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单击此处编辑母版标题样式,编辑母版文本样式,第二级,第三级,第四级,第五级,2/20/2018,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,单击此处编辑母版标题样式,编辑母版文本样式,第二级,第三级,第四级,第五级,2018/2/20 Tuesday,#,Far Eastern University - Institute of Nursing,CASE PRESENTATION,FEU NRMF HOSPITAL,OBSTETRICS WARD,Group Three,Peng Sijing (Stone ), Li Xiaojing (Cathy ), Miao Chunmei (Mano), Nie Fengyan (Zara),Far Eastern University - Insti,1,C,ontent,Introduction,1,History,Physical Assessment,3,Laboratory and Diagnostic Exams.,4,2,Medications and IV fluid,5,2,6,Nursing Care Plan,ContentIntroduction 1History P,Introduction,3,Patient A, 30 years old, G1P0, pregnancy uterine 39weeks and 2 days, cephalic in labor, admitted at FEU-NRMF,HOSPITAL,on February 8, 2018.,CHIEF COMPLAINT: Hypogastric Pain,Introduction3 Patient A,History,4,HISTORY OF PRESENT PREGNANCY:,LMP: May 9,2017 AOG by LMP: 39 weeks 2 days EDC by LMP: February 12, 2018,PMP: April 8, 2017 AOG by EUTZ: 39 weeks 3 days EDC by EUTZ: February 12, 2018,First Trimester,* On the 1 month of missed period (June 2017): cessation of menses, nausea and vomiting. Self-pregnancy test was done, which revealed a positive result.,* She consulted a private obstetrician where diagnostic tests such as complete blood count, urinalysis, VDRL/RPR and hepatitis B antigen screening were done. All revealed normal results except for urinalysis which revealed,urinary tract infection,. She was prescribed,Cefuroxime 500mg BID for 1 week, and repeat urinalysis afterwards was normal.,* Transvaginal ultrasound for pregnancy evaluation revealed a single intrauterine pregnancy compatible to 15 weeks and 2 days age of gestation (August 2017).,* She was given multivitamins and Folic acid 1 tablet once a day which she took regularly.,* She denies any history of accidents, trauma, or any exposure to radiation and toxic chemicals.,* Patient,had an episode of colds and took cefuroxime 500mg twice a day for 5 days,.,* She also took,Loratadine 10mg once daily for her allergic rhinitis.,History4HISTORY OF PRESENT PRE,History,5,HISTORY OF PRESENT PREGNANCY:,Second Trimester,* Quickening was felt on the 5th month of pregnancy (October 2017).,* She had regular intake of Multivitamins 1 tab daily, Ferrous sulfate 1 tablet once a day, and Calcium 1 tablet twice a day. Only urinalysis was done at the health center revealing that she had,urinary tract infection,. she was prescribed,Cefuroxime 500mg BID for 1 week,to which she was compliant.,* Transabdominal ultrasound for gender determination was done on the 7th month of pregnancy revealing single intrauterine pregnancy compatible to 28 weeks and 4 days age of gestation (November 2017).,* She denies any history of accidents, trauma, illness, or any exposure to radiation and toxic chemicals.,History5HISTORY OF PRESENT PRE,History,6,Third Trimester,* Subsequent prenatal check-ups were regular as well as intake of multivitamins 1 tablet once a day, Ferrous sulfate 1 tablet once a day, and calcium 1 tablet twice a day.,* Capillary blood glucose monitoring and 75g OGTT was done which revealed increased results. Exact values were unrecalled by the patient. She was prescribed with,Novo Rapid insulin, 4 units taken 2 hours post meals,. She was also advised to do capillary blood glucose monitoring at home.,* Subjective complaints experienced included,headache and dizziness,. No hypogastric pain, abnormal vaginal discharge, vaginal spotting, dysuria, and fever. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicals,The present condition started 5 hours prior (5:00pm) to admission when the patient experienced,crampy intermittent hypogastric pain radiating to the lower back with a pain scale of 8-9 out of 10,. This was associated with scanty bloody vaginal discharge. She sought consult at our institution and was subsequently admitted.,History6Third TrimesterThe pre,History,7,PAST MEDICAL HISTORY:,The patient had usual childhood diseases such as,mumps, measles, and chickenpox,.,She denies any history of major illnesses, trauma, accidents, or major operations.,She was admitted last June due to,persistent vomiting and dehydration,. Patient has,allergic rhinitis,and was diagnosed,with gestational diabetes,last January maintained,on Novo Rapid insulin 4 units taken 2 hours post meals.,History7PAST MEDICAL HISTORY:,History,8,FAMILY HISTORY:,Father: hypertension,Mother: kidney stones, died due to cardiac arrest,The patient is 3th among 5 siblings with 4 sisters and 1 brother. Her eldest is 33 years old who is a controlled hypertensive with gestational diabetes mellitus. Her second sibling is 32 years old with kidney stones. The 4th sibling is 29 years old who is a controlled hypertensive. The 5th sibling is 20 years old who is apparently well.,History8FAMILY HISTORY:,History,9,PERSONAL AND SOCIAL HISTORY:,Patient is a high-school graduate and currently works as a machine operator,Habits: Non-smoker, non-alcoholic beverage drinker,REPRODUCTIVE HISTORY:,GYNECOLOGIC HISTORY,The patient had menarche at 13 years old which lasted 4 days, light flow, consuming 3 pads per day and not associated with dysmenorrhea. Subsequent,menstruations were irregular, with an interval of approximately 1 to 3 months lasting 3 to 4 days, moderate flow, consuming 4-5 pads per day, and associated with dysmenorrhea.,History9PERSONAL AND SOCIAL HI,History,10,REPRODUCTIVE HISTORY:,OBSTETRICAL HISTORY,The patient is a primigravid,METHOD OF CONTRACEPTION,The method for contraception use is oral contraceptive pills from June 2016 to December 2016. She took the pills everyday before going to bed,SEXUAL HISTORY,At 27 years old with 2 sexual partners. Unknown number of sexual partners of her husband. She is currently in a monogamous heterosexual relationship.,History10REPRODUCTIVE HISTORY:,Review of Systems:,11,Constitutional:,No fever and chills, malaise, weight loss,Hematology:,No easy fatigability, no easy bruise ability, no pallor,CNS:,No headache; no seizure; no loss of consciousness,HEENT:,No blurring of vision; no hearing loss; no tinnitus,Respiratory:,No dyspnea; no cough; no colds; no apnea,CVS:,No orthopnea; no palpitation,GIT:,No diarrhea; no constipation,GUT:,No dysuria, frequency, no urgency,NMS:,No malaise; no arthralgia; no myalgia; no numbness,Review of Systems: 11Constitut,Physical Examination,12,General Survey:,The patient is conscious, coherent, not in cardiopulmonary distress with the following,vital signs: BP : 110 / 80mmHg PR : 81 bpm RR : 19 Temp : 36.2,Sat : 98 %,HEENT:,Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, notonsillopharyngeal congestion,Neck:,Supple neck, no neck vein engorgement, no lymphadenopathies noted,Chest:,Symmetrical chest expansion, no retractions, no lagging,Lungs:,Vesicular breath sounds, no crackles, no wheezes,Heart:,A dynamic precordium, normal rate, regular rhythm, no murmur,Breast:,Symmetrical contour, no dimpling, no palpable mass,no tenderness, no,abnormal ni,pple,discharge,Physical Examination12 General,Physical Examination,13,Abdomen:,Globularly enlarged with a fundic height of 31cms, fundus occupied by breech, fetal back on the right, fetal small parts on the left, cephalic, unengaged, FHT-140s best heard on the right lower quadrant, estimated fetal weight 2,945 grams.,Speculum Exam:,Clean looking cervix with scanty pinking to brownish discharge, non-foul smelling,Internal Exam:,Normal looking external genitalia, nulliparous introitus, vagina admits 2 fingers with ease , 4cms 50 % effaced , intact bag of waters , cephalic , station - 3,Extremities:,No gross deformities, full and equal pulses no edema, no cyanosis, CRT 38.5,in a single measurement, or three temperatures of 38,by discharge.,Maintain a clean environment. Ensure the clients room and bathroom is cleaned frequently and appropriately.,A clean environment may discourage the growth of microorganisms.,Goal Met: Linens separated r/t dirty and clean in restroom, personal care supplies kept off floor, bed linens changed,per d,ay open through to discharge.,Nursing Care Plan26Interventio,Nursing Care Plan,27,Nursing problem 2,Risk for Acute Pain: may be related to increased muscle contractions and psychological reactions,Goals: T,he patient verbalizes reduced discomfort or pain,Nursing Care Plan27Nursing pro,Nursing Care Plan,28,Interventions,Rationale,Evaluation,Assess location, nature(lithotomy position), and duration of pain, especially as it relates to the indication for cesarean birth.,Indicates the suitable choice of treatment. The patient awaiting imminent cesarean birth may encounter varying degrees of discomfort, depending on the indication for the procedure, e.g., failed induction, dystocia.,Goal Met: Patient verbalizes reduced discomfort or pain,Drop anxiety-producing circumstance (e.g., loss of control), give accurate information, and encourage presence of partner.,Levels of pain tolerance are individual and are affected by various factors. Extreme anxiety following an emergency situation may develop discomfort due to fear, tension, and pain affecting the patients ability to cope.,Nursing Care Plan28Interventio,Nursing Care Plan,29,Interventions,Rationale,Evaluation,Educate proper relaxation techniques; position for comfort as possible. Use Therapeutic Touch, as appropriate.,May help in decreasing anxiety and tension, promote comfort and enhance sense of well-being.,Goal Met:
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