Admitting Dx (Cite References) Medical, Surgical, Social

 History and OB History

Pt had prior pre-term delivery, client had an induced delivery with

Pitocin at term of 40weeks and 3 days. Baby was born vaginally

with vacuum assisted and weight 9lbs and 2oz. Client had an

episiotomy done due to prolonged/hypotonic UCs and macrocosmic

baby delivered. Client had lost >500mL of blood loss due to

dysfunctional labor and exhaustion. Newborn APGAR score was 9

and indicative of term baby. Admitting Dx is:

Hypotonic Uterine dysfunction- when pressure of UC is

insufficient (IUPC pressure <25mm Hg) to promote cervical dilation

and effacement (Durham and Chapman, 2019).

Induction of labor-labor that’s deliberately stimulation of UCs

before the onset of spontaneous labor to facilitate a vaginal delivery

(Durham and Chapman, 2019).

Dystocia- abnormal labor that results from abnormalities of the

powers, passenger, or passage (Durham and Chapman, 2019).

Dysfunctional labor- abnormal UCs that prevent the normal

progress of cervical dilation or descent of the fetus (Durham and

Chapman, 2019).

Oxytocin – a Uterotonic drug, that stimulates smooth muscle

producing intermittent contractions (Durham and Chapman, 2019).

Medical History

No known food, drug or environmental allergies

BMI >30 (obese)

Surgical History

A repair episiotomy

Social History

P. J is neg for drug use or elicit drug use and negative for

alcohol/tobacco use. Has good support system (extended family).

Obstetric History

GTPAL

G-2

T-0

P-1

A-0

L-2

Medical Management/ Orders/ Medications & Allergies (2)

Name Dose RT Freq. MOA RN Considerations

Oyxtocin/

Pitocin

10u

in

1000

ml of

LR

IV/

pig

gyb

ack

1mU/

min

Stimulates smooth

musche producing

intermittent

contractions

Once active labor

established d/c to avoid

downregulation, Avoid

tachysystole with Cat 2 &3

on EFM

Prenatal

Vitamins

PO Once/

day

Has fat-vit.

ADEK &watersoluble: all B

vitamins& folic

Assess for s/s of nutritional

deficiency; before/after.

n

/

a

Colace 100m

g

PO Twice

/day

Absorb water at

Lg intestines to

soften/form stool.

Drink with water, assess for

abdominal distention, bowel

sounds.

Ibuprofen 600m

g

PO PRN/

q6hrs

Inhibits

prostaglandin

synthesis. Inhibit

pain/inflammation

Assess for GI bleeding, tarry

stools, allergies and BUN

Citation is on reference page

Chief Complaint

Contractions, rupture of membrane or

bleeding.

Slow, painful contractions with no bleeding.

Abnormal progress of labor and induction of

labor with vacuum assisted vaginal delivery.

Admitting Diagnosis

Hypotonic Uterine dysfunction with

assisted-vaginal delivery

Medical Conditions

Prior Preterm delivery

Diagnostic Test/ Lab Results with dates

and Normal Ranges (3)

Test Norms Date Current

Value

PTT 100,00

-

400,00

0

8/13 155

Potassium 3.5-5.0 08/10 5.1

Rubella 08/10 Immune

BUN 8-20 08/10 44

Creatinine 0.8 –

1.3

08/10 3.0

Bilirubin 0.3-1.2 08/10 2.8

Calcium 9-10.5 08/10 8.7

HIV 08/10 NEG

WBC 3.2-9.8 08/10 10

Hemoglobin 14-17 08/13 10

Hematocrit 41-

51%

08/10 33

Blood type is OCitation is on reference page.

Patient Information

(1)

Name: P. J.

Age:

29

Height/Weight: 5.5/145

Allergies: NKA

Gestational Age: 40weeks/3days

Cultural considerations, ethnicity, occupation, religion,

family support, insurance. (1) (14)

P. J., Pacific Islands-American ethnicity, housewife, Christian

religion. J.P. has large extended family, very active in family

gatherings, church and has large family support, who lives

near her.

Erickson’s Developmental Stage Related to pt. & Cite

References (1)

 In Erickson’s theory of development, P.J is in the

“Intimacy vs Isolation,” ages 19-40. A period of conflicts,

loving relationships with others and success leads to

fulfilling relationships (Slater, 2003). P.J. has many friends

who lives near her and lots of family around her living

status. Friends are very supportive and love to drop by to

visit P.J. This means she has strong, successful relations

with friends and family, leading towards success at

resolving conflicts though she just had a term baby with

complications throughout her labor and delivery, she is

motivated to be a good mother.

Patient Education (In Pt.) & Discharge Planning (home need) 1

Patient is being discharged 10/14/2018. Did not experienced trouble getting

the baby to latch but was given lactation consult. The dietician was

consulted to give proper teaching about losing weight that was gained during

the pregnancy and diet to follow to help restore body image and healing was

due to the vaginal delivery. Patient was given consult by the physician about

medication and importance of mobility. Following are discharge instructions

about signs to notify the physician. Fever greater than 100.4 F for 2 or more

days. Check for vaginal discharge with large clots, increased amount of

bleeding, change to previous lochia color, any bright red bleeding even after

10 days and any foul odor. Report any incision pain or episiotomy pain that

does not resolve with analgesics, foul-smelling discharge, normal lochia

flow patterns, any unusual edema. No heavy lifting for next 3 weeks. Do not

lift anything other than the infant. Do not sit with legs crossed for a prolong

time to prevent thrombophlebitis. Limit stair climbing for next few weeks.

Perineal area should be cleaned front to the back after each voiding and

bowel movement. Blot dry after each wash. Rest when the infant is sleeping

(Durham & Chapman, 2019)

Concept Map

Student Name: Evelyn Lujan

Instructor: Armstrong

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