Summary ROBERT JONES CARE PLAN,, COMPLETE STUDY GUIDE 100% VERIFIED

Running head: CARE PLAN 1 Maternity Care Plan Colette Jarvis University of Northern British Columbia CARE PLAN 2 Formal Care Plan Student Name: Colette Jarvis Dates of Care: November 25-26, 2017 Health Care Setting: Cariboo Memorial Hospital in the labor and delivery room Demographic: Initials of client: JO Age: 27 Sex: Female Marital: Married Religion: None Admitting Medical Diagnoses: Active labor Allergies: Cats and kiwi fruit History of Present Complaint:  Patient’s chief complaint is regular contractions 2-3 minutes apart lasting 60-90 seconds  Patient is managed on an outpatient basis Past Medical History: Medical/Surgical History  Laparoscopic surgery for removal of appendix and cyst in 2005 Obstetrical History  One ectopic pregnancy, and one miscarriage TPTL at 31 weeks’ gestation  Last menstrual period February 19, 2017 first ultrasound April 4, 2017  Confirmed due date November 26, 2017 second ultrasound August 4, 2017  Third ultrasound September 19, 2017  Weekly NST’s as well as weekly blood pressures from 32 weeks’ gestation on  Several episodes of threatened preterm labor but fetal fibronectin is negative  Borderline hypertension during pregnancy, headaches, and visual changes  Augmented via ARM November 25, 2017 at 0847, meconium present  Spontaneous Vaginal Birth at 1148, placenta delivered at 1152 Social History  One daughter, three years old  Married to a logger, nonsmoker, nondrinker  Mother and Father are very supportive  Many family and friends in to visit, good social support systems Family History  Non-contributory G4 T1 P0 A2 L1 Gestational age: 39+6 GBS: Negative Blood group: B+ Rubella: Immune Current Weight: 94.5 kg Height: 170 cm Vital Signs Day 1 Day 2 Temperature: 37.1°C Blood Pressure: 126/58 Pulse: 76/min SpO2: 100% RA Respirations: 20/min Temperature: 36.7°C Blood Pressure: 122/68 Pulse: 80/min SpO2: 99% RA Respirations: 20/min CARE PLAN 3 Laboratory Values and Bloodwork Current Lab Values for November 25/2017 Previous Lab Values N/A CBC and Differential CBC and Differential WBC: *H 13.2 WBC: N/A RBC: 4.4 RBC: N/A HgB: 127 Hgb: N/A Hct: 0.38 Hct: N/A MCV: 84.7 MCV: N/A MCH: 28.7 MCH: N/A MCHC: 339 MCHC: N/A RDW: 14.6 RDW: N/A Platelets: 190 Platelets: N/A Neutrophils: H 9.0 Neutrophils: N/A Lymphocytes: H 3.3 Lymphocytes: N/A Monocytes: 0.8 Monocytes: N/A Eosinophils: 0.1 Eosinophils: N/A Basophils: 0.0 Basophils: N/A RBC Morph: Adequate RBC Morph: N/A Plt Aggregation: Large forms Plt Aggregation: N/A Laboratory Values and Bloodwork Interpretation WBC ↑13.2 Normal 5-10 x 109 /L. White blood cells (WBC’s) fight off infection. A high white blood cell count may be indicative of an infection, stress, inflammation, trauma, allergy, or other diseases; however, this level is normal during the final month of pregnancy and labor (Pagana, Pagana, 2013). Neutrophi l ↑9.0 Normal 2.5-8.0 x 109 /L. Neutrophils primary function is phagocytosis. Acute bacterial infections and trauma stimulate neutrophil production, this level is normal during the final month of pregnancy and labor (Pagana, Pagana, 2013). Lymph ↑11.4 Normal 1.0-4.0 x 109 /L. Measures the number of cells present for cell-mediated immunity, which plays a key role in antibody production. An increase in this can indicate a response to a foreign material and antibody production or immunity to viruses; however, this level is normal during the final month of pregnancy an labor (Pagana, Pagana, 2013). Biophysical Dimension Pain/Altered Comfort When asked if any pain is present, the patient stated she had dull pelvic, perineum pain of 1 on CARE PLAN 4 a scale from 1 to 10. The patient states her pain is well managed with the use of PRN extra strength Tylenol and Ibuprofen. The patients Perineum is intact. Neurologic OBJECTIVE: The patient is awake, alert and oriented to person, place and time, her affect is cheerful, speech is appropriate for communication, GCS is 15, pupils are equal, round reactive to light. Patient has all 6 movement in eyes. Patient is able to follow all commands and has good range of motion in all four limbs. Can push and pull against hands when tension is applied, patient is independent in all activities of daily living (ADL’s). SUBJECTIVE: Patient denies any difficulty with memory. The patient has no trouble with hearing, and no current problems with her vision other than during pregnancy occasionally having troubles with focusing vision. Patient has no problems with strength. Patient denies any one-sided weakness and history of strokes, patient states there is no history of seizures, but headaches were present during pregnancy. Cardiac OBJECTIVE: Heart rhythm sounds regular, S1 and S2 sounds are audible. No added heart sounds note