What patient history has clinical significance to the nurse

Reference no: EM133309806

Case Study: Mary is a 17-year-old primigravida who delivered a baby girl by vaginal delivery two weeks ago. She has been breastfeeding with no problems since she was born. She developed increasing firmness and swelling in her left breast that is causing increasing pain and noticed that her nipples developed cracks two days ago. She made an appointment to see her obstetrician because she had a fever and chills that began this morning and had breast pain that became "unbearable" whenever she tried to breastfeed. Mary is motivated to be a good mom. She has six weeks off before she has to return to work at Subway. She lives with her parents and the father of the baby is not involved. She is alone most of the time while her parents are at work and has lots of questions about caring for and feeding her baby.

Question 1: What patient history has clinical significance to the nurse and why?
The most recent vital signs were:

T: 101.1 F/38.4 C (axillary)
P: 98 (reg)
R: 20 (reg)
BP: 134/86
O2 sat: 98% on room air

Question 2: What patient vital signs have clinical significance to the nurse and why?

GENERAL APPEARANCE: Calm and cooperative. Winces in pain when left breast is touched.
RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular, tachycardic, with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill
NEURO: Alert and oriented to person, place, time, and situation (x4)
BREAST: Lactating; right breast soft, non-tender with evidence of breastmilk. Left breast reddened, warm, painful to touch, small 1 cm fissure present on left nipple
UTERUS: No longer palpable
BLADDER: Voiding without difficulty
BOWELS: Abdomen round, soft/nontender, bowel sounds audible per auscultation in all four quadrants
LOCHIA: Alba
HOMANS: Negative
EPISIOTOMY: Perineum intact

Question 3: What patient assessment findings have clinical significance to the nurse and why?

Question 4: What is the nursing priority at this time?

Question 5: What nursing interventions will the nurse initiate based on the priority at this time?

Reference no: EM133309806

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