NURS 316L – Nursing Care Plan NV

Student Natalie Varela Date 12/15/2018Instructor Pamela Daniels Course N316LPatient Initial KD Unit/ Room# 304 DOB 03/27/1987Code Status Full Height/Weight 5’1 / 145 lbs.Allergies NKA Final EDC/Current Gestational Age: 02/18/2019 / 26 weeksTemp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-1036.7 Oral88 radial 12 RR 98% 131/86 0/10History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with evidence based citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations. If on postpartum, BUBBLE-HE for maternal assessment and if on antepartum/intrapartum, the following apply: fundal height, CV/Thorax, perineum, SVE, and fetal heart rate Category.Chief Complaint (if possible, use patient’s words): I started having lower abdomen pain early in the day and the pain lasted all day. Then I started to have green discharge. HPI (PQRST of chief complaint, along with other pertinent pregnant complications [if any]): 31 y.o. at 26 weeks gestation, arrives to the hospital with prior noted chief complaint.Admit Dx:Relevant Diagnostic Procedures/ Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical and Surgical History, Pathophysiology of Medical Diagnoses (include dates, if not found state so) Supported with Evidence Based CitationsPertinent LabsCurrent CBC: Date taken: 11/19/2018Results Normal ValuesWBC 9.9 K/uL5-10 k/uLRBC 3.06 M/uL4-5.5 M/uLHgB9.5 gm/dL 12-17.4 g/dLHCT 27.5% 36-52 %MPV 7.1 fL7.4-10.4 fLMCV 89.6 fL80-100 fLMCH 31.0 pg27.0-33.0 pgMCHC 34.6% 31.0-36.0 %PLT 275 K/uL140-400 K/uLMg 4.6 mEq/L 1.3-2.1 mEq/LGBS: PositivePrenatal Panel: HIV: NegativeSyphilis: nonreactiveChlamydia: NegativeGonorrhea: NegativeRubella: immuneHepatitis B: NegativePIH panel (if applicable): N/ARelevant Diagnostic ProceduresUltrasound (latest): Transabdominal 11/15/2018Findings: fetus is in cephalic presentation, placenta is located posterior right lateral position. No sign of placenta previa or abruption. The cervix is open 3 cm in diameter. Medical Hx: Chronic hypertension (11/15/2017)Chicken pox (1994)OB Hx: G1P0Surgical Hx: No history of surgeries Family Hx:Erikson’s Developmental Stage (with Rationale). Provide examples of how client meets/doesn’t meet chosen stage (supported by Evidence Based Citations). Socioeconomic/ Cultural/ Spiritual Orientation& Psychosocial Considerations/ Concerns (3) supported withEvidence Based CitationsSocioeconomic Cultural:Spiritual:Three psychosocial concerns, based on above assessments:1.2.3.Potential Health Deviations: aka Risk Diagnoses (AT LEAST TWO) Include THREE independent nursing interventions for each (RISK FOR XXX, AS EVIDENCED BY XXX) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with RationaleSupported with Evidence Based CitationsPriority Nursing Diagnosis(at least 2)Written in three-part statement*Risk Diagnoses NEVER go in this section. Planning(outcome/goal) Measureable goal during your shift (at least 1 per NursingDiagnosis)*Think SMART GOAL* Prioritized Independent and collaborative nursing interventions; include further assessment,Intervention and teaching (at least 4 per goal) Rationale Each must be supported with Evidence Based Citations EvaluationGoal Met, Partially Met,or Not Met& ExplanationMEDICATION LISTMedications(with APA citations)Class/ Purpose Route Frequency Dose (& range)If out of range,why? Mechanism of actionOnset of action Common sideeffects Nursingconsiderations specific to thispatientDocusate SodiumStool Softener PO BID 100 mg 100-300 mg/dayWithin range Acts as a surfactant that softens the stool Abdominal cramps Recommend ambulation and increase of fluidsFerrous SulfateAnti-anemic PO Daily 325 mg 100-200 mg/day; out of range; patient RBC 3.06 M/uLNormalizes RBC production by binding with hemoglobin Constipation Take with a full glass of water or orange juiceLanolinSkin barrier Topical PRN Dime size amount for each nippleForms a temporary barrier over exposed tissue Allergic reaction Apply after breast feedingMethyldopa Anti-hypertensive PO BID 250 mg 250-750 mg/dayWithin range Stimulates the central inhibitory alpha-adrenergic receptors Hypotension Remind patient to get up slowly from bed to prevent feeling dizzyPrenatal Vitamin Supplement PO Daily 1 tab 1-2 tab/dayWithin range Provide supplemental vitamins and minerals ConstipationHeadache Remind patient to eat a well-balanced dietUpdated FII17-NCCReferences2017 Nurses Drug Handbook. (2017). Burlington, MA: Jones & Barlett Learning. Copstead, L. E., & Banasik, J. L. (2013). Pathophysiology. St. Louis, MO: Elsevier.Dunning, M. B., & Fischbach, F. T. (2011). Nurses quick reference to common laboratory & diagnostic tests (5th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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