Case Study for PCW #2 Women’s Health
Sarah Kolowski is a 37 year old G5 P4 A1 L4 now. She just gave birth via a repeat cesarean section, with a BTL, 3 hours ago, to a 35 week baby girl weighing 2016 grams (4 lb. 7oz.), 17.5 inches long (44.45 cm). Baby’s APGARs were 5 and 7. The baby had mild retractions, nasal flaring and mild bilat. crackles, but her O2 sats were 98%, and her color is pink. Mom’s prenatal history is as follows: Blood type: O+ antibodies (-); Rubella Immune; Hep B (-); HIV (-); GBS (+) ROM at the time of delivery. She has preeclampsia with worsening symptoms. She was on magnesium sulfate prior to delivery which was restarted post-delivery. She came in c/o severe HA and partial loss of vision in both e
yes. Her blood pressure at the time was 195/115 with 3+ protein in her urine.
Case History:
Past history: 2 NSVDs, 1 C/S for fetal distress, gestational hypertension with last pregnancy
Social history: Marriedx17 years, has three other children ages 15, 5, and 2 years old. Patient’s mother is at her home watching them. Husband is a self-employed accountant, supportive, and at bedside. Patient is a stay-at-home mom.
Medical history: Except for during pregnancies, patient is in good health
Past surgical history: cesarean section 2 years ago
Family history: Mother has type II diabetes and cardiovascular disease; father unknown
Prior hospitalizations: three for giving birth
Allergies: NKA
VS: T: 98.9BP: 139/95HR:112RR: 16O2: 96% RA
Nurses’ Notes:
35 year old well-developed female lying in bed. A&O x 4. Denies HA and visual changes as well as epigastric and RUQ pain. 1+ pitting pretibial edema, DTRs 2+, no clonus. Breasts soft, nontender with flat nipples. Lungs sounds clear all fields. S1S2 regular without murmur. Bowel sounds hypoactive x 4 quadrants. Denies passing flatus. Foley to gravity draining 30cc of dark yellow concentrated urine. Low transverse surgical dressing clean, dry and intact. Fundus boggy at midline “u” – massaged to firm. Lochia rubra and heavy in amount. IV of LR with Pitocin infusing @ 75cc/ hour via pump. Magnesium sulfate infusing via pump @ 50 cc/ hour into R anterior wrist, site cool to touch and swollen. No hemorrhoids. C/o incisional pain @ level 6/10-stabbing and burning, requested pain medication. Also c/o severe itching and nausea. Is teary-eyed because she doesn’t feel well enough to care for infant and says, “I’m sure the baby needs to eat now.”
Lab Results:
(prior to delivery)
WBC5.3
Hgb. 10.9
Hct.30.7
Platelets109
AST49
ALT60
Uric acid9.7
Creatinine1.5
BUN30
Glucose95
PT12.2
PTT27.5
INR0.9
ABO RHO+
Antibodiesnegative
RPRnonreactive
Postpartum orders:
Magnesium sulfate 2 gms /hour x 24 hours
Pitocin 20 units in 1000cc LR x 1 liter post delivery then LR at 75 cc/hour
Cytotec 800 mcg po prn excessive vaginal bleeding
Zofran 4 mg IVP q6 hours prn nausea and vomiting
Benadryl 25 mg IVP q6 hours prn itching
Toradol 15mg IVP q8 hours ATC x 24 hours
Motrin 600mg po q6 hours ATC after 24 hours
Norco 1 tab po q 4 hours prn breakthrough pain level 3-5
Percocet 2 tabs q 6 hours prn breakthrough pain level 6-10
Colace 1 tab po BID
Bedrest x 8 hours
OOB as tolerated after 8 hours
Diet as tolerated after 2 hours
Abdominal binder
D/C Foley in 24 hours
Remove dressing in 24 hours
In 24 hours D/C magnesium sulfate and convert IV to saline lock with protocol
CBC, CMP in am
Magnesium level q 6 hour. Please don’t forget to put Reffernce
