Anna Vdovichenko

Greenfield Community College Maternal Nursing Assessment NUR 108

Patient (initials): R. F. Dates of care: 4/7/11 Biographical Data: A 36 year old Hispanic female. Currently living in a one story home in a suburban neighborhood. She is living with her husband and her
17 year old daughter. Occupation: LPN. Patient is a full code. No known Allergies. Family History: grandmother- hx of diabetes, grandfather- hx of hypertension, nephew with a club foot

History of Present Illness: Labor and Delivery History:

Include GP(TPAL), Prenatal Care History, Length of Labor, Type of Delivery, EBL, Complications, Postpartum course. Include significant lab data (Prenatal and during hospitalization). Include diagnostic tests and medications that were prescribed during pregnancy and labor. Please give approximate dates when possible. Note: Medication Assessment sheet is to be used for medications that are prescribed post-partum.

Patient admitted 4/4/11 due to pregnancy. G2P2002. LMP-6/25/10 EDC-4/8/11 EGA-39 4/7 Pt. delivered male neonate at 0935hrs on 4/4/11, placenta at 0937hrs by cesarean section followed by tubal ligation. AROM-clear, EBL- 300cc, spinal anesthesia. New Born: alive, 20in in length, 6lbs 12oz; Apgar score-9, 5 min- 9, 10 min- 9; HR-150 Prenatal Labs: Blood type- A+, Rh +, HBsAg status- neg, Mother GBS- neg, syphilis- neg, gonorrhea- neg, chlamydia- neg PP: breastfeeding, hypertension w/slight edema & is taking Labetalol 100 mg PO BID.

____________________________________________________________________________________________________________ Past Medical History: List past medical history (Including Drug Allergies, history of previous pregnancies, deliveries, illnesses, surgeries, other hospitalizations) Please give approximate
dates when possible.

1993-delivery her first child at 40 weeks gestation by cesarean section -developed gestational diabetes at third trimester, well controlled by diet -developed hypertension after pregnancy, stated having hx of hypertension in the family No known drug allergies