C.E is a 23 year old Hispanic female who came to the Hospital on April 12th at eight pm for the reason that she was experiencing contractions at less than ten minutes apart as a result of pregnancy, she reported her pain at 8/10 patients vitals were taken upon admission, her blood pressure was elevated 132/84, patients effacement was at 50% upon admission C.E is a gravida 1, para 1(G:1/P:1), her last menstrual period was on 7/5/13 When C.E came to the hospital her fundal height was 39cm and her estimated date of confinement was 4/12/2014. During pregnancy C.E had no complications and the fetus presented no abnormalities she reported taking prenatal vitamins, and a calcium supplement. C.E had a NSVD (normal spontaneous vaginal delivery) at 0938 April 14th to a healthy female baby C.E was in labor for 7 hours. Patient has an intact perineum; placenta was delivered spontaneously and remained intact, after birth both mother and baby remained in a stable condition.
History of present illness:
40 gestational weeks, term baby, no complications, came to hospital due to contractions and effacement of cervix.
C.E came to the hospital because she was experiencing contractions that did not cease after changing position, occurred at regular intervals and steadily increased in strength, which are experienced after the onset of labor.
Physical Assessment (upon admission)
-reparatory: RR was 20, labored due to pain, clear bilaterally
-cardiovascular: BP 132/84, no history of HNT
GI: no bowel sounds present, patient was kept NPO
Neurologic: Pt alert and oriented x4. Pt is fully awake and reports having pain 8/10
Genitourinary: patient reported urinating before onset of pain
Integumentary: Skin is warm, patient was diaphoretic due to pain and strain.(Lewis 2011).
Reproductive system: effacement at 50% upon admission, no present infections. Blood work panel on 3/12/14 no abnormal blood values were reported.
Blood type 0+
AB screening: negative
Rubella: immunization (given/no date available)
Rh type: Positive
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(with APA citations) Pertinent Lab tests/ Values (with normal ranges),
with dates and rationales
Surgical History: no history
Past medical history:
G/P: Gravida 1 / Para: 1
C.E has experienced 1 pregnancy; which is the one she is currently experiencing, she has given birth once. C.E is a primagravida (Durham, R.F. & Chapman, L, 2013).
No gestational diabetes
No abnormalities during pregnancy
Anemia: may be due to decreased hemoglobin synthesis, defective deoxyribonucleic acid synthesis in RBCs and diminished availability of erythrocyte precursors (Lewis 2011)
Pregnancy: is the fertilization of and development in the uterus of one or more offspring know as...