Data Collection and Care Plan Patient (Code) Age 18 Primary Diagnosis Rupture of membranes. Past Medical History Primary MD Past Surgical History CODE Status Full code Vital Signs: Time T (route) 99 AP 88 R 20 B/P 117/70 R20 O2 Sat 98% Pain: (0-10) 3 Allergies: NKA Wt.68kg Ht. 165 Admission date: 11/29/2021 Diet:Reg How did you assist the client with their diet? Education about eating light meal including soup sandwiches, fruit, juice and water Absence of nausea, vomiting, cramping, diarrhea or Constipation No complaints of nausea, vomiting, or abdomen pain with palpation Neurological Normal Findings: - - Memory intact - - Absence of seizures - - - When upright: Balance steady Gross motor coordination intact Hand grasps strong/equal PERRLA, Foot presses and pulls strong and equal Gag, cough, blink reflexes intact GI/Nutrition Normal: Bowel sounds active in all quadrants Abdomen soft, non-distended, non-tender Receives and tolerates nutrition and fluids Describe your findings : Alert and oriented x 3 Speech is clear Follows commands and converses Behavior appropriate to situation Patient denies numbness tingling or other paresthesia of extremities Respiratory Normal Findings: - - Mucous membranes pink Chest excursion symmetrical Trachea midline If cough present, non-persistent Sputum clear or absent Cardiovascular Normal Findings: - - Skin warm & dry to slightly moist - Pulses palpable or present with doppler - Skin Normal Findings: o Wounds: Normal Findings: o Edges approximated and clean o Surrounding tissues free from signs & o Describe your findings:Breath sounds clear and equal in all lobes..Respirations regular, non-labored, without use of accessory muscles Describe your findings:Regular rhythm, heart sounds S1 S2 present. Blood pressure WNL.Denies chest pain.Periorbital, sacral, pedal & generalized edema absent.Nail beds pink, capillary refill< 3 sec Describe your findings:Color within patient's normTemperature warm, dry to slightly moist.Turgor normal, mucous membranes moist Intact without breakdown, rash, redness, blanching symptoms of infection Dressing dry & intact: drainage absent Wounds: (yes/no?) Findings: No Wounds Mobility/Functional Ability Normal Findings: o Active ROM of all extremities within physical limitations Describe your findings:Tolerates prescribed activity order.Able to complete ADL's. Able to transfer (with/without assistance).Assistive device(s) correctly o Neurovascular assessment for client with cast or traction GU/Elimination Normal Findings: o o o o Describe your findings:Urine clear, straw or amber no unusual color.Bladder non distended. Urine output within established parameters Patient is incontinent of urine of uses a collection device. Output: 250cc Psycho-Social Normal Findings: o Comfort, Rest and Sleep Rates pain as 0 States and appears rested Rests/sleeps during shift Slept well during night Safety: Describe your findings: Describe your findings: Participates in two way conversation, care and treatment plan Able to communicate his/her needs Coping mechanisms intact (client and family)Mood/affect/behavior appropriate to situation o o Describe your findings: verbalize some pain and rate her pain of 3 on a scale of 0 to 10 If Restraints used : Describe care side rails are up. Bed in low position. Diagnostic Testing/Laboratory Data. Group B streptococcus positive. Teaching Needs Identified during the assessment: Teach about positive group B test and the danger it can present to the well being of her baby. In addition educaition about penicillin administration and signs of adverse effect was also provided. Education about techniques to use to reduce pain and anxiety related to labor. Teaching reinforced: SBAR report: I am calling about client Brenda P regarding her pain. she stated it was “not too bad” and rated the pain 2/10 between contractions. She said the pain was “everywhere”. When asked if she needed anything for the pain, she responded “no” that she wanted to have a natural birth. I used therapeutic communication to distract her from the contraction pain. Denies pain medication. Professional Nursing Care Plan The following table provides information to utilize in developing your nursing care plans. Each column in the care plan from should include the appropriate information related to the Nursing Diagnosis. You are expected to develop 3 Nursing Diagnoses with the supporting documentation as noted on the page below. The Nursing Diagnoses are then labeled in priority order where 1 would be the highest priority. (Nursing Diagnosis Priority # ) Any questions that you have concerning the nursing care plans should be directed to your instructor. (I) Data Collection Related to the Nursing Diagnosis Subjective (Nonobservable) Objective (Observable) Subjective data should be clear, concise and specific to the Nursing Diagnosis Objective data should be clear, concise and specific to the Nursing Diagnosis Subjective Data: Objective Data : What the patient or family relates, states, or reports. (Nonobservable) What is observed or measured. May include the client’s behavior, vital signs, lung sounds, urine output, laboratory data, diagnostic testing (etc.) as related to the specific nursing diagnosis. (Observable) 1 2 3 4 (II) Complete NANDA Nursing Diagnosis (IV) Nursing Interventions (V) Scientific Rationales Best Evidence with References (VI) Evaluation of Patient Goals/ Outcomes Choose a NANDA approved diagnosis. The statement should list only one diagnosis and listed in the following format, i.e., problem followed by "Related to (R/T) the disease process Manifested by: (signs and symptoms) is not part of nursing diagnoses and should be written as a separate line. Example: Coping, ineffective family: R/T Temporary family disorganization and role changes. Manifested by significant other's limited personal communication with client. Each statement should be supported by a rationale Should be: 1 Concise 2 Clear 3 Specific 4 Individualized 5 Accomplishable to client and/or family, significant other. 1 Rationale should address how interventions are going to solve the problem and/or attain the outcomes. 2 Rationale should be specific to the interventions, i.e., why giving morphine 10 mg IV, why the client is being turned and positioned in proper alignment every 4 hours. 3 Rationale can be summarized in own words and/or quoted verbatim from sources. 4 For every nursing intervention, there needs to be a rationale. Should address: 1 If the expected revised, state how would revise intervention. 2 What was the client's response to interventions? (III) Goals/Outcomes (Long and Short term) Including timelines/timeframes 1 Could have both short term and long term outcomes throughout NCP, but each client should have one long term goal as part of the NCP. Definitions: Short-term goals: Those goals that are usually met before discharge or before transfer to a less acute level of care. Long-term goals: Those goals that may not be achieved before discharge but require continued attention as by client and/or significant others as indicated. 2 Each diagnosis, if appropriate, could have short-term goals and long-term goals. 3 Statements: Specific - relates to nursing diagnosis. Measurable - tells what to see, hear, or smell. Achievable - realistic for patient. Clear and Concise - don't use “increase” or “decrease” without giving baseline range of data. 4 Timelines (timeframes) for achievement of goals: Should be realistic and specific. Give a date or time at which the expected outcome and nursing interventions are achieved and/or evaluated. Should specific as "by discharge date" or "on going." Student Nam Client Code: 00000-00000 Instructor: Professor Umagat Date: 11/30/2021 Nursing Diagnosis Priority # Pain related to delivery process. Grade: 4th Professional Nursing Care Plan (I) Data Collection Related to the Nursing Diagnosis (II) Complete NANDA Nursing Diagnosis Subjective (Non-observable) Patient state her water broke this morning. (IV) Nursing Intervention s Objective (Observable) Vaginal exam Reveal 50% Pain related to labor process as Electronic fetal monitoring effacement of cervical dilation evidence by regular 4 cm and fetus at 2 station. contractions about 4 minutes Patient moans at contractions apart lasting 50 seconds. Uterus is soft between Patient verbalizes pain as 2 on contractions. a pain scale of 0 to 10. Contractions are regular with Patient shows discomfort moderate intensity. when she says”ouch “ follow Bed rest with side lying by moaning. Contractions are 4 minutes apart and lasting 50 seconds. Patient said “I feel a (III) Goals/Outcomes contraction coming… (Long and Short term) aaaough”. Including timelines/timeframes Monitor patient’s vital signs Patient and boyfriend will be closely every 15 minutes. taught technique used to relieve pain and anxiety of labor such as purse lips and deep breathing massage , relaxation, meditation walking listening to music and yoga. Turn and reposition frequently to avoid complication of immobility during labor. (V) Scientific Rationales Best Evidence with References To assure maternal and fetal well being. And monitor for any variation that pause risk for baby and mother in other to act promptly. Because the water broke the blockage at the cervix is no longer there. Therefore the bed rest will relieve pressure of the fetus on the cervix. A maternal pulse over 120 beets per minute or persistent tachycardia will signal or indicate pulmonary edema. (VI) Evaluation of Patient Goals/ Outcomes Both patient and boyfriend were able to verbalize and demonstrate at least 4 techniques used to relieve pain and anxiety. Patient was turned and reposition every hour and as requesting. Goals are met.
