Hawaii Community College Associate Degree Nursing Program Nursing 254 Intrapartum/Postpartum/Neonatal History and Physical Date of care: 9/18/18 Student Name: Keli’i Mendonca Room #: 306A Patient ID (initials): K,F Birth date: 10/4/95 Language: English Ethnicity: Asian, Caucasian, Native Hawaiian Marital Status: Single Admit date/time: 9/17/18 @ 1610 Reason for Admission: 39 weeks pregnant reporting excessively dry mouth and rapid breathing patterns. LMP: N/A EDD: 9/26/18 GA: 38 Gravida: 2 Para: 1 Total Pregnancies: 2 Term: full Preterm: 2 AB-induced: AB-spontaneous:2 Ectopic: Multi: Living:2 Past Pregnancies Date Mo/yr GA Weeks Length of labor Birth Weight Sex Type of Delivery Anesthesia Preterm Y/N Comp. 2014 37 8 hour s 2312. 12 gram s M SVD Yes Yes N/A Relevant Past Medical History/OB Complications/Delivery Complications Patient has a past medical history of anxiety. The patient exhibited signs and symptoms of dehydration. Medications taken during pregnancy: N/A 1
Tobacco: N/A Alcohol: N/A Illicit Drugs: N/A Allergies:NKDA Breastfeed Formula feed Childbirth Education: Yes No If “yes” describe: Pain Management Plan During Labor: Norco 5/325 mg Q 6hr// Epidural anesthesia. Physician Orders (Use back if no room) Prenatal Labs/Identify the purpose for each Result Activity: Ambulate with assist. High fall risk. Bathroom private. Blood Type A RH Type Positive Care: Apply ice pack to affected area PRN. Urinary straight catheter after 6hrs. Vital signs routine. Antibody Screen Non- reactive HBsAg N/A Code: FULL CODE. HIV Negativ e Chlamydia Negativ e Diet: Regular. Gonorrhea Negativ e HSV Not tested HPV Not tested GBS EBL H&H prior and after delivery Positive Physical Assessment Vital Signs T- 99.1 F oral. HR- 121 RR-19 BP-94/62 Sp02: 99% @ room air General Appearance The mother appears to be resting with her arms around her baby. They appear to be resting comfortably without any physical signs of distress. The mother and baby seem to both be sleeping upon initially meeting.
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- Summer '19
- Nursing, acute pain, Hawaii Community College