Question

Sarah Grace is a 40 years old woman who came for consultation for the first time. She said she moved from Texas to live with her ailing mother who is 76 years old. It is uknown if she had previous prenatal visit but stated she is 32 weeks pregnant.

She appears quiet and reserved about her financial status but only says she previously worked as a grocery cashier. She indicated that she had spontaneous abortion 2 years ago and had previous abortion when she was 15 years old.

She does not indicate if she is married but seemed to be avoiding discussion about her support system.

She is asking questions about how to know if she is in labor and how to prepare for it. Her current health status needs to be assessed. You are going to meet with the patient prior to a doctor interaction. A health history is not available or any previous lab work.

Gather pertinent information that will aid the doctor in helping Sarah Grace. Please be keen on the needs of the patient that may present during your initial interaction.

The CNA had taken her vital signs as follows:

Temp 98.7; BP 190/100; Pulse 98; Resp 22 pulse oximeter 95% Room air.

1. Prepare a care plan with 4 nursing diagnoses, five objective and subjective data, three goals, six interventions and six outcome.

please send answers to my email.

Thank you.

Answer 1

Assessment	diagnosis	Goals	Intervention	Outcome
Subjective data 1.40 years old, 32 week pregnancy and no antenatal check up earlier 2.Spontaneous abortion 2yrs ago 3.previous 2 abortion at 15 years of age. Objective data 1.BP: 190/100 2.oxygen saturation at room air is 95%	1.G4P3A3L0 2.Hypertensive 3.respiratory distress 4. Impending preeclampsia	1.Safe confinement 2.improve her respiratory distress 3.control her hypertension	1.oxygen inhalation 2.hourly BP monitoring 3.proper positioning and complete bed rest 4.send urine to check proteinuria or pus cell, collect and selnd blood for grouping and cross matching 5.NST and monitor fetal movements 6.Fetal heart monitoring	1.saturation improve 2.BP reduces 3.Improved respiration 4.has adequate fetal movements 5.fetal heart rate normal 6.safe delivery with healthy baby and mother.