OB/DR Case Analysis No. 1
Mrs. JMR is a 25-y/o, who is 37 weeks pregnant came in to the provincial hospital last September 19, 2020 5:07 pm with complain of slightly elevated blood pressure of 125/85 mmHg as evidenced by on and off pain at her back. She was admitted to OB-ER at 10:00am.
Mrs. JMR had her prenatal check-up at Kauswagan Health Center before being referred to provincial hospital due to possible labor pains.
Upon initial assessments, Mrs. JMR's baseline vital signs were temperature of 36.7 degree Celsius, pulse of 89 bpm, respiratory rate of 20 cpm and an oxygen saturation of 99%.
The fetal heart tones were 134 and regular. Her current weight is 64 kgs with a height of 5'5 and an endomorphic body build.
Mrs. JMR GTPAL information includes: G- 3, T-2, P-0, A-0, L2. She don't have any history of abortion, minor and major surgical operations. Her family has history of hypertension both sides.
Her menarche started at 14 years old with an interval of 7 days, menstrual flow of 5 days and amounts to 4 napkins per day. There was no edema present in her extremities.
During the initial assessment, Mrs. JMR was still a bit drowsy but was aware of her surroundings. It was noted that she has good personal hygiene, no outstanding orders and dressed appropriately.
At 2:15pm, she stated that she had been having contractions at 6 to 9 minute intervals since 4 pm as recorded. It lasted 30 seconds.
She also stated that she had been having "a lot of false labor" and hoped that this was "the real thing". After 2 hours approximate (4:15pm) her membranes ruptured, her contractions began coming every 4 minutes and lasted 45 to 55 seconds. They were moderately strong then.
The nurse examined Mrs. JMR and found that the baby's head was at +1 station, and the cervix was 4 cm. Dilated and 80 percent effaced. She reported her findings to the doctor and the doctor ordered Demerol 50 mg with Phenergan 25 mg. To be given intravenously when needed.
The doctor gave her a Pudendal block and did a midline episiotomy. At 8:05 pm, Mrs. JMR gave birth to a 7 lbs., 5 oz. (3.317 gm.) Boy in the L.O.A. Position.
The nurse put medicine in the baby's eyes and placed an identifying bracelet on his right wrist and ankle. A matching bracelet was placed on the mother's wrist. At 8:08 p.M. The placenta was expelled.
Guide Questions: ASSESSMENT PHASE
1. Is Mrs. JMR's baseline vital signs within the normal range?
- Will you consider Mrs. JMR's condition at risk? Explain.
2. Is the fetus experiencing possible intrauterine distress? - after knowing the fetal heart tone and other medical informations? Explain.
- What are the signs of Fetal distress?
3. Identify and explain the GTPAL presented.
- What are the importance of knowing GTPAL?
4. During the initial assessment, Mrs. JMR was still a bit drowsy, is it a normal physiologic response during labor? Explain.
5. Do you think Mrs. JMR. is in false labor? Give reasons for your answer.
6. How would you know that Mrs. M. has entered the latent phase?
7. How would you know that Mrs. M. has entered the active phase?
8. How would you know that Mrs. M. has entered the transition phase?
9. Based on the details presented above, At 2:15pm what phase of first stage of labor does Mrs. JMR belongs? Explain.
10. Based on the details presented above, At 4:15pm what phase of first stage of labor does Mrs. JMR belongs? Explain.
11. What is/are the possible causes of slight elevation of blood pressure? - 125/84 mmHg
12. What is/are the possible reasons why Mrs. JMR referred to Provincial Hospital?
13. Explain the following details: "The nurse examined Mrs. JMR and found that the baby's head was at +1 station, and the cervix was 4 cm. Dilated and 80 percent effaced"
Guide Questions: DIAGNOSIS PHASE
1. State the possible nursing diagnoses arising from the case analysis presented.
2. Identify appropriate nursing problems and make a NURSING CARE PLAN.
- Advised to follow the NURSING CARE PLAN FORM FORMAT for accuracy and organization
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