Question

DFC Post Work (SOAP Notes)

Background

Today you are meeting with Laura, a 34 year old woman who is 30 weeks pregnant. Laura has had one previous pregnancy that resulted in the birth of a 4400 g healthy baby, Sarah, who is now 16 months old. Laura is married, and her husband, David, is with her at this visit. David works full time as a Physician Assistant, but the practice that he works for has recently been purchased by a health plan and he is unsure about his job's future right now. Laura works half time as a legal secretary.

Laura and David carefully planned for their first pregnancy. They were married several years ago, but waited to have their first child until they were financially secure enough that Laura could work part time after the baby came. They both made a point of making healthy food choices and avoiding alcohol when they were trying to conceive their first child. They attended both a preconception health education class and a prepared childbirth class.

Sarah proved to be a challenging baby. She is only now beginning to sleep through the night. She had "colic" symptoms until she was almost 6 months old. Laura and David felt strongly about breastfeeding, and had been to classes and read books about breastfeeding. However, they encountered some difficulties with breastfeeding for the first few weeks. These included sore nipples, a breast infection, and a perceived lack of an adequate milk supply. When Laura went back to work 3 months post partum Sarah eagerly took bottles of formula while her mother was at work. Despite Laura's plan to maintain exclusive breastfeeding and pumping of breastmilk for several months, Sarah was soon just nursing a couple of times a day, and stopped nursing altogether 2 to 3 weeks after Laura discovered that she was pregnant again.

Laura and David had wanted another child at some point, but this current pregnancy was not intended. Although they have accepted the pregnancy, they state that they have concerns about the effect that a new baby will have on Sarah, their marriage, and their finances.

Laura and David have good health insurance coverage, but Laura has only been seen 4 times for prenatal care for this pregnancy.

Anthropometric Data

Laura's prepregnancy weight with this pregnancy was 175 #. She is 61 " tall. She gained 55 pounds in her first pregnancy, and lost 20 of those pounds before she became pregnant again. Today her weight is 200#.

Health History

Laura's health history is unremarkable. Her blood pressure today is within normal limits. She denies use of drugs, tobacco.

Laura states that she does not like to exercise. She joined a health club a few years ago, but stopped going after about 6 weeks because she felt out of place and she thought that it was boring. She started a walking program after her first pregnancy with another new mother from her mom’s group, but her friend moved away and Laura doesn’t like to walk alone.

At the beginning of both of her pregnancies Laura experienced considerable nausea and occasional vomiting as well as overwhelming fatigue. Today Laura complains of the onset of several pregnancy discomforts that also bothered her toward the end of her first pregnancy. These include heartburn, intermittent diarrhea and constipation, fatigue, and edema in her ankles.

Laboratory Values

Last week Laura had a 50 gram oral glucose screen. Results at one hour were 120 mg/100 ml. Laura's hematocrit today is 31%.

Supplements

Laura is intermittently taking a standard prenatal vitamin and mineral supplement that contains 30 mg per day of elemental iron. She feels that this supplement has contributed to some of her pregnancy related discomforts. David has recently been to a continuing education conference on nutrition and reproductive health. There were several vendors of nutritional supplements who displayed products at the conference. He is asking your advice today about fish oil, zinc, and calcium supplements in pregnancy.

Answers the following Assessment and plan for patient

a. Synthesis of subjective and objective?

b. Not a medical diagnosis, but discusses problems or issues to be addressed?

c. Risks – injury, fall, infection?

d. Nurse concerns – anxious, depressed, s/s of infection?

e. Interventions

f. Education

g. Consults needed

Answer 1

a. Synthesis of subjective and objective

During the initial stages of both pregnancies, Laura experienced nausea, vomiting , fatigue. This can be an issue to the growing foetus as regards any injury due to fall or otherwise. Besides, the physiological values of her Blood TC, DC , Serum Bilirubin, Hb need to be within normal range. Regular checkup as regards BP maintenance is to be monitored for her health maintenance.

b. Issues to be addressed: Weakness, nausea, fatigue: as regards these regular healthy iron and multi-vitamin diet, regular free hand exercise, prevention of constipation and fibre containing diet, stress free life, sound sleep.

c. Risks: She can lead a healthy life which must be stressfree. She can perform regular light exercise. She has to avoid junk foods, alcohol, smoking. She must also avoid analgesics, painkillers, etc. She must not climb stairs and that's too steep stairs too frequently, during climbing she should walk cautiously. She must not fall.

d. As regards healthy pregnancy, Laura should lead a stressfree life with adequate sleep. She should also take care of her respiratory system and her skin. Oral hygiene should also be maintained. Taking of antibiotics must be avoided . Thus, no new infections are to be allowed to develop.

f. Education: Child education is to be taken after birth. But, pre-natal and anti-natal care must be adopted before and after birth. As already stated, the would be mother must ensure that she leads a stress free healthy and hygienic life, avoid smoking and alcohol, be social and mix with people, have regular walk and be in an environment where there is less or no pollution, fibre rich and vitamin rich diet. She can also go through the journals which are concerned with pregnancy guidelines, child care, Mom care etc. Health and hygiene should be maintained.

e. Intervention: As regards her physiological values, so long as they remain within the ranges, no intervention are needed. If they are deviated, the concerned cause can be astertained and the proper medical intervention can be opted.

g. Consults: Once every month unless there is an absolute emergency. The Dietician's chart must be followed. Stress free happy life with regular exercise should be maintained.