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This document contains a nursing assessment and care plan for a 19-year-old postpartum patient named TM. She was admitted to the maternity ward complaining of headache and swelling. On examination, she had peripheral edema and high blood pressure. Her assessment identified fluid volume deficit and ineffective breastfeeding. The plan was to increase fluid volume through monitoring intake/output, elevating extremities, and giving ordered medications. The initial goal of reducing edema was partially met.

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8 views

Soapie 2

This document contains a nursing assessment and care plan for a 19-year-old postpartum patient named TM. She was admitted to the maternity ward complaining of headache and swelling. On examination, she had peripheral edema and high blood pressure. Her assessment identified fluid volume deficit and ineffective breastfeeding. The plan was to increase fluid volume through monitoring intake/output, elevating extremities, and giving ordered medications. The initial goal of reducing edema was partially met.

Uploaded by

khsh6034
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Maternity Manual 2021-2020

Nursing process_ SOAPIE

Student Name: Areej Alanas


Date: 4/5/2021
Patient Name: TM
Admission date:3/5/2021
G1 T1 P0 A0 L1 M0 (0.5)
LMP : 10/8/2020 EDD : 17/5/2021 GA 38wk
Patient age: 19 y.o
Medical Dx.: PIH ward: post CS
Date of delivary: 3/5/2021 at 4:00 pm, day 1 after surgery.
Cause of CS : breech presentation, high blood pressure.

Chief complain:(0.5)
pt said “I had headache since 2 hr before admission”

History of present illness: (1)

19 y.o maternal pt admitted to maternity ward at 2:00


pm (3/5/2021) complaining of headache ,pt had head
pain in 10 am and this pain was Increase gradually ,
degrease slightly when patient take paracetamol then
return, pain severity on pain scale was 7/10 , pt think
that this pain was due to increase blood pressure ,
the pain was associated with edema in
extremity ,fatigue .
‎
Current Status

S (subjective data) (1):


pt said “ I have swelling in my legs and arms , I don't
know how to breast-feed my baby and I am anxious
about that “.

O (objective data) (1):


(general appearance) : TM , 19 years old , receiving
on bed high fowler position conscious , oriented by 3 (
place , time , person ) , looks comfortable , her facial
expression look rested, good skin color consistency
with genetic background, speaks clearly , good
hygiene and dress , good appetite , she is cooperative ,
has peripheral edema , pt in low sodium soft diet,
height :165 cm , weight before pregnancy 80 kg.

(VS)
T: 36.5c•
BP: 130/88 mmhg
HR: 95 p/m
RR :17 b/m

(medication)
Paracetamol ING 1000mg IV Q12hr PRN
Methyldopa TAB 250mg PO Q6hr
Enoxaparin ING 40mg/0.4ml SQ QDAY \8 hr post OPP
(LAB TEST)

5/4/2021
Lab Test Result

WBC 13.72 (H)


RBC 4.26(N)
MCHC 31.5 g/dl (L)
potassium 4.49(N) mmol/L

Glucose 4.34
mmol/L
MCV 73.7 (L)

Hgb 10.7g/dl(L)
PCV 31.4 %(L)
SODIOM 132
PLT 321(N)
MCH 23.2(L)

2/5/2021
lab test result

UR color Y
lab test result

UR glucose Negative

UR PH (6)

UR protein (+3)

UR WBCs 10-12

UR RBCs 8-10

(P.E)
B : no engorgement ,pt try to feed once but failed (de cit
mom knowledge) ,Symmetric breasts ,no change in
size ,colostrum presence (clear ,yellow) , no masses or
mastitis ,no ssures or bleeding in nibble.
U : 1 cm Under the umbilicus ,Deviated to right side , rm
(Contracted)
B : Urination 7-8 times/day ,no foul oder , no pain
B : bowel movement 12 times/min , defecation 1 time (+
gases) , tenderness abdomen
L : Dark red lochia ( rubra) , no foul oder ,with mucous ,
start one hr after Surgery , about 5-6 bad/day.
E : early ambulation in rst day , edema +2 in both arms
and legs.
E : No signs of infection according to FARREDA. (pubic
incision)
E : No signs of blues , pt in taking in phase.
Respiratory system: no crackles or wheezing ,RR:17
regular and deep.
-The baby with his mother , assessment of the baby :
fi
fi
fi
fi
-vital sign : HR :126 beat/min , abdominal breathing RR:37
breath/min, his weight 2.9 kg
, his skin is smooth ,nostril patent bilaterally , no nasal
discharge , moist mucosa , anterior fontanel is diamond
shape 4 cm and posterior fontanel is triangle almost 1
cm ,the ear flexible pinna , the top of the pinna on
horizontal line with outer canthus of eye , intact spine
without masses or opening , he is voiding and defecate
meconium last night , the umbilical cord is normal the cut
edge clear and the cord clamp still present ,good sucking
reflex , all reflexes are normal and intact (Apgar score 1
min : 7 , 5 min: 8 )

A (assessment data) (1.5):

1- N.D
fluid volume deficit related to fluid loss to subcutaneous
tissue AMB physical exam finding pitting edema +2 and
presence of protein in urine.

2-N.D
ineffective breastfeeding related to Lack of knowledge
regarding effective breastfeeding and latch on technique
AMB pt said “I tried to breast feed my baby and I failed ,
the baby still hungry”

P (plan) (1.5):
Goal : increase fluid volume to normal
Obj : at the end of my shift the pt will be able to show
increase in fluid volume ( decrease edema from +2 to 0 ,
absence or decrease protein in urine).

(interventions) (1.5):

monitor serum
electrolytes, urine All are indicators
protein ,osmolality of uid status and
and urine speci c guide therapy.
gravity.

Elevation increases
Elevate edematous venous return to
extremities, and the heart and, in
handle with care. turn, decreases
edema.

tachycardia and
Monitor and note increased BP are
BP and HR. evident in early
stages.
to manage high
give pt medication
blood pressure
as doctor ordered.
and edema.
fl
fi
Dehydration may
be the result of
Monitor input and
uid shifting even
output closely.
if overall uid
intake is adequate.

assess lung sound all may indicate


and crackles. pulmonary edema.

(evaluation) (1):
the goal is partially met ,edema +1 and still protein in
urine.
fl
fl

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