Essay about L D Careplan

Submitted By rgrickards1969
Words: 4721
Pages: 19

RN Program
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN

LABOR AND DELIVERY

STUDENT NAME: Robin Rickards CLINICAL SITE/UNIT: SOH/L & D CLINICAL DATE: 01/13/15
ALLERGIES (DRUGS, FOODS, ENVIRONMENTAL, LATEX): NKDA
PRIMARY LANGUAGE: English RELIGIOUS AFILLIATION: None SPEAKS AND UNDERSTANDS ENGLISH WELL: Yes
ABLE TO READ ENGLISH: Yes
GROWTH/DEVELOPMENT : ERICKSON According to Erickson, pt. falls in the “young adulthood” phase, with title being, “Intimacy vs. Isolation.” Patient is in this stage based on age only. Patient is single and relies on her mother and sister to help with children. She has no contact with the fathers of her other children or the one she is currently pregnant with.
DEMOGRAPHICS:
Patient initials:

SM

Age:

33
Pre-pregnancy wt: 145 lbs.
Current wt:
185 lbs.
# prenatal visits:
10
Marital Status:

Single
Recreational Drugs OR Alcohol Use During Pregnancy:
Marijuana
Smoking Y/N
Amount:

½ pack per day

Breast/Bottle

Breast
Planned Pain Management

Yes/Epidural
Special Diet

No
Childbirth Classes: Y/N

No
Fall risk

Yes, after administration of epidural

PRENTAL LABS:
Blood Type/RH:

A +
28 Week Rhogam:
Y/N/NA
No
RPR:

NR
Hgb/Hct:

9.7d/dL/30 %
WBC:

12.7 K/uL
Triple Screen:

Not documented
Sickle Cell Screen:

No
HIV/HBSAG:

Negative
Glucose Screen/ 3hr GTT:

Not documented
Rubella Titer:

Positive

GC:

Not documented
Chlamydia:

Negative
Herpes (HSV)

Negative
HPV

Negative

Any special labs obtained

Please see lab results on pg. 10

OBSTETRIC HISTORY:
G:

6
T:

3
P:

2
AB:
(spontaneous/ elective) 1/1
L:

2
Multiple Gestations:

6
Stillbirths/
Neonatal Deaths:
1 death at 1 month of age due to SIDS

Describe each preg.
Year:
Delivery Type (NSVD, LFD, Vacuum, CS, SAB, TAB

Weeks gestation
Sex/Weight:
Pain Mgt.:
Living with patient:
Maternal/Birth/
Neonatal Complications:
1
2001
NSVD
39
M/8lbs., 4 oz.
None
Deceased
None
2
2007
NSVD
40
M/7 lbs., 8 oz.
Epidural
Yes
None
3
2012
NSVD
39
M/6 lbs., 8 oz.
Epidural
Yes
None
4

5

MEDICAL HISTORY: (Note do not leave blanks)
CHIEF CONCERN:
(Reason for coming to the hospital)
NOTE: If pt. is a healthy female without any medical condition simply put her medical Dx. as IUP (intrauterine pregnancy at ____ weeks gestation.

CURRENT MEDICAL HISTORY: MEDICAL DIAGNOSIS THAT CAN BE AFFECTED BY PREGNANCY/LABOR/BIRTH OR CAN NEGATIVLEY EFFECT PREGNANCY Example: diabetes, hypertension, heart disease etc.
Medical complications associated with pregnancy such as preterm labor, PIH, Gestational Diabetes, Placenta Previa, etc.

Medical Diagnosis

IUP at 39 weeks and 2 days gestation
Textbook Clinical Picture
Definition, Signs and Symptoms that should be seen (use citation)
Client’s Actual Clinical Picture
What signs and symptoms your patient actually exhibited.
Premonitory signs and symptoms of labor include: cervical changes, lightening, leg cramps, frequency in urination, low back pain, increased energy, bloody show, and Braxton Hicks contractions (Ricci, 2013.) The patient’s actual clinical picture presents in frequency in urination, low back pain, and Braxton Hicks contraction. Pt. is a scheduled induction.
PAST MEDICAL AND SURGICAL HISTORY:

Kidney stones/Lithotripsy 04/2009, Elective abortion 9/2012

HISTORY OF ANEMIA:

Not documented

HISTORY OF PICA OR AN EATING DISORDER:

None

HISTORY OF ABUSE OR DOMESTIC VIOLENCE: (Past or present) Cont.

None

HISTORY OF PSYCHIATRIC TREATMENT:
(Including depression)

None

ANY PHYSICAL OR LEARNING DISABILITIES:

LIST PRESCRIBED MEDICATIONS
Please see medications list…