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Case Study Obstetric Patient

The document outlines the case study of a 21-year-old postpartum patient who delivered a healthy baby girl through natural spontaneous delivery and was diagnosed with preeclampsia, including assessments of the patient and newborn, laboratory results, anatomy and physiology related to preeclampsia, nursing management recommendations, and postpartum discharge instructions.

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Prinz Lozano
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353 views19 pages

Case Study Obstetric Patient

The document outlines the case study of a 21-year-old postpartum patient who delivered a healthy baby girl through natural spontaneous delivery and was diagnosed with preeclampsia, including assessments of the patient and newborn, laboratory results, anatomy and physiology related to preeclampsia, nursing management recommendations, and postpartum discharge instructions.

Uploaded by

Prinz Lozano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Case Study Obstetric Patient

General Objectives:
After 1 to 2 hours of case presentation with a concept of Care
of At-Risk, High-Risk and sick mother and child, the student
nurses will be able to gain knowledge about the health and
well-being of the patient, enhance their skills in handling a
postpartum mother and show positive attitude to the patient.
Specific Objectives:
1. Have an overview of the Postpartum Assessment including
the patient’s name, age, status and others.
2. Discuss the patient’s Obstetric History, Current health
status, episiotomy, gynecologic history, past illness, history
of family illness and psychosocial history will be followed.
3. Discuss the physical assessment of the patient based on
the assessment findings.
4. Have an overview of the newborns’ data.
Specific Objectives(cont.):
5. Discuss the laboratory examination and it’s diagnostic results.
6. Explain the anatomy and physiology of the involved organ
system according to the diagnosis of the patient and provide a
brief discussion on it’s function.
7. Discuss the appropriate nursing management for the patient.
8. Discuss the post-partal discharge instruction that is specifically
made for the patient.
9. Discuss the appropriate nursing care plan of the patient
10.Discuss the drugs that are given to the patient including its
uses, contraindications and etc.
Postpartum Assessment:
Patient VJMO, a 21 years old Filipina, status is single, lives in
Belgium St., Suba, Cebu City, was admitted on January 23,
2020 at 12:34 pm, gave birth to a female neonate on January
24,2020 at 3:39 pm through Natural Spontaneous Delivery.
Obstetric History:
Patient is a G1P1(1101) pregnancy uterine full term, delivered via
NSD, a live female neonate with AS 9,9 BS 40 weeks weights
2550g, AGA preeclampsia with severe features current health
status: patients vital signs are assessed with a temperature of 36.8
C, pulse rate of 95 bpm, respiration of 21cpm, blood pressure of
130/90 mmHg, an oxygen saturation of 99% breast is full and
engorged, uterus is still palpable, bladder is not distended patient
is able to void, patient has moved bowel since delivery, lochia
serosa and 1 pad not fully soaked, (-) Homan's sign, patient moves
independently and able to take care of baby.
Gynecologic History:
Patient's age of menarche is 13 years old with a regular cycle
of 28 days with a 5-7 days duration and about 2 pads soaked
per day. Experienced dysmenorrhea during the first day of
menstruation. The contraception that they use is condom with
no past surgery of any reproductive organ.
Past Illness:
No known heart and kidney disease. Also, no previous history
of HPN, asthma, TB, or any thyroid disease, DM, Hep B, and
any STDs prior to pregnancy. Experience childhood diseases
like mumps and chicken pox.
History of Family Illness:
There are no presence of renal disease, asthma, or any blood
disorder. No genetic disorders or congenital anomalies and
cognitive impairment in their family. The only present disease
if hypertension.
Psychosocial History
Patient verbalized she drinks alcohol occasionally.
Physical Assessment:
Patient appeared to be pallor, no dental problems, no edema,
no open lesions, no varicose veins, no enlarged lymph nodes.
Newborn Data:
Patient baby is female, weighed 2,550 grams, delivered through normal
spontaneous vaginal delivery at 3:39 PM on january 24, 2020. Fetalic
presentation was cephalic. APGAR score was 9,9. Ballard score was 40
weeks.
ANTHROPOMETRIC MEASUREMENTS:
Fetal head circumference was 33 cm, chest circumference was
30 cm, abdominal girth was 27 cm, and the height was 48 cm.
Number of umbilical blood vessels were 3: 1 veins, 2 arteries.
Patient baby had received eye prophylaxis (erythromycin eye
ointment, vitamin k, hepatitis vaccine on January 24, 2020).
Newborn vital signs are as follows: HR: 124, RR: 52, BT: 36 2.
Laboratory/Diagnostic Results

Date and Examination Results Normal Values Interpretation

January 23, 2020


 Creatinine 0.53 0.51 – 0.95
 Blood Uric Acid (BUA) 3.81 2. 4 – 5.7
 ALT (SGPT)
 LDH 5.14 0 – 41
20 <480

January 23, 2020


 Urine Analysis
Color: Yellow
Volume: 50mL
Transparency: Clear
Gravity: 1.010
 WBC: 5-3/HPF
 RBC: 0-3/HPF

January 23, 2020


 CBC
Anatomy and Physiology:
Pathophysiology:
Nursing Management:
• Nursing Management for Preeclampsia
• 1.) Monitor blood pressure regularly
• 2.) Administer magnesium sulphate as doctor's prescriptions.
• 3.) Monitor intake and output
• 4.) Advise low fat and low salt diet
• 5.) Advise for post natal exercise
• 6.) Monitor antiplatelet therapy
• 7.) Promote bed rest
• 8.) Advise for good nutrition
• 9.) Provide emotional support
Post Partum Discharge Instructions:
• Expect vaginal bleeding like a menses for up to four to six weeks. It will gradually
taper and stop.
• Ibuprofen (Motrin or Advil) and/or Tylenol may be used for any discomfort and
are felt to be safe with breastfeeding.
• To keep your stools soft by eating a high fiber diet.
• Please continue your prenatal vitamins. They help replace iron and will help the
healing process.
• Strenuous exercise should be avoided for four to six weeks.
• Leisure walks are recommended after one to two weeks.
• You may ride in a car at any time. It is not recommended that you drive until you
are completely pain free, usually two to three weeks after delivery.
• Please do not use tampons, douches or resume sexual activity until 6 weeks
postpartum unless you have been evaluated by a doctor. Do not lift heavy
objects for two weeks.
Post Partum Discharge Instructions(cont.):
• Going up and down stairs in moderation is allowed.
• You may shower at any time. Tub baths are generally not recommended.
• Episiotomy care- use the squirt bottle as you find necessary and pat dry.
No extra care is necessary. Sitz baths may help with any discomfort.
• For Cesarean scars- Keep the incision dry. In the shower do not scrub the
incision but .
• Call the doctor sooner if:
• You have a fever of 100.5º F or greater.
• Your pain worsens.
• Your bleeding becomes much heavier, changing a maxi pad every hour for more
than two to three hours, or you start passing several large clots.

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