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This criterion is linked to a Learning OutcomeClinical Judgment Plan of Care Template (20 points/25%)
2. All Clinical Judgment Plan of Care Template sections must be complete and not left blank
3. Content presented in the Clinical Judgment Plan of Care Template is directly relevant to areas of noted weakness.
4. Appropriate medical terminology is used in the Clinical Judgment Plan of Care Template.
patient information:
Name: Georgette Polsky
Age: 26 years
Provider: N. Grant MD
Allergies: erythromycin
Code Status: Full Code
Admit Wt: 181 lbs (82.3 kg)
Pre-pregnancy weight: 145 lbs (65.8 kg)
BMI: N/A
Nursing
Flowsheets
Lab & Diagnostics
Other
VITAL SIGN TREND
Date Temp HR RR BP SpO2 O2
12/14 0800 98.5 °F
(36.9 °C) 84 18 128/74 99% RA
Date Lab Normal Result
12/14 050 Blood type
O Neg
Rubella Immune
GBS negative
HIV Negative
Hep B Negative
Date Fetal heart rate
12/14 0800 135 beats/min
Client Information:
Medical History:
+gestational diabetes
asthma x 7 years
Surgical History:
Right knee arthroscopy, 8 years ago
Cesarean delivery, 5 years ago
Nursing Note: Alerted by the client that she felt dampness on her leg. A large amount of clear fluid was noted at the perineum. +nitrazine; sterile vaginal exam performed. 5 cm/100%/-1. Foot felt on vaginal exam. The fetal heart rate is 130 with moderate variability. The client denies pain.
NURSING ASSESSMENT & NOTES12/14 0945Nursing Note: Alerted by the client that she felt dampness on her leg. A large amount of clear fluid was noted at the perineum. +nitrazine; sterile vaginal exam performed. 5 cm/100%/-1. Foot felt on vaginal exam. The fetal heart rate is 130 with moderate variability. The client denies pain.12/14 0955
Situation: Georgette Polsky is a G2 P1 who was admitted in active labor early this morning at 38 2/7 weeks, and when I performed a sterile vaginal exam, I felt what I thought was afoot.
Background: She is planning on a VBAC. She has gestational diabetes and asthma. She is single and has a friend here for support.
Assessment: Membranes ruptured 10 minutes ago with clear fluid noted. Her vital signs are stable. FHR is 140 with moderate variability. She had an epidural placed at 0600 and is receiving good pain relief. Contractions are every 3 minutes lasting 40 seconds.
Recommendation: I think the baby is breech, and we need to get an ultrasound to confirm.12/14 1010 Nursing Note: Provider to bedside with bedside ultrasound. Confirmation of footling breech. Orders received for cesarean section. The anesthesiologist, and nurse coordinator were notified, and L&D OR was notified. Right, upper forearm IV patent, running LR at 125 mL/hr. The provider completed informed consent, and the client signed.
12/14 1015 Nursing Note: Epidural placed per anesthesiologist.
12/14 1030 Nursing Note: Client to L&D OR2 by cart. The client slid to the table. External fetal monitoring on. FHR 130s with moderate variability were noted. A Foley catheter was placed with 200 mL of clear yellow fluid, and it was returned. External fetal monitoring was removed. Sterile abdominal prep was performed. Time out was completed. Cut time 1030.
12/14 1025 Nursing Note: The client was educated on the cesarean section routine. Plan for the newborn to go to a warmer, be cleaned, be assessed, and then go to a friend at the head of the table so the client may see the newborn. The client would like to hold the newborn on the way to recovery.
12/14 0945 Nursing Note: Alerted by the client that she felt dampness on her leg. A large amount of clear fluid was noted at the perineum. +nitrazine; sterile vaginal exam performed. 5 cm/100%/-1. Foot felt on vaginal exam. The fetal heart rate is 130 with moderate variability. The client denies pain.
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