Week

Scheduled Care* This visit is scheduled with our nurse practitioner, Aimee Neumann. A urine pregnancy test will be done to confirm your pregnancy. She will start your prenatal record including medical and obstetric history and genetics questionnaire. Information regarding prenatal classes, prenatal testing and screening, diet, nutrition, vitamins and activity will be discussed, as well as hospital choice. Blood tests may include blood type, RH factor, rubella titer, syphilis screen, antibody titer, hepatitis screen, blood count, HIV and urine culture. A viability ultrasound will be done the same day as your exam visit. You will meet again with Aimee to discuss lab results, maternal assessment of weight, blood pressure, and physical exam with pelvic exam including cervical cultures and Pap smear if indicated. Genetic testing of the baby can be done via Ultrasound and a two step blood draw. The ultrasound and first lab draw are done between 11 and 13 weeks 6 days gestation. You will meet with your physician at 12 weeks. This will be the first appointment to hear the fetal heart beat with the Doppler. Maternal assessment as above, fetal size and growth and fetal heart tones. Maternal serum screening (MSAFP) for neural tube defects or chromosome abnormalities and cystic fibrosis test drawn, if desired. *This test is Part 2 of the screening test. Maternal and fetal assessment. A routine ultrasound screening is ordered by your physician and done in our office by our Ultrasound Technician. Discuss Prenatal classes. Routine monthly maternal and fetal evaluations with fundal height measurements and fetal heart tones. Discuss choice of breast or bottle feeding, also choice of pediatrician. Discuss fetal movement and pre-term labor signs and symptoms. One hour glucose testing to screen for gestational diabetes and repeat blood count. Rhogam injection if you are RH negative. Routine maternal and fetal evaluation. Discuss labor and delivery procedures including pain management options. Vaginal culture for Group B Streptococcus. Weekly routine visits including maternal and fetal evaluation, assess fetal position and cervical checks for dilatation and effacement. Urine screening. Review signs and symptoms of labor. Instructions to call the maternity ward if labor symptoms appear, including rupture of membranes or painful, regular contractions. Maternal and fetal testing, including non-stress testing and discussion of induction of labor.

Initial Visit 6-8

8-10

11-13

16-22

20

24-32

34 36

36-40

40+

Prental Visits 1st visit 2nd visit 3rd visit Every 2 weeks

Period of Pregnancy As early in pregnancy as possible before four months or during the first trimester During the 2nd trimester During the 3rd trimester After 8th month of pregnancy till delivery.

The poverty threshold, or poverty line, is the minimum level of income deemed adequate in a given country.[1] In practice, like the definition of poverty, the official or common understanding of the poverty line is significantly higher in developed countries than indeveloping countries.[2][3] The common international poverty line has in the past been roughly $1 a day.[4] In 2008, the World Bankcame out with a revised figure of $1.25 at 2005 purchasing-power parity (PPP).[5] Determining the poverty line is usually done by finding the total cost of all the essential resources that an average human adult consumes in one year.[6] The largest of these expenses is typically the rent required to live in an apartment, so historically, economists have paid particular attention to the real estate market and housing prices as a strong poverty line affector. Individual factors are often used to account for various circumstances, such as whether one is a parent, elderly, a child, married, etc. The poverty threshold may be adjusted annually.

Maternal physiological changes in pregnancy are the normal adaptations that a woman undergoes during pregnancy to better accommodate theembryo or fetus. They are physiological changes, that is, they are entirely normal, and include cardiovascular, hematologic, metabolic, renal andrespiratory changes that become very important in the event of complications. The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required. Levels of progesterone and estrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. The woman and the placenta also produce many hormones. The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus grows properly and receives adequate nutrition. Increases in blood sugar, breathing and cardiac output are all required.[citation needed]
Contents
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1 Hormonal 2 Physical 3 Breast size

 o o o o o o

4 Cardiovascular 5 Haematology 6 Metabolic 6.1 Nutrition 7 Renal 8 Gastrointestinal 9 Immune tolerance 10 Musculoskeletal 10.1 Lumbar lordosis 10.2 Males vs. females 10.3 Evolutionary implication 10.4 Postural stability 10.5 Gait 11 References

Hormonal[edit

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Pregnant women experience adjustments in their endocrine system. Levels of progesterone and estrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. Estrogen is mainly produced by theplacenta and is associated with fetal wellbeing. Women also experience increased human chorionic gonadotropin (-hCG); which is produced by the placenta. This maintains progesteroneproduction by the corpus luteum. The increased progesterone production, first by corpus luteum and later by the placenta, mainly functions to relax smooth muscle. Prolactin levels increase due to maternal pituitary gland enlargement by 50%. This mediates a change in the structure of the mammary gland from ductal to lobular-alveolar. Parathyroid hormoneis increased which leads to increases of calcium uptake in the gut and reabsorption by the kidney. Adrenal hormones such as cortisol and aldosterone also increase. Human placental lactogen (hPL) is produced by the placenta and stimulates lipolysis and fatty acid metabolism by the woman, conserving blood glucose for use by the fetus. It can also decrease maternal tissue sensitivity to insulin, resulting in gestational diabetes.[1]

Physical[edit

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Illustration of fundal height at various points during pregnancy

One of the most noticeable alterations in pregnancy is the gain in weight. The enlarging uterus, the growing fetus, the placenta and liquor amnii, the acquisition of fat and water retention, all contribute to this increase in weight. The weight gain varies from person to person and can be anywhere from 5 pounds (2.3 kg) to over 100 pounds (45 kg). In America, the doctor-recommended weight gain range is 25 pounds (11 kg) to 35 pounds (16 kg), less if the woman is overweight, more (up to 40 pounds (18 kg)) if the woman is underweight.

Breast size[edit

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A woman's breasts grow during pregnancy, usually 1 to 2 cup sizes [2] and potentially several cup sizes. A woman who wore a C cup bra prior to her pregnancy may need to buy an F cup or larger bra while nursing.[3] A woman's torso also grows and her bra band size may increase one or two sizes. [2][4] An average of 80% of women wear the wrong bra size,[5] and mothers who are preparing to nurse can benefit from a professional bra fitting from a lactation consultant. [4] Once the baby is born and about 50 to 73 hours after birth, the mother will experience her breasts filling with milk (sometimes referred to as milk coming in) and at that point changes in the breast happen very quickly. Once lactation begins, the woman's breasts swell significantly and can feel achy, lumpy and heavy (which is referred to as engorgement). Her breasts may increase again in size, by another 1 or 2 cup sizes, [2][4] and individual breast size can vary daily or for longer periods depending on how much the infant nurses from each breast. A regular pattern of nursing is usually established after 812 weeks, and a woman's breasts will usually reduce in size, perhaps to about 1 cup size larger than prior to her pregnancy. [2] Many women and medical professionals[6][7] mistakenly think that breastfeeding causes their breasts to sag (medically referred to as ptosis),[8] and as a result some are reluctant to nurse their infants. In February 2009, Cheryl Cole told British Vogue that she hesitated to breastfeed because of the effect it might have on her breasts. "I want to breastfeed," she said, "but Ive seen what it can do, so I may have to reconsider."[9] Research shows that breastfeeding is not the factor that many thought it was. The biggest factors affecting ptosis are cigarette smoking, a woman's body mass index (BMI), her number of pregnancies, her breast cup size before pregnancy, and age.[10][11]

Cardiovascular[edit

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The woman is the sole provider of nourishment for the embryo and later, the fetus, and so her plasma and blood volume slowly increase by 40-50% over the course of the pregnancy to accommodate the changes.[12] The increase is mainly due to an increase in plasma volume through

increased aldosterone. It results in an increase in heart rate (15 beats/min more than usual), stroke volume, and cardiac output. Cardiac output increases by about 50%, mostly during the first trimester. The systemic vascular resistance also drops due to the smooth muscle relaxation and overall vasodilation caused by elevated progesterone, leading to a fall in blood pressure. Diastolic blood pressure consequently decreases between 1226 weeks, and increases again to pre-pregnancy levels by 36 weeks. If the blood pressure becomes abnormally high, the woman should be investigated for preeclampsia and other causes of hypertension. This is due to an increase in plasma volume through increased aldosterone. Progesterone may also interact with the aldosterone receptor, thus leading to increased levels. Red blood cell numbers increase due to increased erythropoietin levels. Cardiac function is also modified, with increased heart rate and increased stroke volume. A decrease in vagal tone and increase in sympathetic tone is the cause. Blood volume increases act to increase stroke volume of the heart via Starling's law. After pregnancy the change in stroke volume is not reversed. Cardiac output rises from 4 to 7 liters in the 2nd trimester. Blood pressure also fluctuates. In the first trimester it falls. Initially this is due to decreased sensitivity to angiotensin and vasodilation provoked by increased blood volume. Later, however, it is caused by decreased resistance to the growing uteroplacental bed.

Haematology[edit

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During pregnancy the plasma volume increases by 50% and the red blood cell volume increases only by 20-30%.[12] Consequently, the hematocrit decreases on lab value; this is not a true decrease in hematocrit, however, but rather due to the dilution. The white blood cell count increases and may peak at over 20 mg/mL in stressful conditions. Conversely, there is a decrease in platelet concentration to a minimal normal values of 100-150 mil/mL. A pregnant woman will also become hypercoagulable, leading to increased risk for developing blood clots and embolisms, due to increased liver production of coagulation factors, mainlyfibrinogen and factor VIII (this hypercoagulable state along with the decreased ambulation (exercise involving legs) causes an increased risk of both DVT and PE). Women are at highest risk for developing clots, or thrombi, during the weeks following labor. Clots usually develop in the left leg or the left iliac venous system. The left side is most afflicted because the left iliac vein is crossed by the right iliac artery. The increased flow in the right iliac artery after birth compresses the left iliac vein leading to an increased risk for thrombosis (clotting) which is exacerbated by the aforementioned lack of ambulation following delivery. Both underlying thrombophilia and cesarean section can further increase these risks. Edema, or swelling, of the feet is common during pregnancy, partly because the enlarging uterus compresses veins and lymphatic drainage from the legs.

Metabolic[edit

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During pregnancy, both protein metabolism and carbohydrate metabolism are affected. One kilogram of extra protein is deposited, with half going to the fetus and placenta, and another half going to uterine contractile proteins, breast glandular tissue, plasma protein, and haemoglobin. An increased requirement for nutrients is given by fetal growth and fat deposition. Changes are caused by steroid hormones, lactogen, and cortisol.

Maternal insulin resistance can lead to gestational diabetes. Increased liver metabolism is also seen, with increased gluconeogenesis to increase maternal glucose levels. [citation needed]

Nutrition[edit source | editbeta]

Main article: Nutrition and pregnancy Nutritionally, pregnant women require a caloric increase of 300 kcal/day and an increase in protein to 70 or 75 g/day.[citation needed] There is also an increased folate requirement from 0.4 to 0.8 mg/day (important in preventing neural tube defects). On average, a weight gain of 20 to 30 lb (9.1 to 14 kg) is experienced.
[citation needed ]

All patients are advised to take prenatal vitamins to compensate for the increased nutritional requirements. The use of Omega 3 fatty acids supports mental and visual development of infants. [13] Choline supplementation of research mammals supports mental development that lasts throughout life.
[14]

Renal[edit

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A pregnant woman may experience an increase in kidney and ureter size. The glomerular filtration rate (GFR) commonly increases by 50%, returning to normal around 20 weeks postpartum. [12] Plasma sodium does not change because this is offset by the increase in GFR. There is decreased blood urea nitrogen (BUN) and creatinine and glucosuria (due to saturated tubular reabsorption) may be seen. Persistent glucosuria may suggest gestational diabetes. The reninangiotensin system is upregulated, causing increased aldosterone levels.

Gastrointestinal[edit

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During pregnancy, woman can experience nausea and vomiting (morning sickness); which may be due to elevated B-hCG and should resolve by 14 to 16 weeks.[citation needed] Additionally, there is prolonged gastric empty time, decreased gastroesophageal sphincter tone, which can lead to acid reflux, and decreased colonic motility, which leads to increased water absorption andconstipation.

Immune tolerance[edit

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Main article: Immune tolerance in pregnancy The fetus inside a pregnant woman may be viewed as an unusually successful allograft, since it genetically differs from the woman.[15] In the same way, many cases of spontaneous abortionmay be described in the same way as maternal transplant rejection.[15]

Musculoskeletal[edit

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Neuromechanical adaptations to pregnancy refers to the change in gait, postural parameters, as well as sensory feedback, due to the numerous anatomical, physiological, and hormonal changes women experience during pregnancy. Such changes increase their risk for musculoskeletal disorders and fall injuries. Musculoskeletal disorders include lower-back pain, leg cramps, and hip pain. Pregnant women fall at a similar rate (27%) to women over age of 70 years (28%). Most of the falls (64%) occur during the second trimester. Additionally, two-thirds of falls are associated with walking on slippery floors, rushing, or

carrying an object.[16] The root causes for these falls are not well known. However, some factors that may contribute to these injuries include deviations from normal posture, balance, and gait. The body's posture changes as the pregnancy progresses. The pelvis tilts and the back arches to help keep balance. Poor posture occurs naturally from the stretching of the woman's abdominal muscles as the fetus grows. These muscles are less able to contract and keep the lower back in proper alignment. The pregnant woman has a different pattern of gait. The step lengthens as the pregnancy progresses, due to weight gain and changes in posture. On average, a woman's foot can grow by a half size or more during pregnancy. In addition, the increased body weight of pregnancy, fluid retention, and weight gain lowers the arches of the foot, further adding to the foot's length and width. The influences of increased hormones such as estrogen and relaxin initiate the remodeling of soft tissues, cartilage and ligaments. Certain skeletal joints such as the pubic symphysis and sacroiliac widen or have increased laxity.[citation
needed]

The addition of mass, particularly around the torso, naturally changes a pregnant mother'scenter of mass (COM). The change in COM requires pregnant mothers to adjust their bodies to maintainbalance.

Lumbar lordosis[edit source | editbeta]

To positionally compensate the additional load due to the pregnancy, pregnant mothers often extend their lower backs. As the fetal load increases, women tend to arch their lower backs, specifically in the lumbar region of their vertebral column to maintain postural stability and balance. The arching of the lumbar region is known as lumbar lordosis, which recovers the center of mass into a stable position by reducing hip torque. According to a study conducted by Whitcome, et al., lumbar lordosis can increase from an angle of 32 degrees at 0% fetal mass (i.e. non-pregnant women or very early in pregnancy) to 50 degrees at 100% fetal mass (very late in pregnancy). Postpartum, the angle of the lordosis declines and can reach the angle prior to pregnancy. Unfortunately, while lumbar lordosis reduces hip torque, it also exacerbates spinal shearing load,[17] which may be the cause for the common lower back pain experienced by pregnant women.[18]

Males vs. females[edit source | editbeta]

Given the demands of fetal loading during pregnancy and the importance of producing offspring to the fitness of human beings, one can imagine that natural selection has had a role in selecting a unique anatomy for the lumbar region in females. It turns out that there are sex differences in the lumbar vertebral column of human males and females, which ultimately helps mitigate some of the discomfort due to the fetal load in females. There are 5 vertebrae in the lumbar region for both males and females. However, the 3 lower vertebrae of a female's lumbar region are dorsally wedged while for males, only the lower 2 of the lumbar region are dorsally wedged. When a female arches her lower back, such as during fetal loading, having an extra dorsally wedged vertebra lessens the shearing force. This lumbar sexual dimorphism in humans suggests high natural selection pressures have been acting to improve maternal performance in posture and locomotion during pregnancy. [17]

Evolutionary implication[edit source | editbeta]

If natural selection has acted on the lumbar region of Homo Sapiens to create this sexual dimorphism, then this sort of trait should also be apparent in the genus Australopithecus, hominins that have been known to be habitually bipedal for at least 2 million years after the earliest bipedal hominins. Currently there are 2 nearly complete australopith lumbar segments; one has three dorsally wedged vertebrae in

the lumbar region while the other has two. An explanation for these findings is that the first one is a female, while the latter is a male. This sort of evidence supports the notion that natural selection has played a dimorphic role in designing the anatomy of the vertebral lumbar region. [17]

Postural stability[edit source | editbeta]

Anatomical planes in a human

The weight added during the progression of pregnancy also affects the ability to maintain balance. In biomechanics, balance refers to ones ability to maintain the center of gravity within the base of support with minimal postural sway. In other words, the moment (or torque) generated by gravity must be balanced by the ankle moment in order to maintain postural stability. Although quiet standing appears to be static, it is actually a process of rocking from the ankle in the sagittal plane.[19]

Maintenance[edit source | editbeta]

Currently, there are 3 main hypotheses suggesting how humans maintain postural stability while standing. 1. Stiffness of ankle joint The stiffness model was first introduced by Winter et al., in 1998, [20] and states that simple stiffness of ankle muscles account for the control of balance during quiet standing. The stiffness of the ankle muscle was determined experimentally by summing up the moments (or torque) left and right about the ankle and dividing it by the sway angle (angle at which the center of mass is displaced from the center of pressure). It was found in both analytical and experimental data (using human subjects) that there was a linear relationship between moments about the ankle muscle and sway angle. Additionally, the stiffness (i.e. total moment divided by sway angle) was found to be very close to 1, indicating a resemblance between the anklejoint and a perfect spring. 2. Moment arm of ankle muscles The moment arm of ankle muscle hypothesis for postural stability was first developed in 1993 by Young et al.[21] and has been primarily seen in cats, though it is speculated that such mechanisms may also exist in humans. Results obtained from Young et al. showed that in the cat ankle joint, many of its muscles have predominant moment arms about the adduction/abduction axis. Smaller moment arms are found in inversion/eversion and about the principle axis of motion, dorsiflexion/extension. Additionally, Young et al. showed that the magnitudes of the moment arms in abduction/adduction and inversion/eversion strongly depended on joint angle. As the joint angle moved increasingly away from the neutral axis, the magnitude

of the of the moment arms also increased. Such a finding suggests that, at least in cats, the coactivation of these agonist-antagonistmuscles is used for immediate stabilization in posture. 3. Proprioception Proprioception means "sense of self". In limbs, proprioceptors are sensors that provide information about joint angle, muscle length, and tension, which is integrated to give information about the position of the limb in space. For postural stability, it has been suggested that stretch receptors may contribute to immediate stabilization in posture. However, researchers have found a weak correlation between muscle length and ankle joint angle, indicating that the stretch reflex is probably not the main contributor to postural stability. Additionally, there is approximately a 30 ms time delay between any stretch receptor response to a change in muscle length, which further supports the idea that stretch receptors may not have a big contribution to postural stability. However, this should not rule out the role of all proprioceptors in maintaining postural stability in humans.[22][23] While these are the three leading hypotheses, of course there is always a possibility that there is a combination of all mechanisms that ultimately allows humans to maintain postural stability during quiet standing. Additionally, it is important to keep in mind that there are also many physiological factors such as weight, internal noise to muscles, etc. that may come into play when trying to understand the factors that contribute to postural stability.

Perception[edit source | editbeta]

Pregnant women have a decreased perception of balance during quiet standing, which is confirmed by an increase in anterior-posterior sway.[24] This relationship heightens as pregnancy progresses and significantly decreases post-partum. To compensate for the decrease in balance stability (both actual and perceived), stance width increases to maintain postural stability.

Response to perturbations[edit source | editbeta]

As measured by a force platform, parameters used to measure postural stability. Adapted from McCrory et al. 2010

Under dynamic postural stability, which can be defined as the response to anterior (front) and posterior (back) translation perturbations, the effects of pregnancy are different. Initial sway,total sway, and sway velocity (see figure for description of variables) are significantly less during the third trimester than during

the second trimester and when compared to non-pregnant women. These biomechanical characteristics are possible reasons why falls are more prevalent during the second trimester during pregnancy. Additionally, the time it takes for pregnant women (any stage of pregnancy) to react to a translational disturbance is not significantly different than that of non-pregnant women. [25] This alludes to some sort of stability mechanism that allow pregnant women to compensate for the changes they experience during pregnancy.

Gait[edit source | editbeta]

Gait in pregnant women often appear as a waddle a forward gait that includes a lateral component. However, research has shown that the forward gait alone remains unchanged during pregnancy. It has been found that gait parameters such as gait kinematics, (velocity, stride length, and cadence) remain unchanged during the third trimester of pregnancy and 1 year after delivery. These parameters suggest that there is no change in forward movement. There is, though, a significant increases in kinetic gait parameters, which may be used to explain how gait motion remains relatively unchanged despite increase in body mass, width and changes in mass distribution about the waist during pregnancy. These kinetic gait parameters suggest an increased use of hip abductor, hip extensor, and ankle plantar flexor muscle groups. To compensate for these gait deviations, pregnant women often make adaptations that can result in muscoskeletal injuries. While the idea of "waddling" cannot be dispensed, these results suggest that exercise and conditioning may help relieve these injuries. [26]

First Level Assessment

I. Presence of Wellness Condition-stated as potential or Readiness-a clinical or nursing judgment about a client in transition from a specific level of wellness or capability to a higher level. Wellness potential is a nursing judgment on wellness state or condition based on clients performance, current competencies, or performance, clinical data or explicit expression of desire to achieve a higher level of state or function in a specific area on health promotion and maintenance. Examples of this are the following A. Potential for Enhanced Capability for: 1. Healthy lifestyle-e.g. nutrition/diet, exercise/activity 2. Healthy maintenance/health management 3. Parenting 4. Breastfeeding 5. Spiritual well-being-process of clients developing/unfolding of mystery through harmonious interconnectedness that comes from inner strength/sacred source/God (NANDA 2001) 6. Others. Specify. B. Readiness for Enhanced Capability for:

1. Healthy lifestyle 2. Health maintenance/health management 3. Parenting 4. Breastfeeding 5. Spiritual well-being 6. Others. Specify. II. Presence of Health Threats-conditions that are conducive to disease and accident, or may result to failure to maintain wellness or realize health potential. Examples of this are the following: A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome) B. Threat of cross infection from communicable disease case C. Family size beyond what family resources can adequately provide D. Accident hazards specify. 1. Broken chairs 2. Pointed /sharp objects, poisons and medicines improperly kept 3. Fire hazards 4. Fall hazards 5. Others specify. E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify. 1. Inadequate food intake both in quality and quantity 2. Excessive intake of certain nutrients 3. Faulty eating habits 4. Ineffective breastfeeding 5. Faulty feeding techniques F. Stress Provoking Factors. Specify. 1. Strained marital relationship 2. Strained parent-sibling relationship 3. Interpersonal conflicts between family members 4. Care-giving burden G. Poor Home/Environmental Condition/Sanitation. Specify.

1. Inadequate living space 2. Lack of food storage facilities 3. Polluted water supply 4. Presence of breeding or resting sights of vectors of diseases 5. Improper garbage/refuse disposal 6. Unsanitary waste disposal 7. Improper drainage system 8. Poor lightning and ventilation 9. Noise pollution 10. Air pollution H. Unsanitary Food Handling and Preparation I. Unhealthy Lifestyle and Personal Habits/Practices. Specify. 1. Alcohol drinking 2. Cigarette/tobacco smoking 3. Walking barefooted or inadequate footwear 4. Eating raw meat or fish 5. Poor personal hygiene 6. Self medication/substance abuse 7. Sexual promiscuity 8. Engaging in dangerous sports 9. Inadequate rest or sleep 10. Lack of /inadequate exercise/physical activity 11. Lack of/relaxation activities 12. Non use of self-protection measures (e.g. non use of bed nets in malaria and filariasis endemic areas). J. Inherent Personal Characteristics-e.g. poor impulse control K. Health History, which may Participate/Induce the Occurrence of Health Deficit, e.g. previous history of difficult labor. L. Inappropriate Role Assumption- e.g. child assuming mothers role, father not assuming his role. M. Lack of Immunization/Inadequate Immunization Status Specially of Children

N. Family Disunity-e.g. 1. Self-oriented behavior of member(s) 2. Unresolved conflicts of member(s) 3. Intolerable disagreement O. Others. Specify._________ III. Presence of health deficits-instances of failure in health maintenance. Examples include: A. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner. B. Failure to thrive/develop according to normal rate C. Disability-whether congenital or arising from illness; transient/temporary (e.g. aphasia or temporary paralysis after a CVA) or permanent (e.g. leg amputation secondary to diabetes, blindness from measles, lameness from polio) IV. Presence of stress points/foreseeable crisis situations-anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources. Examples of this include: A. Marriage B. Pregnancy, labor, puerperium C. Parenthood D. Additional member-e.g. newborn, lodger E. Abortion F. Entrance at school G. Adolescence H. Divorce or separation I. Menopause J. Loss of job K. Hospitalization of a family member L. Death of a member M. Resettlement in a new community

N. Illegitimacy O. Others, specify.___________

Second-Level Assessment
I. Inability to recognize the presence of the condition or problem due to: A. Lack of or inadequate knowledge B. Denial about its existence or severity as a result of fear of consequences of diagnosis of problem, specifically: 1. Social-stigma, loss of respect of peer/significant others 2. Economic/cost implications 3. Physical consequences 4. Emotional/psychological issues/concerns C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem D. Others. Specify _________ II. Inability to make decisions with respect to taking appropriate health action due to: A. Failure to comprehend the nature/magnitude of the problem/condition B. Low salience of the problem/condition C. Feeling of confusion, helplessness and/or resignation brought about by perceive magnitude/severity of the situation or problem, i.e. failure to breakdown problems into manageable units of attack. D. Lack of/inadequate knowledge/insight as to alternative courses of action open to them E. Inability to decide which action to take from among a list of alternatives F. Conflicting opinions among family members/significant others regarding action to take. G. Lack of/inadequate knowledge of community resources for care H. Fear of consequences of action, specifically: 1. Social consequences 2. Economic consequences 3. Physical consequences 4. Emotional/psychological consequences

I. Negative attitude towards the health condition or problem-by negative attitude is meant one that interferes with rational decision-making. J. In accessibility of appropriate resources for care, specifically: 1. Physical Inaccessibility 2. Costs constraints or economic/financial inaccessibility K. Lack of trust/confidence in the health personnel/agency L. Misconceptions or erroneous information about proposed course(s) of action M. Others specify._________ III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at risk member of the family due to: A. Lack of/inadequate knowledge about the disease/health condition (nature, severity, complications, prognosis and management) B. Lack of/inadequate knowledge about child development and care C. Lack of/inadequate knowledge of the nature or extent of nursing care needed D. Lack of the necessary facilities, equipment and supplies of care E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle program). F. Inadequate family resources of care specifically: 1. Absence of responsible member 2. Financial constraints 3. Limitation of luck/lack of physical resources G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety, despair, rejection) which his/her capacities to provide care. H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent, vulnerable/at risk member I. Members preoccupation with on concerns/interests J. Prolonged disease or disabilities, which exhaust supportive capacity of family members. K. Altered role performance, specify. 1. Role denials or ambivalence 2. Role strain 3. Role dissatisfaction

4. Role conflict 5. Role confusion 6. Role overload L. Others. Specify._________ IV. Inability to provide a home environment conducive to health maintenance and personal development due to: A. Inadequate family resources specifically: 1. Financial constraints/limited financial resources 2. Limited physical resources-e.i. lack of space to construct facility B. Failure to see benefits (specifically long term ones) of investments in home environment improvement C. Lack of/inadequate knowledge of importance of hygiene and sanitation D. Lack of/inadequate knowledge of preventive measures E. Lack of skill in carrying out measures to improve home environment F. Ineffective communication pattern within the family G. Lack of supportive relationship among family members H. Negative attitudes/philosophy in life which is not conducive to health maintenance and personal development I. Lack of/inadequate competencies in relating to each other for mutual growth and maturation (e.g. reduced ability to meet the physical and psychological needs of other members as a result of familys preoccupation with current problem or condition. J. Others specify._________ V. Failure to utilize community resources for health care due to: A. Lack of/inadequate knowledge of community resources for health care B. Failure to perceive the benefits of health care/services C. Lack of trust/confidence in the agency/personnel D. Previous unpleasant experience with health worker E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) specifically : 1. Physical/psychological consequences 2. Financial consequences

3. Social consequences F. Unavailability of required care/services G. Inaccessibility of required services due to: 1. Cost constrains 2. Physical inaccessibility H. Lack of or inadequate family resources, specifically 1. Manpower resources, e.g. baby sitter 2. Financial resources, cost of medicines prescribe I. Feeling of alienation to/lack of support from the community, e.g. stigma due to mental illness, AIDS, etc. J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of community resources for health care K. Others, specify __________