Bowie State University Nursing Care Plan

Bowie State University Nursing Care Plan Bowie State University Nursing Care Plan Please use the data and information below to do the care plan. If you need a careplan book I can also upload it. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS screenshot__199_.png screenshot__200_.png maternity_care_plan_sample_example.docx maternity_care_plan_sample_example.docx n381_careplan_format_2016_maternity.doc nurs_381_care_plan_grading_rubric_maternity.docx 1 Sample careplan Postpartum Nursing Care Plan Nurs-381 Bowie State University May 4th, 2018 BOWIE STATE UNIVERSITY NURS 381 2 PRENATAL/INTRAPARTAL/POSTPARTAL/ CARE PLAN FORMAT INTRODUCTION: Provide a brief introduction of your patient to include: initials, age, blood type, PNC, GBS status, GTPAL, gestational weeks, decelerations, membrane rupture, labor induced or augmented, type of delivery- vaginal/cesarean. If cesarean, state the reason and type of incision, previous or intended contraceptive method, race, allergies, code status, past surgical history, reason for admission, fetal presentation and position, pre-pregnancy and total weight gain. Mrs. L.M is a 24-year-old African American woman who was admitted on the 4/23/2018 at 6:50 PM for fall on the same level with intact membrane. She delivered on 4/23/2018 at 7:29 PM by a transverse cesarean section (c. section) with estimated blood loss (EBL) of 800 ml. The baby is doing well rooming with mother. She is 20 hours postpartum, G3 T2 P0 A1 L1, 39 weeks gestation, unknown GBS status, and has blood type O+. Cesarean section was carried out because the mother is HIV positive. She currently weighs 231lbs with a pre-pregnancy weight of 254lbs and had 16 prenatal visits. She is full code and no known allergy. She has a past medical history of bipolar, anxiety, and HIV contracted through rape. She has a past surgical history of cesarean section with her first child 5 years ago. Socially, she smokes cigarette but no history of alcohol consumption or substance use. Patient is not on any contraceptive but planning to get an IUD after 6 weeks. Due to mother to baby transmission of HIV through breast milk, she was told by the gynecologist not to breastfeed the baby. The baby is a boy with APGAR score 9,9, birth weight of 7lbs 12oz, and blood type O negative. Fetal presentation was vertex, position was ROA, and had early deceleration. The baby is receiving zidovudine 1ml IM for HIV prophylaxis. ASSESSMENT Integrate lab data, GYN, medical, and social histories where applicable notably: Hypertension, Diabetes, Heart Disease, COPD, smoking, alcohol, and substance abuse, etc. Note both physiological and psychological problems. Date of Patient Care: 4/24/2018 Problems in NANDA format: 3 Stem & Etiology. Identify ALL applicable problems in each system Vital Signs: BP: 110/58 left brachial, pulse: 83, respiration: 19, Temperature: 97.5?F oral, SPO2: 99%, pain level: 8 on a 0-10 scale. Neurological: Alert and oriented to person, time, place, and situation. Her pupils are round, equal and reacts to light and accommodation, peripheral field is intact by confrontation, clear and effortless speech, and gag reflex is present. History of bipolar and anxiety. She did not like students to assess her baby. At first, she told me not to touch her baby but allow me later. Acute pain related to physical injury (c. section cut) as evidenced by patient pain rating of 8 on a 0-10 scale. Anxiety related to a family history of anxiety as evidenced by patient’s fear of students inflecting harm to her baby. Cardiovascular: No evidence Blood pressure of 110/58, radial pulse of 83, apical pulse of 74, S1 S2 heard, no murmur or adventitious sound heard, lymph nodes are soft and moveable, below knee bilateral +1 nonpitting edema, no edema on face or hands, strong and bounding radial and dorsalis pedal pulse bilaterally, negative Homans’ sign, No visible varicose veins, saline lock 22gauge peripheral IV, EBL of 800. Respiratory: Respiratory rate of 19bpm, SpO2: 99% on room air, capillary refills in 2sec, clear lung sound, denied chest pain, equal chest expansion, deep and regular breathing pattern, denied any shortness of breath, but smokes cigarette. Risk for ineffective peripheral tissue perfusion related to decreased hemoglobin concentration in the blood as evidenced by patient’s smoking history per chart. Bowie State University Nursing Care Plan 4 GI (Assess for bowl elimination and nutrition among others): Normal bowel sounds heard in all 4 quadrants, abdominal tenderness, on a regular diet with no restriction, no change in appetite. No evidence GU: Amber color urine with painless urination. Patient was on indwelling urinary catheter with 350cc urine before labor but was removed at 12 hours postpartum. No evidence Musculoskeletal: Gait is steady but slow, complain of pain with ambulation, non-pitting edema +1. Due to her history of fall and the anesthetic she received during labor, bed rest was recommended with compressive stocking on both of her feet. Integumentary (include skin changes, episiotomy, laceration, incision, and hemorrhoid): Skin is dry and warm to touch, normal skin turgor and color, IV site is dry with no redness or discharge, transverse cesarean section wounds, rates cesarean section pain as 8/10, no hemorrhoids or vaginal hematoma, linea nigra and striae gravidum present on the abdomen. Also, patient admits of itching of her skin. Risk for ineffective peripheral tissue perfusion related to interruption of venous flow as evidenced by patient’s use of compressive stockings. Acute pain related to physical injury as evidenced by a transverse cut underneath the abdomen. Impaired skin integrity related to Cesarean section wounds. Impaired comfort related to treatment regimen as evidenced by patient scratching of her skin. 5 Reproductive (Include assessment of breasts, uterus, perineum, and lochia): Breasts are equal and not engorged, nipples are everted bilaterally, she is not breastfeeding, fundus is firm, midline and at the level of the umbilicus, lochia is scant and rubra, no blood clot. No evidenced Spiritual (Impact of spiritual system on maternal and or newborn care, including infant care practices, rites of passage, and choice of contraceptive method, if applicable): Patient is a Christian and does not belong to any church. Patient stated that her spiritual belief does not prevent her from receiving any medical care deemed appropriate for her heath and the newborn. She is also making arrangement for an IUD contraceptive after six weeks of delivery. No evidenced Sociocultural (Include socioeconomic status and awareness of Ineffective role performance related to insufficient role community resources that support the childbearing family. Note impact preparation as evidenced by changes in usual pattern of of cultural belief system on expectations for maternal behavior during responsibility. the postpartum period. (For example, is the mother allowed to leave the home right after birth? If not, how long must she wait before she and the baby are allowed to leave the home?): Patient is African American woman born and raised in Washington DC. Patient is currently living in Washington DC. She has two children with different men. Patient alleged of not currently marry. The father of the newborn is providing financial and social support as well as patient’s mother. When patient was asked whether the family is ready to accept the newborn, she responded “for my previous births, I lived with my mom for months. This is the first time I must handle it with my boyfriend. I don’t know how it will turn out.” 6 Psychological (Include maternal-infant bonding behavior): Patient was seen excited playing and singing for the baby. She was discouraged not to breastfeed the baby due to mother to baby transmission of HIV. She seems to be confident and experience with childcare since this is her second child even though more teaching will be done before their discharge. However, she complained of fatigue because she slept less than 4 hours for the past 24 hours. Bowie State University Nursing Care Plan Developmental (Maternal Development, age, and impact on acceptance of parenting role and parenting behavior) use Eric Erickson’s Psychosocial Stages of Development Theory: Patient is a 24-year-old multiparous, and she is responding very well with her new role as a mother of two children. She does not breastfeed the baby, and check and changes the baby’s diaper frequently. She also makes the baby comfortable by swaddled and adjusting the thermostat to a comfortable setting. Disturbed sleep pattern related to lifestyle disruption as evidence by fatigue. No evidenced. Laboratory & Diagnostic Results: If lab/diagnostic data is not available, discuss expected normal values with rationales Lab Result 04/24/18 at 07:13 AM Normal Value Implications/rationales RPR Non-reactive Non-reactive Rapid Plasma Reagin test for the presence of syphilis. A 7 GBS Unknown Negative Rubella Immune 7 IU/mL or less (Negative) Hepatitis Negative Negative HIV Positive. Negative reactive test could indicate a higher risk of preterm labor or miscarriage for mother and/or IUGR, preterm birth, stillbirth, or congenital infections for the baby. Test for the presence of Group B streptococcal bacteria. A positive test could mean baby has the possibilities of being infected. Babies are given antibiotics and monitored for 48 hours after delivery. . Antibody titer indicates immunity to rubella, and a negative antibody titer means the mother is not immune. If mother is infected with rubella during first trimester, baby could be born with congenital infection. Tests for presence of the Hepatitis A.B and C surface antigen which indicates artificial immunity. Lack of immunity means the mother is more vulnerable to contracting the virus which could be transmitted to the baby during birth. Tests for the presence of HIV antibodies. Presence of HIV 8 Chlamydia negative negative Gonorrhea Negative Negative WBC 13000 cells/dL 4500 – 15,000 cells/dL antibodies in the mother’s blood indicate HIV infection that can be transmitted to the baby if adherence to ART is not met. Mothers with HIV always have a caesarean section to prevent exposure to maternal blood. This test for the presence of chlamydia bacteria. A positive test would indicate that mother is infected with chlamydia which can cause neonatal conjunctivitis in the newborn as the baby passes through the birth canal. Test for the presence of gonorrhea bacteria. A positive test would indicate that mother is infected with gonorrhea which can cause neonatal conjunctivitis in the newborn as it passes through the birth canal. Could also mean preterm birth or IUGR for the baby. Indicates ability to fight infection. A WBC that is too high indicates that mother is currently fighting an infection, one that could be passed to the baby. A count that is too low can means the mother is 9 Hemoglobin 9.4 g/dL 11.1 – 15.9 g/dL Hematocrit 28.8 % 34.0– 46.6% Platelet 136 x 103 cells/dL 150-379 x 103 cells/dL vulnerable to infections that could also be transmitted to the baby. Indicates O2 carrying capacity. A low value could indicate that mother is hypoxic or hypoxemic. This would mean low oxygenation for the baby as well which will put the baby in distress. Indicates proportion of RBCs to blood volume. Is normally low during pregnancy due to physiological anemia. A low value indicates that mother is hypoxemic or hypoxic which can cause intrauterine growth restriction and distress to the baby during labor Indicates clotting ability. Bowie State University Nursing Care Plan A higher than normal platelet count means that the mother is more prone to forming thrombi, which could harm the baby if mother develops a PE or if clot affects placental perfusion. A lower than normal count indicates that the mother is more prone to hemorrhage which can also harm baby due to hypo-perfusion of the placenta. This test in important 10 Other NA because pregnant mothers are in a hypercoagulation state. NA NA Medications: Include ALL applicable meds: Antibiotics, Antiviral, Tocolytics, Betamethasone, Induction/Augmentation meds, Comfort/Pain Management. (Extend table as needed) Generic/Trade Name Dosing/Safe Classification Reason for Use Side Effects Oxycodone/acetaminophen/ 5mg/325mg/ Narcotic analgesic For pain (Percocet) Q4h PO Dizziness, drowsiness, nausea, and vomiting Nursing/Pregnancy Implications Assess blood pressure, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess the level of sedation. Assess bowel function routinely. To minimize constipation increased fluid intake and laxatives should be instituted. PO may be administered with food or milk to minimize GI 11 Ferrous Sulfate/Femiron 325 mg (65 Fe) Antianemics Iron supplements Headache, dizziness, syncope, nausea and vomiting, dark stools, diarrhea, constipation myalgia, and staining of teeth. Antihistamine Relief of allergic symptoms. Blurred vision, tinnitus, dry mouth, dizziness, headache, and nausea. Q12h PO Benadryl/diphenhydramine irritation. Assess its effectiveness. Assess bowl function for constipation and diarrhea. Also, assess patient for signs and symptoms of anaphylaxis i.e. rash, pruritus, laryngeal edema, and wheezing. Assess patient degree of itching. Monitor carefully, assess patient for signs of delirium, other anticholinergic side effects and fall risk. PRIORITIZED DIAGNOSES: Prioritize ALL the diagnosis from the assessment above. Extend the table as needed 12 NANDA STEM ETIOLOGY (related to) S/S (as evidenced by) Acute pain Physical injury. patient verbalize pain rating of 8 on a 0-10 scale. Impaired comfort Treatment regimen. Patient scratching of her skin. Disturbed sleep pattern Lifestyle disruption Complain of fatigue and Sleeping less than 4 hours in the past 24 hours. Ineffective role performance Insufficient role preparation Patient verbalize concern of changes in usual pattern of responsibility. Impaired skin integrity Cesarean section. Transverse cut on her lower abdomen. Anxiety Family history of anxiety Patient’s fear of people harming her baby. Using the pattern below, develop a nursing care plan for the problem with the highest priority. 13 NURSING DIAGNOSIS #1 Nursing Diagnosis (State fully): Acute pain related to physical injury as evidenced by patient verbalization of pain rating of 8 on a 010 scale. Goal: Patient will verbalize a pain level of less than 3 on a scale of 0-10 by the end of the shift. Outcomes (3) Patient will: 1. Verbalize a pain level less than 3. Interventions with cited Rationales State enough Interventions for the 3 outcomes Nurse will: 1. Conduct and document a comprehensive pain assessment by using an appropriate pain assessment tool. Rationale: determining the location, intensive, characteristics, and the impact of pain on function and quality of life are critical to determine the underlying cause of pain and effectiveness of treatment (Ackley & Ladwig et al., 2017, pg. 640). 2. Manage acute pain by using a multimodal approach. Evaluation Statement(s) supported with Patient’s Response (clinical data) to Interventions Patient was asked to rate pain level on a 0-10 scale. Patent rate a pain level of 2. Bowie State University Nursing Care Plan Goal was met on 4/24/2018. 14 Rationale: combining two or more drugs with different mechanisms of action (multimodal) for providing analgesia enhances pain relief by administering low dose of each drug, resulting in less severe side effects (Ackley & Ladwig et al., 2017, pg. 641). 3. Assume that pain is present if the patient is unable to provide a self-report and has undergone a procedure that is thought to produce pain and conduct an analgesic trial. Rationale: pain is associated with actual or potential procedure (Ackley & Ladwig et al., 2017, pg. 641). 4. Obtain and review an accurate and complete list of medications the patient is taking or has taken. Rationale: accurate medication reconciliation can guide analgesic development and prevent errors associated with medications (Ackley & Ladwig et al., 2017, pg. 641). 15 5. Selecting route of analgesic administration based on patient’s condition and pain characteristics. Rationale: routes have different rate of onset and duration. Oral route is preferred because of its convenience and relative steady blood levels (Ackley & Ladwig et al., 2017, pg. 641). 6. Explain the pain management approach to the patient. Rationale: one of the most important steps toward improved control of pain is a better patient’s understanding of the nature of pain, treatment, and the role play by the patient in pain control (Ackley & Ladwig et al., 2017, pg. 641). 7. Provide rest period to facilitate, sleep, comfort and relaxation. Rational: Fatigue may cause a patients’ experience with pain The patient was able to understand the pain management approach after teaching at the end of the shift. Also, patient conform to the taking of analgesics. Goal was met on 4/24/18. 16 exaggerated. Patient can be encouraged to rest, and this helps to reduce pain (Potter et al, 2013, pg. 980). 8. Guide patient to use guided imagery to distract pain. Rationale: This technique provides physiological and behavioral change to pt. it decreases BP, pulse, respiration and oxygen consumption. It also decreases muscle tension which provides a sense of peace and relaxation to the patient” (Potter et al, 2013, pg. 978). . After teaching, patient was able to demonstrate the use of guided imagery. Patient also verbalized relaxation and rate a pain level as 2/10. Goal was met on 4/24/2018 17 NURSING DIAGNOSIS #2 Nursing Diagnosis (State fully): Disturbed sleep pattern related to lifestyle disruption as evidence by fatigue. Goal: Patient will sleep for at least 6 hours and verbalize rested by the end of the shift. Outcomes (3) Patient will: 1. Have a minimum of 6 hour of sleep. Interventions with cited Rationales State enough Interventions for the 3 outcomes Nurse will: 1. Establish patient’s routine sleep patterns and compare with current sleep pattern and explore things that interfere with sleep. Rationale: Knowledge of factors that affect sleep enables the client to implement changes in lifestyle and prebedtime activities (Gress et al, 2010, pg. 384). 2. Plan activities to fit patient’s natural body rhythm by. Evaluation Statement(s) supported with Patient’s Response (clinical data) to Interventions Goal was not met. Patient could not sleep. Will continue with current intervention and change as needed. 4/24/2018 18 Rationale: Sleep practices affect the natural body rhythm. It is therefore essential to plan care such that activities are performed during patient awake period (Gress et al, 2010, pg. 384). 3. Advise patient to limit visitors as possible. 2. Statements of feeling well rested Rationale: Family visit can be overwhelming for postpartum patients. In as much as they provide support for patient, they can also constantly wake patient up. It is therefore necessary to advise patient to limit the number of visitors (Gress et al, 2010, pg. 392). 19 4. Teach patient to use infant nap time as a nap time. 3. Verbalizes plan to implement bedtime routines. Goal was not met. Patient was still restless. Will continue with current intervention and change as needed. 4/24/2018 Rationale: Patients can benefit from baby’s nap time if they find it difficult maintaining longer sleep (Gress et al, 2010, pg. 389). 5. Administer pain medication as prescribed Rationale: Pain medication can aid sleep if the difficulty is due to pain. Some pain medication also contains sleeping agents which helps with sleeping (Potter et al, 2013, pg. 942). 6. Provide a conducive sleeping environment for patient by adjusting the thermostat, controlling noise, and lightening. Patient was asked to verbalize some of the plans for bedtime routine. Patient responded “avoid soda, coffee and excessive fluid, adjusting the room temperature to my comfort” Goal was met on 4/24/2018 20 Rationale: Factors such as temperature, noise, and light affect sleep. It is therefore important to control noise and help patient adjust the thermostat and lights to suit her preference (Gress et al, 2010, pg. 391). 7. Avoid foods like coffee, excessive fluid, and foods that cause heartburn. Rationale: Coffee, soda, and tea … Bowie State University Nursing Care Plan Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool’s honor code & terms of service . Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10