The document outlines a nursing portfolio for a 27-year-old pregnant patient named Aaliya, who is experiencing vaginal spotting and abdominal cramping. It includes patient bio-data, medical history, nursing diagnoses, and a nursing care plan aimed at managing her acute pain, anxiety, and risk for hemorrhage. The care plan emphasizes monitoring vital signs, administering pain medication, and providing emotional support while addressing potential complications related to her gestational diabetes and previous cesarean section.
The document outlines a nursing portfolio for a 27-year-old pregnant patient named Aaliya, who is experiencing vaginal spotting and abdominal cramping. It includes patient bio-data, medical history, nursing diagnoses, and a nursing care plan aimed at managing her acute pain, anxiety, and risk for hemorrhage. The care plan emphasizes monitoring vital signs, administering pain medication, and providing emotional support while addressing potential complications related to her gestational diabetes and previous cesarean section.
The document outlines a nursing portfolio for a 27-year-old pregnant patient named Aaliya, who is experiencing vaginal spotting and abdominal cramping. It includes patient bio-data, medical history, nursing diagnoses, and a nursing care plan aimed at managing her acute pain, anxiety, and risk for hemorrhage. The care plan emphasizes monitoring vital signs, administering pain medication, and providing emotional support while addressing potential complications related to her gestational diabetes and previous cesarean section.
The document outlines a nursing portfolio for a 27-year-old pregnant patient named Aaliya, who is experiencing vaginal spotting and abdominal cramping. It includes patient bio-data, medical history, nursing diagnoses, and a nursing care plan aimed at managing her acute pain, anxiety, and risk for hemorrhage. The care plan emphasizes monitoring vital signs, administering pain medication, and providing emotional support while addressing potential complications related to her gestational diabetes and previous cesarean section.
Portfolio Shaherbano Malik 3rd Year 5th Semester Clinical Instructor Mam Naseem Akhtar ..
Objectives
To promote, protect and maintain the health of pregnant women
To detect high risk cases and give them special attention
To foresee complications and prevent them
To remove anxiety associated with pregnancy
To reduce maternal and infant mortality and morbidity
..
PATIENT BIO-DATA
Name: Aaliya W/O: Ahmed Age: 27 years Religion: Muslim Sex: Female Marital Status: Married Occupation: house wife Educational Level: Address: Sukkur Ward: Antenatal 2 Bed Number:07 Operation: c section Medical Diagnosis: spontaneous abortion Date of Admission: 25 -11- 2024 Mode of admission (OPD or Emergence): Time of admission: 9 : am Allergies:nill Registration Number:89703 Emergency Contact Name/ Mobile Number ..
CHIEF COMPLAINT OR REASON FOR VISIT /PRESENT COMPLAINT:
History of Present Illness: A 27 years old 32 weeks pregnant female patient Aaliyal came here via opd with the complain of vaginal spotting and abdominal cramping and SpottingFetal movement,and Normal vaginal bleeding .she has also a gestational diabetes, and mild tenderness in lower abdomen. Past history illnesses: She had a previous pregnancy 2 year’s ago with c section and also hypertension during pregnancy. Immunizations: 2 dose of coronavirus has completed. Allergies to drugs, animals, insects, or other environmental agents: she has no any allergies from animals and other environmental agents.
Accidents and injuries: she had no any accident in past or present.
Hospitalization for serious illnesses: she visits sometimes in hospital when she is ill but she was admitted in hospital before 2 year’s when she had c section.
Medications/ Drug history: She is not using any other drugs or medication.
Family History of Illness: Her mother has also diabetes and hypertension and their is nothing any other family history.
Life Style : she belongs to Middle class family but her way of dressing was nice and hygienic she was taking her proper diet. Personal habits: She is a house wife and she takes care of her house including her childrens and husband she wakes up early
morning and she likes to cook food and she also watches tv when she is Free at home. ..
Diet: she is taking simple diet like wheat, rice , vegetables and sometimes she eats non vedge
Because she is Hindu she is taking 3 time meal in per day or 2 cups of tea daily.
Sleep patterns: she sleeps 7 to 8 hours in night daily but now she sleeps uncomfortable because pain and spotting and abdominal cramping. Activities of daily living (ADLs): Instrumental ADLs: she is not using any instrumental ADLs.
Recreation and hobbies: she likes to cook food.
She watches tv shows sometimes and some time she aplic some clothes when she is Free at home.
Elimination Pattern: Her elimination pattern in not stable she has frequent urination and burning sensation in urine when she urinate regularly and she has excessive urination.
VITAL SIGNS
✓ Temperature:98.6 f ✓ Pulse:100 beat per minute ✓ Respiration: 26 b/min ✓ Blood Pressure:140 /90 ..
Acute pain related to • Short term goal: I will Administer pain medication as Goal is achieved. Subjective data abdominal cramping monitor patients’ vital ordered and monitor patient's Patient has vaginal and pain. signs and check patients’ response. bleeding, mild tenderness Anxiety related to fear physically. 2. Encourage patient to in lower abdomen, of unknown cause of • Independent: practice relaxation techniques, gestation diabetes and bleeding and pain. I will Encourage patient to such as deep breathing and hypertension. Fear related of practice relaxation progressive muscle relaxation. Objective data miscarriage, ectopic techniques such as deep 3. Position patient for comfort Vital signs: pregnancy,or other breathing and progressive and provide emotional support BP: 140/90 complications. muscle relaxation. and counseling. Temp: 98.6 F • Long term goal: 4. Monitor vaginal bleeding, Resp :26 b/min I will administer pain clots, and tissue passage, and Pulse 100 b/min medication as prescribed by prepare for potential Investigation doctors . hemorrhage. Urine analysis: Proteinuria I will administer ringer/ and glycosuria 5. Encourage patient to report normal saline as prescribed by any changes in bleeding or 2. Blood tests: Elevated doctors. blood sugar levels 3. pain. Ultrasound: Fetal growth restriction 4. Other investigations: Non-stress test (NST) and biophysical profile (BPP) ..
Drug card
Trade name Generic name Availability Indication Contraindication Side effects
Mifeprex Mifepristone 200 mg Medical Confirmed or suspected Diarrhea termination of ectopic pregnancy Dizziness pregnancy up to Intrauterine device (IUD) 70 days gestation Nausea in place And for Vomiting fever/chills Chronic adrenal failure treatment of early pregnancy Weakness Concurrent long-term loss, miscarriage corticosteroid therapy Headache Bleeding disorders or concurrent anticoagulant
therapy
Allergy to mifepristone, misoprostol, or other prostaglandins.
