cp gdmCASE PRESENTATION

7/26/2019 cp gdmCASE PRESENTATION

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Laboratory

Haematology

(Full Blood Count (FBC))- White Blood Cell

!/"#/ "$% $%&%% $"'%! $" #/L (Full Blood Count (FBC))- Red Blood Cell

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(Full Blood Count (FBC))- +ae,oglobin

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!%'! . (Full Blood Count (FBC))- Mean Cell olu,e

!/"#/ "$% $%&%% 00'1 2l (Full Blood Count (FBC))- Mean Cell +ae,oglobin

!/"#/ "$% $%&%% %'! pg (Full Blood Count (FBC))- Mean Cell +ae,oglobin Con entration

!/"#/ "$% $%&%% ! '1 g/dL (Full Blood Count (FBC))- Red Cell 3istribution Width

!/"#/ "$% $%&%% $4'0 . (Full Blood Count (FBC))- 5latelet

!/"#/ "$% $%&%% $0 $" #/L (Full Blood Count (FBC))- 5er entage O2 Neutrophil

!/"#/ "$% $%&%% 11'1 . (Full Blood Count (FBC))- 5er entage o2 Ly,pho yte

!/"#/ "$% $%&%% !'# . (Full Blood Count (FBC))- 5er entage O2 Mono yte

!/"#/ "$% $%&%% 4' . (Full Blood Count (FBC))- 5er entage O2 6osinophil

!/"#/ "$% $%&%% $' . (Full Blood Count (FBC))- 5er entage o2 Basophil

!/"#/ "$% $%&%% "'$ . (Full Blood Count (FBC))- Absolute Neutrophil

!/"#/ "$% $%&%% 0'"$ $" #/L (Full Blood Count (FBC))- Absolute Ly,pho yte

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'% $" #/L (Full Blood Count (FBC))- Absolute Mono yte



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(Renal 5ro2iles)- 7rea

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(Renal 5ro2iles)- 9odiu,

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$"4'" ,,ol/L (Renal 5ro2iles)- Creatinine

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Shoo er /( Sha 8a orator 8B6 nu

C5 Assess,entDate/Time

Nursing Care Plan

Nursing Diagnosis : Mother ;orried regarding 2etal ;ell beingObjective : Mother understood and ,ore al,

ntervention : - Assess ,other<s ondition- 6 plained regarding urrent ondition- 6n ourage ,other to as= any >uestion that she don<t understand- 9hare e perien e ;ith ,other ;ho has sa,e proble,- 6 press 2eeling to do tors or nurses so that inter?ention an be arried out- Moral support 2ro, 2a,ily ,e,bers and sta22 in ;ard- C8@/FMC/F+R/5ad hart ,onitoring as ordered

Evaluation : Currently ,other understoodHealth E!ucation : - FMC/F+R/C8@/5ad hart ,onitoring



- 8o in2or, stat i2 less 2etal ,o?e,ent- Rest in bed

Discharge Plan : - 8CA- Medi ation- MC- 5N- 3is harge note- :n2or, - sta22 - in2or, by

C5 Assess,entDate/Time

Nursing "ssessment "!ult

ADMISSION INFORMATION

#o!e of "!mission : Wal=ing "!mit $ia : 8rans2er/Re2errel "ccom%anie! by : +ospital 9ta22 9el2"ccom%anie! tems : Ad,ission For,Patient on : : Line"llergy : No Previous "!mission : No #e!ication &rom Home : No 'eason for current a!mission : @ 5$ D !!/% E 1/0 @3M ;ith deranged B95

Vital sign/Measurement (/P : $ "/01Tem%erature : !0C

Pulse/"( : 4#/,inSPO) : #4'es%iration : /,inPain Score : /$"

Measurement *t : $1!=gHt : 01 ,

GCS Score Eye O%en : *$erbal res%onse : %#otor res%onse : 1

Total Score : $%/$%

Inform if abnormalities Patient (elongings :

NURSING ASS SSM NT #ental Status : Cons ious Emotional Status : Cooperati?e Orientate! to : 8i,e 5la e 5erson



"ctivity +evel : A,bulatory "bility to %erform "D+ : :ndependent 'es%iration : Nor,al S,in ntegrity : :nta t Hearing : Nor,al $ision : @ood -lasses : NoNutritional status : @ood AppetiteSlee% %atterns : Nor,al S%eech : @ood (la!!er Patterns : Nor,al (o.el Patterns : Nor,al Prosthesis :

FA!! RIS" ASS SSM NT

Score# $%&' lo( ris)* &+%'' me,ium ris)* '+ an, -ig-er -ig- ris). Toim lement re0enti0e measures History of fall : No Secon!ary Diagnosis

HDT0D#1 : es

"mbulatory ai! : None/ bed rest/ nurse assist $ or $ acces : None

-ait : Nor,al/ bed rest/ ;heel hair #ental status : Oriented to o;n ability Total #orse &all Score : $%'""

Initiate fall ris) care lan for score more t-an &'

S"IN INT RGRIT1 ASS SSM NT Sensory Perce%tion : No :,pair,ent #oisture : Rarely Moistly "ctivity : Wal=s #obility : No li,itations Nutrition : 6 ellent &riction an! Shear : No apparent proble, S,in ntergrity "ssessment : !'""

Initiate lan of care if score 23 or less

41SC5OSOCIA! Occu%ation : Odd Gob E!ucation : 5ri,ary #arital Status : Married

+ives .ith : 9pouse 2no.le!ge of current illness : es Communication +anguage use! : MalayEmo Status/'eaction to "!mit : Cal, &inancial "ssistance 'e3uire! : No

4!AN OF CAR Plan of care : An iety Alteration in Blood 9ugar



isit 9u,,aryDate/Time

History dmi$$ion re0iew

Shoober A/p Shanmugham, 31YG2P1 @ 33W + 6/78MP 9 1/2/15:DD 9 ,/11/15

4 91/ GDM on d/c ! ne"#$ d%agno&ed) MG.. @ 15; 9 !%-/5%7@ 1-; 9 5%1/ %@ 32; 9 %2/7%5) not $een dietitian et) BSP 9 %* / -%3 / 7%7 / 7%*2/ 1 pre' &car (or breech %n 2)1)"<P6

Referred #a$e from KK for GDM with deranged BSP and (o h dromnion$) not #om( ian#e to dia eti# dietotherwi$eno $ign and $ m(tom$ of a our no fe0er no =R.6/=.6 $ m(tom$o/e

ert #on#iou$. 37BP 9 12*/7 mmhgPr ,-/min(/a$oft non tender uteru$ @ 3!;

ree#hno $#ar tenderne$$. S(arameter @ 33)3!;

ree#h" ++

P a#enta P=S*MP G2 P1 @ 33/ 2 + /7 GDM "%-h deranged .SP

#urrent#omforta eto erating weam u ating we

no P& eedno a domina (ainno $how/88no heada#he/di>>ine$

M goodo/e

ert #on#iou$warm (eri(herie$4R. ?2$not ta#h #ardi#



not ta#h (noie#. 37BP 1*,/ ,PR ,*8ung 9 # ear 4&S 9 DR Ma d 9 $oft non tender P anStri#t dia eti# dietBSP monitoringK6& for in$u in if BSP deranged4 o$e &S monitoring

K4.o refer dietitian #m


History M Re0iew$/w Dr Sundar Dr >>r Dr atinShoober A/p Shanmugham, 31YG2P1 @ 3 W8MP 9 1/2/15:DD 9 ,/11/15

4 91/ GDM on d/c ! ne"#$ d%agno&ed) MG.. @ 15; 9 !%-/5%7@ 1-; 9 5%1/ %@ 32; 9 %2/7%5) not $een dietitian et) BSP 9 %* / -%3 / 7%7 / 7%*) " 149 %,2/ 1 pre' &car (or breech %n 2)1)"<P6Referred #a$e from KK for GDM with deranged BSP and (o h dromnion$) not #om( ian#e to dia eti# dietotherwi$eno $ign and $ m(tom$ of a our no fe0er no =R.6/=.6 $ m(tom$o/e


ree#hno $#ar tenderne$$. S



(arameter @ 33)3!;ree#h" ++


#urrent#omforta eto erating weam u ating weno P& eedno a domina (ainno $how/88no heada#he/di>>ine$

M goodo/e

ert #on#iou$warm (eri(herie$4R. ?2$not ta#h #ardi#not ta#h (noie#BP9 11*/7* mmhPr9 , /min.em( 378ung 9 # ear 4&S 9 DR Ma d 9 $oft non tender P anStri#t dia eti# dietBSP monitoringStart in$u in9$/# a#tra(id unit$ .DS$/# in$u atard unit$ <

4 o$e &S monitoringK4.o refer dietitian.o refer (harma# for inAe#tion ite#hni ue


History M Re0iew$/w Dr 8i anaShoober A/p Shanmugham, 31YG2P1 @ 3 W + 1/78MP 9 1/2/15:DD 9 ,/11/15

4 91/ GDM on d/c ! ne"#$ d%agno&ed) MG.. @ 15; 9 !%-/5%7@ 1-; 9 5%1/ %@ 32; 9 %2/7%5



) BSP 9 %* / -%3 / 7%7 / 7%*) " 149 %,2/ 1 pre' &car (or breech %n 2)1)"<P6Referred #a$e from KK for GDM with deranged BSP and (o h dromnion$) not #om( ian#e to dia eti# dietotherwi$eno $ign and $ m(tom$ of a our no fe0er no =R.6/=.6 $ m(tom$o/e



ree#h" ++


#urrent#omforta eto erating weam u ating weno P& eedno a domina (ain

no $how/88no heada#he/di>>ine$M good

o/e ert #on#iou$warm (eri(herie$4R. ?2$not ta#h #ardi#not ta#h (noie#BP9 1*7/ mm"gPR 9 ,3 /min.em( 378ung 9 # ear

4&S 9 DR Ma d 9 $oft non tender uteru$ 3!w #e(ha i# ree#hBSP9 ,%!/!%3/ %,/,%1P anStri#t dia eti# dietBSP monitoring4<ntinue in$u in9$/# a#tra(id unit$ .DS$/# in$u atard unit$ <4 o$e &S monitoring



K4


HistoryAM 0 * W&/" Dr %c4$ 5oShoober A/p Shanmugham, 31YG2P1 @ 3 W + 2/78MP 9 1/2/15:DD 9 ,/11/15

4 91/ GDM on d/c ! ne"#$ d%agno&ed) MG.. @ 15; 9 !%-/5%7@ 1-; 9 5%1/ %@ 32; 9 %2/7%5

) BSP 9 %* / -%3 / 7%7 / 7%*) " 149 %,2/ 1 pre' &car (or breech %n 2)1)"<P6Referred #a$e from KK for GDM with deranged BSP and (o h dromnion$) not #om( ian#e to dia eti# dietotherwi$eno $ign and $ m(tom$ of a our no fe0er no =R.6/=.6 $ m(tom$o/e



ree#h" ++



M good



o/e ert #on#iou$warm (eri(herie$4R. ?2$not ta#h #ardi#not ta#h (noie#BP9 1*7/ mm"gPR 9 ,3 /min.em( 378ung 9 # ear 4&S 9 DR Ma d 9 $oft non tender uteru$ 3 wee'$Sing eton #e(ha i#: ; 2% )2%, 'gBSP9 ,%!/!%3/ %,/,%1P anStri#t dia eti# dietBSP monitoring4<ntinue in$u in9$/# a#tra(id unit$ .DS))))))6n#rea$ed to $/# #tra(id ,/ / u$/# in$u atard unit$ < )))))))))6 #rea$ed to $/# 6n$u atard , u <4 o$e &S monitoring

K4


History m re0iew$/w Dr Sundar Dr a$hreena *-** "Shoober A/p Shanmugham, 31YG2P1 @ 3 W + 3/78MP 9 1/2/15:DD 9 ,/11/15

4 91/ GDM on d/c ! ne"#$ d%agno&ed) MG.. @ 15; 9 !%-/5%7@ 1-; 9 5%1/ %@ 32; 9 %2/7%5) BSP 9 %* / -%3 / 7%7 / 7%*) " 149 %,2/ 1 pre' &car (or breech %n 2)1)"<P6Referred #a$e from KK for GDM with deranged BSP and (o h dromnion$) not #om( ian#e to dia eti# dietotherwi$eno $ign and $ m(tom$ of a our no fe0er no =R.6/=.6 $ m(tom$o/e

ert #on#iou$. 37



BP 9 12*/7 mmhgPr ,-/min(/a$oft non tender uteru$ @ 3!;


ree#h" ++



M goodo/e

ert #on#iou$warm (eri(herie$4R. ?2$not ta#h #ardi#not ta#h (noie#BP9 11-/7 mm"gPR 9 -3 /min.em( 378ung 9 # ear

4&S 9 DR Ma d 9 $oft non tender uteru$ 3 wee'$Sing eton #e(ha i#: ; 2% )2%, 'gBSP27/-/15 9 %5/ %7/!%7/7%32,/-/15 9 %7/ %*/5%!C(t refu$a for .<S'een for 8S4SP an'ee( (t for nowStri#t dia eti# dietBSP monitoring

4ontinue in$u in9in#rea$e $/# a#tra(id 1*/,/, u .DSin#rea$e $/# in$u atard 1*u <4 o$e &S monitoring

K4to oo' 8S4S date at 37/52re2er dieti ian

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cp gdmCASE PRESENTATION