1 CARE OF THE MOTHER, CHILD AND ADOLESCENT

(WELL CLIENT)  0-3 (SICK BABY)

- Needs immediate life- saving measures such as
resuscitation, intensive CPR, ET/Ambulatory Bag,
APGAR SCORING oxygen and complete monitoring of temperature
SOURCE:
 Lecturer
 Fundamentals in Nursing notes GORDON’S FUNCTIONAL HEALTH PATTERNS

SOURCE:
 Lecturer – Ma’am Shezel Jheane Matel
- Developed in 1952 by Dra. Virginia Apgar
- Is the quick Ax of the physical condition of the
newborn in its first moments of life
- Given 1 minute and 5 minutes after birth - Method devised by Marjorie Gordon
- Not designed to predict neurological outcome - To be used by nurses in the nursing process
- APGAR stands for ACTIVITY, PULSE, GRIMACE, - Sequence of related behaviors that assists the nurse
APPEARANCE AND RESPIRATION in collecting and organizing data
- Can be used for nursing Ax in any practice areas for
PARAMETER SCORES 0 SCORES 1 SCORES 2 clients of all ages and in Ax of families and
communities
ACTIVITY Flaccid, Some Active
Muscle Tone limp, no flexion of motion of
movement extremities flexion
PULSE No heart Less than More than 1. HEALTH PERCEPTION- HEALTH MANAGEMENT
Heart Rate rate or 100 bpm 100 bpm PATTERN
absent - Based on culture and life experiences. Women either
GRIMACE No Grimace and Grimace view pregnancy as an illness, a natural or healthy
Reflex response some and pulls state or a combination of both
Irritability to airways motion with away,
being stimulation coughs or  HEALTHY PREGNANCY AS NORMAL PART
suctioned sneezes - Active participants on their social circles and career
during
- Choose provider with similar view
suctioning
- Pre- natal care
APPEARANCE Completely Pink body, Pink body,
 ILLNESS PERSPECTIVE
Color cyanotic, acrocyanotic pink
- Withdraw from work and social obligation
pale or extremities
bluish- - May make unhealthy pregnancy choices
gray - Deny pregnancy
RESPIRATION No Slow, Strong,
Respiratory breathing irregular lusty cry ACTIVITIES:
Rate or absent breathing,  Aware of participation in management of pregnancy
weak cry or  Expects an uncomplicated pregnancy on basis of the
whimpering woman’s or significant other’s active involvement in
her own care
 Able to state complications of pregnancy
 7-10 (WELL BABY)  Engage in health promotion behaviors specific to
- In good shape and doesn’t need more than routine pregnancy
post-delivery care
- Rarely needs resuscitation 2. NUTRITION- METABOLIC PATTERN
 4-6 (AT RISK) - Goal of optimizing maternal and fetal health
- Needs more help in breathing like suctioning - Good nutrition is essential for normal growth and
nostrils, massaging the back, or giving oxygen development

Transcribed by: Kristine Maderazo and Vance Jowie Anne S. Sedilla| BSN- CVSU MAIN BATCH 2022
2 CARE OF THE MOTHER, CHILD AND ADOLESCENT
(WELL CLIENT)  Has appropriate weight and height and has gained
 MATERNAL NUTRIENT DEFICIENCIES adequate weight for gestational age of pregnancy
- Developmental and physiological disadvantages  Eat three meals a day and two snacks
- Due to pre- pregnancy nutrition/ weight, finances,  Focusing on increased amounts of veggies and
culture fruits, drinks healthy fluids (including at least 8
glasses of water a day)
RECOMMENDATIONS:  Has elastic skin turgor
A. Well- Balanced Diet  PINGGANG PINOY
- Weight gain (25-35 lbs.)
- 300 calories or more a day
- Increase vitamins and minerals
o Fe- 27 mg
o Folic Acid- 600 mg
- Fats/ Carbs for energy needs

B. Calories
- Begin to increase calories in 2nd and 3rd trimester
PREGNANT: +300/day
LACTATING MOTHER: +500/day

C. Protein (CHON)
- Increase of 70g a day
- 3-day or 7-day diet
- Ask them what food they eat and amount
Good Sources of CHON
1.Soy
2.Meat
3.Monggo

D. Calcium
- may require calcium supplements with vitamin D
- the rapid deposit in fetal bones and teeth during the
3rd trimester of pregnancy requires adequate
maternal calcium stores from early pregnancy and
continued calcium intake to prevent maternal bone
demineralization (due to decreased calcium level)

E. Fats
- Provides valuable source of energy for the body

F. Carbohydrates/ Carbs (CHO)

- Provides fiber necessary for proper bowel
movement functioning
- CHO needs to be sufficient to prevent
KETOACIDOSIS from protein use of energy

ACTIVITIES:
 Follows diet changes of pregnancy as
recommended

Transcribed by: Kristine Maderazo and Vance Jowie Anne S. Sedilla| BSN- CVSU MAIN BATCH 2022
3 CARE OF THE MOTHER, CHILD AND ADOLESCENT
(WELL CLIENT) - has increased total daily sleep somewhat
PINGGANG PINOY CONSISTS OF:
33%- Carbs
33%- Veggies
17%- Protein
17%- Fruits
3. ELIMINATION PATTERN
 FETUS
- Elimination through the placenta (CO2, H2O, Urea)
 PREGNANT WOMAN
- Common discomfort of pregnancy due to enlarging
uterus and hormonal influences
- Urinary frequency, constipation, hemorrhoids
ACTIVITIES:
 Experiences occasional constipation from Fe
therapy of pregnancy usually connected by
increased fluids and more dietary fiber
 Voids 7- 10 times a day depending on amount of
fluid consumed
 No known hemorrhoids or difficulty in elimination
 voiding without excess frequency
, urgency or burning and understands signs of UTI
 Increased fluid on pregnant woman
4. ACTIVITY- EXERCISE PATTERN
 FETUS
- Early pregnancy: Spontaneous movements and
reflexes
- Quickening: At 20 weeks
 PREGNANT WOMAN
- Needs physical activity at least 30 minutes/day of
aerobic exercise (walking, swimming)
- Avoiding high-risk sports
ACTIVITIES:
 Includes ADL and can do them independently
 Note if client is on bed rest
 Walks three times a week for 20 minutes without
reports of fatigue and soreness
 Active at home with housework or occupation
5. SLEEP- REST PATTERN
- Generally, sleeps 7 to 8 hours a night
Transcribed by: Kristine Maderazo and Vance Jowie Anne S. Sedilla| BSN- CVSU MAIN BATCH 2022
with
fatigue of pregnancy. Nap for 1 hour on weekends
and 30 minutes after work
- sleeps on side with two pillows for comfort
- uses no sleep aids
- able to relax and initiate sleep without difficulty
- listen to soft music to enhance relaxation
- how the client sleeps
6. COGNITIVE- PERCEPTUAL PATTERN
 FETUS
- Senses (vision, hearing, taste, smell, touch,
proprioception, vestibular sense)
- 25 WEEKS: able to respond to sudden noise
 PREGNANT WOMAN
- Psychological and cognitive changes
- Emotional changes (progesterone affects mood)
- Increased sensitivity and analysis of experiences
- Experiences mood swings, emotional lability,
irritability and changes in sexual desire
- Transitioning process to motherhood
ACTIVITIES:
 Ensuring safe passage
- Decides prenatal care options
 Ensuring acceptance of the child
- Receptivity of partner
 Binding into her unknown child
- Integrate fetus as part of self but also as
separate being
 Learning to give result
- Examines meaning of giving, gifts for
herself/baby
 Realizes the need to decrease work activity and
increase next periods as she near the end of
pregnancy
 Answers questions in appropriate tone and
words
- Has intact memory
- Reads about pregnancy and early
parenthood to prepare for birth
7. SELF- PERCEPTION – SELF-CONCEPT PATTERN
 ACCEPTANCE OF BODY IMAGE
- Ambivalence
- Acceptance
4 CARE OF THE MOTHER, CHILD AND ADOLESCENT
(WELL CLIENT) ACTIVITIES:
 “I have a satisfying love life and I’m enjoying
- Yearning for pre-pregnant state my life with my husband
 Engaged in sexual intercourse x-times with
 INFLUENCES IN ASSUMING MATERNAL ROLE a desire to become pregnant
- Internal (personality, maturity level)  Engage in intercourse with patterns
- External (societal, family) acceptable to both partners
 No know STIs in past or present
ACTIVITIES:
 State she is excited about pregnancy after a year *Ensure the client about the confidentiality of
of trying to conceive information
 Well- groomed, wears maternity clothes “because
I want” 10. COPING STRESS- TOLERANCE PATTERN
 Believes she looks “me” during pregnancy  PERCEPTION OF STRESSORS AND COPING FOR ALL
LIFE ASPECTS AFFECTED
8. ROLE- RELATIONSIP PATTERN
 PREGNANCY AFFECTS WHOLE FAMILY  ANXIETY
- Without partners - Greatest in 1st and 3rd trimesters
- Isolation on dependent family - May decrease blood flow to uterus/ fetus
- May be demonstrated through:
 PARTNER 1. Psychosomatic complaints/ behaviors
- Possible resentment, financial stress, potential for 2. Dreams/ Fatigues
abuse, concern about role 3. Smoking/ Substance Abuse

 CHILDREN  STRESS RELIEVING STRATEGIES ENCOURAGED

- Changed relationship with mother
ACTIVITIES:
 EXTENDED FAMILY/ EXPECTANT GRANDPARENTS  Concerned about fatigue after work
- Reminded of own aging  Walks 3 times for 20 minutes to “center
myself and feel good”
ACTIVITIES:  Smiles often, has good sense of humor
 Lives with husband of 3 years
 Visits extended family 11. VALUE- BELIEF PATTERN
 Shares family roles with husband; accepts this  FULFILLMENT VS. LOSING PART OF SELF
balance  SHIFTING IN RELATIONSHIPS
 Has many friends who support her pregnancy - Mother
 Perceives extensive employee and employer - Friends
support with her pregnancy and time off after  INFLUENCE/ CHANGING IN SPIRITUAL VALUE
delivery
ACTIVITIES:
9. SEXUALITY- REPRODUCTIVE PATTERN  Finding meaning in pregnancy
- the pregnant woman’s body image and merging  Spiritual influence on pregnancy care
of this body image with her definition of decisions
femininity greatly influences feelings about her
sexuality
- women may experience different sexual feelings
during pregnancy
- nursing intervention is to support the couple’s
needs

Transcribed by: Kristine Maderazo and Vance Jowie Anne S. Sedilla| BSN- CVSU MAIN BATCH 2022
5 CARE OF THE MOTHER, CHILD AND ADOLESCENT
(WELL CLIENT) - May note constipation and may need to splint
(place pressure on the perineum or on the
posterior vaginal wall) in order to defecate.
REVIEW OF SYSTEMS
 Vaginal Discharge
- The pt. should be asked about a change/
SOURCE: increase in vaginal discharge and if present,
Lecturer – Ma’am Shezel Jheane Matel whether there are any associated symptoms.

 ADDITIONAL  Vulvar Lesions

 Abdomino- pelvic - Presence of raised or ulcerative vulvar lesions
- Gynecologic
- Urinary  Vulvar Pruritus/ Burning
- G.I.  Sexual Dysfunction
 Breast - Abnormalities of arousal (decreased libido)
 Other - Pain with intercourse (dyspareunia)
- Anorgasmia (inability to achieve orgasm)

 Abnormalities of Uterine Bleeding

- Assessment of menstrual flow  Symptoms of UTI
 Amenorrhea- lack of bleeding - Dysuria
 Polymenorrhea- short/ long interval - Urinary frequency
intermenstrual - Urinary urgency
 Menorrhagia- excessive bleeding - Hematuria
 Metrorrhagia- intermenstrual
- The post- menopausal pt. should be asked about  Symptoms of Urilithiasis
the presence of any bleeding - Flank pain and hematuria
- All women should be asked about post-coital
bleeding  Urinary Incontinence
 Urinary Retention
 Pelvic Pain
- Should be characterized as cyclic or noncyclic
- The mode of onset, character, radiation, severity
 Nausea
and duration.
 Vomiting
- Whether there is pain with intercourse
 Constipation
- May be related to genitourinary tract and
 Stools with bld
gastrointestinal tract
 Pain with defecation
- Associated with the abdominal wall musculature,
 The need to splint to defecate
fascia or nerves often increased with activities
 Incontinence of stool or flatus
such as lifting

 Symptoms of uterine/ vaginal prolapse

 Presence of breast masses
- Patients with genital tract prolapse may be aware
 Discharge (note if unilateral/bilateral/color)
of a sense of pelvic pressure.
 Pain (hormonal changes)
- May note urinary incontinence with activities that
 Prior history of breastfeeding
increase intra-abdominal pressure such as
 Mass noted (note how long this has been present
coughing, sneezing, or with athletic activities
and whether it varies in size with the menstrual
such as running
cycle)

Transcribed by: Kristine Maderazo and Vance Jowie Anne S. Sedilla| BSN- CVSU MAIN BATCH 2022
6 CARE OF THE MOTHER, CHILD AND ADOLESCENT
(WELL CLIENT)

- To assess for non- gynecologic conditions that

warrant treatment
- Non- gynecologic conditions have associated
gynecologic symptoms
- History of significant weight loss/ weight gain
- Hirsutism
- Symptoms of depression

Transcribed by: Kristine Maderazo and Vance Jowie Anne S. Sedilla| BSN- CVSU MAIN BATCH 2022