NUR 4130 Shadow health uncomplicated delivery.VERIFIED

Shadow health uncomplicated delivery. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A co mbination of open and closed questions will yield better patient data. The following details are facts of the patient's case. • Finding: Asked about patient's status • Finding: Reports feeling alright (Found) Pro Tip: At the start of your conversation, check in with a patient about their current feelings so you can immediately build rapport through empathetic communication. Example Question: How are you feeling? • Finding: Asked about patient's needs • Finding: Denies needing anything (Found) Pro Tip: At the start of your conversation, check in with a patient about their current feelings so you can immediately build rapport through empathetic communication. Example Question: Do you need anything? • Finding: Asked about feelings towards pregnancy or delivery • Finding: Reports nervousness (Found) Pro Tip: At the start of your conversation, check in with a patient about their current feelings so you can immediately build rapport through empathetic communication. Example Question: How are you feeling about giving birth? • Finding: Reports excitement over being a mom (Available) Pro Tip: At the start of your conversation, check in with a patient about their current feelings so you can immediately build rapport through empathetic communication. Example Question: How are you feeling about giving birth? • Finding: Asked about patient's symptoms • Finding: Reports lower back pain (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: Are you having any symptoms? • Finding: Reports sharp contraction pain (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: Are you having any symptoms? • Finding: Followed up on pain • Finding: Reports feeling contractions low in her groin (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: Where is the pain from your contractions? • Finding: Reports 6/10 pain during contractions (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: How would you rate the pain during contractions? • Finding: Asked about relieving factors • Finding: Reports walking helped alleviate pain (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: Does anything help your pain? • Finding: Reports walking stopped being effective for pain relief 15 minutes prior (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: Does walking still help your pain? • Finding: Asked about current position • Finding: Reports current position is acceptable (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: How is the position you're in? • Finding: Asked permission to conduct physical exam • Finding: Reports wanting minimal touching (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: Is it OK if I conduct some physical exams? • Finding: Asked about contractions • Finding: Reports contractions every 5 minutes (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: How often do you have contractions? • Finding: Reports contractions began 5 hours ago (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: When did the contractions begin? • Finding: Reports not being sure how long contractions last (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: How long do the contractions last? • Finding: Asked how long she has been in labor • Finding: Reports labor started 5 hours prior (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: How long have you been in labor? • Finding: Asked if water has broken • Finding: Reports concern that water has not broken (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: Has your water broken? • Finding: Asked about pregnancy timeline • Finding: Reports being 39 weeks into pregnancy (Found) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: How far along are you? • Finding: Reports due date was projected for 5 days from now (Available) Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed. Example Question: When was your projected due date? • Finding: Asked about prenatal visits • Finding: Reports receiving prenatal visits starting at 16 weeks (Found) Pro Tip: Asking a patient about their health and health maintenance throughout their pregnancy can inform you of their readiness for delivery and any problems to look out for. Example Question: Have you been going to prenatal visits? • Finding: Followed up on delay in prenatal visits • Finding: Reports keeping pregnancy a secret from her family (Found) Pro Tip: Asking a patient about their health and health maintenance throughout their pregnancy can inform you of their readiness for delivery and any problems to look out for. Example Question: Why did your prenatal visits start late? • Finding: Reports waiting until after older sister's wedding to disclose pregnancy (Found) Pro Tip: Asking a patient about their health and health maintenance throughout their pregnancy can inform you of their readiness for delivery and any problems to look out for. Example Question: Why did your prenatal visits start late? • Finding: Asked about pregnancy complications • Finding: Denies complications (Found) Pro Tip: Asking a patient about their health and health maintenance throughout their pregnancy can inform you of their readiness for delivery and any problems to look out for. Example Question: Have you had any complications with your pregnancy? • Finding: Asked about preexisting conditions • Finding: Denies preexisting conditions (Found) Pro Tip: Asking patients about their past medical history can help contextualize their current illness and inform you of health considerations that need to be made for this visit. Example Question: Do you have any medical conditions? • Finding: Asked about allergies • Finding: Denies allergies (Found) Pro Tip: Asking patients about their past medical history can help contextualize their current illness and inform you of health considerations that need to be made for this visit. Example Question: Do you have any allergies? • Finding: Asked about hospitalizations • Finding: Denies previous hospitalizations (Found) Pro Tip: Asking patients about their past medical history can help contextualize their current illness and inform you of health considerations that need to be made for this visit. Example Question: Have you ever been hospitalized before this? • Finding: Asked about support system • Finding: Reports strong network of family and friends (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: Do you have a strong support system? • Finding: Reports more family members will arrive soon (Available) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: Do you have more family coming? • Finding: Asked about substance use • Finding: Reports drinking once before she knew she was pregnant (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: Have you drank alcohol while pregnant? • Finding: Denies tobacco use (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: Have you used tobacco while pregnant? • Finding: Asked about education • Finding: Reports recently graduating from high school (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: What education have you received? • Finding: Reports planning to start online college classes soon (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: Do you have plans to go to college? • Finding: Asked about living situation • Finding: Reports living at home with parents (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: What is your living situation like? • Finding: Assessed who will be primary caregiver • Finding: Reports she will be the primary caregiver (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient all of these diverse questions to understand how a patient's behaviors are affecting their health. Example Question: Who will be the baby's primary caregiver? • Finding: Asked about home medications • Finding: Reports taking prenatal vitamins (Found) Pro Tip: Asking a patient what medications they take at home can help you understand their health, what requires medication, and how different prescription affect symptoms differently. Example Question: Do you take any medications? • Finding: Asked about review of gastrointestinal system • Finding: Reports last bowel movement was early in labor (Available) Pro Tip: Asking a patient about any symptoms occurring, system by bodily system, can help you ask about a patient's illness, which may affect some areas more than others. Example Question: Have you had a bowel movement since labor began? • Finding: Denies hemorrhoids (Found) Pro Tip: Asking a patient about any symptoms occurring, system by bodily system, can help you ask about a patient's illness, which may affect some areas more than others. Example Question: Have you gotten hemorrhoids? • Finding: Asked about review of urinary system • Finding: Denies needing to urinate (Available) Pro Tip: Asking a patient about any symptoms occurring, system by bodily system, can help you ask about a patient's illness, which may affect some areas more than others. Example Question: Do you need to urinate currently? • Finding: Asked about review of cardiovascular system Objective Data Collection: 14 of 14 (100%) • Correct • Partially correct • Incorrect • Missed Delivery Table (1/1 point) • Table present and contains birth kit • Table absent • Table present but does not contain birth kit Infant Warmer (1/1 point) • Infant warmer present and working correctly • Infant warmer absent • Infant warmer present but is not working correctly Staff Check (1/1 point) • Team is notified of patient's labor and upcoming delivery • Team could not be notified of patient's labor and delivery Patient Ambulation (1/1 point) • Patient has been taken for a walk within the last hour • Patient has not been taken for a walk within the last hour Temperature (1/5 point) • Normothermic • Hyperthermic • Hypothermic Heart Rate (1/5 point) • Normal • Tachycardic • Bradycardic Respiratory Rate (1/5 point) • Normal • Tachypnea • Bradypnea O2 Saturation (1/5 point) • Normal • Hypoxemia Blood Pressure (1/5 point) • Normotensive • Hypertensive • Hypotensive Blood Type (1/5 point) • O+ • O- • A+ • A- • B+ • B- • AB+ • AB- Std Test (1/5 point) Test does not indicate presence of syphilis or HIV • Test indicates presence of syphilis but not HIV • Test indicates presence of HIV but not syphilis • Test indicates presence of HIV and syphilis Drug Screening (1/5 point) • Negative for substances • Positive for substances Complete Blood Count (Cbc) (1/5 point) • No abnormal levels present • Abnormal levels present Group B Strep Test (See Prenatal Review) (1/5 point) • Negative for Group B Strep • Positive for Group B Strep Insertion Site (1/2 point) • No visible abnormal signs • Erythema • Infiltration Dressing (1/2 point) • Dry and intact • Wet dressing Symmetry (1/2 point) • Symmetric • Asymmetric Appearance (1/2 point) • No visible abnormalities • Rash • Bulging around umbilicus • Distension • Cesarean section scar • Non-Cesarean scarring • Visible masses (warts, cysts, or tumors) • Laceration, lesion, or wound • Bruising General Appearance (1/1 point) • No abnormalities • Pallor • Sunken eyes • Dry lips Right: Appearance (1/3 point) • No visible abnormal findings • Redness • Bruising or other discoloration • Edema • Visible mass • Atrophy • Hypertrophy Left: Appearance (1/3 point) • No visible abnormal findings • Redness • Bruising or other discoloration • Edema • Visible mass • Atrophy • Hypertrophy Symmetry (1/3 point) • Symmetric bilaterally • Asymmetric Breath Sounds (1/2 point) Clear in all areas • Diminished in some areas • Absent in some areas Adventitious Sounds (1/2 point) • No adventitious sounds • Wheezing • Fine crackles • Stridor • Rhonchi • Rales Heart Sounds (1/3 point) • S1 and S2 audible • S1, S2, and S3 audible • S1, S2, and S4 audible • S1, S2, S3, and S4 audible Extra Heart Sounds (1/3 point) • No extra sounds • Gallops • Murmur • Friction rub • Valve clicks Rate And Rhythm (1/3 point) • Regular rate and rhythm • Irregular rate • Arrhythmia Fetus Presentation (1/2 point) • Vertex • Breech • Transverse Lie Fetus Position (1/2 point) • Anterior Posterior Fetal Heart Rate Measurement (1/2 point) • Within normal ranges • Tachycardic • Bradycardic Toco Measurement (1/2 point) • Normal • Abnormal • Care Plan : 17.5 of 17.5 (100.0%) • • Nursing Diagnoses: Definitions & Classifications © NANDA- International, 2017 used by arrangement with Thieme Medical Publishers, Inc., a division of the Thieme Group. 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