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Postpartum Mother and Newborn Profile

Postpartum Mother and Newborn Profile. By: Matt O’donnell , matt mangus and brittany locke. Mother History. Mother’s initials: N. N. Age: 24 years old Caucasian Female Reason for Admission: Premature Rupture of Membranes (PROM) Allergies: NKDA Religion: Baptist

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Postpartum Mother and Newborn Profile

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  1. Postpartum Mother and Newborn Profile By: Matt O’donnell, matt mangus and brittanylocke

  2. Mother History • Mother’s initials: N. N. • Age: 24 years old • Caucasian Female • Reason for Admission: Premature Rupture of Membranes (PROM) • Allergies: NKDA • Religion: Baptist • Education: High school Graduate

  3. History Continued • Work: Waitress • Smoker: Yes Amount: >10 cigarettes a day • Alcohol use: None • Substance Abuse: None • Development Level: Young Adult • Significant Family History: None • Significant Medical/ Surgical History: LEEP, Cervical Dysplasia, History of Migraines and Right Side Sciatica Pain

  4. OB/ Gynecologic History • Gravida 3 Para 1 Term 1 Abortion 1 Living 2 • Patient had vaginal delivery and received epidurals for both pregnancies • LMP: 5/23/2008 • EDD: 3/2/2009 • Number of weeks Gestation: 37 weeks • Problems or complications during this pregnancy: • Premature Rupture of Membranes (PROM) • Frank Breech

  5. OB/ Gynecologic History Continued • Medications during pregnancy: • Prenatal Vitamin • Prenatal vitamins provide extra iron, calcium and folic acid to expecting mothers to prevent anemia, loss of bone density and tubular neural defects. The vitamins are taken once a day.

  6. OB/ Gynecologic History Continued • STIs: Chlamydia (treated in 2005) • GYN disorders of surgeries: LEEP (2005) and Dysplasia (2005 and 2008) • Prenatal classes: Refused to attend • Diet Limitations: None (Regular Diet)

  7. Prenatal Laboratory Data

  8. Prenatal Lab Data

  9. Prenatal Diagnostic Test

  10. Labor and Delivery Data • Type of Delivery: Vaginal (Frank Breech) • Date: 2/11/09 • Time: 1419 • Procedures in Labor: Midline Episiotomy • Pain Management: Epidural • Estimated Blood Loss (EBL): 300 cc • Amniotic Fluid: Clear and moderate amount • Placenta: Intact • Total time in labor: 6 hrs 23 mins

  11. Labor and Delivery Data • Medications during Labor • Epidural • Regional analgesia administered into the epidural space through a catheter. It is a relatively safe way of relieving pain during pregnancy. • Pitocin • Pitocin is a synthetic form of oxytocin that increases uterine contractions of uterine smooth muscle. Used for the induction of labor.

  12. Nursing diagnoses for labor & delivery • Fear related to the uncertainty of pregnancy • Risk for Infection related to a site for organism invasion secondary to premature rupture of membranes • Acute pain related to uterine contractions during labor • Knowledge deficit related to not attending prenatal classes.

  13. Postpartum Vitals 0800 BP: 140/86 P: 77 T: 97.6 R: 20 1500 BP: 127/78 P: 64 T: 97.8 R: 20

  14. Postpartum Assessment Pain: 0920: 7 (Sharp pain, location: nipples and hemorrhoids) Medicated (Darvocet) 1020: 3 1500: 0 Neurological A&O X 4 MAE 100% strength PERRLA no visual disturbances

  15. Postpartum Assessment Cardiovascular Rhythm: steady Rate: regular Capillary Refill: <2 secs Homan’s Sign: negative for both legs Pulses: P +2 Respiratory Pattern: Regular Breath Sounds: Equal Bilaterally Cough: Productive

  16. Postpartum Assessment Integument Skin: Normal Color: Pink Temperature: Warm and dry Incision: Midline Episiotomy (well approximated, 1 degree laceration, no edema and no ecchymosis) Gastrointestinal/ Genitourinary Abdomen: soft BSP X 4 and normoactive Urine: yellow, normal frequency and urgency Hemorrhoids: small cluster Flatus: Present BM: No BM since admitted

  17. Postpartum Assessment Reproductive Breasts: Soft and engorged Nipples: Tender and Sore Fundal Height: Firm (located: Umbilicus) Lochia: Rubra and moderate Bonding Appropriate Talks to baby Touches baby Attentive to babies needs Holds baby Always wants to be with baby and know where the baby is

  18. Postpartum Medications • Scheduled • Docusate Sodium (Senna) • 2 ud tab q day • Stool softener • Ibuprofen (Motrin) • 600mg tab q 6 hrs • Nonopoid analgesic • Prn • Acetaminophen (Tylenol) • 500mg tab q 6hrs • Nonopoid analgesic • Benzocaine 20 % (Americaine Hemorrhoids ointment) • Topical analgesic (numbing agent)

  19. Postpartum Medications Continued Hydrocortisone (Anesol HC 2.5% cream) Corticosteroid (decreases inflammation) Methyl Maleate (Methergine) 0.2mg IM and/or oral Oxytocic (prevention and treatment of PP hemorrhage) Darvocet 1 ud tab q 4 hrs Opoid analgesic Witch Hazel (tucks medicated pads) Herbal/medicinal soothing agent

  20. PP Nutritional Assessment Laxatives/Stool Softeners: Senna-S Prepregnant Weight: 145 lbs Desired Weight: 25-35lbs Physical Appearance: Clean, Healthy, and Fit

  21. PP Nutritional Assessment Cont’d 24hr Diet Recall: Omelette with Toast and Orange Juice Chicken Salad w/Ranch Dressing and Ginger Ale Food Stamps: No Food Stamps or WIC Who Shops?: Mother Racial/Ethic Diet Considerations: No Diet Restrictions

  22. PP Nutritional Assessment Cont’d Concerns about Nutritional Habits: Less Sodium intake Total Weight Gain During Pregnancy: 25 lbs BMI: 24 Healthy Fluid Intake: 2000 cc

  23. PP Nutritional Assessment Cont’d Breast/bottle feeding: Breast Feed Snack Pattern: Occasional Snacks Exercise Pattern: Non Mentioned Who Cooks? Single Mother Diseases related to Nutrition: None

  24. Postpartum Lab Data

  25. Postpartum Nursing Diagnosis Acute pain related to trauma to perineum during labor and delivery Risk for infection related to a site for organism invasion secondary to postpartum period Impaired comfort related to involution of uterus and engorged breasts Constipation related to decreased peristalsis secondary to pregnancy

  26. Newborn Data Gender: Female Gestational Age: 37.2 weeks Birth Weight: (3012 gms) (6 lbs 10 oz) Birth Length: (44.5cm) (17.5 inch) Apgar Scores: 1min: 9 5min: 9 Type of feeding: Breast feeding Age at the time of assessment: 18hrs

  27. Newborn Vital Signs 0800 Temperature: 98.4 Pulse: 130 Respiration Rate: 35 1500 Temperature: 98.7 Pulse: 135 Respiration Rate: 42

  28. Newborn Assessment Skin: Pink and slightly jaundice Mouth: Moist and pink Moro, sucking, rooting, tonic neck, grasping and babinski reflexes: All present Abdomen: Soft, non-distended and BSP X 4

  29. Newborn Assessment Cont’d Cord: Drying Fontanels: Soft and Level Tone: Good Cry: Appropriate for circumstance Extremities: Symmetrical and full range of motion

  30. Newborn Assessment Cont’d Respiratory: Even and unlabored for both lungs Cardiovascular: Regular/even rate and rhythm Babies Id bracelets and security band: Intact and present 0800, 1000, 1200, and 1400 Feedings: 0600, 0920, 1150 and 1500

  31. Newborn Nursing Diagnosis Risk for imbalanced body temp related to ineffective temperature regulation secondary to extremes of age (newborn) Risk for ineffective infant feeding pattern related to lack of knowledge or commitment of caretaker (feeder) to special feeding needs or regimen Risk for sudden infant death syndrome related to increased vulnerability secondary to maternal cigarette smoking

  32. The End

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