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Woman 20 years old Dx. Postpartum period G1 PARA 1001 last 2 days.…
Woman 20 years old
Dx. Postpartum period
G1 PARA 1001 last 2 days.
Background
Ethnic : Thai
Religion : Buddhism
Occupational : employee at coffee shop
ANC at Nakhornping hospital , 9 times
screening lab
Hct 36%
Rh positive
HBsAg negative
HIV negative
Medication during pregnancy = Ferli-6
No complication during pregnancy
Delivery
Normal delivery
GA 41+1 wks
At 10/9/18 , 07.47 AM
Infant
Male
2,880 gms.
Medication use
5% D/N/2 1,000 ml vein drip
Pethidine 50 mg vein stat
add Synto 30 unit in IV 650cc
620 cc, 500cc ( 10 unit per 1times)
Previous surgery at 15/4/18 At Suphan Buri hospital
allergy to red tilapia fish
Grandmother has DM
Body condition
-Good conscious ,no weakness ,no headache
no pale conjuctiva can do activity by herself
Breast&Lactation
Breast = no breast engorgement ,balance ,no rash
Nipple&Areola = Short nipple ,no redness&swelling ,no crack ,thick areola ,pain when baby sucking and bleeding at nipple
Lactation = good lactation ,baby sucking well
Body temperature&Blood pressure
T 36.4 °C
BP 118/64 mmHg
PR 72-94 bpm
RR 20 t/m
Belly&Fundus
Abdomen=no rash ,no scar ,no diastasis recti,
striae gravidarum ,linea nigra
Uterine well-contracted, FH below umbilical level 1 FB, No pain
Bladder
empty bladder
urinate 1 time
urine is yellow, clear, no strong smell ,no dyspepsia
Bleeding&Lochia
fresh blood , no blood clot
,change pad every 2 hours, no foul smell
Bottom
Rt. medio-lateral pain score 5/10
R E E D A
Bowel movement
No defecate yet.
Blue
Reject for psychological problem
Baby
Active
good movement
V/S stable
Bonding
Baby stay with mother.
Good relationship between husband and family
Birth control
pre-pregnancy use emergency contraceptive pill
1 time.