Question Answered step-by-step Formulate a Nursing Care Plan. Identify 1 actual and 1 potential problem, a total of 2 NCPs based on your assessment. Minimum of 5 Nursing Implementation or intervention each NCP. SCENARIOYou are now on duty at OB Ward of Lorma Medical Center for a 6-2 shift. Your group together with Ms. GelayCurtis-Smith, your Clinical Instructor, reported 30mins before the time. Upon arrival at the unit and giving courtesy callto the staffs on duty, your CI conducted pre-conference. She led the group in a short prayer before giving instructionson your activities for the whole shift. Uniform, grooming and paraphernalia were also checked. Ms. Curtis-Smith thenoriented you with the physical set up of the unit as well as the staff nurses. She then instructed the group to join theendorsement and rounds as well. After the rounds, each student was given their own patient. You were not assignedinitially to any patient but you will be in-charge of first admission or trans-in.At around 8:12am, Nurse Kai received a call from PACU regarding patient who will be “back-to-room”. Your CIthen instructed you to check and prepare the bed for the patient.At 8:22am, the client was wheeled in at Room 306 per gurney by Nurse Gav, PACU staff. You and your CI wentto receive the patient as well as to receive endorsement from Nurse Gav. As per endorsement, patient is Mrs. LhouQuia, 23 y/o, under the care of Dr. Rick, with a diagnosis of PU 39weeks AOG; S/P NSD. Patient arrived at ER at around12:30am, with ruptured BOW and initial IE of 6cm. She was immediately brought to Delivery Room where shesuccessfully delivered a healthy baby boy via NSD with mediolateral episiotomy at around 6:15am. The pregnancy,labor and delivery had been unremarkable. Placenta was delivered spontaneously 15 minutes after the delivery of thebaby.Nurse Gav also endorsed the following: (1) Patient is receiving a venoclysis of D5LR 1L to run at 8hrs, to followPNSS 1L at same rate, then to discontinue; (2) To start diet (DAT) once fully awake (3) Paracetamol (Aeknil) 300mg IVsingle dose and Tranexamic acid (Hemostan) 500mg IV as STAT dose given at PACU at 7am; (4) To start oralmedications of Amoxicillin (Himox) 500mg/cap 1 cap BID for 7days and Mefenamic acid (Ponstan) 500mg/cap 1 cap TID PRN for pain once on diet; (5) Watch out for bleeding and (-) urine output after 4-6hrs and refer.Upon receiving endorsement, VS was checked and recorded at 8:30am, as follows: BP 120/80mmHg PR 82bpmRR 18 breaths/min O2SAT 98% Temperature 36.5. Mrs. Lhou Quia is conversant but claimed to feel slightly tired anddizzy. Assessment was continued with the guidance of your Clinical Instructor.After providing privacy, you started assessing the patient’s breast and noted white, yellowish sticky fluid leakingfrom the nipples. The patient then asked, “Is that pus coming from my breast? Is it safe to breastfeed my baby?” As aresponse, you explained that it is safe for her to breastfeed since that is colostrum. You explained what colostrum andits benefits for her baby is. Breast were also noted to be full, with no visible lumps or dimpling, and nipples are notinverted, no cracks or fissures noted. Areolas are darker in color and has bigger diameter. You proceeded withassessing the abdominal part to check for the uterus. Upon palpation, fundus is at midline at the level of umbilicus, firmand contracted. Bladder on the other hand is not distended although the patient has not voided yet as claimed but withnormoactive bowel sounds. Genitalia was also assessed to check for possibility of hemorrhage. Her vaginal dischargehas presence of small clots, moderate in amount, dark-red in color, no offensive or foul-smell. Her episiotomy site wasrepaired through episiorrhaphy. Mrs. Lhou Quia verbalizes that she has pain on her episiotomy site, “I can’t sit properlybecause I have pain in there”, she verbalizes pointing on her perineum. You used the numeric pain scale to assess theseverity of her complaint and she claimed it is 8/10. Site was noted to have minimal redness, but neither hematomanor ecchymosis noted. No other lacerations on the perineal area noted. Hemorrhoids are not evident. Lastly, youexamined the lower extremities; there was no pain claimed by the patient, no tenderness on the calf as you dorsiflexher foot. There was no swelling or redness on both legs, no edema noted and pedal pulses are congruent. After theassessment, you thanked the patient and instructed her to use the call bell when needed.At around 10:00am, Nurse Angel, Nursery staff came to room-in Baby Boy Quia. You received the baby andbrought him to the mother to initiate breastfeeding. Mrs. Lhou Quia seemed passive as you assisted her in breastfeedher baby and she insisted that she is still tired and needs reinforcement on proper positioning and latching. “I don’tknow if I can do it correctly since I am a first time mom”, she claimed. You noticed that the baby’s lips are tucked in andunder and you hear clicking and smacking noise as he tries to suck her mother’s breast. He also started to appearirritated and started to cry. You then assisted the mother in proper positioning and latching of her baby to facilitateeffective breastfeeding. Health teachings were also imparted as well as encouragement.FORMAT: ASSESSMENTNURSING DIAGNOSISPLANNINGIMPLEMENTATIONRATIONALEEVALUATIONSubjective:  Independent:     Dependent: Objective:   Collaborative:     Example of a Nursing Care Plan:Image transcription textASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION SubjectiveRisk for imbalanced After 48 hours of Independent: GOAL MET. After 48 “I’m not sure if my baby isnutrition related to intervention, the . Encourage mother to breastfeed as . Waiting too long to star… Show more… Show more  Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

Question Answered step-by-step Formulate a Nursing Care Plan. Identify 1 actual and 1 potential problem, a total of 2 NCPs based on your assessment. Minimum of 5 Nursing Implementation or intervention each NCP. SCENARIOYou are now on duty at OB Ward of Lorma Medical Center for a 6-2 shift. Your group together with Ms. GelayCurtis-Smith, your Clinical Instructor, reported 30mins before the time. Upon arrival at the unit and giving courtesy callto the staffs on duty, your CI conducted pre-conference. She led the group in a short prayer before giving instructionson your activities for the whole shift. Uniform, grooming and paraphernalia were also checked. Ms. Curtis-Smith thenoriented you with the physical set up of the unit as well as the staff nurses. She then instructed the group to join theendorsement and rounds as well. After the rounds, each student was given their own patient. You were not assignedinitially to any patient but you will be in-charge of first admission or trans-in.At around 8:12am, Nurse Kai received a call from PACU regarding patient who will be “back-to-room”. Your CIthen instructed you to check and prepare the bed for the patient.At 8:22am, the client was wheeled in at Room 306 per gurney by Nurse Gav, PACU staff. You and your CI wentto receive the patient as well as to receive endorsement from Nurse Gav. As per endorsement, patient is Mrs. LhouQuia, 23 y/o, under the care of Dr. Rick, with a diagnosis of PU 39weeks AOG; S/P NSD. Patient arrived at ER at around12:30am, with ruptured BOW and initial IE of 6cm. She was immediately brought to Delivery Room where shesuccessfully delivered a healthy baby boy via NSD with mediolateral episiotomy at around 6:15am. The pregnancy,labor and delivery had been unremarkable. Placenta was delivered spontaneously 15 minutes after the delivery of thebaby.Nurse Gav also endorsed the following: (1) Patient is receiving a venoclysis of D5LR 1L to run at 8hrs, to followPNSS 1L at same rate, then to discontinue; (2) To start diet (DAT) once fully awake (3) Paracetamol (Aeknil) 300mg IVsingle dose and Tranexamic acid (Hemostan) 500mg IV as STAT dose given at PACU at 7am; (4) To start oralmedications of Amoxicillin (Himox) 500mg/cap 1 cap BID for 7days and Mefenamic acid (Ponstan) 500mg/cap 1 cap TID PRN for pain once on diet; (5) Watch out for bleeding and (-) urine output after 4-6hrs and refer.Upon receiving endorsement, VS was checked and recorded at 8:30am, as follows: BP 120/80mmHg PR 82bpmRR 18 breaths/min O2SAT 98% Temperature 36.5. Mrs. Lhou Quia is conversant but claimed to feel slightly tired anddizzy. Assessment was continued with the guidance of your Clinical Instructor.After providing privacy, you started assessing the patient’s breast and noted white, yellowish sticky fluid leakingfrom the nipples. The patient then asked, “Is that pus coming from my breast? Is it safe to breastfeed my baby?” As aresponse, you explained that it is safe for her to breastfeed since that is colostrum. You explained what colostrum andits benefits for her baby is. Breast were also noted to be full, with no visible lumps or dimpling, and nipples are notinverted, no cracks or fissures noted. Areolas are darker in color and has bigger diameter. You proceeded withassessing the abdominal part to check for the uterus. Upon palpation, fundus is at midline at the level of umbilicus, firmand contracted. Bladder on the other hand is not distended although the patient has not voided yet as claimed but withnormoactive bowel sounds. Genitalia was also assessed to check for possibility of hemorrhage. Her vaginal dischargehas presence of small clots, moderate in amount, dark-red in color, no offensive or foul-smell. Her episiotomy site wasrepaired through episiorrhaphy. Mrs. Lhou Quia verbalizes that she has pain on her episiotomy site, “I can’t sit properlybecause I have pain in there”, she verbalizes pointing on her perineum. You used the numeric pain scale to assess theseverity of her complaint and she claimed it is 8/10. Site was noted to have minimal redness, but neither hematomanor ecchymosis noted. No other lacerations on the perineal area noted. Hemorrhoids are not evident. Lastly, youexamined the lower extremities; there was no pain claimed by the patient, no tenderness on the calf as you dorsiflexher foot. There was no swelling or redness on both legs, no edema noted and pedal pulses are congruent. After theassessment, you thanked the patient and instructed her to use the call bell when needed.At around 10:00am, Nurse Angel, Nursery staff came to room-in Baby Boy Quia. You received the baby andbrought him to the mother to initiate breastfeeding. Mrs. Lhou Quia seemed passive as you assisted her in breastfeedher baby and she insisted that she is still tired and needs reinforcement on proper positioning and latching. “I don’tknow if I can do it correctly since I am a first time mom”, she claimed. You noticed that the baby’s lips are tucked in andunder and you hear clicking and smacking noise as he tries to suck her mother’s breast. He also started to appearirritated and started to cry. You then assisted the mother in proper positioning and latching of her baby to facilitateeffective breastfeeding. Health teachings were also imparted as well as encouragement.FORMAT: ASSESSMENTNURSING DIAGNOSISPLANNINGIMPLEMENTATIONRATIONALEEVALUATIONSubjective:  Independent:     Dependent: Objective:   Collaborative:     Example of a Nursing Care Plan:Image transcription textASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION SubjectiveRisk for imbalanced After 48 hours of Independent: GOAL MET. After 48 “I’m not sure if my baby isnutrition related to intervention, the . Encourage mother to breastfeed as . Waiting too long to star… Show more… Show more  Health Science Science Nursing Share QuestionEmailCopy link Comments (0)