MATERNAL DATA BASE I. PERSONAL DATA Name: P.

C Address: Centro Sur, Camalaniugan, Cagayan Age: 24 Civil Status: Married Occupation: Housewife Educational Attainment: High School Graduate Nationality: Filipino Religion: Roman Catholic

A.

Vital signs BP: 110/80 mmHg Temperature: 36.7 C RR: 21 cpm PR: 78 bpm

B.

General Appearance My patient is about 52 in height, brown complexion.

Her look is appropriate to her age. Her weight is 45 kg and when the baby is growing, her weight is also increasing.

C.

Gordons 11 Functional Pattern 1. Health Perception-Health Management Pattern a. Past Health History

My patient is in good health condition and according to her, she has no allergies in foods, or in any kind of drugs. She have never been hospitalized. b. Present Health History My patient was in good health and according to her she doesnt have serious illness. c. Family Health History According to my patient, they dont have any serious illness or hereditary illness in their family. d. Daily Practices According to her, she brushes her teeth three times a day and sometimes she go for dental check-up for dental carries. She doesnt smoke and drink liquor. She used drugs over the counter when shes sick. She completed her immunization and took exercise to maintain healthy condition and to prevent illness. 2. Nutritional-Metabolic Pattern According to her, she eats three times a day and takes snack two times a day, once in the morning and once in the afternoon. There are no foods that she doesnt like, she can feed herself and can swallow liquid and sour foods and she can chew. Her present weight is 50.3 kg but her usual weight is 45 kg. 3. Sleep-Rest Pattern

According to her, she doesnt sleep normally because of frequent urination disturbance, on the day she sleeps two hours as her rest. 4. Elimination Pattern As she said, during her first trimester, she complaints of frequent urination, and she says that she urinates five to six in a day and four to six during the night. Her bowel elimination as she said, the usual color is brown, not too soft and not too hard. The pattern of her bowel movement is every morning. 5. Activity-Exercise Pattern She is always taking a bath everyday and use proper dress. She consider her daily activities in their house as an exercise but only the activities that she can do and appropriate for her to perform during pregnancy. 6. Cognitive-Perceptual Pattern According to her, she has no difficulties and even defect. She can smell, taste, and feel touch. She has the ability to read and write. 7. Self-Perception Pattern She was most concern about her pregnancy and the time when she deliver if she can do or not and her goal is to deliver her baby well. 8. Role-Relationship Pattern My patients dialect is Ybanag but she can speak Ilocano, Tagalog and English. She can speak clear, she expresses

herself verbally. My patient and her husband live to her husbands parents and she turns to her husband and her parents in time of need. Her husband and her parents help in making decisions and finances because they are too young to involve in marriage life. 9. Sexuality-Sexual Function According to her, she started her first menstruation when she was 13 years old. Theres no sexual problem that occurred to her that she told that they dont do sexual intercourse during the entire pregnancy. She didnt use contraceptives.

10. Coping-Stress Management

In relation making, her husband and her parents help her because of being still young and shes doing some activities in their house in order to cope up if she is in stress or tense. 11.Value-Belief System According to her, they are Roman Catholic and they believe and trust Jesus Christ as their source of strengths and they can give their life meaningful.

II.

MENSTRUAL HISTORY A. Menarche The first menstruation occurred at the age of thirteen. B. Characteristics of Menstruation 1. Duration: 5-7 days 2. Color: red 3. Odor: foul odor

4. Consistency: flow was describing scanty and uses five to six sanitary napkins 5. Interval between menses: 30 days C. Discomfort and Nursing Measures She feels dizziness, seldom suffers from dysmenorrhea and once attacked, she takes medicine to relief and take a rest. III. MATERNAL HISTORY A. Obstetrical Score G1 PO T1 PO AO L1

B. History of Present Pregnancy

A. LMP: 7-3-09 B. EDC: 4-10-10 C. AOG: Clinic Visit: ( Aug. 19, 2009, 6 weeks and 5 days ) A. Physiology and Psychology changes of pregnancy, assess the
signs, symptoms, and discomfort associated with pregnancy during: 1. First Trimester Changes in the trimester and discomfort are nausea and vomiting, frequency of urination and headache and linea nigra. 2. Second Trimester At this trimester, the patients enlargement of breast and abdomen, changes in size, shape, and

consistency of her uterus, movement of fetus and frequency urination. 3. Third Trimester At this trimester, the patient sense changes and feels discomfort like backache, mild frontal headache, dizziness, and tingling sensation. Changes of her abdomen and breast, linea nigra formed and nipples become large.

B. Prenatal Check-up: Yes

When: starting August 19, 2009, her first visit Where: Barangay Health Center By Whom: Midwife IV. PAST-HEALTH HISTORY A. Family History (+) Allergy Chickenpox Fever B. Past-Medical History When she was a child, she suffered from fever, cough, colds, headache, stomach pain, mumps, and chicken pox. And she never hospitalized or suffered from serious illness or disease. She takes drug over the counter when she feels sick. V. NUTRITION According to her, she eats three times a day and takes snacks twice a day, one in the morning and one in the afternoon. Because she knows that for a healthy pregnant mother will produce her body Cough Mumps Colds

healthy for a healthy baby inside her womb and she said her preparation for giving birth upon her pregnancy she will eat foods which are rich in nutrients for her supplement for her body and for her baby. She takes also vitamins like Ferrous Sulfate. VI. URINATION As she said, during her first few months or first trimester of her pregnancy, she usually urinates five to six times in a day and four to six in a night and she told that her usual urination will disturb her sleeprest problem, so I tell her that she limit to drink water to avoid frequent urinating.

VII.

BOWEL MOVEMENT According to her, she goes for CR a day before meal but

sometimes, she easily eliminates twice a day.

VIII.

PHYSICAL ASSESSMENT Method Use - inspection - palpation Normal Finding - no presence of edema and lesions - no presence of mass - occipital prominence Abnormal Finding - oily

Area Assessed 1. Face

2. Hair

- inspection

- smooth skull - evenly

- presence of dandruff

3. Head

- inspection - palpation

distributed - straight - normocephalic - symmetric - equal movement - equally aligned - the colors of cornea is transparent, shiny, and smooth and reflex blinking - the color of conjunctiva and

- presence of dandruff

4. Eyes

- inspection

5. Ears

- inspection - palpation

sclera is white - normal visual acuity - no discharge presence

6. Nose

- inspection

- no presence of mass - normal hearing - no nasal discharge - has ability to

7. Mouth

- inspection - palpation

smell -air moves freely - no swelling - no mucus

8. Lips

- inspection - palpation

obstruction - no eruption, spots or pigmentation - no presence of

- pale in color

9. Tongue

- inspection - palpation

mass - reddish - soft - no swelling

10. Gums

- inspection

- no cracks or blisters - slightly rough - no nodules

11. Teeth

- inspection

- has normal sense of taste - not swelling - pinkish in color

- presence of dental carries - lose tooth (molar)

12. Tonsils

- inspection

- no signs of bleeding - no signs of

13. Neck

- inspection

atrophy

- palpation

- yellow white in color - no prosthesis

14. Breast

- inspection - palpation

- reddening - no difficulty of swallowing - no lesions - no irritations - no presence of mass - shape is symmetrical - nipples are at same direction

15. Lungs and Thorax

- inspection -palpation - auscultation

- not tender - no presence of mass - absence of nipples discharge - nipples are not cracked - normal

16. Heart

- inspection - auscultation

breathing pattern - rhythm pattern is regular

- no presence of 17. Abdomen - inspection - auscultation - palpation murmur and wheezes - the sound is clear - regular in rhythm - no presence of murmurs - heart sound is 18. Anal - interview clear - presence of linea nigra and 19.Integument: Skin - inspection - palpation striae gravidanum - uniform in color - soft and smooth - no tenderness - FHB: 130 bpm in the right lower quadrant - absence of 20. Extremities - inspection - palpation fistula - absence of hemorrhoids

21. Neurological

- observation

- smooth and semi form - uniform in color - uniform temperature or within the normal range - irritated

- observation 22. Emotional status

- smooth - no irritation - no presence of masses - conscious and alert - oriented regarding the time and place - absence of amnesia - speech is clear - good balance and proper coordination - calm

ANTEPARTAL ASSESSMENT: difficulty of breathing restlessness irritability

NURSING DIAGNOSIS:

Ineffective breathing pattern (dyspnea) related to increased pressure on the diaphragm.

PLANNING:

After nursing intervention (during home visits), the patient will be able to identify and learned some teachings to reduced shortness of breath.

INTERVENTIONS: Instructed and encouraged patient to sit up right. It allows the weight of uterus to fall away from the diaphragm.

Advised mother to add two or more pillows during bed time, it aid in e respiration

Advised her to limit her activities Encouraged adequate rest periods between activities to prevent tiredness that leads to shortness of breath.

Positioned comfortably

EVALUATION: Goal met as evidenced by: patient was able to identify and learned some techniques to reduce the occurrence of shortness of breath.

INTRAPARTAL ASSESSMENT: Facial grimace Restlessness Presence of perspiration Irritability Sighing

NURSING DIAGNOSIS: Alteration in comfort, related to labor contractions.

PLANNING: Client will complete labor and birth experiencing tolerable level of discomfort. INTERVENTION: Provided comfort measures such as back massage. Supported breathing pattern efforts as needed. Respected necessity to focus during contractions. Encouraged diversional activities like talking. Advised client to have adequate rest periods.

EVALUATION: Goal met as evidence by: the mother can able to tolerate the pain.

ASSESSMENT: Irritability Restlessness Perspiration

NURSING DIAGNOSIS:

As pregnancy advances, lumbar lordosis occurs and postural changes necessary to maintain balance will cause backache/back pain.

PLANNING: During visit, patient will be able to verbalize methods that provide relief. INTERVENTION: Instructed mother to avoid standing in a long period of time. Advised her not to bend in lifting objects instead to stoop. Encouraged mother to wear shoes with a low heels. Demonstrated breathing technique. Provided comfort measures such as back rub, changing position, heat/cold application. EVALUATION: Mother was able to verbalized methods that may provide relief and reduced irritability.

POSTPARTAL ASSESSMENT: Lack of eye contact Irritability Restlessness

NURSING DIAGNOSIS: Self-esteem disturbance related to lack of knowledge regarding psychological changes during postpartal period. PLANNING: After the visit, mother will be able to demonstrate adequate selfesteem despite seemingly inappropriate emotions. INTERVENTIONS: Reviewed client that postpartal sadness is common, knowledge about her reactions can offer a sense of control. Explored the factors that a concern or worthy to her. Assured her that simple postpartal sadness runs a short natural course. Provided client with some relief about expected duration of her sad emotions. EVALUATION:

The mother voices that she understands conflicting emotions commonly occur during postpartal period and probably related to the rapid change in hormone level.

ASSESSMENT: Restlessness Frequent yawning Exhausted

NURSING DIAGNOSIS: Sleep pattern disturbance related to exhaustion due to excitement for the new member of the family. PLANNING: The mother will be able to perceive enough sleep to feel rested during postpartal period. INTERVENTIONS: Provided uninterrupted periods of rest. Provided quite environment and comfort measures

EVALUATION: Goal met