Chapter 1 INTRODUCTION

Pregnancy is a significant event in every womans life. It involves remarkable changes in both physiological and psychosocial aspects of the woman, the husband and the support system of the couple. These changes are usually coupled with numerous adjustments. Therefore, the couple and their support system must be guided during this stage of life. Pregnancy differs from one woman to another and is affected by various factors. The experiences of a pregnant woman can neither be compared to her previous pregnancies. Thus, there are no two pregnancies that are alike.

Figure 1. Electron micrograph of Sperm and Ovum Union

Pregnancy starts when males sperm fertilize females ovum, which would be implanted on the lining of the uterus and undergoes growth and development. This condition may be diagnosed through the signs elicited by the health care provider through various tests/exams and the symptoms reported

by the woman through the manifestation of physiologic changes of the womans body. Through prenatal visit, pregnancy is confirmed along with its

complications and assessment for danger signs. A pregnancy complication is any condition or illness that threatens the mother and/or fetus during pregnancy that may result from a number of possible factors, including preexisting disorders or diseases (e.g., diabetes, high blood pressure) or abnormalities of the sperm or egg. Complications may also result from sexually transmitted diseases, abnormalities in the amniotic fluid (substance that surrounds the fetus during pregnancy), placental abnormalities and viral, bacterial and parasitic infections. With this, prenatal education is very important for the mother to know the measures they should take during pregnancy to safeguard their health from harmful substances, activities and danger signs.

Objectives of the Study These objectives serve as the basis of this study: Patient-centered y To render quality and effective nursing care in order to promote patients wellness. y To be able to help patient in motivating her to continue her pregnancy and the healthcare provided by health workers.

To impart to the client and his family member, information concerning the disease and provide health teaching that will enhance her understanding and cooperation for a better health care.

y y

To be able to help the mother to emotionally cope with her condition. To be able to increase health awareness and self-care responsibility of the family members.

To be able to establish an accepting environment with regards to the condition of the family member.

Nurse-centered y To be able to learn about the various aspects of pregnancy, its nature such as signs and symptoms, manifestations and causes and be able to give proper health care needs to the pregnant mother. y To develop and enhance nursing skills through meeting the needs of the patient and implementing an effective nurse-patient intervention in order to provide quality service. y To impart health teachings to the mother that will direct her into good and proper way of taking good care of her child and thwart the occurrence of diseases for their own benefit.

Nurse-patient y To create an effective nurse-patient relationship with the mother in order to gain trust with one another and be able to meet the needs of the family. y The nurse and the patient together with the family will be able to achieve their goal and duty in the prevention of pregnancy complications and in the promotion of health.

Chapter 2 BACKGROUND OF THE STUDY Personal Data Personal Background Mrs. M.G., 36 years old, Filipino, is a pregnant mother for about 4 months and it would be her second child. She was born on April 16, 1974 without any disease that may cause any complication to her present pregnancy. She got married to Mr. J.G. who is an Overseas Filipino Worker. She is a housekeeper and currently residing at Barangay Baroro, Bacnotan, La Union. She stands 5 feet and 5 inch tall with a weight of 136.41 lbs (62 kg).

Educational Background Mrs. M.G. spent her elementary life in Baroro Elementary School. She spent her high school life in Bacnotan National High School.

Socio Economic/Cultural Background Mrs. M.G. is a housekeeper who has an active social lifestyle. Her husband works abroad as an AutoCAD-designer with a monthly income of 40,000-50,000 pesos. Their family income is adequate for their needs and expenses. They stated that they have a stable income. She was raised with colorful traditions and wonderful customs. She and her husband is a member of Roman Catholic Church with common beliefs. She

is considered to be in middle class society because the couples have enough money to provide their needs and wants. She doesnt believe in superstitions. She doesnt consult quack doctors, instead she refer to her doctor if shes sick. They have a house of their own. They have their own water-sealed comfort room. Their house is surrounded with trees. Their electrical supply came from LUECO. The water supply is gathered through water pump but their potable water is bought from a water station. Their garbage are being collected but sometimes, they tend to burn it or burry. They are able to purchased appliances such as television, personal computer, radio, refrigerator, stove and fan.

Lifestyle and Health Practices Mrs. M.G. does not have any kind of vices. She never has had cigarettes and drinks containing alcohol before and during her pregnancy because she believes that it would put her baby at risk. She stays away from people who are smoking as one of safety measures. She eats 3-4 times a day which comprises eggs, a cup noodles, and a cup coffee in the morning and sometimes a cup of milk instead of coffee. Her meal in the afternoon and evening usually

comprises of fish viand, canned goods and a cup of rice. She has her snack time usually at 10am and 3pm which includes soft drinks, biscuit and junk foods. Whenever she gets hungry at night, she drinks milk or hot chocolate. She is not restricted by their religion from any food. The client voices no food dislikes and intolerances. She is currently taking in vitamin supplements like

Multivitamins+Minerals (Obimin) in a full coated tab, Folic acid (Folicard B) and Ferrous Sulfate.

Activity and Exercises Walking is the clients daily exercise. She does it for 30 minutes. She goes to the seashore every afternoon with the children from her neighbor. Going to the seashore is her resting period. From there, she can feel the air and she can hear the silence of the beach. Doing household chores like sweeping the floor, cooking, washing the dishes and clothes are one of her exercises too. She does not perform any type of heavy labor because she easily gets dizzy and tired. Whenever she feels bored, she watches television at noon and sometimes plays in the computer. The client goes to bed at 7pm and rises at 7am. She usually gets awaken at 3am because of dyspnea or difficulty breathing due to cough and colds. She resumes sleeping at 4am in an orthopneic position to relieve difficulty of breathing. She sometimes takes a nap in the afternoon whenever she feels tired and dizzy. She never used sleep medications.

Toxic Exposure She and her partner have not worked around chemicals or radiation. One of her brothers- in-law is smoking so she keeps away from him. Their family have cat but she explains that she does not play with it and have not

been exposed to the cats litter or feces. Her mother-in-law shares that she immediately cleans the cats feces and washes hands after cleaning it.

Roles and Relationships The client has been married for 9 years. She describes relationship and having their second baby is the best part of her life now. She and her husband consider the baby as a blessing and by that they can say that they are very blessed. The husband is very supportive and involved in the pregnancy though the husband is not in the country. The client states that the family of her husband is also very supportive. Her mother-in-law even goes with them during check up. The pregnancy was introduced already to her parents and siblings who are in Balaoan. They are very happy about her pregnancy but at the same time worried of the unknown possibilities for the future. Nevertheless, her family expresses support to her.

Medical Surgical Background and History Family History Mrs. M.G. grew up with her family in Barangay Baroro, Bacnotan, La Union. Her mother T.A, 74, is hypertensive. Her grandfather died because of cardiac arrest. She has 2 siblings. One of her siblings had been delivered via normal spontaneous delivery while the other sibling was delivered through a cesarean section because of ecclampsia.

Personal History Mrs. M.G. grew up with asthma and hasnt undergone any medication. Though her mother, T.A. is hypertensive, and her grandfathers death is caused by cardiac arrests, she did not show any danger signs of hypertension. She had not experienced any cardiac attack. The client is not diabetic nor anemic. She did not experience having STIs. History of confinement is brought by urinary tract infection (UTI) and her first delivery. The history of Urinary Tract Infection (UTI) occurs during her teenage years wherein she feels burning sensation when urinating. Mrs. M.G. had a history of chickenpox, measles, and mumps during her childhood days. She did not have any history of sexually transmitted infection. She was immunized with BCG, DPT, and OPV. She had been immunized from Hepatitis B but her recent laboratory result proves that the vaccine is currently non-reactive. She didnt have any immunization from Treponema palladium, the causative agent of syphilis, and human papillomavirus (HPV). The client doesnt have any allergies to food and medications and did not undergo to any medical-surgical procedures aside from previous delivery.

Obstetric History Past Pregnancy This is Mrs. MGs second pregnancy with an obstetrical score of G2P1(T1P0A0L1). She had no previous miscarriages, molar pregnancies, and ectopic pregnancies. Her first child had been delivered via cesarean section.

She didnt experience any vaginal spotting, history of reproductive or infertility problems and reproductive surgeries. She never had a Pap smear examination. She has a history of Urinary Tract Infection (UTI) in her teenage years wherein she feels burning sensation when urinating and given Cotrimoxazole for treatment. She had cloudy and reddish urine on her 4th month of past pregnancy so a treatment of Cefalexin was prescribed by her doctor and also for her cough. She also occasionally notices some milky vaginal discharge in her underwear and denies breast pain, lumps and unusual fluid leakage that indicate infection. She was given Ferrous sulfate for iron supplementation and Folicard B for folic acid supplementation during her past pregnancy.

Present Pregnancy Mrs. M.G.s last menstrual period was April 21, 2010. Prior to pregnancy, her menstrual bleeding lasts for 5 days and is sometimes, irregular. She reported some delays of 2 months to 1 month before the occurrence of the next menstrual bleeding and had a menarche at the age of 14. As of August 15, 2010 from her LMP, her estimated age of gestation is 16 weeks and 4 days. Basing it from Bartholomews rule, fundic height seen was at the level between umbilicus and the symphysis pubis which indicates that the estimated AOG is 16-17 weeks while in McDonalds rule, the height from symphysis to fundus was 16.6 cm. The computation for the age of gestation (AOG) using this measurement is 4-5 in terms of months and 16 17 in terms

of weeks. The estimated date of confinement (EDC) through the Nageles rule is on April 28, 2011.

Signs and Symptoms of Pregnancy

The pregnant mother reported that she showed signs of fatigue mild headache, blurring of vision, nausea, vomiting, breast tenderness, tingling sensation of the breast, increasing breast secretion, heartburn and as well as uterine contraction.

Head-to-Toe Assessment

Head:

Hair Hair is equally distributed, smooth and firm, somewhat elastic, there is no hair loss, the scalp is normal and fine, absence of flakes, absence of dandruffs and absence of lice or ticks.

Eyes Conjunctiva and sclera appears normal, clear, and free of swelling or lesions, normal distant visual activity is 20/20 with or without contact lenses, the eye movements are smooth and symmetric throughout all six directions. No redness, swelling or lesions on both eyelids. Eyeballs are symmetrically aligned in sockets without protruding or sinking. The normal direct papillary response is constriction.

Ears Ears are equal in size bilaterally (normally 4-10cm). The auricle aligns with the corner of each eye and within a 10-degree angle of the

vertical position. The skin is smooth with no lesions, lumps or nodules. Color is consistent with facial color. The outer portion of the ears are free from cerumen, normally the auricle, tragus and mastoid process are not tender, the canal walls should be pink and smooth and without nodules. The tympanic membrane should be pearly, gray, shiny, and translucent with no bulging or retraction,. Vibrations are heard equally well in both ears, air conduction sound normally heard longer than bone conduction sound, the patient does not experience any hearing problems like tinnitus, otitis media, hearing loss and others.

Figure 2. Grading Palatine Tonsils Hypertrophy proposed by L. Brodsky

Mouth Lips are not dry, appear red, smooth and without lesions or swelling. The tongue is color pink, moist, with a moderate size with papillae present, the uvula is pink, fleshy, solid structure that hangs freely in the midline, the tonsils are at the scale of +1 or normal, either present or absent, normally pink and symmetric, no exudates, swelling, or lesions are present, throat is normally pink without lesions. 32 pearly whitish teeth

with smooth surfaces and edges no repaired of decayed areas; no missing teeth or appliances.

Neck The neck has normal color, absence of edema, absence of pain, no lymph nodes palpated, symmetric with head centered and without bulging masses. The movement should be smooth and controlled with 45-degree flexion, 55-degree extension, 40-degree lateral abduction, and 70-degree rotation. Trachea is midline.

Breast According to the client, there are no masses at her breast. There is no swelling. Client complains of breast tenderness. Breasts are symmetrical and hang freely. Areolas are dark brown. They are round and 36B in size. Nipples are nearly bilaterally in size and are the same location on each breast, usually everted, but theres a milk secretions and dry.

Chest The client has evenly colored skin tone without unusual prominent discoloration, does not use accessory (trapezius/shoulder) muscles to assist breathing. No pain, no swelling or edema, no rash, no palpable crepitus.

Abdomen- Abdomen appears normal for a pregnant mother. It causes a generalized protuberant abdomen, protuberant umbilicus, fetal heartbeat that can be heard on auscultation, tympany is percussed over the intestines and dullness over the uterus.

Female Genitalia- Client doesnt complain any enlargement or swelling of the lymph nodes. Client doesnt complain for any tenderness.

Upper Extremities Arms are bilaterally symmetric with minimal variation in size and shape. No edema or prominent venous patterning. The color varies depending on the clients tone which is normal, no

mass/swelling/tenderness

Lower

Extremities

The

color

is

pink

which

is

normal,

no

mass/swelling/tenderness/ulcerations/edema. Toes, feet and legs are equally warm bilaterally. Veins are flat and barely seen under the surface of the skin. Hair covers the skin on the legs and appears on the dorsal surface of the toes.

Review of Systems

Upon gathering the data and history of the patient named M.G., we further assessed that she has a normal findings. For her regular diet she stated that she always eating eggs, noodles, fish, crackers, soft drinks. She stated that she had no vices. The group found out that there are no swelling or lesions and her eyes are symmetric. In her hair, we observed that it is smooth and firm, no hair loss, absence of ticks and dandruffs, in ears, they are equally bilateral and no excessive cerumen present, and in mouth, absence of lesions, her lips appeared pink, moist. No edema present on the neck part. Her breasts are tender without any erythema or areas of increased warmth. Nipples are not inverted bilaterally but there is milk discharge and it is dry. Abdomen is soft, non-tender, and rounded. Upon

gentle palpation bilaterally of the posterior lower extremities, there are no areas of warmth, tenderness or swelling.

Vital Signs

The latest vital signs obtained are the following: Temperature= 36.8 degrees Celsius, Pulse Rate = 89 beats per minute, Respiratory Rate = 19 breaths per minute and Blood Pressure = 120/80. All the vital signs appear normal.

Anthropometric Measurements

The mothers weight is 136.41 pounds while her Height is 5 feet and 5 inches tall.

Diagnosis of Pregnancy

Subjective Data: The patient complains of headache, chest pain when tired, difficulty of breathing, abdominal pain, feeling of weakness and fatigue.

Objective Data: The patients vital signs are WNL: oral temperature is 37.6 degrees centigrade, apical pulse is 89, respirations are 19 breaths per

minute and blood pressure is 120/80. Lung sounds are normal. The trachea is midline, respirations are regular and symmetrical on room air, and there is no use of accessory muscles. Skin is normal, warm, and dry. No edema in

the lower extremities bilaterally. Mrs. M.G.s urine was subjected to urinalysis. The result of the urine analysis is as follows: Color= Light/pale yellow; Glucose= negative; Protein= negative; pH= 6.015; Specific

Gravity=1.005; WBC = 2-4/hpf ; RBC= 1-3/hpf; Epithelial cells=moderate; Mucus thread=rare; Amorphous urates=moderate. The urine analysis shows that the patient M.G. doesnt have lactose spilling during pregnancy and has normal and functional kidneys as proven by the glucose and protein content of the urine. The urine has a normal pH (normally ranges from 4.5 to 8). WBC content is normal however, RBC is slightly elevated but not yet considered as hematuria.

Chapter 3 DEVELOPMENT OF PREGNANCY

The growth and development of a new individual starts from the moment of conception. The development is often monitored per trimester. Since the developing fetus inside Mrs. M.G. is 4-5 months, development is monitored per month.

At the Moment of Conception until 1st Month During the first month, Mrs. M.G. is not yet sure whether there is a growing fetus inside her. A week after conception, she noticed the occurrence of morning sickness characterized by nausea and vomiting episodes. A positive pregnancy test assured Mrs. M.G. that she was pregnant. However, it is only a presumptive evidence of pregnancy. From 1st Month to 2nd Month During the second month, M.G. reported tingling sensation in her breast. There was reported disruptions of the activities of daily living of patient M.G. because of fatigue. Frequency of urination increases from usual 5-6 times a day to 7-8 times a day. Client also emphasized urination even at night. Expected changes on skin pigmentation mainly as chloasma, palmar erythema and vacular spider angiomas were not observed by the client. Internal examination done by an ITMRC doctor suggests soft and closed cervix. Thus,

M.G. is positive for Goodels sign. Dark bluish and purplish discoloration of the vagina and vulva were reported by M.G.

From 2nd to 3rd Month During the second month of the pregnancy, the client experienced discharges of white fluids from the breast. According to M.G., she began to feel the kick of her baby. Linea nigra was prominent during the visit and it was reported that it appears on the second month after conception. Stretch marks from previous pregnancy were color white. Fresh stretch marks were noted as per complain by the client. These marks were usually pinkish in color.

From 2nd to 3rd Month From the third month, heartburn was reported to occasionally occur usually 3 hours after meals. Backaches, leg cramps, and varicosities were not prominent.