ANTEPARTAL

CASE STUDY

SUBMITTED BY:

Lagmay, Cezar Bien R.

GROUP I Cluster 2

BSN II-A
September, 2021
ANTENATAL ASSESSMENT TOOL

I. PERSONAL DATA
Name: Abelina Labugen
Address: Brgy. Baay, City of Batac, Ilocos Norte
Date of Birth: July 05, 1980
Age: 41
Religion: Aglipayan
Educational Attainment: High School Graduate
Civil Status: Married
Occupation: None
Monthly Income: None (Source: Husband Php 15,000)

Data of Husband:

Name: Noel Labugen

Address: Brgy. Baay, City of Batac, Ilocos Norte
Date of Birth: September 2, 1982
Age: 39
Religion: Aglipayan
Educational Attainment: High School Graduate
Civil Status: Married
Occupation: Baker
I. SOCIO-ECONOMIC STATUS

The client lives with her husband, older sister and her childrens. The client stated that
her husband stays with his family during weekends in Curimmao, Ilocos Norte.

In addition, their income comes from their small family business which is a Bakery stand.
The client lives at Barangay 13- Baay, City of Batac. The location of their house was far from
the road and the path heading towards their home is not cemented with a narrow pathway
measures 1.5 meters wide. Their house is a first storey concrete house with a galvanized roof.
The house is comprises of 3 bedrooms, a bathroom, a living room and a kitchen inside the
house and a dirty kitchen located outside at the back of their house. Their house is small
enough to accommodate the family but their front yard and back yard are wide enough to
separate them from their neighbor’s. On their backyard they have 4 chickens, 2 dogs, and 5
pigs. In terms of the food of the live stocks, they use feeds for the pigs and their left overs for
the dogs, chickens and also to the pigs in case where there are no feeds available.

There are 5 members of the family wherein it consists of the client, older sister, husband,
the client’s first child and second child.

Their family has a monthly income 15,000 pesos which come from their bakery
business. It was subdivided into: Php 1000.00 -1500.00 (10%) for the food allowance which
includes the grocery like meat, fish, chicken, ingredients and condiments such as oil, soy sauce,
salt, and others, Php 1000.00 – 1500.00 (10%) for the allocation for necessities such as
shampoo, lotion, wipes, diaper, napkins, tissue, detergent soap, body soap, tooth brush, tooth
paste, and cloths. Php 1500.00 – 2000.00 (13%) for the allocation for pig’s feeds or live stocks,
Php 5000.00 – 6000.00 (40%) for the allocation for their business of bakery stand which
includes Baking dishes, tins and pans of different shapes and sizes, Dough proofer and other
condiments such us Cinnamon, Nutmeg, Mace. ...Allspice, Php 600.00- 750.00 (5%) for the
allocation for their electric bill wherein their house has a lesser consumption of electricity which
the family is not fond on using electricity in a long period of time, and Php500–750 (5%) for the
allocation for the gasoline for their tricycle and Php1,000 – Php2000.00-2500.00 (16%) for the
allocation for their savings.

Expenses
Food allowance
Necessities
16% 10% Livestock
10% Business
5%
5% Electric Bills
13% Gasoline
Savings
40%
II. PREGNANCY HISTORY
A. CURRENT PREGNANCY

December 31, 2020 was the last menstrual period of the client with an expected date of
confinement on October 8, 2021. The client’s obstetrical coding is G4P3 with T2P1A0L2M0
coding. Age of gestation is 8 lunar months or 32 weeks and the date of quickening was April 20,
2021.

The signs and symptoms experienced by the client includes the presumptive signs such as
amenorrhea, breast tenderness, quickening, skin changes specifically striae gravidarum and
linea nigra. The probable signs were positive pregnancy test and enlargement of the abdomen
and the positive signs includes movement as observed when measuring the fundic height.

The client’s immunizations/vaccinations received was only Tetanous Diphteria (0.5 mL). The
drugs and medications taken by the client were folic acid 400 mg a day, calcium carbonate
1.25g a day and ferrous sulphate 200 mg a day.

The client was not exposed to any communicable diseases and abdominal pain like slightly
cramping without bleeding was the noted danger signal during her early pregnancy (first
trimester). She suffered from illnesses such as cough and colds.

Regarding the reactions and adaptations to pregnancy, the client was shocked of knowing
that she was pregnant. She was happy and pleased for her fourth pregnancy. She easily
accepts her pregnancy and no feeling of ambivalence. She stated that she is fantasizing the sex
and appearance of the child and she currently planning about the birth if the baby.

On the reactions of the client’s partner and family, they were also shocked and delighted at
the same time because of their excitement to have a new member of their family. The partner’s
reaction was overjoyed and thankful for he will have his first baby and he will be a father.

Expected Date of Confinement (EDC)

a. Naegele’s Rule

12 31 2020 - LMP
-3 +7 _
09 38 2020
+1 -30 +1
10 8 2021 - EDC

Age of Gestation (AOG)

a. McDonald’s Rule
1. AOG in lunar moths = Fundic height (cm) x 2/7
= 28 cm x 2/7
= 8 months

2. AOG in weeks = Fundic height (cm) x 8/7

= 28 cm x 8/7
= 32 weeks
b. Bartholome’s Rule
32 weeks = halfway between umbilicus and xiphoid
process

LMP – 12 31 2020
DOC - 07

DEC 31- 31 = 0
JAN 31
FEB 28
MAR 31
APR 30
MAY 31
JUNE 30
JULY 31
AUG 12

224/7 = 32 weeks - AOG

B. Past Obstetrical History

Year Place of Delivery Type of Delivery Remarks

Normal
Mariano Marcos
Spontaneous
2002 Memorial Hospital Full Term
Delivery
and Medical Center
(Episiotomy)
Normal
Mariano Marcos
Spontaneous
2003 Memorial Hospital Full Term
Delivery
and Medical Center
(Episiotomy)

C. MENSTRUAL HISTORY

The client said that she had her menarche when she was on the 6 th grade at the age of
12. Her menstruation cycle usually lasts for four to five days and she has a regular menstruation
on a 30-day cycle. During the first day, her sanitary napkin was moderately soaked. During her
second and third day her sanitary napkin was fully soaked and she uses an average of 5-6
pads. During the last two days of her menstruation her napkin was minimally soaked. In
addition, she didn’t experience any discomfort just like dysmenorrhea when having
menstruation.

III. HEALTH HISTORY

A. FAMILY HEALTH HISTORY

On the paternal side, Milagros Pascua, the grandmother of the client at the age of 72
died because of old age while the client’s grandfather, Melchor Pascua, 68 of age is still
alive and well. Their children are Banny, Arthur and Ronalyn are all alive and well while the
last born who is the father of the client, Zaldy Pascua diagnosed with hypertension in Gaoat
General Hospital three years ago. The client was unable to remember the medicines taken
by his father but was able to mention some management done when manifestations occur
such as headache and dizziness. Her father takes a bath and consumed 3 pieces of
calamansi to relieve feeling of discomfort.
As for the common illnesses, they experienced fever, cough and colds with
manifestations of headache, sweating, dizziness, fatigue and feeling of restlessness. As for
their management, they usually take OTC drugs such as Paracetamol 500mg every four
hours, carrying out tepid sponge bath every after 30 minutes to lower body temperature for
fever, increasing fluid intake at least eight glasses a day. As for the colds and cough, they
managed it by water therapy, having rest, drink one glass of calamansi juice and taking of
Lagundi Plemex 600 mg for 1 teaspoon 3 times a day until the condition improved. They do
not practice consultation to Physician when suffering from mild illnesses.
As for their lifestyle, they usually wake up around 4:00 to 5:00 AM and sleeps at
around 10:00 PM to 11:00 in the evening. They usually sleep late because of their business
preparation for tomorrow. The family is fond of eating fatty and oily foods. For hygienic
practices, they take a bath twice a day, one full bath in the morning and one partial bath
before going to sleep. One member of the family is smoking once a day. The male members
of the family drinks liquor beer ocassionally.
As for their immunizations, the client was unable to distinguish if all of the family
members received complete immunizations.
On the maternal side, both the grandparents were dead because of old age. Their
children, Juvie and Edmund are healthy and well. While for their last born, Linda Pascua,
the mother of the client has hypertension and was diagnosed five months ago at MMMH and
MC but failed to remember the physician. Her medication prescribed by her doctor is
Lacidipine 4mg which taken every morning. After taking her medication, she applied a
minimal amount of whiteflower oil into her temporal and inhale it to alleviate and relieve the
pain.
As for the common illnesses that the family usually experienced include fever, cough
and colds. For fever, they manage this by taking Paracetamol (Biogesic) 500 mg taken
every four hours until the fever subsides. They also perform tepid sponge bath for every 30
minutes until the body temperature of the febrile family member subsides. They also use
cotton ball half soaked into a vinegar to inhale by the febrile family member for 10 minutes
as it could make the former’s feeling to lighten and go well as claimed by the patient. For the
cough and colds, it was managed by increasing their fluid intake by 8-11 glasses per day
and consuming citrus fruits like orange at least 10 pcs of it every day. They also take either
Tuseran forte capsule 325 mg or Tylenol 500 mg three times a day after meal. The said
managements were effective as the client claimed.
Regarding to the family’s utilization of health care facilities, the patient claimed that
they usually consult at Gaoat General Hospital and sometimes in RHU whenever they feel
something wrong in their body’s condition and when there are emergency cases.
As for their lifestyle, they wake up at 4:00 to 5:00 in the morning and usually sleeps
at 10:00 to 11:00 in the evening. They usually eat their breakfast around 5:00 – 6:00 am. For
their lunch, they usually eat around 12 noon and 7:00 pm for their dinner. For the promotion
of health, they usually take a bath twice a day, full bath in the morning and half bath before
they sleep. As stated by the patient, some of her family members especially the males in the
family drink lambanog occasionally but they do not smoke.
For their immunizations, the patient claimed that some of her family members did not
complete their vaccinations excluding her

B. PERSONAL HISTORY

1. PRESENT HEALTH HISTORY

As for the client’s nutrition she is fond of drinking coffee, usually in the morning during
breakfast and in the afternoon when she takes her snack. She eats her breakfast 7:00 in the
morning, 11:45 for lunch, usually 3:00 when she takes her snack and 8:00 in the evening for her
dinner. In the morning she is the one who prepares for their breakfast and sometimes her
mother will be the one who will prepare for their other meals. The client likes to eat longganisa
and fried rice. She can eat at least 3 cups of rice whenever she likes the dish especially when it
is longganisa or fried rice. And as to her merienda, she usually eats atleast 4 buns of dorongs
pandesal with a water and sometimes with a coffee. She usually She is fond of sleeping and
she almost spend her time sleeping.

She sleeps 10:00 at night and wake up 6:00 in the morning and have her nap time at
1:00 to 5:00 in the afternoon. In the afternoon, the client walks in front of their house as her
exercise and wash their clothes as long as she can. Because according to the client in order to
exercise her arms she washes their clothes as long as she can do it by herself. She cleans the
house in the morning and watch television for about 1 hour during her free time after cleaning
the house.
As for the client’s lifestyle, she does not have any vices such as cigarette, alcohol and
illegal drugs. The client does not experience any emotional distress.

THREE DAY DIET RECALL

09/16/21 09/17/21 09/18/21

BREAKFAST 4 cups of fried rice 2 cups of fried rice 1 cup of fried rice
4pieces of dry fish “adobong pusit” Pork bulalo
1 glass of water 1 cup of hot coffee 1 glass of water
SNACK 2 pieces of hopia and a 1 piece of mamon 2 pieces of pandesal
glass of water 1 glass of water A glass of hot coffee
LUNCH 2 cups of plain rice 2 cups of plain rice 2 cups of plain rice
Pork adobo Pinakbet Pork sinigang
2 glasses of water 2 glassess of water
SNACK 3buns of pandesal 1 skyflakes 4 buns of pandesal
A glass of hot coffee A glass of hot coffee A glass of hot coffee

DINNER 2 cups of plain rice 1 cup of plain rice 1 cup of plain rice
Chicken adobo Pork bulalo Dinengdeng
“dinengdeng” A glass of water A glass of water
A glass of water

The 3-day diet recall of the client shows that she always eats fried rice as her breakfast
and she likes to eat any kind of adobo. She is fond of eating pandesal, bread and hopia as her
merienda. She doesn’t always eat vegetables. She is fond of drinking coffee, and he drinks
coffee 2 times almost every day. As to her fluid intake, she doesn’t always drink water and she
only drink 1 glass of water every meal. And instead of drinking milk she prefers of drinking hot
coffee.

2. PAST HEALTH HISTORY

The client first and last experienced asthma when she was 9 years old for one week as
her childhood diseases with signs and symptoms of cough, wheezing, shortness of breath, and
chest tightness. Her parents managed it by taking over the counter drugs such as Albuterol
salbutamol 2.5 mg with the used of nebulizer every 6 hours with side effects of fast heartbeat,
shakiness, and nervousness and when sleeping she was elevating his head with 2-3 pillows.

As for her childhood illnesses, she suffered from mumps during her elementary level
where she managed it by mixing akot-akot with warm clean water and apply it to affected area.
As a results, she recovered from mumps. She also experienced chicken pox for 1 week. She
wore long sleeves and jogging pants, stayed at home, and took a bath with warm boiled guava
leaves. She was advised by her mother not to pop out fluid blister present on skin. As an
outcome, she recovered after a week.

The client experienced common illnesses such as fever, cough, and colds. She
practiced drinking of 1 glass of warm calamansi juice with 1 teaspoon of honey a day and drink
warm boiled oregano leaves 3 times a day until the cough subsides. When she got fever which
lasts to 1-3 days, she makes do of tepid sponge bath every 30 minutes and taking OTC drug
such as Tempra 500 mg for 3-4 times daily for one tablet after meal to subside the temperature
into normal. She also drinks a plenty of water (7-8 glasses), avoid cold drinks and taking
Neozep Forte 500 mg (OTC drugs) every 6 hours before or after meal when suffered from
colds. If condition gets worst, they usually immediately consult a physician in the RHU Batac.

The client never had a history of surgery. Their health beliefs and practices include the
utilization of herbal medicines for mild illnesses but they consult a doctor when it is severe. Their
family does not believe on faith healers.

As verbalized by the client, she had a complete immunization and there was a scar on
her right deltoid but unable to present her yellow card.

3. SEXUAL HISTORY
IV. PHYSICAL ASSESSMENT

Date of assessment: September 19, 2021

A. GENERAL SURVEY/APPEARANCE

The patient was seen standing in front of their door last September 19, 2021. She was
wearing sleeveless dark blue top and black cotton short. She was neat and well groomed. Her
manner of dressing was appropriate to the kind of weather. Her hair is at shoulder level and
properly combed. She has a fair skin complexion. Apparent age was appropriate and congruent
to her actual age, with proportional height, trunk and body limbs. The gait was rhythmic and
coordinated and she appears to be relaxed. During the interview she was able to answer all the
questions in a clear and coherent manner. She was articulate and very cooperative with a
controlled voice. There were no signs of distress and she was aware of her surroundings.

BMI

Height: 157 cm (last taken during her check-up a week ago)

Weight: 61 kg (last taken during her check-up a week ago)

61 kilograms 61 kilograms
2 = ❑ = 24.74/ within normal
1.57 meters 2.4649 meters

Vital signs:

Body Temperature: 36.9 (left axillary)

Pulse Rate: 83 beats per minute (regular)

Respiratory Rate: 19 breaths per minute

Blood Pressure: 110/70 mmHg (sitting position at right arm)

Weight and Height

a. Johnson’s Rule
Fundic height = 28 cm
K = 155
N = 11 (not engaged)
Fundic Height-nxk
28 cm-11x155 = 1,677 grams – EFW

b. Haase’s Rule
8 months x 5 = 40 cm – EFL

B. ROLL OVER TEST

C. ADMINISTRATION RESULT
Place woman in left lateral position and take The BP of the client is 120/70 mmhg in left
BP lateral position.
Roll woman on her back and take a second The BP of the client is 110/70 mmhg in a
BP supine position.
Take another BP after 5 minutes in the same The BP of the client is 110/70 mmhg in a
position supine position after 5 minutes.
The test is positive if there is a 20 mmHg or There is no elevation of 20 mmhg or more in
more elevation in diastolic pressure the diastolic pressure of the client.

The client is not at risk for developing pregnancy induced hypertension for there is no
elevation of 20 mmHg or more in the diastolic pressure of the client.

D. HEAD-TO-TOE ASSESSMENT

SKIN

 Evenly colored with a fair complexion

 Warm in temperature
 Elastic and returns to original shape quickly
 Skin rebounds and does not remain indented when pressure is released

SCALP AND HAIR

 Natural hair color is black and finely distributed over the scalp
 Hair is firm, smooth and not brittle
 Scalp is clean and no presence of lesions, dandruff and foreign bodies (e.g. lice)

HEAD AND FACE

 Normocephalic
 Head is symmetric, round and erect
 Head held still and upright
 Head is hard with no presence of lesions and masses
 No abnormal movements observed
 The face is symmetric and round in appearance
 No presence of melasma
 No presence of pimples and dark spots on the face
 No moles nor birthmarks present
 Temporal artery is elastic and not tender
 TMJ is not tender, no swelling and no crepitation
 Mouth opens and closes fully between upper and lower teeth

NAILS

 Clean and trimmed

 Pinkish in color
 Hard and immobile
 Normally it is 160-degree angle between the nail base and the skin
 Nail plates are firmly attached to the nail beds and is smooth and firm
 Capillary refill time is 2 seconds and pink tones immediately return to blanched nail bed
when pressure is released

NECK

 Symmetric, head is centered and no bulging masses

 Skin color is appropriate to the body
 Thyroid and cricoid cartilage symmetrically move upward as the client swallows
 C7 is visible and palpable
 Trachea is midline
 Landmarks are positioned midline and the neck is free from nodules
 No swelling, no enlargement, no tenderness and no hardness present

EYES

 The upper lid margin is between the upper margin of the iris and the upper margin of the
pupil

 No white sclera is seen above or below the iris

 The upper and lower lids close easily and meet completely when closed

 The lower eyelid is upright with no inward and outward turnings

 Eyelashes are evenly distributed and curved outward

 Skins on both eyelids are free from redness, swelling and lesions
 Eyeballs are aligned in the socket symmetrically without protruding or sinking

 Bulbar and palpebral conjunctiva is moist, clear and smooth

 Sclera is white

 Palpebral conjunctiva is free from swelling, foreign bodies as well as trauma

 Puncta is visible without redness and swelling

 Cornea is transparent with no opacities

 Lens is free of opacities

 Iris is round, flat and evenly colored (dark brown)

 Pupil is round and centered in the iris

EARS

 Ears are equal in size bilaterally which is 6cm in size

 Auricle aligns with the corner of each eye

 Earlobes are attached

 The skin is smooth without any lesions, lumps and nodules

 Color is the same with the facial color

 Darwin's tubercle is visible

 There's no discharge noted but a small amount of cerumen is the only discharge that is
normally present

 Cerumen color is yellow and is moist

 The auricle, tragus and mastoid process are not tender

 Canal walls are pink and smooth without nodules

MOUTH

 Lips are smooth and moist without swelling or lesions

 Twenty eight pearly whitish teeth are present

 Wisdom teeth are not yet erupted

 Upper molars rest directly on lower molars and the front upper incisors slightly override
the lower incisors

 No decayed areas, no missing teeth

 Color and consistency of tissues along cheeks and gums are even

 Gums are pink, moist and firm with tight margins to the tooth

 No presence of lesions and masses

 Tongue is pink, moist and moderate in size with papillae without lesions

 Tongue's ventral surface is smooth, shiny, pink or slightly pale with visible veins and no
lesions

 Frenulum is midline

 Sides of the tongue are free from lesions, ulcers and nodules

 There is no foul odor of the mouth

 The uvula is fleshy and hangs freely in the midline

NOSE

 Color is the same with the rest of the facial color

 Nose is symmetric, smooth in structure, and slightly pointed

 Client is able to sniff through each nostril when the other one is occluded

POSTERIOR THORAX (INSPECTION AND PALPATION)

 Scapulae are symmetric and nonprotruding

 Shoulders and scapulae are equal in positions

 Ribs sloping downward and the spinous process appears straight

 Doesn't use any accessory muscles to assist in breathing

 Client sits up and relaxed and breaths easily

 Client reports no tenderness, pain or unusual sensations

 Temperature is equal bilaterally

 No palpable crepitus and the skin has no lesions

ANTERIOR THORAX (INSPECTION AND PALPATION)

 Sternum is positioned midlife and straight

 Retractions are not observed

 Ribs slopes downward

 Respirations are relaxed, effortless, and quiet

 Use of accessory muscles is not seen with normal respiratory effort

 Palpation does not elicit tenderness or pain

 No crepitus palpated

 No unusual surface masses or lesions are palpated

ARMS

 Arms are bilaterally equal with each other

 Color is the same bilaterally

 Skin is warm to touch bilaterally from fingertips to upper arms

 Radial pulses are both strong

 Ulnar pulses are not detectable

 Brachial pulses have equal strength

LEGS
 Legs are bilaterally equal in color and size and a scar was seen on her left leg which
measures 1 cm

 Toes, feet and legs are equally warm bilaterally

ABDOMEN

 Presence of linea nigra and striae gravidarum

 Umbilicus is midline and is everted

 Umbilical skin tone is darker compared to the surrounding skin of abdomen

 Abdomen is free from any lesions and rashes

POSTURE AND GAIT

 Good posture

 Evenly distributed weight.

 Able to stand on heels and toes

 Toes pointing straight ahead and equal on both sides

HANDS AND FINGERS

 Hands and fingers are symmetric, non-tender and without nodules

 No presence of edema

 Fingers lie in straight line

 No deformities or swelling

ANKLES AND FEET

 Toes usually point forward and lie flat.

 Toes and feet are in alignment with the lower leg.

 Skin is smooth and free from calluses.

 No pain, swelling and nodules are noted.

 No presence of edema
ADMINISTRATION FINDINGS
The examiner rub both
the hands to warm it, then
FIRST MANEUVER faced the head part and The fundus contains the
(Fundal Grip) using both hands to head which is round,
palpate the fundus part hard and ballotable.
whether it is the head or
the buttocks.
The examiner used both The right side of the
hands in palpating the abdomen is where the
sides of the abdomen. fetal back is located that
One hand used to steady feels smooth like a
SECOND the uterus on one side of resistant. On the left side
MANEUVER the abdomen while the of the abdomen, is the
(Umbilical Grip) other hand used deep but rough side which
gentle pressure and moves indicates that this is
slightly on a circular where the small fetal
motion to feel for the fetal parts are located which
back and small fetal parts. are irregular and nodular
bony prominences.
The examiner used the The presenting part is not
thumb together with the yet engaged wherein it is
fingers to grasp for the plumping up but not just
THIRD lower portion of the moving a lot.
MANEUVER abdomen above the
(Pawlic Grip) symphysis pubis, pressing
it slightly while making
gentle movement from
side to side.
Considering that the head The fetal attitude cannot
FOURTH was in the fundus part, the be determined yet since
MANEUVER fourth maneuver was not the fetal head is in the
(Pelvic Grip) applicable on this part. fundus part hence it has
not descended yet.

E. FETAL HEART TONE (FHT)

Fetal heart tone is slightly heard using the bell of the stethoscope with 143 beats per
minute. Fetal heart tone was much more audible and was heard at the right lower quadrant
of the abdomen. Normal fetal heart tone is 120 – 160 beats per minute.

V. LABORATORY RESULTS
Date of Ordered: 16-Aug-2021 6:57 AM
Physician:
Laboratory Procedures:
Procedure Found Value Reference Value Significance
Blood Typing
ABO Blood Typing O
RH Typing POSITIVE Positive Antibody Screens

Analysis:

The ABO blood typing is used to determine the blood type of the client. Rh typing is
performed to determine the presence or absence of Rh antigen (Farrell, E. (2002). The client
has a positive Rh typing. Hence, she will not repeat and receive antibody screens and Rh
immune globulin.

Procedure Found Value Reference Value Significance

Complete Blood Count
Hemoglobin 122.00 g/L 123-153 Lower than the reference
value
Hematocrit 0.35 0.35-0.44 Within the reference value
RBC 4.06 4.5-5.1 Lower than the reference
value
WBC 8.96 4.50-11.00 Within the reference value
Platelet count 236.00 fL 150-450 Within the reference value

Analysis:
The CBC is to determine the presence of anemia, WBC count to determine the infection
and platelet count to identify clotting activity. The client has slightly decrease in hemoglobin and
red blood cells wherein it is a characteristic of an anemia. According to Wedro (2019), anemia is
a relatively finding in pregnancy in which a hemoglobin level of pregnancy can naturally lower to
10.5 gm/dL. Hence, the client is still in normal condition in terms of complete blood count.
Procedure Found Value Reference Value Significance
Serology Section
HbsAg Screening NON-REACTIVE
Syphilis Anti TP Test NON-REACTIVE
(ICT)
Analysis:
Syphilis is a sexually transmitted disease which can be exposed to pregnant mothers
(Chad, 2019). However, the client has a result of nonreactive which means the pregnant is
negative from syphilis. Hence, the client is not risk in any symptoms of STD.

Procedure Found Value Reference Value Significance

CM and Parasitology Section Urine Analysis
Physical Exam
Color YELLOW
Clarity SLIGHTLY TURBID
Specific Gravity 1.020
pH 6.0
Chemical Exam
Protein POSITIVE 1
Glucose NORMAL
Hemoglobin POSITIVE 1
Ketone POSITIVE 1
Nitrite NEGATIVE
Bilirubin POSITIVE 1
Urabilinogen NORMAL
Leuko Esterase POSITIVE 1
Urinary Crystals
Amorphous Urate RARE
Calcium Oxalate -
Triple Phosphates -
Uric Acid -

Analysis:
Urine test is used to assess bladder and kidney functions, diabetes, dehydration, and
preeclampsia by screening for high levels of sugars, proteins, ketones and bacteria (American
Pregnancy Association, 2019). The client has positive in protein, haemoglobin, ketone, bilirubin
and leuko esterase in the urine. Hence, protein in urine may suggest a possible urinary tract
infection or kidney disease and preeclampsia associated with high blood pressure.
VI. NURSING CARE PLAN

NCP 1

ASSESSMENT:

Objective Data: The client’s house is near their piggery and chicken manures are
scattered around as well as dogs’ poops.

NURSING DIAGNOSIS:
Risk for contamination related to exposure to atmospheric pollutants.

Problem: Risk for contamination

Etiology: Exposure to atmospheric pollutants (piggery, chicken manures, and dogs’ poops).

NURSING GOAL:

After one hour of health teaching, the client will be able to modify environment as
indicated to prevent contamination from atmospheric pollutants.

NURSING INTERVENTION:

RESPONSIBILITIES RATIONALE
Recommend inspection and cleaning of their To identify possible contaminants
surroundings.
Encourage proper cleaning of the piggery To keep the area clean and maintain fresh
daily. air.
Recommend placing the chickens in poultry To maintain cleanliness and prevent
house and locking up their dogs. contamination

NURSING EVALUATION:
After one hour of health teaching, the client was being able to modify environment as
indicated to prevent contamination from atmospheric pollutants.

NCP 1

ASSESSMENT:

Subjective Data: Expresses desire to enhance prenatal lifestyle (nutrition, sleep, and
exercise) with verbalization of “kayat ko nasalun-at etuy sikug ko ita, nu mabalbalin ket healthy
foods kinanayun iti kanek para kadetuy baby’k, adda sakto nga turog ko ken adda kuma
exercise tapno haan nak to marigatan a aganak.”

NURSING DIAGNOSIS:

Readiness for enhanced childbearing process.

NURSING GOAL:

After one hour of health teaching, the client will be able verbalize understanding of care
requirements to promote healthy childbearing.

NURSING INTERVENTION:

RESPONSIBILITIES RATIONALE
Provide necessary referrals such as dietitian. To promote maternal and fetal nutrition.

Provide anticipatory guidance including To encourage acceptance of responsibility

discussion of nutrition regular exercise, and promotes self-care.
comfort measure, rest, breast care, sexual
activity and health habits or lifestyle.

Review nutrition requirements and optimal To decrease the risk of intrauterine growth
prenatal weight gain to support maternal-fetal restriction in the fetus and delivery of low
needs. birth weight infant.

NURSING EVALUATION:
After one hour of health teaching, the client was able to verbalize understanding of care
requirements to promote healthy childbearing.

REFERENCES
American Pregnancy Association. (2019). Getting a Urinalysis: About Urine Test. Retrieved from
[Link]
Chad, H. (2019). University of Rochester Medical Center Rochester, NY. Retrieved from
[Link]
contenttypeid=167&contentid=rapid_plasma_reagin_syphilis
Farrell, E. (2002). The WHO Reproductive Health Library; Geneva:World Health Organisation.
Retrieved from [Link]
[Link]
Wedro, B. (2019). Anemia During Pregnancy. MedicineNet. Retrieved from
[Link]