Kingdom of Saudi Arabia Name of Student:Ruqayyah al momen King Saud bin Abdul Aziz University Section: 1 Antenatal Assessment

Tool 1 .History: Personal History: Name:Mishayel ahmad Nationality:saudi Consanguinity: Cousin Occupation: Assistant Director Housing condition: Apartment Medical and surgical history: Diabetes Mellitus (yeas " Gestational Diabetes") Heart Disease Hypertension ( _) (_ ) Renal Disease ( - ) Allergy and type ( - ) Others : ( -) Type of operation ( - ) Date of admission:2-3_2012 Age:38 years Marital Status: married Address: al hasa al mubaraz Education: Bachelor Family income: good Date:4-3-2012

Viral Infection ( - ) Infections (vaginal, cervical and tubal): (- ) History of previous operation: (_ ) Present condition : Gestational Diabetes Menstrual History: Age of menarche: 13 years Interval: 22 days Amount: normal

Regularity:Regulare Duration:8-10 days

Menstrual pain: mild pain in the abdomen and back and both legs Last menstrual period: 3-7-2012 Obstetric History: Expected date of delivery :10-4-2013

Gravida: G6

Parity: P5

Abortion: 0

Still birth: 0

Number of living children: 5 Type of last delivery: Normal. Family History:

Sex of children:3Boys 2Girls

Diabetes Mellitus (yeas "her mother and father" ) Heart Disease ( yeas "her mother" ) Hypertension ( yeas "her mother and father" Viral Infection ( - ) Mental illness(- ) Allergic condition ( - ) ) Renal Disease ( - )

Congenital abnormalities ( - )

Present complaints of the mother: Increase of blood glucose = 179 mg/dl II .Examination: Physical Examination: General: Vital signs: Temperature Pulse:82 p/min Respiration:22 b/min

Blood pressure:110/80 mmhg Height:168 cm General Well-being: 1. Skin, hair and nail: Skin color is brown ,intact , no lesion, no redness, no dryness, skin turger adequate .she has steria gravida, linea nigra . Head & hair : skull intact skin , no lesion, head is positioned to midline, no masses noted Nails: pink in color,round,fixed& capillary refill 2 sec 2. Mouth gums: mucosa and gingival pink , no masses or lesions ,teeth are white no decay. Tongue protrudes in midline 3. Thyroid: full ROM . Symmetric, no distention or masses . Trachea in midline . Carotid pulses + 2 and equal bilaterally, , thyroid lobes symmetrical size 4. Chest and lung: The chest is symmetrical . clear breath sound . RR 22 b/min 5. Heart: regular ,Clear , S1+S2 are present. No abnormal sound Weight:128 kg

6. Posture and range of motion and Extremities: skin warm , capillary refill 2 sec , pulse present, full ROM ,no ankle edema. But she has distention in her leg Local Examination: Breast Examination: Symmetry and pigmentation: symmetrical by lateral, no pigmentation Type of nipples: flate Colostrum: not present Auxiliary nodes : not enlargement Abdominal Examination: Inspection: Size of abdomen: Bigger than the period of gestation Shape of abdomen: : longitudinal ovoid Scar of previous operation: present Palpation: Fundal Height: Under xiphoid by 1 fingers Position of the fetus: left posteriori Lie: longitudinal lie Engagement of fetal head: no engagement Auscultation: Fetal Heart Rate: 144 p/min Vaginal Examination: Velva condition: Normal Presence of vaginal discharge: no discharge III. Laboratory Investigation: Urine analysis, Albumin and Acetone: not available: GLU: 166(74-106)MG/dl(high) Sugar: not available: Type:(-) Presentation: : cephalic Attitude: flexion Pigmentation: : nil

Crea :31.67(53-88)mmol (low)

NA :136(133-152)MMOL/L AST:24(15-37)U/L URIC:220(155-428) Blood Test: Blood group: B Hematocrit: 0.22% WBC:13.710^3/MM3 Rh: Positive Hemoglobin:10.2g/L

Toxoplasmosis: : not available Others: : not available

Result of ultrasound scanning: : not available

Assessment Objective data Weakness poor muscle tone inadequate food intake lack of interest in food pale skin - Subjective data The patient said" I afraid to eat food that may increase blood sugar I notice that my weight does not change much in the last two months" "

Diagnosis Nutrition imbalance less than body requirements related to Insulin deficiency (decreased uptake and utilization of glucose by the tissues) as evidence by Reported inadequate food intake, lack of interest in food and gain less than 1 kg per month

Plan/out come After 5 hours of nursing intervention the patient will _Gain 1- kg per month, or as appropriate for pregnancy weight. _Maintain fasting serum glucose levels between 60 100mg/dL and 1 hr postprandial no higher than 140 mg/dL

Intervention 1.Establish rapport 2.Ascertain understanding of individual nutritional needs 3.Discuss eating habits and encourage diabetic diet as prescribed by the Doctor 4.Document actual weight, do not estimate. Note total daily intake including patterns and time of eating. 5.Consult dietician/physician for further assessment and recommendation regarding food preferences and nutritional support

Evaluation The goal is met After 5 hours of nursing intervention the patient _Gain weight as appropriate for pregnancy . _Maintain fasting serum glucose levels within normal range between 60100mg/dL

Assessment Objective data -increased urine output. sweating of the skin thirst Subjective data The patient said" I afraid to eat food that may increase blood sugar I notice that my weight does not change much in the last two months" "

Diagnosis Deficient Fluid Volume r/t osmotic dieresis from hyperglycemia absent or deficient insulin functionr

Plan/out come After 5 hours of nursing intervention the patient will maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs.

Intervention -1.Establish rapport 2.Take and record vital signs 3.Monitor the temperature 4.Assess skin turgor and mucous membranes for signs of dehydration 5.Encourage the patient to increase fluid intake 6.Administer IVF as ordered by the Doctor 7.Administer anti-pyretic as prescribed by the Doctor.

Evaluation The goal is met After 5 hours of nursing intervention the patient

Assessment

Diagnosis

Plan/out come

Intervention

Evaluation

Objective data - ""

Risk for fetal injury related to elevated maternal serum glucose levels

After 5 hours of nursing intervention the patient will Maintain fasting glucose levels between 60 100mg/dL and 1 hr postprandial no higher than 140 mg/dL

-.Establish rapport _Assess fetal movement and FHR each visit as indicated -Encourage patient to count/record fetal movements daily -Monitor fundal height each visit -Monitor urine for ketenes. Note fruity breath -Provide information for home blood glucose monitoring and diabetic management. -Note lients diabeti control during hospitalization -Encourage the patient to monitor blood glucose level at home -Provide information about possible effect of diabetes on fetal growth and development

The goal is met After 5 hours of nursing intervention the patient Maintain fasting glucose levels between 60100mg/dL and 1 hr postprandial no higher than 140 mg/dL