Case study

Labor and Delivery case studyKelsi Noeth

My name is Kelsi Noeth, and this is my case study for OB. I chose to do it over my patient from labor and delivery. 1Demographic DataPatients Initials: A.S. 29 y/o Caucasian female Why in the hospital? C-section at 37 weeks, 5 days. In the labor and delivery unitBreastfeeding or formula? BreastfeedingG1P1First child

A.S. is a 29 year old Caucasian female who was hospitalized for going into labor, and ended up needing a cesarean birth. Her cesarean birth was done at 0730 and completed by 0830 on 10/23/2015 with no complications. She was in need of a C-section because the baby was in a breech position due to her uterus having a septum. The septum prevented the healthcare professionals from turning the baby. She had the C-section at 37 weeks, 5 days and received a spinal block to control the pain during the cesarean birth. The baby was a female, and it was her and her husbands first child. She had plans to breastfeed, and did so soon after she got back to her room from the C-section. We took the baby girls blood sugar, and it fell low at 44 so she needed to be formula fed. A.S. soon took a nap until she had to go to the postpartum floor soon after breastfeeding. Her husband and her mother were in the room with her. It was very important that she got some rest after the C-section. 2Past Medical HistoryBlood type: O negativeNegative for HIV, strep, hepatitisNKDAHistory: Pleurisy, Irritable bowel syndromePast Surgeries: Coronary endarterectomyc/o constipation

A.S. has a blood type of O negative. They sent out a sample of the babys blood in order to determine the blood type. This would determine if the mother needed to be given Rhogam, but the patient left the labor and delivery unit before the results of the babys blood came back.

She was negative for HIV, strep, and hepatitis. She had no known drug allergies. Prior to hospitalization, she complained of joint pain, frequent urination, and constipation.

Pleurisy was stated in her past medical history. This is an inflammation in the lining of the lungs and chest (the pleura) that leads to chest pain when you take a deep breath.

She also suffers from irritable bowel syndrome. Irritable bowel syndrome is a group of symptoms that includes pain or discomfort in the abdomen and changes in bowel movement patterns. These all usually occur together. For A.S. in general, her irregular bowel movement patterns caused uncomfortable constipation very frequently. She told me that she has to sleep on a few pillows because of the acid reflux she gets, as well. She states that she has tried increasing her intake of fiber and taking laxatives, but that the side effects are worse than being constipated. She stated that she did not want to always be using the restroom because she was taking a laxative.

The patient has also had a coronary endarterectomy. A coronary endarterectomy involves the removal of occluding material from a coronary artery. She had the surgery for this in May 2013. 3Family Medical History Mother: Type 2 Diabetes

Father: myocardial infarction

Both parents have hypertension .

Her mother was diagnosed with type 2 diabetes one year ago and her father experienced a myocardial infarction, but is no longer living. Both parents had hypertension and took medication daily for it.

Since her mother has diabetes, it was very important that during her pregnancy, she was kept a close eye on and paid special attention to how she was treating her body to avoid getting gestational diabetes. We informed her to continue occasionally monitoring her blood sugars, watch her weight, and watch her diet. She had been overweight in the past, but had since lost over 40 pounds. 4Psychosocial Esthetician, but currently unemployedInsurance: MedicaidEducation: HS diploma and cosmetology schoolNegative for tobacco, drug, or alcohol useMarried to father

A.S. is educated to be an esthetician, and has worked as one in the past. She is currently not working, though, and they are relying on the fathers income. Her insurance is Medicaid. She graduated from high school and proceeded to get general education requirements She moved onto cosmetology school, where she attended for two years. She was negative for tobacco, drug, or alcohol use during pregnancy. She did not smoke or do any drugs before her pregnancy, but drank alcohol occasionally before becoming pregnant. She is married to the father of the baby, as well.

Some stressors include the mother being unemployed. That could cause difficulties with affording things. She also mentioned that her mother plans on being around a lot, but that she does not know how to tell her that she would like to bond with her daughter for the first few weeks with her mother not always being around. This could cause some tension between them. 5Nursing Theory Virginia Hendersons Nursing Need Theory Three assumptions identified

Four major concepts

Fourteen components

Need theory. (n.d.). InNursing Theory. Retrieved from http://www.nursing-theory.org/theories-and-models/henderson-need-theory.php

For my nursing theory regarding A.S. and her needs, I chose Virginia Hendersons Nursing Need Theory. This theory emphasizes the importance of increasing the patients independence so that progress after hospitalization would not be delayed. She has an emphasis on basic human needs.

Henderson identifies three major assumptions in her model of nursing. The first is that nurses care for a patient until a patient can care for him or herself. The second is that nurses will devote themselves to the patient day and night. The third is that nurses should be educated at the college level.

The four major components addressed in the theory are the individual, the environment, health, and nursing.

There are 14 components based on human needs: Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable postures. Sleep and rest. Select suitable clothing. Maintain body temperature within the normal range. Keep the body clean and well groomed. Protect the integument. Avoid dangers in the environment and avoid injuring others. Communicate with others. Worship according to ones faith. Work in a way that gives you a sense of accomplishment. Play or participate in various forms of recreation. Learn. Use available health facilities.

I followed this theory in many ways. We ensured that she had constant access to ice chips. A.S. had a catheter in, so that she could continuously eliminate body wastes. She was still very tired after the surgery and not ready to walk, but I helped her to become comfortable by placing pillows behind her back and under her arms. While she was breastfeeding, we placed another pillow under each arms so she would be even more comfortable. When she wanted to nap, we put the back of the bed down. We ensured privacy by making sure that her clothing were suitable and covered all areas. We monitored her body temperature, along with her other vital signs. We made sure we were willing to listen to her so that she could express any fears she may have regarding motherhood or her C-section. Regarding activities, she said she wanted to go find a job after a few months of motherhood. 6Developmental TheoryImogene Kings Goal Attainment Theory

Roles, stress, space, timeThree interacting systems

Goal attainment. (n.d.). InNursing Theory. Retrieved from http://www.nursing-theory.org/theories-and-models/king-theory-of-goal-attainment.php

To describe the developmental status of the patient, I decided to use Imogene Kings Goal Attainment Theory. This theory describes a dynamic, interpersonal relationship in which a patient develops to attain certain life goals.

Factors that affect the development and attainment of goals are roles, stress, space, and time.

There are three interacting systems: Personal- perception, self, growth and development, body image, space, and time. Interpersonal- interaction, communication, transaction, role, and stressSocial- organization, authority, power, status, and decision making.

It is necessary for the nurse and patient to communicate in order for development to occur and for goals to be achieved. A form of development is an increase in knowledge. I enhanced this at clinical by educating the patient on specific topics, such as not to worry that she could not wiggle her toes because the spinal block needs to wear off. We communicated with the patient to determine any anxieties and fears that the patient may have. Stresses can interrupt the development and goal attainment process. It is important to prevent this from happening. We prevented this by comforting the patient and supplying her with knowledge and education. This education reduced her stress because she was more confident to take on motherhood.

7Growth and Nutritional Status Height: 57Weight: 191 pounds BMI: 29.9 Appearance: Considered overweight Nutrition: Adequate nutrients G1 P1Baby 50% percentileSlightly pre-term so needed blood sugars

A.S. is 5 foot, 7 inches. She weighs 191 pounds, and her pre-pregnancy weight was 165 pounds. Her BMI is 29.9, so she is considered overweight. Her appearance looks relatively normal, though. The patient is gravida 1 para 1 living 1.

She had previously lost around 40 pounds to get her to her pre-pregnancy weight of 165 pounds. During her pregnancy, she gained 26 pounds. She was watching herself very closely during her pregnancy and before to avoid getting type 2 diabetes beforehand like her mother, and to avoid getting gestational diabetes during her pregnancy.

When I asked her, she stated that she was careful to eat an adequate amount of protein, fruits, and vegetables. She got most of her carbohydrates from whole grains.

The baby was in the 50% percentile, which is great. She was slightly pre-term, which means that her blood sugars need to be frequently checked. She is breast-fed every 2-3 hours.

For A.S., it is important that she understands the importance of how to prevent diabetes from occurring and how to reduce her risk of hypertension. Since her mom has diabetes, it is important that A.S. is careful with that she eats, watches her weight, and maintains a proper exercises routine. As far as blood pressure, it is of utmost importance that A.S. understands the importance to drink a lot of fluids and continue exercising. She does not smoke, but she should be educated on the risk of her blood pressure increasing if she were to start smoking. She should also make sure to get her blood pressure checked routinely. She should be advised to avoid alcohol while she is breast-feeding, as well as specific kinds of fish and other foods. 8Focused Physical Assessment Vital SignsT: 97.6 FP: 82RR: 16BP: 140/82O2: 98% on room air General Appearance A&OX4Well-groomedSpeech clear, no slurring

Her vital signs were relatively stable. Her temperature was 97.6 F, pulse was 82 beats/min., respiration rate of 16/min., blood pressure of 140/82, and oxygen saturation of 98% on room air.

For general appearance, she was tired, but alert & oriented x 4. Her speech was clear with no slurring. She was well-groomed, but looked very exhausted. 9Focused Assessment ContinuedLymph Nodes: Non-tender and non-palpable. HEENTFacial features symmetricalDenies sinus painPERRLAHeartRegular rate and rhythm. No murmurs noted. Chest/LungsClear upon auscultation posterior and anterior.

Her lymph nodes were non-tender and non-palpable. Her facial features were symmetrical and she denied having any sinus pain upon palpation. PERRLA.

Her heart had a regular rate and rhythm with no murmurs noted. Her lungs were clear upon auscultation with normal effort, posteriorly and anteriorly. 10Focused Assessment ContinuedExtremities:Cap refill