Brenda Pratton Care Plan II NCLEX questions

Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton

Brenda Pratton Care Plan II + NCLEX questions

SBAR of Patient Condition

Situation:

My name is Fariyal. Patient Brenda Patton is G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment. She is positive for Group B vaginorectal culture and is experiencing contractions. Vaginal exam reveals 50% effacement of cervix, cervical dilation 4 cm, and fetus at -2 station.

Background:

Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment. The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure was positive. The patient's boyfriend is present, and she has phoned her mother to inform her of her admission. The provider has been notified, and prenatal records have been pulled. The lab report indicates that the patient's group B strep vaginorectal culture taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Admission intrapartum orders have been initiated, initial labs have been drawn, and a saline lock has been placed in her forearm.

Assessment:

Her current vital signs are: HR: 88 BPM. Pulse: present. BP: 117/70 mmHg. RR: 20. LOC: appropriate. SPO2: 97%. Temp: 37C.Uterus was soft between contractions. Contractions were regular with moderate intensity with each contraction being 4-5 minutes apart, approximately 50 seconds each. 300 mL of clear, amniotic fluid was noted on the pad where the membrane had ruptured. The fetal baseline heart rate is 149 which showed periods of episodic acceleration.

Recommendations:

I recommend that vital signs be taken every 30 minutes due to rupture of membrane. Continue to monitor fetal heart rate for possible signs of fetal distress due to GBS. Provide supportive care. Take note of any signs of maternal or fetal distress.

Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton

Plan of Care

Nursing Diagnosis Expected Outcomes Nursing Plan / Interventions Scientific Rationale for each intervention (include reference source) Evaluation

Acute pain related to uterine contraction as evidenced by contractions every 4-5 minutes apart each lasting approximately 50 seconds

Short Term:

• Patient uses

nonpharmacological pain management strategies by end of nursing shift

• Patient exhibits

increased comfort levels for pulse, BP, respirations, relaxed muscle tone by end of nursing shift

Long Term:

• Patient reports

satisfactory pain control discharge

• Patient will appear

more relaxed and rest appropriately by discharge

• Patient will use

relaxation techniques, such as deep breathing exercises, visualization, guided imagery

• Assess for signs and

symptoms of pain and use a numeric rating scale to identify pain

• Reassure to patient

that the pain is temporary and there is more than one approach to easing pain

• Provide rest periods to

facilitate comfort, sleep and relaxation

• This will help decrease

muscle tension, perception of pain, and sense of control over pain

(Gulanick & Myers, 2017,

• 327)

• Using a numeric pain

scale will help identify intensity of pain; vital signs may be elevated when patient is in pain and patient’s skin may be pale and cool to the touch; patient may also appear restless and have difficulty concentration

(Gulanick & Myers, 2017,

• 328)

• when pain is perceived

as everlasting, the patient may give up trying to cope and will have a loss of control. Reassurance will encourage the patient to continue following

• patient verbalizes and

demonstrates nonpharmacological pain management strategies such as deep breathing exercises and guided imagery

• Patient’s vital signs are

stable and demonstrates a focused and calm demeanor

• Patient verbalizes

stability of pain

• Patient verbalizes

feeling relaxed and not overly exhausted

Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton

directions and help gain a sense of control.

(Gulanick & Myers, 2017,

• 329)

• The patient's

experiences of pain may become exaggerated as the result of fatigue and decision to not use medication during delivery process. Pain may result in fatigue, which may result in exaggerated pain and exhaustion. Examples include a quiet environment and a darkened room.

(Gulanick & Myers, 2017,

• 329)

Risk for fetal infection related to ruptured membrane as evidenced by positive AmniSure result and positive GBS

Short Term:

• Patient consents to

taking penicillin

• Fetal heart rate will

remain between 110-160 bpm by end of nursing shift

Long Term:

• administer penicillin

• assess fetal heart rate

• assess vital signs of

mother and fetus every 30 minutes; palpate fundus

• educate patient on

penicillin adherence, which includes why patient is taking medication and any side effects to report

• Penicillin is a

prophylaxis for GBS.

(O’Meara, 2019, p. 259)

• assessing fetal heart rate

provides updated status on fetal condition

(Gulanick & Myers, 2017,

• 230)

• Patient consents to

taking penicillin

• EHM shows fetal heart

rate is within normal limits

• EHM shows fetal heart

rate is within normal limits with no complications to the mother or fetus

Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton

• Patient will achieve

healing without any complications to mother or fetus by discharge

• Patient will adhere to

penicillin treatment by discharge

• This will help

physicians and nurses prepare for a potential health threat because GBS can be transferred from mother to newborn in utero or during childbirth.

(Gulanick & Myers, 2017,

• 231)

• Most antibiotics work

best when a constant blood level is maintained; a constant blood level is maintained when medications are taken as prescribed.

(Gulanick & Myers, 2017,

• 262)

• Patient verbalizes the

importance of antibiotic adherence.

Anxiety related to concern for self and fetus as evidenced by positive GBS results

Short Term:

• Patient will follow

through with treatment regimen by the end of nursing shift

• Patient will verbalize

understanding of possible outcome of fetus by the end of nursing shift

• Teach patient the

purpose of penicillin and the importance of completing the treatment to prevent GBS transferring to fetus

• Teach patient of the

possible outcomes if neonate has GBS

• Continuously inform

patient and family members of status of mother and

• Information will help

reduce fears of the unknown

(O’Meara, 2019, p. 423)

• Honesty will help the

patient and her family understanding what is happening and may reduce anxiety

(Gulanick & Myers, 2017,

• 827)
• Patient demonstrates

understanding of penicillin adherence

• Patient verbalizes

understanding of potential outcomes of GBS transmitting to fetus

• Patient will verbalize a

decrease in anxiety

• Vital signs of mother

and fetus will be stable