NURS381 Bowie State University Maternity Care plan Assignment

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libaarovu2003

Health Medical

NURS381

Bowie State University

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hi i'm going to send maternity care plan rubric for grading, the care plan format , and the information needed to do the care plan . i need a professional to do it please .

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Bowie State University Department of Nursing Level 200/300 CARE PLAN GRADING RUBRIC Student______________________________ Date______________ Evaluator______________________________ Score_____% Criteria Below Average Average Excellent Client introduction data to include all assigned criteria. (10%) Client introduction includes 6 or less of 12 assigned criteria. Client introduction includes 9 or less of assigned criteria. (4-6%) Level 200/300 Client introduction includes ten (10) to twelve (12) assigned criteria. Holistic and comprehensive assessment data (20%) Six (6) or fewer areas of the assessment are complete with vital signs, pertinent medical and social histories, and incomplete list of all applicable problems. (problems not stated in NANDA format) Nine (9) or fewer areas of the assessment are complete with vital signs, pertinent medical and social histories, and incomplete list of all applicable problems (NANDA stem & etiology only) Ten (10) to twelve (12) areas of the assessment are complete with vital signs, pertinent medical and social histories, and list of all applicable problems (NANDA stem & etiology only) (0-15%) Level 200/300 (16-18%) Level (19-20%) Level 200/300 ½ of the nursing diagnoses are identified based on the holistic assessment. ¾ of the nursing diagnoses are identified based on the holistic assessment. All nursing diagnoses are identified based on the holistic assessment. (0-2%) Level 200/300 ½ of the nursing diagnoses are correctly listed and prioritized. (3-4%) Level 200/300 ¾ of the nursing diagnoses are correctly listed and prioritized. (5%) Level 200/300 All of the nursing diagnoses are correctly listed and prioritized. (0-2%) Level 200/300 (3-4%) Level (5%) Level 200/300 Diagnoses (20%) (0-3%) Level 200/300 200/300 200/300 (7-10%) Level 200/300 Comments Bowie State University Department of Nursing Level 200/300 CARE PLAN GRADING RUBRIC Planning (10%) Interventions (18%) Rationales (10%) ½ of the nursing diagnoses are prioritized. ¾ of the nursing diagnoses are prioritized. All of the nursing diagnoses are prioritized. (0-2%) Level 200/300 Diagnoses for the care plan is missing two parts. (0-2%) Level 200/300 Goal is appropriate for the diagnosis and written using SMART criteria. (3-4%) Level 200/300 Diagnoses for the care plan is missing one part. (5%) Level 200/300 All parts of the diagnoses for the care plan are correct. (5%) Level 200/300 Goal is appropriate for the diagnosis and written using SMART criteria. The goal is not appropriate for the outcomes. The goal is appropriate for two (2) outcomes The goal is appropriate for all three (3) outcomes. (0-3%) Level 200/300 (4-6%) Level 200/300 (7-10%) Level 200/300 Only One (1) intervention is developed per outcome. Two (2) or fewer interventions are developed per outcome. Three (3) interventions are developed per outcome. (0-3%) Level 200/300 (4-6%) Level (7-9%) Level 200/300 Three (3) interventions are stated using actions verbs. Six (6) Interventions are stated using actions verbs. Nine (9) Interventions are stated using actions verbs. (0-1%) Level 200/300 Three or fewer rationales are not scientific and not cited per APA format. (2-6%) Level 200/300 Three (3) to six (6) of the interventions have scientific rationales with correct citation per APA format. (7-9%) Level 200/300 Seven (7) to nine (9) interventions have scientific rationales with correct citation per APA format. (0-3%) Level 200/300 (4-6%) Level (7-10%) Level 200/300 (3-4%) Level 200/300 Goal is appropriate for the diagnosis and written using SMART criteria. 200/300 200/300 Bowie State University Department of Nursing Level 200/300 CARE PLAN GRADING RUBRIC Evaluation (9%) References and Grammar (3%) Evaluative statement as to whether goal is met, partially met or unmet is made for one or none of the outcomes. Evaluative statement as to whether the goal is met, partially met or unmet is made for two of the outcomes. Re-plan statement(s) for improving the plan of care are not made for unmet and partially met outcomes Re-plan statement(s) for improving the plan of care are made for two unmet and partially met outcomes (0-3%) Level (4-8%) Level 200/300 References on the reference list are not all in the narrative and are not according to APA format. Writing with some correct spelling and grammar (0-1%) Level 200/300 Approved: Undergraduate Curriculum Committee 9-20-18 Faculty Organization 9-27-18 200/300 References in the reference list are not all in the narrative and are not according to APA format. Evaluative statements per outcome stated goal is met, partially met or unmet is made for all three outcome. Re-plan statement(s) for improving the plan of care are made for all unmet and partially met outcomes. (9%) Level 200/300 References in the reference list are in the narrative and are according to APA format. Writing with correct spelling and grammar Writing with correct spelling and grammar (2%) Level 200/300 (3%) Level 200/300 1 BOWIE STATE UNIVERISTY NURS 381 PRENATAL/INTRAPARTAL/POSTPARTAL/ CARE PLAN FORMAT INTRODUCTION: Provide a brief introduction of your patient to include: initial, age, blood type, PNC, GBS status, GTPAL, Gestational weeks, decelerations, membrane rupture, labor induced or augmented, Type of delivery-vaginal/cesarean. If cesarean, state reason and type of incision, Previous or intended contraceptive method, race, allergies, code status, past surgical history, reason for admission, Fetal presentation and position, Pre-pregnancy and total weight gain 2 ASSESSMENT: Integrate lab data, GYN, medical and social histories where applicable notably: Hypertension, Diabetes, heart disease, COPD, smoking, alcohol, and substance abuse etc. Note both physiological and psychosocial problems Date of Patient Care: Problems in NANDA format: Stem & Etiology. Identify ALL applicable problems in each system Vital Signs: Neurological: Cardiovascular: Respiratory: 3 GI (Assess for bowel elimination and nutrition among others) GU: Musculoskeletal: Integument ( include skin changes, episiotomy, laceration, incision, and hemorrhoid) 4 Reproductive (Include assessment of breasts, uterus, perineum, and lochia) Spiritual (Impact of spiritual belief system on maternal and or newborn care, including infant care practices, rites of passage, and choice of contraceptive method, if applicable) Sociocultural (Include socioeconomic status and awareness of Community Resources that support the Childbearing Family. Note impact of cultural belief system on expectations for maternal behavior during the postpartal period. (For example, is the mother allowed to leave the home right after the birth? If not, how long must she wait before she and the baby are allowed to leave the home?) Psychological (Include maternal-infant bonding behavior) 5 Developmental (Maternal Development, age, and impact on acceptance of parenting role and parenting behaviors) Laboratory & Diagnostic Results: If lab/diagnostic data is not available, discuss expected normal values with rationales Lab Result Normal Value Implications/rationales RPR GBS Rubella Hepatitis HIV Chlamydia . 6 Gonorrhea WBC Hemoglobin Hematocrit Platelet Other 7 Medications: Include ALL applicable meds: Antibiotics, Antiviral, Tocolytics, Bethamethasone, Induction/Augmentation meds, Comfort/Pain Management. Extend table as needed Generic/Trade Name Dosing/Safe Classification Reason for Use Side Effects Nursing/Pregnancy Implications . . . 8 PRIORITIZED DIAGNOSES: Extend the table as needed STEM ETIOLOGY S/S 9 NURSING DIAGNOSIS #1 Nursing Diagnosis (State fully): Goal: Outcomes (3) Patient will: Interventions with cited Rationales State enough Interventions for the 3 outcomes Nurse will: NURSING DIAGNOSIS #2 Evaluation Statement(s) supported with Patient’s Response (clinical data) to Interventions 10 Nursing Diagnosis (State fully): Goal: Outcomes (3) Patient will: Interventions with cited Rationales State enough Interventions for the 3 outcomes Evaluation Statement(s) supported with Patient’s Response (clinical data) to Interventions Nurse will: NURSING DIAGNOSIS #3 (Must be a psychosocial problem) Nursing Diagnosis (State fully): 11 Goal: Outcomes (3) Patient will: Interventions with cited Rationales State enough Interventions for the 3 outcomes Nurse will: REFERENCES: Evaluation Statement(s) supported with Patient’s Response (clinical data) to Interventions Care Plan #2 MRN: 1868096 Pacific View Regional Hospital 6475 E. Duke Avenue Room: 201 Patient: Dorothy Grant Sex: Female Age: 25 Physician: John Shelby, M.D. History and Physical for Obstetric Patients Chief Complaint: "My husband beat me and kicked me in the abdomen." History of Present Illness: "He's done this before, but this was the worst." Allergies: NKA Past Medical History: Multiple episodes of trauma inflicted by husband. Gonorrhea treated successfully during last pregnancy. Rh negative - received Rho(D) Immune Globulin during each pregnancy. Gyn History: Last PAP: With first prenatal visit History of abnormal PAP (if yes, describe): No Uterine abnormality/DES: None Menstrual: LMP: 30 weeks ago Menarche (age onset): 11 1/2; has had regular cycles, 28-30 days BCP history: None On BCP at concept (y/n): No hcG+: / / Infectious Diseases (genital herpes; STD; GC; chlamydia; HPV; syphillis; other): GC - treated successfully during last pregnancy OB History: Infertillity: No Pregnancy History: Total Pregnancies 5 AB, Spontaneous 1 Full Term 3 Ectopics 0 Premature 0 Multiple Births 0 AB, Induced 0 Living 3 Past Pregnancies: Date/ Month/ Year GA Weeks Length of Labor Birth Weight (lbs) Sex M/F Type Delivery Anes. Preterm Labor Y/N Comments/ Complications 5/98 40 12 7.2 F NSVD Epidural N None 8/00 40 10 8.5 M NSVD Stadol N None 2/01 40 10.5 8.3 M NSVD Stadol N None Page 2 of 3 Surgical History: None Social History: Tobacco: 1 pack per day Alcohol: Occasional Street Drugs: Tried marijuana "a couple of times" Family History: Married since age 18. Sister is main support. Live in low-income housing. Husband is sole financial support. Insurance through husband's job. Husband's parents divorced after 32 years of marriage. Patient's father alcoholic, physically abused mother. Genetic Screening: All No except for # 17 Yes No Yes No 1 PT ≥ 35 years yes no 10 Cystic fibrosis yes no 2 Thalassemia: MCV < 80 yes no 11 Huntington chorea yes no 3 Neural tube defect yes no 12 Mental retardation/autism yes no If yes, was person tested for fragile X? yes no 4 Coongential heart defect yes no 13 Other inherited genetic or chromosomal disorder yes no 5 Down syndrome yes no 14 Maternal metabolic disorder (e.g., insulin dependent diabetes, PKU) yes no 6 Tay-sachs yes no 15 Self or baby's father had a child with birth defects not listed above. yes no 7 Sickle cell disease or trait yes no 16 Recurrent pregnancy loss, or a still birth yes no 8 Hemophillia yes no 17 Medications/street drugs/alcohol since last menstrual period yes no If yes, agents(s): Beer (occ.), PNV 9 Muscular dystrophy yes no 18 Any other: No Page 3 of 3 Medications: PNV Review of Systems: GENERAL: Good health VITAL SIGNS: BP 132/68 T 97.8 P 86 R 24 Height: 5' 4" Weight: 165 lb HEENT: WNL BREASTS: Firm HEART: Clear LUNGS: RSR OBDOMEN/RECTAL: Pregnant. Rectal deferred. Bruising and abrasion on LLQ consistent with blunt trauma. Tender to palpation. OBSTETRIC/GENITALIA: Weeks Gestation: 30 Vulva: Deferred Vagina: Deferred Cervix: Deferred Uterus/Fundus Height (cm): 29 Adnexa: Deferred Diagonal Conjugate: Deferred Spines: Deferred Sacrum: Deferred Subpubic arch: Deferred Gynecoid pelvic type: Deferred Presentation: Vertex FHR: 130s Fecal Movement: Active Preterm Labor: No SKIN: Warm and dry EXTREMITIES: Movement all extremities MUSCULOSKELETAL: WNL NEUROLOGICAL: WNL Impression: 1. 30 week pregnant female with ecchymosis and abrasion on forearms and left lower abdomen consistent with report of abdominal trauma imposed by husband. 2. Forearms bruised when she put arms up to protect her face and chest. Plan: 1. Admit for observation and monitoring of fetal status. 2. R/O preterm labor. 3. Social services consult. 4. Psych consult. 5. Rho(D) Immune Globulin for Rh negative status. 1501-1900 Report --------------Increasing uterine activity despite Terbutaline administration. Continuous EFM. Contractions frequent with strengthened intensity, 10-15/hour. Sterile vaginal exam at 1700 revealed 6 cm dilation of cervix, 90% effacement, 0 station. Membranes ruptured during exam. Thin meconium present. FHR 140s with average variability and accelerations. Pain level 6/10. Voiding freely. Vital signs stable. Anesthesia consult done, patient requests IV analgesia only. Fentanyl last given at 1830. IV of Lactated Ringer's infusing at 125 ml/hr. Pediatric/ Neonatal team member visited patient, will be present at birth. Sister now at bedside as support person. Prepped for delivery at 1840. 1116-1500 Report --------------Resting at intervals. Continuous EFM. FHR 130s with average variability and accelerations. Contractions increasing in intensity and frequency, every 5-7 minutes, lasting 30-40 seconds. Pain level 4-5/10, Fentanyl 50 mcg IV given at 1400. Working well with breathing techniques. Terbutaline given at 1300 and 1400 for increased uterine activity without noticeable result. Rho(D)immune globulin given at 1200 for Rh negative status. Lungs clear and vital signs stable. Voiding freely in bedpan. Some bloody show present. IV of Lactated Ringer's infusing at 125 ml/hr. 0731-1115 Report --------------Continuous EFM. FHR 130s with average variability and accelerations. Mild contractions every 10-15 minutes lasting for 20-30 seconds. Sterile vaginal exam by MD at 0730 revealed 1-2 cm cervical dilation, 50% effacement, -3 station, and internal os fingertip dilation. Pain level 2-3/10. Betamethasone given as ordered. IV of Lactated Ringer's infusing at 125 ml/hr. Voiding freely. Visits by both social worker and psychiatric clinical nurse specialist. Dorothy anxious and crying at times, expressing concern about what will happen to her and the children. Requesting assistance to locate temporary shelter upon discharge. Reassurance and support offered by staff members. Change of Shift (1901-0730) Report --------------Dorothy admitted to Labor and Delivery Unit from ED at 0410 due to trauma to abdomen from alleged domestic violence. Patient is G 5, P 3, AB 1, 30 weeks gestation. Placed on continuous EFM. Peripheral IV started in left forearm in ED to infuse Lactated Ringer's solution. 500 mL bag infused over 2 hours then maintained at 125 mL/hr for hydration. FHR 140s with average variability. Occasional mild contractions, 4-5/hour. On bedrest with bathroom privileges. Voiding freely in sufficient amounts. Admission labs of CBC and coagulation studies, chemistry 7, UA, and type and screen done in ED. OB ultrasound done in ED revealed normal fundal placement of placenta with no evidence of abruption. No vaginal discharge. Vaginal exam deferred. Pain level 1-3/10. Anxiety level moderate due to concerns about safety of self and fetus. Ecchymosis and abrasions noted on both forearms and lower abdomen. Resting intermittently overnight. Agrees to visits by social worker and psychiatric team member for assistance with safety and domestic issues. 0700 vital signs: pain level 1-2/10, occasional mild contractions, T 98.2, BP 126/68, P 70, RR 18. MRN: 1868096 Pacific View Regional Hospital 6475 E. Duke Avenue Room: 201 Patient: Dorothy Grant Sex: Female Age: 25 Physician: John Shelby, M.D. Medication Administration Record Wednesday START STOP MEDICATION 0701-1900 Lactated Ringer's 125 mL/hr IV continuous 1400 EL Betamethasone 12 mg IM every 12 hours for 2 doses, dose #1 0730 EL Wed 0730 Prenatal multivitamin 1 PO daily 0800 EL ORD. TTBG*. STAT/PRE-OP/ONE TIME Wed 0345 Wed 0730 Wed 1930 TG*. 0730 today Rho(D) Immune Globulin 1 vial (300 mcg) IM x 1 1200 EL 1300 STAT Terbutaline 0.25 mg subQ x 1 1300 EL 1400 STAT Terbutaline 0.25 mg subQ x 1 1400 EL 1901-0700 1930 INJECTION SITE CODE 1. R Deltoid 2. L Deltoid 3. R Anterolateral Abdomen 4. L Anterolateral Abdomen 5. R Lateral Thigh *Time to be given 6. L Lateral Thigh 7. R Anterior Thigh 8. L Anterior Thigh 9. R Ventrogluteal 10. L Ventrogluteal **Time given INIT NURSE EL Emelia Lewis, RN JP Judith Palmer, RN MRN: 1868096 Room: 201 Patient: Dorothy Grant Pacific View Regional Hospital 6475 E. Duke Avenue Sex: Female Age: 25 Physician: John Shelby, M.D. PRN Medication Administration Record Wednesday START Wed 0730 STOP MEDICATION 0701-1900 1901-0700 1400 EL 1730 EL 1830 EL Fentanyl citrate 50 mcg IV every hour PRN pain ORD. TTBG*. STAT/PRE-OP/ONE TIME TG*. INJECTION SITE CODE 1. R Deltoid 2. L Deltoid 3. R Anterolateral Abdomen 4. L Anterolateral Abdomen 5. R Lateral Thigh 6. L Lateral Thigh 7. R Anterior Thigh 8. L Anterior Thigh 9. R Ventrogluteal 10. L Ventrogluteal *Time to be given **Time given INIT NURSE EL Emelia Lewis, RN JP Judith Palmer, RN MRN: 1868096 Pacific View Regional Hospital 6475 E. Duke Avenue Room: 201 Patient: Dorothy Grant Sex: Female Age: 25 Physician: John Shelby, M.D. Laboratory Results DAY/TIME: Wed 0245 HEMATOLOGY WBC 12.0 RBC 3.48 HEMOGLOBIN 11.5 HEMATOCRIT 33 MCV 88 PLATELETS 250,000 DIFF: NEUTROPHIL SEGS NEUTROPHIL BANDS LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS RETICULOCYTES ERYTHROCYTE SEDIMENTATION RATE NEUTROPHILS CHEMISTRY GLUCOSE 90 SODIUM 134 POTASSIUM 4.2 CHLORIDE 105 CO2 21 CREATININE 0.7 BUN 10 URIC ACID CALCIUM PHOSPHORUS MAGNESIUM BILIRUBIN (TOTAL) PROTEIN DAY/TIME: Wed 0245 CHEMISTRY (cont.) ALBUMIN ALKALINE PHOSPHATASE ALT (SGPT) AST (SGOT) LDH CK CK MB AMYLASE LIPASE LIPIDS CHOLESTEROL TRIGLYCERIDE HDL LDL HDL/LDL ENDOCRINE HBA1C T4 TSH URINE COLOR Straw CLARITY Clear GLUCOSE Neg BILIRUBIN 0 KETONES Neg SP GR 1.010 BLOOD Few pH 6.1 PROTEIN 1+ NITRITE LEUKOCYTES (ESTIMATED) MICRO: WBC RBC BACTERIA DAY/TIME: Wed 0245 COAGULATIONS PT 10.6 INR 1.1 PTT 30 FIBRINOGEN 350 FSP 3 D-DIMERS ARTERIAL BLOOD GASES PaO2 O2SATURATION PaCO2 pH 24-HR URINE TOTAL VOLUME PROTEIN CREATININE CREATININE CLEARANCE SEROLOGY VDRL RPR Neg DRUG MONITORING SPECIAL TESTS Type and screen Pacific View Regional Hospital 6475 E. Duke Avenue O negative MRN: 1868096 Patient: Dorothy Grant Room: 201 Sex: Female Age: 25 Physician: John Shelby, M.D. Diagnostic Report DEPARTMENT: Radiology TYPE OF EXAM: OB ultrasound DATE OF EXAM: Wednesday REPORT: Gravid uterus. Fetus in vertex position and active. Size = dates according to LMP. EGA 30 weeks. Estimated weight 1800 g. Placenta in superior, posterior fundus. No evidence of abrupted placenta. IMPRESSION: 1. Pregnancy, 30 weeks gestation. 2. No evidence of trauma to fetus or placenta. 3. Size of fetus = dates according to LMP. James Parmenter, M.D. Signature
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