HELP for "fake patient careplan"

[CRIMSON]

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.

Client Profile: 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.

Scenario: 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.

Assessment: 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 lady partsl 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.

[melmarie23, MSN, RN]

the only issue that I see is a nursing diagnosis related to PROM. There is nothing in that scenario that indicates that the membranes have ruptured.

what about "risk for premature labor r/t multiple gestation pregnancy" ?

[CRIMSON]

it is a risk for/possible complication of r/t stress and history of cervical surgery

[eyknough]

I like dx number one.

Number 2 seems inappropriate because there has been no mention of PROM (unless I missed it).

Same thing for number 3.

We don't want to seem predictive. Of course we're going to be watching for infection, appropriate coping with anxiety and we're going to be trying to reduce risk for injury to mother and fetus.

So far, she's doing fine, except that she needs terbutaline to try and delay labor. There has been no rupture of membranes, and no signs that she is in actual labor.

I think you'd be wise to focus on some of the concerning side effects of terbutaline, as well as possibly a "readiness for enhanced learning" dx. It says she is nervous, but doesn't mention any maladaptive or palliative coping mechanisms. She's ready to learn about how to care for newborn twins. I think you nailed one possible diagnosis in your interventions, fetal oxygenation. I think you should address s/s of fetal hypoxia as a nursing diagnosis, especially since she is cramping (which may lead the mom to not breathe appropriately... pulmonary edema is a possible SE of terbutaline), and may lead her to position herself in ways that hampers oxygenation of her placenta.

So, risk for fetal hypoxia, risk for injury r/t possible preterm labor, anxiety, and readiness for enhanced learning.

You want to be careful with risk for preterm labor, because as nurses we can't really treat it. In school they're picky about that stuff. If you start writing medical diagnoses, as my fundamentals teacher pounded in our heads, you are practicing medicine without a license, and you go directly to jail. lol

Of course, I grasp for straws sometimes... Once I included impaired dentition in a psych care plan.... well it was hard to come up with something! And yes I had to rewrite that dx, goals, interventions and evaluations. Ugh!

[melmarie23, MSN, RN]

I know its a risk of/complication of PROM, but she isnt currently experiencing PROM.

and ignore my other suggestion, she already is experiencing preterm labor.

how about :

risk for infection: risk factor: possible PROM d/t multiple gestation pregnancy (or d/t preterm labor)

risk for infection: risk factors: invasive procedures to prevent preterm birth

impaired physical mobility r/t imposed bed rest to prevent preterm birth

[eyknough]

Be careful with assuming preterm labor. The way I see the situation, she's only having uterine irritability and contractions controlled by the brethine. There are criteria for labor, and I didn't think I saw enough information to assume preterm labor. No contraction duration or frequency information is given. There are no hard core attempts to stop labor.

We all know twins are going to be preterm, but ya have to be careful about adding information that is not there. There is a reason for the amount of information given, because there is enough to get plenty of nursing diagnoses without needing to assume information. It may even be specially designed to try and catch people if they add information to the situation.

Is this for an OB class? Could be a psych question with some OB and med surge thrown in there depending on what you want make of it. I'm starting to think more about the cryosurgery to her cervix. Your risk for infection dx may be right on the money!

[Daytonite, BSN, RN]

when you are given a fake patient, you look at the signs and symptoms the scenario provides to you for your nursing problems (nursing diagnoses). there are 2 actual problems here based on information given in the scenario and i can pick up on one potential problem:

• 32 weeks pregnant with twins (at end of 2nd trimester)
  
• first pregnancy
  
• nervous about having two newborns to care for
  
• history of abnormal pap smear that was treated with cryosurgery of the cervix three years ago
  
• has been feeling cramps lately and is on terbutaline po q 4h to decrease uterine irritability and contractions.
  

those problems are:

• acute pain r/t physical changes and effects of hormones aeb cramps
  
  • outcome: report of discomfort will be decreased.
    
  • outcome: patient will use relaxation techniques effectively.
    
  • outcome: patient will appear relaxed and at ease.
    
  • interventions:
    
    • teach relaxation techniques: deep breathing, visualization, guided imagery, use of soft and relaxing music
      
    • employ comfort measures such as a back rub, changing the linens, repositioning.
      
    • administer analgesics, if ordered
      

  [*]deficient knowledge, newborn care r/t unfamiliar with resources aeb first pregnancy and nervous about having two newborns to care for

  • outcome: will be able to state how to provide appropriate nutritional intake for the babies.
    
  • outcome: will be able to state how to provide a safe place for the babies to rest and sleep.
    
  • outcome: will be able to identify signs and symptoms in the babies that will need medical follow up.
    
  • interventions:
    
    • provide information about baby feeding, nutrition and breastfeeding if mother decides to breastfeed.
      
    • provide information regarding baby sleep cycles and safety with regard to falls and accidental suffocation. discuss normal developmental milestones.
      
    • provide a schedule for immunizations and the importance of regular visits to a pediatrician.
      

  [*]risk for poisoning r/t side effect of tocolytics (the terbutaline) - if you must use a nanda diagnosis, use risk for injury r/t side effect of tocolytics

  • outcome: will have no evidence of cardiac dysrhythmias, chest pain, dyspnea, dizziness, headache, hyperglycemia, hypokalemia, nausea or vomiting.
    
  • outcome: will have ceased having uterine contractions and cramps.
    
  • outcome: prevent maternal injury.
    
  • interventions:
    
    • patient should be placed in a lateral recumbent position with head elevated during the infusion of the drug.
      
    • iv infusions should be done by iv pump.
      
    • monitor serum potassium and glucose levels.
      
    • assess for uterine contractions at least twice a day.
      

[squishy11]

Daytonite, I would like to officially hire you as my nursing care plan tutor! I really can't tell you how awesome you are, and how thankful I am to be a part of this message board!

Have a great holiday... and I am truly thankful for you!

[CRIMSON]

Thank you very much Daytonite you are awesome at picking these things out.

[CRIMSON]

Daytonite,

Again thank you very much. Can you tell me what source you used for these interventions? I have to reference the source and rationale for each.

thank you.

[Daytonite, BSN, RN]

daytonite,

again thank you very much. can you tell me what source you used for these interventions? i have to reference the source and rationale for each.

thank you.

• maternal/newborn plans of care: guidelines for individual care, 3rd edition, by marilynn e. doenges and mary frances moorhouse.
  
• foundations of maternal-newborn nursing, 4th edition, clinical companion, by sharon smith murray and emily slone mckinney