FERRIS STATE UNIVERSITY

DEPARTMENT OF NURSING

OBSTETRIC HISTORY & PHYSICAL EXAM FORM

Student ___Jessica Schultz_________________

Date _____10/12/2013_________

Please review GUIDELINES FOR NURSING HISTORIES before beginning.

BIOGRAPHICAL DATA A. Pt. init. __B.V.__ Age __29__ DOB __12/27/1983_ Religion _Christian_ Race Caucasian/irish A. Marital status (check one) Single Married X Separated Divorced Widowed B. Nearest relative/support person (relationship only) Husband in home/ Mom and Dad 1 mile away___

BRIEF SOCIAL HISTORY

A. Where employed __Vanderwal Dairy Farm___ Occupation __Dairy Farmer/Owner____ B. Highest education __Michigan State University for Dairy Management/class of 2006______________

CURRENT PREGNANCY
A. B. C. D. Expected date of delivery __02/11/2014_ Gravida __1__ Para ____0__ Ab ___0___ Type of childbirth preparation _OB and midwife___ Date last seen by Dr. __10/12/2013 Allergies/sensitivities _____Ragweed/ no known medication allergies________________________ Special problems this pregnancy and treatment ____none ____________________ _____________________________________________________________________ E. Laboratory assessment (if known): Blood type ___O__ Rh ___+___ Fathers blood type _unknown__ Rh ________

Anemia? ___no___ A. Nursing assessment: Pre-pregnant Wt __138_ Present Wt _156__ Ht 52__

G. Minor discomforts (check all that apply): n/a Mood swings n/a Dyspareunia n/a Fatigue n/a Varicosities n/a Insomnia n/a Heart Burn n/a Nocturia X Backache n/a Leg cramps X Constipation n/a Frequent urination Anxiety n/a Pain (where) n/a Vaginal discharge n/a Numbness or swelling of feet, fingers, ankles n/a Itching of skin or vulva n/a Other:

Have you had or been exposed to a major infection? (When) -not that she is aware of (What)

IV. PAST HEALTH AND MENSTRUAL HISTORY Write in this space pertinent information related to residual or chronic illness. _N/A no family history of chronic illness either________________________________________ ____________________________________________________________________

Last X-rays ____2005____ Type ____________Sprained ankle___________________ What medications and vitamins are you taking and why? ____Prenatal vitamins for healthy baby __Occasionally Tylenol 325mg for aches and pains associated with work____________________

V. PAST CONTRACEPTIVE HISTORY

X Oral Norplant IUD X Condoms Gels & Foams DEPO Provera Rhythm

A. Previous Pregnancy History: DOB N/A Sex N/A Birth weight N/A Prem/FT/Stillbirth N/A Living N/A

B.

Previous children with problems after birth? Explain ________N/A______________ ____________________________________________________________________ ____________________________________________________________________

A. Problems with previous pregnancies (excessive vomiting, multiple births, excessive wt. gain, closely spaced pregnancies, etc.) Explain _____no previous pregnancies/ vomiting and morning __ _____sickness were prevalent the first 3 months of current pregnancy____________________________ A. Problems with previous labors and/or deliveries (extended labor periods, excessive bleeding, abnormal fetal position, etc.) Explain _______N/A______________________ _____________________________________________________________________ A. Postpartum problems (sub-involution, infection, excess bleeding, bladder, etc.) Explain ______________N/A______________________________________________ _____________________________________________________________________

VI.

DIET ASSESSMENT No. of meals per day __3_ No. of snacks per day __2_ Fluid intake per day _not enough_ Pica ___none__ Peculiarities (social-cultural, religious, economic, etc.) ______________nothing out of the ordinary American Diet_____________________________________________ _____________________________________________________________________

Typical Daily Food Intake in 24-hr period (sample)

Breakfast Food Muffin or bagel Cream cheese 1 tbl Amount Food

Lunch Amount 1 Food

Dinner Amount 1 chunk/ serving 1 Mashed potatoes 1 cup Food

Snacks Amount Sandwich baggie

1 serving Peanut butter And jelly sand, Pudding cup

Beef roast

Goldfish crackers

Granola bar 1

banana

Canned Grape cup Fruit slices

Sweet corn On cob Gravy biscuit

1 cob

Orange Juice

cup 1

NUTRITION LIMITATIONS What do you consider to be your healthy weight? No- I wouldve liked to lose some weight prior to baby_____ Do you eat at least 3 meals a day? yes Are you on a special diet? Yes, limited caffeine and no raw meat Do you take folic acid? Yes, in my prenatals 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? __hmm I think last year_____ 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? None other than a weight lifting restriction from pregnancy

FEARS/ANXIETIES ABOUT PREGNANCY AND PARENTING Personal Health: none Personal Safety: Sometimes, around the cows when milking but I trust them and they trust me. Fetal Condition: none Early Pregnancy Loss: in the beginning- took multiple attempts and almost a year to conceive. Pregnancy Complications :none Hospital: Delivering in Cadillac is scary so they will travel to Traverse City and hope to make it up in time. Surgery: none Anesthesia: none Perinatal Loss: none Labor/Delivery: labor is kind of scary but I can handle it. Infant Illness: none Infant Attachment: none

Parenting Skills: none A. Perception and knowledge of pregnancy and delivery (in clients own words) ____Its definitely going to hurt but it will be worth it in the end. She knows she will gain more weight and is comfortable with it. She will try to lose weight after she delivers and breast feeds._________________

A. Attitude toward pregnancy She feels good and says she looks good. She still works hard and has a great support system_______________________________________________ A. Questions asked by mother-to-be ___No questions for me____________________ ____________________________________________________________ ____________________________________________________________ WORK/SCHOOL ACTIVITIES EXPOSURE Have you experienced the loss of a co-worker and/or friend at work or school? Not since high school Have you been threatened recently at work or school? no Have you been involved in an argument or fight at work or school? Small family feuds but nothing major Have you recently changed jobs? no Have you recently changed school? no Quit school? no Do you use heavy equipment? Every day Do you work long hours? 12-14 hour days but Ive been cutting back and taking more breaks Do you do heavy housework? no Do you often stand for 30 minutes or more at a time? yes Do you often lift more than 20 pounds? Yes hay bails- not frequently 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 (many cats on the farm but no litter) 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? I used to in high school but havent in years Which one(s)? __cocaine, mushrooms, marijuana, alcohol______________________________ Amount ___enough to get high__________ Frequency ______Socially at parties_______ 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? none 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? yes 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, all over. Her husbands family as well 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 problems with anyone__________ Do you have a car or access to transportation? Yes- 2 cars 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? _31____ Is the babys father here with you today? yes How long have you known the babys father? _12 years___ Is the babys father happy about your pregnancy? Very happy 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? 12 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? none 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- with a savings account for emergencies 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? Not at all Are you having any problems sleeping? no Have you recently thought about suicide? no Have you ever attempted suicide? When? Never even thought about it Have you ever been diagnosed with a mental health condition? No, runs in husbands family though 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: none of those Rape/Sexual Assault? Past Recent Mental Abuse? Past Recent Crime Victim?

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? Socially yes Marijuana? Husband does yes Cocaine? no IV Drugs? no Meth? no Is he bi-sexual? no Does he have multiple partners? No way Is the babys father or your current partner employed? yes VII. PHYSICAL ASSESSMENT

General Appearance (DO NOT put good or WNL): She has good skin turgor and pink cheeks and white skin normal for ethnicity. Shiny, soft, well groomed hair and clothes. Pulse of 88 and respirations of 18. She has a capillary refill of >3 seconds and equal radial pulses. Her pulses are strong and her strength is good and equal in all extremities. She has clear clean skin and nails and her attitude is calm, pleasant, and cooperative. Her respirations are clear bilaterally both anterior and posterior, she has active bowel sounds in all quadrants and complains of no current illness or pain.

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

Constipation r/t decreased gastrointestinal *Assess tract for bowel sounds(monitor frequency and type of stool) *Need to know bowel information in order motility, pressure from enlarged uterus, *Check for abdominal distension supplementary iron (Ackley & Ladwig, 2011. pg.49) *Assess nutritional status and intake vs output *Assess fluid Intake *Include mild exercise in your daily routine To develop an effective treatment plan for preventing constipation and fecal impaction (Sparks & Taylor, 2009. pg. 68). *Assess fluid intake and output to ensure

* Add a laxative to your daily routine and increase fiber accurate fluid replacement (Sparks & Taylor, intake 2005). * Mild exercise will promote muscle tone and c circulation (Sparks & Taylor, 2009. pg. 69). Increased circulation will aid in bowel motillity

Readiness for enhanced self-health

* Listen and answer questions related to exercise and self-care

* Listening and answering questions will allow the pt. to be adequately prepared to set realistic goals

* Assist in writing long term goals as well as short term. (Sparks & Taylor, 2005. pg. 264.) * Assist in developing an exercise regimen reasonable to the patient. find a realistic way to incorporate exercise and activity into your day most days as your primary weight loss strategy (Dion, 2012. para. 4). * Setting goals can serve as tools for self-evaluation as new behaviors are being practiced (Sparks & Taylor, 2005. pg. 264.) * The hope to lose weight was expressed by B.V. Losing weight can be challenging for a postpartum Mother. Support is important. Its smartest to focus on increasing activity and healthy eating rather than calorie counting or dieting. You need to nourish your body to heal from delivery and produce quality breast milk for you baby. A realistic and safe goal is to lose one half to one pound per week(Dion, 2012. para. 3).

Anxiety r/t fear of unknown (Ackley & Ladwig, 2011. Pg. 83)

*Assess level of anxiety and reaction to it. *Listen and allow pt. to express herself *Have patient verbalize and brainstorm things that help promote comfort and encourage pt. to perform these activities.

*Is the anxiety something that she can cope with or is she at risk for other disorders such as ta tachycardia, tachypnea, depression) (Ackley & Ladwig, 2011. pg. 187). *Listening attentively will allow patient to identify anxious behaviors and discover source of anxiety. (Sparks & Taylor, 2005. pg. 38). *Partaking in comforting activities will help give her a sense of control(Sparks & Taylor, 2005. pg.37).

References:
Ackley, B. J., Ladwig, G. B. (2011). Mosbys guide to nursing diagnosis . (3rd ed.). Maryland Heights, MO: Mosby Elsevier Dion, D., (2012). Post pregnancy weight loss tips. Wellness and education. Retrieved from http://www.whallc.com/wellness-and-education/wellness-journal/12-04 05/Post_Pregnancy_Weight_Loss_Tips.aspx Sparks, S. R, Taylor, C. M. (2005). Sparks and Taylors nursing diagnosis reference manual. (6th ed.). Philadelphia: Lippicott Williams & Wilkins