HEALTH HISTORY

I. Demographic Data V. Family History

Name: Matchica, Mary Jane Mother side: HPN
Age: 26 y/0 Father side: HPN
Date of Birth: March 3, 1994
Place of Birth: Negros Orriental VI. Physical Assessment
Address: Skin, Hair, Nails: Skin is brown in color,
warm and dry to touch with good turgor;
Sex: Female
Observed striae gravidarum and linea nigra
Religion: Roman Catholic in the abdomen. No varicose veins seen.
Hair is black in color, scalp is clean and dry.
Nationality: Filipino Fingernails are well manicured and
Civil Status: Single immobile, immediate capillary refill.

Educational Attainment: HS Graduate Head & Neck: Symmetrically round. Hard

and smooth w/o lesions or bumps. Neck is in
Occupation: Housewife full and controlled ROM. Trachea is
II. Chief Complaint midline. No lymph nodes palpated.

Monthly follow up check-up Eyes: Eyes symmetrical. Conjunctiva and

sclera moist and smooth. Eyebrows sparse
III. History of present illness with equal distribution.
Patient is G1P0 and 6 mos pregnant with Ears: Bilateral auricles w/o deformity, lumps
GDM. or lesions. Bilateral canals contain scant
IV. Past Health History amount of dark brown cerumen.

Childhood Illness: Measles when she was 7
years old.
Immunizations: Fully Immunized
Allergies: (-)
Mouth, Throat, Nose & Sinuses: Lips pink,
smooth and moist. Gums pink and moist w/o
inflammation. Tongue midline when
protruded. Frontal and maxillary sinuses
non-tender

Accidents/Injuries: (-) Lungs & Chest: Respiration even, unlabored

and regular. No evidence of wheezing or
Hospitalization for serious illness: (-) crackles.
Medications currently used: GORDON’s FUNCTIONAL HEALTH
PATTERN
 Ferrous Sulfate (Hematinic)
 Calcium Carbonate (Calci Acid) 1. Health Perception – Health
 Multivitamins (Obynal-M) Management Pattern
 Describes health as “good” Eats
healthy foods like fruits, (orange,
banana, apple) vegetables, sabaw
(nilagang baboy) and fish (fried).
Diet is controlled because of GDM.
“Less sweet ako ngayon” as stated
by the patient. Doesn’t smoke nor
drink alcohol.
2. Nutritional- Metabolic Pattern
 Usual food intake before was 6
meals including snacks. Drinks
10-12 glasses of water and
patient is taking multivitamins.
Stopped drinking milk 3 mos ago
as prescribed by the OB. No
difficulty in swallowing, and
allergies. On a diabetic diet
because she was diagnose with
GDM when she was in 12 wks
AOG.
3. Pattern of Elimination
 Patient usually voids 10 times a
day and produces yellow urine
prior to admission. She defecates
once a day every week with soft
brown stool. Does not experience
urinary incontinence and no
history of Urinary Tract
Infection.
4. Activity-Exercise Pattern
 Patient walks in the morning
from 7am-8am. Also helps in
household chores like cleaning
the house and washing the
dishes.
5. Sleep-Rest Pattern
 Usual sleeping time is 9pm-7am.
Before sleeping she drinks water
and watches videos in the phone.
No difficulty in falling sleep.
6. Cognitive-Perceptual Pattern
 Patient is able to read and write.
No hearing problems noted, has
good memory and no vision
problem.
7. Self-Perception -Self Concept
Pattern
 Concerned about her condition
(GDM). She just hope that she
will have a normal delivery.
8. Roles- Relationship Pattern
 Living together with her partner.
Partner works in the market and
earns 700 pesos a day which she
stated that it’s enough to sustain
their daily needs.
 Does not belong to any group
like for example 4Ps.
9. Sexuality- Reproductive Pattern
 Before, she have her
menstruation regularly and uses
contraceptives (pills).
 LMP was on September 25,
2019. Menarche at 11 years old.
 No genital discomfort and no
sexual intercourse happened after
she knew she was pregnant.
10. Coping Stress Tolerance Pattern
 What makes her stress is the
noisy environment. She stated
that it is tolerable and just listen
to music when she cannot take it
anymore.
11. Pattern of Values and Beliefs
 Gives importance to her religion
and belief to God. Goes to
church every Sunday with
partner.
Drug Study
1. Ferrous Sulfate (Hematinic)
Class: Iron Supplement
Action: Ferrous sulfate is a mineral. It
supplies iron to your body, which is needed
to help your blood carry oxygen to your supplement. Do not take multivitamins with
organs milk, other dairy products, calcium
Adverse Effect: Constipation, diarrhea, supplements, or antacids that contain
stomach cramps, or upset stomach. calcium.
Nursing Consideration: Assess nutritional
status, bowel function. Monitor hemoglobin,
Lab Results
hematocrit, iron levels. It may cause
elevated liver enzymes. Take on an empty 12/27/2019
stomach to increase absorption/vitamin c
helps with absorption. Glucose

2. Calcium Carbonate (Calci Acid) Requ Un Ref. Res Unit Ref.

est it valu ult Value
Class: Antacids e
Action: Used to relieve the symptoms of 5.47 m 4.1- 98.5 mg/ 73.87-
heartburn, acid indigestion, and upset mo 5.9 6 dL 106.31
stomach. It is also used to prevent l/L
osteoporosis. When being used as a calcium
supplement, it works to increase the level of
calcium in the body. Interpretation: A level of 4.1 to 5.9
Adverse Effect: Constipation, gas, and mmol/L means you have impaired
bloating. fasting glucose, a type of prediabetes. This
Nursing Consideration: Assess patient for increases your risk of developing type
nausea, vomiting, anorexia, thirst, severe 2 diabetes. A level of 73.87-106.39 mg/dL
constipation, paralytic ileus, and or higher usually means you
bradycardia. Contact physician or other have gestational diabetes.
health care professional immediately if these
signs of hypercalcemia occur. Nursing Consideration:

3. Obynal-M 1. Weight management

Class: Multi-vitamins - It is imperative that client gain the

Action: Are used to provide vitamins that
are not taken in through the diet.
Multivitamins are also used to treat vitamin
deficiencies (lack of vitamins) caused by
illness, pregnancy, poor nutrition, digestive
disorders, and many other conditions.
Adverse Effect: Tooth staining, increased
urination, stomach bleeding, uneven heart
rate, confusion, and muscle weakness or
limp feeling.
Nursing Consideration: Avoid the regular
use of salt substitutes in your diet if
your multivitamin contains potassium. If
you are on a low-salt diet, ask your doctor
before taking a vitamin or mineral
appropriate amount of weight during
pregnancy to prevent excessive
pregnancy weight gain and postpartum
weight retention. 
2. Medical nutrition therapy
- MNT for patients with GDM should
focus on providing necessary nutrients,
normalizing blood glucose levels,
preventing ketoacidosis, and supporting
appropriate weight gain.
3. Self-monitoring blood glucose
 -Nurse should tell client to keep records
of SMBG and a food diary and bring
these to each provider visit. The SMBG
records and food diary should include
the time of the SMBG test and the time,
composition, and amount of food and
beverages that are consumed.
4. Exercise
- Exercise is an important part of glucose
control and decreases blood glucose
levels by increasing glucose transfer into
the cells without insulin. Client should
therefore be informed of the importance
of gentle exercise throughout
pregnancy.  insulin requirements.
NURSING CARE PLAN
Goals & Outcomes:
 Patient will verbalize
understanding of individual
treatment regimen and the need
for frequent self-monitoring.
Intervention:
 Assess understanding of the
effect of stress on diabetes.
Teach patient about stress
management
and relaxation measures.
R: It is proven that stress can increase serum
blood glucose levels, creating variations in
 Teach the importance of
regularity of meals and snacks
(e.g., three meals or 4 snacks)
when taking insulin.
R: Eating very frequent small meals
improves insulin function.

Subjective Data:  Provide information regarding

any required changes in diabetic
“Pinapabawas ni Dra. ang pagkain ko ng management; e.g.,
matamis at kanin kasi mataas daw blood reducing/changing time for
sugar ko.” ingesting carbohydrates.
Objective Data: R: Reducing carbohydrates to less than 40%
-Blood Glucose level last December 27, of the calories ingested reduces the degree
2019 was 98.56mg/dL of a postprandial peak of hyperglycemia.
Because pregnancy provides severe morning
-Urinates from time to time. glucose intolerance, the first meal of the day
V/S: should be small, with minimal
carbohydrates.
BP: 90/60 mmHg
Evaluation:
Wt: 60.5kg
 Goal met. Patient was able to
Nursing Diagnosis verbalize understanding of
Risk for Altered Nutrition: Less Than Body individual treatment regimen and
Requirements the need for frequent self-
monitoring as evidence by client
statement ”Ah ganun pala yun.
Sinabi din yan ni Dra. Sge, ime
maintain ko na ang pagkain ko
ng matatamis at carbohydrates.”