Jose Rizal UniversityCollege of Nursing

Nursing Process of a 7-month pregnant client

In Partial Fulfillment of the Requirement for Nursing Care Management 101 – Related Learning Experience

(Friendly Care Clinic)

Submitted by:Shaneal Alonzo

Jestoni AureJoey BagsarsaArviel Berrei

Jerilee BodotaKate Lou CabahugVon Aarol Calabio

Alma A. CanlasBrian Armond Casabon

Christine ChanAlvin Conde

Submitted to:Mrs. Esperanza Catiis, RN, MAN

Clinical Instructor

Table of Contents

Chapter 1 – Introduction

Objectives

Chapter 2 – Assessment

Nursing Health History

Personal Data of the Patient

Chief Complaints

History of Present Illness

Past Medical History

Family Health History

Social History

Review of System

Physical Assessment

Diagnostic Procedure

Anatomy and Physiology of the Systems affected

a. Pathophysiology

Chapter 3 – Planning

A. List of Prioritized Nursing Diagnoses

B. NCP

C. Drug Study

Chapter 4 – Discharge Planning

Chapter 1 – Introduction

We, group 1 of JRU BSN A314, would like to thank The Friendly Care Clinic for allowing us to

choose a patient for our case. We also thank our clinical instructor, Ms. Catiis, for patiently

teaching us and making sure we learn the most out of our clinical exposure.

Objectives

General Objectives – We did this case study for us to have a deeper understanding of

what physiological changes undergo during pregnancy, thus to give us an idea of how

we could give proper nursing care for our pregnant clients.

Specific Objective - We hope to be able to address the client’s health needs and also to

assess for any health deficit or risks like anxiety, activity intolerance, and fluid volume

deficit.

Chapter 2 Assessment

Personal Data

Name: a.k.a. SunflowerAge: 29Occupation: N/AEducational Attainment: UndergraduateBirthday: July 9, 1978Civil Status: MarriedTemporary Address: San Juan, ManilaPermanent residence: DumagueteHeight:Weight:

G2P1 (T1P0A0L1)AOG: 32 weeks and 5 days

Final Diagnosis:Single live uterine fetus, in variable presentation, 32 & 5 days. Placenta posterior, grade 2. Placenta previa totalis.

Chief Complaint:“ Nagpapacheck up ako kasi suhi daw ung baby ko.’’

History of Present IllnessShe came to the clinic for a pre natal check up. According to her, the last time she had

her last check up, doctor found out that her baby is in breech position. Aside from that, the client has no other difficulties in her pregnancy.

Past Medical HistoryThe client has given birth previously to baby girl through Normal Spontaneous delivery

and she hasn’t experience any difficulties giving birth to her firstborn.

Family Health HistoryAccording to the client, there is no one in the family who has or had any chronic illness,

even hypertension and diabetes. Neither one in the family had complications during and after pregnancy.

Social HistoryShe and her husband has just moved in san Juan, 6 months ago, due to her husband’s

job. She spends some of her time outside their house dealing with her neighbours. She has no difficulty getting along with them because she said that people around them are easy to confide with.

3. Diagnostic Procedures

Ultrasound 

Ultrasound is a commonly used procedure that uses sound waves to produce an image. These sound waves pass through the woman’s abdomen and reflect off the maternal and fetal structures to form a picture on a monitor.   Ultrasound during pregnancy may be used for the following:

Early in pregnancy (six to twelve weeks) to confirm a heart beat, identify twins or triplets, or help predict the due date

Detailed ultrasound after eighteen weeks, to see if the baby is growing and developing as it should, and to help make a diagnosis when a fetal abnormality is found

To locate the fetus and placenta during amniocentesis, which increases the safety of that procedure

Along with fetal heart monitoring, when a pregnancy has gone beyond the due date, to check on the well-being of the fetus and to help with decisions about induction of labour.

Amniocentesis 

Amniotic fluid is the thin watery substance that surrounds the developing fetus in the uterus/womb. Amniocentesis involves removing a small amount (about 4 teaspoons) of this fluid with a needle, for testing in the lab. This test can be done after the 15th week of pregnancy. Amniocentesis is a specific test that is able to tell you if your baby has a normal number of chromosomes (46). It can find Down syndrome and other major chromosome abnormalities. A second test is done to measure the amount of alpha-fetoprotein (AFP) in the amniotic fluid. A higher than normal amount may suggest the possibility of a neural tube defect, such as spina bifida. Normal results can take up to 3 weeks. Concerns are usually identified and given to your doctor or midwife within 10-14 days.

Chorionic Villus Sampling

Chorionic villi form as part of the placenta and are made up of cells that develop from the fertilized egg that has developed into the fetus. Chorionic villi contain the same genes as the fetus and can be examined to rule out chromosomal disorders. Unlike amniocentesis, chorionic villus sampling does not provide information about neural tube defects. (this can be done later by drawing and testing a blood sample from the mother). Chorionic villus sampling (CVS ) involves taking a small sample of tissue for testing in the lab. and is usually done between the tenth and twelfth weeks of pregnancy.

4. Anatomy & Physiology

Reproductive System

The reproductive organs are comprised of a vagina, a cervix, a uterus, fallopian tubes and ovaries. All of these organs work together to help you menstruate, conceive and carry a baby to term.

The uterus, located in a woman's abdomen, is a hollow, elastic reproductive organ, where a baby develops during pregnancy.

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 next to 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 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.Vagina: This tube like structure connects your internal reproductive organs with your external genitalia. It ends at the cervix and is the point of entry for the penis during sex as well as the final passageway through which a baby exits when it is born. 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.

Cervix: This part of your reproductive organs is situated between the vagina and uterus. It secretes mucus that can help or obstruct sperm from fertilizing an egg. The cervix is the opening that sperm must pass through in order to get to an egg. A baby must also go through the cervix as it exits the uterus and enters the vagina. Uterus: Also known as the womb, the uterus is a muscular organ made up of three layers: the peritoneum (outer layer), myometrium (middle layer)and endometrium (inner lining). An egg that has been fertilized will implant itself into the endometrium lining and will continue to develop in the uterus throughout the pregnancy. Fallopian Tubes: The fallopian tubes extend off the upper sides of the uterus and lead up to the ovaries. They have 20 to 25 finger-like structures on their ends that hover just above the ovaries and work to collect the mature egg when it is released. It is in the fallopian tubes that fertilization of the egg will take place.

Ovaries: Women usually have two ovaries, one on each side of the uterus. Ovaries are the storing house for your egg follicles; every month, one of these egg follicles will mature and release an egg into the fallopian tubes. The ovaries are also responsible for producing estrogen and progesterone, which are vital for proper reproductive function. The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.

Changes in the Reproductive System During PregnancyWhen you become pregnant, the part of your body affected first and the part that undergoes the most significant changes is the uterus. It increases to 20 times its original weight, and 1,000 times its initial capacity. The amount of its muscle, connective and elastic tissue, blood vessels, and nerves increases. Its shape changes from elongated to oval by the second month,

to round by midgestation, then back through oval to elongated at term (the end of a normal nine-month pregnancy).

The uterus softens beginning at the sixth week. It changes position as it increases in size, ascending into the abdomen by the fourth month and eventually reaching to the liver. It also becomes more contractile (the tendency to decrease in size), with irregular, painless Braxton Hicks contractions beginning in the first trimester. You may feel these contractions in the last weeks of pregnancy, when they are known as false labor.

Other parts of the reproductive system change along with the uterus. The cervix and vagina have an increased blood supply, which causes a darkening in color apparent by the sixth week. The amount of elastic tissue increases to prepare the way for the stretching that will be required during delivery. Secretions increase, and a mucous plug develops in the cervix. The fallopian tubes, ovaries, and ligaments supporting the uterus all enlarge and elongate. The ovaries, of course, cease to ovulate.

During the fourth month, the uterus grows into the abdomen, causing the abdominal wall to expand to accommodate it. The connective and elastic tissues stretch and straighten, creating thinned areas called striae (stretch marks). While the red of the striae may fade, silver remnants usually remain after delivery. In 50 percent of women, striae develop in the third trimester. Late in pregnancy, the internal pressure from the large uterus may even cause the muscles of the abdominal wall to separate (diastasis).

The Endocrine System and Hormone Function Overview1.       The endocrine system is a major controlling system of the body. Through hormones, it stimulates such long-term processes as growth and development, metabolism, reproduction, and body defense. 2.       Endocrine organs are small and widely separated in the body. Some are mixed glands (both endocrine and exocrine in function). Others are purely hormone producing. 3.       All hormones are amino acid-based or steroids. 4.       Endocrine organs are activated to release their hormones into the blood by hormonal, humoral, or neural stimuli. Negative feedback is important in regulating hormone levels in the blood. 5.       Blood-borne hormones alter the metabolic activities of their target organs. The ability of a target organ to respond to a hormone depends on the presence of receptors in or on its cells to which the hormone binds or attaches. 6.       Amino acid-based hormones act through second messengers. Steroid hormones directly influence the target cell's DNA.  The Major Endocrine Organs

1.       Pituitary gland  2.       Thyroid gland 3.       Parathyroid glands 4.       Adrenal glands

  5.       Pancreatic islets 6.       The pineal gland7.       The thymus gland8.       Gonads

Other Hormone-Producing Tissues and Organs1.       The placenta is a temporary organ formed in the uterus of pregnant

women. Its primary endocrine role is to produce estrogen and progesterone, which maintain pregnancy and ready

breasts for lactation. 2.       Several organs that are generally nonendocrine in overall function, such

as the stomach, small intestine, kidneys, and heart, have cells that secrete hormones.

Pathophysiology

pituitary gland

anterior lobes posterior lobes

Protein synthisis antidiuretic hormones

Thyroid stimulating hormones oxytocin hypothalamus

Adrenocortictropic hormones

Gonadotropic hormones

Prolactine hormones

Respiratory System Anatomy & Physiology

The respiratory system consists of the nose, pharynx (throat). larynx (voice box), trachea (windpipe), bronchi and lungs. Its parts can be classified according to either structure or function.

Structurally, the respiratory system consists of two parts:

The upper respiratory system includes the nose, pharynx, larynx and associated structures.

The lower respiratory system includes the trachea, bronchi, and lungs.

Functionally, the respiratory system consists of two parts:

The conducting zone consists of series of interconnecting cavities and tubes both outside and within the lungs – the nose, pharynx, larynx, trachea, bronchi, bronchioles, and terminal bronchioles—that filter, warm and moisten air and conduct it into the lungsThe respiratory zone consists of tissues within the lungs where gas exchange occurs – the respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli, the main sites of gas exchange between air and blood.

Nose

Pharynx

Larynx

Bronchi

Bronchioles

Terminal bronchioles

Lungs CO2 exhaled

O2 inhaled

Pathophysiology

Respiratory changes during pregnancy

Respiratory Tract. Hormonal changes to the mucosal vasculature of the respiratory tract lead to capillary engorgement and swelling of the lining in the nose, oropharynx, larynx, and trachea. Symptoms of nasal congestion, voice change and upper respiratory tract infection may prevail throughout gestation. These symptoms can be exacerbated by fluid overload or edema associated with pregnancy-induced hypertension (PIH) or pre-eclampsia. In such cases, manipulation of the airway can result in profuse bleeding from the nose or oropharynx; endotracheal intubation can be difficult; and only a smaller than usual endotracheal tube may fit through the larynx. Airway resistance is reduced, probably due to the progesterone-mediated relaxation of the bronchial musculature.

Lung Volumes . Upward displacement by the uterus causes a 4 cm elevation of the diaphragm, but total lung capacity decreases only slightly because of compensatory increases in the diameters of the chest, as well as flaring of the ribs. These changes are brought about by hormonal effects that loosen ligaments.

From the middle of the second trimester, expiratory reserve volume, residual volume and functional residual volume are progressively decreased, by approximately 20% at term. Oxygen consumption increases gradually in response to the needs of the growing foetus, culminating in a rise of at least 20% at term. During labour, oxygen consumption is further increased (up to and over 60%) as a result of the exaggerated cardiac and respiratory work load.

Pulmonary changes during pregnancy

Respiratory function is also altered during pregnancy to meet the added oxygen demands of the fetus. Tidal volume can be increased by 30-40%, expiratory reserve volume can be reduced up to 40%, functional residual capacity can decline by up to 25%, minute ventilation can increase by up to 40%, airway resistance in the bronchial tree can decline by 30%-40%, and total body oxygen consumption can increase by about 10-20%. Dyspnea also occurs.

MechanicalDiaphragm rises 4 cmLess negative intrathoracic pressureDec FRC-Functional Residual Capacityvolume after passive expirationDec ERV-Expiratory Reserve Volumemax volume expired after expirationDec RV-Residual Volumevolume after max expirationNo impairments in diaphragmatic or thoracic muscle motionLung compliance remains unaffected

- Minute ventilation = RR X Tidal volume-Tidal Volume-increasesVolume of air Inspired and expired with each breath- Minute ventilation-increasesVolume inspired or expired in 1 min- RR- remains unchanged- Vital capacity-remains unchangedMax volume that can be forcibly inspired after max expiration

ConsumptionO2 consumption Increases 15-20 % 50 % of this increase is required by the uterusDespite increase in oxygen requirements, with the increase in Cardiac Output and increase in alveolar ventilation oxygen consumption exceeds the requirements.Therefore, arteriovenous oxygen difference falls and arterial PCO2 falls.

Physiologic changes

Dyspnea -increase in desire to breathe70 % of pregnant women experience thisOccurs during 1st trimester without mechanical factorsNo change on PFTsThe lower PCO2 then paradoxically causes dyspneaThe marked change or marked decline in PCO2 results in the sensation of dyspnea

Pulmonary adaptation

AnatomicalIncreased chest diameter, subcostal angle changes, increased diaphragmatic excursion with diaphragm elevated as well

Physiological

Hyperventilation

Increased IC,VC and Minute Volume

Residual volume decreased

Expiratory Reserve Volume decreased

Tidal volume increased by 40%

pO2 increased, pCO2 decreased

arterial pH unchanged

serum bicarbonate reduced

THE CIRCULATORY SYSTEM

Is made of the heart and blood vessels known as arteries and veins. The heart pumps blood throughout your body through the blood vessels. Blood deliveries oxygen and nutrients to the body and carries away carbon dioxide and other waste materials.

ANATOMY OF THE HEART

Location and Size

The relative size and weight of the heart give few hints of its incredible strength. Approximately the size of a person’s fist, the hollow, cone-shaped heart weighs less than a pound. The heart is located within the bony thorax and is flanked on each side by the lungs. Its more pointed apex is directed toward the left hip and rest on the diaphragm, approximately at the level of the fifth intercostal space. Its broader poster superior aspect or base, from which the great vessels of the body emerge, points toward the right shoulder and lies beneath the second rib.

PHYSIOLOGY OF THE HEART

As the heartbeats or contracts, the blood makes continuous round trips in and out of the heart, through the rest of the body, and then back to the heart – only to be sent out again. The amount of work that a heart does is almost too incredible to believe. In one day it pushes the body’s supply of 6 quarts or so of blood through the blood vessels over 1000 times, meaning that it actually pumps about 6000 quarts of blood in a single day!

PHYSIOLOGICAL CHANGES

Total body water rises and blood volume increases by 25 to 40 percent to accommodate the additional needs of the fetus. The rise in blood volume also acts as a safeguard against blood loss during birth. Blood pressure and pulse typically rise and increase cardiac output by 20 to 40 percent; this helps propel the greater blood volume around the body. Because the uterus presses on the pelvic blood vessels, venous return from the lower limbs may be impaired somewhat, resulting in varicose veins.

The Musculoskeletal SystemDuring pregnancy there is an evident change in the physical appearance of the women’s body. The most evident change is the substantial weight gain, anywhere from twenty to forty pounds depending on the individual (Artal and O'Toole, 2003; Paisley et al, 2003). During the conception period the uterus can expand up to 1000 times, causing an anterior orientation of the uterus (Hartmann and Bung, 1999). The development of the uterus leads to the visible ‘waddling’ way of walking during the last trimester. The growth of the uterus causes the body to respond with a shift in the center of gravity. The center of gravity is shifted back over the pelvis in response, preventing women from falling, the body's safety mechanism. Additionally the center of gravity usually shifts higher, with this there is an increased strain on the muscles and ligaments supporting the vertebral column (Wang and Apgar, 1998). The change in the uterus size, leads to the change in center of gravity, leads to in an increased strain on the back muscles, hence, the cause of low back pain experienced by most pregnant women. This musculoskeletal change means pregnant women face difficulty with balance throughout term. Hyperlordosis is seen resulting in progressive lumbar lordosis and rotation of the pelvis on the femur (Hartmann and Bung, 1999). This causes an increase in the anterior flexion of the cervical spine (a hunchback appearance) and adduction of the shoulders (rounding of the shoulders). There is also an increase in the laxity of ligaments throughout the body, causing a decreased stability of the joints (Hartmann and Bung, 1999; Wang and Apgar, 1998).With these changes in mind it is important pregnant women are aware their balance can be compromised. Care should be taken when choosing the exercises to include in a pregnant women's exercise protocol. Taking into account the increased strain from the musculoskeletal changes taking place due to the growing uterus, the exercises chosen should not add additional unneeded stress on the low back.

Hyperlordosis - 'swayback', excessive curvature of the lumbar spine (lower part of spine, closest to the buttocks)

Lordosis – the natural curvature of the lumber spine (lower part of spine, closest to the buttocks)

Laxity - a degree of freedom of movement

Musculoskeletal Changes

Pregnancy is associated with numerous physiological changes. As a result, the physiological response to exercise is altered. The most significant musculoskeletal Change is progressive lumbar lordosis, which causes a shift in a woman's center of gravity (COG). As the fetus grows, the COG is pushed back over the pelvis. To compensate for the change in the COG, pregnant women tend to increase the anterior flexion of the cervical spine and abduct their shoulders.

Consequently, strain on the cervical and lumbar region of the spine, lower back pain and general musculoskeletal soreness are common complaints from pregnant women.In addition to the instability of the musculoskeletal system are hormonal changes. An increase of estrogen and relaxin augments the elasticity of ligaments. The pelvic region and other joints become more flexible, which could potentially increase the risk of injury during everyday activities as well as exercise. Some women may experience a greater degree of complications, which may alter the amount and type of exercise they can participate in.

Pathophysiology

For about half of all pregnant women, low-back pain is inevitable. Physicians who can specify what type of back pain the patient has—lumbar, sacroiliac, or nocturnal—can institute targeted treatment that addresses the relevant pathophysiology. Acetaminophen and certain modalities such as icing the area are the basis of acute treatment in conjunction with ergonomic adaptation and a good low-back exercise program. This will help decrease stress on the low back, making back pain less likely. Before a woman becomes pregnant, encouraging her to become fit and resolving existing back problems is the key to back pain prevention.

Understanding the normal musculoskeletal changes that occur during pregnancy is useful for targeting and treating the sites of a patient's back pain.Lumbar pain. Lumbar pain during pregnancy can stem from multiple sites, most commonly the facet joints, paraspinal muscles, supporting ligaments, or discogenic sources.Posture changes that occur during pregnancy help the woman maintain balance in the upright position as the fetus grows. As pregnancy progresses, the hormone relaxin, which allows pelvic expansion to accommodate the enlarging uterus, increases tenfold, reaching its peak at the 14th week (12,13). Joint laxity is more pronounced in multiparous women than it is during the first pregnancy. In the lumbar spine, joint laxity is most notable in the anterior and posterior longitudinal ligaments, both of which are pain-sensitive structures. As these static supports in the lumbar spine become more lax, they can't as effectively withstand shear forces, and discogenic symptoms and/or pain from the facet joints may increase.As the abdominal muscles stretch to accommodate the growing fetus, their ability to help stabilize the pelvis decreases. The burden shifts to the paraspinal muscles, which become strained at a time when they may be shortened from the increased lordosis of the lumbar spine.

GI Tract Pathophysiology

Pregnancy

Increase intravenous pressure

Distention and engorgement

Painless, intermittent bleeding during defecation Vague feeling of anal discomfort when bleeding occurs

Prolapse of rectal Pain from thrombosis of mucosa from straining external hemorrhoids

Pathophysiology

Hemorrhoids result from activities that increase intravenous pressure, causing distention and engorgement. Predisposing factors include prolonged sitting, straining at defecation, constipation, low-fiber diet, pregnancy, and obesity. Other factors include hepatic disease, such as cirrhosis, amebic abscesses, or hepatitis; alcoholism; and anorectal infections. Hemorrhoids are classified as first, second, third, or fourth degree, depending on their severity. First-degree hemorrhoids are confined to the anal canal. Second-degree hemorrhoids prolapse during straining but reduce spontaneously. Third-degree hemorrhoids are prolapsed hemorrhoids that require manual reduction after each bowel movement. Fourth-degree hemorrhoids are irreducible.

Pathophysiology of Skin Changes During Pregnancy a.k.a. Sunflower

Pregnancy

HyperpigmentationStriae Gravidarum

Hormonal Changes

Dermal and Epidermal Tearing

Increase in Glucocortoid

Hormones

Rapid Stretching of Skin

Increase in Estrogen and Progesterone

Loose of Support in Dermis and

Epidermis

Increase in MSH

Decrease of Collagen and Elastic FibersChloasma/

MelasmaLinea Nigra

Darkening of:-Areolas-Axillae-Genitals

Chapter 3 – Planning

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Cues:

Objective Cues:

Risk for fluid volume deficit related to vomiting

The state in which an individual is at risk of experiencing vascular cellular or intracellur dehydration (duet to active regulatory losses of body water in excess of needs or replacement capability

Within 8 hrs nursing intervention the occurrence of deficit will be prevented

Encourage having meals always on time

Advise to have a regular weighing schedule and note the results

Provide encouragement and pleasant eating environment

Set time for the client to eat

Administer medication as indicated

To avoid loss of appetite

To provide accurate ongoing records of weight loss/gain

To stimulate the appetite of the client

To be able to gain the toss of the patient

To lessen or cure the illness of the patient

After 8 hrs of nursing intervention the patient’s vomiting decreased

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Cues:

“Medyo nanghihina ko” as verbalized by the patient

Objective Cues:

>B/P>P>R>T

(+) Restlessness(+) Paleness(+) Fatigue(+) grimace(+) sweating

Inability for sufficient physiological or psychological energy to endure required task due to fatigue

The patient will regain it’s strength and be able to do simple activities after 8 hours of nursing care

check vital signs

monitor cardio respiratory response to activity

monitory discomfort or pain during movement/activity

assist patient to do simple task

document any findings

To provide baseline data

To monitor her endurance to certain activities if simple task

To monitor activities that must be avoided

To prevent to much fatigue

To provide necessary data if intervention fail

After 8 hours of nursing intervention the patient is able to do simple task and is able to endure desired daily activities

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Cues:

“wala akong gana at medyo nahihirapan ako” as verbalize by the patient.

Objective Cues:

>b/p

>P

>R

>T

(+) Paleness(+) Anxiety (+) Grimace(+) Restlessness(+)Fatigue

Inability to form a valid appraisal of stressor or inadequate choice of practiced responses due to stress

Patient will be able to express this problem more clearly and will be able to respond well to others after 8 hours of nursing intervention

Explore with the client previous method of dealing with problems

Assist the client in positive appraisal of the event and oneself

Communicate verbally to the client

Give moral support

Document findings

To provide data of coping problems

To help the client established her self actualization

To help the client establish proper communication to others.

To remain free of destructive behavior towards self or others.

To provide necessary data when intervention have failed.

After 8 hours of nursing intervention the patient is able to make positive responses to other people

Chapter III ImplementationMedical Management - Drug Study

Name of DrugClassification Adverse effect Medication Contra-indication Nursing intervention

Iberet Antianemics/Pre & Post Natal Vitamins

Allergic reactions, GI effects, hyperbilirubinemia, acneform vulgaris deterioration or acneform exanthema eruption, bright yellow urine discoloration, flushing, dizziness or faintness, peripheral sensory neuropathies, stone formation, crystalluria & oxalosis, black discoloration of stool.

Treatment & prevention of Fe-deficiency & concomitant folic acid deficiency w/ associated deficient intake or increased need for vit B-complex in nonpregnant adults.

Thalassemia, sideroblastic anemia, hemochromatosis & hemosiderosis.

Pernicious anemia. Patients w/ chronic renal failure & receiving acetylsalicylic acid. Hematologic remission may occur while neurological manifestations remain progressive. Serum B12 levels should be regularly assessed in elderly & patients w/ condition leading to vit B12 depletion. Pregnancy, lactation.

Name of DrugClassification Adverse effect Medication Contra-indication Nursing intervention

OB Max Antianemics/Pre & Post Natal Vitamins

Gastric irritation (take OB-Max on full stomach to avoid this).

Pre- & postnatal supplement fortified w/ taurine to meet nutritional needs of mothers & for proper growth & development of baby. For proper mental brain development of the fetus.

Thalassemia, sideroblastic anemia, hemochromatosis & hemosiderosis.

Pernicious anemia. Patients w/ chronic renal failure & receiving acetylsalicylic acid. Hematologic remission may occur while neurological manifestations remain progressive. Serum B12 levels should be regularly assessed in elderly & patients w/ condition leading to vit B12 depletion. Pregnancy, lactation

Chapter IV Discharge Planning

Medication – Aside from the OBMax and Iberet, the client may also be given calcium to ensure an adequate intake of this essential nutrient. A multivitamin that has folic acid prevents neural tube defects, calcium is needed for bone and teeth, and iron is needed to prevent anemia in mother and fetus.

Vitamin/Mineral What it isNeeded Amount for Pregnant Client

What it does Health Teaching

Folic Acid Sometimes called folate, is a B vitamin (B9) found mostly in leafy green vegetables like spinach. Can also be found in citrus fruits such as orange juice, and also beans, breads, cereals, rice, pastas.

400 micrograms of folic acid a day.

Folate prevents the baby from serious abnormalities of the brain and spine. Lack of Folic acid leads to inadequate growth of the fetus, underdeveloped brain, incomplete closure of spinal cord, preterm delivery and low birth weight.

Eat a well-balanced diet that includes rich sources of Folic Acid like broccoli, Brussels sprouts, asparagus, peas, chickpeas and brown rice.

Other useful sources include fortified breakfast cereals, some bread and some fruit (such as oranges and bananas).

Vitamin/Mineral What it isNeeded Amount for Pregnant Client

What it does Health Teaching

Calcium

Good sources of the mineral calcium include milk, cheese and other dairy foods, green leafy vegetables (such as broccoli, cabbage and okra, but not spinach), soya beans, tofu, soya drinks with added calcium, nuts, bread and anything made with fortified flour, and fish where you eat the bones, such as sardines.

1,000 milligrams (mg) per day

It helps keep your bones and teeth strong. When a woman doesn’t get enough calcium from her diet, the body takes it from her bones. If a woman doesn’t get enough calcium in her diet during pregnancy, the calcium the baby needs will be taken from her bones.    

Make sure she gets enough calcium every day: before, during and after the pregnancy. Dairy products are the best food sources for calcium like low-fat or fat-free milk and yogurt, plus hard cheeses (cheddar, Swiss). Other good sources are dark green leafy vegetables (such as broccoli and kale) and tofu processed with calcium sulfate.

Vitamin/Mineral What it isNeeded Amount for Pregnant Client

What it does Health Teaching

Iron Iron is a mineral found in some foods, which is essential for good health and for physical and mental well-being.

The recommended daily intake (RDI) of iron during pregnancy is 22-36mg (10-20mg more than that for non-pregnant women).

During pregnancy women have blood in excess volume, so this excess blood requires an excess amount of iron. During pregnancy not just the blood cells of the mother but the growing child’s cells require oxygen, this is where again the demand for the amount of oxygen is fulfilled by iron.

Eat a well-balanced diet that includes rich sources of iron like beef, liver and kidney, fish, vegetables and fruits,

Exercise – Specific exercises may be carried out to help strengthen muscle tone in preparation for birth. These exercises include:

> Pelvic tilt – Lie on your back with legs hip-width apart, both knees bent, and both feet on the floor. Place arms alongside body with palms down. Keep head and shoulders relaxed. Hold abdominals in as you rotate and tilt your pelvic girdle up toward the ceiling with a smooth and controlled motion. Repeat for 8 times and progress to 3 sets of 8 times.

> Kegel’s exercise – Kegel's strengthens the pelvic floor muscles that support the uterus, bowel and bladder and help prevent possible incontinence. For doing this, all you need to do is pretend you are trying to stop the flow of urine. Practice this a few times so you understand what muscles you need to contract, and keep contracting these muscles a number of times during a day. Contract and hold, and release. Do these exercises in sets of 10, 3-4 times a day. The longer you hold the muscles and the more regularly you practice this exercise, the stronger your muscles will get. In addition, this is a great exercise as it can be done anytime during the day..

>Tailor sit - Sit on a flat, hard surface with your legs crossed in front of you. Tailor Sitting is also called sitting "Cross-Legged" or "Indian Style."

Treatment – The client experiences nothing more than what is normal for pregnant women so no special treatment is needed.

Health Teaching – A pregnant woman should drink at least 8 to 10 glasses of fluids each day. Personal hygiene: daily bathing is important because the pregnant woman generally has increased perspiration and vaginal mucous. Activity/Rest: She should have some type of regular physical activity. Fatigue should be avoided. Exercise during pregnancy could reduce the risk of cesarian birth. She should avoid hyperthermia and drink plenty of water before and after exercise to prevent dehydration. Advise the client to increase fluid intake and prevent dehydration. Eat more fibers, encourage regular BM. No mineral oil it will prevent the absorption of vitamin A, D, E, K. To avoid varicosities elevate the lower extremities 15 minutes. Avoid prolonged standing. Refrain from wearing constricting garments. Backache, wear low-heeled shoes, use firm mattress, wear maternity girdle.

Outpatient follow up – none

Diet – Eat a balanced diet. Just an additional 300 kcalories a day is needed. The addition of two milk servings and one meat serving will meet the 300 kcalorie increase as well as the increased need for calcium and protein.