Student Natalie Varela Date 12/15/2018
Instructor Pamela Daniels Course N316L
Patient Initial KD Unit/ Room# 304 DOB 03/27/1987
Code Status Full Height/Weight 51 / 145 lbs.
Allergies NKA Final EDC/Current Gestational Age: 02/18/2019 / 26 weeks
Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
88 radial 12 RR 98% 131/86 0/10
History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with evidence based citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations. If on postpartum, BUBBLE-HE for maternal assessment and if on antepartum/intrapartum, the following apply: fundal height, CV/Thorax, perineum, SVE, and fetal heart rate Category.
Chief Complaint (if possible, use patients words): I started having lower abdomen pain early in the day and the pain lasted all day. Then I started to have green discharge.
HPI (PQRST of chief complaint, along with other pertinent pregnant complications [if any]): 31 y.o. at 26 weeks gestation, arrives to the hospital with prior noted chief complaint.
Relevant Diagnostic Procedures/ Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical and Surgical History,
Pathophysiology of Medical Diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations
Current CBC: Date taken: 11/19/2018
Results Normal Values
WBC 9.9 K/uL5-10 k/uLRBC 3.06 M/uL4-5.5 M/uLHgB9.5 gm/dL 12-17.4 g/dL
HCT 27.5% 36-52 %
MPV 7.1 fL7.4-10.4 fLMCV 89.6 fL80-100 fLMCH 31.0 pg27.0-33.0 pgMCHC 34.6% 31.0-36.0 %
PLT 275 K/uL140-400 K/uLMg 4.6 mEq/L 1.3-2.1 mEq/L
Hepatitis B: Negative
PIH panel (if applicable): N/A
Relevant Diagnostic Procedures
Ultrasound (latest): Transabdominal 11/15/2018
Findings: fetus is in cephalic presentation, placenta is located posterior right lateral position. No sign of placenta previa or abruption. The cervix is open 3 cm in diameter.
Medical Hx: Chronic hypertension (11/15/2017)
Chicken pox (1994)
OB Hx: G1P0
Surgical Hx: No history of surgeries
Eriksons Developmental Stage (with Rationale). Provide examples of how client meets/doesnt meet chosen stage (supported by Evidence Based Citations). Socioeconomic/ Cultural/ Spiritual Orientation
& Psychosocial Considerations/ Concerns (3) supported with
Evidence Based Citations
Three psychosocial concerns, based on above assessments:
Potential Health Deviations: aka Risk Diagnoses (AT LEAST TWO) Include THREE independent nursing interventions for each
(RISK FOR XXX, AS EVIDENCED BY XXX) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale
Supported with Evidence Based Citations
Priority Nursing Diagnosis
(at least 2)
Written in three-part statement
*Risk Diagnoses NEVER go in this section. Planning
Measureable goal during your shift
(at least 1 per Nursing
*Think SMART GOAL* Prioritized Independent and collaborative nursing interventions; include further assessment,
Intervention and teaching
(at least 4 per goal) Rationale Each must be supported with Evidence Based Citations Evaluation
Goal Met, Partially
or Not Met
Class/ Purpose Route Frequency Dose (& range)
If out of range,
why? Mechanism of action
Onset of action Common side
specific to this
Stool Softener PO BID 100 mg
Within range Acts as a surfactant that softens the stool Abdominal cramps Recommend ambulation and increase of fluids
Anti-anemic PO Daily 325 mg 100-200 mg/day; out of range; patient RBC 3.06 M/uLNormalizes RBC production by binding with hemoglobin Constipation Take with a full glass of water or orange juice
Skin barrier Topical PRN Dime size amount for each nipple
Forms a temporary barrier over exposed tissue Allergic reaction Apply after breast feeding
Methyldopa Anti-hypertensive PO BID 250 mg 250-750 mg/day
Within range Stimulates the central inhibitory alpha-adrenergic receptors Hypotension Remind patient to get up slowly from bed to prevent feeling dizzy
Prenatal Vitamin Supplement PO Daily 1 tab 1-2 tab/day
Within range Provide supplemental vitamins and minerals Constipation
Headache Remind patient to eat a well-balanced diet
2017 Nurses Drug Handbook. (2017). Burlington, MA: Jones & Barlett Learning.
Copstead, L. E., & Banasik, J. L. (2013). Pathophysiology. St. Louis, MO: Elsevier.
Dunning, M. B., & Fischbach, F. T. (2011). Nurses quick reference to common laboratory &
diagnostic tests (5th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.