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Obstetrics Case StudyBy: Alyssa Clarkson

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Demographic Data

Reason for hospitalization: Postpartum

Patient initials: S.M.

Age: 31 years old

Se: !emale

"thni#ity: Cau#asian$%on&'ispani#

Religion: Assem(lies of )od

Code Status: !ull

*eli+ery *ate: ,#to(er 1- /01

Breast or !ormula feeding: Breastfeeding

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Past Medical History

2mmunization Status: Ru(ella & %egati+e 2mmune4

Blood 5ype and Rh Status: ,6

'27: %egati+e

Strep: )roup B Strep & %egati+e

'epatitis: %egati+e

Pre+ious Surgi#al 'istory: 8isdom teeth remo+al Cesarean Se#tion

'ospitalizations: Birth of #hildren

Allergies: Aspirin Seafood espe#ially Shell9sh

Chroni# 2llness: *epression Asthma Migraines

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Family Medical History

Mother: %o pertinent medi#al history

!ather: 'ypertension

Maternal )randmother: 'ypertension *ia(etes ung C

Paternal )randmother: 'ypertension *ia(etesMaternal )randfather: %o pertinent medi#al history

Paternal )randfather: %o pertinent medi#al history

Si(lings: %o pertinent medi#al history

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Psychosocial History

!amily Makeup: 'us(and and #hildren

"mployment: 'omemaker

"du#ation: Ba#helor;s *egree2nsuran#e: Medi#aid

 5o(a##o *rug and Al#ohol

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Physiological Status

*orothea ,rem Selfare *e9#it4 5heory

Patient should identify selfare de9#its and then de9ne their roles tdemands

Patient should (e a self&reliant indi+idual and responsi(le for o=n #as others in their family =ho need #are

Meeting selfare needs is an important #omponent of primary #are

 5he patient;s kno=ledge of potential health pro(lems is needed forselfare (eha+iors

%ursing is a form of a#tion (et=een t=o or more indi+iduals

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Developmental Status

"rik "rikson;s "ight Stages of *e+elopment

 5rust +s. Mistrust

Autonomy +s. Shame

2nitiati+e +s. )uilt

2ndustry +s. 2nferiority

earning 2dentity +s. 2dentity *i>usion

2ntima#y +s. 2solation

)enerati+ity +s. Self&A(sorption

2ntegrity +s. *espair

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Growth and Nutritional Status

BM2: 30.?

'eight: ; @;;

8eight: Pre&pregnan#y: 1@ l(s.

Pregnan#y: 1-? l(s.

Post&pregnan#y: 1-0 l(s.

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Focused Physical ssessment

7ital Signs

)eneral Appearan#e

ymph nodes

'ead and ne#k

"yes

"ars

%ose

Mout

Ba#k and

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!aboratory "esults

'emoglo(in 'emato#rit: -.@ g$d /-.

Ru(ella titer: %egati+e 2mmune4

'epatitis s#reening: %egati+eBlood type: ,

Rh fa#tor: 6

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Medications

%or#o

Motrin

!entanyl

2ron Preparation !errous Sulfate4

,yto#in

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"e#erences

A#etaminophen$hydro#odone /01D4. 2n Drugs.com. Retrie+ed ,#to(er /D /01 fromhttp:$$===.drugs.#om$sf$a#etaminophen&hydro#odone&side&e>e#ts.html

A#kley B. E. ad=ig ). B. /01D4. Nursing Diagnosis Handbook  10th ed.4. Maryland 'eights M

)eorge E. B. /0114. Nursing Theories: The Base for Professional Nursing Practice @th ed.4.