Ghana Health Service Nurse Case Study Report (chapter 2)

CHAPTER TWO

ANTENATAL CARE

Antenatal care is the care rendered to a pregnant women from the time of conception until the beginning of labour. Effective antenatal care includes regular screening which can detect and prevent early complications such as hypertension and diabetes in pregnancy.

This chapter talks about initial contact with client, her first antenatal home visit, subsequent visit made by client to the hospital and subsequent home visit. In addition, the problem identified were prioritized and nursing care plan drawn for the client.

FIRST CONTACT WITH MY CLIENT

My first encounter with my client Madam M.K, gravida 2 para 1 was on 18th August 2023 at 8:40am at Aiyinase Health Centre. She was 36weeks plus 6 days pregnant and had already visited the antenatal clinic five times, upon interaction I introduced myself as a student midwife from Nursing and Midwifery Training College, Esiama. Looking through her maternal health record book made me noticed that, she was a regular attendant. The concept of family centered maternity care was explained to her as a systematic approach to prenatal and birth providing care to the pregnant woman in the context of the family involvement. The information was channeled to her that I wish to take her as my client, to study and take care of her, till she delivers. She agreed to the proposal. I asked if she had any problem. She complained of heart burns and fatigue. She was asked on the cause of the fatigue and she said it was due to the workload at the market. Emotional support was given and I explained to her that, the fatigue may also due to stress of pregnancy and was educated to have enough rest. Client was educated to adopt the habit of reducing her workload and ask for support from family members.

The heartburn was also explained that it was due to reflux  of acidic gastric content  into the oesophagus resulting in burning sensation, so I educated Madam M.K to avoid lying down immediately after eating but sit for some time. Client was educated to avoid too much spicy and fatty food and small but frequent meals at a time. I counselled her to take prescribed antacid and also prop up in bed when sleeping.

All procedures that were to be done were explained to her and was asked if there was any questions on the procedures that have been explained but she said she was alright. Procedure for physical examination was explained to her, to gain her consent, I accompanied her to the examination room, privacy was ensured by using a screen, I helped her change and cover herself with a cloth and asked her to empty her bladder and made her comfortable in a dorsal position on the palpation couch. I washed my hands with soap under running water and dried them with a clean towel. I set a tray for the examination beside the couch and warmed my hands by rubbing them together and gently performed physical examination from head to toe.

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PHYSICAL EXMINATION

On inspection of the head, the hair was neatly permed and combed. There were no lice, dandruff, no ringworm and no facial oedema. The conjunctiva was neither pale nor jaundice. There was no nasal or ear discharge. The mouth, teeth and tongue were clean with no cavities or swellings. The neck was palpated with no thyroid gland and no distended neck vein. The upper limbs were examined for equality and they were equal.

The breast was examined. She was asked to put her hand under her head and both breasts were inspected for size and shape. The breast was of the same size and shape with no lumps and pus were detected which I placed the cotton wool swab on the nipple and gently squeeze it and there was no abnormalities. The nipples were free from sores, cracks, and discharges.

The breast were palpated and examined with no oedema which she did not complain. Both breasts were equal.

With her permission, I exposed her abdomen and covered her chest and lower limbs. I stood at her right side to perform the abdominal examination.

On inspection, the abdomen was ovoid in shape. There were no rashes or scar present but straie gravidarum, linea nigra and fetal movement were all present. I then located the upper border of the symphysis pubic and place a zero mark of the tape measure on it and extended the tape along the midline of the abdomen to the fundus. The symphysiofundal height was 35 cm and maturity was 36 weeks plus 6 days of gestation.

On Fundal palpation I faced the woman and warmed my hands by rubbing them together and placed my palms on each side of the fundus and curved the fingers around the top of the fundus; The fundus was occupied by a soft mass which was the buttocks.

Case Study Report

On lateral palpation, I placed the palm of my hands on both sides of the uterus, midway between symphysis pubis and fundus. I then stabilized the uterus with one hand and examined with the other hand to locate the fetal back for auscultation.  I palpated the entire area from abdominal midline to the lateral and from the symphysis pubis to the fundus in a rotatory manner. The fetal back was located at the right side of the abdomen as a smooth curve was felt, I then changed my hands repeated the palpation for the other half of the abdomen and the limbs were palpated at the left side of the abdomen The lie was  longitudinal.

On pelvic palpation I turned and faced my client’ feet, I then asked her to flex the knees slightly and breath out slowly to relax her muscles. I placed my palms just below the level of the umbilicus and my fingers were directed toward the symphysis pubis. A hard rounded mass was felt showing that head was presenting and so presentation was cephalic and the position was right occipito anterior.

I palpated to identify the descent of the head by locating the anterior shoulder, 2 to 5 cm from the linea nigra where the limbs are located and kept two fingers over it. The number of finger breaths that occupied the space between the symphysis pubis and the anterior shoulder was five fifth above the pelvic brim.

On auscultation fetoscope was warmed by rubbing it in my palm and placed the fetoscope on the mother’s abdomen at the right side where the fetal back was located. I placed my ear against the fetoscope and listened to the fetal heart beat; whilst listening, I felt for the maternal pulse to differentiate the maternal pulse from the fetal heart beat. I then removed my hand from the fetoscope water and dried them with a clean towel. I communicated the findings to her and recorded them into her and started to count the heartbeat for a full minute. The fetal heart rate was 142 beats per minute with good volume and rhythm. I thanked Madam M.K, covered her abdomen. I asked permission to inspect her vulva and she allowed, I washed my hands and on observation, her vulva was clean and well shaved.  The lower limbs were examined for equality and were equal. I told her to lie on her side to examined the back and no abnormality detected. I finally helped her out of the palpation couch and assisted her to dress up, offered her a seat and tidied up the palpation room. I washed my hands with soap under running and record findings in the maternal health records books and the ANC register. I thanked her again for her cooperation. She was educated and encouraged to come to the clinic in case of any problem or in labour. I encouraged Madam M.K to take her routine drugs correctly and to come to antenatal clinic till she delivers. Drugs prescribed were given to client as;

• Tablet ferrous sulphate      200mg bd x 30days
• Tablet folic acid                  5 mg daily x30days
• Tablet multivitamin             200mg bd x30days
•  Caps. Iron iii polymaltose complex    1daily x 30days

I then informed her of my intention to use her for my care study and accepted. I thanked her again for her time and cooperation and also accepting willingly to be use her for the family centered maternity care study. I told her I will come home to visit her and the family on 20/08/2023 so she gave me the specific location. We then exchanged telephone numbers and I informed her on my visit.

FIRST ANTENATAL HOME VISIT

On 20^th August, 2023, I visited the house of Madam M.K . The   purpose of this visit was to assess the condition of the home environment, how she interacts with her family and neigbours and educate her on any problem that I may identify. I got there at 9:00am and met Madam M.K together with her husband and son. I was warmly welcomed and she introduced me to her husband and son. I asked them about their health and they were all doing well. I enquired about the fatigue and heartburns she complained about the last time, she replied that, she was relieved of the fatigue and heartburns.

They live in their own house .She lived with the husband and son in a one room self- contain.  Arrangement of furniture and other items were also good. The source of light is electricity.  Their source of drinking water is pipe and she stores most of their water in rubber containers with a well- fitting lid. The kitchen was neat and things were arranged. A well- fitting container was there where they dispose their waste and finally disposed-off in big container in their locality. The bathroom was inside.  The house was neatly kept and well organized. I told them my findings and congratulated them for keeping the house neat. I asked her about her readiness towards delivery and she brought out her things for inspection. The item for confinement were checked which includes perineal pad, nightwear, four cot sheet, baby oil, cloth, deltol, toothpaste and brush, detergent, bathroom slippers, baby dress, rubber mackintosh, maternal heath record book, baby diaper and all were intact. This made me notice how well the couples were ready and happy to have another baby.

I then congratulated her and prepared their mind towards complication readiness. I told her the need to arrange for transportation so that when labour start she would be taken to the hospital on time. She must also mobilized some donors who will donate blood when the need arises, not forgetting the national health insurance card.

She complained of difficulty to sleep at night due to frequency of micturition. I explained further that the frequency of micturition is due to descent of the fetal head and it will stop when the fetus is delivered and client was encouraged to pass urine as soon as she has the urge, client was encouraged to have supper early, she was encouraged to reduce her fluid intake before going to bed, and she was educated to keep bedpan closer to her bedside to avoid walking out at night.

Client was also encouraged to have adequate rest and sleep, lie on her left lateral side with abdomen supported with pillow. I also asked her to report to the hospital if it becomes severe. I told Madam M.K her next visit which was on the 25/08/2023.

CLIENT’S SUBSEQUENT VISIT TO THE CLINIC

Madam M.K visited the clinic on 25^th August, 2023 at 37 weeks plus 6 days of gestation at 9:00am. I welcomed her and offered her a seat. I enquired about her health and that of the family and she said by God’s grace they were doing well. I asked her again about the difficulty in sleeping at night due to the frequency of micturition, and she said she is now able to sleep as she practiced what I advised her to do. I then realized she was wearing a low heeled sandals. The usual routine examination was done after explaining the procedure to her. I asked her to empty her bladder and she did. I ensured privacy by using a screen on the palpation couch. I helped her to lie in a dorsal position on the couch. General examination from head to toe was done and client was in good health I then exposed her abdomen only, warm my hands by rubbing together and stood on the right side of her. On inspection the abdomen was globular in shape and fetal movement was present. On fundal palpation the buttocks occupied the fundus the symphysio fundal height was 36 centimeters.

On lateral palpation the fetal back was located at the right side of the abdomen as a smooth curve was felt. I then changed my hands repeated the palpation for the other half of the abdomen and the limbs were palpated at the left side of the abdomen. The lie was longitudinal. On pelvic palpation,   presentation was cephalic. The descent was 5/5^th above the pelvic brim. On auscultation, the fetal heart rate was 142 beats per minute. Vital signs checked and recorded B/P 115/67mmHg, weight 62.5kg, temperature 36.0°C, pulse 80bpm. Findings were communicated to her and recorded into her maternal health record book and the ANC register. I asked if there were any complaints and she said she has backache. I explained to her that is normal in later stage of pregnancy due to the physiological change in posture.

Education on birth preparedness and complication readiness were stressed, baby care, breast feeding and family planning. She was also sent to the labour ward and lying in ward for tour to be familiar at the ward. She was encouraged to continue with her routine drugs that were given. I also reminded her of my next home visit on 27/08/2023. I thanked her for coming and saw her off.

SUBSEQUENT ANTENATAL HOME VISIT

On the 27/08/2023. I visited Madam M.K again at 11:50am.This time, met her and her son. She warmly welcomed me and the purpose of my visit was explained. She told me that the husband had informed a taxi driver friend, who has promised to transport her to the hospital when labour set in. She also told me that she had hanged her mosquito net and she was sleeping under it. Further also noticed that, the place is in order and all shoes have been properly arranged. She was congratulated for her cooperation and adhering to the counselling. Her layette too which was already packed in a bag neatly was inspected. She was reminded of her next visit to the clinic which was on the 01/09/2023. I encouraged her to have enough rest one or two hours during the day and eight hours in the night to restore health and also take in her routine drugs regularly as prescribed. I reminded her of her estimated date of delivery on the first ultrasonic scan as 02/09/ 2023. I asked Madam M.K about how she is faring and she said she is relieved of the backache but complained of lower abdominal pain.  Vital signs checked and recorded to be normal;

• Blood pressure     112/70mmHg
• Pulse                     90bpm
• Temperature           36.6°C

NEXT ANTENATAL VISIT TO THE CLINIC

Client visited the antenatal clinic again on the 28/ 08/2023, around 9:00am and was attended to at 9:10am.  Permission was granted to examine her and she agreed. The procedures were explained to her, assessment on vital signs were as follows temperature; 36.8°C, pulse; 62bpm, respiration; 22cpm and blood pressure 100/70mmHg, she weighed 62Kg. Her urine tested negative to both glucose and protein. Client was encouraged to empty her bladder of which she said she did not have the urge to do so and was helped to undress and lie on the couch. After providing privacy, my hands were washed and dried to perform physical examination from head to toe. She looked healthy, Madam M.K was 38weeks plus 3 days.

On abdominal palpation, symphyisiofundal height was 37cm, longitudinal lie, presentation cephalic. Fetal heart was 138pm. All findings were communicated to her and documented in her maternal health records books ad ANC register.

NURSING CARE PLAN DURING   ANTENATAL PERIOD

The nursing care plan is a guide designed to render total individualized care to a client taking into consideration her needs as a unique individual. This involves identifying the client’s problems, analyzing them, setting objectives, and implementing intervention that will meet such objectives. Then evaluation is carried out to ascertain whether the goals has been achieved.

PROBLEM IDENTIFIED DURING ANTENATAL PERIOD

1. Heart burns 18/08/2023
2. Fatigue 18/08/2023
3. Difficulty in sleeping at night       20/08/2023
4. Backache 25/08/2023
5. Lower abdominal pain 27/08/2023

NURSING DIAGNOSIS

° Heart burns related to relaxation of the cardiac sphincter secondary to progesterone resulting in   reflux of the gastric acid.

° Activity intorelance (fatigue) related to inadequate rest.

° Sleeping pattern disturbance (insomnia) related to frequency of micturition at night.

° Impaired body discomfort (backache) related to physiological changes in pregnancy.

° Lower abdominal pain related to pressure of the descent of the fetal head on pelvic nerves.

SHORT TERM OBJECTIVES

Client will be relieved of heart burn within 48houurs.

Client will be relieved of fatigue within 48 hours.

Client will be able to sleep eight hours at night within 5 days.

Client will be relieved of backache within 48 hours.

Client will cope with lower abdominal pain throughout pregnancy

LONG TERM GOAL

Client’s will be able to go through pregnancy successfully without any complication to herself and the unborn baby physically, emotionally and psychologically sound.

NURSING CARE PLAN DURING ANTENATAL PERIOD

DATE/ TIME	NURSING DIAGNOSIS	NURSING OBJECTIVES/ OUTCOME CRITERIA	NURSING ORDERS	NURSING INTERVENTION	DATE/ TIME	EVALUATION	SIGN
18/08/2023 at 9:10am	Heart burns related to relaxation of the cardiac sphincter as action of progesterone resulting in reflux of the gastric acid.	Client will be relieved of heart burns within 48 hours as evidenced by client verbalizing that she does not experience heart burns again.	1. Educate client to avoid too much spicy and fatty foods. 2. Counsel client to avoid lying down immediately after eating but sit for some time. 3. Teach client to wake up slowly from bed in the morning. 4. Educate client to eat in small meal but at frequent intervals. 5. Enquire from client about the type of food and times of eating that precipitate the heart burns.	1. Client was educated to avoid too much spicy and fatty foods such as fried rice. 2. Client was counselled to avoid lying down immediately after eating but sit for some time. 3. Client was taught to wake up slowly from bed in the morning. 4. Client was educated to eat in small meals but at frequent intervals. 5. I enquired from client the type of food and the time she ate that precipitate the heartburns for her to avoid it intake.	20/08/2023 at 9:40am	Goal fully met as evidenced by client verbalized that her heart burns is no more.	E A Y

NURSING CARE PLAN DURING ANTENATAL PERIOD

DATE/ TIME	NURSING DIAGNOSIS	NURSING OBJECTIVES/ OUTCOME CRITERIA	NURSING ORDERS	NURSING INTERVETION	DATE/ TIME	EVALUATION	SIGN
18/08/2023 at 10:40am	Activity intorelance (fatigue) related to inadequate rest	Client will be relieved of fatigue within 48 hours as evidenced by client that she has been relieved of the fatigue.	1. Reassure client that, she will be relief of the fatigue. 2. Educate client to reduce her activities carried out during the day. 3. Counsel client to rest at least 30 minutes within each activity. 4. Tell client to have enough rest and avoid stress. 5. Educate client support person to help her in household chores.	1. Client was reassured that she would be relieved of the fatigue. 2. Client was educated to reduce her activities carried out during the day. 3. Client was counselled to rest at least 30 minutes within each activity. 4. Client was told to have enough rest and avoid stress. 5. Client’s support person supported her in doing her household chores such as sweeping, cooking.	20/08/2023 at 9:40am	Goal fully met as evidenced by client verbalized that she has been relieved of the fatigue.	E A Y

NURSING CARE PLAN DURING ANTENATAL PERIOD

DATE/ TIME	NURSING DIAGNOSIS	NURSING OBJECTIVES/ OUTCOME CRITERIA	NURSING ORDERS	NURSING INTERVENTION	DATE/ TIME	EVALUATION	SIGN
20/08/2023 at 9:30am	Sleeping pattern disturbance (insomnia) related to frequency of micturition at night	Client will be able to sleep at least 8 hours at night within 5 days as evidenced by client verbalizing her ability to sleep soundly with less interaction.	1. Reassure client and provide emotional support.   2. Educate client to sleep at least 2 hours in the day. 3. Counsel client to use diversional therapy such as watching of television to help her sleep. 4. Tell client to minimize noise when sleeping. 5. Tell client drink small amount of water at night	1. Client was reassured and emotional support provided. 2. Client was educated to sleep at least 2 hours in a day. 3. Client was counselled to use diversional therapy such as watching television to help her sleep. 4. Client was told to minimized noise in her room when sleeping to help her have a sound sleep. 5. Client drunk small amount of water at night.	25/08/2023 at 9:20am	Goal fully met as client verbalized her ability to sleep soundly.	E A Y

NURSING CARE PLAN DURING ANTENATAL PERIOD

DATE/ TIME	NURSING DIAGNOSIS	NURSING OBJECTIVES/ OUTCOME CRITERIA	NURSING ORDERS	NURSING INTERVENTION	DATE/ TIME	EVALUATION	SIGN
25/08/2023 at 9:30am	Impaired body discomfort (Backache) related to physiological changes in pregnancy	Client backache will reduce within 48 hours as evidenced by client verbalizing relieve of backache	1. Reassure client that the backache will reduce. 2. Counsel her to have enough rest and sleep. 3. Educate client to sit with back supported. 4. Educate client to sit down when performing household chores. 5. Teach client to wear low heeled sandals.	1. Client was reassured that the pain would be reduced. 2. Client was counselled to have enough rest and sleep. 3. Client sat with back supported. 4. Client sat down when performing household chores.   5. Client was taught to wear low heeled sandals.	27/08/2023 at 12:00 noon	Goal fully met as client verbalized relieve in backache.	E A Y

NURSING CARE PLAN DURING ANTENATAL PERIOD

DATE/ TIME	NURSING DIAGNOSIS	NURSING OBJECTIVES/ OUTCOME CRITERIA	NURSING ORDERS	NURSING INTERVENTION	DATE/ TIME	EVALUATION	SIGN
27/08/2023 at 12 noon	Lower abdominal pain related to pressure of the descent of the fetal head on pelvic nerves.	Client will cope with lower abdominal pains throughout pregnancy as evidenced by client verbalizing that she is able to cope with the reduced pain.	1. Give emotional support to client. 2. Counsel client to have enough rest and avoid stress. 3. Explain to client the cause of the pain. 4. Educate client to use diversional therapy such as watching of television, reading of story books. 5. Demonstrate to client to do deep breathing exercises.	1. Client was given emotional support that pain would be reduced and cause of pain was explained to the client. 2. Client was counselled to have enough rest and avoid stress. 3. The cause of the pain was explained to the client as the fetal head pressing on the pelvis. 4. Client was educated to use diversional therapy such as watching television, reading of story books. 5. Client  did a return demonstration on deep breathing exercises	29/08/2023 at 10:00am	Goal fully met as evidence by client verbalized her ability to cope with the pain.	E A Y

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