Time of assessment:0700
Diagnosis and vital signs (if she is high risk, then elaborate);
Cervical Insufficiency with short cervix-The cervical length is only measuring 1.8 cm. In most women, this cylinder, the cervix, is approximately 2.5 cm or 1 inch long. With the cervix being short it disposes the patient to many risks throughout her pregnancy.
History (include age, gravida & para, medical and OB history, any prenatal problems):
36 year old, Gravida-3, Para-0, fertility-Intrauterine insemination for this pregnancy, in 2011 had a stillborn infant at 20wks and in 2012 pregnancy ended in preterm labor at 19wks with fetus not surviving out of utero.
Father of the baby, whom is her husband
Bilateral clear lung sounds, anterior and posterior. Equal rise ...view middle of the document...
Bowel sounds active X 4.
Self-void with BRP. Denies any pain or bleeding. “Clear and light yellow.”
Active ROM in bed. Upper and lower extremities equally strong. Currently on MD ordered bed rest with BRP.
Fetal heart tones (baseline, accelerations, decelerations, internal or external monitoring):
External Fetal Monior-10 min strip: Baseline:150, 10X10 accelerations.
Contraction pattern (frequency, duration, intensity, internal or external monitoring):
External Toco monitor: No contractions noted at this time.
IV site and fluids:
No IV site at this time.
Abnormal lab/ radiology values and significance:
8/31/13: Gardella-Positive, It has been linked to miscarriage, preterm delivery (before 37 completed weeks of pregnancy), and pelvic infection after childbirth.
Any other significant data:
Cerclage on 6/27/13. Celestone given on 8/26/13 and 8/27/13. NICU consultation done. Bilateral Tubal litigation to be done after labor and the consent has been signed and are on the chart.
Medications (list reason given, time, dosage, and route)
Colace 100mg PO 1tab q daily to soften stool to decrease straining, PreNat Vit 1 tab PO q day for adequate nutritional intake, Protonix 40mg PO q day for acid reflux, Procardia 10mg PO q6hr for treatment of preterm labor(slow contractions), 17-Hydroxyprogesterone injection IM q weekly for reducing risk of delivering too early, Vistaril 25mg PO q4hrs PRN for contractions, Ambien 5mg PO before bed PRN to help sleep, Maalox 30ml PO every 6hrs PRN for indigestion, Zofran 4mg PO every 6hrs PRN for nausea.
Clinical skills performed:
Evaluated fetal status via External Fetal Monitor
Evaluated uterine activity via toco
Nursing diagnosis (be sure to list related to):
1. Anxiety r/t concern for fetus
2. Risk for DVT r/t bed rest
3. Risk for injury r/t prolonged positioning in Trendelenburg
4. Social isolation r/t extended stay away from family