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Case Note 13: Patient Details

Ms. Julia Smith is an 18-year-old woman from the Philippines who recently gave birth to her first child, a female infant, via emergency c-section at the Royal Women's Hospital in Brisbane due to meconium aspiration. The infant has a cleft lip and palate and is being referred to a pediatric surgeon. Julia lives alone with her boyfriend and is depressed due to her unplanned pregnancy and concerns about her baby and upcoming university exams. She has a history of malnutrition and had postpartum hemorrhaging after delivery.

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3K views3 pages

Case Note 13: Patient Details

Ms. Julia Smith is an 18-year-old woman from the Philippines who recently gave birth to her first child, a female infant, via emergency c-section at the Royal Women's Hospital in Brisbane due to meconium aspiration. The infant has a cleft lip and palate and is being referred to a pediatric surgeon. Julia lives alone with her boyfriend and is depressed due to her unplanned pregnancy and concerns about her baby and upcoming university exams. She has a history of malnutrition and had postpartum hemorrhaging after delivery.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CASE NOTE 13

Time allowed: 40 minutes

Todays date
18/07/2019

Notes
Ms Julia Smith is an 18 year old woman who has given birth to her first child in royal women’s
hospital, Brisbane. You are the nurse looking after her.

Patient Details

Name: Ms Julia Smith, student from malasia


Age: 18 years
Admitted: 14/07/19
Discharge: 18/07/19[Mother]
Date Of delivery: 14/07/19
Marital Status: Single
Country of birth: Philippines
Height: 158cm, Weight: 37kg [current]
Social Back ground
Julia is single and lives with her boyfriend. Presently, she does not have contact with her parents,
lives in Philippines

Depressed: unplanned pregnancy, university exam, baby’s health condition

Birth details

Date of Delivery: 14/07/2019,


Emergency caesarean section [meconium aspiration]
Sex: Female
Weight: 2kg at birth [LBW]
Apgar score 3at 1 min, 9 at 10 mins
O2 administered for 30 minutes
Cleft lip and palate noted [pediatric surgery referral], need surgical correction later
On NGT feed 2 hourly and EBM
Risk for aspiration
Bowl and Bladder continence
Feed tolerates well
17/07/2019
Jaundice baby on phototherapy

Obstetric History

15/03/2018
Heavy bleeding? Abortion [no admission in hospitals, verbalized]

10/11/2018
 second pregnancy confirmed
 Attended first antenatal visit at 16 weeks gestation
 4 antenatal visits in total.
 Malnourished, inadequate food intake
 Weight: 32 kg, Height: 164cm on first visit

Post Natal Progress


 Maternal post partum hemorrhage of 600mls
 Blood loss now minimal
 Wound: Clean and Dry
 Hemoglobin on 17/07/19 ;7 mg / dl
 Normal bilirubin: baby
 Baby weight at discharge 1.9 kg

Discharge Plan

 Referral pediatric surgeon : prior to discharge


 Referral dietician: prior to discharge
 Educate regarding NGT feed
 Assistance in baby feeding , bathing
 Observe for complication – contact hospital
 Follow up on bilirubin [7 days ]
 Referral letter to social worker regards university exam{ [20/08/19] hall ticket has to be
collected}
Writing Task

 Write a referral letter to pediatric surgeon, Dr. Charles, Royal Brisbane Women’s
hospital, Butterfield St & Bowen bridge Rd, Hurston QLD 4029, +61736468111,
introducing the child for the further management.
 Write a letter to Ms.Alice Henry, social worker, Brisbane request a home visit to assess
their living condition and to make arrangements for her examination as well as
counseling.
 Write a referral letter to dietician, Ms Mary Thomas, Royal Brisbane women’s hospital,
Butterfield St & Bowen Bridge Rd, Hurston QLD 4029, +61736468111, for assessment
and advice regarding nutritious diet.

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