Question

Guidelines:
Please submit 2 nursing diagnosis for this assignment. Make sure each diagnosis accompanies 3 assessment,
3 interventions/implementations, goals, and evaluation

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 unknown 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.

Answer 1

1. Decreased Cardiac Output related to increased systemic vascular resistance as evidenced by increased blood pressure

Assessment

· Change in blood pressure/hemodynamic readings

· Edema / Shortness of breath

· Alteration in mental status

Goals

· Patient remains normotensive throughout remainder of pregnancy.

· Patient reports absence and/or decreased episodes of dyspnea.

· Patient alters activity level as condition warrants.

Nursing interventions

Record and graph vital signs especially BP and pulse

Institute bedrest with patient in lateral position. Improves venous return, cardiac output, and renal/placental perfusion

Give antihypertensive drug such as hydralazine (Apresoline) PO/IV, so that diastolic readings are between 90 and 105 mm Hg. Begin maintenance therapy as needed, e.g., methyldopa (Aldomet) or nifedipine (Procardia).

Evaluation

Patient has maintained normal blood pressure.

2. Deficient Knowledge related to lack of exposure to information and/or unfamiliarity with resources, misinterpretation as evidenced by verbalization of problem.

Assessment

She is asking questions about how to know if she is in labor and how to prepare for it.

Patient has lack of support system.

Patient had previous abortion when she was 15 years old.   

Goal

· Patient will verbalize understanding of the importance of providing necessary information for data collection.

· Patient will adopt behaviors/lifestyle changes as indicated.

· Patient will follow-a good perinatal care.

Nursing Interventions

Assess the client’s knowledge level and their ability to understand the things.

Provide health education regarding antenatal care, preparation for delivery, newborn care and breast feeding

Clarify their doubts. Recognise their personality.

Provides the oppurtunity to the patients to ask doubts.

Evaluation

Patient has maintained adequate knowledge of perinatal care.