Maternity Health nursing
Kholud Rajab Yousef is 29 years pregnant woman in her 32 gestational weeks, G: 8. P:4 admitted to antenatal wards at 6/12/2011 with complain of dizziness , shortness of breath, palpitation and fatigue, she also have history of varicosities since 5 years ago, which cause acute pain in her legs.
The pt. is on regular diet, not smoker, educational level is high school, she is house wife, her husband educational level is secondary school, he work as taxi driver , he is smoker, their socioeconomic states is poor, she rarely eat meats .
Medical diagnosis: iron deficiency anemia
- History of present illness: pt. complain from dizziness, shortness of breath, palpitation and fatigue, and the result of hematology test indicates Hemoglobin level is 7.4 g/dl, the medical diagnosis is iron deficiency anemia, she complain from acute pain in her both legs and itching, and describe her pain intensity in pain scale from (0 to 10) as 8/10, the pain describe like needle, which increase with working at home, with sexual intercourse, and relief with rest.
- History of past illness:
Past medical history: varicosities since 5 years ago.
Past surgical history: ovarian cystectomy since 2007.
Obstetric history :
The pt. have menarche at age of 11 years, her menstruation is regular, with 28 days interval, duration of menstruation is 6 days, LMP:2/4/2011, EDD: 9/1/2012.
T P A L
4 1 3 4
Obstetric history of past pregnancy:
First pregnancy: is full term 37 weeks, at 7/10/2003, per vaginal delivery, the neonate is alive male with 3 Kg , without complication.
Second pregnancy: is full term 37 weeks, at 16/9/2004, per vaginal delivery, the neonate is alive female with 3.2 Kg , without complication.
Third pregnancy: is spontaneous abortion at 12weeks gestational age.
Fourth pregnancy: is spontaneous abortion at 12weeks gestational age.
Fifth pregnancy: is full term 38 weeks, at 22/4/2006, per vaginal delivery, the neonate is alive female with 3.2 Kg , without complication.
Sixth pregnancy : is preterm pregnancy at 32 weeks, at 15/6/2008, the neonate is alive male with 1.4 Kg.
Seventh pregnancy: is spontaneous abortion at 16 weeks gestational age.
History of family planning:
she used oral contraceptive tablets but stop it cause of headache & varicosities, then she used the depo provera a contraceptive injection and stop it cause she complain from bleeding as side effect from it.
the reason for abortion that she had to carried out heavy things such as gallon of water and rock in home, and her husband is in work, not available to help her.
Orientation: the pt is conscious and oriented by 3 , GCC: 15/15. Ht. 168 cm. wt: 85 Kg.
Blood Pressure : 100/65 mm/HG. Respiration Rate: 24 R/M
Heart rate : 110 P/M Temperature : 37.2 C°
skin : inspection generally skin is white to light brown color, pale, intact, smooth, with cholasma appear in her face, good mobility and turgor , stria garvidarum and linea nigra appear on the skin of abdomen with past surgical incision on her abdomen. Palpation : edematous veins in her both feet’s 3+.
Dark brown, shiny, straight, no dandruff, no lice.
The hair have increase failing during pregnancy.
Is slightly curved, smooth, the profile sign (the angle between nail and nail base is 160°).
Head and neck.
Inspection: the skull is a round symmetric and smooth, appropriately related to body size, facial expression and its appropriates to behavior she appear little anxious. Palpation: no tenderness or mass to palpate, temporal artery is palpate . The tempromandibular joint is smooth movement with no limitation or tenderness. Regional lymphoid are palpable, movable, discrete, soft and non-tender. Trachea is midline, the thyroid gland is palpable.
Auscultation: no bruit is heard with stethoscopes bell on the thyroid
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