NURS 320 MATERNAL NEWBORN Jennifer Humes Room 301 Jennifer Humes, 30-year-old Caucasian female, G4 T2 P0 A1 L2, 33 5/7 weeks gestation. History of chroni c hypertension and gestational hypertension with this pregnancy. Nifedipine XL 30 mg daily. NKDA. Previous pregnancies uncomplicated with NSVDs. One spontaneous abortion at 10 weeks gestation. Woke up early morning feeling wet; wasn’t sure if leaking urine or membranes ruptured. Turned on light and it was blood. Asked a neighbor to come over to watch other children and husband brought her to hospital. They are making phone calls to get family member to come and take care of 5 and 2-year old children. Anxious about this pregnancy and bleeding too. Has mild abdominal pain and contractions. You responded correctly to 5 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status assessment reports r/t change in condition. Fall Risk Increased acuity Status assessment reports r/t 34 weeks gestation and pain, change in center of gravity. Health change Increased acuity Status assessment reports r/t complication of pregnancy and bleeding. Pain level Increased acuity Status assessment reports r/t abdominal pain and mild contractions. Physiological Needs Increased acuity Status assessment reports r/t concern about condition and care of other children. Sensorium Needs Normal acuity Status assessment reports no problems related to sensorium indicated in the report. Jenny Theriot Room 302 Jenny Theriot, 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure what she is feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is going on. Category Your response Explanation Educational Needs Increased acuity Status assessment reports leaking of fluid from vagina, possible contractions and preterm delivery. These should be the subject of teaching and support for the client. Fall Risk Increased acuity Status assessment reports the client is pregnant; this changed her center of gravity and balance. Health change Increased acuity Status assessment reports leaking of fluid from vagina and possible contractions. Pain level Decrease acuity Status assessment does not indicate report of pain. Physiological Needs Increased acuity Status assessment reports leaking of fluid from vagina, possible contractions. Sensorium Needs Normal acuity Status assessment Kesha Jackson Room 303 Kesha Jackson, Kesha Jackson is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1o F., 92 BPM, 16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the baby’s head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it. She came to the OB triage via a bus. Category Your response Explanation Educational Needs Increased acuity Status Assessment reports Kesha will need a lot of education regarding preterm labor precautions, resources for assistance, and caring for her baby once it arrives Fall Risk Increased acuity Status Assessment reports Client is at increased of fall due to changing center of gravity and balance. Health Change Increased acuity Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm labor. Pain Level Increased acuity Status Assessment reports she rates her pain an 8/10 Psychological Increased Status Assessment reports Kesha is homeless, is pregnant, is a teen with developing coping mechanisms, and has Needs acuity a lack of a consistent support system. Sensorium Normal Status Assessment reports no issues reported here. Category Your response Explanation acuity Stephanie Gold Room 304 Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client. You responded correctly to 6 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status Assessment reports r/t change in condition Category Your response Explanation Fall Risk Increased acuity Status Assessment reports r/t physiological shifts of pregnancy/center of gravity Health Change Increased acuity Status Assessment reports r/t malaise/nausea/pain during pregnancy Pain Level Increased acuity Status Assessment reports r/t right upper quadrant pain Psychological Needs Increased Status Assessment reports r/t concern about her baby’s health/her health and absence from nursing school acuity Sensorium Normal acuity Status Assessment reports no indication in report that there is a change in sensorium Physiological Description Your Response Explanation Deficient Fluid Volume False Status assessment reports no generalized edema from fluid shift from intravascular to extravascular at this assessment/nausea not significant enough to cause deficit. Imbalanced Nutrition False Status assessment reports assessments do not show nutrition has been substantially impacted by slight nausea. Injury, risk for fetal True Status assessment reports r/t risk for uteroplacental insufficiency secondary to vasospasm if abdominal pain and malaise/elevated BP indicate preeclampsia/HELLP syndrome. Injury, risk for maternal True Status assessment reports r/t hypertension and vasospasm and potential decreased renal perfusion. Nausea True Status assessment reports experiencing slight nausea off and on this week. Safety Description Your Response Explanation Fall Risk True Status assessment reports r/t shifting center of gravity at 32 weeks gestation and in the third trimester. Injury, risk for maternal
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