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GRID CARE PLANS ON MED SURG, MATERNITY AND OTHERS

Subject: Nursing care plan on acute pain for Desiree, a 28-year-old G2P1, who is admitted to the labor and birth unit. Her birth plan indicates that she is planning natural childbirth without pharmacological interventions. She has attended childbirth education classes. Desiree is considered low risk based on her personal and family health history and physical exam. Her pregnancy has progressed without complications. She is approximately 38 weeks pregnant. Vaginal assessment reveals cervical dilation at 10 cm, 100% effaced, and +1 station. Position of the fetus is LOA. The external fetal monitor indicates a reassuring fetal heart rate at 130 beats per minute. Maternal status is stable. (Learning Objectives 1, 2, 6, and 9)
Desiree says, “I’m not sure I can cope with the pain much longer.” How would you respond, considering her birth plan, stage of labor, and assessment data?

Description

Subject: Nursing Care Plan on severe left-sided unilateral cleft lip and cleft palate for Rose. Mandy just gave birth vaginally to her first child. Mandy and James had attended prenatal classes and had a natural childbirth. They were totally unprepared to see that baby “Rose” has a severe left-sided unilateral cleft lip and cleft palate. James is having a hard time with this and just keeps staring at the baby. Mandy begins to cry and states “I thought I was going to breast-feed my baby and now it’s impossible.” (Learning Objectives 12, 14, and 15)

Subject: Nursing Care Plan on anxiety for Teresa, a 36-year-old primigravida who is expecting twins. She is 26 weeks pregnant. She stays after your “What to Expect with Twins” class to talk to you. Although Teresa is a nurse, she has many questions and concerns. Her twins are a result of years of trying to get pregnant and in vitro fertilization. She is nervous about whether she will have a vaginal delivery or a cesarean section. She is worried about having the babies prematurely. She wants you to tell her everything that could go wrong so she can be prepared. (Learning Objectives 1 and 2)

 

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Patient Medical Diagnosis: Dehydration / Fluid Volume Deficit
Nursing Diagnosis (use PES/PE format): Dehydration / Fluid Volume Deficit r/t electrolyte and acid-base imbalances as evidenced by Tachycardia/weak, rapid HR, decreased skin turgor, and decreased urine output (less than 30mL/hr).

 

Patient Medical Diagnosis: Ineffective Airway.
Nursing Diagnosis (use PES/PE format):Ineffective Airway Clearance r/t. Ineffective cough
As evidence by Adventitious lung sounds (Wheezes, Rhonchi).