OB Neonatal Daily Worksheet 2013 Essay

Submitted By shiannmartin
Words: 655
Pages: 3

OB/Neonatal Daily Worksheet Name: _______Shiann Martin____________
You need to obtain this information for each client (except when doing the postpartum assessment). This worksheet will assist you in developing a daily plan of care, receiving and giving shift report, and discussing your client in post-conference.
Age ___25____ EDD ___4/15/15________ Weeks gestation _____36 wks_________
GBS status:___Not tested_____ Treatment received for + GBS_____Not tested______
Pertinent medical history:
Reynaud’s Syndrome
Gallbladder out in 2005
Wisdom teeth out in 2005
Family history of mental retardation

OB history:
G ____1___P____1___T ____0___ P ___1____ A ____0___ L ___1____
Details of prior deliveries:
No prior deliveries

Pregnancy complications for current pregnancy:
HELLP syndrome

Pathophysiology of any complications:
The findings of this multisystem disease are attributed to abnormal vascular tone, vasospasm and coagulation defects. To date, no common precipitating factor has been found. The syndrome seems to be the final manifestation of some insult that leads to microvascular endothelial damage and intravascular platelet activation. With platelet activation, thromboxane A and serotonin are released, causing vasospasm, platelet agglutination and aggregation, and further endothelial damage. This begins a cascade that is only terminated with delivery.

The hemolysis in HELLP syndrome is a microangiopathic hemolytic anemia. Red blood cells become fragmented as they pass through small blood vessels with endothelial damage and fibrin deposits. The elevated liver enzyme levels in the syndrome are thought to be secondary to obstruction of hepatic blood flow by fibrin deposits in the sinusoids. This obstruction leads to periportal necrosis and, in severe cases, intrahepatic hemorrhage, subcapsular hematoma formation or hepatic rupture. The thrombocytopenia has been attributed to increased consumption and/or destruction of platelets.

Delivery date/time: 3/18/20 at 16:02
Type of delivery: Vaginally
Anesthesia: Epidural Bupivicaine 1.25mg/ml with Fentanyl 2mg/ml
Any complications during labor and delivery: 2nd degree perineal laceration and postpartum hemorrage

Infant sex _____F_______ Birth weight _____2548g_______ Apgar scores ___7 and 8____ Infant feeding: Formula How often _____N/A_______ How much ______N/A______

Breastfeeding How often __Fed at 8 and 11__ How long _Tried for around 30-40 minutes each time__

Maternal blood type/Rh ____B+______ Infant blood type/Rh ____Not tested______
Rhogam given? No

Adacel: Requested____NA_____ Given____Yes_____ Refused___NA______
Jaundice Meter: Time to perform___Could not find in chart____ Results_____N/A________

Medications and indications: Allergies:__________None_______________

Cytotec 200mcg PO to reduce risk of heavy bleeding
APAP 650 mg PO if pain is 1-3 on scale or fever of >102
Motrin 100 mg PO give with APAP after platelet count >80,000

Two priority nursing diagnoses in two or…