NURS 4434 Houston Baptist Week 4 Childbearing Family Postpartum Careplan Worksheet Instructions for the Care plans to be written are found in the respectiv

NURS 4434 Houston Baptist Week 4 Childbearing Family Postpartum Careplan Worksheet Instructions for the Care plans to be written are found in the respective case studies (Week 4 Case Study and GU Case Study). The answers or responses to the case studies will be filled in the respective Care Plan templates (Postpartum careplan template and Care plan template). Responses or answers to Week 4 Case Study Should be filled or written in Postpartum Careplan Template AND responses or answers to GU Case Study Week 5 should be filled or written in Care Plan Template.Every information from external sources should be cited by in-text citation using APA format. Then at the end of the page of responses, references should be done there. I need this assignment in 48 hours prompt. Contact me in case you need any clarification or information. Thank you CLINICAL PERFORMANCEASSESSMENT WORKSHEET
Student Name:
Rating Scale
Date: ________________
Subscales
Week ________
Comments
Grade
1. ASSESSMENT- Gathered data on the pathophysiology of the
illness/disease, medications, culture/spiritual factors, and nutritional status.
Incorporated and interpreted new data correctly. Also, gathered information
regarding epidemiology & stratification as it applies to client.
2. ANALYSIS/NURSING DIAGNOSIS – Formulated nursing diagnoses for
actual & potential health problems relating to health promotion behaviors,
growth and development, medications, nutrition, and cultural and spiritual
awareness; prioritizes problems according to clients’ needs.
3. PLAN/GOAL – Developed client and family goals that promoted
progression toward health. Goals are individualized and SMART (Specific,
Measurable, Attainable, Realistic, Time Frame)
4. INTERVENTIONS – Nursing interventions are individualized for the
client. Each intervention implements care which reflects planning,
organization & flexibility to meet client’s needs that promotes standards of
care and practice.
5. RATIONALE – Identified rationale for nursing actions that support the
plan of care with current professional literature and research findings. Has
significant and complete information regarding health promotion, growth and
development, pathophysiology of the illness/disease, medications, nutrition,
and treatments; calculates dosage, knows appropriate sites for drug
administration, and calculates IV drip rates correctly (if applicable).
6. EVALUATION – Facilitated alteration of care plan to reflect evaluation of
client’s progress toward goals; evaluates effectiveness of specific
interventions; evaluates ways to maintain standards of care & practice;
evaluates criteria that are congruent with clients’ health goals. Applies
concepts of health promotion & dimensions of health when evaluating care &
client outcomes. Reflections of own performance demonstrates self awareness
and identifies areas for growth as well as reflects systematic movement to
meet course learning objectives
.
7. NURSING SKILLS – Performed skills safely & correctly at reasonable
speed; adapts to changes from learned sequence; organizes equipment &
supplies involved in client care; recognizes obvious breaks in technique.
Efficient in use of technology for client care. Demonstrates use of Presence to
promote health and healing.
8. COMMUNICATION – Reported & documented medications,
procedures, treatments & changes in client’s condition & client responses to
care & interventions. Effectively communicated with clients, staff, & faculty.
Maintained confidentiality & adherence to information management policies.
9. PROFESSIONALISM – Prepared to give safe care; adhered to policies &
reported own errors; assumed responsibility for maintaining safety; took extra
precautions to maintain client’s confidentiality; used appropriate channels to
promote a high level of care for the client; selected learning experiences which
require additional preparation; demonstrated prudent judgment in unfamiliar
situations; was punctual; maintained a professional appearance; promoted the
client’s welfare & upheld dignity & professional boundaries; reflected
consideration of cultural and spiritual differences when interacting with clients
& members of the interdisciplinary team.
10. INTERPERSONAL RELATIONSHIPS – Used communication skills in
therapeutic relations; adapted communication to client’s developmental
level; promoted positive group & learning activities & staff relations; was able
to accurately assess own abilities & began to plan for growth in self..
Reflected consideration of cultural and spiritual differences when interacting
with clients & members of the interdisciplinary team.
KEY: F= Failing (1); MI = Must Improve (2); A=Acceptable (3); C=Commendable (4); and E=Excellent (5)
Houston Baptist University
NURS 4434 Care of Childbearing Family
Postpartum Care Worksheet
Student Name
Date of Care
Pt Initials
Rm# Age
GTPAL after delivery
Allergies
Diet
Marital Status Current Wt.
Birth Wt
Gender M/F
Delivery Date & Time Vaginal/CS
Test and result/date
Blood type
Rh factor
Antibody screen
Hgb
Hct
WBCs
Platelets
EDC
Wks. Gestation
Pre-pregnant Wt.
Breast/Bottle Baby’s Blood type
Test and result/date
Rubella
HIV
RPR/VDRL
HbSAg
Gonorrhea
Chlamydia
GBS
Interpretation of abnormal lab results:
Rhogam
Needed?
Given?
Brief Pregnancy history. Feelings about pregnancy. Family configuration. (prior obstetric history.
Brief Labor History (if C-Section, why?).
Present Postpartum history, including level of Activity.
Vital Signs
Date
Time
Temp
Treatment for pain & time:
Pulse
Respirations
BP
Pain 0/10 Site
Reassessment of pain (Time and Results)
Physical Assessment (BUBBLE – HEE)
Breasts
Nipples (condition, secretion)
Abdominal Incision (color,
discharge, approximation)
Fundus (consistency, height,
position)
Bowel (sounds, flatus, stool)
Hemorrhoids
Urinary Elimination
Signs of UTI
Costovertebral Angle
Tenderness
Lochia (type, amount)
Perineum/Episiotomy
(REEDA)
Signs of Thrombophlebitis
(redness, swelling, warmth, or
pain)
Edema (site, extent)
Emotions (explain evidence of
(+) or (-) bonding)
Teaching Needs:
What is your patient’s culture and what information did you learn about the patient’s culture to assist
you in delivering culturally competent care?
Infant Intake and Output:
Time:
Type of
Feeding
Amount
or # of
Minutes
Voids
Stools
Newborn Assessment: Male/Female
Apgar’s: 1 min _______ 5 min _______
Put an X by the
ones that apply
ACTIVITY:
Quiet
Alert/Active
Sleeping
Lethargic
TONE:
Normal
Jittery
Hypo/Hyper
Reflexes (+)
CRY:
Strong
Weak
High-pitched
COLOR:
Pink
Pale
Acrocyanosis
Jaundiced
Meconium stained
Mottled
SKIN:
Warm
Additional Notes when needed:
Bruising
Cool
Petechiae
Newborn Rash
HEAD:
Fontanel
Soft/Flat
Other
Skull molded
Caput/Cephalohematoma
Forcep marks/Abrasions
EYES:
Clear
Other
CHEST:
Breath Sounds Clear/Equal
Decreased R/L
Rales/Rhonchi
Grunting
Nasal Flaring
Retractions
Mild/Moderate
Heart Sounds Regular/Irregular
Murmur
(-) absent / (+) present
Vital Signs:
T______ P______ R______
ABDOMEN
Soft
Distended
Bowel Sounds (-) absent / (+) present
GENITOURINARY (Circle the one
that applies)
Male testes
descended/undescended
Female
normal/discharge
Prioritized Problem List/Nursing Diagnoses, R/T and AEB: (two for Mom and one for baby):
This section is for any additional evaluation of yourself that you may want to share with the instructor
Nursing Skills:
Strengths:
Opportunities for Improvement:
Comments:
Initial Assessment Data r/t Priority Nursing Dx: For the MOM
Rationale for Nursing Dx #1:
1.
2.
Highest Priority Nursing Dx:
3.
4.
Plan: Short Term/ Long Term Goal:
5.
Interventions:
Evaluation:
1.
2.
3.
4.
Skills Used for this Nursing Dx:
5.
Explore potential Legal/Ethical Issues r/t caring for patient:
Safety Concerns when caring for this patient:
Rationale for Nursing Dx #1:
Initial Assessment Data r/t Priority Nursing Dx: for the BABY
1.
2.
3.
Highest Priority Nursing Dx:
4.
Plan: Short Term/ Long Term Goal:
5.
Interventions:
Evaluation:
1.
2.
3.
Skills Used for this Nursing Dx:
4.
5.
Explore potential Legal/Ethical Issues r/t caring for patient:
Safety Concerns when caring for this patient:
Houston Baptist University NURS 4434
SCHEDULED MEDICATION WORKSHEET
Student __________________________________ Date______________________________ Unit & Room ______________________________
Drug Name Class/Action
(Generic &
Trade Name)
Side Effects
Dose/
Route
Recmd
dose
Rationale for your
Patient
Frequency
& Times
Military
Time You
Will Give
Lab values/
Nursing
implications
Week 4 OB Case Study
4/13/2020
Postpartum day 2
Patient states that she has 6/10 pain. M.G’s temperature is 97.8, blood pressure was 119/72, her
respiration is 24. Patient’s fasting glucose was 109 mg/dl.
Baby Vital signs are heart rate 142, respiration 40, temperature 98.6. 48-hour Bilirubin 13.5
mg/dt. What do you think the pediatrician will order?
Mother is trying to breastfeed but after the baby had 2 low blood sugar readings, she was
persuaded to give the baby a bottle. Now the blood sugar is normal but the last three feedings
were 35 mls, 40 mls, and 50mls. Mother is trying to breastfeed but, the baby does not want to
breastfeed any more, because she does not have milk yet. The grandmother likes to feed the baby
so the mother can sleep. What can this mother do to get her baby to breastfeed?
The grandmother is staying with the mother and three-year-old son because the dad has to go to
work.
Both mother and baby will have Q8 VS.
Complete assessment of mother and baby (cite sources).
Care plan for mother and baby.
Prioritize Nursing diagnosis (including R/T and AEB) 3 for both mother and baby.
Cite where you got this information.
HBU Nursing Student Care Plan
Student Name:
Unit/RN
Admitting Diagnosis:
Rm# /Admit Date
Past medical/surgical history (PMHx):
Age/Gender
Co-morbidities:
Code Status
Date:
IV Access
Medication Times (circle)
(PIV, PICC, PORT, IJ, CVAD etc.)
L:
R:
Fluid/Rate:
Allergies
NKDA ?
Diet
(NPO, Full, Renal, etc.)
Fall Risk
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
00:00
Drains, Devices, Wounds
(Foley, JP, Dressings, Restraints, etc).
Pre-shift Report: From the case study given, create what could be received as a Pre-shift report from the previous Nurse and
write it here.
Isolation
Blood Type
Vaccines
Discharge Plan:
Teaching:
LABS: Date/Result/Interpretation Indicate if high, low, or within normal limits (WNL)
Hgb
Hct
WBC’s
Platelets
ABG
pH
PC02
P02
Sa02
Please attach EKG Strip if applicable
PT/PTT
INR
NA+
K+
LFT’s if relevant
BUN
Cr
HgBA1c
Glucose
Other relevant labs
Ordered Diagnostics/Tests
Nursing Assessment Findings/Review of Systems: Chart “by exception.”
Neuro/Head/Neck
Respiratory
(Mucous Membranes, Glasses, Hearing Aids,
NVS/ Pupils, Cranial nerves, motor function,
Clonus, Seizures, Gait, etc.)
(Rate, Rhythm, Pattern, O2 needs, Cough,
Trach/Suctioning etc.)
Nutrition/Endocrine
CV
(Diet, % of meals taken, BG/Trends, Tube Feeds,
TPN)
(Heart Sounds, Pulses, Rhythm, Cap. Refill,
Extremities, Pedal Pulses, Weight Attach EKG to
back)
1. Priority/Nursing dx. Assessment (as
evidenced by)
Plan (Goal- short term or
GI
(Abdomen, Bowel sounds, Bowel Routine, Last
BM)
GU
Integ./MSK/Mobility
(Skin, Turgor, Wounds/Incision (s), Hair, Nails,
ROM, Safety Concerns e.g. call bell in reach, bed
alarm, restraints etc.)
Psychosocial
(Urinary pattern, Total output, Catheters, Kidney
function, Dialysis etc.)
(Emotional State, family dynamics, spirituality,
pertinent health determinants, Legal/Ethical
Issues)
Rationale for Goal(s)
Intervention (Skills Used/Patient Teaching)
Rationale for Goal(s)
Intervention (Skills Used/Patient Teaching)
Rationale for Goal(s)
Intervention (Skills Used/Patient Teaching)
long term)
Evaluation/Follow Up:
2. Priority/Nursing dx. Assessment (as
evidenced by)
Plan (Goal- short term or
long term)
Evaluation/Follow Up:
3. Priority/Nursing dx. Assessment (as
evidenced by)
Evaluation/Follow Up:
Plan (Goal- short term or
long term)
Pathophysiology Algorithm
1-2 credible (published in the last 5 years and peer reviewed) articles or other credible reference(s) required
Etiology that led to the medical diagnosis:
Pathophysiology-What is occurring at the cellular/tissue and/or system level?
Risk Factors
Diagnostic Findings
Diagnosis:
General Objective/Subjective
Clinical Manifestations
Relevant DoH (min. 3) and Rationale
Complications
Gender, health services, environment/working conditions, education and literacy, physical environment, social
support networks, personal health practice and coping skills, social environments, healthy child development,
biology and genetic endowment, culture, financial and social status
General Treatment
Treatment for your client
Clinical Manifestations of YOUR client (objective/subjective)
SCHEDULED MEDICATION WORKSHEET
Student
Drug Name
(Generic &
Trade Name)
Date
Class/Action/
Side Effects Common
and SEVERE
Dose/
Route/Frequency
Is the order within
recommended dosing
limits?
Unit & Room
Rationale for your
Patient
Order
frequency &
Time(s) you
actually gave
Lab values/Nursing implications
(e.g. if giving K supplement what was the most
recent K+ lab? Or if giving insulin what was the
blood sugar? If giving cardiac meds what is the
apical heart rate/vitals?)
Med Surge Week 5 Case Study
GU Case Study
Mr. Harris is a 65y/o white male (weight 245lbs, height 66inches). He has history of kidney
stones (Urolithiasis). He is currently admitted with severe left flank pain, painful urination,
hematuria, and nausea for 3 days. On your initial shift assessment, his V/S are as follows:
BP 140/90, HR 88 RR 24 T 98.0
Mr. Harris takes Ibupofen (Advil) 800g QID for knee pain and Calcium Carbonate (Tums) very
frequently for heartburn. Mr. Harris lives home alone, is a retired truck driver and claims he
doesn’t like cooking and he frequently eats fastfood and drinks 4-6 cups of coffee with cream
daily. On further assessment Mr. Harris has no health insurance, has not seen a primary care
provider since 18 months ago during his last episode of kidney stones.
On examining his diagnostic results intravenous pyelography shows a kidney stone on left ureter.
His BUN 48mg/dl Creatinine 2.8mg/dl
What specific instructions would you give Mr. Harris when he urinates?
What specific nursing interventions can help Mr. Harris?
What risk factors does Mr. Harris have that leads to the development of kidney stones?
What are procedures can be done to remove Mr. Harris kidney stones?
What lab results of Mr. Harris should be of greatest concern for the nurse?
Formulate a discharge plan for Mr. Harris?

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