Antepartum Care UNFOLDING Reasoning ; Anne Jones is a 17-yearold
History of Present Problem: Anne Jones is a 17-year-old Caucasian teenager who thinks
... [Show More] she may be pregnant because she has missed two periods. Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant. Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis. Personal/Social History: Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? 1 | P a g e(Reduction ofRisk Potential) RELEVANT Data from Present
Clinical Significance:
Problem: 1. 17-year-old female reports two missed periods. 2. Reported some spotting last week 3. C/O breast tenderness, swelling, -These are all presumptive signs of pregnancy. increased frequent in urination, and a.m. nausea
4. (+) pregnancy test 5. Provider has ordered urinalysis and pre-natal lab panel RELEVANT Data from Social History:
Clinical Significance:
1. Senior in H/S. 2. Works in a job that requires constant standing 3. Denies use of alcohol/nicotine & is
-Patient is in stable health with no known major medical concerns not on any prescription medications at this point. We know that she will need her nutrition and dietary
4. Reports a daily diet of poor nutritional habits addressed to successfully accommodate a growing fetus. value She will also need a support system and education on what to
5. Does not currently have a support expect in the coming months. We’ll know more when her lab system, as she has not informed panel comes back. anyone of her present situation Patient Care Begins: Current VS:
T: 98.6 F/37.0 C (oral) P: 76 (regular) R: 18 (regular) BP: 125/80
O2 sat: not assessed P-Q-R-S-T Pain Assessment:
Provoking/Palliative: Breast tenderness Quality:
Tender to touch and movement
Region/Radiation: Severity: Timing:
Both breasts
4/10 but better if wears a bra For the past couple of months
RELEVANT
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction ofRisk Potential/Health Promotion and Maintenance) VS Clinical Significance:
Data:
1. Temp, HR, & RR -There really is no significance to her first three VS, but her BP being on the higher are all within end of acceptable is mildly concerning. Considering how young she is and that she expected/acceptabl
isn’t overweight and doesn’t have any other diagnosed medical conditions, we’d like e ranges to see that number be a little lower; especially because as she progresses further into
2. BP is on the upper end of acceptable
line.
Current Assessment: GENERAL
Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm), APPEARANCE: RESP: CARDIAC:
NEURO: HEENT: Chest:
Abdomen: 2 | P a g e
weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite. BMI 18
Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial, brisk cap refill Alert and oriented to person, place, time, and situation (x4)
Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale Breasts tender on palpation, areola darkened and occasional veins present Soft; no masses, uterus palpable below [Show Less]