Specific Objectives

1. Establish rapport with

2. Gather pertinent information about

Activities
1. Magandang umaga po. Ako po si Karlo at
sya po si Mikee kami po ay mga student
nurse sa UST na nakadestino po sa
Jhocson Health Center. Naroon po kami
tuwing lunes at martesmula ngayon
hanggang ika-25 ng marso 2015 ala sieyete
ng umaga hanggang alas dose po ng
tanghali.
Naririto po kami upang makatulungan tayo
sa ating buhay pangkalusugan. Kayo po ba
si Gng. Delira? Puwede po ba kaming
pumasok?
2.1.
Personal Data
Name:
Address:
Birthday: July 1983
Age:
Religion: Catholic
Occupation: House wife
Educational Attainment: HS Graduate
2.2.
Family History
Family has no history

3. Performs Complete Assessment

2.3.
Medical History
2.4.
Gynecological History
2.5.
Obstetrical History
G____P____
T____P____A____L_____
LMP_________________
EDC__________________
AOG_________________
3.1.
Physical
Hair Shiny, black
Eyes- Sclerae- White
Ears- Discharges
Hearing acuity
Nose- Discharges
Lips- Pink/No bleeding
Teeth- Whitish
Throat- No anterior neck enlargement
Extremities No varicosities, no edema, no
cramps
Abdomen- Enlarged
Striae
Umbilicus protruding
FH- 2cm above umbilicus
Bladder- urinary frequency

Bowel Constipated
Genitalia
Discharges
Odorless
Skin
No Cuts/ no bruises
Good skin turgor
Emotional
Normal psychological adaptation to
pregnancy and attainment of the
maternal role are much less researched
areas in modern obstetrics than are
physiologic adaptations. Two notable
researchers in the field are Newton and
Rubin. In the 1950s, Newton9 explored
maternal emotions during pregnancy and
childbirth and their relation to other
aspects of women's lives. At the time,
the general psychological factors that
were believed to affect birth focused on
societal influences that prevented
women from accepting labor as a natural
physiologic function. Newton found that
women who had negative feelings about
pregnancy were more likely to wish they
were men and had fewer motherly
desires. Women who felt positively
toward pregnancy had more motherly
tendencies and were less likely to wish
they were men. She also noted that
feelings about pregnancy often progress
from those of rejection to those of
acceptance. After delivery, women who
felt negatively about birth were more
likely to dislike breastfeeding, avoid
rooming-in care of their babies, and have
fewer children. Conversely, women who
had positive feelings after birth were
more likely to enjoy breastfeeding and
rooming-in and have more children.
3.3 Social
3.4. Mental
Knowledge about the pregnancy
3.5. Spiritual
Belief in supreme being
3.6. Moral
Civil Status

4. Identify Health Need/ Problems of

5. Prioritize health needs/problems

Health Presence of wellness

- Readiness for enhanced capability for
health maintenance
Presence of Health Threats
- Poor home/environmental
condition/sanitation due to poor lighting
and ventilation
Presence of Stress Points/Foreseeable crisis
situations.
- Pregnancy ( experiencing and handling
the changes of pregnancy)
Wellness
- Nature of the problem 3/3 x1=1
- Modifiability of the problem 1/2 x 2 = 1
- Preventive potential 2/3 x 1 = 2/3
- Salience 2/2 x1 = 1
TOTAL; 3 2/3
Presence of health threats
- Nature of the problem 2/3 x1=2/3
- Modifiability of the problem 1/2 x 2 = 1
- Preventive potential 2/3 x 1 = 2/3
- Salience 1/2 x1 = 0
TOTAL: 2 5/6

6. Plan with _____ appropriate nursing

interventions

Foreseeable Crisis
- Nature of the problem 1/3 x1=1/3
- Modifiability of the problem 1/2 x 1 =
1/2
- Preventive potential 1/3 x 1 = 1/3
- Salience 1/2 x1 = 1/2
TOTAL: 1 2/3
Wellness: Readiness for enhanced capability for
healthy lifestyle.
1. Teach mother simple exercise and weight
management
Rationale: Gaining weight is healthy and
necessary during pregnancy, but it's
important to manage your weight and stay
fit. Get some guidelines on healthy weight
gain and safe prenatal exercise.
2. Teach general Health and Safety
Rationale: What's safe and unsafe when
you're pregnant? To discuss about unsafe
intake of caffeine, alcohol, travel, sex,
beauty products, household hazards, and
more.
3. Discuss with the mother about proper

nutrition
Rationale: To give the daily nutritional needs,
her pregnancy diet, food and beverages to
avoid, and pregnancy cravings
4. Teach about the signs and symptoms of
pregnancy
Rationale: To discuss mood swings, morning
sickness, backaches, and breast pain can
be everyday reminders of pregnancy. Learn
about unpleasant prenatal symptoms and
how you can take control of problems during
pregnancy
7.