The Patient I Took Care Of Was A 30-35 Year Old Female

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The patient I took care of was a 30-35 year old female who was one-day postpartum. The patient’s prenatal care prior to the recent few weeks before delivery took place at Barrington Health Center; she then transferred care to Community South. She reported having an allergy to Benedryl, and a GTPAL score of Gravidity 5, Term 4, Abortion 1, and Living 4. The patient’s gestational age was 39 weeks. The patient stated she sought care “regularly” at Barrington Health and did not report specifically how often. Her health information from Barrington Health Center did not transfer over in the patient’s chart, thus, it is unknown exactly how often she sought prenatal care. Once she transferred care to Community South Hospital four weeks prior to…show more content…
Her final vaginal exam was at ten centimeters dilated and one hundred percent effaced. The patient’s support system during labor and delivery was her boyfriend, the father of her child. After her induction via artificial rupture of membranes, she had a intrauterine pressure catheter placed and was prescribed Pitocin at 22milli-units/min. The patient had a spontaneous vaginal delivery, and did not require use of forceps or vacuum extraction. During delivery, the patient did not experience an episiotomy, perineum lacerations, or C-section incisions so she did not require any sutures. Soon after the delivery, the patient had a postpartum hemorrhage with retained placenta. Thus, during postpartum care the primary concern was keeping an eye out for signs of bleeding, and keeping up with routine blood labs. The postpartum BUBBLE assessment findings were Breasts within defined limits, uterus is firm located midline at the umbilicus, bowel sounds were hypoactive across all four quadrants, bladder had a Foley catheter with output of 350 milliliters, lochia rubra of small amount with no odor or clots, and episiotomy/laceration/C-section incisions were not present. After assessing the patient, we took out the Folely catheter as it was ordered to be removed, since it was no longer needed. The patient expressed to the nurse and I that she was experiencing pain in the perineal area, so we gave her ice packs to
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