FERRIS STATE UNIVERSITY DEPARTMENT OF NURSING OBSTETRIC HISTORY & PHYSICAL EXAM FORM Student Rachel Hodges Date

7/19/2013

Please review GUIDELINES FOR NURSING HISTORIES before beginning. BIOGRAPHICAL DATA A. B. C. A. B. Pt. init. JJH Age 33 DOB 05-29-1980 Religion Christian Race Caucasian Marital status (check one) Single Married X Separated Divorced Widowed Nearest relative/support person (relationship only) Parents and husband Where employed Hart Public Schools Occupation High School Teacher

BRIEF SOCIAL HISTORY Highest education BA +20 hours (double major) 1 Para 0 Ab 0

CURRENT PREGNANCY A. Expected date of delivery 10-29-13 Gravida B. Type of childbirth preparation None yet C. Allergies/sensitivities No Known D. Special problems this pregnancy and treatment None E. Laboratory assessment (if known): Unknown Blood type ________ Rh ________ Fathers blood type ________ Rh ________ Anemia? No F. Nursing assessment: Pre-pregnant Wt 135 Present Wt 155 Ht 57 G. Minor discomforts (check all that apply): Mood swings Nocturia Pain (where) Dyspareunia X Backache Vaginal discharge X Fatigue Leg cramps Numbness or swelling of feet, fingers, ankles Varicosities Constipation Itching of skin or vulva Insomnia X Frequent urination Other: Heart Burn Anxiety Have you had or been exposed to a major infection? (When) No (What) N/A Date last seen by Dr. 07-11-13

IV. PAST HEALTH AND MENSTRUAL HISTORY Write in this space pertinent information related to residual or chronic illness. No illnesses. Last X-rays None Type N/A What medications and vitamins are you taking and why? Pre-Natal Vitamins (doctor prescribed) V. PAST CONTRACEPTIVE HISTORY Oral IUD Norplant X Condoms A. Previous Pregnancy History: N/A DOB Sex Birth weight Gels & Foams DEPO Provera Prem/FT/Stillbirth Rhythm Living

B. C. D. E. VI.

Previous children with problems after birth? Explain N/A Problems with previous pregnancies (excessive vomiting, multiple births, excessive wt. gain, closely spaced pregnancies, etc.) Explain N/A Problems with previous labors and/or deliveries (extended labor periods, excessive bleeding, abnormal fetal position, etc.) Explain N/A Postpartum problems (sub-involution, infection, excess bleeding, bladder, etc.) Explain N/A

DIET ASSESSMENT No. of meals per day 2-3 No. of snacks per day 2 Fluid intake per day 1 diet coke and approx 6 glasses of water Pica No Peculiarities (social-cultural, religious, economic, etc.) None Typical Daily Food Intake in 24-hr period (sample) Breakfast Lunch Dinner Food Amount Food Amount Food Amount Granola bar 1 Salad with 1 Variety1 Ranch Chicken Hamburger Tacos Nachos Salad NUTRITION LIMITATIONS What do you consider to be your healthy weight? 130-135 Do you eat at least 3 meals a day? Sometimes, not always Are you on a special diet? No Do you take folic acid? No Do you have current or past problem with an eating disorder? No Do you have any dental problems? No Snacks Food Amount Fruit 2 Cereal Ice Cream

When was your last check up? Dental- June 2013 Do you have any vision problems? No 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 Personal Safety Fetal Condition Early Pregnancy Loss Pregnancy Complications Hospital: Not looking forward to staying overnight in the hospital Surgery Anesthesia Perinatal Loss Labor/Delivery Infant Illness Infant Attachment Parenting Skills A. Perception and knowledge of pregnancy and delivery (in clients own words) I feel that this is going to be an experience for me I know what is going to be taking place; and do worry slightly about the pain. I know the pain and weight gain are just temporary and what needs to take place in this exciting experience. Attitude toward pregnancy Very excited to be a first-time mom! Questions asked by mother-to-be None

B. C.

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? No Have you recently changed school? No Quit school? No Do you use heavy equipment? No Do you work long hours? Yes Do you do heavy housework? Yes Do you often stand for 30 minutes or more at a time? Yes Do you often lift more than 20 pounds? Yes Do you have problems climbing stairs? No Do you play sports? Yes Do you ride in a car more than 1 hour a day? Yes 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? Yes 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? Zero Any marijuana? No Do others smoke around you? No How much alcoholic beverage do you drink per day/week? Zero HOUSEHOLD SOCIAL SUPPORT RESOURCES How many children do you care for in your home? 0 Ages: N/A 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 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: Partner: No Parent: No Friends: No Child: N/A Other: ________________ Do you have a car or access to transportation? Yes Do you have access to a telephone? Yes Do you receive: Food Stamps: No TANF/Welfare: No Help with Child: Care No Help with housing: No WIC: No INFORMATION ON BABYS FATHER Do you know for certain whom the father of the baby is? Yes If yes, what is the age of the babys father? 29 Is the babys father here with you today? Yes How long have you known the babys father? 7 years Is the babys father happy about your pregnancy? Yes

Do you currently live with the babys father? Yes Are you married to the babys father? Yes Is the babys father currently married to someone else? No Does the babys 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? Father is partner, same as above. Is he/she happy about your pregnancy? Does your partner have children not in the home? If yes, how many does he/she have? 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? No Have you recently thought about suicide? No Have you ever attempted suicide? When? No Have you ever been diagnosed with a mental health condition? No Have you been hospitalized for a mental health condition? No 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: Rape/Sexual Assault? No Past Recent Mental Abuse? No Past Recent Crime Victim? No Past Recent Have you ever been investigated for hurting or neglecting a child? No

BABYS FATHER OR CURRENT PARTNER IN THE HOME Does the babys father or your current partner use: Tobacco? No Alcohol? Yes (occasionally)

Marijuana? No Cocaine? No IV Drugs? No Meth? No Is he bi-sexual? No Does he have multiple partners? No VII. PHYSICAL ASSESSMENT General Appearance (DO NOT put good or WNL): Client appears to be gaining weight appropriately for pregnancy. Some edema is present in the feet. No other physical abnormalities are present. Client is very excited about pregnancy and does not have any major complaints. She feels healthy, just larger than normal with very minor symptoms of pregnancy.

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
Nutrition: imbalanced, risk for less than body requirements: intake of nutrients insufficient to meet metabolic needs during pregnancy

Necessary Assessments/Interventions
1. Have client complete a food journal for at least one week for a truer sample of what she is consuming daily. 2. Give client reading material and explain the importance of increasing caloric intake during pregnancy and breastfeeding. 3. Provide examples of meals and sample menus to client that would be healthy choices during pregnancy. 4. Refer client to nutritionist for further dietary counseling.

Rationale
During pregnancy, a baby developing inside the womb receives all its nutrition from its mother. Therefore, advising women on their diet and providing food supplements in pregnancy may help babies to grow and thrive (Ota, Tobe-Gai, Mori, & Farrar, 2012). Studies have shown that antenatal nutritional advice with the aim of increasing energy and protein intake in the general obstetric population appears to be effective in reducing the risk of preterm birth, increasing head circumference at birth (Ota, TobeGai, Mori, & Farrar, 2012). Women should increase their calories by 300 per day starting in the second trimester with 25-35% coming from fat and should consume a minimum of 60 grams of protein per day (UCSF Medical Center, 2013).

Parenting, readiness for enhanced: pattern of providing environment for children or other dependent person/s that is sufficient to nurture growth and development and can be strengthened

1. Provide client with books, pamphlets, and/or videos about parenting that would be useful information for first-time parents.

Being prepared to provide safe care to infants and in a manner that promotes healthy growth and development requires knowledge on a number of key topics including expected growth and development, 2. Refer client to childbirth and parenting classes to how to promote healthy parent-infant relationships, enhance knowledge. and evidence-based information on such issues as safe sleeping environments and the risks of shaking an 3. Reassure client that parenting is a skill that is infant (Ateah, 2013). It is important for first-time developed over time and that no parent is perfect. parents to learn these things before giving birth. Provide stories and advice from real life experiences. Traditionally, this knowledge was passed down from family member, but there is now a need for formal 4. Provide client with information and resources to help prenatal parent education programs. Parents who have make her home environment safe for children. attended these classes have found the content useful, planned to use it in caring for their infant, and indicated that this information should be shared with all expectant parents (Ateah, 2013).

Care giver role strain, risk for: caregiver is vulnerable for felt difficulty in performing family caregiver role

1. Encourage mother and father to share parenting responsibilities. 2. Reassure parents that it is okay to ask for help. 3. Refer client to child care facilities in the area that are certified and convenient for the needs of the family. 4. Provide client with information on postpartum depression and other psychological issues associated with pregnancy and parenting.

Transitioning into parenthood can be difficult for new parents and can cause role strain and fatigue. Fatigue is a serious health concern for mothers that has potential to adversely affect their level of parenting stress, parenting beliefs and behavior (Dunning & Giallo, 2012). Social changes, such as increasing maternal participation in paid employment and the emergence of smaller and more isolated families, have resulted in fathers playing a greater role in both partner support and in the care of their children (May & Fletcher, 2013). It is important for both parents to

be caregivers in the family. This helps to eliminate role strain in either parent. All members of the family can expect to benefit when fathers are prepared for the challenges that they are likely to experience in their transition to parenthood (May & Fletcher, 2013).

References: Ateah, C. A. (2013). Prenatal parent education for first-time expectant parents: making it through labor is just the beginning. Journal Of Pediatric Healthcare, 27(2), 91-97. Dunning, M. J., & Giallo, R. (2012). Fatigue, parenting stress, self-efficacy and satisfaction in mothers of infants and young children. Journal Of Reproductive & Infant Psychology, 30(2), 145-159. May, C., & Fletcher, R. (2013). Preparing fathers for the transition to parenthood: Recommendations for the content of antenatal education. Midwifery, 29(5), 474-478. Ota, E., Tobe-Gai, R., Mori, R., & Farrar, D. (2012). Antenatal dietary advice and supplementation to increase energy and protein intake. Cochrane Database Of Systematic Reviews, (9). UCSF Medical Center (2013). Eating right before and during pregnancy. Retrieved from http://www.ucsfhealth.org/education/eating_right_before_and_during_pregnancy.

GRADING RUBRIC FOR OB OR NEWBORN ASSESSMENT Below Expectations

A. Assessment (15 points) Assessment has >12 blank spaces, has poor analysis (0 points) Does not complete the care plan (0 points) Does not have any interventions (0 points) Does not have any rationales for interventions (2 points) >10 errors in grammar or spelling; ideas are not clearly presented

Needs Improvement
(20 points) Assessment has 9-12 blanks (15 points) Chooses inappropriate nursing diagnoses based on the assessment (15 points) Has chosen inappropriate nursing interventions (15 points) Stated inappropriate rationales for nursing interventions (5 points) <10 errors in grammar or spelling; ideas are almost always clearly presented

Meets Expectations
(25 points) Assessment has 5-8 blank spaces, analysis need to be more in depth (17 points) Chooses 1-2 appropriate nursing diagnoses based on the assessment (17 points) Chooses 2-3 appropriate nursing interventions for each diagnosis (17 points) Stated appropriate rationales for nursing interventions for each diagnosis (7 points) <5 errors in grammar or spelling; ideas are clearly presented

Exceptional
(30 points) Assessment has no blank spaces and exceptional analysis (20 points) Chooses 3 appropriate nursing diagnoses based on the assessment (20 points) Chooses 4 or more appropriate nursing interventions for each nursing diagnosis (20 points) In-depth discussion of the nursing interventions for each diagnosis with evidence-based support outside of textbooks (10 points) APA format is excellent; no errors in grammar or spelling; ideas are clearly presented

B. Nursing diagnosis

C. Interventions

D. Rationale for interventions

E. Grammar, spelling, & clarity of ideas