This Is her third hospitalizing during this pregnancy for preterm labor. She has a MacDonald acreage in place since 12 weeks gestation. She is experiencing irregular uterine contractions with uterine irritability noted to fetal monitoring strip. She is on bed rest with continuing fetal monitoring.
She has Lactated Ringers infusing per peripheral catheter at mill/hrs. History of Past Illness: MD is a GABBY, having miscarried at 8 weeks with a previous pregnancy. She delivered her living children preterm, one at 35 weeks gestation and the other at 34 2/7 weeks gestation, both vaginally. She completed steroid treatment to improve baby's lungs at last hospitalizing. She denies any significant health issues or previous surgeries.
She states she Is healthy with the exception of an Incompetent cervix. Childhood Diseases: MD reports having chicken pox around at 5.She reports having an occasional cold as a child with no memory of any serious Illness. She states she did have an outbreak of poison Ivy at less than 10 years old.
Major adult Illnesses: denies Allergies: AND, no food allergies Immunization: MD states she is up-to-date on the influenza vaccine and ADAPT. She received the ADAPT after birth of last child, age 3. She has received the Hepatitis B series. Medications: Home medications- Prenatal vitamins, 1 tablet q day POP Hospital medications- Indochina MGM POP q x 72 hours Stool 1 MGM IPP q PORN pain Phenomena 12. G q PORN to be administered with Stool Lactated Ringers IV infusion at mill/hrs.
Transfusions: denies Emotional Status: MD denies previous diagnosis of any mental disorders. She states she is depressed and anxious at this time related to fear of the unknown related to APT. Family History: MGM- congestive heart failure, diabetes, passed away age 79 MGM- restrictive lung disease (previous smoker), passed away age 78 PEG- prostate cancer In remission, "abdominal cancer" In remission PEG- depression, TN, ovarian cancer (ATA) Father- passed away age 58 of MI, history TN, hyperglycemia'sMD reports her children are healthy with no known illnesses or diseases Personal and Social History: MD was born in Mobile, AL and moved to Central LA at age 4. She attended Bolton High School and graduated in 1998. She then attended Bienville Beauty School where she earned a license in Cosmetology.
She worked as a hair stylist until the birth of her first child and has since been a stay-at-home mother. Her husband works fulfillment in construction. She does admit the strain of one income has been a concern in the past, but staying home with her children is important to both re and her husband.MD reports a supportive husband and extended family. Environmental: MD states her husband smokes 1 pack of cigarettes daily, outside of the home and never in vehicle while children are present.
She states he does smoke in car with her. Current health habits: MD states she leads a moderately active lifestyle but admits to being out-of-shape. She denies illicit drug use. MD reports socially drinking occasionally, denies doing so during pregnancy. MD states family meals consist of seasonal vegetables as her husband's family are avid gardeners.She dates she wears sunscreen when planning to be outside for a significant amount of time.
Exposure to chemicals or toxins: MD states her past as a hair stylists consisted of exposure to chemicals when dyeing hair. She reports using gloves at that time. She denies any exposure to chemicals or toxins in her daily life at this time. Sexual activity: MD denies any past history of Stud's. Review of Systems: General: Reports overall good health. Denies concerns of health related issues.
Skin: MD reports dry skin to abdomen and legs with occasional itching present. Both relieved with lotion.No reports of lesions or wounds. MD reports she loses more hair during pregnancy but not a significant amount. WENT: Head-stated has occasional headaches relieved with Ethylene, denies dizziness.
Eyes- MD does not wear glasses or contacts, denies blurred vision or change in vision. Ears-denies hearing loss or trauma to ears, denies pain. Nose- Denies history of nosebleeds, does report "stuffy" nose occasionally. Mouth/Throat- MD reports bi-yearly teeth cleaning, no reports of tooth pain, swelling of gums, does states occasional bleeding of gums with brushing. She denies changes in voice, no throat pain.Chest/Lung: MD denies trouble breathing, no wheezing or coughs.
She denies SOB or pain on respiration. Breast: Breast tender with pregnancy with no discharge. MD denies nodules or lumps. Heart and blood vessels: Denies chest pain or palpitations. She states she has never had an EKE, denies history of heart illness or pain.
She does report edema bilaterally to lower legs during pregnancy. Gastrointestinal: MD reports occasional constipation during pregnancy for which she will take a stool softener when needed. She also reports heartburn during pregnancy, denies when not pregnant. She denies gastrointestinal problem history.
Diet: MD states her appetite is good, and she eats balanced meals including fruits and vegetables. She states she reduces her caffeine intake when pregnant but does enjoy Coca-Cola very much. She denies eating out frequently, preferring home-cooked meals. She states her water intake could be better.
She drinks decaf sweet tea. She denies food restrictions based on culture or health. Endocrine: MD denies history of thyroid disorders, denies enlargement or tenderness. MD reports regular menstrual cycle, denies difficulty becoming frequency during pregnancy. She denies history of renal problems or calculi.
Musculoskeletal: MD denies any problems with range of motion to Joints, no redness, swelling or deformities. She reports occasional lower back pain related to pregnancy. She states she moves a little slower when pregnant but otherwise has no problems with Addles. Neurological: MD reports "pregnancy brain" with occasional forgetfulness. She denies syncope or weakness, denies history of seizures or epilepsy. MD denies trouble falling asleep and states she remains asleep through the night.
Psychiatric: MD denies recent mood changes, but does admit to anxiety and "a title" depression related to unknown outcome of pregnancy.Physical Examination Findings General: Age: 32, Race: White, Gender: Female, General Appearance: Healthy, appropriate for 27 weeks gestation, Current Wit. : 172, Height: 5'6", IBM: 27. 9 Vitals: BP 119/68 P 72 Rest.
18 -remap. 98. 4 oral Mental Status: MD exhibits no distress, smiles when appropriate and is pleasant to interact with. Awake, alert & oriented X 4, maintains eye contact when appropriate and exhibits no speech problems. Skin: Color is pale with slight tan line noted to upper arm and upper thigh. No scars or wounds noted.
Turbo good, skin C/D/I. Striate noted to abdomen.Non-pitting edema present to lower legs bilaterally. Hair soft and clean with no signs of aliped, color black. Fingernails and toenails painted light pink, no redness noted to cuticles, no cracking, peeling, or clubbing noted. No calluses noted to feet.
Head: Head evenly contoured in shape with no nodules or intentions palpated. Scalp clean, no sores or lesions noted. No puffiness or edema noted. Temporal arteries palpable with no bruits, thickening or hardness noted.
Eyes: Eyes symmetrical, round and equal in shape. No swelling noted to orbital area. Eyebrows equal and symmetrical.Pupils equal, reactive to light, visual fields are intact.
No mustangs noted. Conjunctiva pink with no drainage noted. No nodules or masses palpated to lachrymal glands. Bilateral red reflex noted on ophthalmic exam, retina intact with no hemorrhage noted.
Ears: Symmetrical and properly aligned. No tenderness or redness of auricles noted. No tenderness or swelling to mastoid area. Tympanis membrane pearly gray and intact, minimal cerement noted.
Whisper test positive to bilateral ears. Unable to perform Urine or Webber test. Nose: Midlines with no lesions or nodules palpated.Internal mucous membranes pink and moist, no discharge or polyps observed.
Septum aligned symmetrical with no tenderness or swelling noted to sinus regions. Olfactory senses intact. Throat and Mouth: 28 teeth present, no decay or cracking noted. Tongue pink and moist.
Abacas and oral mucosa membranes moist, Uvula midlines, tonsils present with no redness or swelling noted. Gag reflex present. Neck: Trachea midlines. No Jugular distention noted. No enlargement to thyroid noted on palpation. No nodules present.
Chest: Chest rise wintertime with respirations.No tenderness to ribs noted with palpation, no bony prominences noted. Respirations even and unlabeled. No adventitious breath sounds noted. No cough, strider or friction rubs noted. Heart: Rate regular, equal rhythm noted.
No murmurs, clicks, gallops or rubs calculated. SSL and SO present. No thrills, heaves or lifts noted. Blood Vessels: pedal pulses 2+ bilaterally, non- varicose veins behind knee noted. Abdomen: II-JP at 266/7. No lesions or nodules noted.
Umbilicus midlines and slightly inverted. Bowel sounds noted all 4 quadrants. No friction rubs or bruits noted.No percussion performed due to uterine contractions and irritability. Resting tone relaxed to palpation.
No tenderness noted upon palpation of kidneys bilaterally. Fungal height CACM. Lymphatic System: No swelling to lymph nodes present, no streaking or tenderness noted. Musculoskeletal System: MD exhibits full ROOM to extremities. No creepiest palpated to knees or ankle areas. No swelling or deformities to Joints noted.
Posture erect with no slumping or curvature noted. Neurological: Gait coordinated and steady. Cranial II-XII intact with no abnormalities noted. Balance coordinated with no assistance needed.Response appropriate to pain, tactile, touch, and vibration.
Dart's 2+, no colons noted. Nursing Diagnosis and Plan: Fear and anxiety r/t uncertainty of outcome and effects of treatments 1 . Identify support person(s) and utilize them during moments of anxiety 2. Encourage questions r/t birth and care of preterm infant 3. Identify stress relieving techniques 4. Use therapeutic touch when appropriate 5.
Encourage family and significant other to participate in diversion activities during times of anxiety Knowledge deficit r/t care and procedures of preterm infant 1.Have Entomologist speak with patient regarding expectations at birth and long- term care 2. Encourage questions r/t birth and care of preterm infant.
