Acute Care: Obstetrics Case Study Intro Page
NURS 333: Clinical Management of the Growing Family
Purpose of the Assignment: The purpose of this paper is for the student to conduct an in-depth assessment of a childbearing woman and her family in order to plan nursing care specific to that client, based on nursing research and AWHONN Standards of Care. The assessment will include the appropriate physiological, psychological, social, cultural, and environmental influences pertaining to the client and her family as it relates to preconception, conception, antepartum, intrapartum, postpartum, and neonatal care.
Student Approach to Assignment: I approached this assignment by using information I gathered while working with laboring and postpartum moms. I also assessed and included information I gathered from their babies while working with them. I assessed my patients from head to toe, mentally, physically, and everything in between to get the best picture of their health in order to better plan for their recovery. I looked at all data including labs, notes, vitals, and personal worries to make sure we left nothing out of their care plan.
Reason for Inclusion of the Assignment in the Portfolio: The reason for including this assignment in my portfolio is because it is a great example of my use of assessment, clinical judgement, and care planning. I get to walk you through what I was seeing and thinking and how I used that to form and better support my patients’ care.
Domain 2: Person-Centered Care:
- End of Program Outcome 6: Communicate effectively with individuals.
- In this paper I show that I communicate effectively with individuals as shown through my teaching of my patient and their family members, answering questions, and facilitating a professional relationship with the family.
Domains 2, 3: Person-Centered Care, Population Health Descriptor
- End of Program Outcome 8: Applies appropriate knowledge of major health problems to guide nursing practice.
- In this paper one of the ways in which I showed my knowledge of major health problems which guided my nursing practice was when I understood that C-sections come with a risk of bleeding and infection at the incision site. Due to this, I made sure to perform thorough assessments on the incision site throughout my shift during rounds to look for signs of bleeding or infection such as a large amount of blood, redness, fever, and more than the expected pain after surgery especially if it radiated from the incision site.
- End of Program Outcome 13: Evaluates nursing care outcomes through the acquisition of data and the questioning of inconsistencies.
- When working with mom and baby I tracked all vitals and assessments within the EMR. I then watched and evaluated the trends of each and based off of the assessments continued or adjusted their care plan. Thankfully their assessments all trended upwards, so we were able to focus on rest and recovery. I also focused on making sure baby was eating and gaining weight and mom was having no signs of bleeding or infection. One of our nursing goals was that mom would have no trouble or pain with breastfeeding. When I first assessed mom was having some pain. Due to this I questioned the pain and brought in a lactation specialist to help evaluate.
- End of Program Outcome 14: Revises actions and goals based on patient data or responses to interventions.
- As discussed in my paper our goal was to make sure that baby was eating well, and mom was able to breastfeed without issue. Mom and baby were doing well, and all was going well, however, mom said she was having some pain with breastfeeding. Due to this I took a step back and changed our interventions. I already was providing pain management and now I decided to ask for a consultation from lactation to help with her breastfeeding. I made sure that each time she was breastfeeding I brought lactation into the room and then I reassessed after each feed to track progress.
Domain 5: Quality and Safety
- End of Program Outcome 16: Identify sources and applications of national safety and quality standards and hospital standards of practice to guide nursing practice.
- There are lots of safety standards in women’s health when it comes to mom. For the hospital we assess all C-section patients’ incisions for signs of infection every time we round. This is so that we can identify a hemorrhage or infection early on so that we can treat it.
Domain 8: Informatics and Healthcare Technologies
- End of Program Outcome 38: Uses informatics to enhance one’s own knowledge base to provide patient centered care and support teaching.
- I used informatics while using the EMR. I charted on all of our patients and were able to get records from outside sources sent to us. I made sure to track trends as well so that we could better assist and care for. This was important because my patient had a risk factor for pre-eclampsia.