Clinical Pickup Report...

Date Created: 2011-01-29

Student: Ibarra, Dolce
Patient Info: 670443 x,x Gender: F Age: 20
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Health History
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Reported No previous health problems,

Diagnosis Section
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Primary Diagnosis: Postpartum, vaginal delivery

Patho-Physiology:
During the postpartum period the reproductive system return to their non-pregnant size and function via involution. Fundus should
be firm and at the midline. Urinary retention can cause fundus to remain boggy and is a risk factor for postpartum hemmorhage.
Fundal height is at the height of the umbilicus at twelve hours postpartum and decreases at a rate of 1cm per day until the uterus is
no longer palpable on day ten. Afterpains are often experienced during involution. Lochia starts out brown-red or red (rubra) and
gradually progresses to brown-pink (serosa) and then to white-pale yellow (alba) as the uterus casts off the uterine lining and other
cells. High urine output and diaphoresis from the elimination of extra fluid volume built up during pregnancy. Maternal temperature
may be elevated for the first day postpartum but should not exceed 100.4?. Blood pressure should remain at the level it was during
labor. Slight bradycardia is normal. Mom is likely hungry and thirsty postpartum due to restricted food and fluids during labor. She
should eat and consume fluids unless medically contraindicated. Mom goes through significant psychological adaptation
postpartum. This occurs in four overlapping stages: beginning attachment and preparation for baby; increasing attachment,
learning to care for baby, and physical restoration; moving toward a new normal; and achieving maternal identity. Bonding
progresses in a predictable sequence starting with fingertip touching, to touching with palms of hands, exploration of the newborns
entire body, enfolding newborn and holding close, eventually progressing to the en face position with baby's face directly in front of
hers. Father's attachment to baby progresses similarly.

Therapeutic Regimen/Current Health Problems:

ssessment of the mother should be head-to-toe with special attention paid to postpartum changes and should include evaluation of
breast for production of colostrum and soreness or redness, palpation of fundus, assessment of bowel sounds and for urinary
distention, monitoring of color and amount of lochia, assessment of the episiotomy site, assessment for DVT, and assessment of
overall emotional status and bonding process. Interventions should focus on preventing hemorrhage and infection, treating pain,
promoting regular bladder and bowel function, promoting rest and healthy parent-newborn attachment including breastfeeding.
Teaching includes breastfeeding tips, baby-care, as well as self-care. Self-care teaching is on breast care, fundal massage,
assessment of lochia, pernieal and episiotomy care, pain management, prevention of constipation, and prevention of fatigue.

Related Functional Changes:

Mom: fatigue, mild pain, knowldege deficits regarding care of newborn, risk of infection, task of assuming new identity of mother are
significant functional changes for patient. Baby: transition to life outside of the womb.

No Medications Found...
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Laboratory Orders
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Test: CBC Date Ordered: 2011-01-25

Test Description/Definition:
Complete Blood Count: To determine general health status and to screen for and monitor a variety of disorders.
Test Significance:
To establish a baseline to compare to postpartum CBC.

Test Result Level

Neutrophils 74.2% WNL

Result Significance: Range: 42-75%
Lymphocytes 14.0% Low
Result Significance: Range: 20-51% Lymphocytes help protect the body from infection. Low numbers of lymphocytes
can increase risk for infection.
Monocytes 11.0% WNL
Result Significance: Range: 2-13%
Eosinophils 1% WNL
Result Significance: Range: 1-4%
Basophils 0.2% WNL
Result Significance: Range 0.0-3.0%
Hemoglobin (Hgb) 12.0 g/dl WNL

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 Result Significance: Range 11.5-15.5 g/dl
Hematocrit (Hct) 36.1% WNL
Result Significance: Range: 33.0-50.3%
Platelet Count 154,000 mm3 WNL
Result Significance: 150,000-450,000 mm3
MCV 81.1 mm3 Low
Result Significance: Range 90-95 mm3; Test measure the size of RBCs. When the MCV is decreased, your RBCs are
smaller than normal (microcytic).
MCH 27.0ug WNL
Result Significance: Range 27-31 ug
MCHC 33.2 WNL
Result Significance: Range: 32-36 g/dl
RDW 13.4% WNL
Result Significance: Range: 11-14.5%
RBC count 4.4 WNL
Result Significance: 4.2-6.1 X 10 6/ug
WBC count 11.6 WNL
Result Significance: Range: 4.5-13.5

Test: Hemoglobin (Hgb) Date Ordered: 2011-01-27

Test Description/Definition:
To measure the amount of RBCs in the blood.
Test Significance:
Postpartum measurement of RBCs.

Test Result Level

Hemoglobin (Hgb) 11.3 g/dl Low

Result Significance: Range: 11.5-15.5 g/dl: Low RBCs may indicate anemia or blood loss.

Test: Hematocrit (Hct) Date Ordered: 2011-01-27

Test Description/Definition:
Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. This
measurement depends on the number of red blood cells and the size of red blood cells.
Test Significance:
To screen for anemia.

Test Result Level

Hematocrit (Hct) 34.6% WNL

Result Significance: Range: 33.0-50.3%

No Radiology Tests Found...

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