Obstetrics Case Study

By: Alyssa Clarkson

Demographic Data

Reason for hospitalization: Postpartum

Patient initials: S.M.
Age: 31 years old
Sex: Female

Ethnicity: Caucasian/Non-Hispanic
Religion: Assemblies of God
Code Status: Full
Delivery Date: October 19, 2015
Breast or Formula feeding: Breastfeeding

Past Medical History

Immunization Status: Rubella - Negative (Immune)

Blood Type and Rh Status: O+
HIV: Negative
Strep: Group B Strep - Negative
Hepatitis: Negative
Previous Surgical History: Wisdom teeth removal, Cesarean Section
Hospitalizations: Birth of children
Allergies: Aspirin, Seafood especially Shellfish
Chronic Illness: Depression, Asthma, Migraines

Family Medical History

Mother: No pertinent medical history

Father: Hypertension
Maternal Grandmother: Hypertension, Diabetes, Lung Cancer
Paternal Grandmother: Hypertension, Diabetes
Maternal Grandfather: No pertinent medical history
Paternal Grandfather: No pertinent medical history
Siblings: No pertinent medical history

Psychosocial History

Family Makeup: Husband and children

Employment: Homemaker
Education: Bachelors Degree
Insurance: Medicaid
Tobacco, Drug, and Alcohol Use: None

Physiological Status

Dorothea Orem
Self-care (Deficit) Theory
Patient should identify self-care deficits and then define their roles to meet the
demands
Patient should be a self-reliant individual and responsible for own care as well
as others in their family who need care
Meeting self-care needs is an important component of primary care
The patients knowledge of potential health problems is needed for promoting
self-care behaviors
Nursing is a form of action between two or more individuals

Developmental Status

Erik Eriksons Eight Stages of Development

Trust vs. Mistrust
Autonomy vs. Shame
Initiative vs. Guilt
Industry vs. Inferiority
Learning Identity vs. Identity Diffusion
Intimacy vs. Isolation
Generativity vs. Self-Absorption
Integrity vs. Despair

Growth and Nutritional Status

BMI: 30.7
Height: 5 6
Weight:
Pre-pregnancy: 165 lbs.
Pregnancy: 197 lbs.
Post-pregnancy: 190 lbs.

Focused Physical Assessment

Vital Signs

General Appearance

Lymph nodes
Head and neck

Eyes

Ears

Nose

Mouth and throat

Chest
Lungs
Genitalia
Back and extremities
Neurological
BUBBLHE

Laboratory Results

Hemoglobin & Hematocrit: 9.6 g/dL & 29.5%

Rubella titer: Negative (Immune)
Hepatitis screening: Negative
Blood type: O
Rh factor: +

Medications

Norco
Motrin
Fentanyl
Iron Preparation (Ferrous Sulfate)
Oxytocin

Summary

Anxiety related to change in role functioning secondary to postpartum as evidenced

by statements of fear regarding youngest sons reaction, homeschooling all of the
children, and discharge from the hospital.
Sleep deprivation related to care of an infant secondary to postpartum as evidenced
by crying newborn, irritability, agitation, and excessive daytime sleepiness.
Readiness for effective breastfeeding related to basic breastfeeding knowledge
secondary to fifth postpartum experience as evidenced by no problems with
newborn latching, adequate newborn positioning, and verbalization that the newborn
is the fifth child she has breastfed.

References
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NJ: Pearson.
Ibuprofen (Motrin) (2014). In Drugs.com. Retrieved October 24, 2015, from http://www.drugs.com/ibuprofen.html
Ladewig, P. A., London, M. L., & Davidson, M. R. (2014). Contemporary Maternal - Newborn Nursing Care (8th ed.,
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Pagana, K. D., & Pagana, T. J. (2014). Mosby's Manual of Diagnostic and Laboratory Tests (5th ed.). St. Louis, MO:
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Stages of social-emotional development - Erik Erikson (2015). In Child Development Institute. Retrieved October
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