Pamela De Guzman is a 17-year-old, G1P1 woman transferred to thepostpartal service following the birth of a 9 lb 4 oz infantboy.
CHIEF CONCERN:
“Should I be bleeding this much?”
HISTORY OF PRESENT CONCERN:
The client gave birth to a 9 lb 4 oz boy under epiduralanesthesia at 7:25 am following a 14-hour labor. Membranes had beenruptured for 26 hours. Modified Crede’s maneuver was used todeliver placenta. Fifteen units of Pitocin in 500 ml of lactatedRinger’s were administered intravenously following birth. Bloodloss from birth is estimated at 750 ml. At present, the clientreports vaginal bleeding is so heavy she is saturating a perinealpad every 20 minutes.
FAMILY PROFILE:
She lives with mother, two older sisters, and two nieces in athree-bedroom house. The family income is from social security andadditional government subsidies. The family members are vegetariansbecause “meat is too expensive.” Pamela has “borrowed” supplies forbaby from sisters. The father of child is said to be supportive butdid not come to be with her in labor.
HISTORY OF PAST ILLNESS:
She had chickenpox at age 5 years. She had facial acne since shewas 12 years old. She had no major illnesses and nohospitalizations.
GYNECOLOGIC HISTORY:
Menarche was at age 10 years; cycle duration: 29 days; menstrualflow duration: 5 days. She has no STIs. She is not using acontraceptive before present pregnancy.
OBSTETRIC HISTORY:
She had no previous pregnancies. This pregnancy was not intendedbut was not unwelcome. She has no complications during pregnancyexcept for minimal edema; proteinuria of 2+ and blood pressureincrease to 140/98 mmHg for last 2 weeks.
REVIEW OF SYSTEMS:
Neurologic: Treated for 5 years when younger for “smallseizures”; no longer takes medication for this
Mouth: Severe malocclusion treated with oral braces since age 14years
Breasts: Mild breast engorgement; pleased to bebreastfeeding
PHYSICAL EXAMINATION:
General appearance: Apprehensive-appearing, slender teenager;temperature: 98.6°F; BP: 100/60 mmHg.
HEENT: Integument: five black comedones present on forehead;mouth: full upper and lower metal braces present; no ulcerations orabrasions on gumlines
Chest: Heart rate: 100 beats/min; no murmurs present; lungs:rhonchi present in upper lobes; respiratory rate: 22breaths/min
Abdomen: Soft; fundus palpated at 2F above umbilicus and boggy;massaged and large firm clot 5 cm in diameter expelled vaginally;fundus somewhat firmer following massage but height did notchange
Perineum: Intact perineum; no external hemorrhoids; lochia:continuous bright red vaginal flow present; no clots
LABORATORY RESULTS:
Hemoglobin: 8.9 g/dl
WBC: 25,000/mm3
Pamela is diagnosed as having mild uterine atony
Devise a written plan case management support plan based onthe patient case scenario below:
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Case Management Support Plan |
Name: Pamela De Guzman ID number: Date: |
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Strengths/Visions Area of need: Physical health (medical)/MentalHealth(dental,medical,medication ,substance abuse,adaptive equip,therapy,behavior supports,other) |
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