FERRIS STATE UNIVERSITY DEPARTMENT OF NURSING

OBSTETRIC HISTORY & PHYSICAL EXAM FORM

Student _____Kelli J. Koop ____________Date ________10/23/13__________ Please review GUIDELINES FOR NURSING HISTORIES before beginning. BIOGRAPHICAL DATA A. B. C. Pt. init. _JLH_ Age _28_ DOB _3/19/85_ Religion _Christian_ Race _Caucasian_ Marital status (check one) Single Married Separated Divorced Widowed Nearest relative/support person (relationship only) __Parents__

BRIEF SOCIAL HISTORY

A. B. Where employed _Currently unemployed_ Occupation __Housewife__ Highest education __College Graduate: __Bachelors in Social Work __

CURRENT PREGNANCY
A. Expected date of delivery _June 22, 2014 _( 1 month pregnant) Gravida _3_ Para _2_ Ab___0_____ B. Type of childbirth preparation _Prenatal care__ Date last seen by Dr. _9/10/13_____ C. Allergies/sensitivities _Cat, seasonal allergies, dogs. __ D. Special problems this pregnancy and treatment _None__ E. Laboratory assessment (if known): Blood type __O___ Rh ___+____ Fathers blood type ___A_____ Rh ___+_____ Anemia? __No____ F. Nursing assessment: Pre-pregnant Wt _130 lb__ Present Wt _130 lb__ Ht _510_____

G. Minor discomforts (check all that apply): --- Mood swings --- Nocturia --- Pain (where) ---

--- Dyspareunia --- Backache --- Vaginal discharge --- Fatigue --- Leg cramps --- 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)

IV. PAST HEALTH AND MENSTRUAL HISTORY Write in this space pertinent information related to residual or chronic illness. __None. ___ Last X-rays __Unknown___ Type ___Unknown____ What medications and vitamins are you taking and why? __Prenatal pills for pregnancy preparation and fetal health. ___ V. PAST CONTRACEPTIVE HISTORY IUD Oral Norplant --- Condoms A. Previous Pregnancy History: DOB Sex Birth weight 9/13/10 F 7 lb. 2 oz. 3/18/13 M 7 lb. 7 oz.

--- Gels & Foams DEPO Provera Prem/FT/Stillbirth Full Term Full Term

--- Rhythm ----Living

B. C.

Previous children with problems after birth? Explain _None__ Problems with previous pregnancies (excessive vomiting, multiple births, excessive wt. gain, closely spaced pregnancies, etc.) Explain __None __ Problems with previous labors and/or deliveries (extended labor periods, excessive bleeding, abnormal fetal position, etc.) Explain __Long 2nd stage of labor with first birth (3 1/2 hours). Required oxygen. ___ Postpartum problems (sub-involution, infection, excess bleeding, bladder, etc.) Explain __4th degree laceration after first birth. __

D.

E.

VI.

DIET ASSESSMENT No. of meals per day __3__ No. of snacks per day __3__ Fluid intake per day __6 cups__ Pica __No___ Peculiarities (social-cultural, religious, economic, etc.) _None__ Typical Daily Food Intake in 24-hr period (sample) Breakfast Lunch Dinner Snacks

Food Toast Eggs Juice

Amount 2 slices 2 4 oz

Food Wrap Yogurt Water

Amount 1 1 16 oz

Food Amount Spaghetti 2 servings Garlic Bread 2 pieces Broccoli 1 serving Water 16 oz

Food Cereal Cereal Cereal

Amount 1 bowl 1 bowl 1 bowl

NUTRITION LIMITATIONS What do you consider to be your healthy weight? _130 lb.___________ Do you eat at least 3 meals a day? Yes Are you on a special diet? No Do you take folic acid? Yes Do you have current or past problem with an eating disorder? No Do you have any dental problems? No When was your last check up? _9/10/13___________ Do you have any vision problems? Corrective Lenses 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 No Personal Safety No Fetal Condition Concerned about health Early Pregnancy Loss concerned Pregnancy Complications concerned Hospital No Surgery No Anesthesia No Perinatal Loss No Labor/Delivery No Infant Illness concerned Infant Attachment No Parenting Skills No A. Perception and knowledge of pregnancy and delivery (in clients own words) __Looking forward to having my third child. I am familiar with what to expect because of my previous two children. Slightly anxious for the delivery because of the complications during the first child (4th degree laceration) __ B. C. D. Attitude toward pregnancy __Astatic Have always planned on having three children, cant wait to meet the little one__ 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? Yes 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? No 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? No 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? 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? __0___ Any marihuana? ___No___________ Do others smoke around you? No How much alcoholic beverage do you drink per day/week? _____None _______________ HOUSEHOLD SOCIAL SUPPORT RESOURCES How many children do you care for in your home? 2 Ages: __3 years old & 7 month old______ Do you care for a family member with a disability? No Do you have a serious illness? No Recent or planned move? Yes 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 No Other _No___ 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? _11 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? __11 Years______ Is he/she happy about your pregnancy? Yes Does your partner have children not in the home? No 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? No Have you recently thought about suicide? No Have you ever attempted suicide? No When? ___N/A_________ 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 Marijuana? No Cocaine? No IV Drugs? No Meth? No Is he bi-sexual? No Does he have multiple partners? No Is the babys father or your current partner employed? Army National Guard VII. PHYSICAL ASSESSMENT General Appearance (DO NOT put good or WNL): Heart beat has regular rate rhythm and depth; capillary refill less than three seconds in hands and feet; respirations clear and audible bilaterally; radial pulses strong and equal; skin clear, warm, pink and intact; reflexes present; no psychological or neurological concerns; symmetrical facial features; mucous membranes pink, moist, and intact; individual appears to be healthy and thriving.

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
Risk for fatigue: related to increased energy demands

Necessary Assessments/Interventi ons

Acupuncture; Energy conservation and activity management; relaxation breathing exercises (Patterson, 2013, pp. 2674)

Rationale
During acupressure sessions, a three-minute massage was delivered to relax participants, and then pressure was applied to four points on both legs and both feet for a total duration of 12 minutes. This intervention significantly reduced participants levels of fatigue and demonstrated moderate effectiveness (Patterson, 2013, pp. 2674). Providing information on energy conservation skills to assist participants in managing fatigue, creation of an energy conservation plan, and evaluation and revision of the plan will help decrease fatigue (Patterson, 2013, pp. 2674). Providing a tape that instructs the patient on relaxation breathing exercises will help manage their fatigue. The tape is comprised of three components: (1) preliminary exercise where participants assume a comfortable position and focus their attention on the lower abdomen; (2) relaxation breathing exercise, where participants relax by taking deep breaths and letting them out slowly; and (3) finish exercise, where patients keep their mind clear and stretch their arms and legs (Patterson, 2013, pp. 2674).

Risk for nausea: related to hormonal changes

Eat small meals throughout the day instead of three large meals; avoid milk products; eating bland food such as crackers and toast. (Wedro, 2012)

It is important not to take too much fluid or food at one time since stretching the stomach may cause the nausea to worsen. With vomiting, the body can become relatively lactose intolerant. Milk products should be avoided for the first 24-48 hours during an episode of nausea and vomiting. As the affected individual begins to feel better, they can begin to reintroduce foods, but to help the stomach readjust, health care professionals often recommend limiting the diet to bland foods such as bananas, applesauce, rice, and toast. (Wedro, 2012)

References Patterson, E., Teresa, & Sidani, S. (2013). Nonpharmacological nursing interventions for the management of patient fatigue: a literature review. Journal Of Clinical Nursing, 22(19/20), 2668Wedro, B. (2012). Nausea and Vomiting. Retrieved from http://www.medicinenet.com/nausea_and_vomiting/page6.htm