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    Assessment of Signs and Symptoms Reason For Admission: Elective Repeat CS

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    Sistine Rose Labajo
    The patient is a 38 5/8 week pregnant G2P1 female admitted for an elective repeat cesarean section. On examination, she has a fundal height of 34 cm and estimated fetal weight of 3565 grams. Her vital signs are stable. Laboratory tests including a CBC, urinalysis, and urine culture show results within normal ranges, though moderate epithelial cells and bacteria were present in the urine, indicating a possible urinary tract infection. The patient reports mild hypogastric pain but no other symptoms. She is scheduled for an elective repeat cesarean section.

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    Assessment of Signs and Symptoms Reason For Admission: Elective Repeat CS

    Uploaded by

    Sistine Rose Labajo
    31 views4 pages
    The patient is a 38 5/8 week pregnant G2P1 female admitted for an elective repeat cesarean section. On examination, she has a fundal height of 34 cm and estimated fetal weight of 3565 grams. Her vital signs are stable. Laboratory tests including a CBC, urinalysis, and urine culture show results within normal ranges, though moderate epithelial cells and bacteria were present in the urine, indicating a possible urinary tract infection. The patient reports mild hypogastric pain but no other symptoms. She is scheduled for an elective repeat cesarean section.

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    The patient is a 38 5/8 week pregnant G2P1 female admitted for an elective repeat cesarean section. On examination, she has a fundal height of 34 cm and estimated fetal weight of 3565 grams. Her vital signs are stable. Laboratory tests including a CBC, urinalysis, and urine culture show results within normal ranges, though moderate epithelial cells and bacteria were present in the urine, indicating a possible urinary tract infection. The patient reports mild hypogastric pain but no other symptoms. She is scheduled for an elective repeat cesarean section.

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    31 views4 pages

    Assessment of Signs and Symptoms Reason For Admission: Elective Repeat CS

    Uploaded by

    Sistine Rose Labajo
    The patient is a 38 5/8 week pregnant G2P1 female admitted for an elective repeat cesarean section. On examination, she has a fundal height of 34 cm and estimated fetal weight of 3565 grams. Her vital signs are stable. Laboratory tests including a CBC, urinalysis, and urine culture show results within normal ranges, though moderate epithelial cells and bacteria were present in the urine, indicating a possible urinary tract infection. The patient reports mild hypogastric pain but no other symptoms. She is scheduled for an elective repeat cesarean section.

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    of 4

    ASSESSMENT OF SIGNS AND SYMPTOMS

    Reason for Admission: Elective Repeat CS

    SIGNS (OBJECTIVE) SYMPTOMS ( SUBJECTIVE)

     Pain scale 1/10


     The patient experienced mild hypogastric pain
     Abd: FH: 34 cm radiating to the LSA not associated watery or
    bloody vaginal discharge.
     EFW: 3, 565 grams.
     Patient has irregular menstrual history 2-3 months
     IE: 1 cm, 80 Eff, St -5, IBOW, Cephalic x 3-4 days, 3-4 pads.

     A: G₂ P₁ (1001) PU 38 ⁵/₈ weeks AOG, CNIC, Prev.


    CS one for CPD (2014 CHH)

     Current Health Status

    VITAL SIGNS

     Blood Pressure: 100/70


     Pulsation Rate : 95
     Respiration Rate : 18
     Body Temperature: 36.4

     WEIGHT: 135 lbs


    LABORATORY AND DIAGNOSTIC STUDY

    LABORATORY TEST

    Date Type of Patient’s Results Normal Values Significance/


    exam Interpretation

    CBC WBC - 4.4 to 11.0 WBC - 4.5 to 11.0 (4,500 to WBC –The result of the
    11,000 WBCs per microliter) client’s WBC count is
    RBC – 4.5 to 5.1 within the normal range.
    RBC - 4.2 to 5.4
    million cells/mcL. RBC – The result of the
    client’s RBC count is within
    the normal range.
    Macroscopic Macroscopic Macroscopic
    Urinalysis Examination: Examination: Examination:

    Color –Yellow Color – Light Yellow to Dark The result of the client’s
    Transparency – Clear Amber Transparency – Urinalysis for the
    Specific Gravity – 1.015 Clear or Slightly Cloudy Macroscopic Examination
    Specific Gravity - c1.005 to (Color, Transparency,
    1.025 Specific Gravity) are within
    the normal range, and have
    no complications are seen
    prior to the procedure.
    DATE TYPE OF PATIENT’S NORMAL VALUES SIGNIFICANCE/
    EXAM RESULTS INTERPRETATION

    Urinalysis Chemical Chemical The result of the client’s Urinalysis


    Examination: Examination: Chemical Examination (Albumin, pH,
    Ketone, Blood, Glucose,
    Albumin – Negative Albumin – Negative Nitrite, Bilirubin, Urobilinogen)
    pH – 6.5 pH - 4.5 - 7.2 are within the normal range, and have
    Ketone – Negative Ketone – Negative no complications are seen prior to the
    Blood – Negative Blood – Negative procedure.
    Glucose – Negative Glucose – Negative
    Nitrite – Negative (0 to trace amounts)
    Bilirubin – Negative Bilirubin – Negative
    Urobilinogen -Normal (0 to 0.2 mg/dL)
    Urobilinogen –
    Normal (0.2-1.0
    mg/dL or <17
    micromol/L)
    The result of the client’s Microscopic
    Urinalysis Microscopic Microscopic Examination (WBC, RBC, Mucus
    Examination: Examination: Thread, Bacteria) are within the
    WBC – 2-5/HPF normal range, and have no
    WBC – 1-3/HPF RBC – 4/HPF complications are seen prior to the
    RBC – 5-7 /HPF Epithelial Cells –None to procedure. However, moderate
    Epithelial Cells – Few (1-5/HPF) Epithelial Cells and microbes are
    Moderate Mucus Threads – None found in the client’s urine which may
    Mucus Threads – Few to Few Bacteria – None to indicate yeast or Urinary Tract
    Bacteria - Few Few Infection.

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