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Case Note 8: Patient Details

Mrs. Joanna Johan, a 40-year-old pregnant woman (25 weeks gestation), was admitted to the hospital with pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM), and generalized edema. Her blood pressure was elevated and she had lost 8 kg in the past 3 weeks. She was started on medication to control her blood sugar and blood pressure, received a blood transfusion, and was referred to an endocrinologist and dietician. Her condition improved and she is scheduled for discharge and follow up as an outpatient, where she will continue monitoring and treatment under the care of a community health nurse.

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232 views3 pages

Case Note 8: Patient Details

Mrs. Joanna Johan, a 40-year-old pregnant woman (25 weeks gestation), was admitted to the hospital with pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM), and generalized edema. Her blood pressure was elevated and she had lost 8 kg in the past 3 weeks. She was started on medication to control her blood sugar and blood pressure, received a blood transfusion, and was referred to an endocrinologist and dietician. Her condition improved and she is scheduled for discharge and follow up as an outpatient, where she will continue monitoring and treatment under the care of a community health nurse.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CASE NOTE 8

Time: Reading – 5 minutes, Writing- 40 minutes

Today’s date: 20/7/19

A 40 years old antenatal woman admitted to the Care Well Hospital, where you are the Head nurse

Patient details

Name: Mrs Joanna Johan


Marital status : Married
Admission date : 15/7/19
Discharge date: 20/7/19

Diagnosis: antenatal mother (25weeks), PIH, GDM


G3P2A1L1

Present illness: Generalized edema and palpitation (3days)

Examination:-

 temp :98 degree Celsius


 Pulse: 114 bts/mt
 RR: 20 brths/mt
 BP: 160/100mm hg
 Hb: 6mg/dl (anemic)
 RBS: 300mg/dl (checked FBS and pre meal sugar levels)
 TSH: 6 mU/L (0.4 mU/L – 4.0 mU/L)
 Height : 165 cm
 Weight: 55 kg (weight loss by 8kg -past 3 weeks)

Past History:-

 H/O abortion (fall 5 years back)


 No H/O GDM or PIH
 Appendectomy - 2005
 ORIF – right radius in 2016
 Hypothyroidism – on tab. Thyroxin 50 mcg (early morning)
 Previous CS with post - partum psychosis (counseling given)
 H/O anemia and blood transfusion ( 1 st pregnancy)
Family History:-

 Mother – Hypertensive
 Father- diabetic
 Husband – peptic ulcer

Social Background:-

 Lives with husband (business man )


 Hobbies – watching tv , gardening
 Prefers to eat cookies chocolates, puddings and fruits

Medications:-

 Labetalol 100mg OD
 Metformin 500 mg BD
 Tab Qten 10mg (sos , sleep)
 Iron and calcium supplements

Nursing management and progress:-

 Monitored blood and urine sugar level regularly


 Anti – diabetic drug given (sugar uncontrolled )
 Referred to endocrinologist –insulin commenced-now controlled
 BP monitored - controlled
 TSH increased – thyroxin dosage increased {100mcg}
 1 pint PRBC administered ( Hb:11mg /dl)
 Weight monitored (further lost noticed by 2 kg)
 Referred to dietician –dietary management
 Condition improved – ready to be discharged

Temp: 98.6 degree Celcius


RR : 20brths/mt
Pulse: 92 bts/mt
BP :130/80mm Hg
FHS :120 bts/mt
FBS: 120mg/dl - still requires insulin
Treatment Plan:-

 Requires routine monitoring – antenatal checkups, vitals, blood and urine sugar
level,weight,FHS
 Educate the need and self administration -insulin
 Health education regarding – dietary mgmnt to be continued
 Instruct to avoid cabbage, spinach ,soya foods,nuts,cookies,chocolates etc
 Advice low salt low fat diet
 Provide iron Iron rich food (anemia )
 Weight loss if- to be informed
 TSH needs to be checked (after 1 week)
 Next follow up scheduled on28/7/19

Task
Using the information in the case note write a letter to Ms Angel Philip,community health nurse
and explain the health status of Mrs Johan and request for home visits to manage her condition.

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