Struggling with an assignment! Pregnant women with history of IV drug use and alcohol abus

[JLVAND]

Hi everyone! I have been out of school for 5 years and am now taking some perinatal courses. I have an assignment that I am struggling with on where to begin! The case study is as follows:

Susan, a 32 year old G2 P1 with a history of IV drug use and alcohol abuse, comes in for an antenatal visit to discuss complaints of sleepless nights, night sweats, and a yeast infection she can't get rid of.

Assignment is as follows:

1. Discuss expected outcomes for this patient.

2. Listing the nursing diagnosis you identified.

3. Create a checklist for teaching pointsI feel like there really isn't a lot of info about this patient. Based on pt history and symptoms, I am guessing she has undiagnosed HIV, or is suffering from alcohol withdrawal. But I can't really base my assignment on these assumptions. How do I go about talking about expected outcomes? Would I say an expected outcome of a HIV diagnosis? Or base my expected outcomes on the symptoms themselves? Really struggling with the expected outcomes bit and am not sure where to start. Does anyone have any insight?

[HopefulRN7]

If you are looking for guidance on this forum it's best to shoot your own ideas out and ask for feedback...when you leave it open-ended without showing your effort, it seems like you're expecting others to do the work for you.

Just a helpful tip...

[Leonardsmom,LPN]

Do you have a nurses diagnosis book? You need to use NANDA labels when making your diagnosis, medical diagnosis such as HIV or alcohol (ETOH) withdrawal will not work. Does the scenario give you information about her current status with drug and alcohol abuse, how may this affect her in her current pregnancy? Any information provided in the scenario about her previous pregnancy, was the baby born alive, premature, does she have custody of the child or did she loose custody because of her drug abuse? How may this impact her thoughts on her current pregnancy? Think about what her physical needs are at this time, her psychosocial needs.

[Here.I.Stand, BSN, RN]

An HIV dx is pure speculation. Millions of pregnant women have trouble with sleeping, Candida, and feeling hot.

Pts in alcohol withdrawal don't generally comd to clinics with these complaints. They're experiencing acute anxiety, tremors, sweats (not *night* sweats), hallucinations, tactile disturbances, headaches, etc, sometimes even seizures. To assess for this, you need to know when she stopped drinking. She has a history -- that could mean she stopped 5 yrs ago and has been attending AA 3x a week since. Had she been actively drinking and stopped 2 days ago, that might be a concern.

But in any case, you don't base a nursing care plan off of a medical dx, nor do you make a medical dx.

If you don't have a NANDA book, get one. There really isn't a lot of info here, but what is she complaining of? She can't sleep. Those sweats are probably not helping her rest. Yeast infections are aggrivating. A NANDA book will help you formulate your observations into approved nursing dx'es.

Once you have your dx, you can then consider what you as a nurse can do to help her