Question: Make Nursing Interventions with Rationale of this Case Scenario:
Case Scenario:
Nursing Diagnosis: "Risk for pregnancy complications related to teenage pregnancy"
Patient Daisy Mercedes was born on April 9, 2003. She was born in Mati, Davao Oriental. Her parents died on her young age, so she was technically an orphan now and sometimes lives with her distant relatives, but they could not essentially foster her due to lack of financial stability.
She stayed at one of the government facilities in their area and spent most of her 15 years of existence. Her education was funded mainly by volunteers and charitable foundations. At the same time, she compensated for it by means of helping in chores and accomplishing tasks in the said foundation.
She grew up with other orphan children with questions in her mind. But to that, she never completely disclosed herself. Patient Daisy is a victim of sexual abuse. She was raped and was unable to resist because of her innocence and because fear to be killed. She doesn't talk that much. Often times, she paces back and forth inside the ward, sit silently on her bed and sometimes quietly stares outside the window. When tried to ask about what she knows of her family, she could only turn silent, and somehow implies to ask the next question to her.
Unfortunately, hesitancy was felt from the kind of thing that was wanted to be discussed. The issue was not forced until her watcher, which has no relation to her, revealed the reason behind her pregnancy.
According to Patient Daisy's watcher, it was on a cold night in November 13, 2021, when Miranda came home from school. Not far from the center, a man, which she can't identified-wearing a mask, blocked and harassed her brutally. She struggled to let go from the ruthless hands of the unaccustomed man. Patient Miranda was threatened that if she'd make any noise, she'd get killed. Ill-fatedly, she was held powerless to the man, and the crime had happened. Fortunate enough that she wasn't killed, she thanked the Lord for sparing her life. Although alive, she felt very much unfair about her situation. She could only tell, "I'm too young to be a mother, why did this happen to me? I'm not ready yet, I don't know what to do" .
Daisy conceived the baby. For the first trimester, she couldn't believe and accept her fate, could not look herself into the mirror and sometimes thought of slight curses to the person who did the crime. But somehow, she felt some feeling of excitement of having a baby unexpectedly. She even verbalized, "There's nothing I can do, it's already happened, I might still commit a sin if I abort my child, and it's not my child's fault."
As the nurse was completing the health history for documentation and monitoring, further information revealed that her LMP was October 25, 2021. No report of infection and medications taken such Folic acid, iron supplements, and vitamins was provided by the health care center near her place. She eats whatever that is provided in the orphanage facility, usually she consumed vegetables and fruits, and approximately she drinks 6-8 glasses of water in a day. She sometimes experiences nightmare at sleep, during 1st trimester and worries about her health and the growing baby.
She was a smoker and occasionally drinks alcohol since she was 14 years old but stopped when she had known of her first pregnancy. Since then she never had a smoke or a drink.
On August 4, 2022 at late evening Daisy was awaken by tense and rigid feeling of uterine contraction that last for 3-5 minutes in irregular interval. She counted and check if it becomes intense and regular. By early morning of August 5, 2022, Daisy complained of extreme abdominal pain and some water leaking on her vagina. The age of gestation by this time is 40 weeks by LMP. She cried out loud when the pain intensified, and was brought to the nearest facility and was admitted at Mati Medical Center around 2:40 am with blood pressure of 120/90mmHg. She was examined by Dr. Casteel and found out that her cervix 3cm Dilated, 50% Effaced, Leaking Bag of water and the baby is on Station: -3 cephalic in presentation, with FHT of 142 beats per minute.