Antepartum Care UNFOLDING Reasoning ; Anne Jones is a 17-year-old (complete case study)

UNFOLDING Reasoning Anne Jones, 17 years old Primary Concept Reproduction Interrelated Concepts (In order of emphasis) 1. Nutrition 2. Patient Education 3. Stress 4. Coping 5. Clinical Judgment 6. Communication NCLEX Client Need Categories Percentage of Items from Each Covered in Category/Subcategory 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% ✓ History of Present Problem: Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods. Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant. Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis. Personal/Social History: Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents. What data from the histories are RELEVANT(Reduction of Risk Potential) RELEVANT Data from Present Problem: 1. 17-year-old female reports two missed periods. 2. Reported some spotting last week 3. C/O breast tenderness, swelling, increased frequent in urination, and a.m. nausea 4. (+) pregnancy test 5. Provider has ordered urinalysis and pre-natal lab panel RELEVANT Data from Social History: 1. Senior in H/S. 2. Works in a job that requires constant standing 3. Denies use of alcohol/nicotine & is not on any prescription medications 4. Reports a daily diet of poor nutritional value 5. Does not currently have a support system, as she has not informed anyone of her present situation and must be interpreted as clinically significant by the nurse? Clinical Significance: -These are all presumptive signs of pregnancy. Clinical Significance: -Patient is in stable health with no known major medical concerns at this point. We know that she will need her nutrition and dietary habits addressed to successfully accommodate a growing fetus. She will also need a support system and education on what to expect in the coming months. We’ll know more when her lab panel comes back. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness P: 76 (regular) Quality: Tender to touch and movement R: 18 (regular) Region/Radiation: Both breasts BP: 125/80 Severity: 4/10 but better if wears a bra O2 sat: not assessed Timing: For the past couple of months