Initial Database for a Pregnant Woman
Content
Far Eastern University Institute of Nursing INITIAL DATABASE I. General Data Name: Hinkle, Jennette Florentino Name of Husband: Romulo Santelices Age: 32 years old Civil Status: Live in Nationality: Filipino Religion: Roman Catholic Occupation: Housewife Residence: Rivera compound, Judea St., Multinational, Paranaque City Birth date: September 28, 1977 The client¶s husband is working as a construction worker. He works 6 days in a week and earns 380Php per day or about 9120Php per month. II. G-P (FPAL) G5 P4 (4-0-1-4) AOG during delivery: 40 3/7 weeks Presentation: Cephalic FHR: 125 bpm Length: 47 cm Weight: 3.5 kg
III. Personal and Social History 1. PATTERNS OF FUNCTIONING A. Respiration The client stated that she never felt out of breath or experienced dyspnea. Analysis: A local change that often occurs in the respiratory system is marked congestion or stuffiness of the nasopharynx, a response to increased estrogen levels. As the uterus enlarges during pregnancy, a great deal of pressure is put on the diaphragm and, ultimately, on the lungs. This crowding of the chest cavity causes an acute sensation of shortness of breast late in pregnancy until lightening relieves the pressure. Respiration rate increases by 1-2 cycles per minute. Reference: Pillitteri pg. 234
B. Circulation The client stated that she did not feel any heart pound. She also added that there are no skip beats and palpitations. She doesn¶t also have any edematous part. Analysis: Changes in the circulatory system are extremely significant to the health of the fetus because they are necessary for adequate placental and fetal circulation. During pregnancy, cardiac output increases to about 25-50% and heart rate is 80-90bpm. On sudden movement, a pregnant woman may experience a bounding palpitation of the heart. This is probably because of circulatory adjustments necessary to accommodate increased blood supply during pregnancy. Reference: Pillitteri pg. 235 & 285
C. Elimination The client stated that she voids for about 10 times during daytime and 10 times at night. She also stated that there is no pain when she is urinating. She stated that he defecates once a day without specific time of the day. She also stated that she does not use enemas, laxatives, or suppositories.
Analysis: The urinary system undergoes many physiologic changes during pregnancy. This include alterations in fluid retention, and renal, ureter, and bladder function. Bladder capacity increases by 1000ml, diameter of the uterus increases by 25%, and frequency of urination increases in the first trimester and last 2 weeks of pregnancy to 10-12 times a day. As the uterus increase in size, it pushes the stomach and intestines towards the back and sides of the abdomen. At about midpoint of pregnancy, this pressure may be sufficient to slow intestinal peristalsis and the emptying time of the stomach, leading to increased heartburn, constipation and flatulence. Progesterone also has an effect on smooth muscle, making the gastrointestinal tract less active. Reference: Pillitteri pg. 237-239
D. Rest and Sleep The client stated that her average number of sleeps is only for about how many minutes. She also stated that she sleeps at about 8 pm and rise at about 5:30 am. She stated that she feels alright when she arises. She stated that she has difficulty in sleeping because she urinates a lot of times in the evening and this interferes with her sleep. She also stated that during the daytime, she take naps which last for about 3 hours. Analysis: Pregnant women rarely have difficulty falling asleep at night because of this increased physiologic need for sleep. Late in pregnancy, a woman often finds herself awakened from sleep at short, frequent intervals by the activity of the fetus To obtain enough sleep and rest during pregnancy, most pregnant women need a rest period during the afternoon as well as a full night of sleep. Reference: Pillitteri pg. 279
H. Personal Hygiene According to the client, she takes a bath once a day. For her breast preparation bfore breastfeeding she washes it with soap. For her mouth care, she is brushing her teeth twice a day as stated. While for her skin care, she applies lotion after taking a bath.
Analysis: Maintaing a proper hygiene can contribute a lot in preventing diseases to occur and promote the social well being of an individual. Hygiene practices are employed as preventative measures to reduce the incidence and spreading of disease
I.
Recreation
The client stated that she is watching shows from televisions and sometimes just the radio and this is what she do for fun. It was also verbalize by the client that she drinks alcoholic beverages and stops at the 7th month of her pregnancy. Analysis: Drinking alcoholic beverages during pregnancy can greatly affect the development of the fetus. pregnant women and women who may become pregnant are warned to abstain from alcohol consumption in order to eliminate the chance of giving birth to a baby with any of the harmful effects. Studies indicate that a baby could be affected by alcohol consumption within the earliest weeks after conception, even before a woman knows that she is pregnant. For that reason, doctor is recommending that women who may become pregnant also abstain from alcohol.
J. Religion The client said that they are a Roman Catholic. She also stated that they do not attend to church regularly. Analysis: Religion at the first place can affect the beliefs and practices of the family concerning about pregnancy, perceptions of the couple towards pregnancy and child bearing is affected.
IV. Medical History A. Past Diseases of the client The client stated that she had chicken pox when she was in grade five. She doesn¶t remember the interventions they have done to cure/treat her pox. She also had measles when she was 25 years old. She stated that she didn¶t do anything to cure it, she just let it heal by itself.
V. Menstrual History Menarche and Succeeding menses The client stated that she had her first menstruation when she was 13 years old. This lasted for about one week. The stated associated sign and symptom of menstruation is breast pains. She stated that the amount of flow is moderate and that she consumes 2 pads per day. She stated that the succeeding menses are the same with her menarche when it comes to the duration, signs and symptoms and the amount of flow. LMP: December 10, 2009 VI. Obstetrical History OB Score: G F (P F A L): G5 P4 (4-0-1-4) VII. History of present pregnancy. Signs and symptoms manifested The client stated that she did not manifest any of the signs and symptoms of pregnancy throughout the first, second and third trimester. She stated that she found out that she was pregnant with the use of a pregnancy test at the seventh month of her pregnancy. Analysis: The most obvious alteration in a woman¶s body during pregnancy is the size of the uterus to accommodate the growing fetus. Striae gravidarum also appear on the sides of the abdominal wall and sometimes on the thighs. Linea Nigra may form, running from the umbilicus to the symphysis pubis. Amenorrhea (absence of pregnancy) also occurs. The resulting increase in the circulation changes the color of the vaginal wall from normal light pink to deep violet (Chadwick¶s Sign). Subtle changes in the breast may also be one of the first physiologic changes of pregnancy a woman notices at about six weeks. Reference: Pillitteri pg. 230-235 Laboratory Exams done to confirm pregnancy The client stated that she used Pregnancy test to confirm her pregnancy. Analysis: The commonly used laboratory tests for pregnancy are based on detecting the presence of human chorionic gonadotropin, a hormone created by the chorionic villi of the placenta, in the urine blood serum of the pregnant woman.
Urine, formerly used extensively for pregnancy testing is now used only rarely in Health Care settings, because blood serum tests give earlier results. Urine tests still form the basis of home pregnancy tests. Reference: Pillitteri pg. 227
Minor Discomforts experienced The client stated that she experienced constipation, backache, cramps, and hemorrhoids during her pregnancy. She stated that she is constipated every time she defecates and she doesn¶t do anything about it. She also stated that during the times she experiences cramps, she dorsiflexes her legs and then ambulates in a short distance. Analysis: The minor discomforts which may be experienced during pregnancy are: Breast tenderness, nausea, vomiting, pyrosis (heartburn), fatigue, varicosities, muscle cramps, hemorrhoids, backache, dyspnea, ankle edema, and Braxton Hicks contractions. These may be relieve using different measures. Reference: Pillitteri pg. 283-288
Prenatal care The client stated that she had prenatal check ±ups in private clinic and in the Moonwalk clinic as well. She had only three prenatal check-ups. Her first prenatal visit was on May 18, 2010. The AOG was 22weeks 5/7, the fundic height is 18cm, fetal heart tone is 156bpm, her BP is 90/60, and her weight is 49 kg. The following visit was on June 18, 2010. The AOG was 27weeks 1/7, the fundic height is 26cm, fetal heart tone is 152bpm, her BP is 100/60, and her weight is 51 kg. Tetanus Toxoid 1 was administered and Folamen capsule was prescribed to be taken once a day. The last visit was on July 18, 2010. The AOG was 31weeks 3/7, the fundic height is 28cm, fetal heart tone is 150bpm, her BP is 100/70, and her weight is 53 kg. Complete Blood count was done and Tetanus Toxoid 2 was administered. Analysis: The purpose of prenatal care is to estimate a baseline of present health, determine the gestational age of the fetus, monitor fetal development, identify women at risk for complications
by anticipating and preventing problems before they occur, and provide time for education about pregnancy and possible dangers. Prenatal visits should be every month until the seventh month, twice a month during the eighth month, and once a week during the ninth month. Reference: Pillitteri pg. 272
EMOTIONAL/ SOCIAL/ SEXUAL HISTORY The client verbalizes that pregnancy is not that easy for her especially during the times she felt the fetal movements. But she doesn¶t have any perception and feelings concerning about pregnancy. While talking about the changes in her appearance and emotions it was just fine with her as stated. The client said that during pregnancy, there was no any sort of change that had happened in their life and even in their sexual relationship with her husband compared when she was not pregnant yet , although about their feelings about sex that they are said to be hard up at some time brought about by the fetus in the mother¶s womb. There was no concerns or worries about their sexual relationship during pregnancy. As stated by the client he depends and turn to his husband for emotional/material support during those times. She considers that their finances are enough for the family, and able to support the newborn of their family. Pregnancy at the first place, did not affect the interpersonal relationship with their family. The client said that this pregnancy was planned between her and her husband. The couple planned for a better future for their baby, for him to finish his studies in the future. And for them to assume the role of a responsible parents on their baby, enabling them to provide the basic needs of the family especially their baby. The couple has decided that this will be their last baby for a reason that the mother experience the thinning of her uterus as diagnosed by the doctor. And the family said that they are utilizing the family planning method specifically Pills. The 28 day pill was used by the mother.
PHYSICAL EXAMINATION (General Assessment) VARIABLE ( Newborn) Height FINDINGS NORMS ANALYSIS AND INTERPRETATION NORMAL
47 cm
Average lengths vary from 48-51 centimetres (19-20 inches) Reference:
Weight
3.5 kg
kidshealth.org ¾ Parents ¾ Growth & Development The average weight of newborn is 2.54.5kg(5lb 8oz to 9lb 12oz) Reference: kidshealth.org ¾ Parents ¾ Growth & Development The temperature of a newborn ranges from 36.5 to 37.5 Reference: Maternal and child Health Nursing pp.632 The heart rate of a a newborn stabilizes to an average of 120 to 160 bpm Reference: Maternal and child Health Nursing pp.633 The respiratory rate of a newborn averages to 30 to 60 beats per minute Reference: Maternal and child Health Nursing pp.633
NORMAL
Temperature
36.8
NORMAL
Fetal Heart beat
125 bpm
NORMAL
Respiratory Rate
47 cpm
NORMAL
(Mother) Height Weight Temperature
5¶ 50 kg 37
The temperature of adults ranges from 36.5-37.5 Reference: Kozier pp.487 (7th edition) The normal pulse rate
NORMAL NORMAL NORMAL
Pulse Rate
71 bpm
NORMAL
ranges from 60-100 bpm Reference: Kozier pp. 496 ( 7th edition) The normal pulse rate ranges from 12-20 cpm Reference: Kozier pp. 505 (7th edition) The normal blood pressure reading averages 120/80 Reference: Kozier pp. 509 (7th edition)
Respiratory Rate
18 cpm
NORMAL
Blood Pressure
120/90
NORMAL
III. Personal and Social History 1. PATTERNS OF FUNCTIONING A. Respiration The client stated that she never felt out of breath or experienced dyspnea. Analysis: A local change that often occurs in the respiratory system is marked congestion or stuffiness of the nasopharynx, a response to increased estrogen levels. As the uterus enlarges during pregnancy, a great deal of pressure is put on the diaphragm and, ultimately, on the lungs. This crowding of the chest cavity causes an acute sensation of shortness of breast late in pregnancy until lightening relieves the pressure. Respiration rate increases by 1-2 cycles per minute. Reference: Pillitteri pg. 234
B. Circulation The client stated that she did not feel any heart pound. She also added that there are no skip beats and palpitations. She doesn¶t also have any edematous part. Analysis: Changes in the circulatory system are extremely significant to the health of the fetus because they are necessary for adequate placental and fetal circulation. During pregnancy, cardiac output increases to about 25-50% and heart rate is 80-90bpm. On sudden movement, a pregnant woman may experience a bounding palpitation of the heart. This is probably because of circulatory adjustments necessary to accommodate increased blood supply during pregnancy. Reference: Pillitteri pg. 235 & 285
C. Elimination The client stated that she voids for about 10 times during daytime and 10 times at night. She also stated that there is no pain when she is urinating. She stated that he defecates once a day without specific time of the day. She also stated that she does not use enemas, laxatives, or suppositories.
Analysis: The urinary system undergoes many physiologic changes during pregnancy. This include alterations in fluid retention, and renal, ureter, and bladder function. Bladder capacity increases by 1000ml, diameter of the uterus increases by 25%, and frequency of urination increases in the first trimester and last 2 weeks of pregnancy to 10-12 times a day. As the uterus increase in size, it pushes the stomach and intestines towards the back and sides of the abdomen. At about midpoint of pregnancy, this pressure may be sufficient to slow intestinal peristalsis and the emptying time of the stomach, leading to increased heartburn, constipation and flatulence. Progesterone also has an effect on smooth muscle, making the gastrointestinal tract less active. Reference: Pillitteri pg. 237-239
D. Rest and Sleep The client stated that her average number of sleeps is only for about how many minutes. She also stated that she sleeps at about 8 pm and rise at about 5:30 am. She stated that she feels alright when she arises. She stated that she has difficulty in sleeping because she urinates a lot of times in the evening and this interferes with her sleep. She also stated that during the daytime, she take naps which last for about 3 hours. Analysis: Pregnant women rarely have difficulty falling asleep at night because of this increased physiologic need for sleep. Late in pregnancy, a woman often finds herself awakened from sleep at short, frequent intervals by the activity of the fetus To obtain enough sleep and rest during pregnancy, most pregnant women need a rest period during the afternoon as well as a full night of sleep. Reference: Pillitteri pg. 279
H. Personal Hygiene According to the client, she takes a bath once a day. For her breast preparation bfore breastfeeding she washes it with soap. For her mouth care, she is brushing her teeth twice a day as stated. While for her skin care, she applies lotion after taking a bath.
Analysis: Maintaing a proper hygiene can contribute a lot in preventing diseases to occur and promote the social well being of an individual. Hygiene practices are employed as preventative measures to reduce the incidence and spreading of disease
I.
Recreation
The client stated that she is watching shows from televisions and sometimes just the radio and this is what she do for fun. It was also verbalize by the client that she drinks alcoholic beverages and stops at the 7th month of her pregnancy. Analysis: Drinking alcoholic beverages during pregnancy can greatly affect the development of the fetus. pregnant women and women who may become pregnant are warned to abstain from alcohol consumption in order to eliminate the chance of giving birth to a baby with any of the harmful effects. Studies indicate that a baby could be affected by alcohol consumption within the earliest weeks after conception, even before a woman knows that she is pregnant. For that reason, doctor is recommending that women who may become pregnant also abstain from alcohol.
J. Religion The client said that they are a Roman Catholic. She also stated that they do not attend to church regularly. Analysis: Religion at the first place can affect the beliefs and practices of the family concerning about pregnancy, perceptions of the couple towards pregnancy and child bearing is affected.
IV. Medical History A. Past Diseases of the client The client stated that she had chicken pox when she was in grade five. She doesn¶t remember the interventions they have done to cure/treat her pox. She also had measles when she was 25 years old. She stated that she didn¶t do anything to cure it, she just let it heal by itself.
V. Menstrual History Menarche and Succeeding menses The client stated that she had her first menstruation when she was 13 years old. This lasted for about one week. The stated associated sign and symptom of menstruation is breast pains. She stated that the amount of flow is moderate and that she consumes 2 pads per day. She stated that the succeeding menses are the same with her menarche when it comes to the duration, signs and symptoms and the amount of flow. LMP: December 10, 2009 VI. Obstetrical History OB Score: G F (P F A L): G5 P4 (4-0-1-4) VII. History of present pregnancy. Signs and symptoms manifested The client stated that she did not manifest any of the signs and symptoms of pregnancy throughout the first, second and third trimester. She stated that she found out that she was pregnant with the use of a pregnancy test at the seventh month of her pregnancy. Analysis: The most obvious alteration in a woman¶s body during pregnancy is the size of the uterus to accommodate the growing fetus. Striae gravidarum also appear on the sides of the abdominal wall and sometimes on the thighs. Linea Nigra may form, running from the umbilicus to the symphysis pubis. Amenorrhea (absence of pregnancy) also occurs. The resulting increase in the circulation changes the color of the vaginal wall from normal light pink to deep violet (Chadwick¶s Sign). Subtle changes in the breast may also be one of the first physiologic changes of pregnancy a woman notices at about six weeks. Reference: Pillitteri pg. 230-235 Laboratory Exams done to confirm pregnancy The client stated that she used Pregnancy test to confirm her pregnancy. Analysis: The commonly used laboratory tests for pregnancy are based on detecting the presence of human chorionic gonadotropin, a hormone created by the chorionic villi of the placenta, in the urine blood serum of the pregnant woman.
Urine, formerly used extensively for pregnancy testing is now used only rarely in Health Care settings, because blood serum tests give earlier results. Urine tests still form the basis of home pregnancy tests. Reference: Pillitteri pg. 227
Minor Discomforts experienced The client stated that she experienced constipation, backache, cramps, and hemorrhoids during her pregnancy. She stated that she is constipated every time she defecates and she doesn¶t do anything about it. She also stated that during the times she experiences cramps, she dorsiflexes her legs and then ambulates in a short distance. Analysis: The minor discomforts which may be experienced during pregnancy are: Breast tenderness, nausea, vomiting, pyrosis (heartburn), fatigue, varicosities, muscle cramps, hemorrhoids, backache, dyspnea, ankle edema, and Braxton Hicks contractions. These may be relieve using different measures. Reference: Pillitteri pg. 283-288
Prenatal care The client stated that she had prenatal check ±ups in private clinic and in the Moonwalk clinic as well. She had only three prenatal check-ups. Her first prenatal visit was on May 18, 2010. The AOG was 22weeks 5/7, the fundic height is 18cm, fetal heart tone is 156bpm, her BP is 90/60, and her weight is 49 kg. The following visit was on June 18, 2010. The AOG was 27weeks 1/7, the fundic height is 26cm, fetal heart tone is 152bpm, her BP is 100/60, and her weight is 51 kg. Tetanus Toxoid 1 was administered and Folamen capsule was prescribed to be taken once a day. The last visit was on July 18, 2010. The AOG was 31weeks 3/7, the fundic height is 28cm, fetal heart tone is 150bpm, her BP is 100/70, and her weight is 53 kg. Complete Blood count was done and Tetanus Toxoid 2 was administered. Analysis: The purpose of prenatal care is to estimate a baseline of present health, determine the gestational age of the fetus, monitor fetal development, identify women at risk for complications
by anticipating and preventing problems before they occur, and provide time for education about pregnancy and possible dangers. Prenatal visits should be every month until the seventh month, twice a month during the eighth month, and once a week during the ninth month. Reference: Pillitteri pg. 272
EMOTIONAL/ SOCIAL/ SEXUAL HISTORY The client verbalizes that pregnancy is not that easy for her especially during the times she felt the fetal movements. But she doesn¶t have any perception and feelings concerning about pregnancy. While talking about the changes in her appearance and emotions it was just fine with her as stated. The client said that during pregnancy, there was no any sort of change that had happened in their life and even in their sexual relationship with her husband compared when she was not pregnant yet , although about their feelings about sex that they are said to be hard up at some time brought about by the fetus in the mother¶s womb. There was no concerns or worries about their sexual relationship during pregnancy. As stated by the client he depends and turn to his husband for emotional/material support during those times. She considers that their finances are enough for the family, and able to support the newborn of their family. Pregnancy at the first place, did not affect the interpersonal relationship with their family. The client said that this pregnancy was planned between her and her husband. The couple planned for a better future for their baby, for him to finish his studies in the future. And for them to assume the role of a responsible parents on their baby, enabling them to provide the basic needs of the family especially their baby. The couple has decided that this will be their last baby for a reason that the mother experience the thinning of her uterus as diagnosed by the doctor. And the family said that they are utilizing the family planning method specifically Pills. The 28 day pill was used by the mother.
PHYSICAL EXAMINATION (General Assessment) VARIABLE ( Newborn) Height FINDINGS NORMS ANALYSIS AND INTERPRETATION NORMAL
47 cm
Average lengths vary from 48-51 centimetres (19-20 inches) Reference:
Weight
3.5 kg
kidshealth.org ¾ Parents ¾ Growth & Development The average weight of newborn is 2.54.5kg(5lb 8oz to 9lb 12oz) Reference: kidshealth.org ¾ Parents ¾ Growth & Development The temperature of a newborn ranges from 36.5 to 37.5 Reference: Maternal and child Health Nursing pp.632 The heart rate of a a newborn stabilizes to an average of 120 to 160 bpm Reference: Maternal and child Health Nursing pp.633 The respiratory rate of a newborn averages to 30 to 60 beats per minute Reference: Maternal and child Health Nursing pp.633
NORMAL
Temperature
36.8
NORMAL
Fetal Heart beat
125 bpm
NORMAL
Respiratory Rate
47 cpm
NORMAL
(Mother) Height Weight Temperature
5¶ 50 kg 37
The temperature of adults ranges from 36.5-37.5 Reference: Kozier pp.487 (7th edition) The normal pulse rate
NORMAL NORMAL NORMAL
Pulse Rate
71 bpm
NORMAL
ranges from 60-100 bpm Reference: Kozier pp. 496 ( 7th edition) The normal pulse rate ranges from 12-20 cpm Reference: Kozier pp. 505 (7th edition) The normal blood pressure reading averages 120/80 Reference: Kozier pp. 509 (7th edition)
Respiratory Rate
18 cpm
NORMAL
Blood Pressure
120/90
NORMAL
