prenatal health asssessment-final

8/4/2019 Prenatal Health Asssessment-final

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I. Demographic Profile

DDL 26 year old female, born December 12, 1984, a Catholic, and is presently living at

Provido Village City Heights, GSC, was assessed last February 02, 2011.

DDL is married. She works as a cashier at a certain department store, and is receiving a

paycheck of 7,000Php per month.

II. Health History

a.) admitting diagnosis/chief complaint

b.) name of obstetrician

A week prior to admission, DDL has been feeling pain during urination, thinking that this

could be harmful to her current pregnancy; she decided to submit herself for admission under

the management of Dr. Ma. Cecilia O. Balbuena.

c.) past illness and surgeries

Accordingly, DDL has always been healthy and she also feels physically well during the

assessment. She never had a history of any serious illness, never been admitted to the hospital,

and she did not undergo any form of operations. However, in some occasions, she does

experience some common illnesses such as influenza, cough, and common cold.

She also has been exposed to chickenpox and mumps when she was still in

elementary.

d.) history of present illness

Last January 28, 2010, DDL consulted Dr. Cecili O. Balbuena for feeling pain duringurination. She was then suggested to have a urinalysis. Thinking that it was just nothing, she

decided not to submit herself for urinalysis.


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Two days prior to admission, she had her consultation, still regarding her condition.

During that time, she had already the symptom of slight left lumbar pain; however, she did not

submit herself for admission.

After 2 days, she felt a moderate pain during urination, with moderate left lumbar pain

and was associated with scanty urination which then prompted her admission.

e.) obstetrical history and immunization

DDL had her last menstrual period last December 19, 2010. Based on the computation,

her expected date of confinement was on September 26, 2011. Her age of gestation during the

assessment was six weeks and four days (6 4/7).

Accordingly, she never was pregnant and never had an abortion prior to her pregnancy

during the assessment.

Leopolds maneuver was not yet applicable during the assessment considering her age

of gestation.

III. Social History

A.) Habits and Patterns

a.) sleeping pattern: DDL sleeps for 8 hours in a day with a nap time of a one hour

during the afternoon.

She sleeps around 10:00 in the evening after her favorite TV series and wakes up

around 6:00 in the morning to prepare breakfast for her husband.

b.) hobbies/activities/exercises: DDL spends her day working at the department store.

Being a cashier, most of the time she was just sitting. Although she makes it a point to do some

form of exercise such as walking during her break-time. When she is at home, she considersdoing the household chores as a form of exercise.

c.) eating pattern: DDL eats at least three times a day; she also has snacks during

afternoon which comprises of bread and juice, or at times, porridge.


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Furthermore, she said she drinks water frequently but at times, when she tends to be

busy, she neglect this very important health practice. In addition, she is fond of drinking colas

and juices. She could consume one 8oz of cola for a day, or sometimes a 2-3 glasses of juice.

B.) Consumption of Alcohol/Drugs: DDL does not drink alcoholic beverages and she does

not used illegal drugs.

C.) Cigarette Smoking: DDL is said to be a non-smoker, though she made mentioned that she

did try to smoke when she was in High-school due to curiosity.

D.) Home Conditions: DDL and her husband are living in a small, yet well ventilated rented

house at Provido Village City Heights. The house is made of concrete and woods. Even though

the house is small, it seems that it was well managed and well kept. The presences of pests like

rats, mosquitoes, and/or cockroaches are not evident in the vicinity of the house.

E. Familial/ Hereditary Disease: DDLs grandparents (on the fathers side) are said to be

hypertensive, while her grandparents (on her mothers side) are known to be both hypertensive

and diabetic. DDL parents are known to be hypertensive. Other than the one mentioned, other

type of diseases that her parents might have are unknown.


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IV. Review of Systems/ Physical Assessment

Her Physical Assessment reveals the following:

General appearance: She was lying on bed, conscious, coherent and oriented to time and

place. She is also responsive to verbal stimulation and is not in any form of distress. She has a

mesomorphic body built. She was wearing a white patients gown. She was well-groomed and

no body odor was noted during the whole assessment. She responds to the questions and

interacts with calmness during the physical assessment.

Vital Signs:

Components Actual Value Normal Value Remarks

Temperature 36.9 C 35.6-37.4 C Normal

Pulse Rate 80 bpm 60-100 bpm Normal

Respiratory Rate 17 cpm 16-22 cpm Normal

Blood Pressure 100/ 80mmHg 110/70-130/90

mmHg

Normal

Cardiac Rate 81 bpm 60-100 bpm Normal

Height: 5 feet and 1 inch (51)

Weight: 52kgs

Integumentary:

a.) Skin: She has a fair complexion. Chloasma or melasma is not noted. Her skin is

moist, smooth and warm to touch.


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Temperature is uniform and falls within normal range both on upper and lower extremities. She

has good skin turgor; skin springs back to previous state when pinched after 1-2 seconds.

Presence of edema and tenderness on skin surfaces were not noted.

b.) Nails: The fingernail plates were colorless, smooth in texture and have a convex

curvature with an angle of about 160. Nail beds are pinkish indicative of good arterial

circulation. Epidermis surrounding the nails is intact. After performing the blanch test, there is a

prompt return of usual color in 2 seconds. Toenail plates were also colorless, smooth in texture,

and have a convex curvature. The nail beds are also pinkish with surrounding epidermis intact.

c.) Hair and Scalp: There is an even distribution of thin, oily and naturally dark black

hair over the scalp. Infections or infestations were not noted upon inspection. Minimal body hair

is noted.

Head and Neck:

a.) Skull: The head configuration is round, normocephalic and symmetrical with frontal,

parietal and occipital prominences. Head circumference is 53.7cm and the size is in proportion

with the body. She has smooth skull contour, uniform consistency and without any nodules and

masses.

She has symmetrical facial features, palpebral fissures equal in size and symmetrical

nasolabial folds.

b.) Face: Hollowness on periorbital region is slightly evident. Facial movements are

symmetrical as the patient was able to elevate and lower the eyebrows, close the eyes tightly,

puff the cheeks and smile.

c.) Eyes and Ears: The eyebrows are thick, evenly distributed and the skin on the area

is intact. It is symmetrically aligned and with equal movement. The eyelashes are equallydistributed and curled slightly outward. The skin on the eyelids is intact with no discharges or

discoloration. The lids close symmetrically. She has 15 involuntary blinks for one whole minute

which moves bilaterally. When lids close, sclera above cornea is not visible. She has

transparent bulbar conjunctiva with no lesions noted. The palpebral conjunctiva is shiny, smooth


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and slightly pale in color and lesions are absent. No edema, tenderness or tearing on the

lacrimal sac and nasolacrimal duct.

The cornea is transparent, shiny, smooth and with visible details of the iris. Her iris

appears to be dark brown while the pupil is black. The pupils are equal in size, with a pupillary

size of 3 mm with a round and smooth border. The pupil constricts in direct response of light

stimulation while the non- illuminated pupil also constricts as a consensual response. This

reaction indicates proper functioning of the oculomotor and trochlear cranial nerves. Pupil

constricts when looking at near objects and dilates when looking at far objects which indicate a

normal pupil reaction and accommodation. She was able to see objects in the periphery while

looking straight ahead. Both of his eyes are coordinated and move in unison with parallel

alignment upon performing the extraocular movements. During the interview, the patient does

not wear any corrective lenses. She also verbalizes that she does not wear corrective glasses.

No other inflammation, discharge, lesion or tenderness was observed.

Ears are bilaterally equal in size upon inspection. Auricles equally align with the outer

canthus of the eye and have the same color as of that the facial skin. The pinna is symmetrical

and the external canals are clean with no foul smelling discharge. Skin around the area is

smooth with no lesions. Canal walls are pink and smooth without nodules. Gross hearing in

each ear is symmetrical .She responds to the questions accurately and is oriented and coherent

to environmental sound stimuli. She can hear normal voice tones as well as ticking of the clock

during the watch tick test.

d.) Nose and Sinuses: The external nose is symmetrical in size; nasal bridge is located

in the midline. External nasal skin is the same with facial color. Nasal mucosa is pink, moist,

lined with enough amount of hair and free from exudates and other unusual discharges. Nasal

septum is set at the midline with intact skin. Both nostrils are symmetrical and patent as air is

able to move freely inside it upon inhalation and exhalation and without unusual discharges and

lesions noted. Nasal hairs were noted in sufficient amount. Tenderness is not felt upon palpationof maxillary and frontal sinuses.

e.) Mouth and Pharynx: The lips have uniform pinkish-reddish in color, with smooth

appearance. Her lip has also a symmetrical contour with no lesions noted and was able to purse

lips. The oral mucosa has a uniform pink color and appears to be hydrated. The gums are pink


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with no ulcerations noted. Incomplete set of teeth was noted. Missing teeth are right second

premolar on the upper jaw and on the second and third molar on the left side of the lower jaw is

missing. The tongue is positioned centrally, pink in color, able to move freely. Tenderness or

palpable nodules were not noted. Tongue base is smooth. The frenulum is at the midline.

Salivary duct openings have no swelling or discolorations noted. The color is the same

with the buccal mucosa and the floor of the mouth. The soft palate is smooth and light pink in

color. The hard palate is lighter pink and more irregular in texture compared to that of the soft

palate. The uvula is positioned at the midline. The tonsils are pink, smooth and are not inflamed.

Discharges are absent. Gag reflex is present.

f.) Neck: The muscles on the neck are equal in size and head is located on the center.

No marked lesions were noted. Head movement is coordinated and smooth with no signs of

discomfort. There is bilaterally equal strength on the sternocleidomastoid and trapezius

muscles.

Lymph nodes are not palpable. Trachea is centrally placed in the midline of the neck.

The thyroid gland is slightly enlarged upon inspection but ascends when asked to swallow. No

bruit heard upon auscultation.

Thorax and Lungs:

a.) Posterior thorax and lungs

The surrounding skin is intact with uniform temperature. The chest wall is intact and no

masses or tenderness noted. Chest expansion is full and symmetric when the client takes a

deep breath and has a respiratory excursion of 2 cm. Vocal fremitus is bilaterally symmetrical

and is heard most clearly at the apex of the lungs. Diaphragmatic excursion is 1.5 cm. No

adventitious sounds noted.

b.) Anterior thorax and lungs

She has a quiet, rhythmic and effortless respiration. There were no significant scars

noted on the anterior thorax. Lateral diameter is larger than the anteroposterior diameter. Vocal


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tactile fremitus is bilaterally symmetrical and is decreased over the heart and breast tissue. No

adventitious sounds noted. Respiratory rate is 17 cpm.

Cardiovascular and Peripheral Vascular System:

No pulsations, lifts or heaves noted on aortic, pulmonic, tricuspid and apical areas noted

upon inspection and palpation. Aortic pulsations are present on the epigastric area. Jugular

distention is absent. Capillary refill time result is 2 seconds. Carotid arteries have symmetric

pulse volumes and full pulsations. No sound heard upon auscultation.

Peripheral pulses have full pulsations with symmetrical pulse volumes. Peripheral leg

veins are symmetric in size. Original color returns in 10 seconds after performing Buergers test.

Cardiac rate is 81 bpm.

Breast and Axilla: Breast was symmetrical and uniform in color. No tenderness masses

and bulges. Darker pigmentation of nipples and areola were noted. Nipples were, symmetrical

with no tenderness, masses and nodules noted. Fullness of breasts and tingling sensation were

noted as per verbalization of the client. Tubercles of Montgomery are slightly enlarged.

Growth of hair in axilla is minimal with no tenderness and masses upon palpation.

Axillary nodes are impalpable.

Abdomen: Flat, nontender abdomen, no linea nigra present. Fundus is not yet palpable.

Abdomens contour is soft and round with no signs of spleen orliver

enlargement

Gastrointestinal:

Reproductive:

Musculoskeltal:


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Neurologic:

CRANIAL NERVES TYPE FUNCTION ASSESMENTOLFACTORY SENSORY Smell -Able to distinguish varying

substances according to their odor

(e.g. alcohol, perfume, vinegar).OPTIC SENSORY Vision and visual

fields-Able to read imprints by the aid ofreading glasses; able to distinguishcounting by fingers

OCULOMOTOR,TROCHLEAR,ABDUCNES

MOTOR EOM; moveseyeballs up and

down, moveseyeballs left and

right

-brisk eye opening-Able to move EB up and down-Able to move EB left and right

TRIGEMINAL SENSORY Sensation of thecornea

-blinks upon stimulation of thecornea

FACIAL MOTOR AND

SENSORY

Facial

expressions

-able to close eyes tightly, puff

cheeks, smile, and elevateeyebrows

AUDITORY SENSORY Equilibrium;hearing

-Able to hear normal voice

GLOSSOPHARYEAL

MOTOR ANDSENSORY

Swallowingability; tongue

movement

-Good swallowing ability-Able to move tongue vertically andlaterally

VAGUS MOTOR ANDSENSORY

Sensation of thepharynx, larynx,swallowing, and

vocal cordmovement

-Intact speech-Symmetrical palate [soft] as patientsays Ah!

SPINALACCESSORY

MOTOR Head movement;shrugging of

shoulders

-Able to move head vertically, andlaterally against resistance-Equal strength upon shrugging theshoulders

HYPOGLOSSAL MOTOR Protrusion oftongue

-Able to move tongue vertically andlaterally


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V. Laboratory Results with significance and interpretation

Diagnostic Exam: Urinalysis

DateTaken

Name ofLaboratory

Procedure

Purpose ofLaboratory

Procedure

Result NormalValue

Clinical Significance

February03, 2010

UrinalysisSpecimen:Urine

A urinalysis parameter commonly used in the evaluation of kidney function andcan aid in the diagnosis of various renal diseases.

a.) color Shows the

degree of

concentration.

Lightyellow

Pale

yellow

to Dark

Amber

-Turbid may be form of hematuria,

spermatozoa, prostatic fluid, & fat

droplets.

-Red-colored urine may indicate presence

of blood pigments.

-Yellow-Brown reveals obstructive

jaundice.

-Orange urine from urinary antiseptic.-Dark brown to black may be due to

malignant melanoma.

b.)transparency

Also shows the

degree of

concentration.

Hazy Clear May indicate presence of bacteria, pus,

RBC, WBC, phosphates in the urine.

c.) reaction As part of the

acid-base

balance, the

kidneys remove

excess

hydrogen ions

from the blood

and excrete

them in the

urine. In

abnormal

physiology, a

urine pH

greater than 6.5indicates the

presence of

bicarbonate in

the urine.

pH 5 4.6-7.5 Decreased:

-Metabolic & Respiratory acidosis

-DM

-Diarrhea

-Starvation

-Renal Failure

Increased:

-Metabolic & Respiratory alkalosis

-Bacteriuria

-Vegetarian Diet

-NGT suctioning

-Prolonged Vomiting


11/18

DateTaken

Name ofLaboratoryProcedure

Purpose of LaboratoryProcedure

Result NormalValue

Significance

d.) albumin The presence of urinaryalbumin is an indicator ofglomerular disease. The

nephritic syndrome producesa great loss of albumin in theurine. The renal loss also maybe associated with systemicdisease that causesglomerular damage

negative negative May indicate nephrotic

syndrome, renal

disorder associated

with hypertension, DM,

systemic lupus

erythematus,

amyloidosis

e.) sugar Glycosuria (glucose in the

urine) is usually an indicator

of significant hyperglycemia &

DM. When a fasting specimen

is obtained, it is highly specific

& accurate in the detection ofglucose in the urine.

negative negative Presence of sugar

indicates DM,

hyperthyroidism &

stress.

d.) specific gravity Measurement of the ability of

the kidneys to concentrate &

excrete urine. Concentrated

urine has a higher specific

gravity because the proportion

of components to water in its

composition is greater. Diluted

urine has a lower specific

gravity because it contains

fewer components in

proportion to the amount of

water.

1.010 1.005-

1.030

Decreased:

-Overhydration

-Diuresis

-Hypotension

-Pyelonephritis

-Glumerulonephritis

-Renal Tubular

Dysfunction

-Severe renal damage

-Diabetes Insipidus

Increased:

-Dehydration

-Fever

-Profuse Sweating

-Vomiting

-Diarrhea

-Glycosuria

-Proteinuria-CHF

-Adrenal Insufficiency

-Altered secretion of

ADH


12/18

DateTaken



Result NormalValue

Significance

b.) RBC Normal urine may exhibit a fewRBCs without any significantpathologic cause. The

presence of few cells isconsidered acceptable underhigh power field (HPF)microscopic visualization.Significant hematuria isindicated by one episode ofgross hematuria or oneepisode of high-gradehematuria, with an RBC countgreater than 100 cells perHPF.

1-2HPF

Negative Indicates presence of

benign tumor, cancer,

urinary calculi,

glomerulonephritis.

lupus nephritis,

sclerosis, UTI

c.) Pus cells An elevated WBC count in the

urine indicates pyuria (pus in the

urine). The microscopic urinalysis

findings of 5 to 10 WBCs per HPF

is a significant elevation that

indicates the presence of urinary

tract infection.

20-

25HPF

0-2 HPF Indicates presence of

Urinary Tract Infection

d.)Bacteria Fewe.)Urates crystals Few


13/18

Diagnostic Exam: Urinalysis

DateTaken


Purpose ofLaboratoryProcedure

Result NormalValue


February

10, 2010

Urinalysis

Specimen:Urine

A urinalysis parameter commonly used in the evaluation of kidney function and

can aid in the diagnosis of various renal diseases.

a.) color Shows the

degree of

concentration.

Lightyellow

Pale

yellow

to Dark

Amber

-Turbid may be form of hematuria,

spermatozoa, prostatic fluid, & fat

droplets.

-Red-colored urine may indicate presence

of blood pigments.

-Yellow-Brown reveals obstructive

jaundice.

-Orange urine from urinary antiseptic.

-Dark brown to black may be due to

malignant melanoma.

b.)transparency

Also shows the

degree of

concentration.

Hazy Clear May indicate presence of bacteria, pus,

RBC, WBC, phosphates in the urine.

c.) reaction As part of the

acid-base

balance, the

kidneys remove

excesshydrogen ions

from the blood

and excrete

them in the

urine. In

abnormal

physiology, a

urine pH

greater than 6.5

indicates the

presence of

bicarbonate in

the urine.

pH 5 4.6-7.5 Decreased:

-Metabolic & Respiratory acidosis

-DM

-Diarrhea

-Starvation-Renal Failure

Increased:

-Metabolic & Respiratory alkalosis

-Bacteriuria

-Vegetarian Diet

-NGT suctioning

-Prolonged Vomiting


14/18

DateTaken



Result NormalValue

Significance

d.) albumin The presence of urinaryalbumin is an indicator ofglomerular disease. The

nephritic syndrome producesa great loss of albumin in theurine. The renal loss also maybe associated with systemicdisease that causesglomerular damage

negative negative May indicate nephrotic

syndrome, renal

disorder associated

with hypertension, DM,

systemic lupus

erythematus,

amyloidosis

e.) sugar Glycosuria (glucose in the

urine) is usually an indicator

of significant hyperglycemia &

DM. When a fasting specimen

is obtained, it is highly specific

& accurate in the detection ofglucose in the urine.

negative negative Presence of sugar

indicates DM,

hyperthyroidism &

stress.

d.) specific gravity Measurement of the ability of

the kidneys to concentrate &

excrete urine. Concentrated

urine has a higher specific

gravity because the proportion

of components to water in its

composition is greater. Diluted

urine has a lower specific

gravity because it contains

fewer components in

proportion to the amount of

water.

1.005 1.005-

1.030

Decreased:

-Overhydration

-Diuresis

-Hypotension

-Pyelonephritis

-Glumerulonephritis

-Renal Tubular

Dysfunction

-Severe renal damage

-Diabetes Insipidus

Increased:

-Dehydration

-Fever

-Profuse Sweating

-Vomiting

-Diarrhea

-Glycosuria

-Proteinuria-CHF

-Adrenal Insufficiency

-Altered secretion of

ADH


15/18

DateTaken



Result NormalValue

Significance

b.) RBC Normal urine may exhibit a fewRBCs without any significantpathologic cause. The

presence of few cells isconsidered acceptable underhigh power field (HPF)microscopic visualization.Significant hematuria isindicated by one episode ofgross hematuria or oneepisode of high-gradehematuria, with an RBC countgreater than 100 cells perHPF.

0-1HPF

Negative Indicates presence of

benign tumor, cancer,

urinary calculi,

glomerulonephritis.

lupus nephritis,

sclerosis, UTI

c.) WBC 0-1

HPFd.)Bacteria Few May indicate the

presence of urinarytract infection.

e.)Urates crystals Few


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Diagnostic Exam: Complete Blood Count

Date

Taken

Name of

Laboratory

Procedure

Purpose of Laboratory

Procedure

Result Normal

Values


June 02,

2010

Hematology

Hemoglobin Used to measure the severity

of anemia, which is

characterized by a low

hemoglobin value, or

polycythemia, which is

characterized by a high

hemoglobin value. It is also

used to monitor the result ofmedical or nutritional treatment

for the condition.

99g/L 120-160g/L Decreased:

-Anemia

-Cirrhosis

-Hemolysis

-Leukemia

Increased

-Congestive Heart Failure-COPD

-Dehydration

-Erythrocytosis

Hematocrit Used to evaluate blood loss,

anemia, polycythemia &

dehydration. The hematocrit

value is elevated when the # of

RBC increases or when the

volume of plasma is reduced.

On the other hand, hematocrit

value falls when there is

excessive loss of RBC, as in

anemia or after blood loss.

0.37-

0.47

0.315 Decreased:

-Hemorrhage

-Anemia

-Fluid Overload

Increased:

-Congestive Heart Failure

-COPD

-Dehydration

-Erythrocytosis

Leukocyte Constitutes the total # of 5

types of leukocytes present in

1 mm3 of blood. It is a general

indicator of infection, tissue

necrosis, inflammation or bonemarrow activity.

5-10

x8 /L

11.8 x

1012/L

Decreased:

-Leukopenia

-Anemia

-Viral Infection

Increased:

-Leukocytosis

-Abscess

-Acute Infection

-Seizure


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Date

Taken

Name of

Laboratory

Procedure

Purpose of Laboratory

Procedure

Result Normal

Values


Neutrophils Neutrophils are the most

active cells & respond to

tissue damage or infection.The two types of neutrophils

are segmented and bands.

They are phagocytes that

provide an early, rapid

removal of cellular debris & a

large # of bacteria. Of all the

leukocytes, neutrophils are

the largest in group.

0.80 0.50-0.70 Increased:

-Bacterial Infection

-Severe burns-Rheumatic fever

-Ketoacidosis

Lymphocytes Consists of the B-cells & T-

cells that are responsible for

the activities of the immune

system.

0.16 0.25-0.40 Decreased:

-Aplastic Anemia

-Renal Failure

-Terminal Cancer

-Immunoglobulin

Deficiencies

Monocytes

Removes debris or foreign

particles from the articulation.

In the work of phagocytosis,

monocytes perform the samework as neutrophils, but their

# is greater & they are

capable of more work.

0.04 0.03-0.08 Increased:

-Acute Infection (bacteria,

viral, mycotic, rickettsial,

protozoan)

-Chronic Myeloid Leukemia-Ulcerative Colitis

Decreased:

-Hairy Cell Leukemia

-Bone Marrow Failure

-Aplastic Anemia

Thrombocyte Used to assess the bone

marrows ability to produce

platelets & to identify the

destruction or loss of

platelets in the circulation. It

is also used to evaluate the

untoward effects of

chemotherapy or radiation

treatment. Platelets function

is to initiate the process of

coagulation.

270 150-350

x109 /L

Decreased:

-Dengue Hemorrhagic fever

-Thrombocytopenia

Increased:

-Thrombocytosis

-Multiple Myeloma

-Iron Deficiency Anemia

-Lymphomas

-Renal Disease infection or

inflammation


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prenatal health asssessment-final

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