A 41 y/o pregnant woman G2P1(10010), 34 weeks and 3 days, her last menstrual period was April 5, 2016, Expected date of delivery on January 12, 2017 with chief complaint of vaginal bleeding 5 days ago, and abdominal contraction. “Dinugo ako nung isang lingo at ngaun naninigas ang tyan ko” as verbalized by the client. She has antenatal care at Lucena Health Center. At 28 weeks gestation, she was admitted at Lucena Hospital due to vaginal bleeding, Ultrasound showed placenta previa totalis and fetal omphalocele. Received 4 doses of dexamethasone 6mg every 12 hours. Her past OB history, delivered an alive baby girl, full term via normal spontaneous delivery weighing 2500g at lucena hospital, year 2013. Her GYN history, menarche at age of 14, regular monthly menstruation for 7 days without dysmenorrhea. She use oral contraceptive pills for 3 years prior this present pregnancy. Her past medical history revealed negative history of hypertension, diabetes, tuberculosis, anemia and heart disease. No allergy to foods and drugs. No significant surgical history. With family history of Diabetes on maternal and paternal side. Patient lives with his husband at Lucena. Positive history of alcohol intake occasionally 2-3 bottles but not during this pregnancy, denies any smoking and drug use before. She completed secondary education, currently stay as a housewife. His husband is working as a farmer, not a Philhealth member with low economic status. Medical diagnosis: PU 34 weeks and 3 days cephalic in preterm labor G2P1(10010), To consider fetal multiple congenital anomalies (ventriculomegaly, dilated 3rd ventricle, ascites, omphalocele, cardiomegaly, atrioventricular septal defect, bilateral cleft lip and palate), to consider chromosomal anomaly, Placenta previa totalis, to consider placenta accrete, Intrauterine growth restriction; Myoma uteri, intramural. To consider single umbilical artery. Admitting vital sign as follows BP: 120/80, HR 90, RR 18, Temp. 36. 4, FHT 120’s LLQ, Fundic height: 32cm. Upon assessment patient is alert, coherent, gravid, pallor, (+) bipedal edema, (+) vaginal bleeding. No cervical examination was done. Transabdominal ultrasound revealed single live intrauterine pregnancy, in cephalic presentation, with good cardiac and somatic activities. Placenta is anterior, grade II, totally covering the os. Biophysical profile (BPP) score is 10/10 with High normal amniotic fluid volume. Patient laboratory was done, CBC with platelet, Blood typing, Coagulation study, urinalysis and virology including HbSag, HCv-ab, HIV-ab). With stand by 4 units of packed RBC properly screened and cross matched Give 3 Nursing Diagnosis from the case scenario
A 41 y/o pregnant woman G2P1(10010), 34 weeks and 3 days, her last menstrual period was April 5, 2016, Expected date of delivery on January 12, 2017 with chief complaint of vaginal bleeding 5 days ago, and abdominal contraction. “Dinugo ako nung isang lingo at ngaun naninigas ang tyan ko” as verbalized by the client. She has antenatal care at Lucena Health Center. At 28 weeks gestation, she was admitted at Lucena Hospital due to vaginal bleeding, Ultrasound showed placenta previa totalis and fetal omphalocele. Received 4 doses of dexamethasone 6mg every 12 hours. Her past OB history, delivered an alive baby girl, full term via normal spontaneous delivery weighing 2500g at lucena hospital, year 2013. Her GYN history, menarche at age of 14, regular monthly menstruation for 7 days without dysmenorrhea. She use oral contraceptive pills for 3 years prior this present pregnancy.
Her past medical history revealed negative history of hypertension, diabetes, tuberculosis, anemia and heart disease. No allergy to foods and drugs. No significant surgical history. With family history of Diabetes on maternal and paternal side. Patient lives with his husband at Lucena. Positive history of alcohol intake occasionally 2-3 bottles but not during this pregnancy, denies any smoking and drug use before. She completed secondary education, currently stay as a housewife. His husband is working as a farmer, not a Philhealth member with low economic status.
Medical diagnosis: PU 34 weeks and 3 days cephalic in preterm labor G2P1(10010), To consider fetal multiple congenital anomalies (ventriculomegaly, dilated 3rd ventricle, ascites, omphalocele, cardiomegaly, atrioventricular septal defect, bilateral cleft lip and palate), to consider chromosomal anomaly, Placenta previa totalis, to consider placenta accrete, Intrauterine growth restriction; Myoma uteri, intramural. To consider single umbilical artery.
Admitting vital sign as follows BP: 120/80, HR 90, RR 18, Temp. 36. 4, FHT 120’s LLQ, Fundic height: 32cm. Upon assessment patient is alert, coherent, gravid, pallor, (+) bipedal edema, (+) vaginal bleeding. No cervical examination was done. Transabdominal ultrasound revealed single live intrauterine pregnancy, in cephalic presentation, with good cardiac and somatic activities. Placenta is anterior, grade II, totally covering the os. Biophysical profile (BPP) score is 10/10 with High normal amniotic fluid volume.
Patient laboratory was done, CBC with platelet, Blood typing, Coagulation study, urinalysis and virology including HbSag, HCv-ab, HIV-ab). With stand by 4 units of packed RBC properly screened and cross matched
Give 3 Nursing Diagnosis from the case scenario.
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