Obstetrics Case Study

By: Blayre Helm

Reason for Hospitalization

BR is a 34 year old, Caucasian female

Admitted for scheduled caesarian section on day of clinical
37 weeks pregnant
Suffers from gestational diabetes
First time mother
Gravida: 1, Para: 1 (after the delivery of her child)

Enhanced desire to breastfeed

Past Medical History

Rubella: Immunization given 3/11/15

Blood Type: B
Rh Status: +
HIV: Negative
Strep: Negative
Hepatitis: Negative
Previous Surgeries: Myomectomy
Previous Birth History: none

Family Medical History

Mother: Diabetes Mellitus Type II

Brother: Deletion of distal chromosome 18

Psychosocial History

Family make-up: Nuclear family made up of her and her husband

Employment: Not employed
Education: High school diploma
Insurance: Medicaid
Tobacco, Drug, and Alcohol use: Never
Home environment: Safe with no stated or noted potential hazards
Activates: No stated activates that the patient or her husband enjoyed
Psychosocial stressors

Physiological Status

Virginia Hendersons Need Theory

Increase the patients independence so that progress after
hospitalization is not delayed

Nursing care designed to accommodate physiological needs

Developmental Status

Erik Eriksons Psychosocial Development

8 stages of development

Nursing care designed to accommodate developmental needs

Growth and Nutritional Status

Height %: the patient is 54, therefore has a height % of 46.6%

Weight %: the patient is 210 lbs, therefore has a weight % of 83.7%
Weight for height %: not applicable (not a newborn)
BMI: 33.97
Appearance: Obese but pregnant
Nutritional status: Follows gestational diabetic diet
Nurse counseling: Balance in proteins, fats, and carbs
After patient gives birth it is important for the patient to maintain a healthy diet and
exercise so the risk for Type II DM is reduced

Focused Physical Assessment

Vital Signs: BP: 137/84, Temp: 98.8, HR: 109, RR: 16, SpO2: 95%
General Appearance: White female appears her stated age and in no acute distress
Lymph nodes: No clavicular, parotid, occipital, submandibular, cervical, or sub-clavicular
adenopathy
Head and neck: No thyroid enlargement
EENT: conjunctiva, eyelids, ears, nose, and lips WNL; dentition appears to be in adequate
state
Chest/Lungs: clear to auscultation, normal respiratory effort
Heart: normal rate and rhythm
Back and Extremities: normal to inspection, no edema or cyanosis on any extremity, range
of
motion WNL
Neurological : extremely deep tendon reflection intact

Labs

Rubella: immunization given 3/11/15

Rh factor: +
Hepatitis screening: Negative
RDW: 20.8 (high)
Neutrophils: 75.9% (high)

Medications

Acetaminophen: 650 mg, q6h, for pain

Calcium Carbonate: 500 mg, q6h PRN, for dyspepsia
Magnesium Hydroxide: 30 mL, nightly PRN, for constipation
Ondansetron: 4 mg, q6h PRN, for nausea
Oxycodone: 10 mg, q4h PRN, for severe pain levels 7-10 on
a scale of 0-10

Nursing Implications

Overall, this patient is a healthy female who will be in pain due to her
Caesarian section. She is very anxious about becoming a new mother and
wanting to entirely breastfeed, which is a new concept to her.
Nursing Dx:
Readiness for enhanced breastfeeding r/t maternal requests and infant nutritional
needs e/b the infant having proper alignment and latch-on techniques.
Acute pain r/t surgical injury e/b pain being stated as >5 on a scale of 0-10.
Knowledge deficit r/t becoming a new mother and starting to breastfeed as e/b
inability to correctly position her newborn during breastfeeding.

References
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