COLLEGE OF NURSING

GUIDE FOR ASSESSING A MATERNITY CLIENT

NURSING HISTORY
A. Personal Data

Name: MARICEL VARGAS

Age: 30

Educational attainment: college level

Occupation: housewife

Nationality: Filipino

Address: #360 mabini st. calumpang Marikina

B.MENSTRUAL HISTORY

a. Menarche-at what age first menstruation occurred

14 yrs old, when I was got menstruation

b. Characteristic of menstruation as to:

1. duration- 3 days only

2. color- red

3. odor- natural

4. consistency-

5. Internal between menses- 1 month is my interval of menses

c. Maternal History

1. History of the present pregnancy

A.LMP- nov 18, 2010 is my last menstrual period.

EDC- July 3, 2011, my expectation date of confinement.

AOG-

b. physiological & psychological changes of pregnancy, asses the signs,

symptoms and discomfort associated w/ pregnancy during the:

First trimester- In this period I usually felt vomiting, sleepy and being
tiredness. This is the first changes on my body.

Second trimester- I Gain more weight, because I always want to eat more
foods. I crave for something, and then I don’t like to eat all the foods
prepared on me. I felt that I’m too choosy about the foods that I eat.

Third trimester- I felt my abdomen is too big enough for me.

c. prenatal check-up: yes_/___ No____ When: East avenue medical center

d. reaction/feelings regarding the present pregnancy

1. Is it a planned or unexpected pregnancy?

It is planned both of me & my husband is deciding to have our own family.

e. Reaction/feelings regarding the newly born baby

1. Is there any expectation to as to sex and appearance of the baby?

Yes, when we do sex we usually think already about the appearance of our
baby.

f. Reaction and feelings about breast-feeding?

1. Is the mother aware of the advantage of breast feeding?

Yes, it is very important to breast feed your baby because it contains more
nutrients than other milk that we bought on groceries. Babies need our milk
on the first period when we gave birth.

g. Reactions and feelings about family planning

1. Are they (couple) aware of family planning?

Yes, we are aware about it. We decided to have our own family so that we
planned it already. Other is not ready to plan so that they got a big mistake
on their lives; maybe they abort the child because they not ready to support
the family.

2. Are they in favor? If yes, were they able to try any contraceptive method?

Yes, others used it when they are not ready to have a baby.

3. Do they have misconceptions about it? What are these misconceptions?

Maybe, others think about it, like not enough budgets to support their
financial needs or they are not ready to plan.

c. Past Health History

Refer to your hand out that was given in nursing 101(Fund’s of nsg.)

3. Family History

In my family we have a heart disease, I don’t know if it can affect when I

deliver my baby

4. Personal & Social History

5. Patterns of Functioning

II. Clinical Appraisal

A head to the assessment of the client with emphasis on the following

changes on the following:

A. Breasts
Color and appearance (flat, inverted, protruded) nipples
-I think my breast is protruded.
Nipple discharges
-Nothing, it doesn’t have any discharges on it.
Shape, size & symmetry of the breasts
-It is obligated, and it became big.
Sign of engorgement (pain, dilated, veins, sensation of heaviness and
fullness)
-When it became big, I felt more pain on it and my breast is too heavy
and full.

B. Abdomen
Tone of the abdominal wall
- My abdomen area is saggy, it became elastic.
Presence of striae
Shape
-obligated
Presence of operative dressings
Fundic height
C. Perineum
Appearance, color
-it is elastic and saggy, it is slightly brownish.
Appearance of episiotomy incision (fresh, edematous, drug, bleeding)
-its appearance became enlarge, and sometimes it bleed.
Lochial discharges (color, consistency, color, and amount)
-reddish brown, it is not already firm, many amount on my discharges
III. Laboratory Exams
-all is undergo observation; I hope no problem is occurred.
IV. Drug Study Guide-purposeof this session is to expose clients to range
the method.
V. Plan of Care- addresses the entire nursing care planning process,