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OB Patient: K.J, Nurse will assess the extent of perineal or vagina…
OB Patient: K.J
Diagnostic Tests
WBC: 14.9
RBC: 3.82
Hgb: 10.7
MCV: 84.8
MCH: 28.0
Hct: 32.4
RDW: 20.0
Plt count: 206
TDAP Vaccination 6/6/23
Blood type: B positive
Antibody Screen: negative
Hepatitis B Surface Antigen: nonreactive
Hepatitis C Antibody: nonreactive
Gestational Glucose Screening: 114 mg/dL
Treponema Pallidum Antibody: Nonreactive
Maternal Serum AFP: 45 ng/mL
Mean Corpuscular Volume: 84.3 fL (80.0-100.0)
Rubella Immune Status: 25 IU/mL (>=15)
Body Mass Index after giving birth: 32.7
Height: 5 ft 2 in
Assessment
GI: Bowel sounds active, non-tender, passing flatus. Non-distended. Patients funds is at midline and firm and has no pain.
Respiratory/pulmonary: Respiratory excursion is clear. Respiratoy effort is normal and unlabored. Symmetrical expansion and retraction. Patient O2 sat is 94% on room air.
Integumentary: Patient's skin is warm to touch. Skin is dry. No rash on skin. Does not show any edema in the legs.
Cardiac: Regular rhythm. Regular rate. Heart is S1 and S2.
Neuro/psych: Patient is alert and oriented to person, place, and time. Patient is able to respond to questions towards towards the nurse about her baby. Patient is pleasant and cooperative and excited to take her new baby home. Patient is able to understand education regarding bottle feeding, and caring for the newborn.
GU: Patient has a UTI infection and takes antibiotics for it. Patient is dieurising. Urine is clear. Patient reports no burning with urination. Patient has bleeding in the vagina and wears a pad. Patient has some blood clots. There is no foul odor. Patient also has a perineal laceration by the vagina. Stitches are in place.
Musculoskeletal: Patient walks independently and can ambulate in the hallway, and to the bathroom.
BUBBLE-HED DATA: Breasts: Soft and firm. Breast is also becoming engorged due to milk coming in. Uterus: Fungus is firm and right at the level of the Umbilicus. Bladder: Patient is diuresis and emptying out completely. Patient was very hungry and thirsty after giving birth. Bowel: Patient has hyperactive bowel sounds when listening to a stethoscope. Patient stated that she was hungry. Patient had a full breakfast and lunch after giving birth at the hospital. Patient is passing flatus. Lochia: Thick red color with blood clots. No foul odor present. Episiotomy: Patient had a laceration while giving birth and there are stiches in place around the vagina. No discomfort noted from the patient. Thrombus: Patient does not show any signs of warmth, redness, pain, or tenderness in the legs. Patient has no history of blood clots. Emotions: Mom is excited to bring new baby home. Nurse completed a postpartum depression. Patient score did not indicate any signs of depression. Discomfort for pain: Patient does have pain in laceration area. Nurse prescribed pain medication that patient takes. Patient states the pain medication helps.
MEDICATIONS
Multivitamin 1 TAB PO DAILY
Esomeprazole magnesium 20 mg capsule, delayed release PO daily (Reason: Heartburn)
Butalbital-acetaminophen-caff 50-325-40 mg capsule 1 CAP PO 4H PRN (Reason: headache) 1-2 tablets q 4 hours not to exceed 6 tablets in 24 hours
Escitalopram oxalate 10 mg tablet PO DAILY
Ondansetron 4 mg PO 8H tablet, disintegrating
Nitrofurantoin 50 mg PO DAILY (must administer with meal/food)
Triamcinolone acetonide 0.1% ointment 1 application topical BID. Apply BID to affected areas when flaring. Avoid face and genitals.
Acetaminophen 650 mg PO Q4H PRN
Ephedrine Sulfate 5-10 mg IVPUSH Q15M PRN
Ibuprofen 800 mg PO Q8H PRN
Lanolin Cream 0gm TOPICAL PRN
Phenylephrine/Sodium Chloride 100 MCG IVPUSH Q3M PRN
Polyethylene Glycol 17 gm PO DAILY PRN
Senna 8.6 mg PO BID PRN
Tucks 1 each topical PRN
Ampicillin Sodium 2 gm in Sodium Chloride 100 mls @ 200 mls/hr IV Q6H
Carboprost Tromethamine 250 mcg IM Q15M PRN
Fentanyl 100 mcg IVPUSH Q1H PRN
Lidocaine HCI 20 ml INTRADERMA PRN
Methylergonovine Maleate 0.2 mg IM Q2H PRN
Oxytocin/Sodium Chloride 30 unit in 500 mls @ 250 mls/hr
Nursing Problems
Risk for Bleeding #1 (due to the laceration with stiches)
Client-focused outcome (Cross & Vera, 2023)
Patient will monitor for signs of bleeding and notify the healthcare provider immediately if bleeding becomes very red and has blood clots. (Cross & Vera, 2023)
Interventions (Cross & Vera, 2023)
Nurse will assess vital signs frequently by looking for evidence of bleeding such as tachycardia and hypotension. (Cross & Vera, 2023)
Nurse will promote using a hot sit bath or a heat lamp for episiotomy extension. (Cross & Vera, 2023)
Risk for Impaired Urinary Elimination #2 (Due to patient having a UTI from pregnancy)
Client-focused outcome (Ackley et al., 2008)
Patient will monitor for signs of worsening symptoms of UTI such as voiding frequency, cloudy urine, fever, chills, tract symptoms, flank pain, and or urinary incontinence.
Interventions (Ackley et al., 2008)
Nurse will review the results of urinalysis for the presence of urinary infection: WBC, RBC, bacteria, positive nitrates. (Ackley et al., 2008)
Nurse will perform a physical assessment to look and inspect the perineal skin integrity, percussion, and palpate of the lower abdomen to look for bladder distention or an enlarged kidney. (Ackley et al., 2008)
Nurse will educate the patient the importance of completing the full antibiotic treatment for her UTI (Ackley et al., 2008)
Risk for Pain #3 (Due to giving birth through the vagina and having a perineal laceration)
Client-focused outcome (Mills, 2023)
Patient will report to the nurse on a scale of 1-10 of how bad the pain is and inform nurse when pain gets worse and what makes the pain better. (Mills, 2023)
Interventions (Mills, 2023)
Nurse will administer analgesics as prescribed. (Mills, 2023)
Nurse will monitor the healing site (perineal care) and observe any signs of possible complications, such as an infection. (Mills, 2023)
Nurse will use distractions to help mother reduce pain when not with the newborn by encouraging position changes, meditation and or breathing exercises. (Mills, 2023)
Primary Diagnosis: Premature Rupture of Membranes and Irregular uterine contractions
Pathophysiology: Is the condition in which the chorioamnion is disrupted before the onset of labor. (Kelly, 1995)
Subjective Data: Patient came into the OB at Avera Hospital because she felt her membranes rupture. Patient was then induced to go into labor, and received oxytocin to help induce labor.
Factors impacting discharge: Type of delivery (vagina, C-section birth), maternal health (pain, bleeding), baby health (feeding patterns, jaundice), support systems (father involvement, friends, grandparents)
Nurse will assess the extent of perineal or vagina lacerations. (Cross & Vera, 2023)