Question

I need 2 care plan with 2 nursing diagnosis for this scenario.

8:52 1 LTE sim case scenarion and forms Case Scenario Simulation: Sarah Grace is a 40 years old woman who came for consultation for the first time. She said she moved from Texas to live with her ailing mother who is 76 years old. It is uknown if she had previous prenatal visit. She appears quiet and reserved about her financial status but only says she previously worked as a grocery cashier. She indicated that she had spontaneous abortion 2 years ago and had previous abortion when she was 15 years old She does not indicate if she is married but seemed to be avoiding discussion about her support system. She is asking questions about how to know if she is in labor and how to prepare for it. Her current health status needs to be assessed. You are going to meet with the patient prior to a doctor interaction. A health history is not available or any previous lab work. Gather pertinent information that will aid the doctor in helping Sarah Grace. Please be keen on the needs of the patient that may present during your initial interaction. The CNA had taken her vital signs as follows: Temp 98.7; BP 190/100; Pulse 98; resp 22 pulse oximeter 95% Room air. Urine sample was collected and shows negative for glucose and positive for albumin.

Answer 1

Answer :

Nursing care plan includes

* Assessment : subjective data and objective data.

* diagnosis

* goal or expected out come

* planning

* implementation

* rationale

* evaluation

1. Nursing diagnosis :

Assessment :

Subjective data :

Client says that she had two abortions and came for health check up and she may complaints about head ache.

Objective data :

Increased blood pressure 190/100 mm of hg.

Nursing diagnosis :

Hypertension or increased blood pressure related to stress or fluid overload or some hormonal changes as evidenced by elevated blood of the client that is 190/100 mm of hg.

Expected outcome or goal :

Client maintaines normal blood pressure after implementing nursing interventions.

Planning :

* assess vital signs.

* keep head end elevation.

* to administer diuretics.

* to administer anti hypertensive drugs.

* educate regarding dietary modifications.

* educate exercises.

* daily monitoring.

Implementation :

* checked vital signs blood pressure is 190/100 mm of hg.

* kept head end elevation position with the support of pillows.

* administered furosimide 40 mg bd. Intra venously.

* administered anti hypertensive drugs like amlong 5 mg od per oral.

* educated regarding dietary habits and physical exercises and daily monitoring of level of blood pressure.

Rationale :

* it will give base line data.

* head end elevation may lowers the blood pressure.

* by excretion of over fluids we can reduces the blood pressure.

* drugs may decreases the blood pressure by acting on blood vessels like relaxing, amlong is calcium channel blockers.

* through proper education the client may get adequate idea regarding problems and it's interventional uses.

Evaluation :

After implementation of nursing interventions client reduced her blood pressure level from 190/100 mm of hg to 140/90 mm of hg.

Nursing diagnosis 2.

Assessment :

Subjective data : client is asking doubt regarding how to identify the labour and how to prepare for this.

Objective data :

Knowledge deficit regarding pregnancy and it's complications.

Nursing diagnosis :

Knowledga deficit regarding preganacy and labour related to poor information available from parents as evidenced by client is asking many doubts regarding labour and abortions.

Expected outcomes or goal :

Client may improve her knowledge regarding pregnancy and labour after providing health education.

Planning :

* assess the knowledge levels of client and her parents.

* education regarding pregnancy and it's physiological changes.

* educate diet and it's modifications.

* educate rest and sleep.

* education regarding delivery process and or abortions causes.

Implementations :

* assessed the knowledge levels of client.

* educated regarding physiological changes during pregnancy.

* educated regarding dietary changes like low salt diet due to she is having blood pressure hypertension.

* rest and sleep at least extra 2 hrs than the normal.

* educated regarding causes for abortion that is high blood pressure and albumin levels.

* explained complecations like echlampsia and prevalence echlampsia.

* explained labour process by demonstration on mannequin.

Rationale :

* it will provide base line data.

* she may get some idea due to some explanation.

* to reduce blood pressure and reduce complications.

* reduces the stress and fetal blood circulation improves.

Evaluation :

After providing education she some what cleared her doubts.