Shadow Health 346 Non-Reassuring Fetal Status Case Review and Notes Documentation / Electronic Health Record with complete solutions.

Student Documentation Model Documentation Subjective Patient is multigravida with two children living at home. Patient is full term and would like to have this baby naturally without any pain medication. Objective Notes Student Documentation Luna Morales is a 35-year-old Puerto Rican woman who experienced non-reassuring fetal status. At my last check, she was still in the early phase of labor and the fetal heart rate had returned to normal. Ms. Morales reported contraction pain in her upper abdomen, rating it 5/10 on a pain scale. Her contractions last for one minute and occur every five minutes. During her pregnancy, Ms. Morales did not experience any complications with her health or the baby’s. The NRFS was her only complication. She has not received any medications and does not wish to, pending her desire to have a natural vaginal birth. Her birth plan includes use of natural pain management strategies including yoga breathing, position changes, and smelling essential oils diffused through her bracelet. Model Documentation Objective Patient has normal vitals. She is healthy and has no drug allergies. She is 3cm dilated and ready to have the baby. Patient had no visible abnormalities. Slight edema is present in the right and left ankles and feet, symmetric bilaterally. Breath sounds were clear in all areas with no adventitious sounds. Heart sounds had regular rate and rhythm, with S1 and S2 audible and no extra sounds present. Vitals are normal. Fetal presentation is vertex, fetus position is posterior. Care Plan : 5 of 8 (62.5%) Nursing Diagnosis 1 out of 1 International classification for nursing practice (ICNP) nursing diagnoses (v2019_06_27) [Data set]. (2019). International Council of Nurses (ICN). do/projects/ehealth-icnptm/icnp-download Diagnosis Student Response Model Answer Explanation Points Earned labor pain labor pain Ms. Morales has expressed feeling pain in her abdomen in line with the onset of her labor starting 7 hours ago. Since starting labor, the patient's uterine contractions, which occur every five minutes and last one-minute long, have prompted a "dull" pain in her upper abdomen area. In turn, Ms. Morales can expect the pain to dissipate once she has given birth and her contractions have ended. A chronic pain diagnosis, on the other hand, would stipulate a duration of pain that extended beyond three months. Additionally, Ms. Morales's mobility has not been impaired.