DFC Post Work (SOAP Notes)
Background
Today you are meeting with Laura, a 34 year old woman who is 30weeks pregnant. Laura has had one previous pregnancy that resultedin the birth of a 4400 g healthy baby, Sarah, who is now 16 monthsold. Laura is married, and her husband, David, is with her at thisvisit. David works full time as a Physician Assistant, but thepractice that he works for has recently been purchased by a healthplan and he is unsure about his job's future right now. Laura workshalf 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 firstchild until they were financially secure enough that Laura couldwork part time after the baby came. They both made a point ofmaking healthy food choices and avoiding alcohol when they weretrying to conceive their first child. They attended both apreconception health education class and a prepared childbirthclass.
Sarah proved to be a challenging baby. She is only now beginningto sleep through the night. She had \"colic\" symptoms until she wasalmost 6 months old. Laura and David felt strongly aboutbreastfeeding, and had been to classes and read books aboutbreastfeeding. However, they encountered some difficulties withbreastfeeding for the first few weeks. These included sore nipples,a breast infection, and a perceived lack of an adequate milksupply. When Laura went back to work 3 months post partum Saraheagerly took bottles of formula while her mother was at work.Despite Laura's plan to maintain exclusive breastfeeding andpumping of breastmilk for several months, Sarah was soon justnursing a couple of times a day, and stopped nursing altogether 2to 3 weeks after Laura discovered that she was pregnant again.
Laura and David had wanted another child at some point, but thiscurrent pregnancy was not intended. Although they have accepted thepregnancy, they state that they have concerns about the effect thata new baby will have on Sarah, their marriage, and theirfinances.
Laura and David have good health insurance coverage, but Laurahas only been seen 4 times for prenatal care for thispregnancy.
Anthropometric Data
Laura's prepregnancy weight with this pregnancy was 175 #. Sheis 61 \" tall. She gained 55 pounds in her first pregnancy, and lost20 of those pounds before she became pregnant again. Today herweight is 200#.
Health History
Laura's health history is unremarkable. Her blood pressure todayis within normal limits. She denies use of drugs, tobacco.
Laura states that she does not like to exercise. She joined ahealth club a few years ago, but stopped going after about 6 weeksbecause she felt out of place and she thought that it was boring.She started a walking program after her first pregnancy withanother new mother from her mom’s group, but her friend moved awayand Laura doesn’t like to walk alone.
At the beginning of both of her pregnancies Laura experiencedconsiderable nausea and occasional vomiting as well as overwhelmingfatigue. Today Laura complains of the onset of several pregnancydiscomforts that also bothered her toward the end of her firstpregnancy. These include heartburn, intermittent diarrhea andconstipation, fatigue, and edema in her ankles.
Laboratory Values
Last week Laura had a 50 gram oral glucose screen. Results atone hour were 120 mg/100 ml. Laura's hematocrit today is 31%.
Supplements
Laura is intermittently taking a standard prenatal vitamin andmineral supplement that contains 30 mg per day of elemental iron.She feels that this supplement has contributed to some of herpregnancy related discomforts. David has recently been to acontinuing education conference on nutrition and reproductivehealth. There were several vendors of nutritional supplements whodisplayed products at the conference. He is asking your advicetoday about fish oil, zinc, and calcium supplements inpregnancy.
Answers the following Assessment and plan forpatient
a. Synthesis of subjective and objective?
b. Not a medical diagnosis, but discusses problems or issues tobe addressed?
c. Risks – injury, fall, infection?
d. Nurse concerns – anxious, depressed, s/s of infection?
e. Interventions
f. Education
g. Consults needed
