Description
The instructions are in the case study document. Use the patients details in there to fill out the care plan template writing care plans. When done, please return the Care plan template with care plans written and works cited including references. Every information needed for this work to be done is in the Case Study document.
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Explanation & Answer
Attached.
CLINICAL PERFORMANCEASSESSMENT WORKSHEET
Student Name:
Date:
Houston Baptist University
NURS 4434 Care of Childbearing Family
Antepartum Care Worksheet
Student Name
EDC
Date
Wks Gestation
Pt’s Initials
GTPAL
Room Age
Current Wt
Allergies
Pre-Pregnancy Wt
Marital Status
Pre-shift Report:
Maria Garcia aged 34 years old, parity 1 gravid 2, brought in with complaints of dizziness and blurred vision. Today’s temperature is
98.8 Fahrenheit, respiration of 28 beats per minute and blood pressure of 143/85 mmHg. Her postprandial glucose level is 193mg/dl.
She has gone for an obstetric ultrasound, which indicates that the baby may be large for gestational age. Today plans to put patients on
a low calorie diet and monitoring of pre and postprandial blood sugar levels. The patient is instructed to monitor fetal movement.
Besides, She due for obstetrician check- up next week. However, she is requesting too home to check on her son and check on her
mother who stays with her but she is out of town
Test and result/date
A+
Blood type
Positive
Rh factor
Antibody screen Negative
12.7
Hgb
35.5
Hct
6.5
WBCs
204
Platelets
Test and result/date
Immune
Rubella
Negative
HIV
Negative
RPR/VDRL
Negative
HbSAg
Negative
Gonorrhea
Negative
Chlamydia
Negative
GBS
Interpretation of abnormal lab results
Maria has elevated blood glucose with a random blood sugar of 193 mg/dl (80 to 140 mg/dl) and fasting blood
sugar of 149mg/dl (less than 100mg/dl). Hematocrit levels are slightly lowered (Normal range for the female is
37% to 48%). Also, Maria has diminished white blood cell count of 6.5 (Normal range is 4,000 to 11,000 per
microliter of blood) and lowered platelets count of 204 (Normal range is 150, 000 to 450,000 platelets per
microliter of blood
Medical diagnosis
Gestational diabetes mellitus
Reasons for hospitalization
Dizziness
Blurred vision
Steroid Doses and Dates:
dexamethasone
Diet:
Low-calorie diet
Activity:
Bed rest
Discussion of medical diagnosis. What are signs and symptoms, etiology, diagnostic tests used, current
treatment/medication orders, possible emergency states, and medical interventions
Gestational diagnosis- refers to the degree of elevated blood glucose during pregnancy
Signs and symptoms: polyuria, polydipsia, and blurred vision
Etiology: affects 60 to 80% of pregnant women
Time
FHR:
Monitor
Mode
FHR
Baseline
000hrs 132b/mins 136b/min
Monitor mode
E = External
I = Internal
FHR
Variability
viable
oooohrs
o
FHRV
++ = marked
+ = moderate
- = minimal
0 = absent
Maternal Vital Signs
Time BP T P
143/81 98.8 71
R
28
Accelerations
Deceleration
Type
0
Accelerations
++ = 15 X 15
0 = none
Voided/
catheter
voided
Hourly
IV rate
0
Duration
Monitor
Mode
external
30mins
Decelerations
E = Early decelerations
V = Variable deceleration
L = Late deceleration
P = Prolonged deceleration
3o mins
supine
Intensity
mod
Intensity
mmHg
Mild= mild
Mod= moderate
Str= strong
Medications Maternal
are given Position
Magnesium
sulphate
Frequency
Pain
0
Resting
Tone
143/81
Resting Tone:
mmHg
Soft = soft
Mod = Moderate
H = Hard
Other (DTRs,
clonus..)
none
Discuss family configuration, cultural/spiritual assessment, and financial/emotional health.
Prioritized Problem List/Nursing Diagnoses, R/T and AEB: (two for Mom and one for baby):
Mother: Risk for unstable blood glucose
The risk for none prone behavior related
Risk of infection
Baby: Risk of premature birth
This section is for any additional evaluation of yourself that you may want to share with the instructor
Nursing Skills:
Cultural awareness, it is vital in giving complete patient-centered care. Understanding and putting into consideration
of patient’s cultural beliefs and values assist in planning and delivery of nursing care
Professionalism refers to putting ethical considerations into practice...