How are you my dear students? How did you find our discussion today? Now, its time to have some thinking and plotting moment and do some assessment with this patient I will present now. Obstetric History: Patient’s Demographic History Patient A is a 25-yearS-old female, born on June 06, 1994. Currently residing in P-5 Ambago, Butuan City and devoted as a Roman Catholic. Patient A was living with her cohabitant for more than 5-years now. She is a high school graduate and due to socioeconomic instability, she decided to stop and help her mother to earn money. 2. History Prior to Admission Prior to admission Patient A experienced pain in her abdomen, as she verbalized, “Sakit kaayo akong tiyan, Ma’am labi na tung nag bati nako. Ni sulti na dayon ko sa akong pares nga manganakay nako. Mao to kuha dayon mig sakyanan padulong sa Provincial Hospital. Patient A was a multipara mother G3P3 (3003) with 40 weeks AOG. On September 9, 2021 at exactly 6:20 AM the patient was seen irritable with grimace face and obviously in pain, she was assessed by the ER nurse an Internal Examination (IE) was performed and it showed 5cm. they took the vital signs, and vital signs are as follows, T –36.5°C, P –90 bpm, R –15 bpm, BP – 100/80 mmHg O2sat – 98% Patient A was endorsed to Delivery Room at exactly 9:30 AM with ruptured amniotic fluid, with a streak of blood seen in the patient's diaper. Patient A was on D5LR 1L newly hooked at the left metacarpal vein, dry, intact and free from any signs of infection. Fetal heart tone at normal range, 131 bpm. The staff nurse on duty received and put the patient in the Labor room. She was instructed to be in side-lying position towards the left side to prevent vena cava compression. She complained of labor pains every 10-15 minutes in a duration of 60 seconds. The doctor prescribed two drugs in preparation for the delivery, an oxytocin 10 cc. # 1 amp; methergine 0.2 mg/ml # 1 amp. As her Student Nurse, she was endorsed to you for labor watch monitoring and was instructed to record her progress of labor appropriately using the Partograph attached to the patient's chart. Patient A was having a hard time with her labor. She complained of labor pains every now and then. She informed you that she is not comfortable of just lying down and wanted to stand. You taught her to do some squatting to help facilitate the bearing down of the baby. Around 12:30 Pm, the patient verbalized that she wanted to push down for she feels she cant bear anymore the pain. The staff nurse instructed the patient to go back to the bed for she wanted to performed IE. Upon checking it, it was now 10 cm dilated. The nurse asked you to get the FHT before transferring the patient to Delivery room. FHT now displayed as 145 bpm with BP of 110/60 mmHg. After the BP was taken, the patient was transferred to the delivery room through wheelchair and positioned properly. The mother was put into lithotomy position. After a few minutes of pushing effectively, the baby's head was finally out. However, as she pushes, she also moved a lot, thus causing perineal laceration. She successfully delivered a healthy baby girl at 12:50 pm through Normal Spontaneous Vaginal delivery. The doctor requested you to prepare a Lidocaine anesthesia 5 cc. and 1 pack of Chromic 2/0 suture to be used for the repair of the laceration. Analyze the Clinical case situation presented here. Do your nursing assessment of the Obstetric history of Patient A. Do the following tasks: List down actual and potential problems and prioritize it. Formulate 1 Nursing Care Plan of your identified priority problem.
How are you my dear students? How did you find our discussion today? Now, its time to have some thinking and plotting moment and do some assessment with this patient I will present now.
Obstetric History:
- Patient’s Demographic History
Patient A is a 25-yearS-old female, born on June 06, 1994. Currently residing in P-5 Ambago, Butuan City and devoted as a Roman Catholic. Patient A was living with her cohabitant for more than 5-years now. She is a high school graduate and due to socioeconomic instability, she decided to stop and help her mother to earn money.
2. History Prior to Admission
Prior to admission Patient A experienced pain in her abdomen, as she verbalized, “Sakit kaayo akong tiyan, Ma’am labi na tung nag bati nako. Ni sulti na dayon ko sa akong pares nga manganakay nako. Mao to kuha dayon mig sakyanan padulong sa Provincial Hospital. Patient A was a multipara mother G3P3 (3003) with 40 weeks AOG.
On September 9, 2021 at exactly 6:20 AM the patient was seen irritable with grimace face and obviously in pain, she was assessed by the ER nurse an Internal Examination (IE) was performed and it showed 5cm. they took the vital signs, and vital signs are as follows,
T –36.5°C,
P –90 bpm,
R –15 bpm,
BP – 100/80 mmHg
O2sat – 98%
Patient A was endorsed to Delivery Room at exactly 9:30 AM with ruptured amniotic fluid, with a streak of blood seen in the patient's diaper. Patient A was on D5LR 1L newly hooked at the left metacarpal vein, dry, intact and free from any signs of infection. Fetal heart tone at normal range, 131 bpm. The staff nurse on duty received and put the patient in the Labor room. She was instructed to be in side-lying position towards the left side to prevent vena cava compression. She complained of labor pains every 10-15 minutes in a duration of 60 seconds. The doctor prescribed two drugs in preparation for the delivery, an oxytocin 10 cc. # 1 amp; methergine 0.2 mg/ml # 1 amp.
As her Student Nurse, she was endorsed to you for labor watch monitoring and was instructed to record her progress of labor appropriately using the Partograph attached to the patient's chart. Patient A was having a hard time with her labor. She complained of labor pains every now and then. She informed you that she is not comfortable of just lying down and wanted to stand. You taught her to do some squatting to help facilitate the bearing down of the baby.
Around 12:30 Pm, the patient verbalized that she wanted to push down for she feels she cant bear anymore the pain.
The staff nurse instructed the patient to go back to the bed for she wanted to performed IE. Upon checking it, it was now 10 cm dilated. The nurse asked you to get the FHT before transferring the patient to Delivery room. FHT now displayed as 145 bpm with BP of 110/60 mmHg.
After the BP was taken, the patient was transferred to the delivery room through wheelchair and positioned properly. The mother was put into lithotomy position. After a few minutes of pushing effectively, the baby's head was finally out. However, as she pushes, she also moved a lot, thus causing perineal laceration. She successfully delivered a healthy baby girl at 12:50 pm through Normal Spontaneous Vaginal delivery. The doctor requested you to prepare a Lidocaine anesthesia 5 cc. and 1 pack of Chromic 2/0 suture to be used for the repair of the laceration.
Analyze the Clinical case situation presented here. Do your nursing assessment of the Obstetric history of Patient A.
Do the following tasks:
- List down actual and potential problems and prioritize it.
- Formulate 1 Nursing Care Plan of your identified priority problem.
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