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NURS 316L – Nursing Care Plan NV Paper

Words: 620, Paragraphs: 54, Pages: 3

Paper type: Essay , Subject: Nursing

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 5’1 / 145 lbs.

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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

36.7 Oral

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 patient’s 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.

Admit Dx:

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

Pertinent Labs

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

GBS: Positive

Prenatal Panel:

HIV: Negative

Syphilis: nonreactive

Chlamydia: Negative

Gonorrhea: Negative

Rubella: immune

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

Family Hx:

Erikson’s Developmental Stage (with Rationale). Provide examples of how client meets/doesn’t 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

& Explanation



(with APA


Class/ Purpose Route Frequency Dose (& range)

If out of range,

why? Mechanism of action

Onset of action Common side

effects Nursing


specific to this


Docusate Sodium

Stool Softener PO BID 100 mg

100-300 mg/day

Within range Acts as a surfactant that softens the stool Abdominal cramps Recommend ambulation and increase of fluids

Ferrous Sulfate

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

Updated FII17-NCC


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.

About the author

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