SOUTHUNIVERSITYCOLLEGEOFNURSING

NursingProcessWorksheet
STUDENT:_______EricaClipps___________________NSG3038_
PatientInitials:___TM______

Age:____32______

FACULTY__BabyPlace_____
Gender:__F___NKDA

HistoryofPresentIllness/AdmittingDiagnosis(whathappenedthatbroughtthemin,whathashappenedsince,subsequentdiagnosis)32yearoldfemale26.4weeks
pregnant,T5,F1,P2,ABI0,ABS1,Ecto0,Mu0,Liv2,amnioticfluidnormal,fetalmovementnormal,placentaouter2.3cmfromcervix,contractions
absent.AdmittedtoAPwithcervicalinsufficiency,sheis5ft7inweighing273lbs,herprepregnancyweightwas275,soshehaslost2lbsoverallduringthis
pregnancy.PLTw/cervix4cmdilatedand90%effaced.PreviousCSat26wksPTLbreechbabypassed.
PastMedical/SurgicalHistory
Medical:Diabetes,SVDX1atterm
Surgical:CSectionX2,D&C
Assessment:
Subjectivefindings
Increasedvaginalpressure
Pressurewhensittingupwithsharpvaginalpain
Feelsanxietyaboutlossofanotherbaby
Doesnothavemuchofanappetiteduetostress
Objectivefindingsbecomprehensiveinyourassessmentfindings
- General/VS:Welldeveloped;wellnourished,restinginbednoacutephysicaldistressbutvisiblyanxious(Temp:98.4oral;BP:132/72;resp:18roomair(O 2
Sat98%);pulse:92regular,FHR:145
- Neuro:A&OX3
- Resp:all5lobescleartoauscultation,O2sat98%onroomair;resp.18
- Cardiac:Normalrhythm,goodpulse(2+:dorsalalispedis,radialandapical),noJVD
o IVAccess:leftAntebrachialRegion20g
o Fluids/Drips:None
- GI:Soft;bowelsoundspresent,nogas,nodiscomfort,nontender
- GU:urineclear;noabnormalodor
- Skin:IntactexcludingIVsite
- MS:Bilateralhandstrength;bilateralflexionandextensionstrengthinlowerextremities
- Psychosocial/Family:deniesuseoftobacco(ofanyform);deniesuseofalcohol;Husbandisverysupportive(Hospitalstaff);interactswithstaffappropriately
- PertinentLabs/Radiology/otherexams:Ultrasoundshowsfetalfootincervix
ProblemList:

Nursing Process Worksheet Winter 2012 LS

PTL26.4weeks
PriorityNursingDiagnosis
Anxiety/Ineffectivecoping
Outcomes/Goals(whatdoyouwanttohappen):
ShortTerm
TeachpatientnaturalrelaxationtechniquesandvisitpatientroomQ12hourstoreiterateandensuresheisusingthemandassestheireffectiveness(Music,knitting
orcrafts,slowyoga,breathing,conversationtohearfamiliarcomfortingvoices,etc.)
LongTerm
- Havesocialworkerandcounselorseepatientbytheendofthisshiftandfollowupwithin7daystobetterassistwitheffectivecopinginpreparationforany
outcome

Interventions(howareyougoingtomakeithappen)ANDtherationale:****5interventions****
Placeanasterisk*bytheinterventionsthatmaybecarriedoutbythoseotherthananRN
1.Assessforthepresenceanddegreeofdepressionandanxiety.
2.Assessforstatementsofguiltorselfblameforthetraumaticeventorthepatient'sownsurvival.
3.Assessforthepresenceanddegreeofsuicidalideation,includingaplan,means,pastattempts,familyhistory,andabilitytoagreetoacontractforsafety.
4.Assesstheeffectivenessofrelationshipswithfamily,friends,andcoworkers.
5.Encouragethepatienttoavoidaggravatingfactorsthatmayfurtherexacerbatelabor.
Evaluation(didithappen):
Providetheparametersthatwillbeusedtoevaluatewhether,ornot,theoutcomehasbeenachieved
1.Assessmentfindingwarrantedinterventionthroughcounselling.
2.AssessmentfindingshowsincreasedfearandanxietyfrombusylifestyleandchoicesthatledtopreviousandmayleadtocurrentPSVD/CS.
3.Doesnotdisplay.Suicidalbehaviorbutisatincreasedrisk
4.Familyandstaffisverysupportiveandthisappearstohelpdecreaseanxietylevels.
5.Usingdistraction,communicationandothernomedicalinterventionsseemtohelpwithcopinganddecreaseanxiety.

Medication List: ***List medication that relates to the medical or nursing diagnosis***

Ampicillin, 1.5G, IV, Q12H, 250ml/hr, infuse over 2 hours (D/C)

Antibiotic/antiinfective

Nursing Process Worksheet Winter 2012 LS

Prophylaxis for GBS

Fever, rash, hypotension accompanied by flushing, nephro/ototoxic, vasculitis
Monitor for signs of reaction, monitor temperature

BuSpar (buspirone) 5mg tab/Q8h

Antianxiety (nonbenzodiazepine)
Treat and possibly prevent recurrent panic attacks
Dizziness, drowsiness, blurred vision
Patient is on bed rest, but bathroom use, ensure patient safety by keeping bed lowered, ensure the room is
well lit, clear floor and assist with ambulation

Prenatal vitamin w/ iron

Essential vitamin supplement for mother and fetal development
Constipation, allergic reaction
Hypersensitivity, erythema at injection site, fever, headache, muscle weakness
Monitor for signs of hypersensitivity and constipation (ensure regular BM)

References
Doenges, M. M. (2010). Nursing Care Plans: Guidlines for Individualizing client care across the life span. Philedelphia:
Davis.

Nursing Process Worksheet Winter 2012 LS