obstetrics case study

8/18/2019 Obstetrics Case Study

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Obstetrics Case StudyBy: Blayre Helm


2/13

Reason for Hospitalization

BR is a 34 year old, Caucasian female

Admitted for scheduled caesarian section on day of clinical

37 weeks pregnant

u!ers from gestational dia"etes

#irst time mother

$ra%ida: &, 'ara: & (after the deli%ery of her child)

*nhanced desire to "reastfeed


3/13

Past Medical History

Ru"ella: +mmuniation gi%en 3-&&-&.

Blood /ype: B

Rh tatus: 0

H+1: 2egati%e trep: 2egati%e

Hepatitis: 2egati%e

're%ious urgeries: yomectomy

're%ious Birth History: none


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Family Medical History

other: ia"etes ellitus /ype ++

Brother: eletion of distal chromosome &5


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Psychosocial History

#amily make6up: 2uclear family made up of her and her hus"and

*mployment: 2ot employed

*ducation: High school diploma

+nsurance: edicaid /o"acco, rug, and Alcohol use: 2e%er

Home en%ironment: afe with no stated or noted potential haards

Acti%ates: 2o stated acti%ates that the patient or her hus"and eno

'sychosocial stressors


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Physiological Status

1irginia Henderson8s 2eed /heory

+ncrease the patient8s independence so that progress afte

hospitaliation is not delayed

2ursing care designed to accommodate physiological n


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Developmental Status

*rik *rikson8s 'sychosocial e%elopment 5 stages of de%elopment

2ursing care designed to accommodate de%elopmental


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ro!th and "utritional Status

Height 9: the patient is .84, therefore has a height 9 of 4

=eight 9: the patient is >&? l"s, therefore has a weight 9

=eight for height 9: not applica"le (not a new"orn)

B+: 33


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Focused Physical #ssessment

1ital igns: B': &37-54, /emp: @5: @.9

$eneral Appearance: =hite female appears her stated age and in no acu

ymph nodes: 2o cla%icular, parotid, occipital, su"mandi"ular, cer%ical, oadenopathy

Head and neck: 2o thyroid enlargement

**2/: conuncti%a, eyelids, ears, nose, and lips =2D dentition appears tostate

Chest-ungs$ clear to auscultation, normal respiratory e!ort

Heart: normal rate and rhythm

Back and *tremities: normal to inspection, no edema or cyanosis on anyof motion =2

2eurological $ etremely deep tendon reFection intact


10/13

%abs

Ru"ella: immuniation gi%en 3-&&-&.

Rh factor: 0

Hepatitis screening: 2egati%eR=: >?


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Medications

Acetaminophen: ;.? mg, E;h, for pain

Calcium Car"onate: .?? mg, E;h 'R2, for dyspep

agnesium Hydroide: 3? m, nightly 'R2, for co

ndansetron: 4 mg, E;h 'R2, for nausea

ycodone: &? mg, E4h 'R2, for se%ere pain le%ea scale of ?6&?


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"ursing &mplications

%erall, this patient is a healthy female who will "e in pain due to Caesarian section< he is %ery anious a"out "ecoming a new mowanting to entirely "reastfeed, which is a new concept to her<

2ursing :

Readiness for enhanced "reastfeeding r-t maternal reEuests and infantneeds e-" the infant ha%ing proper alignment and latch6on techniEues

Acute pain r-t surgical inury e-" pain "eing stated as . on a scale of

Inowledge deJcit r-t "ecoming a new mother and starting to "reastfeeina"ility to correctly position her new"orn during "reastfeeding<


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References

Ackley, B?&4)< Nursing Diagnosis Handbook (&?th ed?&.)< Big Ba"ies: An *ploration of $estational ia"etes< International Journal Of Childbirth 4>64;<

ia"etes diet 6 gestational: edline'lus edical *ncyclopedia< (>?&3, August .)< Retrie%ed eptem"er &@https:--www, eptem"er &)< Retrie%ed eptem"er &@, >?&., fromhttp:--www

adewig, '?&4)< Contemporary maternalne!born nursing care (5th ed?&., fromhttp:--www?&>-ta"les-&>s?>?@

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