PRENATAL ASSESSMENT

I. GENERAL SURVEY

The prenatal assessment to which our group conducted was

made possible last October 9, 2009 at 10:00 am at their residence at

West St. Anthony Village, Brgy. San Antonio, Agdao, Davao City.

Our pregnant client, Mrs. Amalia Supisa during the assessment

was not well groomed since her hair was not combed well and properly

kept. Her fingernails and toenails were not trimmed. As observed,

sweating was evident. During the assessment time at her house, she

was then seated in front of us. She didn’t wear any dentures but able

to speak with clarity on our natïve dialect. She can mobilize her body

without any limitations on the range of motion. We consider her to be

an endomorph since her body is big. The client was willing to

cooperate with the assessment. She has a sense of time orientation,

the environment and the people she interacts with. She was able to

interact with us though most of our conversations were initiated by the

group.

II. Vital Signs

 Actual Vital Signs at 10:30 Normal Range

AM
Temperature 35.6

Pulse Rate 78

Cardiac Rate 84

Respiration Rate 20

Blood Pressure 120/80

Our client, Mrs. Amalia Supisa is 41 years old and resides at West Village,

Barangay San Antonio, Agdao, Davao City.

She is G_ T_P_A_L_M. Her last menstrual period was on Feb. 18, 2009.

Thus, her Estimated Time of Confinement will be on __________. She did not

remember anymore the exact date of her menarche, but she was sure that it

started when she was 13 years old.The age of gestation is 7 months or 28

weeks.

She is 5’2” tall with 68 kilograms. She had never experienced measles or

rubella during her childhood. She recalled that she only had mumps when she

was 13 years old and had her first asthma attack when she was 15 years old.

She never memorized all the immunizations she had but she verbalized of being

immunized with BCG , poliomyelitis and measles but there were no valid

supporting data that were presented to us to validate what she verbalized. She

said that all her certificates were left to her elder sister at Samal. Her tetanus
toxoid was completed on 1998, based on the her records at the health center. On

her past pregnancy, that is last year, she experienced difficulty in breathing

because of her asthma or what she coined as ‘hubak’ at the first trimester. Her

blood type is O. And this was her first prenatal visit on her 14th child. When she

was asked if where she will deliver her baby, she said they are planning to

deliver it to a ‘lying-in’ near their residence because her ‘manghihilot’ already

died. On our urine testing, her albumin test yielded with a +1.0 result but said that

she collected the specimen after she had eaten her breakfast. Her glucose test

result was negative; specific gravity is 1.010 ; pH was 6.5. We also observed

during her assessment that varicose veins were visible on her both lower

extremities and said that, whenever she’s pregnant, the varicose veins were

present. We had checked also for any edemas on her feet because it may

indicate one of the signs of PIH; but yielded negative. Other signs and

symptoms were also been assessed to the client such

as:_________________________. Aside from assessing for albumin test, we

also checked for the presence of thrombophlebitis through Homan’s Test and

checking also for edemas or swellings.

We also performed the Leopold’s maneuver to determine the position of

the fetus inside the mother's uterus. The____________The fundic height is 25

cm. And the fetal heart tone was heard on the Left Lower Quadrant with a fetal

heart tone of 144 beats per minute.

 On our assessment on the neurological system, the client experienced

mild headaches and to relieve the pain, she rests because she thought that it

may be just because of her works.

On the cardiovascular system, our client experienced

anemia._____defend! There were no edemas found on her upper extremities

and lower extremities especially at the ankles, face and fingers; but varicose

veins were found at both legs. Her cardiac rate is within normal range with 84

beats per minute. The blood pressure was 120/80, while the fetal heart rate was

144 beats per minute.

Our client experiences asthma as what she verbalized, “naga hutoy man

ko sa una katong mga 3 months pa ni, pero karon wala naman. Naa man gud

koy piang diri sa akong bukton, mao sigurong gi-hubak ko ato.”

On the gastrointestinal system, she had nausea and vomiting on her 1st

month of gestation. Swollen gums were also noted ____; ptyalism____.

Flatulence was also present.

On the renal system, our client said that her urgency to urinate increases.

As our urine testing using the biostick, the urine glucose was negative; while the

protein test yielded a positive result of +1. 010.

Any history of Diabetes Mellitus and goiter were not present upon

assessing the endocrine system.

When it comes to the reproductive system, she feels pain sometimes on

her abdominal area and quickening is also felt.

 On the client’s skin, linea negra was present on her abdomen. Stria

gravidarum_______. There was no chloasma seen on the neck of the client.

Vascular spider________.

On the skeletal system, backache was present especially after her works.

On her nutritional status, our client’s family prefers buying food on the

‘carenderia’, especially at lunch time. Her diet consists of two cups of rice each

meal. She always eat vegetables especially ‘pakbet’ and ‘lao-uy’; but seldom

eats fruits. She could only eat fruit at least once a week. They always eat meat

especially chicken, used as their ginisa. Fish is always present on their dining

table whether its dried fish or fresh. She never drinks milk and other dairy

products, she prefers coffee rather than milk. She sometimes eat foods rich in

fats and oils such as “humba” and dairy products. And she rarely eats sweets.

Our client never smokes and drinks only during fiestas, and holidays such

as Christmas, New Year. Her son, Dennis smokes not more than 2 sticks per

day.

As we asked about how she will feed her coming new family member, she

verbalized, “Mix lang ni akong ipa-totoy sa iya kay ma-busy man jud gud ko ba.”

She also affirmed that she will complete the immunizations of her child. And as

we discussed about family planning, she said that DMPA injectibles is her choice

of method in birth controlling.