Professional Documents
Culture Documents
Maternity 335
Spring2008
(1)
Introduction:
Demographic data :
- Client name: A.M.K
.Age: 33years-
.Address: halhoul-
-
.Hospital: AL-Makased hospital-
:Chief complain
The pt refereed from out pt clinic due to decrease fetal
movement , then did ultrasound and the fetal in breech
.presentation
Past history
Medical history: pt has hepatitis B , no hypertension , no
.diabetes , and no tuberculosis
Surgical history: previous cesarean , abortion at 2005 , then did
.DNC
(2)
Allergic : as my pt said she has allergy from ,and unknown
allergy to the medication ,she never experience allergy for odor
or dust , and didn't suffer from any abnormalities for any plant
.or trees
.Medications: she didn't take any regular medication
.Gynecological disorder: she did DNC
Obstetric history
Data of all previous pregnancy: the first birth was in 31/7/2004.
after complete 36 weeks she did elective C/S delivery ,female
baby, unhealthy , she has imperforate anus, thy did colostomy ,
spinal bifida , hips dislocated , enlargement of bladder ,
ABGAR score was 6/9 under general anesthesia , she didn't
remember a lot about prenatal , intrapartum, but she said that
.post partum period was very long & tired
she delivered male baby complete 38 weeks, by , 3/3/2008
C/S delivery due to breech position ,spinal anesthesia , post
partum ,the first 24hr of bed , then she walked 5min, she felt of
dizziness, then back pain , she tokes sedative , the codition of
new born is good , the baby was active & the ABGAR score
.was 9/9
Family history
Her grand other was diabetic pt ,and hypertensive pt , her
husband's relatives have mental problem, down syndrome, heart
disease, two member of them had congenital problem
.abnormality and they died
(3)
Labor & it's stages
I deal with my pt on post natal word after C/S , so I deal in 4th
.stage of labor
Physical assessment
Vital signs : BP = 110/60
P = 71
T = 36.5
R = 17
Weight
.Befor delivery her wt was 96 kg , now her wt is 85 kg
.Height : 168 cm
: Skine
Pink in color , smooth in texture , brown patches at the face,
.vertical lina niagra
Heart
Lub-dub heart sound ,so regular rhythm 71 beat/ min , clear
heart beats and strong . she had no heart abnormalities , no
.murmur or hypotension
Breast
Both are symmetrical, no redness or swelling, the nipple is small
.inverted, soft breast & no congestion , areola patches
(4)
:Abdomen
the fundus is under the umbilicus, the operation site transverse
incision. she has abdominal pain due to the operation , transfer
.incision . the abdomen is distend, she also has bowl movement
Back
Has good postured shape , spinal vertebral is normal shape , she
has lower back pain due to pregnancy & spinal anesthesia , there
.is no disc
Extremities
Both are symmetrical , have good reflexes , no edema , no
.varicose vein or DVT , can walk & eat alone
Pelvic area
.Normal skin ,clean , no discharge , no congenital anomalies
:Path physiology
C/S birth accomplished through on abdominal incision in to the
uterus. The incidence of C/S birth is nearly 18% for the first
mother .70% for repeat procedures. This rate result from the
combination of the increased safety of C/S and the use of fetal
. monitors , which provide for early detection of fetal problems
(5)
Placenta factor ((*
placenta previa-
premature separation of placenta-
umbilical cord prolapsed-
(6)
Laboratory tests
Prenatal tests
Test Value Normal value Meaning of
abnormal
values
WBC 10.1K/ul K/ul 4.1-10.9 Normal
RBC 4.95M/uL 4.6-6.2M/uL Normal
Hgb g/dl 12.9 12-18g/dl Normal
PLT 121K/UL 140-440K/UL Ubnormal due
to hepatitis B
Glucose 106 70-110 Normal
Postnatal tests
Test Value Normal value Meaning of
abnormal
values
WBC 10.6K/ul K/ul 4.1-10.9 Normal
RBC 4.00M/uL 4.6-6.2M/uL Ubnormal
Due to the
bleeding
during surgery
Hgb g/dl 10.9 12-18g/dl Normal
PLT 121K/UL 140-440K/UL Ubnormal
Due to
hepatitis B
Glucose 106 70-110 Normal
(7)
BLOOD GAS
Ph 7.30 -
Po2 18.4-
MEDICATION
:Action
Iron, which helps builds and replace blood cells that deliver
oxygen throughout the body, is an important part of a healthy
diet. Iron can be found in foods such as red meat, liver, whole
wheat, kidney beans, prunes and raisins. If you're not getting
enough of these foods, an iron supplement is recommended.
Iron dietary supplements are particularly important for
menstruating woman, who may be at risk for iron deficiency due
to blood loss, as well as pregnant women, who have a greater
need for iron to support enlarged blood volume, and fetal and
placental needs. Many multi-vitamins contain iron, but separate
iron vitamin supplements are also available in varying dosages
to fit your particular needs
:Nursing action
.remove any impaction palpable on digital exam -1
.Rational : to remove constipation causes
administer laxatives of choice , stool softener , bulk agent , -2
.and enemas as prescribed
.Rational: To facilitate & soften stool
.encourge a high fibers diet specially vegetable-3
Rational :Vegetable contains fibers which consider laxative
.that facilitate deification
. Aske pt for food intake -4
. Rational : to determine the case of constipation
. Encourage pt to walk -5
.Rational: to encourage the peristalsis movement
: Nursing action
.Checked the C/S site-1
.Rational: To prevent infection
.Checked the dressing -2
Rational: To reduce the infection
.recourse
Checked the wound if the wound if the.3
wound bleeding or discharge, swelling or
.redness
Rational: To mention the wound clean
.and dry
.Clean the wound -4
.Rational: To prevent infection
(11)
.Exercise-3
Rational: To strength the muscluses and
.to prevent the stiff of muscles
:Nursing Action
.change position and walks-1
.Assess the temp of skin-2
.wash the skin with warm water and dry it -3
.doingmassage it needed -4
Rational: To prevent bed source and skin ulcer to mention
.the skin as soft
Psychological:- she was feard from deliver baby has the same
problem, so when she saw the child she was happy, and about
.the operation she don`t care because she did it befor
-:Conclusion
this case very interesting, I learned from this case many
thinks like the procedure use of the operation, and care the
wound after the operation, I learned how to deal with mother
in post partum, what the benefit from cesarean section and in
.the same time what the disadvantage from it
---------------------------------------------------------------------
-:Refrences
.patient file-1
. From patient-2
Gil Bert and human, manual of high risk pregnancy and delivery,-3
.third edition 2003
Lenin (1995)pharmacology, Philadelphia, Lippincoot Company, -4
.fourth edition
.pillitter, Adel, maternal and child health nursing fourth edition -5
.http:// www.rashaduniversity. Com/poshem.html -6
.http://www.med.umich.edu/1 libr/wha/wha pphem crs.htm -7
(14)