Question

Case Scenario Simulation:

Sarah Grace is a 40 years old woman who came for consultation for the first time. She said she moved from Texas to live with her ailing mother who is 76 years old. It is uknown if she had previous prenatal visit but stated she is 32 weeks pregnant.

She appears quiet and reserved about her financial status but only says she previously worked as a grocery cashier. She indicated that she had spontaneous abortion 2 years ago and had previous abortion when she was 15 years old.

She does not indicate if she is married but seemed to be avoiding discussion about her support system.

She is asking questions about how to know if she is in labor and how to prepare for it. Her current health status needs to be assessed. You are going to meet with the patient prior to a doctor interaction. A health history is not available or any previous lab work.

Gather pertinent information that will aid the doctor in helping Sarah Grace. Please be keen on the needs of the patient that may present during your initial interaction.

The CNA had taken her vital signs as follows:

Temp 98.7; BP 190/100; Pulse 98; Resp 22 pulse oximeter 95% Room air.

write two nursing diagnosis, 3 objective 3 subjective, 6 nursing intervantion, 2 Goals and evaluation

Answer 1

• Nursing diagnosis are.

1) Fatigue related to pregnancy as evidenced by Patient's verbalisation

2) Risk for infection related to low immunity strength.

•1) subjective data- Patient told that she doesn't have any laboratory study .

Objective data- Assessing health history of the patient.

2) Subjective data- Patient told that she had two abortion previously.

Objective data-Assessing the patient if she is suffering from any complications of abortion.

3) Subjective data- Patient told that she is 32 weeks pregnant.

Objective data- Assessing the fetal development.

• Nursing intervention

1) Vital signs are assesed to determine baseline data.

2)USG is done to determine fetal development.

3) Laboratory diagnosis is be done to determine any sign of infection, anemia.

4) Protein rich food is provided to increase energy level of the patient.

5) Mental Support is provided.

6) Health teaching is provided to the patient related to self care and baby care.

• Goals.

1)To improve patient's health status.

2) To reduce risk for infection.

•Evaluation

1) The Patient will free from Anxiety and health status will be improved.

2) Risk for infection will be reduced to some extent.