A Case In Pregnancy

Nursing Health History A case of Ana Lee, female, 26 y/o, married, Roman Catholic, Filipino, living in San Pablo Street Ormoc City, has a chief complaint of dull pain at the lumbar area with 5/10 in intensity for 2-3 minutes intermittently and is relieved at bedrest. Pain started 3 days ago due to prolonged standing. History of Present Illness According to the patient, after the way of the cross, she sat down to rest because she felt a dull pain in the lumbar area, she did not seek any medical attention or take medicines since the pain receded when she is able to rest and since she is currently pregnant and thought that it was only due to fatigue of prolonged standing. Past Health History As a child she suffered having measles, chicken pox, fever, cough and colds. She has been hospitalized at age 14 diagnosed with Dengue Fever with mild gingival bleeding and has never been hospitalized ever since. She denies having allergies to any food or medications, denies surgery, and accidents. On March 24 she had her first shot of Tetanus vaccine and in the last 2 years she had 3 shots of Hepatitis B vaccine. Obstetrical History This is the patients first pregnancy ( Primagravida ). Last Menstrual Period (LMP) was October 29, 2008, Amenorrhea for 6months 3weeks 1 day. Prior to pregnancy, menstrual cycle is regular every 30 days with menarche at age 12. No history of fevers, rashes or communicable diseases. Experiences breast tenderness and nausea but controlled by small frequent meals. Quickening felt at 18weeks. Prenatal vitamin is folic acid with iron. Family Health History She has a father who is diagnosed with prostate cancer at age 48 and a mother who is alive and well at age 42. She has 2 sisters who is alive and well ages 32 and 28 who had daughters ages 3 and 2 respectively. She also has 2 brothers ages 22 and 19 who are alive and well. Mother and sisters denies having any complications or problems during pregnancy.

Review of Systems Integumentary System • • • • • •

Brown and uniformed in color except for palms and nail beds which is lighter in color; no pallor or cyanosis. Linea nigra or darkening of the linea alba is visible. Increased freckles or pigmentation in the face. Striae are visible in the lower abdomen. Areola is darkened. Slight edema on both lower extremities from feet to knee.

Sensory System • • •

Visual acuity is 20/20 as verbalized by patient with recent check-up. Nasal stuffiness, snoring, congestion. Ptayalism, excessive secretion of saliva.

Respiratory System • • •

Tactile Fremitus is equal in vibrations and decreasing. Increased respiration at 20/min Shortness of breath

Cardiovascular System • • •

Normal rate, rhythm and heart sounds No murmurs noted during auscultation. Heart rate at 80 beats per min.

Gastrointestinal System • • •

Decreased bowel sounds of 4-15/min. Abdomen is rotund in shape and fundus is three finger breadths above umbilicus. Increased nausea and vomiting.

Urinary System • •

Frequent urination minimum of 5 times/ day Nocturia of 2 times/ night

Musculoskeletal System

• • • •

Developing lordosis of the lumbar spine. Leg weakness Increase in weight Widening of pelvis.

Neurological System • •

Headaches. Dizziness and lightheadedness.

Reproductive organ • • • • •

Uterus is enlarged. Increase vaginal discharge. Breasts enlarged and tender; no lumps or masses. Nipples and areola darkened. Veins in the breast are more apparent and blue.

Physical Assessment Body Parts Vital signs: BP: 110/80 mmHg PR: 80 bpm RR: 20/ min Temp: 37.1 ۫C Weight: 104 lbs. Head & Face

Hair

Scalp Skin

Eyes

Inspection

-normocephalic and symmetrical. - Capable of facial movements like elevation of eyebrows, lowering of eyebrows, closing of eyes, able to smile grin and frown, facial movements symmetrical. -black in color -evenly distributed and thick -no signs of alopecia -no lice -lighter in color than skin tone. -no lesions, no dandruff -moist & oily -Color brown is consistent; -pink nail beds -slight edema of lower extremities -freckles on the face are more pronounced. - Hair in eyebrow are thick evenly distributed; eyebrow are symmetrical and of equal movements. - Eyelashes are equally distributed and are curled outward -Eyelids closes symmetrically, -Sclera is off white in color -Iris is round, black in color -No redness noted, no edema noted, no

Palpation

-no lumps, no masses

-smooth -absence of lumps. -no rashes -no flushes

Percussion

Auscultation

Nose

Mouth

Neck

Ears

Chest and Thorax

inflammation, no lesion noted -visual acuity 20/20 as verbalized by patient from latest visit to the optometrist. -nasal stuffiness. -no swelling -no discharges -Nasal septum positioned in midline -Nose is symmetrical -Color of nose is brown -No deformity noted -Evenly distributed ciliary hairs. -Lips is dark pink in color; moist - Ability to purse lips -Mouth is symmetrical aligned to pharynx -Lips is symmetric -Tongue moves freely -Tongue in midline -Teeth color is off white -Soft and hard palate is pink -no gingival hypertrophy noted -complete set of teeth 32 -No enlargement of thyroid glands -Trachea in midline -No masses and nodules noted

-brown in color -Tenderness and masses not noted -Symmetrical -Hair follicles noted - Cerumen noted -Good hearing acuity -Hears normal voice tones -symmetric, elliptic, smaller ante posterior than transverse

-red glow on transillumination of sinuses. - No tenderness noted

-no masses or lumps noted

-small, mobile, non tender nodes -Thyroid has small, smooth, lateral lobes, palpable on either side of trachea. -Ears firm and non tender

- retraction or bulging of

- bilateral symmetry

- upper lobesbronchovesicular

diameter - ribs slope downward from nipple line -lordotic in posture

intercostals spaces during inspiration or expiration; symmetric expansion

Abdomen

Upper and Lower Extremities

Genitalia

sounds above sternum and scapulas; equal expiratory phases -normal rate, rhythm and heart sounds; no murmurs are present

Heart

Breasts

in tone

-supple; symmetric in size and contour; -darker pigmentation of nipple and areola, tone firms expelled of colustrum. -striae present in lower abdomen -umbilicus is in midline and protruding. -rotund shape -linea nigra visible -absence of scars, lesions. -symmetrical -skin appears moist -edema noted in both lower extremities -normal hair distribution -Pigmented -urinary and vaginal orifices visible and appropriately located - vagina is dark pink -vaginal discharge odorless -vaginal folds smooth and flattened

-tender -no masses or lumps.

-nontender

-no masses or lumps noted -skin warm -pulses palpable -full range of motion

-Decreased bowel sounds of 3-10/min.

Functional Health Pattern Health Perception / Health Management Pattern The client is trying to follow a healthy lifestyle now that she is pregnant by eating more nutritious food such as vegetables; she manages to stay healthy by taking vitamins such as folic acid. In compliance with the doctor’s advice she stopped smoking and drinking coffee but reports having difficulty in stopping coffee intake. Nutritional & Metabolic Pattern She is 158cm tall and weights 104 lbs. She eats more than 3 meals a day depending on her appetite but reports of having great appetite of cheese burgers after 18 weeks gestation. Doctor’s advice was to decrease fatty foods and cold drinks intake. She drinks 6-7 glasses of water a day but increased during hot days. Prior to pregnancy, she eats low nutritive value foods such as junk foods, skips meals and crash dieting. Activity & Exercise She has no musculoskeletal impairment & exercises regularly at 4:30 am through hiking everyday. Usual activities are dancing, watching movies, hanging out with friends. She is having difficulty in breathing properly when in supine position ever since there is evident fetal growth. Values & Beliefs She is a roman catholic & goes to church with family every Sunday. Respects Church practices & Obligations and sometimes believe in superstitions. She is a frequent visitor of the Blessed Sacrament in the Adoration Chapel where she prays her novenas. Self Perception / Self-Concept She expresses worry when she is alone in the house. She reports having anxiety on how labor is going to be. She is a confident woman but when she got pregnant, she expresses a little bit of insecurity because of the changes she is now experiencing. Sexuality & Reproduction This is the client’s first pregnancy. She is sexually active until 4th month of pregnancy. Prior to marriage, she was with 5 monogamous relationships with all having sexual relations. She reports not having used any contraceptives before pregnancy. Coping / Stress

Prior to pregnancy, her coping was with smoking, alcohol and coffee. Now she is fond of watching TV & sleeping because it relaxes her. She asks her mother and sister for advice and on what to expect during pregnancy, this lessens her anxiety. She prays at the Adoration Chapel everyday to reduce stress. Roles & Relationship Ana Lee lives with her husband & is supported as well. She is a first time mom. She is the 3rd child in her family & states good relationship with her family, friends & relatives. According to her, her family may sometimes give some space because of her mood swings but is always able to help and attend to her needs. She also lives with a maid who does all the chores that is why she claims she has no problem with regards to household chores. Elimination She urinates frequently and has a urine color of amber. She has no difficulty in urinating. Her bowel movement decreases during pregnancy from regular to 5 times a week. Her stools are not that hard and not soft either, type 3 on a Bristol stool Chart. Problem with fecal elimination is compensated when she eats lots of papaya. Cognitive No sensory deficit. She is oriented to time, place & person. She is responsive when asked about current status and role. Sleep & Rest The client reported an altered sleeping pattern, she sleeps 12:00 A.M. - 4:30 A.M.; hikes at the Ormoc Plaza for 45 minutes; eats breakfast at 7:00 A.M. the goes back to sleep at 7:30 A.M.-12:00 NOON; she rises, takes a bath, eats lunch and watches television until about 4:00 P.M.; she rests at 4:00-6:00 P.M. then eats her dinner with husband and watches TV until midnight. The cycle goes on everyday and reports that waking up at dawn took a lot of getting used to because she usually wakes up at 8am.

PLANNING/ CUES / PROBLEMS NURSING INTERVENTIONSNURSING DIAGNOSIS RATIONALE

SCIENTIFIC BASIS EVALUATION

PHYSIOLOGIC ALTERATION IN COMFORT: PAIN Many pregnant woman experience OBJECTIVESNEED LORDOSIS backache due8primarily to the increased After 8hrs of 1. Review the necessity of goodRELATED 1. TO T oLUMBAR protect back ligaments After hrs of implementation, ACCOMPANYING PREGNANCY. curvature OBJECTIVES : holistic nursing posture during pregnancy. objectives are completely met as of the lumbosacral care the patient evidence by:vertebrae that occurs as the uterus enlarges & becomes heavier. -will grimaced face be able to: 2. Teach the use of nonsteroid hormones -experience pharmacologic techniques before, 2. To distract attention and release Circulating -Client verbalizes decrease in pain and cause a softening & relaxation pelvic -increased putting hands at the back while comfort after, and if possible during pain tension. discomfort from 5/10 – of 2/10. joints, contributing to the walking/supporting walking. concerning lumbar back while activities such as relaxation, problem, if woman doesto notverbalize learn how to pain as evidenced guided imagery, music therapy, -Client was able correct this curvature, the by lowered pain distraction and massage. nonpharmacologic methods that strain onprovide the muscles intensity from 5/10 3. To promote non-pharmacologic pain relief.and ligaments will cause backache. SUBJECTIVES : to 2/10. 3. Provide comfort measures such as management. Source -Client : touch, repositioning and use of was able to demonstrate Maternal-Newborn nursing womens health "Magsinakit likod labi na -Report pain jud is day ang akong heat/cold packs. relaxation skills and & diversional care, 7thactivities. edition by Sally B. Alds page 366 kon magsige ko ug tindog" as verbalized by controlled 4. To prevent fatigue. the patient. 4. Encourage adequate rest periods. -Verbalize nonpharmacologic 5. Help client plan ways to rest daily 5. To reduce pressure in veins of lower methods that with feet elevated. extremities & vulva provide relief. 6. Teach client the pelvic tilt 6. Helps prevent or reduce back strain & -Demonstrate use exercise. strengthens abdominal muscle tone by of relaxation skills making lumbar spine more flexible. and diversional activities as 7. To maintain body balance. indicated for individual 7. Teach client to place her feet 12-18 situation. inches apart. 8. To moderate-height heel reduces the amount of spinal curvature necessary 8. Wearing shoes with low heels. to maintain an upright posture. 9. Advise woman to squat and not to bend over to pick up objects.

9. Avoid back strain. SOURCE : MATERNAL & CHILD HEALTH NURSING THIRD EDITION BY LIPPINCOTT PAGE 262