Obstetric Nursing Case Presentation

Jun 18th, 2015
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Alabama State University
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22 hours PTA (January 2, 2012, 2 am) patient experienced diffuse headache grade 8/10 lasting for 3 hours spontaneously relieved, not accompanied by blurring of vision, nausea and vomiting, chest and abdominal pain,. No consult was done, no medication has taken. 14 hours PTA (8am), BP was noted to be elevated at 160/100, however no headache and blurring of vision noted. 3 hours after, patient took 1 tab of Methyldopa 200mg/tab. There was a good fetal movement. 5 hours PTA (7pm), BP was elevated at 180/100, however asymptomatic, patient took sublingual nifedepine 5 mg/tab. 2 hours PTA (10PM), BP was rechecked and 170/ 100, still asymptomatic, patient took 1 tab methyl dopa 250mg/tab. Bp was checked after 30 mins and still elevated at 170/100. Patient decided to seek consult and was subsequently admitted.

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Name: ADMITTING HISTORY:22 hours PTA (January 2, 2012, 2 am) patient experienced diffuse headache grade 8/10 lasting for 3 hours spontaneously relieved, not accompanied by blurring of vision, nausea and vomiting, chest and abdominal pain,. No consult was done, no medication has taken. 14 hours PTA (8am), BP was noted to be elevated at 160/100, however no headache and blurring of vision noted. 3 hours after, patient took 1 tab of Methyldopa 200mg/tab. There was a good fetal movement. 5 hours PTA (7pm), BP was elevated at 180/100, however asymptomatic, patient took sublingual nifedepine 5 mg/tab. 2 hours PTA (10PM), BP was rechecked and 170/ 100, still asymptomatic, patient took 1 tab methyl dopa 250mg/tab. Bp was checked after 30 mins and still elevated at 170/100. Patient decided to seek consult and was subsequently admitted.Patient denies any hospitalization, surgery, and illness during her childhood days. In 2008, patient was diagnosed with Systemic lupus erythematosus(SLE). Initially she had malar rash, hair loss, intermittent fever and joint pains. Currently maintained on calcium carbonate, prednisone 30mg OD, and hydrochloroquine 200mg/tab OD. That year, she also had Diabetes Mellitus type II. She was previously maintained on Metformin 500 mg/tab since 2008 and discontinued on 5 mos. AOG; currently maintained on Insulin humulin N prebreakfast,- 18 u, predinner- 10u, Humalog premeal- 8u on daily CBG monitoring. Usual pre-meal 77mg/dl, lo

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