NURS 4434 Houston Baptist University Antepartum Care Worksheet

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Onfvyr

Health Medical

NURS 4434

Houston Baptist University

NURS

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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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Hi Mbah this is your case study. Please review and be prepare to discuss this on our collaborate blackboard meeting at 1000. Dr. Terri Knudtson Houston Baptist University NURS 4434 Care of Childbearing Family Antepartum Care Situation Learning Objectives: After careful reading of narrative and supporting data student will construct an Antepartum Care Worksheet 1. Interpret provided blood test results; Pre-shift report, Reason for hospitalization; Discussion of medical diagnosis; discussion of obstetric and pregnancy history; Fetal monitoring; and Maternal vital signs. 2. Discuss family configuration; cultural/spiritual assessment, and financial/emotional health. 3. Prioritize Problem List/Nursing Diagnosis, R/T and AEB -- three for mom and three for baby. 4. Review and record medications including drug name, dose, side effects (look-up) on Scheduled Medication Worksheet. 5. Compose detailed Care Plan for mother including: Highest Priority Nursing DX; Plan; Intervention; Rationale; Evaluation; Skills Used; Legal Ethical Issues; and Safety Concerns 6. Compose detailed Care Plan for infant including: Highest Priority Nursing DX; Plan; Intervention; Rationale; Evaluation; Skills Used; Legal Ethical Issues; and Safety Concerns 7. Present Nursing Skills; Your Strengths; What Opportunities for improvement there may have presented to you in this situation. CASE STUDY After meeting with course instructor at 0630 on 3/16/20 you proceed to meet the charge nurse who then assigns you Tarka RN. Nurse Tarka takes you to room 564 to meet client Maria Garcia. Mary Garcia is 34-year-old married woman with one child (a son) that is thee years old. This was a vaginal delivery. She is pregnant with second baby and thinks she is 34 weeks pregnant. She weighs 220 pounds. Patient has scant prenatal care. Her husband brought her in last night because she was dizzy with blurred vision. She states that she “has no pain at this time.” Her temperature 98.8, blood pressure was 150/81, her respirations 34. The patient’s last postprandial glucose test was 193 mg/dl. Patient’s fasting glucose was 149 mg/dl. Her blood pressure was 143/85, respiration 28, and temperature 98.8 She is concerned that “she has to go home to take care of her three-year-old son because her husband has to go to work” and her mother (who lives with her) is out of town. Fetal heart monitoring was reassuring, but ultrasound indicated that the baby may be large for gestational age. Patient states that “her baby seems to be moving less” and she is afraid that her baby may come early. Test results Blood type Rh factor Antibody screen Hgb Hct WBCs Platelets A+ Positive negative 12.7 35.5 6.5 204 Rubella HIV RPR/VDRL HbSAg Gonorrhea Chlamydia GBS Immune negative Negative Negative negative Negative negative New doctor’s order: Pt. put on a calorie restrictive diet and pre and postprandial blood sugar test. Pt. to monitor her blood pressure. Pt. is instructed to monitor fetal movement. Mary has orders to see her obstetrician next week. Complete assessment of mother and baby (cite sources). Care plan for mother and baby. Prioritize Nursing diagnosis (including R/T and AEB) 3 for both mother and baby. Cite where you got this information. OB Case Study Week 1 Houston Baptist University NURS 4434 Care of Childbearing Family Antepartum Care Situation Learning Objectives: After careful reading of narrative and supporting data student will construct an Antepartum Care Worksheet 1. Interpret provided blood test results; Pre-shift report, Reason for hospitalization; Discussion of medical diagnosis; discussion of obstetric and pregnancy history; Fetal monitoring; and Maternal vital signs. 2. Discuss family configuration; cultural/spiritual assessment, and financial/emotional health. 3. Prioritize Problem List/Nursing Diagnosis, R/T and AEB -- three for mom and three for baby. 4. Review and record medications including drug name, dose, side effects (look-up) on Scheduled Medication Worksheet. 5. Compose detailed Care Plan for mother including: Highest Priority Nursing DX; Plan; Intervention; Rationale; Evaluation; Skills Used; Legal Ethical Issues; and Safety Concerns 6. Compose detailed Care Plan for infant including: Highest Priority Nursing DX; Plan; Intervention; Rationale; Evaluation; Skills Used; Legal Ethical Issues; and Safety Concerns 7. Present Nursing Skills; Your Strengths; What Opportunities for improvement there may have presented to you in this situation. CASE STUDY After meeting with course instructor at 0630 on 3/16/20 you proceed to meet the charge nurse who then assigns you Tarka RN. Nurse Tarka takes you to room 564 to meet client Maria Garcia. Mary Garcia is 34-year-old married woman with one child (a son) that is thee years old. This was a vaginal delivery. She is pregnant with second baby and thinks she is 34 weeks pregnant. She weighs 220 pounds. Patient has scant prenatal care. Her husband brought her in last night because she was dizzy with blurred vision. She states that she “has no pain at this time.” Her temperature 98.8, blood pressure was 150/81, her respirations 34. The patient’s last postprandial glucose test was 193 mg/dl. Patient’s fasting glucose was 149 mg/dl. Her blood pressure was 143/85, respiration 28, and temperature 98.8 She is concerned that “she has to go home to take care of her three-year-old son because her husband has to go to work” and her mother (who lives with her) is out of town. Fetal heart monitoring was reassuring, but ultrasound indicated that the baby may be large for gestational age. Patient states that “her baby seems to be moving less” and she is afraid that her baby may come early. Test results Blood type Rh factor Antibody screen Hgb Hct WBCs Platelets A+ Positive negative 12.7 35.5 6.5 204 Rubella HIV RPR/VDRL HbSAg Gonorrhea Chlamydia GBS Immune negative Negative Negative negative Negative negative New doctor’s order: Pt. put on a calorie restrictive diet and pre and postprandial blood sugar test. Pt. to monitor her blood pressure. Pt. is instructed to monitor fetal movement. Mary has orders to see her obstetrician next week. Complete assessment of mother and baby (cite sources). Care plan for mother and baby. Prioritize Nursing diagnosis (including R/T and AEB) 3 for both mother and baby. Cite where you got this information.
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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...


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