Nursing Care plan and Drug study
Make a Nursing Care plan and Drug study based on the given scenario Case Scenario: Mrs Beltran, a 30-year-old woman, gravida 1, para 1 who gave birth at term, birth weight 3.5 kg. Mrs Beltran and her son, 5 days of age, were seen in the lactation clinic for sore nipples. She experienced breast fullness during the third post-partum day, and by the fifth day they are painfully engorged.
Following engorgement, her nipples began to crack.
Nipples now “seem to hurt all the time”. She reports that severe nipple pain occurs with latch-on.
Mrs Beltran appeared to be tired and downhearted. She reports that her baby was crying a lot, did not sleep well and was not gaining weight well. Her baby starts well but soon stops, apparently because he was not getting enough.
He would then cry and be reluctant to take the breast again. Her vital signs were: BP: 130/90 mmHg, PR: 95 bpm, RR: 20 CPM and Temp: 37.8 C.
A maternal breast examination revealed moderately engorged breasts. Nipples are everted, approximately 1 cm in size with a linear fissure diagonally from 2 to 8 o’clock on the left side and 10 to 4 o’clock on the right.
She was given ibuprofen to reduce the discomfort and pain.
NURSING CARE PLAN FORMAT
| ASSESSMENT | NURSING DIAGNOSIS | PLANNING | INTERVENTION | RATIONALE | EVALUATION |
| Subjective
| Problem, Etiology, Signs(P.E.S) Format | Short Term Goal: S.M.A.R.T + Evidence | Independent * Assessment
* Therapeutic
* Educative
Dependent * Assessment
* Therapeutic
* Educative
Interdependent/Collaborative * Assessment
* Therapeutic
* Educative
| Short Term Goal Evaluation | |
| Objective
| INFERENCE Scientific Explanation (Diagram Form) | Long Term Goal: S.M.A.R.T + Evidence | Long Term Goal Evaluation |
DRUG STUDY FORMAT
| DRUG | CLASSIFICATION | INDICATION | SIDE EFFECTS | ADVERSE EFFECTS | NURSING RESPONSIBILITIES |
| Generic Name:
Brand Name:
Dosage:
Route:
Frequency:
|
| ||||
| MECHANISM OF ACTION
| CONTRAINDICATIONS
|
