Student Name

Student Number:

Date: 28/10/208

Client’s Name (Initials): M.R.M

DOB: 20/12/992 Age: 25 Marital Status: Married/widow/single/divorcee

Religion: Muslim Occupation: House wife.

Years of marriage: 7 years.

Menstrual history
• Age at menarche: 13 y.o
• Duration of menstruation: 28 days
• Regularity of periods: Regular
LMP : 18/2/2018

Admitted from: Emergency department

Mode of Arrival: Conscious and alert

OBSTETRIC HISTORY
Gravida Nature of Bad Outcome of Puerperium
or parity Delivery obstetric pregnancy (a child) & Family
History if planning
any History
Full term Pre Term Sex Alive SB Any other

1 Yes — — Male Yes — — Healthy

mother &
new born
2 Yes — — Male Yes — — Healthy
mother &
new born
3 Yes — — Female Yes — — Healthy
mother &
new born

Family planning practices:

The family uses condoms and the pill as a method of contraception.

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Reason For admission

- Rapture of membrane, 2 hours prior to admission.

- abdominal pain.

Past medical & surgical history

- Sickle cell anemia, since 10 y.o .

- Tonsillectomy, 12 years ago.

History of medication use at home

No history of medication use at home.

Family History

No family history of chronic illnesses.

Current Medical Diagnosis

PPROM .

Subjective Data:

25 years old female patient , admitted from emergency department at 27/10/2018, at 35 weeks 6 days
gestation, patient states that she drained small amount of clear watery vaginal discharge, 2 hours prior
to coming to the hospital. Patient is also complaining of dizziness, fatigue, and mild abdominal pain.

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Patient is multigravida, G3,P2,A0,L2 , LMP was on 18/2/2018. Patient is a known case of sickle cell
anemia. With history of tonsillectomy 12 years ago. No family history of chronic illnesses.

Objective Data:
Vital signs:
Temperature oral: 36.5 C
Peripheral pulse rate: 80
Respiratory rate: 18 br/min
Systolic blood pressure: 106 mmHg
Diastolic blood pressure: 70 mmHg
SpO2: 100%
General: Alert and oriented, no acute distress.
Eye: pupils are equal, round and reactive to light .
HENT: Normocephalic, normal hearing, oral mucosa is moist .
Neck: supple, no tenderness.
Respiratory: normal lung sounds, normal breathing pattern, symmetrical chest wall expansion, bilateral
breathing sounds within normal limits.
CVS: normal heart sounds, normal heart rate, regular rhythm, normal peripheral perfusion.
Breast: the breast tissue, nipples, and the area surrounding the breast are normal.
GI: Inspection: abdomin is round, no scars, linea nigra, striae gravidarum.
Palpation: soft, no tenderness, cephalic presentation, no palpable uterine contractions.
Auscultation: fetal heart sound (133bpm).
Genitourinary: no inguinal tenderness, no urethral discharge.
Musculoskeletal: normal range of motion, normal gait, no tenderness, no swelling.
Integumentary: warm , dry, intact, no rash.
Neurologic: alert, oriented.
Psychiatric: cooperative, appropriate judgment, able to make sensible decisions.

LABORATORY TESTS:

Test Category Test Name Normal Range Patient Specific Result Interpretation
Lab Values
Complete blood WBC 4-11 11.90x10^9/L Normal

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count
Hgb 130-180 88.0 g/L low Patient is anemic.

Hct 0.36-0.46 0.282 L/L low Patient is anemic.

Platelet 150-450 297x10^9/L Normal

General Sodium Lvl 135-145 136 mmol/L Normal

chemistry.
Potassium Lvl 3.6-5.1 4.1 mmol/L Normal

Chloride Lvl 98-107 107 mmol/L Normal

Co2 22-29 18.8 mmol/Llow Patient is anemic

Glucose random 0-8.8 6.72 mmol/L Normal

DIAGNOSTIC TESTS:

Test Name Specific findings for patient Significance of results in relation to the disease

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 process for this patient including nursing
implications for care.
- Single viable Patient is 36 weeks and 1 day pregnant.
Pelvic - Fetal cardiac activity is
ultrasound positive.
( for pregnancy - Fetal movements are
follow up). normal.
- Cephalic presentation.
- Placenta is posterior.
- Biparietal diameter.
-

MEDICATIONS:

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Drugs Order/ Mode of drug actions Indications Adverse effects Nursing
Classifications consideration
Ampicillin Ampicillin acts as an prevent and treat a  nausea, vomiting, itching Determine
(Antibiotic) irreversible inhibitor of number of bacterial , and blood dyscrasias, previous
500mg the enzyme infections, such as seizures and serum hypersensitivit
Inj ,IV transpeptidase, which is respiratory tract sickness y reactions to
needed by bacteria to infections, urinary penicillins,
Q6hr make the cell wall.[2] It tract infections, cephalosporins,
inhibits the third and meningitis, and other
final stage of bacterial salmonellosis, and allergens prior
cell wall synthesis endocarditis. to therapy.
in binary fission, which
ultimately leads to
cell lysis; therefore,
ampicillin is usually
bacteriolytic.

Prostin Synthetically prepared To terminate pregnancy Headache, tremor, tension. Observe patient
(Prostaglandins member of the from twelfth week Transient hypotension, carefully, after
) prostaglandin E2 series through second flushing, cardiac insertion of the
that appears to act trimester as calculated arrhythmias, Nausea, drug. Rupture
3mg directly on myometrium from first day of last vomiting, diarrhea, of the
Tab, vag and on gastrointestinal, regular menstrual Chills, fever, dehydration, membranes is
bronchial, and vascular period; to evacuate diaphoresis, rash. not a
Q6hr
smooth muscle. uterine contents in contraindicatio
Stimulation of gravid management of missed n to drug, but
uterus in early weeks of abortion or intrauterine be aware that
gestation is more potent fetal death up to 28 wk profuse
than that of oxytocin. gestational age; to bleeding may
manage benign result in
hydatidiform mole; expulsion of
cervical ripening prior the
to labor induction. suppository.
Assess for
wheezing,
chest pain,
dyspnea, and
significant
changes in BP
and pulse .

Erythromycin inhibit protein Pneumococcal Nausea, vomiting, Monitor GI

(Antibiotic) synthesis by binding to pneumonia, Mycoplasm abdominal symptoms after
the 23S rRNA a pneumoniae (primary cramping, diarrhea, PO
molecule (in the 50S atypical pneumonia), heartburn, anorexia, administration;
subunit) of the acute pelvic Fever, eosinophilia, if symptoms
500mg bacterial ribosome inflammatory disease urticaria, skin eruptions, persist after
blocking the exit of the caused by Neisseria fixed drug eruption, dosage
Tab, PO
growing peptide chain. gonorrhoeae in females anaphylaxis reduction,
Q6hr
of sensitive sensitive to penicillin, physician may
microorganisms. infections caused by prescribe drug
susceptible strains of to be given

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staphylococci, with meals in
streptococci, and certain spite of
strains of Haemophilus impaired
influenzae.  absorption.

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1. Nursing Diagnosis *:
Decreased capacity for physical work at usual level related to decreased hemoglobin as evidenced by inability to maintain usual
level of physical activity and increased rest requirements .
Goals and Expected Nursing Interventions*
Outcomes
- Assess the clients ability to
The client will perform activities of daily
verbalize increased living ( ADLs ), and the
energy and demands of daily living.
improved well being.
- Monitor hemoglobin,
hematocrit, RBC count, and
reticulocyte counts.
- Provide supplemental oxygen
therapy , as needed.
Rationale for Nursing Interventions Evaluations
- Fatigue can limit the client’s Patient verbalised feelings of
ability to participate in self-care increased energy and improved well
and perform her role being.
responsibilities in family and
society, such as working
outside the home.
- Decreased RBC index are
associated with decreased
oxygen-carrying capacity of the
blood.
- Oxygen saturation should be
kept at 90% or greater.

- Teach strategies for energy - Assure patient can moblize

conservation. whiteout problems.

You must write the patient’s highest priority nursing diagnosis and follow it completely through the process.
* Nursing Interventions must include nursing assessment and a minimum of THREE nursing applications.

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2. Nursing Diagnosis *:
Anxiety related to labor as evidenced by patient stated that she feels nervous and anxious.
Goals and Expected Nursing Interventions* Rationale for Nursing Interventions Evaluations
Outcomes
- Assess physical reactions to - Anxiety can be characterized Goal partially met as patient stated
Patient will report anxiety . by physical symptoms such that she is feeling less anxious and
anxiety diminished and as pain, nausea, weakness, is she is trying to be positive.
managed within 30 or dizziness that have no
mins. apparent physical case.

-Provide emotional support to the - Being supportive and

patient. approachable promotes
communication.

-Provide information about the - Obtaining insight allows the

labor progress and the condition of patient to identify new ways
the Fetus. to deal with it.

-Assist the patient in developing - Discovering new coping

new anxiety reducing skills (e.g, methods Provides the patient
relaxation, deep breathing, with a variety of ways to
positive visualization, and manage anxiety.
reassuring self statements).

You must write the patient’s highest priority nursing diagnosis and follow it completely through the process. * Nursing
Interventions must include nursing assessment and a minimum of THREE nursing applications

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3. Nursing Diagnosis *:
Risk for infection related to the process of labor induction.

Goals and Nursing Interventions* Rationale for Nursing Interventions Evaluations

Expected
Outcomes
-Assess perineal area . - Provide early detection of an Goal was met as evidenced by patient
Patient will injury. delivered without complications.
accomplish
delivery without -Provide perineal care, as -Reduces risk of infection
complications. indicated.

-Check BP and pulse per -Assesses maternal well-being and

protocol after induction begins detects the development of
and before increasing oxytocin. hypotension/ hypertension.

-Evaluate monitor tracing closely. -Careful monitoring is essential to

Note rate and Evaluate monitor determine client/fetal response to
tracing closely. procedure, to identify adverse
reactions, and to produce an
effective labor pattern.

You must write the patient’s highest priority nursing diagnosis and follow it completely through the process. * Nursing
Interventions must include nursing assessment and a minimum of THREE nursing applications

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