Good

Patient Initials

DF

Sex

F

Age

27

Room

LDR2

Admitting Date

03/05/2021

Reason for Admission:

Term pregnancy admission for delivery

Attending physician/Treatment team:

APN

Consults during hospitalization:

No

Present Diagnosis: (Why patient is currently in the hospital)

Labor / delivery

ER Management: (if applicable)

N/A

Allergies:

No known allergy

Code Status: Full Code

Isolation: (type and reason)

No isolation

Admission Height: 4.11inches

Admission Weight: 125lbs

Pre-pregnancy BMI:25.25kg/m2

Arm Band Location (colors & reasons)

White band, Newborn Id band

Communication needs: (verbal, nonverbal, barriers, languages)

Verbal; English is her second language. Speaks English fluently, No language barriers

Past Medical History: (pertinent & how managed)

Thyroid disease

Significant Events during this hospitalization: (include date, event and outcome)

Hypothyroidism complicating pregnancy

Tests/Treatments/Interventions impacting clinical day’s care: (include current orders)

N/A

Year

Week gestation

Outcome (SAB, IAB, NSVD, C/S)

Sex of Infant

Complications to pregnancy, labor/birth, or postpartum

2021

40 2/7

NSVD

M

Hypothyroidism

2019

39 5/7

HEALTH ASSESSMENTS Postpartum or Labor: depending on focus of care plan

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

8:10

T

98.2

P

86

R

20

B/P

113/59

Pulse Ox

98

Pain Score

0

Time

12:51

T

98.3

P

96

R

20

B/P

119/69

Pulse Ox

98

Pain Score

9

Postpartum Assessment:

(for PP care plan only)

B:

U:

B:

N/ A

B:

L:

E:

L:

E:

Respiratory Assessment and Interventions:

S/O:

She is breathing at a regular rate

Interventions:

Cardiovascular Assessments and Interventions:

S/O:

Heart rate was within normal range, skin was pink and there was no edema.

Interventions: Encourage ambulation

Gastrointestinal Assessment and Interventions:

S/O:

Diet: She is taking regular diet.

Interventions: Regular diet as she tolerates.

Musculoskeletal Assessment and Interventions:

S/O: Moves all extremities with no pain. No numbness

Interventions: Encourage ambulation

Neurosensory Assessments and Interventions:

S/O: No numbness or Tingling

Interventions: None

Renal Assessment and Interventions:

S/O: She was able to void

Intervention: she needs to void every 2 to 3 hours

Skin Assessment and Interventions:

S/O: Access for sores, skin color and breakdown, no pressure ulcer, skin was intact.

Intervention: Continue to monitor skin and maintain good patient care.

Endocrine Assessment and Interventions:

S/O: Patient has hypothyroidism

Intervention: Monitor input and out

Pain Assessment and Interventions:

S/O: Contraction

Pain score: 9

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

No pain medication was given as it was toward delivery of the baby.

Vascular Access: (IV site) Assessment and Interventions:

S/O

No redness or swelling.

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change)

Continue to monitor for redness and swelling.

Endocrine Assessment and Interventions:

S/O: Patient has Hypothyroidism and no gestational diabetes

Intervention:

Post-operative /procedural: Assessment and Interventions:

S/O: Patient has second degree laceration

Intervention:

Psychosocial Assessment/Interventions: (mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

Patient living with her partner with another child

No smoking, No substance abuse.

Advance Directives/Ethical considerations:

None

Cultural/Spiritual Assessment and Interventions: (religious preference, adaptations & modifications, end of life decisions)

No cultural practice currently

Growth & Development Assessment and Interventions: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

According to the Erikson stage of development this patient is in the intimacy vs. isolation period. This is because this stage pertains with person between the age 20 and 40 and it involve young adult struggles to form close relationships and to gain capacity for intimate love.

Maternal Diagnostic Data

Results and date

Normal Lab Values

Significance to your patient

Blood type (A, B, AB, O)

O+

RH Factor (“+” or “-“)

+

Antibody screen (if Rh negative)

Negative

Prenatal H & H

13.5/38.8

Postpartum H & H

Rubella status

Immune

GBBS

Negative

WBC

9.5 (03/05/21)

RBC

4.26 (03/05/21)

Platelets

173

HIV

Negative

Hepatitis B

Negative

GTT

Normal

Newborn Diagnostic Data

Blood type (A, B, AB, O)

N/A

RH Factor (“+” or “-“)

Coombs test

Blood glucose

Cord blood bilirubin

TCB/Serum bilirubin (please note whether value is TCB or serum and hour of life test completed

Glucose

PLEASE NOTE: The physiology/pathophysiology discussion should be in the student’s own words. Cite the source of the information using APA format.

Normal Physiology Discussion: (All care plans must have a brief discussion of the normal physiology related to their specific patient. (Examples: Labor care plan: Discuss what is happening physiologically during labor and birth. Postpartum care plan: Describe normal postpartum physiology.)

The patient at this point is going through recovery and involution. This is the process by which the uterus is transformed from pregnant to non- pregnant state during the postpartum period. first 1-2hours check vital signs every 15minutes, check the bleeding, check the fundus, Palpate the abdomen to check where the uterus is located if it is firm. She can get up after 2 hours to empty her bladder to prevent bleeding. During this period, the uterus can be found between the umbilicus and the symphysis pubis, but after 6-12 hours after delivery the uterus is found on the umbilicus. The uterus reduces each day by 1cm below the umbilicus by help of contraction (Ricci 2017). By the 14 days the uterus descends to the pelvic cavity, and you cannot palpate. After one week the uterus is decreased to 50 percent in size and at six weeks it’s mostly reduced to the prepregnant size. During this period, mother would not need to take a bathtub but rather shower to prevent infections. Vaginal bleeding is a common thing to find after delivery but intensity of it reduces the third to fourth day, if it intensifies or the newborn mum experiences heavy discharge, she will need to call the healthcare provider. At this period, the mother is not supposed to engage in any sexual intercourse until vagina discharge clears up. The mother must be check her diet and ensure taking more prenatal vitamins and food rich in fiber to prevent constipation.

Pathophysiological Discussion: (If your patient is experiencing a pathophysiological disease process please address in your own words. Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s general health? Describe the current disease process the patient is encountering: etiology, epidemiology, pathophysiological mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. (Include appropriate references and use APA format.)

Hypothyroidism: This is a condition in which there is an inadequate amount of circulating thyroid hormones triiodothyronine (T3) and thyroid (T4), causing a decrease in metabolic rate that affects all body systems. Most individual that have mild hypothyroidism are not frequently diagnosed, but the hormone disturbance can leads to medical treatment complication. To prevent the complications in future pregnancy, the mother should be instruct to begin treatment by administration of thyroid hormone replacement therapy and also monitor for cardiovascular compromise like chest pain, palpitations, rapid heart rate, shortness of breath.

Safety: (expected and actual needs)

Access to the call light

Socks with grips on the bottom of them

Top side rails up.

Matching Id bands

Bed on lowest position

Discharge Plan: (Briefly state when, with whom, and to where the patient anticipates being discharged)

The patient will be discharge on the 03/07/21 with her partner to the house

Teaching needs: (Identify the teaching needs for this mother and/or family; bullet points OK)

. She would need to schedule a follow up doctor’s appointment when they go home.

. Avoid heavy lifting and strenuous exercise

. Try to get as much rest as she can as they will be up frequently at night with the baby

.Good nutrition and adequate fluids are necessary for tissue repair, healing, breast feeding and general health.

.Elevate their feet when sitting or lying down and making sure they drink lots of water to help get rid of the excess fluid.

.She can takes shower as many time she want but avoid tub bath or swimming until after postpartum checkup.

. To contact health care provider whenever there is frequency or burning urination, temperature is 100.4 and above, unrelieved pain, no bowel movement for four days or longer.

The patient would need to be educate on the care of newborn:

Breastfeeding, latching on, positioning, mother’s nutrition

Safety: falls, rear facing car seat, safe handling swaddling, baby bath, diapering

When to call the physician: elevated temperature, difficulty breathing, poor appetite, feeding intolerance.

Medications

Classification

Dose, Route, Frequency

Purpose/Mechanism of Action (Why is THIS patient on this medication?)

Levothyroxine

(Synthroid)

75mcg daily PO

Oxytoxin

30-0.9UT/500ml IV

Lactated

125/hr

PRN

Route; IV

Fentanyl (SUBLIMAZE)

injection

100 mcg

Every 4 hrs

Terbutaline

(BRETHINE)

injection

0.25 mg

SQ

PRN

(provide subjective and objective assessments)

INCLUDE 2 COUTCOMES

(S-M-A-R-T)

(specific nursing actions- MUST include a rationale with each intervention)

(INCLUDE at LEAST 3 INTERVENTIONS AND RATIONALES)

(include whether outcome was met, partially met or unmet)

If the outcome is “unmet” what is your plan to meet outcome in the future?

5 POINTS

4 POINTS

3 POINTS

2 POINTS

1 POINT

O POINTS

SCORE

PATIENT INFORMATION AND HEALTH ASSESSMENT
:

-INCLUDES: Patient Demographics, Reproductive History, Physical, Psychological, Psychosocial, Cultural/Spiritual, Growth and Development, assessments and interventions

-Lab Work/Diagnostic Data

Patient demographics, health assessments, reproductive history, physical, pyschological, psycosocial, cultural/spiritual, growth and development assessments and interventions  complete. Lab work and diagnostic data complete

Minor omissions from patient demographics, reproductive history, physical, psychological, psychosocial, cultural/spiritual, G&D assessments and interventions. Most of lab data complete.maternal.

50% of information required for this category is in place. Items are missing and/or documented information is inaccurate or irrelevant. 

75% of patient demographics, health assessment and interventions are missing and/or inaccurate

Data collection and assessments reflects that no effort was applied to this section of the assignment resulting in a flawed plan of care. 

/5

0 POINTS

PHYSIOLOGICAL/ PATHOPHYSIOLOGICAL DISCUSSION;

-INCLUDES “signs and symptoms” ; APA references cited

Physiology discussion completed; relevant to specific patient; given with accurate details related to client’s status in the childbirth process; includes a pathophysiology discussion if relevant to patients current health APA references noted.

Physiology discussion completed providing minimal detail. Pathophysiology discussion omitted when relevant to patient’s current health status. APA references omitted.

Physiology discussion is omitted or not relevant to patient’s current status in childbirth process. Pathophysiology discussion omitted when it should have been included on care plan. APA references omitted.

/2

1 POINT

SAFETY ASSESSMENT, DISCHARE PLAN, TEACHING NEED:

– Include expected and actual needs

– Discharge plan: briefly state when and with whom

-Identify the teaching needs for this mother and/or family (list in bullet points )

Maternal safety needs addressed. Discharge plan addressed: when/with whom. Discharge teaching needs for maternal self-care and newborn care listed in bullet points

Maternal safety needs addressed. Discharge plan addressed. Discharge teaching needs incomplete for maternal self-care and newborn care.

Nominal mention of maternal safety needs, Discharge plan not addressed. Discharge teaching needs missing or contain limited information

Safety assessment not addressed. Discharge plan not noted. Incomplete teaching needs 

/3

PHARMACOLOGY:

Complete accurate description of current meds, including purpose for this patient, side effects, and all other data listed in chart

List all MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug

Most of the MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug

List some MAR meds but does not include relevant side effects and nursing considerations specific to patient

Only some of the current meds are written & discussed in the meds section. Info is incomplete with many omissions noted. The meds are not integrated in the plan of care

/3

NURSING DIAGNOSIS (INCLUDE 3 NURSING DIAGNOSIS):

-Risk for diagnosis are in lower priority than active nursing diagnosis

Nursing diagnosis table is complete with 3 diagnosis. Appropriate for patient; priority levels included. NANDA approved. Diagnosis also includes all parts and information

At least 2 of 3 nursing diagnosis are appropriate for patient/priority level included. NANDA approved. Does not include all parts or info is listed in wrong part of diagnosis

Not all nursing diagnosis appropriate. Priority level is incorrect or not included.  May also not be NANDA approved and may not include all parts

Diagnosis selected reflects that no effort to interpret info was applied resulting in a flawed plan of care. NANDA format is not complete or used correctly

I POINT

NSG DIAGNOSIS #1: ASSESSMENT:

Appropriate for chosen diagnosis. Includes objective & subjective historical data that support actual or risk for nursing diagnosis

Includes all pertinent data related to nursing Dx., and does not include data that is not related to Dx

Includes all pertinent data related to nursing Dx., but also includes data not relate to Dx

Doesn’t include all pertinent related data to nursing Dx. May include data not relating to Dx

Not all relevant subjective & objective data is collected. There is an absence of the use of inquiry to collect info relevant to the individual’s disease & circumstances.

/3

NSG DIAGNOSI #1:

OUTCOMES:

Outcomes should be specific to the patient Dx., The outcome statement should also contain the following 4 criteria: measurable, attainable, realistic, and timed. All criteria should be present to be a specific patient expected outcome

Outcomes statement is specific to pt. Dx. and contains all 4 measurable criteria. Should have 2 outcomes.

Outcomes statement is specific to pt. Dx. and it only contains two of the 4 measurable criteria

Outcomes statement is not specific to pt. Dx. and it only contains 1 of the 4 measurable criteria

Some of the outcome criteria identified to achieve goals will lead to the resolution or control of the related factors and purely based on coincidence

/3

NSG DIAGNOSIS #1:

INTERVENTIONS AND RATIONALES:

Include interventions or nursing actions that directly relate to the patient’s goal; are specific in action, frequency and contain rationale. The number of interventions should be appropriate to help patient/family meet their goal

Interventions portion contains adequate # of interventions to help pt./family meet outcome, and interventions are specific in action and frequency, and are listed with rationales

Interventions portion contains adequate # of interventions to help pt./family meet outcome, but may not be specific, labeled or listed with rationales

Intervention portion doesn’t include adequate # of interventions to help pt./family meet outcome. May also not be specific, labeled or listed with rationales

Inappropriate interventions are included in the plan of care. Interventions are not realistic & appropriate to the patient’s current status

NSG DIAGNOSIS #1:

EVALUATION:

Includes all data that is listed as criteria in outcome statement. Based on this data, outcome is determined to be met, partially met, or not met. If outcome was not met or partially met, plan of care is revised or continued and a new evaluation date/time is set

Evaluation portion does contain data that is listed as criteria in outcome statement. Does describe outcome as met, partially met or not met. If outcome partially met or not met, includes revision and or a new evaluation date time

Evaluation portion does contain data that is listed as criteria in outcome statement, but does not describe outcome as met partially met or not met. May also not include a revision or new evaluation date/time

Evaluation portion does not contain data that is listed as criteria in outcome statement. May also not describe outcome as met, partially met or not met. May also not include revision or new evaluation date/time

Does not clearly evaluate if the outcome is met; evaluation is purely based on if interventions are applied to patients care

I POINT

NSG DIAGNOSIS #2: ASSESSMENT:

Appropriate for chosen diagnosis. Includes objective & subjective historical data that support actual or risk for nursing diagnosis

NSG DIAGNOSI #2:

OUTCOMES:

Outcomes should be specific to the patient Dx., The outcome statement should also contain the following 4 criteria: measurable, attainable, realistic, and timed. All criteria should be present to be a specific patient expected outcome

NSG DIAGNOSIS #2:

INTERVENTIONS AND RATIONALES:

Include interventions or nursing actions that directly relate to the patient’s goal; are specific in action, frequency and contain rationale. The number of interventions should be appropriate to help patient/family meet their goal

NSG DIAGNOSIS #2:

EVALUATION:

Includes all data that is listed as criteria in outcome statement. Based on this data, outcome is determined to be met, partially met, or not met. If outcome was not met or partially met, plan of care is revised or continued and a new evaluation date/time is set