NURSING 113 -Revised Maternity Soap Notes

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Name: Mrs. Sandra Pt. Encounter Number: Date: 05/22/2018 Age: 24 Sex: SUBJECTIVE CC: “My wife just delivered a baby at home and she is bleeding too much. Please help!” HPI: Patient was broug... ht to the ER with profuse bleeding and retained placenta. Pt. is in hypovolemic shock, in and out of consciousness, sweaty, cool to the touch, and extremely pale. BP 90/65, very weak pulse, rapid heart rate and labored breathing. Husband told us she just had another stillbirth and it was a high risk pregnancy due to anemia and pregnancy-induced hypertension. GTPAL (2-0-2-2-0). Pt. had regular antenatal check-ups at primary health center. Because of her high- risk status and her previous stillbirth (26 weeks), the health officer was worried and advised pt. to go to a hospital to deliver the baby. Unfortunately patient didn’t take the advice and had a local private doctor attended her delivery, which was very painful and resulted in another stillbirth (this time 28 weeks). MD immediately administered oxygen and blood transfusion (PRBCs), but it was too late. Pulse and blood pressure dropped rapidly and patient died. Doctors and nurses worked very hard but could not save her life. Medications: Methyldopa 125mg per day for pregnancy induced hypertension. ( Prenatal Iron supplement for anemia) PMH Allergies: NKA Medication Intolerances: NONE Chronic Illnesses/Major traumas - Stillbirth in 2017 (26 weeks fetus). Hospitalizations/Surgeries - 2017 due to stillbirth. Family History Father has hypertension. Mother is in good health. Social History Pt. lived with her husband and in-laws in a remote village. Her husband was a day laborer and the family’s sole wage-earner (low economic level). Family mentioned that patient did not think her husband would pay for her to go to have a baby in the hospital. No history of smoking or drinking. ROS https://www.coursehero.com/file/62689473/Revised-Maternity-Soap-Notespdf/ This study resource was shared via CourseHero [Show More]

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