North Shore Community College Maternal Newborn Case Study

Physical assessment:Document what you see in your case study, if it does not apply or is not stated indicate as ‘n/a’.

Nursing diagnosis: Students are to write up 3 nursing diagnoses (2 actual and 1 risk-for) using the NSC Care Plan Template. At least 1 diagnosis must be physiological. The other diagnoses may be physiological or psychosocial. Nursing diagnosis must be relevant to the assigned patient. (NANDA approved dx related to, as evidenced by)

See link for NANDA approved nursing diagnosis.

https://challengesandinitiatives.trubox.ca/wp-content/uploads/sites/601/2018/12/Nanda-Nursing-diagnosis-list-2018-2020.pdf

Goals: Each nursing diagnosis should have one short-term and one long-term goal, appropriate nursing interventions, and evaluation. Must be directly related to the nursing diagnosis.

Intervention: Includes interventions or nursing actions that directly relate to the patient’s goals. Further details noted in relation to the execution of nursing care interventions (action and frequency). The number of interventions is appropriate to help patient or family meet their goal (minimum of 4 interventions per goal stated).

Labs: Document lab values along with normal ranges for each value and interpret the value.

Medication: Students are to write up 3 medications used in the virtual learning experience on the appropriate NSC Medication Sheet.

NORTH SHORE COLLEGE HOSPITAL
1400 S. Wolf Rd., Wheeling, Illinois 60090
Patient: MAGGIE GARDNER
Room: 204
Sex: Female
Age: 41
MRN: 0868085
Physician: John Shelby, M.D.
Mrs. Gardner came to the Emergency Department accompanied by husband with chief complaint of unresolved fatigue,
joint pain, oral mucosa ulcerations, swelling in hands and feet, low-grade fever, rash on her face that appeared 4 days
ago, abdominal cramping. Mrs. Gardner reported that fatigue has gotten worse in the last few weeks, anxiety has
increased significantly with several periods of intense anxiety since finding out she was pregnant. Joint swelling
intermittent.
Mrs. Gardner has had six pregnancies to date with no living children. She has had fertility problems when initially
attempting to get pregnant. Mild depression after first pregnancy, joint pain, fatigue, cold intolerance, hair loss and mouth
sores after her fourth pregnancy. Physician at the time attributed this to stress. Based on her LMP, she is 22 weeks
pregnant. Her pregnancy history record indicates that she was pregnant 6 times; had 1 full term; 1 preterm; 2 spontaneous
abortion; no ectopic, no multiple births and no living children.
Physician’s notes indicated that during his examination, patient was very drowsy and appears anxious and tearful at
times, stable. Patient is being admitted to r/o Lupus. Complains of unresolved fatigue, joint pain, multiple oral mucosa
ulcerations, swelling hands and feet, rash on her face and low grade fever. FHR 132. Patient states she has felt the baby
move. Fundal height 22 cm. Patient denies contractions, fluid leakage, vaginal drainage. Vaginal exam deferred.
Significant lab work findings: CBC: Hgb – 9.5; Hct – 31; ESR – 31; CRP – Positive; U/A 3+ protein and RBSs 2-3; Plan
is to have Rheumatology consult; OB ultrasound to assess placental function; Social services consult for in-home help
for patient’s mother and to advance diet as tolerated.
Mrs. Gardner’s family history indicates that her mother has Rheumatoid arthritis. Older sister has Hashimoto’s
Thyroiditis (diagnosed age 32). Younger sister undergoing fertility treatments. Brother has Psoriasis. Father had
unspecified heart problems. No contact with father for 15 years. Relationship with younger sister tense at this time. She
filled out a genetic screening form where Sickle cell disease or trait was checked.
Mrs. Gardner takes Prenatal multivitamin daily, Ibuprofen 200 mg 1 tablet every 4 to 6 hours as needed. She is alert and
oriented X 3, she is very tired, but very anxious, she is tearful at times and husband is very supportive and always at
bedside. She is 5’6” and weighs 180 pound.
Mrs. Gardner had an OB ultrasound with assessment of placental abnormalities. Estimated weight 1200 grams, size
equal to dates of LMP. Fetus without obvious anomalies. Placental assessment: partial placenta previa present. Placenta
grade II with multiple calcifications and infarcts noted in placenta. Some larger indentations extend down toward the
uterine wall. Comma-like and basal echogenic densities noted. Impression on the OB ultrasound report showed 1.) No
fetal anomalies noted; 2.) Need further study to determine adequacy of placental function; 3.) Multiple areas of
calcification and infarction noted; 4.) Follow-up with serial ultrasounds to monitor placental function; 5.) Doppler studies
may also be indicated.
Impression:
1. Anxiety
2. High-risk pregnancy
3. Rule out Lupus
4. Fatigue
Plan:
1. Admit for high-risk pregnancy evaluation and rule out Lupus
2. Rheumatology consult
3. Pastoral care consult (own pastor is okay)
4. Begin Buspirone 5 mg one TID
NORTH SHORE COLLEGE HOSPITAL
1400 S. Wolf Rd., Wheeling, Illinois 60090
Patient: MAGGIE GARDNER
Room: 204
Sex: Female
5. Ibuprofen one 4 times/day
6. Bedrest with bathroom privileges
7. Limited visitors.
Age: 41
MRN: 0868085
Physician: John Shelby, M.D.
Nursing Process – OB Care Plan (RR 07/24/2020)
Student’s Name: _____________________________________
Course: PNP 125 _______
Date: ___/___/_______
Instructor: ___________________________
ASSESSMENT
I. Patient Information
Patient’s initial:
Age:
Marital status:
Occupation:
Culture/Ethnical background:
Religion:
Language spoken:
GTPAL__________________
When did prenatal care begin:
ETOH:
Allergies:
Recreational drug use:
EDD:
Delivery Date:
Maternal Blood Type_____ Rubella Titer_______STI status____________H/H__________________
Infant’s initials __________ Sex________Condition__________Weeks Gestation: ______________Breast or Formula feeding_______
Infant’s Blood type________ Other Bloodwork (i.e. Torch, accucheck, bilirubin) ________________
II. Assessment
History-Medical:
History- Surgical:
History- Psychosocial:
Nursing Diagnosis:
PNC: where was prenatal care provided?
Pregnancy: (brief description of current pregnancy)
Complications of pregnancy: (current)
Labor and delivery:
Labor onset:
Labor length: 1st stage
Type of delivery:
Pain medication:
Membrane status on time of admission:
Anesthesia:
Presentation:
Additional Notes:
Lab tests, ultrasound, amniocentesis, etc. results:
Nursing Diagnosis:
2nd stage
3rd stage
Fluid color:
Complications of delivery:
Type of delivery:
Parent-Infant interaction. Describe (mother/father, grandparents & sibling):
Physical assessment findings:
Vital signs: Pulse________Temp__________RR____________BP__________SpO2___________
Breasts:
Uterus:
Bladder:
Bowel:
Lochia:
Episiotomy/laceration:
Homan’s Sign:
Emotional status:
Abdomen (if C/s incision/dressing/bowel sounds
Lung sounds:
Heart sound:
Patient teaching needs:
Nursing Diagnosis:
MEDICATION SHEET
Medication
(Dose, Route, Frequency)
Nursing Diagnosis:
Classification
Diagnosis/Indication
Action of Drug
Nursing Concerns
(side effects, nurse
monitoring)
Medication
(Dose, Route, Frequency)
Nursing Diagnosis:
Classification
Diagnosis/Indication
Action of Drug
Nursing Concerns
(side effects, nurse
monitoring)
Nursing Diagnosis
(4 from NANDA list)
Nursing Diagnosis:
Goal (2 goals)
1 short term
1 long term
Nursing Interventions
(at least 5 nursing
interventions)
Nursing Rationale
(Reason for each
corresponding intervention
Evaluation/Recommendations
Nursing Diagnosis
(4 from NANDA list)
Nursing Diagnosis:
Goal (2 goals)
1 short term
1 long term
Nursing Interventions
(at least 5 nursing
interventions)
Nursing Rationale
(Reason for each
corresponding intervention
Evaluation/Recommendations
CLINICAL SKILLS EXPECTATION SUMMARY
Childbearing Family Nursing (OB)
Instructor Signature
Evaluation of labor Patterns
______________________________________________
C- section orientation
_______________________________________________
Fundal assessment
_______________________________________________
Newborn assessment
_______________________________________________
Ophthalmic medications
_______________________________________________
Feeding newborn- breast/formula _____________________________________________
Circumcision care
_______________________________________________
Bathing/diapering/cord care _______________________________________________
Communication/patient teaching ______________________________________________
Comments:
Nursing Diagnosis:
Date Observed
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________