Brenda Pratton Care Plan II + NCLEX questions

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: . Recommendations: Plan of Care Nursing Diagnosis Expected Outcomes Nursing Plan / Interventions Scientific Rationale for each intervention (include reference source) Evaluation Short Term: 1. 1. Patient will use relaxation techniques, such as deep breathing exercises, visualization, guided imagery 2. Assess for signs and 1. This will help decrease muscle tension, perception of pain, and sense of control over pain (Gulanick & Myers, 2017, p. 327) 2 ( 1. patient verbalizes and demonstrates nonpharmacological pain management strategies such as deep breathing exercises and guided imagery 2. Patient’s vital signs are stable and demonstrates a focused and calm demeanor 3. Patient verbalizes stability of pain 4. Patient verbalizes feeling relaxed and not overly exhausted Risk for fetal infection related to ruptured membrane as evidenced by positive AmniSure result and positive GBS Short Term: 1. Patient consents to taking penicillin 3. discharge 1. administer penicillin 2. assess side effects to report 1. Penicillin is a prophylaxis for GBS. (O’Meara, 2019, p. 259) 3 1. Patient consents to taking penicillin 2 4. Patient verbalizes the importance of antibiotic adherence. Anxiety related to concern for self and fetus as evidenced by positive GBS results Short Term: 1. Patient will follow through with treatment regimen by the end of nursing shift 2. 1. Teach patient the purpose of penicillin and the importance of completing the treatment to prevent GBS transferring to fetus 2. Teach patient of the possible outcomes if 1. Information will help reduce fears of the unknown (O’Meara, 2019, p. 423) 2. Honesty will help the patient and her family understanding what is happening and may reduce anxiety (Gulanick & Myers, 2017, p. 827) , 2017, p. 827) 1. Patient demonstrates understanding of penicillin adherence 2. Patient verbalizes understanding of potential outcomes of GBS transmitting to fetus Citation O'Meara, A. (2019). Lippincott CoursePoint for O'Meara: Maternity, Newborn, and Women's Health Nursing. [CoursePoint]. Retrieved from Gulanick, M., & Myers, J. L. (2017). Nursing care plans: diagnoses interventions, & outcomes. 9th edition. Saint Louis, Missouri, an imprint of Elsevier Inc. Medications Indications Side Effects Patient Teaching Penicillin Piggyback infusion of IU of penicillin IV first dose Prophylaxis for GBS Side Effect: Nausea, diarrhea, epigastric distress, Cl: serum-sickness like reactions, laryngeal edema, and anaphylaxis Teach medication adherence and to continue and finish with treatment Advise patient to avoid alcohol Does not work with viral infections Take one hour before or two hours after meals Signs of anaphylaxis: hives, itching, rashes, wheezing Promethazine Piggy back infusion of 12.5 mg of promethazine IV Antiemetic and antihistamine Nausea • Side Effects: • • drowsiness, dizziness, fatigue, ringing in the ears, problems with balance or coordination, hallucinations, blurred vision Cl: Tx of lower respiratory symptoms May cause postural hypotension, therefore get up slowly from a lying down or sitting position NCLEX Questions 1. Penicillin may cause which adverse reaction? 2. An anaphylactic reaction to penicillin will most likely appear as: 3. If a patient shows signs of an anaphylactic reaction to penicillin, which antibiotic will the nurse expect the provider to order? 4. True or False: Once symptoms subside, patients can stop taking their antibiotics? 5. AmniSure tests for which diagnosis in a pregnant patient?