CEBU NORMAL UNIVERSITY
College of Nursing
PRENATAL CASE # 1
Name (Initial): A.M.V. Age: 25 years old Household No.: 2020-0410LMP
Occupation: Housewife LMP: December 12, 2020 EDC: September 19, 2021
Educational Attainment: High School Graduate G 1 P 0 T 0 P 0 A 0 L 0 M 0
Husband’s Name (Initial): L.M.N. Age: 30 years old Occupation: Security
Guard
Educational Attainment: College Graduate (BS Criminology)
I. HISTORY
A. Heredo-familial Tendencies:
[ ] Allergies (drug &
[ √ ] Hypertension [ ] Heart Disease
food)
[ √ ] Diabetes
[ ] Asthma [ ] Renal Disease
Mellitus
B. Childhood Disease:
[ √ ] Others
(specify)
[ ] Chickenpox [ ] Measles [ ] Mumps
Coughs, colds, and
flu
[ ] German Measles [ ] Malaria [ ] Schistosomiasis
[ ] Hepatitis A/B [ ] Leprosy [ ] STD
[ ] Tuberculosis [ ] Others (specify)
C. Communicable Diseases:
D. Menstrual History:
Menarche: 14 years old Duration: 3-5 days
Flow : [ ] Scanty [ √ ] Moderate [ ] Profuse
Interval: [ √ ] Regular [ ] Irregular
Dysmenorrhea [ ] Yes [ √ ] No
E. Medical and Surgical History:
Medical (any serious illness or hospital confinement)
None.
Surgical (abdominal or reproductive region)
None.
II. OBSTETRICAL HISTORY
Year Pregnancy Duration Mode of LB/SB Sex/ Birth Place of Status of
of Labor Deliver Weight Deliver Immunization
y y
July 2021 TT2
(7 mos.
AOG)
June 2021 TT1
(6 mos.
AOG)
III. GENERAL EVALUATION
A. Physique: [ √ ] sthenic [ ] asthenic [ ] hypersthenic
B. Patient’s emotional/ intellectual profile:
[ √ ] conscious [ √ ] coherent
[ ] malingering
[ ] incoherent [ √ ] cooperative [ ] uncooperative
C. Vital Signs: Temperature36.5 C__ Pulse Rate75 beats/min_ Respiratory Rate 22 cycles/min_
0
Heartrate 70 bpm___ Blood Pressure 100/70 mmHg_ Height 160cm Weight 59
kg
D. Skin: [ ] infection [ ] scars [ √ ] chloasma
[ ] Allergies [ √ ] Others: Skin is warm and dry, with light pink nail beds
__________
E. Face: Eyes— color of conjunctiva Pinkish
Eyelids— puffiness: [ ] Yes [ ] No
Lips—color:
- fissure/cracks: [ ] [ ] No
Yes
- symmetrical: Halves [ ] [ ] No
Yes
- angular stomatitis [ ] [ ] No
Yes
Teeth - carries: [ ] [ √ ] No
Yes
- missing: [ ] [ ] No
Yes
- false dentures [ ] [ ] No
Yes
F. Neck: engorgement of blood vessels: [ ] No
[ ]Yes [ ] No
lymph nodes enlargement:
[ ] Yes [ ] No
gland thyroid enlargement: [ ] Yes
G. Chest (breast): nodes: [ ]Yes [ ] No H. Lower
inverted nipples: [ ] Yes [ √ ] No Extremity:
secretions: [ ] Yes [ √ ] No Edema
[ ] Yes [ ] No [
scars:
[ ] Yes [ ] No ] Yes
dimpling:
others: Enlarged breasts, [ ] No
tenderness, and tingling
sensation
Varicosities [ ] Yes [ ] No
I. Abdomen :
: Inspection Size [ √ ] Compatible to AOG [ ] Small [ ] Large
Shape [ ] Ovoid [ √ ] Globular
Striae [ √ ] Present [ ] Absent
Linea Negra [ √ ] Present [ ] Absent
Scars [ ] Present (Specify)
[ ] Absent
Palpation: Height of Fundus (Fundal height approximates with AOG)
Fetal Small Parts [ ] Left [ √ ] Right [ ] Others
Fetal back [ √ ] Left [ ] Right [ ] Others
Lie Longitudinal Lie
Presentation/Position Cephalic Presentation
Status of Presenting Parts Not Engaged
Quickening started @ April 8, 2021 weeks AOG
Auscultation: Fetal Heartbeat/min. and Location 148 bpm
J. Bowel Pattern Mother has a successful bowel movement upon waking up.
K. Usual Sleep Pattern Mother sleeps 6-7 hours per night and naps 1-2 hours in the afternoon.
L. Past History/Familial Disease (Please Check)
[ ] Rheumatic Fever [ √ ] Diabetes Mellitus [
] Asthma
[ √ ] Hypertension [ ] Kidney Disease [ ]
Heart Disease
[ ] Hepatitis [ ] HIV
IV. GESTATIONAL AGE COMPUTATION
Gestation Age: December 12, 2020 (LMP) – August 31, 2021 (current date)
Gestational Age = December (20)+January (31)+February (28)+March(31)+April (30)+May
(31)+June (30)+July (30)+August (31)
Gestational Age = 262 days or 37 3/7 weeks
V. Assessment on Family Planning Method (s) Used:
Specify Method (s) Duration of Use Problems Encountered
VI. Current Medications/Supplements
Name of Drug Classification Dosage
OB plus Prescribed supplement 1 tab once a day
VII. IMPRESSION ON PRESENT PREGNANCY
A. Expectant Mother’s Reaction on Present Pregnancy
1. Physical Mother feels uncomfortable due to experiencing shortness of breath when climbing
up stairs and backache when standing or walking for prolonged period of time. Mother
integrates exercise with household chores.
2. Psychological No history of depression; excited for her baby
3. Spiritual Mother entrusted Almighty God her pregnancy as well as the outcome.
4. Financial Mother shared that her parents and in-laws are very supportive of her pregnancy
and provides financial help throughout the pregnancy. Moreover, she shared that they have
enough savings for her upcoming delivery.
B. Expectant father’s reaction to the pregnancy Husband is excited to become the father of their
baby boy.
VIII. RECOMMENDATIONS
A. Identified Nursing Problem:
- Risk for unstable blood glucose as evidenced by insufficient diabetes managements
- Ineffective breathing pattern related to uterine expansion as evidenced by shortness of
breath
- Interrupted family processes as evidenced by change in intimacy
B. Health Teaching
- Deep breathing exercises
- Value of couple’s intimacy
- Reducing the risk of having type 2 diabetes mellitus
C. Laboratory Tests
- Complete Blood Count
- Urinalysis
D. Prescribed Vitamins and Supplements
- OB plus
__DELA CRUZ, MIKE RENZO S.____ _____AUGUST 31, 2021-
_____________
Student Nurse Date of Examination
_____________________________ Sean Kristoffer S. Polito, RN, CNN, MSN(c)
Health Center Staff Clinical Instructor
PERFORMANCE RUBRICS IN DETERMINING THE AGE OF GESTATION, FETAL
POSITION AND PRESENTATION AND FETAL HEART BEAT
Name: __________________________________ Date:_____________ Rating: ________
Area : __________________________________ Level: ______________________
Please check the appropriate value column:
Scale Description Rating
Advanced Performs all tasks accurately and independently; 4
well organized
Performs all task properly and independently; some
Accomplished 3
steps were interchanged or omitted; organized
Performs most task properly; requires some
Developing 2
guidance; less organized
Performs few tasks properly; requires some
Beginning 1
guidance; unorganized
Levels of Achievement
Procedure
4 3 2 1
1 Washes hands then dry, making sure it is not cold to touch
2 Explains the procedure to the client
3 Places the client in the dorsal recumbent position. Provide privacy
4 Fixes the woman’s clothing and the top sheet enough to expose the
abdomen.
Uses the tape measure and takes the fundal height. Inform the
5
instructor of the estimated age of gestation.
6 Compute and inform the instructor of the estimated age of gestation
Leopold’s Maneuver Step 1. Facing the head part of the client,
7 palpate the fundus with your fingers. Feel for either soft, irregular
mass or hard round freely movable mass.
Leopold’s Maneuver Step 2. Presses gently with palms on each side
8 of the abdomen. Determines whether the oval shape of the is parallel
with the long axis of the mother.
Leopold’s Maneuver Step 3. With thumb and forefinger, presses into
9 the lower abdomen just above the symphysis. Checks if the mass is
hard, movable or fixed.
Leopold’s Maneuver Step 4. Facing the leg of the client, and with the
use of the first three finger of each hand, presses deeply into the
10
pelvis moving towards the inlet. (Inform the instructor of your
finding)
Locates the fetal heartbeat by pressing the bell of the stethoscope pf
the chosen quadrant based on your diagnosis as to the position of the
11
fetus, while at the same time pressing the side opposite that quadrant.
Inform the instructor of your findings.
12 Warm attitude of the nurse evident throughout the procedure.
Nurse sensitive to feelings, discomfort of the patient during the
13
procedure.
14 Nurse’s hands are light and skill was evident.
15 Complete the prenatal record.
_______________________________
________________________________
Student’s Name & Signature Clinical Instructor’s Name &
Signature
CLINICAL NURSING PERFORMANCE EVALUATION IN PRENATAL CARE
Name of Student: ______________________________ Clinical Assignment:___________________
Clinical Instructor: _____________________________ Inclusive Dates: _____________________
Please check the appropriate value column:
Ratin
Scale Description
g
Advanced Performs all tasks accurately and independently; well organized 4
Performs all tasks properly and independently; some steps were
Accomplished 3
interchanged or omitted; organized
Performs most task properly; requires some guidance; less
Developing 2
organized
Performs few tasks properly; requires some guidance;
Beginning 1
unorganized
Levels of Achievement
PARAMETERS
4 3 2 1
Assessment
1. Completes the prenatal case record
2. Determines the client’s child’s birth and emergency plan
3. Interviews the patient’s family or significant others
4. Studies the maternal health records
5. Organizes, analyzes, synthesizes and summarizes the collected
data
Nursing Diagnosis
6. Identifies the patient’s nursing problems
7. Identifies the defining characteristics of the nursing problems
8. Identifies the etiology of the nursing problems
9. States the nursing diagnosis concisely and precisely
Planning
10. Identifies nursing diagnosis that needs to be prioritized
11. Develops immediate and long-terms goals
12. State the goals in realistic and measurable terms
13. Identifies nursing interventions appropriate for goal attainment
14. Identifies outcomes that are realistic and measurable
15. Identifies critical times for the attainment of outcomes
16. Involves the patient, his family or significant others, nursing
team member, and other health team member in all aspects of
planning
Implementation
17. Puts the nursing care plan into action
18. Coordinates the activities of the patient, his family or significant
others, nursing team members and other health team members.
19. Records the patient’s responses to the nursing actions
20. Revises the nursing care plan as needed
Evaluation
21. Collects objective data
22. Compare the patient’s behavioral outcomes with the expected outcomes.
23. Includes the patient, the family, significant others, nursing team
members and other health care team members in the evaluation
24. Determine the extent to which the goals were achieved
PARAMETERS Levels of Achievement
Professionalism
25. Submits written requirements on time
26. Reports to clinical assignment punctually
27. Seek supervision of clinical mentor when needed
28.Relates with peers and superior professionally
29. Wears the prescribed duty uniform appropriately
30. Complete pertinent records according to protocol
TOTAL
Rating: _______________________
Date: ________________________
____________________________
Signature of Student
____________________________
Signature of Clinical Instructor
