 MISSION

VISION Republic of the Philippines

A premier university in historic
Cavite recognized for
excellence in the development
of morally upright and globally
competitive individuals.
CAVITE STATE UNIVERSITY
Don Severino Delas Alas Campus
Indang, Cavite
Cavite State University shall provide
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through
quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for
global competitiveness.

College of Nursing

PREGNANT WOMAN

Presented by:

LEVEL 2 / SECTION 5/ GROUP # 4

AIRA MARIE C. DOROTEO

Presented to:

Prof. _________________ , RN, MAN

Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Clinical Instructors, Level II or III

Date:

Month xx, year

In Partial Fulfillment of the Requirement in NURS 50/55 or NURS 60/65 for the Degree Bachelor of
Science in Nursing
 TABLE OF CONTENTS

I. Demographic Data………………………………………………………………………………….1
II. Reason for Seeking Health Care…………………………………………………………………1
III. History of Present Illness…………………………………………………………………………..1
IV. PastMedical History………………………………………………………………………………...1
V. OB-Gynecological History………………………………………………………………………….1
VI. Heredo-familial History…………………………………………………………………………...1-2
VII. Gordon’s Functional Health Patterns……………………………………………..2-
VIII. Physical Examination…………………………………………………………………….5-12
IX. Review of Systems…………………………………………………………………………13
I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name: R.L.C
B. Address: 430, Kayquit 3 Indang, Cavite
C. Age: 25 yrs old
D. Birth Date: August 31, 1994 Date of Interview: Sept. 7, 2019
E. Birth Place: Indang, Cavite Primary Informant: Client
F. Gender: Female Secondary Informant:
G. Civil Status: Married Other Data Sources:
H. Religion: Roman Catholic
I. Highest Educational Attainment: High School Graduate
J. Occupation: Sensus Worker
K. Monthly Income / Budget: 5,000-7,000 php/month

II. REASON FOR SEEKING HEALTH CARE

Home Visit

III. HISTORY OF PRESENT ILLNESS

IV. PAST MEDICAL HISTORY

The client has been hospitalized when she is young due to her Amoeba wherein she is 10 years
old as she remembered. The client has also went for check-ups in health center due to her asthma but
she stated that it is mild and she used to use a nebulizer once a day as a method of healing. Currently,
the client's asthma doesn't affect her present condition. The client stated that she has completed all the
immunizations needed when she is young. The client has never been injured or included in an accident
as well as an operation but the client has a food allergy in squid balls in which every time she eaten it
there was a reddening spots in her body. The client stated that when she is 21 years old, she happened
to felt a small breast nodes in one of her breast but she added that she felt no pain and the breast
nodes felt not anymore.

V. OBSTETRIC-GYNECOLOGICAL HISTORY (if applicable)

VI. HEREDO-FAMILIAL HISTORY
A. Genogram
Paternal Side Maternal Side
CT DU DM MR

64 y/o 65 y/o 59 y/o 55 y/o

JT LB A&W CVA CA
A&W 25 y/o 36 y/o
unknown LEGENDS: will depend on what is used.

NDT ET GB

A&W 5 y/o 3 y/o PIH 8 y/o COPD

A&W A&W A&W

VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management

The client perceives her health to be good and view her pregnancy as a blessing and not
an illness. She stated that she has always strived to maintain a healthy and safe lifestyle for
the reason that her pregnancy was very sensitive. "Hangga't kayang ingatan, iingatan", she
added. The client believes that her employment as a sensus worker cannot be a hindrance to
her present condition but served a safety measure she withdraw from the work and followed
the instructions of the doctor. The client is currently in a bed rest as recommended by the
doctor.

The client said to have never tried smoking and she denied being an alcoholic beverage
drinker as well as an illicit drug user. She believes that those are not safe for her pregnancy.
 With this current pregnancy, the client was prescribed vitamins such as Foralivit capsule twice
daily, calcium carbonate only once a day, and sanofi thrice daily during her prenatal check up
to which she took religiously and without fail.

The client has a cough 4 months ago this current year and the only medication that she
implemented is to drink calamansi juice continuously. The client believes that in able to keep
her healthy, eating leafy vegetables and carried out her doctor suggestions and instructions
very well and without fail. Having enough sleep daily and drinking 6-8 glasses of water daily
is a must to maintain her healthy lifestyle. The client recently had an U.T.I due to lack of water
intake. As an action, she immediately consulted her doctor and given her antibiotic that last
for 7 days. The immediate action was helped her in fast recovery "dati masakit, ngayon hindi
na", she added. The client also don't do exercise except for light household chores activities.

B. Nutritional – Metabolic

During a 24 hour period, the client usually consumes three main meals together with a
snacks which is usually a bread and a milk during night. She has no food supplements and
vitamins taking unless it was prescribed by the doctor. She believes water intake can influence
her health conditions as she had U.T.I not a long ago. Since the client has no work anymore, she
mostly focused on her food and fluid intake as the main goal to her pregnancy. The client noticed
that she gain weight from 39 kilograms to 44 kilograms as expected to a pregnant woman. It is
stated that a normal expected weight of a pregnant woman should be in 25-35 lbs. Meanwhile,
she is 149 cm in terms of height. The client also stated that there is no change in her appetite as
usual it is normal without nay discomfort or difficulties. She has no food diet or restrictions except
for eating much more of leafy vegetables and fruits as recommended.

The client’s skin condition seen to be color as her skin tone, warm, has a smooth skin
without signs of edema or swelling but there is a scars in her lower extremities. She has a good
skin turgor, skin is intact, and no bruises or lesions. However, there are mosquito bites not more
than 1cm on both arms especially in the elbow part. The client has a body temperature taken
axillary which is 35.6 C.

The client has a regular prenatal care to monitor her condition. She regularly has a check-
up monthly or if the doctor scheduled her in a specific time and date and even when there is a
pain felt she immediately consult her doctor. The client said that she actively participated in
 programs about pregnancy in which she believe that it is necessary to have knowledge. She is
accompanied by her mother or sister for the reason that her husband is in work.

*3-day Diet Recall

MEALS Date & Day Date & Day Date & Day
Breakfast (time)
Snacks (if any) - amount per serving - amount per serving - amount per serving
Lunch (time)
Snacks (if any) - amount per serving - amount per serving - amount per serving
Dinner (time)
Snacks (if any) - amount per serving - amount per serving - amount per serving
Total Fluid Intake ___mL ___mL ___mL

C. Elimination

When reflecting on her voiding pattern, client stated she voided approximately once per
day dependent on her fluid and food intake, and about the same amount at home in the evening.
The client experienced difficulty in bowel elimination as complaint. She has never used
suppositories, supplements or other medication for constipation that is due to her pregnancy and
has a complaint of not being farted after meal. The client described her stool as hard formed,
black in color as she takes iron vitamin for her pregnancy, and in consistent amount with no
hemorrhoids seen. Meanwhile, her urinary elimination is mostly every morning daily without
discomfort of difficulties felt. The client has a firm abdomen when palpated and has a symmetrical
and rounded abdomen.

D. Activity – Exercise

As discussed in the health perception-health management pattern, the client has no

physical activities nor sports except light weight household chores because she is in a bed rest
pregnancy. She believes instructions of her doctor are must and meant for her own good towards
the health of the baby. The client mostly watched in television and has her mobile phone when
she has a leisure time at all times. She has a preschooler child that she helped to read after
school. She also stated she is very independent in performing her personal activities. The client
has no signs of tremors or swelling.

*7-Day Activity Table

Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
12 nn
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
12 mn
 *Katz Index of Independence in Activities of Daily Living
Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or personal With supervision, direction or
assistance needed personal assistance or total
care
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
TOTAL POINTS:

E. Sleep – Rest

According to the client, she thoroughly enjoys sleeping and will generally achieve 6-8
hours of sleep per night. However, her sleeping hours depends on her stomach pain. The
client usually experienced difficulty in sleeping due to constipation or cramps. She believes
that sleeping provides her with enough rest. The client usually on a left side position on her
bed together with a two pillows for the head and one pillow for the thigh. She says she is much
more comfortable in sleeping with extra pillows. She states she awakens during at night
sometimes to urinate and experiences difficulty returning to sleep. She has no sleeping pills
taken, “hinahayaan kona lang kung hindi makatulog.”

*7-Day Sleep Diary

Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep
Sleeping Time
Waking Time
Bedtime Rituals
Feeling upon
waking up
 Problem
Encountered

F. Cognitive – Perceptual

The average brain shrinks approximately 5-10 % in weight between the ages of 20
and 90 resulting in a decrease in working memory, however, the brain can adapt and grow new
cells. But this is dependent on physical activity, stimulation and learning (Santrock, 2006).
The client finished her secondary education and she understands Tagalog and English. She
does not wear reading glasses as she can read in far and near text. She is not experiencing
dizziness and blurred vision. The client also hears very clearly except the distance of whom she
is speaking is way too far. She smells strong and weak odor and not noticed changes in her
ability to touch. As of the interview, the client feels no pain and with a pleasant and calm mood.
However, she admits having a mood swings or easy to get angry mostly when her siblings does
not follow her. She states no change in sexual desire and her pregnancy was very accepted by
her family and husband. She answers questions quickly, relatable, and with focus. The client
can also remember her recent memory for the week or month passed.

G. Self-Perception – Self-Concept

According to the client, she was very happy for her current pregnancy. She is excited to
see herself with her growing baby. The client feels scared due to her condition but despite of
that she is excited to be a mother. The client is seen to be calm, can dress appropriately, and
has hygienic environment. Throughout the assessment, the client has a change in volume of
voice and without hesitation to answer readily. She states answers with eye contact and with
some gestures. The client views her body image as positive but sometimes negative. During
her first child pregnancy, she felt depressed and get conscious of her body changes. In her
second child pregnancy, she does not felt depression anymore but felt stressed for the reason
that her condition was very sensitive. Currently, she states acceptance in her body image in her
third child pregnancy. The client says her husband helped her to make decisions especially
during her first pregnancy which happened to be miscarriage. When asked, any music helped
her to relieved stress or even loneliness. The client describes herself as, “mabait kapag mabait
 saken.” She feels good about herself but sometimes compared to other pregnant women who
are not sensitive as she is.

H. Role-Relationship

The client is a mother, daughter, sister, wife, friend, employee, and work colleague. She
views her primary roles at this stage of her life as being a wife, mother, daughter and a friend.
She feels the support of her family especially her husband. The client states she does not live
alone. In their original house, she lived with her 6 years old son and her husband. However, her
husband’s workplace is in Batangas so he goes home every weekend only. She cannot perform
her role due to her condition. Currently, the client is in her parent house for the reason that she
can’t be leave unattended because of her sensitive pregnancy. She is also with her relatives
which helped her in needs for assistance of daily activities. The client has a good relationship
with her parents and siblings. She loves her husband and enjoys close relationship with her
son. Her friends and family in the same residence accepted and very supportive in her
pregnancy. She does not belong to any social groups and mentioned that she does not have
any social activities participated even before pregnancy. “Hindi ako naglalabas ng bahay,” she
added.

I. Sexuality – Reproductive

The client had her menarche when she was 12 years old. She has no problem with her
menstruation ad usually experienced dysmenorrhea during menstruation. She had her last
menstrual period on March 14, 2019. They are not using contraceptive method. However, she
used to use pills and withdrawal as a contraceptive method but it does not last longer only for
about 5 months.

The client has experienced minimal interest in being sexually active and cites a definite
loss of libido due to her condition. She believes sexual intercourse is not appropriate to
pregnancy especially with her sensitive case. She has no history of vaginal bleeding nor history
of sexual transmitted disease (STD). A good health maintenance plan includes regular health
 screenings, including pap smears, self-breast examination and mammograms (Beifer &
Harrison 2004, p.215).

J. Coping-Stress

The client verbalized that whenever she has a problem, she is sharing it with her husband
sometimes with her parents. She cites her husband as being her primary support and states
they have always talked through as a family any issues which may effect on her coping
mechanisms. The client mentioned that the big event that changed her life was 7 years ago
when she suffered from miscarriage to her first child. Again her husband and family were her
primary means of support during that time.

Being aware of what causes stress, how you react and having a network of support are all
strategies which can help you to manage and control stressful events (Andrew 2005, p.59). She
feels she has accepted the outcomes from that event and moved forward. The client considered
financial aspect as an important concern to her pregnancy but somehow relieved because of
her membership in Philhealth. She also added she get stressed every time her son and sisters
were not following her. The client clarify that she have never tried to drink alcohol, use
medication or take drugs to relieve stress. She believes that those things can harm her baby.
She does not think that she is problem to her family.

K. Value-Belief

An individual’s sense of spirituality can be influenced by culture, life experiences and

religious beliefs (Brush, 2000). The client is practicing Roman Catholic and does not have any
concerns related to ability to practice usual spiritual or religious customs. She admits not a
spiritual person as others but she has a faith which she believes is the most important. She has
been married to her husband for many years and values her relationship with him. She
mentioned that they do not have religious restrictions. The client pray before going to sleep.
She occasionally goes to church due to her condition which she easily feel pain mostly when
she is walking for a long period of time
IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date / Time of Exam: ____________

T = __OC
PR = __ bpm
RR = __ cpm
BP = __/__ mmHg
Pain (if any…since this is the 5th vital sign, using the PQRST method)
Provoking factor
Quality
Region/radiation
Severity (using pain or face pain scale)
Time

B. Anthropometric Data (only those applicable)

Height = __ cm (for both adult & pedia) BMI = __ (for adult)
Weight = __ Kg (for both adult & pedia) IBW = __ (for adult & pedia)
Head Circumference = __ cm (for pedia)
Chest Circumference = __ cm (for pedia)
Abdominal Circumference = __ cm (for pedia0

C. General Appearance
1. Body build and height-weight proportionality
2. Posture and Gait
3. Over-all hygiene and grooming
4. Body and breath odor
5. Obvious signs of distress / illness
6. Mental status
7. Attitude
8. Affect/mood; appropriateness of responses
9. Quantity and quality of speech
10. Relevance and organization of thoughts

LINTEGUMENT
Skin
I: color, uniformity,
edema, lesions
P: moisture, temp.
turgor
Hair
I: evenness of growth
thickness, texture,
oiliness, infection
or infestation, body
hair
P: smoothness
Nail
I: plate shape, texture,
bed color,
surrounding tissues
P: Blanch test
HEAD
Skull and Face
I: size, shape ,
symmetry
: facial features
: eyes for edema
and hollowness
P: nodules, masses,
depressions
Eyes and Vision
I: eyebrows for
distribution &
alignment, quality &
movement
: eyelashes for
evenness of
distribution &
direction of curl
: eyelids for surface
characteristics,
position in relation to
cornea, ability to
blink & frequency
: bulbar & palpebral
conjunctiva for
color, texture, and
lesion
I/P: lacrimal gland
sac, nasolacrimal
duct for edema,
tenderness / tearing
I: cornea for clarity,
texture & sensitivity
I: pupils for color,
shape, symmetry of
size, direct and
consensual reaction
to light, &
accommodation
* Visual Acuity (near
& far vision test)
* Visual Field Test
* EOM Test
Ears and Hearing
I: auricles for color,
symmetry and
position
: external canal for
cerumen, lesions,
pus or blood
P: auricles for texture,
elasticity and areas
of tenderness
* Gross Hearing Acuity
Tests: normal voice
tone and whispered
voice
* Watch Tick Test
* Tunning Fork Tests:
- Weber for bone
conduction
- Rinne’s to compare
air and bone
conductions
Nose and Sinuses
I: nose deviation in
shape size, color,
flaring, discharge;
: nasal mucosa for
redness, swelling,
growth or discharge
Pa: tenderness,
masses,
displacements;
: nasal patency
: maxillary and
frontal sinuses for
tenderness
Pe: the above sinuses
for tenderness
Transillumination Test
Mouth / Oropharynx
I: lips for symmetry of
contour, color,
 texture, moisture,
lesion
: teeth for alignment,
loss, dental filings
and caries;
: gums for bleeding,
color, retraction,
lesions, swelling
: tongue for position,
color & texture;
movement, as well
as the base of the
tongue, mouth floor
and frenulum
: salivary gland
ducts for swelling,
redness
: palates for color,
shape, texture,
presence of bony
prominences
: uvula for position &
mobility
: oropharynx for color
& texture
: tonsils for color,
discharge, and size
Test for Gag Reflex
P: nodules, lump and
excoriated areas
NECK
Neck Muscles
I: abnormal swelling or
masses, head
 movement, and
muscle strength
Lymph Nodes
P: enlargement
Trachea
P: lateral deviation
Thyroid Gland
I: symmetry and visible
masses, rise during
swallowing
P: smoothness
A: bruit
THORAX & LUNGS
Posterior Thorax
I: shape & symmetry
from posterior-lateral
views; spinal
alignment for
deformities
Pa: temperature,
bulges, tenderness,
abnormal
movements,
respiratory
excursion, vocal
fremitus
Pe: for symmetry of
resonance;
diaphragmatic
excursion
A: breath sounds

Anterior Thorax
I: breathing pattern,
coastal and
costovertebral angle
Pa: respiratory
excursion, tactile
fremitus
Pe: symmetry of
resonance
A: breath sounds
Heart
I: precordium for
pulsations & lifts or
heaves
A: heart sounds (S1,
S2, etc.)
Central Vessels:
Carotid Arteries
P: volume, quality
A: bruit
Jugular Veins
I: distention
Peripheral Vessels
I: presence or
appearance of
superficial veins,
signs of phlebitis
*Buerger’s Test
*Capillary Refill
Breast & Axillae
I: breast for size,
symmetry, contour or
shape, discoloration,
retraction,
 hypervascularity,
swelling, edema
: areaola for size,
shape, symmetry,
color, surface
characteristics,
masses, lesions
: nipples for size,
shape, position,
color, discharge,
lesion
P: lymph nodes,
breast, areola &
nipples for
tenderness, masses,
nodules, discharge
ABDOMEN
I: skin integrity, contour
& symmetry, hernia,
distention (girth),
movements
associated w/
respiration,
peristalsis & aortic
pulsations
A: bowel, vascular, &
peritoneal friction rub
sounds
Pe: all quadrants /
regions for tympany
and deviations
Pa: light to deep
palpations ALL
quadrants from least
 painful to most
painful for masses,
tenderness, muscle
guarding; liver
(bimanual) and
bladder palpation
* Leopold’s Maneuver
for OB clients for If necessary /
presentation, lie, applicable /
engagement, significant
attitude, position
MUSCULOSKELETAL
Muscles
I: size, contractures,
fasciculations,
tremors
P: tonicity, flaccidity,
spasticity,
smoothness of
movement, strength
Bones
I: structure, deformity
P: edema, tenderness
Joints
I: swelling
P: tenderness,
smoothness of
movement, swelling,
crepitation, nodules
NEUROLOGIC
Mental Status
- Language
- Orientation
- Memory
- Attention Span /
Calculation
Consciousness Level
Glassgow Coma Scale
Cranial Nerves
- I to XII For Adult
Reflexes
- Deep, superficial & For Pedia
pathologic
- Neonatal Reflexes
Gross Motor/Balance
* Walking Gait
* Romberg
* Standing on 1 foot w/
eyes closed
* Heel-toe walking
Fine Motor
- Upper Extremities:
* Finger-Nose Test
* Alternate Supination
& Pronation of hands
on knees
* Finger to Nose & to
RN finger
* Fingers-to-fingers
* Fingers-to-thumb
- Lower Extremities:
* Heel down opposite
skin
* Toe / Ball of Foot to
RN’s finger
Sensory Function
* Light/Deep Touch
* Pain Sensation
* Temperature If necessary /
* Position / Kinesthetic applicable /
* Tactile Discrimination significant
GENITALS
*For males:
I: pubic hair for
distribution, amount,
characteristics
: penis shaft and
glans for lesions,
nodules, swelling,
inflammation
: urethral meatus for
swelling,
inflammation,
discharge
: inguinal areas for
bulges or swelling
P: penis for
tenderness,
thickening, nodules
: scrotum for
appearance, size and
symmetry, and
underlying testes,
epididymis and
spermatic cord
: inguinal areas for If necessary /
palpable bulge applicable /
* For females: significant

RECTUM & ANUS

I: anus and
surrounding tissue
 for color, integrity,
lesions
P: anal spinchter
tonicity, nodules,
masses and
tenderness
: if male, prostate
gland for tenderness
: if female, cervix
through the anterior
rectal wall for
tenderness

If necessary /
applicable /
significant

XI. Review of System (include only those that are significant to the case under study)
A. Neurologic
B. Pulmonary
C. Cardiovascular
D. Hematologic
E. Immunologic
F. Gastrointestinal
G. Renal
H. Musculoskeletal
I. Reproductive
J. Integumentary