Health History Additions for Childbearing Woman - Nursing Past Paper PDF

HEALTH ASSESSMENT COLLEGE OF NURSING STUDENT COUNCIL REFERENCE NO: 2024-111-HA5 ACADEMICS COMMITTEE A.Y. 2022-2023 TRANSCRIBED BY: J.J. Carampot, C.E. Espina...

HEALTH ASSESSMENT COLLEGE OF NURSING STUDENT COUNCIL REFERENCE NO: 2024-111-HA5 ACADEMICS COMMITTEE A.Y. 2022-2023 TRANSCRIBED BY: J.J. Carampot, C.E. Espina CONTRIBUTORS: DISCLAIMER: Please use at your own discretion. Tranx CN is not intended as a substitute for resource materials such as handouts, videos, and books provided by the college. While all information is subjected for quality control, the CNSC Academics Committee cannot guarantee that this handout will be free of error. College of Nursing Faculty/Professors are not liable for any mistakes or false information that may inadvertently be included in this transcript. 6 CONTENT ADDITIONAL INFO TEXTBOOK common chief complaints of ★ → pregnant women. PRESENT OBSTETRIC HISTORY Last Menstrual Period (LMP) – first day TABLE OF CONTENTS History since LMP I.Patient’s Profile Signs and symptom of pregnancy II. Present Obstetric History ★ Example: Missed period, bloating, A. Methods of Estimating AOG cramping, nausea, vomiting, etc. B. Methods of Estimating EDD/EDC Weight gain III. Past Obstetric History ★ Estimated normal weight gain per trimester: A. Gravidity/Gravida 1st Trimester +3 lbs or +1.4kg B. Parity/Para C. Preceding Pregnancies and Prenatal 2nd Trimester +11 lbs or +5kg Outcomes (TPALM) D. OB Scoring 3rd Trimester +11 lbs or +5kg E. Pregnancy History IV. Past Health History Age of Gestation (AOG) V. Family Health History Estimated Date of Delivery (EDD) or Estimated Date A. Genetic Disorders of Confinement (EDC) B. Inheritable Diseases Genetic predispositions C. Congenital Anomalies VI. Social History METHODS OF ESTIMATING AOG VII. Health Maintenance Activities DETERMINING WEEKS OF AOG A. Schedule of Prenatal Visits 1. Add the no. of days between the LMP and the ---------------------------------------------------------------- current date of consultation. PATIENT’S PROFILE 2. The formulated answer is then divided by 7. Summary of information about an individual patient quotient - number of weeks It's important to consider age, race, and chief remainder - number of days complaint due to their implications on reproductive health and pregnancy outcomes: Adolescent pregnancies and Age advanced maternal age carry specific risks. Genetic factors prevalent in Race certain racial or ethnic groups may influence pregnancy risks. Reason for Seeking Care Chief Pregnancy-related issues that Complaint need urgent evaluation ★ Abdominal pain, headache, contractions, bleeding, and urinary symptoms are CARAMPOT, ESPINA | 1 of 5 McDONALD’S RULE Used in second and third trimester Determine the fundic height in cm by measuring the distance from the notch of the symphysis pubis to the fundus FH / 4 = AOG IN MONTHS METHODS OF ESTIMATING EDD/EDC NAEGELE’S RULE January to March: Count back 3 calendar months from first day of LMP then add 7 days April to December: Count back 3 calendar months from first day of LMP then add 7 days and 1 year BARTHOLOMEW’S RULE OF FOURS Measures AOG by determining the position of the fundus in the abdominal cavity 12 Weeks Slightly above the symphysis pubis 20 Weeks Level of umbilicus 28 Weeks Halfway the umbilicus and xiphoid process DATE OF QUICKENING (Q) 36 Weeks Level of the xiphoid process PRIMIGRAVIDA: Date of Q + 4 months and 20 days = EDC MULTIGRAVIDA: Date of Q + 5 months and 4 days 40 Weeks Slightly below the xiphoid process = EDC CARAMPOT, ESPINA | 2 of 5  Woman who has not NULLIGRAVIDA and never has been pregnant Woman who is PRIMIGRAVIDA pregnant for the first time Woman who is or has MULTIGRAVIDA been pregnant for at least a second time PARITY/PARA Number of pregnancies carried to the period of viability (20 weeks or greater) whether born dead or alive at birth Multiple pregnancies are counted as ONE Usually listed as: o Term (37-42 weeks gestational age) o Preterm (20-36 6/7 weeks gestational age) o Post term (more than 42 weeks gestational age) USING THE GESTATION CALCULATION WHEEL A woman who has NOT “First day of LMP” arrow is placed on that date, as NULLIPARA carried any pregnancy the other arrow, labeled to the stage of viability “Expected Delivery Date” shows the expected date of delivery. A woman who has delivered one of a fetus or fetuses who reached the stage of viability. PRIMIPARA Any ABORTION is NOT included in the counting of parity A woman who has completed two or more MULTIPARA pregnancies to the stage of viability PRECEDING PREGNANCIES AND PRENATAL PAST OBSTETRIC HISTORY OUTCOMES (TPALM) COMPONENTS OF OB SCORING GRAVITY/GRAVIDA Number of full-term Number of pregnancies regardless of duration and T births outcomes, including present pregnancy. Number of preterm P births CARAMPOT, ESPINA | 3 of 5  A Number of Abortions d. episiotomy or laceration, and degree 5. Length of labor 6. Medications and anesthesia used Number of currently L 7. Complications during labor and delivery living children 8. Postpartum complications Number of multiple PAST HEALTH HISTORY M pregnancies 1. Medical History 2. Surgical History 3. Medications OB SCORING (GP TPALM) 4. Communicable Diseases 5. Allergies 6. Injuries and Accidents 7. Childhood Illnesses 8. Immunization TETANUS TOXOID IMMUNIZATION SCHEDULE FOR PREGNANT WOMEN FAMILY HEALTH HISTORY Diseases or pregnancy-related conditions that have affected the family of the pregnant client: ➔ Preterm labor or delivery ➔ Hypertensive disorders of pregnancy ➔ Multiple births(relatives of patient’s mother) ➔ Chromosomal abnormalities ➔ Genetic disorders ➔ Inheritable diseases ➔ Congenital anomalies ➔ Neuromuscular diseases ➔ Psychiatric disorders ➔ Any history of abuse, neglect or substance ➔ abuse GENETIC DISORDERS Tay-Sachs Disease PREGNANCY HISTORY ★ A genetic condition that causes damage Applicable for those who had prior pregnancies and, ultimately, the death of nerve cells 1. Complications during pregnancy (neurons) in the brain and spinal cord. 2. Duration of gestation Gaucher’s Disease 3. Date of delivery ★ Genetic disorder where fat-laden Gaucher 4. Type of delivery cells build up in areas like the spleen, liver a. vaginal versus cesarean and bone marrow b. if cesarean – reason Sickle-Cell Anemia c. forceps or vacuum extraction CARAMPOT, ESPINA | 4 of 5  ★ It inhibits the ability of hemoglobin in red ➔ Prolonged standing or sitting blood cells to carry oxygen. ➔ Heavy lifting ➔ An extremely loud, cold, wet INHERITABLE DISEASES ➔ environment Huntington’s Chorea ➔ Work with chemicals (lead or mercury) ★ A brain disorder in which brain cells, or ➔ One-way commute greater than 1 hour neurons, in certain areas of your brain start to break down. ETHNIC BACKGROUND CONGENITAL ANOMALIES ASIAN, High risk for Cleft Lip ASIAN INDIAN, Thalassemia ★ Openings or splits in the upper lip MEDITERRANEAN ORIGIN Cleft Palate (Greece, Italy, Cyprus, ★ Openings or splits on the roof of the mouth Middle Eastern) Neural Tube Defect ★ The beginnings of the embryo’s nervous Tay-Sachs system (the neural tube) failing to close ASHKENAZI JEWS Disease completely before birth. Gaucher’s Disease SOCIAL HISTORY FRENCH CANADIANS Tay-Sachs 1. Alcohol Use (And possibly Cajuns) Disease 2. Drug Use 3. Tobacco Use AFRICAN AMERICANS Sickle Cell 4. Sexual Practice Disease/Trait 5. Travel History 6. Work Environment 7. Home Environment HEALTH MAINTENANCE ACTIVITIES 8. Hobbies and Leisure Activities 1. Sleep 9. Stress 2. Diet 10. Ethnic Background 3. Exercise 4. Use of Safety Devices COMPLICATIONS FROM DRUG ABUSE 5. Health check-ups ➔ Spontaneous abortion ➔ Preterm delivery SCHEDULE OF PRENATAL VISITS ➔ Congenital anomalies ➔ Stillbirth As soon as the woman misses FIRST VISIT a menstrual period when HARMFUL EFFECTS OF SMOKING pregnancy is suspected ➔ SGA infant ★ Small for Gestational Age 1ST - 6TH MONTH Once a month ★ Defined as a birth weight of less than 10th OF PREGNANCY percentile for gestational age ➔ Preterm labor 7TH - 8TH MONTH Twice a month ➔ Spontaneous abortion OF PREGNANCY ★ Miscarriage ★ Pregnancy loss before 20 weeks gestation 9TH MONTH Four times a month or every ➔ Low APGAR score week ★ APGAR score is a test given to newborns soon after birth ★ A baby who scores a 7 or above on the test is considered in good health. RISKY ACTIVITIES The following may put the pregnant client at risk for preterm labor or congenital anomalies for the newborn: CARAMPOT, ESPINA | 5 of 5