Beruflich Dokumente
Kultur Dokumente
Points
Allowed
Labs
13
Safety Actions
Orders/Nursing Interventions
Culture
Nursing Diagnosis
Goals/Outcomes
Nursing Interventions
Rationale
12
Evaluation
Medications
Class/Clinical Concepts
Total Grade
100
Points Earned
Date: 09/23/2015
MD/CNM: Campbell
Resp 16 BP 106/56 HR 75
Uterine Activity
External or IUPC? External If IUPC, why placed? n/a
Frequency:3-4 Duration: 60-80 sec Intensity:Mild
Did patient deliver? Not during shift What type of delivery? n/a
If cesarean section, why?n/a
List 2 patient-specific safety actions implemented during your shift:
1. Patients was no info which meant that none of her identifiers were displayed for others to
see it (whiteboard, etc). For her safety, her identify was under strict protection because she did
not want the father of the baby to know where she was. He had been known to threaten her and
the baby.
2. Verify allergies and identification bracelet on patient and make sure the patient had an allergy
bracelet on.
List 3 orders that are specific to and appropriate for your patient.
1. Penicillin order d/t patient being GBS+.
2. Checks every 30 minutes after the start of Pitocin to check the pt status, and FHR status.
3. Education on pain management, specifically in regards to possibly receiving an epidural.
List 3 nursing interventions performed during your shift. (Do not repeat the same
interventions you use in your care plan).
1. Assisted with comfort measures (ie: back/leg rubs and applying sacral pressure) to promote
relaxation and well-being during contractions.
2.Assessed degree of discomfort through verbal and non-verbal cues.
3. Encouraged patient to void every 1-2 hours.
Culture:
Compete and attach Cultural Assessment Tool
Nursing Care Plan
Nursing Diagnosis
Select one problem area and develop your three-part nursing diagnosis. Use your nursing care
plan textbook to assist you to write the three part nursing diagnosis statement (nursing diagnosis
r/t etiology aeb data) Remember, risk for nursing diagnosis do not have aeb data.
Dx Risk for ineffective coping
aeb situation crises
Planning must reflect nursing diagnosis
List one goal and two outcomes that you would like your patient to achieve. (The patient
will) Outcomes should be behavioral, measurable, realistic, and include a time frame
during which you cared for the patient.
Goal Patient will demonstrate effective coping by 1330 hrs (end of shift).
Outcome 1) Patient will identify effective coping behavior by 1330 hrs (end of shift).
Outcome 2) Patient and support system will engage in activities to maintain and enhance
control by 1330 hrs (end of shift).
Nursing Interventions
List four nursing interventions for the diagnosis you selected. (The nurse will)
Cite rationale in APA format. Use your textbook or a nursing care plan reference. Remember
that each outcome must be supported by at least one obstetrical nursing intervention with an
obstetrical rationale.
1) The nurse will ascertain patients understanding and expectations of the labor process.
Rationale: The patients coping skills are most vulnerable during labor, specifically as the
contractions become more intense. Lack of knowledge, misconceptions, or unrealistic
expectations can have a negative impact on coping abilities (Doenges, Moorhouse, & Murr,
2011).
2) The nurse will encourage verbalization of feels.
Rationale: Helps nurse gain insight into individual needs, and assists patient to deal with concern
(Doenges, et.al, 2011).
3) The nurse will reinforce use of positive coping mechanisms and relaxation techniques.
Rationale: Assist patient in maintaining or regaining control. Enhance feelings of competence,
and self-esteem. The stressors of labor can threaten the womens self-esteem, especially if she
has not coped positively with past experiences and/or successfully accomplished the task of
pregnancy (Doenges, et.al, 2011).
4)Demonstrate behaviors and techniques support system can use to assist with pain control
and relaxation. Provide information regarding, water, music, imagery, aromatherapy and
correct misconceptions.
Rationale: Encourages choice of multiple options, enhances coping and self-esteem of patient
and her support group (Doenges, et.al, 2011).
Evaluation-Goal and outcomes met/partial met or not met? Include rationale for your answer.
1) Goal: Met, patient was able to effectively demonstrate effective coping by 1330 hrs.
2) Outcome 1: Patient was able to identify coping behaviors through verbalization of feelings,
and gaining an understanding of the laboring process by 1330 hrs.
3) Outcome 2: Patient and her support system were able to correctly verbalize and demonstrate
activities they could do to help patient maintain control during the laboring process by 1330 hrs.
Medications:
Reference your text book and drug guide to provide information for all of the following
medications (even if your patient did not receive these medications).
**Include obstetrical action, dose, route, frequency, action, side effects (maternal and fetal), and
obstetrical indications for use.
1. Cervidil (Dinoprostone)
Actions: Softens the cervix and facilitates cervical dilation and effacement.
Indications: Patients at or near term that need assistance facilitating induction of labor.
Route: Vaginal insert
Dosage: Insert at 10 mg, released 0.3 mg/hour over a 12 hour period that needs to be taken out
when labor is active.
Side Effects:
Mother: Diarrhea, vomiting, nausea, backache, headache, fever, irregular uterine contractions,
shivering, vaginospasms, myocardial infarction
Fetus: Abnormal fetal heart rate, fetal heart deceleration, late fetal heart deceleration, fetal
distress
2. Pitocin (oxytocin)
Actions: Stimulates contractions of uterine smooth muscle by increasing intracellular calcium
contractions thus mimicking contractions of spontaneous labor.
Indications: Induction of labor, postpartum hemorrhage, termination of pregnancy
Route: Inj, IV, nasal
Dose: Initial 0.5-1 mu/min IV, gradually increase in increments of 1-2 mu/min every 30-60
minutes until desired contraction pattern has been established. Once contractions have been
reached and labor has progressed to 5-6 cm dilation, the dose may be reduced by similar
increments
Side Effects:
Mother: nausea, vomiting, hypertensive episode, ventricular premature beats, afibrinogenemia,
subarachnoid hemorrhage, postpartum hemorrhage, brain damage, coma, CNS defect,
convulsions in newborn, pelvic hematoma, rupture of uterus and death
Infant: cardiac dysrhythmia, fetal bradycardia, ventricular premature beats, retinal hemorrhage,
low Apgar score at 5 minutes
3. Cytotec (Misoprostol)
Actions: Induction of labor and cervical ripening (d/t prostaglandins), can also be used for
NSAID induced gastric ulcer and termination of pregnancy in combination of mifepristone.
Indications: Induction of labor
Route: oral, vaginally
Dose: Cervical ripening: 25mcg vaginally (gel) every 3-4 hours (max dose, 400 mcg) or 200 mcg
vaginally for 24 hours or until active labor
Induction of labor: initial, 50 mcg orally every 4 hours for 2 doses, then 100 mcg every 4 hours
until membrane ruptures (max 5 doses)
Side Effects:
Mother: abdominal pain, diarrhea, cardiac dysrhythmia, chest pain, myocardial infarction, GI
hemorrhage, anemia, thromboembolic disorder, test allergic shock, deafness symptom, rupture of
uterus, TSS
What concepts learned in class did you put into practice today?
The concepts I learned were specifically learned during the comfort measure class that was taken
at St.Marys. I established a positive relationship with my patient early on, so she really trusted
and respected what I had to say about the laboring process. Her family intently listened to some
of the pain management techniques that I learned, to alleviate some discomfort. I even made
them a copy of the pamphlet that I was provided so that they could refer back to it, at the end of
my shift.
One concept I put into practice from class was family dynamics. My patients family was not
your traditional nuclear family, but more of an extended family dynamic. It was great to see them
interact and work together towards making the patient more comfortable and relaxed during her
last couple of hours of pregnancy.
Pledge: I have neither given nor received aid, other than acknowledged, on this assignment,
nor have I seen anyone else do so.
Signed: Allegrah Nguyen
Nutrition
Infant Care
Infant Feeding
Other Information/Comments
What healthcare/folk medicine practices will you/do you follow related to after birth or newborn care?
No
What religious or spiritual beliefs or customs can we help you with during your stay?
No
Is there any care we provide that differs from your customs/beliefs? If so, describe in detail.
No
Who will help you and your newborn while you are here and at home?
Patients Mother
Adapted from: Cooper, M., Grywalski, M., Lamp, J., Newhouse, L., & Studlien, R. (2007). Enhancing cultural
competence: A model for nurses. Nursing for Womens Health, 11, 148-159.
Bishop Score
Dilation
0
0 cm
1
1-2 cm
2
3-4
cm
6070%
-1/0
3
5-6
cm
80%
or >
+1/+
2
--
Consiste Firm
Medium Soft
ncy
Position Poster Midposit Anteri -ior
ion
or
Total
score
Score
2
1
2
1
0
6
Reference
Doenges, M., Moorhouse, M., & Murr, A. (2011). Nursing care plans guidelines for
individualizing patient care across the life span (8th ed.) [CD ROM]. Philadelphia: F.A.
Davis.