Professional Documents
Culture Documents
Submitted by:
Darnalet Ong
Jill Hazel Jocson
Carissa Joy Salado
TABLE OF CONTENTS:
I.
II.
III.
INTRODUCTION
THEORETICAL FRAMEWORK
NURSING HEALTH HISTORY
A. CHIEF COMPLAINT
B. BRIEF SUMMARY OF THE PATIENT CONDITION
C. GENERAL APPEARANCE
D. HISTORY OF PRESENT ILLNESS
E. PAST MEDICAL HISTORY
F. FAMILY HISTORY
G. DEVELOPMENTAL HISTORY
H. ENVIROMENTAL HISTORY
I. OB/GYNE HISTORY
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
ACKNOWLEDGEMENT
First of all, we would like to extend our deepest gratitude for all the people who had been
part of this study. We are giving thanks to Ms. Ernestina Claudia C. Que our School Directress
for her support and encouragement. To our school Dean Ms. Maria Liane D. Luna for sharing her
knowledge and expertise. To our adviser Ms. Emmy Macaraeg for her patience and limitless
guidance made possible the presentation of this study.
To our clinical instructors, Ms. Jessica Amba and Presentacion Q. Romero for guiding us
and motivating us to do our best, and also our classmates and friends for their support and
participation in this case study, especially to our family and relatives for their patience, for going
home late this past few weeks and also their guidance.
Finally, we are giving thanks to the Almighty God for giving us the strength, knowledge
and graces to be able to finish this study. We are thankful for his proper guidance throughout the
course of doing this case study.
I. INTRODUCTION
Gestational Diabetes is a type of diabetes mellitus or increase sugar in the blood that only
occurs in pregnant women. The prevalence of gestational diabetes is approximately 2% to 3% of
all women who do not begin a pregnancy with diabetes become diabetic. Usually at the midpoint
of pregnancy when insulin resistance becomes most noticeable, termed Gestational Diabetes
Mellitus (GDM). The symptoms will fade again at the completion of pregnancy, but the risk of
developing insulin dependent response to carbohydrate or from excessive resistance to insulin.
Before insulin was produce synthetically in 1921, women with Diabetes either failed to survive
pregnancy. Risk factors for Gestational Diabetes include obesity, Age over 35 years old, history
of large babies 10lb or more, history of unexplained fetal loss, history of congenital anomalies in
previous pregnancies, history of unexplained prenatal loss, family of diabetes.
Our patient is 35 years old, her name is Mrs. D.C. residing at Tondo Manila, Shes living
with her husband and its her first pregnancy. She works before as sales lady in one of the malls
in Manila which is Tutuban. During the 2nd week of September. The patient decided to seek for
medical consultation.
Interventions and care plan for the client, monitor vital signs, blood sugar and schedule and
cluster nursing time and interventions. Keep patients routine as consistent as possible, encourage
participation in activities of daily living.
OBJECTIVES
A. General
This case study was conducted to enhance our knowledge and develop our skills on how to
provide best possible care to a patient with condition like gestational diabetes.
B. Specific
To be able to know our responsibilities such as promoting health, prevent further harm or
illness, as well as restoration of health according to the extent of our knowledge and
skills.
To gain knowledge about Gestational Diabetes
To discuss the pathophysiology, anatomy and physiology, signs and symptoms.
To familiarize ourselves the different treatment modalities of Gestational Diabetes.
HEALTH
Originally, Roy wrote the health and illness are on a continuum with many different states or
degrees possible. More recently, she states that health is the process of being and becoming an
integrated and whole person. Adaptation is defined as the process and outcome whereby thinking
and feeling, as individuals and in groups, use conscious awareness and choice to create human
and environmental integration.
A Chief Complaint
Bi pedal edema
B Brief Summary of patients condition
This is a case of 35 years old. Gravida 1 Para 0. With 28 weeks age of
gestation
C General Appearance
52 in height 75 kg weight, ambulatory, conscious and coherent
D History of present illness
During the 2nd week of September. The patient decided to seek for
medical consultation
E Past medical history
During her childhood year she experience chickenpox, and measles.
During his adolescent years, she experienced common illness like
cough, colds and fever.
1 Obstetrics
- Uterus is regularly enlarged containing single alive fetus in CEPHALIC
presentation. Fetal heart rate is 157 b/min. absence of gross fetal
abnormality. Fetal sex is MALE. Amniotic fluid is anterior, high-lying.
Adnexal are clear.
2 Immunization: patient received during the course of her pregnancy the
following immunizations.
TT1
7
TT2
TT3
Hospitalization
No history of hospitalization.
Injuries
The patient never had serious injuries
Transfusions
The patient never received any blood transfusion.
Medication taken
The patient took (ferrous sulfate) as her vitamin during pregnancy
Allergies
No allergies noted
5
6
7
MATERNAL
Grandfathe
r
87
years old
Grandmother 85
years old
Grandfathe
r
80 years
8
old
Mother
55 years old
Father
60 years old
Patient
35 years old
LEGEND:
Deceased
Diabetes
Asthma
Hypertension
Gestational Diabetes
INTERPRETATION
On the paternal side of our patient, was noted to have diabetes mellitus. Whereas on the
maternal side of our patient, her grandmother was noted to have asthma. But, both of her parents
did not inherit any of the above conditions as well as on patient.
G. DEVELOPMENTAL HISTORY
THEORY
AGE
Psychosoci Middle
al
(Erick Adult(35
Erickson)
y/o)
DEVELOPMENTAL
TASK
Intimacy vs Isolation
CLIENT
DESCRIPTION
INTERPRETATION
Patient verbalized
that her husband
was
her
first
sexual partner.
Moral
(Lawrence
Kohlberg)
Middle
Adult(35
y/o)
Post
Conventional The patient gives
Morality
respect to the
opinions of other
people.
H. ENVIRONMENTAL HISTORY
Our patient D.C is a Saleslady; she lived with her husband in apartment in Tondo,
Manila. The apartment type is built in light materials. Her workplace is surrounded by fast food
chains were she ate mostly.
I.
OB/GYNE HISTORY
LMP- Feb 27, 2015
EDC- Nov 27, 2015
AOG-28 weeks
1. MENARCHE AGE:
12 Years old
2. DURATION OF MENSTRUATION:
Three-five days
3. CHARACTERISTICS:
Bright red
4. ASSOCIATED SYMPTOMS:
Dysmenorrhea
5. GRAVIDA-PARITY:
G1P0
6. COMPLICATIONS:
Gestational Diabetes
IV. GORDONS
PATTERN
1.Health
Perception
and Health
management
BEFORE PRE-NATAL
VISIT
-prior to patient condition she
said that ang isang taong
malusog ay yung walang sakit
at nagagawa niya ang mga
gawain sa pang araw- araw.
And also, she has always been
DURING PRE-NATAL
VISIT
- During her prenatal visit
the patient saidkailangan
ko na maging aware sa
condition ko at iwasan ang
pagkain na makakasama sa
akin. .she thinks that the
ANALYSIS
The patient needs
additional information
regarding her health
condition because she
perceived that her
unhealthy
eating
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2.Nutrition
and
Metabolism
habits
was
the
common culprit to her
condition
Another
misconception
because her condition
supported
and
accompanied with her
pregnancy although
she need to modify
her eating habits it is
not
the
common
reason of condition
The
patient
has
misconception again.
Because it is not
normal that frequent
in
urination
is
observed
during
pregnancy due to the
compression of the
bladder by the gravid
uterus
Shes developing
normal patterns of
behavior during
pregnancy
3.Elimination
-The
urination
was
increased because of her
condition. (Have diabetes
during pregnancy.)
4.Activity
and Exercise
5.Sleep and
Rest
6.Cognitive
Perceptual
7.SelfPerception
and SelfConcept
Needs
additional
health teaching
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husband.
8.Sexuality
Reproduction
9.Roles and
Relationship
10.Coping
and Stress
Tolerance
11.Values and
Belief
V. REVIEW OF SYSTEMS:
A. CONSTITUTIONAL SYMPTOMS
Weakness
Nurse: Sa inyong pagbubuntis ano ano po baa ng inyong nararamdaman sa inyong katawan?
Patient: Ako ay nanghihina
Sleeping Problem
Nurse: Ilang oras po ang inyong tulog sa magdamag?
Patient: Siguro umaabot sa anim hanggang walong oras
B. EYES
Nurse: May panlalabo bas a inyong mga mata ngayong buntis kayo?
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C. NOSE
Nurse: May problema po ba kayo regarding sa inyong pang amoy?
Patient: wala naman po akong problema sa pang amoy
D. INTEGUMENTARY
Nurse: Sa inyo po bang balat, may napapansin po ba kayong pagbabago dito?
Patient: Meron
Nurse: Kagaya po ng ano?
Patient: Pansin ko kasi na nag-dry na yung balat ko
G. CARDIOVASCULAR
Nurse: May pagkakataon bang nahahapo kayo o sumusikip ang dib-dib niyo?
Patient:Tuwing malayo nilalakad ko hinahapo ako pero di sumisikip dib-dib ko
H. RESPIRATORY
Nurse: Sa paghinga niyo po ba ay may problema kayong napapansin?
Patient: Wala naman akong problema sa paghinga
I.GASTROINTESTINAL
Nurse: Ilang beses po kayong kumakain sa isang araw?
Patient: Nakakatatlo hanggang apat na beses
Nurse: Ano po yung mga karaniwang pagkain ang kinakain ninyo?
Patient: Sa ngayon, nagbabawas ako sa kanin at sa mga matatamis na pagkain. Madalas mga
prutas at gulay ang kinakain ko.
J.GENITOURINARY
Nurse: Sa isang araw po ba, ilang beses po kayo umiihi?
Patient: Umaabot ito sa walo hanggang sampu
K.MUSCULOSKELETAL
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L.PSYCHIATRIC
Nurse: Ano po ang inyong balak para sa inyong unang magiging anak?
Patient: Syempre, bibigyan ko siya ng magandang buhay. At magsusumikap ako sa pagtatrabaho
para sa kinabukasan ng aking anak.
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FINDINGS
NORMAL
INTERPRETATION
37.0C
36.4C-37.4C
Normal
25 c/min.
12-20 c/min.
-Pulse Rate
90 b/min.
60-100 b/min.
Has difficulty of
breathing
Normal
-Blood Pressure
130/100 mmHg
120/80 mmHg
-Fundic Height
29 cm
29 cm
Normal
Weight
75kg
35kg
overweight
BMI
0.32
18.9-24.9
Overweight
15
BODY
PARTS
ASSESSMEN
T
TOOL
A.SKIN
1.Skin color, -Inspection
odor
and -Palpation
lesions
2.
Texture, -Palpation
temperature,
moisture,
turgor,
and
edema.
3. hair
B.EYES
1.External Eye
-Inspection
2.
Eyelid -Inspection
placement,
swelling,
discharge and
NORMAL
FINDINGS
-Skin color;
Pale, white
with pink,
yellow,
brown
or
olive tones
to dark or
black.
-The skin is
lesion free
Common
Skin
Variations:
-Birthmarks
-Milia
-Erythema
-Skin
is
warm and
slightly
moist.
-Inner
canthus
distance
approximate
ly
2.5cm,
horizontal
slant, and
no
epicanthus
folds.
-Transient
edema
absence of
tears.
ACTUAL
FINDINGS
ANALYSIS
INTERPRETATION
-Dryness
skin
of
-Tear is
evident.
Normal
-Teary eyes
are evident.
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lesions.
3. Sclera and -Inspection
conjunctiva for
color,
discharge,
lesions,
redness, and
lacerations.
4. Iris and the -Inspection
pupils.
5.Eyebrows
-Inspection
Eyelashes
C.BREASTS
1.
Shape, -Inspection
symmetry,
color,
tenderness,
discharge,
lesions
and
masses.
D.ABDOME
N
1.Shape
of -Inspection
abdomen
-Auscultation
2.Umbilicus
-Inspection
-Palpation
-Clear and
free
of
discharge,
lesions,
redness, or
lacerations.
-Clear
and Normal
free
of
discharge,
lesions,
redness,
or
lacerations.
Normal
-Brown iris,
brusfields
spots white
flecks
on
the
periphery of
the iris.
-Symmetric
in shape and
movement,
not
meet
midline.
-Evenly
distributed
and curried
outward.
-Pupils
are Normal
equal, round
and reactive
to light and
accommodati
on.
(PERRLA)
-Symmetric in Normal
shape
and
movement,
not
meet
midline.
-Evenly
distributed
and
curried
outward.
Normal
-Enlarged
and
engorged
breasts
Normal
-Prominent -Prominent in
in
supine supine
position.
position.
-fetal
heart
tone
-Pink,
no -Pink,
has
discharge,
Linea Nigra,
no
odor, no discharge,
redness.
Normal
Normal
Normal
3.Bowel
Sounds
Fetal
tone
-Auscultation
-Palpation
heart -Doppler
the fetus
-theres
quickening
start
in
20weeks of
gestation
-Occur
-Occur every Normal
Normal
every
10- 10-30sec.
30sec.
-It sounds like
-It sounds clicks, gurgles
like clicks, or growls.
gurgles or
growls.
It sounds
like clicks,
gurgles or
growls.
157 b/min
120-160
b/min
Normal
4.Masses and
Tenderness
-Palpation
-Soft to
palpate and
without
masses or
tenderness
-Hard to
palpate and
with masses
or tenderness
-Hard to
palpate
because of
the fetus
inside.
Due to pregnancy
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PATHOPHYSIOLOGY
Predisposing factors
precipitating factors
Sedentary lifestyle
35 years old
Female
Carbohydrate intake
Obesity
Sodium Glucose
intake
Family History
Diabetes Type II
Exercise
Pregnancy
Placenta
Hormones
(HPL)
Blood Glucose Level
Insufficie
nt insulin
Inability of glucose to enter
cells for energy
Insulin
Production
19
Polydipsia
Polyuria
Polyphagia
Weight gain
LABORATORY/DIAGNOSTIC RESULTS
BLOOD CHEMISTRY
Glucose
Blood Glucose
1st hr
2nd hr
3rd hr
WBC count
RBC count
Result
5.01 mmol/l
4.32mmol
77.76
7.01
100.10
8.97
110.46
4.58
130.44
CBC
Result
10-60
Hemoglobin
133
Hematocrit
0.40
Normal Values
4.8-10
M: 4.5-5.5 x 10
F: 4.0-5.5 x 10
M: 120- 183
F:110- 148
M: 0.38-0.54
F:0.36-0.48
150-400 X 10
1-3 mins
Platelet
Bleeding time
STAB:
SEG:
LYMPH:
MONO:
EOS:
BASO:
Normal Values
420-6.40 mmol/l
0.72
0.28
Analysis
Normal
Normal
Normal
0.00-0.05
0.55-0.75
0.20-0.38
0.03-0.07
0.01-0.05
0.00-0.01
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Color:
Transparency:
Sugar:
Albumin:
PH:
Specific Gravity:
Ketone:
URINALYSIS
microscopic
Yellow
Pus cells:
S1 turbid
RBC:
positive
Ephitelial cells:
Trace
Bacteria:
5.0
Amorphonsurdler:
1.010
Mucous threads:
Crystals:
microscopic
3-7/hpf
1-2/hpf
++
+
+++
+++
calcium oxalatet
21
ASSESSMENT
Subjective:
Nagmamanas ang
aking paa As
verbalized by the
patient
Objective:
-Bipedal edema
V/S
T: 37.3
PR: 95
RR: 25
Bp: 150/90
NURSING
DIAGNOSIS
Excess fluid volume
r/t excess sodium
intake as manifested
by bipedal edema
PLANNING
INTERVENTION
RATIONALE
EVALUATION
To obtain baseline
data
To promote venus
return
Intake of fluid up to
500mL is equivalent
to 0.5 kg increase in
weight due to fluid
retention
To prevent stasis of
edema and reduce
risk of further injury
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ASSESSMENT
Subjective:
Nababahala ako sa
aking kalagayan
As verbalized by
the patient
NURSING
DIAGNOSIS
Anxiety r/t changes
in health status as
manifested by
restlessness, foot
shuffling, and
PLANNING
INTERVENTION
RATIONALE
EVALUATION
After 8hrs of
nursing
interventions the
patient will describe
a reduction in the
Assess level of
anxiety
To be able to give
appropriate nursing
intervention
Goal met.
The patient level of
anxiety decreased
The presence of a
23
fidgeting
Objective:
-restlessness
-foot shuffling
-fidgeting
level of anxiety
experienced
Reassure patient
that she is safe. Stay
with the patient
Maintain a calm
manner while
interacting with
patient
ASSESSMENT
Subjective:
lalo akong
tumataba as
verbalized by the
patient
Objective:
-The patient is 78kg
now, compared
before 45kg.
-Increased food
intake 3-4 cups of
rice, compared
NURSING
DIAGNOSIS
Imbalanced
nutrition more than
body requirements
r/t inability to
absorb nutrients
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Document patients
nutritional status on
admission, noting
skin turgor, current
weight, food intake,
body built
Useful in defining
degree or extent of
problem and
appropriate choice
of interventions
Encourage small,
frequent meals, low
in calorie and
sodium
Maximizes nutrient
intake without
undue
fatigue/energy
expenditure from
eating large meals
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ASSESSMENT
Subjective:
Gusto kong
malaman kung ano
yung sakit ko as
verbalized by the
patient
Objective:
- Request for
information
- Inaccurate followthrough instructions
Encourage
mobilization
NURSING
DIAGNOSIS
Knowledge deficit
r/t cognitive
limitation as
evidenced by
request for
information
To promote healthy
lifestyle
Provides assistance
in planning a diet
with nutrients
adequate to meet
metabolic need
PLANNING
INTERVENTION
RATIONALE
EVALUATION
After 4-6hrs of
nursing
interventions the
patient will1. Participate in
learning process
2. Verbalize
understanding of
disease process and
treatment
3. Demonstrate
awareness in
preventing the
reoccurrence of the
disease
Assess readiness to
learn
Goals met.
The patient gained
information about
her condition
Promote an
environment
conducive to
learning
Establish objectives
and goals for
learning at the
beginning of the
session
Provide instruction
and specific written
information for
patient to refer to
schedule for
medications and
follow-up for
documenting
response to therapy
26
Evaluation
-Goal met
- The patient
will
know
how to do
blood sugar
testing.
28
Method of
Evaluation
Goal met
The patient
will
know
how
to
maintain
healthy diet.
Evaluation
30
Objectives
Perform
proper
exercises.
Content
Learn
the
proper
exercise
techniques
and practices
to
avoid
injuries and
helps improve
body
condition.
getting
regular,
moderate
physical
activity.
- Simple walk
for
15-30
mins
every
day.
Evaluation
-Lecture
-YouTube
-Actual
-Goal met
-Video
-Healthy
performance
presentation
Lifestyle
-Interview
of the proper Book
with
the
exercise for -health care patient
pregnant
provider
-Observation
woman.
for
the
possible
improvement
in the body
her blood
sugar
numbers,
physical
activities,
everything
she eat and
drink in a
daily record
book.
activities and
sugar level.
provider
XI.DISCHARGE PLANNING
MEDICATION:
1. Doctors order.
ENVIROMENT
1. Discuss patient on how to handle things around her such as emotion about her condition
having Gestational Diabetes.
TREATMENT:
1. Instruct patient to keep glucose level under control by managing her healthy diet.
2. Instruct patient maintain a healthy weight gain by keeping daily records of her diet,
physical activity and glucose level number.
HEALTH EDUCATION:
1. Eating a healthy diet meal plan.
2. Moderate physical activity to help control patient.
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