Postpartum Case Study
Postpartum case study
1. Title page: Date: 05/10/11 Instructor:
2. Patient data: C O MR#0882470 financial#110941625
G:2 P: 1001 Room:
Age: 37 Allergies: PNC, Codeine Date of care
3. Medical history: None
4. Obstetrical history: C/S 12/27/07 40 wks 7.4 lbs Female, H/O post partum depression
Week gestation first seen 13 4/7 weeks
5. Labor/Delivery Summary: Induced at 40 weeks Stage 1 (onset to complete dilatation) 05/09/11 05:20 Oxytocin Started Complete dilation 10cm effacement 100% 05/10/11 00:22. Stage 2 (Birth) 05/10/11 01:22 Spontaneous APGAR at 1 min 9 at 5 min 9. 9lbs 3 oz
Stage 3 (placenta) 05/10/11 01:27spontaneous, intact 3 vessels 300 cds
Anesthesia: Epidural Marcaine 2.5 mg 05/10/11 00:00
Episiotomy: 2nd degree laceration perineum 20 sutures
6. Infant Sex: F Weight: 9lbs 2 oz APGAR: at 1 min 9 at 5 min 9
Circumference Head: 35.9 inches Abdomen: 33.0 inches Chest: 35.9 inches
Breastfeeding
7. Mother
Postpartum assessment: Pt alert oriented X3 speech clear. No head trauma, eye’s perrla, ear, nose and mouth clear. Breast soft non tender, nipples no abnormalities. Heart strong and regular. Lungs clear bilaterally. Upper extremities no edema, skin dry, pink, warm,skin turgor elastic and intact. Bowel sounds present fundal height: below umbilicus and firm. Lochia amount scant color rubia (red). No voiding difficulty urine yellow last BM 05/10/2011. Flatus passing yes. Perineal 2nd degree laceration. Lower extremities no edema humans sign negative. Pain 0 in a 0 to 10 scale.
Nursing diagnostic: Caregiver Role Strain
Nursing
1. Title page: Date: 05/10/11 Instructor:
2. Patient data: C O MR#0882470 financial#110941625
G:2 P: 1001 Room:
Age: 37 Allergies: PNC, Codeine Date of care
3. Medical history: None
4. Obstetrical history: C/S 12/27/07 40 wks 7.4 lbs Female, H/O post partum depression
Week gestation first seen 13 4/7 weeks
5. Labor/Delivery Summary: Induced at 40 weeks Stage 1 (onset to complete dilatation) 05/09/11 05:20 Oxytocin Started Complete dilation 10cm effacement 100% 05/10/11 00:22. Stage 2 (Birth) 05/10/11 01:22 Spontaneous APGAR at 1 min 9 at 5 min 9. 9lbs 3 oz
Stage 3 (placenta) 05/10/11 01:27spontaneous, intact 3 vessels 300 cds
Anesthesia: Epidural Marcaine 2.5 mg 05/10/11 00:00
Episiotomy: 2nd degree laceration perineum 20 sutures
6. Infant Sex: F Weight: 9lbs 2 oz APGAR: at 1 min 9 at 5 min 9
Circumference Head: 35.9 inches Abdomen: 33.0 inches Chest: 35.9 inches
Breastfeeding
7. Mother
Postpartum assessment: Pt alert oriented X3 speech clear. No head trauma, eye’s perrla, ear, nose and mouth clear. Breast soft non tender, nipples no abnormalities. Heart strong and regular. Lungs clear bilaterally. Upper extremities no edema, skin dry, pink, warm,skin turgor elastic and intact. Bowel sounds present fundal height: below umbilicus and firm. Lochia amount scant color rubia (red). No voiding difficulty urine yellow last BM 05/10/2011. Flatus passing yes. Perineal 2nd degree laceration. Lower extremities no edema humans sign negative. Pain 0 in a 0 to 10 scale.
Nursing diagnostic: Caregiver Role Strain
Nursing