Client Profile Log Antenatal - Complete
Client Profile Log Antenatal - Complete
Antenatal care: State whether client had ANC, where and number of visits.
Client received antenatal care at a private doctor and had a total of 6 visits with
normal booking parameters. Femina Bahamas-Dr. Nina Graham
Antenatal clients: Diagnosis, admission details
Diagnosed with preterm premature rupture of membrane. Admitted via private vehicle
with pelvic pressure and back pain denying per vaginal bleed. Patient has no known
medical illness or allergies. On arrival to ward pt. oriented x3 in nil obvious respiratory
distress. Physical assessment showed no abnormalities. Abdominal exam-small,
round abdomen, linea Negra present, fetal movement felt, fetal heart rate 145-
150bpm, fundal height 26cm, lie undetermined and pv loss clear.
Assessment:
V/S- T 96.8, P100, R 20, B/P 116/69, SPO2 97%, FHR 153-157
- Fundal height-28cm
- Lie, presentation, position of fetus- Lie-longitudinal, presentation and
position undefined.
- Fetal heart rate- 153-157bpm
- Contractions- no contractions
- Per vaginal loss (PV loss)- yellow discharge
- Urinalysis- Ascorbic acid-10, Glucose-negative, Bilirubin-negative, Ketone-
trace, specific gravity-1.01, Blood- non hemolyzed 10 trace, pH-6.5, protein-
negative, urobilinogen-02 normal 3.2, nitrite-negative, leukocyte-moderate
- Weight- 183lbs
Doctors’ orders:
Activity- Bed rest
Diet: full diet once not contracting
Vitals-q4hrly
Meds- Dexamethasone 2mg IM then 12 mg 12 hrs later
Ampicillin 2g IV stat then 1g IV q6hr
Revised 0804/SNS/revised ejw09/revised kmm22
Gravol 50mg IV stat the tid
Flagyl 2mg IV/po stat
Erythromycin 500mg IV stat then 500mg IV q8hr
IV Fluids:
Type: Erythromycin 500mg Rate: q8h _ Site: Left anterior antecubital arm
Blood investigations: