When I have to do a careplan on an actual patient I have seen, assessed and have accessed their file it is NO problem. However, they have given us a patient with extremely LIMITED info and asked us to write: 3 Outcomes/Goals, 3 interventions for each outcome and rationales.
Below is the information I was given and what I am thinking of, any suggestions is appreciated.
: Mrs. Adams, a 26 year old, is 32 weeks pregnant with twins. This is her first pregnancy and she is nervous about having two newborn to care for. She has a history of abnormal pap smear that was treated with cryosurgery of the cervix three years ago.
mrs. Adams is very compliant with all her prenatal appointments. She has been feeling cramps lately and is now having non-stress test once a week. Her last non-stress test was reassuring, but the doctor is watching her closely. Mrs. Adams is pt on Terbutaline PO Q 4H to decrease uterine irritability and contractions.
Presently Mrs. Adams is not dilated and her cervix is still thick.
THAT IS IT, no other info.
WHAT I HAVE COME UP WITH SO FAR:
Anxiety r/t threat to maternal and/or fetal well being secondary to risk of preterm labor.
-Assess level of anxiety upon admission and Q hourly thereafter and encourage verbalization of anxieties prn.
-Assess level of understanding of the diagnosis, treatment and prognosis at time of initial assessment.
-Identify and initiate strengths, coping mechanisms, support systems and spiritual needs at time of initial assessment.
-Teach use of stress reducing techniques that have been beneficial in the past prn.
-Refer to pastoral care at patients request anytime during shift.
Risk for Infection: maternal or fetal r/t possible complication of PROM
-Assess for risks of infection and VS at time of initial assessment
-Assess for s/s of localized or systemic infection (e.g. elev. temp, increas. HR, change in drainage of secretions, mailase) at time of initial assessment.
-Assess for risks of PROM at time of initial assessment
-Teach patient to identify s/s of infection at time of initial assessment (e.g. elev. temp, increas. HR, change in drainage of secretions, mailase)
-Request orders for CBC, urinalysis
Risk for Injury: fetal r/t premature labor/birth
-Assess for risks of premature labor/birth at time of initial assessment (e.g. multi-gestation, chorioamnionitis, PROM, HTN, smoking, drug use)
-Assess for s/s PTL/birth & VS at time of initial assessment and Q hourly (e.g. uterine cxn's, cervical changes, cramping, increased vaginal discharge, tachycardis, fetal engagement, low back pain, pelvic pressure, "balling up", diarrhea).
-Teach importance of maintaining strict bedrest and lateral position at time of initial assessment
-Assess for cervical changes at time of initial assessment and at any time of change of complaints by patient during shift.
Any suggestions or help appreciated.
Thanks in advance.