Acute Care Assignment NURS 331- OB Clinical Case Study Student

Acute Care Assignment
NURS 331- OB Clinical Case Study
Student Approach to the Assignment
This extensive holistic assessment was focused on a 15 year old mother and her family.
During her first prenatal appointment, she was diagnosed with bladder cancer, so all of her
family and staff members consider her daughter to be the “miracle child” because it would have
continued to go unnoticed if she did not get the check-up. Information was collected through a
personal interview with the mother as well as from her chart. This case study explores topics
such as intrapartal and postpartum procedures, case analysis, risk factors, nursing diagnosis,
symptoms, and treatment.
Reason for Inclusion of the Assignment in the Portfolio
This is significant towards my portfolio because it displays how I have encountered a
more complex patient, not only physically but emotionally as well. This paper demonstrates
having to be culturally sensitive to an adolescent mother and help support her through her
transition into becoming a mother.
 Critical Thinking
 Uses decision-making skills in making clinical or professional judgment
- Example: Even though she was physically successful in caring for a child, she
mentally still was in the mindset of an adolescent herself. Also, when asked
questions about her personal health, she would look to her mother as if she was
waiting for her permission to answer. Due to her age and some of her risk factors
(ex. newly diagnosed with bladder cancer, raped by father at age ten, baby in
special nursery unit), I used my decision-making skills to make a clinical
judgment on the way I introduced my questions during the interviews and my
teaching about postpartum care. I also told her nurse that she may be at risk for
postpartum depression and preventative teaching should be given to her.
 Evaluates nursing care outcomes through the acquisition of data and the questioning
of inconsistencies
- Example: After her delivery, she had a spiked blood pressure that continued to
remain high and was evaluated for preeclampsia. She denied the common
symptoms of headache and blurry vision. By the time I arrived on the shift, it was
documented that her blood pressure would increase during one moment of the day
then decrease with no certain pattern. Even after the doctor was notified, nothing
was done to change it so the nurse had me check her blood pressure every 4 hours
and document the readings.
 Nursing Practice
 Implements traditional nursing care practices as appropriate to provide holistic
health care to diverse populations across the lifespan
- Example: The care that was provided included my patient, her newborn, and her
family as a whole. Education was given to both the mother and grandmother
about the status of the newborn and what to expect with her breathing treatments
before she can be discharged for home (ex. getting off of SPAP, then nasal
cannula, and finally being on room air). I also took her blood pressure every four
hours since she was being monitored for preeclampsia and assessed her emotional
status of everything that was going on with her.
 Communication
 Uses therapeutic communication within the nurse-patient relationship
- Example: While conducting my BUBBLE HE assessment, I made sure to explain
everything I was doing when I was doing it and afterwards I stayed in her room to
answer any questions or concerns she had regarding her health. I also made sure I
was at eye level with her and demonstrated positive body language that
represented I was attentive and cared.
 Culture
 Articulates an understanding of how human behavior is affected by culture, race,
religion, gender, lifestyle, and age
- Example: Since she is still a child herself, she looks to her mother when
answering questions regarding her health. Even when she was asked about her
race, she paused and looked to her mother as if she was unsure. Coming from a
poor background, she is very gracious for every little thing she gets and has a
praise and worship session in her room every hour to praise God for his
generosity. Her mother is very humble and is thankful that her 15 year old became
pregnant because she also found out she had bladder cancer.