercise in pregnancy as there is a risk of diversion of uterine blood flow to the skeletal muscles. Blood flow to kidneys, skin and mucosa increases. Cardiac output increases by 30-50% with 15% increase in heart rate and 25-30% increased stroke volume. Much of this adjustment occurs prior to 12 weeks of gestation and so impaired cardiac function is likely to present problematically in early pregnancy or with the sudden increase in pre-load in the third stage of labour. Cardiac examination in pregnancy: Many women have a third heart sound after mid-pregnancy. Diastolic murmurs should be considered potentially pathological. Systolic flow murmurs are common. Page | 28 ECG - left axis deviation is common, sagging ST segments and inversion or flattening of the T wave in lead III may also occur. Respiratory system Tidal volume increases by about 200 ml, increasing vital capacity and decreasing residual volume. In later stages of pregnancy, splinting of the diaphragm may occur with some decrease in tidal volume. Respiratory rate does not alter significantly. Increased oxygen consumption by approximately 20%. State of compensated respiratory alkalosis - arterial pCO 2 drops, arterial pO2 remains unchanged and decrease in bicarbonate prevents pH change. Lower maternal pCO2facilitates oxygen/carbon-dioxide transfer to/from the fetus. Many women complain of feeling short of breath in pregnancy without explanatory pathology. The mechanism of this is not fully understood Alimentary system Appetite is usually increased, sometimes with specific cravings. Progesterone causes relaxation of the lower oesophageal sphincter and increased reflux, making many women prone to heartburn. Gastrointestinal motility is reduced and transit time is consequently longer. This allows increased nutrient absorption. Constipation is common. The gallbladder may dilate and empty less completely. Pregnancy also predisposes to the precipitation of cholesterol gallstones. Gums become spongy, friable and prone to bleeding. Good dental care is important. Urinary tract The increased blood volume and cardiac output during pregnancy cause a 5060% increase in renal blood flow and glomerular filtration rate (GFR). This causes an increased excretion and reduced blood levels of urea, creatinine, urate and bicarbonate. Mild glycosuria and/or proteinuria may occur because the increase in GFR may exceed the ability of the renal tubules to reabsorb glucose and protein. Increased water retention causes a reduction of plasma osmolality. The smooth muscle of the renal pelvis and ureter become relaxed and dilated, kidneys increase in length and ureters become longer, more curved and with an increase in residual urine volume. Bladder smooth muscle also relaxes, increasing capacity and risk of UTI. Page | 29 Approximately 5% of pregnant women have bacteriuria, often asymptomatic, and there is a greater risk of developing pyelonephritis in pregnancy. Haematological Dilutional anaemia is caused by the rise in plasma volume. Elevated erythropoietin levels increase the total red cell mass by the end of the second trimester but haemoglobin concentrations never reach pre-pregnancy levels. A modest leukocytosis is observed. A normal pregnancy creates a demand for about 1000 mg of additional iron. This equates to 60 mg elemental iron or 300 mg ferrous sulfate per day. Serum iron falls during pregnancy whilst transferrin and total iron binding capacity rise. Levels of some clotting factors (VII, VIII, IX and X) and fibrinogen increase whilst fibrinolytic activity decreases. These changes protect from haemorrhage at delivery but also make pregnancy a hypercoagulable state with increased risk of thromboembolism. See also the separate article on Venous Thromboembolism in Pregnancy. One study found that during early pregnancy: antithrombin activity remained unchanged, protein S activity decreased significantly and there was a potentially biologically significant increase in protein C activity (see the separate article onThrombophilia).[6] Serum alkaline phosphatase increases during pregnancy - due to placental production. Serum albumin decreases. Metabolic Changes in energy requirements in pregnancy remain controversial - healthy levels of fat deposition and variation in women's physical activity levels cause uncertainty as to the recommendations that should be made for this time. The basal metabolic rate increases slowly over the course of pregnancy, by 1520%. In women with normal BMIs, energy requirement does not increase significantly during the first trimester, increases by about 350 kcal/day in the second trimester and 500 kcal/day in the third. Active energy expenditure tends to fall over pregnancy. Normal weight gain is approximately 12.5 kg (usually at a rate of 0.5 kg per week for the final 20 weeks). 5 kg is the fetus, placenta, membranes and amniotic fluid and the rest is maternal stores of fat and protein and increased intra- and extravascular volume. Page | 30 Skin Hyperpigmentation of the umbilicus, nipples, abdominal midline (linea nigra) and face (chloasma) are common due to the hormonal changes of pregnancy. Hyperdynamic circulation and high levels of oestrogen may cause spider naevi andpalmar erythema. Striae gravidarum ('stretch marks') are common. Musculoskeletal Increased ligamental laxity caused by increased levels of relaxin contribute to back pain and pubic symphysis dysfunction. Shift in posture with exaggerated lumbar lordosis leading to the typical gait of late pregnancy. VI. MEDICAL – SURGICAL MANAGEMENT 1. Procedure Procedure/Date Indications/Analysis Nursing Rsesponsibilities (PRE, INTRA, POST) 2. Pharmacotherapeutics / Medicine (IV Fluids, Drugs) Generic name, brand name, classification, stock D5LR 1 L 5% Dextrose in Lactated Ringer's Classification: Hypertonic Nonpyrogenic Parenteral fluid Electrolyte Nutrient replenisher Indication,Dosage, frequency Indication: is useful for daily maintenance of body fluids and nutrition, and for rehydration Dosage: 31 gtts/min, to run for 8 hours Nursing Responsibilities PRE:  Check Doctor’sorder  Verify patient  Assess fluid intake and output  Check for the consistency of the IV fluid, do not administer unless solution is clear and container is undamaged.  Caution must be exercised in the administration of parenteral fluids, especially those Page | 31 containing sodium ions to patients receiving corticosteroids or corticotrophin.  Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis.  Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. INTRA:  Practice 10 rights in medication  Observe asepsis  Properly label IV fluid POST  Discard unused portion Generic Name: Cephalexin Brand Name: Keflex Classification: firstgeneration cephalosporin Stock: 500 mg (given postpartum) Indications: To fight infection Dosage: 500 mg Frequency: q6 PRE:  Check Doctor’sorder  Verify patient  Explain effects/indication of medications  Determine history of hypersensitivity reactions to cephalosporins and penicillin and history of other Page | 32 drug allergies befor e therapy is initiated.  Lab tests: Evaluate renal and hepatic function periodically in patients receiving prolonged therapy.  Monitor for manifestations of hypersensitivity (see Signs & Symptoms, Appendix F). Discontinue drug and report their appearance promptly. INTRA:  Practice 10 rights in medication  Take with meals POST:  Take medication for the full course of therapy as directed by physician.  Keep physician informed if adverse reactions appear.  Be alert to S&S of superinfections.The se symptoms should be reported promptly and appropriate therapy instituted.  Do not breast feed while taking this Page | 33 drug. Generic Name: Mefenamic Acid Brand Name: Ponstan Classification: NSAIDS Stock: 500 mg (given postpartum) Indications: To relieve pain Dosage: 500 mg Frequency: q6 PRE:  Check Doctor’sorder  Verify patient  Explain effects/indication of medications  Assess patients who develop severe diarrhea and vomiting for dehydration and electrolyte imbalance.  Lab tests: With longterm therapy (not recommended) obtain periodic complete blood counts, Hct and Hgb, and kidney function tests.  INTRA:  Observe 10 rights in giving medication  Take with meals to avoid GI upset POST:  Discontinue drug promptly if diarrhea, dark stools, hematemesis, ecchymoses, epistaxis, or rash occur and do not use again. Contact physician.  Notify physician if Page | 34 persistent GI discomfort, sore throat, fever, or malaise occur.  Do not drive or engage in potentially hazardous activities until response to drug is known. It may cause dizziness and drowsiness.  Monitor blood glucose for loss of glycemic control if diabetic.  Do not breast feed while taking this drug without consulting physician. VII. PROGRESS NOTES Day No. October 2, 2013 Existing cues/problems Interventions Actually Done (Nursing and Collabaration) Clients Response The patient was in experiencing the active stage of labor and has a cervical dilatgation of 4 cm according to the physician. The patient feels a bit anxious about her delivery and verbalized that she hopes that her delivery will be happen smoothly. Sheis also anxious about the baby’s health and about what could happen once she’s on the delivery room. Support and encouragements were given to boost the patients outlook and make Page | 35 her feel comfortable VIII. Discharge Plans Compliance -Medications -Diet -Exercise Follow up checkup Content The patient will be instructed regarding her home medications and teaching her the proper nutritional diet of a lactating mother, some helpful teachings on alleviating breast pain. Also an increase in oral fluid intakewouldbe part of the teaching instructions to help her lactation be good. The patient will be having a follow up checkup regarding the next step which is to choose the proper birth control method the patient will use. Strategy One-on-one discussion with patient and relatives about health teaching plans One-on-one discussion of the schedule. Page | 36 IX. SUMMARY OF CLIENT’S STATUS OR CONDITION AS OF LAST DAY OF CONTACT Problems encountered(actualand resolved) This is the last interaction with the patient. Before the transfer to the delivery room, the patient looks relaxed and confident. The patient verbalized that she was a bit axious in the outcome. But then before the transfer to the DR the patient was relaxed because of the support of the people around her. ____________________________ Page | 37