the_whatsername

I am a new to all of this too, and my teacher recommended that we watch videos by hawlknurse on youtube. She has great (according to my teacher, because I have nothing to really compare with) videos demonstrating the basic HOW TOs of assessment. As far as the sounds, they tell us not to be too frustrated with not getting it right off, that it comes with experience and if we hear something that sounds abnormal, to get our clinical instructor to help us distinguish what it is that we are hearing. I don't know if I much help, I just wanted to let you know that not knowing right now does not mean you are alone. I feel so lost too...lol. Keep your head up, experience will teach you more than any book I hear. At least, I hope

Thank You so much! I am so new to this and I know I am probably making this more difficult than it should be. I just have been feeling very overwhelmed and the stress of it all is getting to me. You've helped me understand better HOW to work a care plan and I thank you for breaking it down like you did.

I am a level one RN student on my first OB clinical rotations and care plans are still very new to me. I must turn in a concept map with supporting data for each of my diagnoses and an intervention sheet with at least 6 interventions and patient responses to each. Minus the patient responses, here is what I have so far: #1 Nursing Diagnosis Acute Pain r/t uterine contractions and stretching of cervix and birth canal Supporting Data External monitoring of contractions, Patient states "I am hurting," noticeable facial grimace, muscle tension, increased RR, Client rates pain as 9/10, diaphoresis Goal Client will report that pain management regimen relieves pain to satisfactory level Outcome Client will maintain Interventions Assess pain level every hour and PRN Administer Stadol IV every 4 hrs and PRN Assist with epidural Provide nonpharmacologic techniques Encourage client to try different positions Teach simple breathing and relaxation techniques Limit visitors as she desires Keep informed about the progress of labor and Baby's condition Prevent pain when possible during procedures #2 Nursing Diagnosis Fatigue r/t childbirth Supporting Data Unknown (help) Goal Patient will verbalize increased energy and improved well-being Outcome Patient will verbalize environment is suitable for satisfactory rest during my shift Interventions Assess level of fatigue PRN Allow client to express what best helps her relax Limit visitors as she requests Prepare the environment to promote rest Administer pain medication to relieve pain and promote rest Limit the number of times she is interrupted Try to administer medication, check VS, or or other actions in one room visit Teach methods to help relax #3 Nursing Diagnosis Anxiety r/t fear of unknown and situational crisis Supporting Data Facial tension, increased perspiration, increased pulse (?) ----- (This doesn't sound right) Goal Patient will have vital signs that reflect baseline and will verbalize decreased anxiety Outcome Patient will have a relaxed facial expression and body posture between contractions Interventions Determine the couple's plans for birth and work with them as much as possible Explain all activities, procedures and issues that involve the client Stay with client as much as possible during labor ? ? #4 Nursing Diagnosis Risk for Infection r/t multiple lady partsl exams and tissue trauma Supporting Data Unknown (help) Goal Patient will remain free from infection Outcome Patient will free from signs of infection as evidenced by normal VS during my shift Interventions Assess and report signs of infection such as Swelling, discharge, increased body temp and warmth Follow Standard Precautions Use sterile technique when inserting Foley Use appropriate hand hygiene Teach patient proper perineum care Teach patient the symptoms of infection and when to report to physician Teach patient proper episiotomy care Monitor VS