Nội dung text WK2 - History Taking of Normal Pregnant Client.pdf
J.A.K.E 1 of 5 Bachelor of Science in Nursing 2YA NCMA217 RLE: HISTORY TAKING OF NORMAL PREGNANT CLIENT Discussed by: Prof. Marlyn Cabading Prof. Donato Mirador HISTORY TAKING OF NORMAL PREGNANT CLIENT Maternal & Child Health Nursing - Involves the care of the woman and family throughout pregnancy and childbirth, and it is also including care of the children and family - Aim: “Every pregnancy will result to a healthy Mother, healthy baby and a healthy family unit.” Goals of MCN • Health promotion – by educating clients to be aware if the good health through health teaching/health education and role modeling • Health Maintenance & Prevention of Illness – by intervening to maintain health when risk of illness is present • Health Rehabilitation – by preventing further complications from an illness; bringing client back to optimal status of wellness or helping the client accept inevitable death AIM OF MCN: “Every pregnant client will result to a healthy mother, healthy baby and a healthy family unit.” Duties and Responsibilities in Maternal Care 1. To look after all pregnant women 2. To advice all pregnant women and postpartum women about the following: 3. To identify women who are at RISK and refer to nearest hospital 4. To diagnose and treat minor problem of pregnancy 5. To give emergency treatment to major problems of pregnancy and refer immediately 6. To encourage regular PRENATAL CHECK UP; FREQUENCY OF VISITS (depends on the health condition of the woman and doctor’s order) • First Trimester: every month • Second Trimester: every two weeks, more frequently if problems exist • Third Trimester: weekly up to 42 weeks NOTE: o Talk to every woman individually and LISTEN to what she says o RISK FACTORS are conditions that a woman has in her medical history or history of previous pregnancies and deliveries, that put her at risk for COMLICATIONS Antepartum Care - Refers to the medical and nursing care given to the pregnant woman bet. conception and onset of labor - Consideration is given to the physical, emotional, and social needs of the woman, the unborn child, her partner, and other family members. Developmental Task of Pregnancy • Acceptance of the biological fact of pregnancy - “I am pregnant” • Acceptance of the fetus as a distinct individual and a person to care of - “I am going to have a baby” • Prepare realistically for the birth and parenting of the child - “I am going to be a mother” Maternal Adaptations to Pregnancy First trimester • Ambivalence, fear, fantasies, and anxiety • Pregnant woman places main focus on self Second trimester • Tranquil period • Acceptance of the reality of pregnancy • Increased interest in fetus Third trimester • Anticipates labor and delivery; assumes mothering role • Fantasies and dreams about labor common. • Nestling behaviors History Taking of Normal Pregnant Client - involves asking questions relevant to a patient’s current and previous pregnancies. Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential. - Taking an obstetric history requires asking a lot of questions that are not part of the “standard” history taking format, therefore it’s important to understand what information you are expected to gather. - It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely, therefore your history should be gynaecology focussed (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy). Steps in History Taking 1. Establish rapport (by introducing yourself and explain the visits in order to gain trust of the client and the family) 2. Relax and make the environment private setting 3. Have somebody with the patient during interview (in case nga na ibang language ang gamit nila, meron kang interpreter sa pamilya nila in order to you to understand the client) 4. Use Ms. Mrs. NOT – Mother, Ate, etc (wag feeling close mars, chos) 5. Prepare your questions, so that you can focus on the answers of the client. 6. As an open – ended questions, when possible, to increase client level of comfort and confidence (ex. Tell me about the issues you’ve been experiencing [sa open-ended question madami ka ng info makukuha mula sa client]) Component of Normal Pregnant Health History a) Demographic Data - Name - Date of birth - Age - Address - Marital status (married Church, civil) live in partner - Religion (Roman Catholic, INC., Seventh Day, Jehovah’s witness, etc.) [need mong alamin para alam mo kung papaano mo sila maaapproach lalo na pag dating sa health conditions] - Allergies for medication (identify the classification of drug) (Dito sa Demographic Data mag ca case presentation dito, pero REMEMBER kapag nag case presentation wag gagamitin ang FULL NAME ng patient pero sa form ang nakalagay is
NCMA217 RLE: HISTORY TAKING OF NORMAL PREGNANT CLIENT (MAM CABADING & SIR MIRADOR) J.A.K.E 2 of 5 FULL DATA about sa client. Gamitin lamang ang kanilang alias or nickname. Always observe the privacy of the client) b) Alcohol / tobacco cigar use (consumption – ilan ang nakokonsumo or nanagamit sa isang araw, frequency – gaano kadalas gumamit or uminom, brand – mighty bayan, camel, marlboro, tanduay, empi, red horse, duration – gaano na katagal gumagamit or umiinom) c) Medical condition (specify the condition, duration, action taken) d) Treatment (doctor, albolario, others) e) Work (type of work, schedule, condition, salary bracket) (sa salary bracket kapag ayaw sabihin sainyo or feel nyong ayaw ipaalam wag pilitin mars [kaya ka nasasaktan eh char], gumawa ng ibang way para malaman mo kung magkano kinikita nila if arawan or monthly) f) Children detail (make a chart) - Name (from eldest to youngest) - Date of birth - Sex - School/grade (government or private school) - Other adult in household g) Need identified (health, financial, health education, family relations, sanitation) (sa sanitation wag defensive kapag mali yung ginagawa nila, educate them) h) Plan during delivery who to involve and where to deliver Gynecologic and Obstetric History • Chief complaint • History of illness (past medical history) • Menstrual pattern - Cycle (days) – irreg or regular - Duration of flow – was it equaled or exceeded - Amount of flow (based on pad’s use if soaked or not) - – masyado bang malakas or tama lang - Associated pain - Intermittent bleeding - Age of menarche • Contraception current method, satisfied with the method? • Infections (during vaginal and rectal exams) • Any difficulty in conception current and previous • Description of each pregnancy and outcome • Describe any maternal, fetal, neonatal complications • Hospitalizations (when, where, what is the cause) • Childhood diseases (what specific health problem) • Surgical history • Medication and allergies - Over the counter medication - Herbal preparation • Health maintenance - Diet and nutritional status - Exercise, elimination, sleep, hobbies - Immunization and date administered Family Profile - Who lives with her, living condition, total family members - Occupation – does the woman involve heavy lifting, long hours of standing, handling toxic substances (bawal humawak ng kahit anong toxic substance ang buntis dahil makakasama ito sa baby) - Education (grade school, high school, college level) [kinakailangan malaman ang mga ito upang alam mo kung papaano ang approach at ano ang level of language na pwede mong gamitin para ma intindihan ng client yung mga bagay- bagay) History of Family Illness - Family illness such as (HPN, Diabetes, asthma, allergies, cancer) on both the father and mother - There are illnesses that could become a potential problem during pregnancy or one that could be transferred to the fetus Obstetric History - History of pregnancies-include number of past pregnancies, outcome, complications, labor time, type of delivery, complications, infant status, and birth weight - Gravida / Gravidity – number of times a woman is or has been pregnant regardless of the outcome. A current pregnancy is included in this count. o Nulligravida – never been pregnant o Primigravida – pregnant for the first time o Multigravida – A woman who has had 2+ pregnancies - Para / Parity – number of pregnancies that reach the age of viability (include the live births and still birth) the number of fetus does not determine the parity. o Nullipara – 0 pregnancies beyond viability o Primipara – one pregnancy that has reached viability o Multipara - 2+ two or more pregnancies that have reached viability - Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age 20 – 24 weeks, 5 to 6 months - Grand Multigravida – woman who delivered 5 or more infant - Term – If the baby born anytime between 37 – 42 weeks - Preterm – If the baby born before 37 weeks - Abortion – if the baby delivered before the age of viability - LMP – Last menstrual period GPTPALM Score • Gravida – number of pregnancies • Para – total no. of deliveries > 20 weeks AOG • Term – total no of infants born at term / 37 weeks / more • Preterm – total no. of infants born before 37 weeks • Abortion – total number of spontaneous or induced abortions below 20 weeks gestation • Living – total number of children currently living Multiple – total number of multiple pregnancies General Rule • Multiple gestation (twins/triplets etc) is counted as one pregnancy and counted as P1 (one parity) • Still birth/intrauterine fetal demise (IUFD) – is counted as one viable pregnancy • If it falls bet. 37 – 42 weeks it is under a term pregnancy • If it falls less than 37 weeks but more than 20 weeks it is counted in preterm pregnancy • If the product of conception was delivered before the age of viability (20-24 weeks) it is considered abortion • Primigravida- a woman who is pregnant for the first time • Primipara- a woman who has given birth to one and child past of age of viability • Multigravida- a woman who has two or more pregnancies • Nulligravida- a woman who has never been pregnant and is not currently pregnant.
NCMA217 RLE: HISTORY TAKING OF NORMAL PREGNANT CLIENT (MAM CABADING & SIR MIRADOR) J.A.K.E 4 of 5 Fundal Height - Measurement of fundal height from the top of symphysis pubis to the end of the fundus with a flexible, non-stretchable tape measure; used as a gross estimate of dates • Above the level of symphysis – bet. 12 – 14 weeks • At the umbilicus or 20 cm – about 20 weeks • Rises about 1 cm/week until 36, after which it varies To find out how many days a month has: Age of Gestation • JAN - 31 days example: LMP June 11, 2020 • FEB - 28/29 days 6 - 11 - 2020 • MAR - 31 days - 30 • APR - 30 days 19 Jun • MAY - 31 days 31 Jul • JUN - 30 days 31 Aug • JUL - 31 days 30 Sep • AUG - 31 days 31 Oct • SEPT - 30 days 30 Nov • OCT - 31 days 31 Dec • NOV - 30 days 31 Jan • DEC - 31 days 23 Feb 257/7 = 37 wks AOG LMP Aug 12, 2020 = 195/7 = 27.85 = 28 1/7 wks AOG Mc Donald’d Rule - determines AOG in month by measuring from - symphysis pubis (cm) to the fundus - used if the woman does not know or not sure of her LMP Fundic Height in cm x 8 = AOG in weeks 7 Fundic Height in cm x 2 = AOG in months 7 - measure the fundal height with a tape measure if the woman is more than 20 weeks’ pregnant. - Hold the tape from the top of symphysis tot the top of uterine fundus - Normal fetal heart rate 120-140 BMP Bartholomew’s Rule - Estimate age of gestation by the relative position of the uterus in the abdominal cavity - To determine age of gestation by fundic location - 3rd mo. – the fundus is palpable above symphysis pubis - 4th mo.- midway between symphysis pubis and umbilicus - 5th mo. – the fundus is palpable at the level of umbilicus - 9th mo. – the fundus is below xiphoid process Haase’s Rule - to determine the length of the fetus in centimeter • First half of pregnancy (1 - 5 months) months 2 • Second half of the pregnancy (5-10 months) month x 5