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comp care plan using the template provided below with only one medical and nursing diagnosis 

 

Patient: 

Age: 35 y/o 

Occupation: Housewife

Education: Completed only up to the 5th grade 

Support person: Husband and mother 

G3P1; 27 weeks and 4 days 

Allergies: NKDA

Blood type: A+

Code status: Full code 

DS is a 35 year old pregnant female who is 27 weeks and 4 days gestation. She presented to the emergency room because of bright red vaginal bleeding that has been occurring for 1 month. Patient states bleeding was spotty during the first week, but has been significant over the last 5 days. The patient also reports some contractions, but denies any continuing abdominal pain. She denies any recent trauma. Patient denies smoking or alcohol use, and denies domestic abuse. Patient is a stay-at-home mother and states that she walks for an hour three times a week. Patient reports history of previous C-section and previous abortion. Patient denies any complications during previous C-section. Patient presents as anxious due to current condition. 

Vital signs: BP 100/60; P 102 bpm; RR 20; Temp 37.0 C; O2 sat 98%

Labs: H/H 6.9/21; WBC 12,000; RBC 4.3; Plt 130

          Iron: 49 mcg/dL; TIBC: 207 mcg/dL 

General appearance: No apparent distress, appeared clinically stable, but pallor noted. Lips dry. 

Patient complains of decreased appetite. 

Patient is AAOx3. 

Weight: 42 kg

Uterine height: 30 cm

Blood clots present with placental tissue upon inspection of vaginal discharge. 

Contractions present every 4 minutes. 

FHR: 138 bpm 

Transabdominal US showed partial occlusion of internal cervical os

Patient was diagnosed with placenta previa, defined as the implantation of placenta in the lower uterine segment near or at internal cervical OS. Patient was instructed to remain on bed rest until 37 weeks gestation and was given a blood transfusion x2 Units while in the hospital. Vaginal exam was avoided and not done. Patient was prescribed iron and was educated on steroid therapy for fetal lung maturity. 
 

Care plan

 

Medical Diagnosis:
____________________________________________________________________________________________________________________________________________________________
Subjective Data:
____________________________________________________________________________________________________________________________________________________________
Objective Data:
____________________________________________________________________________________________________________________________________________________________
Priority Nursing Diagnosis:
____________________________________________________________________________________________________________________________________________________________
Expected Outcome:
____________________________________________________________________________________________________________________________________________________________
Nursing Actions:
*Must include assessment, interventions, and patient teaching, accompanied by rationale for doing each.
 

Action (3)

 

 

 

Rationale (3)

 

 

Nursing Evaluation
____________________________________________________________________________________________________________________________________________________________

Modification of Plan of Care
______________________________________________________________________________
______________________________________________________________________________

 

 

SCIENCE
HEALTH SCIENCE
NURSING

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