POSTPARTUM VAGINAL DELIVERY UNFOLDING CLINICAL REASONING CASE STUDY.

History of Present Problem 7:00 am First Day Post-Delivery Night Shift Report: Anne Jones is a 17-year-old G1 P1 39 weeks’ gestation who delivered a healthy male infant at 2032 yesterday. Placenta delivered at 2045. No pain medication was given. She received a 250 mL bolus of Pitocin 30 units/500 mL IV after the delivery of the placenta then received 200 mL/hour until the IV bag was completed. The uterus is firm, one finger breadth below umbilicus and midline — Lochia moderate rubra. Mid-line episiotomy is well approximated, slightly bruised and perineum is slightly swollen. She had an ice pack applied to perineum throughout the night. Anne is up and ambulating ad lib and voiding without difficulty. She had 500 mL in/850 mL urine out. Vital signs: BP: 124/78, P: 74, R: 18, T: 98.6 F/37.0 C, O2: 98% room air, Pain 3/10 in perineum. She is on a regular diet. She was positive for Group Beta strep (GBS) and received a total of three doses of ampicillin IVPB during labor, her blood type is B-, and rubella positive. Infant Report: Infant Apgars were 8 and 9. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. Baby has breast fed and latched on for five minutes on both sides three times, and Anne is holding and talking to her baby. She plans on having the baby circumcised. The baby had three wet and meconium diapers. Cord blood was sent. Personal/Social History: Anne has her mother with her and seems to be relaxed but nervous. The father of the baby is not involved. She plans on breastfeeding for “awhile.” Anne still lives at home, and her mother is planning on helping with the new baby and appears supportive. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Report: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: You complete your first assessment: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breastfeeding P: 76 (regular) Quality: Cramping and tenderness of perineum R: 18 (regular) Region/Radiation: Uterus and perineum BP: 125/80 Severity: 4/10 O2 sat: 98% room air Timing: When breastfeeding and continuous for perineum Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Assessment Data: Clinical Significance: Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary concern? What primary health-related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology of Problem in OWN Words: Primary Concept: Current Assessment: Mom GENERAL APPEARANCE: Calm and quiet appears tired. Baby in a crib next to the bed. RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, 1+ edema in lower extremities bilaterally NEURO: Alert and oriented to person, place, time, and situation (x4) BUBBLE 3 BREAST: Lactating; soft, non-tender with evidence of colostrum UTERUS: Fundus boggy 1 cm above umbilicus and deviated to the right BLADDER: Voiding without difficulty. Denies any burning with urination. Hasn’t voided yet this morning. BOWELS: Abdomen soft/non-distended, bowel sounds audible per auscultation in all four quadrants, positive flatus, no BM since delivery. LOCHIA: States hasn’t changed pad this morning, peri-pad saturated with rubra lochia, small clots noted. EPISIOTOMY: Perineum slightly bruised and swollen, small hemorrhoids noted. EXTREMITIES: Calves cool to touch, no tenderness bilaterally EMOTIONAL: Quiet appears fatigued, currently interacting with baby