Case Study ( )اسم القسم نسا داخلى ( 3&2) الشهر Student Name: 1. Eman Mohamed Ahmed 2. Esraa Mohamed Salama 3. Nada Mahmoud morsy 4. Norhan Mahmoud ebrahim 5. Hadeer Nabil Salah 6. Hayam magde Mahmoud 1 Case Study Sociodemographic data Special unit…geriatric gynecology……………….. Patient’s name:Mariem Ahmed Elsayed ……………………………… Hospital No…2265478965………… Date of admission…14/3/2023…………………………….. Stay period:…one day…………. Age:………24 ……. Sex………female……………. Levelofeducation……bacalory………………….. Occupation…teacher…………. Marital status…married……………………… Religious…muslim……………. Present History: -Diagnosis/ Present illness:…… postpartum period……………………………. -Chief complaints on admission: …backache ,contractions of uterus and rupture of membranes……………………………………………… -Associated signs and symptoms: non …………………………………………………… -Onset / Duration /Frequency: graduall…………………………………………… -Predisposing…factors: younger age ,primary labor, unstable emotional feeding, and unrealistic expectations of pain …………………………………… …………………………………………………………………………………… Past History: Medical: -Diagnosis / Duration:……_……………………………………………………………. -Diagnosis / Duration:………_…………………………………………………………. -Diagnosis / Duration:………_…………………………………………………………. Surgical: -Name of surgery / Duration:…non …… ………………………………………………….. -Name of surgery / Duration:…non ……………………………………………………….. Allergy history:……non………………………………………………………………… 2 Family history: -Diagnosis / Relation:……non …………………………………………………………… -Diagnosis / Relation:……non …………………………………………………………… Life style habit-----sedentary life style------------------------------------------------------Patient’s physical assessment Assment BUBBLEHE B:-Breast Inspection and palpation of breast soft and normal appearance and nipple soft pliable ,intact not finding any abnormality such as ( redness, heat,pain ,cracked, and fissures nipple, inverted nipple, palpable mass ,painful ,and bleeding) U:-Utrues Normal size and shape, mobile, regular, firm urine contraction, 2cm below umbilical and non tender B- Bladder Normal voiding ( amount ,color, not burning ) B:-bowel Normal habit not constebation or diarrhea L:- lochia Assess lochia after delivery for type ,color ,odor ,amount In first 3 day lochia rubra ( bright red ,small clots ,and non foul odor ) E:- episiotomy and perineum Not finging because she had delivered by ccesarean section H-homans signs ( Nigtive homans signs and not signs of DVT such as ….sudden ,unexpected pain in the back of the leg ,Tachycardia or shortness of breath, edema, redness, or warmth of localized) E:- Emotional state assess for bounding and emotion state for mother and not finding any abnormality such as depression Definition of state - The fourth stage of labour is the first hour following the full expulsion of the placenta, after baby is born. It is the time that the woman's body stabilises and the baby fully adjusts to life outside the womb. It is a time to rest, eat and drink for the mother and for the baby to be fed, checked, weighed and measured. 3 physiology of postpartum period — is the period after delivery of conceptus when maternal physiological and anatomical changes return to the nonpregnant state. The postpartum period, also known as puerperium, starts following the expulsion of the placenta until complete physiological recovery of various organ systems. The postpartum period divides into three arbitrary phases, i.e., acute phase - the first 24 hours after delivery of the placenta, early – up to 7 days, and late – up to 6 weeks to 6 months Clinical manifestations According to patient …………………………………………… Abdominal pain Exhausted Dizziness …………………………………….. …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… According to literature Alert and euphoric Exhausted Bleeding Empty after carrying her baby around for so long Weak, light-headed and faint Hungry and thirsty Eager to remove drips and epidurals, etc. Uncomfortable, stingy and cramping Tired and disinterested Abdominal pain episiotomy pain ……………………………………... ………………………………………….. …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… 4 Complications According to patient According to literature …………………………………………… …………Nill………………………………... ……………………………... ………………………………………….. Cardiovascular diseases …………………………………………… Other medical conditions often …………………………………………… reflecting pre-existing illnesses Infection or sepsis …………………………………………… Excessive bleeding after giving …………………………………………… birth (hemorrhage) …………………………………………… A disease of the heart muscle that makes it harder for your heart to …………………………………………… pump blood to the rest of your …………………………………………… body (cardiomyopathy) …………………………………………… A blockage in one of the pulmonary arteries in the lungs often caused by blood clots that travel to the lungs from the legs (thrombotic pulmonary embolism) Stroke High blood pressure (hypertensive) disorders of pregnancy A rare but serious condition that occurs when amniotic fluid or fetal material, such as fetal cells, enters the mother's bloodstream (amniotic fluid embolism) Anesthesia complications …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… ………………………………………….. 5 Diagnostic measures Lab investigation: According to literature Lab Investigation According to patient Patient's Results Normal Range Nursing Considerations WBC 10.5 4.5 to 11.o Normal RBC 4.5 3.8 to 5.2 Normal HGB 9.5 11.6 to 15 Abnormal MCH 28 27 to 31 Normal MCV 85 80 to 100 Normal PLT 250 150.000 to 450.000 Normal Radiological examination: According to literature Type of examination Nill According to patient Check for what done Nill Patient's Results Nill 6 Nursing Considerations Nill Medical management according to patient No. 1 Drug name Route Dose / Frequency Side effect Nausea Normal saline ORAL 2*3 vomiting headache 2 CEFTRIAXONE IM/ IV once 3 Voltarin IM Nursing Consideration Check blood pressure each 2 hours conistpation Abdominal distress fatigue nausia Abdominal pain iching fever Once Surgical management According to patient According to literature …………Nill………………………………..………Nill…………………………... …………………………………………… ………………………………………….. …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… ………………………………………….. …………………………………………… 7 Nursing management According to patient Monitor the vital signs every 4 hours Examine both the mother and the newborn physically to note any signs of postpartum complications or defects .……………………………………... According to literature Advise the mother to :- Follow your doctor's orders. Don't skip your follow-up appointments and do take it easy. ... Get as much rest as you can. ... Instruct the woman to avoid Accept help from friends and family. ... lifting heavy objects for the Eat healthy meals. ... first three weeks after birth. Get some exercise. ... Advise the woman to allot a rest period every Spend some quality time with your partner. ... day, or to rest and Join a mommy support sleep while her newborn is also asleep so she group…………………………………………… can regain her A home visit after the discharge is usually energy.………………………………………….. recommended to check on how the family is Eat healthy meals doing now that they have a newborn in the Administer prescribed house.…………………………………………… medication …………………………………………… .…………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… …………………………………………… 8
