Rita Garcia is a 23-year-old student G2P2000, weight 130lb, height 5’5. She is married. NKDA. A+, hep -, HIV -, Rubellaand Varicella Immune, GBS + She has no past medical history and no surgical history.
Some of the spaces in the Clinical Judgement Plan are not provided in the prompt that was given but you can make up information to fill up the spaces. You can find all the information needed attached below, if any other information is needed please feel free to let me know. Thankyou.
Requirements:
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
TIME OUT!!! Student instructions:
Include Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values
(With normal ranges), include dates and rationales supported with Evidence Based Citations
Include 2-3 nursing interventions for abnormal labs and for all diagnostic procedures
ASSESSMENT/History of Present Illness /REVIEW OF SYTEMS
TIME OUT!!! Student instructions:
Physical Assessment Findings including presenting signs and symptoms that you will complete for this patient supported with Evidence Based Citations
TIME OUT!!! Student instructions:
To be sure your clinical judgement statements written below are accurate. You need to review the defining characteristics and related factors associated with and see how your patient data match. Do you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated?
References
Use APA format and hanging indents for all references.
If you have any questions, please consult the APA 7th Edition.
Rita Case Study
Directions: Use the following information to complete your Concept Map
Scenario
History of Present Problem:
Pt arrived at the hospital complaining of strong regular contractions stating” I am in so much pain, the contractions are crazy strong and I feel so much pressure”
Rita Garcia is a 23-year-old student G2P2000, weight 130lb, height 5’5. She is married. NKDA. A+, hep -, HIV -, Rubellaand Varicella Immune, GBS +
She has no past medical history and no surgical history. History of Postpartum Blues with her first baby. Her oldest child is 3 ½ years old She delivered a 9 pound 12-ounce baby boy at 41-week gestation, following an 18-hour Pitocin-augmented labor with epidural anesthesia this morning.
Her second stage was two hours. She was given a mediolateral episiotomy, and the baby’s head was delivered by vacuum extractor after she experienced difficulty pushing. Her estimated blood loss (EBL) was 400 mL right after delivery. Immediately after delivery her VS were BP 110/70, temperature 98, pulse 68, and respirations 20. She did not breastfeed her first child states baby did not want the breast. She attended breastfeeding class and is planning on breastfeeding this child, her goal to exclusively breastfeed but is open to supplementing. Rita is upset her husband could not make it to the delivery due to having to work. Rita is also concerned about having to leave her older child with a neighbor as she has no family in the area.
She has been clinically stable and is about to be transferred to the postpartum unit after a two-hour recovery period. Oxytocin 20 units in 1000 mL of Lactated Ringer’s is infusing at a fixed rate of 125 mL/hr in a 20 g. peripheral IV in her left hand. Type and screen done on admission, Hgb 12.6/Hct 38.
Her last set of vital signs were:
• T: 99.4 F/37.4 C
• P: 95
• R:18
• BP: 110/67. She has gotten up to void once and had 50 mL of blood-tinged urine. Her fundus is firm at the umbilicus, and has a small amount of dark red lochia. She is physically exhausted and has been anxious since delivery because her labor and delivery were harder than she ever expected, she was expecting an easier delivery since it was her second baby.
Rita delivered two hours ago and has just been transferred to the postpartum floor. She has an IV of Lactated ringers, which is to be discontinued when it is completed. Upon assessing her, the postpartum nurse notes that the Rita is trickling bright red blood from the vagina and has soaked a large pad into the under padabout 30 to 40 minutes after she changes it. Her perineum is swollen and red, no bruising noted and stitches appear intact and wound edges are approximated from her mediolateral episiotomy. Her vital signs are BP 90/68, pulse 110, and respiration 28. She appears restless.
Rita arrived in her room ten minutes ago. You were delayed by another mother who required pain medication, but the nursing assistant collected the first set of vital signs posted below. You introduce yourself, orient her to the room and unit, and begin your BUBBLE-HE assessment:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.9 F/37.6 C (oral) Provoking/Palliative: Vaginal delivery
P: 110 (regular) Quality: Cramp
R: 28 (regular) Region/Radiation: Lower abdomen
BP: 90/68 Severity: 6/10
O2 sat: 98% room air Timing: Started one hour after delivery
Lab Results:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
Complete Blood Count (CBC): Current: High/Low/WNL? Previous:
WBC (5-15.0 mm 3/Pregnant)
18.5 13.5
Hgb (12-16 g/dL) 7.9 12.6
Hct (33-45%)
28 38
Platelets (150-450x 103/μl)
158
140
Neutrophil % (42-72) 72 68
PT/INR: 0.9
PTT: 30
Fibrinogen: 44
Current Assessment:
GENERAL APPEARANCE: Appears uncomfortable, restless
RESP:
Breath sounds clear with equal aeration bilaterally, non-labored
respiratory effort
CARDIAC: Pink, warm/dry, no edema, heart sounds regular with no abnormal
beats, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert and oriented to person, place, time, and situation (x4)
BUBBLE-HE
BREAST: Lactating; soft, non-tender with evidence of drops colostrum
UTERUS: Right of umbilicus, slightly boggy
BLADDER:
Voided 50 ml after delivery, bladder distended
BOWELS: Abdomen soft/non-tender, bowel sounds audible per auscultation in
all four quadrants
LOCHIA:
Rubra. Soaked entire peri pad with 10-12” diameter puddle of
blood weight= 550 mL
HOMANS: Negative
EPISIOTOMY: Perineum is swollen and red, no bruising noted and stitches appear intact and wound edges are approximated from her mediolateral episiotomy.
Care Provider Orders:
Establish large bore peripheral IV
Administer 0.9% Normal Saline 1000 mL IV bolus
Oxytocin 20 units in 1000 mL Lactated Ringers (LR) infuse over 30 minutes. Titrate to vaginal bleeding (AWHONN Guideline)
Methylergonovine 0.2 mg IM x1stat
The following meds are standing orders and in the hemorrhage cart to be given as needed if oxytocin ineffective:
Carboprost 250 mcg IM PRN Misoprostol 800 mcg rectal or SL PRN
Contact OR for possible D&C or repair
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