Student Name: Patricia Pineda Date: 03/08/2017 Assessment Submitted: 04/27/17
Maternal Initials: L. P Clinical Faculty: Yvette, Rolle, DNP, CNE, OB-RNC
Hospital Clinical Site: Texas Children’s Hospital Pavilion for Women
NOTE: This care plan follows directly from the Assessment Data you have collected in your Antepartum/Intrapartum Physical Assessment. Assessment forms must be submitted along with this care plan and the grading.
Submit your Antepartum/Intrapartum Assessment and Care Plan to your clinical faculty.
Prioritized Nursing Diagnoses:
Complete the Care Plan below only on the #1 Nursing Diagnosis that you identify here.
1. Acute pain related to inflammation of the…show more content…
This is my third day at the hospital.”
Supporting Objective Data: Patient is 19 y.o., Hispanic, at her 31w3d pregnancy, G2P1, NKDA, was diagnosed with acute pancreatitis on March 5th, 2017, came to the hospital because of complaints of upper abdominal pain along with vomiting and nausea. She has no previous history of any health or medical problem. She is fully awake, alert, oriented x4, cooperative, clean, and relax watching TV. She is on bed rest with bathroom privileges with assistance. The patient has no sleep problems other than hospital required interruptions. Nutritional intake is normal (three meals a day). No family members support presented, while my shift lasted, but patient stated that husband and other family members were coming to see her late evening. Her LMP is dated on 07/31/2016 and her estimated delivery date is on 05/07/2017. In her first three days at the hospital, elevated variations in pancreatic enzymes were noted (amylase 117 and lipase 332). Vital signs taken on 03/08/17 are as follows: T: 98.8 F, P: 72, R: 18, BP: 120/78, current height and weight are as follow: 157.5cm and 115lb 9.6oz. Sp02 96% on room air. The patient is taking the following medications: Aluminum/ magnesium hydroxide/ simethicone 4 times daily PRN, Dextrose 5% lactated ringers (D5 LR) continuous infusion (IV), Diphenhydramine PO Tabs 25mg, Fentanyl 10 mcg/ml in sodium chloride 0.9% (NS) 50 PCA infusion IV