Health it and ehrs principles and practice 6th edition

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Labor SKINNY Reasoning

Anne Jones, 17 years old

Primary Concept

Pain

Interrelated Concepts (In order of emphasis) • Reproduction

• Stress

• Clinical Judgment

NCLEX Client Need Categories Percentage of Items from Each

Category/Subcategory

Covered in

Case Study Safe and Effective Care Environment

• Management of Care 17-23% ✓

• Safety and Infection Control 9-15%

Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity

• Basic Care and Comfort 6-12% ✓

• Pharmacological and Parenteral Therapies 12-18% ✓

• Reduction of Risk Potential 9-15% ✓

• Physiological Adaptation 11-17% ✓

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Anne is a 17-year-old, gravida 1 para 0 who is 39 weeks gestation and admitted to the labor room for

observation at 1200. She began having contractions three hours ago at 8 to 10-minute intervals with each

contraction lasting 30 seconds. She states her pain is 3/10. Her membranes are intact. On admission, a vaginal

exam indicates cervical dilation is 1 cm, 80% effacement, and 0 station.

After two hours of observation, her cervix is 2-3 cm/ 80% effacement/0 station and contractions are now 4-

5 minutes apart, lasting 60-70 seconds and pain remains 3/10. Fetal lie is longitudinal with a cephalic

presentation. You have her prenatal records from her visits to the office. She is Group Beta Strep (GBS)

positive and received antibiotics at 36 weeks. Her blood type is B-.

Personal/Social History: Anne’s mother is with her. Anne is not married and the father of the baby is not involved. She appears to be

relaxed although she states she is a bit nervous. She wants a natural non-medicated birth and her mother will

help coach her. She plans on breastfeeding for “awhile”. She attended childbirth preparation classes with her

mother.

What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Anne is placed on a fetal monitor and

the nurse collects the following strip:

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

Fetal Heart Rate Strip Assessment: Fetal Monitoring Strip:

Interpretation:

Clinical Significance:

Patient Care Begins:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: Clinical Significance:

Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Began 3 hours ago

P: 76 (regular) Quality: Cramping that comes and goes, lasting 40 sec after 1 hour 60- 70 sec.

R: 18 (regular) Region/Radiation: Uterus

BP: 125/80 Severity: 3/10

O2 sat: 98 Timing: 8-10 min then 4-5 mins

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT Assessment Data: Clinical Significance:

Current Assessment:

General

Appearance:

Calm, body relaxed, no grimacing, appears to be slightly anxious.

Respiratory: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort

Cardiac: Pink, warm & dry, slight ankle edema, heart sounds regular with no abnormal beats, pulses

strong, equal with palpation at radial, brisk cap refill

Neuro: Alert and oriented to person, place, time, and situation (x4)

HEENT: Normal cephalic

Chest: Breasts tender on palpation, areola darkened and occasional veins present