J.C.

Case Study 1

Case study NURS 208 9-28-11 Mrs. Lattamore Dayna Lancaster

J.C. Case Study 2

JC is a 30 year old white female being cared for at Princess Anne Hospital she was admitted on September 20th she presented with abdominal and lower back pain. Mrs. JC has been married for six years prior to current child she has no children of her own. Mrs. JC was originally born and raised in Fallon, Nevada. She is not a smoker and during her pregnancy she had not consumed any alcohol. After discharge JC plans to be a stay at home mother until Breanna is one year of age. Patient has been diagnosed with perineal tear, and vaginal childbirth. JC has a 20 gauge peripheral IV site in his left posterior forearm. Currently JC has a full code and she is allergic to sulfur drugs. She responds to verbally commands well though she does seem to be lethargic due to recent vaginal delivery. She has been placed on a regular diet as of 0400 on 9/20 post delivery. JC does not require assistance with ADLs. On September 21st 2011 at 0304 JC gave birth to a 4lb 7oz baby girl by the name of Breanna. JC was 38 gestational weeks when she went into labor, she had a vaginal birth. Childbirth also called labor, birth; is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus. The process of normal human childbirth is categorized in three stages of labor: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta. In many cases, with increasing frequency, childbirth is achieved through caesarean section, the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth.

Perineal tear is a system used to quantify the severity of trauma to the perineum during vaginal childbirth. Delivery may lead to overstretching of the vagina, causing tears in the perineal tissue between the vagina and rectum. Lacerations are classified into four categories. A first degree tear is a laceration limited to superficial perineal skin or vaginal mucosa.

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Meds:
Trade name: Zofran Generic Name: ondansetron

Classification: Antiemetic Action: prevents nausea and vomiting by blocking serotonin peropjerally, centrally, and in the small intestine Use: Prevention of nausea, vomiting associated with cancer chemotherapy, radiotherapy, and prevention of postoperative nausea, vomiting. Bulimia, pruritis, alcoholism, hyperemesis gravidarum Dosage: hyperemesis gravidarum: PO/IV: 4-8 mg bid- tid Side Effects: headache, dizziness, drowsiness, fatigue, diarrhea, constipation, abdominal pain, musculoskeletal pain, wound problems, shivering, fever, hypoxia, urinary retention Adverse Effects: bronchospasm (rare) Patient Teaching: instruct patient to report diarrhea, constipation, rash, changes in respirations, or discomfort at insertion site. Teach patient reasons for medication and expected reactions. Nursing implementation: IV: give iv after diluting a single dose in 50 ml of 0.9% NaCl or D5w, 0.45% NaCl; give over 15 minutes

Trade name: Motrin Generic Name: ibuprofen Classification: nonsteroidal anti-inflammatory; nonopiate analgesic, antipyretic Action: in hibits prostaglandin synthesis by decreasing enzyme needed for biosynthesis; analgesic, antiiflammatory, antipyretic Use: primary dysmenorrheal, gout, dental pain, fever, musculoskeletal disorders, fever, migraine, rheumatioid arthritis

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Dosage: self treatment of minor aches/ pains: PO: 200mg q4-6hrs may increase to 600mg; max 1200mg. moderate-sever pain: IV: 400-800mg q6hrs as an adjunct to opiate agonist therapy. Antiinflammatory: PO: 300-800mg tid-qid: max 3.2g/day. Antipyretic: PO: 400mg q4hrs; max 1200mg/day Side Effects: headache, nausea, anorexia Adverse Effects: CV thrombotic events, MI, stroke, hepatits, GI bleeding, ulceration, necrotizing entercolitis, GI perforation, nephrotoxicity, anaphylaxis, stevens- Johnson syndrome, necrotizing fasciitis, blood dyscrasias Patient Teaching: caution patient not to exceed recommended dose; acute poisoning may occur. Tech patient that therapeutic response takes one month. Advise patient to use sunscreen to prevent photosensitivity. Advise patient with allergies that allergic reaction may occur. Caution patient to avoid alcohol ingestion, salicylats, NSAIDs; GI bleeding may occur Nursing implementation: IV: must be well hydrated prior to administration. Discard unused portion. PO: give with food or milk to prevent GI upset. Administer crushed or whole.

Trade name: Percocet Generic Name: oxycodine/ acetaminophen Classification: Opiate analgesic Action: Inhibits ascending pain pathways in CNS, increases pain threshold, alters pain perception. Use: Moderate to severe pain. Dosage: PO: 10-30 mg q4hrs; CONT REL 10mg q12hrs in opiate-nave patients Side Effects: drowsiness, confusion, dizziness, headache, fatigue, sedation, euphoria, nausea, vomiting, anorexia, rash

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Adverse Effects: Respiratory depression Patient Teaching: advise patient to avoid CNS depressants: alcohol, Sedative/ hypnotics. Discuss in detail all aspects of product, including purpose and what to expect. Advise patient to make position change slowly to lesson orthostatic hypotension. Nursing implementation: give with antiemetic if nausea, vomiting occur. Medication should be slowly withdrawn after long-term use to prevent withdrawal symptoms. Store in light-resistant container at room temperature. Assessment: B- No engorgement noted, nipples not tender or cracked, pt currently breast feeding U- Firm, 2 finger widths below umbilicus, no lochia expelled when palpated B- Bladder empty, normal output, yellow in color, no burning or pain when voiding B- Passage of flatus regular at this time, bowel sounds in all four quadrants hypoactive, last BM 9/19/11 L- Rubra, scant to lite amount, no odor present E- No episiotomy preformed, No redness, edema, echamosis, discharge, approximation, pt had right urethral tear H- No hemorrhoids or hematomas visable or present H- No pain or warmth in calves when feet flexed, capillary refill present and reactive E- Pt affect happy and energetic, support form husband, no depressant noted. Extreme interest in baby, eye, touch contact, elated response to infant LAB: WBC RBC HGB HCT MCV 9-20 14.5 4.36 13.8 39.1 90

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MCH MCHC RPW OB platelet MPV Urinaylasis Color Specific gravity Ph Protein Urobilinogen Other labs Hbsag RPR HIV Genetic screen GBS

32 35 11.6 271 7.9 9-20 yellow 1.020 7.5 trace 0.2

neg non routine Neg denied Neg

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References Donald Venes, A. B. (2005). Taber's Cyclopedic Medical Dictionary. In A. B. Donald Venes, Taber's Cyclopedic Medical Dictionary (pp. 1-2518). Philadelphia: F. A. Davis company. Nan Forte, M. S. (2009). WebMD. Retrieved May 25, 2011, from http://www.webmd.com Skidmore-Roth, L. (2011). Mosby's Drug Guide For Nurses Ninth Edition. In L. Skidmore-Roth, Mosby's Drug Guide For Nurses Ninth Edition (pp. 1-1118). Littleton: John Wiley & Sons, Inc.