Make a comprehensive Nursing Care Plan basing from the situation below. Contents of the Plan are the following. Make a tabular NCP. Again, check the rubrics at the end of the module as your guide. CUES NSG OBJECTIVES NSG RATIONALE EVALUATION DX. INTERVENTIONS

Case Studies In Health Information Management
3rd Edition
ISBN:9781337676908
Author:SCHNERING
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Chapter5: Compliance
Section: Chapter Questions
Problem 5.16.1C
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Make a comprehensive Nursing Care Plan basing from the situation below. Contents of
the Plan are the following. Make a tabular NCP. Again, check the rubrics at the end of
the module as your guide.
CUES
NSG
OBJECTIVES
NSG
RATIONALE
EVALUATION
DX.
INTERVENTIONS
SITUATION:
A 39-year-old Cebuana woman who is in her second pregnancy and has had one
live birth and no abortion is seen for prenatal care at 10 weeks' gestation. Her weight is
220 lb, and her blood pressure is 130/80 mmHg. Uterine size is appropriate Tot
gestational age. The patient's past obstetric history includes the spontaneous vaginal
delivery of a 9 lb, 8 oz. male infant at 40 weeks' gestation, 8 years ago at Baguio General
Hospital, The patient reports that the child is doing well. Her family history reveals that
her mother has type 2 diabetes mellitus. A urine dipstick shows 3+ glycosuria and
negative ketones.
She complaints of nausea and vomiting every morning. Foods cannot alleviate
the morning sickness thus; she does not know what food will she take to relieve her
problem. She also stated that she is constipated most of the time. As an OB nurse,
how can you help the client?
Transcribed Image Text:Make a comprehensive Nursing Care Plan basing from the situation below. Contents of the Plan are the following. Make a tabular NCP. Again, check the rubrics at the end of the module as your guide. CUES NSG OBJECTIVES NSG RATIONALE EVALUATION DX. INTERVENTIONS SITUATION: A 39-year-old Cebuana woman who is in her second pregnancy and has had one live birth and no abortion is seen for prenatal care at 10 weeks' gestation. Her weight is 220 lb, and her blood pressure is 130/80 mmHg. Uterine size is appropriate Tot gestational age. The patient's past obstetric history includes the spontaneous vaginal delivery of a 9 lb, 8 oz. male infant at 40 weeks' gestation, 8 years ago at Baguio General Hospital, The patient reports that the child is doing well. Her family history reveals that her mother has type 2 diabetes mellitus. A urine dipstick shows 3+ glycosuria and negative ketones. She complaints of nausea and vomiting every morning. Foods cannot alleviate the morning sickness thus; she does not know what food will she take to relieve her problem. She also stated that she is constipated most of the time. As an OB nurse, how can you help the client?
Let's now check what you have learned from this module 3. Answer the following
exercises and write your answers on a separate sheet of paper and submit to the faculty
concerned.
1. From the situation below, make a COMPLETE FDAR charting.
2. After your FDAR, construct now a comprehensive and a complete nursing
care plan for your client who is at the Delivery room.
Situation:
A 25-year-old G1 PO at 40 weeks' gestation with no known risk factors
was admitted to the Labor and Delivery Unit at Baguio General Hospital with rupture of
membranes 1 hour after her admission. She was admitted last April 1 of 2019 at around
8 in the morning accompanied by his husband. Her contractions upon admission were
4-5 minutes apart.
Upon assessment, she weighed 72 kgs, height is 5 feet and 3 inches, and her vital
signs are as follows: BP - 130/90mmhg, pulse rate is 72, respiratory rate is 14 and
temp. is 36.4 degrees celcius. Fetal Heart Rate is 140/min. quickening of the baby is
within the normal range. Presence of varicosities were noted as well.
During the interview, she mentioned that she is experiencing constipation which
started 7 months ago.
14 hrs prior to admission, she delivered a healthy baby boy weighing. 2.6 kgs
with an APGAR of 8. Mediolateral episiotomy was done to facilitate normal delivery.
Placenta was delivered 30 minutes after the baby came out. Oxytocin 1 ampule was
given immediately.
Lastly, breastfeeding was advised to the mother to facilitate mother-child
bonding. After all the nursing care and interventions were done at the Delivery room,
the mother and the baby was then wheeled at the recovery room for further
management.
Transcribed Image Text:Let's now check what you have learned from this module 3. Answer the following exercises and write your answers on a separate sheet of paper and submit to the faculty concerned. 1. From the situation below, make a COMPLETE FDAR charting. 2. After your FDAR, construct now a comprehensive and a complete nursing care plan for your client who is at the Delivery room. Situation: A 25-year-old G1 PO at 40 weeks' gestation with no known risk factors was admitted to the Labor and Delivery Unit at Baguio General Hospital with rupture of membranes 1 hour after her admission. She was admitted last April 1 of 2019 at around 8 in the morning accompanied by his husband. Her contractions upon admission were 4-5 minutes apart. Upon assessment, she weighed 72 kgs, height is 5 feet and 3 inches, and her vital signs are as follows: BP - 130/90mmhg, pulse rate is 72, respiratory rate is 14 and temp. is 36.4 degrees celcius. Fetal Heart Rate is 140/min. quickening of the baby is within the normal range. Presence of varicosities were noted as well. During the interview, she mentioned that she is experiencing constipation which started 7 months ago. 14 hrs prior to admission, she delivered a healthy baby boy weighing. 2.6 kgs with an APGAR of 8. Mediolateral episiotomy was done to facilitate normal delivery. Placenta was delivered 30 minutes after the baby came out. Oxytocin 1 ampule was given immediately. Lastly, breastfeeding was advised to the mother to facilitate mother-child bonding. After all the nursing care and interventions were done at the Delivery room, the mother and the baby was then wheeled at the recovery room for further management.
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