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Case Study Assessment Data

This case study involves a 15-year old girl, Patient P, who was abandoned and lived in a welfare center. She was sexually abused and became pregnant. At 39 weeks, she delivered a healthy baby girl via normal spontaneous vaginal delivery. Her postpartum assessment showed normal lochia, breast engorgement, and fundus. Her physical exam was largely normal except for signs of past abuse like scars.

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JP2001
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28 views

Case Study Assessment Data

This case study involves a 15-year old girl, Patient P, who was abandoned and lived in a welfare center. She was sexually abused and became pregnant. At 39 weeks, she delivered a healthy baby girl via normal spontaneous vaginal delivery. Her postpartum assessment showed normal lochia, breast engorgement, and fundus. Her physical exam was largely normal except for signs of past abuse like scars.

Uploaded by

JP2001
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE STUDY ASSESSMENT DATA

Case: Read and analyze the given case to do the following activities and answer questions
correctly.

Patient P, 15 years old, S/P NSVD, with live baby girl AOG 39 weeks full term. Patient was
born to parents from Surigao Del Norte, but no longer lives with them. She was technically
abandoned to the relatives who could not easily foster her so she stayed at the Department
of Welfare and Social Development (DSWD) for 15 years. Patient P is a victim of sexual
abuse, was raped and was unable to resist because of her innocence.

Focus assessment includes:

Vital Signs :

Postpartum data:

● Lochia bright red, (+) small clots noted


● (+) Breast engorgement
● Fundus firm and at the level of the umbilicus
● Perineal pad: changed every hour or two

History:

● In September 2007, when Patient P came home from school; upon nearing the
center, a man, whom she identified as a newcomer to the center, blocked and
harassed her brutally. She struggled to let go from the ruthless hands of the
unaccustomed man. Patient P being threatened and scared of getting killed, the
crime had happened.
● Patient P conceived the baby and bore it for 9 months.
○ 1st trimester: Patient P unable to believe and accept her fate but somehow
felt jolt of excitement of having a baby. Verbalized, “Wa naman koy mabuhat,
nahitabo naman to. Basin makasala pa kog ipalaglag nako ang bata na wala
man siya’y sala.”
● On June 29, 2008, Patient p complained of extreme abdominal pain, same date of
her EDC. AOG 39 weeks by her LMP which was September 2007, exact date
unrecalled.
● @ 2:40am, admitted at the hospital, BP 140/90mmHg, fully dilated
Doctor’s order upon admission:
○ #1 D4LR 1L @20gtts/min (dextrose)
○ TPR (temperature, pulse, respiration) q 4
○ Diet: NPO
○ Labs: CBC, Blood Typing, HbsAg
● @ 2:55am, endorsed to DR via wheelchair, endorsed and was admitted in OB-ER,
then positioned on the DR table with final preparation done.
● @ 3: 36am, delivered an alive 6lbs, 13oz and 49cm in length baby girl
○ Head circumference: 32 cm
○ Chest circumference: 30 cm
○ Abd’l circumference: 20 cm
● @ 3:47am, placenta was expelled spontaneously, BP 130/80, uterus was firm and
contracted
○ Meds: Oxytocin 10 units infused to IVF, Methergine 1amp IVTT

After delivery, admitted to OB Ward with repaired episiotomy, temperature monitored until
stable

● Doctor’s order:
○ Diet: Diet as tolerated
○ Ice pack over hypogastrium
○ Perineal care
○ Meds:
■ Oxytocin 10 units infused to IVF
■ Methergine 1amp IVTT
■ Cephalexin 1amp IVTT
■ Mefenamic Acid 500mg 1 cap TID
● May room in
● Breastfeed per demand

PHYSICAL ASSESSMENT

General:
15-year-old, female, Ht. 5’4, PR 82 bpm. RR 21cpm, T 37.3C. Conscious and coherent upon
interaction but answers only the questions she is comfortable with. Pacing inside the ward
and appears withdrawn.

Head:

Round in shape, hair is long, thick and coarse, straight and evenly distributed. Scalp is
smooth and white in color; minimal lesions were noted. Dandruff and lice were seen.

Eyes:

Symmetrical, black in color, almond shape. Pupils constrict when diverted to light, dilated
when gazes afar. Conjunctivas are pink, eyelashes are equally distributed and skin around
the eyes is intact. Eyes involuntarily blink.

Ears:

Clean, no ear wax noted. Approximately of the same size and shape. Can hear normally

Nose:

Narrow nose bridge, (+) discharges noted upon inspection. No swelling of the mucous
membrane and (+) nasal hair were noted.

Mouth:

Complete set of teeth with minimal dental carries noted. Oral mucosa and gingival are pink,
moist and no lesions nor inflammation noted. Tongue is pink, (-) swelling and lesions. Lips
are symmetrical, appears pale without bits noted upon observation

Neck:

Lymph nodes are noted. Able to freely move her neck

Lungs:

No reports of pain during inhalation and exhalation. Absence of adventitious sounds upon
auscultation. RR 21 cpm

Heart:
Audible heart sound. PMI heard between 4 th to 5th ICS. Heart is pumping well, PR 82bpm

Abdomen:

Abdominal movement as with respiration, presence of peristalsis during auscultation.


Presence of rashes and lesions.

Upper Extremities:

○ Skin: White in color, (+) scars of wounds in the arms, neck and legs. Skin
smooth, moist, soft and warm to touch
○ Hands: Medium in size with 5 fingernails each. Nails are short, small, (+)
dusty particles noted
○ Arms: Active ROM

Lower Extremities:

Size of feet is undefined with lines on the sole, (+) scars and lesions. Ten toes noted. Nails
clean and trimmed. Ambulatory

Genitourinary: (+) Episiotomy dry and intact, urinates 2-4 times a day

Perineum: (+) Episiotomy intact, (-) lesions and swelling

Neurological:

○ Behavior: silent but conscious and coherent upon interaction. Sits and walks
if she wants to.
○ Motor Functioning: able to move extremities, (+) active ROM
○ Reflexes: (+) blinking and DTR
○ Sensory: intact, able to distinguish touch, pain, hot and cold.
○

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