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Primary Diagnosis: Pre-eclampsia with Severe features, BUBBLE-HED,…
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BUBBLE-HED
Breasts: Patients breasts were symmetrical, soft, and non-tender. Nipples were intact and pt is not breastfeeding
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Bladder: Patient is able to void without difficulty, urine is light and pt had adequate output
Bowel: Abdomen is soft and non-tender to palpitation. Bowel sounds are present in all four quadrants. Pt reports having a bowel movement and is able to pass flatus
Lochia: Patient has a scant amount, rubra-red in color, no clots, and no odor
Episiotomy/Laceration/C-Section incision: C-section incision is intact, held by staples, no drainage or odor coming from the incision and the incision is open to air. Pt has no hemorrhoids
tHrombus: Patients legs have a normal appearance bilaterally, no swelling, edema, warmth or tenderness
Emotions: Mother is excited to go home and take care of newborn on her own, but she is nervous about giving the newborn a bath at home. The nurse helped the mother give a bath to the newborn.
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Assessment
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Musculoskeletal: Client is ad lib, independent
Client was sent to labor and delivery for a nonstress test due to a diagnosis of cholestasis. Upon admission client had a blood pressure of 180/120 and states headaches have been off an on for the last week. Client was also experiencing right upper quadrant discomfort.
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GU: Client is able to void without difficulty, urine is light and pt has adequate output
Respiratory: Lung sounds were clear, respiratory is non-labored and has regular depth. Pt was on RA
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Integumentary: Skin is warm to touch, dry, and normal for race and ethnicity. Client has impaired skin integrity due to incision from C-section. The incision is clean, dry, and sutures are present.
Cardiac: S1S2 sounds present, regular rhythm, 2+ pulses throughout, Capillary refill < 3 seconds in all extremities
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