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Activity 26 Assessment and Care of Antenatal Woman Ante Natal Case Record - 2

MRS. Lencina is a 21-year-old pregnant woman in her third trimester who presented with complaints of nausea, vomiting, fatigue, dizziness, and constipation. Her obstetric history, medical history, and family history were unremarkable. On examination, she showed signs of mild anemia but was otherwise healthy. Routine antenatal lab tests were normal. She received antenatal counseling, immunizations, and iron supplements and was advised on diet, exercise, rest, and hygiene during pregnancy. No complications were found on screening.

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A J Fathima
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200 views

Activity 26 Assessment and Care of Antenatal Woman Ante Natal Case Record - 2

MRS. Lencina is a 21-year-old pregnant woman in her third trimester who presented with complaints of nausea, vomiting, fatigue, dizziness, and constipation. Her obstetric history, medical history, and family history were unremarkable. On examination, she showed signs of mild anemia but was otherwise healthy. Routine antenatal lab tests were normal. She received antenatal counseling, immunizations, and iron supplements and was advised on diet, exercise, rest, and hygiene during pregnancy. No complications were found on screening.

Uploaded by

A J Fathima
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Activity 26 Assessment

and care of antenatal


woman
ANTE NATAL CASE
RECORD - 2
SUBMITTED TO; MRS.MAHALAKSHMI, H.O.D OF COMMUNITY HEALTH NURSING
SUBMITTED BY; FATHIMA.S, B.SC., NURSING, FINAL YEAR
Activity 26: Assessment and care of antenatal woman
ANTE NATAL CASE RECORD

Activity 26: Assessment and care of antenatal woman


ANTE NATAL CASE RECORD
Serial no;-
Hospital identification no-47/9
Name- MRS. Lencina
Age- 21 yrs
Gravida-1
Para - 0
Address – 113, Anna Street, thiruvanmiyur.
No. of Living children- 0
LMP- 18/6/19
EDD- 25/3/20
Complaints- nausea, vomiting
History of present pregnancy

Trimester Date BP Weight Urine Clinical Remarks


findings

First 17/8/2019 110/60 mm 42kgs Sugar and Hb- 10g/dl Anaemia


of hg albumin
absent
Second 19/12/2019 110/80 mm 45kgs Sugar and Hb- 10.4 g/dl Anaemia
of hg albumin
absent
Third 2/3/2020 110/70 mm 47kgs Sugar and Hb- 10.5 g/dl Anaemia
of hg albumin
absent

Assessment Findings Management / Referral


History taking MRS. Lencina, 21 years old have  She was advised to take
 fatigue enough rest.
 Dizziness  Administered medications
 Nausea such as
 vomiting Tab. folic acid 300mg BD oral
 constipation
Record of Ante Natal Card NIL SIGNIFICANCE
Symptoms Pale conjunctiva Administered Iron sucrose with
Pink lips 500 ml NS through IV
Face looks dull and tired

Obstetric History G1P0L0A0 Family therapy given to prevent


depression
Any Current / Past Systemic Nil
Illnesses
Family History Nil
Personal history No bad habits Provided fibre rich diet
Not allergic to any food and
medications
Watches TV in free time
Constipation is present
Bladder pattern is normal
General Physical examination and Height-154 cms Provided enough rest
measurements Weight- 48 kgs
Temp - 36c
Pulse- 66 b/min
Resp- 28 b/min
Body built- normal
Health status –anaemia
Activity - dull
Abdominal Examination Inspection: Shape- ovoid Regular antenatal check-up is
Size- appropriate to gestation advised.
Contour- flank fullness
Fetal movements- visible
Skin changes- linea Niagara and
striae gravidarum present
Height of the Fundus: 32 Cms
Abdominal girth: 112 cms
Lateral Right- continuous long
curvature (spine)
Left- irregular soft nodules
(fetal limbs)
Grip1- fetal head
Pawlick / Grip2- hard mass
Lie- LONGITUDINAL
Presentation- VERTEX
Position:- LOA
Attitude- flexed
Engagement- not engaged
Laboratory Investigations Blood group- O+ve Health education on iron rich diet
Hb- 10.7 g/dl is given
Blood sugar – nil
VDRL- nil
HIV – nil
Hepatitis B- nil
Health education / prenatal advice Given advises on
during pregnancy  Diet During Pregnancy
 Diet During Pregnancy A pregnant woman needs
 Personal Hygiene more calcium, folic acid, iron and
 Care of Teeth protein than a woman who is not
 Rest and Sleep expecting, according to the
 Physical Work American College of Obstetricians
 Exercise and Gynaecologists (ACOG)
 Comfortable Clothing and Folic acid- leafy green vegetables
Shoes fortified or enriched cereals,
 Smoking /Alcohol breads and pastas, beans, citrus
 Breast Care fruits. 
 Drugs Calcium- milk, yogurt, cheese,
 Protections from Infections and calcium-fortified juices and foods,
Illnesses sardines or salmon with bones,
 Sexual Activities some leafy greens
 Reporting of untoward Signs Iron- meat, poultry, fish, dried
and Symptoms beans and peas, iron-fortified
 Care of New Born cereal.
Family Planning Methods and Protein- meat, poultry, fish, dried
Counselling beans and peas, eggs, nuts, tofu.
 Personal Hygiene
Keep yourself and surrounding
clean

 Care of Teeth
Brush twice daily

 Rest and Sleep


Sleep minimum 8 hrs/day

 Physical Work
Avoid lifting heavy objects

 Exercise
Do exercise regularly

 Comfortable Clothing and


Shoes
Wear loose clothes

 Smoking /Alcohol
Avoid smoking and alcohol
consumption as it affect the
growth of fetes

 Breast Care
Keep your breast clean
Inspect for any changes
If any discharge pain is present
visit the nearby PHC

 Drugs
Don’t take drugs without doctors
prescription

 Protections from Infections


and
Illnesses
Keep your surroundings clean

 Sexual Activities
Practice safe sexual practice

 Reporting of untoward Signs


and Symptoms
if any discharge from vagina,
severe pain, or discomfort consult
the doctor immediately

 Care of New Born


Practice aseptic procedures
Provide kangaroo mother care
Provide exclusive breast feeding.
Family Planning Methods and
Counselling
Take gap of 3 years between 1st
and 2nd child
Use contraceptives
Sterilization should be done after
2 live births

Antenatal Intervention Kick chart assessed Nil significance


Immunized
Antenatal advices given and
antenatal exercises are taught
Assessment of fetal well being is
done
Assessment of risk status is done
Screening for complications such Toxaemias of Pregnancy - nil No complications
as Diabetes- abs
 Toxaemias of Pregnancy Tetanus Protection- inj TT
 Diabetes Administered
 Tetanus Protection Rubella- abs
 Rubella HIV Screening- negative
 HIV Screening Hepatitis B- abs
 Hepatitis B Syphilis- abs
 Syphilis German Measles- abs
 German Measles Rh Status-Rh positive
 Rh Status Prenatal Genetic Screening- nil
 Prenatal Genetic Screening complications

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