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1、Far Eastern University - Institute of Nursing,CASE PRESENTATION,FEU NRMF HOSPITAL,OBSTETRICS WARD,Group Three,Peng Sijing (Stone ), Li Xiaojing (Cathy ), Miao Chunmei (Mano), Nie Fengyan (Zara),Content,Introduction,1,History,Physical Assessment,3,Laboratory and Diagnostic Exams.,4,2,Medications and
2、IV fluid,5,2,6,Nursing Care Plan,Introduction,3,Patient A, 30 years old, G1P0, pregnancy uterine 39weeks and 2 days, cephalic in labor, admitted at FEU-NRMF HOSPITAL on February 8, 2018. CHIEF COMPLAINT: Hypogastric Pain,History,4,HISTORY OF PRESENT PREGNANCY: LMP: May 9,2017 AOG by LMP: 39 weeks 2
3、days EDC by LMP: February 12, 2018 PMP: April 8, 2017 AOG by EUTZ: 39 weeks 3 days EDC by EUTZ: February 12, 2018 First Trimester * On the 1 month of missed period (June 2017): cessation of menses, nausea and vomiting. Self-pregnancy test was done, which revealed a positive result. * She consulted a
4、 private obstetrician where diagnostic tests such as complete blood count, urinalysis, VDRL/RPR and hepatitis B antigen screening were done. All revealed normal results except for urinalysis which revealed urinary tract infection. She was prescribed Cefuroxime 500mg BID for 1 week, and repeat urinal
5、ysis afterwards was normal. * Transvaginal ultrasound for pregnancy evaluation revealed a single intrauterine pregnancy compatible to 15 weeks and 2 days age of gestation (August 2017). * She was given multivitamins and Folic acid 1 tablet once a day which she took regularly. * She denies any histor
6、y of accidents, trauma, or any exposure to radiation and toxic chemicals. * Patient had an episode of colds and took cefuroxime 500mg twice a day for 5 days. * She also took Loratadine 10mg once daily for her allergic rhinitis.,History,5,HISTORY OF PRESENT PREGNANCY: Second Trimester * Quickening wa
7、s felt on the 5th month of pregnancy (October 2017). * She had regular intake of Multivitamins 1 tab daily, Ferrous sulfate 1 tablet once a day, and Calcium 1 tablet twice a day. Only urinalysis was done at the health center revealing that she had urinary tract infection. she was prescribed Cefuroxi
8、me 500mg BID for 1 week to which she was compliant. * Transabdominal ultrasound for gender determination was done on the 7th month of pregnancy revealing single intrauterine pregnancy compatible to 28 weeks and 4 days age of gestation (November 2017). * She denies any history of accidents, trauma, i
9、llness, or any exposure to radiation and toxic chemicals.,History,6,Third Trimester * Subsequent prenatal check-ups were regular as well as intake of multivitamins 1 tablet once a day, Ferrous sulfate 1 tablet once a day, and calcium 1 tablet twice a day. * Capillary blood glucose monitoring and 75g
10、 OGTT was done which revealed increased results. Exact values were unrecalled by the patient. She was prescribed with Novo Rapid insulin, 4 units taken 2 hours post meals. She was also advised to do capillary blood glucose monitoring at home. * Subjective complaints experienced included headache and
11、 dizziness. No hypogastric pain, abnormal vaginal discharge, vaginal spotting, dysuria, and fever. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicals,The present condition started 5 hours prior (5:00pm) to admission when the patient experienced cram
12、py intermittent hypogastric pain radiating to the lower back with a pain scale of 8-9 out of 10. This was associated with scanty bloody vaginal discharge. She sought consult at our institution and was subsequently admitted.,History,7,PAST MEDICAL HISTORY: The patient had usual childhood diseases suc
13、h as mumps, measles, and chickenpox. She denies any history of major illnesses, trauma, accidents, or major operations. She was admitted last June due to persistent vomiting and dehydration. Patient has allergic rhinitis and was diagnosed with gestational diabetes last January maintained on Novo Rap
14、id insulin 4 units taken 2 hours post meals.,History,8,FAMILY HISTORY: Father: hypertension Mother: kidney stones, died due to cardiac arrest The patient is 3th among 5 siblings with 4 sisters and 1 brother. Her eldest is 33 years old who is a controlled hypertensive with gestational diabetes mellit
15、us. Her second sibling is 32 years old with kidney stones. The 4th sibling is 29 years old who is a controlled hypertensive. The 5th sibling is 20 years old who is apparently well.,History,9,PERSONAL AND SOCIAL HISTORY: Patient is a high-school graduate and currently works as a machine operator Habi
16、ts: Non-smoker, non-alcoholic beverage drinker REPRODUCTIVE HISTORY: GYNECOLOGIC HISTORY,The patient had menarche at 13 years old which lasted 4 days, light flow, consuming 3 pads per day and not associated with dysmenorrhea. Subsequent menstruations were irregular, with an interval of approximately 1 to 3 months lasting 3 to 4 days, moderate flow, consuming 4-5 pads per day, and associated with dysmenorrhea.,History,10,REPRODUCTIVE HISTORY: OBSTETRICAL HISTORY The patient is
