Assignment: Create Nursing Care Plan

NURSING MANAGEMENT DURING PREGNANCY

NAME: Adebola Amoo Ross

Beth (age 18) is experiencing her first pregnancy and is now 24 weeks gestation. She tells you that she is “amazed by the changes that have happened to my body already.” Beth wants to understand what additional changes are going to occur to her “besides just getting a really huge belly.” Additionally, Beth relates to you that she is in her senior year of high school, is no longer involved with the baby’s father, and lives at home with her mother and 12-year-old brother. (Learning Objectives 3 and 5).

Definition of the Medical Diagnosis

Pregnancy is a psychosocial phenomenon that is usually characterized by the changes in biological as well as psychosocial adaptations which evolve generally in a healthy manner (Susan, Terri & Susan, 2009). However, some pregnant women may experience some problems or complications due to specific factors or characteristics. These can classify their conditions as high-risk and may negatively affect the mother/child evolution. The detection of this risk calls for the provision of appropriate and quality care by the nurses as well as the healthcare team. The gravid-puerperal period requires a multidisciplinary care because the women require minimal interventions. However, emergencies or life-threatening complications in some situations may occur and thus there is need to identify them effectively. A multi-disciplinary approach consisting of health professionals as well as local administrators is required to ensure that effective actions are performed to ensure that there is a risk-free and quality mother and child assistance (Gaucha, 2016).

The maternal as well as the neonatal morbidity data have been used to improve the technical as well as the scientific knowledge of the nursing practitioners who usually have direct participation during this period and thus ability to create quality strategies. Monitoring pregnant women during prenatal care, or during labor, delivery, or offering assistance to high-risk pregnant women in maternal ICUs are the role of nursing practitioners in obstetrics. This calls for a clinical preparation on the side of nursing practitioners so as to identify the real as well as the potential problems, manage the diagnoses correctly and plan and implement the care (Dennis & Hardy, 2016). Assignment: Create Nursing Care Plan

Common Signs and Symptoms

The common signs and symptoms of pregnancy are both physiological as well as psychosocial. Some of the physiological changes are increase in the size of breasts, increased blood circulation in the genitalia area, stretchmarks in the abdomen, absence of menstruation, pelvic pain/discomfort, intermittent nausea, swollen feet and ankles, vomiting, tiredness, weight gain, increased frequency of urination, and possible heartburn/indigestion. The psychosocial changes may include changes in her social life, dramatic body alterations, fear of raising the child alone without a father, and fear of giving birth or fear of pain during delivery (WHO, 2015).

Potential Complications

Pregnancy is a normal process in which the pregnant woman would be able to manage the problems and issues with the support of healthcare providers. However, there are some complications that might arise during pregnancy. Some of these complications include high blood pressure, preterm labor, gestational diabetes, preeclampsia, or a loss of pregnancy/miscarriage (ACOG, 2014).

 

Head to Toe Assessment

General: Steady movement, normal belly size at 24 weeks of pregnancy, impaired verbal communication due to anxiety.

Vital signs: Temperature, 98.6°F; heart rate, 99 bpm, blood pressure, 122/75 mm Hg; respiratory rate, 22 breaths/min

HEENT

Head : Excess dryness in hair.

Eyes: No eye pain, discharge or itchiness.

Ears: Normal external appearance.

Nose: Dry nasal mucosa with no purulent discharge.

Mouth/Throat: Dry oral mucosa without lesions, no sores or exudate. Healthy gums.

Breast changes : Normal breast changes. Colostrum can be expressed.

Respiratory : Clear to auscultation together with no coughs, rales, or rhonchi.

Cardiovascular: No history of syncope, murmur, palpitations or cyanosis.

Gastrointestinal: The client admits experiencing nausea and some instances.

Genitourinary : No vaginal odor, no swelling or redness observed.

Skin : No visible scars, lesions or rashes.

Abdominal : Fetal movements can be observed. No presence of scars, lesions or rashes.

Fundal height: Present at the upper margin of the umbicus and about three hand breadths from the symphysis pubis.

Abdominal girth: normal increase in abdominal girth. Normal liquor volume.

Musculoskeletal : The client reports instances of back pain. No history of fractures reported.

Neurologic : Client is a bit disoriented. Disturbed sleep patterns.

Diagnostic and Lab Studies Expected Outcomes

There are a number of physiological adaptations that develop throughout normal pregnancy. Some of these changes are confirmed through laboratory tests. However, some of the symptoms and tests may be easily be misinterpreted by some healthcare professional, especially those who are not experts or specialized in pregnancy related problems. The hs-cT nI concentration is one of the factors that is used to test pregnancy complications. For instance, higher values of hs-cT nI is an indicative factor of preeclampsia (ACOG, 2014). Furthermore, hyponatremia can occur in preeclampsia which is indicated by low levels of sodium and potassium. Cardiac evaluation to evaluate history of hypertension or cardiac diseases are also done. 3-hr glucose test is also done to screen for diabetes (Cervellin, Comelli , Bonfanti, Numeroso , & Lippi, 2019). Assignment: Create Nursing Care Plan

All NANDA Nursing Diagnosis

1. Nausea

2. Disturbed sleep pattern related to physical and emotional alterations

3. Anxiety related to labor

4. Imbalanced nutrition

5. Risk of altered breathing related to anxiety

6. Constipation related to pregnancy

7. Impaired urinary elimination related to urinary infection

8. Impaired skin integrity due to edema

3 NANDA Nursing Diagnosis, Goal Interventions and Rationale

1. Nausea is caused by changes in the gastrointestinal and stomach muscles relaxing as well as the pressure on the stomach as a result of the growing weight of the baby in the uterus. This can result from some foods becoming difficult to digest.

Desired Outcomes

· Experience minimal or no nausea

· Reports satisfaction with care

Interventions:

· Assess the nature, frequency and nature of nausea

· Advise on dietary instructions

Rationale:

· Nausea may be caused by visual stimuli and odors thus need to assess on the nature.

· Foods rich in oils and fats as well as some beverages trigger nausea during pregnancy.

2. Disturbed sleep patterns related to physical or emotional alterations

Desired outcome:

· Ensure there is normal sleep patterns

Intervention:

· Counselling on positive self-image

· Advise on dietary observations.

Rationale:

· Counselling helps in ensuring that there is positive self-image to physical and emotional alterations.

· Beverages such as caffeine have an ability to disturb sleep patterns.

3. Imbalanced nutrition caused by insufficient intake of nutrients to meet metabolic demands

Desired outcome:

· Patient able to verbalize the understanding of dietary needs.

· Patient to develop a proper dietary plan within financial resources.

· Patient should display appropriate weight gain.

Interventions:

· Determine the patient’s nutritional status, condition of the hair as well as any instances of weight gain.

· Provide information about the patient’s normal weight gains in the course of the pregnancy which are modified to meet the patient’s needs.

· Provide information about the effect of reduced activity as well as bedrest on protein requirements

· Collaborate with a dietician

Rationale:

· Establishing the patient’s nutritional status helps in establishing the guidelines that are essential in determining dietary needs as well as educating the patients.

· The provision of information regarding normal weight gains are essential in determining whether underweight patients need a diet higher in calories. This is due to the fact that the fetus risks ketosis resulting from dieting that leads to obesity.

· The provision of information regarding to bedrest and reduced activity help in determine the protein needs which are reduced due to decreased metabolic activities.

· Collaborating with a dietitian helps in incorporating specific needs and restrictions to the patient.

 

Evaluation

The patient reports that she is able to have a positive image about pregnancy and towards oneself after counselling. Furthermore, dietary advices resulted to better sleep patterns and balanced nutrition. Assignment: Create Nursing Care Plan

 

References

American College of Obstetricians and Gynecologists (ACOG). (2014). Preeclampsia and high blood pressure during pregnancy. FAQ034. Retrieved May 31, 2016, from http://www.acog.org/~/media/For%20Patients/faq034.pdf?dmc=1&ts=20120730T1500377195

Cervellin G., Comelli I., Bonfanti L., Numeroso F., & Lippi G. (2019). Emergency diagnostic testing in pregnancy. Journal of laboratory and precision medicine: 5(2). doi: 10.21037/jlpm.2019.10.04

Dennis A. & Hardy L. (2016). Defining a reference range for vital signs in healthy term pregnant women undergoing caesarean section. Sage journals. Doi 10.1177/0310057X1604400619

Gaucha E. (2016). Assessing nursing diagnoses and interventions in labor and high-risk pregnancies. SCIELO journals:37(3)

Susan S., Terri K., & Susan C. (2009). Maternity and Pediatric Nursing, 2nd ed. ISBN: 978-1-60913-747.

Cerebral Palsy

Chapter 44: Nursing Care of the Child with a Neuromuscular Disorder

Pamela is a six-year-old who was born with cerebral palsy. She has some health conditions related to cerebral palsy, which include mental impairment, hearing, and vision impairment, as well as spasticity. She is in the hospital for the diagnosis of her condition. NO she is ot.. you did not copy the case study as it is written.

Pamela Souza, 6 years old, was born with cerebral palsy. Pamela suffers from general spasticity, mental impairment, impaired vision and hearing, and hydrocephalus. She has been admitted to the pediatric unit for evaluation of intrathecal spasticity control. This is the focus of the case study and what you should have developed.

Cerebral palsy (CP) is among the groups of health disorders that have significant effects on the movement and coordination of body muscles (Ornoy, 2018). There other main areas that are affected by CP are the vison, sensation as well as hearing. However, the phrase cerebral is used to mean the brain. The word palsy is used to mean weakness or incapability of the body parts to move effectively. Through a lot of researches that has been done, it has been realized that CP is among the most common causes of childhood’s motor inabilities and disabilities. Across the world, about five children in 1000 are affected by cerebral palsy. Assignment: Create Nursing Care Plan

Signs and symptoms of CP

The signs of any symptoms of CP are different from one person to another and might range from minor or mild signs to acute and severe signs. Some patients might have challenges in walking while others might have problems sitting. On the other hand, some people who are affected by CP can have difficulties in grasping objects. Over time, the signs can worsen or become less severe, depending on the brain areas they have changed.

The most common signs are:

· Variations and differences in the muscle tone which include becoming very floppy or stiff.

· I was taking long to adapt some motor skill milestones, which include rolling over, crawling as well as sitting up.

· Difficulties in walking

· Delays in developing speech capabilities

· Stiffness of muscles or excessive flexibilities

· Tremors

· Problems during the process of swallowing

· Blindness and intellectual disabilities (Miller, 2018).

Some children are born with cerebral palsy, but the signs and symptoms do not present themselves until the children reach some months or even years. In most cases, the flags can present themselves at the age of three to four months.

Causes of cerebral palsy

The most common cause of CP is the abnormalities in the development of brain or brain injuries.  These damages affect the brain part that is used in controlling the movement of the body parts, their coordination, and posture. The cost on the brains most often happens before a child is born, but in other instances, it can occur during birth or in the first ten months after birth (Ornoy, 2018). There are other causes of CP, which include:

· Lack of adequate oxygen during the process of child delivery

· Gene mutations that can read to the development of the brain in an abnormal way

· Maternal infections which include herpes simplex

· Infections in the mind which might consist of meningitis

· Bleeding in the brain

· Head injuries can be caused by accidents, falls, or physical abuse.

The people who are at risk for cerebral palsy

Various factors put the children at high risk for CP. These factors include:

· Low birth weight

· Twins or triplet

· Premature birth

· Breech birth

· Rh incompatibility

· Maternal exposure to poisonous or poisonous substances during the pregnancy period

Potential Complications

Various complications are caused by cerebral palsy, which include spasticity as well as contractures.  Other complications include difficulties in feeding, fractures, challenges in communication, vomiting, osteopenia, constipation as well as bowel obstruction. Assignment: Create Nursing Care Plan

 

Head to Toe Assessment

General: difficulties in vision and communication due to brain damage.

Vital signs: Body temperature 86.5°F WHAT?

; heart rate, 98 bpm, blood pressure, 110/73 mm Hg; respiratory rate, 21 breaths/min

HEENT

Head : the hair is black with no abnormalities

Eyes: Eye pain  Why?

and difficulties in seeing correctly,

has some discharge in the eyes. Why?

Pupil reactions?

 

Ears: Normal physical appearance of the ears.

Gross hearing?

Nose:  Has a dry nose with no growth or physical abnormalities.

Mouth/Throat:  the lips are moist, and the mouth has no lesions or sores. The throat has no wounds, and the gums are strong and healthy.

Respiratory : her breath is clear with no difficulties and has no coughs or rhonchi.

Cardiovascular:  the patient has no history of cyanosis, syncope, or palpitations.

heart sounds and rhythm?

Gastrointestinal:  the patients admit having constipation occasionally. Parents are reporting and this is not part of you head to toe assessment

abdominal contour

Bowel sounds

bowel movements

Percussion

Palpation

Appetite

Genitourinary :  the client has no odor in her vagina  She is 6 year old!

and no swelling nor virginal redness.

Urine output

Urine color

Continence

Skin : the skin is smooth with no scars, rashes, nor lesions.

Abdominal circumference:  the abdominal girth has average liquor  WHAT?

volume.  Wrong order

Musculoskeletal : the patients complain of back pain and have a history of fractures.

This is her problem area.. this is a very incomplete assessment

ROM

Spasticity

gait

joints

pulses

Neurologic : the patients have depression, which is making it difficult for her to sleep well.

 

Diagnostic and Lab Studies Expected Outcomes

 

What tests would be done at the present time in the present situation.. she is pre-operative.

She has been admitted to the pediatric unit for evaluation of intrathecal spasticity control. This is the focus of the case study and what you should have developed.

Cerebral palsy can affect any child either during birth or before the child is born. It can be seen as a natural health condition, and some people might also take it as part of life by accepting it. However, some advances have been made in the current diagnosis of CP.  The electroencephalogram can be used in the evaluation of the electrical activity of the patient’s brain (Miller, 2017).  This method can be used to evaluate the condition of Pamela. The CT scan can also be used in creating clear and cross-sectional images of the patient’s brain. Assignment: Create Nursing Care Plan

 

All Pamela Nursing Diagnosis

These are NOT NANDA nursing diagnosis.. You should know this by now.

1. Impaired vision and hearing related to brain damage

2. Mental impairment which makes the patient unable to make quick decisions.

3. Hydrocephalus

4. Spasticity

5. Difficulties in movement

6. Inability to speak

7. Constipation due to difficulties proper digestion.

3 Pamela Nursing Diagnosis, Goal Interventions, and Rationale

 

This pt is pre-operative 

1. Constipation which is caused by gastrointestinal muscles relation, which makes it difficult for the food to be properly digested.

Desired Outcomes

· To minimize and entirely do away with constipation

· Help the patient adapt to healthy eating

Interventions:

· Assessing the nature as well as the degree of constipation.

· I am advising the patient and the guardian on the proper ways of eating a healthy diet.

Rationale:

· Constipation is caused by the inability of the body to digest food properly.

· A lack of proper physical exercise might cause constipation.

0. Impaired vision and hearing related to brain damage

Desired outcome:

· Ensure that the client gets back her vision and hearing ability.

· Help the patient adapt to impaired vision and hearing.

Intervention:

· I was counseling the patient on how to positively adapt to the conditions related to impairment in vision and hearing.

Rationale:

· Counseling helps the patient and the guardians to live positively even when in impairment of vision and hearing.

Evaluation

The patient states that she can adapt to their condition and raise her self-esteem after the counseling section. Taking the medication and exercising has been received positively by the patient and her family.

 

References

Miller, F. (2017). Early-onset scoliosis in cerebral palsy. Cerebral Palsy, 1-14.  https://doi.org/10.1007/978-3-319-50592-3_117-1

Miller, F. (2018). Knee flexion deformity in cerebral palsy. Cerebral Palsy, 1-22.  https://doi.org/10.1007/978-3-319-50592-3_136-1

Ornoy, A. (2018). Animal models of cerebral palsy: What can we learn about cerebral palsy in humans. Cerebral Palsy, 1-12.  https://doi.org/10.1007/978-3-319-50592-3_218-1

Nursing care plan of child with Endocrine Disorder

Jalissa is an eight years old girl who has been admitted to the ICU with head trauma after been involved in a vehicle accident. She is unconscious and has conditions such as loss of weight, decreased skin turgor, and has dry mucous membranes.   You did not copy and paste the entire case study.

Jalissa Twyman, 8 years old, was admitted to the pediatric intensive care unit with a closed head trauma after being involved in a bicycle/motor vehicle accident. Jalissa is unconscious. The nurses caring for Jalissa document a weight loss of 1.82 kg over a 24-hour period, decreased skin turgor, and dry mucous membranes. Urine output for the same 24-hour period is 3.5 L/m2.

Definition of the Medical Diagnosis

The endocrine mechanism is the network that consists of secretes which releases and then produces hormones in use in the controlling of many crucial functions in the person’s body, including the body mechanism to change the calorie present in the body into energy that yields power to organs together with the cells (Whirter, 2016). The endocrine mechanism influences individual heartbeats, the mode your tissues together with bones develop, and also the ability to form a baby. It has an essential function in determining if a person develops thyroid disorders, diabetes, sexual dysfunctions, growth issues, or some hosts in other hormonal diseases or not.

The endocrine disorders are in division into two groups, namely the endocrine diseases, which result when there is more or less production of endocrine hormones by the gland, and this is called a hormonal imbalance. The second group is the endocrine disease as a result of lesions development like the tumors or nodules in an endocrine system that might affect the levels of the hormone or not.

The feedback system in the endocrine aids in the control process of hormonal balance in the bloodstream, if a person’s body has more or less of a given hormone, then the feedback path will signal the appropriate glands to solve the problem. Hormonal imbalances occur in instances when, first, the feedback system experiences troubles on maintaining the proper hormonal levels in a person’s blood flow. Second is when bodies do not remove the hormones out of the blood in an appropriate way. High or low amounts of hormones in the endocrine might be a result of some issues. The first issue is problems encountered in the system entitled to the endocrine feedback. The second issue is a disease. The third issue is gland failure in the stimulation of another gland in the hormonal release; for instance, problems concerning the hypothalamus may disrupt the production of hormones in the pituitary gland. The fourth issue is genetic disorders like the congenital  hypothyroidism or different endocrine neoplasia. The fifth concern, infections in a person’s body. The sixth concern, an endocrine gland injury and, lastly, the endocrine gland tumor. Various endocrine nodules and cysts do not result in cancer. They never spread to the other organ parts. Bulges and tumors in the gland might contradict hormonal release in the organs.

Signs and symptoms of an endocrine disorder and head trauma

There is a wide range of various categories of endocrine diseases. Diabetes what kind of diabetes is she exhibiting?

happens to be a primary disorder of the endocrine that is in diagnosis in the United States. The other types are as follows; Adrenal insufficient,Does not apply to the topic. it is where the adrenal gland produces a minimal hormone known as cortisol or aldosterone. The symptoms may be stomach upset, fatigue, changes in the skin, together with dehydration. Addison’s disorder happens to fall under the adrenal insufficiency. Cushing disease, Does not apply to the topic.an overproduction of the hormones in a pituitary gland that results in adrenal gland overreacting. The same condition by the name Cushing syndrome may happen in individuals and most infants who have higher corticosteroid medications doses.  Assignment: Create Nursing Care Plan

Does not apply to the topic.

Acromegaly or gigantism and some other growth hormonal issues are there is more production of growth hormones by the pituitary glands. A child’s body parts or bones might progressively grow abnormally. If there are lower levels of growth hormone, then the child might stop becoming in terms of height. Hyperthyroidism, in this condition, there is an excess production of thyroid hormones by a thyroid, and this result to sweating, an increase in the heart rate, weight loss, and a state of nervousness. A cause of a thyroid that is overactive is a disorder known as autoimmune, and the disease is known as Graves.

Hypothyroidism,Does not apply to the topic. the gland on thyroid, doesn’t give adequate hormone of thyroid; this leads to constipation, depression, and skin drying. The organ of underactive may lead to slow growth in a child. Some of the hypothyroidism is there during the birth of a child. Hypopituitarism, little or no hormones, is released by the pituitary gland. Several different diseases can cause it. Ladies with the following situation can pause having a period.

Many endocrine neoplasiasDoes not apply to the topic., this is rare, a condition where genetics are decreased by society. It may lead to tumors of the thyroid glands, adrenal, and parathyroid, thus making the hormones being in overproduction. Polycystic,Does not apply to the topic. having production on androgens, may interfere with egg development and the release from the ovaries of a female (Bajaj, Rajput & Jacob, 2013). Polycystic ovary syndrome may lead to an individual being unfertile. Precocious puberty, early abnormal puberty occurs when the gland tells the body in life to produce the sex hormones.

Potential Complications 

While in most of the endocrine disorders are slow and mild to the process, specific endocrine diseases may lead to some of the complications over some time as signaling of hormonal imbalance affects the regular operation of the body. Complications of a particular disorder of endocrine include heart disease, insomnia or anxiety, coma in hypothyroidism, damage of the nerves, failure or loss of organs, reduced life quality, and depression in many of the conditions.

 

Head to Toe Assessment 

General: the patient has closed head trauma and unconscious after been involved in an accident.

Vital signs: Temperature is 99.4°F; heart rate, 90 bpm, blood pressure, 131/77 mm Hg; respiratory rate, 19 breaths/min

HEENT

Head: the hearing is ordinarily stiff and black. How is hearing stiff or black.. and you state above unconscious

Eyes: the eyes lack discharge.

Pupil reactions.. imperative to assess in a TBI

Ears:  the ears have regular physical appearances.

Nose: the nose does not have purulent discharge.    Is there any drainage?

Patency?

Mouth/Throat:  the mouth has no sores, and the mouth is moderately moist with healthy gum.

Respiratory : the patient has a clear breath through it is prolonged. RR is documented as 19 breaths/min  WNL

Cardiovascular:  the patient does not have a history of murmur nor palpitation.  This is not objective documentation of her CV.. it is history

Gastrointestinal:  the client was unconscious, but the guardian admits that the client has been having nausea. Only the person feeling it can give the symptom no nausea

abdominal contour.. marks. She was in a car accident so need to assess for internal damage.

bowel sounds

Percussion

Palapation

Genitourinary :  the client has no vaginal odor in her discharge and has no swelling.   She is achild.. not what you need to assess

Did you read the case study .. there is critical data regarding this system in the case study.

Skin : the skin is moderately tender with no scars or rashes.

Musculoskeletal :  the guardian admits that the patient has been having pain in her back but had not had any fractures.

pulses, capillary refill, ROM?

IV?

Neurologic : the patient has problems in her sleep patterns.      She is unconscious!

Diagnostic and Lab Studies Expected Outcomes

Closed head trauma, which is part of the endocrine disorder, mostly occurs when one is involved in a physical accident that tempers with one’s brain. Most patients might go on a comma after experiencing trauma or brain injury. They are various tests that can be used to examine the patient’s brain status. The CT scan is among the most common lab tests that are used to explore the conditions of the brain.  Blood and urine tests can also be used in examining the patient’s endocrine disorders as a result of brain trauma. Assignment: Create Nursing Care Plan

 

All Jalissa Nursing Diagnosis

1. Decreased skin turgor

2. Weight loss

3. Dry mucus membrane

3 Jalissa Nursing Diagnosis, Goal Interventions, and Rationale  

1. Weight loss is caused by a lack of eating during the time the patient was diagnosed with trauma and went in a comma.

Desired Outcomes

· She is helping the client go back to her healthy life and start eating as usual.

· The patient records an increase in weight though in the usual way.

Interventions:

· Brings the patient back to healthy living.

· We are advising on healthy eating.

Rationale:

· Loss of weight is a highly associated failure to eat adequately.

· Eating adequately, a balanced diet helps one gain a healthy weight.

0. Decreased skin turgor

Desired outcome:

· Ensure that the patient has normal skin turgor

Intervention:

· Guiding on proper feeding

Rationale:

· Decreased skin turgor is related to unfortunate feeding habits.

 

Evaluation 

The patient states that she is capable of living a positive life after trauma and is adapting to proper feeding and adequate physical exercise. The patient is also able to increase weight in inappropriate ways after modifying a good feeding program. Assignment: Create Nursing Care Plan

References

McWhirter, R. J. (2016). Adrenal cortex hormones—Advances in research and application: ScholarlyBrief (13th ed.). ScholarlyEditions.

Bajaj, S., Rajput, R., & Jacob, J. J. (2013). Endocrine disorders during pregnancy. JP Medical.

McDermott, M. T. (2019). Management of patients with pseudo-endocrine disorders: A case-based pocket guide. Springer Nature.