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Patient data: A.D.
36 y/o
Dx: IUGR; baby stopped growing 2 weeks before…
Patient data: A.D.
36 y/o
Dx: IUGR; baby stopped growing 2 weeks before scheduled c/s
G1T1P0L1, AB+, NKA
Hx: c6 c7 disk herniation
Subjective Data: Pt. reports pain of 0/10
"I'm so tired."
"I want to breastfeed, but she is not latching."
"I think I need to use a pump."
"What is the newborn feeding cue?"
"I feel ok."
Reports that she does not feel dizzy due to low blood pressure
"My blood pressure is always somewhat low."
"I don't think I need to go to the bathroom because I didn't drink anything yesterday because I was so nauseous."
"I have been trying to feed her with a spoon."
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Neurological: AOx4 to person, place, time, situation
PERRLA
Patient is communicating well
Reports no dizziness
Reports pain of 0/10 (goal pain of 2/10)
No visual disturbances
Objective Data:
Height - 5'1"
Weight - 137 lbs
Patient appears tense, frazzled, and anxious about newborn
IV in right forearm
Patient will not stop trying to breastfeed which is causing frustration
Very adamant on breastfeeding
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Cardiovascular:
Radial pulses 2+ bilaterally
No edema in lower extremities
Heart rate is regular rhythm
No abnormal heart sounds
No redness noted
Apical heart rate is 61 and WNL
Capillary refill <2 seconds
No murmurs noted
Respiratory:
Breath sounds deep and clear bilaterally
Respirations are even
No adventitious breath sounds heard
No labored breathing
No use of accessory muscles to breathe
Respiration rate is 18
Gastrointestinal:
Abdomen is soft, round, and not tender
Bowel sounds absent
No BM or flatus passed
Musculoskeletal:
Patient can ambulate with little assistance
Full ROM in upper extremities
Muscle strength 5
Extremities non-tender
Integumentary:
Skin is warm
Color is consistent
Linea nigra present
Striae gravidarum present on breasts and abdomen
Uterine laceration from c/s; incision site dry and intact
Incision dressing dry
Breasts:
Nipples are flat
Breasts are full and firm
No cracking or bleeding present
Striae gravidarum present
No engorgement
Uterus:
Fundus felt 2 cm above umbilicus; this is high for after birth
Slightly displaced due to bladder distention
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Psychosocial:
Patient is anxious and tense
First child
Mother and spouse ask a lot of questions about first child, but is still excited
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Surgical Incision:
Incision lower transverse from c/s
Incision site dressing was clean, dry, and intact
Current medications:
Famotidine (help reduce stomach acid) 20 mg, PO
NORCO (for pain) 325 mg PO
Important Labs:
Before birth -->
Hgb: 13.2
Hct: 39.5%
WBC: 11.2
Plt: 148,000
After birth -->
Hgb: 11
Hct: 33.1%
WBC: 14.6
Plt: 143,000
Patient data:
Gestational age: 37 weeks
Delivery date: 09/22/2020
Delivery time: 1227
Type of delivery: c/s due to IUGR
Apgar: 9/9
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Initial observation:
Baby is crying
No circumorally or acrocyanosis present
Extremities are flexed
Red scratches on cheeks from fingernails
No jaundice noted
Objective data:
Overall baby looks healthy
On the smaller side due to IUGR
Was not in the NICU
Birth weight: 5lbs 12.0oz
Current birth weight: 5lbs 9.6oz
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Cardio:
Regular rhythm heard upon auscultation of heart sounds
No abnormal heart sounds heard
No jaundice noted
No acrocyanosis noted
Respiratory:
Breath sounds clear
Regular rhythm
No adventitious sounds heard
No accessory muscles to breathe
Gastrointestinal:
Bowel sounds normoactive
Soft and round abdomen
Skin is warm and dry
Umbilicus intact
Baby is trying to breastfeed with assistance; cannot latch - nipple shield being used
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Musculoskeletal:
No webbing noted
No extra digits or other abnormalities
Baby is lying flat
Symmetrical movements
Spine is straight
Integumentary:
Dry and intact
Warm to touch
Small red scratches on face from fingernails
Mongolian spots on lower back are present
no skin turgor
Color is consistent with slight redness noted
Psychosocial:
Mother has performed a lot of skin to skin care because baby was cold
Mother seems anxious and tense; very concerned for first baby's health; asks a lot of questions
Bother parents are present and loving on the newborn
Newborn is very calm and tired