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FERRIS STATE UNIVERSITY
DEPARTMENT OF NURSING
OBSTETRIC HISTORY & PHYSICAL EXAM FORM
Student _____Anna Rudd______________ Date _________29 June 2013_______________
Please review GUIDELINES FOR NURSING HISTORIES before beginning.
BIOGRAPHICAL DATA
A. Pt. init. __C.S.____ Age ___37___ DOB _11/17/1975_____ Religion __Lutheran____ Race __White____
B. Marital status (check one) Single ( Married X Separated ( Divorced ( Widowed (
C. Nearest relative/support person (relationship only) ___Husband_______________________
BRIEF SOCIAL HISTORY
A. Where employed ____Leslie Public Schools________________ Occupation ____Teacher__________________
B. Highest education _____Masters Degree in Education_______________________________________________
CURRENT PREGNANCY
A. Expected date of delivery __4 July 2013______ Gravida ___4_____ Para ____2____ Ab ____1____
B. Type of childbirth preparation ____Vaginal________ Date last seen by Dr. ___24 June 2013___________
C. Allergies/sensitivities __None_________________________________________________
D. Special problems this pregnancy and treatment _None______________________________ _____________________________________________________________________
E. Laboratory assessment (if known): She doesn’t know her blood type or her husband’s blood type.
Blood type ___Does not know_____ Rh _Does not know_______ Father’s blood type ____Does not know____ Rh ____Does not know
Anemia? _No_______
F. Nursing assessment:
Pre-pregnant Wt _125_____ Present Wt _165_____ Ht __63 inches____
|G. Minor discomforts (check all that apply): |
| |Mood swings | |Nocturia | |Pain (where) |
| |Dyspareunia | |Backache | |Vaginal discharge |
| |Fatigue | |Leg cramps |X |Numbness or swelling of feet, fingers, ankles |
| |Varicosities | |Constipation | |Itching of skin or vulva |
| |Insomnia | |Frequent urination | |Other: |
| |Heart Burn | |Anxiety | | |
| |Have you had or been exposed to a major infection? (When) |
|(What) Swelling of mostly feet and ankles has occurred in the last few weeks of pregnancy in the evenings. |
IV. PAST HEALTH AND MENSTRUAL HISTORY
Write in this space pertinent information related to residual or chronic illness.
The only chronic illness she has dealt with is asthma and it has been well controlled for more than10 years.
Last X-rays _20 June 2013_____________ Type ___ May 2013 dental x-rays_____
What medications and vitamins are you taking and why? __Prenatal vitamins, zyrtec (for allergies), She has inhalers for asthma control
including flovent and albuterol but has not used them as she has not needed them. ____________________
____________________________________________________________________
|V. PAST CONTRACEPTIVE HISTORY |
|YES |Oral |NO |IUD |NO |Gels & Foams |NO |Rhythm |
|NO |Norplant |YES |Condoms |NO |DEPO Provera |N/A | |
|A. Previous Pregnancy History: |
|DOB |Sex |Birth weight |Prem/FT/Stillbirth |Living |
|7/30/2005 |F |7 lb. 12 oz. |FT (40 weeks 6 days) |Yes |
|5/30/2007 |F |7 lb. 8 oz. |FT (41 weeks 2 days) |Yes |
|None |NA |NA |Loss at 11 weeks 4 days |No |
B. Previous children with problems after birth? Explain Both of her children were born with hip dysplasia. Her first daughter was not diagnosed until she was 7 months old and had to have corrective surgery and spent three months in a spica cast. Her second daughter was diagnosed at delivery and the condition was corrected using the Pavlik harness for 12 weeks. Although it is not as common in boys, their family history increases the likelihood that he may have it as well and they will take him to a specialist in the first week following birth for a full evaluation of his hips.
C. Problems with previous pregnancies (excessive vomiting, multiple births, excessive wt.
gain, closely spaced pregnancies, etc.) Explain She did not experience any serious problems with any of her previous pregnancies. She began my other pregnancies overweight (probably 15-20 pounds) but lost 25 pounds about a year and a half before this pregnancy (through diet and exercise….nothing crazy). In many ways, this pregnancy has been easier and more comfortable and she thinks that may be the reason. She exercised more and was in better shape prior to this pregnancy.
D. Problems with previous labors and/or deliveries (extended labor periods, excessive
bleeding, abnormal fetal position, etc.) Explain Both of her labors were fairly long but neither were terrible or particularly difficult.
E. Postpartum problems (sub-involution, infection, excess bleeding, bladder, etc.)
Explain She experienced mastitis in the first six weeks following both births probably due to engorgement and production issues. Both of her children continued to nurse through the infection and treatments. Both of her children nursed for over two years (that means that they both nursed at the same time following her second daughter’s birth!)
VI. DIET ASSESSMENT
No. of meals per day __3__ No. of snacks per day __2__ Fluid intake per day __60-70 ounces
Pica __None______ Peculiarities (social-cultural, religious, economic, etc.)
___________________________________________________NONE__________________
_____________________________________________________________________
Typical Daily Food Intake in 24-hr period (sample)
| Breakfast | Lunch | Dinner | Snacks |
|Food |Amount |Food |Amount |Food |Amount |Food |Amount |
|Coffee |8 oz. |Protein |4-5 oz. |Protein |6 oz. |Granola |1-2 |
| | | | | | |Bar | |
|Greek |5.3 oz. |Vegetable |5-6 oz. |Vegetable |8 oz. |Frozen | 8 oz. |
|Yogurt | | | | |2 servings |Greek | |
| | | | | | |Yogurt | |
| | |Fruit |4-5 oz. |Starch |1 serving |Baby | |
| | | | | | |Carrots | |
| | | | | | |Pretzels | |
| | | | | | |And | |
| | | | | | |Peanut | |
| | | | | | |Butter | |
| | | | | | | | |
| | | | | | | | |
She listed most of her favorite snacks but she trys to limit them to two a day.
NUTRITION LIMITATIONS
What do you consider to be your healthy weight? ___120-125_________
Do you eat at least 3 meals a day? 3
Are you on a special diet? No, she is a calorie counter so she usually watches her intake in terms of calories. She began the pregnancy by adding 300 calories to her usual 1200 but didn’t last very long at her counting! She hasen’t kept very good track for about the last 6 months.
Do you take folic acid? She probably has folic acid in my prenatal vitamin but she does not take it specifically.
Do you have current or past problem with an eating disorder? She has not had trouble with an eating disorder. She was overweight before her first two pregnancies but that did not occur until my late 20’s. She was considered underweight (not unhealthy but underweight) until her early 20’s. She didn’t weigh over 100 lbs. until she was in college so she was often monitored by doctors for food intake when she was young. She didn’t have trouble eating; she was just active and worked out a lot. She thinks as she got older, her metabolism and life style changed and she was less active as she moved from college into the workplace. From about 26-35 her weight was up and down with pregnancy and trying different diets but she finally regulated it with just healthy eating and regular exercise.
Do you have any dental problems? No
When was your last check up? December 2012 (would have been last week but her hygienist got sick).
Do you have any vision problems? No, She has worn contacts or glasses since 1989.
Can you hear without problems? Yes
Do you have any speech problems? No
Do you have any learning problems? No
Do you have any physical limitations? No
FEARS/ANXIETIES ABOUT PREGNANCY AND PARENTING
Personal Health NONE
Personal Safety NONE
Fetal Condition NONE
Early Pregnancy Loss Of course she was more nervous this time because she had experienced a loss. That was extremely sad and she doesn’t know how to describe the feeling of loss in terms of the grieving and disappointment that she felt but it did make this pregnancy a bit more difficult until she could feel him moving everyday.
Pregnancy Complications NONE
Hospital NONE
Surgery She is not inherently afraid of childbirth but she does feel anxiety about induction or a c-section.
Anesthesia NONE
Perinatal Loss NONE
Labor/Delivery Both of her other labors were longer labors (about 30-32 hours for each) and she anticipates that this one may be the same. She did have an epidural with both so she was fairly comfortable a lot of the time.
Infant Illness NONE
Infant Attachment NONE
Parenting Skills
A. Perception and knowledge of pregnancy and delivery (in client’s own words) She only knows what she knows from her own personal experience. She has never had any formal training or education on pregnancy and delivery. She is not inherently afraid of childbirth but she does feel anxiety about induction or a c-section. Because both of her girls were later term there was always a discussion of induction but she preferred to wait and she was lucky enough to have doctors who have supported that decision. Two weeks ago, this baby was breech and she had to discuss methods of turning him or pursuing a c-section. He has since turned back into the head down position but is also very active and may still be turning now (he almost did it during the ultrasound). In the event that she would have to have a c-section or induction for a medical reason she knows that she can handle it but she does have anxiety over trying to control a situation with a lot of medical intervention. She will still have the epidural. She thinks that she has found her fear of the pain of childbirth is also greater than her fear of having an epidural. She remembers both of her other labors as a peaceful and happy time. She was in a lot of pain and in both cases she experienced labor for over 15 hours before the epidural but she would not change the fact that she felt very present and at peace because there was some pain control available. She experienced mild depression following the first birth (maybe only the first two days and never diagnosed, just in her opinion) but not the second. It’s also possible that she wasn’t depressed but just felt a little fear about the unimaginable change in her life (she stated that even happy changes can be frightening because it’s still change).
Attitude toward pregnancy She has been fairly comfortable through all of her pregnancies. She did not experience much morning sickness or discomfort. Of course, right now she’s five days from my due date. She’s carrying around 40 extra pounds, she’s a little irritable and uncomfortable but she believes that it is worth having a child.
B. Questions asked by mother-to-be: None
WORK/SCHOOL ACTIVITIES EXPOSURE
Have you experienced the loss of a co-worker and/or friend at work or school? No
Have you been threatened recently at work or school? No
Have you been involved in an argument or fight at work or school? No
Have you recently changed jobs? In 13 years, she had switched grade levels three times but no major changes.
Have you recently changed school? No
Quit school? No
Do you use heavy equipment? No
Do you work long hours? Sometimes. Recently school ended with students but she has still been working 5-6 hours everyday on administrative work in her classroom. She’s starting a new program and it involves a lot of paperwork so she has been doing a lot more sitting and working recently as opposed to her usual up and around with children. She teaches four years olds so she seldom sits down at her job.
Do you do heavy housework? Not if she can help it!
Do you often stand for 30 minutes or more at a time? Yes, but in the past few weeks have been sitting more.
Do you often lift more than 20 pounds? Just her kids. They both weigh just over 40 pounds but she has stopped lifting them recently.
Do you have problems climbing stairs? No
Do you play sports? Before this pregnancy she ran about 10-15 miles a week depending on her training. In the early weeks of this pregnancy she ran a 10K and just after she suspected she was pregnant she ran a 5K. Her doctor said that she could still run and she walked regularly but she was a little nervous to continue running. Following the loss of their last pregnancy she was much more cautious than she might have otherwise been.
Do you ride in a car more than 1 hour a day? No
Do you have a disability that limits activity? No
Are you exposed to:
Paint thinners or oven cleaners? No
Strong cleaners? No
Cat litter? No
Mercury or lead? No
Ceramics, stained glass, or jewelry making products? No
Have you eaten raw or uncooked meat? No
Do you wear your seat belt? Always
How many sexual partners have you had in the past year? 1
Are you now using/taking or have you ever taken/used hard drugs? No
Which one(s)? _________________N/A_______________________________________
Amount _____N/A____________________ Frequency ________N/A__________________
How many cigarettes do you smoke daily? ___0__ Any marihuana? __None____________
Do others smoke around you? Yes, her husband smokes but he does not smoke in our house.
How much alcoholic beverage do you drink per day/week? Prior to pregnancy, she enjoyed wine frequently with dinner (1-2 glasses) and an occasional mixed drink. She’s a social drinker if she’s with friends but not necessarily a heavy drinker. She has a fear of losing control and she thinks that has probably always kept her from being a heavy drinker. She also has a lot of alcoholism on both sides of her family and has seen the effects that the disease can have on a family and a person. She was raised in Europe and had alcohol available at a younger age (not necessarily allowed by her parents(). She thinks that probably changed her views as she was growing up too.
HOUSEHOLD SOCIAL SUPPORT RESOURCES
How many children do you care for in your home? 2
Ages: _____6 & 7___________
Do you care for a family member with a disability? No
Do you have a serious illness? No
Recent or planned move? No
Do you feel sleepy or tired a lot? No more than any other normal person who works all day and takes care of children in the evening.
Do you feel safe where you live? Yes
Do you or anyone in your house ever go to bed hungry? No
Do you have any problems that keep you from health care appointments? No
Do you have family who will help you? Yes
Do you have friends you can count on when you need help? Yes
Are you not getting along with or arguing with your: None
Partner NONE
Parent NONE
Friends NONE
Child NONE
Other ______N/A__________
Do you have a car or access to transportation? Yes
Do you have access to a telephone? Yes
Do you receive: None
Food Stamps NONE
TANF/Welfare NONE
Help with Child Care NONE
Help with housing NONE
WIC NONE
INFORMATION ON BABY’S FATHER
Do you know for certain whom the father of the baby is? Yes
If yes, what is the age of the baby’s father? 40
Is the baby’s father here with you today? Yes
How long have you known the baby’s father? 17 years
Is the baby’s father happy about your pregnancy? Yes
Do you currently live with the baby’s father? Yes
Are you married to the baby’s father? Yes
Is the baby’s father currently married to someone else? No
Does the baby’s father have children not in the home? No
If yes, how many children does he have? N/A
What is his/her age? N/A
How long have you known your partner? N/A
Is he/she happy about your pregnancy? N/A
Does your partner have children not in the home? N/A
If yes, how many does he/she have? __N/A______
LIFE STRESSORS MENTAL HEALTH VIOLENCE/ABUSE
Was your pregnancy planned? Yes
Do you want to parent this child? Yes
Do you have enough money to pay for food, housing, & bills? Yes
Have you recently experienced an extremely stressful event (house fire, tornado, death)? No
Do you feel overwhelmed, sad, hopeless, or lost pleasure in the things usually enjoyed? No
Are you having any problems sleeping? She actually sleeps very well
Have you recently thought about suicide? No
Have you ever attempted suicide? When? No
Have you ever been diagnosed with a mental health condition? She took Zoloft for anxiety for a short period of time in her 20’s but if she exercises and manages her stress level she doesn’t really have any trouble with anxiety.
Have you been hospitalized for a mental health condition? Asthma (one hospitalization at 22 years old for 5 days).
Did you attend or currently attend mental health counseling? No
Are you ever afraid of your partner? No
In the last year, has anyone at home hit, kicked, punched, or otherwise hurt you? No
In the last year, has anyone at home often put you down, humiliated you or tried to control what you can do? No
In the last year, has anyone at home threatened to hurt you? No
Have you in the past or recently been a victim of: None
Rape/Sexual Assault? NONE
Past Recent NONE
Mental Abuse? NONE
Past Recent NONE
Crime Victim? NONE
Past Recent NONE
Have you ever been investigated for hurting or neglecting a child? No
BABY’S FATHER OR CURRENT PARTNER IN THE HOME
Does the baby’s father or your current partner use:
Tobacco? Yes
Alcohol? No
Marijuana? No
Cocaine? No
IV Drugs? No
Meth? No
Is he bi-sexual? No
Does he have multiple partners? No
Is the baby’s father or your current partner employed? Yes
VII. PHYSICAL ASSESSMENT
General Appearance (DO NOT put “good” or WNL):
She has been in good physical health for most of her life (other than being overweight during a period of time). She has never missed a yearly exam and has to produce regular health updates for her work. She’s fairly active and exercises and tries to eat sensibly. She also works really hard to encourage her children to maintain a healthy lifestyle including making smart choices with food and exercise (and her husband too: she tries to get him to quit smoking). Currently she looks healthy and happy. She is dressed appropriately for the weather and presents with good hygiene. Her legs and feet present with some edema.
Educational Needs/Interventions
On the basis of your assessment, list at least TWO nursing diagnoses for your patient, interventions (min 3/nursing diagnosis), assessments for each nursing diagnosis, and the rationale for your actions. Please have supporting evidence from the literature for your plan. Be sure your assessment and interventions correspond to your Nursing Diagnosis.
|Nursing Diagnosis |Necessary Assessments/Interventions |Rationale |
| |Anxiety: |Anxiety: |
| |“Assess the client’s level of anxiety and physical reactions to anxiety…” (Ladwig |By getting a base level for the patient’s anxiety, the nurse is able to get a |
|Anxiety r/t medical interventions |&Ackley, 2011, p. 187). |better understanding of the amount of intervention necessary. |
|regarding the labor process as evidenced|“…use empathy to encourage the client to interpret the anxiety symptoms as normal”|It is important to have the client understand that her fears and anxiety are |
|by patient stating fears regarding |(Ladwig & Ackley, 2011, p. 187). |normal. Induction and caesareans are not normal labor processes, but are |
|possible cesarean or induction. |“Guided imagery can be used to decrease anxiety” (Ladwig & Ackley, 2011, p. 188). |sometimes necessary for the safety of the baby and mother. |
| |“Intervene when possible to remove sources of anxiety” (Ladwig & Ackley, 2011, p. |Guided imagery may help calm the mother and help her relax or relieve anxious |
|Risk for powerlessness related to the |188). |feelings about what might happen regarding her birth plan. |
|labor process as evidenced by patient | |Sometimes the nurse may have to intervene by removing extra members from the room|
|stating she “does have anxiety over |Powerlessness |or just remove stimuli that can increase anxiety. |
|trying to control a situation with a lot|“Establish a therapeutic relationship with the client…” (Ludwig & Ackley, 2011, p.| |
|of medical intervention” |598). |Powerlessness |
| |“Encourage the client to share his or her beliefs, thoughts, and expectations…” |In order to effectively address the client’s emotional feelings, the nurse must |
|Impaired comfort related to enlarged |(Ludwig & Ackley, 2011, p. 598). |establish a therapeutic relationship with him or her. The client is more likely |
|abdomen, swollen feet, lower back pain |“Have the client assist in planning care whenever possible…” (Ludwig & Ackley, |to open up about their feelings if he or she trusts the nurse. |
|as evidenced by physical assessment and |2011, p. 598). |By encouraging the client to share her feelings, the nurse is demonstrating |
|patient stating “she has general |“Allow time for questions… Have the client write down questions, and encourage the|genuine interest and concern for her feelings. |
|pregnancy discomforts.” |client to record a summary of answers received, or provide written material that |By allowing the client to participate in planning the care, some power of |
| |reinforces answers” (Lugwig & Ackley, 2011, p. 599). |decision making and control is given back to the patient. This may help remedy |
| | |feelings of powerlessness. |
| |Impaired Comfort: |By allowing time for questions, the nurse can reduce anxiety and allow the |
| |“Assess client’s current level of comfort” (Ladwig & Ackley, 2011, p. 246). |patient to feel more in control of the situation if she knows what is going on |
| |“Manipulate the environment as necessary to improve comfort” (Ladwig & Ackley, |and what will happen next. |
| |2011, p. 247). | |
| |“Provide distraction techniques such as music, television, or games” (Ladwig & |Impaired Comfort: |
| |Ackley, 2011, p. 247). |By beginning with assessment of the patient’s level of comfort, the nurse has a |
| |“Inform the client of options for control of discomfort…” (Ladwig & Ackley, 2011, |baseline to work from. |
| |p. 247). |This could involve changing positions, being put on bed rest, moving to a cooler |
| | |room. Anything that could enhance comfort in the external environment could be |
| | |useful. |
| | |If the patient has another task to focus on, she may be less likely to focus on |
| | |the general discomforts that come with pregnancy. |
| | |By educating the client on options for control of the discomfort, she may feel |
| | |more empowered to make decisions, as well as, be able to play a more active role |
| | |in her plan of care. |
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References:
Ladwig, G. B., & Ackley, B. J. (2011).Mosby's guide to nursing diagnosis (3rd ed.). Maryland Heights, Mo.: Mosby/Elsevier.
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