Antepartum / Intrapartum ISBAR and Clinical Learning - Direct Patient Documentation

BSNLevel3DirectPatientCareDocumentation072023.pdf

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Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 1 of 13

Student Name: D#: Date:

Course: Session: Year:

DIRECTIONS

This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning setting. All information within this packet must be handwritten, (with the exception of the reflection journal) reviewed with your faculty on your assigned clinical day and submitted within 24 hours (or as directed by course coordinator). If additional space is needed, please use the back of each page. If any area within this packet was not performed, line out and place “N/A” in that section.

• Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the clinical learning evaluation. Satisfactory rating meets the following:

– Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5).

• Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines.

• I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been received. Students should deliver a hand-off report at the end of their shift to the bedside nurse.

• Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results with why they were drawn specifically for your patient and healthcare provider orders with why they were specifically ordered for your patient.

• ATI® Active Learning Templates Required:

– Diagnostic Procedure: Select one diagnostic procedure from the healthcare orders table and complete one Active Learning Template: Diagnostic Procedure. The selected diagnostic procedure should be one in which you have not previously completed a template for this session.

– Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table and complete one Active Learning Template: Therapeutic Procedure. The selected therapeutic procedure should be one in which you have not previously completed a template for this session.

– Nursing Skill: Select one nursing skill from the healthcare orders table and complete one Active Learning Template: Nursing Skill. The selected nursing skill should be one in which you have not previously completed a template for this session.

– Medications: Complete one Active Learning Template: Medication for each medication classification in which you have not previously completed a template.

• Reflection Journal – Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing your clinical learning experience. Reflective journaling provides a format to share your knowledge, skills, experiences and personal reflection related to concepts and strategies learned throughout your program. What could you or did you delegate and to whom? Include ways you plan to care for yourself throughout your program. The reflection journal is required to be a typed Word document, Times New Roman 12-point font and minimum of one page and no more than three pages. At least one time during the session, faculty will select one of the following questions for you to reflect on. 1. Describe how racial/health disparities, health equality/inequality, and social justice/injustice could apply to the clinical

site/agency’s community. Consider the population and determine why this may be occurring. 2. Transportation and housing are drivers of health and equity. Describe the steps you would take as a nurse

to evaluate transportation and housing for your identified community population and what actions you could perform to identify resources.

3. How can nurses be change agents and advocate for their community? Provide at least two specific examples.

Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses

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I-SBAR

I – Introduce Yourself

Your Name:

D#:

Your Title:

Reason for being there:

S – Situation

Patient:

Age:

Gender/Identity:

Height/Weight:

Allergies:

Code Status:

Advance Directive (durable power of attorney, living will, other) and Clinical Significance:

Privacy Code:

Date of Care/Time:

Attending Physician:

Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance:

Pathophysiology of Primary Medical Diagnosis:

B – Background

Include clinical significance with each:

Past Medical History: Past Surgical History:

Immunizations Received:

Social History/Socioeconomic Factors:

A – Assessment

Vital Signs:

B/P HR RR TEMP SP02 PAIN

Falls risk: Accu-check:

IV Site: IV Fluids: Lab/Test Results:

I and O

Isolation Isolation Precautions: Y N Contact Air Droplet

RESPIRATORY

CARDIOVASCULAR

NEUROLOGICAL

GI/GU

INTEGUMENTARY

PSYCHOLOGICAL FAMILY – SUPPORT

SAFETY Teaching needed:

Quality in Safety Education Nurses (QSEN) Risk(s) Identified:

R – REQUEST/ RECOMMENDATION

Hand off report to: From:

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Initial Assessment Findings & Time Vital signs: T: P: Resp: Sp02: BP: Height: Weight: Apical HR: Intake: Output: Pain scale used with rationale: O (Onset): Did your pain start suddenly or gradually get worse?

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, where?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant or does it come and go?

Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

Bowel incontinence:

Bowel plan: Last BM:

Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils):

Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence: Toileting plan:

Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.):

Abuse screen (physical, elderly, child, sexual, etc.):

IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change):

Psychological/Psychosocial/Family Support/Religious/ Cultural Dynamics:

Growth and Development: (Developmental stage according to Erikson and your assessment findings):

Ongoing Assessment Findings & Time Vital signs: T: P: Resp: Sp02: BP: Height: Weight: Apical HR: Intake: Output: Pain scale used with rationale: O (Onset): Did your pain start suddenly or gradually get worse?

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, where?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant or does it come and go?

Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

Bowel incontinence:

Bowel plan: Last BM:

Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils):

Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence: Toileting plan:

Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.):

Abuse screen (physical, elderly, child, sexual, etc.):

IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change):

Psychological/Psychosocial/Family Support/ Religious/ Cultural Dynamics:

Growth and Development: (Developmental stage according to Erikson and your assessment findings):

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NURSING NOTES

Date/Time Nursing Note

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What assessment findings/cues are associated with your patient’s rhythm?

Identify the priority treatment based on your assessment findings (cues) and how you would evaluate for effectiveness.

LABS & DIAGNOSTICS

Test Result/ Date Norm Reason out of norm/reason for

drawing if normal or N/A if not drawn

WBC

RBC

Hgb

Hct

Plt

Chol

Trig

LDH

APTT

AST

ALT

Tdl*

Test Result/ Date Norm Reason out of norm/reason for

drawing if normal or N/A if not drawn

Glu

BUN

Creat

CO2

Phos

Mag

T. Pro

Alb

Tdl*

What patient findings would you anticipate with these laboratory findings?

* Therapeutic drug level

Telemetry Rhythm Strip

If applicable: Attach your patient’s rhythm strip below and determine the following information:

PRI: QRS: QT: Rate: Rhythm:

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HEALTHCARE PROVIDER PRESCRIPTIONS (ORDERS)

Items Order/ Frequency

Prioritization (Prioritize the healthcare provider prescriptions (orders) based on your assessment cues)

Reason (explain specifically why ordered for this patient and teaching required)

Diet

I/O

Activity

Accu-check

Foley

NG tube

PEG tube

PEJ tube

Chest tube

Trach

Suctioning

Drains

Ostomy

Dressing change and/or wound care

Treatments

Restraints

Safety devices

Special equipment

Other

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THE CLINICAL JUDGMENT MEASUREMENT MODEL The Clinical Judgment Measurement Model (CJMM) identifies six cognitive skills needed to make appropriate clinical judgments. Complete the following section using the CJMM and reflecting on all the data/cues (Assessment, Labs/Diagnostics, Prescriptions/Orders and Patient Information) from your assigned patient.

Recognize Cues – Identify relevant and important information from different sources (e.g., medical history, vital signs).

List the data/cues that are relevant and are interpreted as clinically significant.

Significant Data/Cue 1

Significant Data/Cue 2

Significant Data/Cue 3

Significant Data/Cue 4

Significant Data/Cue 5

Analyze Cues – Organizing and linking the recognized cues to the patient’s clinical presentation.

Interpret the relevant clinical data/cues. Identify the top three most likely problems. Is additional data needed to confirm the clinical significance of the cues at this point? Be specific; what additional data is needed to confirm?

Potential Problem 1 Potential Problem 2 Potential Problem 3

Additional Data Additional Data Additional Data

Prioritize Hypothesis – Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.).

Of the potential problems you identified, which problem(s) is most likely present? Which problem is the most concerning and why?

RECOGNIZE CUES

ANALYZE CUES

PRIORITIZE HYPOTHESIS

GENERATE SOLUTIONS

TAKE ACTION

EVALUATE OUTCOMES

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

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Generate Solutions – Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.

Based on the most urgent problem, what are the priority actions/interventions? For each priority action, what are the desired outcomes?

Priority Action/Intervention 1 Priority Action/Intervention 2 Priority Action/Intervention 3

Expected Outcomes Expected Outcomes Expected Outcomes

Are there any interventions or actions that should be avoided? Include rationale.

Take Action – Implementing the solution(s) that addresses the highest priorities.

How should the interventions or actions above be accomplished? (Performed, administered, requested, communicated, taught, documented, etc..).

List environmental and/or individual factors impacting the ability of the nurse to generate solutions and take action.

Environmental Factor 1

Individual Factor 1

Environmental Factor 2

Individual Factor 2

Environmental Factor 3

Individual Factor 3

Evaluate Outcomes – Comparing observed outcomes against expected outcomes.

Compare observed outcomes to expected outcomes – has the patient’s status improved, declined or remain unchanged?

Does the observed outcome match expected outcome? If not, what are the additional actions/interventions that should be considered?

Observed Outcomes Observed Outcomes Observed Outcomes

Matches Expected Outcome? Matches Expected Outcome? Matches Expected Outcome?

If the patient status has not improved, what other issues may be present?

List environmental and/or individual factors impacting the achievement of outcomes.

Environmental Factor 1

Individual Factor 1

Environmental Factor 2

Individual Factor 2

Environmental Factor 3

Individual Factor 3

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Priority (Top 3) Discharge Instructions and Evaluation of Effectiveness of Teaching (Include resources to mitigate SDOH and healthcare disparities.

Include teach/back and/or verbalized understanding)

CONCEPT MAP

Student Name: Date:

Priority (Top 3) Interventions, Rationales and Education to

Perform for Nursing Diagnosis

Potential and Actual Complications (Include dietary risk factors)

Priority (Top 3) Contributing Social Determinants of Health (SDOH)/

Healthcare Disparities Factors

Priority (Top 3) Information/Findings/ Signs and Symptoms (Cues)

Priority (Top 3) Lab Values/Diagnostic Results Related to Nursing Diagnosis

Identify how the Four Spheres of Care (AACN, 2019) were addressed

while caring for your patient. If a sphere is not applicable, provide rationale and/or exploration of how this could be incorporated into care.

1. Wellness, Disease Prevention (includes physical and mental

health needs). 2. Chronic Disease Management

(includes managing chronic disease and preventing further complications).

3. Regenerative /Restorative Care (includes complex acute, trauma

and critical care and acute exacerbations of chronic conditions). 4. Hospice/Palliative Care (includes end of life care and supportive care

for complex diseases and/or rehabilitative care).

Priority (Top 3) Patient Outcomes and Actions to evaluate the Outcomes

Priority (Top 3) Medication(s) and Patient Teaching r/t Diagnosis.

(Include medication side effects and nursing interventions for each)

Nursing Diagnosis

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Active Learning Template – Diagnostic Procedure

Student Name:

Procedure Name: Review Module Chapter:

Description of Procedure:

Considerations

Indications Nursing Interventions (pre, intra, post)

Interpretation of Findings Client Education

Potential Complications Nursing Interventions

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Active Learning Template – Therapeutic Procedure

Student Name:

Procedure Name: Review Module Chapter:

Description of Procedure:

Considerations

Indications Nursing Interventions (pre, intra, post)

Outcomes/Evaluation Client Education

Potential Complications Nursing Interventions

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Active Learning Template – Nursing Skill

Student Name:

Skill Name: Review Module Chapter:

Description of Skill:

Considerations

Indications Nursing Interventions (pre, intra, post)

Outcomes/Evaluation Client Education

Potential Complications Nursing Interventions

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Active Learning Template – Medication

Student Name: Medication/Time Due:

Review Module Chapter: Category Class:

Purpose of Medication

Expected Pharmacological Action Therapeutic Use

Complications Medication Administration

Contraindications/Precautions Nursing Interventions

Interactions Client Education

Evaluation of Medication Effectiveness Safety & Risk Considerations

I-SBAR
Initial Assessment Findings and Time:
Telemetry Rhythm Strip:
Healthcare Provider Orders
Concept Map
Active Learning Template:
Active Learning Template:
Active Learning Template:
Active Learning Template:

Student Name: Esther Ogueri
Course: NR327
D Number: 41091349
Session: [July]
Year: 2023
D Number 1: 24th July 2023
Your Name: Esther Ogueri
D Number 2: 41091349
Your Title: Student Nurse
Reason for being there: Clinical
Patient: T.T
Age: 29
Gender: Female
HeightWeight: 140 lbs / 5.5'
Allergies: None
CodeStatus: Full
PrivacyCode:
DateofCare: 30th July 2023
Safety-Teaching Needed: Fall prevention measures, monitoring blood pressure at home.
Safety-QSEN: Risk of falls due to hypertension-induced dizziness and edema.
DateofCare 10: Current nurse
Recommendation:
Respiratory 3: Clear and equal breath sounds bilaterally
I and O: 2250mL and Output of 1800 mL
Cardiovascular 3: Regular rate and rhythm, no murmurs
Neurological 3: Normal neurological status, oriented to person, place, and time.
GIGU: Occasional nausea reported, no vomiting. Bowel movements regular. Urinary output within normal limits.
Integumentary 5: No skin breakdown or abnormalities noted. Edema present in lower extremities.
Psychological Family Support: Patient's husband present for emotional support and involvement in care decisions.
IVsite: left forearm
IVfluids: Normal Saline (0.9% Sodium Chloride) at a rate of 100 mL/hour.
results: CBC, Urinalysis
AttendingPhysician:
Signficance: A 29-year-old woman with preeclampsia. She is in the postpartum department recovering from labor and delivery. She had a vaginal delivery.
Pathophysiology: Preeclampsia is a pregnancy-specific illness that causes high blood pressure (hypertension) and organ damage, usually in the kidneys and liver, after the 20th week of gestation. Preeclampsia's etiology is unknown, however placenta issues are suspected.
PastMedicalHistory: None
PastSurgicalHistory: None
SocialHistory:
Immu Receieved: Pfizer-BioNTech and Moderna for COVID-19
BP: 150/90 mmHg
BP 2:
FallsRisk: High risk
AccuCheck: Blood glucose levels
HR: 80 beats/m
HR 2:
RR: 16 b/min
RR 2:
TEMP: 37°C
TEMP 2:
SPO:
SPO2:
PAIN: 4/10
PAIN 2:
ClinicalSignificance: None
Isolation Precautions Yes: Yes
Contact Air: Off
Contact Air 1: Yes
Contact Droplet: Off
Isolation Precautions No: Off
Request-From 2: Oncoming shift nurse
Request-From:
Vital Signs-T 2: 37°C
Vital Signs-T 3: 37.2°C
Vital Signs-P: 84 bpm
Vital Signs-P 2: 88 bpm
Vital Signs-Resp: 16 bpm
Vital Signs-Resp 2: 20 bpm
Vital Signs-SpO2: 98%
Vital Signs-SpO2 2: 99%
Vital Signs-BP : 150/90 mmHg
Vital Signs-BP 1: 2250mL
Vital Signs-BP 3: 2500 mL
Vital Signs-BP 2: 1800 mL
Vital Signs-BP 4: 1950 mL
Vital Signs-BP 2: 128/76 mmHg
Vital Signs-Height: 5.5'
Vital Signs-Height 2: 5.5'
Vital Signs-Weight: 140 lbs
Vital Signs-Weight 2: 140 lbs
Vital Signs-Apical HR: 80
Vital Signs-Apical HR 2: 84
Pain Scale Used with Rationale: Numerical Rating Scale (NRS); to assess pain intensity on a scale of 0 to 10.
Pain Scale Used with Rationale 3: Numerical Rating Scale (NRS); to assess pain intensity on a scale of 0 to 10.
AbInspection: Soft and non-tender, normal bowel sounds, regular contour.
AbInspection 2: Soft and non-tender, normal bowel sounds, regular contour.
Genitourinary: No burning with urination, normal frequency, clear urine.
Genitourinary 2: No burning with urination, normal frequency, clear urine.
Pelvic: Last menstrual period (LMP) 6 weeks ago.
Pelvic 2: Last menstrual period (LMP) 6 weeks ago.
Rectal: No bleeding or hemorrhoids observed.
Rectal 2: No bleeding or hemorrhoids observed.
Integumentary: Intact skin with no rashes, lesions, or wounds.
Integumentary 2: Intact skin with no rashes, lesions, or wounds.
Specialty assessment: No specific specialty assessments indicated
Specialty assessment 2: No specific specialty assessments indicated.
Abuse screen: No evidence of abuse.
Abuse screen 2: No evidence of abuse.
IV access: Peripheral IV, 20-gauge, in left forearm. Normal Saline at 100 mL/hour. IV site intact, last dressing change 6 hours ago.
IV access 1: Patient's husband present, providing emotional support.
IV access 4: Patient's husband present, providing emotional support.
IV access 3: Middle adulthood (Erikson's stage), age-appropriate findings observed.
IV access 5: Middle adulthood (Erikson's stage), age-appropriate findings observed.
IV access 2: Peripheral IV, 20-gauge, in left forearm. Normal Saline at 100 mL/hour. IV site intact, last dressing change 6 hours ago.
Urinary incontinence: Absent
Urinary incontinence 2: Absent
Toilet Plan: Encourage voiding every 2-3 hours.
Toilet Plan 2: Encourage voiding every 2-3 hours.
Bowel incontinence: Absent.
Bowel incontinence 2: Absent
Last Bowel Movement: 12 hours ago.
Last Bowel Movement 2: 6 hours ago.
Neurological: Alert and oriented, intact cranial nerves, normal sensory and motor function, reflexes present.
Neurological 2: Alert and oriented, intact cranial nerves, normal sensory and motor function, reflexes present.
Musculoskeletal: Full range of motion, normal pulses in extremities, normal muscle strength.
Musculoskeletal 2: Full range of motion, normal pulses in extremities, normal muscle strength.
Bowel Plan: Encourage regular toileting, monitor for constipation
Bowel Plan 2: Encourage regular toileting, monitor for constipation
Pain Scale-P: Continuous Pian
Pain Scale-P 1: Gradually
Pain Scale-P 2: Better with rest, worse with movement.
Pain Scale-P 3: Gradually got worse.
Pain Scale-Q: Mild pain
Pain Scale-Q 2: Dull and achy.
Pain Scale-R: No
Pain Scale-R 2: No radiant noted
Pain Scale-S: Mild
Pain Scale-S 2: 5 out of 10.
Pain Scale-T: Come and go
Pain Scale-T 2: Comes and goes
HeadNeck: No abnormalities noted.
Head Neck 2: No abnormalities noted.
Respiratory: Clear breath sounds, even breathing effort, no use of accessory muscles.
Respiratory 2: Clear breath sounds, even breathing effort, no use of accessory muscles
Cardio: Regular heart rate and rhythm, no murmurs or abnormal sounds.
Cardio 2: Regular heart rate and rhythm, no murmurs or abnormal sounds.
Text Field 1: 28/7/2023
Text Field 31:
Text Field 16: 29/7/2023
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Text Field 4: 28/7/2023
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Text Field 17: 29/7/2023
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Text Field 7: 28/7/2023
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Text Field 18: 30/7/2023
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Text Field 10: 28/7/2023
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Text Field 19: 30/7/2023
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Text Field 13: 29/7/2023
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Text Field 20: 30/7/2023
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Text Field 3: Assessed patient's vital signs and neurological status. Blood pressure within target range, no signs of neurological deficits.
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Text Field 26: Reviewed IV site and dressing, observed for signs of infiltration or phlebitis. IV site intact, no redness or swelling noted.
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Text Field 6: Patient reported pain at 4 out of 10 on the pain scale. Administered prescribed pain medication as per the order.
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Text Field 27: Engaged in therapeutic communication with the patient and her husband, addressing concerns and providing emotional support.
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Text Field 9: Monitored intake and output, ensuring fluid balance is maintained. Encouraged patient to drink fluids to meet daily requirements.
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Text Field 28: Collaborated with the healthcare team to ensure the patient's care plan aligns with her cultural and religious beliefs.
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Text Field 12: Assisted patient with ambulation to prevent falls. Provided education on fall prevention measures to patient and family.
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Text Field 29: Educated the patient and her husband on self-monitoring blood pressure at home and recognizing signs of worsening preeclampsia
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Text Field 15: Conducted a head-to-toe assessment, including respiratory, cardiovascular, abdominal, and musculoskeletal systems. No significant abnormalities identified.
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Text Field 30: Conducted fetal heart rate monitoring, reassuring the patient about the baby's well-being.
Text Field 60:
PRI:
PRI 1: N/A
PRI 2: N/A
PRI 3: Mildly elevated white blood cell count (WBC) (12,000/mm³) may indicate the presence of an infection or inflammation in the body.
PRI 4: Hemoglobin (Hgb) level of 12 g/dL and hematocrit (Hct) of 36% may suggest mild anemia, which could lead to symptoms such as fatigue and weakness.
Telemetry Rhythm Strip text box: N/A
QRS:
QT:
Rate:
Rhythm:
Result Date 12:
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Result Date 13: 100 mg/dL
Result Date 14: 29/7/2023
Result Date 16:
Result Date 15: 29/7/2023
Result Date 17:
Test Opt 1: CBC
Test Opt 3:
Test Opt 2: Urinalysis
Test Opt 4:
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Reason 13: Routine lipid profile
Reason 14: Hemoglobin: 11.2 g/dL (slightly below normal) - Related to anemia, common in pregnancy.
Reason 16:
Reason 15: Protein in Urine: 2+ (significant proteinuria)
Reason 17:
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Order Frequency 1: Regular diet as tolerated
Order Frequency 2: Every 8 hours
Order Frequency 3: Every 4 hours
Order Frequency 4: Ambulate every 2 hours
Order Frequency 5: Before meals and at bedtime
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Reason 37: High
Reason 60: To assess fluid balance and hydration status.
Reason 38: High
Reason 61: To assess fluid balance and hydration status.
Reason 39: High
Reason 62: To monitor the patient's overall health and detect any changes.
Reason 40: High
Reason 63: To prevent complications associated with immobility.
Reason 41: High
Reason 64: To monitor blood glucose levels in case of gestational diabetes or other related conditions.
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Significant Data/Cue 2: Elevated white blood cell count (WBC) of 12,000/mm³ indicating a possible infection or inflammation.
Potential Problem 2: Infection or Inflammation
Additional Data 2: Elevated white blood cell count (WBC) of 12,000/mm³
Prioritize Hypothesis 2: Most Likely Present Problem: Infection or Inflammation (elevated WBC) Most Concerning Problem: Gestational Diabetes Reasoning: Infection or inflammation is most probable due to the high white blood cell count. Gestational diabetes is the most urgent issue to treat since it may harm both mother and child. Preventing pregnancy and delivery problems requires early gestational diabetes diagnosis and care.
Additional Data 3: Hemoglobin (Hgb) level of 12 g/dL and hematocrit (Hct) of 36%
Additional Data 4: Accu-check (blood glucose monitoring) to assess blood glucose levels
Potential Problem 3: Mild Anemia
Potential Problem 4: Gestational Diabetes
Significant Data/Cue 3: Hemoglobin (Hgb) level of 12 g/dL and hematocrit (Hct) of 36% suggesting mild anemia.
Significant Data/Cue 4: Blood pressure of 128/76 mmHg within target range.
Significant Data/Cue 5: Ambulatory activity every 2 hours to prevent complications associated with immobility.
Significant Data/Cue 6: Accu-check (blood glucose monitoring) to assess for gestational diabetes or related conditions.
Priority Action/Intervention 5: Administer broad-spectrum antibiotics as prescribed.
Expected Outcomes 4: Reduction of infection/inflammation signs, normalized WBC count, improvement in patient's condition.
Expected Outcomes 5: Stable blood glucose levels within target range, prevention of complications related to uncontrolled diabetes during pregnancy.
Expected Outcomes 6: Increase in hemoglobin and hematocrit levels, improvement in symptoms of mild anemia, and prevention of worsening anemia.
Are there any interventions or actions that should be avoided? 2: Avoid prohibited drugs during pregnancy to protect the baby. Rationale: Some drugs may harm the growing fetus and should be avoided during pregnancy to protect the mother and child.
Take Action 5: Administer broad-spectrum antibiotics as prescribed. Administered by the nurse following the healthcare provider's prescription, ensuring correct dosage and route.
Environmental Factor 8: Availability of appropriate antibiotic medications.
Observed Outcomes 4: Reduction in WBC count and improvement in infection/inflammation signs.
Matches Expected Outcome? 4: Yes.
what other issues may be present 4: Reevaluating the antibiotic therapy and considering a change in the medication if the infection does not show significant improvement.
what other issues may be present 5: Reviewing the glucose monitoring and dietary plan for gestational diabetes, and making adjustments if blood glucose levels are not well controlled.
what other issues may be present 6: Complications related to the infection or gestational diabetes that require further investigation and management.
Matches Expected Outcome? 5: Yes
Matches Expected Outcome? 6: Yes
Observed Outcomes 5: Stable blood glucose levels within target range with dietary modifications.
Observed Outcomes 6: Increase in Hgb and Hct levels with iron supplementation.
Environmental Factor 9: Availability of healthcare resources and facilities.
Individual Factor 8: Proper storage and handling of antibiotics.
Individual Factor 9: Patient's compliance with prescribed treatments and medications.
Individual Factor 10: Access to a registered dietitian for dietary guidance.
Individual Factor 11: Patient's health literacy and understanding of self-care management.
Individual Factor 12: Access to laboratory facilities for monitoring Hgb and Hct levels.
Individual Factor 13: Patient's socioeconomic status and access to resources for healthcare.
Environmental Factor 10: Availability of glucose monitoring equipment.
Environmental Factor 11: Support from the healthcare team and access to specialized care.
Environmental Factor 12: Availability of iron supplementation.
Environmental Factor 13: Availability of social support and family involvement in care.
Take Action 6: Initiate glucose monitoring and dietary modifications for gestational diabetes management. (Performed, Taught)
Take Action 7: Provide iron supplementation and monitor Hgb and Hct levels for anemia management. (Administered, Monitored, Documented)
Priority Action/Intervention 6: Initiate glucose monitoring and dietary modifications for gestational diabetes management.
Priority Action/Intervention 7: Provide iron supplementation and monitor Hgb and Hct levels for anemia management.
Student Name 2:
Date 2:
Interventions for Nursing Diagnosis: Interventions: Diet and glucose monitoring. Rationale: To maintain stable blood glucose levels throughout pregnancy and avoid issues for mother and baby. Education: Help the patient control gestational diabetes by monitoring blood glucose, analyzing findings, and eating a balanced diet. Interventions: Take recommended iron supplements. Rationale: To treat moderate anemia and boost hemoglobin and hematocrit levels to promote patient health during pregnancy. Education: Explain the benefits of iron supplementation and their adverse effects, such as constipation. Recommend increasing fluid and fiber consumption. Interventions: Monitor infection and use medicines as directed. Rationale: Reduce white blood cell count and prevent infection or inflammation. Education: Teach patients to finish antibiotics and recognize allergic reactions.
Signs and Symptoms: Elevated white blood cell count (WBC) indicating possible infection or inflammation. Mild anemia indicated by hemoglobin (Hgb) level of 12 g/dL and hematocrit (Hct) of 36%. Accu-check (blood glucose monitoring) for gestational diabetes management.
Lab Values Related to Nursing Diagnosis: WBC count: 12,000/mm³. Hgb level: 12 g/dL, Hct level: 36%. Accu-check: Blood glucose levels within target range
Nursing Diagnosis: Risk for Gestational Diabetes
Potential and Actual Complications: Potential complications: Uncontrolled gestational diabetes can lead to macrosomia, fetal distress, and increased risk of cesarean delivery. Actual complication: Anemia may lead to fatigue and decreased oxygen-carrying capacity.
Priority (Top 3) Patient Outcomes and Actions to evaluate the Outcomes: Desired Outcome: Stable blood glucose levels within target range. Evaluation: Monitor blood glucose levels regularly and review trends for consistency. Desired Outcome: Improvement in Hgb and Hct levels. Evaluation: Monitor Hgb and Hct levels regularly and assess for an increase in values. Desired Outcome: Resolution of signs of infection/inflammation. Evaluation: Monitor vital signs, white blood cell count, and assess for improvement in infection-related symptoms.
Priority (Top 3) Discharge Instructions and Evaluation of Effectiveness of Teaching: Wellness, Disease Prevention: Glucose monitoring and dietary modifications to prevent complications of gestational diabetes. Chronic Disease Management: Managing gestational diabetes and addressing mild anemia. Regenerative/Restorative Care: N/A (Not applicable to this specific case of preeclampsia). Hospice/Palliative Care: N/A (Not applicable to this specific case of preeclampsia).
Medication Side Effects 2: Discharge Instruction: Provide a written meal plan with nutritious food options and portion control to manage blood glucose levels. Evaluation: Assess the patient's ability to understand and follow the meal plan through teach-back. Discharge Instruction: Encourage regular follow-up appointments with a healthcare provider to monitor blood glucose and anemia levels. Evaluation: Verify that the patient has scheduled and attended follow-up appointments. Discharge Instruction: Provide information on community resources for food assistance and financial support for healthcare services if needed. Evaluation: Ensure the patient is aware of and has access to relevant community resources.
Priority Contributing Social Determinants of Health (SDOH)/Healthcare Disparities Factors: Limited access to nutritious food options in the patient's neighborhood. Lack of health insurance or limited access to healthcare resources. Limited social support or inadequate family involvement in care.
Priority Medication(s) and Patient Teaching r/t Diagnosis: Iron supplementation (Ferrous sulfate): Side Effects: Constipation, dark stools. Nursing Intervention: Advise the patient to increase fluid and fiber intake, monitor for constipation, and report any severe discomfort.
Description of Procedure: The Complete Blood Count (CBC) is a popular blood test that examines red blood cells, white blood cells, and platelets.
Procedure Name: Complete Blood Count (CBC)
Review Module Chapter: Hematological Disorders
Indications: Anemia, infection, and other hematological abnormalities are assessed by CBC in preeclampsia patients.
Interpretation of Findings: The CBC may show anemia (low hemoglobin and hematocrit levels), high white blood cell count (indicating illness or inflammation), and platelet abnormalities.
Potential Complications: The CBC is a normal, non-invasive treatment with no known consequences.
Nursing Interventions: Pre: Check identity and phlebotomy allergies. Intra: Help the phlebotomist draw blood and calm the patient. Post-venipuncture: Watch for bleeding or hematoma.
Client Education: Inform the patient about the CBC's purpose, the technique, and the need of discussing the findings with the doctor.
Nursing Interventions 1: Pre: Inform and calm the patient about the process. Intra: Identify and draw blood with the phlebotomist. Post: Label and rush the blood sample to the lab.
Student Name 4: Esther Ogueri
Description of Procedure 2: What a patient says about the pain she is experience is the best evidence or indicator of that pain.
Procedure Name 2: Pain Mangement
Review Module Chapter 2:
Indications 2: Signs and symptoms realating to pain. Patients report of pain. Guarded and protective ehavior, loss of appetite, inabaility to perform activities of daily living.
Outcomes Evaluation 2: Expected outcomes- patient uses pharmatcological and nonpharmacological pain relief strategies. Evaluation: Continue pain management. Assess pain regularly. Administer pain medicationd as prescripted.
Potential Complications 2: Inadequate assessment of pain. Inadequate understanding of how patient perceives his pain. Difference in the information received, and lifestyle.
Nursing Interventions 2: Pre- acknowledge reports of pain immediately. Intra: Prevent the stressots or sources of discomfort whenever possible. Determine the pain method that is works for you. Post: Report to the physician when interventions are unsucessful an ineffective.
Client Education 2: Instructed patient on importance of pain management.Take pain medication as ordered. Do not wait for pain to get worse.
Nursing Interventions 3: Observe for nonverbal indicators of pain: moaning, guarding, crying grimance.
Student Name 3: Esther Ogueri
Description of Procedure 5: To collect information on the health status of the patient.
Skill Name 5: Physical Assessment
Review Module Chapter 5:
Indications 3: Getting information about physical health of the patient, such as establishing baseline status and detection of health abnormalities.
Interpretation of Findings 3: Patient will begin to develop a therapeutic relationship with the nurse, and feel comforable discussing concerns. The will collect adequate information to determine the current statusof the patient's health and any detriment to health.
Potential Complications 3: cultural insentitivety- Uncooperative patient.
Nursing Interventions 4: Pre: Introduce yourself to patient. Perform necessary hygiene, provide privacy. Intra:Explain process of physical assessment. Ask permission before performing any physical assessment if the patient on any religious or cultural requirement. Post: Explain each performance before you start.
Client Education 3: Educate patient on assessment process, and what it will entail, and what will be done with the information, including health promotion and preventive.
Nursing Interventions 5: Discuss patient's concerns and educate patient on assessment process. Alterations of assessment may be necessaryif patient is not willing to allow physical assessment.
Student Name 6: Esther Ogueri
Review Module Chapter 6: Magnesium sulfate (IV parenteral)
Medication 6:
Category Class 6: mineral/electrolyte
Expected Pharmacological Action 4: Treatment/ prevention of hypomagnesemia. treatment of hypertension. Prevent seizure associated severe eclampsia. or preeclampsia, or acute nephritis.
Complications 4: Drowsiness, decrease of respiratory rate, hypotension, and muscle weakness.
Contraindications Precautions 4: Hypermagnesemia, hypocalcemis, anuria, and heart block. For OB, avoid using for more than 5-7 day for preterm labor. Avoid continous use during active labor or within 2 hrs of delivery.
Interactions 4: Drug to drug: it potentiate calcium channel blockers and neuromusclar blocking agents.
Therapeutic Use 4: Replacement in deficiency states. Resolution of eclampsia.
Medication Administration 4: For Eclampsia and preeclampsia, IM IV (adults) 4-5 g by IV infusion, then 4-5 g IM q 4hr.
Nursing Interventions 6: Hypomgnesemia /Anticonvulsant: Monitor pulse, BP, respirations, and ECG frequently throughout administeration of parentalmagnesium sulfate.
Client Education 4: Explain purpose of medication to patient and family.
Safety & Risk Considerations: Monitor patient closely. Accident overdoage of IV magneseium has resulted in serious patient harm or death.
Evaluation of Medication Effectiveness 4: Normal serum magnesium concentrations. Control of seizures associated with toxemiasof pregnancy.