Case Study—Juanita Perez_Client in Labor Case Scenario

Case Study—Juanita Perez_Client in Labor Case Scenario Juanita Perez is a 22-year-old married female who is in active labor. Mrs. Perez is a gravida I who was admitted 4 hours ago at 39 and 5/7 weeks gestation. Mrs. Perez has had an uncomplicated, planned pregnancy and is 6 centimeters (cms) dilated. Mrs. Perez’s cervix is 100% effaced and the baby is at—1 station. Her uterine contractions are every 3 to 4 minutes lasting 60 to 90 seconds and are of moderate to severe intensity. Nursing Assessment Mrs. Perez vital signs are: blood pressure—122/ 74; heart rate—90 beats per minute; respiration rate—24 breaths per minute; temperature—99.2°F. orally. The fetal heart rate is 135 baseline with accelerations with uterine contractions. Mrs. Perez has a moderate bloody show and amniotic fluid leakage appears clear. Mrs. Perez tells you; I really want “to go naturally.” “I am trying not to take the epidural anesthesia, but it is really painful.” My husband is trying to help me maintain my breathing and concentration with the techniques we learned in class. “I don’t know how much longer I can take this!” 1. Select potential nursing diagnosis: 2. Fill out the grid with NOC indicators and the appropriate Likert scale. Select the appropriate point on the Likert scale to measure the client’s current status. INDICATOR Mild pain Mild to moderate pain Moderate pain Moderate to severe Severe pain Decrease pain level 3. Write outcomes to help resolve the symptoms (defining characteristics) 4. Select appropriate NIC activities & interventions for the NIC activities: Nursing Interventions and Rationales: EVALUATE After putting into effect the nursing interventions, the results of the care should be evaluated by determining if the outcomes were met. If the outcomes are acceptable, the care plan is resolved. If the outcomes are not acceptable, further assessment should be done to answer the following questions: NOC Indicator Rating at admission Rating 15 minutes later Rating 30 minutes later Decrease pain level QUESTIONS 1. Was the correct nursing diagnosis chosen? 2. Was the outcome appropriate? 3. Were the interventions appropriate in this situation? 4. What other interventions might have been helpful? Changes in the nursing diagnosis, outcomes, and interventions should be made as needed. This is continued use of critical thinking to ensure appropriate nursing care. References: The Ackley/Ladwig text Ackley and Ladwig’s Nursing Diagnosis Handbook – 13th Edition (elsevier.com)

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